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| Transcriber's Note |
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| The following corrections were made to the original text: |
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| Hyphenation made consistent: antisocial, court-martial, courtyard, |
| everyday, framework, housebreaking, petit mal, poorhouses, |
| psychopathologist, reenlisted, readmitted, viewpoint. |
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| Accents made consistent: Beitraege, Delbrueck, Gefaengnispsychosen, |
| Geistesstoerungen, naive, regime, Seelenstoerung. |
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| Krankheitsformen, Lasegue, nocturnal, Pelman, phantastica, |
| staunchly, traveled, Wilmanns, Zeitschr. |
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| Punctuation: Eight changes made. |
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STUDIES IN
FORENSIC PSYCHIATRY
CRIMINAL SCIENCE MONOGRAPH No. 2
_Supplement to the Journal of_
THE AMERICAN INSTITUTE OF CRIMINAL LAW
AND CRIMINOLOGY
STUDIES IN
FORENSIC PSYCHIATRY
BY
BERNARD GLUECK, M.D.
INSTRUCTOR IN PSYCHIATRY AND NEUROLOGY IN THE MEDICAL
DEPARTMENTS OF GEORGE WASHINGTON AND GEORGETOWN
UNIVERSITIES
FROM THE CRIMINAL DEPARTMENT
GOVERNMENT HOSPITAL FOR THE INSANE
DR. WILLIAM A. WHITE, SUPERINTENDENT
BOSTON
LITTLE, BROWN, AND COMPANY
1916
KRAUS REPRINT CO.
New York
1969
_Copyright, 1916_,
BY LITTLE, BROWN, AND COMPANY.
_All rights reserved_
Published, September, 1916
LC 16-20410
_Reprinted with the permission of the author_
KRAUS REPRINT CO.
A U.S. Division of Kraus-Thomson Organization Limited
Printed in U.S.A.
EDITORIAL ANNOUNCEMENT
This volume is one of a series of Monograph Supplements to the Journal
of Criminal Law and Criminology. The publication of the Monographs is
authorized by the American Institute of Criminal Law and Criminology.
Such a series has become necessary in America by reason of the rapid
development of criminological research in this country since the
organization of the Institute. Criminology draws upon many independent
branches of science, such as Psychology, Anthropology, Neurology,
Medicine, Education, Sociology, and Law. These sciences contribute to
our understanding of the nature of the delinquent and to our knowledge
of those conditions in home, occupation, school, prison, etc., which are
best adapted to elicit the behavior that the race has learned to approve
and cherish.
This series of Monographs, therefore, will include researches in each of
these departments of knowledge insofar as they meet our special
interest.
It is confidently anticipated that the series will stimulate the study
of the problems of delinquency, the State control of which commands as
great expenditure of human toil and treasure as does the control of
constructive public education.
ROBERT H. GAULT, }
_Editor of the Journal of Criminal }
Law and Criminology. }
Northwestern University._ }
}
FREDERIC B. CROSSLEY, } COMMITTEE ON PUBLICATION
_Northwestern University._ } OF THE
} AMERICAN INSTITUTE
JAMES W. GARNER, } OF CRIMINAL
_University of Illinois._ } LAW AND CRIMINOLOGY.
}
HORACE SECRIST, }
_Northwestern University._ }
}
HERMAN C. STEVENS, }
_University of Chicago._ }
PREFACE
When, in 1810, Franz Joseph Gall said: "The measure of culpability and
the measure of punishment can not be determined by a study of the
illegal act, but only by a study of the individual committing it," he
expressed an idea which has, in late years, come to be regarded as a
trite truism. This called forth as an unavoidable consequence a more
lively interest on the part of various social agencies in the
personality of the criminal, with the resultant gradually increasing
conviction that the suppression of crime is not primarily a legal
question, but is rather a problem for the physician, sociologist, and
economist. Whatever light has been thrown in recent years upon this most
important social problem, criminality, did not issue from a
contemplation of the abstract and more or less sterile theses on crime
and punishment as reflected in current works on criminal law and
procedure, but was the result of research carried on at the hands of the
physician, especially the psychopathologist, sociologist, and
economist. The slogan of the modern criminologist is, "intensive study
of the individual delinquent from all angles and points of view", rather
than mere insistence upon the precise application of a definite kind of
punishment to a definite crime as outlined by statute. Indeed, the whole
idea of punishment is giving way to the idea of correction and
reformation. This radical change of tendency cannot be looked upon as a
mere misdirected sentimentality on the part of modern society, but is
the inevitable result of the final conviction that the solely punitive
criminology upon which society has been relying in its efforts to
eradicate criminal behavior from its midst has proved a total failure.
The idea of punishment as a deterrent of crime is, as a consequence,
gradually losing its hold upon modern criminologists, and in its stead
we have been experimenting for some time past with such measures as
probation, suspended or indeterminate sentence, and parole. Now it can
not be too strongly emphasized that in giving these measures a fair
trial we ought to guard against those very same grave errors which were
chiefly responsible for the failure of the old, solely punitive methods,
namely, the dealing with the criminal act rather than with the
individual committing it. If these new measures of probation, suspended
sentence, and parole, which are perfectly adequate in theory, are to
justify their existence in the practical everyday handling of the
problem of criminology, we must not fail to take into full account the
very obvious natural phenomenon that human beings vary within very wide
limits in their susceptibility to correction or reformation, that some
individuals because of their psychological make-up, either qualitative
or quantitative, are absolutely and permanently incorrigible and present
a problem which can be dealt with in only one effective way--namely,
permanent segregation and isolation from society. It is on this very
important account that the psychopathologist's place in criminology is
fully justified. In endeavoring to aid in the solution of the problem of
criminology, the psychopathologist need not seek new methods of
procedure but may safely rely upon those which have aided him in
elucidating in a very large measure the problem of mental disease. For
criminology is an integral part of psychopathology, crime is a type of
abnormal conduct which expresses a failure of proper adjustment at the
psychological level.
It was not until the advent of the Kraepelinian School of psychiatry,
with its intensive search for facts and the resultant more accurate
delineation and classification of types of mental disorder, that we
began to acquire real insight into psychopathology and were enabled to
render more accurate prognoses. This more or less purely descriptive
method of study is at present being followed by an intensive analysis of
the facts thus gained as exemplified in the present psychoanalytic
movement. It is conceded by all thoughtful observers that criminology
will have to follow the same route on its way to final solution. The
series of studies here presented reflect an effort in this direction. It
is aimed to present a series of well-rounded-out case histories of
criminal types as studied from the psychopathologist's viewpoint, and in
one instance, at least, an attempt is made at an accurate and intensive
psychological analysis of the biological forces which were at the bottom
of a career of habitual stealing. No attempt is made at hard and fast
formulations. Our knowledge concerning the criminal is still too meager
to justify one in drawing dependable conclusions. But it is felt that
this clinical material emphasizes sufficiently the necessity of the
psychopathological mode of approach to the problem of criminology. For
that matter, the excellent work being carried on by Dr. William Healy in
connection with the Chicago Juvenile Court and by psychopathologists in
a number of other cities attests that this need is being gradually
recognized by society. One desires only to express the hope that the
time is not far distant when our penal and reformatory institutions will
likewise serve the purpose of clinics for the study of the delinquent,
and that such clinical instruction will form part of the curriculum of
at least every public prosecutor.
I desire to express my indebtedness to Messrs. Lea and Febiger, the
J. B. Lippincott Co., and to the editors of the American Journal of
Insanity, and the Journal of the American Institute of Criminal Law and
Criminology, for their kind permission to reprint some of the material
herein presented.
Before concluding this preface I desire to avail myself of this
opportunity of expressing my sincere gratitude to Dr. William A. White,
Superintendent of the Government Hospital for the Insane, for his kind
and very stimulating advice and encouragement which made these studies
possible.
GOVERNMENT HOSPITAL FOR THE INSANE,
January, 1916.
CONTENTS
CHAPTER PAGE
PREFACE v
I PSYCHOGENESIS IN THE PSYCHOSES OF PRISONERS 1
II THE NATURE AND TREATMENT OF THE PSYCHOSES OF PRISONERS 66
III THE FORENSIC PHASE OF LITIGIOUS PARANOIA 132
IV THE MALINGERER: A CLINICAL STUDY 156
V THE ANALYSIS OF A CASE OF KLEPTOMANIA 239
INDEX 267
STUDIES IN FORENSIC PSYCHIATRY
CHAPTER I
PSYCHOGENESIS IN THE PSYCHOSES OF PRISONERS
That mental disorder may be due to causes purely psychic in nature is
acknowledged by everyone. The older psychiatrists laid much stress on
this point, a revival of which may be seen in the present-day widespread
psychoanalytic movement. The reaction to the all too-embracing
materialistic tendencies which have dominated psychiatric thought in
recent decades was bound to come. It was especially the clinician who
gave the impetus to this movement, because in pursuing the materialistic
bent he found himself totally helpless as a therapeutist in the great
majority of mental cases, and was therefore eventually forced to seek
more promising paths.
Bleuler's attitude towards this question, because of the prominent
position he occupies in the world of psychiatry, is interesting.
"Bleuler, who succeeded Forel as Professor of Psychiatry and Medical
Director of the Cantonal Insane Asylum (Burghoelzi) at Zurich, having
become convinced that no solution could be arrived at along this
anatomical path for the many riddles offered by the disturbed mental
life, had for years chosen the psychological path. He was led to take
this course because he knew that of the chronic inmates of the asylum,
only about one-fifth showed anatomical changes of the central nervous
system sufficient to explain the mental deviations exhibited."[1]
The results already achieved by this change of attitude in psychiatry
are sufficient justification for its existence.
One became especially convinced of the potency of mental factors in the
production of mental disease from the observation and study of the
psychoses of criminals. Here the conflicts which lead an individual to
seek in mental disorder a satisfactory compromise are so concrete as to
leave no doubt concerning cause and effect.
Kraepelin[2] asserts that mental disorders occur ten times as frequently
in prison as in freedom. The criminal, who in most instances is already
burdened with a more or less strong predisposition to mental disorder,
upon being placed in prison finds himself at once in a most favorable
environment for a mental breakdown. It is true, imprisonment acts more
deleteriously upon the psyche of the criminal by passion, the accidental
criminal, but even the recidivist who would be expected to feel less
keenly the painful loss of freedom, falls a prey to the deleterious
effects of prison life. The unfavorable hygienic surroundings which are
found in most prisons, the scarcity of air and exercise, readily prepare
the way for a breakdown, even in an habitual criminal. Above all,
however, it is the emotional shock and depression which invariably
accompany the painful loss of freedom, the loneliness and seclusion,
which force the prisoner to a raking occupation with his own mind, to a
persistent introspection, making him feel so much more keenly the
anxiety and apprehension for the future, the remorse for his deed, that
play an important role in the production of mental disorders. This is
especially true when it concerns an accidental criminal, one who still
possesses a high degree of self-respect and honor. Imprisonment
furnishes us with a great variety of mental disorders, the origin of
which can be traced in a more or less direct manner to the emotional
shock and influence upon the psyche which it brings about.
The psychogenetic origin of the psychoses of criminals can be
established far more clearly in prisoners awaiting trial. Here the
deleterious effect of confinement upon the physical health can be ruled
out almost entirely, and the etiologic factor must be sought for
exclusively in the emotional shock which the commission of the crime and
its attending consequences provoke. The strong effect upon the psyche
produced by the detection and confinement, the raking hearings and
cross-examinations, and the uncertainty and apprehension of the outcome
of it all are the factors that are at play here.
Reich,[3] in 1871, was the first one to call attention to the mental
disorders of prisoners awaiting trial. He could observe the development
of mental symptoms even during the first hours of confinement, and the
relation between the psychosis and the emotional shock of the situation
at hand could not be doubted. He describes this acute mental disturbance
as follows:--"Already in the first hours or days after imprisonment, or
soon after a severe emotional shock, a sort of psychic tension sets in.
The prisoner becomes silent, chary of words, lost in brooding. He
observes little that goes on about him and remains motionless in one
spot. His face takes on an astonished expression, the gaze is vacant and
indefinite. If he makes any movements at all they are hesitating,
uncertain, as those of a drunken man. Vertigo and aura-like sensations
appear; severe anxiety overpowers the patient, which with the entire
force of a powerful affect crowds out all other concepts and sensations
and dominates the entire personality. Consciousness becomes more and
more clouded, soon illusions, hallucinations, and delusions appear, and
the prisoner becomes especially taken up with ideas of unknown evil
powers, of demons and spirits, and of being persecuted and possessed by
the devil. Simultaneously they complain about all sorts of bodily
sensations. In isolated cases one may observe convulsive twitchings of
the voluntary and involuntary musculature. Finally severe motor
excitements set in. The patient becomes noisy, screams, runs aimlessly
about, destroys and ruins everything that comes his way. With this the
disease has reached its height. At this stage consciousness is entirely
in abeyance and the disorder is followed by complete amnesia." Reich
supposes that this acute prison psychosis may be included in that large
group of abnormal psychic processes, developing from affect and
affect-like situations.
Reich's important work remained the only one on the subject until 1888,
when Moeli again called attention to it. Moeli[4] spoke of patients in
whom an apparent total blocking of all thought processes took place.
They would exhibit complete ignorance of the most commonplace facts,
would forget such well-known things as their own name, place of birth,
or age; were unable to recognize the denominations of coins, etc. He
noted, however, that although the answers these patients gave were
false, they had a certain relation to the question. For instance, coins
of a lower denomination would be mistaken for higher ones, postage
stamps were called paper, etc. They also showed a marked tendency to
elaborate all sorts of false reminiscences about their past life. Along
with this failure of the simplest thought and memory activity, these
individuals were otherwise well-ordered and behaved.
The reader will at once recognize in the above description the
well-known Ganser symptom-complex, the several variations of which have
been so frequently discussed of late years. Ganser[5] further showed
that these cases frequently evidenced vivid auditory and visual
hallucinations. At the same time there existed a more or less distinct
clouding of consciousness, with the simultaneous presence of hysterical
stigmata, especially total analgesia. After a short time recovery took
place, the patients suddenly awoke as if from a dream and evidenced a
more or less complete amnesia of the events which had transpired.
Numerous discussions concerning this disease-picture have appeared of
late years in literature. The Ganser syndrome, or twilight state, has
been enlarged upon, and several variations of this condition have been
isolated. The chief contention, however, of the various authors on this
subject seems to be whether this symptom-complex should be considered as
hysterical or whether it should be placed among the large group of
degenerative states. Both views are ably defended by prominent
psychiatrists. I have recently observed the Ganser syndrome in an
undoubted case of toxic-exhaustion psychosis.
Raecke[6] designated this disease-picture described by Moeli and Ganser
as an hysterical twilight state in psychopathic individuals. These
conditions were developed in them as the result of emotional excitement
in imprisonment. The constant hearings, the confusing cross-questioning,
the fear of punishment, finally the injurious effect of solitary
confinement, shock and weaken the slight mental tension of the prisoner
to a marked extent. As a result of this, we have on the one hand a
condition of apathy, of inability to concentrate the mind, of incapacity
to think and of a sort of feeling of being wholly at sea, accompanied by
vertigo and other nervous manifestations, while on the other hand the
physical despair, the obstinacy of the prisoner, now increase to
pathological maniacal attacks, now again are changed to stubbornness,
mutism, with refusal of food. At the same time the more or less constant
wish to be considered sick, and in consequence to be freed from
imprisonment (and in this we see perhaps the hysterical component), may
influence deleteriously and in a peculiarly modifying way the
disease-picture. The various questions put to the patient by the
examiner may act as so many suggestions. Raecke further calls attention
to the manifold similarities which these conditions may show with
catatonic processes. In these hysterical twilight states, quite aside
from mutism, negativism, and catalepsy, peculiar mannerisms were noted,
a sort of affected, childish way of speaking, motor stereotypies,
swaying of the head, running in a circle, queer actions, and sudden
expressions of senseless word combinations. In a later work Raecke[7]
describes a symptom-complex, which he designated as "hysterical stupor
in prisoners", and in which the catatonic symptoms exist in a still more
pronounced manner. The severe forms of this disorder, which may extend
over weeks and months, are liable to be confused with progressive
deteriorating processes, especially so because those symptoms which were
wont to be considered by many as positively unfavorable prognostically,
may be found here in very deceptive imitations. Thus the affected, silly
behavior, impulsive actions, temporary verbigeration, senseless word
salad, grimacing, stereotypy, attitudinizing, etc., which these patients
exhibit, may easily be mistaken for the typical catatonic picture of
dementia praecox. According to Raecke's view the hysterical stupor is
closely related to the Ganser twilight syndrome. Stuporous conditions
may introduce the latter, and, vice versa, Ganser complexes may creep
into the stupor. Raecke's stupor, like Ganser's twilight syndrome,
frequently develops in criminals immediately after arrest or as a result
of great physical or psychic exertion. Sometimes the stupor is preceded
by convulsions, at other times by a prodromal stage of general
nervousness. In still other cases, unpleasant delusions and elementary
hallucinations precede the stupor, which may follow immediately after
this prodromal state or may be again preceded by a short attack of mania
with clouded consciousness. In contrast to the genuine catatonia,
Raecke's stupor as well as Ganser's twilight state, are characterized by
_a high grade of impressionability to things in the environment, which
may at any time suddenly cause a complete transition from an apparently
deep stupor to normal manner and behavior_. Headaches, vertigo, and
various hysterical stigmata are common to both the hysterical stupor and
the Ganser twilight state. At times recovery takes place suddenly, but
as a rule it is gradual and remittent in character. The duration of the
disorder differs. It may last for hours or months, and there generally
remains a more or less pronounced amnesia for the entire period of
stupor.
Kutner,[8] in a work on the catatonic states in degenerates, describes
this condition at length. Although recognizing a good many hysterical
features in these patients, he prefers to place these catatonic
conditions under the general group of the psychoses of degeneracy. He
does not add anything worthy of note to what Raecke had to say
concerning this mental disorder, but the differentiating points which he
advances between it and the genuine catatonia are of interest and should
be mentioned here. Among these he mentions, first, the development of
the disorder upon a grave degenerative basis; second, the sudden
development of the psychosis as the immediate result of a situation
strongly affective in nature, such as a threatening or beginning
prolonged imprisonment; third, the more or less sudden disappearance of
the entire symptom-complex upon a change of environment; and lastly, the
lack of secondary dementia. This absence of dementia cannot be explained
by mere assertions that these cases have perhaps not been followed out
long enough. Bonhoeffer kept account of some of these cases for as long
as ten years, and in none of them could he observe any sign of a
deteriorating process.
It may, perhaps, be of interest to finally mention here Raecke's
fantastic form of degenerative psychosis, which is nothing more nor less
than another attempt at describing the original Ganser twilight state in
a modified form.
It will be seen from the preceding that the disease-pictures described
by Reich, Moeli, Kutner, Ganser, Rish, and others, are so closely
related that any attempt at separation must of necessity be more or
less of an artificiality. The question whether this condition, because
of certain isolated hysterical components, deserves to be considered as
hysterical in nature, is by no means solved. The mere presence of
physical, so-called hysterical, stigmata, is not sufficient to call a
disorder hysterical. Bonhoeffer, who, in opposition to such authors as
Wilmanns, Birnbaum, Siefert, and others, insists that this
so-called prison-psychotic-complex in its narrower sense is of
hysterical nature, does so because he claims to be able to see in these
patients the dominance of a wish factor, namely, the wish to be
considered insane, and consequently to be transferred to an institution
for the insane.
He explains the recovery of these patients upon being transferred to
such an institution on the basis of the fulfillment of this wish. My
experience has been that it is very difficult in most instances to
differentiate these acute psychogenetic states from certain hysterical
conditions. Some of them show a good many hysterical symptoms, while in
others such symptoms are absolutely wanting. One of the cases herein
reported illustrates this point especially well. This patient was
admitted to our hospital on two occasions, the first time while awaiting
trial on a charge of murder, and the second time soon after conviction
and sentence to life imprisonment. His first attack showed very little,
if anything, of a hysterical nature, while his second attack had so many
features of hysteria that it could hardly be considered anything but a
psychosis of an hysterical nature.
CASE I.--E. E., Negro, aged 32 years. One sister insane, a brother is
said to be subject to convulsions. Patient's birth and childhood
normal; attended school for three or four years, where he made normal
progress. He entered upon the life of a common laborer when quite
young, and always managed to earn a substantial livelihood for himself
and family. With the exception of typhoid fever at six or seven years,
he was never ill before. He used alcoholics in moderation, and denies
venereal history. Criminal history is uncertain; according to his
statements he was arrested but once before, for fighting. It appears
that he was working as usual until August 19th, when he was arrested
on a charge of assault and robbery. The patient has a hazy
recollection of this; he cannot say how long ago it was, but thinks it
was sometime in August; he was arrested at night; cannot state at just
what time, but is certain that it was after sunset; does not know who
arrested him; says there were several of them; does not know whether
they were policemen or detectives. The police records show that he was
arrested on the night of August 19th, after a desperate fight. The
following day he suddenly became insane in his cell at the fourth
precinct station house. He became very excited; commenced to shout
that he had been shot in the abdomen by an enemy. When offered food he
threw it at the policeman through the bars of his cell door, and then
began beating his head against the walls of his cell. He was
transferred to the observation ward at the Washington Asylum Hospital.
The records of that institution show the following: On admission he
was yelling, cursing, and very much excited; completely disoriented;
repeated the same sentence over and over again in a singing fashion.
He talked to the Lord, and answered imaginary questions; had auditory
and visual hallucinations, and various delusional ideas; thought
someone was talking to him constantly; that he was being shot at every
few minutes, and yelled with anguish at every supposed shot. He cried
and sang alternately. Owing to his marked excitement he had to be
kept in constant restraint.
On admission to the Government Hospital for the Insane, on August 23d,
three days after the onset of the disorder, he was in a semi-stupor;
no replies could be gotten to questions, and his attention to the
extent of looking at the examiner could be engaged only after vigorous
shaking. General hypalgesia was present; he responded but very feebly
to pin pricks. He was absolutely passive to the admission routine, and
offered no resistance whatever to what was being done to him. His body
did not show any resistance to passive movement, on the contrary, it
was rather limp. He was lying in bed staring in a fixed manner
straight ahead of him and would emit an occasional grunt, and a few
unintelligible words. He refused nourishment, was untidy in habits,
and appeared to be wholly oblivious to his environment. Respiratory
and cardiac action somewhat accelerated, pulse rapid and feeble.
August 25th:--Continues in the same stuporous state; absolutely
oblivious to his surroundings; refuses food; untidy in habits. Aside
from an unintelligible word or two, has not spoken any since
admission. There are several beginning pustules on his back.
August 28th:--Some improvement noted; asks for water spontaneously;
when spoken to says his back aches, and that they are pouring water on
him. "I read the book, I went to church." Unable to feed himself or
dress without assistance; totally disoriented.
August 30th:--Came out in the hall today, and spent the time sitting
quietly on a settee; does not take any interest in his surroundings;
has not spoken any spontaneously. Answers are given in a brief and
retarded manner, preferably in monosyllables, and not to the point. On
being questioned concerning orientation, says: "My back, church, the
book", "they are burning me up." Appearance indicates marked
confusion.
September 3d:--The patient suddenly became clear mentally this
morning; seems to have completely recovered from his stupor; attends
to his wants, and answers questions in a clear, coherent manner.
Approached the physician this morning and asked for a laxative; says
that he remembers nothing that transpired during the period since his
arrest, and a day or two ago, when he began to see things more
clearly; complains of pain in back; does not know where he is, and
thinks he came here yesterday.
"What is your name?"
"E. E."
"Age?"
"I will be 33 the 16th of this coming April."
"When were you born?"
"In 1879."
"What is your occupation?"
"I am supposed to be a huckster."
"Where were you born?"
"At Columbus, South Carolina."
"What day is this?"
"Sunday." (correct)
"Date, month and year?"
"It's the 9th month, 1911, I don't know the date; I have not seen an
almanac."
"What is the time?"
"I don't know, sir; I think it is pretty near one o'clock." (correct)
"Where did you come from?"
"I don't know where I came from; they hit me over the head."
"When did you come here?"
"I don't know; I look out of that building that looks like the House
of Rep." (After studying the surrounding country a while, says:)
"Let's see, this must be Anacostia, ain't it; I never was out here
before." (correct)
"How long did it take you to get here?"
"I don't know, sir."
"Name of this place?"
"You've got me now."
"Where is it located?"
"It seems to be in Anacostia, the way I can figure it out." (correct)
"What sort of a place is it?"
"Well, to my judgment, it looks as though it's all right."
"Who are these people about you?"
"I don't know, sir."
"Is there anything wrong with them?"
"Well, I don't know, I am afraid to say; I don't know the nature of
anybody but myself."
"Why do you suppose you are being asked these questions?"
"Well, I think it is to sound my knowledge."
"Why were you sent here?"
"I don't know, sir."
"How do you feel?"
"I feel all right, with the exception of my back."
"Are you happy or sad?"
"Well, I am neither one."
"Are you worried about anything?"
"No, sir."
"Did anything strange happen to you for which you can't give yourself
an account?"
"I can't understand what happened to me, or why I am here."
"Do you hear voices talking to you?"
"No, sir."
"Do you see any strange things?"
"No, sir, I don't see anything strange, only my surroundings."
"Do you ever have fits or convulsions?"
"No, sir."
"Did you ever try to commit suicide?"
"No, sir, and ain't never going to try it."
"Is anybody trying to harm you in any way?"
"Yes, I really believed somebody tried to do something to me."
The foregoing questions were answered without any hesitation and in a
prompt manner.
September 6th:--Today, patient gave in a coherent and relevant manner
his past history. He talked freely, and all evidence of suspiciousness
or evasiveness was absent. Upon examination he was found to be
perfectly oriented in all spheres; free from delusions and
hallucinations, and possessing quite a degree of insight into his
recent mental disorder. While reluctant to admit that he had been
insane, he fully realized that something was wrong with him. He showed
a normal emotional reaction to the situation at hand; felt satisfied
with his surroundings, and was very much concerned and anxious about
his release. Special intelligence tests failed to reveal any
intellectual defect. He was found, however, to be a rather ignorant
negro. Memory and attention were unimpaired. Apperception good;
physical examination showed him to be a well-developed man of medium
size, height five feet, three inches, weight 150 pounds. Aside from
several pustules on the back, he showed no physical disorders.
Neurological examination, negative.
September 14th:--Patient was today discharged by a jury, as not
insane. He presented a normal appearance upon leaving the Hospital.
Insight was good, and there existed a total amnesia for the period
between August 19th, when he was arrested, and September 3d, when he
recovered from his stupor.
This case illustrates in an excellent manner the development of a mental
disorder as an immediate consequence of a situation strongly affective
in nature,--in this instance, threatened imprisonment for a grave
offense.
The emotional shock of the arrest called forth in this, to all
appearance, previously normal individual, a marked excitement
accompanied by hallucinations and fleeting delusional formations. This
excitement, which required the application of constant restraint, was
followed by a stuporous state and total clouding of consciousness. Upon
being removed to a hospital, and surrounded by a new environment,
patient gave evidence, after a sojourn of only a few days, of the
salutary effect of such procedure. On September 3d, ten days after
admission, the stupor disappears, and the only residue of the one-time
psychosis is a complete amnesia for the entire period. The amnesia and
the hypalgesia, which the patient manifested on admission, are the two
symptoms which may perhaps be considered as more or less hysterical in
nature. Aside from this, it is difficult to see wherein the psychosis
resembles an hysterical disorder. Another point which should be
mentioned here in passing, and which will be dilated upon later, is the
medico-legal importance of this class of cases. This patient was wanted
for assault and robbery in an adjoining State. Upon his admission to
this institution an inquiry was received from the U. S. Attorney for the
District of Columbia as to the probable duration and course of this
man's disorder, as they had in possession extradition papers from the
authorities of the State in which the crime was committed. It was only
by recognizing the nature of this disorder that we were able to furnish
the authorities with intelligent information concerning the prognosis of
the case, and which the course of the disease corroborated in every
detail. By recognizing the fact that these disorders are consequences of
the criminal act, the possibility of considering the man insane at the
time of the commission of the act is obviated in a large measure.
CASE II.--R. S. C., a white male, age 48 years, who is now serving a
life sentence for murder. One brother and one sister died of
tuberculosis. Another sister and two maternal aunts were insane.
Father alcoholic. Patient has always been regarded as rather sickly.
Had the usual diseases of childhood and has been subject all his
lifetime to frequent headaches. His school career was very irregular
in character and he never advanced beyond the elementary subjects.
Socially, he belonged to a very ordinary stock of frontiersmen and his
chief occupation consisted of farming and certain minor speculations.
He apparently led an honest and more or less industrious life. Married
in 1886, and his conjugal career is uneventful. In March, 1901, he
moved to Addington, Indian Territory. This was a newly-established
frontier town and he had bought, sometime previously, several lots
there, intending to establish himself in the lumber business. Soon
after this he got into some financial difficulty with a town-site
boomer, and finally, in a fit of passion, shot and killed the latter
and wounded a relative of his own. He was admitted to the Government
Hospital for the Insane, December 13, 1901, from the Indian Territory.
From the medical certificate which accompanied him on admission it
appeared that soon after the commission of the crime the patient began
to show evidence of insanity by incoherent talk, false ideas,
nervousness, and outbursts of vicious excitement. Later, this was
followed by mutism, refusal to eat, and stupor. On admission to this
hospital he was in a deep stupor, absolutely oblivious to everything
about him. Eyes were wide open and staring, pupils dilated, voluntary
movements markedly in abeyance. He was mute except for an occasional
incoherent mumbling to himself. He evidenced no initiative in feeding
himself, but swallowed food when it was placed in his mouth. Habits
were very untidy; involuntary evacuation of bladder and bowels were
present. His mental content could not be determined at the time, as
his replies were indistinct and monosyllabic, and were obtained only
after much effort. He appeared to comprehend what was wanted of him,
although this was not absolutely certain. His perception was very
dull, ideation slow and laborious. His attention could be gained only
after considerable difficulty, and he had to be aroused first from a
more or less profound stupor. Spontaneous speech was almost wholly
absent, but occasionally he would utter a word or two about his wife
and children. No delusions or hallucinations could be elicited.
Physical examination showed him to be quite thin and emaciated. Gait
slow and unsteady. Voluntary movements retarded. Knees trembled and
knocked against each other. No paralyses or pareses noted. Marked
general tremors were occasionally seen. Musculature well developed but
flaccid. All deep reflexes diminished. Cremasteric absent. Other
superficial reflexes were noted to be normal. Organic reflexes
abolished. Involuntary urination and defecation. There was a systolic
murmur present and a slight impairment of the upper lobe of the right
lung. Breath very offensive. He remained in this stuporous condition,
leading a more or less passive existence, for about a month after
admission. For two months following this he was quite agitated, and
his outward reactions indicated that he was quite depressed. On
April 25th, about four and a half months after admission, when asked
how long he had been in the Hospital, he replied three days. From that
time on he began to improve. Consciousness became clearer. In June, he
talked and acted quite rationally. He had a total amnesia of what had
transpired during his stuporous and agitated states and a retrograde
amnesia for several days prior to, and including the commission of the
murder. He continued clear mentally and in a more or less normal state
until the latter part of November, 1902, when he again went into a
stupor. From this time until the later part of April, 1903, he had
alternating periods of stupor and lucidity, with amnesia for the
stuporous states. On June 21, 1903, he was discharged as recovered and
returned to the Indian Territory to undergo trial for his offense.
Unfortunately, no mention is made in the hospital records of any
possible relation between his periodic stuporous states and any
environmental condition which may have provoked these; nor does there
appear in the hospital records any mention of the degree of insight,
if any, the patient possessed at the time of his release from the
institution.
He remained in jail at Ardmore, I. T., until April 8, 1904, when he
was tried and found guilty of murder in the first degree. He was then
returned to jail and after about a year's sojourn there was sentenced
to life imprisonment and transferred to the United States Penitentiary
at Leavenworth. He was readmitted to the Government Hospital for the
Insane on March 25, 1906, from the United States Penitentiary at
Leaven worth. No medical certificate accompanied him on admission and
it is therefore impossible to set, even an approximate date, for the
onset of his present mental disorder; but inasmuch as he had not been
in prison even a year before his transfer to our hospital, and as it
usually takes several months to carry out the required legal
proceedings, his mental disorder must have set in quite soon after his
confinement in the penitentiary.
He was again in a stuporous condition on his readmission to our
hospital, and absolutely oblivious to his surroundings. For about
twenty-four hours he was wholly inaccessible, would not reply when
spoken to, and had to be aroused from a sort of lethargic state before
his attention could be gained at all. On the following day
consciousness cleared up to some extent and he recognized some of the
attendants whom he had known on his previous admission. He remained,
however, more or less confused for several days, after which his
mental horizon became clear, and simultaneously with this, delusions
of suspicion and persecution became evident. He did not know how long
he had been in this confused state and had a complete amnesia for the
entire period. Stated that he had been poisoned and that attempts to
kill him had been made at the Penitentiary. He knew he had been doped
any number of times. Aside from this paranoid complex he had a
complete left-sided functional hemiplegia with all the concomitant
signs. Left visual field considerably contracted. From May, 1906, to
February, 1907, he passed through a number of stuporous periods,
during which he was confined to bed from a few days to a week at a
time. At these times he would lie with a vacant and staring
expression, and questioning would often fail to elicit any reply. At
times he would partake only of liquid nourishment, then again would
have to be spoon-fed. During his lucid intervals he would be up and
about and more or less cheerful. Occasionally played games with his
fellow patients. He continued to be very suspicious; frequently spoke
of being doped and poisoned. Refused to take medicine, and at times
refused to take nourishment because he believed it to be doped. A
stenogram of February 10, 1907, shows him to have acquired some
grandiose ideas and to be still disoriented to a large extent. Some of
his replies were absolutely unreliable. For instance, when asked how
long he had been here he replied: "If I came on March 25th, I have
been here for three hundred and sixty-five thousand days. It is
reasonable but you wouldn't understand it. When a man is answering for
something he should not answer for, every day amounts to a thousand
years with the Lord." He stated that he knew that attempts were being
constantly made to affect him with chemical substances; these were
placed in his food and rubbed on the walls of his room, making him
dizzy and giving him a sort of peculiar feeling, etc. He could hear of
things occurring in distant places and even in foreign countries just
as though he were there. He could tell what was going to happen; had
no trouble at all to look into the future. He attributed this ability
to some superhuman power, but which was natural to him. This power was
bestowed upon him by the superhuman power itself. In prison every
possible means to kill him were used but without success. They even
tried to chloroform him for a day and a night, but could not kill him.
May, 1907:--Still delusional, hypochondriacal; paralysis very much
improved. Complains at times of quiverings in the right extremities
and a numbness of the left side.
August, 1907:--Has been again in a stuporous state for four days.
Still entertains paranoid ideas, hypochondriacal. This was followed by
a lucid period which lasted until November 25th, when he again went
into a profound stupor and became totally oblivious to everything
about him.
April, 1909:--Very much disturbed for about a week. Complained that
the physicians and attendants were torturing him in order to drive
him insane. Called them brutes and threatened to starve himself to
death.
December, 1909:--Neurological Examination--Hemiplegia almost entirely
disappeared, but numerous physical stigmata still persist. Has been
uninterruptedly clear mentally since his last stuporous state, in
November, 1908.
January, 1911:--Clear mentally. Answers questions coherently and
readily. Attention easily gained and held without difficulty. Memory,
for both recent and remote events, fair, with complete amnestic gaps
for the stuporous periods. He shows the characteristic hysterical
make-up. He is morbidly suggestible and suspicious. He is markedly
egotistical; becomes easily irritated at the least provocation. Is
extremely hypochondriacal and shows a marked tendency to exaggeration
of actual ills. Constantly laments his fate of being compelled to stay
in a place of this sort, which is a thousand times worse than a
prison. Is certain that his trial was crooked and irregular and that
he had not been given a fair chance. His sentence is inhuman and
unjust, as he was not responsible for the crime he committed; he
remembers nothing of the occurrence and consequently must have been
insane at the time. He is inclined to a great deal of fantastical
day-dreaming, writes poetry and religious dissertations. He is
constantly bewailing his unfortunate lot in letters to people of high
station, imploring their compassion on the poor, down-trodden martyr.
Is clear mentally throughout and no definite delusions nor
hallucinations can be elicited. His morbid suspiciousness, however,
leads him to interpret various occurrences in his environment in a
more or less delusional manner.
August, 1911:--No change from the above note except that the physical
stigmata have almost completely disappeared. Patient has an adequate
amount of insight into his stuporous state, but does not realize that
his entire make-up is more or less pathological in character.
The patient had finally sufficiently recovered to be able to be
returned to the Penitentiary, and as he was very desirous of the
change, he was, accordingly, discharged from further treatment,
March 25th, 1912, to be returned to the United States Penitentiary,
Leavenworth, Kansas. At this date, November, 1915, I am informed that
the patient gets along very well at the Penitentiary, working in the
hospital of that institution.
We are dealing here with an individual who, to start with, comes from a
badly tainted family. He leads an honest, more or less industrious life,
until one day, in a fit of passion, he shoots and kills a man with whom
he has some financial differences. Being uncorrupted and of a
non-criminal make-up, the enormity of his crime suddenly dawns upon him
with its full force. He is unable to withstand the emotional shock which
the realization of his deed provokes, breaks down under the stress, and
develops a mental disorder. He is removed to a hospital and under the
salutary influence of new environment gradually recovers his normal
mental health. Simultaneously with this he begins to nourish the hope
that he may escape punishment for his deed. The amnesia for the period
during which the crime was committed lends support to his optimistic
views concerning the outcome of the case, and his mind becomes, in
consequence, wholly taken up with the idea of being acquitted of the
murder charge. He remembers nothing of the deed, and therefore must have
been absolutely unaware of what he was doing at the time. His hopes are
shattered when he is found guilty and sentenced to life imprisonment.
His nervous system is unable to withstand this blow and it yields a
second time, only in a more pronounced manner.
One need not enter into a lengthy discussion in order to show that we
have here a mental disorder, the origin of which can be definitely
traced to psychic causes, the emotional shock accompanying the crime and
conviction. Cause and effect are clearly in evidence here. We have
before us a well-defined psychogenetic psychosis. In addition to this
the course of this man's mental disturbance was influenced to such an
extent by his immediate environment that one could practically shape the
symptomatology thereof at will. Once, after a prolonged period of a
state which might be considered almost normal to the individual, he
induced the attending physician to bring his case for consideration
before the staff conference with a view to being returned to prison. At
this conference it was decided that in view of the very deleterious
influence which prison life has had in the past upon this patient it
would not be advisable at this date to send him to the penitentiary.
Upon being told that he would have to remain at the hospital, patient
again became morose, hypochondriacal, refused nourishment, and commenced
to hold himself aloof from the other patients. His suspiciousness and
vague persecutory ideas with reference to the personnel of the hospital
became more pronounced, and he could see no other reason for being kept
here than that the officials are continuing in their persecutions of
him. I am convinced, without a doubt, that should this man be pardoned,
all the manifestation which he now possesses, and which may be
considered as pathologic in character, would at once disappear. The
difference in the symptomatology of the two attacks serves to
illustrate how difficult it is to positively state what relation these
disorders have to hysteria. Here we have an individual whose past life
fails to indicate anything which may be taken as of an hysterical
character. He develops a psychogenetic disorder in consequence of his
crime, the symptomatology of which shows little, if anything, of an
hysterical nature. In due course of time he gets well, and after having
thrust upon him a life sentence, again returns to us with a mental
disorder, the chief feature of which is a functional hemiplegia. There
is very little doubt that by studying a cross-section of his second
attack we could easily place it under the group of hysteria.
Considering, however, the history of the case _in toto_, we would have
to proceed rather cautiously in judging of the hysterical element
thereof.
CASE III.--G. W. W., white, male, aged 26 years, whose hereditary
history cannot be definitely determined. It appears that mother was a
janitress in Boston, and had several children by various fathers.
Patient grew up in an orphanage, and worked on farm until age of 18,
when he drifted to Denver, Colorado, and enlisted in the U. S. Navy.
He served one enlistment with a good record, was a good sailor, and
got along well in every respect. He reenlisted the second time about
the middle of 1909, when at the instigation of a fellow sailor he
deserted from the Navy in company with the latter. On August 20, 1910,
they held up the captain of a ship with the intention of obtaining
some money which was stored on board the vessel. In the encounter the
captain was killed by the patient's companion, who made his escape,
while the patient was apprehended and held on a charge of murder. On
August 24th, he was placed in jail at Oakland, California. From the
beginning he was regarded by the jail officials as rather silly and
defective. He did not appear to be very much interested in his case,
and never spoke of his own initiative to his attorney about it. On
May 8, 1911, he was seen for the first time by a psychiatrist. He was
then found to be very distractible and inattentive, seemed suspicious
and excited and assumed stiff attitudes. He was well oriented, and
recognized that he was on trial for murder. It might be mentioned here
that although the jail officials apparently noted from the first that
the patient was not right, the legal proceedings were continued, and
it was only on the 4th or 5th day of his trial that his conduct became
such as to strongly suggest that he was insane. A psychiatrist was
then called in and he pronounced the patient insane, whereupon the
proceedings were stopped at this juncture. Examination at that time
revealed the following:--General sensation markedly reduced;
hypalgesia, he allowed needles to be stuck into his tongue without
flinching; walked in a stiff and stooping fashion; no Romberg;
moderate vaso-motor stasis, with bluish, cold hands. Gait
uncharacteristic. Eyes reacted to light, directly and consensually,
and to accommodation. Patellar, Achilles and arm reflexes markedly
exaggerated and equal. No foot clonus, no Babinski; abdominal
reflexes present, cremasteric not elicited; catalepsy not always
present.
Mental Examination:--Attitude was variable, but was distinctly that of
one in a stupor. Arms, hands and legs, placed in uncomfortable
positions, would remain fixed indefinitely, _i.e._, so observed from
20 to 30 minutes. Did not resent liberties taken with him; smiled in a
silly fashion at each person. Orientation perfect; no insight;
hallucinations and delusions could not be elicited. Attention could
only be gained with great difficulty, and held for a very short time.
Retardation was present; movements were slow and stiff. When
stimulated, however, he responded promptly and had no retardation.
Speech and writing showed nothing characteristic.
May 11:--Flexibilitas cerea more marked; mutism; retention of saliva;
eats food voluntarily; bowels require frequent attention.
May 20:--Requires spoon-feeding; sleeps well; remains always in bed in
stiff attitudes.
June 1:--For three or four days refused food, except for one or two
meals daily. At times suddenly surprises attendants by sensible
remarks, as: Another patient said, "That is G. W. W.," and patient
promptly replied, "No, it is Rip Van Winkle." Negativistic signs more
marked. Knows physician when eyes are pushed open. At times tries to
whistle.
June 13:--For past week has been noisy and excited. When he hears
dishes rattle, yells "Chow-chow" for a long time. Continued hot bath
for one hour always relieves this excitement. Physical signs negative;
Wassermann negative; blood and urinary analysis negative.
June 18:--Admitted to the Government Hospital for the Insane. The
Marshal who accompanied the patient from California to this
institution states that the patient was resistive and negativistic;
that he assumed various constrained attitudes; was untidy, mute, and
refused food. All these tendencies were markedly influenced, however,
by positive requests of the Marshal. When told that he would be
chastised if he did not give up his untidy habits, these disappeared,
etc. On admission to the Government Hospital for the Insane the
patient had to be carried into the ward, as he refused to walk. He was
mute, negativistic, and assumed various uncomfortable and constrained
attitudes. Every now and then he would snap at those who handled him,
and this would be accompanied by a growl. He was very resistive to the
taking of a bath, and suddenly snapped at the attendants who cared
for him. When reprimanded, however, by the Supervisor, and told that
he would have to take the bath, he quietly underwent the procedure.
Physical Examination:--Pupils widely dilated. Face somewhat distorted.
Pupillary reflexes normal; although limbs would remain in a fixed
attitude when so placed, he did not evidence the typical flexibilitas
cerea. It seems as though he anticipated the passive movements, and
there was present a certain amount of voluntary intent. All
superficial reflexes active; winced when pricked with a pin but there
was a decided hypalgesia present. He refused food; was mute, and
apparently oblivious of everything about him. This, however, was only
apparently so, as he showed by various acts that he was more or less
aware of his surroundings. For instance, during the examination he
suddenly snapped at the examiner, and upon the latter's discomfiture
he emitted a momentary giggle. When feeding-tube was placed in his
nose, preparatory to feeding, he jumped up and said, "I'll drink it,"
and drank the entire contents of the pitcher. While some parts of his
body remained absolutely fixed, restrained and immovable, his face was
constantly undergoing various grimacing motions, accompanied now and
then by the snapping of his jaws and a growl. During the following
several nights he was very noisy, excitable, singing and shouting
throughout the night. Mental content could not be determined at this
date.
June 28, 1911:--He remains in same apparent stuporous and catatonic
attitude. For past few days has exhibited various childish and silly
acts of a meaningless and monotonous nature. Still mute except for an
occasional growl. Became very untidy today, but when reprimanded and
told he must use the toilet he did so.
July 1, 1911:--Patient has been very noisy on several occasions in the
past few days, but always becomes quiet when requested to do so.
Continues negativistic, stuporous and attitudinizing. Today he was
overheard saying: "I am a monkey; want to go out in the yard and sit
on the benches; there was no plea of insanity; who are those boys?
Come in, boys; water, won't drink it because there is poison in it, it
looks good, so try it. Don't believe there is anything in it." He
persevered in repeating these phrases.
July 2:--Sang all morning in an undertone. Would stop singing and
recommence his facial grimaces when anyone entered his room.
July 3:--For the first time since admission patient answered examiner
to questions.
Q. "What is your name?"
A. "George Washington."
Q. "How old are you."
A. "36."
Q. "When born?"
A. "1884."
Q. "Occupation?"
A. "Farmer."
Q. "Where born?"
A. "Around Boston."
Q. "What day is this?"
A. "Someone says Tuesday."
Q. "What date?"
A. "June 17, 1911."
Q. "How long have you been here?"
A. "I cannot tell you."
Q. "What is the name of this place?"
A. "U. S. Hospital."
Q. "Who brought you here?"
A. "Can't tell you, he looks like a monkey."
Q. "How long did it take you to get here?"
A. "One night and twenty-four hours."
Q. "When did you come here?"
A. "I cannot tell you when I did come here."
Q. "Don't you really know the name of this place?"
A. "Well, sailors in the Navy call it the 'Red House.'"
Q. "Where is it located?"
A. "Washington, D.C."
Q. "What sort of a place is it?"
A. "Why, it's as good as any place else."
Q. "Who are these people about you?"
A. "They might be soldiers; what are they out there for?"
Q. "Is there anything wrong with them?"
A. "How should I know?"
Q. "Are any of them insane?"
A. "Darn'd if I know."
Q. "How do you feel?"
A. "How did I get cured of my headache? I'll stick a pitchfork through
you, and if a pitchfork goes through you, it will go through me too."
Q. "Are you sick?"
A. "I was sick; had a pain in the head."
Q. "How do you feel now?"
A. "Oh, pretty good."
Q. "Is there anything wrong with your mind?"
A. "I don't know, I can't tell you."
Q. "Do you hear any strange noises or voices?"
A. "Can you go over to that tree? Sounds like a baby squealing; it's
the man that choked the baby."
Q. "Do you ever see strange things?"
A. "Did I ever see strange things? I might read about them in the
magazine."
Q. "Do you ever hear voices?"
A. "I hear voices say to you; 'You are not guilty.'"
Q. "How much money are you worth?"
A. "$100; I'll give it you for my life."
As will be seen from the foregoing stenogram, the patient is only
partially oriented, perhaps more so than he shows, because of his
tendency to answer questions in a sort of careless manner. There is a
slight suggestion of "by speaking" (Vorbeireden). The stenogram also
suggests the possibility of the existence of fallacious sense
perceptions. Of the utmost importance, however, for our consideration,
is the fact that the occurrence which brought about the mental
breakdown plays an important role in the consciousness of the patient.
Amid what may be considered an almost total oblivion to his immediate
environment, he hears the voices tell the examiner that he is not
guilty, he would give the $100 which he possesses for his life. These
are unmistakable signs of the psychogenetic nature of the disorder.
July 31:--Patient is well oriented, talks in a retarded manner;
questions are answered for the most part correctly; occasionally, only
nearly correct. His memory is good for remote events, but very much
clouded for events which have transpired since the commission of the
crime. Partial insight is present. He realizes that there must have
been something wrong with him. Emotionally not deteriorated. Refuses
to discuss his crime, saying it makes him feel bad; talks in a
childish, affected tone of voice, and undergoes various grimacing
movements; gives frequent evidence of being fully aware of occurrences
in his environment; talks and eats voluntarily and is tidy in habits.
Occasionally laughs in a silly, affected manner. Flexibilitas cerea
and catalepsy entirely disappeared; gained considerably in weight;
continues to show marked tendency to be influenced by occurrences in
his environment. In general, shows a decided improvement in his
condition.
We are dealing here with an individual whose past career is uneventful,
as far as is known. He is charged with murder, and upon being tried for
this develops a mental disorder. The symptomatology of his psychosis
could easily be mistaken for that of catatonic praecox, and, as a matter
of fact, had been so diagnosed by the first observer. In studying the
case more thoroughly, however, it becomes unmistakably evident that we
are not dealing here with a case of catatonia. In the first place, the
immediate relation between the emotional shock of the crime of murder
and the probable punishment for it, and the development of the mental
disorder must be taken into consideration. This is not a mere accidental
relationship. But even if we grant that this point cannot be definitely
decided, the psychogenetic character of this case cannot be doubted when
we remember how the entire symptomatology is absolutely dependent upon
and influenced by occurrences in the patient's environment. He refuses
to eat, a symptom very common in catatonia, but it is indeed a rare
occurrence for a catatonic in the midst of a negativistic stupor and
mutism to say, "I'll drink it," and actually drink voluntarily the
entire contents of the pitcher in order to avoid tube-feeding. He is
untidy in his habits, another common catatonic characteristic, but is it
to be expected that a catatonic, in the height of his disorder, will
abstain from his filthy habits when threatened to be punished for these?
Many more instances of similar nature could be cited in this case.
Another feature which removes all doubt of the psychogenetic nature of
this disorder is the important part which the mental experience which
was active in the production of the disorder played in the fashioning
of its symptomatology. I alluded before to the patient's answer to the
question of whether he heard voices.
The disorder itself, as far as the symptomatology is concerned, is not
absolutely typical of any one of the acute psychogenetic states. It
partakes of Kutner's "catatonic states in degenerates" as well as
Raecke's confusional hallucinatory disturbances in these individuals.
That the patient can be classed as one having a degenerative soil is not
at all certain in this case.
I have considered briefly the importance of a proper recognition of
these cases from the viewpoint of rendering a proper prognosis. There
is another important question which must be discussed in connection with
these cases and that is the question of malingering. Picture to yourself
an individual, who, to all appearances, has led a normal existence, and
never showed anything mentally which might be considered pathologic. He
commits a crime, and upon being arrested or upon being placed on trial
for his offense, suddenly lapses into a condition of apparently complete
dementia. The man, who formerly showed nothing in his conduct and
behavior indicative of a mental disorder, suddenly changes into a state
where he does not know his name, age, or his whereabout. His answers to
questions are irrelevant and of a remarkedly silly coloring. He begins
to act in a childish, affected manner, executing many silly, meaningless
acts, or he may break out in a wild furious excitement, loudly
proclaiming his innocence, and threatening those who arrested him. In
addition to this, it is noted that this apparently pathologic condition
can be definitely influenced by using strict and positive measures. The
untidy habits of the patient may be corrected by urging or threats. The
man who has been mute and refuses to eat can be made to talk and eat
voluntarily by threatening him with tube-feeding. Furthermore, in the
midst of this apparently total dementia, total blocking of all thought
processes, the patient frequently surprises those about him by very
sensible remarks of a very clever and pertinent nature, indicating that
although apparently oblivious of his environment, he knows what is going
on about him.
A picture like this may readily arouse the suspicion that we are dealing
with a malingerer, and, indeed, some very prominent German psychiatrists
have reported as malingerers cases similar to this. The trained
psychiatrist, if unfamiliar with this class of cases, will find himself
at a loss to know under what known group of mental disorders to place
this condition, as it will at once become apparent to him that it does
not fit into any of the well-known psychoses.
In defense of the genuineness of the psychotic manifestations of these
patients, I would recall again the transitory mental disturbances of
students undergoing examinations. The genuine loss of all knowledge of
well-known facts which the old-time strict and severe schoolmasters
frequently provoked in school children, differs very little from the
pseudo-dementia with which we are dealing here. It concerns a similar
total blocking and inhibition of all thought processes, and, like all
psychogenetic disorders, has a tendency to disappear upon the removal of
the causative factor.
Still, nobody would think for one moment that the child malingers when
it is unable to answer questions, though these might concern well-known
facts. The consequences of failure to recognize this acute
prison-psychotic-complex as a genuine mental disorder may prove to be
very disastrous when we remember to what extent the symptomatology of
these psychoses is dependent upon environmental conditions.
THE DEGENERATIVE PSYCHOSES
I have considered thus far those psychogenetic mental disorders, the
etiologic factor of which consisted of a single, more or less isolated
emotional occurrence. We have seen that the majority of these patients
showed very little, if anything, in their past life which was in any way
incompatible with leading a more or less successful existence in the
community in which they lived. These patients, we might say, would never
have been brought to the attention of the psychiatrist had it not been
for the occurrence in their life of an experience which provoked a
mental breakdown.
I will now consider a group of cases, in whom the degenerative soil is
so prominent that they have been properly called "Psychoses of
Degeneracy." They should, however, be considered here, because the
various psychotic manifestations of these individuals are purely
psychogenetic in nature, and evoked by a certain milieu in which the
individual was placed. As my material is derived from the criminal
department of the Government Hospital for the Insane, the causative
factor in these cases will again be found to be imprisonment. These
cases differ from the so-called acute prison-psychotic-complex in that
the etiologic factor does not consist in a single emotional experience.
We are not dealing here with patients in whom the commission of a crime
is an accidental occurrence in their life, that is, still uncorrupted
individuals upon whom the criminal act in itself might act in a
deleterious manner. The patients belonging to this group are, as a rule,
old offenders, who have long been hardened to crime, and whose entire
life is an uninterrupted chain of conflicts with the law. To this group
also belong those high-strung individuals with early antisocial
tendencies, who from childhood show a marked degree of egotism and
self-love; who are very vindictive and revengeful in their reaction to
frictions in social life. Upon falling into the hands of the law, they
are incapable of adjustment to the new situation, react in an insane and
wild manner to the prison routine, and, in consequence, frequently
commit grave offenses during imprisonment.
We owe our present knowledge of the psychopathology of these individuals
to the excellent work of the followers of the great Magnan, who
contributed so richly to the study of degeneracy.
Siefert[9] was the first to clearly differentiate the purely endogenetic
disorders from those dependent upon a degenerative soil, and evoked
exclusively by outside influences. He divided the eighty-seven cases of
psychoses in criminals studied by him into two distinct groups, namely,
the real psychoses and the degenerative psychoses. Under the former
thirty-three cases he places the well-known forms of dementia praecox,
epilepsy, paresis, etc. These, according to him, are not in the least
influenced by the milieu in which they occur (in this instance, prison
environment). His fifty-four cases of degenerative psychoses, on the
other hand, were characterized above all by the fact that they stood in
the most intimate relation with the environment in which they occurred,
and were wholly influenced by the same. The pathologic, degenerative
soil which permitted of the development of the psychosis in these
individuals consisted of irritability, lability, autochthonous
fluctuations of mood, fantastic day-dreaming, a heightened subjectivity
to the environment, inability to form correct critical judgment
concerning unpleasant occurrences about them and a strong tendency to
suggestibility. On the physical side these patients were subject to
headaches, migraine, restlessness and anxiety, often associated with
disturbances of heart-action, hypochondriacal complaints, and a tendency
to become easily tired upon physical or psychic exertion. They also
showed, as a rule, intolerance for alcohol, and were wont to react to
alcoholism in a strongly pathologic manner.
Siefert divides his fifty-four cases of degenerative prison psychoses
into the following groups:--
First:--Hysterical degenerative state. These consist of undoubted cases
of grave hysteria, with convulsions, physical stigmata, endogenous
states of ill-temper, confusional states, Ganser twilight syndromes,
etc.
Second:--Simple degenerative states. These differ from the preceding
group in that hysterical stigmata are wanting. These patients are
subject to severe maniacal outbreaks, motor excitements, mutism, attacks
of anxious, delirious states, with confusion, etc.
Third:--Fantastic degenerative forms. This group concerns markedly
degenerated individuals with a pathologically exaggerated imaginative
faculty, a strong auto-suggestibility, a tendency to deceit and lying,
to inherent fluctuations of mood and hysterical stigmata. On this basis
there develop conditions of pseudologia-phantastica, systematized
delusional formations of all sorts, delirious psychoses, etc.
Fourth:--Paranoid degenerative forms. This group he again subdivides
into the querulent and hallucinatory paranoid forms. The former may
resemble the typical "Querulantenwahn", a psychosis artificially built
up out of extraneous circumstances, and one which rarely develops in
freedom, but is of very frequent occurrence in prison. The hallucinatory
paranoid form consists of fallacious sense perceptions and delusions of
a persecutory nature, often substantiated by a strongly hypochondriacal
element; in short, a picture which simulates very closely the real
paranoid state.
Fifth:--Prison psychotic states with simulated symptoms.
Sixth:--Dementia-like processes. The individuals belonging to this group
are habitual criminals in whom the criminal tendencies become evident at
a very early period in life, and who, without giving distinct evidence
in their past history of a mental disturbance, develop after prolonged
confinement a progressive change of character which eventually leads to
frequent rebellious outbreaks against the prison management. They become
absolutely unmanageable, neglect their work and duties, and finally have
to be transferred to an insane asylum. Here they show nothing
characteristic of the well-known dementing processes, as hebephrenia,
for example; but very frequently, although quite young, their entire
manner and behavior suggest a certain dilapidation and deterioration.
Siefert considers the above-mentioned disease processes as entirely
dependent upon and provoked by prison life, in individuals with a
tendency to mental deterioration. He comes to the conclusion that the
prison psychoses are reactions of pathologic nervous organizations to
definite deleterious conditions of life. They are nothing more than
irradiations, distortions, and new creations, on the same degenerative
soil which also conditioned the crime.
The importance of Siefert's momentous work cannot be doubted, but
whether he was justified in his many subdivisions of the degenerative
states is questionable. His own description of the various forms
immediately suggests the difficulty of clearly differentiating one from
the other.
Bonhoeffer,[10] in a monograph devoted to the subject, endeavors to
establish the existence, on the basis of degeneracy, of acute psychotic
processes which do not belong to either the manic-depressive,
hysterical, or epileptic temperaments, which cannot be placed under any
of the known forms of dementia praecox, and which develop as wholly
independent psychotic manifestations in particularly predisposed
individuals. The material which served for his thesis was gathered from
the Berlin Observation Ward for Criminals, among the inmates of which
institution he found a great number of degenerative psychoses. In a
recent work on the subject of psychogenesis he upholds his former views,
and believes he has been able to separate his cases into three distinct
groups. The first group comprises certain unstable individuals who show
a tendency to the development of simple paranoid psychoses. It concerns
patients of a very labile make-up with increased affective reactions,
with marked tendencies to impulsions and antisocial acts. These cases
are characterized by the fact that they do not concern psychogenetic
psychotic exaggerations of a certain temperamental predisposition, but
psychically evoked disease states which appear to be irreconcilably
opposed to the original personality.
He calls attention to the epileptic seizures of these individuals, which
have been so ably described by Bratz.[11] In contradistinction to the
genuine endogenetic epilepsy, these patients manifest epileptic seizures
as reactions to situations purely psychic in nature. In them, without
ever resulting in epileptic dementia, there occur along with the
epileptic seizures attacks of unconsciousness, of excitement, dream
states, and porio-maniacal outbreaks. They differ from the genuine
epilepsy by the absence of the characteristic dementia, of attacks of
_petit mal_, and by the fact that the seizures are never purely
endogenous in origin. They are always due to extraneous causes,
eminently such of a psychic nature. He believes that more frequently
even than actual epileptic seizures are the dream states, excitements,
and maniacal outbreaks brought about in these individuals by emotional
experiences, and as a result of certain ideas and concepts. He places in
this group the proverbial "wild man", the man who goes into a frenzy
upon seeing a policeman, etc. Although alcohol may in these individuals
prepare the way, the immediate causative factor, however, is the
emotional experience, or the recollection of such an experience.
These psychogenetic excitements of degenerates often simulate
symptomatologically genuine epilepsy so far as the ferocity of the
excitement and the state of consciousness are concerned. In some cases
the retention of suggestibility during the attacks shows clearly the
psychogenetic character of the disorder, while in others the tendency
toward the theatrical and exaggeration is so marked that we are forced
to think of an hysterical component. Certain slight symptomatologic
features of these psychogenetic states of excitement in degenerates
appear to furnish a differentiating point between them and the true
epileptic condition. Bonhoeffer refers to the strong tendency to
disgust-evoking manifestations, to copro-practice which manifest
themselves in the soiling of the walls and face with excrements, the
drinking of urine, etc. Another characteristic is the frequent total
misunderstanding of the situation by these individuals in that
they consider themselves to be threatened with impending grave
physical danger. In consequence of this they manifest a certain
over-aggressiveness, which goes far beyond mere protective reactions,
and manifests itself in a senseless breaking and demolishing of
furniture. These individuals can be easily distinguished by their
superficial intellectual endowment, by a tendency to change of
occupation, and early criminality. During imprisonment and under the
influence of the stress incident thereto, they develop an acute paranoid
symptom-complex, a delirium of reference, accompanied by ideas of
prejudice, isolated elementary hallucinations, and irresistible desire
to a depressive recapitulation of their past, and a nervous, irritable
temper. Consciousness is not clouded, and they remain perfectly oriented
in all spheres. The duration of the disorder may vary from a few months
to two years, with occasional intermissions. The delusional formation
continues only for a short period, and in no instance leads to a
retrospective change of the content of consciousness. Very frequently
the process subsides upon the removal of the patient into a new
environment without leaving any change in the personality of the
individual. Insight is not always perfect. The delirium of reference and
prejudicial ideas concerning the prison personnel may remain
unconnected.
The cases belonging to his second group are those well-known pestilent
individuals who from childhood show an abnormally affective reaction to
frictions in social life, in so far as their highly exaggerated,
egocentric self-consciousness permits them to endow every unpleasant
experience with a personal note of prejudice. They are the poor martyrs,
who somehow never seem to get what is coming to them in this world, who
are ever ready to assert their rights and leave no stone unturned until
they receive what they consider full justice. Such individuals may pass
through life, if fortunate enough, without developing a real psychosis.
They are then merely burdensome and uncheering elements within their
narrow social sphere. Should they, however, meet with an experience,
which to them appears as an injustice, they may at once develop typical
paranoid pictures, the characteristic feature of which is that the
psychic experience which forms the origin of the trouble remains always
in the foreground. Bonhoeffer identifies these conditions with
Wernicke's psychoses of hyperquantivalent ideas. He very justly says:
"The narrower the sphere of activity in which these individuals live,
the more frequent the opportunities for conflict are offered by law,
discipline, and subordination, the easier it is to develop a psychotic
exacerbation of the abnormal temperament even on a lesser pathological
basis. This is the reason why officialdom and especially the narrow
limits of prison life bring out so forcibly these psychogenetic
disorders. In prisoners the psychogenetic character of the disorder
becomes especially apparent. One sees how in many cases the transfer
from one prison to another, to an observation station, to an insane
asylum, puts an end to the process. In certain instances the process
seems to revive itself again when the individual is placed in a similar
environment."
Of Bonhoeffer's three subdivisions of degenerative states the preceding
one would as a whole appear to me to be especially deserving of a
separate classification. Anyone who has had any experience with insane
criminals will recall that group of cases in whom the entire psychosis
seems to be more or less centered about a certain idea; in most
instances, about the idea of not having received a just trial. These
individuals, without showing any intellectual impairment, in fact
without showing any characteristic which would fit their mental
disturbance into any of the known psychoses, constantly evidence a sort
of paranoid habitus, a paranoid trend which is exclusively directed
against those who had anything to do with their conviction and
safe-keeping. The most trivial occurrences in their environment are
endowed by them with a personal note of prejudice. The delay of a
letter, the refusal to grant some of their unusual requests, an
attendant's accidental failure to sweeten their coffee sufficiently, the
slightest deviation from the routine greeting of the visiting physician;
in short, any such trivial, insignificant occurrence is at once endowed
with a special meaning, and explained in a more or less delusional
manner. Yet these individuals can reason in a perfectly rational manner
on any subject which is not concerned with their conviction or
confinement. They are as a rule intellectually bright and keen, and fail
to show any evidence of emotional deterioration. On the contrary, their
emotions are of such fine and sensitive nature that incidents which an
ordinary individual would overlook entirely, offend them to a marked
degree, and are reacted to by them in a very decisive manner. Indeed,
one frequently asks himself whether their persecutory ideas deserve to
be endowed with the value of actual delusions. I fully agree with
Sturrock[12] when he says: "If I refuse to allow a prisoner full scope
because he has lifted a knife from the table with which to attack the
charge warder, I do not call it a delusion of persecution if he spends
the night threatening to murder me because I do not give him justice."
One must remember that this is in a measure the normal attitude of the
captive towards the captor, and can be seen in a more or less pronounced
degree among criminals enjoying a short respite from the law. The
essential point here is not the so-called psychosis, but the soil which
made the development possible. Not all prisoners, by far, react in this
manner to the prison environment. It is only those degenerative
individuals who have shown this well-marked paranoic trend all
their lifetime, who furnish these cases. As a general rule these
conditions are seen in habitual offenders whose entire life has been a
round of conflicts with everything they come in contact, and who,
outside of prison, figure chiefly in the saloon and gambling house
brawls.
That these conditions deserve a more definite classification than the
nondescript paranoid state cannot be doubted. These paranoid
manifestations are distinct reactions to a definite situation, in this
instance, conviction and imprisonment, of individuals whose peculiarly
degenerative make-up makes such reactions possible. The question of the
particular coloring which these disorders may assume can only take a
secondary position to that of the character or make-up with which we are
dealing.
Bonhoeffer further speaks of a certain hysterical element in these
cases, but does not believe that on this account these paranoid
manifestations should be considered as hysterical. He rather believes
that they are more closely allied to the epileptoid temperament. The
hysterical component manifests itself in either hysterical stigmata, or,
as has often appeared to him, in the fact that the falsifications of
memory which these individuals frequently manifest concern themselves
solely with the simple overvalued paranoid ideas, and lead to a complete
blocking out of unpleasant recollections of the individual's past
career. Thus, previous sentences, imprisonments, etc., are totally
forgotten. In this, perhaps, we might see the well-known wish factor of
hysteria.
The cases which comprise his third group show such a varying
symptomatology that it is difficult to form an exact idea of just what
characterizes them.
After perusing the work of Bonhoeffer, one feels that the author's
endeavors to subdivide his material into this or that group are somewhat
artificial. Granted that we are dealing with mental disorders, whose
existence can be possible only by a certain degenerative predisposition,
the question arises, "Of how much practical value is this constant
endeavor at classification and subdivision of the psychotic
manifestations which these individuals show?" One must acknowledge that
the salient feature here is not the particular coloring which these
psychoses assume, but, as we have stated before, the soil upon which
they develop. At most, we might say that the symptomatology of these
psychoses would depend on the question whether it is the ideational
sphere which is mostly concerned, or the affective sphere. Turning to
Wilmanns' excellent contribution to this subject one again
meets with the same endeavors at subdivision and classification. Lack
of space will not permit us to enter into an extensive discussion of
this author's work. We have already indicated here and there in passing,
some of the essential points in the views of this author.
One turns with quite a degree of relief to the momentous work of
Birnbaum[13] on the Psychoses of Degeneracy. As far as can be
ascertained the author does not endeavor to subdivide his degenerative
states into so many types and forms. According to him, the essential
characteristics of the degenerative psychoses--namely, the extraordinary
determinability and influence which outside impressions have upon the
disorder, the mode of genesis and the psychological evolution of the
delusions, etc.,--may be attributed to the essential ear-marks of the
degenerative character; that is, to the exaggerated auto-suggestibility,
the great instability of the existing conditions and mental pictures,
the disharmony between the perceptive and imaginative capacities and the
preponderance of a lively fantastic coloring to the dry thinking of
these individuals. They do not form disease processes of a definite
characteristic form, but episodic psychotic manifestations on a
degenerative soil, and the manifold phases of the collective forms are
to be considered as repeated fluctuations about the psychic equilibrium
of these individuals. He further noted that the symptomatology of these
disorders remained limited to a relatively well systematized delusional
fabric, which, however, in contradistinction to paranoia, does not
persist for any length of time, but disappears for certain definite
reasons. They do not form any typical symptom-complex. The delusional
ideas may take on any character; hallucinations may occur in all fields
of the sensorium; consciousness may or may not be clouded, but is
usually so in the beginning of the disorder. Recoveries are as a rule
gradual, but may set in quite suddenly. Insight may or may not be
present. The course of the disorder, like its symptomatology, offers
nothing of a definite, characteristic nature.
Thus we see that the distinguishing feature of Birnbaum's degenerative
psychoses does not lie in their mode of appearance, in their
symptomatology, but in the mechanism of their evolution, and, above all,
in their total dependence upon extraneous influences. They are typical
psychogenetic disorders, the psychic etiology of which is potent not
only in the incitation of the processes, but in the modeling and
fashioning of them. Although Birnbaum notices the close relation that
exists between these psychoses and the hysterical psychotic
manifestations, he would separate them distinctly from hysteria.
CASE IV.--A. C., colored female, age 32 on admission to the Government
Hospital for the Insane, on June 18, 1909. Father died of dropsy; one
brother was killed in a railroad accident; one sister suffered from
St. Vitus' dance; another died of tuberculosis. Patient was born in
Jamestown, Virginia, was healthy as a child. Does not remember having
had the usual diseases of childhood; had a severe attack of typhoid
fever when quite young. Attended school until fourteen years of age,
having reached the third grade. Upon leaving school she went to work
as chambermaid and soon became addicted to the excessive use of
alcohol, as a result of which she got into numerous fights and
quarrels. In 1895, while intoxicated, she stabbed a man in the back
and was sent to Albany Penitentiary for five years and eleven months.
During her sojourn there she was sent to the Matteawan Hospital for
Criminal Insane, where she remained forty-five days. Upon being
discharged she returned to her home and lived with her mother,
assisting her with washing and ironing, following which she led the
life of a prostitute for about two years. In 1901 she was sentenced to
thirty months imprisonment at Moundsville, Virginia, for theft.
Previous to this she had been confined in the Government Hospital for
the Insane for about a month with an attack of delirium tremens. After
the expiration of her sentence at Moundsville, she returned to
Washington and soon after was again arrested for housebreaking and
robbery and sentenced on two counts to twenty years imprisonment at
Moundsville. While there she had more or less trouble all the time;
had numerous fights with other colored women, in several of which she
sustained injuries. On February 12, 1907, while working in the sewing
room, she became implicated in a quarrel with another inmate, whom she
stabbed in the left side of the neck with a pair of scissors. In
describing the incident she says: "I pushed them in as far as they
would go, twisted them around, opened them and then pulled them out."
The woman lived about five minutes after this. The quarrel presumably
originated because her antagonist called her some name and accused her
of having to serve a "young life sentence." She then told this woman
to go back to Anacostia and get the baby she threw over the Anacostia
Bridge, at which the latter became quite angry and attacked her with a
pair of scissors which culminated in the murder. A. C. was placed in a
cell after this and the next day transferred to a dungeon, where she
remained until her transfer to this Hospital. While in the dungeon she
suffered a great deal with headaches and nervousness; she was
absolutely isolated, no one came to her cell, ate her meals through
the bars. In this condition she remained about three months. She says
she prayed a good deal during this period, because she was told that
she might have to stand trial for murder, in which event they would
surely hang her. She was admitted to this institution the first time
on May 8, 1907, on a medical certificate which stated that one sister
died of pulmonary tuberculosis, and that another is now afflicted with
chorea. The patient was addicted to the excessive use of alcohol and
cocaine and is considered to be a sexual pervert. Ever since she was
admitted to the penitentiary she has exhibited signs and symptoms of
insanity; her present symptoms are described as ungovernable temper,
attacks of extreme nervousness, attacks of fits resembling those of
acute mania, with loss of judgment and complete disregard for the
consequences of any of her acts. Delusions of persecution were also
noted. Her mother stated that the patient throughout her lifetime
would frequently have outbursts of temper, and her brother would tie
her down during these attacks to prevent her from injuring members of
the family. Physical examination on the first admission was negative.
Mentally she complained of being nervous and easily awakened at night;
consciousness was clear; she was well oriented; no hallucinations or
delusions could be elicited. Intellectually she appeared to be above
the average negro in intelligence; she read and wrote, spelled
correctly and used good English. Her memory was good for both past and
recent events. Throughout her entire sojourn here she was oriented to
time, place and person; except for having stated at one time in a sort
of careless and apparently indifferent way that she had heard someone
calling her by name, and upon looking for the person could find no
one, she manifested no hallucinatory disturbances. No delusional ideas
were elaborated at any time. Her conduct here was characterized
throughout by marked irritability; she frequently threatened to get
even with the ward physician, saying she did not propose to fight
open-handed any more and would not enter into a fight without a
weapon. She frequently broke window lights without any apparent
reason; often was very surly in manner; then again was pleasant and
agreeable and assisted with the work on the ward. She assaulted
several of the nurses when an attempt was made to restrain her, in
order to prevent her breaking window lights. When spoken to about
these outbursts of temper she would deny all knowledge of them, saying
that she never threatened nor assaulted anyone. She was discharged as
recovered on January 12, 1909, and returned to Moundsville
Penitentiary. She was again admitted to the Government Hospital for
the Insane on June 18, 1909, on a medical certificate which stated
that she was very irritable and had a mania for breaking windows; that
she was suffering from delusions. No further evidence of insanity was
given. On admission she was sullen and disagreeable, had a frown on
her face, sat on a chair looking out of the window and was exacting in
her demands. She requested to be removed to another ward, where she
thought it would be livelier; asked for various medicines, etc. When
told that her requests could not be granted, she became very cross and
abusive, making threats of things she would do. In the afternoon
scratched her arm with a pin and quite a flow of blood was produced,
which necessitated restraint. At this she became very excited and
endeavored to break the wristlets and get out of the room, proclaiming
loudly that if she was going to have wristlets on she would rather be
back at Moundsville. She was not very communicative concerning her
return to the Hospital; told one of the nurses that she had "carried
on high" to get back, and that Moundsville was "a hell of a place."
The following day she begged continuously for hypodermics, complained
of headache and tried to produce emesis by putting her finger down the
oesophagus. When questioned, she answered promptly and intelligently,
but in a sullen manner; stated that on her return to the penitentiary
she was placed in a cell formerly occupied by the woman whom she had
killed, and that this made her nervous, and frightened her. She would
not sleep on the bed provided but used for sleeping purposes a box
intended for a table. She said she cried and prayed a great deal until
finally, after three weeks, was transferred to another ward. She said
that she behaved well and caused no trouble after having been removed
from the first cell and does not know why they transferred her over
here. Her entire sojourn here on this occasion was characterized by
irritability, impulsiveness and destructiveness to property. She was
fault-finding to a great extent and threatened the life of some of
those about her. She was surly, selfish, and showed a marked tendency
to lying. She was shrewd in her endeavors to get herself into the good
graces of those in charge of her and on one occasion stated that she
was pregnant in order to receive more considerate treatment. This,
like many other of her assertions, was false. She was oriented
throughout; memory good; no hallucinations or delusions could be
elicited; she was very unstable emotionally; reasoning and judgment
were defective. Her entire symptomatology was controlled and fashioned
almost wholly by her immediate environment. When refused a privilege
she would become surly, abusive and threatening to those about her,
would destroy everything she could lay hands on, and attack the nurses
when the opportunity was favorable. The granting of a privilege again
would serve to keep her in a rather tranquil mood. She remained this
time until June 21, 1910, when she was again returned to the
penitentiary at Moundsville. From information obtained from some
officials of that penitentiary, it appears that she is continuing to
have her old-time outbursts of temper, during which she becomes
absolutely unmanageable, and the only way to deal with her seems to
be to isolate her and leave her absolutely alone until she is over her
disturbed state. Between these attacks she behaves quite well, but
such behavior has to be encouraged by the granting of various
privileges.
CASE V.--J. J. M., aged 24 years, white male, is a well-built young
man, whose family history is unknown owing to his refusal to give it.
He was born at Chester, South Carolina, in 1885. Childhood and school
life uneventful as far as is known. He was a bright scholar of
ordinary intellectual attainments. His industrial career, which began
early in life, was, according to his statements, normal. He admits,
however, losing several positions on account of outbreaks of temper
during which he had fights with other employees. He had several
gonorrhoeal infections, the first one at the age of fifteen; was
infected with lues at a very early age. He used alcoholics to a
certain extent, and admits having been intoxicated on numerous
occasions. In 1906 he was struck on the head with a club by a
policeman. Later in the same year he received an injury to the head
during a street riot. Neither of these injuries was accompanied by any
untoward symptoms. In 1907 or 1908 he was struck on the head by an
overhead pump while riding on top of a car. Was unconscious for some
time afterwards, later got up and walked unassisted to a nearby
station, where he took a train to Cincinnati. There he was confined to
a hospital for ten days, undergoing treatment for this injury. He left
the hospital one day without being properly discharged; had no ill
after effects from this injury. In the summer of 1909 he was arrested
in Washington, in company with another fellow, for robbery. They were
both released on bond. The patient, however, left the jurisdiction,
and when the police went to a nearby city to arrest him he met them
with a loaded pistol. After considerable effort he was finally subdued
and arrested. His companion received a short term sentence, while the
patient was committed to five years in the Leavenworth Penitentiary.
At that time he was living on the earnings of a professional
prostitute, to whom he claims he had been married for several years.
From correspondence between him and this woman it appears that he
fully sanctions her mode of life. Soon after his arrival at the prison
the physician noted his excitable and irritable disposition, which
became progressively aggravated, finally necessitating his transfer to
the observation ward, on December 9, 1910, a little over a month after
his imprisonment. The records of the observation ward of the
Leavenworth Hospital show the following:--
December 12, 1910:--Patient says he is frightened and asks to go to
bed; put to bed at 4 P.M.
December 22, 1910:--While nurse Miller was taking the afternoon
temperatures of the several patients at the guard's desk, he was
suddenly attacked by M., who began to beat Miller about the head and
face, drawing blood. It was noted that M. and another prisoner had
resolved themselves into a select coterie for the purpose of being
loud and boisterous and disobeying the hospital rules generally. Not a
day passes that some gross breach of prison discipline is not
committed by them.
December 23, 1910:--M. told the nurse: "If my wife don't write pretty
soon, I am going to jump off the landing and kill myself." He
complained that the attendant and nurses were talking about him, and
that he feels sometimes like going over and smashing some of them,
adding: "I know I am a damn fool for thinking that they are fixing up
against me, but I can't help it. I know I am going crazy; I wish I
could kill myself, cut my throat or something." This patient is
decidedly worse, easily excited, suspicious, hypersensitive, imagines
persons are plotting against him. When in conversation, gesticulates
with both hands, wags his head and looks wildly out of the eyes. A
particular instance of his excitable temper is a startled wild look
upon being awakened to have his temperature taken in the morning.
December 24, 1910:--Says he is scared of something, doesn't know what,
and wants to go to bed. Continues to receive epilepsy tablets.
January 2, 1911:--Complains of pains through the head and acts as if
frightened. His eyes have a glassy appearance and pupils are dilated.
At times a suicidal mania attacks him, seemingly using all his
strength to overcome it.
His further sojourn there was characterized by maniacal outbursts,
during which he would attack those about him. He showed an utter
disregard for prison rules, absolutely refused to obey orders, and
when an attempt was made to enforce these, his condition became
noticeably aggravated, and the maniacal attacks more frequent. He
frequently spoke of being frightened at something, of the attendants
plotting against him, and persecuting him. During one of his
depressions he made a superficial cut on his neck with a piece of
glass which necessitated the application of physical restraint. One
day two physicians who examined him spoke in his presence of the
advisability of operating on his head. Following this he constantly
spoke of his fear of being cut up by the physicians, whom he
designated as a bunch of anarchists, and the elaboration of this fear
remained the dominant feature of his mental disorder. He continued,
however, to be profane, vicious and unruly in his behavior. His
periodic outbursts of rage were as furious as formerly, he tore up his
bed-clothing and personal attire during these fits of anger, which
continued to be more or less reactive in character. He is noted as
having had several attacks of convulsive seizures closely resembling
epilepsy. Patient was admitted to the Government Hospital for the
Insane on April 7, 1911. On admission he was very nervous and
apprehensive, would jump and become startled when touched or
approached by anyone and when spoken to became highly wrought up
emotionally. His body fairly shook with excitement, pupils dilated,
face became flushed and he could hardly speak on account of the
emotional upset. He spoke of having come from a hell, from a dungeon
where a bunch of anarchists were persecuting him, and were going to
cut him up and operate on him, that he had heard them talk about it.
He was imperfectly oriented, somewhat confused, and to all appearances
lacked full appreciation of his new environment. He quieted down,
however, at the close of the day and slept well during the night.
Physically he was slightly emaciated. No neurological disturbances
were noted except that he complained of headaches. When an attempt was
made the following morning by a physician to examine him, he flew into
a rage, became highly emotional, profane and threatening, showed
marked apprehensiveness and expressed the fear of being cut up. He
reiterated the persecution of him by the officials at the
penitentiary, that he did not care what happened to him, whether he
went to hell or heaven, etc. He spoke of killing himself before he
would submit to an operation. He refused to eat, saying that the food
was not fit to eat, and that he would refrain from taking nourishment
until he was given better food. A visit from his wife served to
appease him. When given a Hospital night-gown to wear he threw it
away, saying he could not sleep in coarse clothing, and this had to be
finally substituted by a silk one which his wife brought him. For two
weeks following this he was allowed the freedom of the courtyard,
where he was quiet and well-behaved, except when spoken to by the
physician. At times he would turn with lightning suddenness into a
maniacal state, and his paranoid ideas would come to the front, among
which his fear of being operated upon was always predominant. At this
time he had not completely transferred his paranoid ideas to the
officials here. His clouded consciousness cleared up completely. He
read the newspapers daily, took an active part in his immediate
environment, and except for the periodic outbreaks of rage when
talking to the physician, he showed no outward conduct disorder. He
was taking nourishment regularly after a special diet was ordered for
him. After a sojourn of about a month, the attention of the officials
was called to the fact that the patient was planning an escape by
overpowering the attendants, in which plot his wife, who was at that
time an inmate of a disreputable house, was to assist him by
furnishing him a gun. It was thought advisable to take special
precautions with the man, and consequently his freedom of the
courtyard had to be curtailed, and he was confined to his room. This
was immediately followed by a marked exacerbation of his psychotic
manifestations. He became very unruly, abusive and threatening. His
outbursts of fury assumed the character of an excited epileptic. They
differed, however, from this, in being accompanied by clear
consciousness, and in not being endogenetic in their occurrence, but
distinctive reactive manifestations to definite situations. Every
refusal of a request was followed by one of those outbreaks, during
which he would be profane, abusive, destructive and violent,
threatening to kill the officials who had anything to do with his
safe-keeping, and would elaborate an ill-defined general paranoid
trend towards them. He was simply persecuted by a bunch of unchristian
anarchists who were running this place; that they would see him in
hell first before they would make him behave himself; that he is not
here to please anybody except himself; that he recognizes no
superiority other than Jesus Christ, etc. Conversely, the granting of
a privilege served to bring him to a perfect calm, when he would talk
in a rational and coherent manner, and be free from psychotic
manifestations. The granting of the privilege of seeing his wife
served to get him to submit himself to a thorough examination, which
could not be attempted before. The objective examination revealed no
intelligence defect. His reasoning and judgment were unimpaired,
memory good, and aside from his paranoid ideas, which consisted in his
belief that the officials were persecuting him, and that they were
trying to operate on his head, no psychotic manifestations could be
determined. Hallucinations had not been evidenced at any time and he
possessed no insight. Recently he requested the physician to
administer him a dose of 606, for which he was very grateful. He also
entered of late into an active correspondence with some attorneys in
town with a view to having something done for his case. On July 15,
1911, he appeared before the staff conference of the medical officers
of the Hospital for the purpose of determining whether his condition
was such as to warrant his transfer back to the penitentiary. Although
having been tranquil and normal for several weeks prior to this, upon
entering the examining room he at once became highly emotional,
abusive and threatening, and everyone who saw him at that time was
impressed with the great affective lability which the patient
possessed. For a day or so following this experience he continued to
be very emotional, irritable and boisterous. Later on his privileges
were again returned to him and he resumed a tranquil state of mind,
which existed until the time of his transfer to the prison on
August 10, 1911. He told the supervisor who accompanied him to the
depot that he intended to behave himself when he returned to prison,
so that he might enjoy the benefit of his good term allowance and thus
have his sentence shortened. Upon his return to the penitentiary he
was immediately placed under observation on account of his peculiar
behavior.
The records of that institution show the following:--
August 16:--Became very profane during the afternoon and evening,
declaring that the prison authorities were holding up his mail from
his wife, and was very profane and vindictive in speaking of the
officials.
August 17:--Cursing the prisoners of parole room I as they were coming
in from exercise, stating that they were a lot of G.d d....d s..s
of b.....s and that they were holding up his mail.
August 18:--Shouting and cursing through his window during the
evening. Got out of bed at 2 A.M., and began to swear and fight an
imaginary foe, keeping it up for two hours.
August 19:--Continues to use the most profane language he can towards
the prisoners or anyone whom he chances to see.
August 20:--Was very excitable and irritable during the day and
evening. Attempted to throw his food in the guard's face, cursing the
officials for keeping his wife away from him; claims that he can hear
her calling him outside of his cell at night.
August 21:--Cursed the guard because he would not allow him to go out
of isolation; sang and whistled during the evening.
August 22:--Very profane and vindictive in his accusations towards the
prison officials.
August 23:--Denounced the guard as a black-hander, and said that the
guard is bribing the prison officials to hold him in isolation, but
that he will not give the guard a damned nickel.
August 29:--Actions and language continue along the same line except
that they are growing progressively worse; cursing the officials,
prisoners, etc.; claims they are keeping his wife away from him, and
that his mail is being held up; is afraid of being murdered, and says
that he is being kept here while his wife is starving; constantly uses
loud and profane language.
August 30:--Prisoner whistled and sang during the evening,
interspersed with very vile language.
August 31:--Became very violent today, cursing officials, claiming
that he was being kept away from his wife and child who were starving.
Kept shouting, singing and cursing at intervals all day and far into
the night.
September 7:--Continues to have periods of violence almost daily; has
hallucinations that he is being haunted by some imaginary foe, whom he
sees sitting on his bed when he wakes up at night--a red-headed fellow
by the name of Smith. Says that he can hear his wife and child crying
outside of his cell, and repeatedly requests that he be allowed to go
home to them. Says that his wife and children are starving, and that
the prison officials are trying to starve him. Complains of pains in
his head, and that his eyes hurt him and that he is going blind. He is
inclined to be destructive of late, breaking his electric globes,
smashing stool, throwing magazines against window and cell bars.
September 14, 1911:--Says he knows that red-haired Smith is trying to
steal his wife, and that he is following him all over the country;
that he was about to kill him in Jacksonville, Florida, but that he
jumped out of a window. His violent attacks are becoming more severe
and pronounced, and he requires constant watching to prevent him from
doing himself bodily harm. He was also noted to have occasional mild
attacks of _petit mal_.
On his way to Washington from the penitentiary at Leavenworth, upon
his second transfer to this institution, the patient had been
shackled to another prisoner who was supposed to be suffering from
pulmonary tuberculosis. M. kept on begging the guards to be separated
from this prisoner, and this request was finally granted. While going
through the State of Iowa he jumped out through the window of the
moving train. He was handcuffed at the time. After having gone about
thirty miles he was recaptured. He had removed handcuffs soon after
his escape from the train.
September 27:--On admission the patient limped and complained of great
pain in both knees. Knees were swollen, bruised and discolored, and
there was marked tenderness on touching. Patient entered the ward
quietly, recognized those about him, and answered questions
rationally. Said that aside from having been hurt in the knees, his
left shoulder pained him a great deal. Upon being placed in bed he was
asked by the examiner why he was sent here, to which he replied: "To
get killed, I suppose." Further questions failed to elicit any
answers, and the interview had to be discontinued.
September 28:--Patient answered the following questions to the
attendant on the ward:--
Q. "What is your name (full Christian name and surname)?"
A. "J. J. M."
Q. "How old are you?"
A. "25."
Q. "When were you born?"
A. "1885."
Q. "What is your occupation?"
A. "Railroad man."
Q. "Where were you born?"
A. "Charleston, South Carolina."
Q. "What day is this?"
A. "Don't know."
Q. "What month, date and year is it?"
A. "August, 1911. Don't know date of month."
Q. "What time is it?"
A. "Don't know."
Q. "Where did you come from?"
A. "Leavenworth."
Q. "Who brought you here?"
A. "Bunch of cut-throats, Sons of ---- tried to starve me to death all
the way down."
Q. "How long were you in coming?"
A. "Don't know."
Q. "When did you come?"
A. "Don't know what time it was."
Q. "What is the name of this place?"
A. "Don't know."
Q. "Where is it?"
A. "On an island, I guess, some damn thing across the river."
Q. "What sort of a place is this?"
A. "Mad-house."
Q. "Who are these people about you?"
A. "Here to murder me."
Q. "Is there anything wrong with them?"
A. "Nothing but black-hands anarchists."
Q. "Who am I?"
A. "J. S." (correct)
Q. "Why do you suppose I am asking you all these questions?"
A. "Don't know."
Q. "Why were you sent here?"
A. "To be dumped off, I guess."
Q. "How do you feel?"
A. "Pretty bad this morning, my head hurts me."
Q. "Are you sad or happy?"
A. "Neither one."
Q. "Are you worried about something?"
A. "Why, sure I am."
Q. "Did anything strange happen to you for which you can't give
yourself an account?"
A. "No."
Q. "Do you hear voices talking to you?"
A. "Yes, hear you talking to me now."
Q. "Do you see any strange things?"
A. "No."
Q. "Do you ever have fits or convulsions?"
A. "No."
Q. "Did you ever try to commit suicide?"
A. "No."
Q. "Is there anybody trying to harm you in any way?"
A. "Yes, those black-hands anarchists."
Q. "How much money are you worth?"
A. "Nothing."
The foregoing two cases are representative of a group which
unquestionably forms the most difficult part in the problem of caring
for the insane criminals. Here we have a couple of individuals whose
entire psychotic manifestations, if such they may be considered, consist
of a most wild and vicious rebellion against imprisonment. They are
individuals who cannot be kept under any prescribed mode of living, and
when this is insisted upon, they react to it in an insane manner.
Bonhoeffer justly termed them "wild men", for wild indeed they are when
in one of their tantrums. The question arises, "Wherein lies the cause
of this rebellion against discipline?" It certainly cannot be wholly
attributed to the environment, for these individuals behave in a similar
manner even when removed to the far more lenient regime of a hospital.
We must seek an explanation for the behavior of these individuals in the
individual himself, in his make-up.
Looking at the life history of the two foregoing patients we find them
both to be of the most depraved class of society. The one is a
professional prostitute; the other subsisting upon the earnings of a
prostitute. Their relation with man has always been characterized by a
sort of vicious vindictiveness. Their high-strung emotional make-up
brought them into serious conflict with those about them on many
occasions before. Being finally taken hold of by the law and made to
submit to a certain well-regulated mode of existence, their inherent
characteristics assert themselves in a most decisive way and they react
to the situation in the manner of a trapped tiger, stopping at no means
to gain their point. The one commits a homicide during one of her
outbreaks of passion; the other risks his life to obtain his purpose, by
jumping out of a moving train with his hands shackled. Their life seems
to be one long series of impulsions, fostered and sustained by the
extreme lability of their emotions. Intellectually they show no defect.
They are keen and alert to every opportunity which presents itself to
them and are very shrewd in the execution of their criminal acts.
Finding themselves under a regime which exacts from them a certain
submission to rules, to regulations, they begin to misinterpret ordinary
occurrences in their environment in a sort of delusional manner: They
are persecuted by the warden because the latter insists upon making them
behave themselves; the keepers are a bunch of anarchists, whose entire
occupation seems to be to persecute them and down them. This for no
other reason than because they are made to work and to behave
themselves. J. J. M. tells me that he will not behave himself, that he
is not here to please anyone but himself and recognizes no authority
other than that of Christ. The other says she raised so much hell at the
prison that they had to send her back to the hospital. The
distinguishing feature of their psychotic manifestations is that they
are provoked essentially by definite situations. They are not a mere
wild, misdirected, meaningless series of insane acts, such as one would
expect from a demented person, but distinct reactions to situations.
Refuse them a request and they at once become wild, abusive and vicious,
smashing up everything that they can lay hands on; conversely, when
granted some of their unreasonable requests, it serves at once to
appease them for the time being at least. Their conduct, however, is
very detrimental to the prison regime, as discipline cannot be
maintained with such disturbing elements about. Their interpretations of
discipline are considered as delusions of persecution, their outbursts
of temper as typical maniacal outbreaks, and consequently they are
shipped off to an insane asylum. Now the question arises whether we are
doing our duty by society in declaring these individuals as
irresponsible for their acts. In other words, should these individuals
with marked and incorrectible criminalistic tendencies, be, so to speak,
licensed to ignore the law in its entirety by giving them the protection
of an insane asylum? Of course, from a broad, humane point of view, we
must realize and appreciate that there is something distinctly wrong
with these individuals, that their mental endowments are the essential
factors which determine their behavior. On the other hand, we must not
forget that these individuals fully realize that once they have been
sent to an insane asylum, they are protected from punishment by law for
all future time and they are ever ready to utilize this knowledge, as
has been my experience with quite a number of recidivists, who somehow
never get into an insane asylum until they are in the hands of the law.
The scope of this paper will not permit me to enter into an extensive
discussion on the treatment of these cases. I will say this,
however,--that we are very far from having solved satisfactorily the
question of the care of this particular class of insane criminals. As
this paper is not primarily a discussion of the degenerative psychoses,
I will refrain from reporting further cases. I believe I have shown by
the preceding two cases that the mental disturbances of the degenerative
individuals are essentially psychogenetic in origin.
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