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another woman (Mrs. M.) for whom she sewed at times, had had some towels
stolen from her and that one of the servants told her that she (the patient)
was suspected. (Later inquiries by the husband confirmed the correctness of
the fact that the patient was told this.) After a day or two the patient
became considerably upset about this and talked about being accused of steal-
ing. The husband then took- her to the theater in order to divert her, but
there she became quite uneasy, said people were talking about her, were
calling her a thug. Next day she fainted on the street and was taken to a
general hospital, with the statement that she had "carbolic acid" poisoning.
There it is stated that she claimed not to have taken "carbolic acid." She
was depressed and imagined everybody was against her. She was discharged
the subsequent day and sent to the observation pavilion. The notes from
the latter place describe her as worrisome and restless, and as saying that
the whole world was against her, that everybody was making fun of her and
wanted to get her out of the way.

Under Observation. — For six weeks the patient presented a condition which
was characterized by a more or less pronounced restlessness which manifested
itself at times merely in a certain tenseness, but sometimes by twisting her
fingers, pulling at her hair, walking up and down, biting her finger, and the
like, and not infrequently .by a certain uneasy talkativeness. What she said
at such times was often poorly arranged, with unfinished sentences and mlich
repetition, so that it was often quite impossible to understand what she was
talking about. A few samples may illustrate this : "Are you a Catholic ? You
know I did not do anything wrong to anybody. You know I went to the
place, I went to the theater and they said that I — I went to the theater — I
never did anything wrong in my life — they said — ^you took me for a person
that I was not, I never did anything in my life — I am innocent, innocent,
innocent. I never hurt anybody's head in my life — what are they trying to
do to me?" etc. Or, "I didn't accuse myself of anything — I am not — I only
knew but one person — a woman told me one time that — the only one I knew
about is Mr. B. — there was a woman one time said he was responsible for
some girl's death, I don't know anything else — they said — the girl — the girl
— that girl — they said she — she — I don't know — ^there was something queer—
they said — that is the only thing I know about, I know nothing about anybody
else—" etc.

There were many utterances which denoted a certain sense of confusion or
perplexity, and she often looked half puzzled, half anxious or distressed. She
spoke of being "in a muddle," "mixed up" — "I don't seem myself, I am not
at all collected"— "I don't remember anything" — "Everything is dim" — "I don't
know what it is all about" — "I feel as if something were woven around me."
Or, "There is something in my life that is interwoven."

A very prominent feature in her condition also was an expression of guilt
which seems to have come chiefly in the form of accusatory hallucinations



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and toward which her attitude was invariably one of protest and denial: "I
thought a woman was accusing me of something I didn't do; she lies" —
"I didn't do no wrong; I am innocent of what they are trying to accuse me
of" — "He says guilty, guilty — I am not guilty." We shall presently see that
there are essentially three types of misdeeds she is defending herself against,
namely theft, hurting people, and sexual matters, but she also was at times
much more general about her profession of innocence. Thus she said, "They
blame me for something I never did; I never, never did anything wrong."
Or again, evidently referring to the accusatory voices, she said, "I don't know
what they are talking about," and at one time she expressed a vagueness directly
by saying, "There is somehing I am innocent of but I don't know what it is
about." For the rest she said such things as "I don't owe any bills to anybody, I
thought they said I did." Or, "Whatever I saved I saved honestly ; I think they
think I stole things, but I didn't ; the only thing I am guilty of is petty thieving."
(When questioned about the latter she explained, much more clearly than when
she talked about the more indefinite matters, that when she was a salesgirl
she sometimes took little remnants of silk.) Again she said, evidently refer-
ring to the matter mentioned in the history, "She gave me things but she
need not say I tried to steal things; I didn't really steal things." Another set
of ideas is as follows : "I never hurt anybody in my — the idea, I never harmed
anyone in my life." The protests about sexual matters were as follows: "I
never knew any man but my husband; I would slap any man who got fresh
with me"— "I think they think— I am not bold"— "They said I had a child
before I was married, but I didn't" — "I have no children; they say I have but
I haven't" — "I never had anything to do with a negro; I said yesterday I got
something from a negro and gave it to my husband. My God, this is not true,
I never had anything from a negro" — "People think I want to break up my
home." She also mentioned Chester G. several times, a man who evidently
was a questionable character and whom she had known earlier in life, as she
told us when she was less stirred up. It was at that time that she told us
that she heard his name called in the theater. The following evidently refers
to this: "They think I know something about Chester G. I never saw him
since I am married," or again, "Isn't G. whom they want? He has two names."
(He actually went under two names as was found out later.)

A certain feeeling of danger was also expressed at times. She asked
whether she was going to be sent to the electric chair, or said, "You are going
to hang me" — "The woman in there said I was going to the electric chair.
Please don't write that; I have done nothing wrong" — "People want to get
me out of the way" — "I am afraid you are trying to hurt me" — "What are
they going to do with me here?"

It is obvious that with the pronounced tenseness which we have described
it was difficult to get the patient to concentrate. Therefore, orientation ques-
tions were sometimes not answered at all. She simply went on talking in the
manner described, or quite often answered that she did not know. At other
times she seemed to give a little more attention and then quite often gave
answers which looked as if she were disoriented. She said she did not know
how she got here and later that "it was all like a trance." But in the same
interview, for instance, in which she said she did not know where she was
and claimed not to know what the physician was, she begged him to "do some-
thing for her head," and later also spoke of the place as a hospital, though
she added that it was a queer hospital. Moreover, when her husband came,
during this period in which she appeared superficially to be so confused, she



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gave him a detailed account of where to find certain things in the home. Or
on one occasion, when asked who the nurse and the stenographer were, she
claimed not to know, but later in appealing to them called both by name.
At one time when asked for her husband's address she said, "He lives with
me here," and then denied knowing her own address, yet later during the same
visit she gave it correctly. At the third interview with one particular physi-
cian she was asked whether she knew that the doctor had talked to her before;
she said, "Yes, but it is all dim."

In addition to the traits thus far described, there are a few which in view
of the further course of the psychosis should perhaps arrest our attention.
Thus she said now and then, "They have taken my mind off," or, "I have
been hypnotized all the time I have been here." Although similar statements
might occur in certain benign psychoses, there is a certain malignant ring to
them. Perhaps of some importance is also the following: On one occasion,
when she spoke of being accused of having had children, and she was asked
how many she was accused of having, she burst out laughing, quite in con-
trast to her usual mood, and said, "A small orphan asylum I guess; I guess
they thought I had them like chickens." But this was the sum total of any
traits that might in any way arouse one's suspicion as to a more ominous
outlook at this stage of her psychosis.

At the end of the period just described, the patient, who was quieting
down somewhat, said to one of the nurses, pointing to her visiting husband,
"This is R. S. ; you can have him," but when confronted with the statement
she became again somewhat uneasy and said, "No, you can't have him, he
didn't do anything, he never hurt any one, it is Chester G. you mean." Again:
"There are two R. S.'s, mine never hurt any one." This statement that there
were two men by her husband's name was made several times during this short
transition period.

Then followed a month in which her condition varied somewhat; now she
was quite clear and placid, said herself that her mind was clear, but that it
had been "confused and mixed up," yet even then, when asked personal ques-
tions, she was apt to say, "I have told you all I know about myself; I am
imaginative and make little out of big things" (sic). At other times she
answered even less well; simply said, "I don't know," or replied to all ques-
tions, "I want to go home." Again, she was entirely silent and for a few days
there was a marked but uneven reduction of activity, during which she sat
in bed with a half-puzzled, half-absorbed expression, sometimes mumbling to
herself, and resistive to any interference, even striking those about her. Now
and then a direct statement of perplexity still occurred: "Sometimes I am
myself, sometimes I anil not." (What do you mean by that?) "I don't under-
stand anything, I can't explain it, I want to go home." During this entire
period she was at times found masturbating shamelessly.

Then followed a period of about three months, not well demarcated, dur-
ing which she was fairly natural and repeatedly said that her mind was all
right now, and during which for the most part all perplexity had disappeared,
and only now and then short spells occurred when she said she did not know
where she was. Yet even then some ideas were produced, associated with
hallucinations, which showed that the vague feeling was still present, that some-
how some one wished to implicate her in some way: "Do you know any-
thing about my case outside; could they hold me for things I don't know
anything about?" — "They are trying somehow to connect me; why do they
say pictures? I never gave my picture to any man; they say it was found
somewhere." Or, "Lots of people's names are mentioned whom I worked for;



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they are trying to connect me with things I know nothing about." Or, "Mr. B.
once gave Mrs. D. an awful beating. Mrs. D. saved the bloody clothes and
showed them to me. Now I think these clothes have been found, but I
wasn't a witness." Similar ideas were also spoken of in a more retrospective
manner: "Mrs. D. and Mr. B. used to go out together and register as S. (the
patient's name). I think they were trying to hurt me for years." — "I thought
Mr. B. wanted to get me out of the way so there would be no divorce; then
he would not be corespondent in the divorce case. I thought there was a
divorce case going on in the South. There they do not take a negro's word,
do they?* (Why divorce?) "Somebody said Mrs. D. was going to have a
divorce and I did not want to be brought into it." (Why negro?) "Only a
negro and I knew anything that would get him a divorce." And finally she
said : "When I came here a woman said, *You look as if you had a child,* "
or, "Outside they said my little brother (14 years of age) was my child," and
**When I came here a woman whispered into my ear, *He is your little boy.* "

It was during this period also that she gave, at various occasions, frag-
ments of a retrospective account regarding the onset of her psychosis and the
pronounced stage of it; that is, the first six weeks after her arrival here.
The main facts of this are as follows : She claimed that when she was told
that she was suspected of having taken the towels she went to Mrs. M. and
told her she had not taken them. Mrs. M. said she had not been suspected;
"Then I got depressed without knowing why."

Then she spoke of her experience at the theater. While there, she claims,
she thought there was a "concocted scheme" — "I think now it was a scheme
to break up my home" — "I only heard a certain voice; it was Mrs. D. ; she
had a terrible nerve to get up and condemn me. I got an awful blow; it
was the last place I expected it, at the theater." This woman, she claimed,
also mentioned the name of Chester G. and said he was wanted for a crime.
On another occasion she said that at the theater some one was wanted for
murder, "I wanted to yell — afterward they spoke my name, 'Elizabeth S. $50,* "
or "Later she mentioned my name, then a crash came," or "My whole
system went crash" — "and I got a heavy feeling, I felt I was going to
faint." Again she spoke of having gone to a moving picture show (not clear
whether this is the same as the theater but it probably is). Then "Something
came over my whole system; my lips, my arms, eyes, everything; my whole
body; I walked out as if I were in a trance, all in a quiver; I thought they
wanted to use some influence over me; they wanted to break up my home,"
or "Some hypnotism was put over me; Mrs. D. and Mr. B.'did it."

Then she also said that while still at home she heard her name called;
that it sounded like some one in distress, "like my uncle," and that he said,
"remember." At the general hospital they said she was wanted for murder.
She evidently remembered clearly what happened both at the general hospital
and at the observation pavilion, yet stated that the first part of her stay here
seemed hazy.

For the following nine months during which she was still under our obser-
vation, the patient was again somewhat diflFerent, though again the transition
was by no means a sharp one. In the first place, she was out of contact with
her environment more than before and often sat in self-absorption somewhat
slovenly in her appearance unless the nurses attended to her, and for a time
at least wet the bed quite frequently. Sometimes throughout the period she
suddenly attacked the nurses. Some of these attacks were plainly associated
with hallucinations— thus she said that they made remarks about her, or "They



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need not bring the whole family into it." At other times she had crying
spells; again laughed boisterously.

The ideas giving expression to her feeling that there was an attempt to
implicate her somehow were now almost absent, though now and thea a state-
ment such as, "It seems they want to get rid of me," or "Nonsensical people
are writing about the electric chair," showed that there was still occasionally
a feeling that there was something going on against her, which was similar to
what we have seen before; or she spoke of having been "niggered" here; or
complained of the harsh treatment that she had been subjected to. Such
statements were usually associated with crying. On the other hand, as has
been stated, she also quite often laughed boisterously. When asked what she
laughed about she was sometimes unable to tell, but once she said, "I think
of funny things." (Tell us about them.) "Well, for example, I see a paper
and it says, Hoch der Kaiser — but I don't like Germans; suppose some one
docs a mean trick and you say Hoch der Kaiser to get back at them." Or she
spoke of other hallucinations which were also more incomprehensible than her
former ones, "Some one said pails of jelly, seventeen cents — my father paid
for them," or, "Some one said foundling; I didn't come from foundlings."
Once she said: "Mrs. D. is the whole shooting match here; they want to
get something on me here; they will never get any immorality on me." But
as a rule her former denials were no longer in evidence, Sexual hallucina-
tions were evidently also quite prominent : "They talk a lot of smut ; they ought
to wash their mouths out" — "I know why I am kept here, for the filth of
social aristocracy." (What do you mean?) "Does not socialism mean free
love?" She also claimed that her husband was talking "smut" at her. Her
attitude toward her husband settled down to an admitted indifference and dis-
like. "We never were made for each other; there was a lack of understand-
ing between us; I never dreamt it was so terrible."

Of some interest is the fact that at one time she Evidently mixed up the
incidents connected with Mrs. D. and those connected with Mrs. M. by say-
ing, in speaking of Mrs. D., "She gave me some towels and said she paid for
them" (Mrs. D. had given her silver and she was accused of stealing towels
from Mrs. M.).

It should be added that fainting spells occurred at no time while she was
under our observation.

In May, 1916, the patient was transferred to the general wards of the Man-
hattan State Hospital, where she remained for another year. The report from
there states that while at times she was occupied somewhat, she was for the
most part without much initiative and appeared self-absorbed. Till the end
she was by no means free and natural. Sometimes for the first six months
she had spells of screaming and irritability in which she suddenly attacked
those about her. These gradually disappeared. Occasionally she made state-
ments which still resembled her old ideas — "Something is going on but I doi\'t
know what it is," or, "They confine all people to one person." And when she
was finally discharged June 4, 1917, it was demonstrated that she had no insight
whatever into the morbid nature of the state she had gone through or of the
ideas she had held, nor had she any desire to join her husband. She was taken
to the house of her sister in another state.

Case 6. — Elizabeth H., aged 20, single, was admitted to Psychiatric Insti-
tute March 7, 19(M.

Family History. — ^The father is living and well. A paternal aunt was insane.
The mother died in her ninth confinement. The patient has eight brothers and



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sisters: one dead, the rest living, patient being the eighth. They are said to
be well, with the exception of a sister who had nervous spells with "crying
and fainting," which ceased with marriage.

Personal History. — ^The patient was 2*72 years old when her mother died.
At first she was taken care of by an aunt, then sent to an orphan asylum,
and from her fourth year she was brought up by her stepmother, who treated
her badly, so that she always desired to get away from home. Yet she was
of a jolly disposition, liked company, "was always with the crowd," and
worked rapidly.

When 5 years old she fell on her head, was unconscious for some hours,
but recovered without sequelae. When 16 she was married and is said to
have been happy.

When 17 (May, 1901) she had her first child. Two days after childbirth
the sister who was taking care of her accidently broke a bottle of medicine.
The patient got inordinately irritated at this. Then she also got irritated at
the sister because the latter used to leave her alone to talk with a neighbor
(a rather giddy woman, as the patient said). Five days after childbirth she
began to feel blue and her milk stopped flowing. On the tenth day she tried
to get up but felt too weak. She was feverish, sleepy. At the same time she
was annoyed when the baby cried. The baby was taken away. About the
sixteenth day, according to the patient's own statement, she got up but felt
lightheaded, had no energy, had a "sill)r" feeling; "I got to laughing and could
not stop." She complained of noises in the head but not of voices. Her people
say she seemed to take no interest in anything, laughed in a silly manner,
had a far away look, and a voracious appetite. Five weeks after childbirth
an operation for laceration of the cervix was performed at a hospital. When
she returned from the hospital she was quite natural. After this the only
difference was that she would no longer associate with the woman to whom
the sister had talked, because she felt this woman had made her sister
neglect her.

When 19 (July, 1903) she had a miscarriage. For a week she felt weak.
About this time the sister-in-law's baby died and she was anxious for a time
about her own child.

Present Attack. — She had an influenza about three months before admis-
sion (in bed a day, feverish, coughing, sneezing). For two weeks she felt
rather downhearted and unable to do her work.

Two months before admission, while at her stepmother's house, she and
the latter had a quarrel. The stepmother scolded her, accused her of having
stolen some things from the house, and threatened to have her arrested. It
is said that the patient turned white on this occasion, seemed much affected
and slept badly that night. She became abnormal at once, seemed dazed, let
the food burn on the stove, wept much, complained of a full feeling in the
head, felt dull, drowsy, could not work. Retrospectively the patient said she
felt her memory was going, that she could not think well: "I had to force
myself to speak." She also claimed that for three days she did not speak
at all. At night she imagined that the stepmother was haunting her. Then
she began to say that some things in her house were not her own. She explained
later that this was because she thought her husband had given these things
away and that this was connected in her mind with the fact that at one time
her sister had jokingly said that the patient on her death should leave her
watch and chain to her. She began to say that she was bad, and expressed



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the idea that she should not have been married, and again that they were
pouring kerosene over the child.

Two weeks before admission she was taken to her sister's home. There
she is said to have been quiet, motionless in bed, with a dull expression, pale.
Yet she spoke at times, then chiefly about having stolen, and she seemed afraid
of being arrested; when she heard wagons outside she thought the patrol
wagon was coming for her. She had attacks of throbbing in the head, palpi-
tation, numbness and stiffness in the body and limbs. These would last for
an hour or so. She claimed these attacks were due to electricity, ether, or
opium, and that she was being poisoned. Again, she spoke of having lice,
and said bugs were in the bed. She heard voices, singing "Nearer my God to
Thee," saw angels on the wall, smelled bad odors. Toward the end she refused
food.

At the observation pavilion she is described as being rigid and resistive,
again passive. She thought she was in a church; was getting the communion.

Under Observation. — On admission the patient looked pale (hemoglobin, 70
per cent.), had a coated tongue, dry lips, a temperature of 99.8 (this did not
persist). She appeared dull, was resistive, gazed about fixedly and in a per-
plexed manner, half dazed, half uneasy.

For about two weeks she was kept in bed. During this time she was often
quiet, gazing about in a dull, yet at the same time perplexed, manner; for the
most part there was a reduction of activity and her movements were rather
slow. She was apt to resist when anything was done for her, frequently refused
food and had to be spoonfed. She also held her urine and had to be catheter-
ized. Sometimes she masturbated. The most prominent feature was the fact
that when anything happened her attention, seemed to be easily attracted by it, "
and she was apt to comment on it in a perplexed whining manner. Thus,
when dishes were brought, "These ain't my dishes," or, when something was
said, "I didn't say that," or "I hear boats and whistles; I never lived on the
water," or, when she took hold of her hair, "Who put all that hair on me,"
or, when the doctor came, "I don't know you," or "That ain't mine."

She also often gave direct expression to her feeling of perplexity by saying,
"I am all twisted" — "They got me twisted." Or she said she was "dizzy."

Sometimes she made depressive statements, "I am no good" — "Throw me
in the river" — "I stole from everybody, I ought to have been locked up in
the court house," and often she said, "I have been in a bad house" — "I ought


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