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

A. "U. S. Hospital."

Q. "Who brought you here?"

A. "Can't tell you, he looks like a monkey."

Q. "How long did it take you to get here?"

A. "One night and twenty-four hours."

Q. "When did you come here?"

A. "I cannot tell you when I did come here."

Q. "Don't you really know the name of this place?"

A. "Well, sailors in the Navy call it the 'Red House.'"

Q. "Where is it located?"

A. "Washington, D.C."

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

A. "Why, it's as good as any place else."

Q. "Who are these people about you?"

A. "They might be soldiers; what are they out there for?"

Q. "Is there anything wrong with them?"

A. "How should I know?"

Q. "Are any of them insane?"

A. "Darn'd if I know."

Q. "How do you feel?"

A. "How did I get cured of my headache? I'll stick a pitchfork through you, and if a pitchfork goes through you, it will go through me too."

Q. "Are you sick?"

A. "I was sick; had a pain in the head."

Q. "How do you feel now?"

A. "Oh, pretty good."

Q. "Is there anything wrong with your mind?"

A. "I don't know, I can't tell you."

Q. "Do you hear any strange noises or voices?"

A. "Can you go over to that tree? Sounds like a baby squealing; it's the man that choked the baby."

Q. "Do you ever see strange things?"

A. "Did I ever see strange things? I might read about them in the magazine."

Q. "Do you ever hear voices?"

A. "I hear voices say to you; 'You are not guilty.'"

Q. "How much money are you worth?"

A. "$100; I'll give it you for my life."

As will be seen from the foregoing stenogram, the patient is only partially oriented, perhaps more so than he shows, because of his tendency to answer questions in a sort of careless manner. There is a slight suggestion of "by speaking" (Vorbeireden). The stenogram also suggests the possibility of the existence of fallacious sense perceptions. Of the utmost importance, however, for our consideration, is the fact that the occurrence which brought about the mental breakdown plays an important role in the consciousness of the patient.

Amid what may be considered an almost total oblivion to his immediate environment, he hears the voices tell the examiner that he is not guilty, he would give the $100 which he possesses for his life. These are unmistakable signs of the psychogenetic nature of the disorder.

July 31:--Patient is well oriented, talks in a r.e.t.a.r.ded manner; questions are answered for the most part correctly; occasionally, only nearly correct. His memory is good for remote events, but very much clouded for events which have transpired since the commission of the crime. Partial insight is present. He realizes that there must have been something wrong with him. Emotionally not deteriorated. Refuses to discuss his crime, saying it makes him feel bad; talks in a childish, affected tone of voice, and undergoes various grimacing movements; gives frequent evidence of being fully aware of occurrences in his environment; talks and eats voluntarily and is tidy in habits.

Occasionally laughs in a silly, affected manner. Flexibilitas cerea and catalepsy entirely disappeared; gained considerably in weight; continues to show marked tendency to be influenced by occurrences in his environment. In general, shows a decided improvement in his condition.

We are dealing here with an individual whose past career is uneventful, as far as is known. He is charged with murder, and upon being tried for this develops a mental disorder. The symptomatology of his psychosis could easily be mistaken for that of catatonic praec.o.x, and, as a matter of fact, had been so diagnosed by the first observer. In studying the case more thoroughly, however, it becomes unmistakably evident that we are not dealing here with a case of catatonia. In the first place, the immediate relation between the emotional shock of the crime of murder and the probable punishment for it, and the development of the mental disorder must be taken into consideration. This is not a mere accidental relationship. But even if we grant that this point cannot be definitely decided, the psychogenetic character of this case cannot be doubted when we remember how the entire symptomatology is absolutely dependent upon and influenced by occurrences in the patient's environment. He refuses to eat, a symptom very common in catatonia, but it is indeed a rare occurrence for a catatonic in the midst of a negativistic stupor and mutism to say, "I'll drink it," and actually drink voluntarily the entire contents of the pitcher in order to avoid tube-feeding. He is untidy in his habits, another common catatonic characteristic, but is it to be expected that a catatonic, in the height of his disorder, will abstain from his filthy habits when threatened to be punished for these?

Many more instances of similar nature could be cited in this case.

Another feature which removes all doubt of the psychogenetic nature of this disorder is the important part which the mental experience which was active in the production of the disorder played in the fashioning of its symptomatology. I alluded before to the patient's answer to the question of whether he heard voices.

The disorder itself, as far as the symptomatology is concerned, is not absolutely typical of any one of the acute psychogenetic states. It partakes of Kutner's "catatonic states in degenerates" as well as Raecke's confusional hallucinatory disturbances in these individuals.

That the patient can be cla.s.sed as one having a degenerative soil is not at all certain in this case.

I have considered briefly the importance of a proper recognition of these cases from the viewpoint of rendering a proper prognosis. There is another important question which must be discussed in connection with these cases and that is the question of malingering. Picture to yourself an individual, who, to all appearances, has led a normal existence, and never showed anything mentally which might be considered pathologic. He commits a crime, and upon being arrested or upon being placed on trial for his offense, suddenly lapses into a condition of apparently complete dementia. The man, who formerly showed nothing in his conduct and behavior indicative of a mental disorder, suddenly changes into a state where he does not know his name, age, or his whereabout. His answers to questions are irrelevant and of a remarkedly silly coloring. He begins to act in a childish, affected manner, executing many silly, meaningless acts, or he may break out in a wild furious excitement, loudly proclaiming his innocence, and threatening those who arrested him. In addition to this, it is noted that this apparently pathologic condition can be definitely influenced by using strict and positive measures. The untidy habits of the patient may be corrected by urging or threats. The man who has been mute and refuses to eat can be made to talk and eat voluntarily by threatening him with tube-feeding. Furthermore, in the midst of this apparently total dementia, total blocking of all thought processes, the patient frequently surprises those about him by very sensible remarks of a very clever and pertinent nature, indicating that although apparently oblivious of his environment, he knows what is going on about him.

A picture like this may readily arouse the suspicion that we are dealing with a malingerer, and, indeed, some very prominent German psychiatrists have reported as malingerers cases similar to this. The trained psychiatrist, if unfamiliar with this cla.s.s of cases, will find himself at a loss to know under what known group of mental disorders to place this condition, as it will at once become apparent to him that it does not fit into any of the well-known psychoses.

In defense of the genuineness of the psychotic manifestations of these patients, I would recall again the transitory mental disturbances of students undergoing examinations. The genuine loss of all knowledge of well-known facts which the old-time strict and severe schoolmasters frequently provoked in school children, differs very little from the pseudo-dementia with which we are dealing here. It concerns a similar total blocking and inhibition of all thought processes, and, like all psychogenetic disorders, has a tendency to disappear upon the removal of the causative factor.

Still, n.o.body would think for one moment that the child malingers when it is unable to answer questions, though these might concern well-known facts. The consequences of failure to recognize this acute prison-psychotic-complex as a genuine mental disorder may prove to be very disastrous when we remember to what extent the symptomatology of these psychoses is dependent upon environmental conditions.

THE DEGENERATIVE PSYCHOSES

I have considered thus far those psychogenetic mental disorders, the etiologic factor of which consisted of a single, more or less isolated emotional occurrence. We have seen that the majority of these patients showed very little, if anything, in their past life which was in any way incompatible with leading a more or less successful existence in the community in which they lived. These patients, we might say, would never have been brought to the attention of the psychiatrist had it not been for the occurrence in their life of an experience which provoked a mental breakdown.

I will now consider a group of cases, in whom the degenerative soil is so prominent that they have been properly called "Psychoses of Degeneracy." They should, however, be considered here, because the various psychotic manifestations of these individuals are purely psychogenetic in nature, and evoked by a certain milieu in which the individual was placed. As my material is derived from the criminal department of the Government Hospital for the Insane, the causative factor in these cases will again be found to be imprisonment. These cases differ from the so-called acute prison-psychotic-complex in that the etiologic factor does not consist in a single emotional experience.