CASE V.—J. J. M., aged 24 years, white male, is a well-built young man, whose family history is unknown owing to his refusal to give it. He was born at Chester, South Carolina, in 1885. Childhood and school life uneventful as far as is known. He was a bright scholar of ordinary intellectual attainments. His industrial career, which began early in life, was, according to his statements, normal. He admits, however, losing several positions on account of outbreaks of temper during which he had fights with other employees. He had several gonorrhoeal infections, the first one at the age of fifteen; was infected with lues at a very early age. He used alcoholics to a certain extent, and admits having been intoxicated on numerous occasions. In 1906 he was struck on the head with a club by a policeman. Later in the same year he received an injury to the head during a street riot. Neither of these injuries was accompanied by any untoward symptoms. In 1907 or 1908 he was struck on the head by an overhead pump while riding on top of a car. Was unconscious for some time afterwards, later got up and walked unassisted to a nearby station, where he took a train to Cincinnati. There he was confined to a hospital for ten days, undergoing treatment for this injury. He left the hospital one day without being properly discharged; had no ill after effects from this injury. In the summer of 1909 he was arrested in Washington, in company with another fellow, for robbery. They were both released on bond. The patient, however, left the jurisdiction, and when the police went to a nearby city to arrest him he met them with a loaded pistol. After considerable effort he was finally subdued and arrested. His companion received a short term sentence, while the patient was committed to five years in the Leavenworth Penitentiary. At that time he was living on the earnings of a professional prostitute, to whom he claims he had been married for several years. From correspondence between him and this woman it appears that he fully sanctions her mode of life. Soon after his arrival at the prison the physician noted his excitable and irritable disposition, which became progressively aggravated, finally necessitating his transfer to the observation ward, on December 9, 1910, a little over a month after his imprisonment. The records of the observation ward of the Leavenworth Hospital show the following:—

December 12, 1910:—Patient says he is frightened and asks to go to bed; put to bed at 4 P.M.

December 22, 1910:—While nurse Miller was taking the afternoon temperatures of the several patients at the guard's desk, he was suddenly attacked by M., who began to beat Miller about the head and face, drawing blood. It was noted that M. and another prisoner had resolved themselves into a select coterie for the purpose of being loud and boisterous and disobeying the hospital rules generally. Not a day passes that some gross breach of prison discipline is not committed by them.

December 23, 1910:—M. told the nurse: "If my wife don't write pretty soon, I am going to jump off the landing and kill myself." He complained that the attendant and nurses were talking about him, and that he feels sometimes like going over and smashing some of them, adding: "I know I am a damn fool for thinking that they are fixing up against me, but I can't help it. I know I am going crazy; I wish I could kill myself, cut my throat or something." This patient is decidedly worse, easily excited, suspicious, hypersensitive, imagines persons are plotting against him. When in conversation, gesticulates with both hands, wags his head and looks wildly out of the eyes. A particular instance of his excitable temper is a startled wild look upon being awakened to have his temperature taken in the morning.

December 24, 1910:—Says he is scared of something, doesn't know what, and wants to go to bed. Continues to receive epilepsy tablets.

January 2, 1911:—Complains of pains through the head and acts as if frightened. His eyes have a glassy appearance and pupils are dilated. At times a suicidal mania attacks him, seemingly using all his strength to overcome it.

His further sojourn there was characterized by maniacal outbursts, during which he would attack those about him. He showed an utter disregard for prison rules, absolutely refused to obey orders, and when an attempt was made to enforce these, his condition became noticeably aggravated, and the maniacal attacks more frequent. He frequently spoke of being frightened at something, of the attendants plotting against him, and persecuting him. During one of his depressions he made a superficial cut on his neck with a piece of glass which necessitated the application of physical restraint. One day two physicians who examined him spoke in his presence of the advisability of operating on his head. Following this he constantly spoke of his fear of being cut up by the physicians, whom he designated as a bunch of anarchists, and the elaboration of this fear remained the dominant feature of his mental disorder. He continued, however, to be profane, vicious and unruly in his behavior. His periodic outbursts of rage were as furious as formerly, he tore up his bed-clothing and personal attire during these fits of anger, which continued to be more or less reactive in character. He is noted as having had several attacks of convulsive seizures closely resembling epilepsy. Patient was admitted to the Government Hospital for the Insane on April 7, 1911. On admission he was very nervous and apprehensive, would jump and become startled when touched or approached by anyone and when spoken to became highly wrought up emotionally. His body fairly shook with excitement, pupils dilated, face became flushed and he could hardly speak on account of the emotional upset. He spoke of having come from a hell, from a dungeon where a bunch of anarchists were persecuting him, and were going to cut him up and operate on him, that he had heard them talk about it. He was imperfectly oriented, somewhat confused, and to all appearances lacked full appreciation of his new environment. He quieted down, however, at the close of the day and slept well during the night. Physically he was slightly emaciated. No neurological disturbances were noted except that he complained of headaches. When an attempt was made the following morning by a physician to examine him, he flew into a rage, became highly emotional, profane and threatening, showed marked apprehensiveness and expressed the fear of being cut up. He reiterated the persecution of him by the officials at the penitentiary, that he did not care what happened to him, whether he went to hell or heaven, etc. He spoke of killing himself before he would submit to an operation. He refused to eat, saying that the food was not fit to eat, and that he would refrain from taking nourishment until he was given better food. A visit from his wife served to appease him. When given a Hospital night-gown to wear he threw it away, saying he could not sleep in coarse clothing, and this had to be finally substituted by a silk one which his wife brought him. For two weeks following this he was allowed the freedom of the courtyard, where he was quiet and well-behaved, except when spoken to by the physician. At times he would turn with lightning suddenness into a maniacal state, and his paranoid ideas would come to the front, among which his fear of being operated upon was always predominant. At this time he had not completely transferred his paranoid ideas to the officials here. His clouded consciousness cleared up completely. He read the newspapers daily, took an active part in his immediate environment, and except for the periodic outbreaks of rage when talking to the physician, he showed no outward conduct disorder. He was taking nourishment regularly after a special diet was ordered for him. After a sojourn of about a month, the attention of the officials was called to the fact that the patient was planning an escape by overpowering the attendants, in which plot his wife, who was at that time an inmate of a disreputable house, was to assist him by furnishing him a gun. It was thought advisable to take special precautions with the man, and consequently his freedom of the courtyard had to be curtailed, and he was confined to his room. This was immediately followed by a marked exacerbation of his psychotic manifestations. He became very unruly, abusive and threatening. His outbursts of fury assumed the character of an excited epileptic. They differed, however, from this, in being accompanied by clear consciousness, and in not being endogenetic in their occurrence, but distinctive reactive manifestations to definite situations. Every refusal of a request was followed by one of those outbreaks, during which he would be profane, abusive, destructive and violent, threatening to kill the officials who had anything to do with his safe-keeping, and would elaborate an ill-defined general paranoid trend towards them. He was simply persecuted by a bunch of unchristian anarchists who were running this place; that they would see him in hell first before they would make him behave himself; that he is not here to please anybody except himself; that he recognizes no superiority other than Jesus Christ, etc. Conversely, the granting of a privilege served to bring him to a perfect calm, when he would talk in a rational and coherent manner, and be free from psychotic manifestations. The granting of the privilege of seeing his wife served to get him to submit himself to a thorough examination, which could not be attempted before. The objective examination revealed no intelligence defect. His reasoning and judgment were unimpaired, memory good, and aside from his paranoid ideas, which consisted in his belief that the officials were persecuting him, and that they were trying to operate on his head, no psychotic manifestations could be determined. Hallucinations had not been evidenced at any time and he possessed no insight. Recently he requested the physician to administer him a dose of 606, for which he was very grateful. He also entered of late into an active correspondence with some attorneys in town with a view to having something done for his case. On July 15, 1911, he appeared before the staff conference of the medical officers of the Hospital for the purpose of determining whether his condition was such as to warrant his transfer back to the penitentiary. Although having been tranquil and normal for several weeks prior to this, upon entering the examining room he at once became highly emotional, abusive and threatening, and everyone who saw him at that time was impressed with the great affective lability which the patient possessed. For a day or so following this experience he continued to be very emotional, irritable and boisterous. Later on his privileges were again returned to him and he resumed a tranquil state of mind, which existed until the time of his transfer to the prison on August 10, 1911. He told the supervisor who accompanied him to the depot that he intended to behave himself when he returned to prison, so that he might enjoy the benefit of his good term allowance and thus have his sentence shortened. Upon his return to the penitentiary he was immediately placed under observation on account of his peculiar behavior.

The records of that institution show the following:—

August 16:—Became very profane during the afternoon and evening, declaring that the prison authorities were holding up his mail from his wife, and was very profane and vindictive in speaking of the officials.

August 17:—Cursing the prisoners of parole room I as they were coming in from exercise, stating that they were a lot of G.d d....d s..s of b.....s and that they were holding up his mail.

August 18:—Shouting and cursing through his window during the evening. Got out of bed at 2 A.M., and began to swear and fight an imaginary foe, keeping it up for two hours.

August 19:—Continues to use the most profane language he can towards the prisoners or anyone whom he chances to see.

August 20:—Was very excitable and irritable during the day and evening. Attempted to throw his food in the guard's face, cursing the officials for keeping his wife away from him; claims that he can hear her calling him outside of his cell at night.

August 21:—Cursed the guard because he would not allow him to go out of isolation; sang and whistled during the evening.

August 22:—Very profane and vindictive in his accusations towards the prison officials.

August 23:—Denounced the guard as a black-hander, and said that the guard is bribing the prison officials to hold him in isolation, but that he will not give the guard a damned nickel.

August 29:—Actions and language continue along the same line except that they are growing progressively worse; cursing the officials, prisoners, etc.; claims they are keeping his wife away from him, and that his mail is being held up; is afraid of being murdered, and says that he is being kept here while his wife is starving; constantly uses loud and profane language.

August 30:—Prisoner whistled and sang during the evening, interspersed with very vile language.

August 31:—Became very violent today, cursing officials, claiming that he was being kept away from his wife and child who were starving. Kept shouting, singing and cursing at intervals all day and far into the night.

September 7:—Continues to have periods of violence almost daily; has hallucinations that he is being haunted by some imaginary foe, whom he sees sitting on his bed when he wakes up at night—a red-headed fellow by the name of Smith. Says that he can hear his wife and child crying outside of his cell, and repeatedly requests that he be allowed to go home to them. Says that his wife and children are starving, and that the prison officials are trying to starve him. Complains of pains in his head, and that his eyes hurt him and that he is going blind. He is inclined to be destructive of late, breaking his electric globes, smashing stool, throwing magazines against window and cell bars.

September 14, 1911:—Says he knows that red-haired Smith is trying to steal his wife, and that he is following him all over the country; that he was about to kill him in Jacksonville, Florida, but that he jumped out of a window. His violent attacks are becoming more severe and pronounced, and he requires constant watching to prevent him from doing himself bodily harm. He was also noted to have occasional mild attacks of petit mal.

On his way to Washington from the penitentiary at Leavenworth, upon his second transfer to this institution, the patient had been shackled to another prisoner who was supposed to be suffering from pulmonary tuberculosis. M. kept on begging the guards to be separated from this prisoner, and this request was finally granted. While going through the State of Iowa he jumped out through the window of the moving train. He was handcuffed at the time. After having gone about thirty miles he was recaptured. He had removed handcuffs soon after his escape from the train.

September 27:—On admission the patient limped and complained of great pain in both knees. Knees were swollen, bruised and discolored, and there was marked tenderness on touching. Patient entered the ward quietly, recognized those about him, and answered questions rationally. Said that aside from having been hurt in the knees, his left shoulder pained him a great deal. Upon being placed in bed he was asked by the examiner why he was sent here, to which he replied: "To get killed, I suppose." Further questions failed to elicit any answers, and the interview had to be discontinued.

September 28:—Patient answered the following questions to the attendant on the ward:—

Q. "What is your name (full Christian name and surname)?"

A. "J. J. M."

Q. "How old are you?"

A. "25."

Q. "When were you born?"

A. "1885."

Q. "What is your occupation?"

A. "Railroad man."

Q. "Where were you born?"

A. "Charleston, South Carolina."

Q. "What day is this?"

A. "Don't know."

Q. "What month, date and year is it?"

A. "August, 1911. Don't know date of month."

Q. "What time is it?"

A. "Don't know."

Q. "Where did you come from?"

A. "Leavenworth."

Q. "Who brought you here?"

A. "Bunch of cut-throats, Sons of —— tried to starve me to death all the way down."

Q. "How long were you in coming?"

A. "Don't know."

Q. "When did you come?"

A. "Don't know what time it was."

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

A. "Don't know."

Q. "Where is it?"

A. "On an island, I guess, some damn thing across the river."

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

A. "Mad-house."

Q. "Who are these people about you?"

A. "Here to murder me."

Q. "Is there anything wrong with them?"

A. "Nothing but black-hands anarchists."

Q. "Who am I?"

A. "J. S." (correct)

Q. "Why do you suppose I am asking you all these questions?"

A. "Don't know."

Q. "Why were you sent here?"

A. "To be dumped off, I guess."

Q. "How do you feel?"

A. "Pretty bad this morning, my head hurts me."

Q. "Are you sad or happy?"

A. "Neither one."

Q. "Are you worried about something?"

A. "Why, sure I am."

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

A. "No."

Q. "Do you hear voices talking to you?"

A. "Yes, hear you talking to me now."

Q. "Do you see any strange things?"

A. "No."

Q. "Do you ever have fits or convulsions?"

A. "No."

Q. "Did you ever try to commit suicide?"

A. "No."

Q. "Is there anybody trying to harm you in any way?"

A. "Yes, those black-hands anarchists."

Q. "How much money are you worth?"

A. "Nothing."

The foregoing two cases are representative of a group which unquestionably forms the most difficult part in the problem of caring for the insane criminals. Here we have a couple of individuals whose entire psychotic manifestations, if such they may be considered, consist of a most wild and vicious rebellion against imprisonment. They are individuals who cannot be kept under any prescribed mode of living, and when this is insisted upon, they react to it in an insane manner.

Bonhoeffer justly termed them "wild men", for wild indeed they are when in one of their tantrums. The question arises, "Wherein lies the cause of this rebellion against discipline?" It certainly cannot be wholly attributed to the environment, for these individuals behave in a similar manner even when removed to the far more lenient regime of a hospital. We must seek an explanation for the behavior of these individuals in the individual himself, in his make-up.

Looking at the life history of the two foregoing patients we find them both to be of the most depraved class of society. The one is a professional prostitute; the other subsisting upon the earnings of a prostitute. Their relation with man has always been characterized by a sort of vicious vindictiveness. Their high-strung emotional make-up brought them into serious conflict with those about them on many occasions before. Being finally taken hold of by the law and made to submit to a certain well-regulated mode of existence, their inherent characteristics assert themselves in a most decisive way and they react to the situation in the manner of a trapped tiger, stopping at no means to gain their point. The one commits a homicide during one of her outbreaks of passion; the other risks his life to obtain his purpose, by jumping out of a moving train with his hands shackled. Their life seems to be one long series of impulsions, fostered and sustained by the extreme lability of their emotions. Intellectually they show no defect. They are keen and alert to every opportunity which presents itself to them and are very shrewd in the execution of their criminal acts. Finding themselves under a regime which exacts from them a certain submission to rules, to regulations, they begin to misinterpret ordinary occurrences in their environment in a sort of delusional manner: They are persecuted by the warden because the latter insists upon making them behave themselves; the keepers are a bunch of anarchists, whose entire occupation seems to be to persecute them and down them. This for no other reason than because they are made to work and to behave themselves. J. J. M. tells me that he will not behave himself, that he is not here to please anyone but himself and recognizes no authority other than that of Christ. The other says she raised so much hell at the prison that they had to send her back to the hospital. The distinguishing feature of their psychotic manifestations is that they are provoked essentially by definite situations. They are not a mere wild, misdirected, meaningless series of insane acts, such as one would expect from a demented person, but distinct reactions to situations. Refuse them a request and they at once become wild, abusive and vicious, smashing up everything that they can lay hands on; conversely, when granted some of their unreasonable requests, it serves at once to appease them for the time being at least. Their conduct, however, is very detrimental to the prison regime, as discipline cannot be maintained with such disturbing elements about. Their interpretations of discipline are considered as delusions of persecution, their outbursts of temper as typical maniacal outbreaks, and consequently they are shipped off to an insane asylum. Now the question arises whether we are doing our duty by society in declaring these individuals as irresponsible for their acts. In other words, should these individuals with marked and incorrectible criminalistic tendencies, be, so to speak, licensed to ignore the law in its entirety by giving them the protection of an insane asylum? Of course, from a broad, humane point of view, we must realize and appreciate that there is something distinctly wrong with these individuals, that their mental endowments are the essential factors which determine their behavior. On the other hand, we must not forget that these individuals fully realize that once they have been sent to an insane asylum, they are protected from punishment by law for all future time and they are ever ready to utilize this knowledge, as has been my experience with quite a number of recidivists, who somehow never get into an insane asylum until they are in the hands of the law. The scope of this paper will not permit me to enter into an extensive discussion on the treatment of these cases. I will say this, however,—that we are very far from having solved satisfactorily the question of the care of this particular class of insane criminals. As this paper is not primarily a discussion of the degenerative psychoses, I will refrain from reporting further cases. I believe I have shown by the preceding two cases that the mental disturbances of the degenerative individuals are essentially psychogenetic in origin.

REFERENCES

[1] VAN RENTERGHEM, A. W.: Journal of Abnormal Psychology, Jan.-Feb., 1915.

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

[3] REICH: "Ueber Akute Seelenstoerungen in der Gefangenschaft." Allgem. Zeitschr. f. Psych., 1871, Bd. 27, p. 405.

[4] MOELI: Ueber irre Verbrecher, 1888.

[5] GANSER: "Ueber einen eigenartigen hysterischen Daemmerzustand." Archiv f. Psych., 30, 1889.

[6] RAECKE: "Hysterischer Stupor bei Gefangenen." Allgem. Zeitschr. f. Psych., 18. 409, 1901.

[7] RAECKE: "Beitrag zur Kenntniss des hysterischen Daemmerzustandes." Allgem. Zeitschr. f. Psych., 18. 115, 1901.

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

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

[10] BONHOEFFER: "Klinische Beitraege 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 praecox and progress toward demential end-results in the same proportion as the general run of dementia praecox cases do, whether or not they have come in conflict with the law. Occasionally we also see a case of organic brain disease or manic-depressive psychosis, and in more frequent instances a case of epilepsy. The other, and according to many authorities, by far the most predominant group of mental disorders met with in imprisonment, belongs to the so-called "prison psychoses", and bears definite, unmistakable ear-marks which differentiate it from the former group. These are, as we have stated, products of a particularly degenerative soil plus definite environmental conditions, and are of the utmost importance both from a purely clinical and an administrative point of view.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 role. 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 gonorrhoeal 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 naive 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 praecox, 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 reenlisted 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 gonorrhoea 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 praecordium, 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.