Chapter I: Psychogenesis in the Psychoses of Prisoners (1)

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.