The Patient Was…

The patient was a middle-aged man whom I, as a medical student, encountered in a secure setting at the Manhattan Psychiatric Center. I was one of a group of about forty students who were bused from our school campus on the Upper West Side of Manhattan, in New York City, to Ward’s Island in the middle of the East River separating the boroughs of Manhattan and Queens. The area had a long and somewhat ignoble history as the former site of Blackwell’s Island Lunatic Asylum and The New York Asylum for the Insane that opened in 1863, but was now the respected Manhattan Psychiatric Center, an inpatient facility for mental patients.

We were there as part of our clinical exposure to the specialty of Psychiatry. The Center housed patients with various psychiatric illnesses of varying degrees of severity, but the common denominator was that they were regarded as unsafe to be allowed out in general society. Some had criminal histories, some did not, but all were confined.

The Professor of Psychiatry in charge of the facility and responsible for our educational experience during our brief time at the Center was an individual whom I shall call Dr. 123 4567, reflecting the correct number of syllables in the name but maintaining the doctor’s anonymity.

The patient selected for our interaction had a form of dementia called General Paresis. Fairly rare now, due to better recognition and earlier treatment of its cause, but commoner in earlier times, the condition is due to tertiary or late-stage syphilis of the brain. A published description of the symptomatology of the disease includes ideas of great wealth, immortality, thousands of lovers, unfathomable power, apocalypsis, nihilism, self-guilt, self-blame, or bizarre hypochondriacal complaints. Our patient manifested primarily delusions of grandeur, perhaps the most typical symptom.

We had been brought to an indoor amphitheater, a tiered lecture hall, and on the stage down in the front was a desk at which sat Dr. 123 4567. Expressionless, imperious, intimidating, the doctor radiated confidence and authority. The patient had not yet made an appearance, and we students were nervous as a group, aware that within the institution resided some dangerous individuals, and not knowing what to expect.

Dr. 4567 made a few introductory remarks, explaining a bit about General Paresis, its origins and symptomatology. Then, the doors at the high back of the amphitheater opened and our patient slowly entered. He paused for a long moment, regarding us below him in the auditorium with evident disdain, and  dismissed with a wave the uniformed attendants on either side of him who stepped away as if programmed.

The patient slowly made his way down the central steps that divided the two sections of the auditorium. If the doctor at the front was imperious, the patient was regal. We in our seats didn’t know how these two were going to interact, but the tension was palpable.

The patient reached the bottom of the auditorium, stepped up onto the stage, merely nodded at Dr. 4567, turned to us, and began to give an account of himself that was so utterly fantastic that we sat in silent awe. The life he described, the untold riches, the glamour, the power, the privilege, the brilliance  —  it was all too fantastic. And it went on, and on, and on.

Finally, Dr. 4567 spoke up gently and said that we had heard enough, that we appreciated the patient’s presence, but that it was time for him to leave the stage. The patient ignored the doctor and continued his oration. Dr. 4567 spoke up again, louder and more forcefully. The patient again did not react or stop speaking. Finally, the doctor half rose from a seated position, and basically ordered the patient to stop speaking and to leave the theater. The patient looked at the doctor with contempt, faced us again, and continued to regale us with fantastic stories.

At this point the doctor signaled to the two attendants who had remained quietly at the top of the amphitheater. They started to walk slowly down the steps toward the stage. The patient saw them, looked thoughtful for a moment, then stopped talking. He looked at the doctor condescendingly, slowly stepped down from the stage, and began to walk up the center aisle to meet the attendants coming down. They joined him as he continued up to the rear of the auditorium. We students were watching it all unfold, mouths agape.

The patient reached the top of the amphitheater, attendants now on either side of him.  He turned to face the stage where the doctor now stood, in seeming control of the situation. The patient raised his right arm, as if to bless us all. Then, just before exiting the theater, he uttered, in stentorian tones, the most memorable final words I have heard in my medical career.

“Dr. 123 4567…F–K YOU!”