She was married at 24. After a second confinement, at the age of 26, the patient had her first attack of manic excitement, from which she recovered in four months. She had, subsequently, at the ages of 28, 30, 32, 35, 43, and 45, other attacks of the same nature, each one lasting about four months. No precipitating cause was known for any of them. Only one of the attacks, the fifth, (none were well observed) seems to have shown features different from an elated excitement with irritability. At the end of this attack she was said to have been "dull" for a month.
Her husband died four years before the present admission, evidently soon after her sixth attack.
The present attack:
About two months before admission the patient began, without appreciable cause, to be sleepless, complained of headaches and appeared downhearted and sad. She sat about.
After a week she would not get out of bed and remained in bed until she was sent to the Observation Pavilion, getting up only to go to the closet. She said very little and would not eat much. About a month before admission she began to say that she did not want to live, begged her daughter to throw her out of the window. About two weeks before admission she began to insist that she heard the voice of her brother (living in Ireland) calling her. She got out of bed to look for him.
At the Observation Pavilion she was described as slow, looking about in an apprehensive manner, bewildered, dazed, saying "I am dead—there is poison in it (not clear in what)—I am dead, you are dead."
Under Observation: 1. On admission the patient had a coated tongue, foul breath, constipation, lively knee-jerks and a pulse of 110. She appeared dull, inactive, lay in bed with her eyes closed. She would open them when urged but appeared drowsy and her face was strikingly immobile. At times she moaned a little. She could be made to respond in various ways such as
shaking her head, or making some motions as though to indicate that she could not give any explanations. All movements were slow. She also responded to a few questions by "I don't know."
Two days after admission the condition was not essentially different except that she was a little uneasy when urged to speak, corrugated her forehead, said "Everything is dark," again "I am very sick," or she turned away her head.
On the fourth day, i.e., January 26, the picture altered, inasmuch as she was much more responsive. She was found sitting up in bed and, at times, a little uneasy. She was slow in her movements and answers, speaking in a whisper and sometimes a little fretfully. The answers, though slow, were, however, by no means given in the shortest possible manner, but with variations, e.g., from "I don't know," to "I could not tell you," or "I can't tell that either." She said herself that everything had "been so dark—it is light now, but it gets so dark sometimes." She denied knowing where she was, even in what city, also denied knowing the month, adding to the latter answer "the nurse can tell you." She could not tell where she had been before coming to the hospital, or how she came. Finally, she also claimed not to know her age, her birthday or the date of her marriage; but she gave the current year correctly, the place where she went to school, the names of some of her teachers, and the year of her arrival in the United States. She also stated in answer to questions that she came to the hospital "to get well." She repeatedly said "I am so sick," or "I am so stupid," or "My mind is mixed up, twisted," or "My mind is not so good," or "I am so tired." What could be obtained of a content was as follows: When she spoke of being "twisted," she said, "I got all kinds of medicine." (How does it affect you?) "Through my head and it made me hot inside." Again, when asked whether anybody had done anything to her, she said "No, I have done wrong myself, by speaking bad of my neighbors." She claimed to hear voices "all over," but could not tell what they said. When, in the evening of that day, the nurse asked her why she did not talk more, she said, "God damn it, I am all twisted, my brain is mixed up, my system is all upset, the doctor made me stupid with questions, and the medicine I have taken made me all stupid and I am inhaling gas now." Then she again settled into a dull state and was found