Studies in Forensic Psychiatry.

by Bernard Glueck.

PREFACE

When, in 1810, Franz Joseph Gall said: "The measure of culpability and the measure of punishment can not be determined by a study of the illegal act, but only by a study of the individual committing it," he expressed an idea which has, in late years, come to be regarded as a trite truism. This called forth as an unavoidable consequence a more lively interest on the part of various social agencies in the personality of the criminal, with the resultant gradually increasing conviction that the suppression of crime is not primarily a legal question, but is rather a problem for the physician, sociologist, and economist. Whatever light has been thrown in recent years upon this most important social problem, criminality, did not issue from a contemplation of the abstract and more or less sterile theses on crime and punishment as reflected in current works on criminal law and procedure, but was the result of research carried on at the hands of the physician, especially the psychopathologist, sociologist, and economist. The slogan of the modern criminologist is, "intensive study of the individual delinquent from all angles and points of view", rather than mere insistence upon the precise application of a definite kind of punishment to a definite crime as outlined by statute. Indeed, the whole idea of punishment is giving way to the idea of correction and reformation. This radical change of tendency cannot be looked upon as a mere misdirected sentimentality on the part of modern society, but is the inevitable result of the final conviction that the solely punitive criminology upon which society has been relying in its efforts to eradicate criminal behavior from its midst has proved a total failure.

The idea of punishment as a deterrent of crime is, as a consequence, gradually losing its hold upon modern criminologists, and in its stead we have been experimenting for some time past with such measures as probation, suspended or indeterminate sentence, and parole. Now it can not be too strongly emphasized that in giving these measures a fair trial we ought to guard against those very same grave errors which were chiefly responsible for the failure of the old, solely punitive methods, namely, the dealing with the criminal act rather than with the individual committing it. If these new measures of probation, suspended sentence, and parole, which are perfectly adequate in theory, are to justify their existence in the practical everyday handling of the problem of criminology, we must not fail to take into full account the very obvious natural phenomenon that human beings vary within very wide limits in their susceptibility to correction or reformation, that some individuals because of their psychological make-up, either qualitative or quant.i.tative, are absolutely and permanently incorrigible and present a problem which can be dealt with in only one effective way--namely, permanent segregation and isolation from society. It is on this very important account that the psychopathologist's place in criminology is fully justified. In endeavoring to aid in the solution of the problem of criminology, the psychopathologist need not seek new methods of procedure but may safely rely upon those which have aided him in elucidating in a very large measure the problem of mental disease. For criminology is an integral part of psychopathology, crime is a type of abnormal conduct which expresses a failure of proper adjustment at the psychological level.

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

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

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

GOVERNMENT HOSPITAL FOR THE INSANE, January, 1916.

STUDIES IN FORENSIC PSYCHIATRY

CHAPTER I

PSYCHOGENESIS IN THE PSYCHOSES OF PRISONERS

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

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

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

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

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

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

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

Reich,[3] in 1871, was the first one to call attention to the mental disorders of prisoners awaiting trial. He could observe the development of mental symptoms even during the first hours of confinement, and the relation between the psychosis and the emotional shock of the situation at hand could not be doubted. He describes this acute mental disturbance as follows:--"Already in the first hours or days after imprisonment, or soon after a severe emotional shock, a sort of psychic tension sets in.

The prisoner becomes silent, chary of words, lost in brooding. He observes little that goes on about him and remains motionless in one spot. His face takes on an astonished expression, the gaze is vacant and indefinite. If he makes any movements at all they are hesitating, uncertain, as those of a drunken man. Vertigo and aura-like sensations appear; severe anxiety overpowers the patient, which with the entire force of a powerful affect crowds out all other concepts and sensations and dominates the entire personality. Consciousness becomes more and more clouded, soon illusions, hallucinations, and delusions appear, and the prisoner becomes especially taken up with ideas of unknown evil powers, of demons and spirits, and of being persecuted and possessed by the devil. Simultaneously they complain about all sorts of bodily sensations. In isolated cases one may observe convulsive twitchings of the voluntary and involuntary musculature. Finally severe motor excitements set in. The patient becomes noisy, screams, runs aimlessly about, destroys and ruins everything that comes his way. With this the disease has reached its height. At this stage consciousness is entirely in abeyance and the disorder is followed by complete amnesia." Reich supposes that this acute prison psychosis may be included in that large group of abnormal psychic processes, developing from affect and affect-like situations.

Reich's important work remained the only one on the subject until 1888, when Moeli again called attention to it. Moeli[4] spoke of patients in whom an apparent total blocking of all thought processes took place.

They would exhibit complete ignorance of the most commonplace facts, would forget such well-known things as their own name, place of birth, or age; were unable to recognize the denominations of coins, etc. He noted, however, that although the answers these patients gave were false, they had a certain relation to the question. For instance, coins of a lower denomination would be mistaken for higher ones, postage stamps were called paper, etc. They also showed a marked tendency to elaborate all sorts of false reminiscences about their past life. Along with this failure of the simplest thought and memory activity, these individuals were otherwise well-ordered and behaved.

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

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

Raecke[6] designated this disease-picture described by Moeli and Ganser as an hysterical twilight state in psychopathic individuals. These conditions were developed in them as the result of emotional excitement in imprisonment. The constant hearings, the confusing cross-questioning, the fear of punishment, finally the injurious effect of solitary confinement, shock and weaken the slight mental tension of the prisoner to a marked extent. As a result of this, we have on the one hand a condition of apathy, of inability to concentrate the mind, of incapacity to think and of a sort of feeling of being wholly at sea, accompanied by vertigo and other nervous manifestations, while on the other hand the physical despair, the obstinacy of the prisoner, now increase to pathological maniacal attacks, now again are changed to stubbornness, mutism, with refusal of food. At the same time the more or less constant wish to be considered sick, and in consequence to be freed from imprisonment (and in this we see perhaps the hysterical component), may influence deleteriously and in a peculiarly modifying way the disease-picture. The various questions put to the patient by the examiner may act as so many suggestions. Raecke further calls attention to the manifold similarities which these conditions may show with catatonic processes. In these hysterical twilight states, quite aside from mutism, negativism, and catalepsy, peculiar mannerisms were noted, a sort of affected, childish way of speaking, motor stereotypies, swaying of the head, running in a circle, queer actions, and sudden expressions of senseless word combinations. In a later work Raecke[7]

describes a symptom-complex, which he designated as "hysterical stupor in prisoners", and in which the catatonic symptoms exist in a still more p.r.o.nounced manner. The severe forms of this disorder, which may extend over weeks and months, are liable to be confused with progressive deteriorating processes, especially so because those symptoms which were wont to be considered by many as positively unfavorable prognostically, may be found here in very deceptive imitations. Thus the affected, silly behavior, impulsive actions, temporary verbigeration, senseless word salad, grimacing, stereotypy, att.i.tudinizing, etc., which these patients exhibit, may easily be mistaken for the typical catatonic picture of dementia praec.o.x. According to Raecke's view the hysterical stupor is closely related to the Ganser twilight syndrome. Stuporous conditions may introduce the latter, and, vice versa, Ganser complexes may creep into the stupor. Raecke's stupor, like Ganser's twilight syndrome, frequently develops in criminals immediately after arrest or as a result of great physical or psychic exertion. Sometimes the stupor is preceded by convulsions, at other times by a prodromal stage of general nervousness. In still other cases, unpleasant delusions and elementary hallucinations precede the stupor, which may follow immediately after this prodromal state or may be again preceded by a short attack of mania with clouded consciousness. In contrast to the genuine catatonia, Raecke's stupor as well as Ganser's twilight state, are characterized by _a high grade of impressionability to things in the environment, which may at any time suddenly cause a complete transition from an apparently deep stupor to normal manner and behavior_. Headaches, vertigo, and various hysterical stigmata are common to both the hysterical stupor and the Ganser twilight state. At times recovery takes place suddenly, but as a rule it is gradual and remittent in character. The duration of the disorder differs. It may last for hours or months, and there generally remains a more or less p.r.o.nounced amnesia for the entire period of stupor.

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

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

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

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

CASE I.--E. E., Negro, aged 32 years. One sister insane, a brother is said to be subject to convulsions. Patient's birth and childhood normal; attended school for three or four years, where he made normal progress. He entered upon the life of a common laborer when quite young, and always managed to earn a substantial livelihood for himself and family. With the exception of typhoid fever at six or seven years, he was never ill before. He used alcoholics in moderation, and denies venereal history. Criminal history is uncertain; according to his statements he was arrested but once before, for fighting. It appears that he was working as usual until August 19th, when he was arrested on a charge of a.s.sault and robbery. The patient has a hazy recollection of this; he cannot say how long ago it was, but thinks it was sometime in August; he was arrested at night; cannot state at just what time, but is certain that it was after sunset; does not know who arrested him; says there were several of them; does not know whether they were policemen or detectives. The police records show that he was arrested on the night of August 19th, after a desperate fight. The following day he suddenly became insane in his cell at the fourth precinct station house. He became very excited; commenced to shout that he had been shot in the abdomen by an enemy. When offered food he threw it at the policeman through the bars of his cell door, and then began beating his head against the walls of his cell. He was transferred to the observation ward at the Washington Asylum Hospital.

The records of that inst.i.tution show the following: On admission he was yelling, cursing, and very much excited; completely disoriented; repeated the same sentence over and over again in a singing fashion.

He talked to the Lord, and answered imaginary questions; had auditory and visual hallucinations, and various delusional ideas; thought someone was talking to him constantly; that he was being shot at every few minutes, and yelled with anguish at every supposed shot. He cried and sang alternately. Owing to his marked excitement he had to be kept in constant restraint.

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

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

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

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

September 3d:--The patient suddenly became clear mentally this morning; seems to have completely recovered from his stupor; attends to his wants, and answers questions in a clear, coherent manner.

Approached the physician this morning and asked for a laxative; says that he remembers nothing that transpired during the period since his arrest, and a day or two ago, when he began to see things more clearly; complains of pain in back; does not know where he is, and thinks he came here yesterday.

"What is your name?"

"E. E."

"Age?"

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

"When were you born?"

"In 1879."

"What is your occupation?"

"I am supposed to be a huckster."

"Where were you born?"

"At Columbus, South Carolina."