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and disobedient, was undemonstrative to the family on their visits, laughed and giggled to herself without cause, and would sit and dream for hours. During 1916 and 1917 the behavior of the patient underwent a general slump. She grew careless in her appearance, slovenly and gluttonous in her eating, surly, openly autoerotic; she showed bizarre behavior, such as throwing herself flat on the floor in the school-room, and had outbursts of screaming, kicking and striking attendants and children, so that she had to be sent to the hospital with these attacks every few days. In April, 1918, the patient's behavior was described as untidy night and day, openly autoerotic, and given to such queer activities as rushing into the diningroom and snatching all the food off the table.

Mental Examination, July, 1918.—The patient was found idly fingering her dress and unbuttoning it to the waist. At times she would break into empty, mirthless laughter without any obvious association or relation to questioning. She allowed her reflexes and pupils to be tested, but when asked to hold up her right hand, she held up her left hand, and then both hands. When asked to name such objects as key, watch, pin, etc., she would not speak, but nodded her head in the affirmative if the examiner called these articles by their right name. For the most part she answered questions by nodding her head, except on two occasions when she gave her name and the city where she lived. It was impossible to get any cooperation from her in response to questions as to orientation and memory; she did not show the slightest appreciation of her environment. Physical examination, negative.

Discussion. It is unfortunate that we know little about the patient previous to admission. The parents' account of her disposition and make-up, with seclusiveness, day-dreaming, vacant laughter and episodic emotional explosions, shows that we are dealing with an individual whose course and development from the start has differed from that of the ordinary feeble-minded individual of 10 years' "mental age.” So far as we know, the patient's shut-in characteristics did not begin to assert themselves at any definite date. There has been a gradual introversion of the personality with a progressively downward curve of adaptability, of interests and activities to the dementia-like condition of the present time. From a study of the facts of this case one is inclined to believe that the developing schizophrenic process and the mental retardation are merely associated phenomena, and do not bear the relation to each other of cause and result.

(2) C. D.; æt. 15. Male. Family history, negative.

Nothing backward was noted in his early development except a difficulty in articulation until the age of 6. He attended private school for Ś years, but did poorly. The father states that his lack of progress did not seem to be so much a difficulty in learning, as a peculiarity of disposition. The patient was “never like other boys”; he stayed by himself, was not fond of play, was sensitive, “reflective," timid and shy. On admission to The Training School, July, 1917, his mental age,” according to the BinetSimon test, was 9 years, basal year 4, with scattering from 4 to 9 years.

Behavior Notes. During the first few months the patient harped on certain institutional requirements which conflicted with his religious ideas, such as doing cottage work on Sundays and having Sunday religious services in the afternoon instead of the morning. The cottage matron describes his behavior as follows: "He bursts out laughing without any reason. Most of the time he just sits and dreams, and when working at the loom will drop the shuttle and sit staring into space. He seems to be thinking either on religious subjects or other mature material. He is moody and wants to be left alone; will throw himself on the grass for hours at a time as if in a deep study."

Mental Examination, July, 1918.—The patient came to the office without reluctance. His gait was short and sidling, with a good deal of hip movement. During the examination he sat quietly except for twirling a bit of string in his fingers. His face wore a constant, shallow, vapid smile which seemed to have little or no emotional value and impressed one almost as silly coquettishness. His response to questions was more or less stereotyped and delivered in short, jerky sentences with the same formula of utterance, as follows: (Long pause following the question, while the patient gazed into space with head poised on one side. After a second he would start and say:) " Let's see did you speak to me? Oh! yes, how old am I? Well, I am 15 years.” With this manner of jogging through the mental status he was found to be correctly oriented and to have a good memory for remote and recent events. He could retain 7 digits after once hearing them, and get the gist of test stories with one reading. General information and calculation were good. He described his mood as happy except when he felt languidly revengeful for the imposition of Sunday labor. He mentioned occasional imaginary voices whispering to him, but could not tell what they said, he spoke of once seeing an imaginary person standing by his bed, and admitted continuous rumination along religious lines. He and God are alike because they are “both good and incapable of sin.” (Does God ever talk to you?) “No.” (Where does your mind run when you sit and stare?) “I just sit that way and my mind dwells on nothing and I don't know and nobody knows but God. God and I are alike because we are both good.” (Why don't you take an interest in something?) “I like to rest.” (Do you think that is right?) · Yes! God likes it because I do.". There were no ideas of reference nor tendency to the mind-reading complex.

Physical examination, negative.

Discussion. This patient, with a shut-in constitutional make-up and a history of gradually narrowing range of interests, activities and contacts with the world of reality, represents a psychopathological condition resembling that of A. B. in the early course of her development. We see the same dogged persistent rebellion against authority in the case of this patient, associated with fantastic ruminations along religious lines, and vague hallucinatory experiences. Any attempt to keep in touch with the real world in the form of cottage duty, school work, handicraft, etc., has failed, and we see him slipping daily more and more into the world of fantasy, as outwardly expressed by his increased preoccupation, seclusiveness and general inaccessibility.

(3) E. F., æt. 23. Male. Family history, negative.

The patient did not begin to talk until 2 years or to walk until 19 months. With failure to get on in public school he attended a class for defective children for 8 months. His father described him as always very nervous, hard to manage, shy, preoccupied, seclusive, given to temper tantrums with crying and overtures of affection afterward. The psychological examination on admission to The Training School, 1913, showed a “mental age" of 8 years (basal year 4, with scattering from 4 to 12 inclusive).

Behavior Notes. The patient has no ambition to work or play and talks to himself a great deal. He is always quarreling with the other boys and sometimes runs around in a circle and screams without any observable provocation. He has a mania for picking up strings. He talks a great deal, but cannot do the simplest things in handicraft or cottage work. In making beds he will put on the bed clothes and take them off again several times. When dressing he will dress and undress himself, as if unable to stop until told to do so. Dusting and scrubbing and sweeping are away beyond him. "He likes to stay by himself and is always being offended by some imaginary trouble that could be easily remedied if one could only get him to tell what the trouble is.”

Mental Examination, July, 1918.—The patient came to the office from the laundry where he had been dismissed because of a quarrel in which he tore up sheets. He told of the episode with naiveness and with no residual of anger nor any other emotion; he answered questions relevantly, but when left to his own conversational originality he talked about nothing but a tooth on the right side, which, according to the institutional records, has been a chronic topic of conversation without cause for a number of years. He was correctly oriented for time and place. His mood was a jocular smoothing over of his obsessive-like behavior in dressing and undressing. There were no hallucinations nor delusions. He said that he had “scarey spells” brought on by sudden noises and people “ hollering" at him. (Do you have nervous spells) “I get scarey sometimes when people around me yell." (What are you afraid of ?) “I am afraid of birds, black birds and doves and hens.” (Why?) “I am afraid of the feathers.” (In what way?) “They just seem alive and going to jump at me." (Why do you sometimes dress and undress without stopping?) “ It's the neuralgia in this tooth.” (How does that work?) “Well, you see, this right side of my face is always sore and I keep putting my clothes on and taking them off to see if I can do it without touching my face.” The patient's memory was poor. He gave his age, but could not tell the date of admission to or how long he had been at the institution. He repeated 7 digits after once hearing them and retained 3 phrases for 5 minutes. Physical examination, negative.

Discussion.—In considering the facts in this case one is struck by an adaptive level below that of the average individual with a “mental age” of 9 years. The patient cannot wash or dress himself without help, or tie his shoes. Associated with this is a peculiar obsessive-like behavior, such as dressing and undressing continuously, for which he gives somewhat peculiar motives. His explanation for this conduct impresses one as frankly childlike, rather than an attempt to smooth over any delusional material. His emotional outbursts of anger followed by childish penitence are akin to the tantrum-like reactions which seem to be a fairly frequent occurrence with the feeble-minded. However, his queer episodic behavior coupled with seclusiveness, preoccupation and poor adaptability are suggestive of an essentially schizophrenic process.

(4) G. H., æt. 25. Male. Family history, negative.

The patient did not walk until 3 years, and was slightly backward in school. His disposition was described as nervous, excitable, morose, obstinate, seclusive and hard to manage. Prior to admission he is said to have done “ office work” for his father. Psychological examination on admission, October, 1916, showed a “mental age” of 8 years (basal year of 4 with scattering, which brought him up to 8 years).

Behavior Notes.—“ Patient is practically worthless in any kind of work. He will stand and stare and cannot do the simplest things. This does not seem as if it were because the patient is not bright, but because he is thinking of something else. He will not associate with the other boys, but sits around by himself, talking, always about his father and family. While at work in the field he sometimes starts and runs a quarter of a mile without giving any reason for his conduct. At night he often sits on his bed for 2 or 3 hours muttering and holding imaginary conversations, in which he talks of jails and asylums and prisons without much connection."

Mental Examination, July, 1918.-The patient hurried into the office saying, “Do you think there is any hope for my mind, doctor?” (What is the matter with your mind?) “I am all right. I do my work all right.


Do you think there is any hope for my mind?” When the patient's attention was fixed he would answer relevantly, giving his name, age and birthplace, but if left to himself drifted immediately to the above topic. When questioned about his peculiar behavior in dressing and muttering to himself at work, he said, "My mind is in bad shape. I get scared when I see a hearse and I run. My hands look red-everything looks red. When I go to bed at night I talk to imaginary people. I imagine people are talking about me and sometimes they are after me. Everybody is against me. My father is against me and my brother.” The patient could not be induced ever to go beyond this point in the discussion of his imaginations. When his attention was fixed he was found to be oriented as to time, place and person. His memory for remote events was good. He was able to repeat 7 digits after once hearing them and remembered the test phrases for 5 minutes.

Discussion. It is unfortunate that the records in this case give us little idea of the patient's developmental traits and his assets in the form of work, play and general interests prior to admission. Fundamentally, his psychopathological picture has not changed since he entered the institution 2 years ago. During this period the following characteristics stand out in his behavior and general adaptability, in more or less striking contrast to that of his colleagues of corresponding “mental age,” viz.: Lapses of attention due to preoccupation and day-dreaming ; poverty of interests; seclusiveness; adaptive inferiority far below his "mental age”; stereotyped harping on home matters, with suspicions and feelings of injustice; probable hallucinations of hearing; and peculiar behavior, such as tearing about the grounds, gesticulating, and shouting queer utterances about Harry Thaw, jails, etc. One feels that the patient had an original defect, in connection with which there has been a gradual decline in assets and a tendency to withdraw into a world of fantasy and rumination.

Summary.—These four cases show a psychopathological picture of a schizophrenic process, which so far as we make out from the data at our disposal seems to have been co-existent from the start with the mental retardation, or may have been implanted as a “ Pfropfhebephrenic.": As has been pointed out in the individual cases, one notices a progressive adaptive inferiority, quite out of keeping with the behavior accredited to the ordinary feeble-minded patient of an 8 years' “mental age.” Attention should also be called to the occurrence in the above cases of the so-called shut-in constitutional make-up, which has been described since Meyer's analysis of the neurotic constitution in

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