Chapter II: The Nature and Treatment of the Psychoses of Prisoners (1)

Those who still believe in an exclusively materialistic theory of mental disorder must find it extremely difficult to maintain their doctrine in the face of the many incontrovertible facts brought to light through modern research in the field of psychopathology.

The modern trend in psychiatry is distinctly in the opposite direction. We no longer today insist upon material changes in cells and tissues for every psychotic phenomenon, but rather endeavor to investigate mental life, be it normal or abnormal, from the biologic point of view. We are being constantly confronted with the undeniable fact that whatever may be the physical substratum of mental disorder, it does not aid us in understanding the peculiar expression which a given psychosis chooses to assume. Why it is that one paretic greets us with the exalted mien of his grandiose delirium, while another spreads about him the gloom of a depressive delirium--the changes in the pyramidal cells do not explain. There must be, then, factors other than material ones which determine this.

Mental life, after all, expresses itself in a series of reactions destined to result in a proper adaptation to environmental conditions, and the causes which determine a given reaction may be psychic as well as physical in nature. Indeed, in the realm of psychopathology we see indubitable evidence of the predominance of psychic causes of mental disorder over physical ones, and the subject under discussion here further emphasizes this.

The problem of the prison psychoses, although extensively discussed in psychiatric literature in the last half century, is far from being solved, and for this and many other reasons deserves further attention. The psychotic manifestations of prison life are of sufficient frequency to deserve some definite place in our nosological tables; they develop in a milieu artificially created by society, and if this milieu is responsible for the production of mental disorder, it is of the utmost importance, both from a preventative and curative standpoint, to investigate the causes operative here, and lastly, these psychoses concern individuals who form one of the most important problems society has to deal with, and any light which the study of psychotic conditions in these individuals may throw upon the general problem of crime and the criminal, should be very much welcomed.

I fully believe that in time the study of the psychotic phenomena developing in criminals will give us a correct insight into the nature of the criminal personality and thus aid in the solution of that problem which baffles criminologists today.

We know that while pure experimental psychology and psychopathology have aided us in understanding the human mind both in health and disease, we owe the bulk of our knowledge in this field to the investigations of Nature's phenomena and experiments. The human mind, the most complex and intricate organ, lends itself but very feebly to analysis when all its component parts work in unison, and it is only when through disease it has become, so to speak, disintegrated into its various units, that a more ready access to it becomes possible. This is being fully appreciated both by psychologists and psychopathologists. Mental medicine, however, if it is viewed from the present-day broad conception of the term, must not confine itself exclusively to psychotic manifestations in the strictest sense of the word, but should embrace within its realm that great mass of unfortunates who populate our prisons, poorhouses and reformatories. It is now being universally recognized that the pauper, the prostitute, and the criminal classes are primarily products of mental defect and degeneracy and as such must come within the purview of mental medicine. This being the case, the same truisms which apply to the insane in general must likewise apply to the above-mentioned types.

We are here especially concerned with criminals who, because of a mental breakdown, have come under the observation of a psychiatrist, and if we agree with many eminent criminologists that the present juvenile state of this science and the ineffective methods of dealing with crime are due to a lack of proper scientific understanding of that anomalous species which is grouped under the term "criminal man", why not endeavor to solve this problem by approaching it from the psychiatric point of view. If the study of psychopathology has given us such valuable data concerning the normal mind, why not expect that a similar study applied to the insane criminal will bring to light some important facts concerning crime and the criminal in general. It is for this reason that that large group of mental disorders developing in criminals during imprisonment which has been included under the term "prison psychoses" is of special importance to the psychiatrist.

The older extensive literature on this subject, although very interesting from an historical standpoint, offers very little that is of scientific value, and it is only within recent years that a more rational approach to this problem has been attempted. It is easily conceivable that this branch of mental medicine must have shared the fortunes of psychiatry in general in its various phases of evolution, so that in the history of the prison psychoses are reflected the various views which in their day have dominated psychiatry. At present it is the school of degeneracy of Magnan and Moebius which is especially concerned with this problem.

Briefly stated, the exponents of this subject belong in a general way to either of the following two schools. The one maintains that the mental disorders occurring in prison differ in no way from those met with in freedom and that imprisonment at most but lends to them a peculiar common coloring which in itself, however, is not of essential importance. The other school takes a directly opposite view. The followers of the latter maintain that the mental disorders which they are wont to term "prison psychoses" are products of predisposition plus external factors. They differ from the true endogenous psychoses in that they are purely psychogenetic in character, and that their highly colored and extremely variable symptomatology is nothing more than a reactive manifestation of a particularly predisposed psyche to definite environmental conditions. According to them we are not dealing here with mental disorders whose origin, course, and termination are independent of the crime and imprisonment, as is the case in the ordinary well-known forms of functional and organic disorders developing in prison, but with psychotic manifestations which bear the most intimate relation to some definite situation, and which are characteristically colored and shaped by the prison milieu.

As a matter of fact, the population of institutions for insane criminals divides itself into two distinct and unmistakable groups. On the one hand we meet with the well-known functional and organic psychotic entities such as occur in individuals in freedom; we see patients who in the course of their careers as insane people have come in conflict with the law either accidentally or because of their insane ideas. In them the psychosis develops and takes its definitely determined course independently of the milieu in which the individual happens to be placed. In the majority of instances they suffer from the various forms of dementia praecox and progress toward demential end-results in the same proportion as the general run of dementia praecox cases do, whether or not they have come in conflict with the law. Occasionally we also see a case of organic brain disease or manic-depressive psychosis, and in more frequent instances a case of epilepsy. The other, and according to many authorities, by far the most predominant group of mental disorders met with in imprisonment, belongs to the so-called "prison psychoses", and bears definite, unmistakable ear-marks which differentiate it from the former group. These are, as we have stated, products of a particularly degenerative soil plus definite environmental conditions, and are of the utmost importance both from a purely clinical and an administrative point of view.

The term "reactive manifestation", as applied here, is a happy one, and inasmuch as the accidental criminal differs from the habitual criminal as day differs from night, we will expect a different sort of reaction to a more or less similar situation in the two instances. To illustrate:--An apparently healthy and in most instances law-abiding and non-corrupt individual, as a result of a series of overwhelming and uncontrollable circumstances, commits murder in a fit of passion. Upon being arrested and upon the sudden realization of the enormity of his deed the entire constitution experiences a tremendous shock and reacts to it accordingly. He falls into a stupor, into utter oblivion of the world about him, becomes in turn excited and confused, his senses begin to functionate in a fallacious manner, and he thus succeeds in shutting out from consciousness, for the time being at least, the entire unbearable situation. Upon emerging from his stupor he has a more or less complete amnesia for the deed and its attending circumstances, and finding himself confronted with accusations, cross-examinations, and lastly, conviction, he at once sets about, so to speak, to square himself with the situation. What does he do? He develops a quite limited, well-organized delusional system in which he finds himself absolutely innocent, his accusers are the guilty ones, and the entire situation is nothing more nor less than a well-planned plot to destroy him. His supposed victim has not been murdered at all, but is living and secretly active in plotting and scheming against him, the accused.

In this artificially created world he lives with comparative ease, and has thus succeeded in reaching a proper adjustment to the situation.

The most interesting part of it all is that this so well-organized and apparently fixed delusional system may disappear at once and the various false ideas may become entirely corrected as soon as the provocative agent which is at the bottom of it all is removed. This is a fair example of what has been termed an acute prison psychosis, and occurs with considerable frequency among prisoners awaiting trial. Naturally, these psychoses, being, as they are, psychologically motived, are extremely variable in their manifestations, but at the root they are all alike and impress the observer as something entirely different from the pure endogenous mental disorders. They are all psychically evoked reactive manifestations of a particularly predisposed constitution to definite deleterious environmental conditions. Some of the cases reported in the first paper of this series are good examples of this type of mental disorder.

We owe our knowledge of these disorders to the contributions of Reich, Moeli, Kutner, Ganser, Rish and others, authors who, although describing a more or less identical symptom-complex, have given to it different names, such as hysterical stupor, Ganser symptom-complex, catatonia of degenerates, etc. The distinguishing features of this disorder are its psychic origin, that is, its development in consequence of some strongly affective experience, and its high grade of impressionability to things in the environment which may at any time suddenly cause a complete transition from deep stupor to normal manner and behavior.

The symptomatology consists of an acute delirioid, hallucinatory episode, usually followed by a more or less complete amnesia which may go back far enough to include the experience which provoked the disorder. Such delusional formation as takes place after the disappearance of the fulminant symptoms may well be considered as part of the repair process, a mechanism which in most instances reflects the individual's endeavor to adjust himself to an unpleasant, unbearable situation, and must not be looked upon necessarily as an indication of the progressiveness of the disorder.

As we have stated before, complete correction of all delusional ideas may suddenly take place upon the removal of the causative factor at the bottom of the entire situation.

As to the treatment of this acute prison psychotic complex theoretically, we should have no difficulty in deciding this question. We are dealing with the sequelae of some definite situation, and the removal of that situation may be, and actually is, in most instances, sufficient to bring about recovery. When we come, however, to deal with concrete instances in daily practice, the problem does not lend itself so easily to solution.

What of the man who upon being arrested following the commission of murder, develops a psychosis while awaiting trial, or who having been found guilty of murder develops a psychosis while awaiting execution? The first question which the psychiatrist is called upon to decide in many instances is that of malingering. To the lay mind and to the minds of many of our eminent--but psychiatrically uninformed--jurists the question of malingering suggests itself at once. To them it is perfectly evident that this development of a mental disorder, in the wake of a criminal act, is nothing but a timely preparation for the "insanity dodge." The clinical pictures presented by the acute prison psychosis are especially apt to awaken suspicions of malingering in the minds of the untrained. We see individuals who apparently never before showed any evidence of mental disorder, and who immediately following the commission of a criminal act manifest pictures of grave alienation. Many of them don't know how much twice two is, are absolutely ignorant of the most elementary subjects, remember nothing of the deed, and most important of all fashion their deliria in such a way as to entirely negate the deed, or at any rate justify it.

But why cannot all these manifestations be genuine? Many of us no doubt recall the effect which examinations have upon certain students. The emotional accompaniment of the examination, especially the emotion of fright, causes many a student to forget facts which he knew as well as his own name, and which he is able readily and fully to recollect as soon as the examination is over. Are we to assume that these students are malingering? Decidedly not. Why then should we question at all the genuineness of a mental disorder developing in an individual who faces the gallows or a life-long imprisonment? As a matter of fact cases of pure malingering are among the rarest things which the psychiatrist observes. Wilmanns,[1] in his study of 277 cases of insanity of prisoners, found but two cases of simulation, and in a later review of the diagnoses of the same series of cases, the two cases of malingering do not appear at all. Bonhoeffer[2] in a study of 221 cases of insane criminals found 0.5 per cent of malingerers. This is the experience of everyone who comes in contact with these cases, and there are others who go so far as to maintain that every malingerer of mental symptoms is mentally defective.

But let us assume that we have succeeded in convincing those concerned of the genuineness of the disease at hand; what line of treatment should be recommended? In the first place, we must remember that the mental disorder, if it belongs to the group we are discussing here, is the result of a criminal act, and following in its wake, and that therefore the plea of insanity as an excuse for the deed must manifestly be excluded. But may not this type of reaction furnish us an index to the original personality of the culprit? In other words, should we consider an individual absolutely normal, if, in reaction to some stressful situation, he breaks down mentally and develops a psychosis? The majority of authorities maintain that these individuals are decidedly abnormal, and that it is only a poorly-knit organism which permits of that sort of reaction. Birnbaum,[3] for instance, insists that the possibility of a psychic incitation of a mental disorder is the criterion of a degenerative soil. This is undoubtedly too extreme a view, but the more one observes these cases, the more one is inclined to hesitate in calling these individuals normal in the accepted sense of the term. Let us assume for the moment that these psychotic reactions are indices of an abnormal personality. Is this defect of sufficient import to render the individual irresponsible in the eyes of the law? This question, I fear, cannot be answered very readily. Looking at it from a purely juridical standpoint, we must say no; because an individual is so loosely organized as to break down mentally under a given stress, does not at all imply that a knowledge of the difference between right and wrong is excluded. The jurist is willing to concede to the proposition of a poorly-organized nervous system, a degenerative make-up, a psychopathic constitution; but if these defects are such as to manifest themselves in crime, society must be given the inalienable right to protect itself from such defectives. The result is that either no extenuating circumstances are considered at all, and the individual is dealt with in the ordinary way, or he is adjudged insane and committed to a hospital for the criminal insane, whether or no insanity exists at the time of trial. Thus we have on the one hand a prison population which more properly belongs under the regime of a hospital, while on the other hand, we insist on keeping individuals locked up in hospitals for the insane, whether or no they show actual psychotic symptoms. If one of the latter class endeavors to obtain his release by habeas corpus, a tremendous howl is immediately raised by the public about the "insanity dodge", the worthlessness of expert testimony and the unpardonable offense of letting loose upon society a dangerous criminal. If we stop to consider for a moment, we must admit that in the great majority of instances, we are not dealing here with dangerous criminals. The man who as a result of a series of overwhelming circumstances over which he had little or no control, kills another in a fit of passion, is not necessarily a dangerous criminal. In the majority of cases it is fair to assume that such an individual will never again in his life have to cope with a similar set of circumstances. The great majority of these people have led, up to that single crime of their life, an honest, peaceful existence, and the instances of an accidental criminal turning recidivist are extremely rare.

Society looks on complacently at the repeated sentencing of the habitual criminal and watches without alarm the never failing phenomenon of how each successive imprisonment only serves to deprave him more profoundly; it never considers the danger of letting this type of criminal loose to prey upon it; just so he has served his just and legally prescribed sentence. But let the victim of the "insanity dodge" prejudice endeavor to gain his freedom, and society is at once up in arms.

Thus the matter stands, and until the public learns to know its criminals as they actually are, this problem will remain unsolved. The prognosis of the acute prison psychotic complex is good in the majority of instances. The removal to a hospital regime usually serves to put a stop to the process and it is important for the expert witness to bear this in mind for obvious reasons.

We have thus far discussed the psychoses developing in prisoners awaiting trial, and we shall now turn to that group of cases which are sent to us from penal institutions which serve for the confinement of the convicted criminal.

At the outset we shall endeavor to draw a distinction between the class of individuals we have just discussed, and that which we are about to consider now. We have seen that the former is made up of individuals who in most instances have come in conflict with the law for the first time, and that the mental disorder which they develop stands in the closest relation with some definite experience in their life. The patients who come to us from prisons and penitentiaries on account of some mental disorder which developed while they were undergoing sentence are in most instances habitual criminals with a marked criminal career back of them. They differ so essentially from the preceding group, that what has been said about the former can hardly apply here.

The first really worthy contribution to this subject was made by Siefert,[4] the physician in charge of the psychiatric department of the penitentiary at Halle. He published, in 1907, the results of a study of eighty-three prisoners who became insane while serving sentences. He divided his patients into two sharply differentiated groups, the true psychoses, _i.e._, the well-known forms of functional and organic mental disorders, and the degenerative psychoses, _i.e._, psychotic episodes developing upon a soil of degeneracy and which according to him form the typical prison psychoses. Before we go any further it must be mentioned that Siefert did not take into consideration the mental disorders developing in prisoners awaiting trial.

"The true psychoses develop out of endogenous causes, attack and manifest themselves in the prisoner in the same way as in any law-abiding individual in freedom. They are not essentially influenced by changes of environment and there exists no intimate relation between the coloring of the symptomatology and the influence of the imprisonment. The degenerative psychoses, on the other hand, develop upon the well-characterized degenerative soil of the habitual criminal, and are products of predisposition plus environmental influence. They stand in the most intimate relation to the deleteriousness of prison life, and are therefore influenced to the greatest extent by change of environment."

On studying critically Siefert's work one gains the conviction that the author not only undertakes to solve certain clinical questions, but endeavors to investigate the problem of the relation between crime and mental disorder. Although he paid the strictest attention to the individual symptoms and described in an excellent manner the manifold and varying symptomatology of these psychoses, he did not succeed in isolating a symptom-complex which might be considered as typical of the degenerative psychoses, and thus deserve the independence of a distinct clinical entity. Above all he occupied himself with the investigation and delineation of the various anomalous individualities, the degenerative constitutions upon which these psychotic manifestations engraft themselves. Thus he divided his prison psychoses into groups like the "simple degenerative", "hysterical degenerative", "phantastic degenerative", etc. Siefert undoubtedly overshot the mark in his clear-cut differentiation between the various types, but he unquestionably contributed a most important work on this subject.

Let us now endeavor to illustrate what he means by this degenerative soil giving rise to these psychoses. As we have stated, the great majority of them are full-fledged habitual criminals and can be easily recognized by their "degenerative habitus." They are that indolent, obstinate, querulent, unapproachable, and irritable class of prisoners who form the bane of prison officials. Constantly in trouble of some sort, they are subject to frequent disciplinary measures, which, however, serve not in the least to improve their conduct. Their extremely fluctuating mood and emotional instability calls forth a quite unfounded wild rebellion against the prison regime. They are constantly after the physician with numerous hypochondriacal complaints, such as a nervous heart, digestive disturbances, insomnia, etc. In short, they impress one as something abnormal, something entirely different from the ordinary prisoner. On this basis, now and then more marked, definite psychotic manifestations engraft themselves. Here and there one of them starts to speak of nightly visions, complains about a feeling of anxiety, speaks of suspicious noises and voices in the vicinity, and finally makes a superficial, ineffectual attempt at suicide. Others become suddenly more antagonistic, vehemently assert their innocence, speak of being the victims of false accusations, etc. Still others suddenly develop a wild, maniacal state, destroy everything within reach, become markedly hallucinated, elaborate various persecutory ideas, and finally have to be transferred to an insane asylum. Here they soon quiet down, the active symptoms subside without leaving any trace behind them, insight may or may not be complete. The characterological anomaly which is at the bottom of the disorder, however, remains, and any necessity for the application of more stringent administrative measures may serve to set the entire process aflame again.

Another group of psychopaths who are prone to develop prison psychoses are those primitive, superficially endowed individuals with a high degree of auto-suggestibility, a marked tendency to phantastic lying, and instability of mood, individuals who have always led a sort of humdrum existence without aim or goal of any kind in view. They drift very early into a life of crime and vagabondage, become addicted to all of the vices which cross their path, are markedly egotistical, have no conception of social life, frequently desert their wives and families, and a great many of them finally end their days in jails or poorhouses.

Upon being imprisoned they are unable to adjust themselves to the strict regime, find difficulty in acquainting themselves with the prison regulations and in consequence have to be frequently disciplined. As a result they begin to misinterpret things in the environment and see in these disciplinary measures nothing but persecution on the part of the prison officials. They become suspicious, seclusive, introspective, spend sleepless nights, until suddenly, in the stillness of night, they perceive isolated phonemes. This strengthens their suspicions. They refuse food, become apprehensive, the hallucinations reach a more definite character, until finally they manifest a well-marked persecutory delirium, or may fall into a semi-delirious stuporous state, show numerous catatonic symptoms, become destructive and untidy, and in general present a picture very similar to true catatonia.

Removal to the hospital ward frequently serves to put a stop to the process at once, and often before reaching the hospital for the insane they show no traces of the acute mental disorder.

The foregoing are types of degenerative psychoses met with in imprisonment, and there can be no question that the prison milieu is the etiologic factor here.

To speak here of a progressive disorder to which imprisonment only gives a characteristic coloring is entirely erroneous. A psychosis which is definitely brought on by a certain environment and which is corrected as soon as the environment is changed, must be looked upon as the product of that environment. That the degenerative soil which permits of the development of these disorders cannot be looked upon as a basic disorder, something like dementia praecox, is likewise unquestionable. These individuals have always shown the same traits of character; it is these very same anomalies which brought them in their childhood days in conflict with the school authorities, which later made them inmates of reformatories, and which finally were at the bottom of their habitual criminality. Finally, the total absence of progression to more or less definite end-results excludes the possibility of an organically determined progressive disorder. A psychosis which develops in imprisonment and progresses irrespective of the change of milieu is not a prison psychosis in the sense that this term is here used. The following cases are illustrative of the type under discussion.

CASE I.--A. F., aged 31 years; admitted to the Government Hospital for
the Insane April 7, 1911. Father alcoholic; died of cancer of liver
and stomach. Mother died of tuberculosis. One brother has been
confined in the Gowanda State Hospital for the Insane for past five or
six years; has always been an excessive alcoholic. One sister, aged
42, has tuberculosis. One of her children died of tuberculosis of the
bones. Another sister is hyper-religious and eccentric.

Patient was born at Olean, New York, in 1871. He knows of nothing
unusual attending his birth or childhood. He entered school at the age
of six, and attended irregularly for six or seven years. He was
usually older than the other children in his class, and was held back
a year in the third and fourth grades. He left school at the age of
fourteen, while in the fourth grade. He then worked in a shoe store,
commencing at a salary of four dollars per week, and receiving six
dollars per week at the time of his separation. As far as is known he
did his work well, as he was promoted during his stay there. Soon
after commencing to earn money he began to indulge in alcoholics. He
became intoxicated one day and set fire to a store, which resulted in
the death of a human being. It did not take much at that time to
intoxicate him--two or three glasses of whiskey being sufficient. He
does not definitely say why he set the place on fire; adding, "Perhaps
I was drunk and did not know what I was doing and maybe I just wanted
to see the fire. I always did like to see fires. Of course, I did not
know that somebody was going to get burned to death." He is not
certain whether he felt sorry for the deed, adding: "Why should I
care? I did not know the man that was burned. He was no relative or
friend of mine; anyway, the people around there said he was no good,
and that it served him right." He was sent to the Elmira Reformatory,
where he remained three years, when he was transferred to the New York
State Hospital for Criminal Insane at Matteawan. He did not like the
Reformatory a bit, they were nagging him all the time. He says it was
like a deaf and dumb asylum; a fellow could not even talk when he
wanted to, and if he did he was paddled for it. The paddling didn't
make him behave, because, he adds: "You can't make a fellow behave by
beating him all the time." He was later transferred to Dannemora,
spending about two years in all, in both these institutions. He did
not like it at the hospital either, because they made him work, and he
hated to work; so finally he asked to be transferred back to Elmira,
which request was granted him. On returning there he was put to work
at brick-laying, but could not get along with the fellow in charge,
the latter was too much of a bully and worked him too hard, so
finally, they shipped him to the new reformatory at Napanoch, New
York. Here he was given employment by the physician in charge of the
hospital, and after ten months of good conduct, was paroled. He says
he behaved well these ten months because he was treated well by the
doctor. Upon being paroled, he returned to Olean and obtained a
position in a tannery where he worked for six months, receiving two
dollars per night. He was drinking heavily all this time, and one
night, failing to return to work, owing to his intoxicated condition,
was discharged. He states that the above is the longest he ever worked
at any occupation since. Shortly after being discharged, he was
arrested in company with several others for robbing a post office. He
was about twenty-three years of age then. He claims that he had
nothing to do with this robbery, and it was just an unfortunate
accident that he got mixed up in it. He was placed in the jail, and
while there the warden tried to poison him. He developed various ideas
that poison was placed in his food, that his stomach was all dried up,
and because he would not eat, he adds: "They sent him over to this
Hospital,--the Government Hospital for the Insane."

He was admitted here the first time on May 29, 1904, on a medical
certificate which stated: "About April 19, 1904, he refused to take
food and claimed to be kidnapped. He had delusions of
persecution--said his head was full of nails and requested that his
brain be cut up. Said the President was his friend."

On August 1st, he eloped while at work in company with another
patient. The record of his mental disturbance at that time is very
meagre, and nothing of a definite nature can be obtained from it.

From here he beat part of his way, and walked part of the way to
Cincinnati, where he had a sister living. One night he heard her
talking to her husband about sending him back to the hospital, so he
robbed them of what money they had in the house, bought a revolver and
returned to Olean. He says he bought the revolver to protect himself
from a certain police captain at Olean. He frequently refers to this
man in a vindictive and abusive manner. States that this police
captain was after him all the time; that whenever any crime was
committed in the city, he was immediately suspected. He was "tired of
this" and bought the gun, intending to kill the police officer if he
should bother him any more. Here he adds: "Anyhow, the cur was killed
afterwards, I am glad of it." After a series of crimes, tramping and
debauchery, during which he suffered from an attack of delirium
tremens, and served a sentence of nine months in a Pennsylvania jail,
he was again arrested for a post office robbery and sentenced to five
years at Leavenworth, whence he was transferred to this institution
April 7, 1911.

As has been stated, he commenced to indulge in alcoholics at a very
early age and has continued this habit during his lifetime. He states
that he had an attack of delirium tremens, during which he received a
severe burn on his left arm by jumping out of a window into a bonfire,
while trying to escape imaginary persecutors. During the years
1903-04, he was addicted to the steady use of morphine and cocaine. He
has led a very loose sexual life; has been infected with gonorrhoea on
numerous occasions, and contracted syphilis several years ago. He has
never married. He intended to marry once, but the girl, he discovered,
was not true to him, so he gave her up. He is a Catholic, attends
church occasionally when at liberty, and was in the habit of going to
confession while at the Penitentiary.

The medical certificate on his present admission stated that on the
night of March 20, 1911, the patient was reported for shouting while
in his cell, claiming that invisible enemies were shocking him with
electricity. There were no symptoms observable before that. Has
delusions of persecution in which invisible enemies are continually
shocking him with electricity and other means and are planning to do
him other bodily harm.

He complained of not being able to sleep and of being tortured. Said
they wired his cell and gave him an electric shock; that he spoke to
the President of the United States and was told that the latter would
visit him.

On March 22d, complained of being choked by supposed workmen. Later he
stated that he had been kidnapped at Erie, Pennsylvania, and expected
the President of the United States to get him out in a few days. He
requested the doctor to send for a priest, complained that they had
failed to send for the President as promised. Said that he had
received a severe shock the night before from the people upstairs, and
stated that they had stored two thousand volts to turn on him.
Following this, he was restless at night and was apprehensive of being
burned to death. Finally he wrote a letter to the President in which
he complained that his life and health were in grave danger; that he
was the victim of a conspiracy, and was being detained illegally at
the Penitentiary, stating that when he was walking peaceably along the
railroad track, he was kidnapped by enemies who had a design upon his
life. He was arrested and while in jail these same officers robbed the
post office and later accused him of the crime. They bribed a witness
to testify at the trial against him and because of this he received an
unjust sentence of five years. He believed that the friends of the
chief of police of his home town, Olean, New York, were paying large
sums of money to the warden of the Leavenworth Penitentiary in an
endeavor to have him electrocuted, and that their efforts had nearly
proven successful, as he had been tortured night and day for the past
month, in fact he was unable to stand it any longer, and if the
President did not come to his relief at once, he intended to take the
matter in his own hands and make short work of the warden. He thought
he was accused of the murder of the police officer who was killed in
his home town, but he insisted that at the time of the murder he was
locked up in jail, hence could not have done this.

The patient continued in this trend of thought and conduct until his
transfer to this institution, April 7, 1911.

On admission here he talked in a coherent manner, was clear mentally
and quite well oriented. He reiterated the story given above,
namely,--that he was kidnapped in Pennsylvania on a trumped-up charge
of post office robbery, was tried by a "phony" court and sentenced to
five years at Leavenworth. Soon after arriving there the warden had an
electrical apparatus rigged up with which he was tortured constantly.
He complained to the doctor about this and begged to be put in a cell
so he could get some sleep as he could not sleep in his cell on
account of these electric shocks. He heard them saying from above that
they were going to torture him. One night they had him paralyzed on
one side.

In an endeavor to explain these persecutions he stated that probably
the railroad police who arrested him were friends of the police
captain at Olean with whom he had had trouble for a long time, and who
was later killed by someone; that probably they blamed him for this
killing, and that for this reason they framed up the charge of post
office robbery against him. He believed that the electrocuting which
he was receiving at Leavenworth was a part of this scheme to get rid
of him, as he knew that the police captain at Olean was a friend of
the warden of the Penitentiary. In giving this recital he was somewhat
irritable and nervous, constantly rubbing his head and face in a
troubled manner. He kept to himself, making no acquaintances with
those about him and was apparently somewhat worried and apprehensive.
He slept well the first night, stating that nobody bothered him. He
stated that he was not insane, that there was nothing wrong with his
mind. When asked why he was sent here, said simply because of a trick,
that he was told that he was coming to the President to secure a
pardon, and instead of this, was brought to this institution. He was
quite unstable emotionally, very surly and irritable, and soon
transferred his persecutory ideas to the officials of this
institution. He complained of having electricity on him; stated that
the warden at Leavenworth rigged up a wireless apparatus whereby he
could send wireless messages to him constantly. Stated that he had
been chloroformed at night and that his body was lined with electric
wires through which electricity was running all the time. He became
very abusive to the physician, stating that the latter was in league
with the officials at the penitentiary to torture him. This state of
affairs continued, with the addition of the delusional idea that the
physician was endeavoring to hypnotize him, until the early part of
September, 1911, when he acquired full insight into his mental
disturbance, realizing fully that the various ideas which he expressed
were delusional, and that he must have been suffering from mental
disorder at the time.

Mental examination revealed no defect, and his knowledge was quite in
accord with his educational advantages. Morally, he was distinctly
defective. Physical examination showed various stigmata of
degeneration, such as asymmetry of the face; large outstanding and
flattened ears; narrow and dome-shaped palate; irregularly placed
teeth; prominent parietal bones; two symmetrical depressions on the
occiput; congenital flat-footedness; and a sullen facial expression.
His arms were covered with tattoo marks. Sense of pain somewhat
diminished. Sympathetic reactions could not be elicited. Wassermann
reaction with blood serum nearly complete positive.

The patient finally recovered from his mental disorder, and on
January 16, 1912, was returned to the penitentiary to serve out the
remainder of his sentence. At this writing, November, 1915, nothing
further has been heard from him.

We have before us an individual who to start with, is badly tainted hereditarily. His childhood history is indefinite, aside from his statements of having been usually the lowest in his class at school. He launched upon an industrial career at a very early period in life and simultaneously with commencing to earn money he began to indulge in alcoholics. His industrial career was cut short soon after. He gets drunk and sets fire to a store, causing the death of a human being. This, at the age of seventeen. His moral status can readily be surmised when we remember his reply to the question as to whether he was sorry for the deed. "Why should I be sorry? I didn't know the man that was burned." The usual course of the law was taken in the case and he was placed in a reformatory. He spent nearly six years between that institution and hospitals for the criminal insane, when he was released on parole. It is of interest to note here how he reacted to the stress of confinement in the reformatory. We find that on two occasions during this period it became necessary to transfer him to an insane asylum. We shall have occasion to refer to this again later.

If there ever existed in him any chance for reform, the reformatory apparently killed it, for his life since then has been an uninterrupted chain of crime and debauchery. He has been a prey to all the vices of modern civilization; he is a confirmed alcoholic, was addicted to the habitual use of morphine and cocaine; has been infected on numerous occasions with gonorrhoea; has contracted syphilis and received a serious burn during an attack of delirium tremens. In all, he spent eight of the past fourteen years in penitentiaries, jails, and institutions for the criminal insane, and has, now, an indictment for larceny hanging over him. Released from a six years' confinement he finds himself thrown upon his own resources and is confronted for the first time with the problem of providing for himself. The poorly-begotten organism, whose start in life, already deficient in those attributes and forces which are so essential for an effective struggle for existence and which was rendered still more deficient by a six years' sojourn among criminals, finds himself unable to cope with conditions as they exist, and several months after his release from imprisonment we again find him arrested for robbery. Being taken hold of by the law does not mend matters in the least. On the contrary, we see the same tendency to break under the stress of imprisonment, with the overwhelming burden of an enforced routine existence, reassert itself as on the former occasion, and in reaction to the situation he develops a psychosis which necessitates his transfer to an insane asylum. Placed under the less exacting regime of a hospital, he soon recovers and avails himself of the first opportunity for an escape which presents itself. Finding himself again at freedom he endeavors to find some explanation for his unfortunate position in life and in the midst of this he discovers that his sister is planning to return him to the hospital. Even his own sister is against him. He begins to assume that paranoid view of life which characterizes his later existence. Now he knows where the trouble lies. The whole world is against him; no wonder he can't get along; his own sister is trying to force him back into the hands of his persecutors. His own deficiencies and incapacities he projects upon the environment. It is the world about that is at fault; not he. They are after him all the time. He buys a gun with which to protect himself, and with renewed antagonism against society in general he defiantly launches upon a career of crime and vice. Again taken hold of by the law, the old story repeats itself. He lands in an insane asylum.

Upon an analysis of the content of his psychosis, we find that he elaborates a story of having been kidnapped in Pennsylvania, upon a trumped up charge of robbery, taken before a "phony" judge and given an unjust sentence of five years. The police officers who arrested him were friends of the murdered police captain at Olean and were hired to do this job, because he (the patient) was suspected of having had something to do with this murder. He dreads being placed in the penitentiary because he knows the warden is likewise against him, being a friend of the murdered police captain and might perhaps be in league with his persecutors and take this opportunity of avenging himself upon the suspected murderer, and sure enough, soon after his arrival at the penitentiary, the warden has an electrical apparatus rigged up with which to torture him, etc. His psychosis takes the usual course, he recovers soon after having been removed from the oppressing environment.

The question arises here, "Are we dealing with a psychosis which engrafts itself upon the individual without any apparent cause, a psychosis possessing a course and termination wholly independent of outside influences, a psychosis having no tangible relation to any definite situation; or have we here a psychogenetic disorder, a pathologic reaction of a degenerative constitution to an unfavorable situation, a paranoid picture developing as an outgrowth of the individual in reaction to a definite experience?" In other words, are we dealing here with a case of dementia praecox, or with one of the degenerative psychoses? If we agree with Stransky[5] that dementia praecox depends upon an intrapsychic ataxia, that it is the disturbed cooerdination between the intellectual and affective faculties of the individual which makes the picture of dementia praecox what it is; this is not a case of dementia praecox. The acute emotional reaction to all situations which this man manifests, the development of the psychosis in consequence of the depth of his feelings concerning the unpleasant experiences and the entire absence of this important incooerdination between his feeling and acting, would, in itself be sufficient to separate his psychosis from dementia praecox. If we agree with Kraepelin and others that dementia praecox has a more or less definite onset, a more or less definite course and termination in a dissolution of the individual's psyche, our case is not one of dementia praecox. Our patient has had the same attributes of character and personality always. There is no indication in his life history of a definite onset of a retrograde process, or of any progression towards dissolution. His psychosis, such as it is, is the outgrowth of his degenerative personality, and if we assume this to be true, if we consider the psychotic manifestations of this individual as a pathologic expression of his anomalous personality, the question arises--to what extent have his criminal acts likewise been pathologic expressions of the same underlying degenerative basis? I believe that the relation between the criminality and mental alienation of this man is analogous to that existing between two branches of the same tree. The same degenerative soil which makes the development of the psychosis possible in one case, expresses itself in crime in another instance. The factors which determine whether the one or the other phase will manifest itself, depend largely upon environmental conditions, and are accidental in nature. The stresses which these defective individuals meet with in freedom need not have such a strong influence upon them as to produce a psychosis. The want of moral attributes makes it possible for them readily to surmount many difficulties by means of some criminal act, difficulties which in a normal person would require extraordinary effort to remove. When placed, however, under the stress of imprisonment where they can neither slip away from under the oppressive situation, nor square themselves with it by some criminal act, the organism becomes affected to such a degree that the development of a psychosis is greatly facilitated. The character of the delusional fabric of these individuals is such that one can easily find a ready and more or less correct explanation for it. It is chiefly a compensatory reaction in an endeavor to make a certain unpleasant situation acceptable.