Studies in Forensic Psychiatry Part 9

I shall not enter into a detailed discussion of this case. It is simply quite ill.u.s.trative of the absolute necessity for permanent segregation of mental defectives.

When some of this clinical material was first published in 1912 it met with very gratifying recognition at the hands of those who were interested in criminalistics.

I wish to take this opportunity of expressing my particular appreciation of Dr. Healy's kind words of approbation and encouragement.

We all must agree that the first essential step towards a better understanding of criminal types consists in a thorough study of the criminal individual, such as is reflected, for instance, in the very excellent book by Healy on the "Individual Delinquent." Such studies have thus far, however, with but rare exceptions, not been made at the proper source,--that is, in the criminal laboratory, the penal inst.i.tution.

The work which is being done with the juvenile offender is, of course, very important and very valuable; but in order that this work may be checked up scientifically it must be supplemented by thorough catamnestic studies of the juvenile offenders. This, I believe to be the only rational way of approach to the problem.

This will in time, I believe, furnish us data concerning the criminal which will enable us to evaluate in a correct manner the various traits and characteristics of the juvenile offender and thus enable us to render a correct prognosis in a given case. Once we shall reach a stage in the science of criminology when we shall dare to say of a juvenile offender, as we now unhesitatingly say of the leper, "Here is a human being who will always be a danger to his fellow-man and, therefore, should be permanently isolated from his fellow-man", the problem of recidivism will be solved.

We cannot, however, arrive at a proper conception of the nature of a juvenile offender by merely studying a cross section of him at any given moment of his life. In order to understand man, especially abnormal man, we must study him in a longitudinal section; we must note his mode of reaction to experiences in everyday life, under all manner of conditions and circ.u.mstances; we must investigate the motives and desires which prompt his conduct; we must find out how effectually he adapts himself to the environment in which he happens to be placed and in how far he is able to modify the world about him so as to make it subservient to his needs and wants. The same problems which confront criminology today, psychiatry had to face some years ago. In order to be able to rationally and scientifically deal with the insane the psychiatrist found it essential to establish certain criteria which might enable him to tell, with some degree of certainty, what the future life of a given insane person will be. In the last a.n.a.lysis it is this same thing which we are aiming to attain in our dealings with the criminal. The problem which is constantly before us in dealing with juvenile delinquency is what might be expected of the future life of the juvenile under consideration and what must be done towards directing his future into proper channels. So, after all, it should be our aim to establish certain criteria by means of which we should be able to render a proper prognosis. That we possess no such criteria at present can be denied by no one.

As I have already stated, psychiatry had to face the same problems. With the advent, however, of the Kraepelinian school these have in a great measure been solved. Kraepelin, by studying the entire life history of his patients, was able to show that certain disease pictures when studied in cross section may simulate one another very closely clinically and at the same time be of the most diverse significance prognostically. He further showed that certain acute psychotic disturbances are merely the outward expressions of an underlying progressive disorder, and though the acute manifestations may disappear and leave no apparent trace behind them, the great majority of these individuals will spend the rest of their lives in inst.i.tutions for the insane. By calling attention to certain symptom-complexes, which are especially characteristic of certain mental disorders, he gave us the means by which we are able at the present time to predict with a fair degree of certainty what the future life of a given patient will be. We can now tell without great fear of contradiction which of our patients are going to spend the rest of their lives in inst.i.tutions.

Now, criminality is generally conceded to be an expression of a diseased personality and there is no reason why the same principles which served to advance our knowledge of psychiatry should not be employed here.

In the foregoing study we aimed to carry out these principles, but we believe that better results still could be obtained at the hands of a trained psychiatrist right at the penitentiary. The reasons for this are quite obvious. The relations.h.i.+p between prisoner and physician would then be quite a different one, the data could be more readily verified with the a.s.sistance of the machinery of the law, and the subjects would be in a more accessible mood than when suffering from a mental disorder.

As a matter of fact the best work thus far done on the mentality and disorders of mentality of prisoners was done by a prison physician, Dr.

Siefert, of Halle.

Thus we see that the question of the degenerative prison psychoses has an important relation to the question of criminology in general.

This becomes at once apparent, if we accept the contention of many authorities that the degenerative soil which makes the development of these psychoses possible, is likewise responsible for the criminality of these individuals; in other words,--if we agree that crime and psychosis are here branches of the same tree. Manifestly any discussion of the treatment of these psychoses must of necessity touch upon the vastly broader problem of the treatment of the habitual criminal, the recidivist, and therefore a slight digression from the subject at hand will be unavoidable.

If we admit that it is the prison environment which serves to bring out the prison psychosis, it is perfectly evident that the first therapeutic indication is the removal of the prisoner from that environment as soon as the disorder is recognized. This problem is at present dealt with in several ways. There are certain penal inst.i.tutions, especially in Europe, which have within their walls a psychiatric department for the reception of these cases. Others send their insane convicts to the criminal department of some hospital for the insane. In this country there are States in which still a third system is in vogue, namely, the confinement of these cases in special hospitals for insane criminals.

Now the points to be kept in mind in the treatment of the insane criminal are, briefly stated, these:--First, they should of course come under the supervision of a trained psychiatrist. Second, the transfer from prison to hospital must take place with as little delay as possible and not be burdened with a lot of red-tape procedures. Third, the hospitals for the housing of these patients must be fully equipped in accordance with the modern ideas of hospital construction, and at the same time afford ample security for the prevention of escapes. Fourth, the interest of the inmates of the general hospital for the insane and the feelings of their friends and relatives must be kept in mind, when we begin to advocate the populating of our hospitals for the insane with criminal characters.

The psychiatric annex in connection with the penal inst.i.tution meets all these requirements better than any arrangement for the care of the insane criminal. An annex of say fifty beds, in connection with every State Penitentiary would obviate entirely the delay in transferring a patient from prison to hospital and _vice versa_. As soon as a prisoner begins to show signs of mental disorder, and a prison physician trained in psychiatry will be able to recognize these early signs, or as soon as there is the least suspicion of mental disorder, the patient could be transferred without delay to the psychiatric department. Here they should be kept under observation for at least six months. This will be sufficiently long in most instances to enable the physician to determine whether he is dealing with a progressive deteriorating psychosis or with one of those transitory prison psychoses. In the cases of the former, _i.e._, if it is definitely established that the patient is a dementing praec.o.x or a paretic, the fact that he happens likewise to be a criminal is really of little or no importance. A demented individual is never dangerous enough to require confinement in an especially secure hospital, though he is a prisoner, and unless he is criminally insane, _i.e._, unless he manifests dangerous or criminal tendencies as a result of his mental disorder, really forms no special administrative problem.

He could be kept either in the prison annex until the expiration of his sentence, if there be room for him, or could be transferred to the nearest hospital for the insane and treated the same as any other insane patient.

It is the second group, however, _i.e._, those patients suffering from the transitory prison psychoses, which especially justify the establishment of psychiatric annexes in connection with prisons. We have seen how detrimental to prison discipline these individuals are, even when in a condition which might be considered normal to them, and we can easily surmise what it must mean to care for them in prison during one of their mental upsets. It is therefore of the utmost importance, both for the prison administration and for the individual, that these patients should be transferred to a properly appointed hospital in as short a time as possible, and this can be done most readily when the hospital and prison are within the same walls, and more or less under the same management. On the other hand, we owe it to the prisoner to bring him under proper care as soon as possible. The practice of sending these individuals to criminal departments of general hospitals for the insane has many objections. In the first place, no matter how modern the equipment of such departments, most of them cannot afford the proper kind of treatment to these individuals. The idea that the removal from prison to a criminal department of an insane hospital will have a beneficial effect upon the prisoner because of the more lenient environment into which he is taken is entirely delusional in the case of the degenerated habitual criminal. These individuals, if the public safety is to be kept in mind, can receive but very limited privileges in a hospital for the insane. The modern hospital is not constructed with the idea of caring for dangerous criminals, and in many instances the habitual criminal, who because of his dangerous tendencies and ever readiness to escape, has to be constantly kept under lock and key, would be much better off if he were treated within the enclosure of the prison. There the construction of the place permits of a wider lat.i.tude of outdoor exercise. An annex located within the enclosure of a prison could well afford to allow its patients the freedom of the enclosure, while this can manifestly not be done in a general hospital for the insane. Then again, there is the unavoidable delay attendant upon the commitment of a prisoner to an insane hospital. As I have already stated elsewhere, it is not a rare occurrence to receive patients into the hospital who have entirely recovered from their mental disorder before leaving the prison. Furthermore, the expense and danger always connected with the transfer of insane criminals from prison to hospital and back again, if the hospital is any distance from the prison, must be kept in mind.

A word to those who, from a false altruistic standpoint, insist that the insane criminal requires no different treatment from that which the ordinary insane patient does. This is very true in the case of prisoners who develop mental disorders which have no relation to crime or imprisonment. These do not require special measures of treatment. It is likewise true of the psychoses of the accidental criminal, but it is entirely different with the criminal who suffers from a degenerative prison psychosis. Here we are not dealing with individuals who tend to dement, who have little or no conception of whether they are in a prison or in a hospital. In short, we are not dealing here with paretics or senile dements, who, although being at the same time prisoners, remain subject to the same unavoidable lot of the paretic or the senile dement.

The habitual criminal who suffers from a degenerative psychosis, unless he is in a stupor, is constantly on the alert for a chance to escape. No matter how delusional or hallucinated he may be, he always manages to keep in mind that the thing which he most desires is to be free from the hands of his captors, and anyone who has had to deal with this cla.s.s will bear me out in this. The shrewdness with which they carry out their escapes is amazing, and some of the more depraved ones do not hesitate to commit serious a.s.saults in order to gain their freedom. Here, measures other than those used with the ordinary insane patient are required.

Now as to special hospitals for insane criminals which certain States have. Of course the same objections, namely, as to the delay in getting the patient under treatment and the danger of transfer, etc., hold true also here; but these hospitals, it seems to me, have the additional disadvantage that they necessitate the segregation of all insane criminals, irrespective of whether they suffer from a recoverable psychosis or from a dementing process. In other words, here we have an admixture of cases who unfortunately fell into the hands of the law because of some mental disorder and who certainly should be confined as any other patient in an ordinary hospital for the insane, and patients in whom the crime and mental disorder are expressions of the same underlying degenerative defect, and who in a great majority of instances suffer from recoverable transitory mental disorders.

To insist upon keeping a paretic all his lifetime in such an inst.i.tution is highly irrational, to say the least. The most rational, and the only scientific way, of dealing with the insane criminal is to bring about a state when the psychiatric hospital will be made accessible to him just as easily as the surgical and medical wards are, and this can only be accomplished by having psychiatric annexes in connection with prisons.

The only serious objection which can be raised against this plan is that in time the annex will be made up exclusively of a very dangerous and troublesome population, but this objection likewise applies to the special hospital for the insane criminal. Certainly it is far safer to have this cla.s.s of cases within the prison enclosure than to allow their acc.u.mulation in a general hospital for the insane.

Lastly, the psychiatric annex in the penitentiary would form the proper nucleus for the scientific study of the criminal, whence that much needed information concerning this type of man could emanate and be utilized for the rational treatment of the problem of crime.

We have thus far discussed the treatment of prison psychoses in these individuals while undergoing sentence, but what of them after the expiration of their sentences? We are now approaching the problem of recidivism.

Certain it is that society has thus far failed to deal effectually with this problem, and one need not search very deeply for the cause of this.

Society has been relying princ.i.p.ally upon its punitive methods in dealing with the habitual criminal, and so long as a given offense was punished according to a given statute it felt that it had done its duty.

The factor of the personality of the criminal was entirely neglected. In time we have come to realize that our punitive methods not only do not tend to do away with recidivism, but enhance it. It is an undeniable fact that each additional imprisonment only serves to deprave the habitual criminal more deeply, and to release him after the expiration of an arbitrary sentence is to let loose another parasite to prey upon society. Of late years, however, there has been a tendency toward individualization in criminology. "It is the criminal and not the crime that we must deal with," is the modern slogan, and starting from this point of view we have already found out some very interesting facts. We find in looking over the life histories of our habitual criminals that they had shown antisocial and abnormal traits from their earliest youth; that in their early manhood they populated the reformatories and that their recidivism is due to some underlying anomaly which always differentiates them from normal men.

In this chapter we have seen how this underlying anomaly served under certain stressful situations to give rise to mental disorder, and have concluded that crime and psychosis must be, in these individuals, branches of the same tree. If this is true the question arises whether the habitual criminal does not rather belong in a hospital than in a prison. It is a little premature to decide this at the present day, but it is unquestionably certain that it is the psychiatrist who will in time furnish us the most valuable data concerning the "criminal character." It is he who will eventually bring to light unshakable proof that in the habitual criminal we must see an anomalous human being, who stands in the same relation to normal man as disease does to health, and then, the problem of recidivism as well as that of the psychoses of criminals will be easier of solution.

REFERENCES

[1] WILMANNS: "Ueber Gefangnispsychosen." Halle a. S., 1908.

[2] BONHOEFFER: "Klinische Beitrage zur Lehre von den Degenerationspsychosen." Halle a. S., 1907.

[3] BIRNBAUM: "Zur Frage der psychogenen Krankheitsformen."

_Zeitschr. f. d. ges. Neurolog. u. Psych._ 1910.

[4] SIEFERT: "Ueber die Geistesstorungen der Strafhaft." Halle a.

S., 1907.

[5] STRANSKY: "Ueber die Dementia Praec.o.x, Streifzuge durch Klinik und Psychopathologie." Wiesbaden, 1909.

CHAPTER III

THE FORENSIC PHASE OF LITIGIOUS PARANOIA

Maudsley[1] has long ago said: "It would certainly be vastly convenient and would save a world of trouble if it were possible to draw a hard and fast line and to declare that all persons who were on one side of it must be sane and all persons who were on the other side of it must be insane. But a very little consideration will show how vain it is to attempt to make such a division. That nature makes no leaps, but pa.s.ses from one complexion to its opposite by a gradation so gentle that one shades imperceptibly into another and no one can fix positively the point of transition, is a sufficiently trite observation. Nowhere is this more true than in respect of sanity and insanity; it is unavoidable, therefore, that doubts, disputes and perplexities should arise in dealing with particular cases."

No small amount of the disrepute into which expert medical testimony has fallen is due precisely to a failure on the part of the legal profession to appreciate these truisms. To the legal mind the transition from mental well-being to mental disease is exemplified by that wholly artificial, and to the psychiatrist's mind, subsidiary question of legal certification. The law takes no cognizance of the conditions necessitating this change; it only concerns itself with the delimiting frontier, viz.:--certification. Legally, the insane has become such through the filling out and signing of certain papers and through having submitted himself to a certain prescribed legal procedure. The physician, on the other hand, because of his peculiar relations.h.i.+p to the patient, and as a result of his particular training, looks upon this legal procedure as a necessary evil and merely as typifying the conventional mode by which society settles its accounts with its diseased members. Our legal brethren fail to appreciate, furthermore, the fact that an individual may be very seriously ill mentally and urgently require hospital treatment, without, however, showing those gross disorders of conduct which go to make up the legal evidence and diagnosis of insanity. Neither do they seem to recognize the possibility of a seriously unbalanced individual making quite a normal impression, at any rate before a jury of laymen at the time of his appearance in Court. Nowhere in psychiatry is this so apt to be the case as in that form of mental disease known as paranoia, where we are dealing with a diseased personality which in many respects still approaches and resembles normal man.

The paranoiac, while he may harbor the most intricate and well-organized system of delusions, still remains approachable to us, and intellectually may be not only on a par with the average normal individual, but not infrequently gives the impression of being his superior. Nevertheless, this usually well-endowed human being at a certain point in his career goes off at a tangent and spends the rest of his life in the pursuit of a phantom. The paranoiac, starting out with vague, ill-defined ideas, succeeds in elaborating, step by step, a well-organized system of thought, of ideas which finally a.s.sume an all importance in the conduct of his life and remain unshakable.

Kraepelin[2] defines this condition as a mental disorder which is essentially characterized by a gradual and systematic evolution of a well-organized and intricate system of persecutory and grandiose delusions. It is chronic and incurable in its course and does not lead to any appreciable deterioration in the intellectual sphere. The litigious form of this disorder is particularly characterized by a persistent and unyielding tendency toward litigious pursuits. It is for this reason that this form of paranoia is of particular interest forensically. The law is the tool with which these individuals work, and the Courts their battle-grounds. The least provocation suffices to start the stone rolling, launching the unfortunate upon a career of endless litigation. As a rule the disorder originates in connection with some adverse decision or order of the authorities, which the patient considers an unjust one. Whether injustice has actually been suffered by the patient matters not and remains absolutely of no consequence as far as the course of the disease is concerned. The paranoiac litigant is unable to see the law as others see it, and in this respect he does not differ greatly from primitive man, whose conception of legality is that of a collection of concessions for himself and prohibitions for others.

To be sure, a tendency to excessive litigation is occasionally met with in what appear to be normal people. Such pursuits, however, become pathological when they are based upon a delusional interpretation of actual occurrences or upon actual delusions, and are not amenable to reason.

According to Tanzi[3] the theme underlying the delusional system of litigious paranoiacs is avarice, and the whole may be looked upon as the slow and permanent triumph of a preconception. "The paranoiacal preconception gradually conquers all evidence to the contrary, and in spite of reality, public opinion and common sense, it becomes organized into a coordinated system of errors which become the tyrants of the intellectual personality and remove it by degrees outside the bounds of normality." The litigant constantly busies himself with his grievances, loses all interest in everything else, and begins to fight for his rights. He stops at no means and is the bane of judges and court officials. Naturally, he has to be refused all aid, either because he is unjust or because the courts find no remedy for his troubles. He refuses to settle actual grievances, carries the case from one court to another and finally develops an insatiable desire to fight to the bitter end.

The statutes appear to him inadequate and even the fundamental principles of law fail him. He cannot abide by the ultimate decision after all the usual means of justice have been exhausted. In his attempts to gain justice he writes to magistrates, legislators and various other people in prominence. It is only after years of persistent misfortune both to himself and the objects of his delusions, which only serve to harden him against his fortunate opponents, his incapable lawyers, the corrupt judges and his ignorant and craven-hearted relatives, that this master of procedure is betrayed into the expression of threats or the commitment of some other offense which conveys him summarily from the civil to the criminal courts, and the unrepentant pursuer becomes the defendant, unless, indeed, the insane asylum has become his refuge. (Tanzi.)

This is precisely what happened with the patients whose histories are here recorded. With all this the paranoiac remains plausible, converses rationally and coherently, shows himself to be exceedingly well-informed on current events, amazes his listeners with his really wonderful memory and his ability to quote _ad infinitum_ from law books and statutes.

Absence of hallucinations is the rule. Memory and the capacity to acquire new knowledge remain intact, and reasoning and judgment on matters of everyday life which do not touch his more or less circ.u.mscribed delusional field may remain quite normal. In short, he shows none of those tangible signs and symptoms upon which we must so frequently rely in our efforts to convince a jury of laymen of the existence of mental disorder. It is only when we take into consideration the entire life history of a paranoiac, which unfortunately is frequently ruled out as hearsay evidence, that the real state of affairs becomes manifest. We then see that where it concerns his delusional field the paranoiac's judgment is formed, not as a result of observation, or logic and reasoning, but as a result of an emotion, a mere feeling that this or that proposition is true. In every adverse decision of the court he sees a deep-laid conspiracy to deprive him of his rights. His lawyers are incompetent and in collusion with his persecutors; the judge is corrupt or ignorant of the law, and the legislators negligent in their duties in not writing into the statutes laws which would take care of his grievance. He constantly harps upon what he calls "the principle of the thing", losing, gradually, all concern in the real issues involved.

Indeed, in watching the amount of attention a paranoiac bestows upon his grievances, the zest with which he takes up every newly discovered flaw in the law, and the dexterity with which he weaves it into the maze of his delusional system, the idea forces itself upon one's mind that what the paranoiac least desires is a settlement of his grievances. One can readily imagine the void in the unfortunate's life were he to be deprived of this all-engrossing, and to him really life-giving, _casus belli_. Thus, not infrequently, when one grievance is actually settled, another soon appears and a.s.sumes the center of the stage. The means these individuals use in their efforts to convince the authorities of the righteousness of their cause or of the genuineness of the persecutions to which they are subjected, are really amazing in their ingenuity. They are supported to a considerable extent by retrospective falsifications of memory, and when occasion arises, by a conscious distortion of facts, and prevarication, a point very justly emphasized by Bischoff.[4]

This author relates the case of a paranoiac woman who was in litigation with her father over some trifling inheritance left by her mother, and who accused her father of a murder, and insinuated that she had heard her grandfather call him a fratricide.

The reputation and character of the objects of their delusions are unsparingly attacked by the paranoiac litigant, and this not infrequently results in bringing matters to a head, where as defendant in a criminal suit for libel the paranoiac is recognized in his true light and sent to a hospital for the insane. Before, however, this final scene in the litigious career is enacted, especially where the persecuted has turned persecutor, the objects of his delusions have not infrequently suffered an untold amount of anguish and financial ruin, through having been obliged to play the part of defendants in civil suits based on nothing else but the distorted fancy of a diseased mind.

While one may readily detect the part played by avarice in the pursuits and activities of these individuals, it requires close contact with them, especially in the capacity of one who stands between them and freedom, in order to fully appreciate the degree of malevolence which they frequently exhibit. Indeed, the study of litigious paranoia, more than anything else, ill.u.s.trates how much method there may really be in madness. Were an alleged lunatic standing as a defendant in a criminal suit to use one-tenth of the amount of ingenuity and conscious direction of his symptoms that the average paranoiac uses, he would furnish the champions of the idea of malingering of mental disease with enough material to convict a dozen lunatics.

The chief aim of this paper is to ill.u.s.trate by means of two interesting case histories the forensic importance of this form of mental disorder.

It is not intended, however, to enter here into an academic discussion of the problem of paranoia. The term "Paranoia" is even pre-Hippocratic, and any attempt to indicate, even in the briefest manner, the changes which this concept has undergone throughout the ages would require considerably more s.p.a.ce than we have at our disposal. I shall, therefore, merely mention that in reviewing the history of paranoia one is unmistakably struck by the fact that those view points and ideas concerning this subject which have indelibly impressed themselves upon it occupy themselves with a study of the personality of the paranoiac rather than with the disease picture as such. Some of the investigators have gone so far as to maintain that paranoia is not a disease at all in the sense that typhoid fever is a disease or pneumonia is a disease, but that the paranoiac picture is rather the expression of an anomalous individuality and, as one author puts it, it is the evolution of a crooked stick. Sander[5] recognized this when he so admirably stated that the abnormal condition develops and unfolds itself in the same way that the normal mind unfolds itself in the normal individual.