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diff --git a/19168.txt b/19168.txt new file mode 100644 index 0000000..1dc9d5f --- /dev/null +++ b/19168.txt @@ -0,0 +1,8968 @@ +Project Gutenberg's Studies in Forensic Psychiatry, by Bernard Glueck + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Studies in Forensic Psychiatry + +Author: Bernard Glueck + +Release Date: September 3, 2006 [EBook #19168] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK STUDIES IN FORENSIC PSYCHIATRY *** + + + + +Produced by Suzanne Lybarger, Brian Janes, Laura Wisewell +and the Online Distributed Proofreading Team at +http://www.pgdp.net + + + + + + +--------------------------------------------------------------------+ + | | + | Transcriber's Note | + | | + | The following corrections were made to the original text: | + | | + | Hyphenation made consistent: antisocial, court-martial, courtyard, | + | everyday, framework, housebreaking, petit mal, poorhouses, | + | psychopathologist, reenlisted, readmitted, viewpoint. | + | | + | Accents made consistent: Beitraege, Delbrueck, Gefaengnispsychosen, | + | Geistesstoerungen, naive, regime, Seelenstoerung. | + | | + | Spellings corrected or made consistent: Babinski, Delinquenti, | + | Krankheitsformen, Lasegue, nocturnal, Pelman, phantastica, | + | staunchly, traveled, Wilmanns, Zeitschr. | + | | + | Punctuation: Eight changes made. | + | | + | The HTML version of this ebook has each correction individually | + | marked in the text. | + | | + +--------------------------------------------------------------------+ + + + + + 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. + + +REFERENCES + +[1] VAN RENTERGHEM, A. W.: _Journal of Abnormal Psychology_, Jan.-Feb., +1915. + +[2] KRAEPELIN, E.: "Psychiatrie." Achte Auflage. Leipzig, 1910. Bd. 1. + +[3] REICH: "Ueber Akute Seelenstoerungen in der Gefangenschaft." +_Allgem. Zeitschr. f. Psych._, 1871, Bd. 27, p. 405. + +[4] MOELI: Ueber irre Verbrecher, 1888. + +[5] GANSER: "Ueber einen eigenartigen hysterischen Daemmerzustand." +_Archiv f. Psych._, 30, 1889. + +[6] RAECKE: "Hysterischer Stupor bei Gefangenen." _Allgem. Zeitschr. f. +Psych._, 18. 409, 1901. + +[7] RAECKE: "Beitrag zur Kenntniss des hysterischen Daemmerzustandes." +_Allgem. Zeitschr. f. Psych._, 18. 115, 1901. + +[8] KUTNER: "Ueber Katatonische Zustandsbilder bei Degenerierten." +_Allgem. Zeitschr. f. Psych._, 67, p. 363. + +[9] SIEFERT: "Ueber die Geistesstoerungen der Strafhaft." Halle a. S. +1907. + +[10] BONHOEFFER: "Klinische Beitraege zur Lehre von den +Degenerationspsychosen." Halle a. S. 1907. + +[11] BRATZ: "Dass Krankheitsbild der Affect-Epilepsie." _Aerzt. +Sachverst._ Berlin, 1907. XIII. 112-116. + +[12] STURROCK: "Certain Insane Conditions in Criminal Classes." _Journal +of Mental Science_, 56. 1910, p. 653. + +[13] BIRNBAUM: "Psychosen mit Wahnbildungen und wahnhafte Einbildungen +bei Degenerierten." Halle a. S. 1908. + + + + +CHAPTER II + +THE NATURE AND TREATMENT OF THE PSYCHOSES OF PRISONERS + + +Those who still believe in an exclusively materialistic theory of mental +disorder must find it extremely difficult to maintain their doctrine in +the face of the many incontrovertible facts brought to light through +modern research in the field of psychopathology. + +The modern trend in psychiatry is distinctly in the opposite direction. +We no longer today insist upon material changes in cells and tissues for +every psychotic phenomenon, but rather endeavor to investigate mental +life, be it normal or abnormal, from the biologic point of view. We are +being constantly confronted with the undeniable fact that whatever may +be the physical substratum of mental disorder, it does not aid us in +understanding the peculiar expression which a given psychosis chooses to +assume. Why it is that one paretic greets us with the exalted mien of +his grandiose delirium, while another spreads about him the gloom of a +depressive delirium--the changes in the pyramidal cells do not explain. +There must be, then, factors other than material ones which determine +this. + +Mental life, after all, expresses itself in a series of reactions +destined to result in a proper adaptation to environmental conditions, +and the causes which determine a given reaction may be psychic as well +as physical in nature. Indeed, in the realm of psychopathology we see +indubitable evidence of the predominance of psychic causes of mental +disorder over physical ones, and the subject under discussion here +further emphasizes this. + +The problem of the prison psychoses, although extensively discussed in +psychiatric literature in the last half century, is far from being +solved, and for this and many other reasons deserves further attention. +The psychotic manifestations of prison life are of sufficient frequency +to deserve some definite place in our nosological tables; they develop +in a milieu artificially created by society, and if this milieu is +responsible for the production of mental disorder, it is of the utmost +importance, both from a preventative and curative standpoint, to +investigate the causes operative here, and lastly, these psychoses +concern individuals who form one of the most important problems society +has to deal with, and any light which the study of psychotic conditions +in these individuals may throw upon the general problem of crime and the +criminal, should be very much welcomed. + +I fully believe that in time the study of the psychotic phenomena +developing in criminals will give us a correct insight into the nature +of the criminal personality and thus aid in the solution of that problem +which baffles criminologists today. + +We know that while pure experimental psychology and psychopathology have +aided us in understanding the human mind both in health and disease, we +owe the bulk of our knowledge in this field to the investigations of +Nature's phenomena and experiments. The human mind, the most complex and +intricate organ, lends itself but very feebly to analysis when all its +component parts work in unison, and it is only when through disease it +has become, so to speak, disintegrated into its various units, that a +more ready access to it becomes possible. This is being fully +appreciated both by psychologists and psychopathologists. Mental +medicine, however, if it is viewed from the present-day broad conception +of the term, must not confine itself exclusively to psychotic +manifestations in the strictest sense of the word, but should embrace +within its realm that great mass of unfortunates who populate our +prisons, poorhouses and reformatories. It is now being universally +recognized that the pauper, the prostitute, and the criminal classes are +primarily products of mental defect and degeneracy and as such must come +within the purview of mental medicine. This being the case, the same +truisms which apply to the insane in general must likewise apply to the +above-mentioned types. + +We are here especially concerned with criminals who, because of a mental +breakdown, have come under the observation of a psychiatrist, and if we +agree with many eminent criminologists that the present juvenile state +of this science and the ineffective methods of dealing with crime are +due to a lack of proper scientific understanding of that anomalous +species which is grouped under the term "criminal man", why not endeavor +to solve this problem by approaching it from the psychiatric point of +view. If the study of psychopathology has given us such valuable data +concerning the normal mind, why not expect that a similar study applied +to the insane criminal will bring to light some important facts +concerning crime and the criminal in general. It is for this reason that +that large group of mental disorders developing in criminals during +imprisonment which has been included under the term "prison psychoses" +is of special importance to the psychiatrist. + +The older extensive literature on this subject, although very +interesting from an historical standpoint, offers very little that is of +scientific value, and it is only within recent years that a more +rational approach to this problem has been attempted. It is easily +conceivable that this branch of mental medicine must have shared the +fortunes of psychiatry in general in its various phases of evolution, so +that in the history of the prison psychoses are reflected the various +views which in their day have dominated psychiatry. At present it is the +school of degeneracy of Magnan and Moebius which is especially concerned +with this problem. + +Briefly stated, the exponents of this subject belong in a general way to +either of the following two schools. The one maintains that the mental +disorders occurring in prison differ in no way from those met with in +freedom and that imprisonment at most but lends to them a peculiar +common coloring which in itself, however, is not of essential +importance. The other school takes a directly opposite view. The +followers of the latter maintain that the mental disorders which they +are wont to term "prison psychoses" are products of predisposition plus +external factors. They differ from the true endogenous psychoses in that +they are purely psychogenetic in character, and that their highly +colored and extremely variable symptomatology is nothing more than a +reactive manifestation of a particularly predisposed psyche to definite +environmental conditions. According to them we are not dealing here with +mental disorders whose origin, course, and termination are independent +of the crime and imprisonment, as is the case in the ordinary well-known +forms of functional and organic disorders developing in prison, but with +psychotic manifestations which bear the most intimate relation to some +definite situation, and which are characteristically colored and shaped +by the prison milieu. + +As a matter of fact, the population of institutions for insane criminals +divides itself into two distinct and unmistakable groups. On the one +hand we meet with the well-known functional and organic psychotic +entities such as occur in individuals in freedom; we see patients who in +the course of their careers as insane people have come in conflict with +the law either accidentally or because of their insane ideas. In them +the psychosis develops and takes its definitely determined course +independently of the milieu in which the individual happens to be +placed. In the majority of instances they suffer from the various forms +of dementia praecox and progress toward demential end-results in the same +proportion as the general run of dementia praecox cases do, whether or +not they have come in conflict with the law. Occasionally we also see a +case of organic brain disease or manic-depressive psychosis, and in more +frequent instances a case of epilepsy. The other, and according to many +authorities, by far the most predominant group of mental disorders met +with in imprisonment, belongs to the so-called "prison psychoses", and +bears definite, unmistakable ear-marks which differentiate it from the +former group. These are, as we have stated, products of a particularly +degenerative soil plus definite environmental conditions, and are of the +utmost importance both from a purely clinical and an administrative +point of view. + +The term "reactive manifestation", as applied here, is a happy one, and +inasmuch as the accidental criminal differs from the habitual criminal +as day differs from night, we will expect a different sort of reaction +to a more or less similar situation in the two instances. To +illustrate:--An apparently healthy and in most instances law-abiding and +non-corrupt individual, as a result of a series of overwhelming and +uncontrollable circumstances, commits murder in a fit of passion. Upon +being arrested and upon the sudden realization of the enormity of his +deed the entire constitution experiences a tremendous shock and reacts +to it accordingly. He falls into a stupor, into utter oblivion of the +world about him, becomes in turn excited and confused, his senses begin +to functionate in a fallacious manner, and he thus succeeds in shutting +out from consciousness, for the time being at least, the entire +unbearable situation. Upon emerging from his stupor he has a more or +less complete amnesia for the deed and its attending circumstances, and +finding himself confronted with accusations, cross-examinations, and +lastly, conviction, he at once sets about, so to speak, to square +himself with the situation. What does he do? He develops a quite +limited, well-organized delusional system in which he finds himself +absolutely innocent, his accusers are the guilty ones, and the entire +situation is nothing more nor less than a well-planned plot to destroy +him. His supposed victim has not been murdered at all, but is living and +secretly active in plotting and scheming against him, the accused. + +In this artificially created world he lives with comparative ease, and +has thus succeeded in reaching a proper adjustment to the situation. + +The most interesting part of it all is that this so well-organized and +apparently fixed delusional system may disappear at once and the various +false ideas may become entirely corrected as soon as the provocative +agent which is at the bottom of it all is removed. This is a fair +example of what has been termed an acute prison psychosis, and occurs +with considerable frequency among prisoners awaiting trial. Naturally, +these psychoses, being, as they are, psychologically motived, are +extremely variable in their manifestations, but at the root they are all +alike and impress the observer as something entirely different from the +pure endogenous mental disorders. They are all psychically evoked +reactive manifestations of a particularly predisposed constitution to +definite deleterious environmental conditions. Some of the cases +reported in the first paper of this series are good examples of this +type of mental disorder. + +We owe our knowledge of these disorders to the contributions of Reich, +Moeli, Kutner, Ganser, Rish and others, authors who, although describing +a more or less identical symptom-complex, have given to it different +names, such as hysterical stupor, Ganser symptom-complex, catatonia of +degenerates, etc. The distinguishing features of this disorder are its +psychic origin, that is, its development in consequence of some strongly +affective experience, and its high grade of impressionability to things +in the environment which may at any time suddenly cause a complete +transition from deep stupor to normal manner and behavior. + +The symptomatology consists of an acute delirioid, hallucinatory +episode, usually followed by a more or less complete amnesia which may +go back far enough to include the experience which provoked the +disorder. Such delusional formation as takes place after the +disappearance of the fulminant symptoms may well be considered as part +of the repair process, a mechanism which in most instances reflects the +individual's endeavor to adjust himself to an unpleasant, unbearable +situation, and must not be looked upon necessarily as an indication of +the progressiveness of the disorder. + +As we have stated before, complete correction of all delusional ideas +may suddenly take place upon the removal of the causative factor at the +bottom of the entire situation. + +As to the treatment of this acute prison psychotic complex +theoretically, we should have no difficulty in deciding this question. +We are dealing with the sequelae of some definite situation, and the +removal of that situation may be, and actually is, in most instances, +sufficient to bring about recovery. When we come, however, to deal with +concrete instances in daily practice, the problem does not lend itself +so easily to solution. + +What of the man who upon being arrested following the commission of +murder, develops a psychosis while awaiting trial, or who having been +found guilty of murder develops a psychosis while awaiting execution? +The first question which the psychiatrist is called upon to decide in +many instances is that of malingering. To the lay mind and to the minds +of many of our eminent--but psychiatrically uninformed--jurists the +question of malingering suggests itself at once. To them it is perfectly +evident that this development of a mental disorder, in the wake of a +criminal act, is nothing but a timely preparation for the "insanity +dodge." The clinical pictures presented by the acute prison psychosis +are especially apt to awaken suspicions of malingering in the minds of +the untrained. We see individuals who apparently never before showed any +evidence of mental disorder, and who immediately following the +commission of a criminal act manifest pictures of grave alienation. Many +of them don't know how much twice two is, are absolutely ignorant of the +most elementary subjects, remember nothing of the deed, and most +important of all fashion their deliria in such a way as to entirely +negate the deed, or at any rate justify it. + +But why cannot all these manifestations be genuine? Many of us no doubt +recall the effect which examinations have upon certain students. The +emotional accompaniment of the examination, especially the emotion of +fright, causes many a student to forget facts which he knew as well as +his own name, and which he is able readily and fully to recollect as +soon as the examination is over. Are we to assume that these students +are malingering? Decidedly not. Why then should we question at all the +genuineness of a mental disorder developing in an individual who faces +the gallows or a life-long imprisonment? As a matter of fact cases of +pure malingering are among the rarest things which the psychiatrist +observes. Wilmanns,[1] in his study of 277 cases of insanity of +prisoners, found but two cases of simulation, and in a later review of +the diagnoses of the same series of cases, the two cases of malingering +do not appear at all. Bonhoeffer[2] in a study of 221 cases of insane +criminals found 0.5 per cent of malingerers. This is the experience of +everyone who comes in contact with these cases, and there are others who +go so far as to maintain that every malingerer of mental symptoms is +mentally defective. + +But let us assume that we have succeeded in convincing those concerned +of the genuineness of the disease at hand; what line of treatment should +be recommended? In the first place, we must remember that the mental +disorder, if it belongs to the group we are discussing here, is the +result of a criminal act, and following in its wake, and that therefore +the plea of insanity as an excuse for the deed must manifestly be +excluded. But may not this type of reaction furnish us an index to the +original personality of the culprit? In other words, should we consider +an individual absolutely normal, if, in reaction to some stressful +situation, he breaks down mentally and develops a psychosis? The +majority of authorities maintain that these individuals are decidedly +abnormal, and that it is only a poorly-knit organism which permits of +that sort of reaction. Birnbaum,[3] for instance, insists that the +possibility of a psychic incitation of a mental disorder is the +criterion of a degenerative soil. This is undoubtedly too extreme a +view, but the more one observes these cases, the more one is inclined to +hesitate in calling these individuals normal in the accepted sense of +the term. Let us assume for the moment that these psychotic reactions +are indices of an abnormal personality. Is this defect of sufficient +import to render the individual irresponsible in the eyes of the law? +This question, I fear, cannot be answered very readily. Looking at it +from a purely juridical standpoint, we must say no; because an +individual is so loosely organized as to break down mentally under a +given stress, does not at all imply that a knowledge of the difference +between right and wrong is excluded. The jurist is willing to concede to +the proposition of a poorly-organized nervous system, a degenerative +make-up, a psychopathic constitution; but if these defects are such as +to manifest themselves in crime, society must be given the inalienable +right to protect itself from such defectives. The result is that either +no extenuating circumstances are considered at all, and the individual +is dealt with in the ordinary way, or he is adjudged insane and +committed to a hospital for the criminal insane, whether or no insanity +exists at the time of trial. Thus we have on the one hand a prison +population which more properly belongs under the regime of a hospital, +while on the other hand, we insist on keeping individuals locked up in +hospitals for the insane, whether or no they show actual psychotic +symptoms. If one of the latter class endeavors to obtain his release by +habeas corpus, a tremendous howl is immediately raised by the public +about the "insanity dodge", the worthlessness of expert testimony and +the unpardonable offense of letting loose upon society a dangerous +criminal. If we stop to consider for a moment, we must admit that in the +great majority of instances, we are not dealing here with dangerous +criminals. The man who as a result of a series of overwhelming +circumstances over which he had little or no control, kills another in a +fit of passion, is not necessarily a dangerous criminal. In the majority +of cases it is fair to assume that such an individual will never again +in his life have to cope with a similar set of circumstances. The great +majority of these people have led, up to that single crime of their +life, an honest, peaceful existence, and the instances of an accidental +criminal turning recidivist are extremely rare. + +Society looks on complacently at the repeated sentencing of the habitual +criminal and watches without alarm the never failing phenomenon of how +each successive imprisonment only serves to deprave him more +profoundly; it never considers the danger of letting this type of +criminal loose to prey upon it; just so he has served his just and +legally prescribed sentence. But let the victim of the "insanity dodge" +prejudice endeavor to gain his freedom, and society is at once up in +arms. + +Thus the matter stands, and until the public learns to know its +criminals as they actually are, this problem will remain unsolved. The +prognosis of the acute prison psychotic complex is good in the majority +of instances. The removal to a hospital regime usually serves to put a +stop to the process and it is important for the expert witness to bear +this in mind for obvious reasons. + +We have thus far discussed the psychoses developing in prisoners +awaiting trial, and we shall now turn to that group of cases which are +sent to us from penal institutions which serve for the confinement of +the convicted criminal. + +At the outset we shall endeavor to draw a distinction between the class +of individuals we have just discussed, and that which we are about to +consider now. We have seen that the former is made up of individuals who +in most instances have come in conflict with the law for the first time, +and that the mental disorder which they develop stands in the closest +relation with some definite experience in their life. The patients who +come to us from prisons and penitentiaries on account of some mental +disorder which developed while they were undergoing sentence are in most +instances habitual criminals with a marked criminal career back of them. +They differ so essentially from the preceding group, that what has been +said about the former can hardly apply here. + +The first really worthy contribution to this subject was made by +Siefert,[4] the physician in charge of the psychiatric department of the +penitentiary at Halle. He published, in 1907, the results of a study of +eighty-three prisoners who became insane while serving sentences. He +divided his patients into two sharply differentiated groups, the true +psychoses, _i.e._, the well-known forms of functional and organic mental +disorders, and the degenerative psychoses, _i.e._, psychotic episodes +developing upon a soil of degeneracy and which according to him form the +typical prison psychoses. Before we go any further it must be mentioned +that Siefert did not take into consideration the mental disorders +developing in prisoners awaiting trial. + +"The true psychoses develop out of endogenous causes, attack and +manifest themselves in the prisoner in the same way as in any +law-abiding individual in freedom. They are not essentially influenced +by changes of environment and there exists no intimate relation between +the coloring of the symptomatology and the influence of the +imprisonment. The degenerative psychoses, on the other hand, develop +upon the well-characterized degenerative soil of the habitual criminal, +and are products of predisposition plus environmental influence. They +stand in the most intimate relation to the deleteriousness of prison +life, and are therefore influenced to the greatest extent by change of +environment." + +On studying critically Siefert's work one gains the conviction that the +author not only undertakes to solve certain clinical questions, but +endeavors to investigate the problem of the relation between crime and +mental disorder. Although he paid the strictest attention to the +individual symptoms and described in an excellent manner the manifold +and varying symptomatology of these psychoses, he did not succeed in +isolating a symptom-complex which might be considered as typical of the +degenerative psychoses, and thus deserve the independence of a distinct +clinical entity. Above all he occupied himself with the investigation +and delineation of the various anomalous individualities, the +degenerative constitutions upon which these psychotic manifestations +engraft themselves. Thus he divided his prison psychoses into groups +like the "simple degenerative", "hysterical degenerative", "phantastic +degenerative", etc. Siefert undoubtedly overshot the mark in his +clear-cut differentiation between the various types, but he +unquestionably contributed a most important work on this subject. + +Let us now endeavor to illustrate what he means by this degenerative +soil giving rise to these psychoses. As we have stated, the great +majority of them are full-fledged habitual criminals and can be easily +recognized by their "degenerative habitus." They are that indolent, +obstinate, querulent, unapproachable, and irritable class of prisoners +who form the bane of prison officials. Constantly in trouble of some +sort, they are subject to frequent disciplinary measures, which, +however, serve not in the least to improve their conduct. Their +extremely fluctuating mood and emotional instability calls forth a quite +unfounded wild rebellion against the prison regime. They are constantly +after the physician with numerous hypochondriacal complaints, such as a +nervous heart, digestive disturbances, insomnia, etc. In short, they +impress one as something abnormal, something entirely different from +the ordinary prisoner. On this basis, now and then more marked, +definite psychotic manifestations engraft themselves. Here and there one +of them starts to speak of nightly visions, complains about a feeling of +anxiety, speaks of suspicious noises and voices in the vicinity, and +finally makes a superficial, ineffectual attempt at suicide. Others +become suddenly more antagonistic, vehemently assert their innocence, +speak of being the victims of false accusations, etc. Still others +suddenly develop a wild, maniacal state, destroy everything within +reach, become markedly hallucinated, elaborate various persecutory +ideas, and finally have to be transferred to an insane asylum. Here they +soon quiet down, the active symptoms subside without leaving any trace +behind them, insight may or may not be complete. The characterological +anomaly which is at the bottom of the disorder, however, remains, and +any necessity for the application of more stringent administrative +measures may serve to set the entire process aflame again. + +Another group of psychopaths who are prone to develop prison psychoses +are those primitive, superficially endowed individuals with a high +degree of auto-suggestibility, a marked tendency to phantastic lying, +and instability of mood, individuals who have always led a sort of +humdrum existence without aim or goal of any kind in view. They drift +very early into a life of crime and vagabondage, become addicted to all +of the vices which cross their path, are markedly egotistical, have no +conception of social life, frequently desert their wives and families, +and a great many of them finally end their days in jails or poorhouses. + +Upon being imprisoned they are unable to adjust themselves to the strict +regime, find difficulty in acquainting themselves with the prison +regulations and in consequence have to be frequently disciplined. As a +result they begin to misinterpret things in the environment and see in +these disciplinary measures nothing but persecution on the part of the +prison officials. They become suspicious, seclusive, introspective, +spend sleepless nights, until suddenly, in the stillness of night, they +perceive isolated phonemes. This strengthens their suspicions. They +refuse food, become apprehensive, the hallucinations reach a more +definite character, until finally they manifest a well-marked +persecutory delirium, or may fall into a semi-delirious stuporous state, +show numerous catatonic symptoms, become destructive and untidy, and in +general present a picture very similar to true catatonia. + +Removal to the hospital ward frequently serves to put a stop to the +process at once, and often before reaching the hospital for the insane +they show no traces of the acute mental disorder. + +The foregoing are types of degenerative psychoses met with in +imprisonment, and there can be no question that the prison milieu is the +etiologic factor here. + +To speak here of a progressive disorder to which imprisonment only gives +a characteristic coloring is entirely erroneous. A psychosis which is +definitely brought on by a certain environment and which is corrected as +soon as the environment is changed, must be looked upon as the product +of that environment. That the degenerative soil which permits of the +development of these disorders cannot be looked upon as a basic +disorder, something like dementia praecox, is likewise unquestionable. +These individuals have always shown the same traits of character; it is +these very same anomalies which brought them in their childhood days in +conflict with the school authorities, which later made them inmates of +reformatories, and which finally were at the bottom of their habitual +criminality. Finally, the total absence of progression to more or less +definite end-results excludes the possibility of an organically +determined progressive disorder. A psychosis which develops in +imprisonment and progresses irrespective of the change of milieu is not +a prison psychosis in the sense that this term is here used. The +following cases are illustrative of the type under discussion. + + CASE I.--A. F., aged 31 years; admitted to the Government Hospital for + the Insane April 7, 1911. Father alcoholic; died of cancer of liver + and stomach. Mother died of tuberculosis. One brother has been + confined in the Gowanda State Hospital for the Insane for past five or + six years; has always been an excessive alcoholic. One sister, aged + 42, has tuberculosis. One of her children died of tuberculosis of the + bones. Another sister is hyper-religious and eccentric. + + Patient was born at Olean, New York, in 1871. He knows of nothing + unusual attending his birth or childhood. He entered school at the age + of six, and attended irregularly for six or seven years. He was + usually older than the other children in his class, and was held back + a year in the third and fourth grades. He left school at the age of + fourteen, while in the fourth grade. He then worked in a shoe store, + commencing at a salary of four dollars per week, and receiving six + dollars per week at the time of his separation. As far as is known he + did his work well, as he was promoted during his stay there. Soon + after commencing to earn money he began to indulge in alcoholics. He + became intoxicated one day and set fire to a store, which resulted in + the death of a human being. It did not take much at that time to + intoxicate him--two or three glasses of whiskey being sufficient. He + does not definitely say why he set the place on fire; adding, "Perhaps + I was drunk and did not know what I was doing and maybe I just wanted + to see the fire. I always did like to see fires. Of course, I did not + know that somebody was going to get burned to death." He is not + certain whether he felt sorry for the deed, adding: "Why should I + care? I did not know the man that was burned. He was no relative or + friend of mine; anyway, the people around there said he was no good, + and that it served him right." He was sent to the Elmira Reformatory, + where he remained three years, when he was transferred to the New York + State Hospital for Criminal Insane at Matteawan. He did not like the + Reformatory a bit, they were nagging him all the time. He says it was + like a deaf and dumb asylum; a fellow could not even talk when he + wanted to, and if he did he was paddled for it. The paddling didn't + make him behave, because, he adds: "You can't make a fellow behave by + beating him all the time." He was later transferred to Dannemora, + spending about two years in all, in both these institutions. He did + not like it at the hospital either, because they made him work, and he + hated to work; so finally he asked to be transferred back to Elmira, + which request was granted him. On returning there he was put to work + at brick-laying, but could not get along with the fellow in charge, + the latter was too much of a bully and worked him too hard, so + finally, they shipped him to the new reformatory at Napanoch, New + York. Here he was given employment by the physician in charge of the + hospital, and after ten months of good conduct, was paroled. He says + he behaved well these ten months because he was treated well by the + doctor. Upon being paroled, he returned to Olean and obtained a + position in a tannery where he worked for six months, receiving two + dollars per night. He was drinking heavily all this time, and one + night, failing to return to work, owing to his intoxicated condition, + was discharged. He states that the above is the longest he ever worked + at any occupation since. Shortly after being discharged, he was + arrested in company with several others for robbing a post office. He + was about twenty-three years of age then. He claims that he had + nothing to do with this robbery, and it was just an unfortunate + accident that he got mixed up in it. He was placed in the jail, and + while there the warden tried to poison him. He developed various ideas + that poison was placed in his food, that his stomach was all dried up, + and because he would not eat, he adds: "They sent him over to this + Hospital,--the Government Hospital for the Insane." + + He was admitted here the first time on May 29, 1904, on a medical + certificate which stated: "About April 19, 1904, he refused to take + food and claimed to be kidnapped. He had delusions of + persecution--said his head was full of nails and requested that his + brain be cut up. Said the President was his friend." + + On August 1st, he eloped while at work in company with another + patient. The record of his mental disturbance at that time is very + meagre, and nothing of a definite nature can be obtained from it. + + From here he beat part of his way, and walked part of the way to + Cincinnati, where he had a sister living. One night he heard her + talking to her husband about sending him back to the hospital, so he + robbed them of what money they had in the house, bought a revolver and + returned to Olean. He says he bought the revolver to protect himself + from a certain police captain at Olean. He frequently refers to this + man in a vindictive and abusive manner. States that this police + captain was after him all the time; that whenever any crime was + committed in the city, he was immediately suspected. He was "tired of + this" and bought the gun, intending to kill the police officer if he + should bother him any more. Here he adds: "Anyhow, the cur was killed + afterwards, I am glad of it." After a series of crimes, tramping and + debauchery, during which he suffered from an attack of delirium + tremens, and served a sentence of nine months in a Pennsylvania jail, + he was again arrested for a post office robbery and sentenced to five + years at Leavenworth, whence he was transferred to this institution + April 7, 1911. + + As has been stated, he commenced to indulge in alcoholics at a very + early age and has continued this habit during his lifetime. He states + that he had an attack of delirium tremens, during which he received a + severe burn on his left arm by jumping out of a window into a bonfire, + while trying to escape imaginary persecutors. During the years + 1903-04, he was addicted to the steady use of morphine and cocaine. He + has led a very loose sexual life; has been infected with gonorrhoea on + numerous occasions, and contracted syphilis several years ago. He has + never married. He intended to marry once, but the girl, he discovered, + was not true to him, so he gave her up. He is a Catholic, attends + church occasionally when at liberty, and was in the habit of going to + confession while at the Penitentiary. + + The medical certificate on his present admission stated that on the + night of March 20, 1911, the patient was reported for shouting while + in his cell, claiming that invisible enemies were shocking him with + electricity. There were no symptoms observable before that. Has + delusions of persecution in which invisible enemies are continually + shocking him with electricity and other means and are planning to do + him other bodily harm. + + He complained of not being able to sleep and of being tortured. Said + they wired his cell and gave him an electric shock; that he spoke to + the President of the United States and was told that the latter would + visit him. + + On March 22d, complained of being choked by supposed workmen. Later he + stated that he had been kidnapped at Erie, Pennsylvania, and expected + the President of the United States to get him out in a few days. He + requested the doctor to send for a priest, complained that they had + failed to send for the President as promised. Said that he had + received a severe shock the night before from the people upstairs, and + stated that they had stored two thousand volts to turn on him. + Following this, he was restless at night and was apprehensive of being + burned to death. Finally he wrote a letter to the President in which + he complained that his life and health were in grave danger; that he + was the victim of a conspiracy, and was being detained illegally at + the Penitentiary, stating that when he was walking peaceably along the + railroad track, he was kidnapped by enemies who had a design upon his + life. He was arrested and while in jail these same officers robbed the + post office and later accused him of the crime. They bribed a witness + to testify at the trial against him and because of this he received an + unjust sentence of five years. He believed that the friends of the + chief of police of his home town, Olean, New York, were paying large + sums of money to the warden of the Leavenworth Penitentiary in an + endeavor to have him electrocuted, and that their efforts had nearly + proven successful, as he had been tortured night and day for the past + month, in fact he was unable to stand it any longer, and if the + President did not come to his relief at once, he intended to take the + matter in his own hands and make short work of the warden. He thought + he was accused of the murder of the police officer who was killed in + his home town, but he insisted that at the time of the murder he was + locked up in jail, hence could not have done this. + + The patient continued in this trend of thought and conduct until his + transfer to this institution, April 7, 1911. + + On admission here he talked in a coherent manner, was clear mentally + and quite well oriented. He reiterated the story given above, + namely,--that he was kidnapped in Pennsylvania on a trumped-up charge + of post office robbery, was tried by a "phony" court and sentenced to + five years at Leavenworth. Soon after arriving there the warden had an + electrical apparatus rigged up with which he was tortured constantly. + He complained to the doctor about this and begged to be put in a cell + so he could get some sleep as he could not sleep in his cell on + account of these electric shocks. He heard them saying from above that + they were going to torture him. One night they had him paralyzed on + one side. + + In an endeavor to explain these persecutions he stated that probably + the railroad police who arrested him were friends of the police + captain at Olean with whom he had had trouble for a long time, and who + was later killed by someone; that probably they blamed him for this + killing, and that for this reason they framed up the charge of post + office robbery against him. He believed that the electrocuting which + he was receiving at Leavenworth was a part of this scheme to get rid + of him, as he knew that the police captain at Olean was a friend of + the warden of the Penitentiary. In giving this recital he was somewhat + irritable and nervous, constantly rubbing his head and face in a + troubled manner. He kept to himself, making no acquaintances with + those about him and was apparently somewhat worried and apprehensive. + He slept well the first night, stating that nobody bothered him. He + stated that he was not insane, that there was nothing wrong with his + mind. When asked why he was sent here, said simply because of a trick, + that he was told that he was coming to the President to secure a + pardon, and instead of this, was brought to this institution. He was + quite unstable emotionally, very surly and irritable, and soon + transferred his persecutory ideas to the officials of this + institution. He complained of having electricity on him; stated that + the warden at Leavenworth rigged up a wireless apparatus whereby he + could send wireless messages to him constantly. Stated that he had + been chloroformed at night and that his body was lined with electric + wires through which electricity was running all the time. He became + very abusive to the physician, stating that the latter was in league + with the officials at the penitentiary to torture him. This state of + affairs continued, with the addition of the delusional idea that the + physician was endeavoring to hypnotize him, until the early part of + September, 1911, when he acquired full insight into his mental + disturbance, realizing fully that the various ideas which he expressed + were delusional, and that he must have been suffering from mental + disorder at the time. + + Mental examination revealed no defect, and his knowledge was quite in + accord with his educational advantages. Morally, he was distinctly + defective. Physical examination showed various stigmata of + degeneration, such as asymmetry of the face; large outstanding and + flattened ears; narrow and dome-shaped palate; irregularly placed + teeth; prominent parietal bones; two symmetrical depressions on the + occiput; congenital flat-footedness; and a sullen facial expression. + His arms were covered with tattoo marks. Sense of pain somewhat + diminished. Sympathetic reactions could not be elicited. Wassermann + reaction with blood serum nearly complete positive. + + The patient finally recovered from his mental disorder, and on + January 16, 1912, was returned to the penitentiary to serve out the + remainder of his sentence. At this writing, November, 1915, nothing + further has been heard from him. + +We have before us an individual who to start with, is badly tainted +hereditarily. His childhood history is indefinite, aside from his +statements of having been usually the lowest in his class at school. He +launched upon an industrial career at a very early period in life and +simultaneously with commencing to earn money he began to indulge in +alcoholics. His industrial career was cut short soon after. He gets +drunk and sets fire to a store, causing the death of a human being. +This, at the age of seventeen. His moral status can readily be surmised +when we remember his reply to the question as to whether he was sorry +for the deed. "Why should I be sorry? I didn't know the man that was +burned." The usual course of the law was taken in the case and he was +placed in a reformatory. He spent nearly six years between that +institution and hospitals for the criminal insane, when he was released +on parole. It is of interest to note here how he reacted to the stress +of confinement in the reformatory. We find that on two occasions during +this period it became necessary to transfer him to an insane asylum. We +shall have occasion to refer to this again later. + +If there ever existed in him any chance for reform, the reformatory +apparently killed it, for his life since then has been an uninterrupted +chain of crime and debauchery. He has been a prey to all the vices of +modern civilization; he is a confirmed alcoholic, was addicted to the +habitual use of morphine and cocaine; has been infected on numerous +occasions with gonorrhoea; has contracted syphilis and received a serious +burn during an attack of delirium tremens. In all, he spent eight of the +past fourteen years in penitentiaries, jails, and institutions for the +criminal insane, and has, now, an indictment for larceny hanging over +him. Released from a six years' confinement he finds himself thrown upon +his own resources and is confronted for the first time with the problem +of providing for himself. The poorly-begotten organism, whose start in +life, already deficient in those attributes and forces which are so +essential for an effective struggle for existence and which was rendered +still more deficient by a six years' sojourn among criminals, finds +himself unable to cope with conditions as they exist, and several months +after his release from imprisonment we again find him arrested for +robbery. Being taken hold of by the law does not mend matters in the +least. On the contrary, we see the same tendency to break under the +stress of imprisonment, with the overwhelming burden of an enforced +routine existence, reassert itself as on the former occasion, and in +reaction to the situation he develops a psychosis which necessitates his +transfer to an insane asylum. Placed under the less exacting regime of a +hospital, he soon recovers and avails himself of the first opportunity +for an escape which presents itself. Finding himself again at freedom he +endeavors to find some explanation for his unfortunate position in life +and in the midst of this he discovers that his sister is planning to +return him to the hospital. Even his own sister is against him. He +begins to assume that paranoid view of life which characterizes his +later existence. Now he knows where the trouble lies. The whole world is +against him; no wonder he can't get along; his own sister is trying to +force him back into the hands of his persecutors. His own deficiencies +and incapacities he projects upon the environment. It is the world about +that is at fault; not he. They are after him all the time. He buys a +gun with which to protect himself, and with renewed antagonism against +society in general he defiantly launches upon a career of crime and +vice. Again taken hold of by the law, the old story repeats itself. He +lands in an insane asylum. + +Upon an analysis of the content of his psychosis, we find that he +elaborates a story of having been kidnapped in Pennsylvania, upon a +trumped up charge of robbery, taken before a "phony" judge and given an +unjust sentence of five years. The police officers who arrested him were +friends of the murdered police captain at Olean and were hired to do +this job, because he (the patient) was suspected of having had something +to do with this murder. He dreads being placed in the penitentiary +because he knows the warden is likewise against him, being a friend of +the murdered police captain and might perhaps be in league with his +persecutors and take this opportunity of avenging himself upon the +suspected murderer, and sure enough, soon after his arrival at the +penitentiary, the warden has an electrical apparatus rigged up with +which to torture him, etc. His psychosis takes the usual course, he +recovers soon after having been removed from the oppressing environment. + +The question arises here, "Are we dealing with a psychosis which +engrafts itself upon the individual without any apparent cause, a +psychosis possessing a course and termination wholly independent of +outside influences, a psychosis having no tangible relation to any +definite situation; or have we here a psychogenetic disorder, a +pathologic reaction of a degenerative constitution to an unfavorable +situation, a paranoid picture developing as an outgrowth of the +individual in reaction to a definite experience?" In other words, are +we dealing here with a case of dementia praecox, or with one of the +degenerative psychoses? If we agree with Stransky[5] that dementia +praecox depends upon an intrapsychic ataxia, that it is the disturbed +cooerdination between the intellectual and affective faculties of the +individual which makes the picture of dementia praecox what it is; this +is not a case of dementia praecox. The acute emotional reaction to all +situations which this man manifests, the development of the psychosis in +consequence of the depth of his feelings concerning the unpleasant +experiences and the entire absence of this important incooerdination +between his feeling and acting, would, in itself be sufficient to +separate his psychosis from dementia praecox. If we agree with Kraepelin +and others that dementia praecox has a more or less definite onset, a +more or less definite course and termination in a dissolution of the +individual's psyche, our case is not one of dementia praecox. Our patient +has had the same attributes of character and personality always. There +is no indication in his life history of a definite onset of a retrograde +process, or of any progression towards dissolution. His psychosis, such +as it is, is the outgrowth of his degenerative personality, and if we +assume this to be true, if we consider the psychotic manifestations of +this individual as a pathologic expression of his anomalous personality, +the question arises--to what extent have his criminal acts likewise been +pathologic expressions of the same underlying degenerative basis? I +believe that the relation between the criminality and mental alienation +of this man is analogous to that existing between two branches of the +same tree. The same degenerative soil which makes the development of the +psychosis possible in one case, expresses itself in crime in another +instance. The factors which determine whether the one or the other phase +will manifest itself, depend largely upon environmental conditions, and +are accidental in nature. The stresses which these defective individuals +meet with in freedom need not have such a strong influence upon them as +to produce a psychosis. The want of moral attributes makes it possible +for them readily to surmount many difficulties by means of some criminal +act, difficulties which in a normal person would require extraordinary +effort to remove. When placed, however, under the stress of imprisonment +where they can neither slip away from under the oppressive situation, +nor square themselves with it by some criminal act, the organism becomes +affected to such a degree that the development of a psychosis is greatly +facilitated. The character of the delusional fabric of these individuals +is such that one can easily find a ready and more or less correct +explanation for it. It is chiefly a compensatory reaction in an endeavor +to make a certain unpleasant situation acceptable. + + CASE II.--J. H., aged 37. Admitted to the Government Hospital for + the Insane, March 8, 1909. Maternal grandfather died suddenly from + unknown cause. Was a race-track operator. Father alcoholic. Mother + suffered from vertiginous attacks. There were twenty-one children in + the family, fifteen of whom died in infancy. One brother died of brain + tumor. One sister is neurotic; her eight year old son suffers from + congenital heart disease. Patient was born in Manchester, England. He + was the twentieth child; mother was over forty years old at the time + of his birth. He was an unusually small and puny infant and remembers + using crutches when a child. At seven he was bitten by a dog and + dragged about on the ground for a great distance; when finally + rescued was unconscious for a long time. No further ill-effects. + School life was characterized throughout by truancy and disobedience + and finally terminated in expulsion. At that early period of life he + already showed marked egotism, extreme vindictiveness and an utter + disregard for consequences. The immediate cause of his expulsion from + school was a fistic encounter with a teacher. At the age of eleven, + his family immigrated to this country. He states that he was different + from other boys of his age, did not care for the ordinary childhood + sports, and the only friends he had were a young sister and a dog. He + states that he couldn't get along somehow with the other boys, that he + often thought that the whole world was trying to down him and + persecute him. About that time someone stole his dog. He brooded over + this so much that he finally jumped into a creek, intending to commit + suicide, but was rescued by bystanders. He has made several other + attempts at suicide in later life. In describing these he elaborates + them with a lot of fanciful trimming, dilates on the importance of the + various situations attending them, and how much uproar they caused + among those who knew of them. At the age of fourteen he had a quarrel + with another boy. Upon being reprimanded by the latter's father, he + could not rest until he had obtained a gun and fired at the boy's + father while the latter was sitting at the supper table with his + family. In relating this incident he states with great vanity that he + fully intended to kill the boy's father; he wasn't going to be + insulted by anyone and let it go at that. Here was probably the first + well-illustrated instance of his pathologic emotionalism, the tendency + to a complete dominance of a certain affect. He was committed to some + sort of an industrial school for a year. Upon his release from there + he went to work in a machine shop in his native town. One day a couple + of gentlemen and a lady walked through the shop and stopped in front + of the machine on which he was working. He did not like this, became + angered, picked up the dog which followed them and threw it into the + oil tank which fed his machine. At sixteen he ran away from home. He + gives a history of an industrial career and apparently he had no + difficulty in learning a trade, and it is quite likely that he was a + skilled workman. His entire industrial career, however, is + characterized by an inability to fit harmoniously into the situation + at hand, not because of an intellectual deficiency, but because of the + disharmony between his various mental faculties. His extreme + sensitiveness and emotionalism, his vindictiveness, the total lack of + a sense of responsibility, his impulsive existence, all these, were + always at play in his relations with man. If to these be added his + extreme egotism and vanity, the reasons for his conflicts become + clear. "Here, the foreman thought he knew more than I did." "There, I + did not like the way they were running the business," etc. Among his + occupations, saloon-keeping and professional gambling played an + important role. He finally gave up all attempts at leading an honest + existence and turned to crime. Our record of the man in this regard is + rather incomplete, but according to his record at the Secret Service + Bureau, he was sentenced in 1890 to a two years' term for highway + robbery. In 1902 to three years for counterfeiting; in 1904 to three + and a-half, and in 1908 to six years for the same offense. These + sentences were incurred under various aliases. He married at a very + early age. He says he made up his mind one night to get married and + two days later was married. His conjugal life, like everything else he + engaged in, proved a failure and was characterized by repeated + desertions. He commenced using alcoholics at a very early age and has + indulged excessively all his lifetime. He has had several gonorrhoeal + infections, and has an active luetic infection at the present time. + On May 5, 1908, he was sentenced to a six years' term of + imprisonment. Soon after it became necessary to perform an operation + for appendicitis, and upon recovering he began to complain of having + been cut open and of having had poison put inside of him. The U. S. + Government sent men down to the prison who were threatening to kill + him. He saw detectives from Washington whom he recognized. He was very + apprehensive and refused to submit himself to an examination, and made + homicidal attacks upon the officers. On March 8, 1909, he was admitted + to this institution. His conduct here was characterized throughout his + entire stay by the same attributes of character which were at play + throughout his entire antisocial existence. He was at all times very + emotional. He was very sensitive, becoming offended on the least + provocation, and when laboring under some imaginary grievance his + antagonism and vindictiveness knew no bounds. He was constantly + plotting and scheming some means of inciting a revolt among the other + inmates and took every opportunity to put himself forth as the + champion of the other patients. He was very egotistical and vain and + showed a marked tendency to interpret most trivial occurrences in his + environment as having some reference to him. He was always ready to + endow every incident with a personal note of prejudice. He showed + throughout marked fluctuations of mood. One never knew what sort of a + reception one would meet. He was a pathological liar, was keenly alert + to everything that transpired about him and was always ready to + utilize every incident to his own advantage. He was depraved to a very + marked degree morally. He gave his past history without the least sign + of regret and when questioned concerning the reason of his criminal + life, he objected strenuously to being called a criminal, insisting + that what he did was right. At times he impressed one by his mode of + reaction to various daily occurrences as being as naive as a child + and suggestible to a very marked degree. He frequently threatened to + commit suicide if refused some of his impossible requests and showed a + marked tendency to hypochondriasis and exaggeration of actual ills. On + this basis he developed various persecutory ideas, exclusively against + those who had anything to do with his care and safe-keeping. The + warden at the jail before he came here tried to poison him and took + the opportunity of accomplishing this while he (the patient) was + undergoing an operation. The Government sent Secret Service men down + to watch him and persecute him. Here the physicians are doing the same + thing. They are trying to down him, to make his life miserable for + him, etc. Throughout his sojourn here he was clearly oriented, knew + everything that was going on and failed to show the least indication + of the existence of a deteriorating process. He showed also a marked + tendency to write a good deal of poetry and fiction in which he spoke + of himself as a martyr who had been persecuted and downed all his + lifetime. His stories were of a fantastic, adventurous kind, in which + gambling, shooting, and similar highly melodramatic situations were + enacted. On July 17, 1911, he was returned to prison as recovered. + Another point of interest in this case and one to which I have briefly + alluded before, was his tendency to the exaggeration of symptoms and + to malingering, but the malingering which he manifested was of the + kind that the child manifests in an endeavor to attract attention to + itself and to arouse the sympathy of those about him. + +Here again we have before us a kaleidoscopic picture of the life of a +human being who from childhood showed tendencies so antisocial, so +criminalistic, that it is hard to get away from the belief that most of +the attributes which went to make him just what he is, must have been +inherited. Let us take this poorly-begotten organism and follow it +through life. We shall see how its existence has been a continuous round +of conflicts with everything it came in contact. He entered school and +meets with the first obligation, with the first necessity for a +well-regulated, purposive existence. What is the result? Truancy, +disobedience, and finally expulsion--not because of intellectual +deficiency, but because of those same attributes which later served to +put him in the penitentiary. It was the first evidence of his pathologic +emotionalism and vindictiveness. We next see him in an effort to lead an +industrial life, but here, too, everything he does proves a failure, and +likewise not because of intellectual deficiency, but because of a +disharmony, a disproportion, between his various mental faculties. He +could not, somehow, submit himself to any well-regulated existence. His +egotism and absolute lack of the sense of responsibility made it +impossible for him to adjust himself effectively to the world about him. +He next tries matrimony, and the same story reasserts itself. His +conjugal life is characterized by repeated desertions; and thus he +becomes steadily more debased, more depraved, sinks to the level of the +professional gambler and finally even this becomes too strenuous for +him, and he turns to a life of crime. At the age of forty we find him +with a record of numerous arrests, and as far as known, one-fourth of +his lifetime has thus far been spent in jails and penitentiaries. The +characterological anomalies at the bottom of his career came to the +front already in his childhood days. Before completing his fourteenth +year we find him deliberately planning the murder of a human being +because of an insult. His idea concerning that situation has not +changed in the least since then. He now speaks of it without the least +sign of remorse or regret. As a matter of fact, he is inclined to +impress one as being rather proud of that deed, and he cannot see the +criminality of it. The atavistic nature of his act in throwing the dog +into the oil tank is quite evident. Then his attempts at suicide +throughout his lifetime, evidence of a pathologic emotionalism, must +also be remembered. These are a few examples of his mode of reaction to +everyday occurrences in life. Is it at all strange that he has developed +finally into the habitual criminal? On the contrary, it would be rather +strange that an individual with such attributes should turn out to be an +honest, peaceful citizen. He likewise was a prey to all the vices of +modern civilization, and these, as in the preceding case, unquestionably +added to the dissolution of the originally defective organism. We +finally meet with an illustration of the other phase of his mode of +reaction. Following imprisonment on a charge of robbery, he develops a +psychosis which necessitates his transfer to an insane asylum. Brief as +the description of his psychosis has been, it is sufficient to +illustrate that here we are likewise dealing with a psychogenetic +disorder manifesting itself as a reactive expression of a degenerative +constitution to an unpleasant situation. Shortly after his arrest he is +being operated upon for appendicitis and upon recovery elaborates the +idea that the warden of the jail, one of the members of that large class +against whom he has been warring all his lifetime, takes this +opportunity of placing poison in his body. He sees and hears people +around his cell whom he recognizes as Secret Service men sent down from +Washington to torture him. On his transfer to our Hospital he readily +carries over his delusional ideas to the officials here. He is simply +being persecuted by a bunch of anarchists, who are trying to down him +and make life miserable for him. + +It has long ago been questioned by psychiatrists whether these so-called +delusional ideas of this class of patients deserve to be endowed with +the value of delusions. Let us not forget that a similar attitude toward +officialdom exists in the minds of criminals enjoying a respite from the +law. It is the officers of the law, society's institution for the +prevention and punishment of crime, that these people have to fear, and +when they speak of being persecuted by those who have their care and +safe-keeping in hand, it is not, necessarily, a pathological +manifestation. The only difference between such paranoid ideas in the +criminal at freedom and the one in confinement is that in the latter +case, coupled with the stress of confinement, the stress of a forced +routine existence, these ideas assume enormous proportions and in some +instances become supported by fallacious sense perceptions. Their +exaggerated self-consciousness, their great tendency to introspection, a +tendency which is very much enhanced by confinement and plenty of +leisure time for such indulgence, and their paranoid attitude toward law +and its officers, makes it possible for them to endow the least +significant occurrence in their environment with a personal note of +prejudice. The least deviation from the normal routine has a meaning to +them, a meaning which is readily interpreted as some evidence of +persecution, of prejudice, etc. The course of their disorder shows so +much evidence of this psychogenetic character that it is impossible to +think that we are dealing with a psychosis which apparently has no +relation to the situation at hand. Every symptom which they manifest +can be traced to some definite cause and can be clearly explained as +being of the nature of a reaction, of a motivated expression to a +definite experience. It is, I believe, unnecessary to enter into a +lengthy discussion to show that we are not dealing here with a case of +dementia praecox, but with one of the degenerative psychoses and we will +consider the criminal tendencies of this individual likewise as +expressions of that same degenerative soil which permitted of the +development of the psychosis. On July 17, 1911, the patient was returned +to the penitentiary to serve out the remainder of his sentence. + + CASE III.--P. F., alias H., white male, aged 42. Admitted to the + Government Hospital for the Insane, March 11, 1910. + + Father is a chronic alcoholic; one brother a wanderer, has not been + heard from for twenty years; one sister a suicide; one sister left + home at the age of eighteen and has not been heard from since. + + Patient was born in England in 1868. Was a healthy child as far as he + knows; no history of spasms or convulsions. Talked and walked at the + usual age. Of the diseases of childhood he had whooping cough, measles + and scarlet fever, from which he apparently made good recoveries. + Entered school at the age of seven; attended irregularly until he was + twelve years old. After leaving school he made an attempt at learning + a trade and worked as apprentice for some time. At fifteen he + endeavored to enlist in the British Navy, but was rejected on account + of palpitation of the heart. In 1884, at the age of sixteen, he joined + the Royal Marines; soon found this to be disagreeable to his tastes, + and wanting to secure his discharge, he stole a suit of clothes off a + dummy with the avowed purpose of being discharged for the offense. + Was arrested, plead guilty, and served a sentence of one month. In + 1886, at the age of eighteen, he enlisted in the Royal Fusileers and + deserted therefrom about a month later. He then reenlisted in the + eighteenth Royal Irish Fusileers, shortly after deserted, and then + gave himself up; was court-martialed, dishonorably discharged, and + given a sentence of six months which he served in Brixton's Military + Prison, London. In 1887, at the age of nineteen, under the name of + Henry Sayers, he joined the Welsh Division of the Royal Artillery, + whence he deserted two months later and sold a kit and coat belonging + to another recruit; was apprehended, tried and given a sentence of six + months. In all, he was dishonorably discharged from the service seven + times. In 1892, at the age of twenty-four, he immigrated to this + country. On arriving here he worked about a month at railroading and + then enlisted in the Army, deserted after serving three months, and + crossed the Canadian Border. He subsequently returned and gave himself + up to a sheriff, was court-martialed, dishonorably discharged, and + given a sentence of one year and a half. After being released he + resumed his nomadic existence but in a more pronounced manner. Since + 1895, he has had no definite occupation, subsisting on begging, + stealing, and peddling minor articles, chiefly on the two former. He + has spent most of his life since then in penitentiaries and + workhouses, and when at liberty, in cheap boarding-houses and + missions. As far as he can recall he has been arrested twenty-two + times for vagrancy since 1895, served four years at Moundsville and + Atlanta for robbery, and six months for theft. He commenced to indulge + in alcoholics at a very early age and has been an excessive drinker + all his life. Has been intoxicated on numerous occasions and has had + delirium tremens twice. In 1897 he indulged in opium smoking for + thirteen days and in 1904 sniffed cocaine for a similar period. On + three or four occasions in his life he has had sexual experiences + with men and there is a definite history of inversion. He has been + married twice. His conjugal life with his first wife was a very + unhappy one. He attributes this entirely to his own fault. There were + three children from this union, all of whom died in infancy. He left + his first wife without obtaining a divorce from her and subsequently, + in 1898, married again. This union was happier than the former one. + His second wife, however, died in 1905. There were no children from + this union. He acquired gonorrhoea and syphilis in 1899. In 1907 he + prepared an elaborate attempt at suicide, purchased a dagger for this + purpose, and set June 13th for the date. He was, however, arrested + shortly before this and thus his plan was frustrated. He stated that + it was not disgust of life that drove him to do this. He simply had a + desire to see whether he had the nerve to execute such an act. On + February 2, 1910, was arrested for vagrancy and begging, and given a + sentence of 180 days in the workhouse. While in his cell he attempted + suicide by inflicting superficial cuts over the praecordium, wrists and + calves of his legs with a piece of broken table knife. These were very + insignificant in nature. While confined in the workhouse he developed + various fallacious sense perceptions, saw visions of weird and + fantastic nature, and frequently these would take on a religious and + sexual coloring--he would see nuns' heads. He also developed auditory + hallucinations and would hear voices of a disagreeable nature. He was + subject to peculiar sensations as though there was a wire framework + inside him which made him squirm. This necessitated his transfer to + this institution. + + On admission he was well-nourished, but prematurely gray. He had + numerous tattoo marks on his body; on the right forearm a woman in + tights and the head of another; on the left forearm initials U. S., + flag, ship and cross; over the dorsum of left hand a star, and a band + across the wrist. His vision was impaired to some extent; otherwise + negative. Aside from a futile attempt at suicide which he made shortly + after admission, his conduct has been excellent. He has never been + known to become involved in altercations or quarrels with his fellow + patients and has obeyed fully the rules and regulations of the + Hospital. He was somewhat circumstantial during a lengthy + conversation, but in a superficial interview he made quite a natural + impression. He was clearly oriented and showed no memory defect. His + answers to the intelligence tests failed to show any intellectual + impairment. His emotional tone was unvaried. He was always very + polite, courteous and optimistic, and very popular with the + attendants. He willingly assisted with the ward work at all times, was + keen and alert, fully cognizant of everything that transpired about + him. He spent his time reading and rarely associated with his fellow + patients, whom he considered below him intellectually. He believed in + reincarnation, and thought himself to have been in a former being + Pharaoh of Egypt and the Earl of Warwick. He had tactile, auditory and + visual hallucinations of a religious and sexual coloring. These were, + however, transitory in type and perhaps better called + pseudo-hallucinations, as he was able to bring them on and cause their + disappearance at will. He was frank in his statements and discussed + the various ideas without hesitation. He was inclined to write a great + deal, especially poetry of the waste-basket variety, and considered + himself quite proficient in this respect. On February 2, 1911, he + appeared before the Staff conference where the advisability of + granting him parole of the grounds was considered. Upon being refused + this privilege he again attempted suicide by making several + superficial cuts across the wrists. These were quite insignificant in + nature. At the present writing the patient, I am told, if anything, + had improved somewhat. At any rate he shows no intellectual impairment + nor evidence of any progressive mental disorder. Patient was + eventually discharged on April 7, 1915, as unimproved and went to work + in a steel-plant in the District of Columbia. He soon, however, + reverted to his old alcoholic habits, came in conflict with the law + and was sentenced to the workhouse. While his strictly psychotic + symptoms subsided it is quite evident that the original defective + constitution which has been responsible for all of his past + difficulties has not improved. + + Here is another individual who started out in life with a heavy + hereditary burden. His early childhood, as far as can be determined, + was normal. He entered school and here met the first obligation. He + wavered, showed a tendency, that early, to be unable to lead a + well-regulated life and in consequence his school attendance was + irregular. The next difficulty he met was in attempting to learn a + trade. He soon found this too strenuous and sought an environment less + exacting in nature, and at fifteen we see him endeavoring to enlist in + the Navy. This is probably the first indication of his "wanderlust." + He was rejected, and after another year's effort to get along in his + immediate environment, finally succeeded in entering the Navy. Soon, + however, he found out that Navy life was not what he had pictured it + to be. It, likewise, was too exacting. He had to live up to prescribed + rules, obey orders--things to which he could not reconcile himself, + and in consequence failed of a proper adjustment. He knew he could not + stand it, he must get out. He must seek something more suitable, + something less exacting. In looking for a way out of the situation he + availed himself of the first opportunity, stole a suit of clothes with + the avowed purpose of being discharged for the offense. Here is the + starting point of his criminal career. He did not reflect upon the + consequences. He knew he must gratify his desire to get out of the + Navy, must do it at any cost, and yielded to temptation. This yielding + to temptation, this lack of power of resistance, characterized his + entire life. He yielded to every vice that crossed his path; he stole, + he drank, he became a morphine habitue, he sniffed cocaine, acquired + gonorrhoea and syphilis in his promiscuous sexual trends, and lastly + yielded to sexual perversion. After having served his first sentence + he was released and again found himself thrown upon his own resources. + He had not, as yet, reached the stage of the habitual criminal with + the utter disregard for property rights, nor had he reached that + nonchalance of the hobo, whose philosophy rests upon the dogma that + the world owes him a living, that tomorrow will provide for itself + somehow. He began to yearn for the service again. There, at least, he + was provided with shelter and food. There, at least, he did not have + to worry for the tomorrow. He entered the Army, deserted, re-entered, + deserted again, and kept this up until he was dishonorably discharged + seven times. He could stand it just so long. His lack of stability, + his inability for any continuous purposive effort, made him slip from + under the stress. He has less dread for the future now. He was + beginning to acquire that naive philosophy that somehow the world + would provide for him. We next hear of him across the ocean. Here his + "wanderlust", his love of adventure, reasserts itself, but somehow he + did not fit into existing conditions, and unable, because of his + particular organization, because of his disequilibrated mentality, to + create for himself a suitable environment, his existence continued to + be an unbroken chain of conflicts, of contradictions, and of failure. + He finally tried matrimony, but here, too, he soon felt the + overwhelming burden of duties and obligations. He was not assisted in + sustaining these by any moral sense, by any paternal feelings--and + after a more or less continuous struggle to cope with the situation, + left wife, situation and all. He realized subjectively that he and his + wife were not congenial. As a matter of fact, his entire life has been + a continual round of uncongenialities, of inability for a proper + concourse with men and things in the world. Throughout his life his + ego occupied the center of the stage. It is he that has to be + satisfied first. After leaving his wife he resumed his nomadic + existence and sometime later married again. But by this time he was a + full recidivist, as well as an accomplished hobo. The nomad was no + longer able to adjust himself to a communal existence. Besides, it + required effort. He was expected to provide and he could not be + expected to do anything. Fate was in his favor--his wife died. It must + not be forgotten that by this time he had made full use of the kind + oversight of the law. He had been arrested innumerable times, he had + breathed the atmosphere of the workhouse and partaken of the + penitentiary menu. The once unfinished product had been shaped and + polished by the machinery of the law and order of our modern + civilization so that all dread and fear of punishment had lost its + value with him. At last the organism which was originally begotten + from decayed stock, which had been tossed and knocked about through + its entire existence, and preyed upon by all the vices that modern + civilization affords, began to falter and shake. He developed a + psychosis. I shall not enter here into an extensive discussion as to + the diagnosis of the disorder. The total absence of any indication of + progression in this man's mental disorder, the pliability of the + various delusional ideas and hallucinatory experiences, his perfect + control over them in the matter of bringing them on and causing their + disappearance at will, speaks sufficiently against dementia praecox. + + + CASE IV.--A. W., colored, aged 28. Mother suffers from neuralgia and + headaches; one sister died of pulmonary tuberculosis. One brother is + now serving a sentence at Moundsville Penitentiary for assault and + battery. Another brother has been frequently arrested for various + offenses. + + Birth and childhood of patient apparently uneventful. During childhood + fell from a fence following which he was unconscious for some time. + Entered school between the ages of seven and eight, and attended + regularly for about two years, when he became unruly and + ungovernable--would play truant on frequent occasions, and finally + left school before finishing the fourth grade. He worked around home + for a little while, and was arrested the first time when eleven or + twelve years old, for assault. At fourteen he was again arrested for + some minor offense, and shortly afterwards was sentenced to one year + in jail. On August 20, 1902, at the age of eighteen was arrested for + carrying concealed weapons and discharging them in the street, for + which offense he served five months in jail. March 3, 1903, sentenced + to serve thirty days for larceny, and on the same date was further + charged with disorderly conduct, for which he was given fifteen days + in the workhouse. May 1, 1903, he was sentenced to sixty days in jail + for petty larceny; July 18, 1903, charged with fornication, but charge + was withdrawn. August 31, 1903, sentenced to thirty days in jail for + being drunk and disorderly, and committing assault. November 1, 1903, + sentenced to fifteen days in the workhouse on a charge of disorderly + conduct. November 17, 1903, sentenced to twelve years for assault and + highway robbery. He commenced using alcoholics at a very early age, + and has indulged heavily since then. He was admitted to the + Moundsville Penitentiary, December 13, 1903, where he remained until + July 4, 1908, when he was transferred to Leavenworth. His record at + the penitentiary is a very bad one, he was frequently punished for + various offenses and showed a constant tendency to disobey rules and + get into altercations with fellow prisoners. He was in solitary + confinement several times, and forfeited almost all of his good time. + Frequently became mildly excited, singing, shouting, praying and + cursing in the most irrational manner. This state of excitement + persisted unremittingly for seventy-two hours on one occasion. He + declared that his lungs were rotting with tuberculosis or some other + foul disease, and that he was suffocating. He persisted in exposing + himself in a nude condition and refused nourishment. + + He was admitted to the Government Hospital for the Insane, + December 24, 1909. + + Physical examination showed him to be a well-developed, healthy negro. + Both deep and superficial reflexes exaggerated; ankle clonus both + sides; hyperaesthesia of abdomen and face. He stated that two or three + months prior to his admission to this Hospital he became suspicious of + his food; had a burning in his stomach after eating; believed that his + health was failing him; his breath became short; voice weak and lungs + rotting. Early in December, 1909, he believed that he had been + chloroformed by the prison officials for five days; he was not certain + how this was done but believed that it might have been poured through + the keyhole. During this period he sang like a graphophone; voices + said "move his head", and his head would move itself. When his eyes + were open he saw nothing unusual but when they were shut he could hear + them operating a machine on his body; they were pumping his stomach, + and he became a skeleton. This was done to him through prejudice; did + not know who was prejudiced against him, but at the prison they know + all about it. Said he had not slept a wink since his admission to the + Hospital; his breath is short; he has pains around his heart, but + thinks he is getting better now. + + He was a negro of limited mental capacity and possessed very little + acquired knowledge. He was clean and tidy in his habits, keenly + interested in his environment, and well oriented in all spheres. He + lacked insight into the nature of his trouble. Attention could be + easily gained and held; he comprehended well and readily, and showed + no memory defect. There was a very marked tendency to hypochondriasis + and exaggeration of actual ills. Soon after admission the active + symptoms of his disorder disappeared, and he gradually acquired an + adequate amount of insight, realizing that he had been insane. His + conduct, at first orderly, now assumed the same character as that at + prison. He frequently became involved in altercations with other + patients and on several occasions manifested decidedly vicious + tendencies. He was almost absolutely unamenable to the Hospital + regulations and on that account had to be frequently reprimanded. He + incited the other patients in his ward to all sorts of misdemeanors, + and when not having any complaints himself, would fight the other + patients' battles. He remained clearly oriented throughout. He was + decidedly deficient morally--could not see where his life had been an + unsocial one, and did not even promise to lead a better one in the + future. + + Here, again, we see disease and crime rampant in the family history of + a man who himself began to manifest criminal tendencies at a very + early age. His school career is characterized by truancy, and he never + made an effort at an industrial career. At the age of eleven or + twelve, we already find him arrested for an offense against the + person, and before having reached his twentieth year he has received a + penitentiary sentence of twelve years. His psychosis is unquestionably + one belonging to that large group developing on a degenerative basis, + the same soil which is at the bottom of his criminal career. What his + future life is going to be may readily be surmised; he has not yet + reached his thirtieth year--and by turning him loose at the expiration + of his present sentence, society adds only another parasitic and + infective organism to gnaw at its roots. It would be indeed ridiculous + to expect the boy who at the age of nineteen was placed in the + environment of a penitentiary--the hot-bed of crime--to be turned out + a better man after having spent twelve years there. Something over two + years has elapsed since the original publication of this paper and I + am able to furnish some additional data concerning this case. + + Upon the expiration of his sentence we were obliged to discharge the + patient because he showed no symptoms of mental disease, and in + consequence we had no authority for holding him in a hospital for the + insane. He was discharged in March, 1912. In October of the same year + he was again arrested, charged with assault with a dangerous weapon + and received a seven-year penitentiary sentence. + + There can be very little doubt as to what his future career will be + following this second penitentiary sentence. + + + CASE V.--W. A., white male, aged 36 on admission to the Government + Hospital for the Insane, January 18, 1911. Father was an alcoholic; + mother neurotic, one sister insane, one uncle suicide. Mother enjoyed + good health during her pregnancy with the patient, but birth was an + extremely difficult one. + + Patient learned to talk and walk at the age of five, when he was + severely scalded which necessitated his confinement to bed for a long + time. Entered school at the age of seven and attended for about eight + years, reaching the 6th grade. He experienced no difficulty in + learning but played truant on frequent occasions. His industrial + career constitutes an uninterrupted chain of failures. He was + frequently discharged for various offenses and quarrels with his + associates. He commenced to indulge in alcoholics at a very early age + and has been an excessive drinker all his life. Married in his + twentieth year and managed to live with his wife for six years, when + she left him on account of infidelity, non-support and drunkenness. + One miscarriage and one apparently healthy child were the results of + this union. + + He came in conflict with the law for the first time at the age of + twelve or thirteen for some offense against the person. We have an + incomplete record of his criminal career, but this can easily be + surmised when we take into consideration that part of it which we do + possess. Between March, 1903, and December, 1910, he was arrested + thirteen times for assault, twenty-eight times for disorderly, and + drunk and disorderly, twice for housebreaking, once for petty larceny + and twice for vagrancy. Habitual drunkenness, destruction of private + property, and depredation on house furniture, add to the list of + charges against him. During this period he served a penitentiary + sentence, was tried for murder, and acquitted on a second trial on a + plea of self-defense, and on four different occasions, was ordered to + be examined mentally. Following a debauch, during which he was + arrested three times for assault, he developed a mental disorder in + jail while awaiting trial, which necessitated his transfer to the + Government Hospital for the Insane. + + He developed the idea that someone was always around him looking for a + chance to kill him. Continually heard strange voices and noises. Was + very nervous and irritable. + + The records accompanying him stated that for years he had had a + particularly bad and dangerous temper. That he had had several + previous attacks of mental disorder; had repeatedly committed + assaults, and was found not guilty of murder seven years ago--an act + of insanity. Had been arrested by the Washington police about + seventy-five times. + + His mental disturbance soon cleared up, and on admission to the + hospital he was absolutely free from any psychotic manifestations. + + He was a well-developed man of average intellectual attainments. He + was somewhat unstable emotionally, and his promises to lead a better + life in the future were usually accompanied by a good deal of crying. + He was a monumental liar, and although endeavoring to impress the + examiner with the idea of being quite remorseful about his past life, + it was clearly evident that his moral status was a very low one and + that his promises and resolutions were merely brought forth to aid him + in securing his freedom. He was extensively tattooed and showed + remains of an old syphilitic lesion. + + Upon his release from the Government Hospital for the Insane, he was + given a year's sentence in the workhouse, and the Press has been + reporting frequent misdemeanors performed by him in the workhouse. + + This case is interesting only in so far as it illustrates + exceptionally well the role of alcoholism in the habitual criminal. It + is, however, very difficult to decide whether the alcohol should be + considered here the cause of the man's degeneracy or its result. It + would appear that whatever injurious effect inebriety had upon this + man, and unquestionably it had, he owes his anomalies of character to + causes over which he had no control. We find that his father was a + chronic alcoholic, his mother a neurotic, a maternal aunt insane, and + an uncle a suicide. That these pathological traits in the antecedents + left their impressions on him cannot be doubted for one minute. He was + abnormal before environment and personal habits had had time to make + themselves felt. He, too, oscillated between penal institutions and + the Hospital for the Insane all his lifetime. That the same + degenerative basis lies at the bottom of both his moral and mental + alienation, cannot be doubted. Here, too, we are able at this date to + furnish other additional information. The patient was eventually + discharged from the Hospital for a similar reason as in the preceding + case, and in spite of all his promises and new resolutions was + readmitted to the Hospital on October 13, 1913 with an attack of + delirium tremens. + +Let us endeavor to see now in what respects the above individuals +simulate one another, and whether this similarity is of sufficient +import to warrant the grouping of them into one category. Commencing +with the family history we find disease and crime manifest in the +antecedents, either direct or indirect, of all of them, that in all +probability because of this, not one of these unfortunates was brought +into the world with a sufficient impetus to carry him successfully to +his goal. In every instance we find that the characterological anomaly +became manifest already during their school career. It was the +persistent truancy, disobedience and antagonism to submission to a +well-regulated existence and not so much the incapacity to learn, which +distinguished them from the other children in school. The same +attributes of character which were at the bottom of their conflicts with +the school authorities brought them into the hands of the police +authorities soon afterwards. The contact with the outside world soon +served to bring out other pathological traits of character. We now see +them manifest a pathologic emotionalism, an unbounded egotism, a +relentless vindictiveness and an apparently total disregard of +consequences. Frictions with the surrounding world, which a normal +individual meets in an ordinary manner with a view towards an efficient +adaptation to existing conditions, were reacted to by them in a +distinctly antisocial manner, with methods entirely void of +consideration of the rights of others, an attribute so essential for a +proper concourse with man. Thrown finally upon their own resources, when +they had to rely for their existence upon some industrial pursuit, we +find them lacking the most essential prerequisite for the efficient +struggle for existence--definiteness of purpose, and continuity and +persistence of effort. We find them leading a harum-scarum existence, +drifting from place to place, and from occupation to occupation, never +able to remain at any one undertaking for any length of time. + +The next features which stand out prominently in the lives of these +individuals are their recidivism and the fact that every one of them +came under the observation of an alienist on one or more occasions in +his life. What is at the bottom of all this? We cannot, of course, deny +the very evident fact that these individuals differ from normal man and +that this difference is due to their inferiority. But what characterizes +this inferiority? Is it the lack of something which normal man +possesses, or is it rather a disproportion, a disharmony between the +various individual mental faculties of these individuals? In other +words, is their inferiority a quantitative or qualitative one? Taking +pure intelligence into consideration we find that they show no +deficiency in this particular sphere. On the contrary, most or all of +them show a degree of shrewdness and keenness which absolutely precludes +the existence of an intelligence defect _per se_. Their recidivism is +not due to an inability to distinguish between right and wrong. They +know very well what is and what is not right, at any rate, as well as +the average person, but they feel decidedly different from the average +person about this distinction. They are what they are because of a +discord, a disproportion between their various psychic attributes. The +exaggerated egotism, which is so common to these individuals, serves to +establish a pathologic degree of self-consciousness. This in turn makes +them feel with an extraordinary keenness the everyday frictions in +life, and now the pathologic emotionalism comes into play and being +unsupported by any sense of altruism and morality they give way to their +feelings in some criminal act. Their pathologic vindictiveness should +also be mentioned. A sustained real or imaginary injury can never be +forgotten by them. + +These, in brief, I believe to be the characterological anomalies which +distinguish the individuals herein reported from normal man and which at +the same time are sufficiently common to all of them to justify their +segregation into one distinct group of criminals. + +I shall not enter here into a discussion of what part, if any, +environment played in the shaping of the lives of these individuals, for +several reasons, chief among which, however, is the fact that I have not +had the opportunity of investigating thoroughly the environmental +conditions in which they grew up and am therefore unable to evaluate +properly this phase of the question. The fact, however, that my cases +were culled from various sources and that the anomalous traits +manifested by them were already present at an age when environment could +hardly have had any lasting influence upon them, leads me to believe +that it is heredity that is responsible for the major portion of this +anomalous product. However, we shall leave this question to the decision +of the practical eugenists. Personally I fully believe that we are +dealing here with a type in which heredity plays an important role. I +fully believe that these individuals were always the same as they are +now and that the probabilities are that they will always remain so. +Assuming then, for the moment, that we are correct, the question +arises:--"Has society dealt with these individuals in a proper manner?" + +This question must be answered decidedly in the negative. I will not +enter here into an extensive discussion of a system of penology which +might be specifically applicable to this class of individuals. I can +only agree fully with the current opinions of eminent criminologists on +this subject. + +At the 1911 Congress of Criminology and Anthropology at Cologne, the +following resolution among others was adopted:--"Hardened and +professional criminals, recidivists, who present a great danger to +society must be deprived of their liberty for as long a time as they are +dangerous to the mass. Their liberty should be as a general rule, +conditional." + +Archibald Hopkins, Esq., has been recently quoted by Gault as +follows:--"The Head of Scotland Yard, in London, said not long ago that +nine-tenths of the serious crimes there were committed by men who had +served one or more terms of imprisonment and who might be regarded as +belonging permanently to the criminal class. His judgment was that if +they could be eliminated from such a situation, violation of the law +would be diminished to less than a third of what it has been. Why cannot +this be done? Let the Courts be clothed with power, after two or more +offenses, in its discretion, to pronounce a man incorrigible, who shall +be sentenced for life, to whom no pardon shall issue. By an arrangement +between the general government and the states, a colony could be +established, say in the Island of Guam, where escape would be +impossible, and where, under military guard, convicts could be made to +earn their own living. Surely society has the right to protect itself +from these incorrigibles, who are released only to prey on it again. +They also are the class who rapidly produce their kind, and at present +society puts no obstacle in the way. + +"It is exactly as if, instead of forming colonies to which all +lepers are compelled to go and remain, we permitted them, after a brief +term in the hospital, to go where they please and to marry and produce +more lepers. The incorrigible criminal is worse than the leper because +he deliberately and purposely defies society and spreads his contagion. +It can hardly be questioned that the permanent segregation of the +professional criminal class would very greatly diminish crime, nor can +it be questioned that society has the right to adopt such a measure of +protection, nor that it would not be entirely practicable." (See Journal +of American Institute of Criminal Law and Criminology, April, 1912, +pp. 821 f.) + +The only argument, and a very weighty one it is, which can be raised +against the foregoing proposition, is whether the incorrigible criminal +is sufficiently characterized by such unmistakable features as would +enable us to recognize him when we see him, and thus justify his +permanent isolation from the community. I believe he is, and the cases +here reported are fair representatives of that class. Another problem +which presents itself is: "Where shall we put the incorrigible +criminal?" If we agree that he owes his criminality to causes over which +he has no control and that the crime here is the outgrowth of a +degenerative personality, a personality which is distinctly abnormal, +it would seem that he belongs in a hospital rather than a penal +institution, but is this unequivocally so? It is unquestionably true +that these individuals are abnormal, that without actually being insane +they evidence from their earliest childhood a more or less distinct +deviation from the normal; they may therefore be considered as +"border-line cases," _i.e._, cases which deviate from normal man and +incline toward the insane through numerous gradations. As soon, however, +as their abnormality manifests itself in distinct incorrigible +antisocial tendencies, the right of society to protect itself from such +an element must be considered. When free from actual psychotic +manifestations (which very easily engraft themselves upon this +degenerative soil) these individuals do not belong in a hospital for the +insane. Here they serve only as a very troublesome and disturbing +element, and wield an undesirable influence over many easily +impressionable insane patients. They do not belong in a general penal +institution because of the very deleterious influence they exert on the +accidental but uncorrupted convict with whom they come in close contact +in these institutions. It is my opinion that these individuals, forming +as they do a distinct species of humanity, should be segregated into +colonies especially designed for them, where under proper medical +supervision, they should be made to earn their subsistence by means of +some useful occupation. It is very obvious that an indeterminate +sentence is the only rational way of approach to this problem and this +should be supplemented by the vesting of the parole power in the hands +of a board composed, not exclusively of members of the legal profession, +but largely of physicians, and particularly those trained in +psychopathology. + +The foregoing cases, while distinctly abnormal mentally, owe their +recidivism to a qualitative rather than a quantitative defect. + +Since the original publication of this paper, I have had occasion to +observe a number of recidivists in whom the defect was essentially a +quantitative one, _i.e._, patients ranging in intelligence all the way +from idiocy to moronism. + +The following case is a good illustration of this type:-- + + R. W. (colored) was admitted to this Hospital for the first time from + the District of Columbia Reform School on February 8, 1898. He was at + that time serving a sentence for housebreaking. He was twenty years + of age at that time and examination showed him to possess the + intelligence of an imbecile. During his sojourn here he had several + maniacal outbreaks, but recovered from these and was discharged into + the care of his parents on November 23, 1898. Sometime in 1900 he was + again sent to the Reform School and was readmitted to this Hospital on + November 17, 1900. He suffered at this time from an acute + hallucinatory episode from which he soon recovered and was allowed to + go out on a visit on February 20, 1901. He never returned from this + visit but on July 23, 1902, was sentenced to twelve months + imprisonment for larceny. While serving this sentence he was admitted + to the State Hospital for the Insane at Norristown, Pennsylvania, + where he suffered from an acute maniacal attack with persecutory + delusions. He was discharged from that institution, by order of the + Court, on September 29, 1903. On January 1, 1904, he was arrested for + housebreaking and sentenced to three years imprisonment at the United + States Penitentiary at Moundsville, Virginia. From the above + institution he was admitted to this Hospital on May 8, 1905, + suffering from an acute maniacal attack. He soon recovered again and + was discharged on August 18, 1906, with a diagnosis of imbecility with + recurrent mania. He was readmitted here October 3, 1907, and + discharged April 1, 1909. On January 23, 1910, he was given a two + months workhouse sentence for petty larceny. On September 7, 1912, he + was again sentenced to four years in the Penitentiary for grand + larceny, from which institution he was readmitted here on January 19, + 1915. + +I shall not enter into a detailed discussion of this case. It is simply +quite illustrative of the absolute necessity for permanent segregation +of mental defectives. + +When some of this clinical material was first published in 1912 it met +with very gratifying recognition at the hands of those who were +interested in criminalistics. + +I wish to take this opportunity of expressing my particular appreciation +of Dr. Healy's kind words of approbation and encouragement. + +We all must agree that the first essential step towards a better +understanding of criminal types consists in a thorough study of the +criminal individual, such as is reflected, for instance, in the very +excellent book by Healy on the "Individual Delinquent." Such studies +have thus far, however, with but rare exceptions, not been made at the +proper source,--that is, in the criminal laboratory, the penal +institution. + +The work which is being done with the juvenile offender is, of course, +very important and very valuable; but in order that this work may be +checked up scientifically it must be supplemented by thorough +catamnestic studies of the juvenile offenders. This, I believe to be +the only rational way of approach to the problem. + +This will in time, I believe, furnish us data concerning the criminal +which will enable us to evaluate in a correct manner the various traits +and characteristics of the juvenile offender and thus enable us to +render a correct prognosis in a given case. Once we shall reach a stage +in the science of criminology when we shall dare to say of a juvenile +offender, as we now unhesitatingly say of the leper, "Here is a human +being who will always be a danger to his fellow-man and, therefore, +should be permanently isolated from his fellow-man", the problem of +recidivism will be solved. + +We cannot, however, arrive at a proper conception of the nature of a +juvenile offender by merely studying a cross section of him at any given +moment of his life. In order to understand man, especially abnormal man, +we must study him in a longitudinal section; we must note his mode of +reaction to experiences in everyday life, under all manner of +conditions and circumstances; we must investigate the motives and +desires which prompt his conduct; we must find out how effectually he +adapts himself to the environment in which he happens to be placed and +in how far he is able to modify the world about him so as to make it +subservient to his needs and wants. The same problems which confront +criminology today, psychiatry had to face some years ago. In order to be +able to rationally and scientifically deal with the insane the +psychiatrist found it essential to establish certain criteria which +might enable him to tell, with some degree of certainty, what the future +life of a given insane person will be. In the last analysis it is this +same thing which we are aiming to attain in our dealings with the +criminal. The problem which is constantly before us in dealing with +juvenile delinquency is what might be expected of the future life of the +juvenile under consideration and what must be done towards directing his +future into proper channels. So, after all, it should be our aim to +establish certain criteria by means of which we should be able to render +a proper prognosis. That we possess no such criteria at present can be +denied by no one. + +As I have already stated, psychiatry had to face the same problems. With +the advent, however, of the Kraepelinian school these have in a great +measure been solved. Kraepelin, by studying the entire life history of +his patients, was able to show that certain disease pictures when +studied in cross section may simulate one another very closely +clinically and at the same time be of the most diverse significance +prognostically. He further showed that certain acute psychotic +disturbances are merely the outward expressions of an underlying +progressive disorder, and though the acute manifestations may disappear +and leave no apparent trace behind them, the great majority of these +individuals will spend the rest of their lives in institutions for the +insane. By calling attention to certain symptom-complexes, which are +especially characteristic of certain mental disorders, he gave us the +means by which we are able at the present time to predict with a fair +degree of certainty what the future life of a given patient will be. We +can now tell without great fear of contradiction which of our patients +are going to spend the rest of their lives in institutions. + +Now, criminality is generally conceded to be an expression of a diseased +personality and there is no reason why the same principles which served +to advance our knowledge of psychiatry should not be employed here. + +In the foregoing study we aimed to carry out these principles, but we +believe that better results still could be obtained at the hands of a +trained psychiatrist right at the penitentiary. The reasons for this are +quite obvious. The relationship between prisoner and physician would +then be quite a different one, the data could be more readily verified +with the assistance of the machinery of the law, and the subjects would +be in a more accessible mood than when suffering from a mental disorder. +As a matter of fact the best work thus far done on the mentality and +disorders of mentality of prisoners was done by a prison physician, Dr. +Siefert, of Halle. + +Thus we see that the question of the degenerative prison psychoses has +an important relation to the question of criminology in general. + +This becomes at once apparent, if we accept the contention of many +authorities that the degenerative soil which makes the development of +these psychoses possible, is likewise responsible for the criminality of +these individuals; in other words,--if we agree that crime and psychosis +are here branches of the same tree. Manifestly any discussion of the +treatment of these psychoses must of necessity touch upon the vastly +broader problem of the treatment of the habitual criminal, the +recidivist, and therefore a slight digression from the subject at hand +will be unavoidable. + +If we admit that it is the prison environment which serves to bring out +the prison psychosis, it is perfectly evident that the first therapeutic +indication is the removal of the prisoner from that environment as soon +as the disorder is recognized. This problem is at present dealt with in +several ways. There are certain penal institutions, especially in +Europe, which have within their walls a psychiatric department for the +reception of these cases. Others send their insane convicts to the +criminal department of some hospital for the insane. In this country +there are States in which still a third system is in vogue, namely, the +confinement of these cases in special hospitals for insane criminals. +Now the points to be kept in mind in the treatment of the insane +criminal are, briefly stated, these:--First, they should of course come +under the supervision of a trained psychiatrist. Second, the transfer +from prison to hospital must take place with as little delay as possible +and not be burdened with a lot of red-tape procedures. Third, the +hospitals for the housing of these patients must be fully equipped in +accordance with the modern ideas of hospital construction, and at the +same time afford ample security for the prevention of escapes. Fourth, +the interest of the inmates of the general hospital for the insane and +the feelings of their friends and relatives must be kept in mind, when +we begin to advocate the populating of our hospitals for the insane with +criminal characters. + +The psychiatric annex in connection with the penal institution meets all +these requirements better than any arrangement for the care of the +insane criminal. An annex of say fifty beds, in connection with every +State Penitentiary would obviate entirely the delay in transferring a +patient from prison to hospital and _vice versa_. As soon as a prisoner +begins to show signs of mental disorder, and a prison physician trained +in psychiatry will be able to recognize these early signs, or as soon as +there is the least suspicion of mental disorder, the patient could be +transferred without delay to the psychiatric department. Here they +should be kept under observation for at least six months. This will be +sufficiently long in most instances to enable the physician to determine +whether he is dealing with a progressive deteriorating psychosis or with +one of those transitory prison psychoses. In the cases of the former, +_i.e._, if it is definitely established that the patient is a dementing +praecox or a paretic, the fact that he happens likewise to be a criminal +is really of little or no importance. A demented individual is never +dangerous enough to require confinement in an especially secure +hospital, though he is a prisoner, and unless he is criminally insane, +_i.e._, unless he manifests dangerous or criminal tendencies as a result +of his mental disorder, really forms no special administrative problem. +He could be kept either in the prison annex until the expiration of his +sentence, if there be room for him, or could be transferred to the +nearest hospital for the insane and treated the same as any other insane +patient. + +It is the second group, however, _i.e._, those patients suffering from +the transitory prison psychoses, which especially justify the +establishment of psychiatric annexes in connection with prisons. We have +seen how detrimental to prison discipline these individuals are, even +when in a condition which might be considered normal to them, and we can +easily surmise what it must mean to care for them in prison during one +of their mental upsets. It is therefore of the utmost importance, both +for the prison administration and for the individual, that these +patients should be transferred to a properly appointed hospital in as +short a time as possible, and this can be done most readily when the +hospital and prison are within the same walls, and more or less under +the same management. On the other hand, we owe it to the prisoner to +bring him under proper care as soon as possible. The practice of sending +these individuals to criminal departments of general hospitals for the +insane has many objections. In the first place, no matter how modern the +equipment of such departments, most of them cannot afford the proper +kind of treatment to these individuals. The idea that the removal from +prison to a criminal department of an insane hospital will have a +beneficial effect upon the prisoner because of the more lenient +environment into which he is taken is entirely delusional in the case of +the degenerated habitual criminal. These individuals, if the public +safety is to be kept in mind, can receive but very limited privileges in +a hospital for the insane. The modern hospital is not constructed with +the idea of caring for dangerous criminals, and in many instances the +habitual criminal, who because of his dangerous tendencies and ever +readiness to escape, has to be constantly kept under lock and key, would +be much better off if he were treated within the enclosure of the +prison. There the construction of the place permits of a wider latitude +of outdoor exercise. An annex located within the enclosure of a prison +could well afford to allow its patients the freedom of the enclosure, +while this can manifestly not be done in a general hospital for the +insane. Then again, there is the unavoidable delay attendant upon the +commitment of a prisoner to an insane hospital. As I have already stated +elsewhere, it is not a rare occurrence to receive patients into the +hospital who have entirely recovered from their mental disorder before +leaving the prison. Furthermore, the expense and danger always +connected with the transfer of insane criminals from prison to hospital +and back again, if the hospital is any distance from the prison, must be +kept in mind. + +A word to those who, from a false altruistic standpoint, insist that the +insane criminal requires no different treatment from that which the +ordinary insane patient does. This is very true in the case of prisoners +who develop mental disorders which have no relation to crime or +imprisonment. These do not require special measures of treatment. It is +likewise true of the psychoses of the accidental criminal, but it is +entirely different with the criminal who suffers from a degenerative +prison psychosis. Here we are not dealing with individuals who tend to +dement, who have little or no conception of whether they are in a prison +or in a hospital. In short, we are not dealing here with paretics or +senile dements, who, although being at the same time prisoners, remain +subject to the same unavoidable lot of the paretic or the senile dement. +The habitual criminal who suffers from a degenerative psychosis, unless +he is in a stupor, is constantly on the alert for a chance to escape. No +matter how delusional or hallucinated he may be, he always manages to +keep in mind that the thing which he most desires is to be free from the +hands of his captors, and anyone who has had to deal with this class +will bear me out in this. The shrewdness with which they carry out their +escapes is amazing, and some of the more depraved ones do not hesitate +to commit serious assaults in order to gain their freedom. Here, +measures other than those used with the ordinary insane patient are +required. + +Now as to special hospitals for insane criminals which certain States +have. Of course the same objections, namely, as to the delay in getting +the patient under treatment and the danger of transfer, etc., hold true +also here; but these hospitals, it seems to me, have the additional +disadvantage that they necessitate the segregation of all insane +criminals, irrespective of whether they suffer from a recoverable +psychosis or from a dementing process. In other words, here we have an +admixture of cases who unfortunately fell into the hands of the law +because of some mental disorder and who certainly should be confined as +any other patient in an ordinary hospital for the insane, and patients +in whom the crime and mental disorder are expressions of the same +underlying degenerative defect, and who in a great majority of instances +suffer from recoverable transitory mental disorders. + +To insist upon keeping a paretic all his lifetime in such an institution +is highly irrational, to say the least. The most rational, and the only +scientific way, of dealing with the insane criminal is to bring about a +state when the psychiatric hospital will be made accessible to him just +as easily as the surgical and medical wards are, and this can only be +accomplished by having psychiatric annexes in connection with prisons. +The only serious objection which can be raised against this plan is that +in time the annex will be made up exclusively of a very dangerous and +troublesome population, but this objection likewise applies to the +special hospital for the insane criminal. Certainly it is far safer to +have this class of cases within the prison enclosure than to allow their +accumulation in a general hospital for the insane. + +Lastly, the psychiatric annex in the penitentiary would form the proper +nucleus for the scientific study of the criminal, whence that much +needed information concerning this type of man could emanate and be +utilized for the rational treatment of the problem of crime. + +We have thus far discussed the treatment of prison psychoses in these +individuals while undergoing sentence, but what of them after the +expiration of their sentences? We are now approaching the problem of +recidivism. + +Certain it is that society has thus far failed to deal effectually with +this problem, and one need not search very deeply for the cause of this. +Society has been relying principally upon its punitive methods in +dealing with the habitual criminal, and so long as a given offense was +punished according to a given statute it felt that it had done its duty. +The factor of the personality of the criminal was entirely neglected. In +time we have come to realize that our punitive methods not only do not +tend to do away with recidivism, but enhance it. It is an undeniable +fact that each additional imprisonment only serves to deprave the +habitual criminal more deeply, and to release him after the expiration +of an arbitrary sentence is to let loose another parasite to prey upon +society. Of late years, however, there has been a tendency toward +individualization in criminology. "It is the criminal and not the crime +that we must deal with," is the modern slogan, and starting from this +point of view we have already found out some very interesting facts. We +find in looking over the life histories of our habitual criminals that +they had shown antisocial and abnormal traits from their earliest youth; +that in their early manhood they populated the reformatories and that +their recidivism is due to some underlying anomaly which always +differentiates them from normal men. + +In this chapter we have seen how this underlying anomaly served under +certain stressful situations to give rise to mental disorder, and have +concluded that crime and psychosis must be, in these individuals, +branches of the same tree. If this is true the question arises whether +the habitual criminal does not rather belong in a hospital than in a +prison. It is a little premature to decide this at the present day, but +it is unquestionably certain that it is the psychiatrist who will in +time furnish us the most valuable data concerning the "criminal +character." It is he who will eventually bring to light unshakable proof +that in the habitual criminal we must see an anomalous human being, who +stands in the same relation to normal man as disease does to health, and +then, the problem of recidivism as well as that of the psychoses of +criminals will be easier of solution. + + +REFERENCES + +[1] WILMANNS: "Ueber Gefaengnispsychosen." Halle a. S., 1908. + +[2] BONHOEFFER: "Klinische Beitraege zur Lehre von den +Degenerationspsychosen." Halle a. S., 1907. + +[3] BIRNBAUM: "Zur Frage der psychogenen Krankheitsformen." +_Zeitschr. f. d. ges. Neurolog. u. Psych._ 1910. + +[4] SIEFERT: "Ueber die Geistesstoerungen der Strafhaft." Halle a. +S., 1907. + +[5] STRANSKY: "Ueber die Dementia Praecox, Streifzuege durch Klinik und +Psychopathologie." Wiesbaden, 1909. + + + + +CHAPTER III + +THE FORENSIC PHASE OF LITIGIOUS PARANOIA + + +Maudsley[1] has long ago said: "It would certainly be vastly convenient +and would save a world of trouble if it were possible to draw a hard and +fast line and to declare that all persons who were on one side of it +must be sane and all persons who were on the other side of it must be +insane. But a very little consideration will show how vain it is to +attempt to make such a division. That nature makes no leaps, but passes +from one complexion to its opposite by a gradation so gentle that one +shades imperceptibly into another and no one can fix positively the +point of transition, is a sufficiently trite observation. Nowhere is +this more true than in respect of sanity and insanity; it is +unavoidable, therefore, that doubts, disputes and perplexities should +arise in dealing with particular cases." + +No small amount of the disrepute into which expert medical testimony has +fallen is due precisely to a failure on the part of the legal profession +to appreciate these truisms. To the legal mind the transition from +mental well-being to mental disease is exemplified by that wholly +artificial, and to the psychiatrist's mind, subsidiary question of legal +certification. The law takes no cognizance of the conditions +necessitating this change; it only concerns itself with the delimiting +frontier, viz.:--certification. Legally, the insane has become such +through the filling out and signing of certain papers and through having +submitted himself to a certain prescribed legal procedure. The +physician, on the other hand, because of his peculiar relationship to +the patient, and as a result of his particular training, looks upon this +legal procedure as a necessary evil and merely as typifying the +conventional mode by which society settles its accounts with its +diseased members. Our legal brethren fail to appreciate, furthermore, +the fact that an individual may be very seriously ill mentally and +urgently require hospital treatment, without, however, showing those +gross disorders of conduct which go to make up the legal evidence and +diagnosis of insanity. Neither do they seem to recognize the possibility +of a seriously unbalanced individual making quite a normal impression, +at any rate before a jury of laymen at the time of his appearance in +Court. Nowhere in psychiatry is this so apt to be the case as in that +form of mental disease known as paranoia, where we are dealing with a +diseased personality which in many respects still approaches and +resembles normal man. + +The paranoiac, while he may harbor the most intricate and well-organized +system of delusions, still remains approachable to us, and +intellectually may be not only on a par with the average normal +individual, but not infrequently gives the impression of being his +superior. Nevertheless, this usually well-endowed human being at a +certain point in his career goes off at a tangent and spends the rest of +his life in the pursuit of a phantom. The paranoiac, starting out with +vague, ill-defined ideas, succeeds in elaborating, step by step, a +well-organized system of thought, of ideas which finally assume an all +importance in the conduct of his life and remain unshakable. + +Kraepelin[2] defines this condition as a mental disorder which is +essentially characterized by a gradual and systematic evolution of a +well-organized and intricate system of persecutory and grandiose +delusions. It is chronic and incurable in its course and does not lead +to any appreciable deterioration in the intellectual sphere. The +litigious form of this disorder is particularly characterized by a +persistent and unyielding tendency toward litigious pursuits. It is for +this reason that this form of paranoia is of particular interest +forensically. The law is the tool with which these individuals work, and +the Courts their battle-grounds. The least provocation suffices to start +the stone rolling, launching the unfortunate upon a career of endless +litigation. As a rule the disorder originates in connection with some +adverse decision or order of the authorities, which the patient +considers an unjust one. Whether injustice has actually been suffered by +the patient matters not and remains absolutely of no consequence as far +as the course of the disease is concerned. The paranoiac litigant is +unable to see the law as others see it, and in this respect he does not +differ greatly from primitive man, whose conception of legality is that +of a collection of concessions for himself and prohibitions for others. +To be sure, a tendency to excessive litigation is occasionally met with +in what appear to be normal people. Such pursuits, however, become +pathological when they are based upon a delusional interpretation of +actual occurrences or upon actual delusions, and are not amenable to +reason. + +According to Tanzi[3] the theme underlying the delusional system of +litigious paranoiacs is avarice, and the whole may be looked upon as the +slow and permanent triumph of a preconception. "The paranoiacal +preconception gradually conquers all evidence to the contrary, and in +spite of reality, public opinion and common sense, it becomes organized +into a cooerdinated system of errors which become the tyrants of the +intellectual personality and remove it by degrees outside the bounds of +normality." The litigant constantly busies himself with his grievances, +loses all interest in everything else, and begins to fight for his +rights. He stops at no means and is the bane of judges and court +officials. Naturally, he has to be refused all aid, either because he is +unjust or because the courts find no remedy for his troubles. He refuses +to settle actual grievances, carries the case from one court to another +and finally develops an insatiable desire to fight to the bitter end. +The statutes appear to him inadequate and even the fundamental +principles of law fail him. He cannot abide by the ultimate decision +after all the usual means of justice have been exhausted. In his +attempts to gain justice he writes to magistrates, legislators and +various other people in prominence. It is only after years of persistent +misfortune both to himself and the objects of his delusions, which only +serve to harden him against his fortunate opponents, his incapable +lawyers, the corrupt judges and his ignorant and craven-hearted +relatives, that this master of procedure is betrayed into the expression +of threats or the commitment of some other offense which conveys him +summarily from the civil to the criminal courts, and the unrepentant +pursuer becomes the defendant, unless, indeed, the insane asylum has +become his refuge. (Tanzi.) + +This is precisely what happened with the patients whose histories are +here recorded. With all this the paranoiac remains plausible, converses +rationally and coherently, shows himself to be exceedingly well-informed +on current events, amazes his listeners with his really wonderful memory +and his ability to quote _ad infinitum_ from law books and statutes. +Absence of hallucinations is the rule. Memory and the capacity to +acquire new knowledge remain intact, and reasoning and judgment on +matters of everyday life which do not touch his more or less +circumscribed delusional field may remain quite normal. In short, he +shows none of those tangible signs and symptoms upon which we must so +frequently rely in our efforts to convince a jury of laymen of the +existence of mental disorder. It is only when we take into consideration +the entire life history of a paranoiac, which unfortunately is +frequently ruled out as hearsay evidence, that the real state of affairs +becomes manifest. We then see that where it concerns his delusional +field the paranoiac's judgment is formed, not as a result of +observation, or logic and reasoning, but as a result of an emotion, a +mere feeling that this or that proposition is true. In every adverse +decision of the court he sees a deep-laid conspiracy to deprive him of +his rights. His lawyers are incompetent and in collusion with his +persecutors; the judge is corrupt or ignorant of the law, and the +legislators negligent in their duties in not writing into the statutes +laws which would take care of his grievance. He constantly harps upon +what he calls "the principle of the thing", losing, gradually, all +concern in the real issues involved. + +Indeed, in watching the amount of attention a paranoiac bestows upon his +grievances, the zest with which he takes up every newly discovered flaw +in the law, and the dexterity with which he weaves it into the maze of +his delusional system, the idea forces itself upon one's mind that what +the paranoiac least desires is a settlement of his grievances. One can +readily imagine the void in the unfortunate's life were he to be +deprived of this all-engrossing, and to him really life-giving, _casus +belli_. Thus, not infrequently, when one grievance is actually settled, +another soon appears and assumes the center of the stage. The means +these individuals use in their efforts to convince the authorities of +the righteousness of their cause or of the genuineness of the +persecutions to which they are subjected, are really amazing in their +ingenuity. They are supported to a considerable extent by retrospective +falsifications of memory, and when occasion arises, by a conscious +distortion of facts, and prevarication, a point very justly emphasized +by Bischoff.[4] + +This author relates the case of a paranoiac woman who was in litigation +with her father over some trifling inheritance left by her mother, and +who accused her father of a murder, and insinuated that she had heard +her grandfather call him a fratricide. + +The reputation and character of the objects of their delusions are +unsparingly attacked by the paranoiac litigant, and this not +infrequently results in bringing matters to a head, where as defendant +in a criminal suit for libel the paranoiac is recognized in his true +light and sent to a hospital for the insane. Before, however, this final +scene in the litigious career is enacted, especially where the +persecuted has turned persecutor, the objects of his delusions have not +infrequently suffered an untold amount of anguish and financial ruin, +through having been obliged to play the part of defendants in civil +suits based on nothing else but the distorted fancy of a diseased mind. + +While one may readily detect the part played by avarice in the pursuits +and activities of these individuals, it requires close contact with +them, especially in the capacity of one who stands between them and +freedom, in order to fully appreciate the degree of malevolence which +they frequently exhibit. Indeed, the study of litigious paranoia, more +than anything else, illustrates how much method there may really be in +madness. Were an alleged lunatic standing as a defendant in a criminal +suit to use one-tenth of the amount of ingenuity and conscious direction +of his symptoms that the average paranoiac uses, he would furnish the +champions of the idea of malingering of mental disease with enough +material to convict a dozen lunatics. + +The chief aim of this paper is to illustrate by means of two interesting +case histories the forensic importance of this form of mental disorder. +It is not intended, however, to enter here into an academic discussion +of the problem of paranoia. The term "Paranoia" is even pre-Hippocratic, +and any attempt to indicate, even in the briefest manner, the changes +which this concept has undergone throughout the ages would require +considerably more space than we have at our disposal. I shall, +therefore, merely mention that in reviewing the history of paranoia one +is unmistakably struck by the fact that those view points and ideas +concerning this subject which have indelibly impressed themselves upon +it occupy themselves with a study of the personality of the paranoiac +rather than with the disease picture as such. Some of the investigators +have gone so far as to maintain that paranoia is not a disease at all +in the sense that typhoid fever is a disease or pneumonia is a disease, +but that the paranoiac picture is rather the expression of an anomalous +individuality and, as one author puts it, it is the evolution of a +crooked stick. Sander[5] recognized this when he so admirably stated +that the abnormal condition develops and unfolds itself in the same way +that the normal mind unfolds itself in the normal individual. + +The cases herein reported have been under my observation now for several +years at the Government Hospital for the Insane, and I am indebted for +permission to report them to Dr. William A. White, Superintendent of the +Hospital. + + CASE I is a white man, aged 64 on his first admission to the + Government Hospital for the Insane, July 9, 1907. This commitment was + the direct outcome of a trial for perjury which took place in May, + 1906, in the Supreme Court of the District of Columbia, at which the + patient was found guilty. While awaiting sentence he was adjudged + insane and sent to this Hospital. The evidence was gathered from the + Reports of the Maryland Court of Appeals, dating as far back as 1874, + and forms only an incomplete account of the patient's legal + activities, inasmuch as many of his law transactions never reached the + higher courts and consequently are not reported. In setting aside + 1,296 magistrate's judgments obtained by the patient and amounting in + the aggregate to $127,836 debt and $2,348 costs, the Court states, + among other things, as follows:-- + + "The gross iniquity of this whole transaction, manifest enough upon + its face, is abundantly so by proof. The inference is irresistible + that the magistrate who issued these judgments merely wrote them out + on his docket without summoning witnesses and without the semblance + even of an _ex parte_ trial." + + It was further brought out at the perjury trial in 1906 that in 1877 + the patient had obtained 619 judgments against the A. E. Company, + aggregating approximately $50,000. These were likewise set aside by + the higher Court. We thus see that as far back as 1874 this king of + litigants had already had set aside by the higher Courts as many as + some 1,900 distinct and separate judgments. How many more of those + based on the same flimsy tissue of his distorted imagination he + actually realized on is not known. As far as can be ascertained, the + issue of insanity was never raised, at any rate by the Court, prior to + the perjury trial, and it was only when this master litigant, after + having been active as a complainant for a great number of years, at + last betrayed himself into committing a criminal offense that the + issue of insanity was brought up. + + A prominent Maryland Judge, who had known X---- for over forty years, + had the following to say concerning him:--"I have known X---- for + forty years, and he is a general nuisance and menace; he is crazy on + getting money, and for years has been manufacturing bogus judgments + against citizens of this and Montgomery Counties and the + A. E. Company. At one time he held judgments against that Company for + a million dollars for an imaginary wrong, all of which were eventually + gotten rid of on the ground that they were fraudulent. He also, in + some fraudulent way obtained judgments against our County + Commissioners, without their knowledge, for $1,500, which were + impounded by Judge M---- of the United States Court at B----, where as + a then non-resident he brought suit to recover on them. He then went + down to Dickinson County, a remote section of Southwestern Virginia, + and obtained other judgments for some four or five million dollars + against the County and various citizens, which were obtained by + perjury and forgery. They were eventually set aside. His brother died + in 1907, and I became one of the sureties on the executor's bond; last + year a judgment turned up here against the executor and his sureties + for $17,000, which purported to have been given by the Circuit Court + for said D---- County. It was a forgery all the way through; even the + Seal of the Court to the certificate was a forgery. I wrote the Judge + of the Court and he answered very promptly, stating that no such suit + had ever been entered and that the judgment was a myth. We succeeded + in impounding this judgment. No one up here feels safe when X---- is + at large. We have suffered a great deal of trouble and expense in + trying to protect ourselves against him, and everybody regards him as + being not only insane but also a very dangerous man." + + On admission to the Government Hospital for the Insane, July 9, 1907, + he was found to be a fairly well-preserved man for his age, entered + freely into conversation, comprehending readily what was said to him + and exhibiting no difficulty in elaborating his ideas. He talked in a + slow, deliberate and rather mysterious manner and a low tone of voice. + The family history as given by him was negative. He himself had the + usual diseases of childhood, but, aside from chronic indigestion, had + had no severe illness. He gave his occupation as that of physician. In + 1862 he enlisted in the Union Army as a nurse and was discharged six + months later; claims that in 1865 he graduated in medicine from the + University of Maryland, which profession he practiced at W---- until + 1881. He then moved to Ohio, because, he says, he could endure no + longer the persecution of a good many enemies which he had made on + account of his service in the Union Army. In Ohio, he states, he + engaged in the manufacture of proprietary medicines and claims to have + sold out his business sometime later for $50,000. + + Some idea of the patient's daily conduct may be had from the + statements of his landlady, with whom he lived for a considerable + time. + + It seems that he occupied a room on the top floor, which he would + allow no one to enter. If anyone rapped on the door he would open it + very slightly and cautiously, conducting conversation through a crack + in the door. He led the life of a hermit, living in absolute + seclusion, cooking his own meals in his room. After he was removed to + the Hospital this room was entered and newspapers were found piled as + high as the ceiling; many of the articles in them were underscored, + and numerous clippings were pasted on doors and windows as well as on + walls; everything was covered with dirt and dust, and the cooking + utensils were strewn all over the room. This lady said that during his + stay there he was always very suspicious, kept the blinds drawn, and + seemed to be constantly afraid that something was going to happen. + + Examination of the patient soon after admission revealed a + well-organized and very extensive delusional system, which, according + to his story, apparently had its inception during the Civil War. It + seems that he had caused the apprehension and execution of a + Confederate spy, and ever since then, he states, the relatives and + friends of this man have been persecuting him. In 1889 he was granted + a pension of $25 per month, but he did not think that this was a fair + deal inasmuch as he was not a nurse, but a physician, and should + receive at least a hundred dollars per month. He states that he came + originally to Washington to have this matter straightened out, but on + account of his enemies was unsuccessful. His worst persecutions he + believed to have been instigated by the A. E. Company because he had + judgment against this Company for about $50,000. He stated that this + was obtained in a damage suit which he brought against this Company + because they wanted to charge him expressage of something like 40c on + a prepaid package. Following this damage suit, the Express Company's + agents, especially members of the R. family, have been spying on him + and persecuting him; he finally sued a member of this R. family and + obtained judgment against him in the Circuit Court of Virginia for + $9,000. When asked to explain how he figures out these exact amounts + of damage, he is ready with a thousand plausible reasons why the + amounts were as he gives them. He was finally charged with perjury, + found guilty, and while awaiting sentence was adjudged by a jury to be + of unsound mind and sent to the Government Hospital for the Insane. + + He believes that members of this R. family were behind this because + they were afraid that the patient would collect on his judgments, + which by this time, amounted to something like $20,000, and which, as + he put it, "were good, valid and subsisting, not reversed or otherwise + vacated." + + During his sojourn in the Government Hospital for the Insane, he was + always very suspicious and seclusive, keeping to his room practically + all the time and aloof from the other patients in the ward. He adhered + very tenaciously to his delusional system and believed himself fully + justified in all his litigious pursuits. With all this he was clear + and coherent in conversation, his memory was quite well-preserved, and + he had no difficulty in keeping himself fully informed on current + events. Aside from the very evident caution and very profound + suspicious attitude which he manifested during a conversation, he made + no abnormal impression. + + In October, 1908, he was paroled by a Justice of the District of + Columbia Supreme Court to his brother's care in Ohio; and patient's + reasons for this parole are interesting: He states that he was told by + the District Attorney that he would be paroled if he were to go to + Ohio and vote for President Taft. This he says he did, believing he + had carried out the terms of his parole, promptly returned to + Washington and resumed his former activities. The first thing he did + upon his return was to have the following two bills introduced in + Congress, both of which are wholly based on his delusional ideas:-- + + "H. R. Bill xxxx, January 11, 1910. Mr. A. introduced the following + bill, which was referred to the Committee on Military Affairs and + returned to be printed:--A bill to correct the military record of + X----. Be it enacted in the Senate and House of Representatives of the + United States of America, in Congress Assembled, that the Secretary of + War be and is hereby authorized and directed to correct and amend the + military record of X----, late assistant surgeon instead of nurse, so + as to read: X----, Assistant Surgeon of the United States Army, on the + 12th day of April, 1863, and to place the name of X---- upon the + retired list of the United States Army as Assistant Surgeon." + + The second bill was as follows:-- + + "Senate Bill xxx. Referred to the Committee on Claims. A bill for the + relief of X----. Be it enacted by the Senate and House of + Representatives of the United States of America, in Congress + Assembled, that the Secretary of the Treasury be and he is hereby + authorized to pay out of any money in the Treasury, not otherwise + appropriated, to X----, formerly a resident of W., in the State of + Maryland, the sum of $45,600, being the amount of the loss sustained + by said X---- in property and business while he was performing + important service for the Government in the year 1863, and in + recognition of valuable service rendered the United States, and + compensation for loss resulting from his causing the arrest of a + Confederate Spy, at the opening of the Gettysburg campaign, thereby + defeating the Confederate plan to capture the two thousand or more + government wagons loaded with the munitions of war of the Union Army, + which sum shall be in full of all claims and demands upon the part of + said X---- against the Government of the United States by reason of + the premises." + + The patient was soon apprehended and returned to the Government + Hospital for the Insane, where he is at present. + + In an extremely interesting brief of his case, prepared by the patient + himself, which, unfortunately, is too lengthy to be given in its + entirety here, he states, among other things:-- + + "I was indicted on the 2nd of April, 1906, by the grand jury of said + court, for perjury; the grand jury was about to adjourn, as they had + no evidence upon which to indict me, but they were called back to do + so in order to please the A. E. Company. The grand jury was authorized + to indict me in order to please the A. E. Company, as I was later told + by several members of that jury. I have also been told by numerous + detectives that they were hired by the A. E. Company to watch me." He + continues in his brief:--"I was kept in jail until the eve of the 13th + of February, 1905, when the jail doors were suddenly thrown open and I + was told to go home, the same as the circumstances related in the + Bible concerning St. Paul and Silas, who were in prison and during the + night their chains fell off, the prison doors opened and they were set + free by the hand of God. I believe the same thing happened to me; I + was released by the hand of God." + + He further states:--"There are more than 17,000 newspapers in the + United States, and these people had it printed in 10,000 of them that + I had committed perjury. I sued them for slander, and a more just and + upright case or grievance for bringing suit could never be found." + + Attention might be called here to the grandiose phase of his disorder. + His was no common slander; it was published in 10,000 newspapers. + Neither was his release from prison an ordinary everyday occurrence, + but resembled the Biblical episode of St. Paul's release from prison. + Later on, when through advancing years his intellect is becoming more + and more enfeebled, he expresses his grandiose ideas in a more direct + and naive manner. He tells the physician that he knows the law better + than any living authority; that none of the so-called judges around + town can compare with him; that he has made a brief of a case which + could not be duplicated by anyone. He is likewise the greatest + physician, and he will prove this when he gets to court. At this + writing he is beginning to show evidence of senile deterioration and + is no longer the keen manipulator of the law of years ago. He + endeavors now to gain his ends by more direct and extremely puerile + and childish methods. To illustrate:--His physician had left the + institution about a year ago, and soon afterwards X---- produced an + affidavit purporting to have been made by this physician in which he + set forth that X---- was sound mentally; that this physician came to + this conclusion after a thorough examination of X----, etc., etc. Upon + the physician's return to the Hospital X---- was asked concerning this + by him, but he stolidly maintained that it was genuine and given him + by the questioner. This famous litigant has reached a stage where + things simply are as he wants them to be. Whether this poor derelict + will be permitted by his deluded or unscrupulous attorneys to end his + days in peace at the Hospital, time alone will tell. Thus far his + lunacy case has been carried by them to the Court of Appeals. + + + CASE II.--Y. was found guilty of libel in the Criminal Court of the + District of Columbia, and while awaiting sentence was adjudged insane + by a jury and admitted to the Government Hospital for the Insane, + June 22, 1911, at the age of 56. Y. is an attorney by profession, + comes from a prominent family in Ohio, and has received an excellent + education. According to information obtained from his father and + sister, it appears that one sister and a nephew are insane; that the + patient himself has been considered insane by members of his immediate + family since 1889, when, as the result of a court-martial for + disobedience, he was discharged from the Navy, where he then held the + grade of ensign. Immediately following this discharge he took up the + study of law and began to specialize in maritime affairs, handling + almost exclusively sailors' grievances against the Navy Department. He + spent a great deal of time working up these cases, occasionally + writing contributions to the Maritime Register, for which publication + he was a regular correspondent for several years. In these papers he + would constantly harp on the irregularities and illegalities of many + of the government affairs. At home he always acted in a peculiar + manner, never had much to say to anyone, was unreasonable, + fault-finding and complaining; he always wanted things his own way. + Several years ago he came to live with his sister, accompanied by his + wife and child. Although he paid nothing for board and lodging for the + three, he complained about the food and had something to say in + criticism for every little inconvenience. He would frequently leave + town without saying a word to any member of his family, and would + reappear just as suddenly. He kept to his room almost constantly, + leaving same only for his meals. On one occasion he wrote his wife, + who at the time was staying with her child at his sister's house, that + she should watch this sister, as he feared she might try to poison the + child. Sometime in 1910, he came to his home town, had an interview + with the Judge of the Probate Court, and left town without visiting + any of his relatives, although they lived only four squares distant. + At that time this Judge told the patient's father that he thought the + patient was mentally unbalanced. He was always considered by his + relatives as being of a morose disposition, vindictive and selfish. On + a later visit to his parental home he acted very strangely about the + house, disarranged things, kept the rooms in disorder, and was busy + writing constantly. At this time he left home suddenly without taking + leave of anyone. A few years ago, while home on a visit, he declared + that his father was incompetent to manage his own affairs, instituted + legal proceedings to have himself appointed committee for his father, + petitioning the court on the ground of his father's insanity. In this, + of course, he was defeated. + + The patient himself states that he graduated from Annapolis in 1878, + between which year and 1883 he traveled in Europe and South + America as midshipman. In 1883 he entered the Cincinnati Law School, + where he remained one year. After this he states he acted in the + capacity of Judge Advocate General for a short time while on shore + duty. He then went to sea again and finally resigned from the Navy in + 1887, with the grade of ensign. (As has already been indicated above, + the patient was dismissed from the Navy for disobedience and + disrespect.) He then entered the practice of law in Cincinnati, at + which he continued until his appointment to the Department of the + Interior on June 1, 1904, at a salary of $1,000 per annum. Here he + remained until 1908 in the capacity of clerk, when he resigned, + receiving at that time the same salary. He says he was moderately + successful financially as a lawyer, and did a good deal of literary + work. He is especially proud of a case which he conducted in the Court + of Appeals, where he obtained a decision setting aside a Naval + court-martial. He says that this is the only decision of its kind ever + rendered, and on that account he is very proud of this. According to + his own story, he was always moderate in his habits, and prior to his + marriage in November, 1902, he had never come in conflict with anyone. + The latter part of this statement is contradicted by his relatives, + who state that for more than twenty years past, the patient has + exhibited an uncontrollable desire to sue people for all sorts of + imaginary grievances, and that on this account he frequently came into + serious conflicts. The patient is inclined to put all the blame for + his difficulties to his wife, whom he describes with a great deal of + rancor as the descendant of an insane and illegitimate grandfather and + illy-favored mother. He thinks that his wife was slightly unbalanced, + accuses her of being responsible for the death of their first child, + and of various other misconduct. However, everything went tolerably + well until April, 1906, when their second child was born. The doctor + who attended Mrs. Y. during her confinement, a very prominent local + physician, testified in open court at that time, that from his + observation of the patient's acts he believed him to be insane. This, + the patient said, precipitated a lot of trouble between him and his + wife. He does not enter into details concerning the difficulties he + had with the physician, but the details are extremely illuminating. It + appears that the patient refused to pay this doctor's bill and was + sued for the debt. At the time of the trial he gave as his defense the + following two reasons why he should not pay this bill:--The first one + was that inasmuch as this doctor lived in a part of the city which + would necessitate the crossing of a railroad grade in order to reach + the patient's house, and that on this account there was a possibility + of his being detained at the crossing during an emergency call, he had + no right to take the case in the first place, and therefore he was not + entitled to payment. His second reason was that inasmuch as this + doctor wore a beard, he carried more germs into the house than would + otherwise have had access to it; therefore he should forfeit his fee. + In 1907 his wife obtained a divorce on the grounds of cruelty and + non-support, and was given the custody of the child; this had the + effect of launching the patient upon a new series of litigation. His + first retaliating measure was the abduction of the child, which + brought about his indictment by a grand jury and subsequent arrest. + The reason he gave for taking the child out of the District was that + his wife lived in a house over an old abandoned cellar, and that it + was therefore an unhealthy place for the child. Upon regaining his + freedom he began to investigate the ground upon which the grand jury + indicted him, and soon, he states, he discovered that the District + Attorney's office committed a gigantic fraud by having maliciously + misrepresented the case to the grand jury; this body, he says, was led + to believe that the Ohio decree granting his wife the guardianship of + the child held good in the District, whereas the law of the District + specifically states that no extra-territorial decree should be + recognized within the District. He further discovered that Mr. J., his + wife's attorney, knowingly and maliciously became a party to this + fraud, and he immediately proceeded to file charges of mal-practice + against this attorney before the Grievance Committee of the District + Bar Association. The result of this was that the patient was charged + with libel in the Criminal Court. To his great surprise, he says, the + Court recognized this charge and found him guilty of same. While + awaiting sentence he was adjudged insane by a jury and committed to + the Government Hospital for the Insane. He believes this commitment is + the result of a deep-laid conspiracy on the part of the District + Attorney's office and some of the District Judges. These officials, he + believes, were afraid of him because at a hearing before a Senate + Committee he started to expose their fraudulent conduct. The judges + were prejudiced against him throughout, and it might be interesting to + mention here that among the multitudinous bills which he had proposed + for enactment into law since in the Government Hospital for the + Insane, there is one which is intended to abolish entirely the Courts + of the District of Columbia, so that unfortunates like him might get a + chance before unprejudiced judges. This deep conspiracy against him, + he is convinced, dates as far back as 1906, when the Ohio Courts + appointed his wife guardian of his child. + + No great difficulty need be experienced in forming an opinion of this + man's mental status after having followed his history thus far, but + when we further read that, during his sojourn in the Government + Hospital for the Insane, he has evinced the most persistent tendency + to weave into his delusional system every important occurrence of + local or even national interest, that he sees a clear relationship + between his case and the recent change of administration, and is fully + convinced that many important officials held over from the last + administration owe considerable gratitude to him; when he is seen in + his self-assumed most important role of the man of destiny, flooding + Congress, the Courts and many high officials with petitions, charges, + writs, and proposed investigations; when one sees the criminal code as + transformed by him; then one begins to get a proper perspective of the + grandiose phase of this man's mental disorder. It is impossible, of + course, with the limited space at our disposal, to even give the + briefest outline of his activities, but it might be stated that only + within the past several months he has succeeded in very ingeniously + getting his case before a considerable number of senators and + congressmen and many other prominent officials. Among the bills which + he proposes to have enacted into law, is one, as has been mentioned, + to abolish entirely the Courts of the District of Columbia. Of course, + courts which cannot administer justice, as he sees it, must be + abolished. + + On his admission to the Government Hospital for the Insane, he really + welcomed the procedure, stating that at last he had the opportunity to + be under the supervision of a trained physician who would soon + discover that he was absolutely sane and would render a report to that + effect, thus vindicating him. Unfortunately for the physician, he did + not see his way clear to render such a report, and Y's amiability soon + changed into a very bitter antagonism towards the one who had + immediate charge of him, showing a great deal of rancor in his attacks + upon him, in spite of the fact that he has been accorded all sorts of + privileges. He has, of course, by this time consigned many hospital + officials to life imprisonment, and the amount of damages which he + expects to collect from them and the Government runs into fabulous + sums. He soon began to solicit the grievances of his fellow patients, + establishing, so to speak, a law office in miniature upon the ward; + and whereas formerly these patients in the criminal department merely + aired their grievances as they saw them, they now accompany them with + quotations from the statutes concerning these points furnished by this + legal missionary. Soon, however, even the insane patients on his ward + began to distrust him, and at the present time there is hardly an + attendant or patient in the building who cares to associate with Y. He + missed no opportunity of playing upon the credulity of the younger and + less sophisticated attendants in the criminal building, at first + begging and urging them to carry his petitions to their destination in + a surreptitious manner, and finding this of no avail threatening them + with fines and imprisonment as accomplices in this gigantic crime of + keeping him confined in a hospital. When not out walking he keeps + himself constantly busy making out documents, briefs, petitions, + bills, etc. He is very seclusive, keeping himself aloof from the other + patients, as he considers himself very much their superior. + + Now this master litigant, this profoundly diseased man, succeeds in + making quite a normal impression in a casual interview, and in his + writings he frequently succeeds in conveying the idea of being quite + normal. Each isolated fact looks plausible enough to the casual + observer. He talks quite rationally, shows a remarkably well-preserved + memory, has never exhibited hallucinations or those gross disorders of + conduct which to the lay mind form the _sine qua non_ of mental + disease. It is only after a close study of the entire life history, of + the many fine shades of deviation from the normal which this man + exhibits, that one discovers that his mind is very seriously affected + indeed, and that because of his plausibility he belongs to a rather + dangerous type of mentally diseased individuals. + +The chief aim of this paper has already been indicated, and we shall +adhere to our original intention of rendering it as free from purely +didactic considerations as is consistent with clearness. For this reason +the case histories given above were considerably abbreviated and only +such an account rendered as would suffice to convince even a layman that +the two individuals in question are seriously affected mentally. Of this +there should not be the slightest doubt in anyone's mind, neither should +one encounter here any diagnostic difficulties. The only difficult +point, and a point which may become of considerable forensic importance, +is the exact estimation of the duration of the illness in each instance. +From the available data at hand it would seem that in the case of X----, +the disease had its inception in the episode during the late Civil War, +though the possibility of retrospective falsification must be kept in +mind; while Y seems to have been launched upon his litigious career by +his dismissal from the Navy. It is therefore but fair to assume that in +both instances the disease has existed for a great number of years. +Nevertheless, it was only when these individuals faced the bar as +defendants in criminal suits that the disease was recognized in either +case. One may readily see, therefore, how easily mental disease may +remain undetected, especially if one neglects to take an inventory of +the individual's past life. I have already alluded to the difficulty +frequently experienced in having evidence of this nature accepted in a +court of law, and here, it seems to me, is room for a good deal of +reform in procedure. Thus far society's side of this problem has been +chiefly emphasized; but what about these unfortunate derelicts, X---- +and Y? Both of them are at present confined in the criminal department +of the Government Hospital for the Insane with criminal charges pending +against them. Assuming that our contentions with respect to their mental +status are correct, what possible justification is there to hold them +responsible before the law for their acts? Nevertheless, the same sort +of procedure is constantly taking place; individuals are being sent +daily to hospitals for the insane, presumably for the purpose of giving +them the best possible chance for recovery, the best modes of treatment, +while at the same time the law persists in carrying them as individuals +charged with crime, thus throwing many obstacles in the way of proper +care and treatment. With many of these individuals the mere fact that +there is still a criminal charge pending against them seems to act in a +deleterious manner upon their mentality, while in the great majority of +instances, owing to the fact that they must be carried as criminals, +unusual precautions have to be resorted to both in their confinement +and in the matter of various privileges, thereby vitiating in a great +measure all attempts at treatment. + +These are some of the problems which present themselves from a study of +life histories such as are here reported, a better mutual understanding +concerning which between the lawyer and the physician would +unquestionably tend to a more enlightened administration of the law. + + +REFERENCES + +[1] MAUDSLEY: "Responsibility in Mental Disease." + +[2] KRAEPELIN, E.: "Psychiatrie." Achte Auflage. Leipzig, 1910. Bd. 1. + +[3] TANZI: "Mental Disease." + +[4] BISCHOFF: "Lehrbuch der Gerichtlichen Psychiatrie." 1912. + +[5] SANDER: Quoted by White. "Outlines of Psychiatry." Fourth Edition. + + + + +CHAPTER IV + +THE MALINGERER: A CLINICAL STUDY + + +I + +The following study is undertaken less for the purpose of discussing the +psychology of malingering than with the object in view of illustrating +by means of clinical records the type of individual who malingers. The +opinion is a general one that malingering is a form of mental reaction +to which certain individuals resort in their effort to adjust themselves +to a difficult situation of life. Being a form of human behavior, it +should have been approached, therefore, with the same attitude of mind +as any other type of behavior. + +A perusal, however, of the literature on the subject, especially of the +contributions of the older writers, reveals that with certain isolated +exceptions the subject was viewed primarily from the standpoint of the +moralist. Even today one sees in certain quarters a good deal +made--certainly a great deal more than the facts would justify--of the +"insanity dodge" in criminal cases. It is true that today, +notwithstanding the still broadly prevalent tendency to view with +suspicion every mental disorder which becomes manifested in connection +with the commission of crime, the danger of error in this respect has +been reduced to a minimum owing to the more advanced stage of +psychiatry, and therefore the practical importance of the subject of +malingering is not so great as it was formerly. We find, nevertheless, +justification for the further study of this subject in the fact that, +aside from its purely psychiatric importance, the more intensive study +of the malingerer offers a solution for some of the important problems +in criminology. As one of the results of this more intensive study may +be mentioned the gradually-gained conviction that malingering and actual +mental disease are not only not mutually exclusive phenomena in the same +individual, but that malingering itself is a form of mental reaction +manifested almost exclusively by those of an inferior mental make-up; +that is, by individuals concerning whom there must always be +considerable doubt as to the degree of responsibility before the law. As +a result of this recognition cases of pure malingering in individuals +absolutely normal mentally are becoming rarer every day in psychiatric +experience. + +The conviction was further gained that malingering as well as lying and +deceit in general, far from being a form of conduct deliberately and +consciously selected by an individual for the purpose of gaining a +certain known end, is in a great majority of instances wholly determined +by unconscious motives, by instinctive biologic forces over which the +individual has little or no control. This is one of the factors which +determines the growing realization among present-day psychiatrists of +the extreme difficulty to state in a given case which is malingered and +which genuine in the symptomatology. That such views should encounter +opposition among our jurists is perfectly natural, threatening as it +does with complete annihilation that wholly artificial concept of the +"freedom of will" upon which our laws are based. + +In touching upon the subjects of "responsibility" and "freedom of will" +I incur the danger of adding to the general misunderstanding which still +exists between the physician and jurist concerning crime and the +criminal. + +Speaking from personal convictions, I see no real justification whatever +for this misunderstanding, unless it be the difference in the mode of +approach to the subject on the part of the two. The jurist is compelled +by existing statutes to look upon crime largely in the abstract--not as +it concerns the individual who committed the deed, but as it is affected +by the statutes covering it. The physician, on the other hand, sees in +the criminal act a form of reaction to an intrinsic or extrinsic +stimulus by a feeling, willing, and acting human being, and proceeds +accordingly to analyze in a concrete manner the forces which brought +about this particular form of reaction in this particular individual. As +a result of this mode of approach to the subject he is enabled to +conceive of "responsibility" as something fluid, something extremely +variable, and which may be affected by a thousand-and-one things, and +not as something absolutely fixed and invariable and which may be +definitely foreseen by a set of statutes. + +Any attempt to bring about this most desirable uniformity of approach to +the subject of criminology between the jurist and the physician must be +based primarily upon intensive study of the personality of the criminal. +Such is the aim of this paper. + + +II + +In the last analysis malingering is to be looked upon as a special form +of lying, and its proper understanding will necessitate a clear insight +into lying in general. + +Lying, a very natural and generally prevalent phenomenon, may manifest +itself in all gradations--from the occasional, quite innocent "white +lie" as it occurs in a perfectly normal individual to the pathological +lying exhibited in that mental state known as "pseudologia phantastica." +Its proper understanding, however, no matter under what circumstances +and to what degree it be manifested, will be possible only through a +strict adherence to the theory of absolute psychic determinism. + +Lying, like every other psychic phenomenon, never occurs fortuitously, +but always has its psychic determinants which determine its type and +degree. + +Naturally many of these determinants are quite obvious and readily +ascertainable. One has only to recall the lying and deceit practiced by +children. But many others, if indeed not most of them, are active in the +individual's unconscious motives and accessible objectively as well as +subjectively only with great difficulty and by means of special +psychological methods. + +The degree of participation of unconscious motives in lying will be +determined in the individual case by the extent of repression +necessitated because of social, ethical, and aesthetic considerations. It +is for this reason that lying is most prevalent and exhibited with the +least amount of _critique_ in those individuals who either have never +developed those restraining tendencies which a normal appreciation of +social, ethical, and aesthetic consideration demands, or in whom these +restraining influences have been weakened or abolished by some exogenous +insult to the nervous system--as, for instance, the tendency to +fabrication dependent upon chronic alcoholism or morphinism. A beautiful +illustration of the latter type is furnished by General Ivolgin in +Dostoieffsky's "Idiot." + +The child's tendency to lying and deceit is dependent to a large extent +upon the undeveloped state of those restraining forces. To state, +however, that this is the sole mechanism underlying the phenomenon of +lying would be to state only half a truth. For it is an undeniable fact +that, no matter how strongly endowed an individual may be with ethical +or moral feelings, still there comes a time when these are entirely +forgotten and neglected; when, finding himself in a stressful situation, +the instinctive demands for a most satisfactory and least painful +adjustment, no matter at what cost, assert themselves. It is then that +the lie serves the purpose of a more direct, less tedious gratification +of an instinctive demand. The resort to this mode of reaction, to +evasion of real issues for the purpose of gratification of instinctive +demands, is not characteristic of man alone, but is quite prevalent even +in some very low forms of life. We will have more to say about this +later. It is an important tool in the struggle for existence among all +living beings; it is one of the mechanisms by means of which the weaker +inferior being escapes annihilation at the hands of the stronger, +superior being. + +Malingering, it will be seen later, appears to certain individuals to be +the only possible means of escape from and evasion of a stressful and +difficult situation of life. The lack of _critique_ which permits such +an abortive attempt at adjustment and the inherent weakness and +incapacity to meet life's problems squarely in the face which drives +them to resort to such a means of defense are some of the traits of +character which serve to distinguish these individuals from what is +generally conceived to be normal man. + +The extent to which lying and allied behavior depend upon unconscious +motives has never been so well illustrated as in recent psychoanalytic +literature, especially in a paper by Brill.[1] This author is so +thoroughly convinced of the value of conscious lying as an indicator of +unconscious strivings and motives that he frequently asks his patients +to construct--artificially--dreams which he finds to be of valuable aid +in the analysis of the patient's unconscious. After citing a number of +examples Brill states: "These examples suffice to show that these +seemingly involuntary constructions have the same significance as real +dreams, and that as an instrument for the discovery of hidden complexes +they are just as important as the latter. Furthermore, they also +demonstrate some of the mechanisms of conscious deception. The first +patient deliberately tried to fool me by making up what he thought to be +a senseless production, but what he actually did was to produce a +distorted wish. He later admitted to me that for days he was on his +guard lest I should discover his inverted sexuality, but it never +occurred to him that I could discover it in his manner. That his +artificial dreams have betrayed him is not so strange when one remembers +that _no mental production, voluntary or involuntary, can represent +anything but a vital part of the person producing it_." + +Were this thesis on malingering to succeed in nothing else than in +bringing home to our legal brethren this important truth of absolute +psychic determinism, that a man is what he is and acts as he does +because of everything that has gone before him--because of ontogenetic +as well as phylogenetic instinctive motives--it will have fully +established its _raison d'etre_. For a realization of this truth would +at once annihilate from our minds that deceptive notion of the "freedom +of will" upon which our laws are based, and will be certain to bring +about a more enlightened solution of the problem of the criminal, all +attempts at which, we are constrained to state, have thus far[A] +undeniably been huge failures. + +[A] Intimate contact with members of the legal profession, both +professionally and socially, for some years past has convinced me that +the average lawyer still looks upon the ideas concerning crime and the +criminal expressed by physicians of a forensic bent as totally +unpractical and visionary. It would take only a brief visit to a +criminal department of any modern, well-conducted hospital for the +insane to convince any fair-minded individual that the physician handles +the problem of the criminal not only in a more scientific and rational +manner than does one not possessed of this particular training, but also +in an eminently more practical manner, even so far as dollars and cents +are concerned. I have frequently had patients come under my observation +who for a great number of years had been oscillating between penal +institutions and hospitals for the insane, in whom each additional +sentence did not only fail to bring about the hoped-for reformation, but +served to render them more depraved and criminally inclined, and who +would have undoubtedly continued this checkered career throughout life, +had not their true, unreformable nature been discovered and thus caused +their permanent isolation from society, not by the jurist but by the +physician. Should reformation ever take place in any of these +individuals it is safe to assume that the one who was clear-visioned +enough to discover the cause of their antisocial existence would +likewise be competent enough to know when this cause has disappeared. + +The psychic mechanism of lying is the same both in the occasional and in +the pathological liar--in both it is the expression of a wish--but the +difference in the personalities of the two is a very decided one. On the +one hand we have an individual who closely approaches normal man, while +on the other hand one who is closely allied to the mentally diseased. +The difference between the pathological liar and the habitual criminal, +aside from the moral phase of lying, is perhaps but a very slight one, +when we keep in mind that in both instances we are dealing with +individuals who habitually resort to a form of reaction in their +attempts at adjustment to reality which aims at a direct, simple, and +least resistant means for gratification. In both we are dealing with a +type of mental organization which is primarily incompetent to face +reality in an adequate, socially acceptable manner, and therefore has to +resort to constant deceit and lying, and in which those inhibitions +determined by social, ethical, and aesthetic considerations are equally +impotent. The marked egotistic trend which constantly comes to the +surface in the habitual liar when he attempts to play the part of the +hero and central figure in the most fantastic, bizarre, and impossible +adventures is likewise frequently at the bottom of the escapades of the +habitual criminal. The two traits are frequently, though by no means +always, concomitant manifestations in the same individual. + +When, in 1891, Anton Delbrueck[2] published the first comprehensive study +of the pathological liar, he not only succeeded in very accurately +delineating a more or less distinct psychopathological entity, but also +furnished additional proof in substantiation of the fact, well known in +psychiatry but as yet unrecognized by the legal profession, that the +transition from mental health to mental disease is not a sudden one; +that any dividing line which would have for its purpose the strict +separation of the mentally sound from the mentally diseased must of +necessity be a purely imaginary one, and one not justified by existing +facts. + +The transition from absolute mental health to distinct mental disease is +never delimited by distinct landmarks, but shows any number of +intermediary gradations. Nowhere is this better illustrated than in the +pathological liar. Here one sees how a psychic phenomenon regularly +manifested by perfectly normal individuals may gradually acquire such +dimensions and dominate the individual to such an extent as to render +him frankly insane. + +To endeavor, however, to definitely state where normality leaves off and +disease begins would be, to say the least, to attempt something +well-nigh impossible. And yet this is just what the jurist constantly +demands of the alienist. The law as it is laid down in the statutes, +especially in this country, does not permit of any intermediary stages +between mental health and mental disease. An individual, according to +law, must either be sane or insane. This point seems to me to be of very +vital importance, and I shall have occasion to refer to it again in the +consideration of our clinical material. + +The part played in lying by disturbances of the apprehensive, retentive, +and reproductive faculties will not be discussed here in detail. These +undeniably have their influence in facilitating the mechanism of lying. +But to attribute this phenomenon wholly to disturbances of this nature +would be to assign to it a purely passive role, whereas experience +teaches that back of every lie are active forces, either conscious or +unconscious, which give birth to it and determine its type and degree. + +The following two cases will illustrate better than any formal +description could what is meant by pathological lying, a +psychopathological state for which Delbrueck proposed the term +"Pseudologia phantastica": + + E. W. S., a colored male, aged thirty-two years, was admitted to the + Government Hospital for the Insane from Fort D. A. Russell, Wyoming, + on January 29, 1912, on a medical certificate which stated the + following: "Patient is a native of Porto Rico; has been sailor and + soldier; has occasionally used alcoholic beverages, but usually the + light wines or beer; is very good-natured, occasionally melancholy and + lachrymose; gave a history of 'fits', and was previously discharged + from the army on this account. He was thought to be 'queer' in his + organization and had more or less trouble with the men, who made fun + of him. He was sent to the hospital from the guard-house in October, + 1911, and his mental condition noted at that time. His present + symptoms were described as delusions of grandeur: 'Queen Victoria was + his instructor in English', 'King Edward of England was his school + chum.' He thinks he was royal interpreter. He does speak a number of + languages fluently and, so far as we can learn, with fair correctness + (?)." + + On admission to this hospital the patient was in excellent health + physically; Wassermann reaction with the blood-serum negative. + Mentally he was clearly oriented in all respects and fully in touch + with his immediate environment. He comprehended readily what was said + to him, and his replies, aside from his extreme tendency to + fabrication, were coherent and to the point. Intelligence tests showed + him to be intellectually about on a par with the average negro of his + social and educational status. + + When asked to give his family and past personal history, he recited + the following: He knew nothing of his grandparents or parents, and + denied having any living sisters or brothers. One brother died in + Chicago in 1906; thinks he must have been murdered, because he himself + was almost murdered in November, 1911, when they attempted to + assassinate President Taft out in Wyoming. King Mendilic, of Cape + Town, Africa, now dead for seven years, was his cousin. The patient + himself was Prince of Abyssinia, where he reigned for eight years, + having remained in that country from 1896 to 1899, and conducting the + affairs of state the remaining five years by correspondence, with the + approval of Lord King Edward. He stated he was born in Porto Rico in + 1876, and calculates his present age as thirty-four, as this is 1912. + About two months ago he received a letter from Queen Alexandra of + England telling him he was thirty-two years, ten-twelfths and two days + old, or thirty-two years, two months, two weeks, and two days. Asked + how much ten-twelfths of a year was, he said: "Three months, three and + two days." When told that ten-twelfths of a year equaled ten months, + he replied: "The calendar of the English era, which is 'our calendar', + does not correspond with the American calendar, but, being in America, + I believe I ought to figure from their standpoint." He left Porto Rico + at the age of six; does not know who took care of him up to this time, + as he never knew his parents, stating that he was just thrown on the + mercies of the country. At the age of six, upon the recommendation and + advice of King Alfonso of Spain, he was taken to England by Queen + Victoria, who came to Porto Rico especially for this purpose. When + asked his opinion as to why Queen Victoria should have taken so much + interest in him he stated that he did not know positively, but it may + have been because he was related to King Solomon of Bible fame. + Requested to explain this relationship to King Solomon, he traces it + in the following manner: He was a cousin of King Mendilic, who in turn + was the "third reigning seed" or stepson of King Solomon. Queen + Victoria, whom he calls "Mother Victor", because she took the place of + his mother, sent him to "Hammenotia School" in Oxford University, + which he attended for four and a half years, received his diploma, and + was transferred to Cambridge College. Here he attended for four years. + At the former school he learned the alphabet, went up to the seventh + grade, learned some medicine about herbs, etc. "I learned some + medicine, not all of it. I didn't practice it much; just practiced it + enough to do the country good. At that time we didn't have any + doctors." At Cambridge he learned "The Reigning of the Thornes", or + the laws of the country. Upon request he described in minutest detail + the city of Cambridge. When asked whether he remembered a large oak + tree which grew on the banks of the river flowing through the city, he + replied: "I should say I do; many a time I sat on the banks of this + river during my student days." Earlier in his student days at + Cambridge he learned German, French, and English. It should be + remarked here that the patient actually did know a few common phrases + in several languages which he picked up during his sailor days. But he + always insisted that he knew thoroughly twenty-two languages, and when + asked to enumerate these he found himself in deep water and was + obliged to invent the languages for the occasion. Nevertheless he + stuck to this story, and was always ready to launch upon the task of + enumerating his twenty-two languages. + + After his four years' sojourn at Cambridge, Mother Victoria sent him + to "Saint Palestine", Jerusalem, where he remained for fourteen + months, learning the constitution of the country, by-laws, etc. Mother + Victoria and Father Edward (Queen and King of England) brought him up + so that he could properly reign over Abyssinia. He states that he saw + Queen Victoria frequently, and was at her funeral in August, 1910, + shortly after the death of Pope Leo. Lord King Edward died about three + months later. The Queen died about the age of seventy-six, as did King + Edward at the same age, from grief and senility. Here he adds that his + maternal grandmother was sister to Queen Victoria. While at the + English Court he held the position of "Prince of Escorts." He left + Jerusalem to go to school at Sydney, Australia, for one year. He then + went to sea on Lord Edward's naval reserve boat, which he had + permission to use. Remained at sea for three years and four months, + visiting China, France, Japan, Germany, Austria, Turkey, Italy, + Havana, Archipelago. When asked to repeat these countries, he omits + some of them and adds others. + + He then came to the United States for the purpose of electioneering, + stump-speaking, etc., all to benefit the government. He then became a + United States interpreter in the Philippines from 1896 to 1902, at a + salary of $75 per month and expenses. He then returned to Porto Rico, + where he remained until 1910. Following this he attended the funerals + of Queen Victoria, Pope Leo, Lord Edward, and his cousin Mendilic, and + finally came to Chicago, where he enlisted as first-class sergeant in + the United States Army. He was sent to Fort D. A. Russell, Wyoming, to + serve in the Hospital Corps, at a salary of $48 per month and + maintenance. There everything went well until he got to worrying and + crying, so they sent him here. He acted thus because he was + ill-treated, was not treated right for a man of his abilities, was + sworn at too much, and called bad names by the enlisted men. They did + this because they were jealous of his "politicalness", his education; + he never swore, drank, or gambled like the others did. Was robbed of + his every possession in Cheyenne, Wyoming, by members of the Ninth + Cavalry and Eleventh Infantry. Lost $1400 in the past five months in + cash and property. They robbed him of his horse, buggy, clothes, and + jewelry, including chain, watch, finger ring, a pair of jasper + earrings. He could hear them talking about him day and night; feared + to leave his room, for he was continually threatened. They were going + to kill him. On this account he was taken to the hospital and kept + under close guard, because they could protect him. He had to leave at + night. He did so after having received a telegram from the + Surgeon-General of the Army, asking him to report to the Hospital + Corps at St. Elizabeth's Hospital, Washington, D.C. As one of the main + reasons why they had it in for him he gives the following: There was a + car line running from Fort D. A. Russell to Cheyenne, the fare being + ten cents. The men wanted it reduced to five cents. As the one in + charge of the canteen he had it in his power to approve or disapprove + of this reduction. He disapproved of it because he didn't think that + ten cents was an excessive charge for a three-mile ride, especially + since they spent so much money on drink, etc. He had a runabout motor + car, so they thought this was why he disapproved of it. "In + consequence they were on my trail." Part of the way to Washington he + came in a private car, but this they deprived him of at Omaha, + Nebraska. Perhaps they did this because they thought it was too large + for him, but, inasmuch as it was assigned for his private use, they + had no business taking it away from him. + + During the recital of the foregoing the patient was bright and alert, + and his attention was easily gained and very well held. He quickly + understood everything that was said to him, and replies were prompt, + relevant, and coherent, though, of course, entirely colored by his + bizarre fabrications. + + During his sojourn at this hospital he was a model patient in every + respect, worked diligently with a farm gang, though frequently + dilating upon the fact of having the responsibility of the whole gang + on his shoulders. On several occasions he gave evidence of being of a + highly sensitive make-up, becoming readily insulted, but he always + reacted to these real or imaginary insults in a mild and kind sort of + way, always preferring to go out of people's way rather than + retaliate. Hallucinatory disturbances were never manifested. + + The story of his past life was gone over with him on a number of + occasions, but on each occasion he gave a different, highly fantastic + recital of his past adventures, always using high-sounding words and + phrases and high-sounding names, many of which he mispronounced. Many + of the words used by him were of his own coinage, if one were to judge + by the sound of them. He was always very pleasant and agreeable, and + enjoyed reciting his past immensely. In all these bizarre and + marvelous adventures he played the chief role and occupied the center + of the stage. + + He was finally induced to give an explanation of his extreme love for + lying, which he gave as follows: "_It isn't because I don't know + better, doctor, but because I think it will make me feel better, + that's all. When I tell of all these big things it makes me feel that + I am a little above the common herd of negroes, and then I never tell + anything to hurt anybody._" + + He stated that he couldn't really separate the true from the false in + his stories, and that he seemed to have little or no control over this + tendency to exaggerate things and to weave into real occurrences all + sorts of manufactured detail. "I know one thing, doctor; that it's + been a habit of mine all my life. I have always tried to exaggerate a + bit. It makes me feel, for the time being, that I'm above the other + negroes, that's all. I know I always try to make an honest living, and + this habit of mine never interfered with me." + +A good deal more could be furnished from the records of this man's case +in illustration of his pathologic disposition to lying. An ordinary +negro soldier, he succeeds in projecting himself, by means of his ready +and very fertile fantasy, into the most wonderful situations and in +rubbing shoulders with royalty. If we inquire into the causes operative +here we first of all see in the fabrications of this individual an +unbounded craving for compensation for a natural deficiency--in this +instance a racial deficiency. What this man lacks in reality he +endeavors to substitute in his fantasy. There can be no doubt that the +tendency to lie has reached such dimensions and intensity in this man's +mental make-up as to make him absolutely believe in his own impossible +fabrications, to render him absolutely helpless in the mazes of his +fantastic creations. He is assisted in this by his craving for +self-esteem, by his extreme need of compensation for a real deficiency, +by his ready and fertile fantasy, one absolutely devoid of _critique_, +by his extreme suggestibility, and, lastly, what is of great importance, +by his extremely defective apperceptive faculties and consequent +falsifications of memory. + +The latter defect was particularly well illustrated in the following +note from my records of the case. He was asked, in the course of my +examination, to repeat a simple story known as the "Shark Story", which +I shall reproduce here in full for the sake of making clear my point:-- + + "The son of a Governor of Indiana was first officer of an Oriental + steamer. When in the Indian Ocean the boat was overtaken by a typhoon + and was violently tossed about. The officer was suddenly thrown + overboard. A life preserver was thrown to him, but on account of the + heavy sea difficulty was encountered in launching a boat. The crew, + however, rushed to the side of the vessel to keep him in sight, but + before their shuddering eyes the unlucky young man was grasped by one + of the sharks encircling the steamer and was drawn under the water, + leaving only a dark streak of blood." + +In reproducing it he said:-- + + "The son of a Governor of an Oriental steamer was the captain. Now, + doctor, I can't think of those little stories. It isn't because I + haven't brains enough; it's because I'm so poor a scholar at reciting. + I always was." "What happened to the captain?" "That I can't + recollect, neither." "What happened to the ship?" + +Here, instead of answering my question, he said: "Doctor, I suppose you +have heard about the big wreck that happened out on the ocean." (This +was when the terrible _Titanic_ disaster was on everybody's lips and the +papers were full of the tragedy.) The patient regularly read the papers. +"Tell me about this wreck." + + "Well, the steamer was 1200 miles from the land--north-northerly + course. It was first reported that 1800 lives were lost; afterwards + they found out for certain, through the communication with General + Wood, that it was only 1300. Mrs. Zelia Smith, she was on the vessel." + (Patient's name is Smith.) "She is Commissioner Hodges's daughter. She + was counted lost, for instance, and was found alive. I knew her well; + I knew a good many other people on that boat." "About how many people + did you know?" "Well, I just only remember some. For instance, Major + B----; I knew him well, of course. I dare say I knew all the others, + but I knew him best. The boat was in charge of E. C. Smith." "Did you + know Captain Smith?" "Yes, sir; I knew him. I didn't know him + personally; I only made one voyage with him from Angel Island." "When + was that?" "In 1907." "What was the name of the wrecked ship?" "I + can't recall that, neither; _Tripoli_, I think it was; she is close on + 1500 feet long." "How much money was she supposed to be worth?" "I + don't know, sir; there were several heirs who had charge of the ship. + She was called the sister-ship _Trinic_ and was worth about $25,000. + That, perhaps, may not cover her upper-deck cabins." "Did you ever + travel on her?" "No, sir; I never was on her. I was on the _Trinic_, + the sister-ship. The White Star people own these boats. I used to run + a transport between the White Star Line and the Yellow Star Line." + Here he was told that the examiner did not know of the existence of a + Yellow Star Line, and he replied: "Oh yes, doctor; you heard of the + Flying Squadron that reports all these disasters and signals the other + ships." + +Thus we see that with partial truths, with facts only partially and +imperfectly recalled as a framework, he builds his fantastic tales. He +read the newspapers regularly, but could not even recall the name of the +ill-fortuned ship, or any particulars about the accident. But what of +that?--he could readily fill in the hiatuses with his fabrication. He +failed entirely in the attempt to reproduce the story given him, and +used the talk about the _Titanic_ disaster as a subterfuge--as a ready +means of escape from the difficulty in which he found himself. + +He himself threw some light upon the part played by his craving for +self-esteem in his statement: "When I tell of all these big things it +makes me feel that I'm a little above the common herd of negroes." He +unquestionably believes in these tales, if they are real enough to make +him feel above the common herd of negroes. His suggestibility was well +illustrated by the suggested river at Cambridge, "on the banks of which +he sat many a time during his student days." + +The facility with which his imagination, his fantasy, works was +demonstrated by the "ink-blotch" test to which he was subjected. This +test, in brief, consists of a series of ink blotches which are shown the +patient, with the request to describe them as they appear to him. The +following are several of his replies: (1) "A woman sitting on a man, +seems like she's got a little weaving in her hand; a little stick, +sticking out from the weaving, seems like the man's elbow is sticking +out back of the shawl." (2) "It seems to me I have seen a volcano that +looks like that. I think it is a ship out at sea. I can see the +lifeboats lashed to the side, several ripples of water behind." (3) "A +figure of a woman with a hand purse or a disfigured arm near the wrist. +Her mouth is open and she is looking around. The wind carried her hat +off; she has a muff on her right hand. Seems like there is a neck-piece +around the muff." + +Notice the detail with which he describes the blotches. In this one +ordinary speech seemed to have been insufficient to describe the blotch, +and he had to resort to a neologism. "Is that supposed to be a +'perpendicament'? It's got a head like a sea devil; the upper part seems +like a peacock trying to peck him in the back of the head." + +There remains one other thing to be inquired into in this case, and that +is the history of epilepsy which accompanied the patient. He was never +observed in an epileptic seizure at the military post from which he came +to us, and no seizures were observed in this hospital. His own +statements concerning this are, like everything else he said, quite +totally unreliable. But in repeated examinations he persisted in his +statement that he had had but one "spell" in his life, but that he +frequently suffered from fits of melancholy. In all probability this one +seizure was hysterical in nature, phenomena of which type not +infrequently manifest themselves in the pathological liar, as will be +seen in the next case. + +Here one sees how lying, a mental phenomenon which is looked upon as +quite a normal manifestation in a great many people, has reached such +dimensions in this individual and has succeeded in dominating his +personality to such an extent as to definitely remove him out of the +pale of normality and place him within the sphere of the mentally +diseased. + +There is, of course, no question here about the genuineness of his lying +as a symptom of mental aberration; _i.e._, the fabrication as manifested +by this individual is something over which he has no more control than +the dementia praecox patient has over his delusions. In both instances +the symptoms are spontaneous and genuine expressions of a pathological +mentality. And yet when such pathological phenomena become manifest in +association with some concrete difficulty in the individual's life, say +in connection with a threatened punishment for a crime committed, the +genuineness of the symptoms is frequently doubted. + +One, of course, can readily see with what facility an individual of the +type under discussion could malinger mental symptoms. Reality and +fiction have about identical values in this type of mental make-up, and +it is frequently impossible to separate the genuine from the fictitious +in their mental productivity. + +It is likewise quite easy to divine why an individual of this sort would +resort to malingering in his effort to extricate himself from a +difficult situation which he is organically unable to meet squarely in +the face. On the contrary, it would be strange indeed were an individual +of this type to refrain from resorting to this form of defense. Of +course, even the man whose history we have just quoted may still be +considered mentally responsible before the law were we to judge him by +the legal standards of responsibility. But as physicians we need not on +this account refrain from attempting to delineate these mental types in +their true colors. + +The situation is well illustrated in the following case. Here the +symptom of pathological lying is associated with pathological swindling +and criminality and offers a fertile field for seeds of malingering. + + E. D. C., a white male, aged thirty-four, came to us on April 16, + 1914, from the penitentiary at Stillwater, Minn., where he was serving + a sentence of ten years for white slavery. He was admitted on a + medical certificate which stated that his father was supposed to have + died from pulmonary tuberculosis. The patient gave a history of + epilepsy until fourteen years of age, likewise of having been a + patient in a Vienna hospital for the insane for one and a half years, + in 1900 and 1901. So far as was known to the prison authorities, he + was mentally depressed and had delusions since his arrival at the + Minnesota State Prison on October 11, 1913. The present symptoms were + described as mental depression; says that everybody is persecuting + him; also has the delusions that he has or can invent a wonderful + electric machine which he wants to sell to the government for a + hundred million dollars; said he would shoot himself and die in + prison. Physical condition was not good. Patient suffered from + obstinate constipation, peculiar shuffling gait, suggesting partial + loss of control of legs and feet. Complained of constant headache on + the top of his head. No fever. + + On admission to this hospital the patient was in poor physical health + and very anaemic. He was quite slender in stature and somewhat + effeminate in manners and speech. He walked with a very marked limp of + the right leg, stating that he had been afflicted in this manner ever + since his first attack of mental trouble at the age of nineteen. + Patellar reflexes were markedly exaggerated on both sides, the left + more so than the right, and ankle clonus was present on the left side. + Babinski phenomenon was absent. While the reflexes were being tested + he volunteered the information that his left patellar reflex was very + much stronger than the right. He was a very glib talker and spoke + fluently in five foreign languages. He gave his name as E. J. B., + Count de C., the son of the chamberlain to the Austrian Emperor and of + a famous Austrian countess. In the official papers which accompanied + him to the hospital the above name was followed by several aliases. He + talked in an affected, whining manner, constantly complained of + various bodily ailments, and showed a marked tendency to + hypochondriasis. He spoke of himself as a poor, down-trodden, and + persecuted unfortunate who is being constantly misunderstood. The + whole "white slavery" episode for which he is unjustly made to suffer + ten years' imprisonment was a trumped-up affair on the part of the + sheriff, who was bound to make a case out of it. He married the girl + with the best of intentions, and when arrested was with her on the way + to the Atlantic coast, preparatory to sailing for Paris, where he + intended to give her a splendid time. She testified against him at the + trial because she was scared into it by the officials, and, being + naturally of a weak nervous organization, she gave in. He was certain + he was going to die if he had to serve out his sentence, because + prison life is so different from the life he has led in the past. He + is entirely too refined to be able to stand the rough life of + imprisonment. Referred the examiner to the Austrian Embassy, which + could readily establish his noble descent and get him out of this + terrible predicament. When, later in his sojourn here, he was + interviewed by several gentlemen from the Austrian Embassy he + maintained the same attitude of wronged innocence, notwithstanding the + fact that these gentlemen confronted him with an undoubtedly genuine + photograph of himself, obtained from the Austrian police. It seems + that he was quite a famous character in Austria, and had served a + sentence there under a different name for a similar offense (white + slavery). Soon after his arrival at the Government Hospital for the + Insane he began to scheme for his escape, and on one occasion + attempted to saw the guards in his room with an improvised saw. He + likewise began to associate freely with the more dangerous element of + the criminal department of this hospital, quite likely with a view + towards getting assistance for his escape. He spoke with reluctance of + his ideas concerning the inventions, adding that he had decided to + quit talking about these things, because, although he is quite + convinced of the extreme value of these original ideas of his, people + have told him he was crazy wherever he expressed them. As an + illustration of some of these extremely valuable original ideas the + following may be mentioned. It concerns a bed-bug trap which he + invented, and which he described as a paper pocket which is placed in + the bed and scented with oil of pine so as to attract the bed-bugs. + These make their home in this paper pocket and lay their eggs there, + after which it is removed and burned. In the course of time (about two + months) he fully recovered from that serious leg affliction from which + he stated he had been suffering since the age of nineteen. + + When an attempt was made to obtain his past history it was soon + discovered that it was so fantastically colored with fabrications as + to be entirely worthless, so far as a reliable account of his past + life is concerned. As an instance of pathological lying, however, it + was a masterpiece. He was requested to write out briefly his past life + history, and in this abbreviated form it covered twelve + closely-typewritten pages. We will not burden the reader with a + complete reproduction of his story, although I assure you it makes + very interesting reading material, but will simply review it briefly. + + He speaks of the confession made to him several years ago by the lady + whom he had always looked up to as his mother. She told him that she + was only his foster-mother, and that in reality he was the son of the + Austrian chamberlain and a famous countess. The latter turned him over + into this lady's care when he was quite young, following her divorce + from the chamberlain. She furnished him with the authenticated proof + of the fact that he was entitled to a fabulous fortune left by his + parents. Unfortunately the lady died after a brief illness, during + which he practically sacrificed his life to save her, and thus his + most important witness is forever inaccessible. The papers which could + readily prove his noble descent were, most unfortunately, taken from + him when he was arrested and are probably destroyed by this time. + + His foster-mother, he states, was regularly supplied with funds by his + real mother, gave him an excellent education and traveled with him + extensively. In a plea for clemency he dwells upon the fact that his + father died insane, that he himself suffered from epilepsy in his + youth, and that at the age of twenty he spent a year in an insane + asylum in Austria. + +As an instance of his tendency to dramatization, of the part his ego +plays in the recital of his past exploits and of the tendency to crave +sympathy and compassion, a characteristic quite common to these +pathological swindlers, the following, his own description of the +circumstances which brought about his admission to the Vienna Insane +Asylum may be quoted:-- + + "While on vacation, I met at Wertersee, which is a fashionable summer + resort, a girl with the name L. Adle von D. I had left my tutor + behind. She was the first girl I met, and my romantic character, my + easily-excited nervous system, overpowered me and I fell in love, in + love as deep as a man can fall. A few months after that I was engaged + to her, and we should have been married on the 23d of April, 1899. On + the 22d of April my beautiful beloved bride was riding horseback with + me in the park, when at once her horse frightened, threw her off, + dragged her for a distance and then left her behind, a motionless, + bleeding mass. I saw right away that she was dead, lost to me, lost + forever; there was but one way not to lose her, and that was to follow + her soul, and that as quickly as possible. There in the park beside + her I took my pistol and shot myself. The public had gathered and + stopped me, and then I don't know what happened. I only remember that + I was ill for a long time, and then I was ill again, and they told me + L. was alive, and then I found out that she was not alive and I was + ill again." + +Of course, the entire episode is a fabrication. The patient admitted +quite as much, but the interesting thing in this episode is the fact +that it illustrates how rigidly dependent lying is upon unconscious +motives. Had this episode really taken place, the patient, because of +his particular make-up, would have acted, in all likelihood, just the +way he behaved in his fantastic adventure. + +After his year's confinement in the insane asylum his foster-mother +traveled with him in France, England, Egypt, and Turkey, in order to +divert his mind. Finally arriving at Transylvania, he became infatuated +with a poor girl named P., whom he christened L. in memory of his former +love, and married. The highly dramatic adventures of this second +matrimonial venture are altogether too numerous to describe in detail. +He describes in a very dramatic style how this lady was kidnapped from +him by a family of New York artists and spirited away across the ocean; +how after awakening from his unconsciousness, induced by some dope +administered to him in a tea which he had with these artist-friends the +night before, he at once made for the dock, arriving there just as the +ship carrying his wife was disappearing from sight; how he pursued them +across the Atlantic, to England, the continent, and so on, finally +locating them in Cape Town, South Africa; how upon arriving there he was +mortally wounded to find his beloved wife performing upon the stage of a +cheap, dirty place. An excerpt from his description of this eventful +voyage is as follows: "We passed Las Palmas, Asuncion, and St. Helena. +Christmas and New Year's were celebrated on board the ship, but I did +not care much for it. I was too much in distress. Would I find her +there? Would I reach her in time? How would I find her? Would she be +alive? My excitable fantasy awakened in me the most terrible suspicions. +I suffered dreadfully, and it seemed to me we would never arrive. But we +did at last, and some time in the beginning of January, 1906, I landed +in Cape Town." This is how he discovered her: "I knew I was going to see +something terrible, but I remained there--I had to. There were the rope +dancers, the clowns, and the music, but I had no interest in them. I was +waiting for L., my wife, and she came. On a small, mean stage L., my +beloved wife, appeared with painted cheeks and shining eyes, dressed up +in tights. She was dancing a mean dance and singing an obscene song +before an audience consisting mostly of drunken sailors. So I found my +wife L. and the music played. It was surely wonderful that I could +control myself at such a moment. At once it seemed to me that I had no +reason to be astonished. I was quiet and decided and waited until the +show was over, and after the show I went behind the stage, and when my +wife came out, laughing and happy, with a couple of other girls, I +stepped near her and said simply 'L.' She gazed at me and fainted." Thus +he finishes another tableau in his adventurous career. Several other +similarly dramatic adventures follow in his history, the last of which +landed him, wholly unjustifiably, in prison for ten years. When asked +why all his love adventures ended so disastrously, he replied: "Doctor, +all my life I have been suffering from a 'superaltruistic monomania to +help girls in distress,' and that is how I'm repaid." + +Any discussion on "freedom of will" and responsibility in connection +with an individual of this type is, of course, quite futile and really +of no practical importance. This man ought to be permanently isolated +from the community, but not because he happens to have violated a given +statute, but because his grave mental defect--in all probability an +incurable defect--tends to express itself in criminal traits. + +Back of this fantastic lying we see again that instinctive craving for +compensation by means of a resort to the imagination and fantasy, a +subterfuge rendered easy by those inherent defects enumerated in +connection with the preceding case. + +All the frankly psychotic manifestations, such as his delusional ideas +and his grave affection of the lower extremity which served to put him +in a hospital for the insane, were, of course, entirely malingered. + +This brings us to the subject of malingering proper. + + +III + +In malingering we see the application of deceit and lying to a definite +situation. That which is a habitual type of reaction in some +individuals, as was illustrated in the foregoing cases, comes to the +fore in others only under certain stressful situations of life. While in +the habitual fabricator the most prominent motives are those of an +egotistic nature, a craving for self-esteem as compensation for an +inherent defect, in the malingerer we see a resort to this form of +reaction as a means of self-preservation, as a means of escape from a +particularly painful situation. + +There was a time in the history of psychiatry when malingering was a +frequent subject of discussion in psychiatric literature. This was due +not so much to any inherent practical importance of the phenomenon of +malingering as such as to the faulty conception that this phenomenon was +something which by its very existence ruled out the existence of mental +disease. More scientific studies of personality which led to a direction +of our attention to the malingerer rather than to malingering as an +isolated mental phenomenon brought with it a complete change of attitude +towards the entire subject. + +Today, far from harboring the notion that malingering and mental disease +are mutually exclusive, we are beginning to look upon malingering itself +as the expression of an abnormal psychic make-up. Furthermore, far from +believing, as of old, that the proverbially insane is supposed to be +totally devoid of discretion in his conduct, we know that there may be a +good deal of method in madness, and that even the frankly insane +malinger mental symptoms when the occasion requires it. No experienced +psychiatrist would today, for instance, consider the oft-quoted story of +the alleged madness of Ulysses as evidence of malingering. + +The story is told that Ulysses, in order to escape the Trojan war, +feigned insanity. He yoked a bull and a horse together, plowed the +seashore, and sowed salt instead of grain. Palamedes detected this +deception by placing the infant son of the King of Ithaca in the line of +the furrow and observing the pretended lunatic turn the plow aside, an +act of discretion which was considered sufficient proof that his madness +was not real. Without attempting to pass upon the case of Ulysses, we +may say without fear of contradiction that no one would today depend +upon such criteria. Experience teaches us that an individual may be very +seriously mentally affected and at the same time show sufficient +discretion of conduct to avoid threatening danger and to seek those +means which best subserve his immediate needs and wants. Not only is +this true, but we have arrived at a stage where we are prone to look +upon a great many of the psychoses as the direct expressions of the +individual's wish--as a haven sought out by himself within which he +seeks shelter from the tempests of life. One of my patients tells me +that the gun which he used in the alleged homicide was not loaded with +bullets, but with paper wadding put there by his enemies, hence his +alleged victim could not have been killed; in fact, he knows that this +man is alive and having a good time on the money furnished him by his, +the patient's, enemies. Another instance is that of a colored man who is +serving a life sentence for murder. Among the many symptoms which this +fairly advanced dementia praecox case shows is the one that he considers +himself a white man; that his dark color is due to some paint which he +used in order to disguise himself; and that, inasmuch as the murder with +which he is charged was supposed to have been committed by a colored +man, he is not guilty of it. The motives here are quite obvious. Both +these individuals find life much more bearable believing, as they do, in +their innocence of the crimes imputed to them. Many other examples could +be cited to prove that symptoms in mental disease do serve a definite +purpose; that there may be indeed considerable method in madness. + +Nevertheless, the observation is not uncommon that whenever such method +is detected under circumstances where some ulterior motive may be ascribed +to it the lay mind, and not infrequently psychiatrically-trained +physicians, are at once ready to question the genuineness of the +symptoms. It is the more curious that the so-called "insanity dodge" cry +is frequently raised under circumstances where it would seem to be the +least justifiable, as, for instance, in the case of an individual +battling for his life before the bar of justice. + +A little inquiry, however, into this phenomenon will help us to +understand it better. It has its root primarily in that very common +tendency of man to impute to his neighbor a type of behavior, a form of +reaction, of which he would gladly avail himself were he in his +neighbor's place, and the weapon he would use under the circumstances +would very likely be that exquisitely human trait, deceit, malingering. +It is a weapon which has played a tremendous part in the evolutionary +struggle, not only of man but of all living things; in a broader sense, +it may be looked upon as an organic function, as an endowment, thanks +to which the weak, inferior being is able to avoid the danger of +becoming the prey of the stronger, superior being. This function is very +well illustrated in those animals which are able to acquire the color of +their immediate surroundings in order to render themselves more +difficult of detection. It is common among various insects, reptiles, +and amphibians. The chameleon may be especially mentioned in this +connection. Even the eggs acquire, in the process of natural selection, +the color of the place where they are deposited, and the cuckoo which is +about to cheat a couple of another species by placing her eggs in their +nest for them to hatch selects that species the color of whose eggs most +closely resembles that of her own, in order to assure herself of the +success of the deception. The simulation and malingering practiced by +the fox is common knowledge. Malingering, an instinctive function +originally, has, in the process of evolution, become an act of reason +with certain animals. One is forced to believe, from a survey of +mythological writings, that primitive man must have had recourse to +simulation and all else that this term stands for whenever he was +confronted with an especially difficult problem in his struggles for +existence. To the gods was attributed, among other special propensities, +the ability to assume any shape or form, else how could they have +performed all those miraculous escapades? Thus we are told that Jove +transformed himself into an eagle when he carried off Ganymede. +Achilles, the son of a goddess, sought to avoid the iniquitous fate +which drove him to Troy by disguising himself as a woman. Deception is a +common weapon of defense with the savage and with the inferior races of +today. It is the tool by means of which these individuals render things +as they want them to be; it is with them the means for a more direct, +less difficult, less tedious solution of the problems of life. + +The child in whose development the various steps of phylogeny are +recapitulated shows this tendency to deception, to simulation, and +dissimulation in a very pronounced degree. Lombroso, who was the first +to demonstrate that so-called moral insanity is but a continuation of +childhood without the adjunct of education, cites many facts, not +excepting his own example, to show that the child is naturally drawn to +fraud, to deception, to simulation. The child simulates either because +of fear of injury and punishment or because of vanity or jealousy. +Ferrari,[3] in his excellent work on juvenile delinquency, discusses the +various motives for deception and malingering in the child. According to +him, deception is, first of all, instinctive with the child. It +malingers because of weakness, playfulness, imitation, egotism, +jealousy, envy, and revenge. Deception frequently forms for it the only +available weapon of defense against the parents and teachers. + +Penta[4] cites many well-authenticated cases of malingering of mental +symptoms in children. Of special interest is Malmstein's case of a girl +of eight years who, in order to deceive her father and render him less +severe in his treatment of her, and in order to gain the sympathy of +those in the house who were in the habit of giving her sweets, feigned +complete muteness for five months, after which time, no longer able to +resist the desire to speak, she went into the woods, where, believing +herself unobserved, she began to sing. St. Augustine, in his +confessions, speaks of his childhood in the following manner: "I cheated +with innumerable lies my teachers and parents from a love of play and +for the purpose of being amused."[B] Penta, after a thorough discussion +of the subject of malingering in children, comes to the conclusion that +children use all the diverse forms of fraud, from simple lying to +simulation, much more frequently than is believed or known. It may with +them as with some lower animals simply be an instinctive playfulness, a +habit or a necessity, as a weapon consciously and voluntarily wielded. +This inherent tendency is, of course, modified to a considerable extent +by the environment under which the child was brought up. Finally, the +independence which the growing human being acquires from this form of +reaction is in direct proportion to the ability he has acquired through +education and precept to meet life's problems squarely in the face. We +will see, later on, how the type of individual who is most likely to +malinger has in reality never fully outgrown his childhood; that his +reactions to the problems of everyday life are largely infantile in +character. + +[B] Cited by Penta. + +Thus we see that malingering has its _raison d'etre_; that, after all, +it is not at all strange that the suspicion of its existence should be +so frequently raised by our legal brethren--yes, and medical brethren, +too; that in reality it ought to be a very common manifestation. +Nevertheless, paradoxical though it may seem, cases of pure malingering +of mental disease are comparatively rare in actual practice. +Wilmanns,[5] in a report of 277 cases of mental disease in +prisoners, cites only two cases of pure malingering, and in a later +revision of the diagnoses of the same series of cases the two cases of +malingering do not appear at all. Bonhoeffer,[6] in a study of 221 +cases, found only 0.5 per cent of malingering. Knecht,[7] in an +experience of seven and a half years at the Waldheim Prison, did not +observe a single case of true malingering. Vingtrinier[8] claims not to +have found a single case of true malingering among the 43,000 +delinquents observed by him during his experience at Rouen. Connolly, +Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted +by Penta as having expressed themselves that pure malingering is +extremely rare. Penta, on the contrary, observed about 120 cases during +his four years' service in the prison in Naples. He gives as the reason +for this unusually high percentage of cases observed by him the fact +that two-thirds of the inmates of the prison belonged to the Camorra, an +organization whose members are gleaned from the lowest and most +degenerate stratum of society, and in whom the tendency for deception +and fraud in any form is highly developed. + +The question naturally arises, What is the reason for this rarity of +cases of malingering? Is it because man has reached a state of +civilization where he no longer resorts to deception? Decidedly not. The +reason lies almost wholly in our changed attitude of today towards this +question. As we acquire more real insight into the workings of the human +mind we are prone to become more tolerant towards the human weaknesses, +and in our study of the malingerer it is the type of individual, his +mental make-up, which interests us most, rather than the malingered +symptoms. It is for this reason that today the number of authorities is +indeed small who do not look upon malingering _per se_ as a morbid +phenomenon, as an abortive attempt at adjustment by an individual who is +quite incapable of adequately coping with the vicissitudes of life. In +my own limited experience of several years with insane delinquents I +have yet to see the malingerer who, aside from being a malingerer, was +not quite worthless mentally. + +Our discussion of malingering,--_i.e._, of the exhibition of a +fictitious mental state by an individual for the purpose of rendering +more bearable or more pleasant a particularly painful or difficult +situation of life, or for the purpose of entirely annihilating such a +situation and of removing it from consciousness by substituting for it a +state of affairs wholly created from the individual's fantasy,--would +indeed be incomplete if we were to omit from our consideration at least +that much of Freud's psychology as pertains to this subject. + +Thus far we have considered principally the views of what may be termed +the descriptive school of psychiatry, though we have briefly touched +upon the instinctive biologic roots of this primitive mode of approach +to the problems of life, malingering of mental symptoms. + +With the consideration of the Freudian psychology we enter upon the +interpretative phase of psychiatry and to a very large extent of mental +life in general. + +Freud holds that a great part of mental life can either partially or +entirely be summarized under two principles, which he terms the +"pleasure principle" and the "reality principle" respectively.[9] These +two opponents are constantly facing one another in our inner life. The +former represents the primary, original form of mental activity, and is +characteristic of the earliest stages of human development, both in the +individual and in the race; it is, therefore, typically found in the +mental life of the infant, and to a less extent in that of the savage. +Its main attribute is a never-ceasing demand for immediate gratification +of various desires of a distinctly lowly order, and at literally any +cost. It is thus exquisitely egocentric, selfish, personal, and +antisocial. The activities of this "pleasure principle", however, +constantly come into conflict with the "reality principle." The rigid +requirements of our environment, of the social system in which we live, +deny us the fulfillment of many, if not most, of our most dearly coveted +desires, without, however, being able to abrogate these entirely. + +There are two ways in which these forbidden desires may become +satisfied. On the one hand, the instinctive striving, finding it quite +out of the question to gain expression through the desired channels, may +become sublimated into a form which is in accord with our social and +ethical requirements, or the forbidden strivings and desires may find +gratification in the individual's fantasy. We are here particularly +concerned with the latter mode of psychic adjustment. This mode of +adjustment is the usual way in which conflicts with reality are solved +by the child and the savage. For them a rigid recognition of reality, +such as is necessitated by the normal adult in his struggles for +existence, does not take place. In fact, the evolution from childhood to +adult life, from savagery to civilization, consists in nothing else than +in the progressive recognition of reality and the adjustment thereto. +One of the forms of getting away from reality, or a falsification of +conditions as they actually exist, was expressed by one of Freud's +patients as the "omnipotence of thought" (_Allmacht der Gedanken_). It +is a state of mind in which the individual believes in the omnipotence +of his thoughts; that his mere thinking possesses tremendous power; that +no sooner he thinks of a certain deed than the same is accomplished; +that an enemy, for instance, is actually harmed by merely wishing him +harm. This mode of thinking forms the basis for many magic ceremonials. +It is this latter mechanism,--_i.e._, the endowment of one's own +thoughts with an omnipotent power,--which is also frequently illustrated +in malingering. It is sufficient for the type of individual who +malingers to merely say the word, and the most fantastic creation of his +fancy immediately becomes a reality and is apperceived by him as such. A +mere verbal denial of guilt on his part is sufficient to make him +believe fully in his innocence and act accordingly. When we inquire into +the origin of this facility in transforming fantasy into reality, for +this omnipotence of the mere word or thought, we find it in the totally +unreasonable overcompensation of these individuals for their feeling of +impotence and weakness. This feeling of weakness and helplessness +naturally becomes more acute under especially stressful situations of +life, and hence it is that the criminal, especially the habitual +criminal, who always uses deceit and simulation in his vain attempts at +meeting life's difficulties squarely in the face, regularly resorts to +malingering when confronted with a serious criminal charge or when life +in prison becomes especially unbearable to him. A good illustration of +an attempt at falsification of reality for the purpose of annihilating a +particularly stressful situation by means of a mere assertion of a state +of affairs such as he would wish them to be, with a total disregard for +the real facts which constantly stare him in the face, is furnished by +the following case:-- + + M. came from a good family and led a normal life, earning a + substantial livelihood as printer up to the age of about thirty-eight. + At this time one of his children died, and this, together with poor + physical health, is said to have brought on a severe depression, + during which he was actively suicidal and very self-accusatory. + Several months later he lost another child by fire, and at this time + also claimed to have obtained positive proof of his wife's infidelity. + His mental depression became very much more aggravated; he attempted + suicide on a number of occasions, was very suspicious and + apprehensive, developed persecutory delusions, feared he was going to + be burned to death or suffer some other horrible fate. This condition + finally necessitated his admission to the Government Hospital for the + Insane on May 28, 1897, at the age of forty. Here he gradually + improved, and was discharged into the care of his father on + October 22, 1899. + +On February 19, 1903, he was readmitted as a D.C. prisoner, having shot +and killed a man who seduced one of his daughters. Some idea concerning +the type of individual we are dealing with here can be had already when +we keep in mind his mode of reaction to the various stressful situations +in his life enumerated above. All went well with him so long as he was +not called upon to make a difficult adjustment, but with the loss of his +child he develops a mental disorder. That he should have reacted to his +daughter's injury with murder is quite in line with his general +inability and incompetency for proper adjustment, and the development of +a mental disorder which has kept him in an institution for the past +twelve years and will in all probability keep him there the rest of his +life, in reaction to the committed murder, further emphasizes the +general vulnerability of his nervous system. Let us see how he attempts +to adjust himself to the situation; how he faces reality in his +psychosis. + +He does just what primitive man has done and what the child of today +does. Not being able to face reality, he annihilates it and substitutes +for it a world created out of his fantasy, in which he plays every +conceivable role but the real one,--_i.e._, that of a patient accused of +murder. We will see that he does this by the mere fiat of his word--that +magic dexterity which has served so well primitive man in his struggles +with reality. + +Let me reproduce some of his letters, of which he hands me at least one +daily. Here is one addressed to King George V: + + DEAR SIR: I wish to return at once to England to the Cissel Hotel. You + told me not to take my wife back after the courts here had granted me + a divorce, so I look to you to just please come on here in person and + have me released, as the United States Senate has given permission for + you to come and release me. I am the young man that rescued you from + drowning at River View, and after telling you my case you advised me + to get a divorce. The guests from the hotel were wishing for me to + return when on here, as also my family. + + Please find enclosed check for your expenses and give prompt action. + + Very respectfully, + (W. H. M.) HOWARD HALL, + Washington, D.C. + +The check:-- + + U. S. Treasury, + Pa. Ave. and 15th Street. + + WASHINGTON, D.C., October 1, 1914. + + Please pay to King George of England Ten Thousand Dollars for + professional services. + $10,000 W. H. M. + +Thus by the mere stroke of the pen he, a poor mortal accused of murder +and indefinitely confined to an institution, succeeds in putting himself +in touch with King George, in drawing _ad libitum_ upon the United +States Treasury, in ridding himself of the wife whom he accuses of +infidelity, and in annihilating old age by styling himself "The young +man," when in reality he is fifty-seven years of age at present. + +His belief in these statements is absolutely unshakable, notwithstanding +the fact that he retains a clear orientation concerning his immediate +environment, and thus has the actual state of his affairs constantly +forced to his attention. + +His grandiose compensation has such dimensions as to gratify every +imaginable wish of his. He came here because he was divorced from his +wife, not because of any crime he had committed. He is the son of the +supervisor in charge of this building. He owns this institution and +built it for a place in which he could count his money. He had forty-six +wagon-loads of this. He will live 250 years, because he has taken the +severest punishment to secure this. He refuses to assist with the ward +work, because he pays $1.50 a day for board and is not supposed to do +any work. He was brought here to select a woman for his wife. They +brought him a lot of blue-eyed blondes and also a lot of Baltimore and +St. Louis beauties, etc. + + W. H. M., Owner, Washington Asylum, 5000 Branch Hospitals, five + million employees. + + ANACOSTIA, D.C., Fri., Nov. 6, 1914. + + DEAR MR. PRESIDENT: + + I came over here to take out forty-six wagons loaded with greenbacks. + I respectfully had it arranged to have the Senate hold me here on + account of so much wealth until I thought it safe to return. Please + sign this and return it by mail. The Senate ordered me to write it to + you, as there is no crime against me. + + WASHINGTON, D.C., Fri., Nov. 6, 1914. + + DR. W. AND STAFF OFFICERS OF WASHINGTON ASYLUM: + + Please allow Mr. W. H. M. to pass out the gate at once free. + + Very respectfully, + W. W. + + Please don't delay this one minute. + +Thus we see that the entire content of this man's delusional fabric is +intended, first, to serve the purpose of annihilating the painful +reality, and, second, to substitute for it a beautiful world in which he +finds himself free and young again, enjoying his fabulous riches and +many blue-eyed beauties. It is the only compromise possible for him, and +the fact that it is nothing but a day-dream does not in the least +detract from its compensating possibilities for this individual's +painful reality. This man's mental disorder has been so obvious ever +since its inception that the question of malingering never suggested +itself to anyone, and yet the underlying mechanism in this case differs +in no particular essential from the cases usually considered as +malingerers. In both instances the psychosis represents an attempt to +get away from a painful reality by individuals who are quite incapable +of meeting such reality face to face. + +A more detailed consideration of Freudian psychology, especially such as +concerns the subjects of determinism, defense, and compensation, would +give one a still clearer insight into the subject under discussion, but +to do so would lead us considerably beyond the scope of this paper. From +what has been said thus far it will be seen that the mental processes +underlying the mental state of malingering differ in no essential from +those operative in the human mind generally; that man in his endeavor to +reach a satisfactory compromise between the two underlying principles of +his conduct,--_i.e._, that of pleasure and reality,--frequently resorts +to his fantasy; that malingering in its broader sense,--_i.e._, the +attempt to evade reality,--is a common mode of reaction in primitive +man, the child of today and in the undeveloped mind, in all of these +instances signifying an inability to meet stern reality in the face, and +that, therefore, malingering, when it does occur, should at least not be +looked upon as an aggravating circumstance, which is not infrequently +the case when the malingerer happens to be facing a court of law. + +That this mode of reaction is at times resorted to by individuals who +had always been looked upon as being far from incompetent only proves +that under special stress, especially mental stress, man readily sinks +to a lower cultural level and resorts to the defensive means common at +this level. + +Clinically, malingering is to be considered from three distinct +viewpoints:-- + +1. Malingering in the frankly insane; + +2. Malingering in those apparently normal mentally; and + +3. Malingering in that large group of border-line cases which should +rightly be looked upon as potentially insane and as constantly verging +upon an actual psychosis. + +It may be difficult to convince the lay mind, and especially the legal +mind, that an individual may be suffering from an actual psychosis and +at the same time malinger mental symptoms. It is the legal mind +especially, working as it does with well-differentiated, +sharply-defined, and wholly artificial concepts, that demands a sharp, +strict differentiation between the mentally well and the mentally sick. +By means of man-made statutes a line has been created, on one side of +which they would place all the mentally well and on the other side all +the mentally diseased. By the same token they cannot conceive how an +individual placed on one side of the line may be able to manifest a type +of reaction, a form of conduct, which is by common consent considered as +being something essentially characteristic of the man on the other side +of the line, losing sight of the fact that in the evolution of the human +mind Nature is far from drawing such sharp differentiations as are +exemplified by legal statutes. It would certainly be very convenient, +and expert testimony would certainly have been spared the disrepute into +which it has fallen, were Nature more accommodating in this respect. But +Nature does not work in this fashion; differentiation in Nature takes +place through infinite gradations, and between the absolutely well +mentally and the frankly insane there is a host of individuals +concerning whom it is almost next to impossible to state to which of the +above two groups they belong. Thus it is that the frankly insane at +times manifest conduct which taken by itself differs in no way from +normal conduct, and that the so-called normal individual at times +exhibits a type of reaction which is essentially of a psychotic nature. + +To the psychiatrist it is a matter of common occurrence to see the +mentally diseased not only dissimulate very ingeniously and tactfully +mental symptoms so that it is frequently impossible to convince a jury +of laymen of the existence of mental disorder, but at times, when the +necessity arises, they consciously accentuate their symptoms or frankly +malinger. + +There is nothing strange about this. There is absolutely no reason why +the insane, in his desire to gain expression for his wishes and +strivings, should not avail himself of the same means that normal man +uses. + +The following case illustrates this very clearly:-- + + W. J. C., a well-educated, fairly efficient newspaper reporter, after + a period of indefinite, vague, neurasthenic complaints lasting several + weeks and which brought about his discharge from the staff of a local + newspaper, awoke one July morning, picked up his infant child and, + throwing it against the opposite wall of the room, inflicted fatal + injuries upon it. After this he turned his face to the wall and + remained quietly in bed. There was no ascertainable cause present for + this act. The child was in the habit of entering the patient's room + every morning and playing with him before he arose from bed. It was + apparently on the same errand on this fatal morning. Shortly after + getting up the patient wanted to leave the house in his night clothes, + but was prevented from doing so and held until the police arrived. Six + and one-half hours later,--_i.e._, on July 27, at 12.30 P.M.,--he was + seen by me at the Government Hospital for the Insane. + + On admission to the hospital he was very restless and anxious, walked + up and down the room, hands in his pockets, would sit down for a few + minutes, then walked the floor again. Later in the day he was visited + by a newspaper reporter, a friend of his, with whom he conducted a + clear and coherent conversation, and when told by the latter that the + child was dead he assumed a markedly depressed facial expression. In + reply to my questions intended to bring out his attitude towards the + whole affair, he usually stated, "I don't know," and on one occasion + in a very agitated manner said, "So help me God, doctor, I don't know + anything about this." Later in the day he gave a clear and coherent + account of his past life, and a detailed mental examination failed to + bring out any gross mental disorder. He showed, however, considerable + uncertainty about the length of time certain events of the preceding + day consumed. He could not tell exactly when he retired the previous + evening. He remembered, however, going to bed, likewise that his wife + came to his room sometime during the night and asked him to fill the + babe's milk bottle. He didn't remember whether he did this or not. The + next thing he remembered was sitting in the parlor of the house, + sometime in the morning, and was able to describe accurately those who + were present. + + During the remainder of the afternoon he was morose and depressed, + refused to eat his supper, and continued in a restless state. He was + again seen by me at 7.30 in the evening in company with two other + physicians. The patient approached one of the physicians, extended his + hand to him, and in a familiar manner said, "Hello, Mr. C." When told + that this was not Mr. C., patient exclaimed "Oh!" in a confused and + astonished manner, said, "Where am I?" and reeled over on the floor as + if in a swoon. He was told to sit up in the chair, which he did. + + "What date is this?" "August 26, 1910" (July 27, 1910). + + "How long have you been here?" "Since July 25, 1910." + + "How long a period would that make?" "One month--oh no, one day; this + is August 10, 1910." + + "What were you sent here for?" "Don't know." + + "Who brought you here?" "Don't know--oh yes, two policemen." + + "What is your babe's name?" "Don't know." + + "What is your wife's name?" "Don't know." + + He was then given a newspaper clipping in which the whole affair was + fully described. He read the account through, but without exhibiting + the slightest emotion, and said, "Isn't that awful, doctor?" + + "How do you feel about this affair of your babe being dead?" "I don't + know anything about it." + + "How much is 2 times 3?" After considerable delay and in an absorbed + mood he said, "70." + + "How much is 6 times 7?" After a long pause he said, "Don't know." + + "Which is the largest newspaper in Washington?" "Don't know." (Patient + was on the staff of a local newspaper.) + +When we remember that only several hours before this the patient gave a +coherent account of his past life and showed nothing grossly psychotic, +the foregoing symptoms, such as the lack of knowledge of his wife's or +babe's name, inability to solve problems such as 2 times 3, the fainting +spell, etc., must be looked upon as unquestionably malingered. When +examined the following day he showed still further signs of malingering, +the detailed account of which must, however, be omitted on account of +lack of space, and yet this man was unquestionably insane; the act +itself (the infanticide) was unquestionably an insane act, as will be +shown later. We have mentioned the fact of his neurasthenic symptoms and +how as a result of these he lost his position. The physical examination +of the patient revealed certain neurological signs, such as +exaggeration of the patellar reflexes, lateral nystagmus of both eyes, +which determined us to look further into the question of his physical +state, especially in view of a history of luetic infection five years +before. A spinal puncture was accordingly performed, and the spinal +fluid findings were as follows: Fluid clear, pressure moderately +increased, Noguchi butyric acid reaction positive, a rather uncommonly +heavy granular type of precipitate, cells per cubic millimeter 129. +Differential cell count: Lymphocytes, 94 per cent; phagocytes +2.2 per cent; plasma cells, 0.25 per cent; unclassified cells, +2.25 per cent. Wassermann reaction with spinal fluid negative, both +active and inactivated. Wassermann reaction with the blood-serum +negative. This, however, became positive later on in the disease. The +above findings indicate unquestionably that he was suffering from +cerebral syphilis. + +It is not necessary to enter into further detail concerning the progress +of this case. Suffice it to say that with proper treatment he entirely +recovered and was so discharged on June 14, 1911. + +There can be no doubt that this man malingered mental symptoms, neither +need there be the slightest doubt about his having suffered from an +actual mental disorder. The motive for his malingering is perfectly +obvious. Finding himself suddenly confronted with a charge of +infanticide, and rent by the various conflicting emotions which a +realization of this carries with it, he resorted to the common weapon of +defense, malingering of mental symptoms. We have seen that he deceived +no one but himself; that in reality he was a very seriously affected +individual. It was fortunate for him that because of some lucky turn of +events he landed in a hospital instead of in jail. + +A more or less similar case recently received the maximum sentence of +life imprisonment for manslaughter. In this instance the case was +chiefly observed by jail officials instead of physicians in its early +course. + +The foregoing case, it seems to me, illustrates very well that, while we +are fully justified in assuming a relationship of cause and effect in +many cases of malingering, in many others malingering and actual mental +disease are concomitant phenomena, having a common root in the same +diseased soil. Thus Pelman[10] holds simulation in the mentally normal +to be extremely rare, and he always finds himself at a loss to +differentiate between that which is simulated and that which represents +the actual traits of the individual. My own experience prompts me to +agree with Pelman. This confusion and difficulty of differentiation +between actual mental disease and malingered symptoms may manifest +itself in two ways. The same individual may be suffering at one time +from a frank mental disorder, and at some later period, finding himself +in a stressful situation, malinger a psychotic state, or, as we saw in +the preceding case, malingering of symptoms may manifest itself during +the course of a frank mental disorder, as will be further illustrated in +succeeding cases. Pelman's statement, however, applies most forcibly to +that mass of border-line cases which will be discussed later. + + T. W. was admitted to the Government Hospital for the Insane from the + United States Penitentiary, Leavenworth, Kan., on June 16, 1910, at + the age of twenty-nine. He was serving at the time a sentence of eight + years for post-office robbery. His own version of his family and past + personal history is unreliable. He claimed to have suffered from a + paralysis of both arms from March, 1904, until March, 1906, and that + he was at that time confined to a sanitarium. He would not give the + name of that institution, and the whole story may have been + fictitious. At any rate, if he did suffer from this paralysis it was + very likely functional in type, as at the time of his admission here, + four years later, he showed no traces whatever of this. He admitted + having been arrested several times before for drunkenness and + disorderly conduct. His industrial career was very irregular. + + The onset of the present attack, as described in the medical + certificate which accompanied him on admission, was as follows:--"On + the evening of April 17, 1910, patient suddenly began to shout, sing, + and pray, claiming that the spirit of God had entered his heart and + that he had a mission to perform. This mission was to go among the + prisoners and preach the Gospel. He then manifested this in a very + erratic manner; ideation was disturbed and disconnected, and there was + present psychomotor restlessness. A probable diagnosis of + manic-depressive psychosis was made by the prison physician." + + On admission to this hospital the patient was well nourished + physically, talked readily and coherently, was clear mentally, + although he stated he did not know the nature of this hospital, adding + spontaneously that he knew it was not an insane asylum. His + productivity was chiefly of a religious nature. He stated he was the + real Elijah III, the real prophet; that the vision of Jesus Christ + came to him in his cell, handed him a cross, and told him to pick up + his clothes and follow Him. The warden at the penitentiary was jealous + of his ability to preach the Gospel, and in consequence tried to get + two men to kill him, but these could do him no harm, because he had + the spirit of God in him. The warden also tried to poison him. He + complained of a fever in his stomach from the food the warden gave + him, stated he could see crosses in the corner of his room, and was + continually mumbling something to himself in a low voice. He rested + well on the first night of his sojourn here, and the following morning + told the attendant that he had seen God standing behind him at + intervals during the night. On June 28, 1910, he developed a marked + religious excitement, preached loudly while out in the yard, and + wildly gesticulated in a manner as if he were addressing someone + above. He continued intermittently excited until the early part of + August, 1910. It should be noted here that at this time there were two + other cases confined in the same building, two cases of dementia + praecox, who manifested similar religious excitement. It is of + importance to note this, inasmuch as suggestion plays a considerable + role in the choice of the malingered symptom, and because one of the + characteristics of the type of individuals under consideration is a + high degree of suggestibility. + + In his conduct in the ward he was quiet and orderly, frequently talked + in a rational and coherent manner, but invariably brought into the + conversation his delusional ideas. In his demeanor towards me he was + very evasive, suspicious, and showed a marked disinclination to enter + into a protracted interview. Soon after an unsuccessful attempt to + examine him more thoroughly he handed me a letter addressed to Judge + Landis at Chicago, in which he ordered said Judge to remove Voliva + from Zion City and turn the latter over to him, the patient, as the + rightful heir and the only real Elijah III. Following this there was + another tranquil period, during which the patient's conduct was quite + good. About a month later another attempt was made to examine him in + detail, but so soon as he noticed my intention to take notes of the + examination he became very suspicious and evasive and absolutely + refused to cooeperate. This episode was likewise soon followed by a + letter as follows. The letter was addressed to the warden of the + United States Penitentiary at Leavenworth, Kan., and he requested that + it be mailed immediately, as it was very important. It was correctly + dated and read:-- + + "DEAR SIR: When you receive this letter you will immediately take + steps to have me returned to the penitentiary, where I have a divine + mission to perform. You old ... do you realize that you are fooling + with the prophet Elijah, the Lord's chosen? Have you no fear of the + wrath that God shall bestow on you if you even dare to offend His + divine servant? Don't you ever for a minute think that you can + connive to beat me out of my property in Zion City, you and that + interloper, L. L. Voliva. I shall have it all just as the Lord meant + I should, and I shall carry on the work just as the Divine Master + meant I should. For what matter it if the world is against us, so + long as God is for us? Now, you old reptile, on receipt of this you + will immediately discharge the chaplain; he has no business there. + When I get back I'll take his place, for I am Elijah III, the Lord's + anointed. + + (Signed) "T. W. ELIJAH III, Station L, Washington, D.C." + + In the meantime it was noted that the patient was very shrewd in his + various schemes for making his escape from the hospital; that he very + ingeniously managed to manufacture all sorts of weapons, and that he + seemed to be especially delusional when in conversation with the + hospital officials. + + Soon after the patient planned and executed a very daring escape, + taking with him two other patients, but was soon apprehended and + returned to the hospital. All of this led me to suspect that the + patient was simulating a good many of his symptoms, and that, at any + rate, he was very much exaggerating his psychotic state. + + However, there was a certain element of contradiction, a certain lack + of consistency, present in his behavior which is entirely atypical of + the pure malingerer. His explanations of his ideas were flat and + somewhat dilapidated, and resembled to a certain extent the + explanations of a dementia praecox case. In other words, there was no + doubt that the patient malingered, but there was likewise no doubt that + he suffered from a psychosis. On several occasions he refused to take + nourishment for several days at a time in reaction to his delusional + ideas. + + Upon his return from his elopement it was felt that, owing to his + dangerous tendencies, a more thorough attempt at evaluating the + relative importance of the genuine and the malingered in his case ought + to be made with a view to returning him to the penitentiary. + + He was accordingly again thoroughly examined on April 8, with the + following results: He reiterated his delusional ideas substantially as + given above. He insisted that he was not insane; that he was railroaded + to this hospital because the warden of the penitentiary and other + United States officials are trying to rob him of his property in Zion + City. "God Almighty meant that Zion City should belong to me." This was + decided on the night when he saw the cross. + + "How many months in a year?" "Twelve." + + "How many days in a week?" "Seven." + + "Name the months." "March, April, June, July, August, October, + November, December, January, and February." + + "What is the last month of the year?" "October." + + "What is the first month of the year?" "March." + + "Which is the Christmas month?" "I'm not certain, but I think it's + January." + + "How does vinegar taste?" "Sweet." + + "How does a lemon taste?" "Sweet." + + "What is the color of an orange?" "Blue." + + "Count from 1 to 20." Counts very slowly and deliberately, omitting 11 + and 15. + + "4 x 2 = 8; 8 x 4 = 28; 9 x 3 = 27; 7 x 4 = 24; 6 x 4 = 22; 6 + 7 = 13; + 19 + 11 = 30; 7 + 8 = 14; 3 x 3 = 9; 4 x 2 = 12; 6 x 4 = 14; + 5 x 2 = 10; 1 + 9 = 10; 9 + 11 = 21; 11 + 9 = 18; 50 + 5 = 11; + 8 / 2 = 4; 27 / 9 = 4." + + "Name the days of the week." "Tuesday, Wednesday, Thursday, Friday, and + Saturday." + + "Name them again." "Monday, Tuesday, Thursday, Friday, Saturday, and + Monday." + + In repeating a very simple story he changed the content entirely, and + omitted some of the most important details of it. + + When we remember that this man was far from being as ignorant as some + of the above answers would suggest, and that, while he unquestionably + suffered from a psychosis, his state of consciousness was altogether + too clear to justify a degree of lack of touch with his environment + such as his replies would indicate, it becomes quite obvious that he + malingered. This, together with his dangerous tendencies, determined us + to return him to the penitentiary, which was done on April 11, 1911. + + He reached the penitentiary on April 13, and on the night of April 20 + he began preaching in a loud tone of voice, claiming that he was the + son of David, and that he was called upon to go forth and preach to the + world. He was removed from his cell to the isolation building, where he + refused to take nourishment until April 23. During this period he spent + most of the time preaching and singing religious songs, and at times + would hold long and heated arguments with some imaginary person, always + on religious topics. From the above date until his transfer to the + Government Hospital for the Insane on September 24, 1911, he continued + in a very disturbed and destructive state, refusing food frequently + for several meals in succession, preached, sang, and cursed in turn, + gave voice to the various delusional ideas manifested above, and gave + objective evidence of suffering from hallucinations. Throughout he + strongly maintained that he did not want to return to the hospital at + Washington, as there was nothing wrong with him mentally. + + The prison physician who examined the patient at the penitentiary + before his second admission to this hospital made the following + notation in the case: "The mental examination of T. W. reveals + inconsistencies that are strongly suggestive of simulation, and I + believe there is in this case a degree of malingering, frequently + associated with prison psychoses, yet that there is a psychosis, in my + opinion, there is no doubt." + + Upon his return to this hospital he became involved in fistic + encounters, on the way to his ward, for which there was very little + provocation. For several weeks following this he was very surly, + dissatisfied, moody, and inaccessible, but showed no other psychotic + symptoms. Four days after admission he subscribed to a local newspaper, + which he read regularly and kept himself well informed on ordinary + topics. He was clear mentally, well oriented in all respects, and + adapted himself readily to his new environment, except that he + absolutely refused to eat the regular food furnished the patients. For + about three weeks he lived practically on fruit and candies which he + purchased, persisting in his determination to starve himself unless he + were given a special diet. This was furnished him, and he had no + further dietetic troubles. No delusions or hallucinations were + manifested, intellectual examination revealed no intelligence defect + (gross), and, aside from his surly mood and his tendency for rather + frequent endogenous depressed periods, he showed no abnormal + manifestations. + + In this state he required no special hospital treatment, and, as he + promised to conduct himself properly if he were returned to the + penitentiary, he was transferred back on February 20, 1912. + + Upon his return he continued, however, to manifest periodic + excitements, with destructiveness, always, however, in reaction to some + environmental irritation. He nevertheless managed to remain in the + penitentiary until the termination of his sentence. + +It is highly doubtful whether proper means will ever be evolved to +enable one to differentiate accurately between that which is genuine and +that which is malingered in cases like, for instance, the foregoing. + +This man unquestionably suffered from a psychosis, and yet there is +likewise no doubt that he malingered. The question of the accurate +differentiation between the genuine and the shammed seems to me, +however, to be strictly an academic one and of very slight practical +importance. What is of importance is the recognition that malingering +and mental disease are here the expression of the same diseased soil, +and that the same source should perhaps be also attributed to this man's +criminalistic tendencies. Crime, mental disease, and malingering should +perhaps here be looked upon as different phases of a mode of reaction to +life's problems which belongs to a lower cultural level, which is +largely infantile in character. + +That this infantile way of facing reality is dependent upon some +constitutional inherent anomaly is attested to by the circumstance that +these individuals practically always react in this manner when forced to +form new adjustments, new adaptations. This repeated recourse to mental +disease as a refuge from a stressful situation is amply illustrated in a +series of cases reported elsewhere. + +The other form in which malingering may be so intertwined with actual +mental disease as to render accurate differentiation quite impossible is +where the individual may be suffering from a psychosis at one time, and +at some later period, finding himself in a stressful situation, malinger +a psychotic state. In these cases the danger of ever committing a +habitual criminal to a hospital for the insane is especially apparent. + +Finding, as these individuals do, a successful and convenient refuge in +a psychosis, it is but natural for them to again seek this refuge when +they find themselves in conflict with the law. But that which was at one +time a spontaneous, unconsciously motivated mental reaction may later +become a conscious volitional act, an only available means of +escape--malingering of mental symptoms. + + J. E. M., aged twenty-seven on admission, June 15, 1912. Family + history obtained from the patient four days after admission is quite + unreliable. He knew nothing of his grandparents, who died in Ireland. + Father was living when last heard from, four or five years ago. He is + moderately alcoholic; a stableman by occupation. Mother died at + fifty-five in Bellevue Hospital, New York City, from some unknown + cause. One brother was drowned. One sister died of tubercular + adenitis. No instance of epilepsy, insanity, or nervous disorder in + any form is known to have existed among his relatives. + + Patient stated that he was born in Ireland on October 12, 1884. He + never attended school, but has learned to read and write a little. + Childhood was uneventful, so far as known. He came to this country at + the age of four, and at twelve or thirteen years of age began selling + newspapers in the streets of New York. His occupational career since + then has been chiefly that of a steamboat and longshoreman laborer + along the docks of New York City. He said he enlisted in the Navy in + 1907 or 1908, was not quite certain as to which year, at San + Francisco, Cal. He served on the U.S.S. _Buffalo_ as coal-passer; was + dishonorably discharged for drunkenness. He then reenlisted and served + as fireman, first class, on the _Milwaukee_ for about three and + one-half years. Says he got along well on the _Milwaukee_, until he + got into his present trouble. He was convicted of sodomy and sentenced + to prison for ten years, January 15, 1911. Patient did not see the + discrepancies in the dates as given by him, but, as stated before, the + history is quite unreliable. + + A letter received from the War Department on June 28 requested + identification of J. E. M. for the purpose of detecting whether or not + he is the same man who under the name of Lee deserted from the Army, + January 14, 1909. The photograph accompanying the letter was that of + the patient. + + He had measles and mumps during childhood, from which he made good + recoveries. Gonorrhoeal and syphilitic infection were denied. + (Wassermann with the blood-serum negative.) During a bar-room brawl in + Panama he was struck on the head with a table leg and rendered + unconscious for fifteen or sixteen hours. This was some time in 1908. + He thinks there was nothing more than a scalp wound, requiring no + treatment beyond a simple dressing. For about a year after, headaches + were present almost continually, occipital in location and of a + tingling sensation. There was likewise a reduction of tolerance for + alcoholics, since then two glasses of whisky being sufficient to + intoxicate him. He does not know whether there was any change in his + mental make-up or faculties following this injury, as he paid no + attention to this. He commenced to indulge in alcoholics at the age of + eighteen or nineteen. He cannot give a detailed account of the extent, + but, as a rule, he spent all his money not needed for living expenses + for whisky. He would become intoxicated every time he went ashore, + stating that there was nothing else to do and no place to which he + could go. Practice of onanism was denied. He claimed to have begun + normal sexual intercourse at about the usual age. Strenuously denied + sexual perversions, in spite of the fact that he is now serving a ten + years' sentence for sodomy. He denied the guilt of this offense; + insisted that he was never arrested before in his life, and believed + the present conviction to have been a trumped-up affair because they + must have gotten sore on him, although he cannot figure out why. + Following his conviction for the above offense he was sent to the + State Penitentiary at Concord, N.H. For a short while after he got + there he got along well; was kept continually at work in the chair + factory. He did not like this work, as he was subjected to the + inhalation of the dust and shavings, and feared he would develop + tuberculosis from this, and asked to be transferred to some other + place. This request was finally granted him, and he was put to work in + the kitchen. He states he did not get along well there; very soon got + into some sort of trouble and was put into a dark dungeon, where he + thinks he remained for about twelve months, strapped to the bed. He + never saw the daylight during this time. He does not know why these + strict measures were taken with him, but it is a fact that he was tied + down. He had no idea of the onset of the present trouble, but stated + that he complained frequently to the doctor of headaches and vomiting. + The headaches were occipital in nature and severe at times. He could + not recall his transfer to this institution nor the events which + transpired during the first two or three days after his arrival here. + + The medical certificate which accompanied him here stated: "Patient + has been convicted of sodomy and is at present serving sentence for + same. First symptoms became manifest about February 6, 1912. Came + under the care of prison physician at Concord, N.H., State Prison with + severe headaches. Previous to above date it is said there were the + following records at above prison in regard to this patient: April 15, + 1911, and August 10, 1911, he had convulsions. These are not described + in detail. The prison physician at the time noted that patient showed + symptoms of organic brain disease. On February 26, 1912, he became + violent, and has had to be restrained since then. For some time + previous to that he had acted peculiarly. The symptoms immediately + preceding his transfer to this institution are as follows: Has to be + restrained to prevent violence to himself and others. Frequently + suspicious when food and drink are offered him. At times noisy when he + desires food and it is not given to him at once. Probable cause + unknown. There is a vague history of head injury aboard ship in the + tropics. Homicidal tendencies were present when the disease first + became manifest." + + Patient was admitted to this institution June 15, 1912, at 10.30 A.M. + On admission he was carried in by two employees. His legs were + shackled and he had wristlets on his hands. He was apparently unable + to stand unassisted, and, when support was removed, fell to the floor. + Pupils were widely dilated; internal strabismus of the right eye was + present. Facial musculature was distorted, and he mumbled to himself + in a low, indifferent tone of voice, over and over again, "Give me + something to eat. I can't do it. Give me something to eat," etc., in a + rapid monotone. He appeared to be in a deep stupor. He did not seem to + realize his whereabouts, and attention could not be gained. He was + totally inaccessible. When put to bed he became quite restless, rolled + out on the floor, and was unable to assist himself back into bed. + Musculature of legs was in a constant mild clonus, and the right foot + was kept in position of talipes equinovarus. Pins pushed deeply into + the skin all over the body caused no reaction. When food was brought + to him he leaped upon it and finished the meal with extreme rapidity, + stuffed his mouth full, never taking sufficient time for mastication + or swallowing, and food was frequently expelled forcibly, probably + from irritation of the air-passages. Questions addressed to him + remained unheeded, but he kept up a constant mumbling in a low + monotone, as described above. He was totally unable to stand on his + feet unsupported, but when lying down his legs were moved about quite + freely in an indifferent manner. When alone in the room he remained + quietly in bed, head and face covered up with a blanket, but as soon + as the room was entered he became restless, grabbing to those about + him and holding on tenaciously. During his first night in the + institution he slept well and was clean in habits. The following + morning he was still inaccessible. He ate his breakfast quite + voraciously, mumbling to himself all the time, "Give me something to + eat" or "Give me something to drink." When water was brought to him he + would endeavor to gulp the entire contents of the vessel at one + effort. + + During the day of June 16, the day following his admission, he was + frequently seen sitting on the side of the bed with quite a pleasant + facial expression, rubbing his arms and legs. When his room was + entered, however, he at once began mumbling to himself similar phrases + as those given above, became quite restless, grabbing at those about + him and not paying any attention to questions put to him. The + following day, June 17, he showed marked improvement; was very much + quieter in behavior when approached; walked back and forth in his room + quite unassisted and in quite a steady manner; was seen looking out of + the window into the yard for about fifteen or twenty minutes. Upon + being approached by any one his gait seemed to become definitely less + steady, and diffused twitchings of the thigh and leg were noted. The + strabismus which was present on the day of admission had entirely + disappeared; pupils slightly dilated. In the forenoon of the 17th he + asked for his clothes and to be allowed to go out in the courtyard + for a walk. A few questions addressed to him were answered coherently + and relevantly. He said, in answer to direct questions, that his name + was J. E. M.; that he did not know his age; that he came off some + ship. Said the name of the ship was _Washington_; that he did not know + how long he was on that ship, but thought it was a good long time. + Asked where he was now, he said he was in the brig. "Where?" "Don't + know." Asked if he were crazy, he said, "No, sir." When he came here? + "A year ago." Asked what was the matter with him. "Nothing, sir. They + kept me tied up too much." Asked when his bowels moved last, he said, + "About a week ago." + + On June 19 he gave a coherent and connected account of his past life. + He talked freely and cooeperated in every way with the interviewer. + Requests were obeyed promptly and intelligently. Physical examination + on that date showed him to be a well-built, well-developed white male. + Face slightly asymmetrical. Skin was soft and smooth, free from + eruption, and covered with numerous elaborate tattoo marks. Linear + depressed scar in the occipital region. Muscle tone was good. Muscular + power was good in upper extremities. On first being tested in the + lower extremities said he could not resist very much passive + movements; upon suggestion, however, the muscular power of the lower + extremities became much stronger and equal to that of the upper + extremities. Grip was strong and equal on both sides. Station and gait + were unimpaired when a steady and erect attitude and firm gait were + suggested to the patient; left alone, he was inclined to be slightly + unsteady on his feet. With eyes closed and feet together, there was + considerable swaying present; said he felt like falling over. + Voluntary movements were performed well. He described accurately a + circle, a square, and triangle in the air with either hand. Movements + were steady and accurate. Cooerdination was slightly impaired in f-f + and f-n tests; the termination of the act was accompanied by a slight + tremor. The musculature of thighs showed a more or less constant + clonic twitching. When attention was called to this he was able to + control it to a certain extent. Upon assuming a sitting posture the + twitchings ceased. He said it was due to weak ankles. There was no + tremor of protruded tongue or lips when showing teeth; fine tremor of + the extended fingers and forearm when extended; no tremor of facial + musculature. There was no paralysis, but there seemed to be a slight + weakening of the lower extremities. No atrophies or hypertrophies + noted. The triceps and radial reflexes were definitely exaggerated. + Upon tapping, the quadriceps tendon caused a brisk marked contraction + of thigh muscles, followed by mild clonus. Tapping of one knee tended + to set musculature of opposite knee in mild clonus of short duration. + Knee kicks were definitely exaggerated. Tendo Achillis exaggerated. No + ankle clonus. Muscular irritability to mechanical stimulation + increased. Superficial reflexes were normal, except plantar defense + reaction was slight. Cutaneous sensibility was unimpaired: heat and + cold readily distinguished. Light touches of pin pricks were felt and + localized all over the body. Sense of position normal. No + astereognosis in either hand. No excessive sweating. Eyes clear; + irides brown; pupils round and regular, moderately dilated, reacted + readily to all tests; eye movements well performed in all directions; + no nystagmus nor strabismus. Vision--20/30 in each eye, improved by + glasses. Skin of vitreous clear; slight weakness of external recti; + cornea clear; field of vision normal for white; both fundi normal + except for slight hyperaemia. Smell, taste, audition, and speech + unimpaired. + + Mentally the patient was clear. He comprehended readily what was said + to him, and his replies were prompt and relevant. He was disoriented + for time. He stated that he knew the nature of this place; that he was + told it the day before by a patient. Claimed to have total or almost + total amnesia for several months past during the year he was confined + in the dungeon of the Concord Penitentiary. He had no idea of the trip + from there down to this hospital. He did not remember his arrival, nor + how he acted the first two days here. Stated that on June 17 he first + began to notice things about him and to realize faintly where he was. + Delusions or hallucinations could not be elicited as having existed at + that time. He spoke of having been bothered at the penitentiary; of + having been chloroformed; that they put stuff in his food, tried hard + to get him out of the way, and because they could not do it sent him + down here. Said the doctor poured ether down his neck. He does not + know the doctor's name, but he knew it was ether, he smelt it, and + that is the reason he could not use his legs on arrival. He had no + idea why he should have been treated thus, but thought perhaps they + had it in for him. Auditory hallucinations could not be elicited. When + asked if he ever saw anything, he said it was pitch dark in the + dungeon and no one could see anything. Said the food tasted bad all + the time, and sometimes made him vomit. On one occasion he noticed + some powder in the beans. No electricity, no shocks, no outside + influence was used on him. He did not know how long he was tied down + in the dungeon, as half the time he did not know anything at all. Said + they put needles in him, and pointed to some marks on his arm as a + result of hypodermics. Facial expression denoted perfect satisfaction; + said he felt fine and did not worry about anything, as he is not of + the worrying kind. Said he had been treated well here. Insight was + imperfect. When asked directly if he had been insane, he replied + "No." When the various symptoms which he manifested on admission were + described to him he was inclined to agree that if he did show these + symptoms he must have been out of his head. Remote memory was not + impaired, so far as could be determined. There was an ill-defined + amnesia extending over several months past, and up to June 17, when he + claimed to have first realized his whereabouts. Attention was + unimpaired. He reacted well to the intellectual tests, with the + exception of the arithmetical problems, which he did poorly. Replies + to ethical questions showed a rather low grade of morality, perhaps + due somewhat to ignorance more than to anything else. In his conduct + on the ward he was absolutely normal following June 17. He spent his + time reading and in conversation with the other patients. He was + perfectly satisfied in his surroundings, frank in his conversation + with those about him, and gradually gained more and more insight into + his condition. He still persisted, however, in his statements that + ether was poured down his back. Said he remembered this distinctly as + having taken place while confined in the dungeon. He was then, + however, inclined to think that probably they did not have it in for + him, and probably they did what they thought was best. In conversation + with him today, on June 19, four days after admission, he showed + perfectly normal behavior in every respect. Was frank in his + statements, spoke of the amnesia mentioned above, and no delusions or + hallucinatory experiences or physical symptoms present on admission + could be detected. + + When finally confronted with the picture sent from the War Department + for his identification he showed some degree of emotional reaction, + stated that the picture was his, but persistently denied ever having + been a recruit in the army. On the whole, he took the matter rather + lightly and good-naturedly. + +The history of this attack illustrates a typical case of hysterical +psychosis. The marked stupor and confusion, the numerous and varied +neurological symptoms, the sensory disturbances, especially the profound +anaesthesia to pin pricks, the amnesia and rapid recovery after change of +environment, all point to this diagnosis. It is a form of reaction +frequently seen in prisoners, and has been designated, for want of a +better term, as prison psychosis. At any rate, there can be no doubt as +to the genuineness of the symptoms presented by the patient. + +If we keep in mind that such a type of psychotic reaction is the result +of the mutual interaction between an unstable, highly vulnerable psyche +and an unfavorable environmental situation--in this instance prison +environment--we understand the more readily the later history of this +case. + +On July 16, 1912, he was discharged recovered and turned over to the +naval authorities to be returned to prison. Soon after his return to +prison he was noted to be melancholy, uncommunicative, was not +interested in condition of self or surroundings, had unsystematized +delusions of persecution. Physically he was noted to be anaemic, showed +general tremors when undergoing examination, reflexes were exaggerated, +positive Romberg was present. The physician who accompanied patient to +the Government Hospital for the Insane on his second admission stated +that on the trip from Portsmouth Prison M. tried to assault a waiter in +a restaurant in Boston, accusing the latter of following him. To the +physician he said, while on the train, "Take your d---- eyes off me, or +I'll brain you." + +He was readmitted to the Government Hospital for the Insane on +February 6, 1913. Physical examination on this admission was negative, +except for some impairment of vision, for which he was given +eye-glasses. Mentally he was found to be disoriented for time, though +perfectly clear mentally, as was shown later in the examination; he said +he did not know the name of the institution, though a minute later he +gave correctly the name of the building in which he was located. He +spoke in a very vindictive manner of the naval officials, who he said +were persecuting him in various ways, and who he reckoned were then +working to send him to some other d---- prison. On February 7, the day +after admission, he wrote the following letter to the Secretary of the +Navy: + + HOWARD HALL, January 29, 1913. + + MR. SECRETARY OF THE NAVY: _Rev. Sir_.--Will you kindly have some + investigating, as I cannot have my life endangered. It is continually + in my food, and times I have found the compounded powders in the air + of my room choking me. Please let me know if you will do so, and I + shall close. + + Respectfully yours, + J. E. M., H. H. 5, Station L. + +No hallucinations could be elicited, and his delusional ideas were +confined to the naval officials. These, he said, were persecuting him; +they sentenced him unjustly in the first place, and threatened to get +even with them. He answered the intelligence tests fairly well, but the +examining physician noted that frequently he gave expression of +consciously giving erroneous replies to questions put to him. +Emotionally he was at first somewhat depressed, but later this +disappeared. In his conduct he was inclined to be very troublesome, +easily irritated, and fault-finding. + +This disorder of conduct, however, became consistently more aggravated +whenever he was in the presence of the physician. While he gradually +became quite friendly with the attendants and willingly assisted with +the ward work, he became quite abusive whenever an attempt was made to +examine him by the physician. This became especially evident in +December, 1913, when the physician who had him in charge during his +first sojourn at the hospital again assumed charge of him. At that time +the patient had been on excellent behavior for a number of months, and +in his daily conduct showed no evidence of a psychosis. He continued, +however, to air his delusional ideas whenever the physician attempted to +examine him. + +Everything went well upon the return of his former physician until +December 22, 1913, when the latter attempted to examine him. The patient +became very abusive and threatening in his attitude, began to air all +sorts of bizarre persecutory ideas, and for about a month he continued +in an excited and destructive state. At the expiration of this period he +apologized to the physician for his conduct, said that he could not help +going on a rampage once in a while, as it is all due to his mean +disposition, and promised to conduct himself in an excellent manner if +he were not returned to prison. This was early in January, 1914, since +which time he has been a model patient in every respect. It is needless +to say that he has not been given, since that time, any occasion for the +development of another tantrum, and accordingly he remained free from +psychotic manifestations. + +He was a model patient after this, assisted willingly with the ward +work, and on one occasion prevented the successful culmination of a +daring plot on the part of several patients to escape from the +institution. + +Upon the recommendation of the hospital authorities and Dr. Sheehan, the +naval officer stationed at this hospital, the remainder of this man's +sentence was commuted, and he was accordingly discharged on June 29, +1914. For about six months prior to this his conduct was exemplary, and, +though through a considerable part of this period he enjoyed freedom of +the grounds, he never showed the slightest inclination to abuse these +privileges. + +The salutary effect of the commutation of this man's sentence is quite +obvious. On the other hand, I am equally certain that had this +particular individual been returned to prison we would have had him +again before long as a very seriously ill patient. + +This case is extremely interesting from many points of view. In the +first place, it gives us some insight into that highly inflammable, +hair-trigger, emotional type of individual who, when thrown into a +stressful situation, is very likely to go to pieces mentally. It is a +type which is always very difficult to manage under a prison regime, and +which in my estimation requires some intermediary place between a +hospital for the insane and a penal institution. It is likewise quite +irrational in our judicial disposition of these cases to impose a +definite sentence. If our prisons are to function as reformatory +institutions, it is quite clear that in this particular case no one can +possibly foretell how long a period it would take to bring about a +reformation. It is as if a man suffering from pulmonary tuberculosis +were told that he must go to a place set aside for such as he and stay +there, say, five years, irrespective of whether he is well at the end of +that time, or whether he might have recovered long before the expiration +of that period. + +In this particular instance we were led to recommend a commutation of +the unexpired term of the sentence by the following considerations: +First of all, I cannot consider sodomy a crime punishable by +imprisonment, unless the act was performed on a subject who either is +incapable of giving his consent or becomes a party to the act against +his will, by force. Anomalies of the sexual function are not crimes, but +diseases, and as such should come under the purview of the physician, +and not the agents of the law. In the second place, this man served in +the navy with an excellent record for about two years, and, so far as we +know, is not inclined to habitual criminality, and therefore deserved at +least another chance. But these considerations are somewhat beside the +issue under discussion. The case, to my mind, illustrates very well how +closely malingering of mental symptoms is related to actual mental +disease, how both manifestations are expressions of the same underlying +diseased soil, and how difficult, nay even impossible, it is to tell in +a given case which of the symptoms are real and which shammed. On his +first admission this man suffered from a grave mental disorder, from +which, so far as anybody could determine, he made a complete recovery. +Thrown back into the same stressful situation, he again finds himself +unable to cope with it, becomes melancholy, suspicious, and mildly +delusional. There is, however, considerable doubt in my mind as to the +genuineness of these symptoms; unquestionably genuine is only the +psychopathic make-up of this individual, which under stress permitted +the development in one instance of a grave psychosis, in another of +malingering. + +Cases like the foregoing are by no means exceptions in criminal +departments of hospitals for the insane. It is on account of this type +of prison population that penal institutions furnish us with ten times +as many insane as free communities. + +Whatever convictions I possess concerning the subject of malingering +were gained from a fairly extensive experience with insane delinquents +at the Government Hospital for the Insane, and when I assert that I have +yet to see a malingerer who, aside from being a malingerer, was likewise +normal mentally, I do so with the full consciousness that my experience +has been a more or less one-sided one. I mean to say that the material +observed by me came to my notice within the confines of a hospital for +the insane, and that my failure, therefore, to see the so-called pure +malingerer is probably due to this circumstance. I shall not argue this +point further, but merely state that it is true I have not had +experience with the detected and convicted malingerer in the jail and +court-room. I have had ample opportunity to study this same genus later +as a patient in the hospital. + +It would be an extremely interesting study to follow up the later +careers of the so-called detected malingerers who are sent to prison and +see how many of them later find their way to hospitals for the insane. A +setting forth of these figures--and I doubt not for one second that the +number is not at all inconsiderable--would not in the least have to be +construed as a criticism of the diagnostic acumen of the original +investigator. It would simply substantiate the truth of our contention +that in the malingerer we see a type of individual who is far from +normal, and in whom malingering as well as frank mental disease is not +at all a rare phenomenon. + +I have no doubt whatever that a considerable number of suspected +malingerers are annually sent to penal institutions, there to be later +recognized in their true light and transferred to hospitals for the +insane; else it would be difficult to account for the fact that mental +disease, according to many authors, is at least ten times as frequent +among prisoners as it is among a free population. Certainly this cannot +be attributed to environment alone, especially not to that of our +modern, well-conducted prisons. The reason lies chiefly in the type of +individual who populates our prisons. A number of them are either insane +when sent to prison or potentially so, and when thrown into a more or +less difficult situation, such as imprisonment, readily develop a mental +disorder. We see this illustrated very well in the highly beneficial +effect which transfer to a hospital for the insane has upon these +individuals. I am convinced that one would not be wrong in agreeing with +the opinions quoted below, that malingering, as such, is a morbid +phenomenon and always the expression of an individual inferior mentally. +It may be looked upon as a psychogenetic disorder, the mere possibility +of the development of which is, according to Birnbaum[11] and others, an +indication of a degenerative make-up, a defective mental organization. +Siemens[12] says: "The demonstration of the existence of simulation is +not at all proof that disease is simulated; it does not exclude the +existence of mental disease." Pelman holds simulation in the mentally +normal to be extremely rare, and he always finds himself at a loss to +differentiate between that which is simulated and that which represents +the actual traits of the individual. Melbruch[13] holds that simulation +is observed solely in individuals more or less decidedly abnormal +mentally, because in the great majority of cases, if there does not +actually exist a frank mental disorder, these individuals lack in a +marked degree psychic balance and are constantly on the verge of a +psychosis. Penta, in a most thorough study of the subject of +malingering, likewise comes to the conclusion that it is always a morbid +phenomenon. It is a tool almost always resorted to by the weak and +incompetent whenever confronted with an especially difficult or +stressful situation. It is, therefore, almost exclusively seen in +hysterics, neurotics and other types of psychopaths, in the frankly +insane, and in grave delinquents. + +With these remarks concerning malingering in the supposedly mentally +normal, we may turn to a discussion of that large group of borderland +cases which furnishes, outside of the frankly insane, the great majority +of malingerers. I am tempted here to borrow Bornstein's classic +description of the type of personality to which I am referring. +According to him, these individuals come into the world with the stamp +of a hereditary taint, with certain somatic anomalies (ears, palate, +formation of skull, growth of hair, etc.), and already as children show +those psychic characteristics which are decisive for their +individuality. They are, above all, characterized by a marked +hypersensitiveness and by a lack of harmonious relationship between the +various psychic functions. This disharmony finds its expression chiefly +in the predominance of the emotional element over the intellectual and +in the entire subordination of the latter to the former. Their feelings, +furthermore, express themselves in an abnormal manner, both as regards +their intensity and duration. The emotional reaction is either +excessively strong or, on the other hand, disproportionately weak +compared with the stimulus, and in spite of the extravagance of the +expression it quickly passes over or remains with an excessive obduracy +for a disproportionately long time. Notwithstanding the apparent +intensity of the outbreak in the former and its tediousness in the +latter case, these emotional upsets almost always lack real depth. They +are usually very superficial, insufficiently grounded, rather dependent +upon accident; transitions from one extreme to the other make up the +daily experiences of these individuals--from intense love to burning +hatred, from deepest reverence to an irreconcilable disgust, from +unshakable loyalty to brutal treachery. They lack energy and initiative, +are undecided, vacillating, and inclined to self-reproach. The +domination of the emotional sphere and the frequent incongruity and +discord between the various forms of emotional expression frequently +lead to the development of morbid doubts, morbid fears, a morbidly +exaggerated egotism, and sensitiveness which leads them to scent +everywhere personal injury and insult. Finally, they frequently show an +overdevelopment of the sexual instincts and various deviations from +normal sexual development. Many of them seem to lack totally in the +power of reason, but act entirely upon impulse, upon the mere feeling +that this or that proposition is true. Many others show a pronounced +tendency to a metaphysic brooding and day-dreaming and to the +transformation into fact of the dreamed air castles, without any regard +to the iron logic of life which they cannot satisfy, with which they +either will not or do not know how to reckon. Turning their backs upon +the demands of life, centered in self, given up to the kaleidoscopic +play of their emotions, which are of short duration, imperfect as to +depth, varying in intensity, and depending upon any and every external +influence, these individuals are very uncertain in their opinions, +judgments, and motives for action. They go through life without any +direction, without any guiding idea, without initiative, and without +will, incapable of any kind of systematic labor, yet at times ready, +under the influence of a temporary affect, to sacrifice everything in +order to carry out what later on proves worthless and vain. Lacking in +sure criteria and guides, they are slavishly dependent upon momentary +external influences, and under unfavorable conditions of life suffer +want and misery and give way to temptation, frequently falling into a +life of vagabondage, drunkenness, and crime. In prison they often +develop mental disorders, are looked upon as malingerers, and oscillate +between prison and the insane asylum, only to begin the old game over +again so soon as they again come in contact with life. + +It is little wonder, then, that the psychiatrist in dealing with these +unfortunates frequently finds himself at a loss to tell where health +leaves off and disease begins. The psychoses which these individuals +develop are in the great majority of instances purely psychogenetic in +character, one of the many distinguishing features of which is a marked +susceptibility of the symptoms to be influenced by external occurrences. +This tendency of the symptoms to shape themselves in accordance with +occurrences in the immediate environment frequently leads to the +suspicion of malingering, because there seems to be altogether too much +discretion displayed by these alleged insane. + +I have elsewhere[14] reported a series of these cases and entered into a +detailed discussion both of the personality and the nature of the +psychoses from which these individuals suffered. Most of my cases had +been both in prison and in hospitals for the insane on more than one +occasion, every arrest and imprisonment having been apparently +sufficient to bring out a fresh attack of mental disease. + +The following case is fairly illustrative of this type:-- + + J. H., white male, age twenty-seven on admission, November 13, 1913. + While serving a year's sentence at the Portsmouth Naval Prison for + fraudulent enlistment the patient told the authorities there that on + August 7, 1909, he had murdered a girl in Rochester, N.Y. He described + the murder in great detail, stated that he met the girl in one of the + Rochester cemeteries, attempted a sexual assault upon her, and when + she resisted he choked her to death. He stated that he did not mean to + kill his victim, but that he had inflicted the fatal injury before he + was aware of it. It was remorse, he said, and the desire to expiate + his crime which prompted his confession. He persisted in this + confession until the naval authorities were persuaded to discharge him + and turn him over to the civil authorities of Rochester, N.Y. Upon + arriving there an alibi was easily established, freeing the patient of + all suspicion of the murder, whereupon it took a good deal of + investigation on the part of the authorities to establish the + patient's real legal status. It was finally decided that he belonged + to the naval authorities, and he was accordingly returned to prison + and was given an additional sentence of a year for this fraud, which + he began to serve on December 13, 1909. While awaiting this new + sentence he assaulted a master-at-arms, who he claimed abused him, and + for this offense he received an additional five years' sentence. He + served this sentence until his first admission to this hospital on + July 16, 1913, on the following medical certificate: First symptoms + became manifest in 1910. The patient manifested fixed delusions of + having murdered a girl on August 7, 1909. Present symptoms: Fixed + delusions of a self-accusatory nature, delusions of persecution; + accused a medical officer whom he had never seen before as being among + those who were hounding him. Becomes excited, violent, profane, + incoherent and obscene in speech, and attempted to assault the + officer. He attempted suicide on February 15, 1910, while at Concord, + N.H., State Prison. + + During the patient's first sojourn at this hospital he conducted + himself in an orderly manner, and, aside from the expression of mild + persecutory ideas with reference to the prison personnel, he was free + from psychotic manifestations. On only one occasion was he involved in + some trouble while here, which was entirely his own fault. He was + discharged on September 23, 1913, diagnosis "Not insane, psychopathic + constitution," and returned to the U.S.S. _Southery_ Prison Ship. Upon + his return there it was noted that he was suffering from a double + benign, tertiary, malarial infection, which it was maintained he had + contracted in this hospital. + + He was readmitted here on March 15, 1914, on a medical certificate + which stated that the patient said he snuffed cocaine prior to + admission to the navy; that the murder he believes he committed was + due, according to his statement, to the refusal of the victim to + permit sexual intercourse. The patient has at present the same fixed + delusion of having committed this murder in 1909. He wants to expiate + his crime to escape those who are continually hounding him. When + irritated he flies into a rage, cries, tries to do himself injury, and + talks incoherently. For no cause, while working in the yard, he struck + a fellow prisoner and pursued him with a shovel. During maniacal + attacks he can be restrained only with much difficulty, smashes + furniture in his cell, and is slovenly in habits. Complains constantly + of numbness and needle-like pains in vertex. As a probable cause, + prison routine was given. It will thus be seen that the same fraud + about the murder, which served at one time to bring him an additional + sentence of a year, was considered at another time one of the symptoms + which justified his return to this hospital. The patient's version of + the reason for his return is as follows: Soon after his transfer to + Portsmouth the guards began to annoy him, calling him crazy guy, hard + guy, etc. He also got into trouble with the sergeant because the + latter cursed him, began to express the same ideas about the murder, + and thought this was the reason they sent him back. + + The mental examination and physicians' notes made during his second + admission showed no gross psychotic symptoms. The patient still + maintained that he actually committed this crime in Rochester, and + related it in great detail. He stated that when he was confined in + Portsmouth Prison he became remorseful over this crime and decided to + confess. His conduct during his second sojourn here was exemplary. He + appeared at conference on April 20, 1914, and a diagnosis of + psychopathic character was made. The opinion was expressed that it was + extremely difficult to pick out the truth from the abnormal elements + in the patient's story, and that there were a great many things in the + general emotional reaction of the patient that fitted into the story. + It was believed that the patient had a sort of determination to get + into difficulties for the sake of posing as a martyr and all that fits + in with the grandiose element of his character. Being oppressed, he is + taking it in a way that is very satisfying to his feelings of + importance. Later during his sojourn here the patient became rather + anxious to be returned to the penitentiary, stating that he had given + up all the ideas which he had expressed on admission, and assured the + physician that he was malingering on both occasions of his transfer to + the hospital. He stated that his chief anxiety which led him to + malinger was that he might be given additional sentences for his + inability to get along in the penitentiary, and he thought the only + way to avoid this would be to be pronounced insane. Patient was + discharged from here to be returned to the penitentiary on July 9, + 1914. + + The patient was readmitted to this hospital on November 13, 1914, on a + medical certificate which states: Diagnosis--Constitutional + psychopathic state, not in line of duty, existed prior to enlistment. + He was in the Government Hospital for the Insane in Washington for + about four months this year. His condition is not improving. A sudden + outburst occurred two days ago and he has been under close confinement + since. He struck a recruit and after confinement in a cell destroyed a + chair and had to be restrained. His retention in the prison in these + barracks is not deemed desirable. + + Nothing essentially new has developed in the case during this + admission. The patient has from the first been quiet, well behaved, a + willing worker in our industrial department, and free from signs of + mental disorder. Of course, he again blamed the guards at the prison + for the trouble which he became involved in and which necessitated his + third admission to this hospital. A letter received from the naval + medical officer stationed at the marine barracks, Norfolk, Va., the + place of the patient's last confinement, was to the effect that while + under observation there the patient made the impression of being a + good worker, and normal in every way, except that he had a quick + temper, and that the only difficulty they had noted was on the + occasion when he assaulted the man at the prison, who appeared against + him at the mast, and that after this scene he was put in the brig, + where he threatened to kill any ---- ---- man who came near him. The + medical officer was impressed with the fact that the patient was + feigning insanity. + + The patient's version of the circumstances which led to this last + admission is as follows: He was reported to the commanding officer by + a guard for some alleged minor infraction of discipline, of which he + claims not to have been guilty. After the guard was through making + his report the patient asked the commanding officer whether this + alleged offense would prevent his release in July of this year, as he + had been promised if he conducted himself well. The officer replied + that it certainly would, upon hearing which he could not restrain + himself, became quite overwhelmed with anger, and struck the guard who + reported him. His behavior which necessitated his readmission took + place following this episode. The patient dwells upon the fact that + prior to this episode he behaved in an excellent manner under the + prison regime for about four months, and that during his sojourn there + he was practically a model prisoner, which was true. + + He certainly has manifested no signs of mental disorder during his + present admission, and still insists that he malingered all of the + symptoms which led to his former two admissions because he feared more + punishment at the hands of the naval authorities unless he was + considered insane. + + _Anamnesis._--The patient comes from a family of farmers in mediocre + circumstances. Grandparents are in Bohemia, and he knows nothing + concerning them. Father died of Bright's disease; was alcoholic. + Otherwise family history negative. + + Patient is uncertain about the time and place of birth, but believes + he is about thirty years of age at present. He entered school at seven + or eight, but proved to be a confirmed truant, and his father finally + had to take him out of school entirely. He was in the habit of running + away from home and school, to wander about the country, where he would + stop at different farm houses, claiming he was an orphan and without a + home, until his father would discover him and bring him back home. + After giving up school definitely he worked as a farm hand, earning + the ordinary wages paid for this labor. He changed places frequently, + was a spendthrift, and assisted his parents financially very little. + This mode of existence he led until 1904, when he forged his father's + name to a $25 check and received a five-year term of imprisonment, + part of which he spent in the Minnesota State Reformatory and part at + the State Penitentiary. In the fall of 1907 he was paroled, but broke + his parole by enlisting in the army, under the name of Kimlicka, at + Fort Snelling, Minn. About a month later the fraud was discovered + through his father. He was given a dishonorable discharge and sent + back to the penitentiary, where he remained about six months. At the + end of this time (December, 1907) he was granted another parole, and + went to work for a man named George Hall, on a farm in Minnesota. He + was there nearly two months, when he cut his foot while chopping wood. + He says that after this accident he was not able to do much work, and + his employer did not seem to like to have him hanging around, so he + went back to prison, which he says paroled prisoners were supposed to + do when they lost their jobs. As his time was up in two months, the + prison authorities made no effort to get him a new job, but kept him + there until his sentence expired. He left the penitentiary in March, + 1908, and went home for a couple of weeks. He then went to Minneapolis + and enlisted in the navy under the name of James Hall, but did not + tell the recruiting officer about his prison or army experiences. + About four months after he enlisted he was caught with another sailor + in civilian's clothes in Newport, R.I. This was against the navy + regulations. Patient says he did this because they did not allow him + in dance halls, theaters, etc., in sailor's clothes. He used to keep + his civilian's clothes in the Y. M. C. A. building in town, and would + change there. He received a dishonorable discharge for this escapade. + He says he had one court-martial before that, in July, 1908. He then + went to Providence, R.I., and enlisted in the army under the name of + Herman Hanson. In Fort Andrews, Boston Harbor, patient was caught in + civilian's clothes again, and got into a brawl with a sergeant. + Patient says the sergeant was drunk and provoked the quarrel. As a + result the patient was put in the guard-house, receiving a sentence of + six months and dishonorable discharge. Two months of this sentence he + served at Fort Andrews, and the rest at Governor's Island. After being + discharged, he hung around New York City for a week, and then went to + Rochester, N.Y. This was in May, 1909. Here he worked on a farm for + Mrs. McCale, and the following month, June, 1909, he enlisted in the + Marine Corps under the name of Vilt. He was sent to the Brooklyn Navy + Yard, but after a week's sojourn there he got into trouble on account + of not having his rifle cleaned. He feared that he would be reported + for this and his previous frauds might be discovered, and he decided + to desert. He returned to Rochester, worked for Frank Little and Roy + Fritz. Soon after he enlisted in the army, this time under the name of + James Hall, but was rejected on account of some nasal defect. This was + at Columbus Barracks. After being rejected in the army he enlisted in + the navy and was sent to Norfolk, Va. He was here likewise rejected on + account of this defect, and while awaiting his discharge papers it was + discovered that he had fraudulently enlisted. He was court-martialed + and given a year. This was on November 20, 1909. His career following + this has already been outlined. + +If one takes into consideration the entire life history of this +individual he will have little cause for surprise at the resort to +malingering by this man when he found himself under an especially +stressful situation. That he malingered every frank psychotic symptom +which he manifested is beyond doubt a fact, even though he would not +have admitted so much himself. But one would commit a serious error if +on this account he would consider the man normal mentally. From +childhood on this man has manifested traits of character which are +absolutely psychopathic in nature. Among these may be especially +emphasized the confirmed truancy and running away from home, the +aimless, constantly-changing industrial career, the inability to pursue +any line of endeavor towards a definite goal, the early criminalistic +tendencies, the repeated commission of military offenses in spite of the +frequent punishments, and, lastly, his total inability to adjust himself +to the prison regime, resulting in serious mental upsets which +necessitated his admission to a hospital for the insane on three +different occasions. It is perfectly natural that he should resort to +malingering of mental disease in his last attempt at evading a stressful +situation. Malingering is frequently the only means of escape for such +as he, unable as they are to meet life's problems squarely in the face. + +It is of no particular value to add more cases illustrative of the type +of mental make-up which leads to malingering, especially since there +exists a more or less complete unanimity of opinion on the subject among +present-day psychiatrists. + + +CONCLUSIONS + +The conclusions which may safely be drawn from the study of malingering +as it is manifested in criminal departments of hospitals for the insane +are as follows:-- + +1. The detection of malingering in a given case by no means excludes the +presence of actual mental disease. The two phenomena are not only not +mutually exclusive, but are frequently concomitant manifestations in the +same individual. + +2. Malingering is a form of mental reaction manifested for the purpose +of evading a particularly stressful situation in life, and is resorted +to chiefly, if not exclusively, by the mentally abnormal, such as +psychopaths, hysterics, and the frankly insane. + +3. Malingering and allied traits, viz., lying and deceit, are not always +consciously motivated modes of behavior, but are not infrequently +determined by motives operative in the subconscious mental life, and +accordingly affect to a marked extent the individual's responsibility +for such behavior. + +4. The differentiation of the malingered symptoms from the genuine ones +is, as a rule, extremely difficult, and great caution is to be exercised +in pronouncing a given individual a malingerer. + + +REFERENCES + +[1] BRILL, A. A.: "Artificial Dreams and Lying," _Journal of Abnormal +Psychology_, vol. ix, No. 5. + +[2] DELBRUeCK, ANTON: "Die Pathologische Luege," Enke, Stuttgart, 1891. + +[3] FERRARI, L.: "Minorenni Delinquenti," Milano, 1895. + +[4] PENTA, PASQUALE: "La Simulazione della Pazzia," Napoli, Francesco +Perrella, 1905. + +[5] WILMANNS: "Ueber Gefangnispsychosen," Halle, S. 1908. + +[6] BONHOEFFER: "Degenerationspsychosen," Halle, S. 1907. + +[7] KNECHT: Quoted by Penta. + +[8] VINGTRINIER: "Des Alienes dans les Prisons," _Annales d'hygiene et +de med.-legale_, 1852-53. + +[9] JONES: Introduction to "Papers on Psycho-analysis." + +[10] PELMAN: "Beitrag zur Lehre von der Simulation," Irrefreund, 1874, +and _Arch. de Neurolog._, 1890. + +[11] BIRNBAUM, K.: "Zur Frage der psychogenen Krankheitsformen," +_Zeitsch. f. d. ges. Neur. u. Psych._, 1910. + +[12] SIEMENS: "Zur Frage der Simulation von Seelenstoerung," _Arch. +f. Psych. und Nerv._, xiv, 1883. + +[13] MELBRUCH: Quoted by Penta. + +[14] GLUECK, BERNARD: "Catamnestic Study of Juvenile Offender," _Journal +of Am. Inst. Crim. Law and Crimin._, viii, No. 2. + + + + +CHAPTER V + +THE ANALYSIS OF A CASE OF KLEPTOMANIA + + +_Introduction._--The past two years have been very profitable ones for +the science of criminology, as they have brought to light two books on +the subject which concretely reflect, on the one hand, the dying out of +the old statistical method of studying the criminal, a method which will +never tell the whole story, and on the other hand, the birth of a new +kind of approach to the study of the criminal, namely--the +characterological approach. The study of crime or antisocial human +behavior from this newer standpoint at once becomes a study of +character, and demands a scientific consideration of the motives and +driving forces of human conduct, and since conduct is the resultant of +mental life, mental factors at once become for us the most important +phase of our study. Both of these books represent epoch-making +culminations of years of hard labor and scientific devotion to +criminology by two eminent students--Drs. Goring[1] and Healy.[2] + +Dr. Goring's book, "The English Convict, a Statistical Study", appeared +in 1913, and is the result of an intense statistical study of 4000 +English male convicts, to which the author devoted about twelve years of +his life. Dr. Healy's book, "The Individual Delinquent", which appeared +in the early part of this year, reflects the results of thoroughgoing +scientific studies of about 1000 repeated offenders, during the author's +five years' experience as Director of the Juvenile Psychopathic +Institute in connection with the Juvenile Court of Chicago. Numerous +reviews of these two books have appeared in medical and criminologic +literature, and we shall only touch very minutely upon the difference in +the methods of approach to the subject of these two authors as they +concern the subject under consideration in this paper. I can do this no +better than by quoting from a critical review of Goring's book by Dr. +White,[3] as it happily touches upon our very subject--namely, stealing. +"Take the more limited concept of 'thief', for example. One man may +steal under the influence of the prodromal stage of paresis who has been +previously of high moral character. Another man may steal under the +excitement of a hypomanic attack; another may steal as the result of +moral delinquency; another as the result of high grade mental defect; +another under the influence of alcoholic intoxication, and so forth, and +so on, and how by any possibility a grouping of these men together can +give us any light upon the general concept of 'thief' is beyond my power +to comprehend." + +When one remembers that the 4000 units with which this really marvelous +statistical machinery has worked for twelve long years had nothing more +in common than the fact that they were English male convicts--the force +of White's argument becomes quite apparent. I need not state that this +view of Goring's work is not intended to detract one iota from the full +measure of credit which this author deserves. His work will stand +forever as one of the monumental accomplishments of the twentieth +century. + +Our views concerning Healy's contribution to the science of criminology +will be reflected in the course of this chapter, which will indicate, I +trust, in a way, his mode of approach to the problem, though he may not +agree with me concerning the details of my interpretation of the case I +am about to report. + +_Definition._--Like many another I dislike the term "kleptomania" and +would much prefer the term "pathological stealing" to denote the +condition under consideration. Pathological stealing is not synonymous +with excessive stealing as one would gather from the sensational use of +the term in the lay press. Neither is Kraepelin's dictum that +Kleptomania is a form of impulsive insanity, necessarily correct. It is +obviously, however, a form of abnormally conditioned conduct. Healy's +criterion of Pathological stealing is the fact that the misconduct is +disproportionate to any discernible end in view. In spite of risk, the +stealing is indulged in, as it were, for its own sake, and not because +the objects in themselves are needed or intrinsically desired. This +definition at once excludes all cases of stealing from cupidity, or from +development of a habit. It furthermore excludes stealing arising from +fetichism, pronounced feeblemindedness and mental disease, such as is +for instance illustrated in the automatic stealing of the epileptic. + +According to Healy, the vast majority of all instances of pathological +stealing are those in which individuals, not determinably insane, give +way to an abnormally conditioned impulse to steal. + +_The Psychoanalytic Study of Anti-Social Behavior._--In introducing the +term "Psychoanalysis" into this chapter I am fully conscious of the task +I have set before me, of writing clearly and convincingly in a work of +this nature on that vast and highly important subject which one at once +links with this term. To strip it of its highly technical +considerations, psychoanalysis is primarily and essentially a study of +motives, intended to bring about a better understanding of human +conduct. We shall leave out from consideration the very intricate +technique which this method of approach to the study of human behavior +employs except to indicate the chief source upon which it relies for its +information, namely, the individual's unconscious, that is, that part of +the individual's personality which is outside of the realm of his +moment-consciousness, and which is inaccessible either to himself or to +the observer except through special methods of investigation. It would +be highly desirable, indeed one would say almost imperative, to give a +full discussion of the "unconscious" before a proper and sympathetic +understanding of what is to follow can be made possible. This, however, +is obviously out of the question in a limited chapter like this. Volumes +have been written on the subject. I will only ask my readers to agree +with me for the sake of gaining proper orientation with reference to the +subject under discussion, in the conclusion which I quote from a +masterly paper on the "unconscious" by White.[4] "We come thus to +the important conclusion that mental life, the mind, is not equivalent +and co-equal with consciousness. That, as a matter of fact, the +motivating causes of conduct often lie outside of consciousness, and, as +we shall see, that consciousness is not the greater but only the lesser +expression of the psyche. Consciousness only includes that of which we +are aware, while outside of this somewhat restricted region there lies a +much wider area in which lie the deeper motives for conduct and which +not only operate to control conduct, but also dictates what may and what +may not become conscious." The foundation upon which the method evolved +by the psychoanalytic school rests has been aptly summed up by Healy, +namely, that for the explanation of all human behavior tendencies we +must seek the mental and environmental experiences of early life. One of +the chief aids in gaining that knowledge we have in the study of the +dream and symbolic life of the individual. The reasons given for our +necessarily limited discussion of the unconscious, are likewise true of +the dream and symbolism. Both of these subjects would require for a +proper elucidation considerably more space than this chapter affords. + +Through the dream the unconscious betrays itself;--the dream represents +the fulfillment of wishes and cravings which because of psychic and +social censorship have become repressed into the unconscious. During +sleep these barriers are in abeyance, and the unconscious psyche is +given the opportunity for full play, albeit in a disguised and highly +symbolic form. The proper interpretation of dreams presupposes a +knowledge of the nature of symbolism in the life of man. + +When we come now to a consideration of the facts brought to light +through the psychoanalytic study of man we are confronted with a still +greater difficulty of presentation. There is so much that is of vital +importance in this new psychology that we hardly know where to begin. As +I am addressing those who are primarily interested for the moment in +criminology, I may do well to begin with the subject of psychic +determinism. In contrast to the common sentiment of all people in favor +of free will in mental processes, the facts elicited by psychoanalysis +point to a strict determinism of every psychic process. Psychoanalytic +investigations have shown that in mental phenomena there is nothing +little, nothing arbitrary, nothing accidental. In his book on the +Psychopathology of Everyday Life, Freud[5] has thrown very convincing +light on this subject. Certain apparently insignificant mistakes, such +as forgetting, errors of speech, writing and action, etc., are regularly +motivated and determined by motives unknown to consciousness. The reason +that the motives for such unintentional acts are hidden in the +unconscious and can only be revealed by psychoanalysis is to be sought +in the fact that these phenomena go back to motives of which +consciousness will know nothing, hence were crowded into the +unconscious, without, however, having been deprived of every possibility +of expressing themselves. Thus we see that no mental phenomenon, and by +the same token no part of human behavior, happens fortuitously, but has +its specific motive, to a very large extent, in the unconscious. + +The question may suggest itself here "why this extensive participation +of the unconscious in mental life", which brings us to a discussion of +the principles of resistance and repression. + +In speaking of the "unconscious" I purposely left out from consideration +the way in which the sum total of its content was separated from the +conscious mental life of the individual, in order to bring it in +alignment with the discussion of the principles of resistance and +repression. The content of the unconscious, broadly speaking, is brought +about through the activity of these two principles. If one endeavors to +unearth by means of psychoanalysis the pathogenic unconscious mental +impulses, or if one endeavors to bring to consciousness some instinctive +biologic craving which may be responsible for the individual's conscious +behavior, one regularly encounters a very strong resistance on the part +of the patient, a force is regularly betrayed whose object it seems to +be to prevent them from becoming conscious and to compel them to remain +in the unconscious. This is Freud's conception of the principle of +resistance and from its constant coming to the fore whenever an endeavor +is made to penetrate into the unconscious, Freud deducts that the +same forces which today oppose as resistance the becoming conscious of +the unconscious purposely forgotten, must at one time have accomplished +this forgetting and forced the offending pathogenic experience out of +consciousness. This mechanism he terms repression. We spoke of an +offending pathogenic experience, or in other words what has been termed +a psychic trauma. But the same principle holds true of certain instincts +which because of their peculiar nature become engaged in a kind of +struggle for existence with the ethical, moral and esthetic attributes +of the personality and are thrust out of the conscious mental structure +as one might say by an act of the will. + +We are especially concerned here with these inacceptable instincts, for +the elucidation of which a brief review of Freud's theories on sexual +instinct is essential. + +Thoroughgoing and painstaking dissection of the human soul, such as has +been practiced by Freud for nearly a quarter of a century and by many +followers of his theories in the past decade, revealed to him a number +of unmistakable facts from the developmental history of the individual +which forced him to postulate his very radical and revolutionary +theories of the sexual instinct in man. Recent behavior studies in the +higher anthropoids have likewise revealed very interesting facts +concerning the sexual instinct of these animals. Freud was led to make +certain assertions from his painfully acquired experience, such as the +unfailing sexual agency in the causation of neurotic manifestations, and +that his experience of many years has as yet shown no exception to this +rule, which quite naturally provoked a good deal of bitter and fanatic +criticism not only from lay people but from experienced physicians. The +cause for this lies in the nature of the thing itself, that much tabooed +subject of sexuality. Unfortunately, as Hitschmann[6] says, physicians +in their personal relations to the sexual life have not been given any +preference over the rest of the children of men and many of them stand +under the ban of that combination of prudery and lust which governs the +attitude of most cultivated people in sexual matters. Especially +unsavory appears to most people Freud's theory of infantile sexuality, a +subject which has heretofore been looked upon chiefly from a moralistic +standpoint, and was spoken of by others merely as odd or as a frightful +example of precocious depravity. It is somewhat strange that of all the +frightful depravities, if we wish to call it so--inherent in man, of the +marked criminalistic components universally present in man which +psychoanalytic studies have revealed--the sex depravity should have +provoked the most fanatic attacks. Indeed to those who are accustomed to +look at man with the psychoanalytic eye, Rochefoucauld's incisive +statement does not at all sound strange. He said, "I have never seen the +soul of a bad man; but I had a glimpse at the soul of a good man; I was +shocked." I therefore crave the indulgence of those of you who are not +familiar with psychoanalytic literature for what I am about to quote +briefly from Freud's theories on the sexual instinct in man. + +Freud lays special stress upon infantile sexuality as it is manifested +in the suckling and in the child. The infant brings with it into the +world the germ of sexuality, which is, however, extremely difficult of +comprehension since at this stage the sexual feelings are not directed +towards other persons but are gratified on the child's own body in a +manner which Havelock Ellis has termed "autoerotic." This autoerotic +gratification is gained through erogenous zones, that is, certain areas +of the body which are peculiarly sensitized to sexual excitations. Among +these erogenous zones may be mentioned the mouth, lips, tongue, anal +region, the neck of the bladder as well as various skin areas and sense +organs. Already in 1879, Lindner, a Hungarian pediatrist, devoted a +penetrating study to the sucking or pleasure-sucking of the child. Freud +emphasizes that the suckling enjoys sexual pleasure, in the taking of +nourishment, which it ever after seeks to procure by sucking independent +of taking food. To many it may occasion surprise to learn that sucking +is exhibited independently of its relation to the hunger instinct. It +is, however, plain that the mouth is at first concerned only with the +gratifying of the hunger instinct; later the desire for a repetition of +pleasurable experience gained in this way is separated from the need of +taking nourishment, thereby transforming this mucous surface into an +erogenous zone. It is likewise difficult to conceive by the +inexperienced in psychoanalysis, that the child derives pleasurable +sensations from the anal zone. Because of the important role which anal +eroticism plays in our case we might speak more fully of this form of +autoeroticism. One not infrequently observes in little children that +they refuse to empty the bowels when they are placed on the closet +because they obtain pleasure from defecation, when the retained stool by +its accumulation excites strong irritation of the mucosa. The importance +which scatological rites and ceremonials, that is, certain peculiar +niceties practiced in connection with the emptying of the bowels, play +in the evolution of the race have been extensively discussed in +literature. Havelock Ellis[7] says in this connection--"The most usual +erotic symbolisms in childhood are those of the scatologic group, the +significance of which has often been emphasized by Freud and his school. +The channels of urination and defecation are so close to the sexual +centers that the intimate connection between the two groups is easily +understood. There is undoubtedly a connection between nocturnal enuresis +and sexual activities, sometimes masturbation. Children not infrequently +believe that the sexual acts of their elders have some connection with +urination and defecation, and the mystery with which the excretory acts +are surrounded, helps to support this theory. Up to puberty scatologic +interests may be regarded as normal; at this age the child has still +much in common with the primitive mind, which, as mythology and folklore +show, attributes great importance to the excretory functions." + +Many of these ceremonials one regularly discovers in the analyses of +neurotics. We shall not dwell further here upon the erogenous zones +activity in the suckling, but emphasizing again its importance along +with the importance of autoeroticism in the sexuality of the suckling +will pass to the next phase of the psycho-sexual evolution of man--the +latent period. + +The germs of sexual excitement in the new-born develop for a time, then +undergo a progressive suppression in a period of partial or complete +sexual latency. During this period, which is normally interrupted at +about the third or fourth year, as result of organic evolutionary +processes and the indispensable help of education, those mental forces +are formed which appear later as inhibitions to the sexual instinct and +narrow its course like dams; mental forces such as disgust, the feeling +of shame, the esthetic and moral standards of ideas. During this "latent +period" a part of these sexual energies is separated from the sexual aim +and applied to cultural and social ends, a process which Freud has +designated by the name sublimation as important for culture, history and +the individual. + +Sublimation or the socialization of the sexuality therefore is the +transformation and utilization of certain components of the sexual +instinct for aims no longer sexual in nature. At the end of the latency +period the child's sexuality reappears, frequently but not necessarily +induced prematurely by seduction. In addition to the autoerotic +gratifications spoken of above, the child is now capable of the choice +of a love-object accompanied by erotic feelings. Because of the +dependency of the child this first choice of a love-object is directed +towards parents and nurses either of his own or of the opposite sex. +"Incest complex"--Now too the child under the influence of occasional +seduction may become polymorphous-perverse, that is, may become subject +to any form of sexual perversion. He likewise shows a preference in the +selection of his love-object for his own sex, homo-sexuality. + +At puberty two significant changes take place in the psycho-sexuality of +the individual. First the primacy of the genital zone asserts itself, +and second, the heretofore autoerotic character of the sexual activity +is lost and the instinct finds its object. In order that the former +change may be successfully brought about, there is necessitated an +amalgamation of all instinctive tendencies which proceed from the +erogenous zones and a subordination of all the erogenous zones to the +primacy of the genital zone. All this is facilitated by the development +of the genital organs and the elaboration of the seminal secretion. To +these conditions there is also added at puberty that "pleasure of +gratification" of sexuality which ends the normal sexual act, the end +pleasure. The second function, the choice of a love-object, is +influenced by the infantile inclination of the child towards its parents +and nurses which is revived at puberty and similarly directed by the +incest barriers against these persons which have been erected in the +meantime. If on account of pathological heredity and accidental +experiences, this amalgamation of the excitations springing from various +sources and its application to the sexual object does not occur, then +there result the pathological deviations of the sexual instinct, +determined in part by earlier processes, such as a preservation of a +definite part of the original polymorphous-perverse tendency. The +perversions are thus developed from seeds which are present in the +undifferentiated tendencies of the child and constitute in adults a +condition of arrested development. + +Thus we see that the sexual impulse does not suddenly emerge as a new +phenomenon at the age of puberty, but that the form assumed at this +period is gradually evolved from rudimentary elements present even in +the earliest years of life. Sexuality is not absent in the child, it is +merely different, being unorganized and imperfectly adapted to its later +functions. All this primordial mass of pleasurable activities enumerated +above, undergoes profound modifications as the result of growth and +education. One part only becomes selected and differentiated so as to +form the adult sexual impulse in the narrower sense. A greater part is +found to be incompatible with social observance, and is repressed, +buried, forgotten. The repressed impulses, however, do not die; it is +much harder to kill old desires than is sometimes thought, they continue +throughout life to strive toward gratification. This they cannot do +directly, and are thus driven to find indirect, symbolic modes of +expression. The energy is transformed into these secondary, more +permissible forms of activity, and furnishes a great part of the +strivings of mankind that lead to social and cultural interests and +development in general--sublimation. (Jones.) + +I don't know whether I have succeeded in putting clearly enough the +Freudian views of sexuality, limited as I have to be in my expositions +of his theories. I do wish, however, to leave the impression which one +must gain from two sentiments frequently expressed by various authors, +namely, "Man sexualizes the universe," and "Man is what his sex is." + +_Sexuality and Criminality._--A method of psychological analysis which +aside from its originally restricted field has already thrown so much +light upon various cultural aspects of life, such as art, poetry, +religion, folklore, and mythology, cannot fail to furnish some very +helpful discoveries for the problem of criminology. As far as +pathological stealing is concerned a number of very suggestive studies +have already appeared, a review of which Albrecht has prepared for the +Journal of the American Institute of Criminal Law and Criminology. The +fact that rich, or at least well-to-do, women are sometimes guilty of +theft in the big Department stores has always received a certain amount +of attention. Studies of this phenomenon have been made by Duboisson, +Contemps, Lasegue and Letulle. In each case examined the woman +declared that some unknown power had suddenly compelled her to touch +some object, and put it in her pocket. + +Stekel,[8] a Viennese psychotherapeutist, claims to have repeatedly +proved to himself by psychoanalysis that the root of all these cases of +kleptomania is ungratified sexual instinct. These women fight against +temptation. They are engaged in a constant struggle with their desires. +They would like to do what is forbidden, touch something that doesn't +belong to them. We cannot give here the analyses reported in the +literature, though I assure you that they carry convincing proof of the +tremendous role sexuality plays directly or indirectly in the causation +of pathological stealing. This is not confined only to thieving +connected with fetichism, numerous cases of which have been reported in +the literature. But even less radical Freudians than Stekel admit the +importance of sexuality in pathological stealing. Thus Healy, who is +eminently fit to speak authoritatively on the subject of recidivism, and +who is unusually conservative in his statements, has the following to +say:-- + +"The interpretation of the causes of this impulse to steal is of great +interest. We have shown in our chapter on mental conflicts how it may be +a sort of relief phenomenon for repressed elements in mental life. The +repression is found often to center about sex affairs." Again, "The +correlation of the stealing impulse to the menstrual or premenstrual +period in woman, leads us to much the same conclusion. Gudden, who seems +to have made the most careful studies of the connection between the two +phenomena, maintains that practically all cases of shoplifters whom he +has examined were, at the time of their offense, in or near their period +of menstruation." Healy does not go beyond this. He is as yet not ready +to agree that some sex difficulty is the only conflict back of +kleptomania. + +With these introductory remarks we will proceed to the discussion of our +case. X----, a colored boy aged 23, was admitted to the Government +Hospital for the Insane on January 16, 1915, from the District Jail, +where he was awaiting trial on two indictments for larceny. + +Anamnesis obtained from the patient, his relatives and official sources +is to the effect that the patient comes from an unusually refined +colored family, his father being a rather prominent colored minister in +this city. The patient is one of eight children, all of whom with the +exception of the patient have led a normal and fairly successful life. +He was born in Washington, D.C., April 17, 1892. Birth and early +childhood up to four years of age were normal. At that time he was +rather seriously bitten by a large St. Bernard dog, following which he +was ill for about two months. He was rather restive under this enforced +confinement and one day in attempting to escape from the house he fell +from a second story window. His relatives attribute all his difficulties +to these two accidents, for it was soon after that his stealing +tendencies became manifest. The patient himself can place only +approximately the onset of his stealing propensities, stating that he +was quite young and that his first theft consisted in stealing ten cents +from his father. It was in connection with this theft that he first +experienced the sensations to be described later. His school career was +irregular owing to the interruptions necessitated by his repeated +sojourns at the Reformatory. He entered school at the age of 7 and at 11 +was sent to the Reform School for the first time. This step was taken by +his father because the patient for some years previously had been +frequently placed under arrest on charges of larceny. He showed, +according to the statements of his relatives, a decided preference for +horses and vehicles of all sorts, which he would utilize for joy riding, +although he not infrequently stole objects of which he could make +absolutely no use. One time, for instance, he stole a dozen bricks from +a neighbor. The Chief Probation Officer of the District of Columbia, who +was an official of the Reformatory during the patient's sojourn there, +states in a letter to the hospital the following: "While there he (X) +gave very little trouble, except in the way of stealing. He would steal +any and every thing he could lay hold of. It mattered not whether the +article was of any use to him or not. After stealing an article or +articles he would make very little effort to hide it, and when taken to +task and charged with having stolen an article he would acknowledge it +but would say that he did not know what made him take the article, only +that something told him to take it and when this thought came to him he +did not have the power to resist it, but felt that he was compelled to +take it. At the Training School we looked upon him as a rather peculiar +subject. We really never considered him insane except that his desire to +steal might be classed in that line." + +It is somewhat difficult to get a coherent and full account of the +patient's delinquencies. His record at the National Training School is +as follows: "Rec. on September 4, 1906, sentenced by the D.C. Juvenile +Court charged with larceny, escaped August 30, 1907. Returned from +elopement September 5, 1907, special parole to father October 23, 1909. +Recommitted by D.C. Juvenile Court February 3, 1910, charge larceny. +May 2, 1911, escaped from Freedman's Hospital while left there for +treatment after operation. Returned on May 25, 1911, from Baltimore, Md. +July 13, 1912, escaped." During his various sojourns there he was noted +to be wilful and unprincipled. Every time he gained his freedom his +father attempted to keep him at school, thus he attended night school +and Law Department of Howard University for short periods. His father +likewise put forth many genuine efforts to reform the boy, plead with +him and begged him, supplied him with considerable spending money, but +his efforts were as fruitless as the various punishments he underwent. +The boy would behave well for a while, but sooner or later he would be +arrested for stealing. Patient states that he stole many times when he +successfully evaded the police, that he frequently took unusual chances +in his escapades, preferred to steal in the daytime and it was this that +led him to believe that God had chosen this particular mode of life for +him, and that as a result of this conviction he practices the habit of +giving one-fourth of his earnings to charity. He had learned from his +father that somewhere the Bible teaches to give one-fifth of the +earnings to charity, but owing to the manner in which he acquired his +possessions he felt that he ought to give more to charity, a rather +characteristic mode of rationalization for a man of his type. + +Aside from the arrests recorded above he has been arrested in the cities +of Baltimore, Philadelphia, and New York, always for stealing, and spent +about 19 months in the Pennsylvania Industrial Reform School. + +His latest arrest and subsequent admission to the Government Hospital +for the Insane was the result of an attempt at housebreaking on +August 1, 1914. He states that he entered this house with the full +intention of robbing it, that he found considerable jewelry and some $30 +in money which he collected on a dresser, when he suddenly began to +think of his mother, and the anxiety he would cause her should he be +caught in the act, whereupon he left everything on the dresser and left +the house. He was detected leaving the house, which brought about his +arrest. Patient states that such acts on his part were not unusual, that +he not infrequently left a robbery incomplete upon thinking of his +mother. + +On admission to this hospital the patient made a normal impression. He +gave a coherent and clear account of his past life, was apparently quite +frank and truthful and endeavored to cooeperate with the examiner to the +best of his ability. He was clearly oriented, free from frank delusions +and hallucinations, but said in explanation of his stealing habits that +it is the influence of God that makes him steal, because he has been so +successful at it, and because he has always given one-fourth of his +income from stealing to charity. (He rationalizes very efficiently in +this manner.) He likewise stated that frequently in the night before he +commits an offense he dreams of a man leading him and instructing him +what to do. He used to think that it was a representative of God whom he +saw in the dream, but since he has had the talk with Dr. H., who told +him that it was only the devil who tempts him to do these things, he has +changed his mind about it. Special intelligence tests revealed no +defect, and his stock of information was commensurate with his +educational advantages. He was well informed on current events and +readily adapted himself to his new surroundings. + +Physical examination showed him to be a fairly well developed colored +male, slight acneiform eruption over back, slight asymmetry of head, +ears close set to head, lobules attached, palate high arched. There was +likewise present a slight depression in right supra-clavicular region, +lung over this area slightly impaired. Heart sounds slightly roughened, +urine and Wassermann with blood serum negative. + +During his sojourn here his conduct has been exemplary. He worked +steadily in Howard Hall workroom and occupied his leisure time in +reading and playing musical instruments, two of which he knows how to +manipulate fairly well. It is significant that as far as known the +patient has not evidenced any tendency to steal since here, although +during the first few days of his sojourn here he experienced the +sensations which usually accompany his stealing escapades. A carefully +kept record of his dreams, in which matter the patient apparently +cooeperated to the best of his ability, likewise failed to reveal any of +the pre-stealing dreams mentioned above. + +_Analysis._--The suggestive points in the patient's history are the +repeated commission of a similar offense, namely, stealing, +notwithstanding the frequent punishment received, the stealing when he +actually had no necessity for it, being at times when he stole well +supplied with money, the stealing of objects for which he had no use and +which he could not convert into money, as stated in the Reform School +Records, the patient's belief in his destiny as a thief and the methods +he employed in atoning for his conduct, such as giving one-fourth to +charity, and lastly the peculiar physical and mental sensations which +accompanied the act of stealing. The inquiry was conducted along these +lines. In the first interview the patient could throw very little light +on his difficulties. He stated that he had tried repeatedly to quit +stealing, that he realized he was causing his parents a great deal of +anxiety on account of his habits, and bringing a good deal of trouble on +himself, that he genuinely regretted his past acts and that he believed +he could possibly abstain in the future from stealing. Later interviews +revealed, as has already been stated, that his first theft was committed +upon his father, when he stole ten cents, and it was upon this occasion +that he first experienced the peculiar bodily and mental sensations. He +describes these in his own words as follows, "I begin to feel giddy and +restless and feel as if I have to do something. This feeling becomes +gradually more marked until I feel compelled to enter a house and steal. +While stealing I become quite excited, involuntarily, begin to pant, +perspire and breathe rapidly as if I had run a race; this increases in +intensity and then I feel as if I have to go to the closet and empty my +bowels. After it's all over I feel exhausted and relieved." The feeling +of exhaustion and relief was in a later interview spontaneously +described by him as being like that one experiences after coitus. In +the early days of his career he used to go to the closet in response to +the anal sensations, but he never had to actually evacuate his bowels so +that of late he does not do this any more. At first he had those +sensations only when stealing from his father, later also when stealing +from his mother, and finally he would experience them whenever he stole. +It is of interest to note here his attitude towards his father. In the +early stages of the analysis he staunchly maintained that he loved +his father very much, that he honored him and felt very sorry for all +the troubles he was causing him, but further inquiry revealed positively +the fact that he showed a decided preference for his mother, that the +latter always took his part when he was punished by his father, that he +felt extremely angry at his father on a number of occasions in the past +because the latter punished him often, but it was only after the +analysis and proper insight on the part of the patient into the +following dream that he admitted that he had sometimes wished his father +dead. He dreamed on February 4th that his father had died, that he could +see his father in a coffin, and his mother, sister and brothers weeping. +"I awoke before I could finish the dream." The first attempts with the +patient at analyzing this dream produced quite an upset, a good deal of +emotionalism and tears, especially when it was suggested to him that the +dream might express a wish. In an interview on February 15th he said +that he no longer thought that the above suggestion was such an +impossibility, that perhaps there was a good deal of truth in it, +although he is certain that consciously he had never entertained such +ideas in reference to his father. There was no affective manifestation +in connection with this statement. + +Another dream which he had the night before the preceding dream is, to +my mind an extremely important one, reflecting as it does the patient's +real conflicts. He dreamed on February 3rd that two of his brothers came +over to visit him. They brought a young girl over that he used to keep +company with, and told him that if he would marry they could get him +out. He replied that he would never marry any girl, and one of his +brothers said, "Then you will never get out of this place." They then +quarreled, the brother insisting that he just had to marry, but he still +refused. The girl plead with him to marry her, saying that she would do +a good deal for him, but he still refused. In parting one of his +brothers said to him, "Then go to your ruin, we will never do anything +for you again." The patient then awoke perspiring and mad as if he had +actually been quarreling. Thus the dream reads "Marry and you'll get out +of here, otherwise go to your ruin, we will never do anything for you." +In other words, "Lead a heterosexual life and your troubles will be +over, continue as you are now, you'll go to ruin." This argument of the +unconscious taken together with the group of sensations which patient +always experienced when stealing, and which he spontaneously likens to +the sensations of a sexual act, and furthermore the quite evident anal +erotic fixation, already throw a good deal of light upon the patient's +difficulties. + +He further dreamed one night that his mother got him a situation with a +widowed man. His duties were to take care of and keep in good order the +man's three horses. One of these horses was a vicious one, the other two +were mild. If one were to think of the three horses as of a phallic +symbol the significance of this dream at once becomes apparent. The +patient associated the vicious horse which always tried to bite him +with his father. Here, too, it was the mother which comes to his aid. + +A number of other dreams recorded by the patient manifest simple wish +fulfillment and are of no especial interest. + +In his habits the patient was always of a jolly, sociable disposition, +enjoyed fun very much and for many years back he had a keen desire to +become a detective. In fact if he had any ambition in life at all it was +this. On many occasions in the past he played detective; he would track +people on many occasions for hours at a time. What is of marked +significance is the fact that on a number of occasions when he did this +he experienced similar bodily sensations as he did when stealing. The +detective sensations were never as intense as those accompanying +stealing and never reached the climax. It was only yesterday that the +patient told me spontaneously in the course of an interview that he +supposed he never reached the climax in his detective experiences +because he has never arrested anyone. Thus we see that along with his +antisocial sublimation of his anal eroticism, the patient attempted a +more useful sublimation. Unfortunately the one depended simply upon his +exertions and bravado, while the other required for its fulfillment +society's recognition of his desire and some ability for detective work. +I am firmly convinced that these two activities of the patient, namely, +stealing and detection of crime, are the results of his endeavor at +sublimating a totally inacceptable homosexual career. On one occasion, +and he claims that it is the only one in his life, a fellow prisoner in +the Reformatory attempted a sexual assault upon him. He retaliated by +striking the fellow on the head with a chair, for which he was severely +punished. While we may rely quite fully upon the information furnished +by the patient and upon that obtained from other sources for the purpose +of building up our theory of the case, it will not be amiss to take into +consideration those points in the patient's conduct while under +observation which further substantiate this theory. + +We have it from a reformatory official that while at that institution +the patient frequently stole articles which were of no value whatever to +him, that he did not attempt to conceal his thefts, and that when +upbraided for his conduct, he stated that he could not help it, etc. At +that institution he evidently entirely relied upon his stealing +sublimation for his sexual gratification. It may be that as yet he had +not become conscious of the possibilities of the detective play. + +In this hospital he had desires for stealing on two occasions, soon +after his admission, but resisted the temptation. Following the +manifestation of our active interest in his case, he became more and +more confident in his ability to withstand these temptations, and as far +as could be judged manifested a genuine desire to reform. Of course the +biologic sex difficulty is still present, its demands are probably just +as insistent as ever, and having rejected, for the present at least, the +possibility of expression through the stealing channel, he resorts to +the only other channel he knows of, detective play. In line with this he +handed me one morning (March 30, 1915) a note which stated that some +information had come into his possession which he thought would be of +very great value to me, and requested a private interview. After +cautioning me as to the method of procedure he assured me that he did +this piece of detective work solely because he felt very grateful for +our effort to help him out of his troubles. We must note the meticulous +manner in which he carried out the entire procedure. For some time past +he had been in the habit of handing me each morning a uniformly folded +sheet of paper containing the dreams of the previous night. On that +morning he had two of these folded sheets in his vest pocket but handed +me only the above mentioned note, because he says he feared that I would +read only the one containing the dream and miss the other. During the +interview which followed as result of the above note, he handed over to +me a bunch of petitions written by a famous litigant in the criminal +department, which were to have been delivered by the patient to his +relatives with the object of getting them to their final destination. +Aside from the fact that the author of these petitions is by no means a +simpleton, or very credulous, it must have taken a good deal of +ingenuity and skill on the part of the patient to gain this fellow's +confidence, knowing as I do that the latter has a special grudge against +the patient because they are the only two in the Howard Hall Department +who enjoy some special privileges in common, such as attending chapel +and amusements, etc. + +This compulsion of attending chapel, as he puts it, with a negro, has +been the litigant's chief grievance during the past two months, and he +has accordingly expressed himself in some very choice language when +speaking of the patient. Nevertheless the patient has succeeded in +gaining his full confidence, and the interest and pleasure which the +patient manifested in detailing to me his mode of procedure in +accomplishing this is really very striking. It was during this interview +that he stated, "I suppose the reason I never reached the climax when +playing detective is because I have never arrested anyone. This is the +work I would like to do, Doctor, I hope some day I'll be able to get a +job with some detective agency." + +I regret to have to omit many interesting details from the analysis of +this case. To me the analysis of this case has been a revelation. For a +number of years past I have been intensely interested in the problem of +recidivism, and although I have had many opportunities to study the +recidivist, and have seen a number of very interesting cases, the +histories of a few of whom I have reported several years ago, I have +always felt that I had never touched the real specific cause of a life +of recidivism in a given individual. Why a man, an apparently +intelligent man, and many of them are far from suffering from a purely +intellectual defect, should choose a career of crime and in spite of +repeated penalties should keep on recurring to it, has always been an +unsolved mystery to me. I have been especially perplexed about those +cases which repeatedly committed the same crime, and although in some +instances an apparently plausible explanation was found in an existing +psychosis, or strong psychopathic make-up, these explanations were in +many instances unsatisfactory. + +Let us see what the repeated commission of theft means to the individual +whose history we have just reported. We have seen that his own +explanation of that series of physical and mental phenomena which always +accompanied the act of stealing were not only very much akin to the +physical and mental state which accompanies the act of sexual congress, +but were actually recognized as such by the man himself. In other words +the motive and instinctive prompting which led this man to the act of +stealing were the same which lead normal men to the act of sexual +congress. It would be inconceivable without further explanation why this +colored boy should repeatedly resort to stealing as a means of sexual +gratification in spite of the trials and tribulations which this carried +with it, when he had all the opportunities to gratify this desire in a +natural heterosexual manner, as others of his race have no difficulty at +all in doing. + +The answer lies in the type of sexual gratification which his stealing +supplied. We have mentioned the anal sensations, the feeling as though +there was something in the rectum of which he had to rid himself, and +which for years led him to run to the toilet soon after the commission +of a theft. To one versed in the psychology and manifestations of the +sex instinct this can only mean one thing, namely, that we are dealing +here with a homosexual whose erotic receptors were concentrated in the +anal region, with an anal-erotic. + +The possibility of a full, happy, satisfied existence for this +individual lies in the gratification of this biologic, instinctive, and +perverse sex-craving. It is the intense revulsion, the protest of his +whole personality against such mode of sex-expression which brought +about the habitual stealing in this individual. So soon as he discovered +that the emotional accompaniment of the act of stealing served to +gratify this biologic sex-craving he clung to it with the tenacity which +characterized his life of recidivism. In other words, the process of +sublimation of which we spoke took an asocial turn in this individual, +with the resultant pathological stealing. + +It would lead us far beyond the scope of this chapter to discuss the +problem of the genesis of homo-sexuality, and we shall not attempt it. + +The impression which I desire to make is that in this case of +pathological stealing we are dealing with a form of asocial behavior +which has its roots in a mighty instinctive, biologic craving, which +demands gratification at any cost. + +Furthermore, because of the nature of this etiologic factor the chances +for reformation are very poor, which prognosis has already been +justified by the subsequent career of this patient. He is at present +again under arrest for grand larceny and housebreaking. + +It would be premature to draw any general conclusions from this study, +or to promulgate any general principles of treatment. All that the +chapter is intended for is to stimulate further interest in +criminologists for research along these lines. + + +REFERENCES + +[1] GORING. C.: "The English Convict." His Majesty's Stationery +Office, London, 1913. pp. 440. + +[2] HEALY, W.: "The Individual Delinquent." Little, Brown, & Company, +Boston, 1915. + +[3] WHITE, W.: "The English Convict." A review in _Journal of Am. Ins. +Crim. Law and Criminology_, vol. v. + +[4] WHITE, W.: "The Unconscious." _The Psychoanalytic Review_, vol. II, +No. 1. + +[5] FREUD, W.: "Psychopathology of Everyday Life." English Translation +by BRILL. The Macmillan Co., 1914. + +[6] HITSCHMANN, E.: "Freud's Theories of the Neuroses." English +translation by C. R. PAYNE. Nervous and Mental Dis. Monograph Series, +No. 17, 1913. + +[7] ELLIS, H.: "Sexual Problems." Modern Treatment of Nervous and Mental +Diseases. Edited by White and Jelliffe, Lea and Febiger. Philadelphia +and New York, 1913. + +[8] STEKEL, W.: "The Sexual Root of Kleptomania." _Zeitschrift f. +Sexualwissenschaft._ George H. Wigand, Leipzig. English Abstract by +ALBRECHT, in _Journ. Am. Inst. Crim. Law and Criminology_, vol. 2, +p. 239. + + + + +GENERAL INDEX + + Accidental criminal, acute prison psychosis in, 71 + + Albrecht, 252 + + Amnesia, circumscribed, 16, 22 + + Amnesia for stupor, 8 + + Anal zone, significance of, 248 + + Anomalous personality, 92 + + Anti-social behavior, psychoanalytic study of, 241 + + Auto-erotic, 247 + + + Ball, 189 + + Behavior, technique of studying, 242 + + Birnbaum, 9, 45, 75, 226 + + Bischoff, 137 + + Bleuler, 1 + + Bonhoeffer, 8, 40, 74, 188 + + Borderline mental cases, 228 + + Bornstein, 227 + + Bratz, 39 + + Brill, 161 + + + Cases + of acute prison psychosis, 9 + simulating an hysterical psychosis, 16 + of catatonia in a degenerate, 24 + illustrating psychoses of degeneracy, 51, 76 + illustrating prison psychosis in habitual criminals, 82, 93, 101, 107 + illustrating the role of alcoholism in the habitual criminal, 111 + of a mentally defective habitual criminal, 120 + of litigious paranoia, 139, 146 + illustrating pathological lying, 164, 176 + illustrating "omnipotence of thought", 192 + illustrating malingering in the insane, 199, 203 + illustrating malingering at one time and psychosis at another, 211 + illustrating malingering in a psychopath, 230 + of kleptomania, 253 + + Catatonia of degenerates, 72 + + Characterological anomalies in degenerates, 116 + + Consciousness, definition of, 242 + + + Deception as a defense, 186 + + Degeneracy, psychosis of, 34 + + Degenerative psychoses, classification of, 36 + character of individual's developing, 36 + clouding of consciousness in, 46 + dementia-like processes in, 37, 41 + egotism in, 35 + epileptic seizures in, 39 + hypochondriasis in, 36 + hysterical elements in, 43 + migraine in, 36 + physical findings in, 36 + self-love in, 35 + recovery in, 8 + + Delbrueck, 163 + + Dementia praecox in prisoners, 70 + + Determinism, psychic, 161, 243 + + + Ellis, Havelock, 248 + + Emotional shock as etiologic factor, 22, 31 + + Environment as etiologic factor, 23 + + Epileptic temperament, 44 + + Erogenous zone, 247 + + Erotic receptors, 265 + + + Ferrari, 187 + + Forel, 1 + + Freud, 190, 191, 196, 244, 245, 246, 248 + + + Ganser's symptom complex, 72 + + Ganser's twilight state and catatonia, 7 + + Gault, 117 + + Goring, 239 + + Grandiose compensation in insane prisoners, 195 + + Gudden, 254 + + + Habitual criminal, characteristics of, 79 + hypochondriasis in, 79 + suicidal attempts in, 80 + projection mechanism in, 90 + + Healy, 121, 239, 241, 252 + + Heredity, tainted, 22 + + Hitschmann, 246 + + Homosexuality, 249 + + Hopkins, Archibald, 117 + + Hysterical psychosis, 220 + stupor, 72 + + + Incest complex, 249 + + Incorrigible criminal, proposed treatment of, 117 + + "Insanity dodge", 73, 185 + + Insanity, legal concept of, 133 + + + Juvenile offender, 122 + + + Kleptomania, case of, 253 + dream interpretation in, 259, 260 + Healy's definition of, 241 + and sexual instinct, 252 + + Knecht, 188 + + Kraepelin, 2, 92, 123 + + Kutner, 8 + + + Lasegue, 252 + + Letulle, 247 + + Lindner, 252 + + Lombroso, 187 + + Lying, mechanism of, 160 + unconscious motives in, 159 + + + Magnan, 35, 69 + + Malingering, classification of, 197 + frequency of, 74 + mechanism of, 160 + in the insane, 198, 199 + psychology of, 192 + in psychopaths, 203 + reasons for, 175, 183, 186 + transitory mental disturbances simulating, 32, 33 + unconscious motives in, 239 + + Maudsley, 132 + + Melbruch, 226 + + Mental factors in production of mental disease, 2 + + Moebius, 69 + + Moeli, 4 + + + Paranoia, litigious, 132 + definition of, 134 + litigious, symptoms of, 134 + + Paranoid symptom-complex under stress, 43 + + Pardon, effect of on mental disorder, 23 + + Pelman, 203, 226 + + Penta, 187, 227 + + Pleasure principle, 190 + + Polymorphous perverse, 249 + + Prison psychosis, cases of, 16, 25 + etiology of, 81 + mechanism of delusion formation in, 93 + prognosis in, 32 + relation to criminal act, 92 + symptoms of, 3 + treatment of, 66 + + Pseudologia phantastica, 159 + + Psychiatric annex in prison, 125 + + Psychogenetic excitement, hysterical components in, 39 + + Psychopathic character, 98 + + Psychosexual development in man, 249 + + Psychosis as a wish, 184 + + + "Querulantenwahn", 37 + + + Raecke, 190 + + Recidivism, 115, 120, 130 + + Reich, 3, 72 + + Repression, 245 + + Resistance, mental, 245 + + Rish, 8, 72 + + Rochefoucauld, 246 + + + Sander, 139 + + Scatological rites, 248 + + Scheule, 189 + + Segregation of criminals, 119 + + Sexuality, Freud's theory of, 246 + and criminality, 250 + + Siefert, 9, 35, 134 + + Siemens, 189, 226 + + Sodomy, 224 + + Stealing, pathological, 252 + automatic in epilepsy, 241 + + Stekel, 252 + + Stransky, 92 + + Sturrock, 43 + + Sublimation, 249, 251, 261 + + + Tanzi, 134, 135 + + Thought, omnipotence of, 191 + + Trauma, psychic, 245 + + + Unconscious, The, 242, 243, 244 + + + Vingtrinier, 189 + + + Wernicke's psychosis, 41 + + White, 240 + + Wilmanns, 9, 44, 74, 188 + + + + + +End of Project Gutenberg's Studies in 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