Studies in Forensic Psychiatry - Bernard Glueck (grave mercy .TXT) 📗

and feet together, there was considerable swaying present; said he felt like falling over. Voluntary movements were performed well. He described accurately a circle, a square, and triangle in the air with either hand. Movements were steady and accurate. Coördination was slightly impaired in f-f and f-n tests; the termination of the act was accompanied by a slight tremor. The musculature of thighs showed a more or less constant clonic twitching. When attention was called to this he was able to control it to a certain extent. Upon assuming a sitting posture the twitchings ceased. He said it was due to weak ankles. There was no tremor of protruded tongue or lips when showing teeth; fine tremor of the extended fingers and forearm when extended; no tremor of facial musculature. There was no paralysis, but there seemed to be a slight weakening of the lower extremities. No atrophies or hypertrophies noted. The triceps and radial reflexes were definitely exaggerated. Upon tapping, the quadriceps tendon caused a brisk marked contraction of thigh muscles, followed by mild clonus. Tapping of one knee tended to set musculature of opposite knee in mild clonus of short duration. Knee kicks were definitely exaggerated. Tendo Achillis exaggerated. No ankle clonus. Muscular irritability to mechanical stimulation increased. Superficial reflexes were normal, except plantar defense reaction was slight. Cutaneous sensibility was unimpaired: heat and cold readily distinguished. Light touches of pin pricks were felt and localized all over the body. Sense of position normal. No astereognosis in either hand. No excessive sweating. Eyes clear; irides brown; pupils round and regular, moderately dilated, reacted readily to all tests; eye movements well performed in all directions; no nystagmus nor strabismus. Vision—20/30 in each eye, improved by glasses. Skin of vitreous clear; slight weakness of external recti; cornea clear; field of vision normal for white; both fundi normal except for slight hyperæmia. Smell, taste, audition, and speech unimpaired.

Mentally the patient was clear. He comprehended readily what was said to him, and his replies were prompt and relevant. He was disoriented for time. He stated that he knew the nature of this place; that he was told it the day before by a patient. Claimed to have total or almost total amnesia for several months past during the year he was confined in the dungeon of the Concord Penitentiary. He had no idea of the trip from there down to this hospital. He did not remember his arrival, nor how he acted the first two days here. Stated that on June 17 he first began to notice things about him and to realize faintly where he was. Delusions or hallucinations could not be elicited as having existed at that time. He spoke of having been bothered at the penitentiary; of having been chloroformed; that they put stuff in his food, tried hard to get him out of the way, and because they could not do it sent him down here. Said the doctor poured ether down his neck. He does not know the doctor’s name, but he knew it was ether, he smelt it, and that is the reason he could not use his legs on arrival. He had no idea why he should have been treated thus, but thought perhaps they had it in for him. Auditory hallucinations could not be elicited. When asked if he ever saw anything, he said it was pitch dark in the dungeon and no one could see anything. Said the food tasted bad all the time, and sometimes made him vomit. On one occasion he noticed some powder in the beans. No electricity, no shocks, no outside influence was used on him. He did not know how long he was tied down in the dungeon, as half the time he did not know anything at all. Said they put needles in him, and pointed to some marks on his arm as a result of hypodermics. Facial expression denoted perfect satisfaction; said he felt fine and did not worry about anything, as he is not of the worrying kind. Said he had been treated well here. Insight was imperfect. When asked directly if he had been insane, he replied “No.” When the various symptoms which he manifested on admission were described to him he was inclined to agree that if he did show these symptoms he must have been out of his head. Remote memory was not impaired, so far as could be determined. There was an ill-defined amnesia extending over several months past, and up to June 17, when he claimed to have first realized his whereabouts. Attention was unimpaired. He reacted well to the intellectual tests, with the exception of the arithmetical problems, which he did poorly. Replies to ethical questions showed a rather low grade of morality, perhaps due somewhat to ignorance more than to anything else. In his conduct on the ward he was absolutely normal following June 17. He spent his time reading and in conversation with the other patients. He was perfectly satisfied in his surroundings, frank in his conversation with those about him, and gradually gained more and more insight into his condition. He still persisted, however, in his statements that ether was poured down his back. Said he remembered this distinctly as having taken place while confined in the dungeon. He was then, however, inclined to think that probably they did not have it in for him, and probably they did what they thought was best. In conversation with him today, on June 19, four days after admission, he showed perfectly normal behavior in every respect. Was frank in his statements, spoke of the amnesia mentioned above, and no delusions or hallucinatory experiences or physical symptoms present on admission could be detected.

When finally confronted with the picture sent from the War Department for his identification he showed some degree of emotional reaction, stated that the picture was his, but persistently denied ever having been a recruit in the army. On the whole, he took the matter rather lightly and good-naturedly.

The history of this attack illustrates a typical case of hysterical psychosis. The marked stupor and confusion, the numerous and varied neurological symptoms, the sensory disturbances, especially the profound anæsthesia to pin pricks, the amnesia and rapid recovery after change of environment, all point to this diagnosis. It is a form of reaction frequently seen in prisoners, and has been designated, for want of a better term, as prison psychosis. At any rate, there can be no doubt as to the genuineness of the symptoms presented by the patient.

If we keep in mind that such a type of psychotic reaction is the result of the mutual interaction between an unstable, highly vulnerable psyche and an unfavorable environmental situation—in this instance prison environment—we understand the more readily the later history of this case.

On July 16, 1912, he was discharged recovered and turned over to the naval authorities to be returned to prison. Soon after his return to prison he was noted to be melancholy, uncommunicative, was not interested in condition of self or surroundings, had unsystematized delusions of persecution. Physically he was noted to be anæmic, showed general tremors when undergoing examination, reflexes were exaggerated, positive Romberg was present. The physician who accompanied patient to the Government Hospital for the Insane on his second admission stated that on the trip from Portsmouth Prison M. tried to assault a waiter in a restaurant in Boston, accusing the latter of following him. To the physician he said, while on the train, “Take your d—— eyes off me, or I’ll brain you.”

He was readmitted to the Government Hospital for the Insane on February 6, 1913. Physical examination on this admission was negative, except for some impairment of vision, for which he was given eye-glasses. Mentally he was found to be disoriented for time, though perfectly clear mentally, as was shown later in the examination; he said he did not know the name of the institution, though a minute later he gave correctly the name of the building in which he was located. He spoke in a very vindictive manner of the naval officials, who he said were persecuting him in various ways, and who he reckoned were then working to send him to some other d—— prison. On February 7, the day after admission, he wrote the following letter to the Secretary of the Navy:

Howard Hall, January 29, 1913.

Mr. Secretary of the Navy: Rev. Sir.—Will you kindly have some investigating, as I cannot have my life endangered. It is continually in my food, and times I have found the compounded powders in the air of my room choking me. Please let me know if you will do so, and I shall close.

Respectfully yours,

J. E. M., H. H. 5, Station L.

No hallucinations could be elicited, and his delusional ideas were confined to the naval officials. These, he said, were persecuting him; they sentenced him unjustly in the first place, and threatened to get even with them. He answered the intelligence tests fairly well, but the examining physician noted that frequently he gave expression of consciously giving erroneous replies to questions put to him. Emotionally he was at first somewhat depressed, but later this disappeared. In his conduct he was inclined to be very troublesome, easily irritated, and fault-finding.

This disorder of conduct, however, became consistently more aggravated whenever he was in the presence of the physician. While he gradually became quite friendly with the attendants and willingly assisted with the ward work, he became quite abusive whenever an attempt was made to examine him by the physician. This became especially evident in December, 1913, when the physician who had him in charge during his first sojourn at the hospital again assumed charge of him. At that time the patient had been on excellent behavior for a number of months, and in his daily conduct showed no evidence of a psychosis. He continued, however, to air his delusional ideas whenever the physician attempted to examine him.

Everything went well upon the return of his former physician until December 22, 1913, when the latter attempted to examine him. The patient became very abusive and threatening in his attitude, began to air all sorts of bizarre persecutory ideas, and for about a month he continued in an excited and destructive state. At the expiration of this period he apologized to the physician for his conduct, said that he could not help going on a rampage once in a while, as it is all due to his mean disposition, and promised to conduct himself in an excellent manner if he were not returned to prison. This was early in January, 1914, since which time he has been a model patient in every respect. It is needless to say that he has not been given, since that time, any occasion for the development of another tantrum, and accordingly he remained free from psychotic manifestations.

He was a model patient after this, assisted willingly with the ward work, and on one occasion prevented the successful culmination of a daring plot on the part of several patients to escape from the institution.

Upon the recommendation of the hospital authorities and Dr. Sheehan, the naval officer stationed at this hospital, the remainder of this man’s sentence was commuted, and he was accordingly discharged on June 29, 1914. For about six months prior to this his conduct was exemplary, and, though through a considerable part of this period he enjoyed freedom of the grounds, he never showed the slightest inclination to abuse these privileges.

The salutary effect of the commutation of this man’s sentence is quite obvious. On the other hand, I am equally certain that had this particular individual been returned to prison we would have had him again before long as a very seriously ill patient.

This case is extremely interesting from many points of view. In the first place, it gives us some insight into that highly