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.