wanted to go and see the boss, but was prevented. At times she tried to get out of the window; again sat gazing, repeating to herself "Always be true." She said she was in love with the boss. When the doctor gave her medicine she thought it was poison. Finally she began to be talkative and elated. At the Observation Pavilion she became very quiet.
Under Observation: She lay in bed indifferent, not eating, unless spoon-fed, when she would swallow. She soiled herself. She answered no questions as a rule, and only on one occasion, when urged considerably, said in answer to questions that this was a hospital, so that she evidently had more grasp on the nature of her environment than her behavior indicated. To her brother who called on her during the first ten days she said she could not find her lover here (an idea inconsistent with the benign stupor picture).
Then she became more markedly stuporous, drooling saliva, very stiff, often lying with head half raised, gazing stolidly, never answering, soiling. Later, after a month, this was less consistent. She now and then went to the closet, sometimes she smiled, ate some fruit brought to her, spoke a little. Repeatedly when people came she clung to them, wanted to go home, again was seen to weep silently. On another occasion she suddenly threw the dishes on the floor with an angry mood, without there being any obvious provocation. Again she got quite angry when urged to eat her breakfast, and on that occasion pulled out some of her own hair. Usually she had to be fed, was stiff, sitting with closed fists, not reacting as a rule in any other way, wholly inaccessible and has been that way for years. The stupor merged into a catatonic state merely by the development of the inconsistency in her affective reactions.
We see then that inconsistencies among the stupor symptoms themselves and the intrusion of definitely dementia præcox symptoms differentiate the malignant from the benign reactions. As a matter of fact, we find, as a rule, that careful examination of the onset reveals further atypical features, sugges
tions or definite evidences of a dementia præcox reaction before the stupor itself appears. One common occurrence is a slow deterioration of character and energy that proceeds for months or years before flagrantly psychotic symptoms appear.
Then when delusions or hallucinations are eventually spoken of by the patient, an appropriate or adequate reaction is lacking. In a benign psychosis false ideas do not appear with an equable mood unless the stupor reaction has already begun.
More important than this, although in benign stupors there may be a reduction or an insufficient affect, it is never inappropriate. This pathognomonic symptom of dementia præcox frequently occurs in the onset to malignant stupors. In fact we often find in reviewing such cases that a plain dementia præcox reaction has been in evidence, that a diagnosis has not been made simply because the stupor picture blotted out this earlier psychosis before an opinion was formed. Frequently these early symptoms are reported in the anamnesis and not actually observed by the physician.
Three cases may be cited as examples of dementia præcox onsets. It will be noted that the ensuing stupors were, like those already quoted, atypical.
Case 23.—Catherine H. Age: 21. Admitted to the Psychiatric Institute October 10, 1904.
F. H. The mother's brother had two attacks of delirium tremens. The mother died when the patient was eleven years old; she is said to have been normal. The father was living.