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?”
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.”
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.