Studies in Forensic Psychiatry Part 4

We are not dealing here with patients in whom the commission of a crime is an accidental occurrence in their life, that is, still uncorrupted individuals upon whom the criminal act in itself might act in a deleterious manner. The patients belonging to this group are, as a rule, old offenders, who have long been hardened to crime, and whose entire life is an uninterrupted chain of conflicts with the law. To this group also belong those high-strung individuals with early antisocial tendencies, who from childhood show a marked degree of egotism and self-love; who are very vindictive and revengeful in their reaction to frictions in social life. Upon falling into the hands of the law, they are incapable of adjustment to the new situation, react in an insane and wild manner to the prison routine, and, in consequence, frequently commit grave offenses during imprisonment.

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

Siefert[9] was the first to clearly differentiate the purely endogenetic disorders from those dependent upon a degenerative soil, and evoked exclusively by outside influences. He divided the eighty-seven cases of psychoses in criminals studied by him into two distinct groups, namely, the real psychoses and the degenerative psychoses. Under the former thirty-three cases he places the well-known forms of dementia praec.o.x, epilepsy, paresis, etc. These, according to him, are not in the least influenced by the milieu in which they occur (in this instance, prison environment). His fifty-four cases of degenerative psychoses, on the other hand, were characterized above all by the fact that they stood in the most intimate relation with the environment in which they occurred, and were wholly influenced by the same. The pathologic, degenerative soil which permitted of the development of the psychosis in these individuals consisted of irritability, lability, autochthonous fluctuations of mood, fantastic day-dreaming, a heightened subjectivity to the environment, inability to form correct critical judgment concerning unpleasant occurrences about them and a strong tendency to suggestibility. On the physical side these patients were subject to headaches, migraine, restlessness and anxiety, often a.s.sociated with disturbances of heart-action, hypochondriacal complaints, and a tendency to become easily tired upon physical or psychic exertion. They also showed, as a rule, intolerance for alcohol, and were wont to react to alcoholism in a strongly pathologic manner.

Siefert divides his fifty-four cases of degenerative prison psychoses into the following groups:--

First:--Hysterical degenerative state. These consist of undoubted cases of grave hysteria, with convulsions, physical stigmata, endogenous states of ill-temper, confusional states, Ganser twilight syndromes, etc.

Second:--Simple degenerative states. These differ from the preceding group in that hysterical stigmata are wanting. These patients are subject to severe maniacal outbreaks, motor excitements, mutism, attacks of anxious, delirious states, with confusion, etc.

Third:--Fantastic degenerative forms. This group concerns markedly degenerated individuals with a pathologically exaggerated imaginative faculty, a strong auto-suggestibility, a tendency to deceit and lying, to inherent fluctuations of mood and hysterical stigmata. On this basis there develop conditions of pseudologia-phantastica, systematized delusional formations of all sorts, delirious psychoses, etc.

Fourth:--Paranoid degenerative forms. This group he again subdivides into the querulent and hallucinatory paranoid forms. The former may resemble the typical "Querulantenwahn", a psychosis artificially built up out of extraneous circ.u.mstances, and one which rarely develops in freedom, but is of very frequent occurrence in prison. The hallucinatory paranoid form consists of fallacious sense perceptions and delusions of a persecutory nature, often substantiated by a strongly hypochondriacal element; in short, a picture which simulates very closely the real paranoid state.

Fifth:--Prison psychotic states with simulated symptoms.

Sixth:--Dementia-like processes. The individuals belonging to this group are habitual criminals in whom the criminal tendencies become evident at a very early period in life, and who, without giving distinct evidence in their past history of a mental disturbance, develop after prolonged confinement a progressive change of character which eventually leads to frequent rebellious outbreaks against the prison management. They become absolutely unmanageable, neglect their work and duties, and finally have to be transferred to an insane asylum. Here they show nothing characteristic of the well-known dementing processes, as hebephrenia, for example; but very frequently, although quite young, their entire manner and behavior suggest a certain dilapidation and deterioration.

Siefert considers the above-mentioned disease processes as entirely dependent upon and provoked by prison life, in individuals with a tendency to mental deterioration. He comes to the conclusion that the prison psychoses are reactions of pathologic nervous organizations to definite deleterious conditions of life. They are nothing more than irradiations, distortions, and new creations, on the same degenerative soil which also conditioned the crime.

The importance of Siefert's momentous work cannot be doubted, but whether he was justified in his many subdivisions of the degenerative states is questionable. His own description of the various forms immediately suggests the difficulty of clearly differentiating one from the other.

Bonhoeffer,[10] in a monograph devoted to the subject, endeavors to establish the existence, on the basis of degeneracy, of acute psychotic processes which do not belong to either the manic-depressive, hysterical, or epileptic temperaments, which cannot be placed under any of the known forms of dementia praec.o.x, and which develop as wholly independent psychotic manifestations in particularly predisposed individuals. The material which served for his thesis was gathered from the Berlin Observation Ward for Criminals, among the inmates of which inst.i.tution he found a great number of degenerative psychoses. In a recent work on the subject of psychogenesis he upholds his former views, and believes he has been able to separate his cases into three distinct groups. The first group comprises certain unstable individuals who show a tendency to the development of simple paranoid psychoses. It concerns patients of a very labile make-up with increased affective reactions, with marked tendencies to impulsions and antisocial acts. These cases are characterized by the fact that they do not concern psychogenetic psychotic exaggerations of a certain temperamental predisposition, but psychically evoked disease states which appear to be irreconcilably opposed to the original personality.

He calls attention to the epileptic seizures of these individuals, which have been so ably described by Bratz.[11] In contradistinction to the genuine endogenetic epilepsy, these patients manifest epileptic seizures as reactions to situations purely psychic in nature. In them, without ever resulting in epileptic dementia, there occur along with the epileptic seizures attacks of unconsciousness, of excitement, dream states, and porio-maniacal outbreaks. They differ from the genuine epilepsy by the absence of the characteristic dementia, of attacks of _pet.i.t mal_, and by the fact that the seizures are never purely endogenous in origin. They are always due to extraneous causes, eminently such of a psychic nature. He believes that more frequently even than actual epileptic seizures are the dream states, excitements, and maniacal outbreaks brought about in these individuals by emotional experiences, and as a result of certain ideas and concepts. He places in this group the proverbial "wild man", the man who goes into a frenzy upon seeing a policeman, etc. Although alcohol may in these individuals prepare the way, the immediate causative factor, however, is the emotional experience, or the recollection of such an experience.

These psychogenetic excitements of degenerates often simulate symptomatologically genuine epilepsy so far as the ferocity of the excitement and the state of consciousness are concerned. In some cases the retention of suggestibility during the attacks shows clearly the psychogenetic character of the disorder, while in others the tendency toward the theatrical and exaggeration is so marked that we are forced to think of an hysterical component. Certain slight symptomatologic features of these psychogenetic states of excitement in degenerates appear to furnish a differentiating point between them and the true epileptic condition. Bonhoeffer refers to the strong tendency to disgust-evoking manifestations, to copro-practice which manifest themselves in the soiling of the walls and face with excrements, the drinking of urine, etc. Another characteristic is the frequent total misunderstanding of the situation by these individuals in that they consider themselves to be threatened with impending grave physical danger. In consequence of this they manifest a certain over-aggressiveness, which goes far beyond mere protective reactions, and manifests itself in a senseless breaking and demolis.h.i.+ng of furniture. These individuals can be easily distinguished by their superficial intellectual endowment, by a tendency to change of occupation, and early criminality. During imprisonment and under the influence of the stress incident thereto, they develop an acute paranoid symptom-complex, a delirium of reference, accompanied by ideas of prejudice, isolated elementary hallucinations, and irresistible desire to a depressive recapitulation of their past, and a nervous, irritable temper. Consciousness is not clouded, and they remain perfectly oriented in all spheres. The duration of the disorder may vary from a few months to two years, with occasional intermissions. The delusional formation continues only for a short period, and in no instance leads to a retrospective change of the content of consciousness. Very frequently the process subsides upon the removal of the patient into a new environment without leaving any change in the personality of the individual. Insight is not always perfect. The delirium of reference and prejudicial ideas concerning the prison personnel may remain unconnected.

The cases belonging to his second group are those well-known pestilent individuals who from childhood show an abnormally affective reaction to frictions in social life, in so far as their highly exaggerated, egocentric self-consciousness permits them to endow every unpleasant experience with a personal note of prejudice. They are the poor martyrs, who somehow never seem to get what is coming to them in this world, who are ever ready to a.s.sert their rights and leave no stone unturned until they receive what they consider full justice. Such individuals may pa.s.s through life, if fortunate enough, without developing a real psychosis.

They are then merely burdensome and uncheering elements within their narrow social sphere. Should they, however, meet with an experience, which to them appears as an injustice, they may at once develop typical paranoid pictures, the characteristic feature of which is that the psychic experience which forms the origin of the trouble remains always in the foreground. Bonhoeffer identifies these conditions with Wernicke's psychoses of hyperquantivalent ideas. He very justly says: "The narrower the sphere of activity in which these individuals live, the more frequent the opportunities for conflict are offered by law, discipline, and subordination, the easier it is to develop a psychotic exacerbation of the abnormal temperament even on a lesser pathological basis. This is the reason why officialdom and especially the narrow limits of prison life bring out so forcibly these psychogenetic disorders. In prisoners the psychogenetic character of the disorder becomes especially apparent. One sees how in many cases the transfer from one prison to another, to an observation station, to an insane asylum, puts an end to the process. In certain instances the process seems to revive itself again when the individual is placed in a similar environment."

Of Bonhoeffer's three subdivisions of degenerative states the preceding one would as a whole appear to me to be especially deserving of a separate cla.s.sification. Anyone who has had any experience with insane criminals will recall that group of cases in whom the entire psychosis seems to be more or less centered about a certain idea; in most instances, about the idea of not having received a just trial. These individuals, without showing any intellectual impairment, in fact without showing any characteristic which would fit their mental disturbance into any of the known psychoses, constantly evidence a sort of paranoid habitus, a paranoid trend which is exclusively directed against those who had anything to do with their conviction and safe-keeping. The most trivial occurrences in their environment are endowed by them with a personal note of prejudice. The delay of a letter, the refusal to grant some of their unusual requests, an attendant's accidental failure to sweeten their coffee sufficiently, the slightest deviation from the routine greeting of the visiting physician; in short, any such trivial, insignificant occurrence is at once endowed with a special meaning, and explained in a more or less delusional manner. Yet these individuals can reason in a perfectly rational manner on any subject which is not concerned with their conviction or confinement. They are as a rule intellectually bright and keen, and fail to show any evidence of emotional deterioration. On the contrary, their emotions are of such fine and sensitive nature that incidents which an ordinary individual would overlook entirely, offend them to a marked degree, and are reacted to by them in a very decisive manner. Indeed, one frequently asks himself whether their persecutory ideas deserve to be endowed with the value of actual delusions. I fully agree with Sturrock[12] when he says: "If I refuse to allow a prisoner full scope because he has lifted a knife from the table with which to attack the charge warder, I do not call it a delusion of persecution if he spends the night threatening to murder me because I do not give him justice."

One must remember that this is in a measure the normal att.i.tude of the captive towards the captor, and can be seen in a more or less p.r.o.nounced degree among criminals enjoying a short respite from the law. The essential point here is not the so-called psychosis, but the soil which made the development possible. Not all prisoners, by far, react in this manner to the prison environment. It is only those degenerative individuals who have shown this well-marked paranoic trend all their lifetime, who furnish these cases. As a general rule these conditions are seen in habitual offenders whose entire life has been a round of conflicts with everything they come in contact, and who, outside of prison, figure chiefly in the saloon and gambling house brawls.

That these conditions deserve a more definite cla.s.sification than the nondescript paranoid state cannot be doubted. These paranoid manifestations are distinct reactions to a definite situation, in this instance, conviction and imprisonment, of individuals whose peculiarly degenerative make-up makes such reactions possible. The question of the particular coloring which these disorders may a.s.sume can only take a secondary position to that of the character or make-up with which we are dealing.

Bonhoeffer further speaks of a certain hysterical element in these cases, but does not believe that on this account these paranoid manifestations should be considered as hysterical. He rather believes that they are more closely allied to the epileptoid temperament. The hysterical component manifests itself in either hysterical stigmata, or, as has often appeared to him, in the fact that the falsifications of memory which these individuals frequently manifest concern themselves solely with the simple overvalued paranoid ideas, and lead to a complete blocking out of unpleasant recollections of the individual's past career. Thus, previous sentences, imprisonments, etc., are totally forgotten. In this, perhaps, we might see the well-known wish factor of hysteria.

The cases which comprise his third group show such a varying symptomatology that it is difficult to form an exact idea of just what characterizes them.

After perusing the work of Bonhoeffer, one feels that the author's endeavors to subdivide his material into this or that group are somewhat artificial. Granted that we are dealing with mental disorders, whose existence can be possible only by a certain degenerative predisposition, the question arises, "Of how much practical value is this constant endeavor at cla.s.sification and subdivision of the psychotic manifestations which these individuals show?" One must acknowledge that the salient feature here is not the particular coloring which these psychoses a.s.sume, but, as we have stated before, the soil upon which they develop. At most, we might say that the symptomatology of these psychoses would depend on the question whether it is the ideational sphere which is mostly concerned, or the affective sphere. Turning to Wilmanns' excellent contribution to this subject one again meets with the same endeavors at subdivision and cla.s.sification. Lack of s.p.a.ce will not permit us to enter into an extensive discussion of this author's work. We have already indicated here and there in pa.s.sing, some of the essential points in the views of this author.

One turns with quite a degree of relief to the momentous work of Birnbaum[13] on the Psychoses of Degeneracy. As far as can be ascertained the author does not endeavor to subdivide his degenerative states into so many types and forms. According to him, the essential characteristics of the degenerative psychoses--namely, the extraordinary determinability and influence which outside impressions have upon the disorder, the mode of genesis and the psychological evolution of the delusions, etc.,--may be attributed to the essential ear-marks of the degenerative character; that is, to the exaggerated auto-suggestibility, the great instability of the existing conditions and mental pictures, the disharmony between the perceptive and imaginative capacities and the preponderance of a lively fantastic coloring to the dry thinking of these individuals. They do not form disease processes of a definite characteristic form, but episodic psychotic manifestations on a degenerative soil, and the manifold phases of the collective forms are to be considered as repeated fluctuations about the psychic equilibrium of these individuals. He further noted that the symptomatology of these disorders remained limited to a relatively well systematized delusional fabric, which, however, in contradistinction to paranoia, does not persist for any length of time, but disappears for certain definite reasons. They do not form any typical symptom-complex. The delusional ideas may take on any character; hallucinations may occur in all fields of the sensorium; consciousness may or may not be clouded, but is usually so in the beginning of the disorder. Recoveries are as a rule gradual, but may set in quite suddenly. Insight may or may not be present. The course of the disorder, like its symptomatology, offers nothing of a definite, characteristic nature.

Thus we see that the distinguis.h.i.+ng feature of Birnbaum's degenerative psychoses does not lie in their mode of appearance, in their symptomatology, but in the mechanism of their evolution, and, above all, in their total dependence upon extraneous influences. They are typical psychogenetic disorders, the psychic etiology of which is potent not only in the incitation of the processes, but in the modeling and fas.h.i.+oning of them. Although Birnbaum notices the close relation that exists between these psychoses and the hysterical psychotic manifestations, he would separate them distinctly from hysteria.

CASE IV.--A. C., colored female, age 32 on admission to the Government Hospital for the Insane, on June 18, 1909. Father died of dropsy; one brother was killed in a railroad accident; one sister suffered from St. Vitus' dance; another died of tuberculosis. Patient was born in Jamestown, Virginia, was healthy as a child. Does not remember having had the usual diseases of childhood; had a severe attack of typhoid fever when quite young. Attended school until fourteen years of age, having reached the third grade. Upon leaving school she went to work as chambermaid and soon became addicted to the excessive use of alcohol, as a result of which she got into numerous fights and quarrels. In 1895, while intoxicated, she stabbed a man in the back and was sent to Albany Penitentiary for five years and eleven months.

During her sojourn there she was sent to the Matteawan Hospital for Criminal Insane, where she remained forty-five days. Upon being discharged she returned to her home and lived with her mother, a.s.sisting her with was.h.i.+ng and ironing, following which she led the life of a prost.i.tute for about two years. In 1901 she was sentenced to thirty months imprisonment at Moundsville, Virginia, for theft.

Previous to this she had been confined in the Government Hospital for the Insane for about a month with an attack of delirium tremens. After the expiration of her sentence at Moundsville, she returned to Was.h.i.+ngton and soon after was again arrested for housebreaking and robbery and sentenced on two counts to twenty years imprisonment at Moundsville. While there she had more or less trouble all the time; had numerous fights with other colored women, in several of which she sustained injuries. On February 12, 1907, while working in the sewing room, she became implicated in a quarrel with another inmate, whom she stabbed in the left side of the neck with a pair of scissors. In describing the incident she says: "I pushed them in as far as they would go, twisted them around, opened them and then pulled them out."

The woman lived about five minutes after this. The quarrel presumably originated because her antagonist called her some name and accused her of having to serve a "young life sentence." She then told this woman to go back to Anacostia and get the baby she threw over the Anacostia Bridge, at which the latter became quite angry and attacked her with a pair of scissors which culminated in the murder. A. C. was placed in a cell after this and the next day transferred to a dungeon, where she remained until her transfer to this Hospital. While in the dungeon she suffered a great deal with headaches and nervousness; she was absolutely isolated, no one came to her cell, ate her meals through the bars. In this condition she remained about three months. She says she prayed a good deal during this period, because she was told that she might have to stand trial for murder, in which event they would surely hang her. She was admitted to this inst.i.tution the first time on May 8, 1907, on a medical certificate which stated that one sister died of pulmonary tuberculosis, and that another is now afflicted with ch.o.r.ea. The patient was addicted to the excessive use of alcohol and cocaine and is considered to be a s.e.xual pervert. Ever since she was admitted to the penitentiary she has exhibited signs and symptoms of insanity; her present symptoms are described as ungovernable temper, attacks of extreme nervousness, attacks of fits resembling those of acute mania, with loss of judgment and complete disregard for the consequences of any of her acts. Delusions of persecution were also noted. Her mother stated that the patient throughout her lifetime would frequently have outbursts of temper, and her brother would tie her down during these attacks to prevent her from injuring members of the family. Physical examination on the first admission was negative.

Mentally she complained of being nervous and easily awakened at night; consciousness was clear; she was well oriented; no hallucinations or delusions could be elicited. Intellectually she appeared to be above the average negro in intelligence; she read and wrote, spelled correctly and used good English. Her memory was good for both past and recent events. Throughout her entire sojourn here she was oriented to time, place and person; except for having stated at one time in a sort of careless and apparently indifferent way that she had heard someone calling her by name, and upon looking for the person could find no one, she manifested no hallucinatory disturbances. No delusional ideas were elaborated at any time. Her conduct here was characterized throughout by marked irritability; she frequently threatened to get even with the ward physician, saying she did not propose to fight open-handed any more and would not enter into a fight without a weapon. She frequently broke window lights without any apparent reason; often was very surly in manner; then again was pleasant and agreeable and a.s.sisted with the work on the ward. She a.s.saulted several of the nurses when an attempt was made to restrain her, in order to prevent her breaking window lights. When spoken to about these outbursts of temper she would deny all knowledge of them, saying that she never threatened nor a.s.saulted anyone. She was discharged as recovered on January 12, 1909, and returned to Moundsville Penitentiary. She was again admitted to the Government Hospital for the Insane on June 18, 1909, on a medical certificate which stated that she was very irritable and had a mania for breaking windows; that she was suffering from delusions. No further evidence of insanity was given. On admission she was sullen and disagreeable, had a frown on her face, sat on a chair looking out of the window and was exacting in her demands. She requested to be removed to another ward, where she thought it would be livelier; asked for various medicines, etc. When told that her requests could not be granted, she became very cross and abusive, making threats of things she would do. In the afternoon scratched her arm with a pin and quite a flow of blood was produced, which necessitated restraint. At this she became very excited and endeavored to break the wristlets and get out of the room, proclaiming loudly that if she was going to have wristlets on she would rather be back at Moundsville. She was not very communicative concerning her return to the Hospital; told one of the nurses that she had "carried on high" to get back, and that Moundsville was "a h.e.l.l of a place."

The following day she begged continuously for hypodermics, complained of headache and tried to produce emesis by putting her finger down the sophagus. When questioned, she answered promptly and intelligently, but in a sullen manner; stated that on her return to the penitentiary she was placed in a cell formerly occupied by the woman whom she had killed, and that this made her nervous, and frightened her. She would not sleep on the bed provided but used for sleeping purposes a box intended for a table. She said she cried and prayed a great deal until finally, after three weeks, was transferred to another ward. She said that she behaved well and caused no trouble after having been removed from the first cell and does not know why they transferred her over here. Her entire sojourn here on this occasion was characterized by irritability, impulsiveness and destructiveness to property. She was fault-finding to a great extent and threatened the life of some of those about her. She was surly, selfish, and showed a marked tendency to lying. She was shrewd in her endeavors to get herself into the good graces of those in charge of her and on one occasion stated that she was pregnant in order to receive more considerate treatment. This, like many other of her a.s.sertions, was false. She was oriented throughout; memory good; no hallucinations or delusions could be elicited; she was very unstable emotionally; reasoning and judgment were defective. Her entire symptomatology was controlled and fas.h.i.+oned almost wholly by her immediate environment. When refused a privilege she would become surly, abusive and threatening to those about her, would destroy everything she could lay hands on, and attack the nurses when the opportunity was favorable. The granting of a privilege again would serve to keep her in a rather tranquil mood. She remained this time until June 21, 1910, when she was again returned to the penitentiary at Moundsville. From information obtained from some officials of that penitentiary, it appears that she is continuing to have her old-time outbursts of temper, during which she becomes absolutely unmanageable, and the only way to deal with her seems to be to isolate her and leave her absolutely alone until she is over her disturbed state. Between these attacks she behaves quite well, but such behavior has to be encouraged by the granting of various privileges.

CASE V.--J. J. M., aged 24 years, white male, is a well-built young man, whose family history is unknown owing to his refusal to give it.

He was born at Chester, South Carolina, in 1885. Childhood and school life uneventful as far as is known. He was a bright scholar of ordinary intellectual attainments. His industrial career, which began early in life, was, according to his statements, normal. He admits, however, losing several positions on account of outbreaks of temper during which he had fights with other employees. He had several gonorrhal 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 una.s.sisted 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 Was.h.i.+ngton, 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 prost.i.tute, 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 pa.s.ses 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 smas.h.i.+ng some of them, adding: "I know I am a d.a.m.n 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 gla.s.sy 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 gla.s.s 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 h.e.l.l, 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 h.e.l.l 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 coa.r.s.e clothing, and this had to be finally subst.i.tuted 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 a.s.sist him by furnis.h.i.+ng 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 a.s.sumed 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 h.e.l.l 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 inst.i.tution 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 d.a.m.ned 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.