I knew about Jonathan Pincus long before he knew of my existence. Everyone in my class knew of him. While I was still struggling through anatomy, Jonathan was applying for a neurology residency at Yale. By the time I finished my study of the capacity for intimacy, completed my pediatric internship, and began my psychiatry residency, Jonathan was a junior faculty member of the Yale Medical School.
As an assistant professor, Jonathan cut a rather dashing figure at the hospital, at least in my eyes. I remember watching him stride confidently down the corridors, white coat open, coattails flying, trailing what looked like contingents of admiring neurology residents and medical students, who walked double-time to keep pace with him.
Everyone who has worked with Jonathan knows his laugh. When Jonathan laughs, patients sit up in bed, medical students grin, and floor nurses mutter, “Shhhhh!” The best thing about Jonathan is that he can laugh at himself (an uncommon trait in a Yale professor). Thus, though Jonathan frequently laughs at me, at my idealism, at my peculiar ability to get us involved with unsavory characters, he is just as likely to laugh at his own foibles.
* * *
Psychiatry Board Examinations are not easy. Psychiatrists must pass tests in neurology as well as psychiatry. Today the tests are different, and the neurology section is all written. But in my day, psychiatrists had to see live neurology patients; psychiatrists had to examine them, actually touch them. (Psychiatrists rarely touch patients. In psychoanalysis, doctors and patients don’t even look each other in the eye.) Then the psychiatrists were quizzed by neurologists. The prospect was intimidating; therefore, psychiatry residents spent months before the boards examining neurology patients.
Word had it that whoever studied for boards with Jonathan Pincus passed with flying colors. Thus, my first encounter with Jonathan, like just about all of my subsequent encounters with him, was as a supplicant. Would he tutor me for the neurology part of the board exams? He agreed. This was the first and, I believe, only time that Jonathan had no misgivings about granting a request of mine.
Jonathan was a patient teacher. Week after week I followed him on rounds and watched as he took histories and performed neurologic examinations on patients who suffered from all sorts of exotic neurologic diseases. (Jonathan taught me to say neurologic, not neurological.) After several weeks observing Jonathan, my turn came. Jonathan sat back and watched as I examined the patient. Afterwards he quizzed me. What symptoms had I noted? What signs had I elicited? What had I overlooked?
Often I found myself at a loss. What was Jonathan getting at?
“The eyegrounds, Dorothy. What about the discs?”
“The discs?”
“Yes, the discs. What did they look like?”
“They were blurred. I couldn’t make them out. I think my ophthalmoscope needs new batteries.”
With that, the famous Pincus laugh burst forth.
“Shhhh,” a private-duty nurse stuck her head into the corridor and frowned.
“Of course, you couldn’t make them out,” Jonathan whispered. “The edges were blurred because the discs were swollen. Why were they swollen?”
“Increased intracranial pressure?”
“Right. Now why does this unfortunate fellow have increased intracranial pressure?”
“Easy. He was admitted for a brain tumor.” I breathed a sigh of relief. Home free. But Jonathan was not finished.
“Good. What else can cause increased pressure?”
Pause. “A subdural hematoma.”
“Good. What else?”
“Infection. Encephalitis.”
“And what else?”
Longer pause. “Ideopathic hydrocephalus.”
“And what else?”
On and on, Jonathan would pursue the questioning until I had exhausted all of the possibilities I knew. Invariably there were several I had overlooked. Then Jonathan would abandon the role of board examiner and teach me what I did not know. Which was plenty.
On the day that I passed the boards, I snuck into Jonathan’s office and deposited a bottle of my favorite wine, Château Margaux, on his desk. The note beside it read, simply, “Thank you.” My days of examining patients with Jonathan Pincus were over—or so it seemed. And indeed such would have been the case were it not for Lee Anne Jameson’s puzzling act of violence. Now, instead of bestowing gifts on him, I found myself in his office, arguing with him.
“Dorothy, suppose this kid you’re telling me about is brain damaged. Suppose she does have seizures. If I testify, and because of me she’s found not guilty, what’s to say she won’t go out and do it again?” Jonathan had a point. Besides, we both knew that violent acts rarely occur during actual seizures. Just before? Sometimes. Afterwards? Maybe. In between? Occasionally. During? Almost never. Still I would not let him off the hook so easily. I had to figure out why Lee Anne was a murderer and I was not. To do this I needed Jonathan. If, ultimately, Jonathan refused to see Lee Anne, at least I would have instilled a little guilt in him.
“Jonathan, she’s made thirty-two visits to the hospital. Something must be wrong.”
“So?”
“Jonathan, you’re the only neurologist I know who can figure her out. I mean, you wrote the book.”
If reason, ethics, and guilt would not prevail, flattery might. Jonathan had co-authored the classic Behavioral Neurology. He was and is one of the few neurologists who is comfortable dealing with the fact that the mind and the brain are inextricably connected. When the brain is out of whack, thinking goes awry; when thinking goes awry, feeling goes awry; when thinking and feeling go awry, behavior goes awry. That’s the way it is. Something was wrong with the way Lee Anne Jameson perceived and reacted to the world. Jonathan had to help me figure out what that was.
As Jonathan tells it, “Dorothy pleaded. She cajoled. She charmed.” I would not argue with his description. I did what I had to in order to convince Jonathan to see Lee Anne. I needed his help and, by hook or by crook, would get it. After thirty minutes of unabashed flattery, Jonathan surrendered.
“O.K., Dorothy. O.K., I’ll see her.” I did not even suspect that my obsequious plea would prove but a practice session for much bigger requests to come.
Jonathan sat behind a desk in a tiny room at the detention center, awaiting the murderess. When she tiptoed in, accompanied by a matron who left her at the door, Jonathan was convinced they had brought him the wrong girl. He described her in his report as, “a slender, frail, sliver of a prepubertal girl, about five feet tall and weighing no more than ninety pounds.” Throughout the examination, their eyes never met. In response to Jonathan’s questions, she emitted the same monosyllables she had produced for me.
Jonathan is one of the few neurologists I know who spends more time talking with his patients than tapping their knees and testing their muscle strength. It’s easy to talk with Jonathan. His relaxed, laid-back attitude and easy laugh instill trust.
Well, Lee Anne wasn’t buying it. She sat, tight lipped, on a metal chair, hands in her lap, looking down. Jonathan moved from behind the desk and took a seat to the side of it. Sitting across a desk from her was too much like a courtroom. But no matter what position he took or what tone he adopted, Jonathan could not make the anxious child comfortable. Maybe her suspiciousness was normal. Maybe anyone in her shoes would keep her mouth shut, he thought. For the past twenty-five years, Jonathan and I have struggled to distinguish between paranoia and good healthy suspiciousness. When in doubt we interpret silence as adaptive.
Jonathan did not give up. He slid low in his metal chair, trying to diminish the difference in height between him and his young patient. Then, in the softest of tones, he asked, “How about that day? The day of the stabbing? What was going on in your life that day?”
No answer. Lee Anne looked upward. Her eyes darted from side to side. Her lips moved, but no sound emerged. Jonathan waited.
“So what was happening that day?”
Lee Anne was startled, as if she had just been tugged back into the real world. She blinked a couple of times, then responded.
“Nuthin’.”
“How about the knife? Do you always carry a knife?” Maybe it was a usual practice where she lived. Maybe all the kids in her neighborhood carried knives. These were years of increasing awareness, a time when doctors were being trained to recognize ethnic and cultural differences. Unfortunately, some of us were so well trained, or so we thought, that we often dismissed the pathological hallucinations and delusions of many sick African-American and Hispanic children as normal religious experiences or cultural beliefs and we failed to treat them. White children, on the other hand, with the very same symptoms, we referred posthaste to child guidance clinics. So much for cultural awareness.
“Nope,” came the response to Jonathan’s question.
“Whom do you know who carries a knife?” Jonathan would not give up. The stabbing occurred years before teenagers came to school armed—decades before students were screened for weapons by walking through metal detectors.
“No one.… My uncle. He cut someone.”
Jonathan tried to appear calm as Lee Anne provided the first clue to her family’s violence and, possibly, to her own.
“Whom did he cut?”
“Someone.”
“When?”
“I dunno. He’s in jail.”
“My uncle.”
At last a hint that tranquillity did not always reign in the Jameson household.
“How about those marks on your arm? On your back? Where did they come from?”
That was it. Jonathan had pushed his luck too far. The door closed and he found himself again on the outside.
They sat in silence, Jonathan looking at Lee Anne, Lee Anne staring down at her hands.
“Do you remember what happened that day?”
Lee Anne shook her head, no.
“How about just before it happened?”
“Sick. Dizzy.” Jonathan could barely hear her.
“How about afterward?”
She shrugged her shoulders.
“What happened afterward?”
Lee Anne’s eyes rolled upward as if she were seeking answers from heaven. Her lips moved silently.
“I called my mother.”
“And then?”
“The police came and got me and took me here.”
The three hours between the murder and the time she called her mother were a blank.
Detectives determined that Lee Anne had walked clear across town, had even waded through a shallow pond. Lee Anne recalled nothing.
Jonathan opened his medical bag and withdrew his elegant Queens Square neurologic hammer, a tape measure, four coins, a safety pin, and the other paraphernalia that neurologists carry around.
Lee Anne cringed and pulled back when he took her arm to tap her biceps tendon. He put down his equipment and, before making another move, explained each test to the frightened child; each step of the way he paused to prepare her. “Now, Lee Anne, I’m going to place a coin in your hand. I want you to feel it and tell me what it is. A quarter? A dime? A nickel?” “Now I’m going to test your sense of pin prick. It won’t hurt. I promise. Tell me if you feel anything.”
The findings from the physical part of the neurologic examination were, as neurologists like to say, fairly unremarkable. For a child who had been wrenched from her mother’s womb and apparently batted around ever since, she had amazingly little to show for it. She was a bit clumsy. Jonathan could skip better than she, but then again, Jonathan had had lots of practice. And unlike Jonathan, when Lee Anne stretched out her arms and spread her fingers, she could not keep them from moving jerkily up and down. “Choreiform movements,” Jonathan noted in his report. But compared with my performance on some of Jonathan’s exercises, Lee Anne wasn’t half bad. Jonathan found what neurologists call “soft signs”—that is, nonlocalized evidence of some sort of brain damage or dysfunction. Many neurologists disdain these kinds of signs. As one contemptuous Yale neurologist put it, “Soft signs are for soft neurologists.”
Had Jonathan not been trained as a child neurologist, trained to measure the circumference of infant skulls, he would have missed one of his most important findings—his only “hard sign.” His tape measure revealed that Lee Anne was microcephalic. Her head, and therefore her brain, were significantly smaller than they should have been. When I studied for boards with Jonathan, he taught me that 95 percent of the time diminished head circumference and diminished intellect go together.
“And what can cause microcephaly?” he demanded during one of our practice sessions.
“Maternal alcoholism. Drug abuse.”
“Good. What else?”
“Birth injury.”
“What else?”
“Cranial synostosis.” I was reaching.
“Good. What else?”
“I don’t know. You tell me.”
“How about maternal infection? That’s a little more common than cranial synostosis, Dorothy, wouldn’t you say?” I had to agree. But I never forgot that lesson. The things I get right the first time often sail right out of my head. I have an unforgiving memory for just about all of my mistakes.
In the end, Jonathan’s neurologic findings proved to be as equivocal as my psychiatric findings had been. The evidence for seizures was slim, but Jonathan ordered an EEG (a brain wave test) anyway. The results were normal.
In our teaching sessions, Jonathan had stressed that a normal EEG did not necessarily mean that a person did not have seizures. In between seizures, even people with grand mal epilepsy might have a normal EEG. If you get three or four EEGs, you stand a better chance of picking up a seizure disorder. But for the most part, psychomotor or temporal lobe epilepsy (now called complex partial seizures), the kind we suspected Lee Anne suffered from, is a clinical diagnosis. Before this diagnosis can be made, the doctor must talk to the patient at length, ask dozens of questions about the patient’s sensations before, during, and after suspected seizures. How much does the patient recall of what happened? Even then, you can’t always be sure.
Lee Anne had many signs and symptoms of a seizure disorder. She had auras, funny feelings in her stomach, peculiar smells no one else perceived, unexplained waves of anxiety. Sometimes she seemed to be in a trance. In fact, that is the way she looked to the kids in front of the school who saw the stabbing and watched her walk slowly into the distance. She also could not remember the time period between the murder and finding herself on a stranger’s doorstep. Amnesia is another classic symptom of epilepsy. But Lee Anne’s EEG was normal and Jonathan and I doubted that Judge Lindsey would be up for a course on the fine points of epilepsy and encephalography. Besides, neither of us was positive that Lee Anne had epilepsy. Years later we would look back at our records and the possibility of a very different sort of picture would emerge—that of a dissociative disorder. This was our first likely diagnostic error. It would not be our last.
A week before Lee Anne’s trial, Jonathan and I collected our notes and whatever records we could get our hands on and sat down in my kitchen to ponder Lee Anne’s condition. What could we say about her to Judge Lindsey to convince him that she should not be sent to a reformatory? Nothing was clear diagnostically. Nothing was definite.
Was Lee Anne brain damaged? Maybe. Her medical history and her neurologic examination convinced Jonathan that she had some central nervous system dysfunction; but, were Jonathan asked exactly where the damage was, he would have been hard pressed to localize it. What we could say was that children with Lee Anne’s kind of medical history and neurologic picture tend to be irritable, impulsive, emotionally labile. They tend to fly off the handle. But, we had to admit, they usually do not kill people.
“How about psychomotor seizures, Jonathan? Do you think she has seizures?” I asked.
“Maybe? What do you mean, maybe? She has auras. She doesn’t remember what happened. She fell to the ground unconscious a couple of times. The medical student saw it. That sure sounds like seizures.” At least it sounded that way to me then. Since then, I have seen several dissociative children with the very same symptoms who do not have epilepsy. But twenty-five years ago I had seen fewer patients and I knew less. “Does she have seizures?” I demanded, as though the forcefulness of my question would clinch the answer.
“Maybe. Let me put it this way, Dorothy. I’m 51 percent sure she has psychomotor seizures.” Jonathan paused, and laughed. “Then again, when I’m 100 percent sure, I’m only right 80 percent of the time.”
“Very funny, Jonathan. That will really go over big with Judge Lindsey next week.”
Now it was Jonathan’s turn to challenge me.
“How about you? Can you say she’s psychotic? Can you say she was insane at the time of the murder?”
“She’s paranoid. We both agree on that. That’s why she carried the knife,” I equivocated.
“But is she crazy?” Jonathan demanded.
I could not answer that. Now that the tables were turned, Jonathan enjoyed putting me on the spot. “Is she insane?” he persisted.
I could not answer directly. Rather, I began to think aloud, “She hears voices. The voices talk to each other. They tell her what to do. All the books say that makes her schizophrenic.” Psychiatrists were taught then (as many are now) that auditory hallucinations of voices talking to each other, especially if they tell the patient what to do, probably indicate schizophrenia. If, in addition, the patient feels controlled by outside forces, the diagnosis is clinched. As it happens, it is not true that these symptoms always indicate schizophrenia. Over the years Jonathan and I have learned that this constellation of symptoms is even more common in dissociative disorders. But twenty years ago, to have suggested that command hallucinations, voices talking to each other, and the sense of being controlled by external forces was anything other than schizophrenia would have been heresy. Even today that idea does not sit well with many of our colleagues.
The older I get, the easier it is for me to understand and almost forgive Freud for renouncing some of his most important discoveries. For example, he took back his assertion that many of his sickest female patients were sexually abused by their fathers. I see now why he decided that these women must have imagined it. Colleagues can be intimidating adversaries when you question the prevailing wisdom. They certainly made Freud’s life miserable. It is a lot easier to recant than be burned at the stake. Jonathan and I have had the fortune or misfortune to stumble into several controversial areas. Colleagues have said some pretty nasty things about us. One of Jonathan’s colleagues called us a “traveling road show”—in print!
“Is she schizophrenic?” Jonathan demanded. We both knew that the answer to that was no. No matter what the books said, it was clear to us both that, whatever caused Lee Anne’s symptoms, she was not schizophrenic. She bore no resemblance to the chronically psychotic patients we had seen in the back wards of state hospitals. Nor did she look like the acutely psychotic, so-called paranoid schizophrenic patients who episodically heard voices, thought people were out to get them, entered the hospital, swallowed their Thorazine, and emerged, temporarily hallucination- and delusion-free.
“So what are you going to tell His Honor?” Jonathan challenged.
“I’ll tell him what her mother told me. She lives in a fantasy world with her imaginary friends. She hears voices.”
“And that’s why she’s violent, Dorothy?”
“No. I’ll explain to him that sometimes she’s paranoid. She misunderstands signals. She feels threatened. Then her voices tell her to defend herself. When that happens, she lashes out.” I stopped. As I listened to myself, I had to admit that I was making a pretty weak psychiatric case. I doubted that Jonathan felt much more confident.
I sat straight up, glowered at Jonathan, and, in my best Judge Lindsey voice, intoned, “Tell me, Professor, you’re a neurologist. Is she or isn’t she a Defective Delinquent?”
Jonathan smiled, recalling the story of my appearance before Judge Lindsey on behalf of Donna. Then Jonathan’s face became serious. He rose and looked directly at me.
“Your Honor,” he began, “there is no single, simple diagnosis that explains what this child did. Yes, Lee Anne Jameson has signs of brain damage. Her head is small and she does badly on I.Q. tests. She is not very smart. There are also indications that she may have a seizure disorder. To that extent, I guess, you might call her a Defective Delinquent. (Jonathan does not mince words.) But most brain-damaged people, most epileptic people, most retarded people, don’t murder. So why did Lee Anne?” Dramatic pause.
“Dr. Lewis, over there near the toaster,” Jonathan nodded in my direction, “has told you that Lee Anne is paranoid. She hallucinates. She hears voices. Sometimes she does what they tell her. Did they tell her to stab her friend? I don’t know and Lee Anne doesn’t remember. What we do know is that she was not in touch with reality that day on the bus when she stabbed her friend. She was not herself.” At that moment, neither Jonathan nor I appreciated the significance of those four words: she was not herself.
Jonathan stopped and thought. He continued. “But you know and I know that most crazy people don’t commit murder. So what was it about Lee Anne’s condition, about her situation, that caused her to lose control and kill her best friend? What secrets could she not tell us? What secrets would her mother not tell us? What secrets, too terrible for words, account for this inexplicable murder?” Jonathan was now interrogator as well as witness, judge, and jury.
Jonathan walked over to my kitchen table where the two volumes of medical records rested and lifted them. “Here they are. Here are the secrets. Thirty-two of them. Thirty-two times Lee Anne came to the hospital. Thirty-two times she tried to tell a doctor what was happening under her roof. But no one would listen. No one could hear.
“Lee Anne Jameson was abused; she was maltreated from the time of conception until the day of the murder. The record of her mother’s syphilis. The burns on her arms. The scars on her back, all bear witness to this abuse.” Jonathan was not finished. “But lots of kids are abused, and they don’t kill anyone. So how come Lee Anne did it?” Jonathan paused.
I stood up and, in a clear, confident voice, picked up the argument. “Maybe, Your Honor, just maybe Lee Anne’s violent household, maybe, just maybe Lee Anne’s brain damage, maybe, just maybe Lee Anne’s paranoia, maybe, just maybe Lee Anne’s voices telling her, urging her to pick up the knife, to protect herself, maybe, just maybe all of her impairments and all of her abusive experiences came together and made it impossible for her to control her behavior that day.” We both sat down. We were drained. But we were great witnesses, especially while testifying in my kitchen.
And that is what we told Judge Lindsey. Of course, we were not nearly so articulate. Courtrooms are scarier than kitchens. In court nothing comes out as smoothly and logically as it should. But somehow, together, without a hard-and-fast diagnosis, we made our point. We managed to convey to Judge Lindsey the way neuropsychiatric vulnerabilities and external events can come together in a child’s life, interact with each other, and cause an explosion of terror and rage. What is more, we were able to convince His Honor that Lee Anne Jameson needed treatment. She should not be sent to a reformatory.
In what seemed to be a compromise of sorts, Judge Lindsey found Lee Anne guilty of what, in an adult court, would have been labeled manslaughter, not murder. Best of all, as a result of our testimony, rather than dispatch her to Long Lane, the correctional school, Lee Anne was permitted to remain at the detention center while her probation officer tried to get her into a residential treatment center.
On the down side, it took the probation officer twelve months and about a dozen applications to find a treatment center willing to take Lee Anne. No place was eager to add a murderess to its population, even a small, skinny one. Eventually a fancy facility, out of state, accepted her. Ironically, Lee Anne was the only one among all of the children who came through the court that year who obtained such a therapeutic (and expensive) disposition.
Jonathan and I celebrated the news of Lee Anne’s acceptance at the treatment center by going out to dinner. “You know, Jonathan,” I thought aloud over dessert, “these days you’ve just got to kill to get good treatment.”
* * *
After dinner Jonathan and I parted, each convinced that we would not be working together in the foreseeable future or, for that matter, ever again. Jonathan would never again allow me to pull him into a murder case. As for me, I knew I would never again have the nerve to ask. But, of course, I did.