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times; said she was going to die. This condition was followed after a few
days by a period in which she was often quite natural, at other times a little
irritable, or again homesick, with considerable insistence on being allowed to
go home, and now and then crying. Retrospectively the patient said that she
felt confused at * first, that nothing looked natural, everything looked alike
and that for this reason she thought she could not see right. But a careful
inquiry into her actual capacity of elaborating impressions at the time of her
psychosis was not made.

She was discharged, recovered, March 26.

Case 3. — Polly V., aged 37, married, was admitted to the Psychiatric Insti-
tute May 4, 1916.

Family History. — It is claimed the family history is negative with the
exception of the fact that one brother had an attack of insanity from which
he recovered.

Personal History. — The patient is a Jewess who was born in Prussian Poland,
emigrated to England and later came to the United States when 25 years old.
Her people are decidedly ignorant and it is difficult to get a very reliable
account of her make-up; but she is said to have been rather quick tempered,
lively, fond of amusements a good mother and a good wife. She was mar-
ried when 20 and has six living children, the youngest 2 years old.

For several months before admission the patient was rather nervous, easily
frightened and fearful about her children. Three months before admission
a cousin and his wife came to live in the same house in which the patient was
janitress. A few weeks before admission this cousin began to complain to
the patient about his wife; when the latter heard this she came to the patient

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(about a week before admission) and made quite a scene, during which she
pulled the patient's hair, and it is claimed that the latter fainted. Moreover,
this woman complained to the landlord that the patient was not taking proper
care of the house, and she got several other women to turn against her as
well. They now threatened to report her to the board of health and to
the charities department for not keeping the house clean. They scared her
also by telling her she would be sent to prison. This made the patient very
nervous, but it is claimed that she got some comfort out of the landlord's
writing to her that he would come and investigate the matter and if the com-
plaints had no foundation he would send away the other women. When at
the appointed time the landlord did not come, the women gibed her and she
was much upset and again fainted. This was only a few days before admission.

She was then sent to her brother's house. There she said she had to go
to prison, to the electric chair; again, that she was going to die.

At the Observation Pavilion she is described as distressed, hearing her
children, saying her children had been taken away from her.

Under Observation. — The patient for the first six weeks showed much
anxiety, distress, and crying, often with more or less restlessness. At times
she was somewhat absorbed when left to herself, and there was little occu-
pation at any time. Occasionally the statement is made in the notes that
she was a little bewildered, but this is rare and, in spite of the fact that
many notes were made, is never substantiated by any definite statements on
her part of a feeling of perplexity. All her utterances referred chiefly to
her children and her anxiety about them: "Will I ever see my children
again?" — "My children have been taken away." More frequently she spoke
of them as having been killed: "Somebody killed my children; they do not
need any mother any more" — "They killed my children. Did they deserve to
be killed? They were good children." Or she claimed she had seen smoke
and knew it meant that her children had been burned, or from the window
she had seen them in the water. Again, when moaning or crying was heard
in the ward, she often thought it was her children who were being killed.
She was, however, not always fully convinced of this. Ohce she said, "If
my children are dead, I don't want to live any more." Less often she feared
that something had happened to her husband: "My husband is sick. Is
my husband dead?" — "Is my husband not dead? I think he is in the water."
And once when she spoke in this way about him, she added, "Is my mother
killed too?" Twice she dreamed that her whole family was burned to death
and was quite stirred up about it in the morning. At one time she said quite
placidly, in strong contrast to the usual distress: "I wont live with my hus-
band any more. I am going to send him to California. I don't want to have
any more children." On the other hand, the ideas about her children were
also formulated in a different way at times, namely, in the form of self-
accusations or in the form of accusatory voices : "I deserve to die on account
of not taking proper care of the children." Quite frequently she repeated,
"I deserve it, I deserve it," or, "They are going to kill me because I say I
don't want my children" — "They think I am not a good mother." In the
beginning she heard her children at night say, "Mother, mother, you were
not good to me." Again: "They say they did not want me any more, that
I did not give them enough to eat." Or: "I did not care for my children,
I did not clothe them, I did not feed them enough."

Repeatedly she said, "I am going to die," or "I am going to be killed,"
and it was quite striking that in contradistinction to the usual distress this
was said as a rule rather placidly.

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With all this there was associated not infrequently a peculiar "sensory-
unreality complex": "There is something stiff in my mouth. My whole body
is stiff. When I get my hand, I don't feel it." Or: "I don't care for my
children. Did you ever hear anything like that?" (all this with marked
distress). "I forget the faces of my children" — "Sometimes I can't remem-
ber my children. I forget all about my home." Again, "I can remember a
little about my children." In connection with some of these utterances she
once said, "I don't know what happened to me."

The test for orientation and for her capacity for intellectual operations
during this entire period gave rather striking results. For an interpretation
of these it is necessary to keep in mind two factors, namely, the patient's
distress, and her illiteracy, and her probably low mental level. For example,
she was never able to read the watch correctly, and she was not able to say
exactly how much money would be left if she went to the store with a
dollar and bought something for a certain amount. She invariably said shq
never had known that. Dates were difficult to obtain from her. Yet at
the same interview she could tell how old her children were when the family
came to the United States. The most striking fact was perhaps that she
sometimes gave very absurd answers about her whereabouts; for example,
she asked at one interview whether this was not Minnesota, yet during that
same interview she knew exactly how long she had been in the hospital.
On another occasion she called the place Castle Garden, again London, again
America. She never could give the sequence of the months, but at an inter-
view at which she gave very defective answers in this respect she knew it
was summer and knew about how long she had been in the hospital. At
another interview she said it was a hundred years since she came, but at the
same time gave the ages of her children correctly. She always claimed not
to know where she came from (the observation pavilion).

It is obvious that the significance of these peculiar answers is difficuh to
interpret, although the two factors first mentioned undoubtedly have an impor-
tant bearing.

By the end of June the picture suddenly changed. She developed a peculiar
motor excitement, with many purposeless, shaking, rubbing motions. Dur-
ing this she began to say, "I don't know what is the matter, I can't under-
st^d anything" — "I don't know the whole trouble," all this being repeated
over and over, and there was only on one occasion an approach to the former
content when she said, "I want forgiveness for my children." This reached
its climax during a still greater restlessness in which she threw herself
about in bed and against other beds and blindly shouted "police! police!"
During this condition her physical health became poor and about ten days
from the onset she was found with coated tongue, high pulse and tremulous
motions, but she was markedly unresponsive and kept up a constant unmodu-
lated moaning. The only thing she said at times during this interview was,
"I know there is some trouble." Henceforth she was changed.

During the period that followed, that is, from July, 1916, to June, 1917,
when the observation ceased, the patient did not change materially. She was
now in a decidedly perplexed state; for the most part, sat around or walked
about slowly with a perplexed frown on her face, and only at times during
brief periods did she become more stirred up. The most prominent feature
in the picture was that of her frequent statements denoting perplexity: "I
don't understand" — "I don't know what is the matter" — "I don't know what
has happened to me" — "How can I understand it? I thought they were doing

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something bad to me" — "Everybody says something and I can't understand"
—"I know there is something the matter with me" — "I know there is trouble"
— "I don't know — they are talking something" — "What shall I do when I
can't understand?" — "I don't know what people say to me" — "I don't know
what is going on" — "In the morning they pull me, everything is pulling me,
I don't know what it means."

The only approach to the sensory-unreality complex of the former period
was seen in the following : "I can see but I don't understand what it
means" — "I think my eyes spoil everything." Again she said, "My eyes are
spoiled, I can't see."

To a much smaller extent depressive ideas came out at times: "I know
I am no good" — "I don't belong to this place" — "It is too good a place, it
is a place for people who know where they are." Or once when the doctor
said to her, "Don't worry, you poor woman," she said, "I am not a poor
woman, I am bad." Whereas in the former condition she said a great deal
about her children, this was very rare and occurred only on a few occa-
sions when she said such things as "They took the children away" — "They
said I don't take care of my children." It was interesting that at such times
she cried, which was not the case on other occasions. One night she got
quite excited and claimed boats were on fire.

It is rather obvious from what has been said that nothing further could
be discovered in regard to her thoughts. Whenever one wanted to find out
what really bothered her or what her ideas were, one was met with her
usual statement that she did not understand, that she did not know what
was going on, and the like.

Similar statements were made when one tried to get at her capacity for
intellectual operations and her orientation. Nevertheless, on persistent ques-
tioning in this direction, it became more and more clear that she knew the
name of the hospital, the names of those about her, knew the time of the
year, in spite of the fact that at first she often said she did not know. On
another occasion she was able to give the names and ages of her children.

After this time the patient was transferred to the general wards of the
Manhattan State Hospital. A report of July, 1918, states: From the obser-
vations made by the ward physicians it is evident that there has been no
marked change for some time. In regard to her condition now, the nurse
says the patient sits about the ward in a rather disinterested manner. She
never speaks unless addressed and she never does any work. Whenever she
gets a chance she wanders away. The reason she gives for running away is,
"I am looking for my six children." In the ward she has to be urged to eat:
however, she appears to be quite well nourished. She keeps herself fairly
tidy and the nurse reports that she has recently improved in this respect.
She does not wet or soil, and she does not have to be dressed or undressed.

On examination by Dr. Kirby the following was found : When inter-
viewed, she is observed to be in a rather constrained attitude, her right
hand being flexed and held rather awkwardly across the chest, the left
hand resting on the chair by her side. She has a somewhat dazed, bewildered
facial expression. When asked about her health, she replied quite promptly.
"I don't know, I am not sick," and she then went on as follows: "I don't
understand anything, I don't know what to tell you, I'm not sick." When
told to put her hand down and assume a more comfortable position, she
resented being touched and pulled away in a half -annoyed way, saying, "Don't
touch my hand." Asked to give the name of the nurse, she says "Miss

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Goldberg," and smiles. The nurse's name is McGoldrick and a good many of
the patients really call her Goldberg. When asked if she knew the examin-
ing physician, she replied, "I don't know if that man is a doctor." At this
point, when asked if she could smile, her face brightened up, she smiled a
little and said, "Fm not sick." When asked about wanting to go home, she
said, "I must go home with my husband, not with a strange man," and her
eyes filled with tears.

She gives the day of the week correctly, knows the number of the ward
in which she sleeps. Asked to give the name of the place, she persistently
says, "I don't know," and later says, "I must go away now," moves to the
edge of her chair and seems a little afraid. This becomes more marked
when the nurse leaves. When asked where she formerly lived, and how
she was taken away from home, and so on, she simply replies, "I don't know,"
without apparently making much effort, although she does not seem apathetio
— on the contrary there is evidence of certain emotional tension throughout
the interview and she makes frequent references to home. (What are the
names of your children?) "I don't know." When the physician says in a sur-
prised way, "What!" she replies, "The bigger one is Rachel and the other one
is Judith." Asked, "Why did you say you did not know?" she replied, "I
didn't know what to tell in English."

To all the rest of the questions asked she is apt to say, "I don't know."
(Is your head clear?) "I don't know." (Are you troubled about anything?)
"I don't know." (Are you happy or sad?) "I don't know. I am not happy —
why should I be happy?" (Why do you at times try to run away?) "To
look for my children — my girl told me (in a letter) to go home and I don't
know where to go."

She is inclined to turn away from the physician and seems anxious to
leave, and finally gets up and walks away. When passed in the hall by the
physician she. said, "I'm not sick; I must go home to my own children."

Case 4. — Ida S., aged 25, married, was admitted to the Psychiatric Insti-
tute June 20, 1913.

Family History. — ^The sister-in-law says that both parents are living and
are well.

Personal History. — ^The patient attended school very little, but can read
and write. Practically nothing is known of her make-up, except that she
was a good housekeeper, naturally cheerful, not worrisome, always helpful to
others. She married her uncle (mother's brother) seven years before admission.
Her first child was bom six years before admission. The birth was unevent-
ful and no mental upset followed it. It is said that she never complained
about her husband and never had any ideas of jealousy about him.

About a month before admission she was confined and the labor was easy.
For three days after childbirth she was normal. On the fourth day she had
a fever which lasted only a day.

About three weeks before admission she got depressed, said she would
never get well, was very sick, had lost all her blood (she was flowing). Some-
times she did not answer questions; again was irrelevant. Finally, she said
everybody was talking about her sickness; that detectives were watching her.
It is also said that she tried to inhale illuminating gas.

Under Observation. — On admission the patient was well nourished, but she
had a sub febrile temperature for a few days, dry lips and a coated tongue.
She sat up in bed, somewhat distressed, whining or crying, sometimes when
she heard sounds she looked alu^ut somewhat frightened ; at times she was aim-

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lessly resistive, or again she appeared rather sullen and had a somewhat dazed
expression. She either did not reply to questions or answered by saying, "I
don't know," or she wanted to be left alone; but when urged she would talk
quickly enough. She then complained of not being able to breathe well, gasped,
said her lips were dry, that her skin itched, that she wanted to go home.
Her orientation was not established on account of her attitude.

For about three months following a day or two after her admission, the
condition was as follows: There was considerable restlessness, associated
with a mood of perplexed distress and often considerable talkativeness. Her
productions were often poorly arranged and many sentences were left unfin-
ished. Her perplexity in addition to being evident in her facial expression
and manner, also manifested itself directly in such frequent statements as
these: "I am all mixed up" — "I don't know where I am" — "I don't know
how long I have been here" — "Everything is changed" — "There is no day
or night" — "A thousand names have been given to me," etc.

For the rather disconnected talk, uttered with the foregoing described
affect of perplexed distress, the following is characteristic (it should, how-
ever, be added that she is not fully conversant with the English language) :

"Now they say the whole place is dirty — but now its people put here —
poor people — and now they say whoever goes out and down below — there
is an awful lot to be said — I couldn't remember exactly, and they say a
whole lot and they all have to go to court — and of course they are all chas-
ing me, out here — and a lot to be said — I am not sure of his name, he
don't belong to me, my companion," etc.

The essentials of the trend which she thus produced were as follows:
"There are lots of people here, good friends and bad friends" — "Half of the
dead people they took out here" — "I see a whole crowd that got burned"—
"The whole world is here"— "Half of New York is here"— -"All the people
are changed" — "Some house burned" — "They are all burned -down" — "Too
many people against one person."

Most of her ideas evidently came to her in the form of hallucinations of
hearing and were chiefly of an accusatory character. She was blamed for
various wicked things, and in her perplexed and distressed manner she kept
protesting and denying them. The sexual accusations of which she spoke
occurred more particularly in the first few weeks.

She said people were talking about her. Often the whistling of the boats
and the footsteps of others seemed to be connected with such voices. Thus
when a boat whistle was heard, she said: "See," or "That hurts me — from
mouth to mouth." "She is called a thief, a crook; some buildings are burned,
and she is blamed for it." "One time my name Ida, Ida, Ida — now that was
— what can I do?" — "They all say it is my fault" — "The whole crowd is
putting the blame on me" — "Everybody is suing me" — "People call me a
whore" — "They say Ida is a whore for business" — "They say I had relations
with men." Some of her perplexed protests were as follows: "I am respect-
able" — "They can't blame it on me" (in connection with her saying that a
whole crowd got burned). Again: "Why should I go and be bad?" — "Every-
body says something different" — "How can one person be for everybody?" —
"I have to be had and it is not my nature" — **My heart and soul say I am
married — so many people for one person" — "But they ain't my husband."

Then she also said much about peculiar bodily sensations and bodily
changes : "I am getting deaf and dumb" — "I am getting sores ; I never had
any sores on my body" — "The whole body itches" — "I cannot breathe, my

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lips are dry" — "My blood is poisoned" — "I never sneeze, I never cough" —
"My body is killed" — "My womb is twisted, some say it is due to child-
birth, others say it is due to immoral life."

In spite of her frequent statements that she did not know where she
was, that there was no day and no night, etc., it was found that when one
could break through this mental attitude sufficiently, she knew more than
would be indicated by her spontaneous utterances. Thus she knew this was
a hospital on an island, knew she came on a boat, had at first been in a
ward down stairs (correct). She gave approximately the date and the year,
understood that one of the examiners was a physician, but was apt to be
uncertain of the other, whom she called Harry Leon (a neighbor whom she
knew only by sight).

From this more agitated state she gradually calmed down and for several
months lay in bed, quiet, or stood or sat about with a rather doleful expres-
sion, at times whining, considerably reduced physically (six months after
admission 36 pounds under weight), sometimes having a fetid diarrhea, and
a rather swollen, red tongue. She now began to soil herself, was inactive,
said Kttle, often only shook or nodded her head when questioned, but she
spoke quickly enough at times when sufficiently urged; often, with a rather
disgusted air, she said she wanted to be left alone, or answered she did not
know or did not care. The prominent content now was that she felt sick,
dirty, that she was disgusting, covered with feces, rotten inside, that she
will die, has poisoned herself, has no body, no eyes, no teeth, no husband,
no children, is no good to anybody, is crazy.

Following this she became more active; at the same time her weight
increased and she gradually returned to her natural state. Nevertheless, even
nine months after admission, she was still languid, though without peculiar

An examination a short time before her discharjge showed that she appre-
ciated fully that she had been mentally unbalanced, but on account of her
lack of education and rather low intellectual level a good retrospective account
of the psychosis was not obtainable. It was, however, possible to demon-
strate that many details of what happened in the hospital during her per-
plexed period were remembered.

Case 5. — Elizabeth S., aged 28, married, was admitted to the Psychiatric
Institute Nov. 24, 1914.

Family History. — Sister denies all heredity, but it was later found that a
brother of the patient is wayward.

Personal History. — Both the husband and the sister claim that the patient
was lively, made friends easily, was fond of amusements, and was in no
way bashful or timid. On the other hand, it is also known that in child-
hood she often used to wet her bed, and later she not infrequently had
fainting spells during her menstrual period.

Up to her marriage she worked as salesgirl, nursegirl, and lady's maid.

She was married three years before admission. After her marriage she
again began to wet her bed at times and had five or six fainting spells since
that time. Several of these occurred on the street, so that she had to be
taken home in an ambulance.

The following incident should be mentioned at this point, because it plays
a part in the later content of the psychosis: After marriage the patient at
times worked for a woman, Mrs. D., doing sewing, and the like. This woman
evidently was of a somewhat questionable character. About three years before

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admission she made the patient a present of some silver spoons and forks.
When the patient looked at these at home she found from the stamp on
them that they evidently had not belonged to Mrs. D., but were the property
of the hotel in which the latter lived. This upset her considerably, and she
told her husband about it. She did not dare \o return the articles to the hotel
for fear that she might then implicate herself in the theft, and therefore hid
them. The woman was also immoral, as the husband states, and about six
months before admission he forbade the patient to associate with her.

Attack. — Eleven days before admission the patient told the husband that

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