MOST psychiatrists state or tacitly assume that dementia praecox is a
disease of a steadily progressive nature, where the first symptom of
dementia is a signal for relentless degradation of the patient's mental
capacity except in the sphere of the more mechanical, intellectual
functions. Yet the experience of every institutional physician denies the
universality of this deterioration, and the statistics in any good text book
demonstrate that many cases are "chronic" rather than "deteriorating."
Woodman[1] has made a careful study of 144 such chronic cases, and shows
what a surprisingly large proportion of these develop a good adaptation to
the artificial environment of the institution. So far as we know, however,
no one has attempted to formulate any definite features of onset which could
be taken as a guide in determining the gravity of the mental derangement.
In fact Bleuler states categorically that "up to the present no correlation
has been discovered between the symptoms of onset and the gravity of the
outcome." Kraepelin has split off from dementia praecox a separate
psychosis--Paraphrenia systematica--which he timidly defends as a clinical
entity apparently because the course is a long one and the deterioration
less marked than in dementia praecox. But he gives us no concise prognostic
data; in fact one feels on reading his paper that the diagnosis must be made
post hoc. This problem is manifestly of equal importance from the social
and the scientific standpoint: until we can predict the outcome our
treatment must be empiric and palliative; we confess ourselves ignorant of
the disease process if we cannot make a prognosis.
[1] R. C. Woodman, N. Y. State Hospital Bulletin, Vol. II, No. 2, 1909.
It is possible to make certain a priori speculations as to prognostic
criteria based on classification and what that implies. We know that pure
paranoia is not a deteriorating psychosis--that it does not necessarily
preclude the possibility of considerable social usefulness--and that it
grades off almost imperceptibly into dementia praecox. The features
differentiating these two diseases should therefore supply us with data for
determining the prognosis. A case undoubtedly, praecox, which shows markedly
the differential features of paranoia, should have a proportionately better
outlook. In a vague way our common sense uses this standard when it makes us
"feel" that the case will have a long course which shows a relatively well
retained personality in conjunction with praecox symptoms. But "feelings"
are hardly objective criteria. What symptoms may we make use of? We may
say that the praecox patient as opposed to the paranoia has a poverty or
inappropriateness of affect, a scattering of thought and a lack of
systematization in his delusions. The weakness of will on which Kraepelin
lays so much stress may be included, though that can probably be derived
from the scattering of thought. What of these symptoms may be analyzed for
our purpose? Affect changes and dissociation in the stream of thought are
themselves signs of the deterioration we wish to predict; to make use of
them we should have at hand some theory as to the relation between their
quality and quantity, and that we have not. There remains the content of
the psychosis, a definitely objective material with which to work. This is
naturally a big problem--almost as wide as insanity itself--and one brief
communication cannot pretend to solve it. What we wish to do is merely to
put forward tentatively the claim of one type of delusion formation to
prognostic value.
Now if delusions are to be an index to deterioration they must in some way
hold a mirror to the changes in the personality, repeat them or prefigure
them. If we generalize our conception of functional dementia, we can say
that one of its most striking features is a destruction of the faculty of
appropriate reaction, a loss of what one may term the sense of reality. The
patient in direct proportion to the degree of his dementia loses his
capacity to recognize the reality of his environment or his relationship to
it, and builds up more and more a world of his own in which he lives
untroubled by the demands of adaptation. No one who has ever argued with a
paranoic will forget how keen a sense of reality he may retain, how logical
his arguments are, and how reasonable his delusions appear, if only some one
point be granted. With the praecox, however, the opposite impression may be
quite as striking. His delusions are bizarre, inconsistent, kaleidoscopic;
he has no logical explanation and cannot even state them consecutively. And
all gradations from pure paranoia to dementia praecox seem to have
corresponding losses in the sense of reality as embodied in delusions.
May we not hope to find in the content of the psychosis some objective
criterion as to the degree in which the sense of reality is lost, with all
that it implies?
But what takes the place of the sense of reality or what causes it to go?
With what tendency of the psychotic individual is it in conflict? The answer
is a psychological truism--the indulgence in fancies. Imagination, of
course, is essential to every human being, no purposeful action can be
instituted without its first being carried out in imagination. Phantastic
thinking begins when the subject fails to apply the test of reality to his
mental image and exclude it if it be not adapted to realization. If
environment or internal inhibitions prevent this realization, however, the
craving: lying back of the fancy must be diverted to a more practical
channel--the normal solution--or the fancy must persist in spite of its
impracticability. This latter process is the germ of the psychosis. But not
its development. A certain compromise may be reached--he who digs for gold
in his back-yard is not so crazy as he who reaches out his hand for the
moon. Nor is the paranoic who chooses to put his interpretation on the
surliness of his employer as far estranged from reality as the praecox who
recognizes his employer in the person of the physician. The content of the
psychosis may then express the relative strength of the two antagonistic
factors, sense of reality and fancy, the two factors whose relative
importance decide the issue for sanity or insanity.
It is easier to imagine than to act, so no human being is free of this
tendency. But what does the normal man do? He diverts these thoughts into
channels where fancy has a legitimate place--he writes romances; he imagines
himself using an instrument to talk with his friend miles away and invents
the telephone; he imagines a better society than the one which galls him,
and writes a "Utopia"; above all he theorizes and speculates. According to
his age or ability these speculations give us alchemy or chemistry,
astrology or astronomy, magic or religion, spiritism or psychology, the
were-wolf or psycho-analysis, phrenology or psychiatry, and so on. Now
three generalizations can be made about these primitive or elaborated
philosophizings: first, they all represent a constructive tendency; second,
the degree to which this constructive tendency is exhibited is historically
a measure of the cultural development of any age, an index of the
development of the sense of reality of the time, that is, the particular
speculation is not only accepted as reasonable but has its practical
application for the period; and third, the more primitive forms of these
speculations are represented in the delusions of insane, particularly
dementia praecox, patients. Following a suggestion of Dr. Hoch we have
termed these ideas "constructive delusions." As they correspond to what was
historically a compromise between reality and phantasy, they should
represent a corresponding mildness or severity in the psychosis where they
appear. Our observations--far from being extensive--have so far demonstrated
this that we feel justified in offering the hypothesis that when such
delusions are present one can base a mild prognosis on their presence with a
rather specific relationship between the crudity of construction and the
degree of deterioration. It must be borne in mind, however, that we make no
claim as to the invariable presence of such delusions when marked
deterioration does not take place. We hope only to show that when present
this particular form of content may constitute a valuable prognostic guide,
as it represents the degree to which the patient has gone in recapitulating
the history of his civilization.
It should be understood that we are not describing highly unusual cases;
many such have been published. A highly typical one is given by Freud in
his analysis of the Schreber case.[2] In this extremely stimulating paper
Freud puts forward the claim that all delusions are an attempt at regaining
health on the part of the psyche. From a broad psychological standpoint,
this is undoubtedly true but the generalization is too wide to be of any
practical psychiatric value. Moreover, by choosing for analysis a case
which was neither dementia praecox nor paranoia but a combination of the
two, he reaches conclusions which are valuable additions to our knowledge of
psychotic processes but merely confuse the issue as to the specific
mechanisms of paranoia and dementia praecox. In Schreber a profound
psychotic reaction corresponded to crude formulations of his fancies,
whereas, when he built these ideas into constructive speculations, he became
relatively sane and an efficient citizen. If Freud had emphasized the point
that this later formulation was more than a vehicle for the cruder thoughts,
that it contained components which were potentially of social value, which
implied a broader contact with the world--had he done this--then the present
paper would be superfluous.
[2] Psychoanalytische Bemerkungen uber einen autobiographischen beschrieben
Fall von Paranoia (Dementia paranoides). Jahrb. f. psychoanalyt. u.
psychopath. Forschungen, Jahrg. III.
The first case we wish to present, John McM., is at present thirty-six years
of age, unmarried, a Catholic. For at least nine years he has been
objectively psychotic, though, according to his own account his delusional
habit of thought began seventeen years ago. He had little education but made
the most of it and has read widely (for one of his station) on such topics
as socialism. He was always somewhat distant and did not make friends
easily. From early childhood he was antagonistic towards his father and
brother and, since his mother's death six years ago, to whom he was strongly
attached, towards an aunt as well. He has struck both his father and his
aunt. His antagonism towards his father is of great importance as a
determinant for his later symptoms. When young he feared him, as he grew
older disputed his authority and, according to the father, always disobeyed
him. He was always shy with women and, as we shall see, his first conflict
in the sexual sphere was solved by a psychotic reaction. Once an efficient
salesman, for the past nine years he has drifted from one position to
another. As he says himself, he lost ambition after he decided not to get
married, and concluded he would not attempt to gain worldly possessions, but
merely enough to subsist on. His early life showed not so much tendency
towards elation and depression as towards imaginative thinking with a
leaning towards day-dreaming and "mysteries." Of late years his reading has
been confined to sexual topics, as discussed by various quacks, astrology,
phrenology, Christian Science, and religion. Although he said he discovered
God for himself he never gave up the Catholic religion. Gradually his energy
has been so engrossed by these interests that he lost position after
position as a result of continually talking of his ideas to his fellow
workers or employers. This tendency eventually led to his commitment, but as
long ago as 1906 a physician said he was insane. For the past six years he
has been cross, stubborn and self-willed so that none of family dared to
speak to him. He even left home and took a furnished room by himself. In
spite of this evident anti-social tendency he speaks of himself as having
been filled during this period with a great hope; he has been looking into
the future and content that he will reach the goal and sees happiness in the
future. For some months he had talked much of the world coming to an end
and said that those who had money should spend it as it would soon do them
no good. He wanted every one to divide his money with him as, he said,
everything belonged to God. Many people were against him and he wrote
letters about this to various officers. It was when he showed some of these
to an assemblyman that he was advised to go to Observation Pavilion.
When he arrived at Manhattan State Hospital he was quiet and agreeable,
cooperated readily with his examination and seemed to take his incarceration
as a matter of course, though he has always had mild arguments to prove that
he should be allowed parole. A certain degree of deterioration is evidenced
by his failure to make much of an effort in this direction, although such
effort would be immediately successful. In his manner he was quiet,
occasionally somewhat affected and when talking of his ideas was apt to
assume an expression bordering on ecstasy. At no time did he show an
inappropriate affect or any evidence of scattering or flight. He could talk
quite objectively of his idea. He had had only one halucinatory experience
and even it should, perhaps, be called merely an illusion. "On the 14th of
March, 1912," he said "I came face to face with God Almighty. He spoke in a
Jewish dialect and was dressed as a carpenter." The patient was in the
Cathedral at the time and that night he had a vision of this man, though
this may have been just a dream. He also heard Bishop H. speak of the man
who had come to prepare the world for the second coming of Christ. The
bishop looked at this patient which meant that he, the patient, was the man.
Before detailing his ideas it may be well to outline their general tendency.
In his psychosis he succeeded in fulfilling the wish of the Persian enemy of
reality:
"Ah, Love, could you and I with Him conspire
To grasp this sorry scheme of things entire,
Would we not shatter it to bits and then
Remould it nearer to the heart's desire."
By the simple expedient of translating his interest from this world to that
of spirits he built up a new Heaven and a new Earth, where he was supreme
and his chief enemy, his father, was subject to him. Beginning with
astrology he found that his father's sign and his showed different
characters, the father's strong in earthly affairs, while the patient's
showed preeminence in spiritual qualities. Passing from astrology to the
Heavens, he discovered that his father had been Jehovah, while he had been
Christ. There had been a struggle between them in which the father had been
temporarily successful. But when his father's spirit had entered into a
body, he had become subject to Christ. In the Heaven to come, Jehovah was
to give way to precedence to Christ, was to enjoy with the Virgin Mary, his
mother, a union of love, as much more fervid as it was to be free from
carnal features. In extolling this life of the spirit the patient excluded
that physical problem which had caused him so much trouble-- the adult
sexual demand which, in the form of marriage he could not agree to meet nor
yet to put out of his mind. At the same time this religious formulation
gave him a comfortable ascendancy over his hated rival, his father. But it
gives him more than this: he has a mission, he says, he must prepare the way
for the new world, the new heaven. This is an objective interest and it is
that, we think, which has a causal connexion with his mild degree of
deterioration-- for he has been what we must regard as a praecox for many
years and yet has lost so little of his personality that to a layman he
would certainly be regarded as little more than a crank. Where his system
fails of having a sane outlet it is of course in the fact that his prophecy
has little to do with anything of advantage to others. It is merely a cover
for self-glorification.
At nineteen he talked to his friend W. of sexual matters, and, being
troubled with constipation and "rheumatism" at the time, he asked the
physician who was treating him as to whether he should indulge himself
sexually. The physician told him to, but he worried over this advice and
went to a priest, who said for him to get married. This he did not wish to
do, and so turned his attention to astrology and phrenology, the other
subjects which his friend talked of. That this was only a cover for his
original sex problem is shown by his conclusions: that he had a weakness in
amativeness--"the faculty of sexual power," his "concentration" on sexual
matters was poor. "If I had more amativeness there would be trouble; I am
glad I haven't so much. I was always more of a companion to my mother, and
when I wasn't with her I went to the theatre with W." He and his father, he
learned, had strong faculties of destructiveness; the patient, however,
could control his by reasoning; his reasoning was so strong that he could
even control his father and settle disputes between father and mother.
Phrenology also taught him his intellectual superiority to his father in
other ways.
From phrenology he learned there was a time to be born; from this he passed
to astrology. His father had arranged that he should be born in the sign of
Virgo, which guaranteed his truthfulness and obedience to his father. He
explained this by speaking of Adam and Eve disobeying God, from whose sexual
intercourse all evils sprang. Manifestly, then, it was his father's
arrangement that he should have to abstain from sexual intercourse.
His father was born in the sign Gemini; this is a fighting sign; the father
selected this sign himself, by his great fighting power; the sign is not a
spiritual one but a worldly one, and shows avarice in great grasping of
worldly things. He never thought that his father was so great, until three
or four years ago. He wrote a minister, asking him what became of God the
Father; he asked another man about religion, and was told how obedient
Christ was to his foster-father Joseph. He thought of how disobedient he
was to his father, and then decided that his father was the God, the Father,
and in the Kingdom of Heaven he was called Jehovah. (Here he identifies
himself with Christ). He says about this "I tried to reason myself away from
it many times, but was finally convinced"--The father came to this world as
John; Jehovah was the patient's father in the other world. In the other
world he had a falling out with the father, and now the father has that
revenge in his soul. He had some kind of a falling out, a fight; his father,
then Jehovah, ruled the third Heaven; one of the twelve, which he says is
about the earth, the earth making the thirteenth; this formulation he
derived from astrology: the first Heaven Aries, the second Taurus, and the
third Gemini, etc.
His father was born in the sign of Gemini, whose symbol is the twins, which
means a duel; and people born in this sign have a dual nature; the father
had a dual nature; and when the father ruled in the third Heaven as Jehovah,
a duel took place between the patient and the father, and the son's spirit
was separated from a body and roamed about. After a time the patient's
spirit got back into the Kingdom by worrying the father, but he was never
admitted in the form of a body. The father and son while still in a body
could both create man and woman; the patient then knew all about creation,
and was endowed with all the powers the father possessed, and helped the
father to build up that kingdom; but when the patient's spirit was separated
from the body his powers became less, so that he could not create a human
being. His physical personality was weakened by this, but the spirit of love
was increased; the father had carried revenge in his soul since then. The
patient was never a ruler of a Heaven, but "I was my father's son--I was
next to him--the sons never become rulers unless they win out;" the
patient's spirit remained out of his body until he was born into this world;
the patient's father came to this world as John, and married Mary McE.; when
the father came on earth he placed himself under the jurisdiction of Christ
this came about automatically when the father was born.
In the next Heaven the patient will be on the same plane as Christ, but
perhaps in a lesser degree. There can be only one father, and he will be
under Christ's jurisdiction. Christ will be supreme. He is part of the
Trinity; there is one God as three united persons; they agree on everything;
Father, Son, and Holy Ghost. These will be possessed of equal powers, but
one will be looked upon as the father, and another Son, and another the Holy
Ghost. In the new Heaven he will have equal rights and powers with the
father.
After the father married two children were born, brothers, the younger being
the patient. He says about this that he was born in the usual way, "The
spirit entered the womb of the mother from outside, and from the seed of the
father, and I was born by the will of the father." Christ was born of Mary
through the will of Jehovah--simply the spirit entered the womb and the word
was made flesh. When the father lived as Jehovah he created Adam and Eve, "I
was simply my father's son and son of Jehovah--perhaps my name was John,
which had some great meaning"--Jehovah was the greatest spirit in the
universe, but is not now, for when he was born he placed himself under the
jurisdiction of Christ; his name is now John, the patient's father. Christ
was selected to be the son of Jehovah; he was selected by Jehovah because
Jehovah had a great personality; his father arranged all of this, and he
even selected the sign that the patient was to be born in. When asked who he
is, he said, "I am who I am--When I was positive that I am who I claim to
be."
When the patient's spirit was thrown out of the body, it caused Adam and Eve
to be created--Eve was a great spirit in the third heaven--the father
thought that if he could create two persons, and they were congenial to each
other, that Adam's soul would be increased or developed by being in company
with Eve. When Adam and Eve were created they were not to have sexual
intercourse; they were merely to come in contact by spoken words--love could
exist without intercourse; it started all the trouble. To Adam and Eve two
sons were born, and the brotherly love that existed turned to fire and
hatred. They probably became jealous of each other, and so one deceived the
other. At one time he said that perhaps the mother made more over one than
she did the other; again, perhaps father and mother might have favored one
more than the other; hence jealousy arose; his brother was born in the sign
of Capricorn, which ordinarily is a sign which is congenial to Virgo; his
brother, however, is a crank and not congenial; the brother is jealous of
the patient, because the mother favored the patient.
He did not take his mother's death to heart, as he had expected for two
years that she would die. His aunt said that he told her it was a good
thing the mother was dead. He says that in the other heaven, Jehovah's wife
was Martha, a sister of the Virgin Mary. In this life she was Mary; the
father may have had many wives in the third heaven; perhaps his mother's
sisters were his wives, as they seem attracted to him. His mother's soul
existed before birth, lived in Jerusalem in the time of Christ, and was
Mary's sister. His mother was born in the eighth sign and could be trusted
with great secrets; his mother kept things to herself. She was both feminine
and masculine; that is, she was strong and sociable. In the sign in which
he was born they have great spiritual conception, keen, searching and
penetrating vision; The symbol is the Virgin, and pride makes them more
feminine than masculine, and they are sensitive; he at one time was more
feminine than now, which was due to his sensitiveness. The sign of Virgo is
the mid-heaven, where love is more intent; there they understand each other,
and there is no disagreement. "The magnet of the male and the magnet of the
female are attracted, and they agree with each other in words spoken; this
is true love, like that which existed between Christ and the Virgin Mother;
the Virgin Mother was born in that sign--there's where she got her name."
When he dies the soul of his mother will enter heaven.
In heaven Christ is to raise his mother's soul from purgatory, and she will
become the Virgin Mary. A spirit rapping in the house, which began shortly
after his mother's death, is her spirit and his guardian angel.
Jehovah was jealous of Christ as a greater spirit, so had him crucified.
Joseph was also jealous of Christ because Mary loved him more.
Further ramifications of his ideas are the cruder conceptions that semen is
the equivalent of thought, and that thoughts of women cause him to have
nocturnal emissions. Semen comes from food; to the sacrament he gives a
definitely sexual significance, and it was following communion that he
realized that he was Christ.
At one time he thought he could live, and that he could marry a girl and not
have sexual intercourse; because if he got married and had sexual love
trouble would arise. He was convinced by what he saw of his friends and
every one else he knew, his aunt, his mother and father, that they did not
get along well. The Divine Power knowing that this could not be in this
world, broke the affections he had for this girl; and he concluded he would
never get married. From a worldly point of view he knew that he was a
failure; he had failed in all his business. But he did not care for worldly
things. When he reached this point he knew that he had a mission to
perform, and began to write and preach religion to people who were qualified
to understand. He wrote many letters, all dealing with religion, saying that
he had to get things ready for the second coming of Christ; that he was the
successor of Christ; and that he was to get things in readiness for the
union of religion; when there should be one Shepherd and one Fold.
Case 2. The next case differs from the first in that the emphasis in the
ideas was laid more on spiritistic and astrological than on religious lines.
Another difference in the problems solved by the psychosis is that the
personality of the patient was not incompatible with an outlet to the adult
sexual demand through the channel of prostitution but a basic similarity
lies in the fact that the delusions center around attachment to her father,
again a family situation. The patient is an unmarried woman now forty-seven
years of age, of whose early life we know nothing. She had applied for aid
to a charity organization who, becoming suspicious on the report of a police
captain that the woman was a street walker, sent her to the Cornell
Psychopathological Clinic for mental examination. She had some petty
complaints of not being fed properly where she lived, of things not being
clean there and of the women around her being queer. Then she launched
spontaneously into her delusional story, needing very few questions to
stimulate a fairly complete recital. Throughout an her talk she showed no
abnormalities in her train of thought. She talked in a quiet way of her
"knowledge" but with enthusiasm, smiling frequently but more in a satisfied
or sociable way than with any silly expression. There was not a trace of
ecstasy in her expression. It would have been hard to say definitely that
she had any inappropriate affect. At a later interview, however, she
admitted recent acts of prostitution with no embarrassment whatever.
Her psychotic experiences began some ten years ago when she entered into
illicit relations with an elderly married man R., in the South. A year
before she had met a "mastermind" who told her that she would never be seen
in the right light. Everything came as he predicted. Her lover soon lost
his sexual capacity and so began to show his power by keeping her under his
control but still at arm's length. But she has fooled him for now she has
his power. This power was in the form of "influences." When they worked on
her she would have a throbbing like a typewriter in her head, and would then
be forced to some act. Such acts included affairs with various men and
through R.'s influences she also lost many positions. For some time she
tried to get him to support her, as it was his "influences" that had ruined
her, but he merely called her a blackmailer and had her put out of his
office. Soon, however, as the result of visions she learned that her father
(who is dead) had become Christ in the other world. It was all his influence
that had been acting on her through the medium of R. From Astrology she
learned that she had been born under two planets--Jupiter, Influence; and
Neptune, Spiritual. Her father's sign was Neptune and he was therefore a
spiritual man. Shortly after his death, she had a vision of him floating up
towards the moon and then she knew that he was joining her ethereally. She
had visions of this Father-Christ.
When we turn to the constructive side of these delusions we find that she
regards all her experiences as having been designed by the Father-Christ to
give her training, training that would increase her psychic powers. For
instance, she said part of her training had been frequent accusations of
dishonor with men she never knew. She had to acquit herself of these
charges; thus she gained power. Then she found that she did not even need to
expostulate. She could defy them, defy the whole world. As soon as she knew
she was not guilty she felt power. Things she WAS guilty of, she knew were
right for her, because she gained power by these experiences. This was
because through them she learned spiritistic facts and knowledge is power.
According to her system one mind acts over another by greater penetrating
power, though the recipient must be powerful too. Sometimes she found that
she had to be reduced by lack of food or other privation to receive
influence. Naturally, too, she could communicate with the dead and had many
examples of this power to offer. She had learned, also, about the influence
of the planets over the human brain and how to learn of conditions which
exist for any person--what he should avoid and what to accept. As the
patient was only seen for little over an hour the details of her system of
ideas could not be obtained but she assured the examiner that she never
could tell all she knows about the spirit world. In general, however, she
said that all her knowledge was useful to her and she could give it to
others individually without effort to herself but that she had no way of
giving it directly to the world. If she had a rest and got well connected
socially perhaps she might be able to do it. People who had met her casually
told her that she had done them good. But she could never tell them about
having seen Christ, they don't understand. The egoism of her faith is shown
by her statement that, having met Christ in practical life, she had no more
use for any church or ritual. Her great hope was for the future. When she
passed away, she was to develop her powers more and when reincarnated was to
come back with the big minds of the world. Once she had a vision of herself
in some high trees and the "Master mind" told her what it meant. In the
future she would have a great mind. She has it now, but the circumstances of
her life are such that it is not recognized.
The essential feature of this case, for our purpose, is that we have in this
woman a paranoid psychosis of a definitely dementia praecox type which after
ten years has shown only suggestive signs of deterioration in her lack of
purpose in work, and her dulling in emotional response. This failure to
deteriorate seems to stand in definite relationship to her system of ideas.
That these have a constructive tendency is shown by the translation of her
cruder thoughts into the setting of the occult with the suggestion of
propaganda and in their pragmatic value. With her "new religion" she has
provided herself with an argument in favor of a life of desultory
prostitution and general vagabondage. She was advised to go to a hospital
but refused, though she will certainly be committed soon, as it is
inevitable that she will run counter to society in some way.
Such cases as these first two are familiar to you all and these have been
chosen for this paper practically at random. Any large hospital will provide
dozens of similar history whose clinical pictures would serve as well as
what we have given. The next two cases represent two special types of
psychoses: one a chronic manic and the other a definite praecox with
recurrent attacks. Any institutional physician is familiar with the
chronically elated patient, who has become a hospital character-- a good
worker often who seems to be sufficiently repaid for his toil by the
privilege of stopping the passerby to expound his ideas. Such a case is
usually diagnosed as a chronic manic or a dementia praecox, according to the
taste of the examiner.
Numerous works have demonstrated how the symbolism of the modern fraternal
organization has grown out of alchemy, mysticism and rosicrucianism. Some
centuries ago these symbols were charged with a literal meaning. If a man,
however, in the 20th century attaches a similar significance to these
symbols he is rightly adjudged insane. For instance, no one in a modern
civilization can retain his mental balance and believe in a literal,
physical rebirth. The patient whose case we shall now briefly recite had
done this. He was observed at only one set interview because it was found
that a few questions, apparently innocent, led to the awakening of some
cruder ideas to which he reacted rather strongly with the statement that the
physician was accusing him of harboring murderous designs which were, as a
matter of fact, not even remotely suggested. The patient C. G., is a Hebrew,
married, age sixty-one. When forty he had an attack of excitement lasting a
few weeks. He was admitted to the Manhattan State Hospital in October 1899
and remained till April 14, 1900 with a similar attack. He was readmitted
in April 1901 again in an excitement and has remained there ever since. It
is claimed that these attacks were all preceded by a spree. The records of
these admissions state that he was excited for some years, apparently with
exacerbations, during which he is frequently noted as being delusional and
hallucinating. No content is noted so that we cannot give the development of
his ideas. He does not hallucinate now. All we know is that for five or six
years he was a rather intractable patient, who worked intermittently but
that of more recent years he has sufficiently adapted himself to the
hospital environment to be granted ground parole which he uses largely to do
a considerable amount of quite useful work. Any one who has once talked to
him is saluted from a distance with the words--"Pleased to meet you,
Doctor!" "Five fingers up!" or "Da liegt der schwarze Hund begraben!" All
this is followed by an elated volubility. When asked what "Pleased to meet
you!" meant, he said that was the password for entrance to the "Fellowship
Lodge" of a certain fraternal order. He produced a match box with the
insignia on it of a Grade in the Lodge. With this match box, once off
Ward's Island, he insisted that it could get him his bread all the world
over and hundreds of friends. He would never have been committed had he not
been drunk and forgotten to make use of his signs. The world belongs to the
Fellowship of Men. He spoke of his wife's ill treatment of him and then
went on to "I am married to the American flag and it will go to the grave
with me." This referred, he explained, to joining the red, white and blue
lodge. "Five fingers up!" was shaking hands, the clasped hands on his match
box. These hands, he said, were those of Moses and the Lord, for Moses was a
"Fellowman," which is like the Fellowship of the Father, Son, and Holy
Ghost. However, he went on to say that Moses, the Trinity and God were all
a dream; Israel and the High Grade are real--the High Grade is the Lord. G.
stands for God and he belongs to the G Lodge, therefore he belongs to God's
Lodge. But he has a uniform of the High Grade at home, so he must be the
High Grade himself. By using the symbols of his order in this way he
disposes of his wife who has not treated him well, identifies himself with
God (while he abolishes the regular God) and endows himself with the
supremest power in a Lodge which he regards as omnipotent in the world.
Another group of his ideas refer to his race. He has been put on Ward's
Island as a result of the great struggle between Christians and Israel. But
Israelites are the head of the Fellowship Lodge, so all Christians must
follow him, the patient.
This is the explanation of "Da liegt der schwarze Hund begraben!" He is like
a dog in the house and he is considered to be nobody, a corpse on the floor.
But he really lies here buried--the missing man of the tribe. Once off
Ward's Island, therefore, he will come to life as head of Israel, and head
of the omnipotent Lodge. Patiently, hopefully, he awaits rebirth. The
egoism of these ideas is obvious. Wherein do the constructive factors lie?
Simply in this: this expansiveness could easily be formulated directly. But
he does not do so. His ideas include two objective and potentially
altruistic interests his lodge and his race. He is interested in them; in
fact one can probably say that it is just in so far as he is insane that the
selfish determination for these interests become manifest.
We have also studied two cases of recurring excitements in patients one of
whom was an evident praecox, the other of doubtful classification. Both
showed queer behavior during their intervals with mild indications of their
ideas which gained freer expression in their attacks. These episodes showed,
of course, markedly a typical feature in a tremendous amount of queer
behavior and more excitement than true elation. As there was nothing in
their ideas essentially different in principle from the cases already
quoted, they need not be further detailed.
The last case, R. E. O'M., is one of no less interest from a formal
standpoint than from a psychological one, while the trend presented is so
copious that it can well serve as a resume of the cases we have just
recited. He is now an unmarried man of thirty-three, and although he was
diagnosed dementia praecox ten years ago is now earning $1200 year as a
stenographer in the government service. His father was an Irishman banished
from Great Britain because of his political agitations. His mother was a
French woman of Huguenot extraction who died of cancer before the patient
reached his teens but to whom he was greatly attached. He has a sister two
years older than himself, given to hysteric attacks, for whom his love is
"Platonic," to use his own term. Although of more than normal intellectual
vigor, judging by his success in school work, he probably always had a
psychotic tendency. At seven or eight he saw a vision of God in the clouds;
at puberty he masturbated considerably and used to stand before the mirror
and "hypnotize" himself. In the fall of 1903 (then twenty-one) he was
staying at a summer hotel where he met a girl who made love to him, when he
began to have frequent emissions. Being caught together out in a storm, in
an effort to protect her his hand found its way to her hair. He was greatly
upset. On returning to the hotel he endeavored to avoid her, and, his father
being slightly ill, he became convinced he was going to die. A month or so
later he moved from Baltimore, which had been his home, and began employment
with the government in Washington. He had more emissions and immediately
developed hysterical heart trouble, and from his retrospective account also
had ideas of people influencing him. A year later (June 1905) a frank
psychosis with considerable manic flavor developed. Secretary of State Hay
had died, and peace negotiations between Russia and Japan were in progress.
He got the idea that he was to succeed Hay (whose face he saw in the clouds)
and that he would make peace between the nations. The accompanying
excitement was so intense that when he came to see his father in Baltimore
the latter had him committed to the Sheppard and Enoch Pratt Hospital.[3] He
remained there for one year and eight months, during which time his mood
showed great variability. At times he would be elated, again depressed or
anxious, often silly with irrelevant laughter. Towards the end of his
admission he had quite long intervals when he appeared normal. Eight months
after his discharge he began to have monthly attacks lasting from one to two
weeks. At the beginning of 1911 he came under the observation of one of us
at the Johns Hopkins Hospital Dispensary. His case was followed minutely
for some months when the following extraordinary clinical picture was seen
to develop with regular periodicity. His interest would gradually withdraw
from his work and an abstracted, "dim" look come into his eyes. He ceased
to sleep either day or night. Ideas, in the intervals latent, would become
more insistent, and he talked of them in a distracted way with occasional
silly laughter and some scattering. At the same time he would show
considerable physical unrest: rocking in his chair, nodding his head,
sucking with his lips, and making occasional grimaces. A sharp word would,
however, bring him to reality and normal behavior and speech, or the same
result could be obtained by his own volition. In fact sufficient effort from
either without or within could, it was several times demonstrated, postpone
the further development of these symptoms for several days. Inevitably,
however, control over his psychosis was lost. He became more excited; was
assaultive till chastised by his father, after which that symptom no longer
appeared; he would give none but irrelevant answers to questions; he
masturbated openly. In the next phase he refused to answer questions
altogether, sat in a chair by the window, rocking and tapping the floor or
wall with his feet; reading a paper in a whisper or tearing it into scraps;
spitting on the floor, his clothes or the window pane and then drawing
pictures with his finger on the wet glass; intermittently chanting the same
air over and over again with words, totally indistinguishable, except for
the name "Jesus Christ" apparently interpolated irregularly in the course of
the song. All this time he wore a silly smile occasionally breaking into a
low chuckling laugh devoid of real emotion. In a short time his clothes and
his immediate surroundings were in a state of horrid filth from his saliva
and the torn papers. Towards the end of the attack he ceased making any
sounds, simply rocked, spat and grinned. He would often pass twenty-four
hours without emptying his bladder, though he never wet nor soiled himself.
Few psychiatrists would have required more than a casual examination to give
a diagnosis of hopeless deterioration, if they saw the patient only in the
latter stage of one of these attacks. Yet in from seven to fourteen days
after the first onset he would go to bed, sleep well, and in the morning
appear perfectly normal and resume his efficient work. And this story had
been repeated regularly once a month for four years! When normal his memory
was hazy for the external events occurring during his attack, corresponding
with his objective lack of contact with his environment, but the
recollections of his ideas showed that he had been living in a perfect riot
of fancies. The inference from this is inevitable that what we regard as a
"Trendless praecox" or a taciturn dement may simply be one who does not
choose to talk and not necessarily a vegetative wreck with neither delusions
nor hallucinations.
[3] For the privilege of using observations made on this patient at the
Sheppard and Enoch Pratt Hospital, we wish most heartily to thank the
Superintendent, Dr. Edward N. Brush.
His ideas were found to be no less interesting than his formal picture. In
fact, if the theory we are now advancing be correct and we had had it then,
we believe it would have been possible to state at the time of his first
attack that his psychosis would not show rapid deterioration; we might even
have gone further and predicted that he would reach some such stage of
relative sanity as he now enjoys. He has presented three types of ideas.
The first is crude expressions of bald sexual fancies; the second is
transitional in that--as many praecox patients do--he gave these ideas a
religious or philosophical setting, but in the hallucinations and delusions
embodying them, still retained his personal connection with the fancies. For
instance, he identified himself with Christ, or he suffered from
psychological influences exerted by others on him. These two types occurred
only during attacks. The third type represented the real constructive
tendency, during his "normal" intervals when he objectivized these ideas in
the form of speculations as to the origin of life, the laws of society,
religion, etc. The second type--the transitional--represented reciprocally
two tendencies: in the psychosis it showed his constructive, healing
capacity, while the development of such fancies, as allied himself directly
with his speculations when "normal," was invariably the signal for another
attack, the severity of which was in direct proportion to the crudity which
his formulations reached. The complexity and number of his theories when
going about his work was tremendous, which could be partially accounted for
by his omnivorous reading. He read all sorts of historical, occult,
scientific and philosophical works, the material of which he absorbed only
in so far as he could weave it into the fabric of his depraved speculations.
This colored his transitional ideas as well, for in each attack he would
have a new dramatization of his fancies determined by what he had just been
reading. To present these ideas with anything like completeness would take
hours. We must be content, therefore, with a few fragmentary examples.
The more important of his crude ideas were: His trouble was caused by loss
of semen (his attacks were always ushered in by emissions), to prevent which
he sometimes put rubber bands around his penis; numerous homosexual fancies,
he was a woman, he had a vagina, there was a maiden head in his forehead
which was operated on to cause him to lose semen; different people made
immoral proposals or had designs on his virginity. These people he all
identified directly or indirectly with his father. Finally there was an idea
that his mother's marriage with his father was not right, that he was not
his father's son, and that his father was inimical to him. He talked of
killing different persons whom at other times he identified plainly with his
father. During an attack he assaulted his father; not infrequently he would
take his father's picture from the wall and spit on it. The relations
between his father and mother were adulterous, he claimed.
If we now take the crude homosexual fancies and study their first
elaboration we find that he had many ideas about eunuchs. They worked on him
by psychological influence. The eunuchs, who could control sun and moon,
influenced him through them. Once he had a vision of the sun approaching him
with which he was physically connected; the vision would disappear if he
lost his virginity. These influences when referred to himself were agencies
causing loss of semen, so that he would become a eunuch himself. At the
time of his heart attack and later he thought there was a snake around his
heart. This was a man who had turned himself into a snake in order to
incorporate himself into the patient's body. His religious fancies
apparently began with his delusion that he was Christ and in connection with
this we find he had the theory that Christ was a virgin. One setting of his
"psychological influence" experience, when he was in bed in one room and
eunuchs were influencing from the next. he duplicated by saying he was
Jesus Christ in one room and God was in the next. He explained after one of
his attacks that his attention was fixed on the windowpane on which he spat
because there was a flower there. During an attack he was heard to say
something about the struggle of men against being raped by ions and flowers.
In these primitive elaborations we find an effort at distortion, a getting
away from the absolutely crude and that the added elements which cause this
distortion are in the form of ideas which imply a certain degree of
philosophizing. The truly constructive delusions appear when he has ceased
to dramatize these theories with himself as the hero and treats them
objectively. We then find that eunuchs are very important people in his
philosophy (the medium of their power we shall see shortly). All women are
eunuchs because they have no testicles. There is no difference between men
and women; if a woman is stronger than her husband, he takes on her
qualities. In India men suckle the children. He says that this is a
well-known fact. A person could change himself into a cancer and so get into
another's body. This is perhaps an echo of something he had read of
Ribbert's theory of neoplasms. Another pseudoscientific theory concerns a
method of reproduction which could be developed, he thought. If a
beautiful, strong man reaches his normal growth, all life above that is
moulded by his ideals. He can develop within himself another personality
which may be divorced from his body. Immaculate Conception takes place this
way. An argument he had in favor of this view was prenatal influence and the
strong influence a woman's belief is supposed to have on pregnancy. Eunuchs
control the sun and moon. The Jews have a secret process of eunuchry; they
have a way of inserting an instrument (a drawing of which he made, showing
distinctly phallic features) by psychological means into the glands or
bodies of men, thus cleaning them out. The eunuchs of the Romans used to
cure their fellow countrymen of snakes growing around the heart by
ingratiating themselves into persons, thus displacing the snakes and killing
them. The government has many eunuchs in their employ. The influences of
these men are malign or beneficial. They can injure enemies of the
government or the government can incorporate them into bodies of other men
to save the latter. All cardinals, most diplomats and many missionaries are
eunuchs. The psychological influence exerted by such individuals may cause a
loss of blood to their victims or they may use this power beneficially. The
Romans, for instance, put blood of crucified people into the hands of
eunuchs, who impregnated it by psychological influence into others. This
would save their lives and eventually save the nation.
The ideas we have mentioned showing rivalry with his father, apparently in
relation to his mother, were largely elaborated in political and religious
disguises in their transition states, which in turn led to an objective
interest in politics and religions. He spoke of killing the President which
may be taken as a disguise for killing his father since he often claimed
that his father was this or that ruler. He also spoke of killing one of his
employers. He was prone to speak of his father as Edward VII. His envy of
this situation of authority was shown when he once told the physician that
his face was suspended in the face of the physician who was a King of
England. But not the real King, he added, Edward VII was the real King.
Again he said that he was Robert Emmet and the physician was Lord Norbury,
the judge who convicted Robert Emmet, after whom the patient was named. In
that role the physician told him it was all up, that there was no more Irish
race. (It must be remembered that his father was a Fenian.) A fruitful
source of speculations about international politics was found in the
transitional ideas he expressed about the extraction of his parents.
Beginning with his cogitations about the friction which actually existed
between his parents, he ascribed this to their differing nationalities and
religions. This led in turn to his fancying that on both sides his blood
was drawn from many sources. He was particularly fond, for instance, of
identifying his father with Hebrews, or Chinese; his mother with Romans,
Italians or Spaniards. His original interest in the union (or disharmony)
of his parents was easily transferred to this international setting and most
of his attacks were heralded by dramatizations of political ar international
situations with which he was intimately connected. This was true of his
first attack when he had an idea that he was to succeed Secretary Hay and
make peace between Russia and Japan (his mother and father). On recovery
these fancies were objectivized into a most intense interest in diplomacy.
He knew the history and achievement of every diplomatist in Europe, though
of course his data were always being distorted to fit with his insane
theories. Intermarriage, for example, was the cause of political trouble.
He developed the ideas as follows: When an Irishman marries one of another
race a confusion of races results; this was what took place in the tower of
Babel; this is what causes disunion between states. He elaborated, too, on
popular associations of certain customs with certain peoples. Gypsies, it is
popularly supposed, frequently abduct children. With the patient this became
an elaborate theory about an Egyptian custom or Egyptian influence. The
Egyptians, he said abducted children and brought them up as their own
acquiring a sinister influence over them because of the belief the children
had that these adults who were their guardians were their real parents. In
one attack he spoke of his father as "An Egyptian influence." This is
plainly the same idea as he put into another form when he remarked that he
would be all right if he could become English. When in his free intervals,
he made it a practice sedulously to cultivate English people.
This undercurrent of rivalry with the father came out in a religious
disguise as well. His first attack when he was for many months interned he
described as a religious mania. By means of identifying himself with Christ
he dramatized both his subjugation and defiance. He went through many
crucifixion experiences; said he was commanded by God. On the other hand he
said Christ was a virgin and retained his virginity in order that he might
discover the secrets of the elders. For this reason he was crucified. The
crudest expression he gave of defiance in a religious form was when he said
"I was two persons in one--God and Jesus Christ. God was damned." The more
constructive tendency was shown by his fasting. This was due to an
experience of some duration when he was translated back to the first
century, was in a convent (sic!) and was tempted by the devil to eat. His
fasting, he claimed, saved the other patients. His most constructive
delusion was that all the churches would come together and then there would
be only one church. During his first attack this was his "prophecy," during
his saner intervals there were endless ramifications of this idea which are
too tedious to recite. It is important to note as evidence of the purely
psychotic character of his ideas that he has never been either religious in
his spirit or in action a propagandist.
Perhaps the most luxurious fancies this patient evolved were around the
theme of semen. We have seen that his emissions were his constant worry, an
increase in their frequency heralded an attack and he was convinced that if
he could but retain this secretion he would be permanently cured; nay more,
if he could retain enough he would grow to be like the giants of old.
Whenever he had an emission he felt on waking a pain in his head and could
never get totally rid of the idea that this was cancer. In his attacks the
cancer was the result of a homosexual assault and in his intervals he
elaborated theories as to the origin of cancer; it came from friction,
therefore coitus could produce it, it might be the result of adultery or
cancer of the breast could come from a man rubbing his penis on the breasts
of a woman; the cancer germs might come from semen if one believed in cancer
and in germs. Life both as vital force and in the biological sense he
identified with semen. Psychic activities too had the same origin which he
explained thus: food taken into the mouth goes into the stomach and becomes
chyle, chyle passes to the scrotum, thence to the spine and brain. Brain
power is in direct proportion to the amount of semen retained. We see now
why eunuchs had such power according to his philosophy. By childish
reasoning, since they could not have emissions, their semen must be
retained. He spoke of psychological influence in these terms: "It is the
transformation from the moisture state of the life principle to the moist
electric state of warmth and its transference from the central ducts and
glands to the head and being thrown out of the head in waves from the top of
the head and eyes. It redounds to the other person's good. Have an eunuch
near you--it tends to make semen go to the head and gives the mental mouth
something to think of. It could be used in a baleful way if one had will
power over another person like hypnotism--(Svengali and Trilby)--In
hypnotism the will goes on the same lines as psychological influence." The
Jews, he said, lay around temples so much that their life had to go into
sensuality or wisdom and it mostly went into wisdom. Continual seminal
losses, he claimed, would lead to a change in personality. "Life," he said,
permeated nature, it could not be lost. Wind was thus identified with it:
"life" goes on a sheet (from an emission), the sheet is washed and the
"life" passes to the water, then is taken up by the air and breathed. Thus
he suffered both immediate and remote effects from emissions. The first
result was to make him incapable of work; by breathing in the "life" later
on he became a degenerate. Wind or the spiral movements of air was another
origin of life. Wind is a spirit, in defence of which he quoted the Greek
pneuma. The words wind and word are the same, the former being derived from
the latter through wird. (Cf. "In the beginning was the word," or "The word
was made flesh"). A cyclone is an effort hampered by civilization of what
the world was originally. Life began as a spiral movement of air. Wind as
the origin of life could be duplicated by mechanical methods or eunuchry.
The sun he claimed was an accident. Men lived for centuries without it,
till an accident, internally, led to vital forces being emanated and that
was the origin of sun. The accident was the cutting of some man's testicles.
Now what was his further course? We have seen that in his attacks he
expressed resentment against his father's domination. At the beginning of
one of them, for instance, which he said was brought on by "Egyptian
influence," he had a dream of an old Hebrew play of father and son. In this
play they were trying to make him return to the old situation of bondage to
his father. This bondage was an actuality. Owing to his monthly attacks he
could hold no regular position and so worked for his father. The latter gave
him no money except occasional small silver but bought for him clothes or
anything else he might need. A psychotic man of nearly thirty, with a
feminine character, he was hopelessly dependent on his father. It is small
wonder that he sought relief in recurring psychotic episodes. But a change
came. On May 12, 1911, his father died suddenly of heart trouble. The
patient was beginning to go into an attack at the time but pulled himself
together, managed the funeral three days later, got his sister home, who had
a hysterical attack at the grave, and then proceeded to indulge in his
postponed attack. The sister was unable to care for him so he was sent again
to the Sheppard and Enoch Pratt Hospital. In a few days he recovered. He
was then talked to, told that this baleful relationship was over and that
there was no longer any reason for his having attacks. With the exception of
one attack at the beginning of 1912 he has had none, and seems to be able to
maintain the mental equilibrium that previously characterized his intervals.
For two and a half years he has been employed in the Customs House,
Baltimore, a position which he secured by competitive examination, and has
received an advance in salary from $900 to $1200 a year. He was recently
written to and replied in exceptional literary form detailing more of his
ideas. They seem to be essentially similar to those held four years ago.
One may be quoted. A favorite "scientific" method with him has always been
(from boyhood, he said) to divide up or distort words so as to get at their
true meaning. This is now his explanation of the word "cancer."
"You may remember the origin of the word 'cancer' was once the topic of our
meeting and strangely this matter has kept revolving itself in my mind ever
since. My new solution is 'Kahns' and 'Ur.' You know there are a good many
people named 'Kahn' and as probably you have noted in the Bible allusion to
the ancient race of the name 'Ur.' Now, you can place what construction you
will on the combination. There are several; here is one: I have heard it
stated that the word 'Ur' originally meant 'wife' hence, from our point of
view the solution is easy, Kahn's Ur or Kahn's wife, but what has puzzled me
is what she is doing in so many people.
"Here's another: Signifying the overcoming of the Jew by Ur or Kahn by Ur
(Kahn by 'er) much on the same principle as the words 'Spanish-American' and
'Graeco-Roman' are used with reference to the late 'unpleasantness' and the
ancient one.
"Here's another: Simply meaning that Kahn is not a Jew at all but simply an
Ur.
"So you see I have not altogether forgotten some of the topics of our
meeting."
If our claims be allowed we should be able to make some deductions of value
to psychiatric theory. The first is an explanation of scattering of
thought. We find that, in all our cases showing constructive delusions, the
utterance of these highly elaborated fancies is not accompanied by
scattering. On the other hand it is an every day experience that a dementia
praecox patient may show no scattering when conversing on indifferent
subjects but that his train of thought loses logical sequence when he
launches into his ideas. These findings may be reconciled by studying the
reaction with types of ideas such as the last patient showed. In his
intervals he was (and is) continually busy with delusional thoughts but of a
constructive character, but was never scattered as long as these were alone
present. As soon, however, as an attack commenced and cruder ideas appeared
he became scattered. Where were these crude ideas in the intervals? They
were represented in his constructive delusions it is true, but in their
native form they did not appear. The cruder fancies must therefore have
been in the unconscious during his intervals. Now actual verbatim records
show with him that these crude ideas did not come to expression in logical
sequence but that each appeared in response to an idea previously in his
consciousness which was a distorted formulation of the crude fancy next to
appear. His utterances during these attacks would have a logical sequence if
they were translated into terms of the underlying crude ideas. The
scattering, therefore, was due to the fact that his utterances were a
mixture of crude and elaborated fancies. Had they been entirely one or the
other there would have been no scattering. During his intervals he dealt
with objective fancies and was logical. As these fancies, however, could be
easily demonstrated to be derived from the unconscious crude ones, which
appeared during his attacks, we are safe in assuming that one factor at
least in the production of an attack was the lifting of some inhibition
which kept the cruder ideas from entering consciousness except in a form in
which they could be objectively viewed and so logically arranged. Scattering
of thought therefore arises from the intermittent action of this censor or
from an incomplete abolition of the inhibition allowing varying formulations
of the crude ideas to gain expression which have no logic surface
connection. If entirely done away with, of course, the latent ideas
appearing in perfect crudity would have a logical connection. The content
of consciousness is what is within the sphere of introspection. We can
therefore say that the praecox who is scattered really does not know his own
ideas. This is, of course, an every day experience for those who examine
such patients. A suitable case left to himself will give expression to a
limited number of delusions which he does not correlate. A few suggestive
questions, however, will educe a mass of delusions, which when pieced
together demonstrate the logical unconscious ideas that give rise to them.
If such a patient be asked "What are your ideas?" he can give no reply. Ask
him, however, if any one is mistreating him and you will start a train of
thought in which one fancied insult leads to another or to delusions which
do not represent mistreatment at all. On the other hand approach a patient
with constructive delusions with the same question as to his ideas and he
will produce a theory of the universe, often with a chronological account of
how these ideas developed. He is insane in that his fancies do not reach an
outlet in action being an end in themselves; but he is sane in so far as he
keeps his ideas within the range of introspection and has not allowed them
to become autonomous. The inferences from this to the laws of normal
association are obvious.
The second point is really a historical one. Psychiatrists are often asked,
"Was Joan of Arc crazy?" "Was Saint Louis a dementia praecox?" In an
endeavor to answer such questions wise books have been written detailing the
"psychoses" of historic or religious leaders. There is probably not a single
delusion expressed by any one of the patients whose cases have just been
recited that is not duplicated or paralleled by the belief of savants of a
few centuries ago or the uneducated of to-day. The last patient said "All
nature is artificial, man made it all. All the world would disappear, if man
lost the power of reproducing. The reproduction of nature by man is founded
on faith--constant reiteration and association with a thing will produce
that thing." Is this not analogous to the working hypothesis of the
alchemists? The more sincere among them sought salvation for their souls. To
gain this they worked with metals to which they ascribed abstract or moral
qualities. Their metallurgy was primarily symbolic, yet they seriously
hoped for results by working with symbols. And to what extent of absurdity
and crudity did they go? Many of their metallurgic terms were sexual
processes. Their "prima materia" was called by the name of many of the
secretions or excretions of the body. A whole school--the
Seminalists--adhered to the view that the great original substance was
semen. Other thought it was hermaphroditic. Paraceleus spoke of the birth
of monsters as a result of sodomy. A natural history[4] written three
centuries ago tells of semen being carried by wind. Notoriously there was
no limit either to the absurdity or crudity of these conceptions. Were these
men--the wisest of their time--insane? Here again we may quote the last
patient--"Insanity," he says, "is the elemental human mind left to itself,
unimproved by other minds." The last is the important phrase. What minds
were there to improve those of the alchemists? What critic was there to
tell Joan of Arc that visions and voices were pathological? That was the
regulation form of inspiration in her day. Comparative mythology like a
comparison of mysticism, alchemy, rosicrucianism and masonry shows that the
human mind left to itself will formulate similar ideas. These ideas,
however, are modified by the advance of learning as time goes on. The
individual whose critical faculty allows him to maintain an idea
incompatible with the knowledge of his age and his fellows is insane.
[4] The Historie of Foure-Footed Beastes, by Edward Topsell, London, 1607.
Our last point is a corollary to the claim we have just made. It has been
the sport of iconoclasts for many years to discount all religious beliefs as
psychopathic. This is not the forum where the problem of science versus
religion may be discussed but these cases have certain features which should
warn us to be wary of such generalizations. We have seen that religious
formulations have been used to embody crude fancies. That does not preclude
the possibility of the formulations having an actual basis. A flag may gain
its importance to a given individual because it symbolizes for him his
native land but that does not prove that the flag has not an existence of
itself. This, however, is a matter of logic and not of psychiatry. Let us
now grant that all religious formulations have an unconscious origin. But
there still remains a wide gulf between patients such as we have been
describing and the devout church-goers. The former show in their productions
how their religious ideas arise, their egocentric quality is patent, they
manifestly are but thin cloaks for selfish wishes. The latter, however,
never in consciousness connect their religious formulations with their
subjective creations. To the true believer his God is as objective a
reality as is the electron of the physicist. Finally, real religious faith
has a pragmatic value. Granting it be only a theory it nevertheless produces
results in conduct. This is in sharpest contrast to religious delusions.
They never lead to sustained effort, they bring with them no social
potentiality. They exist for the comfort of the patient alone.
To sum up: We have endeavored to establish the claim that delusions in
dementia praecox which takes the form of objective speculations rather than
subjective experiences are an evidence of a milder psychotic reaction and
hence warrant a prognosis of chronicity rather than deterioration. From the
cases presented we argue that scattering of thought arises from a failure to
formulate underlying fancies in an objective way; that the insanity of ideas
depends not on themselves but on the critical judgment of the age which
produces them, and lastly that there are essential psychological differences
between creeds and religious delusions.