Psychiatric Contribution to the Study of Delinquency
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The subject of delinquency is one which has attracted the attention of experts in many fields from earliest times. Of late years there has been a tendency to regard delinquency as a manifestation of abnormality if not of disease. There has' been considerable discussion as to whether criminology should not be taken from its close association with law and placed in more intimate relations with psychiatry. In the eyes of some, it is in itself a branch of science. Others regard it as merely a borderline science between law, medicine and economics.
While it is undoubtedly an encouraging fact that the attitude of the community towards delinquency is rapidly changing and is assuming more the position of sympathetic inquiry into the causes and remedies, it is none the less a fact that the law remains as of old,-sternly searching for the responsible parties.
The medical sciences are pushing on into this new and undiscovered field, and are outstripping their phlegmatic, more ponderous and cautious neighbor, the law. The social worker, battling in the wake of the medical man, is impatient at the law's delays, and is somewhat perplexed by the discrepancy between the medical point of view and the legal point of view. We are too apt to blame the law and to exalt science in this connection. As a matter of fact, we are forced to the conviction that the law will be changed the instant that science gives a definite basis for such change. The truth is that medicine, and psychiatry in particular, has not yet delimited the problem or discovered sufficient facts to warrant definitions of such precision that the law can note them.
At a meeting held during the winter of 1916, at the call of the Massachusetts State Board of Insanity, to discuss the problem of the defective delinquent, a great many of those present expressed the wish which is in the minds of all, that the term "defective delinquent" be defined. Dr. Walter E. Fernald, as one of the sponsors of the 'Being Contributions of the Mass. Commission on Mental Diseases, whole No. 173 (1916.21). The former contribution 1916.20, 162 was by Helen M. Wright, entitled "Routine Mental Tests as the Proper Basis of Practical Measures in Social Service: a first study made from 30,000 cases cared for by 27 organizations in Boston and surrounding districts. 2Assistant Professor of Psychiatry, Harvard Medical School, and formerly Chief-of-Staff, Psychopathic Hospital, Boston, Mass., Director, Psychopathic Institute, Juvenile Court, Chicago. 46 HERMAN M. ADLER defective delinquent law, Chapter 959, Acts of 1911, replied that the definition was not important because we all knew what we meant by the term "defective delinquent," in general, and that whatever the definition might be, the law recognized the classification, and that therefore it had become a legal rather than a medical problem. This represents fairly the position of nearly everyone who has to deal with this subject. We all recognize the term, and in a good many instances agree in the diagnosis. We each of us, however, have our own ideas and prejudices in regard to delinquency and nobody wants to set tip a hard and fast definition uch as would be necessary from a legal point of view. While this is an eminently scientific attitude, it has its disadvantages in that it causes disagreements among experts in passing on specific cases, and in that it confuses the judges and other officials who have to deal with the correctional side of the problems involved.
According to the definition contained in the above-mentioned law, a defective delinquent is, first, "an individual who has committed an offense not punishable by death or imprisonment for life, but who ordinarily might be committed to a state prison, a reformatory, jail, or house of correction, to the state farm or the industrial school, a truant school, or to the custody, of the State Board of Charity as mentally defective." Second, "an offender while under commitment to any of the institutions or to the Board named above, who persistently violates the regulations of the institution or the Board in whose custody the offender is, or who conducts himself or lerself so indecently, or immorally, or otherwise so grossly misbehaves as to render himself or herself an unfit subject for retention in said institution or said Board, and who is mentally defective."
The two points in this definition are, in the first place, that the individual is found mentally defective, and, in the second place, that he persistently violates regulations or conducts himself in some unusually offensive manner. Under this law, of course, great latitude is given to the physicians who certify to the diagnosis, in that it is not definitely stated just what constitutes mental defectiveness. In the second place, the element of. delinquency is not fairly defined since a persistent violation of the regulations of the institutions is made sufficient for the diagnogis. While, no doubt, this allows of sufficient liberality in interpreting the law, and in this respect is wise, it is not sufficiently definite in delimiting the classification so that in case of a difference of personal opinion it would be very hard to decide which contestant was right. A PSYCHIATRIC CONTRIBUTION 47 The element of defectiveness usually is interpreted on the basis of some set of intelligence tests, such as the Binet Simon, the Yerkes Bridges, or the Terman scale. Granting, for the moment, that it is possible by means of these tests to determine mental defect accurately, it is the experience of everybody that a group remains that are proved not defective by these scales, who nevertheless present the same problems in regard to delinquencies that are observed in the frankly feeble-minded. According to the defective delinquent law, as proposed, a certain amount of re-classification in the different institutions would be possible and disturbing individuals might be sent to a place especially provided for them instead of being mixed with the more tractable inmates of the schools for the feeble-minded, the state hospitals, and so forth. No provision is made by this act for the group that are proved not defective by intelligence tests and who none the less show in many ways that they are not fully .endowed. In England, August, 1913, a law was passed which is commonly known as the "Mental Deficiency Act of 1913," and which became operative on the first of April, 1914. This act deals not only with defectives in the common understanding of the word, but also with the individual who is not defective or not insane, but, none the less, subnormal. The law, as it stands, begins with a definition of defectives which are divided into four classes: 1. "Idiots, that is to say persons so deeply defective in mind from birth or from an early age as to be unable to guard themselves against common physical dangers. 2. Imbeciles, that is to say persons in whose case there exists from birth or from an early age mental defectiveness not amounting to idiocy, yet so pronounced that they are incapable of managing themselves or their affairs, or in the case of children, of being taught to do so. 3. Feeble-minded persons, that is to say persons in whpse cases there exists from birth or from an early age mental defectiveness not amounting to imbecility, yet so pronounced that they require care, supervision and control for their own protection or for the protection of others, or in the case of children, that they by reason of such defectiveness appear to be permanently incapable of receiving proper benefit from the instruction in ordinary schools. 4. Moral Imbeciles, that is to say, persons who from an early age display some permanent mental defect coupled with strong vicious HERMAN M. ADLER or criminal propensites, on which punishment has had little or no deterrent effect." The main contribution of this law seems to be that its definitions are sufficiently accurate for ordinary purposes, and yet make adequate allowance for the special needs of individual cases. Particularly useful is the definition of moral imbeciles, though the term is open to discussion, which calls for "strong vicious or criminalt propensities, upon which punishment has had little or no deterrent effect." It is not possible to say anything in regard to the workings of the English law, since it went into force only a few months before the outbreak of the European war. It would be interesting to know how the term "mental defect" is interpreted in the application of this law, and whether the certifying physicians will require a failure to pass the Binet-Simon tests in order to allow the diagnosis of "permanent mental defect." Kraepelin, in the 8th edition, of his "Psychiatrie," introduces the term "oligbphrenia" for the English "feeble-minded." He says in discussing this group, that this is an extremely varied group of disease forms showing only a single common characteristic, namely, "early disturbances of the general physic development." Kraepelin considers that these defects are caused generally by a pathological lesion affecting in some way the physical foundations. He recognizes the cause of all defects in spite of many difficulties, as trifold, namely, hereditary degeneration, an injury to the germ plasm, and acquired disease. It is interesting to observe that in the same volume Kraepelin .groups the so-called moral insanity under Psychopathic Personality, and not under the oligophrenias. The main distinction lies in this point, that psychopathic personalities, which include the groups to be mentioned below, are characterized by circumscribed defect of psychic development. This contrasts psychopathic personality with oligophrenia, in that the former is a circumscribed infantilism, whereas the latter is a general or diffuse infantilism. Kraepelin classifies the psychopathic personalities as follows: 1. EXCITABILITY (Die Erregbaren-K PEeELiN). The chief characteristic of this class is that the individuals are, as a rule, brought to the attention of the physician or to the courts as a consequence of a violent excitement, which was the result of external irritation. Usually, this excitement has resulted in actions which have endangered the life and health of the patient himself or of strangers or in some way endangered the pubic safety. After the disappearance A PSYCHIATRIC CONTRIBUTION 49 of the excitement, as a result of the protection and treatment of the psychiatric clinic, opportunity is given to the physicians to get an insight into the personal peculiarities of the patient. The intelligence of these individuals is, as a rule, above the average. The most prominent characteristic was naturally a strong emotional instability. Patients are easily enraged, start a brawl on trivial grounds, fall into the most violent passions with assaults upon themselves or their surroundings. The most important clues to the personalities of these individuals are rendered by the knowledge of the causes which lead to their being brought to the clinic. In 62 per cent of Kraepelin's cases, this cause was attempted suicide; 71 per cent of the women admitted were brought on that account, only 50 per cent of the men. The most frequent causes for the suicidal attempts among the men were disagreements with the wife or sweetheart, unhappy love affairs, unfaithfulness, anger and contentiousness. More rarely, the cause was unemployment, reproaches or charges, threatened punishment; occasional causes, because of the death of a child or of a sweetheart, financial difficulties of various sorts. In a number of cases the suicidal attempt was made in a state of intoxication. Also the contentiousness, unemployment, punishment, etc., were frequently associated with alcoholic indulgencies. The causes in the women were mainly disagreements with relatives, with employers, or neighbors, disagreements with husband or sweetheart, unfaithfulness, jealousy, and so forth. In occasional cases there were criminal charges, a fear of punishment, fear of operation, the death of a relative, illness of the sweetheart, financial difficulty of various sorts. Very frequently these attempted suicides are associated with marked histrionic characteristics. The patient attempts to commit suicide by choking herself with the hands. The patient makes minor scratches on the skin with a knife. They write touching farewell let- •ters or meet the slightest occasion with threats of suicide. As a rule, they quickly calm down and are nearly always glad that the attempt failed. Usually they characterize their attempted suicide as "nonsense," "stupidity," even laugh over it, and declare that they will be very careful in the future not to repeat it. Next to the suicidal attempts the most frequent causes for bringing patients to the hospital were paroxysms of rage, assaults and so on. In this class the male sex predominates. In the paroxysms of rage, the patient may attempt to injure himself or he breaks up the furniture in- the surroundings, threatens the children or the members 50 HERMAN M. ADLER of the family with revolvers, knives, clubs, chairs, and so forth. Very striking is often the minor nature of the existing cause which produces these unmeasured excesses. A simple correction, the denial of a small wish, a little gossip, an unwelcome order of the physician in the hospital, the mere taking of a patient to the place of detention, suffices to evoke a paroxism of rage which increases in severity as the forms of expression take on a violent nature. Alcohol is here again often a factor which the patient may have taken previolisly to drown his sorrows or to strengthen his courage. Consciousness is frequently clouded during these paroxisms. This period of excitement lasts a very short time, rarely lasting longer than a few hours. As soon as the patient has spent himself or has been removed from his environment, composure and clear consciousness rapidly return. As a rule, they are still somewhat irritable, will not eat, give information, but soon they adjust themselves to the situation, and attempt to re-establish their relations with the outer world. The recollection of the incidents is often somewhat unclear. Some patients refuse to believe the details that are told them, they attempt to put their conduct in the best light, place blame on the environment, on the relatives, and so forth. The prognosis is on the whole favorable. Occasionally, the attempt at suicide succeeds. Many patients suffer seriously from the results of the acts of violence or from excessive use of alcoholics. The attacks of excitement may recur frequently according to the temperament and the social conditions of the patient, but, as a rule, the tendency to these attacks diminishes from the end of the 20's. A third of Kraepelin's psychopathic cases belong to this group of excitable ones. Sixty per cent of these were female. The greatest number of the cases belonged to the years betweer 15 and 25. After the 40th and, still more, after the 50th year, there is a rapid decline of the number of cases. The majority of the patients were single. Kraepelin goes on to discuss the relations of this form of psychopathic personality to manic depressive insanity on the one hand, and psychoneurosis on the other. A characteristic of this class is the failure of the self-control in the face of very strong emotional influences. The excitement, however, is associated with definite external causes which passes off after a short period. Between the episodes the patient may appear quite peaceful and sociable till some particular occasion evokes a loss of temper, but, even then, when they are very contentious, they may be calmed. They do n6t show the A PSYCHIATRIC CONTRIBUTION persistent spitefulness which marks permanently as a foe anyone who has seriously incurred their displeasure. 2. INSTABILITY (Haltlose). The second group of psychopathic personality is characterized by the suggestibility of the will which controls the entire life course. The intelligence in most cases is good, in a fewer number it is below the average, or even poor. Some even appear to be above the average. They are usually good observers, have insight into the weakness and peculiarities of their entourage. They know how to display their talents. They have very little perseverance, and no inclination to exert themselves. They are absent minded, easily fatigued, and diverted, and therefore very rarely can follow a systematic educational course to its conclusion. They are very superficial. They easily acquire knowledge, but do not apply it in any way, and soon forget it. Memory is usually poor and untrustworthy. These patients show a remarkably active imagination. They tend- to exaggerate, to embroider their narratives, to picture themselves in ideal situations, to invent stories. They imagine they are wealthy, belong to the nobility and so forth. They buy things on credit at stores under false representations. Often they seem to have no realization of the truth. One patient thought that he hypnotized himself. Of another it was said "he lies even when one is watching him." Many patients show artistic talents. They develop ideas for moving picture scenarios, write sentimental or fantastic poems, occupy themselves with the literary and dramatic problems, read a great deal-papers, books, poetry, 'and so on. One incorrigible tramp declared that what he demanded of life above all was the intellectual luxuries which he had so long gone without. The theater, as a rule, exerts a great attraction for' these people. Some of the patients were actors or comedians, some were musicians that sang and played in restaurants. The fundamental emotional tone often seems to be one of cheerfulness and self-confidence. The patients feel that they are destined to do great things. They want to do something better than the average. In other cases, however, the mood is depressed or at least more sober. The patients feel that they are unlucky. They have doubts as to their future. They worry about their condition in life, complain that their life is a failure, they have no luck, they are lonely and forsaken. Nothing pleases them, everything appears hard, they have no friends. They frequently threaten suicide and even plan it, rarely, however, find the courage to carry it out. As a rule, one can easily distract and HERMAN M. ADLER cheer up these patients. In general the emotional tone, is subject to marked variations. There is great emotional irritability, which may result in violent loss of temper. An important characteristic of the conduct of these patients is their pronounced selfishness. They are, as a rule, good-natured, approachable, and even amiable, but without any deeper attachment or fellow feeling. Their personal welfare plays the most important role in their consciousness. They are not inclined to subject themselves voluntarily to privations. On the contrary, they demand comforts and the satisfaction of their often very immodest requirements, and interpret every limitation as an undeserved insult. They are very pleasure-loving. The most severe disturbances, however, are in the region of the will. This shows itself often most markedly when the patient leaves the protection of his home. It resuits, in the first place, in a very apparent lack of perserverence and thoroughness in work. They usually begin to work with great enthusiasm, but soon lose interest, become distracted, and absent-minded, and commit gross errors and negligence. One says of such a patient "he was very useful when he wanted to be." "A painter made only sketches without ever finishing a picture." The patients may also suffer from hypochondriacal troubles, which interfere with their self-support. These patients are very much worried about their health, easily feel ill, perspire freely, have headaches, extreme prostration after they are beginning to work. This instability becomes a very serious portent for the patients. They lose their positions. Under suitable gaurdianship they are able to live a life free from grosser disturbances, although they are, on the whole, weak and inadequate in their work. They fill in their spare time with loafing, with recreation without previous fatigue, with cures without sickness, and so on. They are, further, extremely open to bad influences, and are ever ready to descend into bad company. They soon get involved in gambling, fast living, and so forth. A very bad influence in this condition. is exerted by ilcohol. Of Kraepelin's male patients, 64 per cent became alcoholic, of the females 20 per cent. The alcohol increases their irritability, reduces still further their weak will, and destroys often the last remnant of ability to work. Occasionally the picture of pseudo-dipsomania is developed. The patient will be sober for months, and then, on an occasion when his weak will is overpowered, will commence to drink inordinately, and will not stop till he is profoundly intoxicated or his means gives out. In this case, it is not a repression which drives the patient to alcohol, but a perfectly A PSYCHIATRIC CONTRIBUTION 53 accidental occasion such as the meeting of a friend or a farewell feast or the like. Therefore one cannot speak of a periodic relapse in these cases. On the contrary, it is external circumstances which are the decisive factors. Furthermore, the patient does not become excited as a result of alcohol, but merely intokicated. An important place in the life of these patients also is sex. These people are usually sexually very active, and under the influence of their emotions, strengthened by alcohol, are guilty of the most shameless excesses. The inability of these patients to resist temptations from without induces the patients to live far beyond their means. They acquire expensive habits, drink champagne, buy unnecessary articles, treat their friends, give magnificent presents to women, and so on. They soon get into financial difficulties, sell or pawn their own or other people's valuables, and thoughtlessly make debts. A large prcentage of these patients-54 per cent of the men, and perhaps 33 per cent of the women-become involved in difficulties with the law in the course of their gradual downward career. In the case of the men, the delinquencies are usually theft. Next in frequency, swindling and forgery. In other words, these are delinquencies which are favored by want and opportunity. Considerably rarer are begging and assault, vagabondage and counterfeiting and so forth. One sees, however, that the criminology of these patients is brought out by their economic incapacities. The principal delinquency in the case of women is prostitution. Almost as frequent, however, is theft, then again swindling. The influence of alcohol can be recognized in all these instances in addition to the social and economic deterioration. The patients themselves are aware of this gradual demoralization. Occasionally, it is true, they assume the attitude of indifference, make no attempt to pull themselves out of the difficulty. As a rule, however, they sense, at least occasionally, the true significance of their condition and evince regret or they repent, and make good resolutions for the future. They may even make an attempt at carrying out these resolutions, but soon give it up and succumb to the first accidental temptation. Very frequently, these patients decide on suicide. A close examination of these attempts shows that the occasion for the suicide was of trival character. A large number of those took place under the influence of alcohol. The method employed in most of these cases is, strange to say, the same in men and women, namely, poison, probably because in this case, we are dealing with individuals with weak will who are disinclined to action. Most of these attempts are carried out in a 54 HERMAN M. ADLER superficial, inadequate, often silly manner, and are usually not successful. A certain group of these cases, especially in women, show some of the symptoms of hysteria. Physically, these patients show a tremor, stigmata of degeneration, increased reflexes, headaches, insomnia, gastric neuroses, and so forth. In another series of cases, an increased sensitiveness to alcohol is noted. The prognosis is rather serious. It is this group which furnishes the members of the so-called asocial group-tramps, criminals, and prostitutes. Under careful guardianship and strict discipline, the easily influenced will may be protected from evil influence. As soon as these patients are left to themselves, h6wever, their ominous tendencies easily gain the mastery, and start the individual on the downward path. Alcoholism which soon becomes incurable, as a rule, seals their fate. This group of cases forms a little, more than one-fifth of the psychopathic iases admitted to the Kraepelin clinic. In this case, the women form a little more than a third in contra-distinction to the excitable ones. In regard to the age of onset of this trouble, the men and the women differ somewhat. The women reach the highest number immediately after leaving the protection of the family or the school, that is between the 15th and the 20th year. From then on, there is a constant diminution, which makes the female sex, practically, disappear from the table, after the 30th to 35th year. This may be due to the fact that most of the permanently deteriorated individuals gradually succumb to prostitution or the minor crimes. Also those that do manage to marry or otherwise find maintenance, are sufficiently protected to prevent the most serious difficulties. The male patients show smaller numbers than the females between the 15th and 20th year. After that, however, the number remains larger than that of the women and reaches its maximum 'between the 25th and the 30th year. It shows principally that there are causes at work which even after the full growth has been attained, tend to weaken the will and self control. There is another factor, however, which counteracts the natural maturity and which increases 'the number of those that have gotten into difficulties on account of their instability, namely, alcohol. Here again it seems that this is a difficulty experienced mostly by unmarried individuals. Little can be said in the case of both of these groups as regards the heredity element-the material at hand being insufficient to draw conclusions. The picture just drawn, thus makes it clear that we are dealing A PSYCHIATRIC CONTRIBUTION 55 with the manifestations of a psychic immaturity. It would seem that a true treatment is excluded from the beginning. The possibilities of education and training depend entirely upon the severity of the disturbance in the individual cases. Of course, the most important thing is to protect them from alcohol. This is extremely difficult under the existing conditions. 3. PSYCHOPATHIC TREND (Triebmenschen). This is a tentative group of psychopathic personalities which have the common characteristic that their conduct is controlled by spasmodic will impulses. Whereas the resolutions of a healthy person especially those which have a broad significance, result from balancing reasons and counter reasons, in these cases one finds a very large proportion of the will impulses originates in tendencies which bob up from the 'unconscious or the subconscious and which press for outlet. Again, the intelligence of these patients is as a rule good, though occasionally not good, but in some instances even excellent. There may be even talents or aesthetic appreciation of music, theatre, and so forth. Most of these patients show a certain 'amount of intellectual activity and artisticness, converse well, have good ideas, express themselves skilfully, are good at repartee, make witty remarks. Sometimes they complain of distractibility and increased fatiguability. These patients have almost regularly a very good opinion of themselves. They are very vain, arrogant, think that they are born to a better sphere than they find themselves in, are special people, are sure of a great future, are boastful and so forth. They are not particular about the truth. They have from early youth a decided tendency to embroider their remarks, to invent, to lie. They often are not conscious of the tendency to this falsification of actualities. Emotionally, these patients are good-natured, sociable, and cheerful. Some are ecstatic, others opinionated, some inconsiderate of others, arrogant and contentious, and present great difficulties to their teachers. On the whole, they appear optimistic and self-confident, but frequently this is subject to marked variations. Occasionally one finds these patients in a depressed or unhappy frame of mind, even in despair. At other times they are irritable, sulky, sensitive, easily wounded, complaining. A large number of these patients express their dissatisfaction with life by means of true suicidal attempts. There are frequent outbursts of temper. Very frequently from time to time there are emotional depressions without any adequate cause. During these the patients become reserved, are silent and feel disgusted 56 HERMAN M. ADLER .about everything. It is just these depressions which form the starting point for all sorts of impulsive acts. Occasionally one observes here -also instances of groundless fear. The most severe disturbances are noted in the actions and conduct. These are influenced in the highest degree by the spasmodic will impulses which throw overboard all sensible intentions and plans. plans. There are three principal forms of these impulsive ones: the profligate, the truant, and the periodical drinker. It is possible that there are a series of other forms of psychopathic personality that belong here. In the first subgroup, that of the profligate, the most marked characteristic is the strong tendency to unlimited squandering. The natural result of the sort of life. these people lead is an accumulation .of enormous debts. A very unfavorable influence on the fate of these patients is exerted by lack of perserverance. They can endure nothing very long, they change their positions or their occupation, often without any cause, wander restlessly from one place to another, make plans upon plans without actually carrying them out. Th6 patients as a rule show little insight into the peculiarities .of their conduct. They do not understand how they could have done these things, or they blame their relatives, neighbors, and so forth. Again alcohol plays an important role in these cases. The second group of these patients shows the instability principally in its tendency to aimless wandering. In one group of cases, the impulse to go away appears quite without warning. The patient suddenly gets an idea he must go to Trieste, Hamburg, Vienna, Paris, occasionally in connection with some pathological depression or anger. Sometimes the accidental possession of a large sum of money may be the cause of this. As soon as they feel the impulse, they proceed to act. The patients disappear, wander and travel about, here, there and everywhere, according to their whim. At times they are weeks and months in foreign lands. These impulses recur sooner or later, often within a few weeks or months. The patient is at no time able to resist these impulses. The age at which this occurs most frequently is .between the 10th and 15th year. It has been observed in the third year.3 This occurs chiefly in the male sex. This group, however, is not a uniform one. Aside from the epileptic and hysterical cases there are a number of individuals who wander because of their lack of family sense, their desire for adventure and so forth. 3Stier, Wandertrieb und pathologisches Fortlaufen bei Kindern, 1913. A PSYCHIATRIC CONTRIBUTION There is a subgroup of cases here in which the unquenchable desire to wander into the world becomes a permanent personal peculiarity. These patients nowhere find rest, and they form the tramp type that is known in all countries. There is a group known as "Orientkunden," Orient tramps. These are people who are attracted to the Orient on account of the ease with which they are able to live there without steady employment, and the freedom from closer supervision of the Western civilization. These people find it difficult, if not impossible, ever to return to the well-regulated conditions of European civilization. The third group under this heading includes individuals who periodically consume enormous quantities of alcohol. This attack apparently is in close connection with depressions which appear without any apparent cause. The patients are irritable, disgusted with their lives, with their surroundings, feel compelled to do anything that will free them from this state of mind. They disappear, wander about, and start to drink inordinately. -Occasionally such a patient may come to the hospital in order to forestall the excesses. In the interval between the attacks the patients are usually very sober and temperate. Frequently, however, they finally become chronic alcoholics. Usually they show a number of other psychopathic traitsmoodiness, lack of endurance, and -so forth. Since these patients usually have average intelligence, they may have good insight into their short comings. This group of impulsive individuals included about two or three per cent of the psychopathic subjects entering the Munich clinic. Practically all were men. The main characteristic of these psychopathic Conditions lies in the overpowering of the normally regulated will and intelligence by spasmodic impulses. In co-operation of the various tendencies that strengthen the will, those attain unusual power which arise in the general moods and vital desires of the individual as opposed to those guiding and inhibiting impulses which ordinarily control them and which are the result of training and experience. One of the fundamental dispositions which give rise to impulsive tendencies is above all the desire to dominate in a purely external fashion. A direct'result of this is the tendency to boast, to lie, to squander money, in so far as an impression is made thereby. The second important vital demand is a life of pleasure. Somewhat harder to explain is the restlessness which underlies the tendency towards vagrancy and dipsomania. Even normal healthy people are familiar with the desire to change their environment after a period of routine and confining duties. Probably a good part of the attraction 58 HERMAN M. ADLER of novelty depends upon the stimulus towards new thoughts and actions and freedom from tiresome routine. Thus one might speak, as the fundamental cause of the restlessness of the individuals, of a sort of demand for liberty. It seems that this may be the same instinct which causes animals to wander about, and which makes captivity so unbearable to the wild animals This has been overcome by laborious domestication, and in man by the development of the social sense. 4. THE ECCENTRICS. A small group of psychopaths whose clinical definition is still very doubtful is the group of eccentrics. They include the pathological liar and SWindler (the "pseudologica phantastica" of Delbrfick), which is characterized in the main by an increased mobility of the fantasy and irregularity and aimlessness of the will. 5. THE ANTI-SOCIAL INDIVIDUALS. The anti-social individuals are included in a group that has adequate intelligence, but has a certain dullness of perception in regard in social customs. They are disinclined to work, are lazy, untruthful, irritable, vain, self-satisfied, and most important of all, are incapable of any deep emotion. Another important accompaniment in these states is a lack of sympathy for others. The sexual desires of these people are awakened early and lead to all kinds of delinquencies. Petty larceny is a frequent accompaniment. Of very serious import to these patients is the tendency to the recurrence of their delinquencies, in spite of warnings and unpleasant experiences. The prognosis in these cases is doubtful, but by no means always unfavorable. A very significant experience with them is that a number of criminals of this group later on developed mental disease, which ended in marked deterioration-especially prominent in these cases was the paranoid form of dementia praecox. The greatest number of these people were unmarried, and about one-fifth were alcoholics. A further number of cases showed active syphilis. Most of these people showed various stigmata of degeneration, cranial deformities, squinting, speech defect, and so forth. Kraepelin proceeds to discuss the relation of the milieu or outer environment to the formation of anti-social-personality, and comes to the conclusion that while it has unquestionably some effect, it is not clear that this need necessarily be an important one, since heredity can always be shown to play a role in these cases. It is impossible in the present state of science, according to Kraepelin, to answer all the questions that have been raised in this connection. One thing may be A PSYCHIATRIC CONTRIBUTION 59 deduced, and that is that this inability to adapt oneself to the demands of human society is the result of an impoverished emotional life. This congenial lack of proper emotional reactions is generally called moral insanity (Prichard, 1835), or the "folie raisonant" of the French. The treatment of these patients must begin so far as possible in early childhood by means of education. Prolonged good effedts can be hoped for only in those cases in which no pronounced criminal tendencies exist. 6. CONTENTIOUS INDIVIDUALS. The intelligence of the contentious individuals is usually moderate though not subnormal. There is an increased emotional irritability and increased egoism. This also is an unclear group, midway between one of the previously mentioned ones and the Querulantenwahr (litigation psychosis). So much for the classification and description of this class of cases as given by Kraepelin. It is clear that we are dealing with a group of individuals who are so nearly normal that it is only in the course of years and by the effect of cumulative evidence that they appear in any way different from the average. There are two main factors to be considered. The one is the intelligence of the individual, his ability consciously and logically to direct his conduct. The other is the emotions. Whatever the peculiarities of the individual, whatever his special experiences in the main, these two factors can be distinguished in his activities. The former is commonly supposed to be the highest attribute of the mind, to have been acquired at a late stage in the development of the species. The latter is of fundamental significance for the organism, and has developed out of the instincts. Both factors exist in every individual and practically never operate independently. In health, the two are well integrated. The emotional impulses, the temperamental tendencies, or, to use the word of the biologist, the tropisms, exert often opposing tendencies towards each other and towards the guiding intelligence There is therefore a very marked distinction between the action of the tropism and that of the intelligence, namely, that the former exercises an episodic effect, whereas the latter is more or less continuous. William James says that "bodily changes follow directly the perception of the exciting fact, and our feeling of the same changes as they occur is the emotion." "Objects excite bodily changes-the 60 HERMAN M. ADLER changes ,are so indefinitely numerous and subtle that the entire organism may be called a sounding board." "Every one of the bodily changes, whatsoever it be, is felt acutely or obscurely the moment it occurs." "If we fancy some strong emotion, and then try to abstract from our consciousness of it all feelings of its bodily symptoms, we find ourselves with nothing left behind." 4 Cannon has recently brought supporting evidence for this theory in his work in connection between the internal secretions-and emotions of pain, hunger, fear and rage.' Granting then that the emotions are transitory and intense, that they are associated with strong physical effects which are felt by the individual, that they create corresponding memories and thus lead easily to habits of many sorts, it would seem that in the analysis of individuals, normal or pathological, a consideration of these factors must come first. It is manifestly impossible to-analyze human nature at all adequately in the present state of our knowledge. It also seems probable that many generations of men must pass before this can be done with such a degree of accuracy that scientific prediction may be possible. This is a situation not unfamiliar to other branches of medicine. Some analogies pertinent to the present inquiry may be made with the study of immunity. Some twenty years ago, the immunologists found themselves confronted with a very similar dilemma. When Ehrlich first proposed his side-chain theory, he suggested that it might be a long time before chemistry would be able to explain the phenomena of immunization as evidently must be done if we are to have an accurate, scientific knowledge of the subject. Assuming symbols for unknown chemical entities, Ehrlich and his school worked out a complex system of immun6logy which has served its purpose most satisfactorily and has advanced the knowledge of the subject beyond all hopes, although in the meantime, chemistry has done very little to increase our definite knowledge of the specific substances involved in these reactions. Similarly, it will take the psychologists, the neuro-pathologists, and the physiologists a long time to work out accurate explanations of the recognized phenomena. The painstaking psychological analysis of the individual cases by time-consuming methods is thus placed in a position similar to chemical analysis of immune bodies. Upon improvement along these well-organized lines depends probably the future 4 ames, Psychology, Vol. 2, p. 446. 5 Cannon, Walter B., The Emotions of Pain, Hunger, Fear and Rage. A PSYCHIATRIC CONTRIBUTION 61 of this field as well as every other biological problem. In the meantime, we need methods which will enable us to deal with the increasing numbers of subjects that come under our professional -care, or that perplex the law courts and the schools. In this sense, I propose to classify the individuals that present mental or social difficulties in three groups. These groups are understood to be meant as symbols for unknown quantities rather than as explanations or precise definitions. The three groups are, in the first place, the group in which the intelligence is found to be below the lowest normal level. This is called the group of defectives, or the inadequate. Into this group fall the -feeble-minded, the "Oligophrenias" of Kraepelin, the end stages of dementia praecox, and of other deteriorating psychoses; of presenile, organic dementia, and so forth. The next group, emotionally unstable, includes individuals who have average intelligence or better, but who show in their conduct and in their careers the predominating influence of the emotions. They are moody, changeable, impulsive, and in general it may be said that their conduct itself does not correspond to their beliefs, or intentions. The third group, the paranoid, includes individuals of average , intelligence or better in whose careers the 'emotional influences are of secondary importance, but whose main difficulties are a result of mistakes in logical thought processes. The well-known characteristics which are exhibited in extreme form by the paranoid psychoses, these individuals show often to a degree which falls just short of a delusional state, egocentric ideas, and prejudices. Everything that occurs about them is referred to themselves. Their first reaction is to determine what effect any extraneous circumstance may have upon themselves. They are selfish, vain and arrogant. If they feel in optimistic mood, they are contemptuous of others. If depressed, they are resentful. Though this is a trait of the intellect, it does not necessarily interfere with thei intellectual abilities, and these people are often very efficient. These three groups can be separated only theoretically. There are many cases that are composite, so that their characteristics fall into two or into all of these groups. Thus, few paranoid individuals go through life without strong emotional reactions which often lead to social difficulties. Similarly, the emotionally unstable will, especially during paroxysms of rage or depression, often exhibit paranoid symptons. The defective group may show paranoid tendencies and 'emotional instability. 62 HERMAN M. ADLER The distinction lies rather in the behaviour of the individual as observed in the course of years than in- a definite quantitative difference to be observed at a single examination. The introspective psychologist will attempt to determine in each individual by psychoanalysis or other means what the mechanism of the disturbance is. He may succeed in doing this, and still be unable to predict the future course of the individual. The behaviourist psychologist will nof lay too much weight on the results of a single examination by whatever method, but will lay more emphasis upon the history of the case, and the previous experiences of the individual and, above all, upon the reaction of the individual-to certain test situations during a period of observation. This behaviourist method offers the hope of a short cut in dealing with these individuals. An examination of a hundred cases of unemployment made at the Psychopathic Hospital gave the following interesting results. These one hundred unselected cases consisted of men between the ages of 25 and 55, who had been admitted to the Psychopathic Hospital in the usual way for examination as to sanity or for treatment, and the following observations were -made: Of these one hundred cases, forty-three were classified as paranoid, thirty-five as defective, twenty-two as emotionally unstable. The paranoid and the defective groups, therefore, form 78 per cent of the cases which fits well With the generalization that the emotionally unstable on the whole are well liked and popular with their fellows, that the paranoid cases, on the other hand, 1are usually very unpopular. The number of different jobs held by the individuals arranged in groups are as follows: The total number of jobs of these hundred men were two hundred and seventy-eight during the five years previous to admission. Of these, the paranoid individuals had one hundred and thirty-four, or an average of 3.1 jobs per patient. The defective had ninety-five, an average of 2.7 jobs. The emotionally unstable had forty-nine jobs, an average of 2.2. This shows that the paranoid individuals changed their employment oftener, almost twice as often, as the emotionally unstable. The months employed showed the same relation. Paranoid individuals averaged 20.6 months for each job. The defective averaged 24.3 months, while the emotionally unstable averaged 50 months for each job. 6 Journal of Mental Hygiene, Vol. I, No. 1, January 1917. A PSYCHIATRIC CONTRIBUTION 63 It will be seen from this, as well as from the descriptions given by Kraepelin, which are corroborated by most of those who have had experience with the social problems connected with mental disease, that there is one important difference between the careers of these people and those of average healthy persons. This is, namely, an apparent inability of the delinquent to learn by experience. This fact is taken note of particularly in the English mental deficiency law, and seems an important point to consider in every case. When Ehrlich devised his side-chain theory, he borrowed a generalization from Weigert. The latter had observed in his pathological studies that when the body is injured in such a way that complete disintegration does not result, the reaction is an over-production of defense by repair. Thus, a fractured bone, when it knits, will produce a union which is stronger than the original bone on account of an increase of callous formation. The same is true in the repair of other tissues. Ehrlich made use of this law which he called Weigert's law, in explaining the reaction of immunity thus: If toxic substances are introduced into the organism in amounts not sufficient to kill, the individual reacts by an over-production of defenses, in other words, by becoming immune. One might apply this to the formation of habits-good or badto the acquisition of emotional control in delinquents. If the individual is exposed to conditions which are not enough to disable him permanently, he should react by an over-production of defenses.. This is implied by the popular proverb, "The burnt child dreads the fire." The defective delinquent in this sense might be termed a burnt child that does not dread the fire: the mere burning with all its unpleasant experiences is not sufficient to create the defense habits which will prevent its recurrence. The thresholds for these reactions must lie at different levels in different individuals. This is a point for analysis in each case. Undoubtedly, there are individuals so far deviated from the average, that practically no amount of experience, even under the most careful guidance, will produce resistance. For the purpose of testing some of these deductions 'a second series of one hundred unselected cases was gathered. These cases were taken in the order of their admission to the hospital, excepting only those that presented no definite social problem. They included both men and women. In each of these cases a thorough mental and physical examination was made, and a psychological examination to 64 HERMAN M. ADLER determine feeble-mindedness, -and a more or less thorough social examination to determine their difficulties in the community. While all of these one hundred cases had been investigated by the social service department, it was not possible to obtain sufficient information about all of them to enable us to classify in the above manner each case studied. There was, however, sufficient information at hand to enable us to classify forty-five of these one hundred cases as follows: Sixteen as inadequate, three as unstable, thirteen as paranoid, and eight as mixed. The unstable group, unfortunately, turns out to be too small to be of much use, and the different combinations in the mixed form are too varied to allow of any correlations. Contrasting the inadequate group with the paranoid group, we find seventeen cases of delinquency in the former and thirty-nine in the latter, or an average of one delinquency to each individual of the inadequate group as compared with three delinquencies to each individual of the paranoid group. The social difficulties of the inadequate group are scattered through a series of delinquencies such as alcohol, sex, lying, swindling, contentiousness, emotional outbursts, and suicidal attempts. In the paranoid group contentiousness and attempted suicides make up- one-half of the social difficulties. An attempt was also made to gain some information as to the careers of the individuals in regard to the three points: (1) Whether the social condition had improved, (2) whether it had remained the same, (3) whether it had become worse. The inadequacy group were fairly evenly divided in these three respects. Six cases had improved socially, three had remained the same, and seven had" 'become worse. In the paranoid group, four had improved, two had remained the same, and seven had become worse. It is, of-course, quite obvious from this statement that these figures cannot-be taken as more than an indication of what a study of this sort if carried consistently through a number of years might show. None the less, while merely straws indicating which way the wind blows,, they are sufficiently suggestive to justify the conclusion that in the psychiatric analysis of delinquency, the emphasis should not be placed upon the delinquency, but upon the delinquent. On account of the attitude that the law takes in this regard, delinquents are classified usually without much thought according to their delinquencies. If this analysis does nothing more, it at least serves to show that such a classification is not only of no use to one A PSYCHIATRIC CONTRIBUTION 65 interested in the therapeutics of this problem, but that it is based upon false assumptions.- The dramatization of a social incident which might have far reaching influence upon the future career of an individual is of great human interest, but after all, of minor psychiatric importance. A person who, in a fit of rage picks up an object and hurls it at another, might find himself merely jeered at by his neighbors if the missile falls short, or may be subjected to a fine in court for breaking a plate glass window, or he may find himself charged with manslaughter or attempted homicide. Each of these criminal charges has an entirely different importance in the eyes of the law. To the psychiatrist they are the results of the same cause. If such an individual is to be classified by his delinquency he might find himself at one time a disturber of the peace, at another time a murderer. Furthermore, just as the individual might commit different sorts of crime, so the same crime might be committed by individuals belonging to entirely different types. It is important, therefore, to be as objective as possible towards what I have above called the dramatization of the incident, to what the newspaper men would call the "news value" of the story, in short, to all those sides of the incident which we have been taught to appreciate by writers of literature and to lay emphasis not so much upon what act was done as upon what sort of act was done. In every given case of delinquency or social difficulty it should be determined whether the difficulty is chiefly due to inadequate intelligence, to emotional instability or to paranoid disposition. Nothing can be gained by endeavoring to increase the intelligence of a mental defective. Nothing can be expected from an attempt to change the personality of the paranoid individual. A great deal can be accomplished, however, in controlling the emotional instability of those whose chief difficulty is the result of such instability, as well as the emotional difficulties of the paranoid and defective group. Classification such as the one suggested in this communication is, of course, entirely too simple to completely satisfy all the demands in the individual cases, and it is to be hoped that this classification may be altered and amplified, or perhaps completely reconstructed till finally a working method may result, but even now, without general information of the subject, such a simple scheme as this one proposed, has served not only to keep the ideas of the examiner grouped in orderly fashion, 'and thus to prevent disorderly and unclear thinking on his 66 HERMAN M. ADLER part, but it has actually appeared to be of benefit when it was applied as a basis of therapy in these cases. It would seem that by careful training based on an analysis of each individual-especially from the behaviourist's point of view, considering the past life-and career rather than the self-explanatory, subjective statements-it should be possible to influence the future conduct of these individuals. While their fundamental equipment cannot be changed any more than that of the other two groups, these people suffer more from the effects of their conduct than from their subjective attitude towards themselves or their environment. Thus, as Kraepelin points out, alcohol is an important factor in producing the final downfall. Extravagence, profligacy, sex excesses, bad companionship, and so forth, are the factors which combine to cause the social difficulties. The siggestibility of these individuals," their intelligence and insight, which is usually quite adequate for their needs, can be made use of in acquiring and strengthening the habits which the individual would never be able to gain if left to himself. What is desired, therefore, is a system of mental and emotional exercises for the purpose of habit formation. This might be designated as orthopsychics. This term is further applicable in that a good many of those cases are instances not of disease in the sense of an acquired, deteriorating process, but rather comparable to physical deformaties. For the present, our experiences in orthopsychics, is limited. We have had a few cases in which, after a preliminary survey at the Psychopathic Hospital, a course of training has been applied, which has consisted above all in arousing the interests and appealing to the pleasure-loving side of the individual. It is a well known fact, for instance, in dealing with wayward young people that even under the most advantageous circumstances and even with the most favorable and friendly environment, the individuals do not do well. This appears to be due to the fact that the emotional impulses are of short duration and leave no strong impression behind them. Therefore, when the novelty of a situation has worn off, there is nothing to hold the interests of the delinquent and tide over the tedious days of monotonous routine. We have proposed in-a number of cases (and have carried it out to some extent in a few) to arrange to change the environment of each individual before the novelty has quite worn off. The length of time in which an individual stays in each home varies in each instance, and must be determined carefully each time. We are all so A PSYCHIATRIC CONTRIBUTION 67 prejudiced by our early ethical training that it is difficult to be perfectly objective in dealing with these people. It is hard to eliminate pedagogic and purely academic demands for that which we consider right. None the less, this must be done, and in every instance, in every disagreement, at every change in the routine of the individual, emphasis must be laid on the fact that it is done from a medical point of view, that is, from a point of view of therapy and help, with kindly feelings toward the patient, and never as a corrective or as a punishment, and above all, never vindictively. This plan has succeeded in a number of non-institutional cases, which were rather better off than the institutional cases, because of the fact that the financial condition of these individuals permitted an adequate provision for their care. The state at present makes no allowance for this sort of therapy, and even experimental work which is as yet hardly to be ventured, requires funds which are at present entirely lacking.
Education and training, therefore, rather than punishment are the methods that hold out a chance of success. These individuals are not able to learn by experience. They receive the equivalents of punishment in their daily life, which are sufficient to influence the formation of adequate resistance in a normal individual. In these individuals, while they often recognize the full significance of those circumstances in which their delinquencies placed them, their experiences have no corrective influence.
To punish such an individual, therefore, is to increase his defeat rather than to strengthen his defenses. It is like administering alcohol to the patient suffering from delirium tremens. It is like injecting diphtheria toxin into the circulation of a patient suffering from diphtheria. We may draw a final analogy from immunology in applying this therapy: The first duty is protection against the immediate effects of the acute attack. In our cases, this means freeing them from their immediate difficulties, supplying them with food and lodging, helping them to recover from alcohol and drug intoxication, relieving their physical symptoms, curing them of, venereal disease, and building up their physical health. In the second place, immunization: This is often in the nature of after care, and cannot be achieved at once, but can be. accomplished by a building up of the defense habits, by training, and not by overwhelming an already breaking organism with the hostile conditions, but by gradually strengthening their habits so that they will meet the particular unfavorable conditions without fear of breakdown. In the group of emotionally unstable, this offers great hope. In the paranoid and defective groups, at least, a palliative effect may be hoped for. At present, the practice is to attend more or less thoroughly to the first of these requirements, that is, relieving the patient's immediate needs. When the after effects have disappeared and the patient once more seems normal, he is sent out into the world, in most cases, merely to repeat the offense that brought him under observation in the first place. Here, where treatment ordinarily leaves off, is where the special and most important part of the therapeutic effort should begin. And in this respect the penal institutions no less than the hospitals for psychopathic cases must assume responsibility.
I wish to express my indebtedness to Miss Helen VI. Anderson of the Social Service Department of the Psychopathic Hospital at Boston, for valuable help in making the tables, in gathering the social information about the cases tabulated, and in trying out some of the deductions in selected cases.