Finding, as these individuals do, a successful and convenient refuge in a psychosis, it is but natural for them to again seek this refuge when they find themselves in conflict with the law. But that which was at one time a spontaneous, unconsciously motivated mental reaction may later become a conscious volitional act, an only available means of escape—malingering of mental symptoms.
J. E. M., aged twenty-seven on admission, June 15, 1912. Family history obtained from the patient four days after admission is quite unreliable. He knew nothing of his grandparents, who died in Ireland. Father was living when last heard from, four or five years ago. He is moderately alcoholic; a stableman by occupation. Mother died at fifty-five in Bellevue Hospital, New York City, from some unknown cause. One brother was drowned. One sister died of tubercular adenitis. No instance of epilepsy, insanity, or nervous disorder in any form is known to have existed among his relatives.
Patient stated that he was born in Ireland on October 12, 1884. He never attended school, but has learned to read and write a little. Childhood was uneventful, so far as known. He came to this country at the age of four, and at twelve or thirteen years of age began selling newspapers in the streets of New York. His occupational career since then has been chiefly that of a steamboat and longshoreman laborer along the docks of New York City. He said he enlisted in the Navy in 1907 or 1908, was not quite certain as to which year, at San Francisco, Cal. He served on the U.S.S. Buffalo as coal-passer; was dishonorably discharged for drunkenness. He then reënlisted and served as fireman, first class, on the Milwaukee for about three and one-half years. Says he got along well on the Milwaukee, until he got into his present trouble. He was convicted of sodomy and sentenced to prison for ten years, January 15, 1911. Patient did not see the discrepancies in the dates as given by him, but, as stated before, the history is quite unreliable.
A letter received from the War Department on June 28 requested identification of J. E. M. for the purpose of detecting whether or not he is the same man who under the name of Lee deserted from the Army, January 14, 1909. The photograph accompanying the letter was that of the patient.
He had measles and mumps during childhood, from which he made good recoveries. Gonorrhœal and syphilitic infection were denied. (Wassermann with the blood-serum negative.) During a bar-room brawl in Panama he was struck on the head with a table leg and rendered unconscious for fifteen or sixteen hours. This was some time in 1908. He thinks there was nothing more than a scalp wound, requiring no treatment beyond a simple dressing. For about a year after, headaches were present almost continually, occipital in location and of a tingling sensation. There was likewise a reduction of tolerance for alcoholics, since then two glasses of whisky being sufficient to intoxicate him. He does not know whether there was any change in his mental make-up or faculties following this injury, as he paid no attention to this. He commenced to indulge in alcoholics at the age of eighteen or nineteen. He cannot give a detailed account of the extent, but, as a rule, he spent all his money not needed for living expenses for whisky. He would become intoxicated every time he went ashore, stating that there was nothing else to do and no place to which he could go. Practice of onanism was denied. He claimed to have begun normal sexual intercourse at about the usual age. Strenuously denied sexual perversions, in spite of the fact that he is now serving a ten years’ sentence for sodomy. He denied the guilt of this offense; insisted that he was never arrested before in his life, and believed the present conviction to have been a trumped-up affair because they must have gotten sore on him, although he cannot figure out why. Following his conviction for the above offense he was sent to the State Penitentiary at Concord, N.H. For a short while after he got there he got along well; was kept continually at work in the chair factory. He did not like this work, as he was subjected to the inhalation of the dust and shavings, and feared he would develop tuberculosis from this, and asked to be transferred to some other place. This request was finally granted him, and he was put to work in the kitchen. He states he did not get along well there; very soon got into some sort of trouble and was put into a dark dungeon, where he thinks he remained for about twelve months, strapped to the bed. He never saw the daylight during this time. He does not know why these strict measures were taken with him, but it is a fact that he was tied down. He had no idea of the onset of the present trouble, but stated that he complained frequently to the doctor of headaches and vomiting. The headaches were occipital in nature and severe at times. He could not recall his transfer to this institution nor the events which transpired during the first two or three days after his arrival here.
The medical certificate which accompanied him here stated: “Patient has been convicted of sodomy and is at present serving sentence for same. First symptoms became manifest about February 6, 1912. Came under the care of prison physician at Concord, N.H., State Prison with severe headaches. Previous to above date it is said there were the following records at above prison in regard to this patient: April 15, 1911, and August 10, 1911, he had convulsions. These are not described in detail. The prison physician at the time noted that patient showed symptoms of organic brain disease. On February 26, 1912, he became violent, and has had to be restrained since then. For some time previous to that he had acted peculiarly. The symptoms immediately preceding his transfer to this institution are as follows: Has to be restrained to prevent violence to himself and others. Frequently suspicious when food and drink are offered him. At times noisy when he desires food and it is not given to him at once. Probable cause unknown. There is a vague history of head injury aboard ship in the tropics. Homicidal tendencies were present when the disease first became manifest.”
Patient was admitted to this institution June 15, 1912, at 10.30 A.M. On admission he was carried in by two employees. His legs were shackled and he had wristlets on his hands. He was apparently unable to stand unassisted, and, when support was removed, fell to the floor. Pupils were widely dilated; internal strabismus of the right eye was present. Facial musculature was distorted, and he mumbled to himself in a low, indifferent tone of voice, over and over again, “Give me something to eat. I can’t do it. Give me something to eat,” etc., in a rapid monotone. He appeared to be in a deep stupor. He did not seem to realize his whereabouts, and attention could not be gained. He was totally inaccessible. When put to bed he became quite restless, rolled out on the floor, and was unable to assist himself back into bed. Musculature of legs was in a constant mild clonus, and the right foot was kept in position of talipes equinovarus. Pins pushed deeply into the skin all over the body caused no reaction. When food was brought to him he leaped upon it and finished the meal with extreme rapidity, stuffed his mouth full, never taking sufficient time for mastication or swallowing, and food was frequently expelled forcibly, probably from irritation of the air-passages. Questions addressed to him remained unheeded, but he kept up a constant mumbling in a low monotone, as described above. He was totally unable to stand on his feet unsupported, but when lying down his legs were moved about quite freely in an indifferent manner. When alone in the room he remained quietly in bed, head and face covered up with a blanket, but as soon as the room was entered he became restless, grabbing to those about him and holding on tenaciously. During his first night in the institution he slept well and was clean in habits. The following morning he was still inaccessible. He ate his breakfast quite voraciously, mumbling to himself all the time, “Give me something to eat” or “Give me something to drink.” When water was brought to him he would endeavor to gulp the entire contents of the vessel at one effort.
During the day of June 16, the day following his admission, he was frequently seen sitting on the side of the bed with quite a pleasant facial expression, rubbing his arms and legs. When his room was entered, however, he at once began mumbling to himself similar phrases as those given above, became quite restless, grabbing at those about him and not paying any attention to questions put to him. The following day, June 17, he showed marked improvement; was very much quieter in behavior when approached; walked back and forth in his room quite unassisted and in quite a steady manner; was seen looking out of the window into the yard for about fifteen or twenty minutes. Upon being approached by any one his gait seemed to become definitely less steady, and diffused twitchings of the thigh and leg were noted. The strabismus which was present on the day of admission had entirely disappeared; pupils slightly dilated. In the forenoon of the 17th he asked for his clothes and to be allowed to go out in the courtyard for a walk. A few questions addressed to him were answered coherently and relevantly. He said, in answer to direct questions, that his name was J. E. M.; that he did not know his age; that he came off some ship. Said the name of the ship was Washington; that he did not know how long he was on that ship, but thought it was a good long time. Asked where he was now, he said he was in the brig. “Where?” “Don’t know.” Asked if he were crazy, he said, “No, sir.” When he came here? “A year ago.” Asked what was the matter with him. “Nothing, sir. They kept me tied up too much.” Asked when his bowels moved last, he said, “About a week ago.”
On June 19 he gave a coherent and connected account of his past life. He talked freely and coöperated in every way with the interviewer. Requests were obeyed promptly and intelligently. Physical examination on that date showed him to be a well-built, well-developed white male. Face slightly asymmetrical. Skin was soft and smooth, free from eruption, and covered with numerous elaborate tattoo marks. Linear depressed scar in the occipital region. Muscle tone was good. Muscular power was good in upper extremities. On first being tested in the lower extremities said he could not resist very much passive movements; upon suggestion, however, the muscular power of the lower extremities became much stronger and equal to that of the upper extremities. Grip was strong and equal on both sides. Station and gait were unimpaired when a steady and erect attitude and firm gait were suggested to the patient; left alone, he was inclined to be slightly unsteady on his feet. With eyes closed 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.