Chapter I: Psychogenesis in the Psychoses of Prisoners (2)

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.