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.