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Nervous and Mental Disease Monograph Series No. 33

A Psychoanalytic Study
of Psychoses with Endocrinoses

By

DUDLEY WARD FAY, Ph.D.

WASHINGTON, D. C.
1922

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NERVOUS AND MENTAL DISEASE MONOGRAPH SERIES No. 33

A Psychoanalytic Study
of Psychoses with Endocrinoses

BY

DUDLEY WARD FAY, PH.D.

NEW YORK AND WASHINGTON

NERVOUS AND MENTAL DISEASE
PUBLISHING COMPANY

1922

NERVOUS AND MENTAL DISEASE
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Edited by

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CONTENTS

FOREWORD

INTRODUCTION ....................................... i

CASE HISTORIES (including in each case the life history, sex
life, fantasies, general observations, the effects of occupa-
tional therapy, physical examination, endocrine diagnosis^
the effects of glandular therapy, condition of the patient
four months later, and the mental diagnosis) ......... F

CONCLUSIONS ON OCCUPATIONAL THERAPY .............. 109

CONCLUSIONS ON GLANDULAR THERAPY ................. I IO"

CONCLUSIONS ON PSYCHOANALYTIC TREATMENT ........ . . 1 1 1.

GENERAL CORRELATIONS ............................. . .. .. 1 1 3-

GENERAL CONCLUSIONS
DISCUSSION

111

FOREWORD

I wish to thank Dr. William A. White, Superintendent of St.
Elizabeth's Hospital, for his permission and support in making
this experiment, Dr. Nolan, D. C. Lewis and Dr. Gertrude H.
Davies for their assistance in studying the cases, and Dr. Shep-
herd Ivory Franz for his advice and criticism in preparing this
thesis. Dr. Lewis furnished the reports of the physical examina-
ations which are included in the case histories.

The names of the patients are fictitious. In quoting their
talk I have often translated obscene words into more technical
language but I have not altered the meaning in any way.

INTRODUCTION

This thesis is a psychoanalytic study of twenty-two male pa-
tients in an experiment on psychoses associated with recognized
endocrine disorders conducted in St. Elizabeths Hospital, Wash-
ington, D. C., by Dr. Nolan D. C. Lewis with the assistance of
Dr. Gertrude H. Davies and myself.1

The object was to discover whether there was any correla-
tion between certain endocrine disorders and certain psychotic
syndromes. It is well known, of course, that there are glandular
troubles among both sane and insane. According to Laignel-
Lavastine2 mental disorders can cause endocrine disturbances,
and endocrine disturbances can cause mental disorders, or the
two processes can coexist. Irrespective of which is the cart or
which is the horse, it would be of value to learn what sort of
mental disturbance is associated with a disorder of each particular
gland or combination of glands, or vice versa.

At one time Kraepelin3 suspected there was some connection
between dementia precox (or schizophrenia) and endocrine dis-
orders, but later considered that he had failed to prove it. In
the recent English translation of the portion of his work which
deals with dementia precox he says : " Many years ago I en-
deavored for a long time to acquire influence on dementia precox
by the introduction of preparations of every possible organ, of
the thyroid gland, of the testes, of the ovaries, and so on,
unfortunately without any result." The results of our study
seem to corroborate his original hypothesis.

From the various white male wards of the hospital there was
selected a group of patients who had recognizable endocrine

1 Lewis and Davies, A Correlative Study of Endocrine Imbalance and
Mental Disease, Journal of Nervous and Mental Diseases, vol. 53-54,
1921.

2 Laignel-Lavastine, M., The Internal Secfetions and the Nervous
System, Nervous and Mental Disease Monograph Series No. 30, 1919,

P- 34-

3 Dementia Praecox and Paraphrenia, 1919.

vii

Vlii INTRODUCTION

disorders. No selection was made on a basis of mental dis-
order; this is important to keep in mind in view of the findings
reported in later sections of this thesis. Our group included
patients ranging from badly deteriorated old timers to newly
admitted boys from the army, navy and civil life. What they
had in common was some kind of a disorder of one or more of
the ductless glands.

I purposely kept myself as much as possible in ignorance of
the glandular disorders of the various patients so that my diagno-
sis of their mental syndromes might not be influenced by their
physical condition. Only after I had drawn up the case histories
and divided them into mental groups did I compare them with
the physical groups and determine the correlations.

The term schizophrenia I used to denote the splitting of the
mind by means of which the patient lives in two worlds, one of
reality, the other of fantasy. In simple schizophrenia without
projection he indulges his cravings in imagination and is at peace
with himself. In schizophrenia with projection he resists his
socially undesirable cravings and refuses to recognize them as
originating in himself ; he projects the blame on others and be-
lieves they put these immoral thoughts and wishes into his mind
or even use physical force on him. The mechanism of pro-
jection grows out of his refusing to face himself and his latent
possibilities for evil, but once he has developed the habit he may
project the most innocent ideas as well.

In making the endocrine diagnoses not only was the physical
condition of the patients examined, but they were subjected to
two tests, the sugar ingestion and the thyroid feeding tests.

The experiment lasted six months. After its conclusion the
ward was broken up and the patients were soon redistributed
throughout the hospital. Four months later I revisited the hos-
pital and noted the condition of all our patients who were still
there.

CASE HISTORIES
ABRAMS

History: He was a Jew thirty-four years old. His father
was a carpenter and the family lived in a village of southern
Russia. The boy attended the local school until his father died
and his mother remarried. He then went to a school in the city
of Pinsk, where he associated with boys who cared little for their
studies and spent their time in each other's rooms, discussing
politics and the condition of the peasants, and dreamed of strikes,
boycotts and revolution. The Japanese war broke out, and the
boys became pacifists hostile to the government. He philoso-
phized and dreamed of the future but neglected school work.
His only sports were swimming and skating. He did not dare
try the examinations for a high diploma but obtained a diploma
for work equivalent to that of an American grammar school.

By teaching during his eighteenth year he earned enough
money to emigrate to the United States, and came to the home of
an uncle. The first year he worked ten hours a day in a chair
factory. During the next four years he attended high school
mornings, worked in the factory afternoons, and taught English
to a class of foreigners in the evenings. "I was just learning
English myself, I had no time to dream. I had physical work
in the factory which I had to do, and that was a stimulus. I felt
self-supporting. I was earning my own way. I was like a
soldier fighting." He was twenty-four years old when he grad-
uated from high school.

In the autumn he entered a college that offered a three-year
course leading to the degree of A.B. He managed to live the
first year on two hundred dollars he had saved. During the
summer vacation he earned a hundred dollars peddling aluminum
kitchen ware from door to door. By December his funds were
gone. The college loaned him money without interest to com-

2 CASE HISTORIES

plete the second year. "That boosted my self respect. If I
hadn't been a good student, they wouldn't have lent me it. I
boasted of it to my relatives. Those were two fine years."

The college advised him to stay out a year and work to earn
money to complete the final year. He went back to peddling
but could not make a success of it. " College had made me finer,
more classical. I didn't like peddling now. I hated to knock on
doors. After two weeks I gave it up. I loafed or worked in the
chair factory the rest of the summer. I didn't like that sort of
work and wanted to return to college. My uncles borrowed
money from banks and let me have it so I could continue my
studies. And that's the reason I failed. I had no solid footing.
I was living on borrowed money. I couldn't concentrate my
mind. The money lent me by the college had no interest
attached and so it didn't worry me. I worried over the interest
my uncles had to pay. What if I failed to get a good position
after I graduated and were unable to repay them. I was proud.
I wanted to do it myself and not feel I had to have the help
of hard-working relatives. And so I failed. I lost at both ends.

" A college education was to me a sort of religion. Most
students go for practical purposes. I looked on it differently
from American boys, as a spiritual endowment rather than
practical. At that time I was soaring, dreaming to be a poet.
But I couldn't write my thoughts as a poet does. I wasn't a
soldier, do you see? I wasn't practical. I was in a passive state.
I dreamed of writing, of being a professor. One of my profes-
sors said I had ' abortive sentimentalism.' Too much poetry, not
enough buckling down to work. I wasted time hanging around
the Y. M. C. A. playing checkers or in the gymnasium. The
personality of the French teacher annoyed me. I flunked French
right along and at midyears I flunked experimental psychology.
In April I was suspended. That burst the bubble. After that
I wanted a change of environment. I peddled for a week,
worked a few days, and then went home. One of the professors
wanted me to assist him in social service in a nearby city. He
put me to work making notes on the condition of back yards,
but I didn't satisfy him, and quit. I started for my married
sister's home, and the train passed through the city where my

CASE HISTORIES 3

college was situated. It was graduation time in June, and one of
the professors and a student got on the train. I hid myself from
them, jealous, disappointed and ashamed. I staid all summer
at my sister's trying to get a job but couldn't. I had to earn
money so I went to New York and got work as dishwasher in
a summer hotel. It was terribly hard. In a week I quit and
returned to my sister's where I attended a state normal school
with free tuition and got my A.B.

"The next year I taught in a small school for boys and was
able to repay part of the debt to my uncles. I got on fairly
well but I didn't want to stay. I returned to my sister's and
studied for an A.M. I worried over lack of money, and studied
also for civil service examinations, neglecting my post-graduate
work. I flunked some courses and quit in May. One of the
teachers said I would have gotten my A.M. if I hadn't dreamed
so much."

The ensuing year and a half was one long succession of jobs
lasting anywhere from one week to six months. He worked as
busboy in restaurants, translated Russian, canvassed for a maga-
zine and a sewing machine company, sold life insurance and
clerked in a store, earning just enough to live on. Half a year
after the United States entered the war he enlisted in a naval
aviation school. " I flunked my exams. They were too tech-
nical ; I don't know mechanics. Then they transferred me to
duty as a seaman in the same camp. I had to leave my class
just as at college. Life was very unpleasant. A scholar hates
to flunk."

Not even as seaman could he give satisfaction. He became
absorbed in his own thoughts and did not seem to comprehend
his duties, and often was seen smiling to himself without ap-
parent reason. He was sent to a psychopathic ward for obser-
vation. There he lay in the sun for hours at a time. He did
not resent this detention and said he had been nervous and needed
a rest. There was nothing the matter with his mind, he declared,
he could think and remember as well as ever. As he made no
improvement he was transferred to St. Elizabeths, where he
stayed in bed for several weeks and had to be tube fed for two

4 CASE HISTORIES

days. Neither in navy or hospital did he associate with anybody.
He denied hallucinations and delusions.

Sex life: He was very reticent about his sex history and
thoughts, and resisted questioning passively but effectively,
answering "I don't know. If that is universal as you say, then
probably I must have experienced it also. I don't remember."
He claimed to have no memory of masturbating but perhaps he
had done- it as a child. He denied having heterosexual inter-
course, but once when he was feeling lonely he had paid a girl
to strip before him, and he stript too, but what happened after
that he "couldn't remember." He liked to dance, but wasn't
much of a ladies' man. They never liked him, but men did.
" It is not desirable to change my temperament. I couldn't
marry for I had no money. A student has no money. I didn't
focus my attention on any particular girl. I wasn't ready to
marry. I didn't have the time to bother — No, that isn't correct,
I had lots of time." Nothing could be elicited on the subject of
perversions. " I'm sure I can't remember whether I've ever
heard of them or not." He used to have two or three night
pollutions a month, usually after a heavy supper. He could
remember no accompanying dreams.

Fantasies: Most of his time was spent in thinking, but he
was disinclined to tell what about, " I don't think of anything in
particular. I think of books I've read. I began day-dreaming
in Russia. Here in this country students play baseball and foot-
ball and haven't much time for thinking. I think of my boyhood
in Russia, of my relatives, of past experiences and scenes, of
people I've met, fancies, imagination. Fancy is playful, colorful
imagination. I don't think of one continuous thing. I make no
effort to. One thought follows another. A young man naturally
has fancies, dreams of the future. As a school boy I dreamed
of writing books, but I'm not good at fiction. I'm better at close
thinking, reasoning, philosophy. It is impossible to think of
nothing. I was evading the issue. A person doesn't like to tell
his thoughts. ("Are they of love?" He snickers.) Yes, I used
to study belles lettres, be romantic, but now I'm like Benjamin
Franklin with both feet on the ground, a practical man. He was
a good model for me.

CASE HISTORIES 5

"At twenty-six I had romantic fancies. I was young and
strong, and finally the dreams ended in sexual intercourse. But
now I don't feel well, and women don't figure in them. I
feast my eyes on the nurses now, a sort of mental healing."

On another day he said, " Here I sit and think. This morn-
ing I thought of our talk yesterday and of my choice of words.
I tried to find better ones. Then I tried for mental exercise to
orient myself, to picture the lay-out of the hospital."

On noticing a picture of a pretty girl on a calendar he smiled
and said, "A picture like that evokes a smile from a young man.
Yes, I like pretty girls very much, sir. ("Do you think about
them much?") No sir, impossible. Well, occasionally. I
hardly ever have unpleasant thought. Pretty girls, largely es-
thetic. I admire beauty (gives a waggish grin). I think of
la fewme, her beauty, her voice. My mind is supreme. I get
imagining, then I realize it isn't reality, and I wake up and check
myself. It's delusional, but I'm matter of fact."

General observations: He had been in the hospital a year
and a half before he was admitted to the endocrine ward. His
sole occupation had been to half-heartedly push a polishing block
along the corridors. Although he had parole of the grounds he
made no use of it, and only left the ward when forced to. Once
I compelled him protesting to walk to a building several hundred
feet away, and then abandoned him. He immediately turned
and plodded back towards his ward, but had paid so little atten-
tion to the surroundings that he had difficulty in recognizing
which building he had come from.

At our first interview he said in a whispering voice, " I feel
weak, no, not weak but tired. I'm in a hospital and want to get
well. I'm getting what I need, food and fresh air. Getting well
and getting a rest to me seem the same thing. The Epicureans
said eat, drink, and be happy. I'm contented at the way things
are for the present. I'm just contented, that's all. I'm here
under authority. I do what I'm told. After I'm discharged I'll
visit my sister for a week, then get a job. I'm not afraid even
of physical work. In an extremity I could go back to chair
making. I might teach, but it's hard to find a job, for I speak

6 CASE HISTORIES

English imperfectly, with a foreign pronunciation, and most
school teachers are women anyway."

A few days later he said, " I'm not feeling very well. I felt
better at college. Sitting quiet is very comfortable. I'm pa-
tiently satisfied." This last phrase pleased him immensely. He
repeated it several times and said it exactly expressed his
sentiments.

After explaining the self-preservative and creative impulses
I asked what he loved most. " My three meals and myself, three
square meals, warmth and a bed. In that respect I'm satisfied.
I like woman's voice and companionship, looking at her, hearing
her voice, but the meals and bed come first, more than la femme."

All day he would sit in a chair or stand gazing out a window
lost in his thoughts, his lips pressed tight together and pushed
forward in a pout. Sometimes he moved them back and forth.
When his tray was set on a nearby table he ate standing up,
though there was a chair a few steps away and another patient
called his attention to it.

When I asked what he thought about so much he replied, " I
think over past experiences or what I've read. Sometimes there
is a vacuum and I think of and look at nothing. I just plod
along. I feel satisfied. I take my situation as a matter of course.
I've gotten so accustomed to this place I don't think I'll ever be
discharged. I'm a stoic. I think I'm sane. I don't see how I'm
insane but I really don't care. I take things as they are. ("What
about your future?") In a hundred years we'll all be dead. I
don't think of it, of anything. I feel fairly well physically and
mentally. I suppose anyone would prefer to be with his kin, but
it's up to the authorities as to discharge. When it's time for it,
it will come. There's nothing to do but sit around and wait and
make baskets. I don't care particularly about basket making."

One day I called his attention to Irgocz squatting in a corner,
eyes closed, and fingers to ears, and told him that was the end
of the road he was traveling, a thing that could hardly be called
a man, a mere vegetable, but it didn't jar him a bit. " He doesn't
seem unhappy. If I get to be like him I suppose I shall still be
patiently satisfied. ("Of what use will all your years of

CASE HISTORIES 7

study be then?") I don't know, but I'm patiently satisfied.
(Then with a gleam of pleasure) : It is dramatic!"

In conversation his voice constantly tended to fade to a
whisper. He now began to mutter to himself, but always stopped
before anyone could get close enough to hear what he was saying.
Another habit developed, of hawking and spitting. He would
stand in the toilet doing this for an hour at a time. There
seemed to be no phlegm, only saliva. Questioning about it
irritated him greatly; it was the only subject that made him
angry. "I'm sure I don't know why I do it. ("Think!") I
don't think. ("You get nothing up, why do it?") For fun, I
suppose. ("Do you think you have any disease?") I'm sure
I don't know. You will have to ask the doctor."

Once I asked what he would do if he were discharged. " I'd
shift for myself. I should have to readjust, buck up against the
world. ("Would you rather stay here and be patiently satisfied
or go out and buck the world?" He hemmed and hawed, evi-
dently thinking he ought to say buck the world. "You really
don't like to answer that question, do you?") No, I don't like to
answer."

Occupational therapy: He consented to begin without urging
and chose basket weaving, which he did beautifully. He
wouldn't bother to learn any other kind of work, and subsequently
admitted he had learned to weave baskets in another hospital. He
became so expert that he could continue his fantasying as he
worked. If lie ran out of material or got stuck, he made no sign
but sat thinking until the instructor noticed his idleness.

After a few weeks he lost what interest he had and began to
beg off, saying he'd rather think or he didn't feel well.

He was very shy with the instructor, refusing to enter her
small store closet with her. Only after she had come out would
he go in. Once he wished to return a tool when she had both
hands full, and when she told him to drop it into her apron
pocket he became much embarrassed and laid it on the window
sill.

Physical examination: Short in stature. Skin dry and
covered with fine flaky scales. Beard very heavy. Hair, male

8 CASE HISTORIES

type distribution, very extensive over chest and abdomen. Gen-
italia normal. Extremities cold and cyanotic. All superficial
and deep reflexes markedly hyperactive, but movements are slow
and deliberate, though with no suggestion of catatonia. Heart
rather rapid.

Endocrine diagnosis: Submyxedema.

Glandular therapy: While he was fed desiccated thyroid
gland, nurses and attendants thought he seemed more alert and
energetic. He talked sensibly with the occupational therapist
and even joked with her. For two weeks he stopped his spitting,
then began again. He went outdoors on his own initiative and
lay on a bench. When asked why he had never done so before,
he said that this was the first weather warm enough to make it
pleasant (April 30). He stopped whispering with me and teas-
ingly complimented my personal appearance.

Four months later: He was still pouting out his lips and
spending hours in spitting. When the male nurse tried to prevent
the spitting he became very excited. He had shown distaste for
food at times and talked of his mouth being dirty. He still
kept by himself, smiling over his fantasies and doing no work.

Mental diagnosis: Simple schizophrenia without projection.
He found the inner world of fantasy so far preferable to the
outer world of reality that he spent most of his time in thought.
Just what his most intimate fantasies were could only be sur-
mised. He would not divulge them. It was clear that some
of them were heterosexual. I suspected others were homosexual
for several reasons; his fear of the topic of homosexuality, his
interest in my physical appearance, and his statement that women
didn't like him but men did. He showed no signs of conflict or
struggle against improper wishes and he projected none of these
onto his environment.

The only painful symptom of his psychosis was the mouth
and throat obsession. There was much affect connected with it.
It looked like a fellatio fantasy, a symbolic cleansing of the mouth
and throat, such as Lady Macbeth's rubbing of her hands to
cleanse them of the king's blood. The constantly pouted lips
indicating oral eroticism supported this theory.

CASE HISTORIES 9

Even his education was an autoerotic pleasure. He made
little effort to apply it in a constructive way, but regarded it as
a spiritual endowment to play with in egotistical isolation. In
this autistic thinking his mind was as he said supreme. But
that he had sometimes attempted a self-cure was shown by his
taking for a model Benjamin Franklin, the man with both feet
on the ground.

BAILEY

History: He was a thin, sallow fellow of thirty-three, the
youngest of three children, and had been much indulged by his
parents. He had always been sensitive, quiet and shut-in. In
childhood he seemed bright and once skipped a grade at school.
He stopped school at thirteen because a teacher unjustly accused
him of throwing a spitball. He would not explain her mistake
to her but absolutely refused to attend school any more. For
the next three years he worked in the family grocery and then
entered a machine shop. He apparently gave satisfaction to his
employers, but if the family asked him any questions about his
work he got very angry. He told me the work had been heavy
there, and he wasn't strong.

At seventeen he quit work and lived at home for fifteen years,
supported by his father. His relatives secured jobs for him,
but he always backed out at the last moment. He worked only
at chores about the house. His amusements were talking and
playing cards with one boy friend, who has since become " queer."
Movies and other outside amusements made no appeal to him.
He had no use for money and refused it when offered. Home
and meals were all he wanted. His family did not consider him
sick, but they continued to indulge him.

After nine years of this life at home he had a "breakdown,"
and was confined to bed for two weeks during which he refused
to eat. A physician was called and informed the family he was
mentally sick. From this time on he did no work whatever
about the home and gradually became untidy. He had to have
his food just so, and insisted on preparing it himself. He
wouldn't change his clothes or bathe and he let his hair grow
long for a year and a half. The family brought barbers to the

2

IO CASE HISTORIES

house, but he would not let them touch his head. He read a
great deal, particularly the daily papers. Finally he became
irritable, smashed dishes and threatened his father and sister.
Very reluctantly the mother consented to his being sent to
St. Elizabeths.

He submitted to being bathed and shorn without fuss, appar-
ently realizing that opposition would be useless. He said he had
worn his hair long and stuffed cotton in his ears as a protection
against cold, and that he had come to the hospital because he
had a cold. He didn't feel well physically but he was mentally
well. The result of his mental examination was fairly good; it
was evident that his failures were due to inattention. He
resented personal questions and said such things were nobody's
business. Whatever answers he made were brief and to the
point. The family history showed no insanity in direct line, but
two cousins were insane.

Sex life: He was very reticent on this subject and delicately
conveyed his sentiments by interpolating that he did not like to
pry into other people's affairs. He hinted he had had heterosexual
experiences but that lack of money had hindered him. Night
emissions he considered shameful, as bad as urinating in bed.
His sister said he had masturbated a great deal.

Fantasies: He would not tell what his thoughts were, but
said they were not unpleasant. However, he never smiled or
showed signs of enjoying his fantasies like Abrams. Sometimes
he muttered about not earning enough wages and having the
family on his hands to support. He once told his sister he had
supported her for years.

General observations: He spent nearly all his time sitting
quietly in a chair or lying on a bed. There was no expression
on his face either of pleasure or distress. He said he didn't feel
sick, but weak. He did not believe there was anything the matter
with his mind. " I have no worries, I just take each day as it
comes. Sometimes I just rest and have no thoughts at all. I
have no plans for the future, and no complaints. I feel bashful,
and if there isn't any particular business to talk about I find it
difficult to make conversation. When I read the papers the

CASE HISTORIES II

big print of advertisements naturally attracts me most. There is
no particular kind of news that I am most interested in." These
answers he gave very slowly after much waiting, and he seldom
looked at me. During our interviews he almost constantly moved
his forehead and scalp and the tops of his ears.

He seemed to be irritable towards his sister and sometimes
was upset after her visits.

Occupational therapy: He refused all attempts to interest
him, saying he felt tired.

Physical examination: Slender type of skeleton. Skin pale.
Body surface presents scanty amount of hair. A few long hairs
about the nipples. None over face. Genital hair of male type.
Genitalia normal. Heart regular but shows incompetence of
valves. Respiration increased. Extremities cold and bluish.
Reflexes normal.

Endocrine diagnosis: Submyxedema.

Glandular therapy: He was given desiccated thyroid gland.
Coincident with the first feeding he consented to try basket
weaving which he was able to do well, and he continued to work
without urging. He did not mutter to himself as much as before
and he took part in the ward work on his own initiative. Form-
erly he did so only when ordered. He stopped lying on his bed
in the day time, and seemed to pay more attention to what was
going on around him although he kept strictly to himself.

Four months later: He seemed unchanged. He still mut-
tered to himself, and felt resentful towards his family for
depriving him of his liberty. He said he wanted to make money
and be free. He would not go on excursions but preferred to
hang about the ward.

Mental diagnosis: Simple schizophrenia without projection.
Finding the demands of reality too hard he retired into himself
and a life of thought. He carefully guarded the secrets of this
inner life. Although he said his thoughts were not unpleasant
he never betrayed any signs of pleasure. The only emotions he
gave outward expression to were irritation and resentment, par-
ticularly towards his family. Probably they had at times re-
proached him for his useless life, and his delusion that he had sup-

12 CASE HISTORIES

ported them was a protective device against the painful realiza-
tion that he had done nothing but sponge off them for fifteen
years. He gave up in early adolescence the struggle for a con-
structive life and retired into himself and the easy satisfactions
of autoeroticism.

CARHART

History: He was a pleasant, courteous little fellow nearly
twenty-one years old. He was the second of five children. The
father was a musician. Nothing was known of the family
history, but a photograph of the mother showed a woman with
a tense, high-strung face. As a child he said he was active, play-
ing first with hoops and carts, and later bicycling and playing
baseball, football, tennis and swimming. He was very imagina-
tive and loved fairy stories. He would imagine toys he did not
possess and play with imaginary toy forts and soldiers. He
wanted the things money would buy and envied the rich riding
past in their automobiles.

He said he was happy as a schoolboy, got along well in
school, and was considered a good fellow. He never failed to
pass and finished the eighth grade at the age of fourteen. He
wanted to continue into high school, but his father said he could
not afford to support him any longer and got him a job as office
boy. For two years he attended night business school. He was
very ambitious to earn money. At the outbreak of the war he
enlisted and saw service at the front in a machine gun unit. The
horrors of battle, the noise and blood and death made a deep
impression on him, but he did not break down under the strain.
After the armistice he was sent to Coblenz in the army of occupa-
tion. He returned with his regiment to the United States in the
summer of 1919 and was discharged from the service. The
family had moved to Chicago during his absence. He rejoined
them there and got a position as clerk in an office.

He didn't get on well in his work and suffered a great deal
from "nervousness." His mind began to be "torn up, and he
couldn't look people in the face." He became depressed and
once stepped purposely in front of an approaching automobile,
"but something seemed to pull him back." He entered a local

CASE HISTORIES I,$

hospital willingly. The records of the hospital stated that he
was emotionally unstable, often depressed, disoriented for time,
heard voices, smelled bad odors from his chest, thought his mind
was changing and going up into the air, and had delusions of
continual emissions of semen.

He was soon transferred to St. Elizabeths and was confined
to bed after his arrival, confused, retarded, hallucinated, and
complaining of headache and gastric upset. In a few days he
was up and around, cheerful and fully oriented, but still hal-
lucinated and suffering transitory excitements.

Sex life: He had a strong sex taboo and considered that such
matters should be hushed up, but as he gained confidence in me
he told me more and more, though he often became emotionally
blocked and changed the subject abruptly.

When he was seven he tried to have intercourse with his
one year older sister but was not able. There was another girl
he wished to try it with but he was too bashful. He had always
been very bashful and modest. He saw her brother smell of her
genitals. He smelled of the " cheese " on his own glans penis
and was disgusted at the fishy odor. He hated the smell of fish
and never ate fish. He hated to look at a penis.

When he was eight he agreed to perform mutual fellatio with
a playmate but the other boy backed out at the last moment.
That wasn't fair (great emotion). His conscience had bothered
him over this attempt. He denied having committed any per-
version. ("Did you ever dream of committing one?") "Yes,
a dream of a darky boy." Then a wave of emotion swept through
him, he jumped to his feet, paced the floor, grabbed a magazine,
and feverishly turned the pages to find anything to get his atten-
tion away from the painful memory. He was so upset that I had
to terminate the interview.

He began masturbation before he reached puberty and had
sometimes indulged in it excessively. When his will power was
strong enough he resisted it. He used to worry over masturba-
tion and night orgasms. At sixteen he tried coitus with a
prostitute but could not get an orgasm. He made several more
unsuccessful attempts before he went to war. In France he tried
again twice and failed. Once he masturbated while still in the

14 CASE HISTORIES

girl's presence and got an ejaculation. In his third attempt at
coitus he got an orgasm but it was not as pleasurable as mas-
turbation.

His mind dwelt a good deal on sex matters. He had heard
of bestiality, and a buddy had described the sensations enjoyed
when allowing fellatio to be done on oneself, which greatly
stirred his imagination. He said that in Coblenz he had several
times gotten an orgasm merely by willing it. He held strange
theories over the predetermination of sex in embryos and be-
lieved in the existence of eunuchs, who had no sexual organs,
and "morfudites," a creature who had the organs of both sexes
and could hold intercourse with either sex or with itself. At
times he talked of his heterosexual experiences with an exuber-
ance of sensual enthusiasm, and at other times he expressed
dissatisfaction over them and stated he was glad he had gone
only with girls who made a business of it, and so had never
ruined any girl's good name.

His sexual preoccupations persisted after his return home.
He slept with a younger brother and often woke up to find
himself on top of the boy with an erection, but he never com-
mitted pederasty on him, the brother "was too small." He
fondled his fifteen-year-old sister and tickled her nipples. Fear
of his father prevented his attempting incest. With great satis-
faction he said he knew his sister loved him very much, and then
asked me if a girl that young could have a baby. If he had
made her pregnant he would have married her, of course. When
I told him the law would not allow them to marry, he became
very angry, said it was the only decent thing to do in such an
eventuality and that some things were higher than the law.

After having an orgasm from will power he went up almost
into " Morphia," it felt like dying. Sometimes it felt like going
up into the air (an interesting corroboration of the theory that
dreams of flying have a sexual meaning) . He would hear a girl's
voice from a distance asking if he wanted coitus, and then she
would "bull" him, that is, cause his semen to go off. It felt
like going to heaven. He too had the power of bulling. By
nodding his head he could break another man's neck without

CASE HISTORIES 15

touching him. That was a headbull. He himself was a bullprick ;
once in a street car he bulled the other passengers, men and
women, till they nearly had orgasms. Then he got scared and
feared they might see something queer in him.

In another talk he showed insight and volunteered that these
bull incidents might have been only imagination. " My thoughts
are lewd. I have a lot of fear, I don't know what of. I'm
like this" (making a gesture indicating vacillation and instabil-
ity). The fear was evident. He had a constant fine tremor
and when spoken to suddenly or told that someone wished to
see him, he would tremble visibly.

Fantasies: Thoughts both pleasant and distressing intruded
constantly into his mind. Our talks were badly interrupted by
these excursions into fantasy. When they were agreeable he
smiled or even laughed aloud, but when they met resistance he
became frightened and excited, often pacing the floor and trying
desperately to find something to divert his attention from the
painful subjects. This explains his statement, "When I'm in
motion, it takes away the fear. Fear is caused by what other
people think of me or want to do to me. I called on the Maker to
remove the fear."

The Maker was the All-powerful, the Creator of all. This
idea was of great emotional importance to him. He took Maker
for his middle name, calling himself John Maker Carhart, and
every letter home began with the set phrase, "Just a few lines
to hope you are in the way of the Maker, and well, and happy."
Every day he wrote a letter to each of his parents. This pre-
occupation with the Creator looked like an attempt to sublimate
his creative libido in religion.

As a child he had many fear dreams. One was of running
down a street with fear coming down out of the sky ; the world
seemed to be coming to an end. Others were of falling off high
places. Recent fear dreams were of men shooting him below
the umbilicus. The night nurse said he trembled in bed as if
having a chill, pinched himself and hunted in his clothes as if
looking for bugs or lice. In the daytime he grabbed at his
trousers and said there were snakes in them.

1 6 CASE HISTORIES

He believed in reincarnations and said he had been living two
billion years and his father had lived fourteen hundred years.
He could not remember his former lives. At death he went into
his mother and was reborn a baby, but this time he had asked
the Maker for manhood. If he were killed now, the world would
come to an end. He feared the doctors were going to injure him.
In one of his former lives he was Pharaoh. A snake bit him
below the umbilicus and killed him. He had a vision of a house
smeared with blood, snake blood, and it was connected with fear.
Another vision was of a lighted candle several feet high coming
up through the floor. (Symbol of the big potent penis. Some
prostitutes had told him his penis was too small.)

He could hear the voice of his father or his first employer.
Sometimes it was the Maker giving him hints. These voices
seemed to be in his head, just like one's conscience. He thought
it might be possible to throw one's voice from one city to another,
but he wasn't sure and couldn't prove it.

He was beginning to believe he had two sets of parents, one
pair tender and loving were back in the old home town, and the
other pair harsh and unsympathetic were the ones in Chicago.
He wanted to revisit both cities and clear up the mystery, then
he would travel all over the world and bring about equality,
brotherhood and happiness. As a boy he had great ambitions,
he had chased the rainbow and wanted to be a big man.

While still in Chicago he had pulled the sun over the horizon
several mornings. That gave him a manly sense of power. On
the way to Washington the sun had been attached by a cord to
the back of his head and was towed behind the train. The back
of his head had burned and felt as if wheels were revolving in it,
and he had suffered much. He had fallen in love with the pretty
nurse in the receiving ward, and his heart grew big and extended
way down into his abdomen.

His father was a magician and had purple eyes. Some day he
would be one and have purple eyes too. Since being in the hos-
pital he had grown very fond of purple. He had "a beautiful
dream of a castle all purple against a blue sky. That was happi-
ness."

CASE HISTORIES 1 7

His mother and little brother were angels, and his sister was
Jewish and owned Jerusalem. Often he grabbed his nose to feel
of it, saying it felt as if it were being drawn into a Jewish shape,
He strongly resisted divulging what significance Jews had for
him. All I could learn was that one of the men in the office in
which he first worked was a Jew and told many smutty stories.

General observations: In the first interview it was apparent
that he was trying to fight off unpleasant ideas. The subjects
that seemed to excite and upset him most were sex, his boyhood,
the Maker, and his little brother. He said he loved his little
brother, that the little fellow was sad and he wanted to comfort
him, then he got very excited and rushed to look out a window.

He talked much about not wanting to hurt people's feelings
and said perhaps he had done so but not enough to kill them
outright. He was excessively polite and anxious not to give
offense, and went about the ward shaking hands with each patient.
He said he didn't want hard feelings with anybody and that he
always tried to make up.

He had partial insight into his condition. He considered he
had just passed through a "period" between youth and man-
hood, and was now safely through it and should be discharged.
He refused to be treated by any physician but would talk with
the analyst because "we're friendly." He was well and ought
not to be locked up like a criminal, especially after all his services
to his country (much emotion). He described the horrors of the
front, the noise, the maiming, the blood, and the danger of death.
Noises bothered him greatly now because they recalled the
sounds of the front. He hoped some day he would be able to
think of these experiences without pain. The horrible sights had
changed him. He used to be effeminate and sensitive but the war
had made a man of him. It was the strain of life at the front
that had made him "unnatural," and he had remained that way
until he became natural in the receiving ward a few weeks previ-
ous. It was not his being in the hospital that had made him
natural. It would have happened anywhere for the period was
over, that was all. He felt very bitter at the doctors for
refusing to allow him to go home. It was just awful for people
to oppose his will.

1 8 CASE HISTORIES

He was reticent about making me his confidant, saying it took
him a long time to decide who was a friend, but that once
accepted as a friend, always a friend. He told about his family
and how united they were. If he should marry he would bring
his wife to his parents' home, he couldn't be separated from them.
Or better still, her parents would come also, and they would all
live together. He called his parents daddy and mama. In the
army he learned to call them father and mother, but now he
preferred to use the old names again. I told him the story of
Oedipus, and he was intensely interested, but when I went on to
narcissism, bisexuality and homosexuality he jumped to his feet,
and said he must leave the office, he wanted to lie down and sleep.
This was his usual reaction to any attempt to discuss these pain-
ful subjects.

He behaved so well that he was given parole of the grounds. One
day, however, he demanded to see the superintendent about being
discharged, and when told the latter was not in his office he be-
came excited and created something of a scene in the administra-
tion building. His physician took away his parole, and he became
very despondent. " My confidence has been broken by being
kept here like in prison. I don't want to spend my life here. It's
a shame. I give up now. After what I did for my country this
is the treatment I get." He grew rather careless in dress and left
off his collar. He was warned that his physician would regard un-
tidiness as a sign he was getting sicker, and he put the collar
back on.

Through promise of good behavior his parole was restored.
He said if he should go home now he would go out in the woods
and die. The hobo life attracted him. He hadn't known the
world could be so harsh and cruel. He refused to acknowledge
he was sick and would not become reconciled to waiting until the
physicians considered him cured. He began to withdraw more
into himself. The night nurse reported he cried a good deal in
bed. He refused to join in the occupational work any longer,
and said the doctors didn't know anything. One evening he
broke parole and went to town. He had no money but got a
night's lodging in a mission and saw the sights of the city the

CASE HISTORIES 19

next day. Then he asked a policeman to help him get to Chicago,
but instead the policeman helped him back to St. Elizabeths. His
parole was again taken up and he was transferred to a less
desirable ward. While out walking with his new wardmates he
made a dash to get away but was captured by an attendant.

Once I succeeded in getting him to tell of his experiences in
France, which he remembered and related well, but when I began
talking about psychology and mental conflicts he got resistive and
distrait and demanded to go.

He resisted the sugar tolerance test because it smacked of
medical treatment, and he was maintaining that he was perfectly
well and was being unjustly deprived of his liberty. The venal
puncture so unnerved him that he nearly fainted. He resented the
removal of blood from his body because that weakened it. He
disapproved of all killing and would eat nothing that had been
killed. This was a result of his horror of war. As a consequence
his diet was much restricted and he complained of not getting
enough to eat. He nearly cut out milk also, but fortunately it
was possible to convince him that it was kinder to milk a cow
than to leave her unmilked.

Although he was friendly towards me and said he felt better
after talking things over with me, he would not face his conflicts
and discuss them.

During the examination after his arrival at the hospital it was
noticed that when painful subjects were touched on he moved
his lips and ran his tongue around behind them. In my office
his hands were held pressed over his genitals much of the time.

Occupational therapy: It was difficult to hold his interest.
He got discouraged at the least obstacle and quit, saying he didn't
feel well or didn't like to work. He never finished anything.

Physical examination: Small type of skeleton. Skin poorly
nourished with several scaly lesions on face, neck and back.
Slight amount of hair in mid-sternal region, and submasculine
type in genital region. Genitalia normal. Heart rapid. Ex-
tremities cold and cyanotic. Reflexes sluggish. Slight tremor of
hands.

Endocrine diagnosis: Submyxedema.

2O CASE HISTORIES

Glandular therapy: None. He refused to take anything re-
sembling medicine. Coaxing and argument were in vain. He
would not take medicine because he was not sick.

Four months later: I found him sitting alone in a washroom.
He remembered me at once, called me by name and seemed
friendly. He was much more introverted and was lost in his
own thoughts most of the time I tried to talk with him. He
showed none of the former desire to get out of the hospital and
no longer wrote home. The records stated he said he liked the
hospital and was not anxious to leave. No mental conflict was in
evidence, he seemed just calmly lost in thought.

Mental diagnosis: Schizophrenia with projection. His mind
was split, part of it living in fantasy. He consciously resisted
homosexual cravings and also projected them unconsciously, as
shown by his saying that fear came from what other people
thought of him and wanted to do to him.

In his regression he returned to his boyhood habit of imagin-
ing and called his parents by the names of childhood. He found
reality too harsh and cruel. The fact that he was held virtually
a prisoner in the hospital he found too painful to face, so he re-
pressed this knowledge, considered himself a voluntary guest and
repeatedly asked for a ring of keys. Reiterated explanations why
a patient could not have keys made no impression whatever, and
within a few minutes he would courteously ask for them again
with calm assurance.

The sister incest wish was conscious. If there were mother
incest wishes also, he either hid them or repressed them. Prob-
ably it was resistance to incest that rendered him impotent in his
attempts at heterosexual intercourse. The idea of reentering the
mother to be reborn is connected with the idea of incestuous
intercourse. His resistance was shown in his asking the Maker
to grant him manhood and stop the rebirths.

The snakes which bit him and pistols which shot him near
the genital region were penis symbols in his projection of the
impulse to take the feminine role in homosexual acts. He
often showed great excitement when these ideas forced their way
into consciousness and he would not discuss them with me. Any

CASE HISTORIES 21

approach I made towards them resulted in mental panic and
flight. Consequently psychoanalytic treatment was powerless
to help him. At first I had had hopes of a cure. Perhaps if he
had consented to taking desiccated thyroid it would have stim-
ulated him to such a degree that he could have suppressed the
perverse cravings sufficiently to be willing to recognize them and
talk of them, and then psychoanalysis could have been used.

He is now introverting more and more. Already the realm
of fantasy has so far displaced reality that he is largely indifferent
to whether he remains in the hospital or not.

DIXON

History: He was a tall, thin, weak-looking fellow with a
long, very narrow head and a high-arched palate. His age was
twenty-nine, and he was the youngest of four children. The
father died of pulmonary tuberculosis when the patient was seven
years old. He surmised there hadn't been much love between
the parents. The father criticized the mother for being too
affectionate towards the oldest son. This older brother used to
beat the patient a great deal.

He went to school until fourteen but had reached only the
fourth grade. He had difficulty in applying himself to his studies.
He didn't care much for rough and tumble games with other boys.
For two years after leaving school he worked as a tabulator of
weights in a coal yard but wasn't successful. At sixteen he
entered the army, didn't like it and bought a discharge. Next
he tried the marine corps and was given a medical discharge
after three months' service.

From seventeen to twenty-six years of age he led a roving,
unsuccessful life, wandering from job to job over all the eastern
portion of the country from Chicago and New York to Florida.
He worked usually as waiter or dishwasher in cheap restaurants
or in the galley of ocean ships for single voyages.

Early in the war he was drafted, and within two months was
in France and served as a cook in a camp far from the front.
Less than three months later he was in hospital on suspicion of
appendicitis (these pains in the abdomen have persisted and may

22 CASE HISTORIES

be connected with the idea of pregnancy). No operation was
performed and he was returned to the United States as a psycho-
pathic patient. Four months after his entering the hospital in
France he was discharged from Saint Elizabeths as recovered
from an undifferentiated psychosis.

He went home and tried one job after another but could not
give satisfaction. He lost them all and became very much wor-
ried. He was returned unprotesting to this .hospital after only
ten months' liberty.

On readmission he complained of fatigue and said he felt
weak and nervous and that his mind was weak and he couldn't
concentrate on anything. He heard voices and felt he was being
imposed upon but that there was nothing much the matter with
him personally. He was fully oriented, his memory was good,
and he did fairly well in the intelligence tests.

Sex life: He remembered, when he was eight years old, see-
ing boys at school masturbate behind their desks and after-
wards smell their hands. At ten he started the practice himself
and indulged almost daily although he considered it immoral.
After puberty he began having intercourse with prostitutes and
liked this better than masturbation. Sometimes he could not
get an erection and the girls laughed at him. He noticed that
he nearly always was impotent if he tried to have intercourse
twice with the same girl. He had to seek a new one. To over-
come his impotence he once bought an expensive " vitality belt."
He felt bashful with girls.

He denied having committed any perversions and felt disgust
for them. He could hardly believe a person could so lower him-
self, yet twice men had offered him money to be allowed to com-
mit fellatio on him. "I refused. It was an awful risk. I
feared their teeth. It may have been done to me in my sleep
but never to my knowledge. I really am afraid to go asleep and
I try to keep one eye open." On shipboard erotic members of
the crew had grabbed him and hugged him but he had fought
them off. Often he had dieted and taken medicine to reduce his
sexual cravings.

" I object to hugging and kissing for it may stir up my body,
my passion. I don't like my mother or sister to kiss me. Mother

CASE HISTORIES 23

kisses me on the cheek. It makes her sick when I go home, she
worries over me. She isn't good to me. She told me once she
wished I was dead. I wouldn't care to live with Mother unless
I was married. I wouldn't sleep with my wife if I had one. It
would tempt us to do it too often. The body ought to rest. My
sister's husband forbid me to come to their house unless he was
there, but I never thought of her body. I let her kiss me but I
don't believe in it."

For four years he had had no coitus and since being in the
hospital no erections. There were occasional night orgasms but
he could recall no accompanying dreams. He had felt no sexual
passion, and tried to keep his thoughts off such subjects.

Fantasies: His first complaint was that people paid too much
attention to him. They thought the same things he did. While
he was reading he could hear a voice in his right ear saying the
words out loud. Probably it was somebody in another room read-
ing through his eyes. He couldn't keep any secrets. Other
people were reading his mind always, everywhere. This " influ-
ence " was always working on him, something like hypnotizing.
He was never free from it. He resisted it, but he was forced to
give an account of everything he did, where he did it, and when.
Nothing could be hidden. He had to commune to some power
everything he had done. Something was sucking his mind, it
wandered off and he couldn't concentrate.

" It seems as if I was an old whore. They can see through
my eyes. My soul is so weak that it is exposed. A whore's soul
is exposed. After taking a walk I think it over three or four
times and see it again, not of my own free will but because I am
forced to. If I hear anyone giggle or laugh I think it is at me."

Voices talked to him of taking both the male and female
roles in fellatio, pederasty and coitus inter femora and of cutting
off his penis. They both urged him to ask other people to commit
perversions with him and accused him of having committed them.
" When the nurse comes near me the voice tells me to order her
to commit fellatio on me. I've heard a voice commanding me
to say that three times since I've been talking to you. When
you approached me a voice urged me to say, 'Doctor, you look

24 CASE HISTORIES

good to me.' ("Have you ever realized that these voices might
be your own thoughts?") No, I never think such things or pay
attention to people's bodies. It seems very degrading and immoral
to me, like the firemen hugging me on board ship. Just now the
voice tried to get me to call you a f ellationist. It says I'm guilty
of fellatio, and yet I haven't really done it.

"That fellow, Carhart, seems to influence me to ask some
fellow to commit pederasty on me. I'm afraid to go to sleep
for fear someone might do it to me. My abdomen feels dead and
it pains and is all swollen. I suspect three or four men, the
attendant and Garland and Mathews. (He told another patient
that I had told him he had a baby inside him. This may explain
the pains that were first diagnosed as appendicitis in France.)
They try to make my left eye bigger than my right. The voices
sometimes tell me not to eat anything, and then if I do start
eating my mind goes blank (emotional blocking from resistance
to fellatio ideas?). I'm a light eater, chiefly bread and coffee.
I vomit fish and greasy things. (Recall Carhart's aversion to
fish.)

" I've had wet dreams of seeing dogs at intercourse. (" Male
or female?") Well, perhaps two males, just like you see in the
street when they jump each other. You seldom see a male and fe-
male doing it, it's usually two males. Yesterday when I was walk-
ing near the edge of the grounds a negro grabbed me fearing I was
trying to escape. My first thought was that he was a fellationist.
I dreamed recently of being at an auction sale of bunches of green
bananas. Mother seemed to be there to buy them, though I
couldn't see her.

" My mind can't be at rest. The patients are too near me.
They have sucked everything I know out of my mind, all I've
been through in my younger days and recently, and now I'm
at their mercy. It seems as if other fellows make me a scapegoat
for their wrong deeds. They run their minds on me, put ideas
into my head like hypnotists. On the Red Cross excursion I was
embarrassed and had to hold my head down. I can't keep my
mind on anything, but just sit and play like a child."

General observations: The constant intrusion of unwelcome
sexual thoughts kept him worried and unhappy. His face was

CASE HISTORIES 25

puckered and furrowed with anxiety on account of this con-
tinual " influence." He was irritable and unsocial and didn't like
to work. Most of his time was spent in wandering miserably
around the institution. He couldn't enjoy himself in the Red
Cross recreation rooms because the other patients kept digging
into his mind.

I often attempted to explain to him mental mechanisms such
as repression and projection, but he vigorously rejected the ex-
planation that his woes might come from his own unconscious
mind. My talks made not the slightest impression on him.

He said he often found his hands crossed over his genitals or
his thumb or finger in his mouth, but of course it was " influence "
that made him do this.

Occupational therapy: He took to the work without urging,
did fairly well and seemed to enjoy it, then got more worried
and resistive and refused to work saying, " I can't do it, I don't
feel well," and making other excuses. He had parole of the
grounds and preferred to go outdoors rather than do handiwork
in the ward.

Physical examination: Tall, slender type of skeleton. Head
elongated. Slight amount of hair over body. Genital hair and
genitalia normal. Perspires easily. Heart normal. Moderate
tremor of fingers. Reflexes sluggish. Pulmonary tuberculosis is
suspected.

Endocrine diagnosis: Submyxedema.

Glandular therapy: Thyroid was first given and seemed to
make him very irritable. He had been peaceable previously, but
now he quarreled with the attendant and complained of him for
being noisy and bossy. " It's been harder to keep my mind on
things today. I feel like throwing my food on the floor. I don't
enjoy nothing." The nurse reported him as restless and more
talkative than usual. The thyroid stimulation seemed only to
increase his difficulties.

A combination of thyroid and orchic was next tried and proved
beneficial. He lost the " influence " for half an hour at a time, and
during these welcome interludes his mind felt free of all outside
control. He said he felt better physically, and his appetite im-

3

26 CASE HISTORIES

proved. He voluntarily joined in the work of the ward and soon
was making all the beds. His facial expression looked somewhat
less worried.

Four months later: I found him lying on his face on the
corridor floor. When I roused him he recognized me at once.
He said he was much bothered in mind. He had given up going
to town on theater parties for he couldn't keep his mind on the
play, nor could he concentrate enough to do occupational work.

Mental diagnosis: Schizophrenia with projection. All his
improper sexual cravings were projected onto other people or on
voices. He had no insight whatever and resisted any explanation.
His resistance to kissing his mother and sister clearly indicated
incestuous impulses as did also the dream connecting his mother
with green bananas (immature or stiff penises?). Probably this
incest resistance was what rendered him impotent towards a
woman after once he had intercourse with her and she had be-
come familiar. Being thus hindered in getting his libido over to
the other sex, his homosexual cravings became very strong. He
did not succumb to them but protected himself through disgust.
Not being able to repress the cravings and too horrified to recog-
nize them as his own, he was forced to project them. His recent
sexual impotence was probably a defense against the perverse
cravings. At night he still had orgasms but the dreams were
repressed. In the former wet dreams of the two playing dogs
the real meaning was sufficiently disguised. Now the meaning
of his wet dreams was probably too apparent to allow them to be
recalled. He accepted dreams as products of his own mind and
did not blame them on outside influence.

The continual influence came of course from his unconscious.
During glandular feeding he was able to completely repress his
unconscious thinking for brief periods, but with total lack of
insight. After the feeding was stopped the repressed thinking
became too strong once more. Except for his inability to repress
the obnoxious cravings and the splitting of consciousness which
resulted, his mind did not seem deteriorated. He was perfectly
oriented, his memory was good, and he could talk intelligently.

CASE HISTORIES 2 7

ENGEL

History: He was a man thirty-nine years old and mentally
deteriorated. It was difficult to get him to tell of his past life,
and the medical records were brief. His boyhood and youth were
spent in a great city, where he received a fair education. After
leaving school at fifteen he loafed at home for several years and
then worked in a tailor shop and a piano factory. At the age of
twenty-two he entered the army and was an officer in the Philip-
pine Guards when taken sick ten years later. He married at
twenty-nine but had no children. His father died of alcoholism
and his mother of tuberculosis. He himself never drank to
excess.

His wife said he overworked in the Philippines and had a
breakdown lasting a month during which he had fearful dreams,
one being that he had killed her. Two years after this illness he
grew depressed and anxious and felt unworthy. One day at
table he rushed out of the dining room greatly excited, saying he
was choking and and his throat felt sticky. He was afraid she
had left him and married another man. Voices accused him of
disgracing himself and called him a thief and coward and other
bad names. He feared he might die or be killed, and made one
half-hearted attempt at suicide.

After reaching St. Elizabeths he was suspicious and had un-
systematized delusions of persecution. A twitching tic of the
mouth was noticed, and sometimes he kept his tongue protruding.
He said he was bad and had wronged his wife, and the police
were after him. He stuffed his ears so as not to hear the per-
secuting voices, and complained of peculiar sensations in his head
and of frontal headaches after the sticky feeling in his throat
and the resultant choking.

Sex life: In answer to my question what was his chief pleas-
ure as a boy he said, " Playing with myself, jerking off." He
added that when he was twelve or thirteen years old a servant girl
of thirty-five gave him all the coitus he wanted. After her he
had relations " with a lady, nice and clean." No further informa-
tion could be obtained.

Fantasies: He had a great habit of scolding at nobody in
particular. During one of these tirades I asked what bothered

28 CASE HISTORIES

him. He answered, "A man wanted to marry me. He called
me good looking. He was stronger that I. You look like the
man who wanted to marry me."

On another occasion he indignantly complained that these
pimps around here called him a fellationist. A fellow patient
told me he sometimes acted as if someone were after him and
exclaimed, " I don't care for any old man or anybody who
bothers me and does things of that kind."

He said he either dreamed of nasty sexual acts or of money
with which he would buy lots of clothes and things.

General observations: His most striking feature was a
strange, persistent smile, mostly in the eyes, as perplexing as that
of Monna Lisa. It could change very quickly into an expression
of frank hostility, and at first I was careful when near him, but
he never offered violence to anybody. I believe the smile denoted
uncertainty and suspicion of other people and an attempt to
discern their sentiments.

A conversation with him was next to impossible. He looked
at one most of the time with this impenetrable smile, and though
he started many sentences seldom finished one; they usually
stopped part way before the meaning became evident. One
day I felt that he was trying to divulge something important
and was on the edge of doing so several times but couldn't quite
decide to take the plunge. He had used the phrase "nice and
clean" again and again, "live nice and clean," etc. I suddenly
asked, "What about dirty?" "That's all the trouble," he re-
plied, " I don't think I ought to live on. I've been sort of
married to everybody. I felt dopy and sleepy in the Philippines.
Now I feel that way too, sometimes. Nice and clean, independ-
ent, nothing annoys me much, live on nice and clean. I get along
pretty well." He was very careless of his clothes and often went
about with fly unbuttoned and genitals half visible. ( " Why do you
do that?") "They ought to look at it." He said fellatio, ped-
erasty and masturbation were all dirty, but heterosexual inter-
course was clean. This information was slowly and laboriously
extracted from him in piecemeal fashion.

CASE HISTORIES 2Q

He usually knew the date, said this was an insane asylum
and knew how long he had been here, but he didn't know
people's names or positions.

Occupational therapy: He could play casino, but forgot his
turn or played ahead of turn. He couldn't seem to learn basket
weaving, and did poor work because he was unable to concentrate.
He could catch a ball even when thrown at him suddenly in a
tricky way. His greatest delight was to take a pencil and cover
a sheet of paper with numbers (he had worked as a commissary
in the army). Sometimes he wrote sentences such as "Please
acknowledge I am a deserter " or " The best thing a man can do
is to keep clean and be respectable."

Physical examination: Medium type of skeleton. Skin scaly.
Hair dry and fragile. Beard scanty. Genital hair normal. Gen-
italia normal. Abdomen protuberant. Heart rate slow. Pupil-
lary excursions limited. Reflexes hyperactive.

Endocrine diagnosis: Submyxedema.

Glandular therapy: Desiccated thyroid gland made him
much more irritable and somewhat more active. His wife said
he talked more freely to her than for years. In the ward he
several times went into the worst fits of storming and scolding
we had yet seen. He said he heard lots of voices all the time.
While formerly he had to be undressed before a bath because if
left to himself he would stop and go off into his thoughts, he
now undressed and bathed himself without urging. He seemed
to grow more uneasy and to fear I was investigating and trying
to fix some crime on him.

Four months later: He appeared the same as before gland-
ular feeding was tried. The summer records stated he had had
delusions of grandeur and of electricity playing on him. He
showed no such symptoms while in the endocrine ward.

Mental diagnosis: Schizophrenia with projection. His
troubles were pretty evident. He had a tic of the lips and
tongue, voices called him a fellationist, and at the outbreak of
the psychosis he had choked and his throat felt sticky. Other
men wanted to marry him, and he angrily resisted their advances.
Dirtiness was " all the trouble," and his main idea in life was to

3O CASE HISTORIES

keep nice and clean and be respectable. He explained that normal
coitus was clean and perversions and masturbation dirty. Prob-
ably he had committed fellatio in the past and this was why his
throat felt sticky. His strong homosexual cravings were vigor-
ously resisted, and the fight still goes on. The feeling of sexual
unworthiness probably antedated such delusions as being a thief
and deserter.

FOSTER

History: He was a deteriorated patient who had been in the
hospital nine years. His age was thirty-five. There was no
history of nervous or mental disorders in the family except that
two paternal cousins were insane. His father was of " primitive
mentality." The patient was the youngest of seven children and
was considered delicate and backward as a boy. He didn't do
well in school and had to be forced to attend. He was always
seclusive and quiet and disliked games and amusements. He
showed such aversion to girls that he was teased about it. After
leaving school he worked as delivery boy in his father's grocery,
for which he received five dollars a week and maintenance.

Some weeks previous to his commitment he had complained
of severe headache with loss of appetite and vomiting, and later
became retarded and stopped work. He acted frightened, wept,
said he was " full of electricity " and blamed himself as " the
cause of it all." In the hospital he continued to show fear and to
blame himself, and remained in a semi-stupor. He would eat
only when threatened with tube-feeding. One day after a bath
he had a clonic convulsion lasting several minutes. He made
several attacks on other patients " because they called him bad
names." He was confused and weepy for three years, then be-
came oriented for place and person and emotionally indifferent.
He talked to voices, but said they didn't bother him. He never
associated with other patients and never worked.

Se^ life: All that the records stated was that he disliked girls.

Fantasies: He frequently laughed and, when asked why,
answered that some certain person in the environment was the
funniest looking one he ever saw. The individuals he pointed
out had nothing unusual about them. It was evident that these

CASE HISTORIES 3!

replies were only excuses to hide the real cause of his pleasure.

General observations: He was untidy and tore his clothes.
He would not wear suspenders and had to hold up his trousers
with one hand when walking. He never spoke unless spoken to,
and would if possible move away without answering. He whistled
a good deal, learning the latest airs from the graphophone, and
he liked to look at pictures, but never read.

The attendant noticed that when out walking he would
respond to greetings from a distance but as soon as a person
approached him he became uncomfortable, looked in another di-
rection and tried to get away.

Occupational therapy: He turned his back on the instructor
and paid no attention to her efforts to interest him.

Physical examination: Skeleton out of proportion with small
pelvis and heavy upper extremities. Skin dry and covered with
scabs. Hair dry and scaly and very fragile. Beard scanty.
Genital hair normal. Genitalia normal. Heart slow. Circula-
tion sluggish. Extremities cold and cyanotic. Patellar reflexes
exaggerated. Gait shambling.

Endocrine diagnosis: Submyxedema.

Glandular therapy: The thyroid test caused him to become
considerably more extroverted. He answered more readily when
spoken to, didn't try to get away as much as formerly, noticed
other patients, put on a bizarre skull cap belonging to the at-
tendant and joined heartily in the resultant laughter, complained
of pains and aches while formerly he never mentioned how he
felt, and even consented after some urging to try basket-weaving.
He also became tidier with his clothes.

Later a combination of thyroid and suprarenal was given him.
The improvement was maintained.

Four months later: He seemed to have returned to his condi-
tion previous to glandular stimulation.

Mental diagnosis: Schizophrenia, with projection in the be-
ginning at least. The meager records of his disease tally in the
main points with the usual schizophrenia. He never got his libido
over to the opposite sex, and he had a sense of unworthiness and
sin due, no doubt, to perverse cravings. Perhaps at first he had
insight, for he claimed he was to blame for it all. After three

32 CASE HISTORIES

years he apparently ceased the struggle against his unworthy
tendencies and began to indulge them in fantasy, for the voices
no longer annoyed him and he became contented. His laughter
was probably over his formerly resisted fancies now freely in-
dulged and not at the unlikely external objects he cited in excuse.

GARLAND

History: He was so deteriorated that he could not give any
of his history. The following facts were selected from the hos-
pital records. The family history was negative. He attended
school till he was fourteen, and failed towards the end in the
sixth and seventh grades. His longest job was in an optical shop
where he ground lenses for seven years at low wages. At the
age of twenty-four he married. He was extremely jealous and
suspicious of his wife, and finally began accusing her of having
sexual relations with almost every man in the neigborhood. He
lost his job in the optical shop because he continually quit work
early to spy on her. He heard voices call him vile names and
feared his brother-in-law wanted to kill him. After losing the
optical job he worked as elevator man and park laborer until
he was committed at the age of twenty-nine. His wife had not
lived with him for two years previous.

The above information came from the family. His own
version at the time of commitment was that noises, like buzzing
bugs or jumbled voices as if several people were speaking at
once, annoyed him and kept him awake. Sometimes he could
distinguish what they said, and it was both pleasant and un-
pleasant. Some told him to do right and others called him bad
names. He could carry on conversations with them. He had
seen unnatural things, but wouldn't say what. He believed his
wife's mother poisoned his food. He felt discontented and was
easily angered, but didn't understand why he was sent to an
insane hospital, for he wasn't insane. The examiner commented
that he was much absorbed in his own thoughts, and was rest-
less and suspicious. He had no insight.

During his nine-year stay in the hospital he had gradually
deteriorated. He didn't associate with other patients but had no

CASE HISTORIES 33

difficulties with them. The voices kept bothering him, however,
and he often answered them angrily and was "profane and
vulgar." Shortly before entering our ward he complained that
magnetic power was being used on him.

Sex life: The record stated nothing beyond that he was
married, suspected his wife of infidelity, and denied venereal
disease and perversions.

Fantasies: In our very first talk he brought up the subject
that troubled him most. " A man isn't responsible when influence
is used on him. I don't see why they use influence on me. I see
myself turned over and shot upside down out the window and
then come back again into the room, and yet I'm standing still in
one place all the time. All day long they turn me over. They've
no right to. It's an offense to the law to turn a man over. And
I'm a married man. Action on the human body is an offense.
They shouldn't go beyond the limit, beyond the law." This was
his greatest annoyance, and his good days were those in which
he said he was not turned over so much.

" Voices say things, thousands of them. I understand them,
but I don't know where they come from. I can't use influence
back again but I can answer. I enjoy their talks. ("Do they
ever say bad names?" He frowns angrily.) I don't approve
of that."

He had many face and head tics. He nodded his head
violently up and down, his eyelids winked, and his lips smacked
loudly. Often in place of smacking he would roll out a long
neologism, " glahba-glahba-glahba-glah." He indulged in these
simultaneous tics and exclamations only when angry and dis-
turbed by his hallucinations and delusions. When they were
agreeable he laughed in glee. The laughter occurred mostly
when looking at pictures of women. This was one of his chief
delights. He poured over Sunday supplements and magazines,
cut out such pictures, carried them around with him, kissed them
and took them to bed with him. The attendant once had to
rescue his photograph of his fiancee. The patient said, " Pictures
talk to me like any human being, not out loud, but influence.
Not as plain as a voice like you, but still I understand what they

34 CASE HISTORIES

say. No particular subjects, just matters of friendship and love."
( Blushes — emotion. )

One night he took to bed a newspaper photograph of a noted
prima donna who was suing for divorce. The following morning
he told me she had spent the night with him in sexual intercourse,
that she was going to settle a hundred thousand dollars on him,
and he would marry her as the Earl of Wellington. On another
occasion the attendant, out of curiosity to see his reaction, offered
to bring a real woman to him. He became panic stricken at once
and angrily forbade the attendant to do so.

At night he was very disturbed and often had regular battles
with imaginary antagonists. I sometimes came into the ward
quietly and listened to him without his knowing it. He seemed
usually to be fighting off another person or resisting masturba-
tion. At intervals he exclaimed, " No, don't do that. Put your
hand down. A nice young man like you," and his voice broke as
if weeping. A " glahba-glah " would be interjected from time
to time. After an hour's conflict he gave in and masturbated
angrily, then became quiet. Patients in neighboring beds told
me that during these struggles he talked of coitus, bestiality,
cunnilingus and analingus. He would shout, " Take that man out
of here. I don't want you. Come back in here." Then he'd leap
out of bed and fight the air with his fists. The struggles ended
in angry masturbation. Once he pounded his jaw as if angry at
himself.

He complained somewhat of trees, saying that trees and cars
did it, made the offense (turning him over), and that plants and
trees annoyed him by talking to him, and he could feel their talk
tap him on the abdomen like a person's finger (homosexual
assault?).

" That gets me," he exclaimed indignantly, " I get the boys
all the time and I want the girls sometimes."

General observations: He was a pleasant, friendly fellow
quite willing to talk unless too badly annoyed by his hallucina-
tions, but it was often hard to understand him, for he had given
meanings of his own to familiar words and thus invented almost
another language. For instance he would rub a forefinger in the
palm of the other hand and talk about " material " and " ingredi-

CASE HISTORIES 35

ents." This was constantly repeated, but I could never discover
the hidden meaning.

The following is a typical conversation: ("What made you
sick in the first place?") "It might have been actual sexual
intercourse at a distance. It might be action. A married man.
Sexual intercourse at a distance. I can't state just the reasons
for it. I never had difficulties at a distance. It seemed to be
action, that's all. Action is movement. From a distance to my
penis. I never had any difficulties. While I was at work elderly
men more than young men bothered me. An affliction. If he
wasn't married, it wouldn't be action against him."

When not constantly stimulated by other people he was liable
to go off into his fantasies, which were usually unpleasant, and
then begin his violent tics and glahba-glah-ing or smacking. He
could play casino but went into these tics while waiting his turn
to play. He liked to join the other patients in playing catch
with a baseball, and was quick and skilful, but lapsed into his
mannerisms if the ball were not thrown to him frequently enough.
When the others heard him begin to glahba-glah they threw a
basket ball at his head, and he would laugh and join the game
again.

A few times he made sexual advances to the nurses. But his
great preoccupation was masturbating. Several times a day he
would retire into the watercloset and indulge in it in spite of
attendants and fellow patients.

Occupational therapy: He could not learn the simplest weave
in basket making and spent fruitless weeks on a stocking cap.
He would continually lapse into fantasy and weave blindly.
Every day the instructor made him do some simple task such as
marking holes on tray bottoms. He could play a game of cards
because the other players continually called him out of his
fantasy.

Physical examination: Slender type of skeleton, well nour-
ished and muscled. Skin presents slight actiniform lesion. Beard
slight, small amount of hair over abdomen. Genital hair normal.
Very large genitalia. Extremities cold and cyanotic with derma-
tographism present. Heart normal. Extensive reflex excursions.

Endocrine diagnosis: Submyxedema.

36 CASE HISTORIES

Glandular therapy: During the thyroid feeding he seemed to
improve. He grew quieter because not so much bothered by his
hallucinations. The masturbating nearly ceased. His mother
visited him and thought him improved both mentally and phys-
ically.

Four months later: He knew me at once. His condition
seemed the same as before thyroid feeding was begun.

Mental diagnosis: Schizophrenia with projection. His
struggle against his perverse cravings was plain to see. Ap-
parently they were all projected and he was not consciously
tempted. At night, however, in a hypnogogic state, they some-
times broke through, and he cried that he would not do these
things but wished he could.

His extreme jealousy of his wife indicates that he must have
been impotent. The obsession of being turned over is probably a
passive pederasty fantasy. Unlike some of the other patients he
has not given in and secured peace by indulging the perverse
cravings, but still fights them as vigorously as in the beginning.

HALSTED

History: He was a clumsy, strong-bodied boy of twenty-one.
His parents and four brothers were living. He was the youngest
of the family and had been much petted. The father was
psychopathic and there had been much family discord. He com-
plained that his wife cared more for her sons than for him, and
when he got excited was severe with the boys. While they
lived in the country he used to wake as early as 3 or 4 A.M., get
up, and wander for hours through the fields and woods. At
present he got angry whenever the mother, a timid weak little
woman, saw another man, and the situation was getting so
intolerable for her that the sons were contemplating taking her
with them and abandoning him. None of the sons would remain
at home. The second son had spasms until he was five. The
mother described the third as nervous and impatient and intol-
erant of noises, and the fourth as over-active. With the excep-
tion of the patient the sons were able to make their way in the
world.

CASE HISTORIES 37

He attended school from five to eighteen, graduating from
the eighth grade after repeating it. School was too hard for him
he said, and he used to play truant a good deal, going off in the
woods with his dog, gun and fishpole. He was always reticent
and a great home boy, and didn't play with other boys much
when his brothers were away.

Until his next older brother and he were ten and eight
respectively their mother slept between them in the same bed,
and she remembered that they used to be jealous and each one
wanted her to face him and turn her back on the other. The
brother then slept apart, but the patient slept with her until well
after puberty. It was noticed that he became more bashful and
shy after puberty. He sucked his fingers till he was twelve.

The excitable father scolded the mother a good deal and this
upset the boy who made faces at the father behind his back.
The father said his other sons used to oppose his will at times,
but that the patient rarely stood up for himself. Once, however,
he refused to hitch up a team when ordered to, and the father
chased him off the place with a revolver. He was slow and
awkward, and the brothers nicknamed him "clum," short for
clumsy. They had been forced to go to work about the age of
fifteen and felt bitter over their limited education. They insisted
that the patient be given a better chance and advised him not to
go to work till he was twenty-one.

The brothers were very affectionate among themselves. One
of the older ones took the patient as his buddy, gave him candy
and other presents, and looked after him in general. He used
to caress this brother's head and hair. All of them kissed each
other even yet. When one of them visited him in this hospital
he called him Honey and kissed him. The father said the boys
were fond of wrestling with each other on a bed and the victor
kissed the vanquished one repeatedly.

After quitting school at eighteen he went to the city and lived
with one of his brothers, and got a job in a parcel check room,
studying stenography at night school. He lost that job soon, and
then got one as telegraph messenger boy but gave that up because
it was too hard. One night he implored his brother to protect

38 CASE HISTORIES

him, saying people wanted to shoot and kill him. He was sent
home, and arrived there in great terror. They soon took him to
a state hospital, where he remained for a couple of years during
which he made long visits home but could not adequately adjust.

He had some delusions about his eyes, and hung up a picture
of a skull on the wall with eyes punched out and strings running
from the holes to all parts of the room. A photograph of his
father he called the devil, one of his mother was God, and one
of himself was Christ. He said he could turn anything into
stone. He got careless of his personal appearance, slept on the
floor, and ate with his fingers. The family noticed that he
didn't like to be kissed by his mother, aunt, and brothers, and
his attitude toward his mother alternated between strong affec-
tion and angry aversion. He would spend two hours in the tub
and lay with his head also under water. Several times he ran
away from home and came back a day or two later disheveled
and famished. He never would give any adequate explanation
of his behavior. They tried him on farm work as a last resort,
but he could not keep his mind on his work. He would stop and
laugh to himself. When asked what he was laughing at, he
would say at the dog or give some other transparent excuse. He
was finally brought to St. Elizabeths.

Sex life: He had no intention of giving out any information
he could possibly hide, and probably feared that he might divulge
something that would prove he was sick. He insisted he was all
right and ought to be let out. I managed to draw out that he had
masturbated about once a month (he told a brother he had done it
as often as two or three times a day), and that he had tried
heterosexual intercourse at twelve. That was the only attempt,
he hadn't much desire later and he felt bashful with girls.
Perversions he denied.

Fantasies: He denied all hallucinations and delusions and
gave no outward sign of any. I told him the story of (Edipus,
and at the mention of mother incest dreams he broke into a
sudden knowing smile. ("Did you ever have one?") "Not
often, not for a long time." When I pushed the question, he
denied he had ever had one.

CASE HISTORIES 39

He denied wet dreams, nightmares, or dreams of coitus, but
said he had day-dreamed of sexual intercourse. He said his
dreams were of finding money on trees and bushes, and of going
fishing. He also used to imagine himself the boy characters in
the Horatio Alger books of which he was very fond.

General observations: He was a clumsy boy, walking in a
rolling, loosejointed manner that had grown much worse in the
last two years. His one main idea was to get out of the hospital.
He insisted he was all right, there was nothing the matter with
him, and if his family cared anything for him, they would come
and take him home. It was noticeable that he preferred to see
his father rather than his mother in spite of childhood love for
her and fear of the father. (Another case, an eighteen-year-old
boy, whose mother incest desires broke into full consciousness,
used to greet his father cordially and rebuff his mother, even
striking her and shouting, "Take this woman away, I've never
seen her before.") He begged money and candy from them like
a child.

He had never confided in anyone and was unwilling to do so
now. At every opportunity he would run away, even when the
father was taking him for a walk about the grounds. He was
deceitful and lied up and down, denying the information given me
by other members of the family. He feared the doctors were
going to hurt him in some way. He disliked being looked at,
and during interviews with me picked nervously at his finger
nails. He said that when he lost his jobs his brothers scolded
him and he was afraid they might put him in prison for it, so he
was anxious to get away from them and did not object to going to
the first hospital.

Since he would not talk freely I used the association word
test in an effort to discover his complexes, but it accomplished
very little because he would not give many free associations
afterwards. I made three tests, embodying in the second and
third tests the words which aroused emotion in the first. By the
time we reached the third test he had learned to give stereotyped
responses to nearly all the former complex-indicators.

Eye, lips, mouth, tongue, suck, sucker and swallow were
associated together and aroused much emotion and resistance.

4O CASE HISTORIES

They made one suspect fellatio. Woods and bushes were linked
and brought back memories of playing hookey and hiding there
from his father with another boy with whom he swam in the
brook and also masturbated. Dirty, slimy, and dog made him
think of dirty dog. Enjoy made him think of having all he
wanted of candy, money, and clothes. Dreams: " Come true,
we wish they would." Observe: "Observer, one who looks.
People looking at you, I don't like to be looked at. (The pre-
occupation with eye may have some connection with this. He
exclaimed once, "When you say eye, I just can't help thinking
of lips.") Voices: " I couldn't think of a word for voices so I
had to think up some other. Insane people hear voices. No,
I don't." Jealous, hate, kill, murder, die were connected. Hate:
"Hateful, they won't do nothing for you, they're mean. To
hate anybody is to kill them." Die: " Dead, they're gone."
Lazy, work, -forget, -failure, and pity recalled how hard his family
had been on him because of his forgetfulness and poor work.
Love, kiss, bad, prick, and cock brought evasive responses after
delay. Father, mother, and brother also caused delayed re-
sponses. Secret caused a blocking of half a minute, and the
response was "secretly." But the longest delay, forty-five sec-
onds, followed spit: "Whistle, Papa spits tobacco." He would
say nothing more, and it was impossible to tell whether the
emotion aroused by spit was connected with the suck-and-swallow
complex or his father-hate.

He escaped from the hospital numerous times and went home.
The family often allowed him to remain there a while, but he
could not accommodate himself to their life and they were forced
to bring him back. After each escape he begged his doctor to
give him another chance in the open endocrine ward and promised
faithfully never to run away again, and then escaped again at
the first opportunity.

Occupational therapy: He was shy and lazy and did not do
good work. He worked only part time and sat around a great
deal in idleness.

Physical examination: Skeleton normal. Skin well nour-
ished. Good muscular development. Genital hair distribution
normal. Small amount of hair around mid-sternal region and

CASE HISTORIES 41

nipples. Axillary hair very scanty. Genitalia normal. Ex-
tremities rather cold. Type of movement slow and deliberate.
Heart rate accelerated. Reflexes hyperactive.

Endocrine diagnosis: Submyxedema.

Glandular therapy: He was given thyroid. Treatment was
much interrupted by his frequent escapes. No change was seen.

Four months later: During the summer he escaped again and
was allowed to stay home for a month until he attacked one of
his brothers for refusing to give him money. He had also bull-
dozed his mother when his father was at work. The attendants
reported he was masturbating frequently. No one had seen him
do this in the endocrine ward. He seemed worse ; more self-con-
tained, introverted, and on the defensive.

Mental diagnosis: Schizophrenia with projection. He had
had considerable experience with insane hospitals and in his
partially recovered condition was smart enough to hide the symp-
toms he knew doctors were looking for. He claimed he was all
right and wanted to go home, so of course he wished to hide
any symptom that he had seen was considered bad. Thus, while
he resolutely denied hearing voices in the hospital, on one of his
escapes he told his cousin he was going to Union Station to find
out about the voices. A stereotyped hospital question is, " Do you
hear voices ? " As far as could be seen he had no delusions or
hallucinations except the vague fear that someone might hurt
him. He would rather sit or lie down than work. One never
saw him smile or give any indication of enjoying his thoughts
particularly.

He had much autoeroticism. The staying in the bath showed
skin eroticism, and the association test disclosed oral eroticism
if not actual fellatio. It will be remembered that he sucked his
fingers for many years.

Signs of his struggle against incestuous and homosexual
impulses were his resistance to his mother and brothers kissing
him and his alternating affection and aversion for his mother.
The flights from home were an attempt at emancipation from the
family, but he was not strong enough to stand alone and had
to return beaten. His childish relation to his mother and his shy-

4

4r CASE HISTORIES

ness and fear of girls prevented his outgrowing the bisexual
stage. His extreme reserve rejected all outside help and his only
hope of cure was to work out the problem by himself unaided.
This he did not seem able to do.

IRGOCZ

History: He was an Austrian Pole twenty-seven years old.
There was no mental or nervous disease in his family with the
exception of a paternal uncle who drank and later committed
suicide. The patient was the first born and was sickly and
delicate as a child. At five he had typhus fever. He attended
school from seven to ten and liked it but had to go to work on a
farm because they were poor. From sixteen to eighteen he was
a laborer and then he emigrated to the United States.

He worked in foundries and factories for rather low wages
but got on all right except in the last place. It was too hot,
and he noticed the other men were jealous of him because of
his good work. They tried to make him mad and looked sus-
piciously at him. He also believed that the food at his boarding
house had been poisoned and complained of it to the police. To
escape from the unpleasant situation he enlisted in the army at
the outbreak of the world war.

Two months later he was removed from a transport ready to
sail for Europe, and put in hospital. His comrades had reported
him to be making silly grimaces and talking to himself. His
version was that everything was all mixed up and the men cursed
him. He was transferred at once to St. Elizabeths.

At first he was tidy and fully oriented and cooperated in his
examination. He said he could think and remember as well as
ever, while in reality his memory for recent events was badly
impaired. Voices called him bad names. Later he went into
a catatonic stupor and had to be tube-fed for a while. During
the following two years he had become disoriented and untidy,
and complained that magnetism was being used on him.

Sex life: According to his statements two years ago he had
never masturbated or committed perversions. He preferred girls
to boys but seldom associated with them. At twenty he had his

CASE HISTORIES 43

first heterosexual intercourse, and stopped after four or five ex-
periences. He was much afraid of venereal disease.

Fantasies: On his admission he said he dreamed of being
home in Poland and of working in the factory. Now he was
absolutely inaccessible, spending all his time in his own thoughts.
They must have been pleasant for he disliked any interruption
and gave no signs of conflict or distress.

General observations: He was absolutely indifferent to the
external world. When standing, his arms were thrust down
inside his trousers though not touching his genitals, and he
walked with eyes downcast or stood staring by a window. In
cold weather he huddled over a radiator, hands clasped over the
nape of his neck. For hours he crouched in a heap in a corner,
eyes shut and fingers stuck into his ears. He seemed to want to
turn in on himself physically as well as mentally. But when the
pantry door opened at meal time he was usually the first to reach
it in spite of his apparent isolation. As he carried his tray to
a table his grin of satisfaction was almost animal-like.

When one forced oneself on his attention he sometimes struck
out in annoyance, and then mumbled an unintelligible mixture of
Polish, German and English punctuated with guffaws of laughter.
I once distinguished the German vulgar term for feces and the
ever-present son-of-a-bitch preceded by profanity. He repeated
this phrase several times with delighted laughter and then pointed
to his teeth. He pressed his lips tight together and pouted them
forward and back a great deal. A Polish-born nurse spoke to
him in his own tongue, but he rebuffed her like the rest.

Occupational therapy: He remained entirely inaccessible.

Physical examination: Medium type of skeleton. Skin pale.
Entire chest and abdomen covered with long, thick hair. Gen-
italia normal. Abdomen protuberant. Heart weak and irregular.
Pupils pinpoint. Reflexes sluggish.

Endocrine diagnosis: Submyxedema.

Glandular therapy: Thyroid was given. The stimulation
seemed to force him to extrovert in spite of himself. He dropped
his hands from his ears from time to time and looked about him
in half surprise as if wondering where he was. He paced rest-

44 CASE HISTORIES

lessly a good deal and didn't stay crouched in corners so much.
The extroversion increased and he was soon pushing a floor
polisher and was even induced to do a little basket weaving.
The attendant reported that in taking a bath he soaped, scrubbed
and wiped himself well. On previous occasions he had made a
few passes and tried to get out of the tub and dress while still
wet.

Four months later: During the summer nurses reported he
had seemed brighter and more alert. He would obey orders and
even made beds. He no longer closed his eyes and ears, hung
his head, or crouched in fixed positions. He became oriented
for place and asked why he was there.

I found him still lost in his thoughts though his eyes and ears
were open. His lips were pressed tight together and protruded
as before. Instead of looking happy or at least contented he now
had a slightly troubled expression.

Mental diagnosis: Schizophrenia with projection. In the
beginning at least he projected his difficulties, and believed other
men persecuted him, and he heard accusing voices. As the(
disease progressed he appeared to give in and to indulge in his
dirty fancies. He showed a bit of waxy flexibility which is a
sign of submission. The lip tic indicated oral eroticism. He
tried to avoid all external stimuli by closing his eyes and ears
and striking off anyone who touched him.

The thyroid feeding seemed to force him out of his comfortable
fantasy life somewhat into the world of reality. The troubled
expression may indicate that the increased pressure of reality
has stirred up some resistance to his fantasies, and conflict has
again ensued.

JACKSON

History: He was an enormously fat man with a huge paunch
and a voracious appetite. His age was forty and the last eight
years had been spent in the hospital. He knew very little about
his family. His father drank periodically and he himself had
drunk too much he said. An uncle had died insane.

The patient was born in Ireland and came to this country
when five years old. He attended school irregularly until he was

CASE HISTORIES 45

fifteen, by which time he had reached the fifth grade. He worked
in a printery, a machine shop and a theater, never earning enough
money to live the way he wanted. Most of his jobs were as
hostler for wealthy families who let him go when they left for
their summer vacations. When motor cars began displacing
horses he should have learned the automobile business, he said,
but something in him didn't want to.

At the outbreak of the Spanish War he enlisted in the army
because he wanted to see the world. After three years he was
honorably discharged. There followed a series of enlistments in
the army and navy with dishonorable discharges and prison
sentences for fraudulent enlistment, drunkenness and stealing.
He finally became upset and believed people were reading his
mind and hypnotizing him and forcing him to say and do things
he didn't intend to. He became terrified because he was sure
some people were going to kill him.

In the hospital he refused to work, did not associate with
other patients, and was certain he was to be killed. Voices
accused him of vile practices, and God gave him instructions
about his eating. He became somewhat grandiose and decorated
his clothes bizarrely.

Sex life: He preferred to keep off this subject. With blush-
ing and shame he said that he considered masturbation harmful
and had never done it much. The record states he had been
caught at it. When he was eighteen a married woman, separated
from her husband, had picked him up and he had gone with her
for two or three years. He disliked even to admit having had
heterosexual intercourse. It was not possible to marry on less
than a hundred dollars a month he said, and he had never earned
that much. At mention of perversions he was instantly on the
defensive, "Better not talk of that."

Fantasies: Voices used to insult him and call him a fella-
tionist, and he would retort. His brain told him that another
man, Satan perhaps, was trying to control him. The tempter
agreed that you could do anything you pleased if only you
confessed it afterward to a priest ; that cleared it all up, but he
insisted no, it couldn't be as simple and easy as that, for you
would get sent to prison for fifteen years just as some men had

46 CASE HISTORIES

been sent to Portsmouth for committing perversions. His brain
was deadening the other man's brain and keeping it down, so he
was winning out (an ingenious dramatization of the conflict with
perverse impulses, into which the fear of consequences was
injected).

"Before I came here, there was a mindreader who used to
say what I thought before I could say it myself. That happens
often now too. I believe there are people all around here who
can do that.

"Voices talk a lot about the Lord. They say the Lord was
assassinated before the birth of Christ. Then the Holy Ghost
went to Bethlehem and had a child by Mary Magdalen, which
was Jesus Christ." This peculiar jumble seemed to be the old
GEdipus complex in a religious disguise. The father was killed
off in favor of the son, and Mary Magdalen symbolized the
soiled mother. The composite Holy Ghost and Christ stood for
both husband and son.

General observations: When he first entered the ward he did
nothing but sit in a chair, frequently wearing his coat over his
head. Gradually he began to extrovert, first singing out of a
book, then pushing the floor polisher and finally joining in
basket weaving. He didn't mix much with the other patients
but seemed to feel no antagonism towards them.

He said that after soldiering three years he thought it was
the place of the army to look after him and not try to get rid of
him for little offenses. He believed he could earn his living out-
side now if the work wasn't too hard. However, he was satisfied
to be kept and cared for. That was all there was in the world
for him. Outside he would have to work for his living, and he
was as well off in here as a working man outside with pick and
shovel. " I think there are lots of people in freedom who if they
were put in here like us couldn't get out again."

Occupational therapy: When the instructor first came to our
ward, he sat all day with a coat over his head. In three days
she had succeeded in getting him to do basket weaving and he
worked every day, improving steadily in ability. He made many
mistakes at first and was impatient of instruction. He would
willingly work all the time if she could furnish him sufficient

CASE HISTORIES 47

material. His general mental condition seemed to improve also.

Physical examination: Heavy type of skeleton with general-
ized adiposity, which is exaggerated on shoulders and abdomen.
Weighs 248. Skin smooth and almost hairless, though there is
a slight beard and some scanty hair about the mammary glands
which are enlarged, being filled up with adipose tissue. Fingers
are short, stubby and without tremors. Breathing is shallow
and emphysematous in character. Penis very small, genital hair
normal. Heart rapid. Reflexes normal.

Endocrine diagnosis: Submyxedema.

Glandular therapy: He had been steadily improving for a
long time before taking desiccated thyroid gland. But with the
first large doses he grew more active, talkative, industrious and
complaining, and talked about getting out of the hospital in a
few months.

Four months later: After occupational therapy had been
discontinued in the ward he began working in the pantry and kept
it up industriously. Perhaps the opportunity to get extra help-
ings of food had something to do with his willingness to wash
dishes. The attendants said he had no sleepy spells and was
fairly energetic. His mental condition showed no particular
change.

Mental diagnosis: Schizophrenia with projection. His diffi-
culties tallied with those of the majority, that is, he had little
interest in women and he was struggling against homosexual
cravings. His description of the wicked brain trying to control
him but losing the fight was an admirable one. He really had
gotten sufficient control of his unpermissible cravings to make a
happy adjustment to institution life.

KIMMEL

History: He was a deteriorated patient forty-eight years old
who had been in the institution nine years. He had a wife and
five children. His mother's father had died of senile dementia
and her sister was insane. One of his own sisters had suffered
from a nervous affection since she was eight years of age. The
others were healthy.

48 CASE HISTORIES

As a child he was considered normal, but at fourteen a horse
kicked him in the head, lacerating the scalp. His father believed
the patient's attitude toward him changed after this experience
(presumably for the worse though the record failed to specify),
and ascribed it to the kick. He left school at seventeen having
completed one year of high school. He worked at farming and
in his father's store and as a laborer. Around the age of twenty
he drank considerably. After marriage he stopped drinking but
he was irritable and excitable. He was serving a second enlist-
ment in the navy when he got sick. He complained he had been
unable to sleep for many nights and had hard headaches. He
was quite weak. Before reaching this hospital he developed
hallucinations and delusions of persecution and had a severe
epileptiform seizure lasting five minutes.

The hospital record mentioned no more epileptiform seizures.
He had had hallucinations of all senses and delusions of persecu-
tion which made him talk in a homicidal manner. Voices insulted
him. At times he was so unruly he had to be confined in the
worst ward. He complained of pain in the upper left arm and
right leg where he said his mother had cut him. No scars were
visible. The right side of his face was somewhat paralyzed. He
said other patients talked about him and cut his abdomen. That
his head felt bound up and he couldn't think well, and electricity
was used on him.

Sex life: During the four months he was under special
observation no one heard him mention any sexual matter. He
ignored questions on sex subjects. The records gave no infor-
mation.

Fantasies: The only audible indications of his fantasies
were his angry arguments with imaginary people who thought
they did better work than he and depreciated his accomplish-
ments.

General observations* He was an ugly-tempered, unkempt
man usually quite lost in his own thoughts and oblivious to the
environment. Though once or twice I saw him go into laughing
fits he generally sat quiet with head hanging or scolding loudly in
great anger. This scolding was almost exclusively about what
blockheads and poor workers other men were and how well he

CASE HISTORIES 49

himself did things though always criticized and never appreciated.
Once in a while he scolded about his food. These tirades oc-
curred during the night as well as the day, and in them he
articulated with difficulty, making extreme grimaces in which he
drew his mouth way over to the left.

Occupational therapy: He was very resistive to the instruc-
tor's efforts to interest him but finally consented to try basket
weaving and managed to complete two pieces. Every morning
he had to be taught all over again as if he had never seen a
basket before. Some days he angrily refused to work telling the
instructor to do it herself. At any time he was liable to stop
work and go into one of his tirades.

Physical examination: Slender type of skeleton. Skin pre-
sents a few brown pigmentations, particularly over shoulders.
Considerable hair over upper chest and about neck. Genital hair
and genitalia normal. Face asymmetrical, elongated on right
side. He has generalized arteriosclerosis and there is an occa-
sional stereotyped choreiform movement of the left side of the
face. Considerable photophobia. Reflexes hyperactive.

Endocrine diagnosis: Submyxedema.

Glandular therapy: The three day test of tolerance for des-
iccated thyroid gland had a bad effect on him. His pulse became
very irregular and rapid and he showed other signs of intolerance.
He grew much noisier. Afterwards he became quiet and somno-
lent again but seemed to have a little more initiative. For
instance, he soaped and scrubbed himself in the bath which
previously the attendant had been obliged to do. Because of his
advanced chronic heart disease no glandular treatment could be
given.

Four months later: His condition was unchanged.

Mental diagnosis: Schizophrenia with projection. His con-
tinual scoldings disclosed an inferior, inefficient man magnifying
his own abilities and accomplishments and decrying other men
who imagined themselves superior to him and failed to appreciate
his true worth. If he had a sexual conflict too, it was now
buried out of the sight of the onlooker, but his history gave
hints that the usual erotic difficulties had once been present.

5O CASE HISTORIES

His change of attitude towards his father at puberty, his
failure to adjust to his home relations so that he left wife and
children and served two enlistments at sea, and the voices in-
sulting him were quite in line with the other schizophrenic cases.
He probably did not develop a psychosis merely because other
people didn't like his work.

LEFFERTS

History: He was a thin, delicate fellow twenty-nine years
old. His father was born in Germany and his mother in Ireland.
Most of his family had died of pneumonia. His mother remar-
ried after his father's death, and the stepfather abused him
when drunk. She died when the boy was sixteen. He went to
school until he was fourteen, at which time he was in the fifth
grade. He didn't have much ambition in school and sometimes
failed to pass. His first job was in a florist's shop, and he
changed jobs a good deal until he was twenty-one, when he
became a department store delivery boy. After three years he
got typhoid fever and lost the position. He also had had pneu-
monia and pleurisy. For a year and a half he worked in a
boiler factory, and then for a half year as a church sexton until
he enlisted in the army at the outbreak of the war with Germany.
Of his army service of two years, a year and a half were
spent in Panama. He had malaria there, and felt sickly and
without ambition. He was brought back to the United States
and discharged in April, 1919. For two months he worked in a
shipyard, then one night in June he felt as if in a trance, as
if electricity filled his body. He saw strange visions and heard
loud noises. His head and stomach swelled up, and something
in his left side swelled up and burst like a balloon, it was a
ball of heathen idolaters and other wicked people. There was a
swelling in his right side too, but it was good and didn't burst,
and his mother's voice from it said, "This is my son," and that
pleased him. His eyes felt as if changed, big, hard, and with
eyelids wide open. Venus, Mercury, and Jupiter were inside him
and talked. The first two were female and didn't insult him,
but Jupiter, a male, called him a son-of-a-bitch. The first two

CASE HISTORIES 5!

i

said he was overloaded with responsibility and that if anything
happened to him the world would go to destruction. While going
through the backyard to the privy he heard two voices disputing.
One said, " Grab him," but the other said, " You can't touch
him." He often heard these two voices disputing afterwards.
For a week he tried to keep on working, though pestered by
visions and voices, then had to quit. He reached St. Elizabeths
in August.

Sex life: He began masturbating at eight, and at one time
did it daily, but realized it was bad for him and gradually
stopped it altogether. He believed he sometimes thought of
girls while doing it. He was bashful with girls and seldom went
with them, preferring the company of boys. He never had a
best girl, and was afraid of rivalry with other fellows over a
girl. Sexual intercourse was not much of a temptation. He
feared making a girl pregnant for he hadn't enough money to
marry. He was very much afraid of venereal disease.

At Panama, when he was twenty-six, he had his only hetero-
sexual experiences, a half dozen in all, but got very little enjoy-
ment or feeling out of them. "Something ran through my
mind." He soon tired of it, and the fear of disease was ever
present. His night orgasms were infrequent and when there
was any dream at all in connection with them it was of normal
coitus. He had never committed perversions.

Fantasies: The kernel of his trouble, he declared, was that
there was something in him that if taken out might do great
damage, and only the devil knew what that something was (per-
verse impulses?).

He dramatized a struggle between two forces, good and evil
like the two disputing voices. He himself was good, backed by
visions of saints in white, crosses in the sky, and a full regalia of
crowns, balls, candlesticks, and moons such as decorated his home
church. A grandiose element entered in also, he was head of the.
Catholic, Jewish, and Turkish religions, higher than the pope, in
fact he was too good for this earth and was expected to rise
to heaven. He had been the sun, Moses, and St. Patrick, and
had been crucified several times. When he was killed in ancient
times, the world came to an end.

52 CASE HISTORIES

Opposed to these good Catholic forces were the Masons and
other wicked secret orders, backed up by various devils and ac-
companied by visions of carpenter squares, scimitars and other
fraternal symbols. Voices accused him of having founded these
orders long ago, and their members came to his bedside at night
and tried to get him to join the orders and to indulge in their
orgies of fellatio and cunnilingus, but he resolutely refused.
Gradually the orders developed into three ; the first was of earth
and pretty good, the second was of the devil and belonged in
hell fire, the third was his own order,* not hostile to the
Catholics, and belonged in heaven. He had no visions in the
day time, but at night he had them frequently. One night when I
entered the ward in the dark he saw horns on my head, and when
Vincent was having an epileptic fit he saw little devils jump out
of his mouth. "The devil shan't get into me," he exclaimed,
" I could catch him from some other fellow, but I fight tempta-
tion."

He was sure his eyes and testicles were removed during his
sleep and others inserted and that the same thing had been done
to his father. He had a fantasy that he had been in Germany,
and they had tried to operate on him there and take out his
testicles to put them in some one else's scrotum, but they all
dropt dead and lost their own power instead (struggle of father
and son to castrate each other. His father had been born in
Germany).

He had many physical delusions ; he was drawn along by the
head as if by a magnet, he grew small and then stretched out to
normal size accordeon-like, he was done up in a ball, and he felt
something go down from his head and out near the pubic region,
and something else rise to take its place. (During this period
he lost his potency and had no erections and had only one night
orgasm for six months. Voices told him he would never have
children.) Something had been taken out of him, and no one had
a right to do it. He had Adam and Eve balls, the right testicle
came from Adam, and the left one from Eve. His testicles had
sprouted like growing beans.

There was often a buzzing like a dynamo in his ears, and he
heard many voices. They called him good and bad names,

CASE HISTORIES 53

threatened to kill him, said the devil must keep away from him,
ordered him to commit fellatio and cunnilingus and submit to
fellatio, and compared a mouth to a vulva and wanted mouths
and vulvas to kiss one another. They never mentioned pederasty.

He dreamed of his parents as he remembered seeing them at
the time of their death, on bed and in casket, and it made him
feel badly, for if they had lived he would have had more advan-
tages and not been forced to go to work too young.

General observations: He was a thin nervous fellow, awk-
ward, restless, and emotional, and with protruding eyes. His
behavior was unvaryingly good, but he said he often felt very
irritable and just like springing at people and walloping them.
He had no insight into his psychosis and insisted that he really
did see and hear these things. If other people couldn't, they
were the ones that were crazy, not he. He was very stubborn
and obstinate in clinging to his delusions and did not want to
listen to any psychological explanations, but interrupted constantly
to give the true version, namely his. He was, nevertheless,
always courteous, friendly and humorous.

After working for two months I had made no progress what-
ever with him. Then he pricked his thumb and got a severe
infection of his whole left hand and wrist during which part of
the thumb had to be amputated. He was sick for a month
and meanwhile his psychosis evaporated. "The voices and all
are dying away, and I see no more visions. The voices told me
those strange things. Perhaps they were fakers and didn't tell
the truth. I don't believe them now. Once in a great while I
hear a voice but I pay no attention to it. I had a mental disease,
I guess. After they put me under ether to cut off my thumb the
visions began leaving. There was something inside me, talking
to me and trying to control me. It sets your brain on fire. You
don't know what you are doing. You might go out of your
head completely. I wouldn't give in, I fought it. The voices
asked if I did fellatio and cunnilingus as if they wanted me
to start doing them."

During the month following this explanation he gained phys-
ically and in emotional control, and then gave this version, "There
was a struggle on all the time, some force trying to get control

54 CASE HISTORIES

of me. I fought it all the time and finally won out, and now it's
gone. ("What would have happened if you had given in?")
Why, something awful. I probably would have gone and done
those bad things they wanted to make me do." He believed he
had cured himself unaided by anything or anybody and resisted
my explanation of the phenomena just as obstinately as during
the psychosis. He much preferred to regard it as supernatural.
When I called his attention to Garland reacting angrily to his
hallucinations, he replied, " He has the power to see things that
you and I can't."

I tried very hard to give him some insight into the delusions
he had suffered, but in vain. His superstitions were sufficient
to explain everything satisfactorily, and it was undoubtedly much
pleasanter to believe he had triumphed over a vile external foe
than to recognize that the tempters were his own repressed
desires. He hung on grimly to the belief that these hellish and
heavenly visitors had been real and he just knew that such things
could happen.

After six weeks I was startled to discover that the delusions
had returned. There was a woman inside him, and "they"
were accusing him of being a Protestant. Devils sported around,
and something inside him was trying to drive him wild. The
nights were full of demons, bats, angels and all. The delusions
were not systematized again however, and no Masons tempted
him to commit perversions.

It was useless to argue with him or to recall the interlude of
the infection. These spirits had departed at that time and now
they had returned, that was all. His conduct remained good and
he still used his parole of the grounds. He didn't do much but
sit around indifferently.

Occupational therapy: He was interested from the begin-
ning and very anxious to work, but was nervous, obstinate and
wilful, refusing instruction, saying he knew how and then blund-
ering ahead with many mistakes. Once when he got all tangled
up in mistakes he burst into tears. Gradually he became less
nervous and more careful. His infected hand put an early stop
to his work.

CASE HISTORIES 55

Physical examination: Skeleton slender. Dome-shaped pal-
ate. Perspires easily. Radial arteriosclerotic pulse under tension
and rapid. Hair, normal male distribution. Genitalia normal.
Thyroid gland, both lobes enlarged about one third and isthmus
is hypertrophied. A noticeable exophthalmos with eye globes
under tension. Fine toxic tremor of fingers. All reflexes ex-
tremely exaggerated.

Endocrine diagnosis: Hyperthyroidism.

Glandular therapy: None. Even the thyroid tolerance test
had to be stopped on the second day because of his excessive
reaction to it.

Four months later: He still had parole and his behavior was
exemplary. The hallucinations and delusions persisted, but were
not yet well systematized again. He said there were men and
women inside him, and they put things in and took things out
of his body, particularly his eyeballs. The symbolism was as
rich as ever with Scottish rites, Satan and the rest.

Mental diagnosis: Schizophrenia with projection. His own
explanation of his psychosis at the time of the infection was very
accurate except he would not admit that the " force " came from
within rather than from without himself. The coincidence of the
disappearance of the perverse cravings with the height of the
infection makes one presume a connection between the two
phenomena, particularly since there are records of many similar
cases in which severe infections apparently cured psychoses.

During the dominance of the perverse tendencies his sexual
power was lost, probably a suppressive act of self-defense. I
have found this phenomenon in many similar cases. When the
improper impulses are again well repressed, potency returns
as it did with this patient. It will be recalled that he stated some-
thing had been taken away from him, that his testes and eyes had
been removed (since some eyes and testes were there, he had to
invent the theory of substitution), and that voices told him he
would never have children. His delayed sexual development
was shown by his timidity with girls, his fear of fighting
another male for the girl he might want, and his lack of satis-
faction in coitus.

56 CASE HISTORIES

His gradual alteration of the, at first, totally bad fraternal
orders was interesting. They became three in number: one, a
male symbol, was "pretty good;" two, symbol of the female
genitalia, was bad and belonged in hell fire ; while three, symbol
of the male genitalia, and normal coitus, was his own and be-
longed in heaven, that is, his male cravings were triumphing
over his female cravings and repressing them.

MATHEWS

History: He was a jack of all trades who had been in the
hospital twelve years. His age was thirty-four. The family
history was negative. The father had been a peddling butcher
in a country town. He drank heavily and one cold night fell out
of his cart and died from exposure. The patient was then seven
years old. The mother was nervous and excitable. She had
twelve chidren ; six by her first husband ; five by her second hus-
band, the patient's father; and one by her third husband, whom
she later divorced.

After his father's death the patient quit attending school
regularly and went to live on a relative's farm where he was
allowed to attend school winters until he was twelve, at which
time he had reached the fourth grade. During the rest of the
year he did farm work. His stepfather didn't care for him, and
the boy didn't want to stay home. After his mother's divorce
he returned to her and helped her keep a country store winters,
and worked on farms summers until he was fifteen, when he went
to the city. When he was seventeen she died of hernia.

From fifteen to twenty years of age he had a long series of
changing jobs, lasting from one day to a year and a half (on a
farm), and including such varied occupations as riveter in bridge
works, store clerk, miller, teamster, shoveler, carpenter, and
physician's man of all work. Sometimes the work was too hard,
other times the pay was not big enough. If he got tired he'd
move on, and he wouldn't wait to be fired when people didn't
like him, he'd get out. Finally, out of work and tired, he
enlisted in the Marines for a secure and steady life and within
two weeks was in this hospital, diagnosed dementia precox.

CASE HISTORIES 57

At first he was restless, incoherent, irrelevant, sometimes
abusive and threatening, and always complaining. He didn't
want to stay and demanded his release, but never seemed put out
when his many requests were refused. He also had quiet, stupid
periods which lasted for months. His own present version of
his psychosis was that he had been very nervous and restless,
and his mind wandered. A thousand different things would
come into it during a day, including bad thoughts that weren't
really so. He feared the attendants wanted to kill him, and be-
lieved other people called him vulgar names, and his conscience
bothered him. He would try to choke himself with a towel,
and beat his head and elbows against the wall. His clothes
burned his skin, so he took them off, tore them up and threw
them out the window. In the fourth year he asked to have his
throat operated on (it was thought because of tonsilitis). In the
eighth year he was reported to be more interested and extro-
verted. He was neater, tidier, began to work, and gave no trouble.
In the ninth year it was noticed that his thyroid was enlarged.
This was followed by protruding eyeballs, tonsilitis, and acute
articular rheumatism, and he complained of perfectly sound
teeth. His mental condition cleared simultaneously, and remained
clear. The exophthalmic goiter remained, the other maladies
disappearing.

He said when a boy his neck bothered and hurt him, es-
pecially the " left muscle," and he noticed it most when running.
He also remembered stories of sheep and heifers escaping from
his father's knife and running wildly with bleeding throats.

Sex life: At eight he committed mutual fellatio with a gypsy
boy. Soon afterwards he began masturbation. Then he attempted
coitus with his sister, who was one year older. He used a heifer
at ten. He got his first orgasm at eleven or twelve, and was
wearing long pants at the time (date probably not accurate; he
said his memory had never been good). He used to have mas-
turbation races with a negro boy. After puberty he had several
coiti interrupt! with his sister. Wet dreams frightened him. He
believed it was injurious to let semen remain in the body, for it
might corrupt the body. The semen ought to be got rid of. He

5

58 CASE HISTORIES

masturbated excessively. At sixteen piles became more or less
chronic. At seventeen, when he moved to the city, he had coitus
with a prostitute. He had had five or six in all, and once was
impotent, but on returning home he masturbated and obtained
an orgasm. Coitus was unnecessary he explained, because he
could masturbate at home, which he did nearly every night. He
had felt "good, hearty, healthy and enjoyed life." At that time
he used cows and mares.

In the hospital he continued the masturbation and committed
fellatio with other patients a few times. He consented once to
allow pederasty, but it hurt so much that he made the other man
stop. He also masturbated on the bodies of other patients. He
remarked with wonder on the hardness of other patients' penises
and said his own was half flabby. These incidents he related
with some shame, but said he had repented and felt forgiven.
He had rationalized masturbation as being necessary ("a man
must do enough to live"), and there was no mental conflict in
connection with it. Day masturbation he had given up, but if he
couldn't go to sleep at night he masturbated and then slept well.
This occurred on the average of every other night. He had
had only two night orgasms in his life, one without a dream ; in
the other he dreamed of heterosexual intercourse and awoke to
find himself in the sexual position on the farmhand he was sleep-
ing with.

Fantasies: The only waking fantasies he had were of hetero-
sexual intercourse while masturbating. As a boy he dreamt of
being chased and caught by the police, and waked up out of
breath; of building a fire; and of seeing his father butcher a
cow upstairs and hang up the quarters. The quarters frightened
him very much. He had always been timid at night.

More recent dreams were of being home again ; of seeing the
face of a handsome negro girl who worked in the hospital
kitchen ; of a nurse who sat down on his bed and, when he put
his arms around her, fainted; and of his half-brother hacking
at his goiter with a knife. This last was " terrible."

General observations: Physically he was a thin, nervous,
quick-moving man with large goiter and protruding eyes. Ex-

CASE HISTORIES 59

ercise tired him very much and he seldom went on walks, prefer-
ring to remain in the ward and work on raffia baskets. The ward
attendant made an assistant of him; he helped serve meals and
look after and govern the retarded and deteriorated patients.

He dated his mental recovery from the onset of the goiter
and said he didn't tire as easily and felt in better health than
before the goiter appeared. His memory for events during the
psychosis was not as good as for events of his life previous to
it. He took an intelligent interest in everything and was of
assistance to me in reporting the behavior of other patients.

Occupational therapy: No urging was necessary to get him
to begin work; he was only too glad to find something to do
and kept at it incessantly. After learning how to weave a raffia
basket he was satisfied to make one after another in the same
pattern, and his weaving was always slack and loose. He hated
to try a new pattern and did so only under compulsion. The
same old way was easiest, and he had no desire to change it.
His baskets sold readily and brought him in quite a little pocket
money.

Physical examination: Medium type of skeleton. Skin nor-
mal in color. Pubic hair normal, but hair absent from rest of
body with exception of slight beard. Genitalia well developed.
Perspires easily and profusely with skin always damp and
clammy. Superficial reflexes hyperactive. Deep reflexes nor-
mal. Pulse 96, full and bounding. Thyroid region is bilaterally
greatly enlarged with prominent superficial veins and bruits
which may be heard by stethoscope on both sides from the bases
of the ears to the clavicles. There is a striking exophthalmos
with several of the eye signs of exophthalmic goiter in evidence.

Endocrine diagnosis: Compensatory hyperthyroidism.

Glandular therapy: A successful thyroidectomy was per-
formed, about half of the goiter being removed.

Four months later: He had entirely recovered from the
operation and felt stronger and better. The annoying pulsation
in his neck was gone, and he no longer woke up at night out of
breath. His mind was as clear as before the operation.

Mental diagnosis: Schizophrenia with projection. The incest,
bestiality and homosexuality in this case were out in the open.

60 CASE HISTORIES

The usual resultant impotence was present also. During his
psychosis he projected his improper desires into voices, felt sin-
ful, and punished himself physically. At times he gave in to his
perverse cravings. Coincident with the development of his goiter
these mental symptoms disappeared. He spoke of his past trans-
gressions with embarrassment but felt that they were forgiven.
He had adjusted himself well to hospital conditions, having re-
duced his sexual activities to masturbation and rationalized
that as necessary and so permissible, and was contented.

His mind seemed perfectly clear and his judgment fair. He
lacked self-confidence and initiative but that can hardly cause
surprise in a man who had spent thirteen years in an institution.
If he could be cured of his hyperthyroidism, he thought he might
adjust to life outside and earn his own living as a farm laborer.

Since the advent of the goiter was coincident with the fading
of the psychosis, it could be regarded as a compensation for the
latter. In that case a removal of the goiter might be followed by
renewed psychotic symptoms. Perhaps not enough was removed
to have any such effect, but certainly the patient's mental condi-
tion became no worse.

NOLAN

History: He was a fat, childish-looking moron of twenty
years. His mother was very nervous and had spells during which
she " sat down and took things easy." One sister had hysterical
spells after which she was confined to bed for a week or so. He
was the youngest of the family and his mother's pet. He attended
school until fourteen and reached the fifth grade. Then he
worked as grocery boy, teamster, and expressman for various
employers, staying from two to six months in a place and leaving
for higher pay. He claimed he never was fired.

He enlisted in the navy in June and went to sea on a
battleship in August. The other sailors teased him, probably on
account of his boob looks and slow mind. They hid his hammock
and blankets (he could not tell of this without weeping), and
said he ought to make a lot of money with his fat rear, but he
" sassed them back."

CASE HISTORIES 6 1

After two months at sea he became nervous and unable to
concentrate, disobeyed orders, and got into trouble with the
officers. He was put in the brig, which broke him up completely,
and was transferred to a hospital when the ship reached port.
He had an obsession that he had been forced to commit some
act that was wrong, and he heard voices saying that on account
of what he had done he would be buried in a Protestant burying
ground instead of in a Catholic cemetery. The voices were some-
times pleasant and sometimes accusatory. He was emotionally
unstable, varying from cheerful talkative periods to fits of
weeping.

Sex life: He had masturbated two or three times a week.
His first heterosexual experience was at seventeen, and he had
had many since. He had never committed perversions, but had
felt tempted to allow pederasty on the battleship, and had about
decided to submit if solicited any more.

Fantasies: By the time I saw him he had recovered from all
but sexual hallucinations and delusions. When first taken sick
he thought he had syphilis because he saw a man write four X's
on a bottle. He saw various visions : his mother's smiling face
in the clouds surrounded by red, white and blue, a little garden
of angels, and a red devil on a blue ball between two lights. He
had been very homesick and used to hear " spoken letters," that
is, the voices of his family and friends saying to him just the
things they would write in a letter. He thought some one had
doped him in the nose. Around Christmas time he said to himself
that he " must stop this stuff, this talking and thinking, that that
was being sick," and from then on he had no more visions and
heard no more voices.

One night in January the night nurse saw him get out of bed
and with a shoe start beating little O'Neil who was sound asleep
in the next bed. My inquiries as to the reason for this attack
brought to light some sexual delusions. While in bed just after
his being sent to hospital he complained of a pain in his abdomen.
A sissified male attendant felt of it, and then remarked to some
others that "it was tight." He took the remark to mean that
the attendant had committed pederasty on him during his sleep

62 CASE HISTORIES

and found his anus tight. He heard the doctors tell his mother
he was in no condition to go home, and he interpreted that 'as
meaning he had been raped in pederasty. He began to fear he
might become pregnant and have a baby in his rectum. His
relief was great when I assured that it was impossible for a male
to become pregnant and that no one could assault him without
waking him up.

The reason he attacked O'Neil was because in his sleep it
had felt as if his thighs and abdomen were being licked and then
his penis sucked. When he woke he suspected O'Neil had been
doing it, but had already discovered the latter was fast asleep
before the nurse interfered. He was not convinced by my ex-
planation that it was only a dream. It seemed too real for that.
A fellow sailor had told him about this fancy method of fellatio
and he had thought it must be very pleasant, but he roused him-
self from sleep because he didn't want an orgasm, for that would
sap his strength.

Now he had delusions of reference. If other patients moved
their lips and tongues, his penis felt as if it were being sucked.
He complained that they looked at him and made him uncom-
fortable, that they ought not to grin at him, and that they seemed
to tie making signals to him. Finally he struck Dixon in the
head, and only the timely arrival of the attendant prevented a
fight. My attempts to explain projection to him made no im-
pression and I had to merely order him to pay no attention to
the others and, when they annoyed him, to go some other place.
He was very indignant and looked like a thundercloud for a week,
then became very happy. ("You were cross a few days ago.")
" You can't be happy all the time. I had a little headache and
didn't feel very good. I don't know why I thought other fellows
were making signals to me, and thinking dirty thoughts. Now I
don't feel that way at all." He told me also that his ears used to
itch and then he thought spirits or something were reading his
mind.

In March after hearing Carhart's diatribes about being locked
up he " almost heard " voices say he would never get out of here,
and he anxiously asked me the truth about it. This was the dying

CASE HISTORIES 63

gasp of the psychosis. He came to look on it all as imagination.

General observations: He was a big, fat boy with a boob
face, and his behavior was what might be expected in a child of
his mental age, nine years. At first he was much worried over
his body and always had a new pain or ache or funny feeling.
He examined his phlegm and feces to see if any nerves had come
out in them, and took great satisfaction in an enema. He was
emotional and wept on any provocation, particularly at mention of
home and mother. He said she loved him most of any of her
children, and he felt he ought to behave well to please her, and
explained what a good boy he had been at home, coming in after
a ten-hour work day and chopping wood for an hour so his father
wouldn't have to.

He was exceedingly lazy, sitting or lying down most of the
day, and refusing to aid in the ward work. When reproved by
a Red Cross girl and told she would give him no more gum and
candy if he didn't work, he got very busy until she was out of
sight. The nurses tried in vain to get him to help in the pantry
until they offered him extra food. After that he was most faith-
ful. When forced to go without breakfast on the day of his
sugar tolerance test, he was deeply grieved and turned his face to
the wall because he could not bear to see the other men eat. His
appetite was enormous.

It was evident he had been teased and ostracized on account
of his childish appearance and dull wits, and he had kept to
himself largely through fear of rebuff and ridicule if he made
friendly advances. The vocabularly test in the Stanford Revision
intelligence test proved to be a good complex-indicator for he
invented meanings for every word he didn't know, and many
of these definitions showed a desire for friends and the feeling
that other people didn't want him around and took advantage of
him. Examples: mosaic, to mose around with someone who
doesn't want you; tolerate, to tantalize one who is under you
and can't protect himself ; brunette, to be brewed with someone,
to be needy, to nag someone ; ochre, to be an ochre with some-
one, to have friends, be chums; achromatic, to be very achro-
matic with someone, to be friends and chum with ; outward, to be

64 CASE HISTORIES

outward with someone, to be awkward; civil, to be civilization
with everyone, correspond with them, enjoy their company, be
kiddish ; piscatorial, pispatorial, have a steady leak out of a vein
or something; sudorific, to be satisfied, don't let them leave the
store till they are well satisfied ; lotus, you have a low test in ex-
amination in school.

Occupational therapy: For the first two days he was induced
to cut a few basket spokes, but after that he quit absolutely and
just sat and lay around.

Physical examination: Weighs 173. Tall, undeveloped type
of skeleton. Protuberant abdomen and general obesity of whole
body. Skin smooth, pink, and hairless except in genital region,
in which hair is scanty and of feminine type. Genitalia normal.
General behavior sluggish. Facial expression that of a young
child with small, fat rounded cheeks and pale blue eyes. Heart
normal. Reflexes normal.

Endocrine diagnosis: Hypothyroidism and infantilism.

Glandular therapy: Desiccated thyroid gland worked a veri-
table transformation on this boy in the three-day test. From
a lazy listless lump he suddenly became active, industrious, worked
all day long on basket weaving and planned the next day's work
ahead. Like a different fellow, wonderful change, shows so much
constructive intelligence, were the comments made by attendants
and occupational therapist. The improvement continued after
the conclusion of the thyroid test. The first Stanford Revision
test, in January during his listless period, gave a mental age of
eight years and seven months and an intelligence quotient of
54 per cent. The test just after the thyroid feeding, in March,
gave a mental age of eight years and nine months and an intelli-
gence quotient of 55 per cent. Later on, a moderate dose of
thyroid was given him daily, and he improved steadily. In
May, his mental age had risen to nine years and eleven months
and his intelligence quotient to 62 per cent. Soon afterwards he
was discharged as recovered.

Mental diagnosis: Schizophrenia with projection, in a moron.
His homosexual cravings were evident, sometimes becoming a
conscious temptation, but usually being projected. His moral

CASE HISTORIES 65

self had a feeling of sin and resisted the cravings, which were
repressed without insight before glandular therapy was begun.
The latter treatment made him more alert and energetic, and
speeded his recovery.

O'NEIL

History: He was a sturdy little fellow twenty-one years old,
and had always lived on his father's farm until he was drafted
into the army. He got on all right on the farm but was never
bright at school. He claimed he reached the eighth grade when
he was eighteen. The Terman intelligence test proved him to be
a moron.

He found it difficult to adjust to the new conditions in the
army, and it was very hard to have to leave home and mother.
He had no complaints to make. He denied with some heat a
question whether the other boys ever made fun of him. " What
right had they to?"

He had always drunk in moderation. In France he was sent
to a hospital because he was resistive, depressed, and 'worried
over the " recent death of his mother from pellagra," and feared
he was going to get it and die too. He became more depressed
and emotional, and declared the Germans had won the war
because he hadn't taken baths regularly. In tears he begged not
to be put into a machine and ground to pieces. He refused food
and said he was going to die.

On admission to this hospital he was disoriented, preoccupied,
resistive, could not remember well, and denied hallucinations
though he appeared to be hearing voices. He stood at a window
for hours.

Sex life: He admitted having masturbated two or three
times a week at one time, but he did it no longer. His first
heterosexual experience was at eighteen. He had had several,
always with prostitutes. He denied any knowledge of perver-
sions with every sign of sincerity.

Fantasies: He had a great habit of snickering and laughing
to himself, which at first I suspected might be due to fantasy but
after further study of him decided was in response to external
stimulus. He watched everything and everybody and broke into

66 CASE HISTORIES

frequent gleeful chuckling whether their actions seemed amusing
or not. He never would tell what he found so funny in all about
him. "It's better to laugh than to cry. It doesn't do to tell
everything you know, does it ? "

Of the fantasies reported in his record he denied any recol-
lection whatever. " I never told them nothing of that. I never
thought it." He said his mother had had pellagra before he
entered the army but recovered and was now living. He had
never believed she was dead. He denied hallucinations and delu-
sions, but said he had been nervous in France and had shaking spells
that lasted for an hour during which he felt cold. He denied he
was afraid of anything. Now his nervousness had disappeared
and he felt as well as he ever did. His amnesia for the psychosis
seemed sincere. His memory for recent events was excellent.
If I chanced to ask him a question I had asked even three months
before, he would retort, "I told you that once." ("Do you
remember everything you tell me?") "Certainly."

General observations: At first he stood all day by a window
reading. Any book would do. I couldn't ascertain whether he
comprehended what he read or not, for in answer to any questions
he would push the book towards me, saying, "There it is, can't
you read?" This resistive attitude he displayed towards every-
body, and seemed perfectly satisfied if left alone. He never
gave any trouble.

I tried the Stanford Revision intelligence test on him in
January and found his mental age to be just eight years, intelli-
gence quotient 50 per cent., the borderline between a moron and
an imbecile. His negativism I considered to be partly a defense
reaction against revealing his low intelligence, for he seemed to
have no unfriendly feelings towards other people. For a month
he would do nothing but read, but on offering extra food the
nurses got him to help in the pantry and he continued to do
steady, efficient work there. About two weeks after beginning
dishwashing the occupational therapist induced him to try wood
carving, and he soon did very well. During a physical examina-
tion he was very nervous, giggling hysterically, and responding
exaggeratedly in all reflexes, but insisted he was not afraid.

CASE HISTORIES 67

He improved slowly and steadily, and was granted parole of
the grounds in April. It was not possible to ascribe his improve-
ment to any particular factor. He saw he was in friendly hands
and so began to lose his apprehension, he liked the wood carving,
and he seemed pleased to be given glandular therapy. That was
medicine, the kind of treatment he was familiar with for sick
people. None of these factors seemed to alter the steady course
of his recovery.

In May his behavior had become fairly normal, and the silly
giggling had almost ceased. The intelligence test now showed a
mental age of nine years and three months and an intelligence
quotient of 58 per cent., a gain of fifteen months and eight points
in five months' time. His father came to town to attend a conven-
tion and made him a visit. After he left, the boy came to my
office of his own accord, the first time he had sought anyone's
company since he entered the hospital. He had received a great
shock and wanted sympathy. His eyes were wet with tears, and
he showed the emotion natural under the circumstances with
none of the old aloofness. He had asked after his mother and
was told that she was dead. She had died while he was in
France in the army, and his father said they had written him
the news at the time. The discovery was a severe blow, for he
had felt sure she was alive and that the records were wrong in
stating she was dead.

" I was a great mother boy, and home won't be the same now
without her. It was hard to leave her and home, and go to war.
I unloaded cars in France and sometimes had to work till late at
night. I got very tired. The first I noticed of the sickness was
that my hands and face got numb like going to sleep, and my feet
got cold. These spells lasted from an hour and a half to two
hours, and my mind was clear during them. I felt smothered,
I couldn't get my breath, I felt as if I would die. I couldn't lie
down, I must have air. Every bone in my body ached. Between
spells I felt all right. These spells lasted nearly up to the time I
reached this hospital. Now I understand about the letter telling
of my mother's death. It must have come after I got sick, and
the doctors were afraid to give it to me, so they just put it in
the records.

68 CASE HISTORIES

" I felt strange here. Nobody was introduced to me. I didn't
know the names of the nurses and attendants. I felt lazy and
wanted to be left alone. It's hard to talk to strangers. I don't
know what to say. You weren't friendly enough at first, you
didn't smile at me. Now I feel better and I want to get to work.
I feel better than I did at home before I was drafted, and I
weigh twenty pounds more."

About sex matters he said he had heard of bestiality at home,
but he had never seen it done nor done it himself. He had always
tried to keep nice and clean. In camp in France he had heard
of pederasty but had never been solicited; he would have told
them where to get off. It was dirty and probably painful. He
had never had any ideas or fears about such things when he
was sick, though he realized that other fellows did (this knowl-
edge and the phrase " nice and clean " may have been acquired
in the endocrine ward).

His father took him home.

Occupational therapy: For a long time he refused to try
any handicraft, but two weeks after he began dishwashing in the
pantry he reluctantly consented to mark holes on a tray bottom.
In spite of his " I can't do it " the instructor led him into wood
carving which he soon did very well. She thought his resistance
was due solely to fear of failure. As soon as he saw he could
carve well, he stopped his reading completely and carved steadily
until he got parole of the grounds.

Physical examination: Short, heavy-set, pink-skinned. Ple-
thoric-appearing face. Hairless over abdomen and chest, but
with male type of genital hair distribution, though somewhat
limited. Genitalia somewhat flabby. Body in general excellently
nourished. Heart beats regular but very fast. Shows very rapid
carbohydrate metabolism. All deep reflexes extremely hyper-
active.

Endocrine diagnosis: Submyxedema with hypoadrenia.

Glandular therapy: Desiccated suprarenal gland was given
for three or four weeks. No sudden change in behavior was
noted. His steady improvement continued with no apparent
acceleration.

CASE HISTORIES 69

Mental diagnosis: Schizophrenia with projection, in a
moron. He seemed perfectly sincere in his amnesia for all the
mental manifestations of his psychosis. All he remembered was
that he had felt cold, nervous, and breathless, and trembled a lot.
Finding it very difficult to adjust to the strange new conditions,
the news of his mother's death was too much to bear, and he
sought refuge in a psychosis. His apparently ridiculous state-
ment that the Germans had won the war because he hadn't bathed
regularly becomes intelligible if interpreted as a symbolic way of
saying that he was dirty (mentally) and the enemy (improper
impulses) was therefore getting control of him. The usual
depression and sense of unworthiness with fear of punishment
and death followed. His catatonia was a form of self-protection
against assault.

As he recovered he developed complete amnesia for the
mental content of the psychosis including his mother's death.
Along with the repressed perverse cravings went the memory
of any previous knowledge of such matters, and he was quite
honest in declaring he had never heard of them. After his re-
covery he regained the memory of sexual ideas that he had held
previous to the psychosis, but he still had amnesia for his mother's
death and had to suffer the agony of her loss a second time. But
the war was over now and home was in sight, and he could
endure the shock.

PURDY

History: He was a slender, serious-looking man with iron
gray hair. His age was forty-two, and he had been in this hos-
pital once before. He denied that there was any mental disease
in the family but his parents had both drunk. He was the oldest
of six sons. He reached only the third grade in school. When
six years old he was struck by a train he said, and remained
unconscious for three days.

He had been a wild boy and liked to be a leader in mischief
and daredeviltry. He stole papers from news stands and coal
from railroad cars, jumped trains and threw bricks at trainmen
from bridges, and tried to excel in stone throwing and high div-
ing. Sometimes he'd stay away from home for a night or two.

7O CASE HISTORIES

These escapades infuriated his father who punished him brutally.
He was tied up by the thumbs naked and beaten with straps, and
chained in the attic and fed only bread and water. The boy
would loose himself and escape by climbing down the water
spouts. When his father was drunk he was knocked and kicked
about. The mother tried to protect him and even stepped between
them, receiving the blows herself. The next brother two years
younger, was a pet and didn't get such abuse, so the patient felt
jealous and used to beat him up himself, though he would not
allow the other boys to do it.

When he was seventeen he was framed up on a charge of
stealing coal from cars, while all he had really done, he claimed,
was to pick it from the tracks. He was sentenced to reform
school for a year, and this injustice started his tendency to be
suspicious. He was unruly in the school and was frequently
punished. This lengthened his term from one year to three.
From his associates he received a thorough schooling in crime
which he never put into practice however.

Before his term was up, his father was accidentally electro-
cuted, and he was pardoned. He realized now that he ought to
take his father's place in the family, but he lacked self-confidence
and felt unworthy and unequal to the task. He noticed that his
affection for his mother seemed to change over to the memory
of his father. He wanted him back and cooled down towards
her.

The Spanish War broke out a few months later and he en-
listed gladly as a means of escape. On his return from Porto
Rico he had fever and was depressed. He felt that humanity
was cruel and that life was a fight. He was not skilled in any
trade and had trouble in getting work. The next youngest brother
was away at work and the other boys were in charity institutions,
so he and his mother lived alone. When she got drunk she
had spells of raving during which he held her on the floor. This
made him feel very badly. He had contracted gonorrhea in the
army and began to worry over whether he might infect her with
it. When I asked him just how he feared he might infect her, he
said through using the same towels. Finally he abandoned her in

CASE HISTORIES Jl

poverty. She died soon afterward, and his treatment of her
caused him much remorse.

At twenty-five he married and had two children. One died
in infancy but the other, a boy, was still living. He was not
successful as a worker and did not provide well for his family.
In hard times his wife took the boy and went to live with her
mother, and then she got the habit and left him when he didn't
consider it necessary. Finally she left him altogether and de-
manded alimony. He became worried and was committed to this
hospital.

His disease was diagnosed hebephrenic dementia precox. The
records state that he had felt badly for three years and had had
delusions that his employers persecuted him. He greatly feared
impotence and believed he had syphilis. He had strayed away
from his church and joined a fraternity which now prevented
his becoming a Knight of Columbus, and all these things had
worried him. His wife said that their married life was very
unhappy. He gambled and drank to excess, though seldom getting
drunk, and refused to support her. He accused her of infidelity,
called her a prostitute and swore the boy wasn't his. He accused
her also of all sorts of immoral practices. One night he had
stolen into her room and tried to strangle her, but the child's
screams frightened him away.

In the hospital he was depressed and sure he was doomed to
die. He nearly succeeded in committing suicide by hanging. He
dreamed he was to be the mother of fifteen little devils, and he
felt that a good and bad spirit had possession of him at different
times. The delusions were fairly fixed in character but his belief
in their reality was inconstant. Following an operation for vari-
cocele, which he held largely responsible for his impotence, he
improved rapidly and was discharged as a social recovery thirteen
months after he entered the hospital.

For the next three years he led an easy life as electrician in a
soldiers' home. When the United States entered the Great War,
he became restless, feeling he should do his bit, and left the home
to work in camp construction. He tried to get in touch with his
wife and child, but the grandmother would not let him see the

72 CASE HISTORIES

boy and said his wife was dead. After the armistice he went back
to work for the same contractors whom he had suspected of
persecuting him before by giving him all the hardest jobs. Soon
the other men began to kid him and say, " Own up, Purdy, that
you're a f ellationist," and that " broke him all up." He became
much upset, and was brought here a second time.

Sex life' When about ten years old he was sleeping with his
mother's sister and rolled against her in bed. He had an erection
and was making copulative movements in his sleep when she
waked him by pushing him away. He masturbated once or
twice a week throughout adolescence and then slowed down, but
revived it again in the army. In the reform school he committed
pederasty once and allowed fellatio. An older fellow offered him
some much coveted tobacco if he would allow pederasty. He re-
fused but consented to allow coitus inter femora from behind.
They were caught and accused of pederasty, and this lengthened
his term.

A few weeks after he was pardoned at the time of his father's
death his mother sent him to have an interview with her con-
fessor, a man she respected greatly, in hope that the priest would
exert a good influence on her wayward boy. But the priest after
praying with him took him to a bedroom and began to play with
him sexually. He was unable to accomplish pederasty but did
coitus inter femora. The shock to the boy was extreme. He
knew such things occurred in penal institutions, but to find that
a priest of the church did them was a blow. He reasoned that
if this respected man did them, so must the rest of the clergy.
All priests and preachers were hypocrites, and the church which
to him had been the holiest thing in life now became despicable.
He pictured the poor " with their noses to the grindstone to earn
money to support the gold cross whose priests were rotten. And
if the priest would seduce me under the cloak of religion,
wouldn't he try to seduce my mother also?" (He showed great
emotion in recalling these memories.) After this experience he
never felt the same again either towards the priest or his mother.
He was disgusted with him and her and himself, with his
brothers, with everything and everybody. It was in this state

CASE HISTORIES 73

of mind that he had his first heterosexual experience. After it he
actually hated the prostitute. He gladly went away to war.

He usually did feel hate for a prostitute after coitus and
sometimes said he never enjoyed intercourse with women as much
as with men. At other times he claimed he preferred normal
coitus, but was much afraid of venereal disease after once having
contracted gonorrhea, and that he committed pederasty on both
sexes and allowed fellatio merely because they entailed no danger
of disease. He indulged in active homosexual acts about once a
week. If his companion refused intercourse, he masturbated
against him. Once he had trouble in arousing sexual feeling in
a boy and to stimulate him started fellatio on him, but had a
revulsion of feeling and quit. This attempt at fellatio had
bothered his conscience a great deal. With that exception he had
never taken the female role in homosexual intercourse. Taking
the male role he considered permissible and he felt no remorse.

He had relations with his wife before they were married, and
she became pregnant. She threatened suicide, and he married
her out of pity to protect her good name. Another man, a lawyer
whom he regarded as a better man than he, had also been paying
her attention and he reasoned that since she had ceded readily
to him she might have also to this superior man. Three months
after the wedding a boy was born. The child resembled Purdy.

He had only one real "love" coitus with his wife he said,
the others were nothing more than relief of passion. Once he
committed cunnilingus on her, and she committed much fellatio
on him but refused to allow pederasty. When he got to feeling
that his employer was giving him all the hardest jobs and he
needed all his strength to make a living, he stopped sexual inter-
course altogether. Then he began to suspect his wife of getting
it elsewhere. He was sure his employer had relations with her
and suspected him of sending a young man to board next door
just to win his friendship and thus get the freedom of his home
and opportunity to seduce his wife. And this young man he had
considered his bosom friend. He wanted to murder all three of
them, his wife and the two men. Doubts whether he was really
the father of the boy haunted him again.

6

74 CASE HISTORIES

He attributed his failing vitality to overwork, but one thing
restored his self-confidence and made him feel equal to anything.
Like Columbus, who discovered a new world, he also had the
courage to do the impossible in that he succeeded in committing
fellatio on himself. After that his spirits revived and he found
he could do things in his work that he had previously thought
impossible. (With every evidence of sincerity he insisted this
incident was true.)

About a year before the present commitment he found a
boarding place in the home of a poor widow with several children.
She was "as homely as sin," but was a devoted mother to her
children, and that aroused his sympathies. He felt like helping
and protecting her as he should have done but did not do for
his own mother when she was in identical circumstances. His
interest in her began to arouse comment, and he hotly resented
suspicions that he had sexual relations with her. Finally, how-
ever, his feelings toward her became erotic and he tried hard to
seduce her. She refused even marriage because her children
didn't like him, but she allowed him to caress and handle her.
After many futile attempts he succeeding in making her erotic,
and she hugged him and sniffed in her emotion. He realized
she would not now resist him, and just at this moment of success
he found himself absolutely impotent. "It was an awful blow.
It showed up my weakness. I just went out of my head and
raved.

" Afterwards I tried to reason out why I couldn't get an
erection and I remembered how she had sniffed in her excitement.
I decided that was what had sucked my strength. Then a
neighbor came in to see me and urged me to go to a hospital.
I recalled that his wife was sickly and so was a young man who
boarded with them, and then I suddenly saw through it all, that
he had been sniffing their strength away." In righteous indigna-
tion he beat the man up, and then felt so strong and elated
in his victory that he got an erection. This was an opportunity
to prove his masculinity to the widow and he attempted inter-
course whether she would or no, but she was not in the mood this
time. The police were called in, and he was taken to a psycho-
pathic hospital.

CASE HISTORIES 75

Fantasies: He had the usual delusions and hallucinations.
"Other minds were influencing me. Some superior power was
working on me and pushing me to do things against my will. The
Catholics used influence on me to my hurt, they used witchcraft.
That influence was beyond my control. When I was first brought
to the hospital I ate my feces and drank my urine to prove I was
brave and that I would not practice Catholicism. I'm a Jew."
(Here he showed the common symbolization of the conflict of
impulses as Catholics versus their religious opponents. Which
party is the wicked one depends on the patient's own religious
convictions. This man was further influenced by his unfortunate
experience with his mother's confessor. Loyal Catholics like
Lefferts make the Masons the devilish tempters who use influence
on them to make them commit sexual perversions.) In addition
people had tried to poison him, and he had felt electricity surge
through him from his feet upwards, and his hair was pulled up.
Another patient had put cocaine up his nose during his sleep and
influenced him, and that had driven him insane.

He had been used as a tool for other people's purposes, they
had hypnotized him and driven him insane and had him brought
here to get evidence on him, for they wanted a scapegoat. He
saw secret service agents in disguise all around him and suspected
me of being one also, though at times he believed I was as I said
a psychologist trying to help him. Once he told me he didn't want
to talk with me, for he feared I would destroy his belief in his
delusions and he preferred to keep them.

" The kernel of my trouble is that my strength and sex power
have been sapped and it is something outside me that has done it."
He was very busy trying to reason out just what had sucked his
strength. One theory was that when struck by the train in his
boyhood he "lost some of what a male is entitled to. I'm not
the man my father was." But the sniffing seemed the likeliest
method. The ward physician had a habit of sniffing and, being
ignorant of the delusion, was much startled when one day the
patient without warning spat copiously in his face. The doctor
thought he had filled his mouth with water at the tap, but he
reassured him later that it was only saliva. He realized now that

76 CASE HISTORIES

people had been sniffing his strength away for a long time, but he
had hit on a method of self-defense. If he sniffed back again,
there was an interchange of strength, the balance of power re-
maining as before. After this discovery his conduct became more
agreeable, for he could hold his own and consequently had nothing
to fear.

He thought of his mother a good deal and wondered if she
could have been raped when as a sixteen-year-old girl she had
crossed the sea from Ireland to America. He remembered hold-
ing her down during her raving spells, and thought what a bad
effect they would have on an embryo. Was it possible that he had
been thus injured before birth?

" When I looked at a man who had a hypnotic eye I felt an
erection and orgasm, but I had no idea of letting him go down on
me. When he looked at me I said to myself I won't take it (the
hypnotism), I won't swallow it (the host or saliva). I resisted,
and he swallowed his host instead. When I see men swallow,
I know they're afraid of what they see in other men's eyes. I
can stare a person in the eye till they swallow their host, or saliva ;
that's their weakness. It seems that I force them to." These
fantasies disclose very obviously his resistance to fellatio, par-
ticularly towards taking the female role.

He suffered a good deal from headache. In a dream the pain
was relieved by a man's committing fellatio on him. " The man
said he was drawing it out of my brain. I felt a great relief in
my forehead, then it went down my body and out my penis. I
woke up and found I had an erection but no orgasm." A number
of times he dreamed that both men and women masturbated him
and committed fellatio on him.

A very vivid dream was of a horsehead on the end of a
derrick. " The horse snuffed up oats and blew them into a box
car for chickens to eat. Then I said to myself, ' Now I see
through it all.' I felt an erection and orgasm and woke up
blowing my breath out." This dream symbolizes his conscious
fantasy that he could sniff up sex power (oats, seed, semen) from
others to use in sexual intercourse. Horsehead and derrick
represent his own head, penis and libido; box is the female

CASE HISTORIES 77

genitals, and chicken is a slang term for a young woman. Both
normal coitus and fellatio ideas are present in the dream.

Just before he was arrested and taken to hospital he used to
sit a great deal on a magnifying lens, but though he puzzled
over it he could not now remember why he did it. " That's where
the insanity comes in; I can't recall the reason." (Protection
against pederasty?)

General observations: He often had insight into mental con-
dition and spoke of his strange sensations. " My mind wavers,
and jumps from one subject to another. I remember having
three ideas in it all at once. It seems like a piano board, the
thoughts chase through it so much. I have trouble articulating.
I'm like a ship without a rudder. I must be a nut. Sometimes I
get into delusions. In the second talk with you I began to be able
to follow one line of thought steadily. Before that my thoughts
were all mixed up. I believe I am coming out of it. I can re-
member back pretty far now." Sometimes his memory became
clouded.

His attitude toward me was variable. I told him he was
mentally sick and that I was trying to help him get well. He
responded at first, but in our fourth talk he said, " The first time
I saw you, I felt I might confide in you. Now I'm getting sus-
picious of you." A month later he said, " I'll confess to you, a
secret service man, an intelligence man, but I won't confess to
a priest. I like your countenance, whoever you are." And
again, "I've been kidded so much, fooled so much, that I feel
fortunate to have someone like you to talk with and rely on in re-
gard to my mental condition." These confidential moods alter-
nated with periods of suspicion in which he began to see me
about the grounds disguised in the garb of both sexes. " You're
a slick one, Doc., you're a secret service man disguised. I'm well
and I want to get out of here."

Occasionally he felt he was misunderstood and became very
depressed and weepy. The paranoid traits appeared at such
times. " When I get out of here, I'll be a bad man, I'll fight for
my rights. People have used me as a tool, a stepping stone."
Once he started to go to his old employers in town to demand an

78 CASE HISTORIES

explanation of "what this is all about." His parole had to be
taken back, and he was confined to a ward.

The masculine protest was shown by his letting his beard
grow and wearing an army uniform. " I'm a man, I'm no molly-
coddle, and I want to prove it." He demanded that I afford him
opportunity for heterosexual intercourse, and when I refused,
escaped to town in search of it, but was recaptured.

The greatest temptations of his life had been to murder his
wife and the men he believed she had relations with, and to com-
mit fellatio and cunnilingus. His greatest regrets were that' he
had not been able to have coitus with the widow when she was
willing, and that he had done cunnilingus on his wife, and had
once begun fellatio on a boy.

One day when he showed resistance toward me he said, " I
keep things back from you because I don't want my belief in
these things destroyed. I prefer my delusions. ("What is a
delusion?") A false belief. They aren't false to me. I have
faith in them. ("Why call them false then?") Because I was
called insane. I've been driven insane by other people. They
sent me here to get evidence on me, that's all. I don't know what
they expect to find. They must have a fall guy, a goat. I don't
want to get sane. I fear my son is not really mine, and the
widow I was so fond of has negro blood because her son's arms
are so very long." He became despondent and quarrelsome and
got into fights with other patients, thinking they were women or
myself in disguise.

In a fortnight he improved once more and his parole was re-
stored. " I'm working my way out of this tangle, out of my
delusions and hallucinations. It's as you say, it is real to the
man himself, but it's all in his own mind just the same. I'm
satisfied my trouble is all in my head and I feel I'm straightening
it out. I feel I can find interesting work and earn my living. At
first I couldn't believe you when you said the mind could get sick,
I didn't realize it could. It seemed some phenomena superior to
man. Now I see it's all in the mind. A man can be anything he
has a desire to be, provided he has will power to back it up."

In another month he seemed fairly normal to his physician,
and the latter allowed him to go on a Red Cross party to town.

CASE HISTORIES 79

He slipped away from the guards in a theater and escaped.
Months later a brother wrote to the hospital that the patient was
getting along all right in freedom and requested that his name
be stricken from the roll.

Occupational therapy: He consented at once to try bead
work, but though interested was rather careless. He seemed to
be more interested in having the instructor sit by him than in
the work itself. He got more indifferent and as soon as parole of
the grounds was granted him, stopped work altogether.

Physical examination: Medium type of skeleton with well
developed muscles. Skin well nourished, perspires easily.
Brown pigmentation on back. Hair of head gray and scanty.
Body hair scanty. Genital hair normal in amount but submas-
culine in type. Genitalia normal. Heart regular but rapid. Ex-
tremities cold and slightly blue. Eyes protrude. Reflexes nor-
mal. Thyroid gland slightly palpable.

Endocrine diagnosis: Hyperthyroidism.

Glandular therapy: He went through the tests which es-
tablished the endocrine diagnosis, but escaped before any real
glandular therapy was begun.

Mental diagnosis: Schizophrenia paranoid. Not only were
his improper sexual impulses projected onto other people but, as
the years went on, he built up a somewhat systematized structure
of persecution in other matters besides sexual. The delusions
themselves did not change so much as did his belief in their
reality. At times he had considerable insight as shown by such
a remark as, " I realize I was nutty, and I may be yet at periods."

It is easy to trace the effect that his mother incest impulse had
on his life. His father's brutal punishments and his mother's
attempt to shield him probably helped to fix his libido on her in
the first place. He felt resistance toward taking his father's
place in the family after the latter's death, and had a revulsion
of feeling toward her, seeming to prefer the father image. His
suffering when during her raving spells he had to hold her on the
floor was perhaps not entirely due to her unlovely condition. He
was quite ready to suspect her of illicit relations with the priest.
His fear of infecting her with gonorrhea was hardly justified.
His incest fears drove him to abandon her even though he knew

80 CASE HISTORIES

it was an unworthy thing to do, and his remorse over this act
followed him all his life. An exaggerated recoil from incest can
cause a certain amount of resistance toward the whole sex, and he
found little satisfaction in heterosexual intercourse, usually pre-
ferring males, though he rationalized this tendency as due to fear
of venereal disease. In marriage he had little pleasure, and said
there had been only one real "love" coitus. Something spoiled
the others. Finally he became somewhat impotent and stopped
relations entirely. The widow attracted him in spite of being
"homely as sin," because she was a devoted mother, and he
likened her to his own mother and resented insinuations that
there was anything erotic in their companionship. Later when he
gave way to his erotic impulses he found himself suddenly im-
potent at the moment of opportunity. In the hospital he had
fantasies of his mother's having been raped while emigrating to
America.

In homosexual matters he rationalized the male role as per-
missible. His cravings to take the female role were sometimes
recognized and resisted, and sometimes repressed and projected.

QUITNER

History: He was a petty officer in the navy thirty-eight
years old, and was serving his fourth enlistment when sent to
hospital. He was one of eight children and was born in Hungary.
When still a little child the family emigrated to America, and
he spent his boyhood and youth in a great city. He attended
school from the ages of six to eleven and reached only the fourth
grade. He didn't do well in his studies and felt humiliated when
other children surpassed him. He nearly cried with shame. Not
only in mind but also in body he felt inferior and was much
ashamed of his small frame and delicate bones.

After leaving school he worked for two years as a cash boy
in a big store, but quit because people teased him. Other jobs
didn't last long. He couldn't adjust and gave them up. He tried
night school but couldn't get on there either. At nineteen he left
home and wandered west to see the world. After he tired of a
job or a city he moved on to another. He reached San Francisco

CASE HISTORIES 8 1

when he was twenty-two and enlisted in the navy. Between
enlistments he roamed about on land from job to job.

He got on all right in the navy until the fourth enlistment,
when it was noticed he was queer, but he still did his work satis-
factorily. He talked much about religion and spiritualism and
knelt like a fire worshiper making obeisance to the sun or to
lighted cigarets. He said he heard voices as if coming from a
telephone receiver, and believed that God spoke through him.
Finally he received an order from God via his mother that the
ship should change its course, and without securing permission
he invaded the captain's cabin and delivered the message to him.
To his great indignation he was arrested and sent to hospital.

He was perfectly oriented and could remember well. He
declared he wasn't crazy and that he could think even better than
formerly. He had hallucinations and delusions of persecution,
was very suspicious, and had no insight whatever. He was tense
and emotional and very talkative.

His suspicious antagonism to the doctors was so keen that he
could not be admitted to the endocrine ward for nearly eight
months. By that time he had quieted down very much, and
while still insisting that he had not been insane and that it was
a dirty trick to shut him up, he behaved well and was willing to
talk courteously with anyone.

Sex life: He made no mention of masturbation. When ten
years old he had been warned to beware of men who might try to
commit pederasty on him, and he saw two negro boys in the act.
At twelve he had his first heterosexual experience. When
eighteen he fell in love with a girl, but his sense of inferiority
caused him to step aside to allow her to get some superior fellow
with better prospects. Then he began his wanderings.

Later in life he had relations with a widow and helped to
clothe her child. The act of coitus he had reduced to a fine art.
Perversions he denied.

Fantasies: He began hearing voices about a year before the
incident with the captain, and at first they were insulting. They
were like spirits and they knew all his past, all his sins. Finally
he made peace with them by confessing and acknowledging his
sins to them, and then they ceased bothering him and became

82 CASE HISTORIES

friendly. " If Garland and Engel would do this instead of fight-
ing the spirits, they would be all right. The spirits are company.
It's impossible to be lonely when you can talk with them. I
answer them noiselessly by making silent movements in my throat
and larynx. Like a medium I get messages from God as over a
telephone. He is interested in me like a father in his son. Father,
mother, son, that is religion. At first the voices were insulting
and sounded as if coming from some distance outside me, but I
coaxed them closer and closer till now they're inside my head
completely.

" I've always been able to mimic girls and women. I've gone
to fancy dress balls disguised as a girl and fooled everyone.
(For my benefit he mimicked a woman very well, and it was
evident that he enjoyed doing it immensely.) But it's dangerous
to act ladylike, for some fellows jump to the conclusion that
you're a pervert. In the navy I was always on guard against
other men's suspecting me of being a pervert and for that reason
I kept alone some. When a fellow feels lonely it's a comfort and a
pleasure to hear his own thoughts as you call them, to hear these
spirits. They talk to each other and I listen, or I join in and talk
with them."

When told these spirits were splits of his own mind and that
he should try to reunite them, the prospect didn't attract him at
all. "I prefer to keep them as they are, they're so comforting
and interesting. I don't want any change. I have seven of these
spirits inside me. They are like my children. I wouldn't
want to lose them any more than a father would wish his children
to die. Besides, I don't see how they can be splits of my own
mind for sometimes I'm sure they tell me interesting things that
I never knew before."

General observations: The first day he entered my office he
looked around suspiciously and admitted he feared a dictaphone
was secreted somewhere. He began the talk by boasting of his
adaptability, saying he could pass as tough or refined at will. He
had always been much interested in religions and believed they
originated in fear; fear first, then worship of the thing feared
( recall his worship of the lighted cigaret, a frequent potent penis
symbol).

CASE HISTORIES 83

In the following interviews he aired lengthy grievances about
his detention and mistreatment. To contradict or reason with
him led to an unending maze of argument in which he delighted.
I finally stopped it short and said I was more interested in his
owr 'Noughts than in what other people had done to him. He
reproached me for not taking more interest in his grievances.
" If I had been a pretty girl, you'd have waked up, straightened
your back, and said, ' Miss Quitner, we'll look into this and see
what can be done.' ("But you wouldn't want to be treated like
a girl.") Yes I would. ("That would be favoritism, not jus-
tice.") Then I want favoritism. I'm looking out for number
one. I want sympathy.

" In tough neighborhoods one has to be tough because if one
is too pleasant and soft, they may take you for a fruiter (fella-
tionist) or a bushwhacker (cunnilinguist). Such fellows are
soft and easy and dreamy like Engel. I found out in the navy
that there were two classes of men, those who stood up for their
rights and those who gave in. (It was clear that he had trained
himself to be touchy and instantly to resent with force any slight,
an overcompensation for feelings of inferiority and fear of being
considered a pervert. Ulster in his restlessness struck him one
day, and he reacted exaggeratedly, attacking Ulster so violently
that he broke one of his own fingers.) Middle-aged pederasts are
called Turks. They go insane. They suffer from it more than
the boy they do it to. It's dangerous on board ship for boys. I
used to warn them of the danger, and the Turks in revenge made
things disagreeable for me."

He showed some antipathy to the women nurses and the
occupational therapist, and was exceedingly conceited, believing
he knew more than the physicians. This made psychoanalytic
work with him difficult. He already was aware, however, that
children had attributes of both sexes and must develop those of
their own sex, neglecting those of the other sex. This he had
striven to do. He was intelligent enough to grasp the conception
of mental mechanisms well, but he felt reluctant to give up his
dearly loved spirit voices. He even wrote a poem about them
which he called Babies in Fairyland.

84 CASE HISTORIES

He said he wanted to go away off into the wilds after regain-
ing his freedom, so that he wouldn't get locked up again. He
came to see clearly that no one had interfered with him so long
as his spirit beliefs hadn't affected his behavior or led him to do
forbidden things like forcing himself on the captain. He had
previously argued that if belief in spirit voices was sufficient
grounds for incarceration in a hospital for the insane, why
weren't Sir Oliver Lodge and other spiritualists locked up too.
He learned to see that if he behaved in a manner acceptable to
his f ellowmen and could do his work, no one would bother much
about his beliefs.

Occupational therapy: He was only mildly interested but
could do good work. He preferred arguments to basket weaving.

Physical examination: Slender type of skeleton. Skin
smooth, dark brown over entire body. Hypertrichosis. Hyper-
hidrosis. Extreme sensitivity to heat and electricity. Front
teeth protrude outward from alveolar process. Reflexes hyper-
active. Fine tremor of fingers. Eyes protrude, pupils dilated
and active. Heart irregular. Thyroid gland slightly enlarged.

Endocrine diagnosis: Hyperthyroidism with associated pitui-
tary dysfunction.

Glandular therapy: Thyroid rather increased his nervous-
ness and argumentativeness. Suprarenal had a better effect.

Four months later: A month previous to my return he had
been discharged as a social recovery from dementia precox. The
records stated that his physical health and his mood improved
steadily. Finally no psychotic symptoms were seen. He said
his behavior during his insanity had been like that of a drunken
man, he wasn't responsible for his acts.

Mental diagnosis: Schizophrenia paranoid. His long
struggle with the feminine side of his nature is evident. The
insulting voices were without doubt his projected perverse crav-
ings. After he had confessed his sins, the voices lost their disturb-
ing quality and became a means of recreation inside his own
head, or in other words the perverse cravings were again re-
pressed deeper into the unconscious. But the habit of projection
kept alive a paranoid fear of hostility from mankind in general.

CASE HISTORIES 85

This had largely disappeared before he entered the endocrine
ward. It is doubtful whether the schizophrenic habit did entirely
cease, but he was at least cunning enough to conceal it from the
physicians and obtain his discharge.

RIEGEL

History: He was a chunky, ill-proportioned sailor twenty-
six years old. He denied there was any mental disease in his
family, but said his mother was nervous and cranky and annoyed
him a great deal. He went to school from eight to sixteen years
of age and reached the eighth grade. He didn't get on well there ;
the teachers were cranky and didn't want to teach him anything,
and he had to learn all by himself. He didn't get on any better
at home; for everybody wanted to be the boss. He liked his
father and brothers better than his mother and sisters. His
mother was too cranky. She called him a lazy loafer and other
worse names.

After leaving school he worked in factories and machine
shops, seldom staying long in one place. The other men wouldn't
show him how, and then the foremen would fire him, or he would
get into a fight with the other men or be laid off when work was
slack. The poor workingman he declared, was oppressed by
every class, by the farmers, the rich, the municipal employees,
everybody. He had expected big jobs and big money and got
only disappointment. The fault was always somebody else's. He
felt everyone was against him.

When in imminent danger of being drafted into the army he
enlisted in the navy and he considered the war and the draft a
fresh imposition. In the navy he had a terrible time trying to
adjust. Eastern boys made fun of western boys like himself,
they guyed him on his short stature and clumsiness and table
manners. He felt helpless and inferior and that everyone was
down on him, and he reacted with hate and anger.

A year later he was removed from duty, as he was unable to
carry out simple orders. He had been doing very unsatisfactory
work as a messman. He was tense, nervous, and untidy, and
defecated in his clothes. He thought the other fellows had it in

86 CASE HISTORIES

for him and were talking about him behind his back. He reached
this hospital after some months and believed he had been sent
here only for discharge. He saw nothing wrong with his mind,
but sometimes it got sleepy, and his legs felt weak.

Sex life: His attitude was very resistive, but I succeeded in
getting some information. He admitted masturbation but
wouldn't tell how often. He had always been bashful and un-
successful with girls. He had never had a best girl, that was all
damn foolishness. A wife was nothing but a moneysucker. He
had never danced, he was too clumsy. He had never had hetero-
sexual intercourse, nor committed perversions.

His wet dreams were of accidents to which he was a spectator
only. Wagons and automobiles ran away, tipped over, and broke
the legs of the passengers who were always men. There was
much blood. These dreams were not unpleasant. Another typ-
ical dream was of work, work, working in the shop. He denied
dreaming of women.

He had not been able to get an orgasm since entering the
hospital.

Fantasies: He sometimes seemed lost in thought, and smiled
or chuckled to himself, but he never would divulge what amused
him. Often he looked furtively at other patients and then went
off into silent glee as if ridiculing them. Any laughter he heard
on the ward he immediately attributed to himself and swore furi-
ously under his breath. The occupational therapist frequently
heard him muttering to himself, and once he exclaimed angrily
to her, "If you call me a fool, I'll be damned if I'll work for
you," when she had said nothing at all. He went away scowling
and would not work for a couple of days.

In answer to questions he denied seeing visions or hearing
voices or feeling that electricity or any outside force or influence
was being used on him. ("Do you think other people are com-
bining in a plan to hurt you?") "Yes, by talking about me.
("What do they say?") Gee, I don't know myself!"

General observations: He had a great sense of grievance
and felt that other people were imposing on him. He was very
self-conscious and constantly on the defensive, looking for slights.
Any friendly advances were rudely rebuffed, for he suspected

CASE HISTORIES 87

some hostile motive or intention to ridicule, and muttered and
glowered hatefully. I have never seen more hate in a human face
than in his.

"I'm not as strong as I used to be. My thoughts are getting
slower. I don't feel like moving myself much. I can't think as
fast as I used to. I've no appetite and I feel lazy. I don't like
this climate. I can't get braced up. I worried myself out, work-
ing in the machine shop. You get to be an old man in a short
while. ("Why don't you mingle with the other patients?")
They're from other cities, and I don't know what to say to them.
They don't want me around. They go on their way, and I go on
mine. You're from another state, and so you're not easy to talk
to.

" People don't care about me ; they have enough to do to take
care of themselves. In the navy one fellow called me short, and
the others laughed (intense emotion). I've always been guyed
about being short. A navy chief had it in for me because I was
from the west. He gave me extra work. They made fun of
westerners, of our table manners and the way we looked. I felt
the other fellows came from better families. Workmen like me
have a hard time. When work is unsteady the money soon goes.
Some people have money already and don't have to worry. Other
people get better chances than I do. You can't help me, and /
can't talk with you, because you're not a shop worker like me.
You loaf around here and do no work. If I was as well fixed
as you I'd feel good too. You're not in my class. I want to keep
to my class. You like women, you're dressed that way, you're
not a bad looking fellow."

Quizzing him on his sex life drove him into such a fury of
hate that I half expected him to leap at my throat. For a month
I paid no attention to him, but every time I entered the ward he
glared at me ferociously. However, he never actually offered
physical violence to anybody. Through gifts of candy he became
sufficiently mollified so that I attempted the Terman intelligence
test. All went well until he began to fail on the harder questions
and realized he was failing. He got so angry that he did poorly
on some problems that I felt sure he could have solved if he had

88 CASE HISTORIES

not been so emotionally upset. Throughout life this has seemed
to be his customary reaction to his failures, and he projected the
blame on other people. His mental age was twelve years, in-
telligence quotient 75 per cent., that is, low average intelligence,
nearly a moron.

Occupational therapy: He began without urging but was
handicapped by his self-consciousness. He was shy about asking
questions and when things went wrong went to pieces. His work
showed no improvement but was of fair quality. Sometimes he
was so ugly that the instructor left him alone.

Physical examination: Short in stature, heavy type, large
head and neck. Skin dry and covered with fine white scars and
a papular eruption. Normal distribution of hair about genitals
with moderate amount over chest. Beard heavy. Genitalia
normal. Heart normal. Eyes very sensitive to light. Deep
reflexes markedly hyperactive with wide extensions and rein-
forcements.

Endocrine diagnosis: Submyxedema.

Glandular therapy: Thyroid made him somewhat more active
physically. Nurses and attendants said he seemed pleasanter and
more contented and didn't look so mean or mutter curses as
before. One of them noticed he acted apprehensive and looked
back over his shoulder, but he said people didn't bother him as
much as they used to. Then he began to masturbate at every
opportunity and became depressed.

Four months later: He had been transferred to a state hos-
pital nearer his home. The record stated he had improved
remarkably. He stopped masturbation, lost his fearfulness, and
became pleasant and courteous. His mind seemed clear, and he
paid attention to his personal appearance. When asked why he
was so much better humored he replied, " Nobody bothers me
now. That's why I don't swear and curse as before."

Mental diagnosis: Schizophrenia paranoid. He was too
suspicious and resistant for one to learn much of his sexual diffi-
culties, but since he projected his more apparent difficulties of
every day life onto others, it is more than probable that he did
the same with his deeper sexual troubles. That he had them

CASE HISTORIES 89

was shown by his ill success with girls and hatred of them and by
his resistance towards his mother and sisters. No doubt he pro-
jected hostile physical and sexual wishes onto the environment, for
as he recovered he admitted that people didn't bother him so
much and finally didn't bother him at all. The change was en-
tirely within him, his environment was not altered. Anal erotic
and sadistic cravings were clearly revealed by his pleasant wet
dreams of accidents, broken legs and blood, in which he was an
interested spectator.

SABIN

History: He was a man thirty-six years old, slow and quiet
and well-behaved. He had lived an uneventful life on a southern
farm, sometimes clerking in stores in the winter, until he was
twenty-one. Then he enlisted in the army to see the world and
spent his five-year enlistment in two barracks. He didn't leave
one of them for six months and his comrades asked him why
he didn't bring his coffin in. During the service he married, his
wife remaining in her parents' home. They had one child, a son.
Apparently he was already slow and retarded before his discharge
from the army. He worked as a visiting nurse in Baltimore,
catheterizing prostate cases, and then was employed as a chore-
man in Shepherd and Enoch Pratt Hospital. After a month
he was fired. He tried for one day to find another job and then,
recalling how kindly the patients were treated at Pratt Hospital,
decided the easiest thing to do was to enter an insane hospital for
protection. He lost heart easily, he said. Accordingly he pre-
sented himself at one of the Maryland state hospitals and re-
quested that he be received. He screwed up his lip and stared
into the distance in an attempt to look crazy. They told him
they saw nothing the matter with him but would take him if he
so desired. This account is the patient's own version.

He was hazy whether he spent three or five years in that
hospital. While there he worked on the farm. One day an
attendant told him he saw no use in a man as young and as well
as he staying there, and he ran away. At first he worked on a
farm not many miles away, but fearing he might be discovered he
left and came to Washington and hired out as a garbage wagoner.

7

9O CASE HISTORIES

It seems that even this was too much for him to do without
surveillance, for after seven months he was arrested and taken to
a hospital with body and clothes in filthy condition, and physically
much run down. He said he had worked long hours and cooked
his own meals in a vacant lot. On admission to St. Elizabeths he
showed considerable mental deterioration.

Sex life: As a child he slept between his parents in the same
bed, but had no recollections of having seen them in coitus. At
puberty he got an erection on seeing his mother accidentally ex-
pose her leg, and he hid and masturbated. She caught him at it
and whipped him. The small negro boys of the vicinity per-
formed perverse acts and offered themselves to the white boys
for five or ten cents. His father had a negro boy working for
him whom he had " bought out of jail " in which he had been
incarcerated for attempting coitus on his mother (according to
patient). The patient tried pederasty on this boy and, failing,
had the boy commit fellatio on him. His father found them
doing it and whipped them. Never again did he commit a per-
version.

His first coitus was at sixteen with a married second cousin
who invited him. This happened several times. At nineteen he
began going with prostitutes. At twenty he again saw his mother
unwittingly expose herself and got an erection. Not long after,
he returned one night unexpectedly and surprised his parents in
intercourse. This seemed to have been a trauma. He felt that
he didn't belong there any longer and never felt at home again.
It was then he joined the army. He claimed not to have mastur-
bated more than a dozen times in his life, but he had coitus about
once a week when possible. While in the army he married, and
enjoyed coitus with his wife until after the birth of their child.
She was then apathetic, and he lost interest and left her. He
denied ever having been impotent, but his fantasies were full of
means to avoid becoming so. During the last few years spent in
hospitals and garbage gathering he had had no intercourse, nor had
he masturbated. There was no desire. His wet dreams were of
heterosexual intercourse.

He used to be pretty passionate he said, and lust and longing
for masturbation made life a misery. Giving in to perversions

CASE HISTORIES 9!

would only increase desire. He felt that way after fellatio with
the negro boy, but he never succumbed again.

Fantasies: The first intelligible fantasy he gave evidence of
was concerning hair. To grow long hair and leave it uncut
was necessary in order to excel in health and potency. If a man
cut his hair while a woman let hers grow, she became the stronger
and sucked his strength. He grew a beard in order to look like
his father who had been a hairy man and had always worn a
beard.

Sometimes the voices mentioned birth, sucking a cow, fellatio,
or son-of-a-bitch, and he thought persons left an influence behind
in every place they had been. The influences left behind by old
men bothered him particularly.

When the attendant tried to get him to help in the ward work,
the voices objected and said the attendant was supposed to do it
himself.

During a moderately dull period in the fourth month he
suddenly divulged a mass of sexual fantasies, all of them con-
cerned with the maintenance of potency. " If a father has coitus
with the mother while he thinks of a living child, he takes strength'
out of the child and puts it into the mother. When the mother
gets old and her sexual organs become flabby, that makes the son
weak, for there is a sexual sympathy between mother and son..
The son should then leave home. My father wanted me to get
out. That was probably the reason. If parents still have inter-
course after they have ceased to be able to beget children, it
sucks the strength of their son. It was using up my manhood.
Before I caught them at coitus I was sucking their strength.
Afterwards I lost strength because they sucked mine. Probably
a mother, when she and the father get old and sexually weak and
their son is passionate and ready to go with girls, goes to the
house of prostitution ahead of her son, disguises herself with
paint and short dresses so he doesn't recognize her, and has inter-
course with him, getting his passion to bolster up her own so she
can use it with the father. My parents were reported dead and
yet I saw my father off on the lawn a few days ago, so my
mother is probably alive too. I have no doubt she has had
intercourse with me to get my passion away. She pretended

92 CASE HISTORIES

death just to fool me ; I don't understand it. If the father has
intercourse with the mother and doesn't make her pregnant, it
harms their living child, makes him weak, makes him want to go
back into her sexual organs and be reborn. All children have
sexual feelings towards their parents."

"If in a group of thirteen men (like my little group in the
army) only four indulge in coitus and the other nine go without,
the four suck the strength of the nine. When I married, my
comrades supported me with their strength and my wife's family
supported her, but her sisters got fellows of their own and lost
interest, and she got less passionate and didn't care whether she
took me or not. I felt as if I were masturbating in her ; I might
as well have done it out the window. Then I left her. It
weakens a man if the woman doesn't respond and breed. When
passion rises between buddies until one gets too strong, he seeks
a girl and absorbs the other fellow's strength. If a man should
receive another fellow in his mouth, his ear, his anus, or his fist,
but people don't allow that, those parts of his body would feel
like repeating the act at the same time the next week. That's
the way I felt after the nigger committed fellatio on me, but I
never did such a thing again."

" Once I worked on the farm of a man who was absent. His
wife was sexually old and worn out, and I got to feeling that way
too. You see I was taking his place. I had to get out. You
don't want a woman whose strength has been used up by some
other man, for it weakens you."

When he was still duller, he talked of having recently had
both active and passive pederasty hallucinations, of girls through
intercourse turning into males, of mothers making penises out of
their skin and flesh and using them for intercourse with their
sons, of boys whose genitals were alternately male and female,
of a man he saw naked in the hospital bathroom who had big
teats and a little penis and claimed to have been his wife, and of
tables without heads which grew hair. " I've a mind to get a gal
and have intercourse with her till I turn her into a boy."

General observations: On admission he wore long hair and
a full beard, and objected to having the beard removed and his
mustache and hair trimmed. He wanted all the hair possible,

CASE HISTORIES 93

because it meant strength both physical and mental. His mind
seemed deteriorated and much of his talk was unintelligible. He
was quiet and apparently emotionless, sitting all day long in a
chair. His expression was dull ; he spoke slowly and seemed to
have difficulty in moving his jaw. A sample of his talk is. " I'll
say it's glass that wheels itself and begets itself and lets you hear
and then collects itself back into line."

To everyone's surprise his mind cleared after a few weeks and
he seemed quite normal. He was interested in everything, was
quick to join in any conversation and became facetious and witty
in a country smart Alec way. When confronted with what he
had said in the previous dull period, he exclaimed that it didn't
make any sense. He said also that he no longer had any queer
ideas. In three weeks he went into another depression, looked
dull and apathetic, heard voices and talked nonsense. Any noise
became a speaking voice to him, as the purr of a radiator, or
squeaking footsteps, and he would report to me what they said.
Sometimes voices shouted indistinctly in his ear.

In two weeks he was alert again and said, " Those voices
come when I feel sick, or bilious, or have indigestion, and leave
when I feel good." These alert and dull periods lasting from two
or three days to a week or two alternated continually. During
the dull periods he could play a slow but good game of checkers
and continue slowly his leather pressing occupational work.
When dull he sometimes used clang associations, and he always
had trouble moving his jaw to speak. He also complained of
feeling weak and tired and not being able to remember well.

Occupational therapy: After hesitating three days he began
to work and continued it without interruption. In his depressed
periods he did poorer work than in his normal ones. He pre-
ferred leather pressing, showed good judgment and artistic feel-
ing and improved steadily. He originated some of his designs.

Physical examination: Large type of skeleton. Powerful
muscular development. No deformities. Skin soft and pliable
but shows localized hyperaemias or "flushings." Perspires very
easily over hairy parts. Face is notably plethoric. Hair, normal
distribution over chest and genital region. Genitalia normal.

94 CASE HISTORIES

Heart normal. Superficial reflexes all present. Deep reflexes
slightly hyperactive.

Endocrine diagnosis: Hypoadrenia.

Glandular therapy: None. He was transferred to another
hospital before treatment could be begun.

Mental diagnosis: Schizophrenia with projection and fea-
tures of circular insanity.

One can see that this man had long had an incestuous love
for his mother, when one considers his getting erections at seeing
her legs as a boy and adolescent, his distress following his find-
ing her in coitus with his father, his resistance towards his wife
after she became the mother of a son, his present fantasies of
incest and impotence and his attempt to look hairy and virile like
his father. The long fear of impotence was probably caused by
the realization that his cravings were directed toward a forbidden
object. Homosexual cravings were also present.

His alternating periods of happy normality and depressed
dullness and confusion were like quick-changing circular insanity.
His different levels of sexual thought are interesting. In his
clear, alert periods his sex attitude seemed fairly normal, in
moderate depressions he was in the CEdipus-homosexual stage,
in deep depressions his thinking became archaic with bisexual
monsters and metamorphoses.

Tocci

History: He was a wiry, delicately built little Italian with
almost feminine agility and grace, but surprisingly strong. His
age was twenty-five. In Italy he had only three years of school-
ing, after which he worked as a farm laborer, tailor and shoe-
maker. At seventeen he came to America to see the world, and
wandered from city to city working as a shoemaker. He went
to night school to learn English but still spoke it so badly that he
was very hard to understand. He felt lonely and unhappy in
this country. " I was sorry to be alone, far away from my family,
and disturbed not to see my people. They told me not to
worry but I worried all the time. If I got sick, who would take
care of me?" He suffered much from headaches.

CASE HISTORIES 95

He was probably drafted into the army. It was difficult for
him to adjust to the new conditions. He deserted and was found
wandering in a confused state of mind. He felt very tired after
doing any work and was much worried over voices in his ear
that sounded as if coming from a telephone receiver. They were
from bad people and said bad things and called him insulting
names.

In this hospital he was catatonic and showed waxy flexibility.
He complained that he couldn't think and that voices persecuted
him. If not guided he bumped into objects when walking. In
the fourth month he grew excited and went naked, then again
became catatonic. From then on, depressions alternated with
manic periods, and he often attacked other patients. He was
grandiose at times and decorated himself. He had spent nearly
two years in the hospital before entering the endocrine ward.

Sex life: Another boy taught him how to masturbate, but
he wouldn't say how much he had indulged. He said it was not
good for one. He never had had heterosexual intercourse, be-
cause he feared disease and if he got sick there was nobody to
care for him or look after him, for he was all alone. He never
had had girl friends. He intended to marry when he was old
enough. When he was seventeen a widow wanted to marry him,
but friends warned him he was too young. Wet dreams fright-
ened him very much ; he had had them nearly every night at one
time. A druggist, however, told him not to worry and said they
wouldn't hurt him, and gave him some pills. In the hospital he
had them about twice a week, but they didn't worry him. No
dreams accompanied them. He denied perversions and showed
disgust at the mention of them.

Fantasies: At first the voices were obnoxious but later they
were of good people and said good things. Usually he could
make out no voices at all, only a faint ringing in his ears. He
said he liked to think of good things, good people, good houses
and good cities.

Once he thought all his family were here in the hospital, and
that he had seen his mother when he went to bed and she had
talked with him. He had hoped he would see her again the

96' CASE HISTORIES

coming night. He called some of the middle-aged patients uncle
and called younger men cousin.

He dreamed of good years, good business, good people and of
talking with them. One dream was of two brothers jealous of
each other. Another was of one man against all of the family,
and of a private in the army. Some dreams seemed to be remi-
niscences of his past life, such as reading and writing in a library,
visiting shoe shops, and planting grain.

General observations: He said he didn't know why he was
brought here, but perhaps it was because he was sick and cold.
When he felt better, he was not so cold. He complained of
sweaty hands and tied rings of string around his fingers and
forearms to prevent the sweating.

The most striking aspect of his behavior was his rapid swings
from depression to elation. On an average the periods lasted only
one day, though fairly frequently there was an intermediate
period of one day in which he was quiet but worked steadily.

In his depressions he usually sat motionless with eyes closed
and refused to eat. Sometimes he huddled with a coat over his
head, complaining that his head was cold. Often he stood in
one place for hours. If asked how he felt he might answer, " All
right," or "I don't feel good."

In the intermediate stages he sat staring gloomily into space,
or did occupational work without speaking to anyone.

In his manic phrase he ranged from happy busyness to great
elation when he wanted to have a finger in every pie and run
everything and everybody. With peals of laughter he would slap
me on the back or put his arm around my waist and whirl me
down the room, or leap up like a cat to intercept the basketball
in midair and scramble wildly after it when it rolled under the
beds. He took the other patients' work away from them, stole
their food, and refused to give up his tools when it was time to
quit. The other patients stopped playing cards with him, for he
insisted on taking every trick no matter what card he played.

He was frugal and reiterated, " I must save." His clothes
were so stuffed with trash he had saved that he often looked like
a circus clown. He was affectionate and constantly insisted on
shaking or kissing one's hand. But stubbornness and wilfulness

CASE HISTORIES 97

were his most prominent traits ; he wanted what he wanted when
he wanted it, and nothing but superior force would make him
desist. He seemed to have no conception of adjusting his wishes
to those of others.

One physical examination had to be given up because he was
so excitable and afraid, and in the second attempt he showed
much fear of the rubber hammer used to test reflexes, and re-
acted exaggeratedly.

Occupational therapy: He took hold of the work with alac-
rity and quickly learned to do all branches of it well. His wil-
f ulness made him impatient of instruction and he went on accord-
ing to his own ideas. In his elated periods he worked rapidly and
even grabbed other patients' work away from them in order to
" help " them. In his depressions he did no work at all. In the
occasional intermediate periods he worked steadily and quietly.

Physical examination: Slender type of skeleton, but well
muscled. Skin normal. Small amount of hair on chest but
normal in genital region. Genitalia normal. Heart rapid. Pupils
dilated. Reflexes were active. Psychomotor activity pronounced.

Endocrine diagnosis: Hypoadrenia.

Glandular therapy: He was fed suprarenal gland. At first
he showed a marked improvement. Instead of having a depres-
sion every day or so, he would remain elated for several days at a
time. When the depressions recurred they lasted barely a half
day and were not so deep but what he could work throughout
them. The attendant said that during them his skin was cold
and clammy, and immediately after them his face was pigmented
brownish, and then the color gradually faded to normal.

By the end of six weeks the good effects of glandular feeding
had begun to wear off. The depressions grew somewhat more
frequent and deeper, and he began once more to refuse food.

Four months later: He seemed much the same. The de-
pressions and elations now lasted about a fortnight each. When
depressed he often became ugly and attacked other patients
viciously, trying to choke them. He had to be confined in an
undesirable ward.

Mental diagnosis: Schizophrenia with projection and fea-
tures of circular insanity. The projection of his bad impulses

98 CASE HISTORIES

into insulting voices was schizophrenia. He had partially suc-
ceeded in repressing them for he seldom heard them any longer,
but the schizophrenic habit persisted in his f antasying good people
and good thoughts. Probably the depressions were due to the
undesired unconscious cravings striving to gain control of his
conscious thinking. At first the glandular feeding helped to
prevent this unwelcome eruption, but the effects gradually wore
off.

He was clearly an undeveloped personality. The homesick-
ness and lack of self-confidence and independence showed his
fixation on the family. At seventeen he even considered marrying
an older woman, a mother substitute. In his bedtime fantasies
his mother came and talked to him.

ULSTER

History: He was a restless, unkempt, unhappy fellow of
twenty-three. A social worker visited his home and reported it
as comfortable and decent, and that there seemed to be no abnor-
mality, alcoholism or degeneracy in the family. His sister said he
had been a normal boy, healthy, well-liked, athletic and got on
well in school. His own version was that he had always been
up against it, that he was bashful and couldn't get used to
strangers, and preferred to stay at home rather than associate
with other boys and girls.

He said he attended school irregularly and finished the sixth
grade. Then he worked in a shipyard and made good wages,
paying his own board and saving money, though too fond of
shooting craps. He was drafted into the army.

His army record stated he was put in disgrace by his comrades
and became listless and depressed. It was thought best to re-
classify him in order to give him another chance in a new unit.
But he grew worse and was put in hospital instead, and event-
ually reached St. Elizabeths.

Sex life: He talked incessantly in a disjointed manner dur-
ing all his waking hours, and usually one could not break this
stream of ideas and get him to answer a question unless one shook
him by the shoulder or give him some other sharp stimulus.

CASE HISTORIES 99

Consequently it was difficult to get any information from him
except by culling it out of his stream of talk, and one could not
be certain what was fact and what was fantasy. Under this
heading I have given only what I believed was fact.

He had much sexual curiosity, but his bashfulness prevented
him from seeking experience. In France he first tried hetero-
sexual intercourse, but did not satisfy himself. " I've never had
a good coitus or seen a vulva. My penis slipped out. The girls
said it was too small (his genitalja were normal). Boys said it
was too small too."

He submitted to pederasty by other soldiers, and that must
have been the cause of his disgrace among his comrades. Once
he said he had committed fellatio also, but denied it in the next
breath.

General observations: In our first talk I asked what he was
here for. " I'm sick in the guts, in the stomach, and spine. (" Are
you getting any better?") I don't think so. This is a state
prison or a reformatory." (I explained it was a hospital for
mental disease, and that he was being kept here only because his
mind was sick. "Do you believe your mind is sick?") Yes, it
always has been. This place is full of nuts. They fatten you up.
He wants to get fat and go home and get an automobile. He
was afraid he was going to get shot. He wants to get home.
He's supposed to be a white rat. I heard that. He wants to
borrow a couple of hundred dollars to get home with, this kid
does. This world is coming to an end. I hear voices all the
time. Catholics and Masons. He ought to fall under a train for
being a Catholic. I'm a clean white kid, I never did anybody
dirty. Father supposed to be a Catholic, mother too. I guess
I'm only afraid to fight with bare fists. I fought in France with
boxing gloves. I want to go home. Being afraid of people.
This kid wants to be rich. They won't tell him nothing. He's
against the Masons and Knights of Columbus and everybody.
This kid would do anybody a favor. (He spies a calendar with
a picture of a pretty girl.) Have coitus with her, with everybody
in the world. I earned thirty dollars a week in the shipyard.
He wants an automobile to ride around in. Spiteful devil, me.

IOO CASE HISTORIES

He (indicating the analyst) says he likes you, and all he does is
write. He won't lend you money or buy an automobile. I'd pay
you back. No, just jump overboard."

This talk was typical of those that followed except that later
he spoke much more freely on sex subjects. The pleas for
money, home and automobile, however, were never omitted in
any interview. This first talk disclosed his main preoccupations.
He had a feeling of sin and remorse and felt he ought to be
punished for it or even commit suicide, and feared others would
punish or kill him. He said that on the trip from France to St.
Elizabeths he thought of throwing himself or being thrown under
a train or into the sea. Then tearfully he protested his innocence
and begged to be allowed to go home and to be given a motorcar
to sport around in. His sense of guilt centered about sexual per-
versions, deceitfulness and cowardice. The conflict between good
and bad impulses was dramatized as the familiar hostility be-
tween Catholics and Masons.

In later interviews he said, " These fellows pick on you. They
pick out your tits. I've never seen a woman's genitals in my life.
He wants to see a woman bare-naked. I never did see fellatio
committed. The world would come to an end. They say it's
coming to an end. Get rid of his dirty thoughts. His mother
(she was dead) knows everything he does. Jerking off in the
street. This kid knows he's a four-flusher, he wants to get
washed out. My penis is burning up in my heart. The blood is
being sucked out of his heart. (He looks at his face in a mirror
and whimpers.) Dirt and filth. His tits, hearts, testes, eyes are
picked out. Burn the tits right out of him. Do cunnilingus and
allow fellatio. Put it in the paper (apropos of my steady writ-
ing). The devil is female and gives dirty thoughts. The voices
suck the blood out of you by talking to you. They tell me to
commit fellatio. Masturbate your father. They're bleeding me
to death. They have no right to. If anybody called him a rat or
accused him of mother incest or fellatio, they'd cut his eyes out
(symbolic castration).

"Please don't suck his tits. ("I'm not doing it.") It feels
that way. They burn. You ought not to suck his tits. You're

CASE HISTORIES IOI

sucking my tits and my eyes. They burn. (He tries to force his
left eye out of its socket with his finger. I expostulate and
stop him.) He might as well help it along if they are going to
suck his eyes out anyway. He wants the dirt cleaned out of his
heart, whitewashed and go home. Whitewash tits, penis, vulva,
anything in your body. Give him a new penis and testes and
guts and kidneys. Wash out his kidneys. He wants to get rid
of his dirty thoughts. He wants new genitals. He wants to get
married.

"He sucks tits, this kid does. No, you mustn't think that
dirt. Jump overboard! jump overboard! (The revolt against
the improper craving can be plainly seen here with the suicide or
punishment wish immediately following.) A little pimp. He
hates everybody in the world, because everybody hates him. He
ain't got no friends. (This shows the germ of paranoia.)

" Men and women talk to me. Some are good and some are
bad. He hears the voices of fellows from between the walls.
Let me do cunnilingus and you put it in the paper. Sisters —
have coitus with them. Brothers and sisters having coitus around
the corner. Do you want me to commit fellatio on you (hits me
in genitals), do you want me to masturbate you for a dollar?
He masturbated cops on the beach with his fist.

" Stink. He smells bad smells sometimes. I'm Kaiser Wil-
helm the Great, the Greatest. That's what they tell you. The
Dutch fight for you. No they didn't. ("Why did you say so
then?") Well, you have to make up things. Steal an auto
but don't get caught. He's damaged goods, in his rectum, they
broke it. I'm a Catholic god. Don't commit fellatio on me. This
kid is nutty."

He frustrated an attempt to make a spinal puncture believing
it was a pederastic assault, "they pulled up my shirt and pulled
down my drawers and did pederasty on me. They jabbed a
needle into my back and set me on fire. This kid never had a
friend and he hates all the world." When the physical examiner
stripped him, he feared a sexual assault. "He wants to have
intercourse with me, do fellatio on me, masturbate me." He
tried to escape from the room, then recovered from his fear, be-

IO2 CASE HISTORIES

came erotic and began to masturbate. Sometimes he started to
leave my office, saying he was going home, and I had to lead
him back to his chair and sit him down in it. He usually mistook
this for a homosexual assault, but made hardly any resistance.

It was evident that he had burning sensations in many parts
of his body, particularly the erogenous zones. He fingered his
left nipple until it was big and stiff, and he occasionally mastur-
bated.

It was not possible to keep him in the fairly open endocrine
ward, because he tried to escape and also made sexual advances
to the occupational therapist and women nurses.

Occupational therapy: His attempt to break out of our ward
on the second day brought his short visit to an end. He was
willing to try basket weaving but his diffuse energy prevented his
concentrating on learning it. He continually dropped his work
and wandered away, and failed to master the simplest weave.

Physical examination: Tall, slender, showing pronounced
psychomotor activity. Muscular development poor. Actiniform
eruption present over back and neck which are much scarred
from old acne infections. Skin in general very poorly nourished.
Genital hair tends to masculine type. A little tuft of hair in
mid-sternal region. Genitalia normal. Abdomen protuberant.
Heart very rapid. Reflexes not reliable.

Endocrine diagnosis: Hyperthyroidism.

Glandular therapy: Suprarenal gland was fed him. No
change was noticed in his behavior.

Four months later: He was still talking steadily but in a
very low tone of voice, and he was quieter physically. He was
easier to control because he was much less restless. It was harder
to talk with him however, for he seemed to be cut off more com-
pletely from outside stimuli. In a low, dull voice he talked of
the same subjects, hugging, kissing, getting new brains and teats,
sucking eyes, and wanting an automobile, a gift of money, and
to go home.

Mental diagnosis: Manic depressive with schizophrenic
features seems the best diagnosis for this unusual psychosis.
After his disgrace in France he became "listless, depressed and

CASE HISTORIES IO3

melancholic," but later his behavior grew more manic in type,
though he repeatedly whimpered and mourned throughout his
restless activity. His actions were rather childish. Every few
minutes he whooped like a boy at play, he noticed all the details
of the environment and wanted to handle and examine every-
thing, and occasionally he dived into a bed and kicked his heels
in the air. The next moment he might be weeping at his face in
the mirror and lamenting that he wanted to be washed clean.
Often his emotion did not harmonize with the occasion. Like
most of the schizophrenic cases he projected his difficulties and
believed other men assaulted or wanted to assault him sexually,
and he turned his perverse cravings into voices, yet throughout it
all he had much insight and knew that if he could wash his mind
clean he would be all right.

His perverse impulses ran the whole gamut, with incest, male
and female perversions, and even such an infantile act as sucking
a nipple. His history disclosed his inability to direct his libido to
the opposite sex, thus leaving him in the childish bi-sexual stage
in which his female component strove towards other males. On
this account he made the devil who tempted him, a female. There
was much craving left in the secondary erogenous zones.

VINCENT

History: He was an epileptic twenty-nine years old and was
born defective. He could not coordinate well in any way. He
enunciated with difficulty. He was badly crosseyed and could
read only the big headlines of newspapers. All his movements
were stiff and clumsy.

The family history Was negative. The father was a prominent
professional man, and the younger brothers were normal. The
family tried to protect him from teasing, and his mother devoted
herself to him, even telling him she would rather lose any of her
other sons than lose him. She taught him at home, and he
learned to read a little.

He had the first epileptic seizure at the age of nine. They
became worse as he grew older. When he was twenty-seven he
had a very severe one lasting over two hours. After it he was

IO4 CASE HISTORIES

hallucinated and was removed to a hospital. He gradually
emerged from the psychosis, but was left in this hospital. Half
a year previous to his entering the endocrine ward his mother
died.

Sex life: When he was eleven a girl over twenty played with
him sexually, and he tried to have coitus and pederasty with her,
but did not know how. He never had another heterosexual experi-
ence because he didn't care to. He was home most of the time
and didn't get acquainted with girls and wasn't much interested
in them.

As a boy he felt that erection and masturbation pulled his
brain. After circumcision at twelve, erections did not cause this
sensation, but at the moment of orgasm he could feel a pull on
the brain and the temples, and then some pain over the eyes.
When he was twenty-four he played sexually with a brother of
twenty years. They masturbated each other and tried pederasty.
The passive role hurt the patient and he allowed only coitus inter
femora, but he committed pederasty on the brother several times.

For a year previous to his psychosis he had masturbated
daily. He thought this was one of the causes of his breakdown,
and stopped doing it oftener than once a month. During a visit
away from the hospital he committed pederasty on a young boy.

After his mother's death he became more interested in other
women. An occupational therapist feeling pity for his afflictions
was kind to him, and he fell in love with the young woman and
dogged her footsteps. "I'm so fond of her I can't keep her off
my mind. I can't keep away from her. Since Mother's death
I've gone more with girls." He was blissfully unaware that his
abnormalities prevented other people from ever feeling any emo-
tion toward him warmer than pity.

Fantasies: The severe seizure which preceded his psychosis
he believed had been caused by his daily masturbation and his
long worrying over his father's danger at the front in France.
("What thoughts did you have about your father?" He
flushes.) "Perhaps I can tell you better some other time.
Father and Mother were devoted to each other and didn't like
to be separated. (He quotes some Bible references about the
Golden Rule.) I worried over whether I'd ever see him again.

CASE HISTORIES IO5

I imagined his dead face in a box looking at me in his sleep.
The household talked about the war till it got on my nerves. The
spell lasted two and a half hours. I saw the Lord looking at me.
He said I was one of his best sons, one of the best ever put out.
Then he pulled me up into the sky. There was a multitude of
angels. It was quite pleasant."

While in the psychosis he dreamed several times that he was
a female having intercourse with a male. In one of the dreams
his male partner was the sun. Always he could feel the male's
semen enter his body. He also had the fantasy that male and
female were joined together in his body, making him a combina-
tion of the two, and he drew a kind of swastika of four arms
and legs united at one point which was his abdomen, and he
named the four limbs north, east, south and west. North and
east were above and to the right and were of heaven and good;
south and west were below and to the left and were of hell and
bad. To the right were five circles of stars and to the left one
line of stars. This swastika became a nude man standing in a
box with the pores of his skin as big as if punched by fingers,
though which the devil tried in vain to inject evil into him.

These fantasies show his bi-sexuality and his craving to take
a female sexual role, and also his resistance to it. Representing
resistance we see, standing in the female symbol of a box, a man
full of vaginas through which the devil (perverse impulses)
tries vainly to inject evil (semen).

As he recovered he dreamed of being in a car crossing a
burning bridge. It falls into the water and he cries for help.
The Lord looks at him and gets three big locomotives to pull the
car out. It then enters tunnels where he becomes master of all
the world. He explained that fire stood for great fear. " When
you disobey the Lord, you fear he will punish your spirit with
fire." This dream seems to picture him falling through sin (fire)
back into mother (water) and being rescued by three big loco-
motives (male potency) so that he can enter tunnels (vaginas),
or in other words he struggles out of his mother fixation and
establishes his heterosexual potency.

After his mother's death he had visions of seeing her stand-
ing beside God and smiling happily at him. Once he heard a

8

IO6 CASE HISTORIES

voice which sounded like hers call out of the West, Oscar, come
home, come," and he answered, " I'm coming as fast as I can."
(" Do you have dreams or visions of your father? ") No, there's
no call for one. I saw my mother's spirit standing beside my
father — my heavenly father. Mother was pleased because I was
one of the best sons ever put out. My father was pleased too.
("Your father?") No, no, my heavenly father."

It is true that since his mother's death he has succeeded in
turning his libido more toward younger women, as evidenced by
his infatuation for the occupational therapist. " I dreamed I
was to marry her. Another night I dreamed I was dead and
she was looking at me in sorrow, for I was her husband." He
never had had a dream of normal heterosexual intercourse.

General observations: Fortunately he seemed not to realize
his defects, and was very happy and cheerful. He found some-
thing humorous in all about him except in the realm of religion
and morality. His Bible was always handy though he could not
read it himself, and he appointed himself monitor of the conduct
of other patients and even the attendants. He reproved swearing
severely and attempted to prevent other patients masturbating
in the toilet. Sometimes he got knocked down for his pains, but
his missionary enthusiasm always revived. He followed one
about like a curious child and butted into any conversation no
matter how private, and always had an opinion to offer -on
every subject. In spite of his inability to read ordinary print he
kept accurate track of the date. " I just keep dates in my mind."

His spells came at irregular intervals and he had never noticed
that they followed any particular emotion or state of mind. An
aura always gave warning of their approach. " The nerves of my
body go dead first — in my fingers and feet. There's a feeling in
the left side of the brain, then over the forehead and eyes. The
numbness creeps up my arms and legs. I see a buzzing of many
lights, either all yellow or all white. They go around in a large
circle like a pinwheel. My head buzzes and roars like a train of
cars inside you. All the parts of my body get deader and deader,
until it's all dead, and then I go unconscious.

" The first spell I had was when we had been waiting five
days for father. Word came that he wouldn't be home for six

CASE HISTORIES IO7

months. I said I was tired of waiting and fell in a fit. I was
seven or eight years old then." The father had been absent
a long time and the boy had meanwhile been the center of his
mother's life. She had been awaiting the father's return with
joyous anticipation. I asked the patient if he thought jealousy
had played any part in the spell, and he broke into sudden loud
laughter. " I wouldn't be a bit surprised if that was the founda-
tion of the whole thing, of my having these spells. Mother
would hold me down during them so I wouldn't move around
much. I'd be weak after them and she'd pay a good deal of
attention to me. I think pressure on the brain and jealousy may
have caused these spells." It will be recalled that the severe
seizure which ushered in his psychosis came at a time when he
had worried over his father's danger in France and had had
visions of his corpse in a coffin. His spells in the hospital no one
was able to connect with any particular emotion or incident.

Occupational therapy: He had parole and didn't work in the
ward but liked to visit the occupational carpenter shop occasion-
ally where, on account of his poor eyesight and incoordinate
movements, he did very poor jig sawing and broke many saws,
but enjoyed it immensely.

Physical examination: Slender type of skeleton. Oxycepha-
lic skull. Arrest of development of lower jaw. Teeth irregular
and notched. Hair distribution normal. Genitalia normal. Ab-
domen protuberant. Heart irregular and rapid. Bilateral in-
ternal strabismus. Chronic middle ear disease. Athetoid facial
expressions. General incoordinations. Numerous tics and
slightly hyperactive deep reflexes. Slurring speech defect which
patient attributes to previous tongue adhesions.

Endocrine diagnosis: Dyspituitarism.

Glandular therapy: He was given desiccated pituitary
(whole gland). Some observers thought his epileptic seizures
occurred less often, but this was difficult to decide, for they had
always been irregular.

Four months later: He seemed a bit duller.

Mental diagnosis: He was a defective and epileptic, who had
recovered from a psychosis with schizophrenic features in which

IO8 CASE HISTORIES

his wishes had been projected into visions and voices. He secured
compensation for his actual sorry condition by causing the Lord
to announce him as one of his finest creations, and after his
mother's death he saw and heard her again. The usual perverse
sexual cravings were also present.

Now he is emerging from the mother-fixation bi-sexual stage
and turning his love impulses toward a permissible object, the
occupational therapist.

CONCLUSIONS ON OCCUPATIONAL THERAPY

With the exception of Irgocz, nearly every patient on the
ward seemed to have improved to some extent before the begin-
ning of glandular therapy. It is difficult to decide just what was
responsible for this betterment. Probably it was a combination
of things, the unusually cheerful ward with its sunny glassed-in
piazza, the care of kindly and capable nurses and attendants,
the encouraging presence of the occupational therapist with her
pleasing personality, interesting work and play and more atten-
tion all around than the average patient in the institution was
receiving.

Of the four patients who improved markedly before glandular
therapy began, Lefferts and Nolan cannot be credited to occupa-
tional work because they did not do enough of it. O'Neil and
Jackson, however, seemed to be drawn out of themselves and
aided by it. The active men who had no parole of the grounds
found occupational work a pleasant way to pass the time. The
worried and dreamy patients worked only when urged. With the
exception of the badly introverted Abrams, every man who got
parole of the grounds preferred freedom outdoors to work in-
doors and dropped work partially or completely.

The work and play undoubtedly made many of the patients
happier, but I believe that only in the cases of Jackson and
O'Neil did they lend any considerable aid towards improvement
or cure.

Occupational therapy however, is a most valuable indicator of
a patient's condition. Any mental improvement or regression is
quickly mirrored in his work.

109

CONCLUSIONS ON GLANDULAR THERAPY

Feeding desiccated glands stimulated the patients in almost
every case. In one or two instances this stimulation seemed to
increase their troubles, and they became more irritable and upset,
but as a rule it proved beneficial in varying degrees. Some gave
the impression of being forced to extrovert and to notice the en-
vironment in spite of themselves; others seemed to develop a
spontaneous normal interest in their surroundings.

The most spectacular change was in the convalescent Nolan,
who out of abject laziness was suddenly transformed into a
fairly energetic boy, interested in his daily work and even plan-
ning it ahead. His improvement lasted throughout the few weeks
until he was discharged. Dixon was enabled to repress his
perverse cravings for half an hour at a time, and thus obtained
periods of respite from the torturing " influence " used on him.
Tocci's depressions, which had come regularly two or three times
a week, now occurred much less frequently and were not so
deep, but this improvement disappeared in a few weeks. O'Neil
and Quitner continued their steady convalescence with no very
apparent acceleration. But Riegel after a few weeks of glandu-
lar therapy improved considerably. For many months his con-
dition had remained stationary in spite of hospital protection and
occupational therapy.

At first the effects of gland feeding were so spectacular that
we expected great benefit from it, but as time passed, the im-
provement gradually faded even while treatment was still being
given. After it was stopped, the patients returned practically to
their former condition with the exception of those who had
previously begun to convalesce. Riegel started to regress before
he was transferred to another hospital.

Although the effects of gland feeding seem to be temporary,
this treatment may possibly be of great value in breaking into
the so-called vicious cycle of mental disease, particularly in the
early stages. A combination of thyroid stimulation and psycho-
analysis might be an excellent method of attacking incipient
schizophrenia.

no

CONCLUSIONS ON PSYCHOANALYTIC TREATMENT

No cure or great improvement can be claimed as due mainly
to psychoanalysis in these twenty-two cases. To be sure, my
purpose was to study rather than treat the patients, but I did
try to help six of them, Carhart, Dixon, Lefferts, Nolan, Purdy
and Quitner. The old deteriorateds such as Engel, Foster, Gar-
land, Irgocz, Jackson and Kimmel were beyond aid from this
source. Mathews and Vincent had already recovered from their
psychoses. Abrams, Bailey, Halsted. O'Neil and Riegel were
too negative and resistant. Tocci was too inattentive in his
elations, and inaccessible in his depressions, and the barrier of
language separated us. Ulster had too much manic push to listen
to anyone. Sabin in his depressed periods was very dull and his
psychosis was of long standing. Unless a patient realizes he is
sick and wishes to get well, the analyst has little chance to help
him.

Purdy, though often suspicious, had considerable confidence
in me and talked freely of his troubles. He got insight into
his improper impulses and their projection and improved con-
siderably so that I felt much encouraged. Then the old paranoid
ideas obtruded and proved too fixed to remove. His remark is
illuminating, that he did not want to talk with me for fear I
would destroy his belief in his delusions and that he preferred to
keep them. But he recovered sufficiently to obtain his freedom.

Lefferts wished to learn nothing new and would listen to no
explanation. He knew all about it already and enjoyed many of
his hallucinations. His stubborn conceit was probably an over-
compensation for his inferior body and lack of physical courage.
During his healthy interlude, coincident with the infection in his
hand, I tried very hard to make him understand mental mechan-
isms, but his obstinate ignorance was impregnable. He had
witnessed supernatural phenomena then, and now he no longer
did; this was sufficient explanation for him. Because he had
gained no insight whatever, it was easy for him to slip back again

in

112 CONCLUSIONS ON PSYCHOANALYTIC TREATMENT

into the psychosis after he had recovered from the infection.

Nolan was of such limited intelligence and vocabulary that it
was practically impossible to explain mental mechanisms to him.
After his talks with me however, he lost his delusions and he
was immensely relieved when I removed his fear of being preg-
nant. His psychosis was gone before he began glandular treat-
ment.

Carhart was struggling desperately to suppress his unworthy
cravings, but he could not overcome his resistance and make a
clean breast of his troubles. I hoped to win his confidence
enough to enable him to break down his reserve and talk freely
with me, but I failed.

Dixon was perfectly willing to talk freely, but he had de-
veloped in self-defense such disgust for homosexual perversions
that he could not face the possibility that cravings of this kind
might originate in himself. Consequently he would not even
consider the hypothesis of projection. He clung tenaciously to
his belief in " influence " and gained no insight whatever.

Quitner, as compensation for a sense of physical inferiority,
had built up great conceit of intellect and believed he knew more
than the doctors. This attitude made him resistant to psycho-
analysis. Furthermore, after the unpleasant cravings had been
once more repressed, he so enjoyed the now innocuous conversa-
tion of his projected voices that he was reluctant to give them up.
But he loved freedom even more, and when he saw that this
schizophrenic habit stood between him and liberty he either
concealed it or reasoned his way out of it. Probably psychoanaly-
sis aided him in his recovery.

Although psychoanalytic treatment showed no conspicuous
results in this particular group of men, I have seen other psy-
chotic patients in St. Elizabeths greatly benefited by its use.

GENERAL CORRELATIONS

The first two tables give the groups according to mental
classification with the endocrine diagnosis following each name,
and vice-versa the groups according to endocrine classification

Mental Diagnosis.

Endocrine Diagnosis.

Abrams

Schizophrenia no projection.
« <i «i

Submyxedema.

Bailey ... ...

Carhart

Schizophrenia wi

th proje

:tion.

Submyxedema.

Hyperthyroidism.
Hyperthyroidism,
compensatory.
Hypothyroidism, infantilism.
Submyxedema with hypo-
adrenia.

Dixon

Kngel

Foster

Garland

Halsted

Irgocz

Jackson

Kimmel

Lefferts

Mathews

Nolan I •», f
O'Neil } M°r°nst

Purdy

paranoid,
ii «

Hyperthyroidism.
Hyperthyroidism,
dyspituitarism.
Submyxedema.

Quitner

R iegel

Sabin

circular.

Hypoadrenia.
Hypoadrenia.

Tocci

Ulster

Manic depressive with schizo-
phrenic features.

Hyperthyroidism.

Vincent

Defective, epileptic with
schizophrenic features.

Dyspituitarism.

with the mental diagnosis following each name, while the last
table gives briefly the facts of each individual case.

In order to see whether the percentage of each mental syn-
drome among our patients corresponded with the percentage

114

GENERAL CORRELATIONS

among a large group of other psychotics, I took as control from
a list of all the male first admissions in the New York State
hospitals for the year ending June 30, 1917, those psychogenic
types that corresponded roughly with our own. From the de-
scription of their method of diagnosis I judged that our two cases
of schizophrenia circular and one case of manic depressive with

II

Endocrine Diagnosis.

Mental Diagnosis.

Carhart

Submy:

cedema.

with hypo-
adrenia

Schizo
more

Dhrenia w th projection.

no
no
paranoid,
with projection,
>n. •

Dixon

Engel

Foster

Garland

Halsted

Irgocz

Jackson

Ki mme]

Abrams

Bailey

Riegel

O'Neil

Sabin

Hypoadrenia.

Schizophrenia circular.

Tocci

Purdy

Hy perthyroidism .

Hyperthyroidism,
compensatory.
Hyperthyroidism,
dyspituitarism.

Schizophrenia paranoid.
Manic depressive schizo-
phrenia.
Schizophrenia with projection.

Schizophrenia paranoid.

Ulster

Lefferts

Mathews

Quitner

Nolan

Hypothyroidism, infantilism.

with projection,
moron.

Vincent

Dyspituitarism.

Epilepsy, schizophrenic.

schizophrenic features would in their diagnosis be called allied
to manic depressive, that our schizophrenia with projection
would be called dementia precox — hebephrenic or catatonic, and
that our schizophrenia paranoid and simple schizophrenia with-
out projection would be called dementia precox paranoid and
dementia precox simple. Whether or not the New York state
group contained endocrine disorders was not stated.

GENERAL CORRELATIONS

in

Schizophrenia.

Projection.

No Projection.

Paranoid.

Circular.

Manic.

Moron.

Improved by occu- |
pational therapy.

Effects of Glandular Therapy.

Abrams .

X

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

X
X

X
X

X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X

X
X

X
X

X
X
X

X
X

X

X
X

X
X

Improved.
Improved.
No treatment.
Considerably improved.
More active and irritable.
Improved.
Improved.
No effect.
Improved.
Improved.
No treatment.
No treatment.
Improved.
Remarkably improved.
Recovery accelerated?
No treatment.
Recovery accelerated?
Improved.
No treatment.
Marked temporary improve-
ment.
No effect.
No effect.

Bailey

Carhart

Dixon

Engel
Foster

Garland

Halsted

Irgocz

Jackson. .

Kimmel

Lefferts

Mathews

Nolan

O'Neil

Purdy

Quitner

Riegel

Sabin

Tocci

Ulster

Vincent

The following table gives the comparisons between our group
and this large group:

New York.

Endocrine.

Number
of Cases.

Percent-
age.

Number
of Cases.

Percent-
age.

Manic depressive

281
89
9

403
95

296

121

61
74
9i

18
6

i

27
6
19
8

4
5
6

0

3
o

3

2

II
O
O

I
2

0

U

0

14
9
SO

0
0

4
9

Allied to manic depressive

Symptomatic depressions

Dementia precox:
Paranoid

Simple

Hebephrenic and catatonic

Allied to dementia precox

Paranoia

Epileptic

Mental deficiency

All dementia precox

1,520
9iS
976

IOO
60

64

22

16
16

IOO
73
73

All dementia precox and paranoia ....

tl6 GENERAL CORRELATIONS

The comparison made above seems to indicate that the dis-
tribution of cases, which had been selected primarily or exclu-
sively for endocrine conditions, does not correspond with the
distribution of cases of functional or so-called functional char-
acter in the admissions into the New York state hospitals.

The most striking difference is that half of our patients
would be called hebephrenic or catatonic dementia precox, while
only 19 per cent, of the New York state hospital patients are
included in that group.

On the other hand the New York paranoid precox group is
27 per cent, of the the total while ours is only 14 per cent.

Even were it true that in New York some of our hebephrenics
and catatonics might be called paranoids, still they would largely
exceed the percentage in New York. Our total percentage of
schizophrenia is greater than their percentage of dementia pre-
cox and paranoia combined.

It is particularly interesting that we did not have one single
case of pure manic depressive insanity although nearly 23 per
cent, of our patients suffered from hyperthyroidism. We had 14
per cent., however, which had some manic depressive symptoms,
while in New York there are only 6 per cent, in this classification.
But if we add together New York's manic depressive, allied to
manic depressive, and symptomatic depressions, they outnumber
ours 25 per cent, to 14 per cent.

We had no case of pure manic depressive, paranoia or symp-
tomatic depression. In simple dementia precox, epileptic psycho-
ses, and psychoses with mental deficiency our percentages are
approximately those of New York.

Of course I realize that one case more or less in our group
would change the percentages considerably, so that they cannot be
taken as fully characteristic, with the exception of our schizo-
phrenia with projection. They form a surprisingly large per-
centage, nearly three times as great as the corresponding group
in New York.

It may be objected that a comparison with the New York
state hospitals alone is not enough but I wish to call attention to
the fact that the reports of various states in other years have
shown very striking similarity in the percentages of distribution

GENERAL CORRELATIONS 1 1/

in communities throughout the East and in other sections of the
country where the conditions of living are practically the same,
so I have considered myself justified in taking New York as
typical of the more populated sections of the nation. The main
reason for selecting New York was because of its excellent
official reports wherein the statistics for all the state hospitals are
combined and clear description is given of their methods of
diagnosis.

GENERAL CONCLUSIONS

Every case was schizophrenia or had schizophrenic features.

The two cases of simple schizophrenia, that is, in which the
patients introverted without projecting their impulses, were both
submyxedema.

The two cases with features of circular insanity were both
hypoadrenia.

The hyperthyroids as a whole seemed to be more extroverted
and to keep in closer contact with reality than the other types.

The feeding of desiccated thyroid gland seemed to reduce
introversion and to cause the patient to come into closer contact
with the environment.

Most of these patients showed or gave indications of the
struggle with perverse impulses of the creative instinct, that is,
the sexual conflict which the Freudian school believes to be the
cause of psychogenic disorders.

118

DISCUSSION

Although it has long been recognized that there are mental
disturbances associated with endocrine changes such as menstrua-
tion and the menopause, still very little has been done to find a
definite correlation of special mental symptoms or groups of
symptoms with the physical disorders of the ductless glands.
So far as I am aware, this is the first serious attempt to psycho-
analyze a group of psychopathic endocrine patients and thereby
get a deeper insight into their mental condition than is ordinarily
given in previous attempts at correlation of mental disturbances
and endocrine disorders. While previous investigators have
often given excellent reports in great detail on the condition and
function of the ductless glands, their descriptions of mental symp-
toms have usually been meager and superficial.

Wechsler4 has been one of the few who have given better
pictures of the mental side, but even his article on the psycho-
neuroses and the internal secretions is more of a suggestion than
a thorough study. Barham5 has given a psychoanalysis of a single
case of insanity with myxedema. After the myxedema had
been cured, the mental disturbances broke out anew as soon as
the patient returned to her former unfavorable environment.

As a result of the present great interest in the endocrine
glands and their relation to the various functions of the organism,
they have been studied from many angles, and a number of
investigators have touched more or less on our phase of the
problem. Several of them have remarked that the adrenal and
sometimes the thyroid glands weighed less among the insane.
Mott6 found the adrenals atrophied in many post mortem ex-
aminations but laid it to the physical disease that caused death

4 Wechsler, I. S., The Psychoneuroses and the Internal Secretions,
Neurological Bulletin, vol. 2, number 199 (May, 1919).

5 Barham, G. H., Insanity with Myxedema, Journal of Mental
Science, vol. 58, number 226 (1912).

« Mott, F. W., Suprarenal Glands in Nervous and Other Diseases,
Archives of Neurology (London), vol. 3, p. 123 (1907).

119

I2O DISCUSSION

rather than to the mental disease. Kojima7 reported after a
very detailed study of oVer one hundred cases that the thyroid
weighed less among the insane. Of course, our classification
according to endocrine dysfunction was not made from observa-
tions on the morbid anatomy of the glands.

Rossi8 found in nine cases of manic depressive insanity
following influenza that there was marked adrenal insufficiency.
In six other manic depressive cases uncomplicated with influenza
there was similar adrenal insufficiency. The use of adrenalin had
good results. Prior9 reported that among epileptics there was
very frequently degeneration in the adrenal cortex. Phillips10
connected sporadic goiter with hyperthyroidism, excitement, agi-
tation, and manic depressive insanity, and connected endemic
goiter with hypothyroidism, apathy, indifference and dementia
precox.

Laignel-Lavastine11 draws correlations between abnormal
mental states and endocrine disorders. With mania he connects
disturbances of thyroid, adrenals, and ovaries. This quite tallies
with our results, for our cases with manic features were hyper-
thyroid and hypoadrenal. As our patients were all male, the
ovaries did not figure. With dementia precox he connects tes-
ticles, ovaries, and pituitary. Our experience is totally different,
for our precox cases showed disorders of thyroid and adrenals.
With epilepsy he associates thyroid, parathyroids, testicles and
ovaries, while our one epileptic, Vincent, showed dyspituitarism.
He cites genital perversions, not stating whether they are fan-

7 Kojima, M., The Ductless Glands in no Cases of Insanity with
Special Reference to Hypothyroidism. Studies on Endocrine Organs of
Dementia Precox, Archives of Neurology (London), vol. 7 (1918).

8 Rossi, S. C, Influenza, Suprarenal Insufficiency and Manic Depres-
sive Psychoses, Anales de la Facultad de Medicina (Montevideo), vol.
4, number 12, p. 801 (Dec., 1919).

9 Prior, G. P. U., Mental Cases of Endocrine Considerations, Journal
of Mental Science (London), vol. 66, number 272 (Jan., 1920).

10 Phillips, N. R., Goiter and the Psychoses, Journal of Mental
Science (London), vol. 65, p. 235 (Oct., 1919).

11 Laignel-Lavastine, M., The Internal Secretions and the Nervous
System, Nervous and Mental Disease Monograph Series No. 30, 1919,
P. 32.

DISCUSSION 121

tasied or actual, and connects them with ovaries, testicles, pros-
tate, and adrenals. Our cases who confessed to having committed
perversions (excluding Sabin and his one unsuccessful attempt
at puberty) had hyperthyroidism and dyspituitarism. If only
fancied perversions are meant, probably every one of our cases
would be included.

Prior states that mentally deficient patients after being fed
for several months on thyroid and pituitary extracts gained
percentages in the Binet-Simon intelligence tests several years in
advance of the grade they reached before treatment began.

Of our two morons Nolan, who had already recovered from
his psychosis, took desiccated thyroid and gained remarkably in
energy and intelligence. His mental age, according to the
Terman test, advanced from eight years seven months to nine
years eleven months, and his intelligence quotient from 54 per
cent, to 62 per cent. O'Neil was emerging from his psychosis
before he began to take desiccated suprarenal, and the speed of
his convalescence did not seem to change during the gland feeding.
His gains in intelligence were practically the same as Nolan's ;
eight years to nine years three months, and 50 per cent, to 58
per cent.

Gushing12 draws attention to the close relation between the
function of the anterior lobe of the pituitary and the gonads, since
if one is hyper or hypoactive the other is also, and thinks the
psychoanalytic school should take cognizance of this in their
theories of infantile sexual complexes. He believes that sexual
precocity or backwardness, due to disturbances of these glands,
might well give rise to abnormal sexual mentality.

Jelliffe deals with the same problem as follows : " Variations
in the actual endocrine organs undoubtedly alter the reactivity of
the individual, so that certain complexes, always difficult in them-
selves even under the best of circumstances, are not as well dealt
with by reason of this (for lack of a better term) what may be
called ' sensitiveness.' We know the complexes are a necessary
part of everyone's evolution. Why should fixation and regression

12 Gushing, Harvey, Psychic Disturbances Associated with the Duct-
less Glands, American Journal of Insanity, vol. 69, p. 965 (1913).

122 DISCUSSION

occur with greater intensity in some people than in others ? Does
a defective hyper-thymus-gonadal group handle an incest complex
more inadequately because of the early appearance of the crav-
ing, thus forcing a repression before its time, with its consequent
readjustment to a narcissistic libido fixation? What does a
thyroidal-adrenal group do with the same situation? If the
psychical factors, and the knowledge of the accidents, traumata,
etc., can be integrated with the constitutional factors, I feel sure
we will be on our road to a real psychiatry.

" For the present all we can hope for is to indicate the lines
along which the correlations can be made. The real indices of
endocrine adjustments are far from being well known. We
have a few facts bearing on extremes, the means are in a jumble.
Psychoanalysis also is in a similar situation. But it does deliver
definite qualities — as for quantity, that is, the force behind the
wish — that is still an important problem. Two patients may
deliver us two similar incest dreams. On the face of them they
have come through the censorship with quite similar distortions
and displacements — yet they may have behind them dynamic
intensities of great variation, so that one patient has awakened
refreshed, shall we say satisfied, the other disturbed, diarrheal
and all cramped up ; the dream has only partly satisfied the wish.
Hence the quantitative factor is in great need of comprehension.
This is a problem for the future."

152 WEST S&TH STREET,
NEW YORK, N. Y.

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