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  | The following corrections were made to the original text:          |
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  | Hyphenation made consistent: antisocial, court-martial, courtyard, |
  | everyday, framework, housebreaking, petit mal, poorhouses,         |
  | psychopathologist, reënlisted, readmitted, viewpoint.              |
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  | Accents made consistent: Beiträge, Delbrück, Gefängnispsychosen,   |
  | Geistesstörungen, naïve, régime, Seelenstörung.                    |
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  | Spellings corrected or made consistent: Babinski, Delinquenti,     |
  | Krankheitsformen, Lasegue, nocturnal, Pelman, phantastica,         |
  | staunchly, traveled, Wilmanns, Zeitschr.                           |
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                               STUDIES IN

                          FORENSIC PSYCHIATRY


                    CRIMINAL SCIENCE MONOGRAPH No. 2
                     _Supplement to the Journal of_
                 THE AMERICAN INSTITUTE OF CRIMINAL LAW
                            AND CRIMINOLOGY


                               STUDIES IN

                          FORENSIC PSYCHIATRY


                                   BY

                          BERNARD GLUECK, M.D.
         INSTRUCTOR IN PSYCHIATRY AND NEUROLOGY IN THE MEDICAL
            DEPARTMENTS OF GEORGE WASHINGTON AND GEORGETOWN
                              UNIVERSITIES

                      FROM THE CRIMINAL DEPARTMENT
                   GOVERNMENT HOSPITAL FOR THE INSANE
                  DR. WILLIAM A. WHITE, SUPERINTENDENT


                                 BOSTON
                       LITTLE, BROWN, AND COMPANY
                                  1916

                           KRAUS REPRINT CO.
                                New York
                                  1969


                           _Copyright, 1916_,

                     BY LITTLE, BROWN, AND COMPANY.

                         _All rights reserved_

                       Published, September, 1916

                              LC 16-20410


             _Reprinted with the permission of the author_
                           KRAUS REPRINT CO.
         A U.S. Division of Kraus-Thomson Organization Limited

                           Printed in U.S.A.




EDITORIAL ANNOUNCEMENT


This volume is one of a series of Monograph Supplements to the Journal
of Criminal Law and Criminology. The publication of the Monographs is
authorized by the American Institute of Criminal Law and Criminology.
Such a series has become necessary in America by reason of the rapid
development of criminological research in this country since the
organization of the Institute. Criminology draws upon many independent
branches of science, such as Psychology, Anthropology, Neurology,
Medicine, Education, Sociology, and Law. These sciences contribute to
our understanding of the nature of the delinquent and to our knowledge
of those conditions in home, occupation, school, prison, etc., which are
best adapted to elicit the behavior that the race has learned to approve
and cherish.

This series of Monographs, therefore, will include researches in each of
these departments of knowledge insofar as they meet our special
interest.

It is confidently anticipated that the series will stimulate the study
of the problems of delinquency, the State control of which commands as
great expenditure of human toil and treasure as does the control of
constructive public education.

    ROBERT H. GAULT,                       }
      _Editor of the Journal of Criminal   }
      Law and Criminology.                 }
      Northwestern University._            }
                                           }
    FREDERIC B. CROSSLEY,                  } COMMITTEE ON PUBLICATION
      _Northwestern University._           } OF THE
                                           } AMERICAN INSTITUTE
    JAMES W. GARNER,                       } OF CRIMINAL
      _University of Illinois._            } LAW AND CRIMINOLOGY.
                                           }
    HORACE SECRIST,                        }
      _Northwestern University._           }
                                           }
    HERMAN C. STEVENS,                     }
      _University of Chicago._             }




PREFACE


When, in 1810, Franz Joseph Gall said: "The measure of culpability and
the measure of punishment can not be determined by a study of the
illegal act, but only by a study of the individual committing it," he
expressed an idea which has, in late years, come to be regarded as a
trite truism. This called forth as an unavoidable consequence a more
lively interest on the part of various social agencies in the
personality of the criminal, with the resultant gradually increasing
conviction that the suppression of crime is not primarily a legal
question, but is rather a problem for the physician, sociologist, and
economist. Whatever light has been thrown in recent years upon this most
important social problem, criminality, did not issue from a
contemplation of the abstract and more or less sterile theses on crime
and punishment as reflected in current works on criminal law and
procedure, but was the result of research carried on at the hands of the
physician, especially the psychopathologist, sociologist, and
economist. The slogan of the modern criminologist is, "intensive study
of the individual delinquent from all angles and points of view", rather
than mere insistence upon the precise application of a definite kind of
punishment to a definite crime as outlined by statute. Indeed, the whole
idea of punishment is giving way to the idea of correction and
reformation. This radical change of tendency cannot be looked upon as a
mere misdirected sentimentality on the part of modern society, but is
the inevitable result of the final conviction that the solely punitive
criminology upon which society has been relying in its efforts to
eradicate criminal behavior from its midst has proved a total failure.
The idea of punishment as a deterrent of crime is, as a consequence,
gradually losing its hold upon modern criminologists, and in its stead
we have been experimenting for some time past with such measures as
probation, suspended or indeterminate sentence, and parole. Now it can
not be too strongly emphasized that in giving these measures a fair
trial we ought to guard against those very same grave errors which were
chiefly responsible for the failure of the old, solely punitive methods,
namely, the dealing with the criminal act rather than with the
individual committing it. If these new measures of probation, suspended
sentence, and parole, which are perfectly adequate in theory, are to
justify their existence in the practical everyday handling of the
problem of criminology, we must not fail to take into full account the
very obvious natural phenomenon that human beings vary within very wide
limits in their susceptibility to correction or reformation, that some
individuals because of their psychological make-up, either qualitative
or quantitative, are absolutely and permanently incorrigible and present
a problem which can be dealt with in only one effective way--namely,
permanent segregation and isolation from society. It is on this very
important account that the psychopathologist's place in criminology is
fully justified. In endeavoring to aid in the solution of the problem of
criminology, the psychopathologist need not seek new methods of
procedure but may safely rely upon those which have aided him in
elucidating in a very large measure the problem of mental disease. For
criminology is an integral part of psychopathology, crime is a type of
abnormal conduct which expresses a failure of proper adjustment at the
psychological level.

It was not until the advent of the Kraepelinian School of psychiatry,
with its intensive search for facts and the resultant more accurate
delineation and classification of types of mental disorder, that we
began to acquire real insight into psychopathology and were enabled to
render more accurate prognoses. This more or less purely descriptive
method of study is at present being followed by an intensive analysis of
the facts thus gained as exemplified in the present psychoanalytic
movement. It is conceded by all thoughtful observers that criminology
will have to follow the same route on its way to final solution. The
series of studies here presented reflect an effort in this direction. It
is aimed to present a series of well-rounded-out case histories of
criminal types as studied from the psychopathologist's viewpoint, and in
one instance, at least, an attempt is made at an accurate and intensive
psychological analysis of the biological forces which were at the bottom
of a career of habitual stealing. No attempt is made at hard and fast
formulations. Our knowledge concerning the criminal is still too meager
to justify one in drawing dependable conclusions. But it is felt that
this clinical material emphasizes sufficiently the necessity of the
psychopathological mode of approach to the problem of criminology. For
that matter, the excellent work being carried on by Dr. William Healy in
connection with the Chicago Juvenile Court and by psychopathologists in
a number of other cities attests that this need is being gradually
recognized by society. One desires only to express the hope that the
time is not far distant when our penal and reformatory institutions will
likewise serve the purpose of clinics for the study of the delinquent,
and that such clinical instruction will form part of the curriculum of
at least every public prosecutor.

I desire to express my indebtedness to Messrs. Lea and Febiger, the
J. B. Lippincott Co., and to the editors of the American Journal of
Insanity, and the Journal of the American Institute of Criminal Law and
Criminology, for their kind permission to reprint some of the material
herein presented.

Before concluding this preface I desire to avail myself of this
opportunity of expressing my sincere gratitude to Dr. William A. White,
Superintendent of the Government Hospital for the Insane, for his kind
and very stimulating advice and encouragement which made these studies
possible.

GOVERNMENT HOSPITAL FOR THE INSANE,
    January, 1916.




CONTENTS


CHAPTER                                                           PAGE

        PREFACE                                                      v

      I PSYCHOGENESIS IN THE PSYCHOSES OF PRISONERS                  1

     II THE NATURE AND TREATMENT OF THE PSYCHOSES OF PRISONERS      66

    III THE FORENSIC PHASE OF LITIGIOUS PARANOIA                   132

     IV THE MALINGERER: A CLINICAL STUDY                           156

      V THE ANALYSIS OF A CASE OF KLEPTOMANIA                      239

        INDEX                                                      267




STUDIES IN FORENSIC PSYCHIATRY




CHAPTER I

PSYCHOGENESIS IN THE PSYCHOSES OF PRISONERS


That mental disorder may be due to causes purely psychic in nature is
acknowledged by everyone. The older psychiatrists laid much stress on
this point, a revival of which may be seen in the present-day widespread
psychoanalytic movement. The reaction to the all too-embracing
materialistic tendencies which have dominated psychiatric thought in
recent decades was bound to come. It was especially the clinician who
gave the impetus to this movement, because in pursuing the materialistic
bent he found himself totally helpless as a therapeutist in the great
majority of mental cases, and was therefore eventually forced to seek
more promising paths.

Bleuler's attitude towards this question, because of the prominent
position he occupies in the world of psychiatry, is interesting.

"Bleuler, who succeeded Forel as Professor of Psychiatry and Medical
Director of the Cantonal Insane Asylum (Burghölzi) at Zurich, having
become convinced that no solution could be arrived at along this
anatomical path for the many riddles offered by the disturbed mental
life, had for years chosen the psychological path. He was led to take
this course because he knew that of the chronic inmates of the asylum,
only about one-fifth showed anatomical changes of the central nervous
system sufficient to explain the mental deviations exhibited."[1]

The results already achieved by this change of attitude in psychiatry
are sufficient justification for its existence.

One became especially convinced of the potency of mental factors in the
production of mental disease from the observation and study of the
psychoses of criminals. Here the conflicts which lead an individual to
seek in mental disorder a satisfactory compromise are so concrete as to
leave no doubt concerning cause and effect.

Kraepelin[2] asserts that mental disorders occur ten times as frequently
in prison as in freedom. The criminal, who in most instances is already
burdened with a more or less strong predisposition to mental disorder,
upon being placed in prison finds himself at once in a most favorable
environment for a mental breakdown. It is true, imprisonment acts more
deleteriously upon the psyche of the criminal by passion, the accidental
criminal, but even the recidivist who would be expected to feel less
keenly the painful loss of freedom, falls a prey to the deleterious
effects of prison life. The unfavorable hygienic surroundings which are
found in most prisons, the scarcity of air and exercise, readily prepare
the way for a breakdown, even in an habitual criminal. Above all,
however, it is the emotional shock and depression which invariably
accompany the painful loss of freedom, the loneliness and seclusion,
which force the prisoner to a raking occupation with his own mind, to a
persistent introspection, making him feel so much more keenly the
anxiety and apprehension for the future, the remorse for his deed, that
play an important rôle in the production of mental disorders. This is
especially true when it concerns an accidental criminal, one who still
possesses a high degree of self-respect and honor. Imprisonment
furnishes us with a great variety of mental disorders, the origin of
which can be traced in a more or less direct manner to the emotional
shock and influence upon the psyche which it brings about.

The psychogenetic origin of the psychoses of criminals can be
established far more clearly in prisoners awaiting trial. Here the
deleterious effect of confinement upon the physical health can be ruled
out almost entirely, and the etiologic factor must be sought for
exclusively in the emotional shock which the commission of the crime and
its attending consequences provoke. The strong effect upon the psyche
produced by the detection and confinement, the raking hearings and
cross-examinations, and the uncertainty and apprehension of the outcome
of it all are the factors that are at play here.

Reich,[3] in 1871, was the first one to call attention to the mental
disorders of prisoners awaiting trial. He could observe the development
of mental symptoms even during the first hours of confinement, and the
relation between the psychosis and the emotional shock of the situation
at hand could not be doubted. He describes this acute mental disturbance
as follows:--"Already in the first hours or days after imprisonment, or
soon after a severe emotional shock, a sort of psychic tension sets in.
The prisoner becomes silent, chary of words, lost in brooding. He
observes little that goes on about him and remains motionless in one
spot. His face takes on an astonished expression, the gaze is vacant and
indefinite. If he makes any movements at all they are hesitating,
uncertain, as those of a drunken man. Vertigo and aura-like sensations
appear; severe anxiety overpowers the patient, which with the entire
force of a powerful affect crowds out all other concepts and sensations
and dominates the entire personality. Consciousness becomes more and
more clouded, soon illusions, hallucinations, and delusions appear, and
the prisoner becomes especially taken up with ideas of unknown evil
powers, of demons and spirits, and of being persecuted and possessed by
the devil. Simultaneously they complain about all sorts of bodily
sensations. In isolated cases one may observe convulsive twitchings of
the voluntary and involuntary musculature. Finally severe motor
excitements set in. The patient becomes noisy, screams, runs aimlessly
about, destroys and ruins everything that comes his way. With this the
disease has reached its height. At this stage consciousness is entirely
in abeyance and the disorder is followed by complete amnesia." Reich
supposes that this acute prison psychosis may be included in that large
group of abnormal psychic processes, developing from affect and
affect-like situations.

Reich's important work remained the only one on the subject until 1888,
when Moeli again called attention to it. Moeli[4] spoke of patients in
whom an apparent total blocking of all thought processes took place.
They would exhibit complete ignorance of the most commonplace facts,
would forget such well-known things as their own name, place of birth,
or age; were unable to recognize the denominations of coins, etc. He
noted, however, that although the answers these patients gave were
false, they had a certain relation to the question. For instance, coins
of a lower denomination would be mistaken for higher ones, postage
stamps were called paper, etc. They also showed a marked tendency to
elaborate all sorts of false reminiscences about their past life. Along
with this failure of the simplest thought and memory activity, these
individuals were otherwise well-ordered and behaved.

The reader will at once recognize in the above description the
well-known Ganser symptom-complex, the several variations of which have
been so frequently discussed of late years. Ganser[5] further showed
that these cases frequently evidenced vivid auditory and visual
hallucinations. At the same time there existed a more or less distinct
clouding of consciousness, with the simultaneous presence of hysterical
stigmata, especially total analgesia. After a short time recovery took
place, the patients suddenly awoke as if from a dream and evidenced a
more or less complete amnesia of the events which had transpired.

Numerous discussions concerning this disease-picture have appeared of
late years in literature. The Ganser syndrome, or twilight state, has
been enlarged upon, and several variations of this condition have been
isolated. The chief contention, however, of the various authors on this
subject seems to be whether this symptom-complex should be considered as
hysterical or whether it should be placed among the large group of
degenerative states. Both views are ably defended by prominent
psychiatrists. I have recently observed the Ganser syndrome in an
undoubted case of toxic-exhaustion psychosis.

Raecke[6] designated this disease-picture described by Moeli and Ganser
as an hysterical twilight state in psychopathic individuals. These
conditions were developed in them as the result of emotional excitement
in imprisonment. The constant hearings, the confusing cross-questioning,
the fear of punishment, finally the injurious effect of solitary
confinement, shock and weaken the slight mental tension of the prisoner
to a marked extent. As a result of this, we have on the one hand a
condition of apathy, of inability to concentrate the mind, of incapacity
to think and of a sort of feeling of being wholly at sea, accompanied by
vertigo and other nervous manifestations, while on the other hand the
physical despair, the obstinacy of the prisoner, now increase to
pathological maniacal attacks, now again are changed to stubbornness,
mutism, with refusal of food. At the same time the more or less constant
wish to be considered sick, and in consequence to be freed from
imprisonment (and in this we see perhaps the hysterical component), may
influence deleteriously and in a peculiarly modifying way the
disease-picture. The various questions put to the patient by the
examiner may act as so many suggestions. Raecke further calls attention
to the manifold similarities which these conditions may show with
catatonic processes. In these hysterical twilight states, quite aside
from mutism, negativism, and catalepsy, peculiar mannerisms were noted,
a sort of affected, childish way of speaking, motor stereotypies,
swaying of the head, running in a circle, queer actions, and sudden
expressions of senseless word combinations. In a later work Raecke[7]
describes a symptom-complex, which he designated as "hysterical stupor
in prisoners", and in which the catatonic symptoms exist in a still more
pronounced manner. The severe forms of this disorder, which may extend
over weeks and months, are liable to be confused with progressive
deteriorating processes, especially so because those symptoms which were
wont to be considered by many as positively unfavorable prognostically,
may be found here in very deceptive imitations. Thus the affected, silly
behavior, impulsive actions, temporary verbigeration, senseless word
salad, grimacing, stereotypy, attitudinizing, etc., which these patients
exhibit, may easily be mistaken for the typical catatonic picture of
dementia præcox. According to Raecke's view the hysterical stupor is
closely related to the Ganser twilight syndrome. Stuporous conditions
may introduce the latter, and, vice versa, Ganser complexes may creep
into the stupor. Raecke's stupor, like Ganser's twilight syndrome,
frequently develops in criminals immediately after arrest or as a result
of great physical or psychic exertion. Sometimes the stupor is preceded
by convulsions, at other times by a prodromal stage of general
nervousness. In still other cases, unpleasant delusions and elementary
hallucinations precede the stupor, which may follow immediately after
this prodromal state or may be again preceded by a short attack of mania
with clouded consciousness. In contrast to the genuine catatonia,
Raecke's stupor as well as Ganser's twilight state, are characterized by
_a high grade of impressionability to things in the environment, which
may at any time suddenly cause a complete transition from an apparently
deep stupor to normal manner and behavior_. Headaches, vertigo, and
various hysterical stigmata are common to both the hysterical stupor and
the Ganser twilight state. At times recovery takes place suddenly, but
as a rule it is gradual and remittent in character. The duration of the
disorder differs. It may last for hours or months, and there generally
remains a more or less pronounced amnesia for the entire period of
stupor.

Kutner,[8] in a work on the catatonic states in degenerates, describes
this condition at length. Although recognizing a good many hysterical
features in these patients, he prefers to place these catatonic
conditions under the general group of the psychoses of degeneracy. He
does not add anything worthy of note to what Raecke had to say
concerning this mental disorder, but the differentiating points which he
advances between it and the genuine catatonia are of interest and should
be mentioned here. Among these he mentions, first, the development of
the disorder upon a grave degenerative basis; second, the sudden
development of the psychosis as the immediate result of a situation
strongly affective in nature, such as a threatening or beginning
prolonged imprisonment; third, the more or less sudden disappearance of
the entire symptom-complex upon a change of environment; and lastly, the
lack of secondary dementia. This absence of dementia cannot be explained
by mere assertions that these cases have perhaps not been followed out
long enough. Bonhoeffer kept account of some of these cases for as long
as ten years, and in none of them could he observe any sign of a
deteriorating process.

It may, perhaps, be of interest to finally mention here Raecke's
fantastic form of degenerative psychosis, which is nothing more nor less
than another attempt at describing the original Ganser twilight state in
a modified form.

It will be seen from the preceding that the disease-pictures described
by Reich, Moeli, Kutner, Ganser, Rish, and others, are so closely
related that any attempt at separation must of necessity be more or
less of an artificiality. The question whether this condition, because
of certain isolated hysterical components, deserves to be considered as
hysterical in nature, is by no means solved. The mere presence of
physical, so-called hysterical, stigmata, is not sufficient to call a
disorder hysterical. Bonhoeffer, who, in opposition to such authors as
Wilmanns, Birnbaum, Siefert, and others, insists that this
so-called prison-psychotic-complex in its narrower sense is of
hysterical nature, does so because he claims to be able to see in these
patients the dominance of a wish factor, namely, the wish to be
considered insane, and consequently to be transferred to an institution
for the insane.

He explains the recovery of these patients upon being transferred to
such an institution on the basis of the fulfillment of this wish. My
experience has been that it is very difficult in most instances to
differentiate these acute psychogenetic states from certain hysterical
conditions. Some of them show a good many hysterical symptoms, while in
others such symptoms are absolutely wanting. One of the cases herein
reported illustrates this point especially well. This patient was
admitted to our hospital on two occasions, the first time while awaiting
trial on a charge of murder, and the second time soon after conviction
and sentence to life imprisonment. His first attack showed very little,
if anything, of a hysterical nature, while his second attack had so many
features of hysteria that it could hardly be considered anything but a
psychosis of an hysterical nature.

  CASE I.--E. E., Negro, aged 32 years. One sister insane, a brother is
  said to be subject to convulsions. Patient's birth and childhood
  normal; attended school for three or four years, where he made normal
  progress. He entered upon the life of a common laborer when quite
  young, and always managed to earn a substantial livelihood for himself
  and family. With the exception of typhoid fever at six or seven years,
  he was never ill before. He used alcoholics in moderation, and denies
  venereal history. Criminal history is uncertain; according to his
  statements he was arrested but once before, for fighting. It appears
  that he was working as usual until August 19th, when he was arrested
  on a charge of assault and robbery. The patient has a hazy
  recollection of this; he cannot say how long ago it was, but thinks it
  was sometime in August; he was arrested at night; cannot state at just
  what time, but is certain that it was after sunset; does not know who
  arrested him; says there were several of them; does not know whether
  they were policemen or detectives. The police records show that he was
  arrested on the night of August 19th, after a desperate fight. The
  following day he suddenly became insane in his cell at the fourth
  precinct station house. He became very excited; commenced to shout
  that he had been shot in the abdomen by an enemy. When offered food he
  threw it at the policeman through the bars of his cell door, and then
  began beating his head against the walls of his cell. He was
  transferred to the observation ward at the Washington Asylum Hospital.
  The records of that institution show the following: On admission he
  was yelling, cursing, and very much excited; completely disoriented;
  repeated the same sentence over and over again in a singing fashion.
  He talked to the Lord, and answered imaginary questions; had auditory
  and visual hallucinations, and various delusional ideas; thought
  someone was talking to him constantly; that he was being shot at every
  few minutes, and yelled with anguish at every supposed shot. He cried
  and sang alternately. Owing to his marked excitement he had to be
  kept in constant restraint.

  On admission to the Government Hospital for the Insane, on August 23d,
  three days after the onset of the disorder, he was in a semi-stupor;
  no replies could be gotten to questions, and his attention to the
  extent of looking at the examiner could be engaged only after vigorous
  shaking. General hypalgesia was present; he responded but very feebly
  to pin pricks. He was absolutely passive to the admission routine, and
  offered no resistance whatever to what was being done to him. His body
  did not show any resistance to passive movement, on the contrary, it
  was rather limp. He was lying in bed staring in a fixed manner
  straight ahead of him and would emit an occasional grunt, and a few
  unintelligible words. He refused nourishment, was untidy in habits,
  and appeared to be wholly oblivious to his environment. Respiratory
  and cardiac action somewhat accelerated, pulse rapid and feeble.

  August 25th:--Continues in the same stuporous state; absolutely
  oblivious to his surroundings; refuses food; untidy in habits. Aside
  from an unintelligible word or two, has not spoken any since
  admission. There are several beginning pustules on his back.

  August 28th:--Some improvement noted; asks for water spontaneously;
  when spoken to says his back aches, and that they are pouring water on
  him. "I read the book, I went to church." Unable to feed himself or
  dress without assistance; totally disoriented.

  August 30th:--Came out in the hall today, and spent the time sitting
  quietly on a settee; does not take any interest in his surroundings;
  has not spoken any spontaneously. Answers are given in a brief and
  retarded manner, preferably in monosyllables, and not to the point. On
  being questioned concerning orientation, says: "My back, church, the
  book", "they are burning me up." Appearance indicates marked
  confusion.

  September 3d:--The patient suddenly became clear mentally this
  morning; seems to have completely recovered from his stupor; attends
  to his wants, and answers questions in a clear, coherent manner.
  Approached the physician this morning and asked for a laxative; says
  that he remembers nothing that transpired during the period since his
  arrest, and a day or two ago, when he began to see things more
  clearly; complains of pain in back; does not know where he is, and
  thinks he came here yesterday.

  "What is your name?"

  "E. E."

  "Age?"

  "I will be 33 the 16th of this coming April."

  "When were you born?"

  "In 1879."

  "What is your occupation?"

  "I am supposed to be a huckster."

  "Where were you born?"

  "At Columbus, South Carolina."

  "What day is this?"

  "Sunday." (correct)

  "Date, month and year?"

  "It's the 9th month, 1911, I don't know the date; I have not seen an
  almanac."

  "What is the time?"

  "I don't know, sir; I think it is pretty near one o'clock." (correct)

  "Where did you come from?"

  "I don't know where I came from; they hit me over the head."

  "When did you come here?"

  "I don't know; I look out of that building that looks like the House
  of Rep." (After studying the surrounding country a while, says:)
  "Let's see, this must be Anacostia, ain't it; I never was out here
  before." (correct)

  "How long did it take you to get here?"

  "I don't know, sir."

  "Name of this place?"

  "You've got me now."

  "Where is it located?"

  "It seems to be in Anacostia, the way I can figure it out." (correct)

  "What sort of a place is it?"

  "Well, to my judgment, it looks as though it's all right."

  "Who are these people about you?"

  "I don't know, sir."

  "Is there anything wrong with them?"

  "Well, I don't know, I am afraid to say; I don't know the nature of
  anybody but myself."

  "Why do you suppose you are being asked these questions?"

  "Well, I think it is to sound my knowledge."

  "Why were you sent here?"

  "I don't know, sir."

  "How do you feel?"

  "I feel all right, with the exception of my back."

  "Are you happy or sad?"

  "Well, I am neither one."

  "Are you worried about anything?"

  "No, sir."

  "Did anything strange happen to you for which you can't give yourself
  an account?"

  "I can't understand what happened to me, or why I am here."

  "Do you hear voices talking to you?"

  "No, sir."

  "Do you see any strange things?"

  "No, sir, I don't see anything strange, only my surroundings."

  "Do you ever have fits or convulsions?"

  "No, sir."

  "Did you ever try to commit suicide?"

  "No, sir, and ain't never going to try it."

  "Is anybody trying to harm you in any way?"

  "Yes, I really believed somebody tried to do something to me."

  The foregoing questions were answered without any hesitation and in a
  prompt manner.

  September 6th:--Today, patient gave in a coherent and relevant manner
  his past history. He talked freely, and all evidence of suspiciousness
  or evasiveness was absent. Upon examination he was found to be
  perfectly oriented in all spheres; free from delusions and
  hallucinations, and possessing quite a degree of insight into his
  recent mental disorder. While reluctant to admit that he had been
  insane, he fully realized that something was wrong with him. He showed
  a normal emotional reaction to the situation at hand; felt satisfied
  with his surroundings, and was very much concerned and anxious about
  his release. Special intelligence tests failed to reveal any
  intellectual defect. He was found, however, to be a rather ignorant
  negro. Memory and attention were unimpaired. Apperception good;
  physical examination showed him to be a well-developed man of medium
  size, height five feet, three inches, weight 150 pounds. Aside from
  several pustules on the back, he showed no physical disorders.
  Neurological examination, negative.

  September 14th:--Patient was today discharged by a jury, as not
  insane. He presented a normal appearance upon leaving the Hospital.
  Insight was good, and there existed a total amnesia for the period
  between August 19th, when he was arrested, and September 3d, when he
  recovered from his stupor.

This case illustrates in an excellent manner the development of a mental
disorder as an immediate consequence of a situation strongly affective
in nature,--in this instance, threatened imprisonment for a grave
offense.

The emotional shock of the arrest called forth in this, to all
appearance, previously normal individual, a marked excitement
accompanied by hallucinations and fleeting delusional formations. This
excitement, which required the application of constant restraint, was
followed by a stuporous state and total clouding of consciousness. Upon
being removed to a hospital, and surrounded by a new environment,
patient gave evidence, after a sojourn of only a few days, of the
salutary effect of such procedure. On September 3d, ten days after
admission, the stupor disappears, and the only residue of the one-time
psychosis is a complete amnesia for the entire period. The amnesia and
the hypalgesia, which the patient manifested on admission, are the two
symptoms which may perhaps be considered as more or less hysterical in
nature. Aside from this, it is difficult to see wherein the psychosis
resembles an hysterical disorder. Another point which should be
mentioned here in passing, and which will be dilated upon later, is the
medico-legal importance of this class of cases. This patient was wanted
for assault and robbery in an adjoining State. Upon his admission to
this institution an inquiry was received from the U. S. Attorney for the
District of Columbia as to the probable duration and course of this
man's disorder, as they had in possession extradition papers from the
authorities of the State in which the crime was committed. It was only
by recognizing the nature of this disorder that we were able to furnish
the authorities with intelligent information concerning the prognosis of
the case, and which the course of the disease corroborated in every
detail. By recognizing the fact that these disorders are consequences of
the criminal act, the possibility of considering the man insane at the
time of the commission of the act is obviated in a large measure.

  CASE II.--R. S. C., a white male, age 48 years, who is now serving a
  life sentence for murder. One brother and one sister died of
  tuberculosis. Another sister and two maternal aunts were insane.
  Father alcoholic. Patient has always been regarded as rather sickly.
  Had the usual diseases of childhood and has been subject all his
  lifetime to frequent headaches. His school career was very irregular
  in character and he never advanced beyond the elementary subjects.
  Socially, he belonged to a very ordinary stock of frontiersmen and his
  chief occupation consisted of farming and certain minor speculations.
  He apparently led an honest and more or less industrious life. Married
  in 1886, and his conjugal career is uneventful. In March, 1901, he
  moved to Addington, Indian Territory. This was a newly-established
  frontier town and he had bought, sometime previously, several lots
  there, intending to establish himself in the lumber business. Soon
  after this he got into some financial difficulty with a town-site
  boomer, and finally, in a fit of passion, shot and killed the latter
  and wounded a relative of his own. He was admitted to the Government
  Hospital for the Insane, December 13, 1901, from the Indian Territory.
  From the medical certificate which accompanied him on admission it
  appeared that soon after the commission of the crime the patient began
  to show evidence of insanity by incoherent talk, false ideas,
  nervousness, and outbursts of vicious excitement. Later, this was
  followed by mutism, refusal to eat, and stupor. On admission to this
  hospital he was in a deep stupor, absolutely oblivious to everything
  about him. Eyes were wide open and staring, pupils dilated, voluntary
  movements markedly in abeyance. He was mute except for an occasional
  incoherent mumbling to himself. He evidenced no initiative in feeding
  himself, but swallowed food when it was placed in his mouth. Habits
  were very untidy; involuntary evacuation of bladder and bowels were
  present. His mental content could not be determined at the time, as
  his replies were indistinct and monosyllabic, and were obtained only
  after much effort. He appeared to comprehend what was wanted of him,
  although this was not absolutely certain. His perception was very
  dull, ideation slow and laborious. His attention could be gained only
  after considerable difficulty, and he had to be aroused first from a
  more or less profound stupor. Spontaneous speech was almost wholly
  absent, but occasionally he would utter a word or two about his wife
  and children. No delusions or hallucinations could be elicited.
  Physical examination showed him to be quite thin and emaciated. Gait
  slow and unsteady. Voluntary movements retarded. Knees trembled and
  knocked against each other. No paralyses or pareses noted. Marked
  general tremors were occasionally seen. Musculature well developed but
  flaccid. All deep reflexes diminished. Cremasteric absent. Other
  superficial reflexes were noted to be normal. Organic reflexes
  abolished. Involuntary urination and defecation. There was a systolic
  murmur present and a slight impairment of the upper lobe of the right
  lung. Breath very offensive. He remained in this stuporous condition,
  leading a more or less passive existence, for about a month after
  admission. For two months following this he was quite agitated, and
  his outward reactions indicated that he was quite depressed. On
  April 25th, about four and a half months after admission, when asked
  how long he had been in the Hospital, he replied three days. From that
  time on he began to improve. Consciousness became clearer. In June, he
  talked and acted quite rationally. He had a total amnesia of what had
  transpired during his stuporous and agitated states and a retrograde
  amnesia for several days prior to, and including the commission of the
  murder. He continued clear mentally and in a more or less normal state
  until the latter part of November, 1902, when he again went into a
  stupor. From this time until the later part of April, 1903, he had
  alternating periods of stupor and lucidity, with amnesia for the
  stuporous states. On June 21, 1903, he was discharged as recovered and
  returned to the Indian Territory to undergo trial for his offense.
  Unfortunately, no mention is made in the hospital records of any
  possible relation between his periodic stuporous states and any
  environmental condition which may have provoked these; nor does there
  appear in the hospital records any mention of the degree of insight,
  if any, the patient possessed at the time of his release from the
  institution.

  He remained in jail at Ardmore, I. T., until April 8, 1904, when he
  was tried and found guilty of murder in the first degree. He was then
  returned to jail and after about a year's sojourn there was sentenced
  to life imprisonment and transferred to the United States Penitentiary
  at Leavenworth. He was readmitted to the Government Hospital for the
  Insane on March 25, 1906, from the United States Penitentiary at
  Leaven worth. No medical certificate accompanied him on admission and
  it is therefore impossible to set, even an approximate date, for the
  onset of his present mental disorder; but inasmuch as he had not been
  in prison even a year before his transfer to our hospital, and as it
  usually takes several months to carry out the required legal
  proceedings, his mental disorder must have set in quite soon after his
  confinement in the penitentiary.

  He was again in a stuporous condition on his readmission to our
  hospital, and absolutely oblivious to his surroundings. For about
  twenty-four hours he was wholly inaccessible, would not reply when
  spoken to, and had to be aroused from a sort of lethargic state before
  his attention could be gained at all. On the following day
  consciousness cleared up to some extent and he recognized some of the
  attendants whom he had known on his previous admission. He remained,
  however, more or less confused for several days, after which his
  mental horizon became clear, and simultaneously with this, delusions
  of suspicion and persecution became evident. He did not know how long
  he had been in this confused state and had a complete amnesia for the
  entire period. Stated that he had been poisoned and that attempts to
  kill him had been made at the Penitentiary. He knew he had been doped
  any number of times. Aside from this paranoid complex he had a
  complete left-sided functional hemiplegia with all the concomitant
  signs. Left visual field considerably contracted. From May, 1906, to
  February, 1907, he passed through a number of stuporous periods,
  during which he was confined to bed from a few days to a week at a
  time. At these times he would lie with a vacant and staring
  expression, and questioning would often fail to elicit any reply. At
  times he would partake only of liquid nourishment, then again would
  have to be spoon-fed. During his lucid intervals he would be up and
  about and more or less cheerful. Occasionally played games with his
  fellow patients. He continued to be very suspicious; frequently spoke
  of being doped and poisoned. Refused to take medicine, and at times
  refused to take nourishment because he believed it to be doped. A
  stenogram of February 10, 1907, shows him to have acquired some
  grandiose ideas and to be still disoriented to a large extent. Some of
  his replies were absolutely unreliable. For instance, when asked how
  long he had been here he replied: "If I came on March 25th, I have
  been here for three hundred and sixty-five thousand days. It is
  reasonable but you wouldn't understand it. When a man is answering for
  something he should not answer for, every day amounts to a thousand
  years with the Lord." He stated that he knew that attempts were being
  constantly made to affect him with chemical substances; these were
  placed in his food and rubbed on the walls of his room, making him
  dizzy and giving him a sort of peculiar feeling, etc. He could hear of
  things occurring in distant places and even in foreign countries just
  as though he were there. He could tell what was going to happen; had
  no trouble at all to look into the future. He attributed this ability
  to some superhuman power, but which was natural to him. This power was
  bestowed upon him by the superhuman power itself. In prison every
  possible means to kill him were used but without success. They even
  tried to chloroform him for a day and a night, but could not kill him.

  May, 1907:--Still delusional, hypochondriacal; paralysis very much
  improved. Complains at times of quiverings in the right extremities
  and a numbness of the left side.

  August, 1907:--Has been again in a stuporous state for four days.
  Still entertains paranoid ideas, hypochondriacal. This was followed by
  a lucid period which lasted until November 25th, when he again went
  into a profound stupor and became totally oblivious to everything
  about him.

  April, 1909:--Very much disturbed for about a week. Complained that
  the physicians and attendants were torturing him in order to drive
  him insane. Called them brutes and threatened to starve himself to
  death.

  December, 1909:--Neurological Examination--Hemiplegia almost entirely
  disappeared, but numerous physical stigmata still persist. Has been
  uninterruptedly clear mentally since his last stuporous state, in
  November, 1908.

  January, 1911:--Clear mentally. Answers questions coherently and
  readily. Attention easily gained and held without difficulty. Memory,
  for both recent and remote events, fair, with complete amnestic gaps
  for the stuporous periods. He shows the characteristic hysterical
  make-up. He is morbidly suggestible and suspicious. He is markedly
  egotistical; becomes easily irritated at the least provocation. Is
  extremely hypochondriacal and shows a marked tendency to exaggeration
  of actual ills. Constantly laments his fate of being compelled to stay
  in a place of this sort, which is a thousand times worse than a
  prison. Is certain that his trial was crooked and irregular and that
  he had not been given a fair chance. His sentence is inhuman and
  unjust, as he was not responsible for the crime he committed; he
  remembers nothing of the occurrence and consequently must have been
  insane at the time. He is inclined to a great deal of fantastical
  day-dreaming, writes poetry and religious dissertations. He is
  constantly bewailing his unfortunate lot in letters to people of high
  station, imploring their compassion on the poor, down-trodden martyr.
  Is clear mentally throughout and no definite delusions nor
  hallucinations can be elicited. His morbid suspiciousness, however,
  leads him to interpret various occurrences in his environment in a
  more or less delusional manner.

  August, 1911:--No change from the above note except that the physical
  stigmata have almost completely disappeared. Patient has an adequate
  amount of insight into his stuporous state, but does not realize that
  his entire make-up is more or less pathological in character.

  The patient had finally sufficiently recovered to be able to be
  returned to the Penitentiary, and as he was very desirous of the
  change, he was, accordingly, discharged from further treatment,
  March 25th, 1912, to be returned to the United States Penitentiary,
  Leavenworth, Kansas. At this date, November, 1915, I am informed that
  the patient gets along very well at the Penitentiary, working in the
  hospital of that institution.

We are dealing here with an individual who, to start with, comes from a
badly tainted family. He leads an honest, more or less industrious life,
until one day, in a fit of passion, he shoots and kills a man with whom
he has some financial differences. Being uncorrupted and of a
non-criminal make-up, the enormity of his crime suddenly dawns upon him
with its full force. He is unable to withstand the emotional shock which
the realization of his deed provokes, breaks down under the stress, and
develops a mental disorder. He is removed to a hospital and under the
salutary influence of new environment gradually recovers his normal
mental health. Simultaneously with this he begins to nourish the hope
that he may escape punishment for his deed. The amnesia for the period
during which the crime was committed lends support to his optimistic
views concerning the outcome of the case, and his mind becomes, in
consequence, wholly taken up with the idea of being acquitted of the
murder charge. He remembers nothing of the deed, and therefore must have
been absolutely unaware of what he was doing at the time. His hopes are
shattered when he is found guilty and sentenced to life imprisonment.
His nervous system is unable to withstand this blow and it yields a
second time, only in a more pronounced manner.

One need not enter into a lengthy discussion in order to show that we
have here a mental disorder, the origin of which can be definitely
traced to psychic causes, the emotional shock accompanying the crime and
conviction. Cause and effect are clearly in evidence here. We have
before us a well-defined psychogenetic psychosis. In addition to this
the course of this man's mental disturbance was influenced to such an
extent by his immediate environment that one could practically shape the
symptomatology thereof at will. Once, after a prolonged period of a
state which might be considered almost normal to the individual, he
induced the attending physician to bring his case for consideration
before the staff conference with a view to being returned to prison. At
this conference it was decided that in view of the very deleterious
influence which prison life has had in the past upon this patient it
would not be advisable at this date to send him to the penitentiary.
Upon being told that he would have to remain at the hospital, patient
again became morose, hypochondriacal, refused nourishment, and commenced
to hold himself aloof from the other patients. His suspiciousness and
vague persecutory ideas with reference to the personnel of the hospital
became more pronounced, and he could see no other reason for being kept
here than that the officials are continuing in their persecutions of
him. I am convinced, without a doubt, that should this man be pardoned,
all the manifestation which he now possesses, and which may be
considered as pathologic in character, would at once disappear. The
difference in the symptomatology of the two attacks serves to
illustrate how difficult it is to positively state what relation these
disorders have to hysteria. Here we have an individual whose past life
fails to indicate anything which may be taken as of an hysterical
character. He develops a psychogenetic disorder in consequence of his
crime, the symptomatology of which shows little, if anything, of an
hysterical nature. In due course of time he gets well, and after having
thrust upon him a life sentence, again returns to us with a mental
disorder, the chief feature of which is a functional hemiplegia. There
is very little doubt that by studying a cross-section of his second
attack we could easily place it under the group of hysteria.
Considering, however, the history of the case _in toto_, we would have
to proceed rather cautiously in judging of the hysterical element
thereof.

  CASE III.--G. W. W., white, male, aged 26 years, whose hereditary
  history cannot be definitely determined. It appears that mother was a
  janitress in Boston, and had several children by various fathers.
  Patient grew up in an orphanage, and worked on farm until age of 18,
  when he drifted to Denver, Colorado, and enlisted in the U. S. Navy.
  He served one enlistment with a good record, was a good sailor, and
  got along well in every respect. He reënlisted the second time about
  the middle of 1909, when at the instigation of a fellow sailor he
  deserted from the Navy in company with the latter. On August 20, 1910,
  they held up the captain of a ship with the intention of obtaining
  some money which was stored on board the vessel. In the encounter the
  captain was killed by the patient's companion, who made his escape,
  while the patient was apprehended and held on a charge of murder. On
  August 24th, he was placed in jail at Oakland, California. From the
  beginning he was regarded by the jail officials as rather silly and
  defective. He did not appear to be very much interested in his case,
  and never spoke of his own initiative to his attorney about it. On
  May 8, 1911, he was seen for the first time by a psychiatrist. He was
  then found to be very distractible and inattentive, seemed suspicious
  and excited and assumed stiff attitudes. He was well oriented, and
  recognized that he was on trial for murder. It might be mentioned here
  that although the jail officials apparently noted from the first that
  the patient was not right, the legal proceedings were continued, and
  it was only on the 4th or 5th day of his trial that his conduct became
  such as to strongly suggest that he was insane. A psychiatrist was
  then called in and he pronounced the patient insane, whereupon the
  proceedings were stopped at this juncture. Examination at that time
  revealed the following:--General sensation markedly reduced;
  hypalgesia, he allowed needles to be stuck into his tongue without
  flinching; walked in a stiff and stooping fashion; no Romberg;
  moderate vaso-motor stasis, with bluish, cold hands. Gait
  uncharacteristic. Eyes reacted to light, directly and consensually,
  and to accommodation. Patellar, Achilles and arm reflexes markedly
  exaggerated and equal. No foot clonus, no Babinski; abdominal
  reflexes present, cremasteric not elicited; catalepsy not always
  present.

  Mental Examination:--Attitude was variable, but was distinctly that of
  one in a stupor. Arms, hands and legs, placed in uncomfortable
  positions, would remain fixed indefinitely, _i.e._, so observed from
  20 to 30 minutes. Did not resent liberties taken with him; smiled in a
  silly fashion at each person. Orientation perfect; no insight;
  hallucinations and delusions could not be elicited. Attention could
  only be gained with great difficulty, and held for a very short time.
  Retardation was present; movements were slow and stiff. When
  stimulated, however, he responded promptly and had no retardation.
  Speech and writing showed nothing characteristic.

  May 11:--Flexibilitas cerea more marked; mutism; retention of saliva;
  eats food voluntarily; bowels require frequent attention.

  May 20:--Requires spoon-feeding; sleeps well; remains always in bed in
  stiff attitudes.

  June 1:--For three or four days refused food, except for one or two
  meals daily. At times suddenly surprises attendants by sensible
  remarks, as: Another patient said, "That is G. W. W.," and patient
  promptly replied, "No, it is Rip Van Winkle." Negativistic signs more
  marked. Knows physician when eyes are pushed open. At times tries to
  whistle.

  June 13:--For past week has been noisy and excited. When he hears
  dishes rattle, yells "Chow-chow" for a long time. Continued hot bath
  for one hour always relieves this excitement. Physical signs negative;
  Wassermann negative; blood and urinary analysis negative.

  June 18:--Admitted to the Government Hospital for the Insane. The
  Marshal who accompanied the patient from California to this
  institution states that the patient was resistive and negativistic;
  that he assumed various constrained attitudes; was untidy, mute, and
  refused food. All these tendencies were markedly influenced, however,
  by positive requests of the Marshal. When told that he would be
  chastised if he did not give up his untidy habits, these disappeared,
  etc. On admission to the Government Hospital for the Insane the
  patient had to be carried into the ward, as he refused to walk. He was
  mute, negativistic, and assumed various uncomfortable and constrained
  attitudes. Every now and then he would snap at those who handled him,
  and this would be accompanied by a growl. He was very resistive to the
  taking of a bath, and suddenly snapped at the attendants who cared
  for him. When reprimanded, however, by the Supervisor, and told that
  he would have to take the bath, he quietly underwent the procedure.

  Physical Examination:--Pupils widely dilated. Face somewhat distorted.
  Pupillary reflexes normal; although limbs would remain in a fixed
  attitude when so placed, he did not evidence the typical flexibilitas
  cerea. It seems as though he anticipated the passive movements, and
  there was present a certain amount of voluntary intent. All
  superficial reflexes active; winced when pricked with a pin but there
  was a decided hypalgesia present. He refused food; was mute, and
  apparently oblivious of everything about him. This, however, was only
  apparently so, as he showed by various acts that he was more or less
  aware of his surroundings. For instance, during the examination he
  suddenly snapped at the examiner, and upon the latter's discomfiture
  he emitted a momentary giggle. When feeding-tube was placed in his
  nose, preparatory to feeding, he jumped up and said, "I'll drink it,"
  and drank the entire contents of the pitcher. While some parts of his
  body remained absolutely fixed, restrained and immovable, his face was
  constantly undergoing various grimacing motions, accompanied now and
  then by the snapping of his jaws and a growl. During the following
  several nights he was very noisy, excitable, singing and shouting
  throughout the night. Mental content could not be determined at this
  date.

  June 28, 1911:--He remains in same apparent stuporous and catatonic
  attitude. For past few days has exhibited various childish and silly
  acts of a meaningless and monotonous nature. Still mute except for an
  occasional growl. Became very untidy today, but when reprimanded and
  told he must use the toilet he did so.

  July 1, 1911:--Patient has been very noisy on several occasions in the
  past few days, but always becomes quiet when requested to do so.
  Continues negativistic, stuporous and attitudinizing. Today he was
  overheard saying: "I am a monkey; want to go out in the yard and sit
  on the benches; there was no plea of insanity; who are those boys?
  Come in, boys; water, won't drink it because there is poison in it, it
  looks good, so try it. Don't believe there is anything in it." He
  persevered in repeating these phrases.

  July 2:--Sang all morning in an undertone. Would stop singing and
  recommence his facial grimaces when anyone entered his room.

  July 3:--For the first time since admission patient answered examiner
  to questions.

  Q. "What is your name?"

  A. "George Washington."

  Q. "How old are you."

  A. "36."

  Q. "When born?"

  A. "1884."

  Q. "Occupation?"

  A. "Farmer."

  Q. "Where born?"

  A. "Around Boston."

  Q. "What day is this?"

  A. "Someone says Tuesday."

  Q. "What date?"

  A. "June 17, 1911."

  Q. "How long have you been here?"

  A. "I cannot tell you."

  Q. "What is the name of this place?"

  A. "U. S. Hospital."

  Q. "Who brought you here?"

  A. "Can't tell you, he looks like a monkey."

  Q. "How long did it take you to get here?"

  A. "One night and twenty-four hours."

  Q. "When did you come here?"

  A. "I cannot tell you when I did come here."

  Q. "Don't you really know the name of this place?"

  A. "Well, sailors in the Navy call it the 'Red House.'"

  Q. "Where is it located?"

  A. "Washington, D.C."

  Q. "What sort of a place is it?"

  A. "Why, it's as good as any place else."

  Q. "Who are these people about you?"

  A. "They might be soldiers; what are they out there for?"

  Q. "Is there anything wrong with them?"

  A. "How should I know?"

  Q. "Are any of them insane?"

  A. "Darn'd if I know."

  Q. "How do you feel?"

  A. "How did I get cured of my headache? I'll stick a pitchfork through
  you, and if a pitchfork goes through you, it will go through me too."

  Q. "Are you sick?"

  A. "I was sick; had a pain in the head."

  Q. "How do you feel now?"

  A. "Oh, pretty good."

  Q. "Is there anything wrong with your mind?"

  A. "I don't know, I can't tell you."

  Q. "Do you hear any strange noises or voices?"

  A. "Can you go over to that tree? Sounds like a baby squealing; it's
  the man that choked the baby."

  Q. "Do you ever see strange things?"

  A. "Did I ever see strange things? I might read about them in the
  magazine."

  Q. "Do you ever hear voices?"

  A. "I hear voices say to you; 'You are not guilty.'"

  Q. "How much money are you worth?"

  A. "$100; I'll give it you for my life."

  As will be seen from the foregoing stenogram, the patient is only
  partially oriented, perhaps more so than he shows, because of his
  tendency to answer questions in a sort of careless manner. There is a
  slight suggestion of "by speaking" (Vorbeireden). The stenogram also
  suggests the possibility of the existence of fallacious sense
  perceptions. Of the utmost importance, however, for our consideration,
  is the fact that the occurrence which brought about the mental
  breakdown plays an important rôle in the consciousness of the patient.
  Amid what may be considered an almost total oblivion to his immediate
  environment, he hears the voices tell the examiner that he is not
  guilty, he would give the $100 which he possesses for his life. These
  are unmistakable signs of the psychogenetic nature of the disorder.

  July 31:--Patient is well oriented, talks in a retarded manner;
  questions are answered for the most part correctly; occasionally, only
  nearly correct. His memory is good for remote events, but very much
  clouded for events which have transpired since the commission of the
  crime. Partial insight is present. He realizes that there must have
  been something wrong with him. Emotionally not deteriorated. Refuses
  to discuss his crime, saying it makes him feel bad; talks in a
  childish, affected tone of voice, and undergoes various grimacing
  movements; gives frequent evidence of being fully aware of occurrences
  in his environment; talks and eats voluntarily and is tidy in habits.
  Occasionally laughs in a silly, affected manner. Flexibilitas cerea
  and catalepsy entirely disappeared; gained considerably in weight;
  continues to show marked tendency to be influenced by occurrences in
  his environment. In general, shows a decided improvement in his
  condition.

We are dealing here with an individual whose past career is uneventful,
as far as is known. He is charged with murder, and upon being tried for
this develops a mental disorder. The symptomatology of his psychosis
could easily be mistaken for that of catatonic præcox, and, as a matter
of fact, had been so diagnosed by the first observer. In studying the
case more thoroughly, however, it becomes unmistakably evident that we
are not dealing here with a case of catatonia. In the first place, the
immediate relation between the emotional shock of the crime of murder
and the probable punishment for it, and the development of the mental
disorder must be taken into consideration. This is not a mere accidental
relationship. But even if we grant that this point cannot be definitely
decided, the psychogenetic character of this case cannot be doubted when
we remember how the entire symptomatology is absolutely dependent upon
and influenced by occurrences in the patient's environment. He refuses
to eat, a symptom very common in catatonia, but it is indeed a rare
occurrence for a catatonic in the midst of a negativistic stupor and
mutism to say, "I'll drink it," and actually drink voluntarily the
entire contents of the pitcher in order to avoid tube-feeding. He is
untidy in his habits, another common catatonic characteristic, but is it
to be expected that a catatonic, in the height of his disorder, will
abstain from his filthy habits when threatened to be punished for these?
Many more instances of similar nature could be cited in this case.

Another feature which removes all doubt of the psychogenetic nature of
this disorder is the important part which the mental experience which
was active in the production of the disorder played in the fashioning
of its symptomatology. I alluded before to the patient's answer to the
question of whether he heard voices.

The disorder itself, as far as the symptomatology is concerned, is not
absolutely typical of any one of the acute psychogenetic states. It
partakes of Kutner's "catatonic states in degenerates" as well as
Raecke's confusional hallucinatory disturbances in these individuals.
That the patient can be classed as one having a degenerative soil is not
at all certain in this case.

I have considered briefly the importance of a proper recognition of
these cases from the viewpoint of rendering a proper prognosis. There
is another important question which must be discussed in connection with
these cases and that is the question of malingering. Picture to yourself
an individual, who, to all appearances, has led a normal existence, and
never showed anything mentally which might be considered pathologic. He
commits a crime, and upon being arrested or upon being placed on trial
for his offense, suddenly lapses into a condition of apparently complete
dementia. The man, who formerly showed nothing in his conduct and
behavior indicative of a mental disorder, suddenly changes into a state
where he does not know his name, age, or his whereabout. His answers to
questions are irrelevant and of a remarkedly silly coloring. He begins
to act in a childish, affected manner, executing many silly, meaningless
acts, or he may break out in a wild furious excitement, loudly
proclaiming his innocence, and threatening those who arrested him. In
addition to this, it is noted that this apparently pathologic condition
can be definitely influenced by using strict and positive measures. The
untidy habits of the patient may be corrected by urging or threats. The
man who has been mute and refuses to eat can be made to talk and eat
voluntarily by threatening him with tube-feeding. Furthermore, in the
midst of this apparently total dementia, total blocking of all thought
processes, the patient frequently surprises those about him by very
sensible remarks of a very clever and pertinent nature, indicating that
although apparently oblivious of his environment, he knows what is going
on about him.

A picture like this may readily arouse the suspicion that we are dealing
with a malingerer, and, indeed, some very prominent German psychiatrists
have reported as malingerers cases similar to this. The trained
psychiatrist, if unfamiliar with this class of cases, will find himself
at a loss to know under what known group of mental disorders to place
this condition, as it will at once become apparent to him that it does
not fit into any of the well-known psychoses.

In defense of the genuineness of the psychotic manifestations of these
patients, I would recall again the transitory mental disturbances of
students undergoing examinations. The genuine loss of all knowledge of
well-known facts which the old-time strict and severe schoolmasters
frequently provoked in school children, differs very little from the
pseudo-dementia with which we are dealing here. It concerns a similar
total blocking and inhibition of all thought processes, and, like all
psychogenetic disorders, has a tendency to disappear upon the removal of
the causative factor.

Still, nobody would think for one moment that the child malingers when
it is unable to answer questions, though these might concern well-known
facts. The consequences of failure to recognize this acute
prison-psychotic-complex as a genuine mental disorder may prove to be
very disastrous when we remember to what extent the symptomatology of
these psychoses is dependent upon environmental conditions.


THE DEGENERATIVE PSYCHOSES

I have considered thus far those psychogenetic mental disorders, the
etiologic factor of which consisted of a single, more or less isolated
emotional occurrence. We have seen that the majority of these patients
showed very little, if anything, in their past life which was in any way
incompatible with leading a more or less successful existence in the
community in which they lived. These patients, we might say, would never
have been brought to the attention of the psychiatrist had it not been
for the occurrence in their life of an experience which provoked a
mental breakdown.

I will now consider a group of cases, in whom the degenerative soil is
so prominent that they have been properly called "Psychoses of
Degeneracy." They should, however, be considered here, because the
various psychotic manifestations of these individuals are purely
psychogenetic in nature, and evoked by a certain milieu in which the
individual was placed. As my material is derived from the criminal
department of the Government Hospital for the Insane, the causative
factor in these cases will again be found to be imprisonment. These
cases differ from the so-called acute prison-psychotic-complex in that
the etiologic factor does not consist in a single emotional experience.
We are not dealing here with patients in whom the commission of a crime
is an accidental occurrence in their life, that is, still uncorrupted
individuals upon whom the criminal act in itself might act in a
deleterious manner. The patients belonging to this group are, as a rule,
old offenders, who have long been hardened to crime, and whose entire
life is an uninterrupted chain of conflicts with the law. To this group
also belong those high-strung individuals with early antisocial
tendencies, who from childhood show a marked degree of egotism and
self-love; who are very vindictive and revengeful in their reaction to
frictions in social life. Upon falling into the hands of the law, they
are incapable of adjustment to the new situation, react in an insane and
wild manner to the prison routine, and, in consequence, frequently
commit grave offenses during imprisonment.

We owe our present knowledge of the psychopathology of these individuals
to the excellent work of the followers of the great Magnan, who
contributed so richly to the study of degeneracy.

Siefert[9] was the first to clearly differentiate the purely endogenetic
disorders from those dependent upon a degenerative soil, and evoked
exclusively by outside influences. He divided the eighty-seven cases of
psychoses in criminals studied by him into two distinct groups, namely,
the real psychoses and the degenerative psychoses. Under the former
thirty-three cases he places the well-known forms of dementia præcox,
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 præcox, 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
  œsophagus. 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
  gonorrhœal 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 régime 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 régime 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 régime, 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 Seelenstörungen in der Gefangenschaft."
_Allgem. Zeitschr. f. Psych._, 1871, Bd. 27, p. 405.

[4] MOELI: Ueber irre Verbrecher, 1888.

[5] GANSER: "Ueber einen eigenartigen hysterischen Dämmerzustand."
_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 Dämmerzustandes."
_Allgem. Zeitschr. f. Psych._, 18. 115, 1901.

[8] KUTNER: "Ueber Katatonische Zustandsbilder bei Degenerierten."
_Allgem. Zeitschr. f. Psych._, 67, p. 363.

[9] SIEFERT: "Ueber die Geistesstörungen der Strafhaft." Halle a. S.
1907.

[10] BONHOEFFER: "Klinische Beiträge zur Lehre von den
Degenerationspsychosen." Halle a. S. 1907.

[11] BRATZ: "Dass Krankheitsbild der Affect-Epilepsie." _Aerzt.
Sachverst._ Berlin, 1907. XIII. 112-116.

[12] STURROCK: "Certain Insane Conditions in Criminal Classes." _Journal
of Mental Science_, 56. 1910, p. 653.

[13] BIRNBAUM: "Psychosen mit Wahnbildungen und wahnhafte Einbildungen
bei Degenerierten." Halle a. S. 1908.




CHAPTER II

THE NATURE AND TREATMENT OF THE PSYCHOSES OF PRISONERS


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

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

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

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

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

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

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

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

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

As a matter of fact, the population of institutions for insane criminals
divides itself into two distinct and unmistakable groups. On the one
hand we meet with the well-known functional and organic psychotic
entities such as occur in individuals in freedom; we see patients who in
the course of their careers as insane people have come in conflict with
the law either accidentally or because of their insane ideas. In them
the psychosis develops and takes its definitely determined course
independently of the milieu in which the individual happens to be
placed. In the majority of instances they suffer from the various forms
of dementia præcox and progress toward demential end-results in the same
proportion as the general run of dementia præcox 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 sequelæ 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 régime 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 régime 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 régime. 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
régime, 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 præcox, 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 gonorrhœa 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 gonorrhœa; 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 régime 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 præcox, or with one of the
degenerative psychoses? If we agree with Stransky[5] that dementia
præcox depends upon an intrapsychic ataxia, that it is the disturbed
coördination between the intellectual and affective faculties of the
individual which makes the picture of dementia præcox what it is; this
is not a case of dementia præcox. 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 incoördination
between his feeling and acting, would, in itself be sufficient to
separate his psychosis from dementia præcox. If we agree with Kraepelin
and others that dementia præcox 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 præcox. Our patient
has had the same attributes of character and personality always. There
is no indication in his life history of a definite onset of a retrograde
process, or of any progression towards dissolution. His psychosis, such
as it is, is the outgrowth of his degenerative personality, and if we
assume this to be true, if we consider the psychotic manifestations of
this individual as a pathologic expression of his anomalous personality,
the question arises--to what extent have his criminal acts likewise been
pathologic expressions of the same underlying degenerative basis? I
believe that the relation between the criminality and mental alienation
of this man is analogous to that existing between two branches of the
same tree. The same degenerative soil which makes the development of the
psychosis possible in one case, expresses itself in crime in another
instance. The factors which determine whether the one or the other phase
will manifest itself, depend largely upon environmental conditions, and
are accidental in nature. The stresses which these defective individuals
meet with in freedom need not have such a strong influence upon them as
to produce a psychosis. The want of moral attributes makes it possible
for them readily to surmount many difficulties by means of some criminal
act, difficulties which in a normal person would require extraordinary
effort to remove. When placed, however, under the stress of imprisonment
where they can neither slip away from under the oppressive situation,
nor square themselves with it by some criminal act, the organism becomes
affected to such a degree that the development of a psychosis is greatly
facilitated. The character of the delusional fabric of these individuals
is such that one can easily find a ready and more or less correct
explanation for it. It is chiefly a compensatory reaction in an endeavor
to make a certain unpleasant situation acceptable.

  CASE II.--J. H., aged 37. Admitted to the Government Hospital for
  the Insane, March 8, 1909. Maternal grandfather died suddenly from
  unknown cause. Was a race-track operator. Father alcoholic. Mother
  suffered from vertiginous attacks. There were twenty-one children in
  the family, fifteen of whom died in infancy. One brother died of brain
  tumor. One sister is neurotic; her eight year old son suffers from
  congenital heart disease. Patient was born in Manchester, England. He
  was the twentieth child; mother was over forty years old at the time
  of his birth. He was an unusually small and puny infant and remembers
  using crutches when a child. At seven he was bitten by a dog and
  dragged about on the ground for a great distance; when finally
  rescued was unconscious for a long time. No further ill-effects.
  School life was characterized throughout by truancy and disobedience
  and finally terminated in expulsion. At that early period of life he
  already showed marked egotism, extreme vindictiveness and an utter
  disregard for consequences. The immediate cause of his expulsion from
  school was a fistic encounter with a teacher. At the age of eleven,
  his family immigrated to this country. He states that he was different
  from other boys of his age, did not care for the ordinary childhood
  sports, and the only friends he had were a young sister and a dog. He
  states that he couldn't get along somehow with the other boys, that he
  often thought that the whole world was trying to down him and
  persecute him. About that time someone stole his dog. He brooded over
  this so much that he finally jumped into a creek, intending to commit
  suicide, but was rescued by bystanders. He has made several other
  attempts at suicide in later life. In describing these he elaborates
  them with a lot of fanciful trimming, dilates on the importance of the
  various situations attending them, and how much uproar they caused
  among those who knew of them. At the age of fourteen he had a quarrel
  with another boy. Upon being reprimanded by the latter's father, he
  could not rest until he had obtained a gun and fired at the boy's
  father while the latter was sitting at the supper table with his
  family. In relating this incident he states with great vanity that he
  fully intended to kill the boy's father; he wasn't going to be
  insulted by anyone and let it go at that. Here was probably the first
  well-illustrated instance of his pathologic emotionalism, the tendency
  to a complete dominance of a certain affect. He was committed to some
  sort of an industrial school for a year. Upon his release from there
  he went to work in a machine shop in his native town. One day a couple
  of gentlemen and a lady walked through the shop and stopped in front
  of the machine on which he was working. He did not like this, became
  angered, picked up the dog which followed them and threw it into the
  oil tank which fed his machine. At sixteen he ran away from home. He
  gives a history of an industrial career and apparently he had no
  difficulty in learning a trade, and it is quite likely that he was a
  skilled workman. His entire industrial career, however, is
  characterized by an inability to fit harmoniously into the situation
  at hand, not because of an intellectual deficiency, but because of the
  disharmony between his various mental faculties. His extreme
  sensitiveness and emotionalism, his vindictiveness, the total lack of
  a sense of responsibility, his impulsive existence, all these, were
  always at play in his relations with man. If to these be added his
  extreme egotism and vanity, the reasons for his conflicts become
  clear. "Here, the foreman thought he knew more than I did." "There, I
  did not like the way they were running the business," etc. Among his
  occupations, saloon-keeping and professional gambling played an
  important rôle. He finally gave up all attempts at leading an honest
  existence and turned to crime. Our record of the man in this regard is
  rather incomplete, but according to his record at the Secret Service
  Bureau, he was sentenced in 1890 to a two years' term for highway
  robbery. In 1902 to three years for counterfeiting; in 1904 to three
  and a-half, and in 1908 to six years for the same offense. These
  sentences were incurred under various aliases. He married at a very
  early age. He says he made up his mind one night to get married and
  two days later was married. His conjugal life, like everything else he
  engaged in, proved a failure and was characterized by repeated
  desertions. He commenced using alcoholics at a very early age and has
  indulged excessively all his lifetime. He has had several gonorrhœal
  infections, and has an active luetic infection at the present time.
  On May 5, 1908, he was sentenced to a six years' term of
  imprisonment. Soon after it became necessary to perform an operation
  for appendicitis, and upon recovering he began to complain of having
  been cut open and of having had poison put inside of him. The U. S.
  Government sent men down to the prison who were threatening to kill
  him. He saw detectives from Washington whom he recognized. He was very
  apprehensive and refused to submit himself to an examination, and made
  homicidal attacks upon the officers. On March 8, 1909, he was admitted
  to this institution. His conduct here was characterized throughout his
  entire stay by the same attributes of character which were at play
  throughout his entire antisocial existence. He was at all times very
  emotional. He was very sensitive, becoming offended on the least
  provocation, and when laboring under some imaginary grievance his
  antagonism and vindictiveness knew no bounds. He was constantly
  plotting and scheming some means of inciting a revolt among the other
  inmates and took every opportunity to put himself forth as the
  champion of the other patients. He was very egotistical and vain and
  showed a marked tendency to interpret most trivial occurrences in his
  environment as having some reference to him. He was always ready to
  endow every incident with a personal note of prejudice. He showed
  throughout marked fluctuations of mood. One never knew what sort of a
  reception one would meet. He was a pathological liar, was keenly alert
  to everything that transpired about him and was always ready to
  utilize every incident to his own advantage. He was depraved to a very
  marked degree morally. He gave his past history without the least sign
  of regret and when questioned concerning the reason of his criminal
  life, he objected strenuously to being called a criminal, insisting
  that what he did was right. At times he impressed one by his mode of
  reaction to various daily occurrences as being as naïve as a child
  and suggestible to a very marked degree. He frequently threatened to
  commit suicide if refused some of his impossible requests and showed a
  marked tendency to hypochondriasis and exaggeration of actual ills. On
  this basis he developed various persecutory ideas, exclusively against
  those who had anything to do with his care and safe-keeping. The
  warden at the jail before he came here tried to poison him and took
  the opportunity of accomplishing this while he (the patient) was
  undergoing an operation. The Government sent Secret Service men down
  to watch him and persecute him. Here the physicians are doing the same
  thing. They are trying to down him, to make his life miserable for
  him, etc. Throughout his sojourn here he was clearly oriented, knew
  everything that was going on and failed to show the least indication
  of the existence of a deteriorating process. He showed also a marked
  tendency to write a good deal of poetry and fiction in which he spoke
  of himself as a martyr who had been persecuted and downed all his
  lifetime. His stories were of a fantastic, adventurous kind, in which
  gambling, shooting, and similar highly melodramatic situations were
  enacted. On July 17, 1911, he was returned to prison as recovered.
  Another point of interest in this case and one to which I have briefly
  alluded before, was his tendency to the exaggeration of symptoms and
  to malingering, but the malingering which he manifested was of the
  kind that the child manifests in an endeavor to attract attention to
  itself and to arouse the sympathy of those about him.

Here again we have before us a kaleidoscopic picture of the life of a
human being who from childhood showed tendencies so antisocial, so
criminalistic, that it is hard to get away from the belief that most of
the attributes which went to make him just what he is, must have been
inherited. Let us take this poorly-begotten organism and follow it
through life. We shall see how its existence has been a continuous round
of conflicts with everything it came in contact. He entered school and
meets with the first obligation, with the first necessity for a
well-regulated, purposive existence. What is the result? Truancy,
disobedience, and finally expulsion--not because of intellectual
deficiency, but because of those same attributes which later served to
put him in the penitentiary. It was the first evidence of his pathologic
emotionalism and vindictiveness. We next see him in an effort to lead an
industrial life, but here, too, everything he does proves a failure, and
likewise not because of intellectual deficiency, but because of a
disharmony, a disproportion, between his various mental faculties. He
could not, somehow, submit himself to any well-regulated existence. His
egotism and absolute lack of the sense of responsibility made it
impossible for him to adjust himself effectively to the world about him.
He next tries matrimony, and the same story reasserts itself. His
conjugal life is characterized by repeated desertions; and thus he
becomes steadily more debased, more depraved, sinks to the level of the
professional gambler and finally even this becomes too strenuous for
him, and he turns to a life of crime. At the age of forty we find him
with a record of numerous arrests, and as far as known, one-fourth of
his lifetime has thus far been spent in jails and penitentiaries. The
characterological anomalies at the bottom of his career came to the
front already in his childhood days. Before completing his fourteenth
year we find him deliberately planning the murder of a human being
because of an insult. His idea concerning that situation has not
changed in the least since then. He now speaks of it without the least
sign of remorse or regret. As a matter of fact, he is inclined to
impress one as being rather proud of that deed, and he cannot see the
criminality of it. The atavistic nature of his act in throwing the dog
into the oil tank is quite evident. Then his attempts at suicide
throughout his lifetime, evidence of a pathologic emotionalism, must
also be remembered. These are a few examples of his mode of reaction to
everyday occurrences in life. Is it at all strange that he has developed
finally into the habitual criminal? On the contrary, it would be rather
strange that an individual with such attributes should turn out to be an
honest, peaceful citizen. He likewise was a prey to all the vices of
modern civilization, and these, as in the preceding case, unquestionably
added to the dissolution of the originally defective organism. We
finally meet with an illustration of the other phase of his mode of
reaction. Following imprisonment on a charge of robbery, he develops a
psychosis which necessitates his transfer to an insane asylum. Brief as
the description of his psychosis has been, it is sufficient to
illustrate that here we are likewise dealing with a psychogenetic
disorder manifesting itself as a reactive expression of a degenerative
constitution to an unpleasant situation. Shortly after his arrest he is
being operated upon for appendicitis and upon recovery elaborates the
idea that the warden of the jail, one of the members of that large class
against whom he has been warring all his lifetime, takes this
opportunity of placing poison in his body. He sees and hears people
around his cell whom he recognizes as Secret Service men sent down from
Washington to torture him. On his transfer to our Hospital he readily
carries over his delusional ideas to the officials here. He is simply
being persecuted by a bunch of anarchists, who are trying to down him
and make life miserable for him.

It has long ago been questioned by psychiatrists whether these so-called
delusional ideas of this class of patients deserve to be endowed with
the value of delusions. Let us not forget that a similar attitude toward
officialdom exists in the minds of criminals enjoying a respite from the
law. It is the officers of the law, society's institution for the
prevention and punishment of crime, that these people have to fear, and
when they speak of being persecuted by those who have their care and
safe-keeping in hand, it is not, necessarily, a pathological
manifestation. The only difference between such paranoid ideas in the
criminal at freedom and the one in confinement is that in the latter
case, coupled with the stress of confinement, the stress of a forced
routine existence, these ideas assume enormous proportions and in some
instances become supported by fallacious sense perceptions. Their
exaggerated self-consciousness, their great tendency to introspection, a
tendency which is very much enhanced by confinement and plenty of
leisure time for such indulgence, and their paranoid attitude toward law
and its officers, makes it possible for them to endow the least
significant occurrence in their environment with a personal note of
prejudice. The least deviation from the normal routine has a meaning to
them, a meaning which is readily interpreted as some evidence of
persecution, of prejudice, etc. The course of their disorder shows so
much evidence of this psychogenetic character that it is impossible to
think that we are dealing with a psychosis which apparently has no
relation to the situation at hand. Every symptom which they manifest
can be traced to some definite cause and can be clearly explained as
being of the nature of a reaction, of a motivated expression to a
definite experience. It is, I believe, unnecessary to enter into a
lengthy discussion to show that we are not dealing here with a case of
dementia præcox, but with one of the degenerative psychoses and we will
consider the criminal tendencies of this individual likewise as
expressions of that same degenerative soil which permitted of the
development of the psychosis. On July 17, 1911, the patient was returned
to the penitentiary to serve out the remainder of his sentence.

  CASE III.--P. F., alias H., white male, aged 42. Admitted to the
  Government Hospital for the Insane, March 11, 1910.

  Father is a chronic alcoholic; one brother a wanderer, has not been
  heard from for twenty years; one sister a suicide; one sister left
  home at the age of eighteen and has not been heard from since.

  Patient was born in England in 1868. Was a healthy child as far as he
  knows; no history of spasms or convulsions. Talked and walked at the
  usual age. Of the diseases of childhood he had whooping cough, measles
  and scarlet fever, from which he apparently made good recoveries.
  Entered school at the age of seven; attended irregularly until he was
  twelve years old. After leaving school he made an attempt at learning
  a trade and worked as apprentice for some time. At fifteen he
  endeavored to enlist in the British Navy, but was rejected on account
  of palpitation of the heart. In 1884, at the age of sixteen, he joined
  the Royal Marines; soon found this to be disagreeable to his tastes,
  and wanting to secure his discharge, he stole a suit of clothes off a
  dummy with the avowed purpose of being discharged for the offense.
  Was arrested, plead guilty, and served a sentence of one month. In
  1886, at the age of eighteen, he enlisted in the Royal Fusileers and
  deserted therefrom about a month later. He then reënlisted in the
  eighteenth Royal Irish Fusileers, shortly after deserted, and then
  gave himself up; was court-martialed, dishonorably discharged, and
  given a sentence of six months which he served in Brixton's Military
  Prison, London. In 1887, at the age of nineteen, under the name of
  Henry Sayers, he joined the Welsh Division of the Royal Artillery,
  whence he deserted two months later and sold a kit and coat belonging
  to another recruit; was apprehended, tried and given a sentence of six
  months. In all, he was dishonorably discharged from the service seven
  times. In 1892, at the age of twenty-four, he immigrated to this
  country. On arriving here he worked about a month at railroading and
  then enlisted in the Army, deserted after serving three months, and
  crossed the Canadian Border. He subsequently returned and gave himself
  up to a sheriff, was court-martialed, dishonorably discharged, and
  given a sentence of one year and a half. After being released he
  resumed his nomadic existence but in a more pronounced manner. Since
  1895, he has had no definite occupation, subsisting on begging,
  stealing, and peddling minor articles, chiefly on the two former. He
  has spent most of his life since then in penitentiaries and
  workhouses, and when at liberty, in cheap boarding-houses and
  missions. As far as he can recall he has been arrested twenty-two
  times for vagrancy since 1895, served four years at Moundsville and
  Atlanta for robbery, and six months for theft. He commenced to indulge
  in alcoholics at a very early age and has been an excessive drinker
  all his life. Has been intoxicated on numerous occasions and has had
  delirium tremens twice. In 1897 he indulged in opium smoking for
  thirteen days and in 1904 sniffed cocaine for a similar period. On
  three or four occasions in his life he has had sexual experiences
  with men and there is a definite history of inversion. He has been
  married twice. His conjugal life with his first wife was a very
  unhappy one. He attributes this entirely to his own fault. There were
  three children from this union, all of whom died in infancy. He left
  his first wife without obtaining a divorce from her and subsequently,
  in 1898, married again. This union was happier than the former one.
  His second wife, however, died in 1905. There were no children from
  this union. He acquired gonorrhœa and syphilis in 1899. In 1907 he
  prepared an elaborate attempt at suicide, purchased a dagger for this
  purpose, and set June 13th for the date. He was, however, arrested
  shortly before this and thus his plan was frustrated. He stated that
  it was not disgust of life that drove him to do this. He simply had a
  desire to see whether he had the nerve to execute such an act. On
  February 2, 1910, was arrested for vagrancy and begging, and given a
  sentence of 180 days in the workhouse. While in his cell he attempted
  suicide by inflicting superficial cuts over the præcordium, wrists and
  calves of his legs with a piece of broken table knife. These were very
  insignificant in nature. While confined in the workhouse he developed
  various fallacious sense perceptions, saw visions of weird and
  fantastic nature, and frequently these would take on a religious and
  sexual coloring--he would see nuns' heads. He also developed auditory
  hallucinations and would hear voices of a disagreeable nature. He was
  subject to peculiar sensations as though there was a wire framework
  inside him which made him squirm. This necessitated his transfer to
  this institution.

  On admission he was well-nourished, but prematurely gray. He had
  numerous tattoo marks on his body; on the right forearm a woman in
  tights and the head of another; on the left forearm initials U. S.,
  flag, ship and cross; over the dorsum of left hand a star, and a band
  across the wrist. His vision was impaired to some extent; otherwise
  negative. Aside from a futile attempt at suicide which he made shortly
  after admission, his conduct has been excellent. He has never been
  known to become involved in altercations or quarrels with his fellow
  patients and has obeyed fully the rules and regulations of the
  Hospital. He was somewhat circumstantial during a lengthy
  conversation, but in a superficial interview he made quite a natural
  impression. He was clearly oriented and showed no memory defect. His
  answers to the intelligence tests failed to show any intellectual
  impairment. His emotional tone was unvaried. He was always very
  polite, courteous and optimistic, and very popular with the
  attendants. He willingly assisted with the ward work at all times, was
  keen and alert, fully cognizant of everything that transpired about
  him. He spent his time reading and rarely associated with his fellow
  patients, whom he considered below him intellectually. He believed in
  reincarnation, and thought himself to have been in a former being
  Pharaoh of Egypt and the Earl of Warwick. He had tactile, auditory and
  visual hallucinations of a religious and sexual coloring. These were,
  however, transitory in type and perhaps better called
  pseudo-hallucinations, as he was able to bring them on and cause their
  disappearance at will. He was frank in his statements and discussed
  the various ideas without hesitation. He was inclined to write a great
  deal, especially poetry of the waste-basket variety, and considered
  himself quite proficient in this respect. On February 2, 1911, he
  appeared before the Staff conference where the advisability of
  granting him parole of the grounds was considered. Upon being refused
  this privilege he again attempted suicide by making several
  superficial cuts across the wrists. These were quite insignificant in
  nature. At the present writing the patient, I am told, if anything,
  had improved somewhat. At any rate he shows no intellectual impairment
  nor evidence of any progressive mental disorder. Patient was
  eventually discharged on April 7, 1915, as unimproved and went to work
  in a steel-plant in the District of Columbia. He soon, however,
  reverted to his old alcoholic habits, came in conflict with the law
  and was sentenced to the workhouse. While his strictly psychotic
  symptoms subsided it is quite evident that the original defective
  constitution which has been responsible for all of his past
  difficulties has not improved.

  Here is another individual who started out in life with a heavy
  hereditary burden. His early childhood, as far as can be determined,
  was normal. He entered school and here met the first obligation. He
  wavered, showed a tendency, that early, to be unable to lead a
  well-regulated life and in consequence his school attendance was
  irregular. The next difficulty he met was in attempting to learn a
  trade. He soon found this too strenuous and sought an environment less
  exacting in nature, and at fifteen we see him endeavoring to enlist in
  the Navy. This is probably the first indication of his "wanderlust."
  He was rejected, and after another year's effort to get along in his
  immediate environment, finally succeeded in entering the Navy. Soon,
  however, he found out that Navy life was not what he had pictured it
  to be. It, likewise, was too exacting. He had to live up to prescribed
  rules, obey orders--things to which he could not reconcile himself,
  and in consequence failed of a proper adjustment. He knew he could not
  stand it, he must get out. He must seek something more suitable,
  something less exacting. In looking for a way out of the situation he
  availed himself of the first opportunity, stole a suit of clothes with
  the avowed purpose of being discharged for the offense. Here is the
  starting point of his criminal career. He did not reflect upon the
  consequences. He knew he must gratify his desire to get out of the
  Navy, must do it at any cost, and yielded to temptation. This yielding
  to temptation, this lack of power of resistance, characterized his
  entire life. He yielded to every vice that crossed his path; he stole,
  he drank, he became a morphine habitué, he sniffed cocaine, acquired
  gonorrhœa and syphilis in his promiscuous sexual trends, and lastly
  yielded to sexual perversion. After having served his first sentence
  he was released and again found himself thrown upon his own resources.
  He had not, as yet, reached the stage of the habitual criminal with
  the utter disregard for property rights, nor had he reached that
  nonchalance of the hobo, whose philosophy rests upon the dogma that
  the world owes him a living, that tomorrow will provide for itself
  somehow. He began to yearn for the service again. There, at least, he
  was provided with shelter and food. There, at least, he did not have
  to worry for the tomorrow. He entered the Army, deserted, re-entered,
  deserted again, and kept this up until he was dishonorably discharged
  seven times. He could stand it just so long. His lack of stability,
  his inability for any continuous purposive effort, made him slip from
  under the stress. He has less dread for the future now. He was
  beginning to acquire that naïve philosophy that somehow the world
  would provide for him. We next hear of him across the ocean. Here his
  "wanderlust", his love of adventure, reasserts itself, but somehow he
  did not fit into existing conditions, and unable, because of his
  particular organization, because of his disequilibrated mentality, to
  create for himself a suitable environment, his existence continued to
  be an unbroken chain of conflicts, of contradictions, and of failure.
  He finally tried matrimony, but here, too, he soon felt the
  overwhelming burden of duties and obligations. He was not assisted in
  sustaining these by any moral sense, by any paternal feelings--and
  after a more or less continuous struggle to cope with the situation,
  left wife, situation and all. He realized subjectively that he and his
  wife were not congenial. As a matter of fact, his entire life has been
  a continual round of uncongenialities, of inability for a proper
  concourse with men and things in the world. Throughout his life his
  ego occupied the center of the stage. It is he that has to be
  satisfied first. After leaving his wife he resumed his nomadic
  existence and sometime later married again. But by this time he was a
  full recidivist, as well as an accomplished hobo. The nomad was no
  longer able to adjust himself to a communal existence. Besides, it
  required effort. He was expected to provide and he could not be
  expected to do anything. Fate was in his favor--his wife died. It must
  not be forgotten that by this time he had made full use of the kind
  oversight of the law. He had been arrested innumerable times, he had
  breathed the atmosphere of the workhouse and partaken of the
  penitentiary menu. The once unfinished product had been shaped and
  polished by the machinery of the law and order of our modern
  civilization so that all dread and fear of punishment had lost its
  value with him. At last the organism which was originally begotten
  from decayed stock, which had been tossed and knocked about through
  its entire existence, and preyed upon by all the vices that modern
  civilization affords, began to falter and shake. He developed a
  psychosis. I shall not enter here into an extensive discussion as to
  the diagnosis of the disorder. The total absence of any indication of
  progression in this man's mental disorder, the pliability of the
  various delusional ideas and hallucinatory experiences, his perfect
  control over them in the matter of bringing them on and causing their
  disappearance at will, speaks sufficiently against dementia præcox.


  CASE IV.--A. W., colored, aged 28. Mother suffers from neuralgia and
  headaches; one sister died of pulmonary tuberculosis. One brother is
  now serving a sentence at Moundsville Penitentiary for assault and
  battery. Another brother has been frequently arrested for various
  offenses.

  Birth and childhood of patient apparently uneventful. During childhood
  fell from a fence following which he was unconscious for some time.
  Entered school between the ages of seven and eight, and attended
  regularly for about two years, when he became unruly and
  ungovernable--would play truant on frequent occasions, and finally
  left school before finishing the fourth grade. He worked around home
  for a little while, and was arrested the first time when eleven or
  twelve years old, for assault. At fourteen he was again arrested for
  some minor offense, and shortly afterwards was sentenced to one year
  in jail. On August 20, 1902, at the age of eighteen was arrested for
  carrying concealed weapons and discharging them in the street, for
  which offense he served five months in jail. March 3, 1903, sentenced
  to serve thirty days for larceny, and on the same date was further
  charged with disorderly conduct, for which he was given fifteen days
  in the workhouse. May 1, 1903, he was sentenced to sixty days in jail
  for petty larceny; July 18, 1903, charged with fornication, but charge
  was withdrawn. August 31, 1903, sentenced to thirty days in jail for
  being drunk and disorderly, and committing assault. November 1, 1903,
  sentenced to fifteen days in the workhouse on a charge of disorderly
  conduct. November 17, 1903, sentenced to twelve years for assault and
  highway robbery. He commenced using alcoholics at a very early age,
  and has indulged heavily since then. He was admitted to the
  Moundsville Penitentiary, December 13, 1903, where he remained until
  July 4, 1908, when he was transferred to Leavenworth. His record at
  the penitentiary is a very bad one, he was frequently punished for
  various offenses and showed a constant tendency to disobey rules and
  get into altercations with fellow prisoners. He was in solitary
  confinement several times, and forfeited almost all of his good time.
  Frequently became mildly excited, singing, shouting, praying and
  cursing in the most irrational manner. This state of excitement
  persisted unremittingly for seventy-two hours on one occasion. He
  declared that his lungs were rotting with tuberculosis or some other
  foul disease, and that he was suffocating. He persisted in exposing
  himself in a nude condition and refused nourishment.

  He was admitted to the Government Hospital for the Insane,
  December 24, 1909.

  Physical examination showed him to be a well-developed, healthy negro.
  Both deep and superficial reflexes exaggerated; ankle clonus both
  sides; hyperæsthesia of abdomen and face. He stated that two or three
  months prior to his admission to this Hospital he became suspicious of
  his food; had a burning in his stomach after eating; believed that his
  health was failing him; his breath became short; voice weak and lungs
  rotting. Early in December, 1909, he believed that he had been
  chloroformed by the prison officials for five days; he was not certain
  how this was done but believed that it might have been poured through
  the keyhole. During this period he sang like a graphophone; voices
  said "move his head", and his head would move itself. When his eyes
  were open he saw nothing unusual but when they were shut he could hear
  them operating a machine on his body; they were pumping his stomach,
  and he became a skeleton. This was done to him through prejudice; did
  not know who was prejudiced against him, but at the prison they know
  all about it. Said he had not slept a wink since his admission to the
  Hospital; his breath is short; he has pains around his heart, but
  thinks he is getting better now.

  He was a negro of limited mental capacity and possessed very little
  acquired knowledge. He was clean and tidy in his habits, keenly
  interested in his environment, and well oriented in all spheres. He
  lacked insight into the nature of his trouble. Attention could be
  easily gained and held; he comprehended well and readily, and showed
  no memory defect. There was a very marked tendency to hypochondriasis
  and exaggeration of actual ills. Soon after admission the active
  symptoms of his disorder disappeared, and he gradually acquired an
  adequate amount of insight, realizing that he had been insane. His
  conduct, at first orderly, now assumed the same character as that at
  prison. He frequently became involved in altercations with other
  patients and on several occasions manifested decidedly vicious
  tendencies. He was almost absolutely unamenable to the Hospital
  regulations and on that account had to be frequently reprimanded. He
  incited the other patients in his ward to all sorts of misdemeanors,
  and when not having any complaints himself, would fight the other
  patients' battles. He remained clearly oriented throughout. He was
  decidedly deficient morally--could not see where his life had been an
  unsocial one, and did not even promise to lead a better one in the
  future.

  Here, again, we see disease and crime rampant in the family history of
  a man who himself began to manifest criminal tendencies at a very
  early age. His school career is characterized by truancy, and he never
  made an effort at an industrial career. At the age of eleven or
  twelve, we already find him arrested for an offense against the
  person, and before having reached his twentieth year he has received a
  penitentiary sentence of twelve years. His psychosis is unquestionably
  one belonging to that large group developing on a degenerative basis,
  the same soil which is at the bottom of his criminal career. What his
  future life is going to be may readily be surmised; he has not yet
  reached his thirtieth year--and by turning him loose at the expiration
  of his present sentence, society adds only another parasitic and
  infective organism to gnaw at its roots. It would be indeed ridiculous
  to expect the boy who at the age of nineteen was placed in the
  environment of a penitentiary--the hot-bed of crime--to be turned out
  a better man after having spent twelve years there. Something over two
  years has elapsed since the original publication of this paper and I
  am able to furnish some additional data concerning this case.

  Upon the expiration of his sentence we were obliged to discharge the
  patient because he showed no symptoms of mental disease, and in
  consequence we had no authority for holding him in a hospital for the
  insane. He was discharged in March, 1912. In October of the same year
  he was again arrested, charged with assault with a dangerous weapon
  and received a seven-year penitentiary sentence.

  There can be very little doubt as to what his future career will be
  following this second penitentiary sentence.


  CASE V.--W. A., white male, aged 36 on admission to the Government
  Hospital for the Insane, January 18, 1911. Father was an alcoholic;
  mother neurotic, one sister insane, one uncle suicide. Mother enjoyed
  good health during her pregnancy with the patient, but birth was an
  extremely difficult one.

  Patient learned to talk and walk at the age of five, when he was
  severely scalded which necessitated his confinement to bed for a long
  time. Entered school at the age of seven and attended for about eight
  years, reaching the 6th grade. He experienced no difficulty in
  learning but played truant on frequent occasions. His industrial
  career constitutes an uninterrupted chain of failures. He was
  frequently discharged for various offenses and quarrels with his
  associates. He commenced to indulge in alcoholics at a very early age
  and has been an excessive drinker all his life. Married in his
  twentieth year and managed to live with his wife for six years, when
  she left him on account of infidelity, non-support and drunkenness.
  One miscarriage and one apparently healthy child were the results of
  this union.

  He came in conflict with the law for the first time at the age of
  twelve or thirteen for some offense against the person. We have an
  incomplete record of his criminal career, but this can easily be
  surmised when we take into consideration that part of it which we do
  possess. Between March, 1903, and December, 1910, he was arrested
  thirteen times for assault, twenty-eight times for disorderly, and
  drunk and disorderly, twice for housebreaking, once for petty larceny
  and twice for vagrancy. Habitual drunkenness, destruction of private
  property, and depredation on house furniture, add to the list of
  charges against him. During this period he served a penitentiary
  sentence, was tried for murder, and acquitted on a second trial on a
  plea of self-defense, and on four different occasions, was ordered to
  be examined mentally. Following a debauch, during which he was
  arrested three times for assault, he developed a mental disorder in
  jail while awaiting trial, which necessitated his transfer to the
  Government Hospital for the Insane.

  He developed the idea that someone was always around him looking for a
  chance to kill him. Continually heard strange voices and noises. Was
  very nervous and irritable.

  The records accompanying him stated that for years he had had a
  particularly bad and dangerous temper. That he had had several
  previous attacks of mental disorder; had repeatedly committed
  assaults, and was found not guilty of murder seven years ago--an act
  of insanity. Had been arrested by the Washington police about
  seventy-five times.

  His mental disturbance soon cleared up, and on admission to the
  hospital he was absolutely free from any psychotic manifestations.

  He was a well-developed man of average intellectual attainments. He
  was somewhat unstable emotionally, and his promises to lead a better
  life in the future were usually accompanied by a good deal of crying.
  He was a monumental liar, and although endeavoring to impress the
  examiner with the idea of being quite remorseful about his past life,
  it was clearly evident that his moral status was a very low one and
  that his promises and resolutions were merely brought forth to aid him
  in securing his freedom. He was extensively tattooed and showed
  remains of an old syphilitic lesion.

  Upon his release from the Government Hospital for the Insane, he was
  given a year's sentence in the workhouse, and the Press has been
  reporting frequent misdemeanors performed by him in the workhouse.

  This case is interesting only in so far as it illustrates
  exceptionally well the rôle of alcoholism in the habitual criminal. It
  is, however, very difficult to decide whether the alcohol should be
  considered here the cause of the man's degeneracy or its result. It
  would appear that whatever injurious effect inebriety had upon this
  man, and unquestionably it had, he owes his anomalies of character to
  causes over which he had no control. We find that his father was a
  chronic alcoholic, his mother a neurotic, a maternal aunt insane, and
  an uncle a suicide. That these pathological traits in the antecedents
  left their impressions on him cannot be doubted for one minute. He was
  abnormal before environment and personal habits had had time to make
  themselves felt. He, too, oscillated between penal institutions and
  the Hospital for the Insane all his lifetime. That the same
  degenerative basis lies at the bottom of both his moral and mental
  alienation, cannot be doubted. Here, too, we are able at this date to
  furnish other additional information. The patient was eventually
  discharged from the Hospital for a similar reason as in the preceding
  case, and in spite of all his promises and new resolutions was
  readmitted to the Hospital on October 13, 1913 with an attack of
  delirium tremens.

Let us endeavor to see now in what respects the above individuals
simulate one another, and whether this similarity is of sufficient
import to warrant the grouping of them into one category. Commencing
with the family history we find disease and crime manifest in the
antecedents, either direct or indirect, of all of them, that in all
probability because of this, not one of these unfortunates was brought
into the world with a sufficient impetus to carry him successfully to
his goal. In every instance we find that the characterological anomaly
became manifest already during their school career. It was the
persistent truancy, disobedience and antagonism to submission to a
well-regulated existence and not so much the incapacity to learn, which
distinguished them from the other children in school. The same
attributes of character which were at the bottom of their conflicts with
the school authorities brought them into the hands of the police
authorities soon afterwards. The contact with the outside world soon
served to bring out other pathological traits of character. We now see
them manifest a pathologic emotionalism, an unbounded egotism, a
relentless vindictiveness and an apparently total disregard of
consequences. Frictions with the surrounding world, which a normal
individual meets in an ordinary manner with a view towards an efficient
adaptation to existing conditions, were reacted to by them in a
distinctly antisocial manner, with methods entirely void of
consideration of the rights of others, an attribute so essential for a
proper concourse with man. Thrown finally upon their own resources, when
they had to rely for their existence upon some industrial pursuit, we
find them lacking the most essential prerequisite for the efficient
struggle for existence--definiteness of purpose, and continuity and
persistence of effort. We find them leading a harum-scarum existence,
drifting from place to place, and from occupation to occupation, never
able to remain at any one undertaking for any length of time.

The next features which stand out prominently in the lives of these
individuals are their recidivism and the fact that every one of them
came under the observation of an alienist on one or more occasions in
his life. What is at the bottom of all this? We cannot, of course, deny
the very evident fact that these individuals differ from normal man and
that this difference is due to their inferiority. But what characterizes
this inferiority? Is it the lack of something which normal man
possesses, or is it rather a disproportion, a disharmony between the
various individual mental faculties of these individuals? In other
words, is their inferiority a quantitative or qualitative one? Taking
pure intelligence into consideration we find that they show no
deficiency in this particular sphere. On the contrary, most or all of
them show a degree of shrewdness and keenness which absolutely precludes
the existence of an intelligence defect _per se_. Their recidivism is
not due to an inability to distinguish between right and wrong. They
know very well what is and what is not right, at any rate, as well as
the average person, but they feel decidedly different from the average
person about this distinction. They are what they are because of a
discord, a disproportion between their various psychic attributes. The
exaggerated egotism, which is so common to these individuals, serves to
establish a pathologic degree of self-consciousness. This in turn makes
them feel with an extraordinary keenness the everyday frictions in
life, and now the pathologic emotionalism comes into play and being
unsupported by any sense of altruism and morality they give way to their
feelings in some criminal act. Their pathologic vindictiveness should
also be mentioned. A sustained real or imaginary injury can never be
forgotten by them.

These, in brief, I believe to be the characterological anomalies which
distinguish the individuals herein reported from normal man and which at
the same time are sufficiently common to all of them to justify their
segregation into one distinct group of criminals.

I shall not enter here into a discussion of what part, if any,
environment played in the shaping of the lives of these individuals, for
several reasons, chief among which, however, is the fact that I have not
had the opportunity of investigating thoroughly the environmental
conditions in which they grew up and am therefore unable to evaluate
properly this phase of the question. The fact, however, that my cases
were culled from various sources and that the anomalous traits
manifested by them were already present at an age when environment could
hardly have had any lasting influence upon them, leads me to believe
that it is heredity that is responsible for the major portion of this
anomalous product. However, we shall leave this question to the decision
of the practical eugenists. Personally I fully believe that we are
dealing here with a type in which heredity plays an important rôle. I
fully believe that these individuals were always the same as they are
now and that the probabilities are that they will always remain so.
Assuming then, for the moment, that we are correct, the question
arises:--"Has society dealt with these individuals in a proper manner?"

This question must be answered decidedly in the negative. I will not
enter here into an extensive discussion of a system of penology which
might be specifically applicable to this class of individuals. I can
only agree fully with the current opinions of eminent criminologists on
this subject.

At the 1911 Congress of Criminology and Anthropology at Cologne, the
following resolution among others was adopted:--"Hardened and
professional criminals, recidivists, who present a great danger to
society must be deprived of their liberty for as long a time as they are
dangerous to the mass. Their liberty should be as a general rule,
conditional."

Archibald Hopkins, Esq., has been recently quoted by Gault as
follows:--"The Head of Scotland Yard, in London, said not long ago that
nine-tenths of the serious crimes there were committed by men who had
served one or more terms of imprisonment and who might be regarded as
belonging permanently to the criminal class. His judgment was that if
they could be eliminated from such a situation, violation of the law
would be diminished to less than a third of what it has been. Why cannot
this be done? Let the Courts be clothed with power, after two or more
offenses, in its discretion, to pronounce a man incorrigible, who shall
be sentenced for life, to whom no pardon shall issue. By an arrangement
between the general government and the states, a colony could be
established, say in the Island of Guam, where escape would be
impossible, and where, under military guard, convicts could be made to
earn their own living. Surely society has the right to protect itself
from these incorrigibles, who are released only to prey on it again.
They also are the class who rapidly produce their kind, and at present
society puts no obstacle in the way.

"It is exactly as if, instead of forming colonies to which all
lepers are compelled to go and remain, we permitted them, after a brief
term in the hospital, to go where they please and to marry and produce
more lepers. The incorrigible criminal is worse than the leper because
he deliberately and purposely defies society and spreads his contagion.
It can hardly be questioned that the permanent segregation of the
professional criminal class would very greatly diminish crime, nor can
it be questioned that society has the right to adopt such a measure of
protection, nor that it would not be entirely practicable." (See Journal
of American Institute of Criminal Law and Criminology, April, 1912,
pp. 821 f.)

The only argument, and a very weighty one it is, which can be raised
against the foregoing proposition, is whether the incorrigible criminal
is sufficiently characterized by such unmistakable features as would
enable us to recognize him when we see him, and thus justify his
permanent isolation from the community. I believe he is, and the cases
here reported are fair representatives of that class. Another problem
which presents itself is: "Where shall we put the incorrigible
criminal?" If we agree that he owes his criminality to causes over which
he has no control and that the crime here is the outgrowth of a
degenerative personality, a personality which is distinctly abnormal,
it would seem that he belongs in a hospital rather than a penal
institution, but is this unequivocally so? It is unquestionably true
that these individuals are abnormal, that without actually being insane
they evidence from their earliest childhood a more or less distinct
deviation from the normal; they may therefore be considered as
"border-line cases," _i.e._, cases which deviate from normal man and
incline toward the insane through numerous gradations. As soon, however,
as their abnormality manifests itself in distinct incorrigible
antisocial tendencies, the right of society to protect itself from such
an element must be considered. When free from actual psychotic
manifestations (which very easily engraft themselves upon this
degenerative soil) these individuals do not belong in a hospital for the
insane. Here they serve only as a very troublesome and disturbing
element, and wield an undesirable influence over many easily
impressionable insane patients. They do not belong in a general penal
institution because of the very deleterious influence they exert on the
accidental but uncorrupted convict with whom they come in close contact
in these institutions. It is my opinion that these individuals, forming
as they do a distinct species of humanity, should be segregated into
colonies especially designed for them, where under proper medical
supervision, they should be made to earn their subsistence by means of
some useful occupation. It is very obvious that an indeterminate
sentence is the only rational way of approach to this problem and this
should be supplemented by the vesting of the parole power in the hands
of a board composed, not exclusively of members of the legal profession,
but largely of physicians, and particularly those trained in
psychopathology.

The foregoing cases, while distinctly abnormal mentally, owe their
recidivism to a qualitative rather than a quantitative defect.

Since the original publication of this paper, I have had occasion to
observe a number of recidivists in whom the defect was essentially a
quantitative one, _i.e._, patients ranging in intelligence all the way
from idiocy to moronism.

The following case is a good illustration of this type:--

  R. W. (colored) was admitted to this Hospital for the first time from
  the District of Columbia Reform School on February 8, 1898. He was at
  that time serving a sentence for housebreaking. He was twenty years
  of age at that time and examination showed him to possess the
  intelligence of an imbecile. During his sojourn here he had several
  maniacal outbreaks, but recovered from these and was discharged into
  the care of his parents on November 23, 1898. Sometime in 1900 he was
  again sent to the Reform School and was readmitted to this Hospital on
  November 17, 1900. He suffered at this time from an acute
  hallucinatory episode from which he soon recovered and was allowed to
  go out on a visit on February 20, 1901. He never returned from this
  visit but on July 23, 1902, was sentenced to twelve months
  imprisonment for larceny. While serving this sentence he was admitted
  to the State Hospital for the Insane at Norristown, Pennsylvania,
  where he suffered from an acute maniacal attack with persecutory
  delusions. He was discharged from that institution, by order of the
  Court, on September 29, 1903. On January 1, 1904, he was arrested for
  housebreaking and sentenced to three years imprisonment at the United
  States Penitentiary at Moundsville, Virginia. From the above
  institution he was admitted to this Hospital on May 8, 1905,
  suffering from an acute maniacal attack. He soon recovered again and
  was discharged on August 18, 1906, with a diagnosis of imbecility with
  recurrent mania. He was readmitted here October 3, 1907, and
  discharged April 1, 1909. On January 23, 1910, he was given a two
  months workhouse sentence for petty larceny. On September 7, 1912, he
  was again sentenced to four years in the Penitentiary for grand
  larceny, from which institution he was readmitted here on January 19,
  1915.

I shall not enter into a detailed discussion of this case. It is simply
quite illustrative of the absolute necessity for permanent segregation
of mental defectives.

When some of this clinical material was first published in 1912 it met
with very gratifying recognition at the hands of those who were
interested in criminalistics.

I wish to take this opportunity of expressing my particular appreciation
of Dr. Healy's kind words of approbation and encouragement.

We all must agree that the first essential step towards a better
understanding of criminal types consists in a thorough study of the
criminal individual, such as is reflected, for instance, in the very
excellent book by Healy on the "Individual Delinquent." Such studies
have thus far, however, with but rare exceptions, not been made at the
proper source,--that is, in the criminal laboratory, the penal
institution.

The work which is being done with the juvenile offender is, of course,
very important and very valuable; but in order that this work may be
checked up scientifically it must be supplemented by thorough
catamnestic studies of the juvenile offenders. This, I believe to be
the only rational way of approach to the problem.

This will in time, I believe, furnish us data concerning the criminal
which will enable us to evaluate in a correct manner the various traits
and characteristics of the juvenile offender and thus enable us to
render a correct prognosis in a given case. Once we shall reach a stage
in the science of criminology when we shall dare to say of a juvenile
offender, as we now unhesitatingly say of the leper, "Here is a human
being who will always be a danger to his fellow-man and, therefore,
should be permanently isolated from his fellow-man", the problem of
recidivism will be solved.

We cannot, however, arrive at a proper conception of the nature of a
juvenile offender by merely studying a cross section of him at any given
moment of his life. In order to understand man, especially abnormal man,
we must study him in a longitudinal section; we must note his mode of
reaction to experiences in everyday life, under all manner of
conditions and circumstances; we must investigate the motives and
desires which prompt his conduct; we must find out how effectually he
adapts himself to the environment in which he happens to be placed and
in how far he is able to modify the world about him so as to make it
subservient to his needs and wants. The same problems which confront
criminology today, psychiatry had to face some years ago. In order to be
able to rationally and scientifically deal with the insane the
psychiatrist found it essential to establish certain criteria which
might enable him to tell, with some degree of certainty, what the future
life of a given insane person will be. In the last analysis it is this
same thing which we are aiming to attain in our dealings with the
criminal. The problem which is constantly before us in dealing with
juvenile delinquency is what might be expected of the future life of the
juvenile under consideration and what must be done towards directing his
future into proper channels. So, after all, it should be our aim to
establish certain criteria by means of which we should be able to render
a proper prognosis. That we possess no such criteria at present can be
denied by no one.

As I have already stated, psychiatry had to face the same problems. With
the advent, however, of the Kraepelinian school these have in a great
measure been solved. Kraepelin, by studying the entire life history of
his patients, was able to show that certain disease pictures when
studied in cross section may simulate one another very closely
clinically and at the same time be of the most diverse significance
prognostically. He further showed that certain acute psychotic
disturbances are merely the outward expressions of an underlying
progressive disorder, and though the acute manifestations may disappear
and leave no apparent trace behind them, the great majority of these
individuals will spend the rest of their lives in institutions for the
insane. By calling attention to certain symptom-complexes, which are
especially characteristic of certain mental disorders, he gave us the
means by which we are able at the present time to predict with a fair
degree of certainty what the future life of a given patient will be. We
can now tell without great fear of contradiction which of our patients
are going to spend the rest of their lives in institutions.

Now, criminality is generally conceded to be an expression of a diseased
personality and there is no reason why the same principles which served
to advance our knowledge of psychiatry should not be employed here.

In the foregoing study we aimed to carry out these principles, but we
believe that better results still could be obtained at the hands of a
trained psychiatrist right at the penitentiary. The reasons for this are
quite obvious. The relationship between prisoner and physician would
then be quite a different one, the data could be more readily verified
with the assistance of the machinery of the law, and the subjects would
be in a more accessible mood than when suffering from a mental disorder.
As a matter of fact the best work thus far done on the mentality and
disorders of mentality of prisoners was done by a prison physician, Dr.
Siefert, of Halle.

Thus we see that the question of the degenerative prison psychoses has
an important relation to the question of criminology in general.

This becomes at once apparent, if we accept the contention of many
authorities that the degenerative soil which makes the development of
these psychoses possible, is likewise responsible for the criminality of
these individuals; in other words,--if we agree that crime and psychosis
are here branches of the same tree. Manifestly any discussion of the
treatment of these psychoses must of necessity touch upon the vastly
broader problem of the treatment of the habitual criminal, the
recidivist, and therefore a slight digression from the subject at hand
will be unavoidable.

If we admit that it is the prison environment which serves to bring out
the prison psychosis, it is perfectly evident that the first therapeutic
indication is the removal of the prisoner from that environment as soon
as the disorder is recognized. This problem is at present dealt with in
several ways. There are certain penal institutions, especially in
Europe, which have within their walls a psychiatric department for the
reception of these cases. Others send their insane convicts to the
criminal department of some hospital for the insane. In this country
there are States in which still a third system is in vogue, namely, the
confinement of these cases in special hospitals for insane criminals.
Now the points to be kept in mind in the treatment of the insane
criminal are, briefly stated, these:--First, they should of course come
under the supervision of a trained psychiatrist. Second, the transfer
from prison to hospital must take place with as little delay as possible
and not be burdened with a lot of red-tape procedures. Third, the
hospitals for the housing of these patients must be fully equipped in
accordance with the modern ideas of hospital construction, and at the
same time afford ample security for the prevention of escapes. Fourth,
the interest of the inmates of the general hospital for the insane and
the feelings of their friends and relatives must be kept in mind, when
we begin to advocate the populating of our hospitals for the insane with
criminal characters.

The psychiatric annex in connection with the penal institution meets all
these requirements better than any arrangement for the care of the
insane criminal. An annex of say fifty beds, in connection with every
State Penitentiary would obviate entirely the delay in transferring a
patient from prison to hospital and _vice versa_. As soon as a prisoner
begins to show signs of mental disorder, and a prison physician trained
in psychiatry will be able to recognize these early signs, or as soon as
there is the least suspicion of mental disorder, the patient could be
transferred without delay to the psychiatric department. Here they
should be kept under observation for at least six months. This will be
sufficiently long in most instances to enable the physician to determine
whether he is dealing with a progressive deteriorating psychosis or with
one of those transitory prison psychoses. In the cases of the former,
_i.e._, if it is definitely established that the patient is a dementing
præcox or a paretic, the fact that he happens likewise to be a criminal
is really of little or no importance. A demented individual is never
dangerous enough to require confinement in an especially secure
hospital, though he is a prisoner, and unless he is criminally insane,
_i.e._, unless he manifests dangerous or criminal tendencies as a result
of his mental disorder, really forms no special administrative problem.
He could be kept either in the prison annex until the expiration of his
sentence, if there be room for him, or could be transferred to the
nearest hospital for the insane and treated the same as any other insane
patient.

It is the second group, however, _i.e._, those patients suffering from
the transitory prison psychoses, which especially justify the
establishment of psychiatric annexes in connection with prisons. We have
seen how detrimental to prison discipline these individuals are, even
when in a condition which might be considered normal to them, and we can
easily surmise what it must mean to care for them in prison during one
of their mental upsets. It is therefore of the utmost importance, both
for the prison administration and for the individual, that these
patients should be transferred to a properly appointed hospital in as
short a time as possible, and this can be done most readily when the
hospital and prison are within the same walls, and more or less under
the same management. On the other hand, we owe it to the prisoner to
bring him under proper care as soon as possible. The practice of sending
these individuals to criminal departments of general hospitals for the
insane has many objections. In the first place, no matter how modern the
equipment of such departments, most of them cannot afford the proper
kind of treatment to these individuals. The idea that the removal from
prison to a criminal department of an insane hospital will have a
beneficial effect upon the prisoner because of the more lenient
environment into which he is taken is entirely delusional in the case of
the degenerated habitual criminal. These individuals, if the public
safety is to be kept in mind, can receive but very limited privileges in
a hospital for the insane. The modern hospital is not constructed with
the idea of caring for dangerous criminals, and in many instances the
habitual criminal, who because of his dangerous tendencies and ever
readiness to escape, has to be constantly kept under lock and key, would
be much better off if he were treated within the enclosure of the
prison. There the construction of the place permits of a wider latitude
of outdoor exercise. An annex located within the enclosure of a prison
could well afford to allow its patients the freedom of the enclosure,
while this can manifestly not be done in a general hospital for the
insane. Then again, there is the unavoidable delay attendant upon the
commitment of a prisoner to an insane hospital. As I have already stated
elsewhere, it is not a rare occurrence to receive patients into the
hospital who have entirely recovered from their mental disorder before
leaving the prison. Furthermore, the expense and danger always
connected with the transfer of insane criminals from prison to hospital
and back again, if the hospital is any distance from the prison, must be
kept in mind.

A word to those who, from a false altruistic standpoint, insist that the
insane criminal requires no different treatment from that which the
ordinary insane patient does. This is very true in the case of prisoners
who develop mental disorders which have no relation to crime or
imprisonment. These do not require special measures of treatment. It is
likewise true of the psychoses of the accidental criminal, but it is
entirely different with the criminal who suffers from a degenerative
prison psychosis. Here we are not dealing with individuals who tend to
dement, who have little or no conception of whether they are in a prison
or in a hospital. In short, we are not dealing here with paretics or
senile dements, who, although being at the same time prisoners, remain
subject to the same unavoidable lot of the paretic or the senile dement.
The habitual criminal who suffers from a degenerative psychosis, unless
he is in a stupor, is constantly on the alert for a chance to escape. No
matter how delusional or hallucinated he may be, he always manages to
keep in mind that the thing which he most desires is to be free from the
hands of his captors, and anyone who has had to deal with this class
will bear me out in this. The shrewdness with which they carry out their
escapes is amazing, and some of the more depraved ones do not hesitate
to commit serious assaults in order to gain their freedom. Here,
measures other than those used with the ordinary insane patient are
required.

Now as to special hospitals for insane criminals which certain States
have. Of course the same objections, namely, as to the delay in getting
the patient under treatment and the danger of transfer, etc., hold true
also here; but these hospitals, it seems to me, have the additional
disadvantage that they necessitate the segregation of all insane
criminals, irrespective of whether they suffer from a recoverable
psychosis or from a dementing process. In other words, here we have an
admixture of cases who unfortunately fell into the hands of the law
because of some mental disorder and who certainly should be confined as
any other patient in an ordinary hospital for the insane, and patients
in whom the crime and mental disorder are expressions of the same
underlying degenerative defect, and who in a great majority of instances
suffer from recoverable transitory mental disorders.

To insist upon keeping a paretic all his lifetime in such an institution
is highly irrational, to say the least. The most rational, and the only
scientific way, of dealing with the insane criminal is to bring about a
state when the psychiatric hospital will be made accessible to him just
as easily as the surgical and medical wards are, and this can only be
accomplished by having psychiatric annexes in connection with prisons.
The only serious objection which can be raised against this plan is that
in time the annex will be made up exclusively of a very dangerous and
troublesome population, but this objection likewise applies to the
special hospital for the insane criminal. Certainly it is far safer to
have this class of cases within the prison enclosure than to allow their
accumulation in a general hospital for the insane.

Lastly, the psychiatric annex in the penitentiary would form the proper
nucleus for the scientific study of the criminal, whence that much
needed information concerning this type of man could emanate and be
utilized for the rational treatment of the problem of crime.

We have thus far discussed the treatment of prison psychoses in these
individuals while undergoing sentence, but what of them after the
expiration of their sentences? We are now approaching the problem of
recidivism.

Certain it is that society has thus far failed to deal effectually with
this problem, and one need not search very deeply for the cause of this.
Society has been relying principally upon its punitive methods in
dealing with the habitual criminal, and so long as a given offense was
punished according to a given statute it felt that it had done its duty.
The factor of the personality of the criminal was entirely neglected. In
time we have come to realize that our punitive methods not only do not
tend to do away with recidivism, but enhance it. It is an undeniable
fact that each additional imprisonment only serves to deprave the
habitual criminal more deeply, and to release him after the expiration
of an arbitrary sentence is to let loose another parasite to prey upon
society. Of late years, however, there has been a tendency toward
individualization in criminology. "It is the criminal and not the crime
that we must deal with," is the modern slogan, and starting from this
point of view we have already found out some very interesting facts. We
find in looking over the life histories of our habitual criminals that
they had shown antisocial and abnormal traits from their earliest youth;
that in their early manhood they populated the reformatories and that
their recidivism is due to some underlying anomaly which always
differentiates them from normal men.

In this chapter we have seen how this underlying anomaly served under
certain stressful situations to give rise to mental disorder, and have
concluded that crime and psychosis must be, in these individuals,
branches of the same tree. If this is true the question arises whether
the habitual criminal does not rather belong in a hospital than in a
prison. It is a little premature to decide this at the present day, but
it is unquestionably certain that it is the psychiatrist who will in
time furnish us the most valuable data concerning the "criminal
character." It is he who will eventually bring to light unshakable proof
that in the habitual criminal we must see an anomalous human being, who
stands in the same relation to normal man as disease does to health, and
then, the problem of recidivism as well as that of the psychoses of
criminals will be easier of solution.


REFERENCES

[1] WILMANNS: "Ueber Gefängnispsychosen." Halle a. S., 1908.

[2] BONHOEFFER: "Klinische Beiträge zur Lehre von den
Degenerationspsychosen." Halle a. S., 1907.

[3] BIRNBAUM: "Zur Frage der psychogenen Krankheitsformen."
_Zeitschr. f. d. ges. Neurolog. u. Psych._ 1910.

[4] SIEFERT: "Ueber die Geistesstörungen der Strafhaft." Halle a.
S., 1907.

[5] STRANSKY: "Ueber die Dementia Praecox, Streifzüge durch Klinik und
Psychopathologie." Wiesbaden, 1909.




CHAPTER III

THE FORENSIC PHASE OF LITIGIOUS PARANOIA


Maudsley[1] has long ago said: "It would certainly be vastly convenient
and would save a world of trouble if it were possible to draw a hard and
fast line and to declare that all persons who were on one side of it
must be sane and all persons who were on the other side of it must be
insane. But a very little consideration will show how vain it is to
attempt to make such a division. That nature makes no leaps, but passes
from one complexion to its opposite by a gradation so gentle that one
shades imperceptibly into another and no one can fix positively the
point of transition, is a sufficiently trite observation. Nowhere is
this more true than in respect of sanity and insanity; it is
unavoidable, therefore, that doubts, disputes and perplexities should
arise in dealing with particular cases."

No small amount of the disrepute into which expert medical testimony has
fallen is due precisely to a failure on the part of the legal profession
to appreciate these truisms. To the legal mind the transition from
mental well-being to mental disease is exemplified by that wholly
artificial, and to the psychiatrist's mind, subsidiary question of legal
certification. The law takes no cognizance of the conditions
necessitating this change; it only concerns itself with the delimiting
frontier, viz.:--certification. Legally, the insane has become such
through the filling out and signing of certain papers and through having
submitted himself to a certain prescribed legal procedure. The
physician, on the other hand, because of his peculiar relationship to
the patient, and as a result of his particular training, looks upon this
legal procedure as a necessary evil and merely as typifying the
conventional mode by which society settles its accounts with its
diseased members. Our legal brethren fail to appreciate, furthermore,
the fact that an individual may be very seriously ill mentally and
urgently require hospital treatment, without, however, showing those
gross disorders of conduct which go to make up the legal evidence and
diagnosis of insanity. Neither do they seem to recognize the possibility
of a seriously unbalanced individual making quite a normal impression,
at any rate before a jury of laymen at the time of his appearance in
Court. Nowhere in psychiatry is this so apt to be the case as in that
form of mental disease known as paranoia, where we are dealing with a
diseased personality which in many respects still approaches and
resembles normal man.

The paranoiac, while he may harbor the most intricate and well-organized
system of delusions, still remains approachable to us, and
intellectually may be not only on a par with the average normal
individual, but not infrequently gives the impression of being his
superior. Nevertheless, this usually well-endowed human being at a
certain point in his career goes off at a tangent and spends the rest of
his life in the pursuit of a phantom. The paranoiac, starting out with
vague, ill-defined ideas, succeeds in elaborating, step by step, a
well-organized system of thought, of ideas which finally assume an all
importance in the conduct of his life and remain unshakable.

Kraepelin[2] defines this condition as a mental disorder which is
essentially characterized by a gradual and systematic evolution of a
well-organized and intricate system of persecutory and grandiose
delusions. It is chronic and incurable in its course and does not lead
to any appreciable deterioration in the intellectual sphere. The
litigious form of this disorder is particularly characterized by a
persistent and unyielding tendency toward litigious pursuits. It is for
this reason that this form of paranoia is of particular interest
forensically. The law is the tool with which these individuals work, and
the Courts their battle-grounds. The least provocation suffices to start
the stone rolling, launching the unfortunate upon a career of endless
litigation. As a rule the disorder originates in connection with some
adverse decision or order of the authorities, which the patient
considers an unjust one. Whether injustice has actually been suffered by
the patient matters not and remains absolutely of no consequence as far
as the course of the disease is concerned. The paranoiac litigant is
unable to see the law as others see it, and in this respect he does not
differ greatly from primitive man, whose conception of legality is that
of a collection of concessions for himself and prohibitions for others.
To be sure, a tendency to excessive litigation is occasionally met with
in what appear to be normal people. Such pursuits, however, become
pathological when they are based upon a delusional interpretation of
actual occurrences or upon actual delusions, and are not amenable to
reason.

According to Tanzi[3] the theme underlying the delusional system of
litigious paranoiacs is avarice, and the whole may be looked upon as the
slow and permanent triumph of a preconception. "The paranoiacal
preconception gradually conquers all evidence to the contrary, and in
spite of reality, public opinion and common sense, it becomes organized
into a coördinated system of errors which become the tyrants of the
intellectual personality and remove it by degrees outside the bounds of
normality." The litigant constantly busies himself with his grievances,
loses all interest in everything else, and begins to fight for his
rights. He stops at no means and is the bane of judges and court
officials. Naturally, he has to be refused all aid, either because he is
unjust or because the courts find no remedy for his troubles. He refuses
to settle actual grievances, carries the case from one court to another
and finally develops an insatiable desire to fight to the bitter end.
The statutes appear to him inadequate and even the fundamental
principles of law fail him. He cannot abide by the ultimate decision
after all the usual means of justice have been exhausted. In his
attempts to gain justice he writes to magistrates, legislators and
various other people in prominence. It is only after years of persistent
misfortune both to himself and the objects of his delusions, which only
serve to harden him against his fortunate opponents, his incapable
lawyers, the corrupt judges and his ignorant and craven-hearted
relatives, that this master of procedure is betrayed into the expression
of threats or the commitment of some other offense which conveys him
summarily from the civil to the criminal courts, and the unrepentant
pursuer becomes the defendant, unless, indeed, the insane asylum has
become his refuge. (Tanzi.)

This is precisely what happened with the patients whose histories are
here recorded. With all this the paranoiac remains plausible, converses
rationally and coherently, shows himself to be exceedingly well-informed
on current events, amazes his listeners with his really wonderful memory
and his ability to quote _ad infinitum_ from law books and statutes.
Absence of hallucinations is the rule. Memory and the capacity to
acquire new knowledge remain intact, and reasoning and judgment on
matters of everyday life which do not touch his more or less
circumscribed delusional field may remain quite normal. In short, he
shows none of those tangible signs and symptoms upon which we must so
frequently rely in our efforts to convince a jury of laymen of the
existence of mental disorder. It is only when we take into consideration
the entire life history of a paranoiac, which unfortunately is
frequently ruled out as hearsay evidence, that the real state of affairs
becomes manifest. We then see that where it concerns his delusional
field the paranoiac's judgment is formed, not as a result of
observation, or logic and reasoning, but as a result of an emotion, a
mere feeling that this or that proposition is true. In every adverse
decision of the court he sees a deep-laid conspiracy to deprive him of
his rights. His lawyers are incompetent and in collusion with his
persecutors; the judge is corrupt or ignorant of the law, and the
legislators negligent in their duties in not writing into the statutes
laws which would take care of his grievance. He constantly harps upon
what he calls "the principle of the thing", losing, gradually, all
concern in the real issues involved.

Indeed, in watching the amount of attention a paranoiac bestows upon his
grievances, the zest with which he takes up every newly discovered flaw
in the law, and the dexterity with which he weaves it into the maze of
his delusional system, the idea forces itself upon one's mind that what
the paranoiac least desires is a settlement of his grievances. One can
readily imagine the void in the unfortunate's life were he to be
deprived of this all-engrossing, and to him really life-giving, _casus
belli_. Thus, not infrequently, when one grievance is actually settled,
another soon appears and assumes the center of the stage. The means
these individuals use in their efforts to convince the authorities of
the righteousness of their cause or of the genuineness of the
persecutions to which they are subjected, are really amazing in their
ingenuity. They are supported to a considerable extent by retrospective
falsifications of memory, and when occasion arises, by a conscious
distortion of facts, and prevarication, a point very justly emphasized
by Bischoff.[4]

This author relates the case of a paranoiac woman who was in litigation
with her father over some trifling inheritance left by her mother, and
who accused her father of a murder, and insinuated that she had heard
her grandfather call him a fratricide.

The reputation and character of the objects of their delusions are
unsparingly attacked by the paranoiac litigant, and this not
infrequently results in bringing matters to a head, where as defendant
in a criminal suit for libel the paranoiac is recognized in his true
light and sent to a hospital for the insane. Before, however, this final
scene in the litigious career is enacted, especially where the
persecuted has turned persecutor, the objects of his delusions have not
infrequently suffered an untold amount of anguish and financial ruin,
through having been obliged to play the part of defendants in civil
suits based on nothing else but the distorted fancy of a diseased mind.

While one may readily detect the part played by avarice in the pursuits
and activities of these individuals, it requires close contact with
them, especially in the capacity of one who stands between them and
freedom, in order to fully appreciate the degree of malevolence which
they frequently exhibit. Indeed, the study of litigious paranoia, more
than anything else, illustrates how much method there may really be in
madness. Were an alleged lunatic standing as a defendant in a criminal
suit to use one-tenth of the amount of ingenuity and conscious direction
of his symptoms that the average paranoiac uses, he would furnish the
champions of the idea of malingering of mental disease with enough
material to convict a dozen lunatics.

The chief aim of this paper is to illustrate by means of two interesting
case histories the forensic importance of this form of mental disorder.
It is not intended, however, to enter here into an academic discussion
of the problem of paranoia. The term "Paranoia" is even pre-Hippocratic,
and any attempt to indicate, even in the briefest manner, the changes
which this concept has undergone throughout the ages would require
considerably more space than we have at our disposal. I shall,
therefore, merely mention that in reviewing the history of paranoia one
is unmistakably struck by the fact that those view points and ideas
concerning this subject which have indelibly impressed themselves upon
it occupy themselves with a study of the personality of the paranoiac
rather than with the disease picture as such. Some of the investigators
have gone so far as to maintain that paranoia is not a disease at all
in the sense that typhoid fever is a disease or pneumonia is a disease,
but that the paranoiac picture is rather the expression of an anomalous
individuality and, as one author puts it, it is the evolution of a
crooked stick. Sander[5] recognized this when he so admirably stated
that the abnormal condition develops and unfolds itself in the same way
that the normal mind unfolds itself in the normal individual.

The cases herein reported have been under my observation now for several
years at the Government Hospital for the Insane, and I am indebted for
permission to report them to Dr. William A. White, Superintendent of the
Hospital.

  CASE I is a white man, aged 64 on his first admission to the
  Government Hospital for the Insane, July 9, 1907. This commitment was
  the direct outcome of a trial for perjury which took place in May,
  1906, in the Supreme Court of the District of Columbia, at which the
  patient was found guilty. While awaiting sentence he was adjudged
  insane and sent to this Hospital. The evidence was gathered from the
  Reports of the Maryland Court of Appeals, dating as far back as 1874,
  and forms only an incomplete account of the patient's legal
  activities, inasmuch as many of his law transactions never reached the
  higher courts and consequently are not reported. In setting aside
  1,296 magistrate's judgments obtained by the patient and amounting in
  the aggregate to $127,836 debt and $2,348 costs, the Court states,
  among other things, as follows:--

  "The gross iniquity of this whole transaction, manifest enough upon
  its face, is abundantly so by proof. The inference is irresistible
  that the magistrate who issued these judgments merely wrote them out
  on his docket without summoning witnesses and without the semblance
  even of an _ex parte_ trial."

  It was further brought out at the perjury trial in 1906 that in 1877
  the patient had obtained 619 judgments against the A. E. Company,
  aggregating approximately $50,000. These were likewise set aside by
  the higher Court. We thus see that as far back as 1874 this king of
  litigants had already had set aside by the higher Courts as many as
  some 1,900 distinct and separate judgments. How many more of those
  based on the same flimsy tissue of his distorted imagination he
  actually realized on is not known. As far as can be ascertained, the
  issue of insanity was never raised, at any rate by the Court, prior to
  the perjury trial, and it was only when this master litigant, after
  having been active as a complainant for a great number of years, at
  last betrayed himself into committing a criminal offense that the
  issue of insanity was brought up.

  A prominent Maryland Judge, who had known X---- for over forty years,
  had the following to say concerning him:--"I have known X---- for
  forty years, and he is a general nuisance and menace; he is crazy on
  getting money, and for years has been manufacturing bogus judgments
  against citizens of this and Montgomery Counties and the
  A. E. Company. At one time he held judgments against that Company for
  a million dollars for an imaginary wrong, all of which were eventually
  gotten rid of on the ground that they were fraudulent. He also, in
  some fraudulent way obtained judgments against our County
  Commissioners, without their knowledge, for $1,500, which were
  impounded by Judge M---- of the United States Court at B----, where as
  a then non-resident he brought suit to recover on them. He then went
  down to Dickinson County, a remote section of Southwestern Virginia,
  and obtained other judgments for some four or five million dollars
  against the County and various citizens, which were obtained by
  perjury and forgery. They were eventually set aside. His brother died
  in 1907, and I became one of the sureties on the executor's bond; last
  year a judgment turned up here against the executor and his sureties
  for $17,000, which purported to have been given by the Circuit Court
  for said D---- County. It was a forgery all the way through; even the
  Seal of the Court to the certificate was a forgery. I wrote the Judge
  of the Court and he answered very promptly, stating that no such suit
  had ever been entered and that the judgment was a myth. We succeeded
  in impounding this judgment. No one up here feels safe when X---- is
  at large. We have suffered a great deal of trouble and expense in
  trying to protect ourselves against him, and everybody regards him as
  being not only insane but also a very dangerous man."

  On admission to the Government Hospital for the Insane, July 9, 1907,
  he was found to be a fairly well-preserved man for his age, entered
  freely into conversation, comprehending readily what was said to him
  and exhibiting no difficulty in elaborating his ideas. He talked in a
  slow, deliberate and rather mysterious manner and a low tone of voice.
  The family history as given by him was negative. He himself had the
  usual diseases of childhood, but, aside from chronic indigestion, had
  had no severe illness. He gave his occupation as that of physician. In
  1862 he enlisted in the Union Army as a nurse and was discharged six
  months later; claims that in 1865 he graduated in medicine from the
  University of Maryland, which profession he practiced at W---- until
  1881. He then moved to Ohio, because, he says, he could endure no
  longer the persecution of a good many enemies which he had made on
  account of his service in the Union Army. In Ohio, he states, he
  engaged in the manufacture of proprietary medicines and claims to have
  sold out his business sometime later for $50,000.

  Some idea of the patient's daily conduct may be had from the
  statements of his landlady, with whom he lived for a considerable
  time.

  It seems that he occupied a room on the top floor, which he would
  allow no one to enter. If anyone rapped on the door he would open it
  very slightly and cautiously, conducting conversation through a crack
  in the door. He led the life of a hermit, living in absolute
  seclusion, cooking his own meals in his room. After he was removed to
  the Hospital this room was entered and newspapers were found piled as
  high as the ceiling; many of the articles in them were underscored,
  and numerous clippings were pasted on doors and windows as well as on
  walls; everything was covered with dirt and dust, and the cooking
  utensils were strewn all over the room. This lady said that during his
  stay there he was always very suspicious, kept the blinds drawn, and
  seemed to be constantly afraid that something was going to happen.

  Examination of the patient soon after admission revealed a
  well-organized and very extensive delusional system, which, according
  to his story, apparently had its inception during the Civil War. It
  seems that he had caused the apprehension and execution of a
  Confederate spy, and ever since then, he states, the relatives and
  friends of this man have been persecuting him. In 1889 he was granted
  a pension of $25 per month, but he did not think that this was a fair
  deal inasmuch as he was not a nurse, but a physician, and should
  receive at least a hundred dollars per month. He states that he came
  originally to Washington to have this matter straightened out, but on
  account of his enemies was unsuccessful. His worst persecutions he
  believed to have been instigated by the A. E. Company because he had
  judgment against this Company for about $50,000. He stated that this
  was obtained in a damage suit which he brought against this Company
  because they wanted to charge him expressage of something like 40¢ on
  a prepaid package. Following this damage suit, the Express Company's
  agents, especially members of the R. family, have been spying on him
  and persecuting him; he finally sued a member of this R. family and
  obtained judgment against him in the Circuit Court of Virginia for
  $9,000. When asked to explain how he figures out these exact amounts
  of damage, he is ready with a thousand plausible reasons why the
  amounts were as he gives them. He was finally charged with perjury,
  found guilty, and while awaiting sentence was adjudged by a jury to be
  of unsound mind and sent to the Government Hospital for the Insane.

  He believes that members of this R. family were behind this because
  they were afraid that the patient would collect on his judgments,
  which by this time, amounted to something like $20,000, and which, as
  he put it, "were good, valid and subsisting, not reversed or otherwise
  vacated."

  During his sojourn in the Government Hospital for the Insane, he was
  always very suspicious and seclusive, keeping to his room practically
  all the time and aloof from the other patients in the ward. He adhered
  very tenaciously to his delusional system and believed himself fully
  justified in all his litigious pursuits. With all this he was clear
  and coherent in conversation, his memory was quite well-preserved, and
  he had no difficulty in keeping himself fully informed on current
  events. Aside from the very evident caution and very profound
  suspicious attitude which he manifested during a conversation, he made
  no abnormal impression.

  In October, 1908, he was paroled by a Justice of the District of
  Columbia Supreme Court to his brother's care in Ohio; and patient's
  reasons for this parole are interesting: He states that he was told by
  the District Attorney that he would be paroled if he were to go to
  Ohio and vote for President Taft. This he says he did, believing he
  had carried out the terms of his parole, promptly returned to
  Washington and resumed his former activities. The first thing he did
  upon his return was to have the following two bills introduced in
  Congress, both of which are wholly based on his delusional ideas:--

  "H. R. Bill xxxx, January 11, 1910. Mr. A. introduced the following
  bill, which was referred to the Committee on Military Affairs and
  returned to be printed:--A bill to correct the military record of
  X----. Be it enacted in the Senate and House of Representatives of the
  United States of America, in Congress Assembled, that the Secretary of
  War be and is hereby authorized and directed to correct and amend the
  military record of X----, late assistant surgeon instead of nurse, so
  as to read: X----, Assistant Surgeon of the United States Army, on the
  12th day of April, 1863, and to place the name of X---- upon the
  retired list of the United States Army as Assistant Surgeon."

  The second bill was as follows:--

  "Senate Bill xxx. Referred to the Committee on Claims. A bill for the
  relief of X----. Be it enacted by the Senate and House of
  Representatives of the United States of America, in Congress
  Assembled, that the Secretary of the Treasury be and he is hereby
  authorized to pay out of any money in the Treasury, not otherwise
  appropriated, to X----, formerly a resident of W., in the State of
  Maryland, the sum of $45,600, being the amount of the loss sustained
  by said X---- in property and business while he was performing
  important service for the Government in the year 1863, and in
  recognition of valuable service rendered the United States, and
  compensation for loss resulting from his causing the arrest of a
  Confederate Spy, at the opening of the Gettysburg campaign, thereby
  defeating the Confederate plan to capture the two thousand or more
  government wagons loaded with the munitions of war of the Union Army,
  which sum shall be in full of all claims and demands upon the part of
  said X---- against the Government of the United States by reason of
  the premises."

  The patient was soon apprehended and returned to the Government
  Hospital for the Insane, where he is at present.

  In an extremely interesting brief of his case, prepared by the patient
  himself, which, unfortunately, is too lengthy to be given in its
  entirety here, he states, among other things:--

  "I was indicted on the 2nd of April, 1906, by the grand jury of said
  court, for perjury; the grand jury was about to adjourn, as they had
  no evidence upon which to indict me, but they were called back to do
  so in order to please the A. E. Company. The grand jury was authorized
  to indict me in order to please the A. E. Company, as I was later told
  by several members of that jury. I have also been told by numerous
  detectives that they were hired by the A. E. Company to watch me." He
  continues in his brief:--"I was kept in jail until the eve of the 13th
  of February, 1905, when the jail doors were suddenly thrown open and I
  was told to go home, the same as the circumstances related in the
  Bible concerning St. Paul and Silas, who were in prison and during the
  night their chains fell off, the prison doors opened and they were set
  free by the hand of God. I believe the same thing happened to me; I
  was released by the hand of God."

  He further states:--"There are more than 17,000 newspapers in the
  United States, and these people had it printed in 10,000 of them that
  I had committed perjury. I sued them for slander, and a more just and
  upright case or grievance for bringing suit could never be found."

  Attention might be called here to the grandiose phase of his disorder.
  His was no common slander; it was published in 10,000 newspapers.
  Neither was his release from prison an ordinary everyday occurrence,
  but resembled the Biblical episode of St. Paul's release from prison.
  Later on, when through advancing years his intellect is becoming more
  and more enfeebled, he expresses his grandiose ideas in a more direct
  and naïve manner. He tells the physician that he knows the law better
  than any living authority; that none of the so-called judges around
  town can compare with him; that he has made a brief of a case which
  could not be duplicated by anyone. He is likewise the greatest
  physician, and he will prove this when he gets to court. At this
  writing he is beginning to show evidence of senile deterioration and
  is no longer the keen manipulator of the law of years ago. He
  endeavors now to gain his ends by more direct and extremely puerile
  and childish methods. To illustrate:--His physician had left the
  institution about a year ago, and soon afterwards X---- produced an
  affidavit purporting to have been made by this physician in which he
  set forth that X---- was sound mentally; that this physician came to
  this conclusion after a thorough examination of X----, etc., etc. Upon
  the physician's return to the Hospital X---- was asked concerning this
  by him, but he stolidly maintained that it was genuine and given him
  by the questioner. This famous litigant has reached a stage where
  things simply are as he wants them to be. Whether this poor derelict
  will be permitted by his deluded or unscrupulous attorneys to end his
  days in peace at the Hospital, time alone will tell. Thus far his
  lunacy case has been carried by them to the Court of Appeals.


  CASE II.--Y. was found guilty of libel in the Criminal Court of the
  District of Columbia, and while awaiting sentence was adjudged insane
  by a jury and admitted to the Government Hospital for the Insane,
  June 22, 1911, at the age of 56. Y. is an attorney by profession,
  comes from a prominent family in Ohio, and has received an excellent
  education. According to information obtained from his father and
  sister, it appears that one sister and a nephew are insane; that the
  patient himself has been considered insane by members of his immediate
  family since 1889, when, as the result of a court-martial for
  disobedience, he was discharged from the Navy, where he then held the
  grade of ensign. Immediately following this discharge he took up the
  study of law and began to specialize in maritime affairs, handling
  almost exclusively sailors' grievances against the Navy Department. He
  spent a great deal of time working up these cases, occasionally
  writing contributions to the Maritime Register, for which publication
  he was a regular correspondent for several years. In these papers he
  would constantly harp on the irregularities and illegalities of many
  of the government affairs. At home he always acted in a peculiar
  manner, never had much to say to anyone, was unreasonable,
  fault-finding and complaining; he always wanted things his own way.
  Several years ago he came to live with his sister, accompanied by his
  wife and child. Although he paid nothing for board and lodging for the
  three, he complained about the food and had something to say in
  criticism for every little inconvenience. He would frequently leave
  town without saying a word to any member of his family, and would
  reappear just as suddenly. He kept to his room almost constantly,
  leaving same only for his meals. On one occasion he wrote his wife,
  who at the time was staying with her child at his sister's house, that
  she should watch this sister, as he feared she might try to poison the
  child. Sometime in 1910, he came to his home town, had an interview
  with the Judge of the Probate Court, and left town without visiting
  any of his relatives, although they lived only four squares distant.
  At that time this Judge told the patient's father that he thought the
  patient was mentally unbalanced. He was always considered by his
  relatives as being of a morose disposition, vindictive and selfish. On
  a later visit to his parental home he acted very strangely about the
  house, disarranged things, kept the rooms in disorder, and was busy
  writing constantly. At this time he left home suddenly without taking
  leave of anyone. A few years ago, while home on a visit, he declared
  that his father was incompetent to manage his own affairs, instituted
  legal proceedings to have himself appointed committee for his father,
  petitioning the court on the ground of his father's insanity. In this,
  of course, he was defeated.

  The patient himself states that he graduated from Annapolis in 1878,
  between which year and 1883 he traveled in Europe and South
  America as midshipman. In 1883 he entered the Cincinnati Law School,
  where he remained one year. After this he states he acted in the
  capacity of Judge Advocate General for a short time while on shore
  duty. He then went to sea again and finally resigned from the Navy in
  1887, with the grade of ensign. (As has already been indicated above,
  the patient was dismissed from the Navy for disobedience and
  disrespect.) He then entered the practice of law in Cincinnati, at
  which he continued until his appointment to the Department of the
  Interior on June 1, 1904, at a salary of $1,000 per annum. Here he
  remained until 1908 in the capacity of clerk, when he resigned,
  receiving at that time the same salary. He says he was moderately
  successful financially as a lawyer, and did a good deal of literary
  work. He is especially proud of a case which he conducted in the Court
  of Appeals, where he obtained a decision setting aside a Naval
  court-martial. He says that this is the only decision of its kind ever
  rendered, and on that account he is very proud of this. According to
  his own story, he was always moderate in his habits, and prior to his
  marriage in November, 1902, he had never come in conflict with anyone.
  The latter part of this statement is contradicted by his relatives,
  who state that for more than twenty years past, the patient has
  exhibited an uncontrollable desire to sue people for all sorts of
  imaginary grievances, and that on this account he frequently came into
  serious conflicts. The patient is inclined to put all the blame for
  his difficulties to his wife, whom he describes with a great deal of
  rancor as the descendant of an insane and illegitimate grandfather and
  illy-favored mother. He thinks that his wife was slightly unbalanced,
  accuses her of being responsible for the death of their first child,
  and of various other misconduct. However, everything went tolerably
  well until April, 1906, when their second child was born. The doctor
  who attended Mrs. Y. during her confinement, a very prominent local
  physician, testified in open court at that time, that from his
  observation of the patient's acts he believed him to be insane. This,
  the patient said, precipitated a lot of trouble between him and his
  wife. He does not enter into details concerning the difficulties he
  had with the physician, but the details are extremely illuminating. It
  appears that the patient refused to pay this doctor's bill and was
  sued for the debt. At the time of the trial he gave as his defense the
  following two reasons why he should not pay this bill:--The first one
  was that inasmuch as this doctor lived in a part of the city which
  would necessitate the crossing of a railroad grade in order to reach
  the patient's house, and that on this account there was a possibility
  of his being detained at the crossing during an emergency call, he had
  no right to take the case in the first place, and therefore he was not
  entitled to payment. His second reason was that inasmuch as this
  doctor wore a beard, he carried more germs into the house than would
  otherwise have had access to it; therefore he should forfeit his fee.
  In 1907 his wife obtained a divorce on the grounds of cruelty and
  non-support, and was given the custody of the child; this had the
  effect of launching the patient upon a new series of litigation. His
  first retaliating measure was the abduction of the child, which
  brought about his indictment by a grand jury and subsequent arrest.
  The reason he gave for taking the child out of the District was that
  his wife lived in a house over an old abandoned cellar, and that it
  was therefore an unhealthy place for the child. Upon regaining his
  freedom he began to investigate the ground upon which the grand jury
  indicted him, and soon, he states, he discovered that the District
  Attorney's office committed a gigantic fraud by having maliciously
  misrepresented the case to the grand jury; this body, he says, was led
  to believe that the Ohio decree granting his wife the guardianship of
  the child held good in the District, whereas the law of the District
  specifically states that no extra-territorial decree should be
  recognized within the District. He further discovered that Mr. J., his
  wife's attorney, knowingly and maliciously became a party to this
  fraud, and he immediately proceeded to file charges of mal-practice
  against this attorney before the Grievance Committee of the District
  Bar Association. The result of this was that the patient was charged
  with libel in the Criminal Court. To his great surprise, he says, the
  Court recognized this charge and found him guilty of same. While
  awaiting sentence he was adjudged insane by a jury and committed to
  the Government Hospital for the Insane. He believes this commitment is
  the result of a deep-laid conspiracy on the part of the District
  Attorney's office and some of the District Judges. These officials, he
  believes, were afraid of him because at a hearing before a Senate
  Committee he started to expose their fraudulent conduct. The judges
  were prejudiced against him throughout, and it might be interesting to
  mention here that among the multitudinous bills which he had proposed
  for enactment into law since in the Government Hospital for the
  Insane, there is one which is intended to abolish entirely the Courts
  of the District of Columbia, so that unfortunates like him might get a
  chance before unprejudiced judges. This deep conspiracy against him,
  he is convinced, dates as far back as 1906, when the Ohio Courts
  appointed his wife guardian of his child.

  No great difficulty need be experienced in forming an opinion of this
  man's mental status after having followed his history thus far, but
  when we further read that, during his sojourn in the Government
  Hospital for the Insane, he has evinced the most persistent tendency
  to weave into his delusional system every important occurrence of
  local or even national interest, that he sees a clear relationship
  between his case and the recent change of administration, and is fully
  convinced that many important officials held over from the last
  administration owe considerable gratitude to him; when he is seen in
  his self-assumed most important rôle of the man of destiny, flooding
  Congress, the Courts and many high officials with petitions, charges,
  writs, and proposed investigations; when one sees the criminal code as
  transformed by him; then one begins to get a proper perspective of the
  grandiose phase of this man's mental disorder. It is impossible, of
  course, with the limited space at our disposal, to even give the
  briefest outline of his activities, but it might be stated that only
  within the past several months he has succeeded in very ingeniously
  getting his case before a considerable number of senators and
  congressmen and many other prominent officials. Among the bills which
  he proposes to have enacted into law, is one, as has been mentioned,
  to abolish entirely the Courts of the District of Columbia. Of course,
  courts which cannot administer justice, as he sees it, must be
  abolished.

  On his admission to the Government Hospital for the Insane, he really
  welcomed the procedure, stating that at last he had the opportunity to
  be under the supervision of a trained physician who would soon
  discover that he was absolutely sane and would render a report to that
  effect, thus vindicating him. Unfortunately for the physician, he did
  not see his way clear to render such a report, and Y's amiability soon
  changed into a very bitter antagonism towards the one who had
  immediate charge of him, showing a great deal of rancor in his attacks
  upon him, in spite of the fact that he has been accorded all sorts of
  privileges. He has, of course, by this time consigned many hospital
  officials to life imprisonment, and the amount of damages which he
  expects to collect from them and the Government runs into fabulous
  sums. He soon began to solicit the grievances of his fellow patients,
  establishing, so to speak, a law office in miniature upon the ward;
  and whereas formerly these patients in the criminal department merely
  aired their grievances as they saw them, they now accompany them with
  quotations from the statutes concerning these points furnished by this
  legal missionary. Soon, however, even the insane patients on his ward
  began to distrust him, and at the present time there is hardly an
  attendant or patient in the building who cares to associate with Y. He
  missed no opportunity of playing upon the credulity of the younger and
  less sophisticated attendants in the criminal building, at first
  begging and urging them to carry his petitions to their destination in
  a surreptitious manner, and finding this of no avail threatening them
  with fines and imprisonment as accomplices in this gigantic crime of
  keeping him confined in a hospital. When not out walking he keeps
  himself constantly busy making out documents, briefs, petitions,
  bills, etc. He is very seclusive, keeping himself aloof from the other
  patients, as he considers himself very much their superior.

  Now this master litigant, this profoundly diseased man, succeeds in
  making quite a normal impression in a casual interview, and in his
  writings he frequently succeeds in conveying the idea of being quite
  normal. Each isolated fact looks plausible enough to the casual
  observer. He talks quite rationally, shows a remarkably well-preserved
  memory, has never exhibited hallucinations or those gross disorders of
  conduct which to the lay mind form the _sine qua non_ of mental
  disease. It is only after a close study of the entire life history, of
  the many fine shades of deviation from the normal which this man
  exhibits, that one discovers that his mind is very seriously affected
  indeed, and that because of his plausibility he belongs to a rather
  dangerous type of mentally diseased individuals.

The chief aim of this paper has already been indicated, and we shall
adhere to our original intention of rendering it as free from purely
didactic considerations as is consistent with clearness. For this reason
the case histories given above were considerably abbreviated and only
such an account rendered as would suffice to convince even a layman that
the two individuals in question are seriously affected mentally. Of this
there should not be the slightest doubt in anyone's mind, neither should
one encounter here any diagnostic difficulties. The only difficult
point, and a point which may become of considerable forensic importance,
is the exact estimation of the duration of the illness in each instance.
From the available data at hand it would seem that in the case of X----,
the disease had its inception in the episode during the late Civil War,
though the possibility of retrospective falsification must be kept in
mind; while Y seems to have been launched upon his litigious career by
his dismissal from the Navy. It is therefore but fair to assume that in
both instances the disease has existed for a great number of years.
Nevertheless, it was only when these individuals faced the bar as
defendants in criminal suits that the disease was recognized in either
case. One may readily see, therefore, how easily mental disease may
remain undetected, especially if one neglects to take an inventory of
the individual's past life. I have already alluded to the difficulty
frequently experienced in having evidence of this nature accepted in a
court of law, and here, it seems to me, is room for a good deal of
reform in procedure. Thus far society's side of this problem has been
chiefly emphasized; but what about these unfortunate derelicts, X----
and Y? Both of them are at present confined in the criminal department
of the Government Hospital for the Insane with criminal charges pending
against them. Assuming that our contentions with respect to their mental
status are correct, what possible justification is there to hold them
responsible before the law for their acts? Nevertheless, the same sort
of procedure is constantly taking place; individuals are being sent
daily to hospitals for the insane, presumably for the purpose of giving
them the best possible chance for recovery, the best modes of treatment,
while at the same time the law persists in carrying them as individuals
charged with crime, thus throwing many obstacles in the way of proper
care and treatment. With many of these individuals the mere fact that
there is still a criminal charge pending against them seems to act in a
deleterious manner upon their mentality, while in the great majority of
instances, owing to the fact that they must be carried as criminals,
unusual precautions have to be resorted to both in their confinement
and in the matter of various privileges, thereby vitiating in a great
measure all attempts at treatment.

These are some of the problems which present themselves from a study of
life histories such as are here reported, a better mutual understanding
concerning which between the lawyer and the physician would
unquestionably tend to a more enlightened administration of the law.


REFERENCES

[1] MAUDSLEY: "Responsibility in Mental Disease."

[2] KRAEPELIN, E.: "Psychiatrie." Achte Auflage. Leipzig, 1910. Bd. 1.

[3] TANZI: "Mental Disease."

[4] BISCHOFF: "Lehrbuch der Gerichtlichen Psychiatrie." 1912.

[5] SANDER: Quoted by White. "Outlines of Psychiatry." Fourth Edition.




CHAPTER IV

THE MALINGERER: A CLINICAL STUDY


I

The following study is undertaken less for the purpose of discussing the
psychology of malingering than with the object in view of illustrating
by means of clinical records the type of individual who malingers. The
opinion is a general one that malingering is a form of mental reaction
to which certain individuals resort in their effort to adjust themselves
to a difficult situation of life. Being a form of human behavior, it
should have been approached, therefore, with the same attitude of mind
as any other type of behavior.

A perusal, however, of the literature on the subject, especially of the
contributions of the older writers, reveals that with certain isolated
exceptions the subject was viewed primarily from the standpoint of the
moralist. Even today one sees in certain quarters a good deal
made--certainly a great deal more than the facts would justify--of the
"insanity dodge" in criminal cases. It is true that today,
notwithstanding the still broadly prevalent tendency to view with
suspicion every mental disorder which becomes manifested in connection
with the commission of crime, the danger of error in this respect has
been reduced to a minimum owing to the more advanced stage of
psychiatry, and therefore the practical importance of the subject of
malingering is not so great as it was formerly. We find, nevertheless,
justification for the further study of this subject in the fact that,
aside from its purely psychiatric importance, the more intensive study
of the malingerer offers a solution for some of the important problems
in criminology. As one of the results of this more intensive study may
be mentioned the gradually-gained conviction that malingering and actual
mental disease are not only not mutually exclusive phenomena in the same
individual, but that malingering itself is a form of mental reaction
manifested almost exclusively by those of an inferior mental make-up;
that is, by individuals concerning whom there must always be
considerable doubt as to the degree of responsibility before the law. As
a result of this recognition cases of pure malingering in individuals
absolutely normal mentally are becoming rarer every day in psychiatric
experience.

The conviction was further gained that malingering as well as lying and
deceit in general, far from being a form of conduct deliberately and
consciously selected by an individual for the purpose of gaining a
certain known end, is in a great majority of instances wholly determined
by unconscious motives, by instinctive biologic forces over which the
individual has little or no control. This is one of the factors which
determines the growing realization among present-day psychiatrists of
the extreme difficulty to state in a given case which is malingered and
which genuine in the symptomatology. That such views should encounter
opposition among our jurists is perfectly natural, threatening as it
does with complete annihilation that wholly artificial concept of the
"freedom of will" upon which our laws are based.

In touching upon the subjects of "responsibility" and "freedom of will"
I incur the danger of adding to the general misunderstanding which still
exists between the physician and jurist concerning crime and the
criminal.

Speaking from personal convictions, I see no real justification whatever
for this misunderstanding, unless it be the difference in the mode of
approach to the subject on the part of the two. The jurist is compelled
by existing statutes to look upon crime largely in the abstract--not as
it concerns the individual who committed the deed, but as it is affected
by the statutes covering it. The physician, on the other hand, sees in
the criminal act a form of reaction to an intrinsic or extrinsic
stimulus by a feeling, willing, and acting human being, and proceeds
accordingly to analyze in a concrete manner the forces which brought
about this particular form of reaction in this particular individual. As
a result of this mode of approach to the subject he is enabled to
conceive of "responsibility" as something fluid, something extremely
variable, and which may be affected by a thousand-and-one things, and
not as something absolutely fixed and invariable and which may be
definitely foreseen by a set of statutes.

Any attempt to bring about this most desirable uniformity of approach to
the subject of criminology between the jurist and the physician must be
based primarily upon intensive study of the personality of the criminal.
Such is the aim of this paper.


II

In the last analysis malingering is to be looked upon as a special form
of lying, and its proper understanding will necessitate a clear insight
into lying in general.

Lying, a very natural and generally prevalent phenomenon, may manifest
itself in all gradations--from the occasional, quite innocent "white
lie" as it occurs in a perfectly normal individual to the pathological
lying exhibited in that mental state known as "pseudologia phantastica."
Its proper understanding, however, no matter under what circumstances
and to what degree it be manifested, will be possible only through a
strict adherence to the theory of absolute psychic determinism.

Lying, like every other psychic phenomenon, never occurs fortuitously,
but always has its psychic determinants which determine its type and
degree.

Naturally many of these determinants are quite obvious and readily
ascertainable. One has only to recall the lying and deceit practiced by
children. But many others, if indeed not most of them, are active in the
individual's unconscious motives and accessible objectively as well as
subjectively only with great difficulty and by means of special
psychological methods.

The degree of participation of unconscious motives in lying will be
determined in the individual case by the extent of repression
necessitated because of social, ethical, and æsthetic considerations. It
is for this reason that lying is most prevalent and exhibited with the
least amount of _critique_ in those individuals who either have never
developed those restraining tendencies which a normal appreciation of
social, ethical, and æsthetic consideration demands, or in whom these
restraining influences have been weakened or abolished by some exogenous
insult to the nervous system--as, for instance, the tendency to
fabrication dependent upon chronic alcoholism or morphinism. A beautiful
illustration of the latter type is furnished by General Ivolgin in
Dostoieffsky's "Idiot."

The child's tendency to lying and deceit is dependent to a large extent
upon the undeveloped state of those restraining forces. To state,
however, that this is the sole mechanism underlying the phenomenon of
lying would be to state only half a truth. For it is an undeniable fact
that, no matter how strongly endowed an individual may be with ethical
or moral feelings, still there comes a time when these are entirely
forgotten and neglected; when, finding himself in a stressful situation,
the instinctive demands for a most satisfactory and least painful
adjustment, no matter at what cost, assert themselves. It is then that
the lie serves the purpose of a more direct, less tedious gratification
of an instinctive demand. The resort to this mode of reaction, to
evasion of real issues for the purpose of gratification of instinctive
demands, is not characteristic of man alone, but is quite prevalent even
in some very low forms of life. We will have more to say about this
later. It is an important tool in the struggle for existence among all
living beings; it is one of the mechanisms by means of which the weaker
inferior being escapes annihilation at the hands of the stronger,
superior being.

Malingering, it will be seen later, appears to certain individuals to be
the only possible means of escape from and evasion of a stressful and
difficult situation of life. The lack of _critique_ which permits such
an abortive attempt at adjustment and the inherent weakness and
incapacity to meet life's problems squarely in the face which drives
them to resort to such a means of defense are some of the traits of
character which serve to distinguish these individuals from what is
generally conceived to be normal man.

The extent to which lying and allied behavior depend upon unconscious
motives has never been so well illustrated as in recent psychoanalytic
literature, especially in a paper by Brill.[1] This author is so
thoroughly convinced of the value of conscious lying as an indicator of
unconscious strivings and motives that he frequently asks his patients
to construct--artificially--dreams which he finds to be of valuable aid
in the analysis of the patient's unconscious. After citing a number of
examples Brill states: "These examples suffice to show that these
seemingly involuntary constructions have the same significance as real
dreams, and that as an instrument for the discovery of hidden complexes
they are just as important as the latter. Furthermore, they also
demonstrate some of the mechanisms of conscious deception. The first
patient deliberately tried to fool me by making up what he thought to be
a senseless production, but what he actually did was to produce a
distorted wish. He later admitted to me that for days he was on his
guard lest I should discover his inverted sexuality, but it never
occurred to him that I could discover it in his manner. That his
artificial dreams have betrayed him is not so strange when one remembers
that _no mental production, voluntary or involuntary, can represent
anything but a vital part of the person producing it_."

Were this thesis on malingering to succeed in nothing else than in
bringing home to our legal brethren this important truth of absolute
psychic determinism, that a man is what he is and acts as he does
because of everything that has gone before him--because of ontogenetic
as well as phylogenetic instinctive motives--it will have fully
established its _raison d'être_. For a realization of this truth would
at once annihilate from our minds that deceptive notion of the "freedom
of will" upon which our laws are based, and will be certain to bring
about a more enlightened solution of the problem of the criminal, all
attempts at which, we are constrained to state, have thus far[A]
undeniably been huge failures.

[A] Intimate contact with members of the legal profession, both
professionally and socially, for some years past has convinced me that
the average lawyer still looks upon the ideas concerning crime and the
criminal expressed by physicians of a forensic bent as totally
unpractical and visionary. It would take only a brief visit to a
criminal department of any modern, well-conducted hospital for the
insane to convince any fair-minded individual that the physician handles
the problem of the criminal not only in a more scientific and rational
manner than does one not possessed of this particular training, but also
in an eminently more practical manner, even so far as dollars and cents
are concerned. I have frequently had patients come under my observation
who for a great number of years had been oscillating between penal
institutions and hospitals for the insane, in whom each additional
sentence did not only fail to bring about the hoped-for reformation, but
served to render them more depraved and criminally inclined, and who
would have undoubtedly continued this checkered career throughout life,
had not their true, unreformable nature been discovered and thus caused
their permanent isolation from society, not by the jurist but by the
physician. Should reformation ever take place in any of these
individuals it is safe to assume that the one who was clear-visioned
enough to discover the cause of their antisocial existence would
likewise be competent enough to know when this cause has disappeared.

The psychic mechanism of lying is the same both in the occasional and in
the pathological liar--in both it is the expression of a wish--but the
difference in the personalities of the two is a very decided one. On the
one hand we have an individual who closely approaches normal man, while
on the other hand one who is closely allied to the mentally diseased.
The difference between the pathological liar and the habitual criminal,
aside from the moral phase of lying, is perhaps but a very slight one,
when we keep in mind that in both instances we are dealing with
individuals who habitually resort to a form of reaction in their
attempts at adjustment to reality which aims at a direct, simple, and
least resistant means for gratification. In both we are dealing with a
type of mental organization which is primarily incompetent to face
reality in an adequate, socially acceptable manner, and therefore has to
resort to constant deceit and lying, and in which those inhibitions
determined by social, ethical, and æsthetic considerations are equally
impotent. The marked egotistic trend which constantly comes to the
surface in the habitual liar when he attempts to play the part of the
hero and central figure in the most fantastic, bizarre, and impossible
adventures is likewise frequently at the bottom of the escapades of the
habitual criminal. The two traits are frequently, though by no means
always, concomitant manifestations in the same individual.

When, in 1891, Anton Delbrück[2] published the first comprehensive study
of the pathological liar, he not only succeeded in very accurately
delineating a more or less distinct psychopathological entity, but also
furnished additional proof in substantiation of the fact, well known in
psychiatry but as yet unrecognized by the legal profession, that the
transition from mental health to mental disease is not a sudden one;
that any dividing line which would have for its purpose the strict
separation of the mentally sound from the mentally diseased must of
necessity be a purely imaginary one, and one not justified by existing
facts.

The transition from absolute mental health to distinct mental disease is
never delimited by distinct landmarks, but shows any number of
intermediary gradations. Nowhere is this better illustrated than in the
pathological liar. Here one sees how a psychic phenomenon regularly
manifested by perfectly normal individuals may gradually acquire such
dimensions and dominate the individual to such an extent as to render
him frankly insane.

To endeavor, however, to definitely state where normality leaves off and
disease begins would be, to say the least, to attempt something
well-nigh impossible. And yet this is just what the jurist constantly
demands of the alienist. The law as it is laid down in the statutes,
especially in this country, does not permit of any intermediary stages
between mental health and mental disease. An individual, according to
law, must either be sane or insane. This point seems to me to be of very
vital importance, and I shall have occasion to refer to it again in the
consideration of our clinical material.

The part played in lying by disturbances of the apprehensive, retentive,
and reproductive faculties will not be discussed here in detail. These
undeniably have their influence in facilitating the mechanism of lying.
But to attribute this phenomenon wholly to disturbances of this nature
would be to assign to it a purely passive rôle, whereas experience
teaches that back of every lie are active forces, either conscious or
unconscious, which give birth to it and determine its type and degree.

The following two cases will illustrate better than any formal
description could what is meant by pathological lying, a
psychopathological state for which Delbrück proposed the term
"Pseudologia phantastica":

  E. W. S., a colored male, aged thirty-two years, was admitted to the
  Government Hospital for the Insane from Fort D. A. Russell, Wyoming,
  on January 29, 1912, on a medical certificate which stated the
  following: "Patient is a native of Porto Rico; has been sailor and
  soldier; has occasionally used alcoholic beverages, but usually the
  light wines or beer; is very good-natured, occasionally melancholy and
  lachrymose; gave a history of 'fits', and was previously discharged
  from the army on this account. He was thought to be 'queer' in his
  organization and had more or less trouble with the men, who made fun
  of him. He was sent to the hospital from the guard-house in October,
  1911, and his mental condition noted at that time. His present
  symptoms were described as delusions of grandeur: 'Queen Victoria was
  his instructor in English', 'King Edward of England was his school
  chum.' He thinks he was royal interpreter. He does speak a number of
  languages fluently and, so far as we can learn, with fair correctness
  (?)."

  On admission to this hospital the patient was in excellent health
  physically; Wassermann reaction with the blood-serum negative.
  Mentally he was clearly oriented in all respects and fully in touch
  with his immediate environment. He comprehended readily what was said
  to him, and his replies, aside from his extreme tendency to
  fabrication, were coherent and to the point. Intelligence tests showed
  him to be intellectually about on a par with the average negro of his
  social and educational status.

  When asked to give his family and past personal history, he recited
  the following: He knew nothing of his grandparents or parents, and
  denied having any living sisters or brothers. One brother died in
  Chicago in 1906; thinks he must have been murdered, because he himself
  was almost murdered in November, 1911, when they attempted to
  assassinate President Taft out in Wyoming. King Mendilic, of Cape
  Town, Africa, now dead for seven years, was his cousin. The patient
  himself was Prince of Abyssinia, where he reigned for eight years,
  having remained in that country from 1896 to 1899, and conducting the
  affairs of state the remaining five years by correspondence, with the
  approval of Lord King Edward. He stated he was born in Porto Rico in
  1876, and calculates his present age as thirty-four, as this is 1912.
  About two months ago he received a letter from Queen Alexandra of
  England telling him he was thirty-two years, ten-twelfths and two days
  old, or thirty-two years, two months, two weeks, and two days. Asked
  how much ten-twelfths of a year was, he said: "Three months, three and
  two days." When told that ten-twelfths of a year equaled ten months,
  he replied: "The calendar of the English era, which is 'our calendar',
  does not correspond with the American calendar, but, being in America,
  I believe I ought to figure from their standpoint." He left Porto Rico
  at the age of six; does not know who took care of him up to this time,
  as he never knew his parents, stating that he was just thrown on the
  mercies of the country. At the age of six, upon the recommendation and
  advice of King Alfonso of Spain, he was taken to England by Queen
  Victoria, who came to Porto Rico especially for this purpose. When
  asked his opinion as to why Queen Victoria should have taken so much
  interest in him he stated that he did not know positively, but it may
  have been because he was related to King Solomon of Bible fame.
  Requested to explain this relationship to King Solomon, he traces it
  in the following manner: He was a cousin of King Mendilic, who in turn
  was the "third reigning seed" or stepson of King Solomon. Queen
  Victoria, whom he calls "Mother Victor", because she took the place of
  his mother, sent him to "Hammenotia School" in Oxford University,
  which he attended for four and a half years, received his diploma, and
  was transferred to Cambridge College. Here he attended for four years.
  At the former school he learned the alphabet, went up to the seventh
  grade, learned some medicine about herbs, etc. "I learned some
  medicine, not all of it. I didn't practice it much; just practiced it
  enough to do the country good. At that time we didn't have any
  doctors." At Cambridge he learned "The Reigning of the Thornes", or
  the laws of the country. Upon request he described in minutest detail
  the city of Cambridge. When asked whether he remembered a large oak
  tree which grew on the banks of the river flowing through the city, he
  replied: "I should say I do; many a time I sat on the banks of this
  river during my student days." Earlier in his student days at
  Cambridge he learned German, French, and English. It should be
  remarked here that the patient actually did know a few common phrases
  in several languages which he picked up during his sailor days. But he
  always insisted that he knew thoroughly twenty-two languages, and when
  asked to enumerate these he found himself in deep water and was
  obliged to invent the languages for the occasion. Nevertheless he
  stuck to this story, and was always ready to launch upon the task of
  enumerating his twenty-two languages.

  After his four years' sojourn at Cambridge, Mother Victoria sent him
  to "Saint Palestine", Jerusalem, where he remained for fourteen
  months, learning the constitution of the country, by-laws, etc. Mother
  Victoria and Father Edward (Queen and King of England) brought him up
  so that he could properly reign over Abyssinia. He states that he saw
  Queen Victoria frequently, and was at her funeral in August, 1910,
  shortly after the death of Pope Leo. Lord King Edward died about three
  months later. The Queen died about the age of seventy-six, as did King
  Edward at the same age, from grief and senility. Here he adds that his
  maternal grandmother was sister to Queen Victoria. While at the
  English Court he held the position of "Prince of Escorts." He left
  Jerusalem to go to school at Sydney, Australia, for one year. He then
  went to sea on Lord Edward's naval reserve boat, which he had
  permission to use. Remained at sea for three years and four months,
  visiting China, France, Japan, Germany, Austria, Turkey, Italy,
  Havana, Archipelago. When asked to repeat these countries, he omits
  some of them and adds others.

  He then came to the United States for the purpose of electioneering,
  stump-speaking, etc., all to benefit the government. He then became a
  United States interpreter in the Philippines from 1896 to 1902, at a
  salary of $75 per month and expenses. He then returned to Porto Rico,
  where he remained until 1910. Following this he attended the funerals
  of Queen Victoria, Pope Leo, Lord Edward, and his cousin Mendilic, and
  finally came to Chicago, where he enlisted as first-class sergeant in
  the United States Army. He was sent to Fort D. A. Russell, Wyoming, to
  serve in the Hospital Corps, at a salary of $48 per month and
  maintenance. There everything went well until he got to worrying and
  crying, so they sent him here. He acted thus because he was
  ill-treated, was not treated right for a man of his abilities, was
  sworn at too much, and called bad names by the enlisted men. They did
  this because they were jealous of his "politicalness", his education;
  he never swore, drank, or gambled like the others did. Was robbed of
  his every possession in Cheyenne, Wyoming, by members of the Ninth
  Cavalry and Eleventh Infantry. Lost $1400 in the past five months in
  cash and property. They robbed him of his horse, buggy, clothes, and
  jewelry, including chain, watch, finger ring, a pair of jasper
  earrings. He could hear them talking about him day and night; feared
  to leave his room, for he was continually threatened. They were going
  to kill him. On this account he was taken to the hospital and kept
  under close guard, because they could protect him. He had to leave at
  night. He did so after having received a telegram from the
  Surgeon-General of the Army, asking him to report to the Hospital
  Corps at St. Elizabeth's Hospital, Washington, D.C. As one of the main
  reasons why they had it in for him he gives the following: There was a
  car line running from Fort D. A. Russell to Cheyenne, the fare being
  ten cents. The men wanted it reduced to five cents. As the one in
  charge of the canteen he had it in his power to approve or disapprove
  of this reduction. He disapproved of it because he didn't think that
  ten cents was an excessive charge for a three-mile ride, especially
  since they spent so much money on drink, etc. He had a runabout motor
  car, so they thought this was why he disapproved of it. "In
  consequence they were on my trail." Part of the way to Washington he
  came in a private car, but this they deprived him of at Omaha,
  Nebraska. Perhaps they did this because they thought it was too large
  for him, but, inasmuch as it was assigned for his private use, they
  had no business taking it away from him.

  During the recital of the foregoing the patient was bright and alert,
  and his attention was easily gained and very well held. He quickly
  understood everything that was said to him, and replies were prompt,
  relevant, and coherent, though, of course, entirely colored by his
  bizarre fabrications.

  During his sojourn at this hospital he was a model patient in every
  respect, worked diligently with a farm gang, though frequently
  dilating upon the fact of having the responsibility of the whole gang
  on his shoulders. On several occasions he gave evidence of being of a
  highly sensitive make-up, becoming readily insulted, but he always
  reacted to these real or imaginary insults in a mild and kind sort of
  way, always preferring to go out of people's way rather than
  retaliate. Hallucinatory disturbances were never manifested.

  The story of his past life was gone over with him on a number of
  occasions, but on each occasion he gave a different, highly fantastic
  recital of his past adventures, always using high-sounding words and
  phrases and high-sounding names, many of which he mispronounced. Many
  of the words used by him were of his own coinage, if one were to judge
  by the sound of them. He was always very pleasant and agreeable, and
  enjoyed reciting his past immensely. In all these bizarre and
  marvelous adventures he played the chief rôle and occupied the center
  of the stage.

  He was finally induced to give an explanation of his extreme love for
  lying, which he gave as follows: "_It isn't because I don't know
  better, doctor, but because I think it will make me feel better,
  that's all. When I tell of all these big things it makes me feel that
  I am a little above the common herd of negroes, and then I never tell
  anything to hurt anybody._"

  He stated that he couldn't really separate the true from the false in
  his stories, and that he seemed to have little or no control over this
  tendency to exaggerate things and to weave into real occurrences all
  sorts of manufactured detail. "I know one thing, doctor; that it's
  been a habit of mine all my life. I have always tried to exaggerate a
  bit. It makes me feel, for the time being, that I'm above the other
  negroes, that's all. I know I always try to make an honest living, and
  this habit of mine never interfered with me."

A good deal more could be furnished from the records of this man's case
in illustration of his pathologic disposition to lying. An ordinary
negro soldier, he succeeds in projecting himself, by means of his ready
and very fertile fantasy, into the most wonderful situations and in
rubbing shoulders with royalty. If we inquire into the causes operative
here we first of all see in the fabrications of this individual an
unbounded craving for compensation for a natural deficiency--in this
instance a racial deficiency. What this man lacks in reality he
endeavors to substitute in his fantasy. There can be no doubt that the
tendency to lie has reached such dimensions and intensity in this man's
mental make-up as to make him absolutely believe in his own impossible
fabrications, to render him absolutely helpless in the mazes of his
fantastic creations. He is assisted in this by his craving for
self-esteem, by his extreme need of compensation for a real deficiency,
by his ready and fertile fantasy, one absolutely devoid of _critique_,
by his extreme suggestibility, and, lastly, what is of great importance,
by his extremely defective apperceptive faculties and consequent
falsifications of memory.

The latter defect was particularly well illustrated in the following
note from my records of the case. He was asked, in the course of my
examination, to repeat a simple story known as the "Shark Story", which
I shall reproduce here in full for the sake of making clear my point:--

  "The son of a Governor of Indiana was first officer of an Oriental
  steamer. When in the Indian Ocean the boat was overtaken by a typhoon
  and was violently tossed about. The officer was suddenly thrown
  overboard. A life preserver was thrown to him, but on account of the
  heavy sea difficulty was encountered in launching a boat. The crew,
  however, rushed to the side of the vessel to keep him in sight, but
  before their shuddering eyes the unlucky young man was grasped by one
  of the sharks encircling the steamer and was drawn under the water,
  leaving only a dark streak of blood."

In reproducing it he said:--

  "The son of a Governor of an Oriental steamer was the captain. Now,
  doctor, I can't think of those little stories. It isn't because I
  haven't brains enough; it's because I'm so poor a scholar at reciting.
  I always was." "What happened to the captain?" "That I can't
  recollect, neither." "What happened to the ship?"

Here, instead of answering my question, he said: "Doctor, I suppose you
have heard about the big wreck that happened out on the ocean." (This
was when the terrible _Titanic_ disaster was on everybody's lips and the
papers were full of the tragedy.) The patient regularly read the papers.
"Tell me about this wreck."

  "Well, the steamer was 1200 miles from the land--north-northerly
  course. It was first reported that 1800 lives were lost; afterwards
  they found out for certain, through the communication with General
  Wood, that it was only 1300. Mrs. Zelia Smith, she was on the vessel."
  (Patient's name is Smith.) "She is Commissioner Hodges's daughter. She
  was counted lost, for instance, and was found alive. I knew her well;
  I knew a good many other people on that boat." "About how many people
  did you know?" "Well, I just only remember some. For instance, Major
  B----; I knew him well, of course. I dare say I knew all the others,
  but I knew him best. The boat was in charge of E. C. Smith." "Did you
  know Captain Smith?" "Yes, sir; I knew him. I didn't know him
  personally; I only made one voyage with him from Angel Island." "When
  was that?" "In 1907." "What was the name of the wrecked ship?" "I
  can't recall that, neither; _Tripoli_, I think it was; she is close on
  1500 feet long." "How much money was she supposed to be worth?" "I
  don't know, sir; there were several heirs who had charge of the ship.
  She was called the sister-ship _Trinic_ and was worth about $25,000.
  That, perhaps, may not cover her upper-deck cabins." "Did you ever
  travel on her?" "No, sir; I never was on her. I was on the _Trinic_,
  the sister-ship. The White Star people own these boats. I used to run
  a transport between the White Star Line and the Yellow Star Line."
  Here he was told that the examiner did not know of the existence of a
  Yellow Star Line, and he replied: "Oh yes, doctor; you heard of the
  Flying Squadron that reports all these disasters and signals the other
  ships."

Thus we see that with partial truths, with facts only partially and
imperfectly recalled as a framework, he builds his fantastic tales. He
read the newspapers regularly, but could not even recall the name of the
ill-fortuned ship, or any particulars about the accident. But what of
that?--he could readily fill in the hiatuses with his fabrication. He
failed entirely in the attempt to reproduce the story given him, and
used the talk about the _Titanic_ disaster as a subterfuge--as a ready
means of escape from the difficulty in which he found himself.

He himself threw some light upon the part played by his craving for
self-esteem in his statement: "When I tell of all these big things it
makes me feel that I'm a little above the common herd of negroes." He
unquestionably believes in these tales, if they are real enough to make
him feel above the common herd of negroes. His suggestibility was well
illustrated by the suggested river at Cambridge, "on the banks of which
he sat many a time during his student days."

The facility with which his imagination, his fantasy, works was
demonstrated by the "ink-blotch" test to which he was subjected. This
test, in brief, consists of a series of ink blotches which are shown the
patient, with the request to describe them as they appear to him. The
following are several of his replies: (1) "A woman sitting on a man,
seems like she's got a little weaving in her hand; a little stick,
sticking out from the weaving, seems like the man's elbow is sticking
out back of the shawl." (2) "It seems to me I have seen a volcano that
looks like that. I think it is a ship out at sea. I can see the
lifeboats lashed to the side, several ripples of water behind." (3) "A
figure of a woman with a hand purse or a disfigured arm near the wrist.
Her mouth is open and she is looking around. The wind carried her hat
off; she has a muff on her right hand. Seems like there is a neck-piece
around the muff."

Notice the detail with which he describes the blotches. In this one
ordinary speech seemed to have been insufficient to describe the blotch,
and he had to resort to a neologism. "Is that supposed to be a
'perpendicament'? It's got a head like a sea devil; the upper part seems
like a peacock trying to peck him in the back of the head."

There remains one other thing to be inquired into in this case, and that
is the history of epilepsy which accompanied the patient. He was never
observed in an epileptic seizure at the military post from which he came
to us, and no seizures were observed in this hospital. His own
statements concerning this are, like everything else he said, quite
totally unreliable. But in repeated examinations he persisted in his
statement that he had had but one "spell" in his life, but that he
frequently suffered from fits of melancholy. In all probability this one
seizure was hysterical in nature, phenomena of which type not
infrequently manifest themselves in the pathological liar, as will be
seen in the next case.

Here one sees how lying, a mental phenomenon which is looked upon as
quite a normal manifestation in a great many people, has reached such
dimensions in this individual and has succeeded in dominating his
personality to such an extent as to definitely remove him out of the
pale of normality and place him within the sphere of the mentally
diseased.

There is, of course, no question here about the genuineness of his lying
as a symptom of mental aberration; _i.e._, the fabrication as manifested
by this individual is something over which he has no more control than
the dementia præcox patient has over his delusions. In both instances
the symptoms are spontaneous and genuine expressions of a pathological
mentality. And yet when such pathological phenomena become manifest in
association with some concrete difficulty in the individual's life, say
in connection with a threatened punishment for a crime committed, the
genuineness of the symptoms is frequently doubted.

One, of course, can readily see with what facility an individual of the
type under discussion could malinger mental symptoms. Reality and
fiction have about identical values in this type of mental make-up, and
it is frequently impossible to separate the genuine from the fictitious
in their mental productivity.

It is likewise quite easy to divine why an individual of this sort would
resort to malingering in his effort to extricate himself from a
difficult situation which he is organically unable to meet squarely in
the face. On the contrary, it would be strange indeed were an individual
of this type to refrain from resorting to this form of defense. Of
course, even the man whose history we have just quoted may still be
considered mentally responsible before the law were we to judge him by
the legal standards of responsibility. But as physicians we need not on
this account refrain from attempting to delineate these mental types in
their true colors.

The situation is well illustrated in the following case. Here the
symptom of pathological lying is associated with pathological swindling
and criminality and offers a fertile field for seeds of malingering.

  E. D. C., a white male, aged thirty-four, came to us on April 16,
  1914, from the penitentiary at Stillwater, Minn., where he was serving
  a sentence of ten years for white slavery. He was admitted on a
  medical certificate which stated that his father was supposed to have
  died from pulmonary tuberculosis. The patient gave a history of
  epilepsy until fourteen years of age, likewise of having been a
  patient in a Vienna hospital for the insane for one and a half years,
  in 1900 and 1901. So far as was known to the prison authorities, he
  was mentally depressed and had delusions since his arrival at the
  Minnesota State Prison on October 11, 1913. The present symptoms were
  described as mental depression; says that everybody is persecuting
  him; also has the delusions that he has or can invent a wonderful
  electric machine which he wants to sell to the government for a
  hundred million dollars; said he would shoot himself and die in
  prison. Physical condition was not good. Patient suffered from
  obstinate constipation, peculiar shuffling gait, suggesting partial
  loss of control of legs and feet. Complained of constant headache on
  the top of his head. No fever.

  On admission to this hospital the patient was in poor physical health
  and very anæmic. He was quite slender in stature and somewhat
  effeminate in manners and speech. He walked with a very marked limp of
  the right leg, stating that he had been afflicted in this manner ever
  since his first attack of mental trouble at the age of nineteen.
  Patellar reflexes were markedly exaggerated on both sides, the left
  more so than the right, and ankle clonus was present on the left side.
  Babinski phenomenon was absent. While the reflexes were being tested
  he volunteered the information that his left patellar reflex was very
  much stronger than the right. He was a very glib talker and spoke
  fluently in five foreign languages. He gave his name as E. J. B.,
  Count de C., the son of the chamberlain to the Austrian Emperor and of
  a famous Austrian countess. In the official papers which accompanied
  him to the hospital the above name was followed by several aliases. He
  talked in an affected, whining manner, constantly complained of
  various bodily ailments, and showed a marked tendency to
  hypochondriasis. He spoke of himself as a poor, down-trodden, and
  persecuted unfortunate who is being constantly misunderstood. The
  whole "white slavery" episode for which he is unjustly made to suffer
  ten years' imprisonment was a trumped-up affair on the part of the
  sheriff, who was bound to make a case out of it. He married the girl
  with the best of intentions, and when arrested was with her on the way
  to the Atlantic coast, preparatory to sailing for Paris, where he
  intended to give her a splendid time. She testified against him at the
  trial because she was scared into it by the officials, and, being
  naturally of a weak nervous organization, she gave in. He was certain
  he was going to die if he had to serve out his sentence, because
  prison life is so different from the life he has led in the past. He
  is entirely too refined to be able to stand the rough life of
  imprisonment. Referred the examiner to the Austrian Embassy, which
  could readily establish his noble descent and get him out of this
  terrible predicament. When, later in his sojourn here, he was
  interviewed by several gentlemen from the Austrian Embassy he
  maintained the same attitude of wronged innocence, notwithstanding the
  fact that these gentlemen confronted him with an undoubtedly genuine
  photograph of himself, obtained from the Austrian police. It seems
  that he was quite a famous character in Austria, and had served a
  sentence there under a different name for a similar offense (white
  slavery). Soon after his arrival at the Government Hospital for the
  Insane he began to scheme for his escape, and on one occasion
  attempted to saw the guards in his room with an improvised saw. He
  likewise began to associate freely with the more dangerous element of
  the criminal department of this hospital, quite likely with a view
  towards getting assistance for his escape. He spoke with reluctance of
  his ideas concerning the inventions, adding that he had decided to
  quit talking about these things, because, although he is quite
  convinced of the extreme value of these original ideas of his, people
  have told him he was crazy wherever he expressed them. As an
  illustration of some of these extremely valuable original ideas the
  following may be mentioned. It concerns a bed-bug trap which he
  invented, and which he described as a paper pocket which is placed in
  the bed and scented with oil of pine so as to attract the bed-bugs.
  These make their home in this paper pocket and lay their eggs there,
  after which it is removed and burned. In the course of time (about two
  months) he fully recovered from that serious leg affliction from which
  he stated he had been suffering since the age of nineteen.

  When an attempt was made to obtain his past history it was soon
  discovered that it was so fantastically colored with fabrications as
  to be entirely worthless, so far as a reliable account of his past
  life is concerned. As an instance of pathological lying, however, it
  was a masterpiece. He was requested to write out briefly his past life
  history, and in this abbreviated form it covered twelve
  closely-typewritten pages. We will not burden the reader with a
  complete reproduction of his story, although I assure you it makes
  very interesting reading material, but will simply review it briefly.

  He speaks of the confession made to him several years ago by the lady
  whom he had always looked up to as his mother. She told him that she
  was only his foster-mother, and that in reality he was the son of the
  Austrian chamberlain and a famous countess. The latter turned him over
  into this lady's care when he was quite young, following her divorce
  from the chamberlain. She furnished him with the authenticated proof
  of the fact that he was entitled to a fabulous fortune left by his
  parents. Unfortunately the lady died after a brief illness, during
  which he practically sacrificed his life to save her, and thus his
  most important witness is forever inaccessible. The papers which could
  readily prove his noble descent were, most unfortunately, taken from
  him when he was arrested and are probably destroyed by this time.

  His foster-mother, he states, was regularly supplied with funds by his
  real mother, gave him an excellent education and traveled with him
  extensively. In a plea for clemency he dwells upon the fact that his
  father died insane, that he himself suffered from epilepsy in his
  youth, and that at the age of twenty he spent a year in an insane
  asylum in Austria.

As an instance of his tendency to dramatization, of the part his ego
plays in the recital of his past exploits and of the tendency to crave
sympathy and compassion, a characteristic quite common to these
pathological swindlers, the following, his own description of the
circumstances which brought about his admission to the Vienna Insane
Asylum may be quoted:--

  "While on vacation, I met at Wertersee, which is a fashionable summer
  resort, a girl with the name L. Adle von D. I had left my tutor
  behind. She was the first girl I met, and my romantic character, my
  easily-excited nervous system, overpowered me and I fell in love, in
  love as deep as a man can fall. A few months after that I was engaged
  to her, and we should have been married on the 23d of April, 1899. On
  the 22d of April my beautiful beloved bride was riding horseback with
  me in the park, when at once her horse frightened, threw her off,
  dragged her for a distance and then left her behind, a motionless,
  bleeding mass. I saw right away that she was dead, lost to me, lost
  forever; there was but one way not to lose her, and that was to follow
  her soul, and that as quickly as possible. There in the park beside
  her I took my pistol and shot myself. The public had gathered and
  stopped me, and then I don't know what happened. I only remember that
  I was ill for a long time, and then I was ill again, and they told me
  L. was alive, and then I found out that she was not alive and I was
  ill again."

Of course, the entire episode is a fabrication. The patient admitted
quite as much, but the interesting thing in this episode is the fact
that it illustrates how rigidly dependent lying is upon unconscious
motives. Had this episode really taken place, the patient, because of
his particular make-up, would have acted, in all likelihood, just the
way he behaved in his fantastic adventure.

After his year's confinement in the insane asylum his foster-mother
traveled with him in France, England, Egypt, and Turkey, in order to
divert his mind. Finally arriving at Transylvania, he became infatuated
with a poor girl named P., whom he christened L. in memory of his former
love, and married. The highly dramatic adventures of this second
matrimonial venture are altogether too numerous to describe in detail.
He describes in a very dramatic style how this lady was kidnapped from
him by a family of New York artists and spirited away across the ocean;
how after awakening from his unconsciousness, induced by some dope
administered to him in a tea which he had with these artist-friends the
night before, he at once made for the dock, arriving there just as the
ship carrying his wife was disappearing from sight; how he pursued them
across the Atlantic, to England, the continent, and so on, finally
locating them in Cape Town, South Africa; how upon arriving there he was
mortally wounded to find his beloved wife performing upon the stage of a
cheap, dirty place. An excerpt from his description of this eventful
voyage is as follows: "We passed Las Palmas, Asuncion, and St. Helena.
Christmas and New Year's were celebrated on board the ship, but I did
not care much for it. I was too much in distress. Would I find her
there? Would I reach her in time? How would I find her? Would she be
alive? My excitable fantasy awakened in me the most terrible suspicions.
I suffered dreadfully, and it seemed to me we would never arrive. But we
did at last, and some time in the beginning of January, 1906, I landed
in Cape Town." This is how he discovered her: "I knew I was going to see
something terrible, but I remained there--I had to. There were the rope
dancers, the clowns, and the music, but I had no interest in them. I was
waiting for L., my wife, and she came. On a small, mean stage L., my
beloved wife, appeared with painted cheeks and shining eyes, dressed up
in tights. She was dancing a mean dance and singing an obscene song
before an audience consisting mostly of drunken sailors. So I found my
wife L. and the music played. It was surely wonderful that I could
control myself at such a moment. At once it seemed to me that I had no
reason to be astonished. I was quiet and decided and waited until the
show was over, and after the show I went behind the stage, and when my
wife came out, laughing and happy, with a couple of other girls, I
stepped near her and said simply 'L.' She gazed at me and fainted." Thus
he finishes another tableau in his adventurous career. Several other
similarly dramatic adventures follow in his history, the last of which
landed him, wholly unjustifiably, in prison for ten years. When asked
why all his love adventures ended so disastrously, he replied: "Doctor,
all my life I have been suffering from a 'superaltruistic monomania to
help girls in distress,' and that is how I'm repaid."

Any discussion on "freedom of will" and responsibility in connection
with an individual of this type is, of course, quite futile and really
of no practical importance. This man ought to be permanently isolated
from the community, but not because he happens to have violated a given
statute, but because his grave mental defect--in all probability an
incurable defect--tends to express itself in criminal traits.

Back of this fantastic lying we see again that instinctive craving for
compensation by means of a resort to the imagination and fantasy, a
subterfuge rendered easy by those inherent defects enumerated in
connection with the preceding case.

All the frankly psychotic manifestations, such as his delusional ideas
and his grave affection of the lower extremity which served to put him
in a hospital for the insane, were, of course, entirely malingered.

This brings us to the subject of malingering proper.


III

In malingering we see the application of deceit and lying to a definite
situation. That which is a habitual type of reaction in some
individuals, as was illustrated in the foregoing cases, comes to the
fore in others only under certain stressful situations of life. While in
the habitual fabricator the most prominent motives are those of an
egotistic nature, a craving for self-esteem as compensation for an
inherent defect, in the malingerer we see a resort to this form of
reaction as a means of self-preservation, as a means of escape from a
particularly painful situation.

There was a time in the history of psychiatry when malingering was a
frequent subject of discussion in psychiatric literature. This was due
not so much to any inherent practical importance of the phenomenon of
malingering as such as to the faulty conception that this phenomenon was
something which by its very existence ruled out the existence of mental
disease. More scientific studies of personality which led to a direction
of our attention to the malingerer rather than to malingering as an
isolated mental phenomenon brought with it a complete change of attitude
towards the entire subject.

Today, far from harboring the notion that malingering and mental disease
are mutually exclusive, we are beginning to look upon malingering itself
as the expression of an abnormal psychic make-up. Furthermore, far from
believing, as of old, that the proverbially insane is supposed to be
totally devoid of discretion in his conduct, we know that there may be a
good deal of method in madness, and that even the frankly insane
malinger mental symptoms when the occasion requires it. No experienced
psychiatrist would today, for instance, consider the oft-quoted story of
the alleged madness of Ulysses as evidence of malingering.

The story is told that Ulysses, in order to escape the Trojan war,
feigned insanity. He yoked a bull and a horse together, plowed the
seashore, and sowed salt instead of grain. Palamedes detected this
deception by placing the infant son of the King of Ithaca in the line of
the furrow and observing the pretended lunatic turn the plow aside, an
act of discretion which was considered sufficient proof that his madness
was not real. Without attempting to pass upon the case of Ulysses, we
may say without fear of contradiction that no one would today depend
upon such criteria. Experience teaches us that an individual may be very
seriously mentally affected and at the same time show sufficient
discretion of conduct to avoid threatening danger and to seek those
means which best subserve his immediate needs and wants. Not only is
this true, but we have arrived at a stage where we are prone to look
upon a great many of the psychoses as the direct expressions of the
individual's wish--as a haven sought out by himself within which he
seeks shelter from the tempests of life. One of my patients tells me
that the gun which he used in the alleged homicide was not loaded with
bullets, but with paper wadding put there by his enemies, hence his
alleged victim could not have been killed; in fact, he knows that this
man is alive and having a good time on the money furnished him by his,
the patient's, enemies. Another instance is that of a colored man who is
serving a life sentence for murder. Among the many symptoms which this
fairly advanced dementia præcox case shows is the one that he considers
himself a white man; that his dark color is due to some paint which he
used in order to disguise himself; and that, inasmuch as the murder with
which he is charged was supposed to have been committed by a colored
man, he is not guilty of it. The motives here are quite obvious. Both
these individuals find life much more bearable believing, as they do, in
their innocence of the crimes imputed to them. Many other examples could
be cited to prove that symptoms in mental disease do serve a definite
purpose; that there may be indeed considerable method in madness.

Nevertheless, the observation is not uncommon that whenever such method
is detected under circumstances where some ulterior motive may be ascribed
to it the lay mind, and not infrequently psychiatrically-trained
physicians, are at once ready to question the genuineness of the
symptoms. It is the more curious that the so-called "insanity dodge" cry
is frequently raised under circumstances where it would seem to be the
least justifiable, as, for instance, in the case of an individual
battling for his life before the bar of justice.

A little inquiry, however, into this phenomenon will help us to
understand it better. It has its root primarily in that very common
tendency of man to impute to his neighbor a type of behavior, a form of
reaction, of which he would gladly avail himself were he in his
neighbor's place, and the weapon he would use under the circumstances
would very likely be that exquisitely human trait, deceit, malingering.
It is a weapon which has played a tremendous part in the evolutionary
struggle, not only of man but of all living things; in a broader sense,
it may be looked upon as an organic function, as an endowment, thanks
to which the weak, inferior being is able to avoid the danger of
becoming the prey of the stronger, superior being. This function is very
well illustrated in those animals which are able to acquire the color of
their immediate surroundings in order to render themselves more
difficult of detection. It is common among various insects, reptiles,
and amphibians. The chameleon may be especially mentioned in this
connection. Even the eggs acquire, in the process of natural selection,
the color of the place where they are deposited, and the cuckoo which is
about to cheat a couple of another species by placing her eggs in their
nest for them to hatch selects that species the color of whose eggs most
closely resembles that of her own, in order to assure herself of the
success of the deception. The simulation and malingering practiced by
the fox is common knowledge. Malingering, an instinctive function
originally, has, in the process of evolution, become an act of reason
with certain animals. One is forced to believe, from a survey of
mythological writings, that primitive man must have had recourse to
simulation and all else that this term stands for whenever he was
confronted with an especially difficult problem in his struggles for
existence. To the gods was attributed, among other special propensities,
the ability to assume any shape or form, else how could they have
performed all those miraculous escapades? Thus we are told that Jove
transformed himself into an eagle when he carried off Ganymede.
Achilles, the son of a goddess, sought to avoid the iniquitous fate
which drove him to Troy by disguising himself as a woman. Deception is a
common weapon of defense with the savage and with the inferior races of
today. It is the tool by means of which these individuals render things
as they want them to be; it is with them the means for a more direct,
less difficult, less tedious solution of the problems of life.

The child in whose development the various steps of phylogeny are
recapitulated shows this tendency to deception, to simulation, and
dissimulation in a very pronounced degree. Lombroso, who was the first
to demonstrate that so-called moral insanity is but a continuation of
childhood without the adjunct of education, cites many facts, not
excepting his own example, to show that the child is naturally drawn to
fraud, to deception, to simulation. The child simulates either because
of fear of injury and punishment or because of vanity or jealousy.
Ferrari,[3] in his excellent work on juvenile delinquency, discusses the
various motives for deception and malingering in the child. According to
him, deception is, first of all, instinctive with the child. It
malingers because of weakness, playfulness, imitation, egotism,
jealousy, envy, and revenge. Deception frequently forms for it the only
available weapon of defense against the parents and teachers.

Penta[4] cites many well-authenticated cases of malingering of mental
symptoms in children. Of special interest is Malmstein's case of a girl
of eight years who, in order to deceive her father and render him less
severe in his treatment of her, and in order to gain the sympathy of
those in the house who were in the habit of giving her sweets, feigned
complete muteness for five months, after which time, no longer able to
resist the desire to speak, she went into the woods, where, believing
herself unobserved, she began to sing. St. Augustine, in his
confessions, speaks of his childhood in the following manner: "I cheated
with innumerable lies my teachers and parents from a love of play and
for the purpose of being amused."[B] Penta, after a thorough discussion
of the subject of malingering in children, comes to the conclusion that
children use all the diverse forms of fraud, from simple lying to
simulation, much more frequently than is believed or known. It may with
them as with some lower animals simply be an instinctive playfulness, a
habit or a necessity, as a weapon consciously and voluntarily wielded.
This inherent tendency is, of course, modified to a considerable extent
by the environment under which the child was brought up. Finally, the
independence which the growing human being acquires from this form of
reaction is in direct proportion to the ability he has acquired through
education and precept to meet life's problems squarely in the face. We
will see, later on, how the type of individual who is most likely to
malinger has in reality never fully outgrown his childhood; that his
reactions to the problems of everyday life are largely infantile in
character.

[B] Cited by Penta.

Thus we see that malingering has its _raison d'être_; that, after all,
it is not at all strange that the suspicion of its existence should be
so frequently raised by our legal brethren--yes, and medical brethren,
too; that in reality it ought to be a very common manifestation.
Nevertheless, paradoxical though it may seem, cases of pure malingering
of mental disease are comparatively rare in actual practice.
Wilmanns,[5] in a report of 277 cases of mental disease in
prisoners, cites only two cases of pure malingering, and in a later
revision of the diagnoses of the same series of cases the two cases of
malingering do not appear at all. Bonhoeffer,[6] in a study of 221
cases, found only 0.5 per cent of malingering. Knecht,[7] in an
experience of seven and a half years at the Waldheim Prison, did not
observe a single case of true malingering. Vingtrinier[8] claims not to
have found a single case of true malingering among the 43,000
delinquents observed by him during his experience at Rouen. Connolly,
Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted
by Penta as having expressed themselves that pure malingering is
extremely rare. Penta, on the contrary, observed about 120 cases during
his four years' service in the prison in Naples. He gives as the reason
for this unusually high percentage of cases observed by him the fact
that two-thirds of the inmates of the prison belonged to the Camorra, an
organization whose members are gleaned from the lowest and most
degenerate stratum of society, and in whom the tendency for deception
and fraud in any form is highly developed.

The question naturally arises, What is the reason for this rarity of
cases of malingering? Is it because man has reached a state of
civilization where he no longer resorts to deception? Decidedly not. The
reason lies almost wholly in our changed attitude of today towards this
question. As we acquire more real insight into the workings of the human
mind we are prone to become more tolerant towards the human weaknesses,
and in our study of the malingerer it is the type of individual, his
mental make-up, which interests us most, rather than the malingered
symptoms. It is for this reason that today the number of authorities is
indeed small who do not look upon malingering _per se_ as a morbid
phenomenon, as an abortive attempt at adjustment by an individual who is
quite incapable of adequately coping with the vicissitudes of life. In
my own limited experience of several years with insane delinquents I
have yet to see the malingerer who, aside from being a malingerer, was
not quite worthless mentally.

Our discussion of malingering,--_i.e._, of the exhibition of a
fictitious mental state by an individual for the purpose of rendering
more bearable or more pleasant a particularly painful or difficult
situation of life, or for the purpose of entirely annihilating such a
situation and of removing it from consciousness by substituting for it a
state of affairs wholly created from the individual's fantasy,--would
indeed be incomplete if we were to omit from our consideration at least
that much of Freud's psychology as pertains to this subject.

Thus far we have considered principally the views of what may be termed
the descriptive school of psychiatry, though we have briefly touched
upon the instinctive biologic roots of this primitive mode of approach
to the problems of life, malingering of mental symptoms.

With the consideration of the Freudian psychology we enter upon the
interpretative phase of psychiatry and to a very large extent of mental
life in general.

Freud holds that a great part of mental life can either partially or
entirely be summarized under two principles, which he terms the
"pleasure principle" and the "reality principle" respectively.[9] These
two opponents are constantly facing one another in our inner life. The
former represents the primary, original form of mental activity, and is
characteristic of the earliest stages of human development, both in the
individual and in the race; it is, therefore, typically found in the
mental life of the infant, and to a less extent in that of the savage.
Its main attribute is a never-ceasing demand for immediate gratification
of various desires of a distinctly lowly order, and at literally any
cost. It is thus exquisitely egocentric, selfish, personal, and
antisocial. The activities of this "pleasure principle", however,
constantly come into conflict with the "reality principle." The rigid
requirements of our environment, of the social system in which we live,
deny us the fulfillment of many, if not most, of our most dearly coveted
desires, without, however, being able to abrogate these entirely.

There are two ways in which these forbidden desires may become
satisfied. On the one hand, the instinctive striving, finding it quite
out of the question to gain expression through the desired channels, may
become sublimated into a form which is in accord with our social and
ethical requirements, or the forbidden strivings and desires may find
gratification in the individual's fantasy. We are here particularly
concerned with the latter mode of psychic adjustment. This mode of
adjustment is the usual way in which conflicts with reality are solved
by the child and the savage. For them a rigid recognition of reality,
such as is necessitated by the normal adult in his struggles for
existence, does not take place. In fact, the evolution from childhood to
adult life, from savagery to civilization, consists in nothing else than
in the progressive recognition of reality and the adjustment thereto.
One of the forms of getting away from reality, or a falsification of
conditions as they actually exist, was expressed by one of Freud's
patients as the "omnipotence of thought" (_Allmacht der Gedanken_). It
is a state of mind in which the individual believes in the omnipotence
of his thoughts; that his mere thinking possesses tremendous power; that
no sooner he thinks of a certain deed than the same is accomplished;
that an enemy, for instance, is actually harmed by merely wishing him
harm. This mode of thinking forms the basis for many magic ceremonials.
It is this latter mechanism,--_i.e._, the endowment of one's own
thoughts with an omnipotent power,--which is also frequently illustrated
in malingering. It is sufficient for the type of individual who
malingers to merely say the word, and the most fantastic creation of his
fancy immediately becomes a reality and is apperceived by him as such. A
mere verbal denial of guilt on his part is sufficient to make him
believe fully in his innocence and act accordingly. When we inquire into
the origin of this facility in transforming fantasy into reality, for
this omnipotence of the mere word or thought, we find it in the totally
unreasonable overcompensation of these individuals for their feeling of
impotence and weakness. This feeling of weakness and helplessness
naturally becomes more acute under especially stressful situations of
life, and hence it is that the criminal, especially the habitual
criminal, who always uses deceit and simulation in his vain attempts at
meeting life's difficulties squarely in the face, regularly resorts to
malingering when confronted with a serious criminal charge or when life
in prison becomes especially unbearable to him. A good illustration of
an attempt at falsification of reality for the purpose of annihilating a
particularly stressful situation by means of a mere assertion of a state
of affairs such as he would wish them to be, with a total disregard for
the real facts which constantly stare him in the face, is furnished by
the following case:--

  M. came from a good family and led a normal life, earning a
  substantial livelihood as printer up to the age of about thirty-eight.
  At this time one of his children died, and this, together with poor
  physical health, is said to have brought on a severe depression,
  during which he was actively suicidal and very self-accusatory.
  Several months later he lost another child by fire, and at this time
  also claimed to have obtained positive proof of his wife's infidelity.
  His mental depression became very much more aggravated; he attempted
  suicide on a number of occasions, was very suspicious and
  apprehensive, developed persecutory delusions, feared he was going to
  be burned to death or suffer some other horrible fate. This condition
  finally necessitated his admission to the Government Hospital for the
  Insane on May 28, 1897, at the age of forty. Here he gradually
  improved, and was discharged into the care of his father on
  October 22, 1899.

On February 19, 1903, he was readmitted as a D.C. prisoner, having shot
and killed a man who seduced one of his daughters. Some idea concerning
the type of individual we are dealing with here can be had already when
we keep in mind his mode of reaction to the various stressful situations
in his life enumerated above. All went well with him so long as he was
not called upon to make a difficult adjustment, but with the loss of his
child he develops a mental disorder. That he should have reacted to his
daughter's injury with murder is quite in line with his general
inability and incompetency for proper adjustment, and the development of
a mental disorder which has kept him in an institution for the past
twelve years and will in all probability keep him there the rest of his
life, in reaction to the committed murder, further emphasizes the
general vulnerability of his nervous system. Let us see how he attempts
to adjust himself to the situation; how he faces reality in his
psychosis.

He does just what primitive man has done and what the child of today
does. Not being able to face reality, he annihilates it and substitutes
for it a world created out of his fantasy, in which he plays every
conceivable rôle but the real one,--_i.e._, that of a patient accused of
murder. We will see that he does this by the mere fiat of his word--that
magic dexterity which has served so well primitive man in his struggles
with reality.

Let me reproduce some of his letters, of which he hands me at least one
daily. Here is one addressed to King George V:

  DEAR SIR: I wish to return at once to England to the Cissel Hotel. You
  told me not to take my wife back after the courts here had granted me
  a divorce, so I look to you to just please come on here in person and
  have me released, as the United States Senate has given permission for
  you to come and release me. I am the young man that rescued you from
  drowning at River View, and after telling you my case you advised me
  to get a divorce. The guests from the hotel were wishing for me to
  return when on here, as also my family.

  Please find enclosed check for your expenses and give prompt action.

    Very respectfully,
        (W. H. M.) HOWARD HALL,
            Washington, D.C.

The check:--

  U. S. Treasury,
  Pa. Ave. and 15th Street.

                             WASHINGTON, D.C., October 1, 1914.

  Please pay to King George of England Ten Thousand Dollars for
  professional services.
  $10,000                                              W. H. M.

Thus by the mere stroke of the pen he, a poor mortal accused of murder
and indefinitely confined to an institution, succeeds in putting himself
in touch with King George, in drawing _ad libitum_ upon the United
States Treasury, in ridding himself of the wife whom he accuses of
infidelity, and in annihilating old age by styling himself "The young
man," when in reality he is fifty-seven years of age at present.

His belief in these statements is absolutely unshakable, notwithstanding
the fact that he retains a clear orientation concerning his immediate
environment, and thus has the actual state of his affairs constantly
forced to his attention.

His grandiose compensation has such dimensions as to gratify every
imaginable wish of his. He came here because he was divorced from his
wife, not because of any crime he had committed. He is the son of the
supervisor in charge of this building. He owns this institution and
built it for a place in which he could count his money. He had forty-six
wagon-loads of this. He will live 250 years, because he has taken the
severest punishment to secure this. He refuses to assist with the ward
work, because he pays $1.50 a day for board and is not supposed to do
any work. He was brought here to select a woman for his wife. They
brought him a lot of blue-eyed blondes and also a lot of Baltimore and
St. Louis beauties, etc.

  W. H. M., Owner, Washington Asylum, 5000 Branch Hospitals, five
  million employees.

                                   ANACOSTIA, D.C., Fri., Nov. 6, 1914.

  DEAR MR. PRESIDENT:

  I came over here to take out forty-six wagons loaded with greenbacks.
  I respectfully had it arranged to have the Senate hold me here on
  account of so much wealth until I thought it safe to return. Please
  sign this and return it by mail. The Senate ordered me to write it to
  you, as there is no crime against me.

                                  WASHINGTON, D.C., Fri., Nov. 6, 1914.

  DR. W. AND STAFF OFFICERS OF WASHINGTON ASYLUM:

  Please allow Mr. W. H. M. to pass out the gate at once free.

      Very respectfully,
          W. W.

  Please don't delay this one minute.

Thus we see that the entire content of this man's delusional fabric is
intended, first, to serve the purpose of annihilating the painful
reality, and, second, to substitute for it a beautiful world in which he
finds himself free and young again, enjoying his fabulous riches and
many blue-eyed beauties. It is the only compromise possible for him, and
the fact that it is nothing but a day-dream does not in the least
detract from its compensating possibilities for this individual's
painful reality. This man's mental disorder has been so obvious ever
since its inception that the question of malingering never suggested
itself to anyone, and yet the underlying mechanism in this case differs
in no particular essential from the cases usually considered as
malingerers. In both instances the psychosis represents an attempt to
get away from a painful reality by individuals who are quite incapable
of meeting such reality face to face.

A more detailed consideration of Freudian psychology, especially such as
concerns the subjects of determinism, defense, and compensation, would
give one a still clearer insight into the subject under discussion, but
to do so would lead us considerably beyond the scope of this paper. From
what has been said thus far it will be seen that the mental processes
underlying the mental state of malingering differ in no essential from
those operative in the human mind generally; that man in his endeavor to
reach a satisfactory compromise between the two underlying principles of
his conduct,--_i.e._, that of pleasure and reality,--frequently resorts
to his fantasy; that malingering in its broader sense,--_i.e._, the
attempt to evade reality,--is a common mode of reaction in primitive
man, the child of today and in the undeveloped mind, in all of these
instances signifying an inability to meet stern reality in the face, and
that, therefore, malingering, when it does occur, should at least not be
looked upon as an aggravating circumstance, which is not infrequently
the case when the malingerer happens to be facing a court of law.

That this mode of reaction is at times resorted to by individuals who
had always been looked upon as being far from incompetent only proves
that under special stress, especially mental stress, man readily sinks
to a lower cultural level and resorts to the defensive means common at
this level.

Clinically, malingering is to be considered from three distinct
viewpoints:--

1. Malingering in the frankly insane;

2. Malingering in those apparently normal mentally; and

3. Malingering in that large group of border-line cases which should
rightly be looked upon as potentially insane and as constantly verging
upon an actual psychosis.

It may be difficult to convince the lay mind, and especially the legal
mind, that an individual may be suffering from an actual psychosis and
at the same time malinger mental symptoms. It is the legal mind
especially, working as it does with well-differentiated,
sharply-defined, and wholly artificial concepts, that demands a sharp,
strict differentiation between the mentally well and the mentally sick.
By means of man-made statutes a line has been created, on one side of
which they would place all the mentally well and on the other side all
the mentally diseased. By the same token they cannot conceive how an
individual placed on one side of the line may be able to manifest a type
of reaction, a form of conduct, which is by common consent considered as
being something essentially characteristic of the man on the other side
of the line, losing sight of the fact that in the evolution of the human
mind Nature is far from drawing such sharp differentiations as are
exemplified by legal statutes. It would certainly be very convenient,
and expert testimony would certainly have been spared the disrepute into
which it has fallen, were Nature more accommodating in this respect. But
Nature does not work in this fashion; differentiation in Nature takes
place through infinite gradations, and between the absolutely well
mentally and the frankly insane there is a host of individuals
concerning whom it is almost next to impossible to state to which of the
above two groups they belong. Thus it is that the frankly insane at
times manifest conduct which taken by itself differs in no way from
normal conduct, and that the so-called normal individual at times
exhibits a type of reaction which is essentially of a psychotic nature.

To the psychiatrist it is a matter of common occurrence to see the
mentally diseased not only dissimulate very ingeniously and tactfully
mental symptoms so that it is frequently impossible to convince a jury
of laymen of the existence of mental disorder, but at times, when the
necessity arises, they consciously accentuate their symptoms or frankly
malinger.

There is nothing strange about this. There is absolutely no reason why
the insane, in his desire to gain expression for his wishes and
strivings, should not avail himself of the same means that normal man
uses.

The following case illustrates this very clearly:--

  W. J. C., a well-educated, fairly efficient newspaper reporter, after
  a period of indefinite, vague, neurasthenic complaints lasting several
  weeks and which brought about his discharge from the staff of a local
  newspaper, awoke one July morning, picked up his infant child and,
  throwing it against the opposite wall of the room, inflicted fatal
  injuries upon it. After this he turned his face to the wall and
  remained quietly in bed. There was no ascertainable cause present for
  this act. The child was in the habit of entering the patient's room
  every morning and playing with him before he arose from bed. It was
  apparently on the same errand on this fatal morning. Shortly after
  getting up the patient wanted to leave the house in his night clothes,
  but was prevented from doing so and held until the police arrived. Six
  and one-half hours later,--_i.e._, on July 27, at 12.30 P.M.,--he was
  seen by me at the Government Hospital for the Insane.

  On admission to the hospital he was very restless and anxious, walked
  up and down the room, hands in his pockets, would sit down for a few
  minutes, then walked the floor again. Later in the day he was visited
  by a newspaper reporter, a friend of his, with whom he conducted a
  clear and coherent conversation, and when told by the latter that the
  child was dead he assumed a markedly depressed facial expression. In
  reply to my questions intended to bring out his attitude towards the
  whole affair, he usually stated, "I don't know," and on one occasion
  in a very agitated manner said, "So help me God, doctor, I don't know
  anything about this." Later in the day he gave a clear and coherent
  account of his past life, and a detailed mental examination failed to
  bring out any gross mental disorder. He showed, however, considerable
  uncertainty about the length of time certain events of the preceding
  day consumed. He could not tell exactly when he retired the previous
  evening. He remembered, however, going to bed, likewise that his wife
  came to his room sometime during the night and asked him to fill the
  babe's milk bottle. He didn't remember whether he did this or not. The
  next thing he remembered was sitting in the parlor of the house,
  sometime in the morning, and was able to describe accurately those who
  were present.

  During the remainder of the afternoon he was morose and depressed,
  refused to eat his supper, and continued in a restless state. He was
  again seen by me at 7.30 in the evening in company with two other
  physicians. The patient approached one of the physicians, extended his
  hand to him, and in a familiar manner said, "Hello, Mr. C." When told
  that this was not Mr. C., patient exclaimed "Oh!" in a confused and
  astonished manner, said, "Where am I?" and reeled over on the floor as
  if in a swoon. He was told to sit up in the chair, which he did.

  "What date is this?" "August 26, 1910" (July 27, 1910).

  "How long have you been here?" "Since July 25, 1910."

  "How long a period would that make?" "One month--oh no, one day; this
  is August 10, 1910."

  "What were you sent here for?" "Don't know."

  "Who brought you here?" "Don't know--oh yes, two policemen."

  "What is your babe's name?" "Don't know."

  "What is your wife's name?" "Don't know."

  He was then given a newspaper clipping in which the whole affair was
  fully described. He read the account through, but without exhibiting
  the slightest emotion, and said, "Isn't that awful, doctor?"

  "How do you feel about this affair of your babe being dead?" "I don't
  know anything about it."

  "How much is 2 times 3?" After considerable delay and in an absorbed
  mood he said, "70."

  "How much is 6 times 7?" After a long pause he said, "Don't know."

  "Which is the largest newspaper in Washington?" "Don't know." (Patient
  was on the staff of a local newspaper.)

When we remember that only several hours before this the patient gave a
coherent account of his past life and showed nothing grossly psychotic,
the foregoing symptoms, such as the lack of knowledge of his wife's or
babe's name, inability to solve problems such as 2 times 3, the fainting
spell, etc., must be looked upon as unquestionably malingered. When
examined the following day he showed still further signs of malingering,
the detailed account of which must, however, be omitted on account of
lack of space, and yet this man was unquestionably insane; the act
itself (the infanticide) was unquestionably an insane act, as will be
shown later. We have mentioned the fact of his neurasthenic symptoms and
how as a result of these he lost his position. The physical examination
of the patient revealed certain neurological signs, such as
exaggeration of the patellar reflexes, lateral nystagmus of both eyes,
which determined us to look further into the question of his physical
state, especially in view of a history of luetic infection five years
before. A spinal puncture was accordingly performed, and the spinal
fluid findings were as follows: Fluid clear, pressure moderately
increased, Noguchi butyric acid reaction positive, a rather uncommonly
heavy granular type of precipitate, cells per cubic millimeter 129.
Differential cell count: Lymphocytes, 94 per cent; phagocytes
2.2 per cent; plasma cells, 0.25 per cent; unclassified cells,
2.25 per cent. Wassermann reaction with spinal fluid negative, both
active and inactivated. Wassermann reaction with the blood-serum
negative. This, however, became positive later on in the disease. The
above findings indicate unquestionably that he was suffering from
cerebral syphilis.

It is not necessary to enter into further detail concerning the progress
of this case. Suffice it to say that with proper treatment he entirely
recovered and was so discharged on June 14, 1911.

There can be no doubt that this man malingered mental symptoms, neither
need there be the slightest doubt about his having suffered from an
actual mental disorder. The motive for his malingering is perfectly
obvious. Finding himself suddenly confronted with a charge of
infanticide, and rent by the various conflicting emotions which a
realization of this carries with it, he resorted to the common weapon of
defense, malingering of mental symptoms. We have seen that he deceived
no one but himself; that in reality he was a very seriously affected
individual. It was fortunate for him that because of some lucky turn of
events he landed in a hospital instead of in jail.

A more or less similar case recently received the maximum sentence of
life imprisonment for manslaughter. In this instance the case was
chiefly observed by jail officials instead of physicians in its early
course.

The foregoing case, it seems to me, illustrates very well that, while we
are fully justified in assuming a relationship of cause and effect in
many cases of malingering, in many others malingering and actual mental
disease are concomitant phenomena, having a common root in the same
diseased soil. Thus Pelman[10] holds simulation in the mentally normal
to be extremely rare, and he always finds himself at a loss to
differentiate between that which is simulated and that which represents
the actual traits of the individual. My own experience prompts me to
agree with Pelman. This confusion and difficulty of differentiation
between actual mental disease and malingered symptoms may manifest
itself in two ways. The same individual may be suffering at one time
from a frank mental disorder, and at some later period, finding himself
in a stressful situation, malinger a psychotic state, or, as we saw in
the preceding case, malingering of symptoms may manifest itself during
the course of a frank mental disorder, as will be further illustrated in
succeeding cases. Pelman's statement, however, applies most forcibly to
that mass of border-line cases which will be discussed later.

  T. W. was admitted to the Government Hospital for the Insane from the
  United States Penitentiary, Leavenworth, Kan., on June 16, 1910, at
  the age of twenty-nine. He was serving at the time a sentence of eight
  years for post-office robbery. His own version of his family and past
  personal history is unreliable. He claimed to have suffered from a
  paralysis of both arms from March, 1904, until March, 1906, and that
  he was at that time confined to a sanitarium. He would not give the
  name of that institution, and the whole story may have been
  fictitious. At any rate, if he did suffer from this paralysis it was
  very likely functional in type, as at the time of his admission here,
  four years later, he showed no traces whatever of this. He admitted
  having been arrested several times before for drunkenness and
  disorderly conduct. His industrial career was very irregular.

  The onset of the present attack, as described in the medical
  certificate which accompanied him on admission, was as follows:--"On
  the evening of April 17, 1910, patient suddenly began to shout, sing,
  and pray, claiming that the spirit of God had entered his heart and
  that he had a mission to perform. This mission was to go among the
  prisoners and preach the Gospel. He then manifested this in a very
  erratic manner; ideation was disturbed and disconnected, and there was
  present psychomotor restlessness. A probable diagnosis of
  manic-depressive psychosis was made by the prison physician."

  On admission to this hospital the patient was well nourished
  physically, talked readily and coherently, was clear mentally,
  although he stated he did not know the nature of this hospital, adding
  spontaneously that he knew it was not an insane asylum. His
  productivity was chiefly of a religious nature. He stated he was the
  real Elijah III, the real prophet; that the vision of Jesus Christ
  came to him in his cell, handed him a cross, and told him to pick up
  his clothes and follow Him. The warden at the penitentiary was jealous
  of his ability to preach the Gospel, and in consequence tried to get
  two men to kill him, but these could do him no harm, because he had
  the spirit of God in him. The warden also tried to poison him. He
  complained of a fever in his stomach from the food the warden gave
  him, stated he could see crosses in the corner of his room, and was
  continually mumbling something to himself in a low voice. He rested
  well on the first night of his sojourn here, and the following morning
  told the attendant that he had seen God standing behind him at
  intervals during the night. On June 28, 1910, he developed a marked
  religious excitement, preached loudly while out in the yard, and
  wildly gesticulated in a manner as if he were addressing someone
  above. He continued intermittently excited until the early part of
  August, 1910. It should be noted here that at this time there were two
  other cases confined in the same building, two cases of dementia
  præcox, who manifested similar religious excitement. It is of
  importance to note this, inasmuch as suggestion plays a considerable
  rôle in the choice of the malingered symptom, and because one of the
  characteristics of the type of individuals under consideration is a
  high degree of suggestibility.

  In his conduct in the ward he was quiet and orderly, frequently talked
  in a rational and coherent manner, but invariably brought into the
  conversation his delusional ideas. In his demeanor towards me he was
  very evasive, suspicious, and showed a marked disinclination to enter
  into a protracted interview. Soon after an unsuccessful attempt to
  examine him more thoroughly he handed me a letter addressed to Judge
  Landis at Chicago, in which he ordered said Judge to remove Voliva
  from Zion City and turn the latter over to him, the patient, as the
  rightful heir and the only real Elijah III. Following this there was
  another tranquil period, during which the patient's conduct was quite
  good. About a month later another attempt was made to examine him in
  detail, but so soon as he noticed my intention to take notes of the
  examination he became very suspicious and evasive and absolutely
  refused to coöperate. This episode was likewise soon followed by a
  letter as follows. The letter was addressed to the warden of the
  United States Penitentiary at Leavenworth, Kan., and he requested that
  it be mailed immediately, as it was very important. It was correctly
  dated and read:--

    "DEAR SIR: When you receive this letter you will immediately take
    steps to have me returned to the penitentiary, where I have a divine
    mission to perform. You old ... do you realize that you are fooling
    with the prophet Elijah, the Lord's chosen? Have you no fear of the
    wrath that God shall bestow on you if you even dare to offend His
    divine servant? Don't you ever for a minute think that you can
    connive to beat me out of my property in Zion City, you and that
    interloper, L. L. Voliva. I shall have it all just as the Lord meant
    I should, and I shall carry on the work just as the Divine Master
    meant I should. For what matter it if the world is against us, so
    long as God is for us? Now, you old reptile, on receipt of this you
    will immediately discharge the chaplain; he has no business there.
    When I get back I'll take his place, for I am Elijah III, the Lord's
    anointed.

    (Signed) "T. W. ELIJAH III, Station L, Washington, D.C."

  In the meantime it was noted that the patient was very shrewd in his
  various schemes for making his escape from the hospital; that he very
  ingeniously managed to manufacture all sorts of weapons, and that he
  seemed to be especially delusional when in conversation with the
  hospital officials.

  Soon after the patient planned and executed a very daring escape,
  taking with him two other patients, but was soon apprehended and
  returned to the hospital. All of this led me to suspect that the
  patient was simulating a good many of his symptoms, and that, at any
  rate, he was very much exaggerating his psychotic state.

  However, there was a certain element of contradiction, a certain lack
  of consistency, present in his behavior which is entirely atypical of
  the pure malingerer. His explanations of his ideas were flat and
  somewhat dilapidated, and resembled to a certain extent the
  explanations of a dementia præcox case. In other words, there was no
  doubt that the patient malingered, but there was likewise no doubt that
  he suffered from a psychosis. On several occasions he refused to take
  nourishment for several days at a time in reaction to his delusional
  ideas.

  Upon his return from his elopement it was felt that, owing to his
  dangerous tendencies, a more thorough attempt at evaluating the
  relative importance of the genuine and the malingered in his case ought
  to be made with a view to returning him to the penitentiary.

  He was accordingly again thoroughly examined on April 8, with the
  following results: He reiterated his delusional ideas substantially as
  given above. He insisted that he was not insane; that he was railroaded
  to this hospital because the warden of the penitentiary and other
  United States officials are trying to rob him of his property in Zion
  City. "God Almighty meant that Zion City should belong to me." This was
  decided on the night when he saw the cross.

  "How many months in a year?" "Twelve."

  "How many days in a week?" "Seven."

  "Name the months." "March, April, June, July, August, October,
  November, December, January, and February."

  "What is the last month of the year?" "October."

  "What is the first month of the year?" "March."

  "Which is the Christmas month?" "I'm not certain, but I think it's
  January."

  "How does vinegar taste?" "Sweet."

  "How does a lemon taste?" "Sweet."

  "What is the color of an orange?" "Blue."

  "Count from 1 to 20." Counts very slowly and deliberately, omitting 11
  and 15.

  "4 × 2 = 8; 8 × 4 = 28; 9 × 3 = 27; 7 × 4 = 24; 6 × 4 = 22; 6 + 7 = 13;
  19 + 11 = 30; 7 + 8 = 14; 3 × 3 = 9; 4 × 2 = 12; 6 × 4 = 14;
  5 × 2 = 10; 1 + 9 = 10; 9 + 11 = 21; 11 + 9 = 18; 50 + 5 = 11;
  8 ÷ 2 = 4; 27 ÷ 9 = 4."

  "Name the days of the week." "Tuesday, Wednesday, Thursday, Friday, and
  Saturday."

  "Name them again." "Monday, Tuesday, Thursday, Friday, Saturday, and
  Monday."

  In repeating a very simple story he changed the content entirely, and
  omitted some of the most important details of it.

  When we remember that this man was far from being as ignorant as some
  of the above answers would suggest, and that, while he unquestionably
  suffered from a psychosis, his state of consciousness was altogether
  too clear to justify a degree of lack of touch with his environment
  such as his replies would indicate, it becomes quite obvious that he
  malingered. This, together with his dangerous tendencies, determined us
  to return him to the penitentiary, which was done on April 11, 1911.

  He reached the penitentiary on April 13, and on the night of April 20
  he began preaching in a loud tone of voice, claiming that he was the
  son of David, and that he was called upon to go forth and preach to the
  world. He was removed from his cell to the isolation building, where he
  refused to take nourishment until April 23. During this period he spent
  most of the time preaching and singing religious songs, and at times
  would hold long and heated arguments with some imaginary person, always
  on religious topics. From the above date until his transfer to the
  Government Hospital for the Insane on September 24, 1911, he continued
  in a very disturbed and destructive state, refusing food frequently
  for several meals in succession, preached, sang, and cursed in turn,
  gave voice to the various delusional ideas manifested above, and gave
  objective evidence of suffering from hallucinations. Throughout he
  strongly maintained that he did not want to return to the hospital at
  Washington, as there was nothing wrong with him mentally.

  The prison physician who examined the patient at the penitentiary
  before his second admission to this hospital made the following
  notation in the case: "The mental examination of T. W. reveals
  inconsistencies that are strongly suggestive of simulation, and I
  believe there is in this case a degree of malingering, frequently
  associated with prison psychoses, yet that there is a psychosis, in my
  opinion, there is no doubt."

  Upon his return to this hospital he became involved in fistic
  encounters, on the way to his ward, for which there was very little
  provocation. For several weeks following this he was very surly,
  dissatisfied, moody, and inaccessible, but showed no other psychotic
  symptoms. Four days after admission he subscribed to a local newspaper,
  which he read regularly and kept himself well informed on ordinary
  topics. He was clear mentally, well oriented in all respects, and
  adapted himself readily to his new environment, except that he
  absolutely refused to eat the regular food furnished the patients. For
  about three weeks he lived practically on fruit and candies which he
  purchased, persisting in his determination to starve himself unless he
  were given a special diet. This was furnished him, and he had no
  further dietetic troubles. No delusions or hallucinations were
  manifested, intellectual examination revealed no intelligence defect
  (gross), and, aside from his surly mood and his tendency for rather
  frequent endogenous depressed periods, he showed no abnormal
  manifestations.

  In this state he required no special hospital treatment, and, as he
  promised to conduct himself properly if he were returned to the
  penitentiary, he was transferred back on February 20, 1912.

  Upon his return he continued, however, to manifest periodic
  excitements, with destructiveness, always, however, in reaction to some
  environmental irritation. He nevertheless managed to remain in the
  penitentiary until the termination of his sentence.

It is highly doubtful whether proper means will ever be evolved to
enable one to differentiate accurately between that which is genuine and
that which is malingered in cases like, for instance, the foregoing.

This man unquestionably suffered from a psychosis, and yet there is
likewise no doubt that he malingered. The question of the accurate
differentiation between the genuine and the shammed seems to me,
however, to be strictly an academic one and of very slight practical
importance. What is of importance is the recognition that malingering
and mental disease are here the expression of the same diseased soil,
and that the same source should perhaps be also attributed to this man's
criminalistic tendencies. Crime, mental disease, and malingering should
perhaps here be looked upon as different phases of a mode of reaction to
life's problems which belongs to a lower cultural level, which is
largely infantile in character.

That this infantile way of facing reality is dependent upon some
constitutional inherent anomaly is attested to by the circumstance that
these individuals practically always react in this manner when forced to
form new adjustments, new adaptations. This repeated recourse to mental
disease as a refuge from a stressful situation is amply illustrated in a
series of cases reported elsewhere.

The other form in which malingering may be so intertwined with actual
mental disease as to render accurate differentiation quite impossible is
where the individual may be suffering from a psychosis at one time, and
at some later period, finding himself in a stressful situation, malinger
a psychotic state. In these cases the danger of ever committing a
habitual criminal to a hospital for the insane is especially apparent.

Finding, as these individuals do, a successful and convenient refuge in
a psychosis, it is but natural for them to again seek this refuge when
they find themselves in conflict with the law. But that which was at one
time a spontaneous, unconsciously motivated mental reaction may later
become a conscious volitional act, an only available means of
escape--malingering of mental symptoms.

  J. E. M., aged twenty-seven on admission, June 15, 1912. Family
  history obtained from the patient four days after admission is quite
  unreliable. He knew nothing of his grandparents, who died in Ireland.
  Father was living when last heard from, four or five years ago. He is
  moderately alcoholic; a stableman by occupation. Mother died at
  fifty-five in Bellevue Hospital, New York City, from some unknown
  cause. One brother was drowned. One sister died of tubercular
  adenitis. No instance of epilepsy, insanity, or nervous disorder in
  any form is known to have existed among his relatives.

  Patient stated that he was born in Ireland on October 12, 1884. He
  never attended school, but has learned to read and write a little.
  Childhood was uneventful, so far as known. He came to this country at
  the age of four, and at twelve or thirteen years of age began selling
  newspapers in the streets of New York. His occupational career since
  then has been chiefly that of a steamboat and longshoreman laborer
  along the docks of New York City. He said he enlisted in the Navy in
  1907 or 1908, was not quite certain as to which year, at San
  Francisco, Cal. He served on the U.S.S. _Buffalo_ as coal-passer; was
  dishonorably discharged for drunkenness. He then reënlisted and served
  as fireman, first class, on the _Milwaukee_ for about three and
  one-half years. Says he got along well on the _Milwaukee_, until he
  got into his present trouble. He was convicted of sodomy and sentenced
  to prison for ten years, January 15, 1911. Patient did not see the
  discrepancies in the dates as given by him, but, as stated before, the
  history is quite unreliable.

  A letter received from the War Department on June 28 requested
  identification of J. E. M. for the purpose of detecting whether or not
  he is the same man who under the name of Lee deserted from the Army,
  January 14, 1909. The photograph accompanying the letter was that of
  the patient.

  He had measles and mumps during childhood, from which he made good
  recoveries. Gonorrhœal and syphilitic infection were denied.
  (Wassermann with the blood-serum negative.) During a bar-room brawl in
  Panama he was struck on the head with a table leg and rendered
  unconscious for fifteen or sixteen hours. This was some time in 1908.
  He thinks there was nothing more than a scalp wound, requiring no
  treatment beyond a simple dressing. For about a year after, headaches
  were present almost continually, occipital in location and of a
  tingling sensation. There was likewise a reduction of tolerance for
  alcoholics, since then two glasses of whisky being sufficient to
  intoxicate him. He does not know whether there was any change in his
  mental make-up or faculties following this injury, as he paid no
  attention to this. He commenced to indulge in alcoholics at the age of
  eighteen or nineteen. He cannot give a detailed account of the extent,
  but, as a rule, he spent all his money not needed for living expenses
  for whisky. He would become intoxicated every time he went ashore,
  stating that there was nothing else to do and no place to which he
  could go. Practice of onanism was denied. He claimed to have begun
  normal sexual intercourse at about the usual age. Strenuously denied
  sexual perversions, in spite of the fact that he is now serving a ten
  years' sentence for sodomy. He denied the guilt of this offense;
  insisted that he was never arrested before in his life, and believed
  the present conviction to have been a trumped-up affair because they
  must have gotten sore on him, although he cannot figure out why.
  Following his conviction for the above offense he was sent to the
  State Penitentiary at Concord, N.H. For a short while after he got
  there he got along well; was kept continually at work in the chair
  factory. He did not like this work, as he was subjected to the
  inhalation of the dust and shavings, and feared he would develop
  tuberculosis from this, and asked to be transferred to some other
  place. This request was finally granted him, and he was put to work in
  the kitchen. He states he did not get along well there; very soon got
  into some sort of trouble and was put into a dark dungeon, where he
  thinks he remained for about twelve months, strapped to the bed. He
  never saw the daylight during this time. He does not know why these
  strict measures were taken with him, but it is a fact that he was tied
  down. He had no idea of the onset of the present trouble, but stated
  that he complained frequently to the doctor of headaches and vomiting.
  The headaches were occipital in nature and severe at times. He could
  not recall his transfer to this institution nor the events which
  transpired during the first two or three days after his arrival here.

  The medical certificate which accompanied him here stated: "Patient
  has been convicted of sodomy and is at present serving sentence for
  same. First symptoms became manifest about February 6, 1912. Came
  under the care of prison physician at Concord, N.H., State Prison with
  severe headaches. Previous to above date it is said there were the
  following records at above prison in regard to this patient: April 15,
  1911, and August 10, 1911, he had convulsions. These are not described
  in detail. The prison physician at the time noted that patient showed
  symptoms of organic brain disease. On February 26, 1912, he became
  violent, and has had to be restrained since then. For some time
  previous to that he had acted peculiarly. The symptoms immediately
  preceding his transfer to this institution are as follows: Has to be
  restrained to prevent violence to himself and others. Frequently
  suspicious when food and drink are offered him. At times noisy when he
  desires food and it is not given to him at once. Probable cause
  unknown. There is a vague history of head injury aboard ship in the
  tropics. Homicidal tendencies were present when the disease first
  became manifest."

  Patient was admitted to this institution June 15, 1912, at 10.30 A.M.
  On admission he was carried in by two employees. His legs were
  shackled and he had wristlets on his hands. He was apparently unable
  to stand unassisted, and, when support was removed, fell to the floor.
  Pupils were widely dilated; internal strabismus of the right eye was
  present. Facial musculature was distorted, and he mumbled to himself
  in a low, indifferent tone of voice, over and over again, "Give me
  something to eat. I can't do it. Give me something to eat," etc., in a
  rapid monotone. He appeared to be in a deep stupor. He did not seem to
  realize his whereabouts, and attention could not be gained. He was
  totally inaccessible. When put to bed he became quite restless, rolled
  out on the floor, and was unable to assist himself back into bed.
  Musculature of legs was in a constant mild clonus, and the right foot
  was kept in position of talipes equinovarus. Pins pushed deeply into
  the skin all over the body caused no reaction. When food was brought
  to him he leaped upon it and finished the meal with extreme rapidity,
  stuffed his mouth full, never taking sufficient time for mastication
  or swallowing, and food was frequently expelled forcibly, probably
  from irritation of the air-passages. Questions addressed to him
  remained unheeded, but he kept up a constant mumbling in a low
  monotone, as described above. He was totally unable to stand on his
  feet unsupported, but when lying down his legs were moved about quite
  freely in an indifferent manner. When alone in the room he remained
  quietly in bed, head and face covered up with a blanket, but as soon
  as the room was entered he became restless, grabbing to those about
  him and holding on tenaciously. During his first night in the
  institution he slept well and was clean in habits. The following
  morning he was still inaccessible. He ate his breakfast quite
  voraciously, mumbling to himself all the time, "Give me something to
  eat" or "Give me something to drink." When water was brought to him he
  would endeavor to gulp the entire contents of the vessel at one
  effort.

  During the day of June 16, the day following his admission, he was
  frequently seen sitting on the side of the bed with quite a pleasant
  facial expression, rubbing his arms and legs. When his room was
  entered, however, he at once began mumbling to himself similar phrases
  as those given above, became quite restless, grabbing at those about
  him and not paying any attention to questions put to him. The
  following day, June 17, he showed marked improvement; was very much
  quieter in behavior when approached; walked back and forth in his room
  quite unassisted and in quite a steady manner; was seen looking out of
  the window into the yard for about fifteen or twenty minutes. Upon
  being approached by any one his gait seemed to become definitely less
  steady, and diffused twitchings of the thigh and leg were noted. The
  strabismus which was present on the day of admission had entirely
  disappeared; pupils slightly dilated. In the forenoon of the 17th he
  asked for his clothes and to be allowed to go out in the courtyard
  for a walk. A few questions addressed to him were answered coherently
  and relevantly. He said, in answer to direct questions, that his name
  was J. E. M.; that he did not know his age; that he came off some
  ship. Said the name of the ship was _Washington_; that he did not know
  how long he was on that ship, but thought it was a good long time.
  Asked where he was now, he said he was in the brig. "Where?" "Don't
  know." Asked if he were crazy, he said, "No, sir." When he came here?
  "A year ago." Asked what was the matter with him. "Nothing, sir. They
  kept me tied up too much." Asked when his bowels moved last, he said,
  "About a week ago."

  On June 19 he gave a coherent and connected account of his past life.
  He talked freely and coöperated in every way with the interviewer.
  Requests were obeyed promptly and intelligently. Physical examination
  on that date showed him to be a well-built, well-developed white male.
  Face slightly asymmetrical. Skin was soft and smooth, free from
  eruption, and covered with numerous elaborate tattoo marks. Linear
  depressed scar in the occipital region. Muscle tone was good. Muscular
  power was good in upper extremities. On first being tested in the
  lower extremities said he could not resist very much passive
  movements; upon suggestion, however, the muscular power of the lower
  extremities became much stronger and equal to that of the upper
  extremities. Grip was strong and equal on both sides. Station and gait
  were unimpaired when a steady and erect attitude and firm gait were
  suggested to the patient; left alone, he was inclined to be slightly
  unsteady on his feet. With eyes closed and feet together, there was
  considerable swaying present; said he felt like falling over.
  Voluntary movements were performed well. He described accurately a
  circle, a square, and triangle in the air with either hand. Movements
  were steady and accurate. Coördination was slightly impaired in f-f
  and f-n tests; the termination of the act was accompanied by a slight
  tremor. The musculature of thighs showed a more or less constant
  clonic twitching. When attention was called to this he was able to
  control it to a certain extent. Upon assuming a sitting posture the
  twitchings ceased. He said it was due to weak ankles. There was no
  tremor of protruded tongue or lips when showing teeth; fine tremor of
  the extended fingers and forearm when extended; no tremor of facial
  musculature. There was no paralysis, but there seemed to be a slight
  weakening of the lower extremities. No atrophies or hypertrophies
  noted. The triceps and radial reflexes were definitely exaggerated.
  Upon tapping, the quadriceps tendon caused a brisk marked contraction
  of thigh muscles, followed by mild clonus. Tapping of one knee tended
  to set musculature of opposite knee in mild clonus of short duration.
  Knee kicks were definitely exaggerated. Tendo Achillis exaggerated. No
  ankle clonus. Muscular irritability to mechanical stimulation
  increased. Superficial reflexes were normal, except plantar defense
  reaction was slight. Cutaneous sensibility was unimpaired: heat and
  cold readily distinguished. Light touches of pin pricks were felt and
  localized all over the body. Sense of position normal. No
  astereognosis in either hand. No excessive sweating. Eyes clear;
  irides brown; pupils round and regular, moderately dilated, reacted
  readily to all tests; eye movements well performed in all directions;
  no nystagmus nor strabismus. Vision--20/30 in each eye, improved by
  glasses. Skin of vitreous clear; slight weakness of external recti;
  cornea clear; field of vision normal for white; both fundi normal
  except for slight hyperæmia. Smell, taste, audition, and speech
  unimpaired.

  Mentally the patient was clear. He comprehended readily what was said
  to him, and his replies were prompt and relevant. He was disoriented
  for time. He stated that he knew the nature of this place; that he was
  told it the day before by a patient. Claimed to have total or almost
  total amnesia for several months past during the year he was confined
  in the dungeon of the Concord Penitentiary. He had no idea of the trip
  from there down to this hospital. He did not remember his arrival, nor
  how he acted the first two days here. Stated that on June 17 he first
  began to notice things about him and to realize faintly where he was.
  Delusions or hallucinations could not be elicited as having existed at
  that time. He spoke of having been bothered at the penitentiary; of
  having been chloroformed; that they put stuff in his food, tried hard
  to get him out of the way, and because they could not do it sent him
  down here. Said the doctor poured ether down his neck. He does not
  know the doctor's name, but he knew it was ether, he smelt it, and
  that is the reason he could not use his legs on arrival. He had no
  idea why he should have been treated thus, but thought perhaps they
  had it in for him. Auditory hallucinations could not be elicited. When
  asked if he ever saw anything, he said it was pitch dark in the
  dungeon and no one could see anything. Said the food tasted bad all
  the time, and sometimes made him vomit. On one occasion he noticed
  some powder in the beans. No electricity, no shocks, no outside
  influence was used on him. He did not know how long he was tied down
  in the dungeon, as half the time he did not know anything at all. Said
  they put needles in him, and pointed to some marks on his arm as a
  result of hypodermics. Facial expression denoted perfect satisfaction;
  said he felt fine and did not worry about anything, as he is not of
  the worrying kind. Said he had been treated well here. Insight was
  imperfect. When asked directly if he had been insane, he replied
  "No." When the various symptoms which he manifested on admission were
  described to him he was inclined to agree that if he did show these
  symptoms he must have been out of his head. Remote memory was not
  impaired, so far as could be determined. There was an ill-defined
  amnesia extending over several months past, and up to June 17, when he
  claimed to have first realized his whereabouts. Attention was
  unimpaired. He reacted well to the intellectual tests, with the
  exception of the arithmetical problems, which he did poorly. Replies
  to ethical questions showed a rather low grade of morality, perhaps
  due somewhat to ignorance more than to anything else. In his conduct
  on the ward he was absolutely normal following June 17. He spent his
  time reading and in conversation with the other patients. He was
  perfectly satisfied in his surroundings, frank in his conversation
  with those about him, and gradually gained more and more insight into
  his condition. He still persisted, however, in his statements that
  ether was poured down his back. Said he remembered this distinctly as
  having taken place while confined in the dungeon. He was then,
  however, inclined to think that probably they did not have it in for
  him, and probably they did what they thought was best. In conversation
  with him today, on June 19, four days after admission, he showed
  perfectly normal behavior in every respect. Was frank in his
  statements, spoke of the amnesia mentioned above, and no delusions or
  hallucinatory experiences or physical symptoms present on admission
  could be detected.

  When finally confronted with the picture sent from the War Department
  for his identification he showed some degree of emotional reaction,
  stated that the picture was his, but persistently denied ever having
  been a recruit in the army. On the whole, he took the matter rather
  lightly and good-naturedly.

The history of this attack illustrates a typical case of hysterical
psychosis. The marked stupor and confusion, the numerous and varied
neurological symptoms, the sensory disturbances, especially the profound
anæsthesia to pin pricks, the amnesia and rapid recovery after change of
environment, all point to this diagnosis. It is a form of reaction
frequently seen in prisoners, and has been designated, for want of a
better term, as prison psychosis. At any rate, there can be no doubt as
to the genuineness of the symptoms presented by the patient.

If we keep in mind that such a type of psychotic reaction is the result
of the mutual interaction between an unstable, highly vulnerable psyche
and an unfavorable environmental situation--in this instance prison
environment--we understand the more readily the later history of this
case.

On July 16, 1912, he was discharged recovered and turned over to the
naval authorities to be returned to prison. Soon after his return to
prison he was noted to be melancholy, uncommunicative, was not
interested in condition of self or surroundings, had unsystematized
delusions of persecution. Physically he was noted to be anæmic, showed
general tremors when undergoing examination, reflexes were exaggerated,
positive Romberg was present. The physician who accompanied patient to
the Government Hospital for the Insane on his second admission stated
that on the trip from Portsmouth Prison M. tried to assault a waiter in
a restaurant in Boston, accusing the latter of following him. To the
physician he said, while on the train, "Take your d---- eyes off me, or
I'll brain you."

He was readmitted to the Government Hospital for the Insane on
February 6, 1913. Physical examination on this admission was negative,
except for some impairment of vision, for which he was given
eye-glasses. Mentally he was found to be disoriented for time, though
perfectly clear mentally, as was shown later in the examination; he said
he did not know the name of the institution, though a minute later he
gave correctly the name of the building in which he was located. He
spoke in a very vindictive manner of the naval officials, who he said
were persecuting him in various ways, and who he reckoned were then
working to send him to some other d---- prison. On February 7, the day
after admission, he wrote the following letter to the Secretary of the
Navy:

                                         HOWARD HALL, January 29, 1913.

  MR. SECRETARY OF THE NAVY: _Rev. Sir_.--Will you kindly have some
  investigating, as I cannot have my life endangered. It is continually
  in my food, and times I have found the compounded powders in the air
  of my room choking me. Please let me know if you will do so, and I
  shall close.

      Respectfully yours,
          J. E. M., H. H. 5, Station L.

No hallucinations could be elicited, and his delusional ideas were
confined to the naval officials. These, he said, were persecuting him;
they sentenced him unjustly in the first place, and threatened to get
even with them. He answered the intelligence tests fairly well, but the
examining physician noted that frequently he gave expression of
consciously giving erroneous replies to questions put to him.
Emotionally he was at first somewhat depressed, but later this
disappeared. In his conduct he was inclined to be very troublesome,
easily irritated, and fault-finding.

This disorder of conduct, however, became consistently more aggravated
whenever he was in the presence of the physician. While he gradually
became quite friendly with the attendants and willingly assisted with
the ward work, he became quite abusive whenever an attempt was made to
examine him by the physician. This became especially evident in
December, 1913, when the physician who had him in charge during his
first sojourn at the hospital again assumed charge of him. At that time
the patient had been on excellent behavior for a number of months, and
in his daily conduct showed no evidence of a psychosis. He continued,
however, to air his delusional ideas whenever the physician attempted to
examine him.

Everything went well upon the return of his former physician until
December 22, 1913, when the latter attempted to examine him. The patient
became very abusive and threatening in his attitude, began to air all
sorts of bizarre persecutory ideas, and for about a month he continued
in an excited and destructive state. At the expiration of this period he
apologized to the physician for his conduct, said that he could not help
going on a rampage once in a while, as it is all due to his mean
disposition, and promised to conduct himself in an excellent manner if
he were not returned to prison. This was early in January, 1914, since
which time he has been a model patient in every respect. It is needless
to say that he has not been given, since that time, any occasion for the
development of another tantrum, and accordingly he remained free from
psychotic manifestations.

He was a model patient after this, assisted willingly with the ward
work, and on one occasion prevented the successful culmination of a
daring plot on the part of several patients to escape from the
institution.

Upon the recommendation of the hospital authorities and Dr. Sheehan, the
naval officer stationed at this hospital, the remainder of this man's
sentence was commuted, and he was accordingly discharged on June 29,
1914. For about six months prior to this his conduct was exemplary, and,
though through a considerable part of this period he enjoyed freedom of
the grounds, he never showed the slightest inclination to abuse these
privileges.

The salutary effect of the commutation of this man's sentence is quite
obvious. On the other hand, I am equally certain that had this
particular individual been returned to prison we would have had him
again before long as a very seriously ill patient.

This case is extremely interesting from many points of view. In the
first place, it gives us some insight into that highly inflammable,
hair-trigger, emotional type of individual who, when thrown into a
stressful situation, is very likely to go to pieces mentally. It is a
type which is always very difficult to manage under a prison régime, and
which in my estimation requires some intermediary place between a
hospital for the insane and a penal institution. It is likewise quite
irrational in our judicial disposition of these cases to impose a
definite sentence. If our prisons are to function as reformatory
institutions, it is quite clear that in this particular case no one can
possibly foretell how long a period it would take to bring about a
reformation. It is as if a man suffering from pulmonary tuberculosis
were told that he must go to a place set aside for such as he and stay
there, say, five years, irrespective of whether he is well at the end of
that time, or whether he might have recovered long before the expiration
of that period.

In this particular instance we were led to recommend a commutation of
the unexpired term of the sentence by the following considerations:
First of all, I cannot consider sodomy a crime punishable by
imprisonment, unless the act was performed on a subject who either is
incapable of giving his consent or becomes a party to the act against
his will, by force. Anomalies of the sexual function are not crimes, but
diseases, and as such should come under the purview of the physician,
and not the agents of the law. In the second place, this man served in
the navy with an excellent record for about two years, and, so far as we
know, is not inclined to habitual criminality, and therefore deserved at
least another chance. But these considerations are somewhat beside the
issue under discussion. The case, to my mind, illustrates very well how
closely malingering of mental symptoms is related to actual mental
disease, how both manifestations are expressions of the same underlying
diseased soil, and how difficult, nay even impossible, it is to tell in
a given case which of the symptoms are real and which shammed. On his
first admission this man suffered from a grave mental disorder, from
which, so far as anybody could determine, he made a complete recovery.
Thrown back into the same stressful situation, he again finds himself
unable to cope with it, becomes melancholy, suspicious, and mildly
delusional. There is, however, considerable doubt in my mind as to the
genuineness of these symptoms; unquestionably genuine is only the
psychopathic make-up of this individual, which under stress permitted
the development in one instance of a grave psychosis, in another of
malingering.

Cases like the foregoing are by no means exceptions in criminal
departments of hospitals for the insane. It is on account of this type
of prison population that penal institutions furnish us with ten times
as many insane as free communities.

Whatever convictions I possess concerning the subject of malingering
were gained from a fairly extensive experience with insane delinquents
at the Government Hospital for the Insane, and when I assert that I have
yet to see a malingerer who, aside from being a malingerer, was likewise
normal mentally, I do so with the full consciousness that my experience
has been a more or less one-sided one. I mean to say that the material
observed by me came to my notice within the confines of a hospital for
the insane, and that my failure, therefore, to see the so-called pure
malingerer is probably due to this circumstance. I shall not argue this
point further, but merely state that it is true I have not had
experience with the detected and convicted malingerer in the jail and
court-room. I have had ample opportunity to study this same genus later
as a patient in the hospital.

It would be an extremely interesting study to follow up the later
careers of the so-called detected malingerers who are sent to prison and
see how many of them later find their way to hospitals for the insane. A
setting forth of these figures--and I doubt not for one second that the
number is not at all inconsiderable--would not in the least have to be
construed as a criticism of the diagnostic acumen of the original
investigator. It would simply substantiate the truth of our contention
that in the malingerer we see a type of individual who is far from
normal, and in whom malingering as well as frank mental disease is not
at all a rare phenomenon.

I have no doubt whatever that a considerable number of suspected
malingerers are annually sent to penal institutions, there to be later
recognized in their true light and transferred to hospitals for the
insane; else it would be difficult to account for the fact that mental
disease, according to many authors, is at least ten times as frequent
among prisoners as it is among a free population. Certainly this cannot
be attributed to environment alone, especially not to that of our
modern, well-conducted prisons. The reason lies chiefly in the type of
individual who populates our prisons. A number of them are either insane
when sent to prison or potentially so, and when thrown into a more or
less difficult situation, such as imprisonment, readily develop a mental
disorder. We see this illustrated very well in the highly beneficial
effect which transfer to a hospital for the insane has upon these
individuals. I am convinced that one would not be wrong in agreeing with
the opinions quoted below, that malingering, as such, is a morbid
phenomenon and always the expression of an individual inferior mentally.
It may be looked upon as a psychogenetic disorder, the mere possibility
of the development of which is, according to Birnbaum[11] and others, an
indication of a degenerative make-up, a defective mental organization.
Siemens[12] says: "The demonstration of the existence of simulation is
not at all proof that disease is simulated; it does not exclude the
existence of mental disease." Pelman holds simulation in the mentally
normal to be extremely rare, and he always finds himself at a loss to
differentiate between that which is simulated and that which represents
the actual traits of the individual. Melbruch[13] holds that simulation
is observed solely in individuals more or less decidedly abnormal
mentally, because in the great majority of cases, if there does not
actually exist a frank mental disorder, these individuals lack in a
marked degree psychic balance and are constantly on the verge of a
psychosis. Penta, in a most thorough study of the subject of
malingering, likewise comes to the conclusion that it is always a morbid
phenomenon. It is a tool almost always resorted to by the weak and
incompetent whenever confronted with an especially difficult or
stressful situation. It is, therefore, almost exclusively seen in
hysterics, neurotics and other types of psychopaths, in the frankly
insane, and in grave delinquents.

With these remarks concerning malingering in the supposedly mentally
normal, we may turn to a discussion of that large group of borderland
cases which furnishes, outside of the frankly insane, the great majority
of malingerers. I am tempted here to borrow Bornstein's classic
description of the type of personality to which I am referring.
According to him, these individuals come into the world with the stamp
of a hereditary taint, with certain somatic anomalies (ears, palate,
formation of skull, growth of hair, etc.), and already as children show
those psychic characteristics which are decisive for their
individuality. They are, above all, characterized by a marked
hypersensitiveness and by a lack of harmonious relationship between the
various psychic functions. This disharmony finds its expression chiefly
in the predominance of the emotional element over the intellectual and
in the entire subordination of the latter to the former. Their feelings,
furthermore, express themselves in an abnormal manner, both as regards
their intensity and duration. The emotional reaction is either
excessively strong or, on the other hand, disproportionately weak
compared with the stimulus, and in spite of the extravagance of the
expression it quickly passes over or remains with an excessive obduracy
for a disproportionately long time. Notwithstanding the apparent
intensity of the outbreak in the former and its tediousness in the
latter case, these emotional upsets almost always lack real depth. They
are usually very superficial, insufficiently grounded, rather dependent
upon accident; transitions from one extreme to the other make up the
daily experiences of these individuals--from intense love to burning
hatred, from deepest reverence to an irreconcilable disgust, from
unshakable loyalty to brutal treachery. They lack energy and initiative,
are undecided, vacillating, and inclined to self-reproach. The
domination of the emotional sphere and the frequent incongruity and
discord between the various forms of emotional expression frequently
lead to the development of morbid doubts, morbid fears, a morbidly
exaggerated egotism, and sensitiveness which leads them to scent
everywhere personal injury and insult. Finally, they frequently show an
overdevelopment of the sexual instincts and various deviations from
normal sexual development. Many of them seem to lack totally in the
power of reason, but act entirely upon impulse, upon the mere feeling
that this or that proposition is true. Many others show a pronounced
tendency to a metaphysic brooding and day-dreaming and to the
transformation into fact of the dreamed air castles, without any regard
to the iron logic of life which they cannot satisfy, with which they
either will not or do not know how to reckon. Turning their backs upon
the demands of life, centered in self, given up to the kaleidoscopic
play of their emotions, which are of short duration, imperfect as to
depth, varying in intensity, and depending upon any and every external
influence, these individuals are very uncertain in their opinions,
judgments, and motives for action. They go through life without any
direction, without any guiding idea, without initiative, and without
will, incapable of any kind of systematic labor, yet at times ready,
under the influence of a temporary affect, to sacrifice everything in
order to carry out what later on proves worthless and vain. Lacking in
sure criteria and guides, they are slavishly dependent upon momentary
external influences, and under unfavorable conditions of life suffer
want and misery and give way to temptation, frequently falling into a
life of vagabondage, drunkenness, and crime. In prison they often
develop mental disorders, are looked upon as malingerers, and oscillate
between prison and the insane asylum, only to begin the old game over
again so soon as they again come in contact with life.

It is little wonder, then, that the psychiatrist in dealing with these
unfortunates frequently finds himself at a loss to tell where health
leaves off and disease begins. The psychoses which these individuals
develop are in the great majority of instances purely psychogenetic in
character, one of the many distinguishing features of which is a marked
susceptibility of the symptoms to be influenced by external occurrences.
This tendency of the symptoms to shape themselves in accordance with
occurrences in the immediate environment frequently leads to the
suspicion of malingering, because there seems to be altogether too much
discretion displayed by these alleged insane.

I have elsewhere[14] reported a series of these cases and entered into a
detailed discussion both of the personality and the nature of the
psychoses from which these individuals suffered. Most of my cases had
been both in prison and in hospitals for the insane on more than one
occasion, every arrest and imprisonment having been apparently
sufficient to bring out a fresh attack of mental disease.

The following case is fairly illustrative of this type:--

  J. H., white male, age twenty-seven on admission, November 13, 1913.
  While serving a year's sentence at the Portsmouth Naval Prison for
  fraudulent enlistment the patient told the authorities there that on
  August 7, 1909, he had murdered a girl in Rochester, N.Y. He described
  the murder in great detail, stated that he met the girl in one of the
  Rochester cemeteries, attempted a sexual assault upon her, and when
  she resisted he choked her to death. He stated that he did not mean to
  kill his victim, but that he had inflicted the fatal injury before he
  was aware of it. It was remorse, he said, and the desire to expiate
  his crime which prompted his confession. He persisted in this
  confession until the naval authorities were persuaded to discharge him
  and turn him over to the civil authorities of Rochester, N.Y. Upon
  arriving there an alibi was easily established, freeing the patient of
  all suspicion of the murder, whereupon it took a good deal of
  investigation on the part of the authorities to establish the
  patient's real legal status. It was finally decided that he belonged
  to the naval authorities, and he was accordingly returned to prison
  and was given an additional sentence of a year for this fraud, which
  he began to serve on December 13, 1909. While awaiting this new
  sentence he assaulted a master-at-arms, who he claimed abused him, and
  for this offense he received an additional five years' sentence. He
  served this sentence until his first admission to this hospital on
  July 16, 1913, on the following medical certificate: First symptoms
  became manifest in 1910. The patient manifested fixed delusions of
  having murdered a girl on August 7, 1909. Present symptoms: Fixed
  delusions of a self-accusatory nature, delusions of persecution;
  accused a medical officer whom he had never seen before as being among
  those who were hounding him. Becomes excited, violent, profane,
  incoherent and obscene in speech, and attempted to assault the
  officer. He attempted suicide on February 15, 1910, while at Concord,
  N.H., State Prison.

  During the patient's first sojourn at this hospital he conducted
  himself in an orderly manner, and, aside from the expression of mild
  persecutory ideas with reference to the prison personnel, he was free
  from psychotic manifestations. On only one occasion was he involved in
  some trouble while here, which was entirely his own fault. He was
  discharged on September 23, 1913, diagnosis "Not insane, psychopathic
  constitution," and returned to the U.S.S. _Southery_ Prison Ship. Upon
  his return there it was noted that he was suffering from a double
  benign, tertiary, malarial infection, which it was maintained he had
  contracted in this hospital.

  He was readmitted here on March 15, 1914, on a medical certificate
  which stated that the patient said he snuffed cocaine prior to
  admission to the navy; that the murder he believes he committed was
  due, according to his statement, to the refusal of the victim to
  permit sexual intercourse. The patient has at present the same fixed
  delusion of having committed this murder in 1909. He wants to expiate
  his crime to escape those who are continually hounding him. When
  irritated he flies into a rage, cries, tries to do himself injury, and
  talks incoherently. For no cause, while working in the yard, he struck
  a fellow prisoner and pursued him with a shovel. During maniacal
  attacks he can be restrained only with much difficulty, smashes
  furniture in his cell, and is slovenly in habits. Complains constantly
  of numbness and needle-like pains in vertex. As a probable cause,
  prison routine was given. It will thus be seen that the same fraud
  about the murder, which served at one time to bring him an additional
  sentence of a year, was considered at another time one of the symptoms
  which justified his return to this hospital. The patient's version of
  the reason for his return is as follows: Soon after his transfer to
  Portsmouth the guards began to annoy him, calling him crazy guy, hard
  guy, etc. He also got into trouble with the sergeant because the
  latter cursed him, began to express the same ideas about the murder,
  and thought this was the reason they sent him back.

  The mental examination and physicians' notes made during his second
  admission showed no gross psychotic symptoms. The patient still
  maintained that he actually committed this crime in Rochester, and
  related it in great detail. He stated that when he was confined in
  Portsmouth Prison he became remorseful over this crime and decided to
  confess. His conduct during his second sojourn here was exemplary. He
  appeared at conference on April 20, 1914, and a diagnosis of
  psychopathic character was made. The opinion was expressed that it was
  extremely difficult to pick out the truth from the abnormal elements
  in the patient's story, and that there were a great many things in the
  general emotional reaction of the patient that fitted into the story.
  It was believed that the patient had a sort of determination to get
  into difficulties for the sake of posing as a martyr and all that fits
  in with the grandiose element of his character. Being oppressed, he is
  taking it in a way that is very satisfying to his feelings of
  importance. Later during his sojourn here the patient became rather
  anxious to be returned to the penitentiary, stating that he had given
  up all the ideas which he had expressed on admission, and assured the
  physician that he was malingering on both occasions of his transfer to
  the hospital. He stated that his chief anxiety which led him to
  malinger was that he might be given additional sentences for his
  inability to get along in the penitentiary, and he thought the only
  way to avoid this would be to be pronounced insane. Patient was
  discharged from here to be returned to the penitentiary on July 9,
  1914.

  The patient was readmitted to this hospital on November 13, 1914, on a
  medical certificate which states: Diagnosis--Constitutional
  psychopathic state, not in line of duty, existed prior to enlistment.
  He was in the Government Hospital for the Insane in Washington for
  about four months this year. His condition is not improving. A sudden
  outburst occurred two days ago and he has been under close confinement
  since. He struck a recruit and after confinement in a cell destroyed a
  chair and had to be restrained. His retention in the prison in these
  barracks is not deemed desirable.

  Nothing essentially new has developed in the case during this
  admission. The patient has from the first been quiet, well behaved, a
  willing worker in our industrial department, and free from signs of
  mental disorder. Of course, he again blamed the guards at the prison
  for the trouble which he became involved in and which necessitated his
  third admission to this hospital. A letter received from the naval
  medical officer stationed at the marine barracks, Norfolk, Va., the
  place of the patient's last confinement, was to the effect that while
  under observation there the patient made the impression of being a
  good worker, and normal in every way, except that he had a quick
  temper, and that the only difficulty they had noted was on the
  occasion when he assaulted the man at the prison, who appeared against
  him at the mast, and that after this scene he was put in the brig,
  where he threatened to kill any ---- ---- man who came near him. The
  medical officer was impressed with the fact that the patient was
  feigning insanity.

  The patient's version of the circumstances which led to this last
  admission is as follows: He was reported to the commanding officer by
  a guard for some alleged minor infraction of discipline, of which he
  claims not to have been guilty. After the guard was through making
  his report the patient asked the commanding officer whether this
  alleged offense would prevent his release in July of this year, as he
  had been promised if he conducted himself well. The officer replied
  that it certainly would, upon hearing which he could not restrain
  himself, became quite overwhelmed with anger, and struck the guard who
  reported him. His behavior which necessitated his readmission took
  place following this episode. The patient dwells upon the fact that
  prior to this episode he behaved in an excellent manner under the
  prison régime for about four months, and that during his sojourn there
  he was practically a model prisoner, which was true.

  He certainly has manifested no signs of mental disorder during his
  present admission, and still insists that he malingered all of the
  symptoms which led to his former two admissions because he feared more
  punishment at the hands of the naval authorities unless he was
  considered insane.

  _Anamnesis._--The patient comes from a family of farmers in mediocre
  circumstances. Grandparents are in Bohemia, and he knows nothing
  concerning them. Father died of Bright's disease; was alcoholic.
  Otherwise family history negative.

  Patient is uncertain about the time and place of birth, but believes
  he is about thirty years of age at present. He entered school at seven
  or eight, but proved to be a confirmed truant, and his father finally
  had to take him out of school entirely. He was in the habit of running
  away from home and school, to wander about the country, where he would
  stop at different farm houses, claiming he was an orphan and without a
  home, until his father would discover him and bring him back home.
  After giving up school definitely he worked as a farm hand, earning
  the ordinary wages paid for this labor. He changed places frequently,
  was a spendthrift, and assisted his parents financially very little.
  This mode of existence he led until 1904, when he forged his father's
  name to a $25 check and received a five-year term of imprisonment,
  part of which he spent in the Minnesota State Reformatory and part at
  the State Penitentiary. In the fall of 1907 he was paroled, but broke
  his parole by enlisting in the army, under the name of Kimlicka, at
  Fort Snelling, Minn. About a month later the fraud was discovered
  through his father. He was given a dishonorable discharge and sent
  back to the penitentiary, where he remained about six months. At the
  end of this time (December, 1907) he was granted another parole, and
  went to work for a man named George Hall, on a farm in Minnesota. He
  was there nearly two months, when he cut his foot while chopping wood.
  He says that after this accident he was not able to do much work, and
  his employer did not seem to like to have him hanging around, so he
  went back to prison, which he says paroled prisoners were supposed to
  do when they lost their jobs. As his time was up in two months, the
  prison authorities made no effort to get him a new job, but kept him
  there until his sentence expired. He left the penitentiary in March,
  1908, and went home for a couple of weeks. He then went to Minneapolis
  and enlisted in the navy under the name of James Hall, but did not
  tell the recruiting officer about his prison or army experiences.
  About four months after he enlisted he was caught with another sailor
  in civilian's clothes in Newport, R.I. This was against the navy
  regulations. Patient says he did this because they did not allow him
  in dance halls, theaters, etc., in sailor's clothes. He used to keep
  his civilian's clothes in the Y. M. C. A. building in town, and would
  change there. He received a dishonorable discharge for this escapade.
  He says he had one court-martial before that, in July, 1908. He then
  went to Providence, R.I., and enlisted in the army under the name of
  Herman Hanson. In Fort Andrews, Boston Harbor, patient was caught in
  civilian's clothes again, and got into a brawl with a sergeant.
  Patient says the sergeant was drunk and provoked the quarrel. As a
  result the patient was put in the guard-house, receiving a sentence of
  six months and dishonorable discharge. Two months of this sentence he
  served at Fort Andrews, and the rest at Governor's Island. After being
  discharged, he hung around New York City for a week, and then went to
  Rochester, N.Y. This was in May, 1909. Here he worked on a farm for
  Mrs. McCale, and the following month, June, 1909, he enlisted in the
  Marine Corps under the name of Vilt. He was sent to the Brooklyn Navy
  Yard, but after a week's sojourn there he got into trouble on account
  of not having his rifle cleaned. He feared that he would be reported
  for this and his previous frauds might be discovered, and he decided
  to desert. He returned to Rochester, worked for Frank Little and Roy
  Fritz. Soon after he enlisted in the army, this time under the name of
  James Hall, but was rejected on account of some nasal defect. This was
  at Columbus Barracks. After being rejected in the army he enlisted in
  the navy and was sent to Norfolk, Va. He was here likewise rejected on
  account of this defect, and while awaiting his discharge papers it was
  discovered that he had fraudulently enlisted. He was court-martialed
  and given a year. This was on November 20, 1909. His career following
  this has already been outlined.

If one takes into consideration the entire life history of this
individual he will have little cause for surprise at the resort to
malingering by this man when he found himself under an especially
stressful situation. That he malingered every frank psychotic symptom
which he manifested is beyond doubt a fact, even though he would not
have admitted so much himself. But one would commit a serious error if
on this account he would consider the man normal mentally. From
childhood on this man has manifested traits of character which are
absolutely psychopathic in nature. Among these may be especially
emphasized the confirmed truancy and running away from home, the
aimless, constantly-changing industrial career, the inability to pursue
any line of endeavor towards a definite goal, the early criminalistic
tendencies, the repeated commission of military offenses in spite of the
frequent punishments, and, lastly, his total inability to adjust himself
to the prison régime, resulting in serious mental upsets which
necessitated his admission to a hospital for the insane on three
different occasions. It is perfectly natural that he should resort to
malingering of mental disease in his last attempt at evading a stressful
situation. Malingering is frequently the only means of escape for such
as he, unable as they are to meet life's problems squarely in the face.

It is of no particular value to add more cases illustrative of the type
of mental make-up which leads to malingering, especially since there
exists a more or less complete unanimity of opinion on the subject among
present-day psychiatrists.


CONCLUSIONS

The conclusions which may safely be drawn from the study of malingering
as it is manifested in criminal departments of hospitals for the insane
are as follows:--

1. The detection of malingering in a given case by no means excludes the
presence of actual mental disease. The two phenomena are not only not
mutually exclusive, but are frequently concomitant manifestations in the
same individual.

2. Malingering is a form of mental reaction manifested for the purpose
of evading a particularly stressful situation in life, and is resorted
to chiefly, if not exclusively, by the mentally abnormal, such as
psychopaths, hysterics, and the frankly insane.

3. Malingering and allied traits, viz., lying and deceit, are not always
consciously motivated modes of behavior, but are not infrequently
determined by motives operative in the subconscious mental life, and
accordingly affect to a marked extent the individual's responsibility
for such behavior.

4. The differentiation of the malingered symptoms from the genuine ones
is, as a rule, extremely difficult, and great caution is to be exercised
in pronouncing a given individual a malingerer.


REFERENCES

[1] BRILL, A. A.: "Artificial Dreams and Lying," _Journal of Abnormal
Psychology_, vol. ix, No. 5.

[2] DELBRÜCK, ANTON: "Die Pathologische Lüge," Enke, Stuttgart, 1891.

[3] FERRARI, L.: "Minorenni Delinquenti," Milano, 1895.

[4] PENTA, PASQUALE: "La Simulazione della Pazzia," Napoli, Francesco
Perrella, 1905.

[5] WILMANNS: "Ueber Gefangnispsychosen," Halle, S. 1908.

[6] BONHOEFFER: "Degenerationspsychosen," Halle, S. 1907.

[7] KNECHT: Quoted by Penta.

[8] VINGTRINIER: "Des Alienes dans les Prisons," _Annales d'hygiene et
de med.-legale_, 1852-53.

[9] JONES: Introduction to "Papers on Psycho-analysis."

[10] PELMAN: "Beitrag zur Lehre von der Simulation," Irrefreund, 1874,
and _Arch. de Neurolog._, 1890.

[11] BIRNBAUM, K.: "Zur Frage der psychogenen Krankheitsformen,"
_Zeitsch. f. d. ges. Neur. u. Psych._, 1910.

[12] SIEMENS: "Zur Frage der Simulation von Seelenstörung," _Arch.
f. Psych. und Nerv._, xiv, 1883.

[13] MELBRUCH: Quoted by Penta.

[14] GLUECK, BERNARD: "Catamnestic Study of Juvenile Offender," _Journal
of Am. Inst. Crim. Law and Crimin._, viii, No. 2.




CHAPTER V

THE ANALYSIS OF A CASE OF KLEPTOMANIA


_Introduction._--The past two years have been very profitable ones for
the science of criminology, as they have brought to light two books on
the subject which concretely reflect, on the one hand, the dying out of
the old statistical method of studying the criminal, a method which will
never tell the whole story, and on the other hand, the birth of a new
kind of approach to the study of the criminal, namely--the
characterological approach. The study of crime or antisocial human
behavior from this newer standpoint at once becomes a study of
character, and demands a scientific consideration of the motives and
driving forces of human conduct, and since conduct is the resultant of
mental life, mental factors at once become for us the most important
phase of our study. Both of these books represent epoch-making
culminations of years of hard labor and scientific devotion to
criminology by two eminent students--Drs. Goring[1] and Healy.[2]

Dr. Goring's book, "The English Convict, a Statistical Study", appeared
in 1913, and is the result of an intense statistical study of 4000
English male convicts, to which the author devoted about twelve years of
his life. Dr. Healy's book, "The Individual Delinquent", which appeared
in the early part of this year, reflects the results of thoroughgoing
scientific studies of about 1000 repeated offenders, during the author's
five years' experience as Director of the Juvenile Psychopathic
Institute in connection with the Juvenile Court of Chicago. Numerous
reviews of these two books have appeared in medical and criminologic
literature, and we shall only touch very minutely upon the difference in
the methods of approach to the subject of these two authors as they
concern the subject under consideration in this paper. I can do this no
better than by quoting from a critical review of Goring's book by Dr.
White,[3] as it happily touches upon our very subject--namely, stealing.
"Take the more limited concept of 'thief', for example. One man may
steal under the influence of the prodromal stage of paresis who has been
previously of high moral character. Another man may steal under the
excitement of a hypomanic attack; another may steal as the result of
moral delinquency; another as the result of high grade mental defect;
another under the influence of alcoholic intoxication, and so forth, and
so on, and how by any possibility a grouping of these men together can
give us any light upon the general concept of 'thief' is beyond my power
to comprehend."

When one remembers that the 4000 units with which this really marvelous
statistical machinery has worked for twelve long years had nothing more
in common than the fact that they were English male convicts--the force
of White's argument becomes quite apparent. I need not state that this
view of Goring's work is not intended to detract one iota from the full
measure of credit which this author deserves. His work will stand
forever as one of the monumental accomplishments of the twentieth
century.

Our views concerning Healy's contribution to the science of criminology
will be reflected in the course of this chapter, which will indicate, I
trust, in a way, his mode of approach to the problem, though he may not
agree with me concerning the details of my interpretation of the case I
am about to report.

_Definition._--Like many another I dislike the term "kleptomania" and
would much prefer the term "pathological stealing" to denote the
condition under consideration. Pathological stealing is not synonymous
with excessive stealing as one would gather from the sensational use of
the term in the lay press. Neither is Kraepelin's dictum that
Kleptomania is a form of impulsive insanity, necessarily correct. It is
obviously, however, a form of abnormally conditioned conduct. Healy's
criterion of Pathological stealing is the fact that the misconduct is
disproportionate to any discernible end in view. In spite of risk, the
stealing is indulged in, as it were, for its own sake, and not because
the objects in themselves are needed or intrinsically desired. This
definition at once excludes all cases of stealing from cupidity, or from
development of a habit. It furthermore excludes stealing arising from
fetichism, pronounced feeblemindedness and mental disease, such as is
for instance illustrated in the automatic stealing of the epileptic.

According to Healy, the vast majority of all instances of pathological
stealing are those in which individuals, not determinably insane, give
way to an abnormally conditioned impulse to steal.

_The Psychoanalytic Study of Anti-Social Behavior._--In introducing the
term "Psychoanalysis" into this chapter I am fully conscious of the task
I have set before me, of writing clearly and convincingly in a work of
this nature on that vast and highly important subject which one at once
links with this term. To strip it of its highly technical
considerations, psychoanalysis is primarily and essentially a study of
motives, intended to bring about a better understanding of human
conduct. We shall leave out from consideration the very intricate
technique which this method of approach to the study of human behavior
employs except to indicate the chief source upon which it relies for its
information, namely, the individual's unconscious, that is, that part of
the individual's personality which is outside of the realm of his
moment-consciousness, and which is inaccessible either to himself or to
the observer except through special methods of investigation. It would
be highly desirable, indeed one would say almost imperative, to give a
full discussion of the "unconscious" before a proper and sympathetic
understanding of what is to follow can be made possible. This, however,
is obviously out of the question in a limited chapter like this. Volumes
have been written on the subject. I will only ask my readers to agree
with me for the sake of gaining proper orientation with reference to the
subject under discussion, in the conclusion which I quote from a
masterly paper on the "unconscious" by White.[4] "We come thus to
the important conclusion that mental life, the mind, is not equivalent
and co-equal with consciousness. That, as a matter of fact, the
motivating causes of conduct often lie outside of consciousness, and, as
we shall see, that consciousness is not the greater but only the lesser
expression of the psyche. Consciousness only includes that of which we
are aware, while outside of this somewhat restricted region there lies a
much wider area in which lie the deeper motives for conduct and which
not only operate to control conduct, but also dictates what may and what
may not become conscious." The foundation upon which the method evolved
by the psychoanalytic school rests has been aptly summed up by Healy,
namely, that for the explanation of all human behavior tendencies we
must seek the mental and environmental experiences of early life. One of
the chief aids in gaining that knowledge we have in the study of the
dream and symbolic life of the individual. The reasons given for our
necessarily limited discussion of the unconscious, are likewise true of
the dream and symbolism. Both of these subjects would require for a
proper elucidation considerably more space than this chapter affords.

Through the dream the unconscious betrays itself;--the dream represents
the fulfillment of wishes and cravings which because of psychic and
social censorship have become repressed into the unconscious. During
sleep these barriers are in abeyance, and the unconscious psyche is
given the opportunity for full play, albeit in a disguised and highly
symbolic form. The proper interpretation of dreams presupposes a
knowledge of the nature of symbolism in the life of man.

When we come now to a consideration of the facts brought to light
through the psychoanalytic study of man we are confronted with a still
greater difficulty of presentation. There is so much that is of vital
importance in this new psychology that we hardly know where to begin. As
I am addressing those who are primarily interested for the moment in
criminology, I may do well to begin with the subject of psychic
determinism. In contrast to the common sentiment of all people in favor
of free will in mental processes, the facts elicited by psychoanalysis
point to a strict determinism of every psychic process. Psychoanalytic
investigations have shown that in mental phenomena there is nothing
little, nothing arbitrary, nothing accidental. In his book on the
Psychopathology of Everyday Life, Freud[5] has thrown very convincing
light on this subject. Certain apparently insignificant mistakes, such
as forgetting, errors of speech, writing and action, etc., are regularly
motivated and determined by motives unknown to consciousness. The reason
that the motives for such unintentional acts are hidden in the
unconscious and can only be revealed by psychoanalysis is to be sought
in the fact that these phenomena go back to motives of which
consciousness will know nothing, hence were crowded into the
unconscious, without, however, having been deprived of every possibility
of expressing themselves. Thus we see that no mental phenomenon, and by
the same token no part of human behavior, happens fortuitously, but has
its specific motive, to a very large extent, in the unconscious.

The question may suggest itself here "why this extensive participation
of the unconscious in mental life", which brings us to a discussion of
the principles of resistance and repression.

In speaking of the "unconscious" I purposely left out from consideration
the way in which the sum total of its content was separated from the
conscious mental life of the individual, in order to bring it in
alignment with the discussion of the principles of resistance and
repression. The content of the unconscious, broadly speaking, is brought
about through the activity of these two principles. If one endeavors to
unearth by means of psychoanalysis the pathogenic unconscious mental
impulses, or if one endeavors to bring to consciousness some instinctive
biologic craving which may be responsible for the individual's conscious
behavior, one regularly encounters a very strong resistance on the part
of the patient, a force is regularly betrayed whose object it seems to
be to prevent them from becoming conscious and to compel them to remain
in the unconscious. This is Freud's conception of the principle of
resistance and from its constant coming to the fore whenever an endeavor
is made to penetrate into the unconscious, Freud deducts that the
same forces which today oppose as resistance the becoming conscious of
the unconscious purposely forgotten, must at one time have accomplished
this forgetting and forced the offending pathogenic experience out of
consciousness. This mechanism he terms repression. We spoke of an
offending pathogenic experience, or in other words what has been termed
a psychic trauma. But the same principle holds true of certain instincts
which because of their peculiar nature become engaged in a kind of
struggle for existence with the ethical, moral and esthetic attributes
of the personality and are thrust out of the conscious mental structure
as one might say by an act of the will.

We are especially concerned here with these inacceptable instincts, for
the elucidation of which a brief review of Freud's theories on sexual
instinct is essential.

Thoroughgoing and painstaking dissection of the human soul, such as has
been practiced by Freud for nearly a quarter of a century and by many
followers of his theories in the past decade, revealed to him a number
of unmistakable facts from the developmental history of the individual
which forced him to postulate his very radical and revolutionary
theories of the sexual instinct in man. Recent behavior studies in the
higher anthropoids have likewise revealed very interesting facts
concerning the sexual instinct of these animals. Freud was led to make
certain assertions from his painfully acquired experience, such as the
unfailing sexual agency in the causation of neurotic manifestations, and
that his experience of many years has as yet shown no exception to this
rule, which quite naturally provoked a good deal of bitter and fanatic
criticism not only from lay people but from experienced physicians. The
cause for this lies in the nature of the thing itself, that much tabooed
subject of sexuality. Unfortunately, as Hitschmann[6] says, physicians
in their personal relations to the sexual life have not been given any
preference over the rest of the children of men and many of them stand
under the ban of that combination of prudery and lust which governs the
attitude of most cultivated people in sexual matters. Especially
unsavory appears to most people Freud's theory of infantile sexuality, a
subject which has heretofore been looked upon chiefly from a moralistic
standpoint, and was spoken of by others merely as odd or as a frightful
example of precocious depravity. It is somewhat strange that of all the
frightful depravities, if we wish to call it so--inherent in man, of the
marked criminalistic components universally present in man which
psychoanalytic studies have revealed--the sex depravity should have
provoked the most fanatic attacks. Indeed to those who are accustomed to
look at man with the psychoanalytic eye, Rochefoucauld's incisive
statement does not at all sound strange. He said, "I have never seen the
soul of a bad man; but I had a glimpse at the soul of a good man; I was
shocked." I therefore crave the indulgence of those of you who are not
familiar with psychoanalytic literature for what I am about to quote
briefly from Freud's theories on the sexual instinct in man.

Freud lays special stress upon infantile sexuality as it is manifested
in the suckling and in the child. The infant brings with it into the
world the germ of sexuality, which is, however, extremely difficult of
comprehension since at this stage the sexual feelings are not directed
towards other persons but are gratified on the child's own body in a
manner which Havelock Ellis has termed "autoerotic." This autoerotic
gratification is gained through erogenous zones, that is, certain areas
of the body which are peculiarly sensitized to sexual excitations. Among
these erogenous zones may be mentioned the mouth, lips, tongue, anal
region, the neck of the bladder as well as various skin areas and sense
organs. Already in 1879, Lindner, a Hungarian pediatrist, devoted a
penetrating study to the sucking or pleasure-sucking of the child. Freud
emphasizes that the suckling enjoys sexual pleasure, in the taking of
nourishment, which it ever after seeks to procure by sucking independent
of taking food. To many it may occasion surprise to learn that sucking
is exhibited independently of its relation to the hunger instinct. It
is, however, plain that the mouth is at first concerned only with the
gratifying of the hunger instinct; later the desire for a repetition of
pleasurable experience gained in this way is separated from the need of
taking nourishment, thereby transforming this mucous surface into an
erogenous zone. It is likewise difficult to conceive by the
inexperienced in psychoanalysis, that the child derives pleasurable
sensations from the anal zone. Because of the important rôle which anal
eroticism plays in our case we might speak more fully of this form of
autoeroticism. One not infrequently observes in little children that
they refuse to empty the bowels when they are placed on the closet
because they obtain pleasure from defecation, when the retained stool by
its accumulation excites strong irritation of the mucosa. The importance
which scatological rites and ceremonials, that is, certain peculiar
niceties practiced in connection with the emptying of the bowels, play
in the evolution of the race have been extensively discussed in
literature. Havelock Ellis[7] says in this connection--"The most usual
erotic symbolisms in childhood are those of the scatologic group, the
significance of which has often been emphasized by Freud and his school.
The channels of urination and defecation are so close to the sexual
centers that the intimate connection between the two groups is easily
understood. There is undoubtedly a connection between nocturnal enuresis
and sexual activities, sometimes masturbation. Children not infrequently
believe that the sexual acts of their elders have some connection with
urination and defecation, and the mystery with which the excretory acts
are surrounded, helps to support this theory. Up to puberty scatologic
interests may be regarded as normal; at this age the child has still
much in common with the primitive mind, which, as mythology and folklore
show, attributes great importance to the excretory functions."

Many of these ceremonials one regularly discovers in the analyses of
neurotics. We shall not dwell further here upon the erogenous zones
activity in the suckling, but emphasizing again its importance along
with the importance of autoeroticism in the sexuality of the suckling
will pass to the next phase of the psycho-sexual evolution of man--the
latent period.

The germs of sexual excitement in the new-born develop for a time, then
undergo a progressive suppression in a period of partial or complete
sexual latency. During this period, which is normally interrupted at
about the third or fourth year, as result of organic evolutionary
processes and the indispensable help of education, those mental forces
are formed which appear later as inhibitions to the sexual instinct and
narrow its course like dams; mental forces such as disgust, the feeling
of shame, the esthetic and moral standards of ideas. During this "latent
period" a part of these sexual energies is separated from the sexual aim
and applied to cultural and social ends, a process which Freud has
designated by the name sublimation as important for culture, history and
the individual.

Sublimation or the socialization of the sexuality therefore is the
transformation and utilization of certain components of the sexual
instinct for aims no longer sexual in nature. At the end of the latency
period the child's sexuality reappears, frequently but not necessarily
induced prematurely by seduction. In addition to the autoerotic
gratifications spoken of above, the child is now capable of the choice
of a love-object accompanied by erotic feelings. Because of the
dependency of the child this first choice of a love-object is directed
towards parents and nurses either of his own or of the opposite sex.
"Incest complex"--Now too the child under the influence of occasional
seduction may become polymorphous-perverse, that is, may become subject
to any form of sexual perversion. He likewise shows a preference in the
selection of his love-object for his own sex, homo-sexuality.

At puberty two significant changes take place in the psycho-sexuality of
the individual. First the primacy of the genital zone asserts itself,
and second, the heretofore autoerotic character of the sexual activity
is lost and the instinct finds its object. In order that the former
change may be successfully brought about, there is necessitated an
amalgamation of all instinctive tendencies which proceed from the
erogenous zones and a subordination of all the erogenous zones to the
primacy of the genital zone. All this is facilitated by the development
of the genital organs and the elaboration of the seminal secretion. To
these conditions there is also added at puberty that "pleasure of
gratification" of sexuality which ends the normal sexual act, the end
pleasure. The second function, the choice of a love-object, is
influenced by the infantile inclination of the child towards its parents
and nurses which is revived at puberty and similarly directed by the
incest barriers against these persons which have been erected in the
meantime. If on account of pathological heredity and accidental
experiences, this amalgamation of the excitations springing from various
sources and its application to the sexual object does not occur, then
there result the pathological deviations of the sexual instinct,
determined in part by earlier processes, such as a preservation of a
definite part of the original polymorphous-perverse tendency. The
perversions are thus developed from seeds which are present in the
undifferentiated tendencies of the child and constitute in adults a
condition of arrested development.

Thus we see that the sexual impulse does not suddenly emerge as a new
phenomenon at the age of puberty, but that the form assumed at this
period is gradually evolved from rudimentary elements present even in
the earliest years of life. Sexuality is not absent in the child, it is
merely different, being unorganized and imperfectly adapted to its later
functions. All this primordial mass of pleasurable activities enumerated
above, undergoes profound modifications as the result of growth and
education. One part only becomes selected and differentiated so as to
form the adult sexual impulse in the narrower sense. A greater part is
found to be incompatible with social observance, and is repressed,
buried, forgotten. The repressed impulses, however, do not die; it is
much harder to kill old desires than is sometimes thought, they continue
throughout life to strive toward gratification. This they cannot do
directly, and are thus driven to find indirect, symbolic modes of
expression. The energy is transformed into these secondary, more
permissible forms of activity, and furnishes a great part of the
strivings of mankind that lead to social and cultural interests and
development in general--sublimation. (Jones.)

I don't know whether I have succeeded in putting clearly enough the
Freudian views of sexuality, limited as I have to be in my expositions
of his theories. I do wish, however, to leave the impression which one
must gain from two sentiments frequently expressed by various authors,
namely, "Man sexualizes the universe," and "Man is what his sex is."

_Sexuality and Criminality._--A method of psychological analysis which
aside from its originally restricted field has already thrown so much
light upon various cultural aspects of life, such as art, poetry,
religion, folklore, and mythology, cannot fail to furnish some very
helpful discoveries for the problem of criminology. As far as
pathological stealing is concerned a number of very suggestive studies
have already appeared, a review of which Albrecht has prepared for the
Journal of the American Institute of Criminal Law and Criminology. The
fact that rich, or at least well-to-do, women are sometimes guilty of
theft in the big Department stores has always received a certain amount
of attention. Studies of this phenomenon have been made by Duboisson,
Contemps, Lasegue and Letulle. In each case examined the woman
declared that some unknown power had suddenly compelled her to touch
some object, and put it in her pocket.

Stekel,[8] a Viennese psychotherapeutist, claims to have repeatedly
proved to himself by psychoanalysis that the root of all these cases of
kleptomania is ungratified sexual instinct. These women fight against
temptation. They are engaged in a constant struggle with their desires.
They would like to do what is forbidden, touch something that doesn't
belong to them. We cannot give here the analyses reported in the
literature, though I assure you that they carry convincing proof of the
tremendous rôle sexuality plays directly or indirectly in the causation
of pathological stealing. This is not confined only to thieving
connected with fetichism, numerous cases of which have been reported in
the literature. But even less radical Freudians than Stekel admit the
importance of sexuality in pathological stealing. Thus Healy, who is
eminently fit to speak authoritatively on the subject of recidivism, and
who is unusually conservative in his statements, has the following to
say:--

"The interpretation of the causes of this impulse to steal is of great
interest. We have shown in our chapter on mental conflicts how it may be
a sort of relief phenomenon for repressed elements in mental life. The
repression is found often to center about sex affairs." Again, "The
correlation of the stealing impulse to the menstrual or premenstrual
period in woman, leads us to much the same conclusion. Gudden, who seems
to have made the most careful studies of the connection between the two
phenomena, maintains that practically all cases of shoplifters whom he
has examined were, at the time of their offense, in or near their period
of menstruation." Healy does not go beyond this. He is as yet not ready
to agree that some sex difficulty is the only conflict back of
kleptomania.

With these introductory remarks we will proceed to the discussion of our
case. X----, a colored boy aged 23, was admitted to the Government
Hospital for the Insane on January 16, 1915, from the District Jail,
where he was awaiting trial on two indictments for larceny.

Anamnesis obtained from the patient, his relatives and official sources
is to the effect that the patient comes from an unusually refined
colored family, his father being a rather prominent colored minister in
this city. The patient is one of eight children, all of whom with the
exception of the patient have led a normal and fairly successful life.
He was born in Washington, D.C., April 17, 1892. Birth and early
childhood up to four years of age were normal. At that time he was
rather seriously bitten by a large St. Bernard dog, following which he
was ill for about two months. He was rather restive under this enforced
confinement and one day in attempting to escape from the house he fell
from a second story window. His relatives attribute all his difficulties
to these two accidents, for it was soon after that his stealing
tendencies became manifest. The patient himself can place only
approximately the onset of his stealing propensities, stating that he
was quite young and that his first theft consisted in stealing ten cents
from his father. It was in connection with this theft that he first
experienced the sensations to be described later. His school career was
irregular owing to the interruptions necessitated by his repeated
sojourns at the Reformatory. He entered school at the age of 7 and at 11
was sent to the Reform School for the first time. This step was taken by
his father because the patient for some years previously had been
frequently placed under arrest on charges of larceny. He showed,
according to the statements of his relatives, a decided preference for
horses and vehicles of all sorts, which he would utilize for joy riding,
although he not infrequently stole objects of which he could make
absolutely no use. One time, for instance, he stole a dozen bricks from
a neighbor. The Chief Probation Officer of the District of Columbia, who
was an official of the Reformatory during the patient's sojourn there,
states in a letter to the hospital the following: "While there he (X)
gave very little trouble, except in the way of stealing. He would steal
any and every thing he could lay hold of. It mattered not whether the
article was of any use to him or not. After stealing an article or
articles he would make very little effort to hide it, and when taken to
task and charged with having stolen an article he would acknowledge it
but would say that he did not know what made him take the article, only
that something told him to take it and when this thought came to him he
did not have the power to resist it, but felt that he was compelled to
take it. At the Training School we looked upon him as a rather peculiar
subject. We really never considered him insane except that his desire to
steal might be classed in that line."

It is somewhat difficult to get a coherent and full account of the
patient's delinquencies. His record at the National Training School is
as follows: "Rec. on September 4, 1906, sentenced by the D.C. Juvenile
Court charged with larceny, escaped August 30, 1907. Returned from
elopement September 5, 1907, special parole to father October 23, 1909.
Recommitted by D.C. Juvenile Court February 3, 1910, charge larceny.
May 2, 1911, escaped from Freedman's Hospital while left there for
treatment after operation. Returned on May 25, 1911, from Baltimore, Md.
July 13, 1912, escaped." During his various sojourns there he was noted
to be wilful and unprincipled. Every time he gained his freedom his
father attempted to keep him at school, thus he attended night school
and Law Department of Howard University for short periods. His father
likewise put forth many genuine efforts to reform the boy, plead with
him and begged him, supplied him with considerable spending money, but
his efforts were as fruitless as the various punishments he underwent.
The boy would behave well for a while, but sooner or later he would be
arrested for stealing. Patient states that he stole many times when he
successfully evaded the police, that he frequently took unusual chances
in his escapades, preferred to steal in the daytime and it was this that
led him to believe that God had chosen this particular mode of life for
him, and that as a result of this conviction he practices the habit of
giving one-fourth of his earnings to charity. He had learned from his
father that somewhere the Bible teaches to give one-fifth of the
earnings to charity, but owing to the manner in which he acquired his
possessions he felt that he ought to give more to charity, a rather
characteristic mode of rationalization for a man of his type.

Aside from the arrests recorded above he has been arrested in the cities
of Baltimore, Philadelphia, and New York, always for stealing, and spent
about 19 months in the Pennsylvania Industrial Reform School.

His latest arrest and subsequent admission to the Government Hospital
for the Insane was the result of an attempt at housebreaking on
August 1, 1914. He states that he entered this house with the full
intention of robbing it, that he found considerable jewelry and some $30
in money which he collected on a dresser, when he suddenly began to
think of his mother, and the anxiety he would cause her should he be
caught in the act, whereupon he left everything on the dresser and left
the house. He was detected leaving the house, which brought about his
arrest. Patient states that such acts on his part were not unusual, that
he not infrequently left a robbery incomplete upon thinking of his
mother.

On admission to this hospital the patient made a normal impression. He
gave a coherent and clear account of his past life, was apparently quite
frank and truthful and endeavored to coöperate with the examiner to the
best of his ability. He was clearly oriented, free from frank delusions
and hallucinations, but said in explanation of his stealing habits that
it is the influence of God that makes him steal, because he has been so
successful at it, and because he has always given one-fourth of his
income from stealing to charity. (He rationalizes very efficiently in
this manner.) He likewise stated that frequently in the night before he
commits an offense he dreams of a man leading him and instructing him
what to do. He used to think that it was a representative of God whom he
saw in the dream, but since he has had the talk with Dr. H., who told
him that it was only the devil who tempts him to do these things, he has
changed his mind about it. Special intelligence tests revealed no
defect, and his stock of information was commensurate with his
educational advantages. He was well informed on current events and
readily adapted himself to his new surroundings.

Physical examination showed him to be a fairly well developed colored
male, slight acneiform eruption over back, slight asymmetry of head,
ears close set to head, lobules attached, palate high arched. There was
likewise present a slight depression in right supra-clavicular region,
lung over this area slightly impaired. Heart sounds slightly roughened,
urine and Wassermann with blood serum negative.

During his sojourn here his conduct has been exemplary. He worked
steadily in Howard Hall workroom and occupied his leisure time in
reading and playing musical instruments, two of which he knows how to
manipulate fairly well. It is significant that as far as known the
patient has not evidenced any tendency to steal since here, although
during the first few days of his sojourn here he experienced the
sensations which usually accompany his stealing escapades. A carefully
kept record of his dreams, in which matter the patient apparently
coöperated to the best of his ability, likewise failed to reveal any of
the pre-stealing dreams mentioned above.

_Analysis._--The suggestive points in the patient's history are the
repeated commission of a similar offense, namely, stealing,
notwithstanding the frequent punishment received, the stealing when he
actually had no necessity for it, being at times when he stole well
supplied with money, the stealing of objects for which he had no use and
which he could not convert into money, as stated in the Reform School
Records, the patient's belief in his destiny as a thief and the methods
he employed in atoning for his conduct, such as giving one-fourth to
charity, and lastly the peculiar physical and mental sensations which
accompanied the act of stealing. The inquiry was conducted along these
lines. In the first interview the patient could throw very little light
on his difficulties. He stated that he had tried repeatedly to quit
stealing, that he realized he was causing his parents a great deal of
anxiety on account of his habits, and bringing a good deal of trouble on
himself, that he genuinely regretted his past acts and that he believed
he could possibly abstain in the future from stealing. Later interviews
revealed, as has already been stated, that his first theft was committed
upon his father, when he stole ten cents, and it was upon this occasion
that he first experienced the peculiar bodily and mental sensations. He
describes these in his own words as follows, "I begin to feel giddy and
restless and feel as if I have to do something. This feeling becomes
gradually more marked until I feel compelled to enter a house and steal.
While stealing I become quite excited, involuntarily, begin to pant,
perspire and breathe rapidly as if I had run a race; this increases in
intensity and then I feel as if I have to go to the closet and empty my
bowels. After it's all over I feel exhausted and relieved." The feeling
of exhaustion and relief was in a later interview spontaneously
described by him as being like that one experiences after coitus. In
the early days of his career he used to go to the closet in response to
the anal sensations, but he never had to actually evacuate his bowels so
that of late he does not do this any more. At first he had those
sensations only when stealing from his father, later also when stealing
from his mother, and finally he would experience them whenever he stole.
It is of interest to note here his attitude towards his father. In the
early stages of the analysis he staunchly maintained that he loved
his father very much, that he honored him and felt very sorry for all
the troubles he was causing him, but further inquiry revealed positively
the fact that he showed a decided preference for his mother, that the
latter always took his part when he was punished by his father, that he
felt extremely angry at his father on a number of occasions in the past
because the latter punished him often, but it was only after the
analysis and proper insight on the part of the patient into the
following dream that he admitted that he had sometimes wished his father
dead. He dreamed on February 4th that his father had died, that he could
see his father in a coffin, and his mother, sister and brothers weeping.
"I awoke before I could finish the dream." The first attempts with the
patient at analyzing this dream produced quite an upset, a good deal of
emotionalism and tears, especially when it was suggested to him that the
dream might express a wish. In an interview on February 15th he said
that he no longer thought that the above suggestion was such an
impossibility, that perhaps there was a good deal of truth in it,
although he is certain that consciously he had never entertained such
ideas in reference to his father. There was no affective manifestation
in connection with this statement.

Another dream which he had the night before the preceding dream is, to
my mind an extremely important one, reflecting as it does the patient's
real conflicts. He dreamed on February 3rd that two of his brothers came
over to visit him. They brought a young girl over that he used to keep
company with, and told him that if he would marry they could get him
out. He replied that he would never marry any girl, and one of his
brothers said, "Then you will never get out of this place." They then
quarreled, the brother insisting that he just had to marry, but he still
refused. The girl plead with him to marry her, saying that she would do
a good deal for him, but he still refused. In parting one of his
brothers said to him, "Then go to your ruin, we will never do anything
for you again." The patient then awoke perspiring and mad as if he had
actually been quarreling. Thus the dream reads "Marry and you'll get out
of here, otherwise go to your ruin, we will never do anything for you."
In other words, "Lead a heterosexual life and your troubles will be
over, continue as you are now, you'll go to ruin." This argument of the
unconscious taken together with the group of sensations which patient
always experienced when stealing, and which he spontaneously likens to
the sensations of a sexual act, and furthermore the quite evident anal
erotic fixation, already throw a good deal of light upon the patient's
difficulties.

He further dreamed one night that his mother got him a situation with a
widowed man. His duties were to take care of and keep in good order the
man's three horses. One of these horses was a vicious one, the other two
were mild. If one were to think of the three horses as of a phallic
symbol the significance of this dream at once becomes apparent. The
patient associated the vicious horse which always tried to bite him
with his father. Here, too, it was the mother which comes to his aid.

A number of other dreams recorded by the patient manifest simple wish
fulfillment and are of no especial interest.

In his habits the patient was always of a jolly, sociable disposition,
enjoyed fun very much and for many years back he had a keen desire to
become a detective. In fact if he had any ambition in life at all it was
this. On many occasions in the past he played detective; he would track
people on many occasions for hours at a time. What is of marked
significance is the fact that on a number of occasions when he did this
he experienced similar bodily sensations as he did when stealing. The
detective sensations were never as intense as those accompanying
stealing and never reached the climax. It was only yesterday that the
patient told me spontaneously in the course of an interview that he
supposed he never reached the climax in his detective experiences
because he has never arrested anyone. Thus we see that along with his
antisocial sublimation of his anal eroticism, the patient attempted a
more useful sublimation. Unfortunately the one depended simply upon his
exertions and bravado, while the other required for its fulfillment
society's recognition of his desire and some ability for detective work.
I am firmly convinced that these two activities of the patient, namely,
stealing and detection of crime, are the results of his endeavor at
sublimating a totally inacceptable homosexual career. On one occasion,
and he claims that it is the only one in his life, a fellow prisoner in
the Reformatory attempted a sexual assault upon him. He retaliated by
striking the fellow on the head with a chair, for which he was severely
punished. While we may rely quite fully upon the information furnished
by the patient and upon that obtained from other sources for the purpose
of building up our theory of the case, it will not be amiss to take into
consideration those points in the patient's conduct while under
observation which further substantiate this theory.

We have it from a reformatory official that while at that institution
the patient frequently stole articles which were of no value whatever to
him, that he did not attempt to conceal his thefts, and that when
upbraided for his conduct, he stated that he could not help it, etc. At
that institution he evidently entirely relied upon his stealing
sublimation for his sexual gratification. It may be that as yet he had
not become conscious of the possibilities of the detective play.

In this hospital he had desires for stealing on two occasions, soon
after his admission, but resisted the temptation. Following the
manifestation of our active interest in his case, he became more and
more confident in his ability to withstand these temptations, and as far
as could be judged manifested a genuine desire to reform. Of course the
biologic sex difficulty is still present, its demands are probably just
as insistent as ever, and having rejected, for the present at least, the
possibility of expression through the stealing channel, he resorts to
the only other channel he knows of, detective play. In line with this he
handed me one morning (March 30, 1915) a note which stated that some
information had come into his possession which he thought would be of
very great value to me, and requested a private interview. After
cautioning me as to the method of procedure he assured me that he did
this piece of detective work solely because he felt very grateful for
our effort to help him out of his troubles. We must note the meticulous
manner in which he carried out the entire procedure. For some time past
he had been in the habit of handing me each morning a uniformly folded
sheet of paper containing the dreams of the previous night. On that
morning he had two of these folded sheets in his vest pocket but handed
me only the above mentioned note, because he says he feared that I would
read only the one containing the dream and miss the other. During the
interview which followed as result of the above note, he handed over to
me a bunch of petitions written by a famous litigant in the criminal
department, which were to have been delivered by the patient to his
relatives with the object of getting them to their final destination.
Aside from the fact that the author of these petitions is by no means a
simpleton, or very credulous, it must have taken a good deal of
ingenuity and skill on the part of the patient to gain this fellow's
confidence, knowing as I do that the latter has a special grudge against
the patient because they are the only two in the Howard Hall Department
who enjoy some special privileges in common, such as attending chapel
and amusements, etc.

This compulsion of attending chapel, as he puts it, with a negro, has
been the litigant's chief grievance during the past two months, and he
has accordingly expressed himself in some very choice language when
speaking of the patient. Nevertheless the patient has succeeded in
gaining his full confidence, and the interest and pleasure which the
patient manifested in detailing to me his mode of procedure in
accomplishing this is really very striking. It was during this interview
that he stated, "I suppose the reason I never reached the climax when
playing detective is because I have never arrested anyone. This is the
work I would like to do, Doctor, I hope some day I'll be able to get a
job with some detective agency."

I regret to have to omit many interesting details from the analysis of
this case. To me the analysis of this case has been a revelation. For a
number of years past I have been intensely interested in the problem of
recidivism, and although I have had many opportunities to study the
recidivist, and have seen a number of very interesting cases, the
histories of a few of whom I have reported several years ago, I have
always felt that I had never touched the real specific cause of a life
of recidivism in a given individual. Why a man, an apparently
intelligent man, and many of them are far from suffering from a purely
intellectual defect, should choose a career of crime and in spite of
repeated penalties should keep on recurring to it, has always been an
unsolved mystery to me. I have been especially perplexed about those
cases which repeatedly committed the same crime, and although in some
instances an apparently plausible explanation was found in an existing
psychosis, or strong psychopathic make-up, these explanations were in
many instances unsatisfactory.

Let us see what the repeated commission of theft means to the individual
whose history we have just reported. We have seen that his own
explanation of that series of physical and mental phenomena which always
accompanied the act of stealing were not only very much akin to the
physical and mental state which accompanies the act of sexual congress,
but were actually recognized as such by the man himself. In other words
the motive and instinctive prompting which led this man to the act of
stealing were the same which lead normal men to the act of sexual
congress. It would be inconceivable without further explanation why this
colored boy should repeatedly resort to stealing as a means of sexual
gratification in spite of the trials and tribulations which this carried
with it, when he had all the opportunities to gratify this desire in a
natural heterosexual manner, as others of his race have no difficulty at
all in doing.

The answer lies in the type of sexual gratification which his stealing
supplied. We have mentioned the anal sensations, the feeling as though
there was something in the rectum of which he had to rid himself, and
which for years led him to run to the toilet soon after the commission
of a theft. To one versed in the psychology and manifestations of the
sex instinct this can only mean one thing, namely, that we are dealing
here with a homosexual whose erotic receptors were concentrated in the
anal region, with an anal-erotic.

The possibility of a full, happy, satisfied existence for this
individual lies in the gratification of this biologic, instinctive, and
perverse sex-craving. It is the intense revulsion, the protest of his
whole personality against such mode of sex-expression which brought
about the habitual stealing in this individual. So soon as he discovered
that the emotional accompaniment of the act of stealing served to
gratify this biologic sex-craving he clung to it with the tenacity which
characterized his life of recidivism. In other words, the process of
sublimation of which we spoke took an asocial turn in this individual,
with the resultant pathological stealing.

It would lead us far beyond the scope of this chapter to discuss the
problem of the genesis of homo-sexuality, and we shall not attempt it.

The impression which I desire to make is that in this case of
pathological stealing we are dealing with a form of asocial behavior
which has its roots in a mighty instinctive, biologic craving, which
demands gratification at any cost.

Furthermore, because of the nature of this etiologic factor the chances
for reformation are very poor, which prognosis has already been
justified by the subsequent career of this patient. He is at present
again under arrest for grand larceny and housebreaking.

It would be premature to draw any general conclusions from this study,
or to promulgate any general principles of treatment. All that the
chapter is intended for is to stimulate further interest in
criminologists for research along these lines.


REFERENCES

[1] GORING. C.: "The English Convict." His Majesty's Stationery
Office, London, 1913. pp. 440.

[2] HEALY, W.: "The Individual Delinquent." Little, Brown, & Company,
Boston, 1915.

[3] WHITE, W.: "The English Convict." A review in _Journal of Am. Ins.
Crim. Law and Criminology_, vol. v.

[4] WHITE, W.: "The Unconscious." _The Psychoanalytic Review_, vol. II,
No. 1.

[5] FREUD, W.: "Psychopathology of Everyday Life." English Translation
by BRILL. The Macmillan Co., 1914.

[6] HITSCHMANN, E.: "Freud's Theories of the Neuroses." English
translation by C. R. PAYNE. Nervous and Mental Dis. Monograph Series,
No. 17, 1913.

[7] ELLIS, H.: "Sexual Problems." Modern Treatment of Nervous and Mental
Diseases. Edited by White and Jelliffe, Lea and Febiger. Philadelphia
and New York, 1913.

[8] STEKEL, W.: "The Sexual Root of Kleptomania." _Zeitschrift f.
Sexualwissenschaft._ George H. Wigand, Leipzig. English Abstract by
ALBRECHT, in _Journ. Am. Inst. Crim. Law and Criminology_, vol. 2,
p. 239.




GENERAL INDEX

  Accidental criminal, acute prison psychosis in, 71

  Albrecht, 252

  Amnesia, circumscribed, 16, 22

  Amnesia for stupor, 8

  Anal zone, significance of, 248

  Anomalous personality, 92

  Anti-social behavior, psychoanalytic study of, 241

  Auto-erotic, 247


  Ball, 189

  Behavior, technique of studying, 242

  Birnbaum, 9, 45, 75, 226

  Bischoff, 137

  Bleuler, 1

  Bonhoeffer, 8, 40, 74, 188

  Borderline mental cases, 228

  Bornstein, 227

  Bratz, 39

  Brill, 161


  Cases
    of acute prison psychosis, 9
    simulating an hysterical psychosis, 16
    of catatonia in a degenerate, 24
    illustrating psychoses of degeneracy, 51, 76
    illustrating prison psychosis in habitual criminals, 82, 93, 101, 107
    illustrating the rôle of alcoholism in the habitual criminal, 111
    of a mentally defective habitual criminal, 120
    of litigious paranoia, 139, 146
    illustrating pathological lying, 164, 176
    illustrating "omnipotence of thought", 192
    illustrating malingering in the insane, 199, 203
    illustrating malingering at one time and psychosis at another, 211
    illustrating malingering in a psychopath, 230
    of kleptomania, 253

  Catatonia of degenerates, 72

  Characterological anomalies in degenerates, 116

  Consciousness, definition of, 242


  Deception as a defense, 186

  Degeneracy, psychosis of, 34

  Degenerative psychoses, classification of, 36
    character of individual's developing, 36
    clouding of consciousness in, 46
    dementia-like processes in, 37, 41
    egotism in, 35
    epileptic seizures in, 39
    hypochondriasis in, 36
    hysterical elements in, 43
    migraine in, 36
    physical findings in, 36
    self-love in, 35
    recovery in, 8

  Delbrück, 163

  Dementia præcox in prisoners, 70

  Determinism, psychic, 161, 243


  Ellis, Havelock, 248

  Emotional shock as etiologic factor, 22, 31

  Environment as etiologic factor, 23

  Epileptic temperament, 44

  Erogenous zone, 247

  Erotic receptors, 265


  Ferrari, 187

  Forel, 1

  Freud, 190, 191, 196, 244, 245, 246, 248


  Ganser's symptom complex, 72

  Ganser's twilight state and catatonia, 7

  Gault, 117

  Goring, 239

  Grandiose compensation in insane prisoners, 195

  Gudden, 254


  Habitual criminal, characteristics of, 79
    hypochondriasis in, 79
    suicidal attempts in, 80
    projection mechanism in, 90

  Healy, 121, 239, 241, 252

  Heredity, tainted, 22

  Hitschmann, 246

  Homosexuality, 249

  Hopkins, Archibald, 117

  Hysterical psychosis, 220
    stupor, 72


  Incest complex, 249

  Incorrigible criminal, proposed treatment of, 117

  "Insanity dodge", 73, 185

  Insanity, legal concept of, 133


  Juvenile offender, 122


  Kleptomania, case of, 253
    dream interpretation in, 259, 260
    Healy's definition of, 241
    and sexual instinct, 252

  Knecht, 188

  Kraepelin, 2, 92, 123

  Kutner, 8


  Lasegue, 252

  Letulle, 247

  Lindner, 252

  Lombroso, 187

  Lying, mechanism of, 160
    unconscious motives in, 159


  Magnan, 35, 69

  Malingering, classification of, 197
    frequency of, 74
    mechanism of, 160
    in the insane, 198, 199
    psychology of, 192
    in psychopaths, 203
    reasons for, 175, 183, 186
    transitory mental disturbances simulating, 32, 33
    unconscious motives in, 239

  Maudsley, 132

  Melbruch, 226

  Mental factors in production of mental disease, 2

  Moebius, 69

  Moeli, 4


  Paranoia, litigious, 132
    definition of, 134
    litigious, symptoms of, 134

  Paranoid symptom-complex under stress, 43

  Pardon, effect of on mental disorder, 23

  Pelman, 203, 226

  Penta, 187, 227

  Pleasure principle, 190

  Polymorphous perverse, 249

  Prison psychosis, cases of, 16, 25
    etiology of, 81
    mechanism of delusion formation in, 93
    prognosis in, 32
    relation to criminal act, 92
    symptoms of, 3
    treatment of, 66

  Pseudologia phantastica, 159

  Psychiatric annex in prison, 125

  Psychogenetic excitement, hysterical components in, 39

  Psychopathic character, 98

  Psychosexual development in man, 249

  Psychosis as a wish, 184


  "Querulantenwahn", 37


  Raecke, 190

  Recidivism, 115, 120, 130

  Reich, 3, 72

  Repression, 245

  Resistance, mental, 245

  Rish, 8, 72

  Rochefoucauld, 246


  Sander, 139

  Scatological rites, 248

  Scheule, 189

  Segregation of criminals, 119

  Sexuality, Freud's theory of, 246
    and criminality, 250

  Siefert, 9, 35, 134

  Siemens, 189, 226

  Sodomy, 224

  Stealing, pathological, 252
    automatic in epilepsy, 241

  Stekel, 252

  Stransky, 92

  Sturrock, 43

  Sublimation, 249, 251, 261


  Tanzi, 134, 135

  Thought, omnipotence of, 191

  Trauma, psychic, 245


  Unconscious, The, 242, 243, 244


  Vingtrinier, 189


  Wernicke's psychosis, 41

  White, 240

  Wilmanns, 9, 44, 74, 188





End of Project Gutenberg's Studies in Forensic Psychiatry, by Bernard Glueck