Studies in Forensic Psychiatry Part 2

CASE II.--R. S. C., a white male, age 48 years, who is now serving a life sentence for murder. One brother and one sister died of tuberculosis. Another sister and two maternal aunts were insane.

Father alcoholic. Patient has always been regarded as rather sickly.

Had the usual diseases of childhood and has been subject all his lifetime to frequent headaches. His school career was very irregular in character and he never advanced beyond the elementary subjects.

Socially, he belonged to a very ordinary stock of frontiersmen and his chief occupation consisted of farming and certain minor speculations.

He apparently led an honest and more or less industrious life. Married in 1886, and his conjugal career is uneventful. In March, 1901, he moved to Addington, Indian Territory. This was a newly-established frontier town and he had bought, sometime previously, several lots there, intending to establish himself in the lumber business. Soon after this he got into some financial difficulty with a town-site boomer, and finally, in a fit of pa.s.sion, shot and killed the latter and wounded a relative of his own. He was admitted to the Government Hospital for the Insane, December 13, 1901, from the Indian Territory.

From the medical certificate which accompanied him on admission it appeared that soon after the commission of the crime the patient began to show evidence of insanity by incoherent talk, false ideas, nervousness, and outbursts of vicious excitement. Later, this was followed by mutism, refusal to eat, and stupor. On admission to this hospital he was in a deep stupor, absolutely oblivious to everything about him. Eyes were wide open and staring, pupils dilated, voluntary movements markedly in abeyance. He was mute except for an occasional incoherent mumbling to himself. He evidenced no initiative in feeding himself, but swallowed food when it was placed in his mouth. Habits were very untidy; involuntary evacuation of bladder and bowels were present. His mental content could not be determined at the time, as his replies were indistinct and monosyllabic, and were obtained only after much effort. He appeared to comprehend what was wanted of him, although this was not absolutely certain. His perception was very dull, ideation slow and laborious. His attention could be gained only after considerable difficulty, and he had to be aroused first from a more or less profound stupor. Spontaneous speech was almost wholly absent, but occasionally he would utter a word or two about his wife and children. No delusions or hallucinations could be elicited.

Physical examination showed him to be quite thin and emaciated. Gait slow and unsteady. Voluntary movements r.e.t.a.r.ded. Knees trembled and knocked against each other. No paralyses or pareses noted. Marked general tremors were occasionally seen. Musculature well developed but flaccid. All deep reflexes diminished. Cremasteric absent. Other superficial reflexes were noted to be normal. Organic reflexes abolished. Involuntary urination and defecation. There was a systolic murmur present and a slight impairment of the upper lobe of the right lung. Breath very offensive. He remained in this stuporous condition, leading a more or less pa.s.sive existence, for about a month after admission. For two months following this he was quite agitated, and his outward reactions indicated that he was quite depressed. On April 25th, about four and a half months after admission, when asked how long he had been in the Hospital, he replied three days. From that time on he began to improve. Consciousness became clearer. In June, he talked and acted quite rationally. He had a total amnesia of what had transpired during his stuporous and agitated states and a retrograde amnesia for several days prior to, and including the commission of the murder. He continued clear mentally and in a more or less normal state until the latter part of November, 1902, when he again went into a stupor. From this time until the later part of April, 1903, he had alternating periods of stupor and lucidity, with amnesia for the stuporous states. On June 21, 1903, he was discharged as recovered and returned to the Indian Territory to undergo trial for his offense.

Unfortunately, no mention is made in the hospital records of any possible relation between his periodic stuporous states and any environmental condition which may have provoked these; nor does there appear in the hospital records any mention of the degree of insight, if any, the patient possessed at the time of his release from the inst.i.tution.

He remained in jail at Ardmore, I. T., until April 8, 1904, when he was tried and found guilty of murder in the first degree. He was then returned to jail and after about a year's sojourn there was sentenced to life imprisonment and transferred to the United States Penitentiary at Leavenworth. He was readmitted to the Government Hospital for the Insane on March 25, 1906, from the United States Penitentiary at Leaven worth. No medical certificate accompanied him on admission and it is therefore impossible to set, even an approximate date, for the onset of his present mental disorder; but inasmuch as he had not been in prison even a year before his transfer to our hospital, and as it usually takes several months to carry out the required legal proceedings, his mental disorder must have set in quite soon after his confinement in the penitentiary.

He was again in a stuporous condition on his readmission to our hospital, and absolutely oblivious to his surroundings. For about twenty-four hours he was wholly inaccessible, would not reply when spoken to, and had to be aroused from a sort of lethargic state before his attention could be gained at all. On the following day consciousness cleared up to some extent and he recognized some of the attendants whom he had known on his previous admission. He remained, however, more or less confused for several days, after which his mental horizon became clear, and simultaneously with this, delusions of suspicion and persecution became evident. He did not know how long he had been in this confused state and had a complete amnesia for the entire period. Stated that he had been poisoned and that attempts to kill him had been made at the Penitentiary. He knew he had been doped any number of times. Aside from this paranoid complex he had a complete left-sided functional hemiplegia with all the concomitant signs. Left visual field considerably contracted. From May, 1906, to February, 1907, he pa.s.sed through a number of stuporous periods, during which he was confined to bed from a few days to a week at a time. At these times he would lie with a vacant and staring expression, and questioning would often fail to elicit any reply. At times he would partake only of liquid nourishment, then again would have to be spoon-fed. During his lucid intervals he would be up and about and more or less cheerful. Occasionally played games with his fellow patients. He continued to be very suspicious; frequently spoke of being doped and poisoned. Refused to take medicine, and at times refused to take nourishment because he believed it to be doped. A stenogram of February 10, 1907, shows him to have acquired some grandiose ideas and to be still disoriented to a large extent. Some of his replies were absolutely unreliable. For instance, when asked how long he had been here he replied: "If I came on March 25th, I have been here for three hundred and sixty-five thousand days. It is reasonable but you wouldn't understand it. When a man is answering for something he should not answer for, every day amounts to a thousand years with the Lord." He stated that he knew that attempts were being constantly made to affect him with chemical substances; these were placed in his food and rubbed on the walls of his room, making him dizzy and giving him a sort of peculiar feeling, etc. He could hear of things occurring in distant places and even in foreign countries just as though he were there. He could tell what was going to happen; had no trouble at all to look into the future. He attributed this ability to some superhuman power, but which was natural to him. This power was bestowed upon him by the superhuman power itself. In prison every possible means to kill him were used but without success. They even tried to chloroform him for a day and a night, but could not kill him.

May, 1907:--Still delusional, hypochondriacal; paralysis very much improved. Complains at times of quiverings in the right extremities and a numbness of the left side.

August, 1907:--Has been again in a stuporous state for four days.

Still entertains paranoid ideas, hypochondriacal. This was followed by a lucid period which lasted until November 25th, when he again went into a profound stupor and became totally oblivious to everything about him.

April, 1909:--Very much disturbed for about a week. Complained that the physicians and attendants were torturing him in order to drive him insane. Called them brutes and threatened to starve himself to death.

December, 1909:--Neurological Examination--Hemiplegia almost entirely disappeared, but numerous physical stigmata still persist. Has been uninterruptedly clear mentally since his last stuporous state, in November, 1908.

January, 1911:--Clear mentally. Answers questions coherently and readily. Attention easily gained and held without difficulty. Memory, for both recent and remote events, fair, with complete amnestic gaps for the stuporous periods. He shows the characteristic hysterical make-up. He is morbidly suggestible and suspicious. He is markedly egotistical; becomes easily irritated at the least provocation. Is extremely hypochondriacal and shows a marked tendency to exaggeration of actual ills. Constantly laments his fate of being compelled to stay in a place of this sort, which is a thousand times worse than a prison. Is certain that his trial was crooked and irregular and that he had not been given a fair chance. His sentence is inhuman and unjust, as he was not responsible for the crime he committed; he remembers nothing of the occurrence and consequently must have been insane at the time. He is inclined to a great deal of fantastical day-dreaming, writes poetry and religious dissertations. He is constantly bewailing his unfortunate lot in letters to people of high station, imploring their compa.s.sion on the poor, down-trodden martyr.

Is clear mentally throughout and no definite delusions nor hallucinations can be elicited. His morbid suspiciousness, however, leads him to interpret various occurrences in his environment in a more or less delusional manner.

August, 1911:--No change from the above note except that the physical stigmata have almost completely disappeared. Patient has an adequate amount of insight into his stuporous state, but does not realize that his entire make-up is more or less pathological in character.

The patient had finally sufficiently recovered to be able to be returned to the Penitentiary, and as he was very desirous of the change, he was, accordingly, discharged from further treatment, March 25th, 1912, to be returned to the United States Penitentiary, Leavenworth, Kansas. At this date, November, 1915, I am informed that the patient gets along very well at the Penitentiary, working in the hospital of that inst.i.tution.

We are dealing here with an individual who, to start with, comes from a badly tainted family. He leads an honest, more or less industrious life, until one day, in a fit of pa.s.sion, he shoots and kills a man with whom he has some financial differences. Being uncorrupted and of a non-criminal make-up, the enormity of his crime suddenly dawns upon him with its full force. He is unable to withstand the emotional shock which the realization of his deed provokes, breaks down under the stress, and develops a mental disorder. He is removed to a hospital and under the salutary influence of new environment gradually recovers his normal mental health. Simultaneously with this he begins to nourish the hope that he may escape punishment for his deed. The amnesia for the period during which the crime was committed lends support to his optimistic views concerning the outcome of the case, and his mind becomes, in consequence, wholly taken up with the idea of being acquitted of the murder charge. He remembers nothing of the deed, and therefore must have been absolutely unaware of what he was doing at the time. His hopes are shattered when he is found guilty and sentenced to life imprisonment.

His nervous system is unable to withstand this blow and it yields a second time, only in a more p.r.o.nounced manner.

One need not enter into a lengthy discussion in order to show that we have here a mental disorder, the origin of which can be definitely traced to psychic causes, the emotional shock accompanying the crime and conviction. Cause and effect are clearly in evidence here. We have before us a well-defined psychogenetic psychosis. In addition to this the course of this man's mental disturbance was influenced to such an extent by his immediate environment that one could practically shape the symptomatology thereof at will. Once, after a prolonged period of a state which might be considered almost normal to the individual, he induced the attending physician to bring his case for consideration before the staff conference with a view to being returned to prison. At this conference it was decided that in view of the very deleterious influence which prison life has had in the past upon this patient it would not be advisable at this date to send him to the penitentiary.

Upon being told that he would have to remain at the hospital, patient again became morose, hypochondriacal, refused nourishment, and commenced to hold himself aloof from the other patients. His suspiciousness and vague persecutory ideas with reference to the personnel of the hospital became more p.r.o.nounced, and he could see no other reason for being kept here than that the officials are continuing in their persecutions of him. I am convinced, without a doubt, that should this man be pardoned, all the manifestation which he now possesses, and which may be considered as pathologic in character, would at once disappear. The difference in the symptomatology of the two attacks serves to ill.u.s.trate how difficult it is to positively state what relation these disorders have to hysteria. Here we have an individual whose past life fails to indicate anything which may be taken as of an hysterical character. He develops a psychogenetic disorder in consequence of his crime, the symptomatology of which shows little, if anything, of an hysterical nature. In due course of time he gets well, and after having thrust upon him a life sentence, again returns to us with a mental disorder, the chief feature of which is a functional hemiplegia. There is very little doubt that by studying a cross-section of his second attack we could easily place it under the group of hysteria.

Considering, however, the history of the case _in toto_, we would have to proceed rather cautiously in judging of the hysterical element thereof.

CASE III.--G. W. W., white, male, aged 26 years, whose hereditary history cannot be definitely determined. It appears that mother was a janitress in Boston, and had several children by various fathers.

Patient grew up in an orphanage, and worked on farm until age of 18, when he drifted to Denver, Colorado, and enlisted in the U. S. Navy.

He served one enlistment with a good record, was a good sailor, and got along well in every respect. He reenlisted the second time about the middle of 1909, when at the instigation of a fellow sailor he deserted from the Navy in company with the latter. On August 20, 1910, they held up the captain of a ship with the intention of obtaining some money which was stored on board the vessel. In the encounter the captain was killed by the patient's companion, who made his escape, while the patient was apprehended and held on a charge of murder. On August 24th, he was placed in jail at Oakland, California. From the beginning he was regarded by the jail officials as rather silly and defective. He did not appear to be very much interested in his case, and never spoke of his own initiative to his attorney about it. On May 8, 1911, he was seen for the first time by a psychiatrist. He was then found to be very distractible and inattentive, seemed suspicious and excited and a.s.sumed stiff att.i.tudes. He was well oriented, and recognized that he was on trial for murder. It might be mentioned here that although the jail officials apparently noted from the first that the patient was not right, the legal proceedings were continued, and it was only on the 4th or 5th day of his trial that his conduct became such as to strongly suggest that he was insane. A psychiatrist was then called in and he p.r.o.nounced the patient insane, whereupon the proceedings were stopped at this juncture. Examination at that time revealed the following:--General sensation markedly reduced; hypalgesia, he allowed needles to be stuck into his tongue without flinching; walked in a stiff and stooping fashion; no Romberg; moderate vaso-motor stasis, with bluish, cold hands. Gait uncharacteristic. Eyes reacted to light, directly and consensually, and to accommodation. Patellar, Achilles and arm reflexes markedly exaggerated and equal. No foot clonus, no Babinski; abdominal reflexes present, cremasteric not elicited; catalepsy not always present.

Mental Examination:--Att.i.tude was variable, but was distinctly that of one in a stupor. Arms, hands and legs, placed in uncomfortable positions, would remain fixed indefinitely, _i.e._, so observed from 20 to 30 minutes. Did not resent liberties taken with him; smiled in a silly fashion at each person. Orientation perfect; no insight; hallucinations and delusions could not be elicited. Attention could only be gained with great difficulty, and held for a very short time.

r.e.t.a.r.dation was present; movements were slow and stiff. When stimulated, however, he responded promptly and had no r.e.t.a.r.dation.

Speech and writing showed nothing characteristic.

May 11:--Flexibilitas cerea more marked; mutism; retention of saliva; eats food voluntarily; bowels require frequent attention.

May 20:--Requires spoon-feeding; sleeps well; remains always in bed in stiff att.i.tudes.

June 1:--For three or four days refused food, except for one or two meals daily. At times suddenly surprises attendants by sensible remarks, as: Another patient said, "That is G. W. W.," and patient promptly replied, "No, it is Rip Van Winkle." Negativistic signs more marked. Knows physician when eyes are pushed open. At times tries to whistle.

June 13:--For past week has been noisy and excited. When he hears dishes rattle, yells "Chow-chow" for a long time. Continued hot bath for one hour always relieves this excitement. Physical signs negative; Wa.s.sermann negative; blood and urinary a.n.a.lysis negative.

June 18:--Admitted to the Government Hospital for the Insane. The Marshal who accompanied the patient from California to this inst.i.tution states that the patient was resistive and negativistic; that he a.s.sumed various constrained att.i.tudes; was untidy, mute, and refused food. All these tendencies were markedly influenced, however, by positive requests of the Marshal. When told that he would be chastised if he did not give up his untidy habits, these disappeared, etc. On admission to the Government Hospital for the Insane the patient had to be carried into the ward, as he refused to walk. He was mute, negativistic, and a.s.sumed various uncomfortable and constrained att.i.tudes. Every now and then he would snap at those who handled him, and this would be accompanied by a growl. He was very resistive to the taking of a bath, and suddenly snapped at the attendants who cared for him. When reprimanded, however, by the Supervisor, and told that he would have to take the bath, he quietly underwent the procedure.

Physical Examination:--Pupils widely dilated. Face somewhat distorted.

Pupillary reflexes normal; although limbs would remain in a fixed att.i.tude when so placed, he did not evidence the typical flexibilitas cerea. It seems as though he antic.i.p.ated the pa.s.sive movements, and there was present a certain amount of voluntary intent. All superficial reflexes active; winced when p.r.i.c.ked with a pin but there was a decided hypalgesia present. He refused food; was mute, and apparently oblivious of everything about him. This, however, was only apparently so, as he showed by various acts that he was more or less aware of his surroundings. For instance, during the examination he suddenly snapped at the examiner, and upon the latter's discomfiture he emitted a momentary giggle. When feeding-tube was placed in his nose, preparatory to feeding, he jumped up and said, "I'll drink it,"

and drank the entire contents of the pitcher. While some parts of his body remained absolutely fixed, restrained and immovable, his face was constantly undergoing various grimacing motions, accompanied now and then by the snapping of his jaws and a growl. During the following several nights he was very noisy, excitable, singing and shouting throughout the night. Mental content could not be determined at this date.

June 28, 1911:--He remains in same apparent stuporous and catatonic att.i.tude. For past few days has exhibited various childish and silly acts of a meaningless and monotonous nature. Still mute except for an occasional growl. Became very untidy today, but when reprimanded and told he must use the toilet he did so.

July 1, 1911:--Patient has been very noisy on several occasions in the past few days, but always becomes quiet when requested to do so.

Continues negativistic, stuporous and att.i.tudinizing. Today he was overheard saying: "I am a monkey; want to go out in the yard and sit on the benches; there was no plea of insanity; who are those boys?

Come in, boys; water, won't drink it because there is poison in it, it looks good, so try it. Don't believe there is anything in it." He persevered in repeating these phrases.

July 2:--Sang all morning in an undertone. Would stop singing and recommence his facial grimaces when anyone entered his room.

July 3:--For the first time since admission patient answered examiner to questions.

Q. "What is your name?"

A. "George Washington."

Q. "How old are you."

A. "36."

Q. "When born?"

A. "1884."

Q. "Occupation?"

A. "Farmer."

Q. "Where born?"

A. "Around Boston."

Q. "What day is this?"

A. "Someone says Tuesday."

Q. "What date?"

A. "June 17, 1911."

Q. "How long have you been here?"

A. "I cannot tell you."