F. H. The occurrence of other nervous or mental disease in the family was denied.
P. H. The patient seems to have been rather shy and goody-goody in disposition. According to her mother this seclusiveness did not begin to be markedly noticeable until the winter before her psychosis, when there was some trouble about getting work. She had previously been to a business school. Then she held a position as stenographer temporarily. When this job was over she had a number of positions that did not last long and was once idle for two months. In February (three months before admission) her father was out of work, which added to her worry.
Onset of Psychosis: Nine days before admission a young man died in the house where they lived. The next day her mother insisted on the patient and her sister going to the funeral. On coming home the patient complained of being afraid and having a funny feeling. She woke up at 2:30 that night and lit all the gas, for which she could give no explanation. The day following, or a week before admission, she was slow, confused, could not get her clothes together. The next day she was restless and worried, giving a superficial explanation for the latter. She played the piano a great deal. The following day she was fidgety and cried. At 4 p.m. she was put to bed and appeared to fall asleep. At midnight when a priest called she said to him privately that she was all over the world, that she went to the 12th floor of the Metropolitan Building, that she sat down and took the man's money, $7, and came right away. She recognized the priest.
Three days before admission she wanted to stay in bed, kept her eyes closed. When spoken to she would smile but did not open her eyes. She did not pass her urine all day. Her mother then gave her some medicine which the doctor had left. The patient immediately had a peculiar attack in which she heaved her breast, drew her head back, clenched her fists and worked her feet. Saliva escaped from the side of her mouth. This attack lasted some three to five minutes.
Her mother then called an ambulance and she was taken to the Observation Pavilion. She thought that the ambulance doctor was an uncle, a soldier in the Philippines, of whom she was very fond. There she remained in bed, with all her muscles relaxed, her mouth constantly open, saying nothing and indeed resisting efforts which were made to get her to open her eyes.
Under Observation: She sat or lay down with her eyes closed and usually limp, although occasionally resistive. There was practically no reaction to pin pricks. Sometimes she opened her mouth as if to speak but rarely did so except in a very low tone and after repeated questioning. Her answers were rarely relevant. To the usual orientation questions she gave no answers that would indicate that she knew where she was. Sometimes she said "Jimmy" when asked her name, and replied to another question, "Jimmy big smile on." Once she said, "I don't know myself—what I am talking for—what I am doing." In general her speech seemed to indicate that her thought was directed entirely inward and that she paid no attention whatever to the questions. In most benign cases such a condition is accompanied by perplexity or a dreamy, dazed expression. This the patient had not. On the other hand, she was sometimes definitely scattered. For example, when asked, How do you feel? she replied, "Large all name." Again to the command, Tell me your trouble, her answer was, "I couldn't tell my mother last night and I can't tell her this night and I can't tell my proud." She referred in a fragmentary way to being crazy and to having been dead. She admitted hearing voices but may not have understood the question.
A week after admission, when visited by her mother, the latter asked her to kiss her. The patient opened her mouth widely and put out her tongue. This is a type of response which we have never seen in our benign cases.
Two days later repeated questioning made it evident that the patient knew more about her environment than would be expected, judging from her other symptoms. She gave the month correctly knew that she was in a hospital and told of having recently been visited by her father. At the same interview she spoke of masturbation, of wanting to marry her uncle, and of having been in bed with her father. The last she referred to as a "fall." Such frank incest ideas are never found in benign psychosis in our experience. Other dementia præcox ideas appeared quite soon, for within three days, when she was talking slightly more freely, she spoke of having often imagined she was having sexual experiences as a result of the influence of a man who lived upstairs, and that even when sitting with her family at the table she felt sexual sensations.
Her condition then remained essentially the same for some time. Then about six weeks after admission she became somewhat less resistive, was frequently seen sitting up in bed, moving her lips considerably (without speech) and regarding the surroundings with a bright interested expression and occasionally smiles. About this time she began exposing herself and chewing her finger nails.
Four months after admission she was noted as being very resistive and negativistic, allowing saliva to accumulate in her mouth and making no attempt to keep the flies off her. At the same time she would keep in her mouth food that had been put there without chewing it.