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six months she began to complain of women molesting her in her bedroom at night. A few days later she displayed acute auditory hallucinations and declared that I was arranging to transfer her to the male side of the institution with the object of amputating her legs. This attack lasted a week after which she relapsed into her usual slightly defiant and suspicious mood. She always declared that her own moral conduct was irreproachable and she had certainly acquired a number of useful friends among those of good repute.

S. B. was admitted with a history of indecent behaviour and intolerance of discipline.

When he was brought to my office he was at first surly, but, when I explained to him that I only wished to hear his point of view, he told me a long story of his inability to get work, and how other people did not understand him. Questions always made him suspicious, and although he answered he seemed to be constantly on guard. He displayed his impatience by repeatedly changing his weight from one foot to the other.

The only abnormal factors I could discover were a certain reserve and suspiciousness with an apparently purposeless occasional furrowing of his forehead. He works well, but is rather impatient of other inmates with whom he associates. At intervals of three or four months he suffers from auditory hallucinations lasting from four days to a week. At these periods he complains that imaginary people talk to him and say unpleasant things about him, and often when in bed he will move his feet about under the clothes as though kicking imaginary people.

At the end of the attack he reverts to his condition on admission.

The above are quoted as typical rather than extreme examples of the dementia praecox type.

The manic depressive cases can naturally only be diagnosed on admission if chance should decree that the acute phase is present. Often a history may be obtained which is very suggestive or even definitely diagnostic.

The persecutory cases I have not further classified because I have been unable to satisfy myself that they belong to any definite clinical group. I have no doubt that many of them are suffering from dementia. praecox. But from the point of view of the physician they are perhaps the easiest cases of all.

W. M. was charged with repeated offences of stealing, burglary. He appears protesting that he is innocent and that his trial has been

prejudiced by the police evidence. He answers questions readily enough but often during the examination he will become mildly defiant, brushing aside questions that he declares are intended to catch him. In the ward he is for a time retiring but sulky and watchful. Any act of ordinary routine is regarded as specially designed to annoy him. He has accused the attendants of tampering with 'things,' and on a few occasions has definitely charged them with doctoring his food. His resentment is displayed by isolated acts of acute violence and by destruction of property.

The psychotic epileptics require no special mention and their periods of irritability when they are liable to acute outbursts or criminal conduct is readily understood.

If I have given the impression that these cases are certifiable under the Lunacy Act during the intervals between exacerbations I would hasten to remove it.

If sent to a Mental Hospital they are discharged as no longer insane. Contact with the outside world even under the most favourable conditions produces only a recurrence of antisocial behaviour.

Psycho-neuroses. Although there are only four cases recorded in this particular group, the condition is not uncommon.

Hysteria reveals its presence often during quite a short interview but some other types such as obsessional conditions are constantly hidden and only come to light almost accidentally. I quote one illustrative case.

S. M. was noted before admission as a low mental type, emotional, unstable, at times dangerous, with little self-control and liable to sexual outbursts which led him to violent attacks on females. On admission I found him of normal height, physically of fair development, rather thin and pale. He was taciturn, resented being questioned, but was not in any way verbally aggressive unless unduly pressed. Although living in association with other patients he took little pleasure in their company and preferred to sit in a corner with a book or paper. He was obedient and did what work was required of him without displaying any enthusiasm. He would have preferred to sit and watch the world go by.

I interviewed him privately on a number of occasions, and although I could get little out of him he was finally persuaded to submit himself to mental tests. On the Terman Revision he graded at 15 years and acquitted himself quite well on the various performance tests. My impression of his general intelligence and capacity was that of an average Med. Psych. VI


man of his class. Some six months after admission he handed me personally the following letter:

SIR, I hope you will excuse me making my application in writing instead of verbally, but my statement being of a lengthy nature it will be more convenient for you to grasp the full facts of the case. On several occasions I have undergone the sensation of strangulation in my sleep. It was as if someone had come in my cell and had taken me by the throat and tried to strangle me. To be precise I have experienced this awful sensation of strangulation on six occasions. Prior to the last occasion I looked upon it simply as an attack of nightmare, due no doubt to my liver being out of order. But it seems something more than a coincidence that my nightmare should take the same course every time. Believe me Doctor, these attacks are awful, the mere thought of them is too awful to contemplate for one moment. They are so realistic. Now, Doctor, is the night attendants having a game with me, or is due to liver complaint, or is it due to supernatural powers. Common-sense says due to liver (That is the question). I can only surmise myself. I no nothing for sure. I'm not mad neither am I lying. I tell the truth here. Now Sir, will you allow me to sleep in a Dormitory of a night. To be candid with you I am getting nervous of a night. I don't want the observation dormitory, there's too much madness there. If you will put me in an ordinary dormitory I will give you my word of honour, I will not abuse your kindness....

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As a result of these dreams the patient became communicative and I was able to obtain the following account of his career.

He was the only child of a father who was drunken and worthless although he had been well educated. His mother kept a small business, quite successfully, the only difficulty being that the father often stole the contents of the till to provide himself with drink. The lad was wellbehaved as a child, attended school regularly and reached standard five at the age of 13. He started work at the pithead but left after twelve months because he could not work overtime. Out of work for two months, then in an iron foundry for six weeks-didn't like it so left. Unemployed for two or three months and then got a job at a ginger-beer factoryleft after two weeks because the hours were too long. He then worked at a pithead for five weeks and at another pit for one month, but left each place because he wouldn't do night work.

At 14 he assaulted a girl-bit her-but states he was drunk at the time. Two months later he threw a stone at a dog and killed it. He insists that the dog attacked him. Within a few weeks of this incident he was charged with sending threatening letters to the girl he had previously assaulted. A few months later he was charged with using obscene language to a station porter, but was under the influence of drink at the time. Within a short period he was caught stealing pigeons, but this was a joke as the pigeons were released. In the same year (at age 161)

he assaulted a female. He had made overtures to her some months previously and when she saw him again he was drunk. She taunted him so he knocked her down. During the whole of this time he had worked for short periods but after this incident he stayed at home and helped his mother in the shop. When he was 18 he courted a girl but she gave him up; consequently he attempted to cut her throat with a razor, but only succeeded in slashing her face, as someone came to her assistance. At this time he began to realize that he always felt aggressive towards women, and whenever he saw a girl whose face and figure appealed to him he was seized with an impulse to strangle her with his hands. At intervals he drank to excess as he found that he could only in this way. secure some freedom from the thoughts that possessed him. His attitude towards men was one of indifference, though he admits that he preferred giving in to fighting and had often been called a coward.

In his 20th year he attempted to strangle three females. They were immoral women that he lured into quiet places. Carnal knowledge was no particular pleasure to him, but on each of these occasions he attempted to strangle the woman. He did not succeed: once he was interrupted and on two occasions he was not strong enough. A year later he wounded a woman with intent to murder. This attack was thought out beforehand. He tried to get at her throat but only succeeded in cutting her face and breast. The lady had taunted him with cowardice. Although he would not at first admit the fact, it slowly became obvious that he suffered from a partial sexual incapacity. Curiously enough he attributed the cause of his obsession to the fact that he had seen his mother treated in this way by his own father during drunken bouts, and that he had heard as a child that his premature birth (at 7 months) had been caused by an incident of the same nature.

During the early interviews he was in a perpetual fear of death by violence such as that portrayed in his dreams, but as the dreams ceased he became calmer. His mother stated that her husband was a drunkard and although he had never struck her, on numerous occasions during their married life he had seized her by the throat in his drunken rage. Her son appears to have associated with men of indifferent character. His mother had regarded him as peculiar from childhood but he had given no serious trouble until he was 14.

It was the pure chance of those most significant dreams that brought to light his true condition.

I have written of these cases fully enough to demonstrate the existence of a mental disorder, and the degree or intensity to which it may attain.

Although at first some of them may appear as inadequate personalities, persons who merely fail to make the social adjustments imposed on them by the community, there is little doubt that a study of each case will from a clinical standpoint afford sufficient evidence to make diagnosis tolerably certain or at least to raise suspicions which must inevitably be confirmed after a short period of observation.

The dementia praecox however ill-defined is yet clinically often easy of recognition.

Rampton State Institution was established for the reception of defectives of dangerous and violent propensities.

This definition of defectives, I think, applies very particularly to the moral imbecile, and as we collect our cases from all parts of England and Wales it is a reasonable presumption that we would receive into the Institution a fair number of moral imbeciles-if such exist. I have classified the actual types above. Many of them are feeble-minded and many suffer from mental disorders of a more or less definite character. They conform to the requirements of Section 1 (d) of the Act in that from an early age they have displayed vicious or criminal propensities.

The only certain permanent mental defect I am able to determine is the presence of a psychosis or a psychoneurosis and in so far as these conditions are incurable or have failed to yield to treatment they can be regarded as constituting the permanent mental defect.

The question of transfer to an Asylum is largely one of the duration of the acute phase of the mental disorder. In an acute psychosis lasting even one or two weeks it would be manifestly absurd to pass them on to Mental Hospitals. This would of necessity mean early discharge with a return to a life of viciousness and crime.

Dr Cyril Burt in his contribution to this symposium has divided mental deficiency into intellectual and temperamental types. With this classification I entirely agree, and especially when he adds that, "It is not therefore utterly impossible for a person of high intelligence to be a temperamental defective; but such a combination must be extremely rare." General emotional instability existing apart from acquired mental disorders is not in my own patients found associated with normal intelligence. There is always an intellectual defect of greater or lesser degree, and this defect is taken in association with general instability as the criterion of feeble-mindedness within the meaning of Section 1 (c) of the Act. Theoretically there must be many cases in whom temperamental defectiveness exists alongside normal intelligence, but they are hardly ever found in institutions. It is possible that our prisons may hold

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