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.