Chapter IV: The Malingerer: a Clinical Study (1)

I

The following study is undertaken less for the purpose of discussing the psychology of malingering than with the object in view of illustrating by means of clinical records the type of individual who malingers. The opinion is a general one that malingering is a form of mental reaction to which certain individuals resort in their effort to adjust themselves to a difficult situation of life. Being a form of human behavior, it should have been approached, therefore, with the same attitude of mind as any other type of behavior.

A perusal, however, of the literature on the subject, especially of the contributions of the older writers, reveals that with certain isolated exceptions the subject was viewed primarily from the standpoint of the moralist. Even today one sees in certain quarters a good deal made--certainly a great deal more than the facts would justify--of the "insanity dodge" in criminal cases. It is true that today, notwithstanding the still broadly prevalent tendency to view with suspicion every mental disorder which becomes manifested in connection with the commission of crime, the danger of error in this respect has been reduced to a minimum owing to the more advanced stage of psychiatry, and therefore the practical importance of the subject of malingering is not so great as it was formerly. We find, nevertheless, justification for the further study of this subject in the fact that, aside from its purely psychiatric importance, the more intensive study of the malingerer offers a solution for some of the important problems in criminology. As one of the results of this more intensive study may be mentioned the gradually-gained conviction that malingering and actual mental disease are not only not mutually exclusive phenomena in the same individual, but that malingering itself is a form of mental reaction manifested almost exclusively by those of an inferior mental make-up; that is, by individuals concerning whom there must always be considerable doubt as to the degree of responsibility before the law. As a result of this recognition cases of pure malingering in individuals absolutely normal mentally are becoming rarer every day in psychiatric experience.

The conviction was further gained that malingering as well as lying and deceit in general, far from being a form of conduct deliberately and consciously selected by an individual for the purpose of gaining a certain known end, is in a great majority of instances wholly determined by unconscious motives, by instinctive biologic forces over which the individual has little or no control. This is one of the factors which determines the growing realization among present-day psychiatrists of the extreme difficulty to state in a given case which is malingered and which genuine in the symptomatology. That such views should encounter opposition among our jurists is perfectly natural, threatening as it does with complete annihilation that wholly artificial concept of the "freedom of will" upon which our laws are based.

In touching upon the subjects of "responsibility" and "freedom of will" I incur the danger of adding to the general misunderstanding which still exists between the physician and jurist concerning crime and the criminal.

Speaking from personal convictions, I see no real justification whatever for this misunderstanding, unless it be the difference in the mode of approach to the subject on the part of the two. The jurist is compelled by existing statutes to look upon crime largely in the abstract--not as it concerns the individual who committed the deed, but as it is affected by the statutes covering it. The physician, on the other hand, sees in the criminal act a form of reaction to an intrinsic or extrinsic stimulus by a feeling, willing, and acting human being, and proceeds accordingly to analyze in a concrete manner the forces which brought about this particular form of reaction in this particular individual. As a result of this mode of approach to the subject he is enabled to conceive of "responsibility" as something fluid, something extremely variable, and which may be affected by a thousand-and-one things, and not as something absolutely fixed and invariable and which may be definitely foreseen by a set of statutes.

Any attempt to bring about this most desirable uniformity of approach to the subject of criminology between the jurist and the physician must be based primarily upon intensive study of the personality of the criminal. Such is the aim of this paper.

II

In the last analysis malingering is to be looked upon as a special form of lying, and its proper understanding will necessitate a clear insight into lying in general.

Lying, a very natural and generally prevalent phenomenon, may manifest itself in all gradations--from the occasional, quite innocent "white lie" as it occurs in a perfectly normal individual to the pathological lying exhibited in that mental state known as "pseudologia phantastica." Its proper understanding, however, no matter under what circumstances and to what degree it be manifested, will be possible only through a strict adherence to the theory of absolute psychic determinism.

Lying, like every other psychic phenomenon, never occurs fortuitously, but always has its psychic determinants which determine its type and degree.

Naturally many of these determinants are quite obvious and readily ascertainable. One has only to recall the lying and deceit practiced by children. But many others, if indeed not most of them, are active in the individual's unconscious motives and accessible objectively as well as subjectively only with great difficulty and by means of special psychological methods.

The degree of participation of unconscious motives in lying will be determined in the individual case by the extent of repression necessitated because of social, ethical, and aesthetic considerations. It is for this reason that lying is most prevalent and exhibited with the least amount of _critique_ in those individuals who either have never developed those restraining tendencies which a normal appreciation of social, ethical, and aesthetic consideration demands, or in whom these restraining influences have been weakened or abolished by some exogenous insult to the nervous system--as, for instance, the tendency to fabrication dependent upon chronic alcoholism or morphinism. A beautiful illustration of the latter type is furnished by General Ivolgin in Dostoieffsky's "Idiot."

The child's tendency to lying and deceit is dependent to a large extent upon the undeveloped state of those restraining forces. To state, however, that this is the sole mechanism underlying the phenomenon of lying would be to state only half a truth. For it is an undeniable fact that, no matter how strongly endowed an individual may be with ethical or moral feelings, still there comes a time when these are entirely forgotten and neglected; when, finding himself in a stressful situation, the instinctive demands for a most satisfactory and least painful adjustment, no matter at what cost, assert themselves. It is then that the lie serves the purpose of a more direct, less tedious gratification of an instinctive demand. The resort to this mode of reaction, to evasion of real issues for the purpose of gratification of instinctive demands, is not characteristic of man alone, but is quite prevalent even in some very low forms of life. We will have more to say about this later. It is an important tool in the struggle for existence among all living beings; it is one of the mechanisms by means of which the weaker inferior being escapes annihilation at the hands of the stronger, superior being.

Malingering, it will be seen later, appears to certain individuals to be the only possible means of escape from and evasion of a stressful and difficult situation of life. The lack of _critique_ which permits such an abortive attempt at adjustment and the inherent weakness and incapacity to meet life's problems squarely in the face which drives them to resort to such a means of defense are some of the traits of character which serve to distinguish these individuals from what is generally conceived to be normal man.

The extent to which lying and allied behavior depend upon unconscious motives has never been so well illustrated as in recent psychoanalytic literature, especially in a paper by Brill.[1] This author is so thoroughly convinced of the value of conscious lying as an indicator of unconscious strivings and motives that he frequently asks his patients to construct--artificially--dreams which he finds to be of valuable aid in the analysis of the patient's unconscious. After citing a number of examples Brill states: "These examples suffice to show that these seemingly involuntary constructions have the same significance as real dreams, and that as an instrument for the discovery of hidden complexes they are just as important as the latter. Furthermore, they also demonstrate some of the mechanisms of conscious deception. The first patient deliberately tried to fool me by making up what he thought to be a senseless production, but what he actually did was to produce a distorted wish. He later admitted to me that for days he was on his guard lest I should discover his inverted sexuality, but it never occurred to him that I could discover it in his manner. That his artificial dreams have betrayed him is not so strange when one remembers that _no mental production, voluntary or involuntary, can represent anything but a vital part of the person producing it_."

Were this thesis on malingering to succeed in nothing else than in bringing home to our legal brethren this important truth of absolute psychic determinism, that a man is what he is and acts as he does because of everything that has gone before him--because of ontogenetic as well as phylogenetic instinctive motives--it will have fully established its _raison d'etre_. For a realization of this truth would at once annihilate from our minds that deceptive notion of the "freedom of will" upon which our laws are based, and will be certain to bring about a more enlightened solution of the problem of the criminal, all attempts at which, we are constrained to state, have thus far[A] undeniably been huge failures.

[A] Intimate contact with members of the legal profession, both professionally and socially, for some years past has convinced me that the average lawyer still looks upon the ideas concerning crime and the criminal expressed by physicians of a forensic bent as totally unpractical and visionary. It would take only a brief visit to a criminal department of any modern, well-conducted hospital for the insane to convince any fair-minded individual that the physician handles the problem of the criminal not only in a more scientific and rational manner than does one not possessed of this particular training, but also in an eminently more practical manner, even so far as dollars and cents are concerned. I have frequently had patients come under my observation who for a great number of years had been oscillating between penal institutions and hospitals for the insane, in whom each additional sentence did not only fail to bring about the hoped-for reformation, but served to render them more depraved and criminally inclined, and who would have undoubtedly continued this checkered career throughout life, had not their true, unreformable nature been discovered and thus caused their permanent isolation from society, not by the jurist but by the physician. Should reformation ever take place in any of these individuals it is safe to assume that the one who was clear-visioned enough to discover the cause of their antisocial existence would likewise be competent enough to know when this cause has disappeared.

The psychic mechanism of lying is the same both in the occasional and in the pathological liar--in both it is the expression of a wish--but the difference in the personalities of the two is a very decided one. On the one hand we have an individual who closely approaches normal man, while on the other hand one who is closely allied to the mentally diseased. The difference between the pathological liar and the habitual criminal, aside from the moral phase of lying, is perhaps but a very slight one, when we keep in mind that in both instances we are dealing with individuals who habitually resort to a form of reaction in their attempts at adjustment to reality which aims at a direct, simple, and least resistant means for gratification. In both we are dealing with a type of mental organization which is primarily incompetent to face reality in an adequate, socially acceptable manner, and therefore has to resort to constant deceit and lying, and in which those inhibitions determined by social, ethical, and aesthetic considerations are equally impotent. The marked egotistic trend which constantly comes to the surface in the habitual liar when he attempts to play the part of the hero and central figure in the most fantastic, bizarre, and impossible adventures is likewise frequently at the bottom of the escapades of the habitual criminal. The two traits are frequently, though by no means always, concomitant manifestations in the same individual.

When, in 1891, Anton Delbrueck[2] published the first comprehensive study of the pathological liar, he not only succeeded in very accurately delineating a more or less distinct psychopathological entity, but also furnished additional proof in substantiation of the fact, well known in psychiatry but as yet unrecognized by the legal profession, that the transition from mental health to mental disease is not a sudden one; that any dividing line which would have for its purpose the strict separation of the mentally sound from the mentally diseased must of necessity be a purely imaginary one, and one not justified by existing facts.

The transition from absolute mental health to distinct mental disease is never delimited by distinct landmarks, but shows any number of intermediary gradations. Nowhere is this better illustrated than in the pathological liar. Here one sees how a psychic phenomenon regularly manifested by perfectly normal individuals may gradually acquire such dimensions and dominate the individual to such an extent as to render him frankly insane.

To endeavor, however, to definitely state where normality leaves off and disease begins would be, to say the least, to attempt something well-nigh impossible. And yet this is just what the jurist constantly demands of the alienist. The law as it is laid down in the statutes, especially in this country, does not permit of any intermediary stages between mental health and mental disease. An individual, according to law, must either be sane or insane. This point seems to me to be of very vital importance, and I shall have occasion to refer to it again in the consideration of our clinical material.

The part played in lying by disturbances of the apprehensive, retentive, and reproductive faculties will not be discussed here in detail. These undeniably have their influence in facilitating the mechanism of lying. But to attribute this phenomenon wholly to disturbances of this nature would be to assign to it a purely passive role, whereas experience teaches that back of every lie are active forces, either conscious or unconscious, which give birth to it and determine its type and degree.

The following two cases will illustrate better than any formal description could what is meant by pathological lying, a psychopathological state for which Delbrueck proposed the term "Pseudologia phantastica":

E. W. S., a colored male, aged thirty-two years, was admitted to the
Government Hospital for the Insane from Fort D. A. Russell, Wyoming,
on January 29, 1912, on a medical certificate which stated the
following: "Patient is a native of Porto Rico; has been sailor and
soldier; has occasionally used alcoholic beverages, but usually the
light wines or beer; is very good-natured, occasionally melancholy and
lachrymose; gave a history of 'fits', and was previously discharged
from the army on this account. He was thought to be 'queer' in his
organization and had more or less trouble with the men, who made fun
of him. He was sent to the hospital from the guard-house in October,
1911, and his mental condition noted at that time. His present
symptoms were described as delusions of grandeur: 'Queen Victoria was
his instructor in English', 'King Edward of England was his school
chum.' He thinks he was royal interpreter. He does speak a number of
languages fluently and, so far as we can learn, with fair correctness
(?)."

On admission to this hospital the patient was in excellent health
physically; Wassermann reaction with the blood-serum negative.
Mentally he was clearly oriented in all respects and fully in touch
with his immediate environment. He comprehended readily what was said
to him, and his replies, aside from his extreme tendency to
fabrication, were coherent and to the point. Intelligence tests showed
him to be intellectually about on a par with the average negro of his
social and educational status.

When asked to give his family and past personal history, he recited
the following: He knew nothing of his grandparents or parents, and
denied having any living sisters or brothers. One brother died in
Chicago in 1906; thinks he must have been murdered, because he himself
was almost murdered in November, 1911, when they attempted to
assassinate President Taft out in Wyoming. King Mendilic, of Cape
Town, Africa, now dead for seven years, was his cousin. The patient
himself was Prince of Abyssinia, where he reigned for eight years,
having remained in that country from 1896 to 1899, and conducting the
affairs of state the remaining five years by correspondence, with the
approval of Lord King Edward. He stated he was born in Porto Rico in
1876, and calculates his present age as thirty-four, as this is 1912.
About two months ago he received a letter from Queen Alexandra of
England telling him he was thirty-two years, ten-twelfths and two days
old, or thirty-two years, two months, two weeks, and two days. Asked
how much ten-twelfths of a year was, he said: "Three months, three and
two days." When told that ten-twelfths of a year equaled ten months,
he replied: "The calendar of the English era, which is 'our calendar',
does not correspond with the American calendar, but, being in America,
I believe I ought to figure from their standpoint." He left Porto Rico
at the age of six; does not know who took care of him up to this time,
as he never knew his parents, stating that he was just thrown on the
mercies of the country. At the age of six, upon the recommendation and
advice of King Alfonso of Spain, he was taken to England by Queen
Victoria, who came to Porto Rico especially for this purpose. When
asked his opinion as to why Queen Victoria should have taken so much
interest in him he stated that he did not know positively, but it may
have been because he was related to King Solomon of Bible fame.
Requested to explain this relationship to King Solomon, he traces it
in the following manner: He was a cousin of King Mendilic, who in turn
was the "third reigning seed" or stepson of King Solomon. Queen
Victoria, whom he calls "Mother Victor", because she took the place of
his mother, sent him to "Hammenotia School" in Oxford University,
which he attended for four and a half years, received his diploma, and
was transferred to Cambridge College. Here he attended for four years.
At the former school he learned the alphabet, went up to the seventh
grade, learned some medicine about herbs, etc. "I learned some
medicine, not all of it. I didn't practice it much; just practiced it
enough to do the country good. At that time we didn't have any
doctors." At Cambridge he learned "The Reigning of the Thornes", or
the laws of the country. Upon request he described in minutest detail
the city of Cambridge. When asked whether he remembered a large oak
tree which grew on the banks of the river flowing through the city, he
replied: "I should say I do; many a time I sat on the banks of this
river during my student days." Earlier in his student days at
Cambridge he learned German, French, and English. It should be
remarked here that the patient actually did know a few common phrases
in several languages which he picked up during his sailor days. But he
always insisted that he knew thoroughly twenty-two languages, and when
asked to enumerate these he found himself in deep water and was
obliged to invent the languages for the occasion. Nevertheless he
stuck to this story, and was always ready to launch upon the task of
enumerating his twenty-two languages.

After his four years' sojourn at Cambridge, Mother Victoria sent him
to "Saint Palestine", Jerusalem, where he remained for fourteen
months, learning the constitution of the country, by-laws, etc. Mother
Victoria and Father Edward (Queen and King of England) brought him up
so that he could properly reign over Abyssinia. He states that he saw
Queen Victoria frequently, and was at her funeral in August, 1910,
shortly after the death of Pope Leo. Lord King Edward died about three
months later. The Queen died about the age of seventy-six, as did King
Edward at the same age, from grief and senility. Here he adds that his
maternal grandmother was sister to Queen Victoria. While at the
English Court he held the position of "Prince of Escorts." He left
Jerusalem to go to school at Sydney, Australia, for one year. He then
went to sea on Lord Edward's naval reserve boat, which he had
permission to use. Remained at sea for three years and four months,
visiting China, France, Japan, Germany, Austria, Turkey, Italy,
Havana, Archipelago. When asked to repeat these countries, he omits
some of them and adds others.

He then came to the United States for the purpose of electioneering,
stump-speaking, etc., all to benefit the government. He then became a
United States interpreter in the Philippines from 1896 to 1902, at a
salary of $75 per month and expenses. He then returned to Porto Rico,
where he remained until 1910. Following this he attended the funerals
of Queen Victoria, Pope Leo, Lord Edward, and his cousin Mendilic, and
finally came to Chicago, where he enlisted as first-class sergeant in
the United States Army. He was sent to Fort D. A. Russell, Wyoming, to
serve in the Hospital Corps, at a salary of $48 per month and
maintenance. There everything went well until he got to worrying and
crying, so they sent him here. He acted thus because he was
ill-treated, was not treated right for a man of his abilities, was
sworn at too much, and called bad names by the enlisted men. They did
this because they were jealous of his "politicalness", his education;
he never swore, drank, or gambled like the others did. Was robbed of
his every possession in Cheyenne, Wyoming, by members of the Ninth
Cavalry and Eleventh Infantry. Lost $1400 in the past five months in
cash and property. They robbed him of his horse, buggy, clothes, and
jewelry, including chain, watch, finger ring, a pair of jasper
earrings. He could hear them talking about him day and night; feared
to leave his room, for he was continually threatened. They were going
to kill him. On this account he was taken to the hospital and kept
under close guard, because they could protect him. He had to leave at
night. He did so after having received a telegram from the
Surgeon-General of the Army, asking him to report to the Hospital
Corps at St. Elizabeth's Hospital, Washington, D.C. As one of the main
reasons why they had it in for him he gives the following: There was a
car line running from Fort D. A. Russell to Cheyenne, the fare being
ten cents. The men wanted it reduced to five cents. As the one in
charge of the canteen he had it in his power to approve or disapprove
of this reduction. He disapproved of it because he didn't think that
ten cents was an excessive charge for a three-mile ride, especially
since they spent so much money on drink, etc. He had a runabout motor
car, so they thought this was why he disapproved of it. "In
consequence they were on my trail." Part of the way to Washington he
came in a private car, but this they deprived him of at Omaha,
Nebraska. Perhaps they did this because they thought it was too large
for him, but, inasmuch as it was assigned for his private use, they
had no business taking it away from him.

During the recital of the foregoing the patient was bright and alert,
and his attention was easily gained and very well held. He quickly
understood everything that was said to him, and replies were prompt,
relevant, and coherent, though, of course, entirely colored by his
bizarre fabrications.

During his sojourn at this hospital he was a model patient in every
respect, worked diligently with a farm gang, though frequently
dilating upon the fact of having the responsibility of the whole gang
on his shoulders. On several occasions he gave evidence of being of a
highly sensitive make-up, becoming readily insulted, but he always
reacted to these real or imaginary insults in a mild and kind sort of
way, always preferring to go out of people's way rather than
retaliate. Hallucinatory disturbances were never manifested.

The story of his past life was gone over with him on a number of
occasions, but on each occasion he gave a different, highly fantastic
recital of his past adventures, always using high-sounding words and
phrases and high-sounding names, many of which he mispronounced. Many
of the words used by him were of his own coinage, if one were to judge
by the sound of them. He was always very pleasant and agreeable, and
enjoyed reciting his past immensely. In all these bizarre and
marvelous adventures he played the chief role and occupied the center
of the stage.

He was finally induced to give an explanation of his extreme love for
lying, which he gave as follows: "_It isn't because I don't know
better, doctor, but because I think it will make me feel better,
that's all. When I tell of all these big things it makes me feel that
I am a little above the common herd of negroes, and then I never tell
anything to hurt anybody._"

He stated that he couldn't really separate the true from the false in
his stories, and that he seemed to have little or no control over this
tendency to exaggerate things and to weave into real occurrences all
sorts of manufactured detail. "I know one thing, doctor; that it's
been a habit of mine all my life. I have always tried to exaggerate a
bit. It makes me feel, for the time being, that I'm above the other
negroes, that's all. I know I always try to make an honest living, and
this habit of mine never interfered with me."

A good deal more could be furnished from the records of this man's case in illustration of his pathologic disposition to lying. An ordinary negro soldier, he succeeds in projecting himself, by means of his ready and very fertile fantasy, into the most wonderful situations and in rubbing shoulders with royalty. If we inquire into the causes operative here we first of all see in the fabrications of this individual an unbounded craving for compensation for a natural deficiency--in this instance a racial deficiency. What this man lacks in reality he endeavors to substitute in his fantasy. There can be no doubt that the tendency to lie has reached such dimensions and intensity in this man's mental make-up as to make him absolutely believe in his own impossible fabrications, to render him absolutely helpless in the mazes of his fantastic creations. He is assisted in this by his craving for self-esteem, by his extreme need of compensation for a real deficiency, by his ready and fertile fantasy, one absolutely devoid of _critique_, by his extreme suggestibility, and, lastly, what is of great importance, by his extremely defective apperceptive faculties and consequent falsifications of memory.

The latter defect was particularly well illustrated in the following note from my records of the case. He was asked, in the course of my examination, to repeat a simple story known as the "Shark Story", which I shall reproduce here in full for the sake of making clear my point:--

"The son of a Governor of Indiana was first officer of an Oriental
steamer. When in the Indian Ocean the boat was overtaken by a typhoon
and was violently tossed about. The officer was suddenly thrown
overboard. A life preserver was thrown to him, but on account of the
heavy sea difficulty was encountered in launching a boat. The crew,
however, rushed to the side of the vessel to keep him in sight, but
before their shuddering eyes the unlucky young man was grasped by one
of the sharks encircling the steamer and was drawn under the water,
leaving only a dark streak of blood."

In reproducing it he said:--

"The son of a Governor of an Oriental steamer was the captain. Now,
doctor, I can't think of those little stories. It isn't because I
haven't brains enough; it's because I'm so poor a scholar at reciting.
I always was." "What happened to the captain?" "That I can't
recollect, neither." "What happened to the ship?"

Here, instead of answering my question, he said: "Doctor, I suppose you have heard about the big wreck that happened out on the ocean." (This was when the terrible _Titanic_ disaster was on everybody's lips and the papers were full of the tragedy.) The patient regularly read the papers. "Tell me about this wreck."

"Well, the steamer was 1200 miles from the land--north-northerly
course. It was first reported that 1800 lives were lost; afterwards
they found out for certain, through the communication with General
Wood, that it was only 1300. Mrs. Zelia Smith, she was on the vessel."
(Patient's name is Smith.) "She is Commissioner Hodges's daughter. She
was counted lost, for instance, and was found alive. I knew her well;
I knew a good many other people on that boat." "About how many people
did you know?" "Well, I just only remember some. For instance, Major
B----; I knew him well, of course. I dare say I knew all the others,
but I knew him best. The boat was in charge of E. C. Smith." "Did you
know Captain Smith?" "Yes, sir; I knew him. I didn't know him
personally; I only made one voyage with him from Angel Island." "When
was that?" "In 1907." "What was the name of the wrecked ship?" "I
can't recall that, neither; _Tripoli_, I think it was; she is close on
1500 feet long." "How much money was she supposed to be worth?" "I
don't know, sir; there were several heirs who had charge of the ship.
She was called the sister-ship _Trinic_ and was worth about $25,000.
That, perhaps, may not cover her upper-deck cabins." "Did you ever
travel on her?" "No, sir; I never was on her. I was on the _Trinic_,
the sister-ship. The White Star people own these boats. I used to run
a transport between the White Star Line and the Yellow Star Line."
Here he was told that the examiner did not know of the existence of a
Yellow Star Line, and he replied: "Oh yes, doctor; you heard of the
Flying Squadron that reports all these disasters and signals the other
ships."

Thus we see that with partial truths, with facts only partially and imperfectly recalled as a framework, he builds his fantastic tales. He read the newspapers regularly, but could not even recall the name of the ill-fortuned ship, or any particulars about the accident. But what of that?--he could readily fill in the hiatuses with his fabrication. He failed entirely in the attempt to reproduce the story given him, and used the talk about the _Titanic_ disaster as a subterfuge--as a ready means of escape from the difficulty in which he found himself.

He himself threw some light upon the part played by his craving for self-esteem in his statement: "When I tell of all these big things it makes me feel that I'm a little above the common herd of negroes." He unquestionably believes in these tales, if they are real enough to make him feel above the common herd of negroes. His suggestibility was well illustrated by the suggested river at Cambridge, "on the banks of which he sat many a time during his student days."

The facility with which his imagination, his fantasy, works was demonstrated by the "ink-blotch" test to which he was subjected. This test, in brief, consists of a series of ink blotches which are shown the patient, with the request to describe them as they appear to him. The following are several of his replies: (1) "A woman sitting on a man, seems like she's got a little weaving in her hand; a little stick, sticking out from the weaving, seems like the man's elbow is sticking out back of the shawl." (2) "It seems to me I have seen a volcano that looks like that. I think it is a ship out at sea. I can see the lifeboats lashed to the side, several ripples of water behind." (3) "A figure of a woman with a hand purse or a disfigured arm near the wrist. Her mouth is open and she is looking around. The wind carried her hat off; she has a muff on her right hand. Seems like there is a neck-piece around the muff."

Notice the detail with which he describes the blotches. In this one ordinary speech seemed to have been insufficient to describe the blotch, and he had to resort to a neologism. "Is that supposed to be a 'perpendicament'? It's got a head like a sea devil; the upper part seems like a peacock trying to peck him in the back of the head."

There remains one other thing to be inquired into in this case, and that is the history of epilepsy which accompanied the patient. He was never observed in an epileptic seizure at the military post from which he came to us, and no seizures were observed in this hospital. His own statements concerning this are, like everything else he said, quite totally unreliable. But in repeated examinations he persisted in his statement that he had had but one "spell" in his life, but that he frequently suffered from fits of melancholy. In all probability this one seizure was hysterical in nature, phenomena of which type not infrequently manifest themselves in the pathological liar, as will be seen in the next case.

Here one sees how lying, a mental phenomenon which is looked upon as quite a normal manifestation in a great many people, has reached such dimensions in this individual and has succeeded in dominating his personality to such an extent as to definitely remove him out of the pale of normality and place him within the sphere of the mentally diseased.

There is, of course, no question here about the genuineness of his lying as a symptom of mental aberration; _i.e._, the fabrication as manifested by this individual is something over which he has no more control than the dementia praecox patient has over his delusions. In both instances the symptoms are spontaneous and genuine expressions of a pathological mentality. And yet when such pathological phenomena become manifest in association with some concrete difficulty in the individual's life, say in connection with a threatened punishment for a crime committed, the genuineness of the symptoms is frequently doubted.

One, of course, can readily see with what facility an individual of the type under discussion could malinger mental symptoms. Reality and fiction have about identical values in this type of mental make-up, and it is frequently impossible to separate the genuine from the fictitious in their mental productivity.

It is likewise quite easy to divine why an individual of this sort would resort to malingering in his effort to extricate himself from a difficult situation which he is organically unable to meet squarely in the face. On the contrary, it would be strange indeed were an individual of this type to refrain from resorting to this form of defense. Of course, even the man whose history we have just quoted may still be considered mentally responsible before the law were we to judge him by the legal standards of responsibility. But as physicians we need not on this account refrain from attempting to delineate these mental types in their true colors.

The situation is well illustrated in the following case. Here the symptom of pathological lying is associated with pathological swindling and criminality and offers a fertile field for seeds of malingering.

E. D. C., a white male, aged thirty-four, came to us on April 16,
1914, from the penitentiary at Stillwater, Minn., where he was serving
a sentence of ten years for white slavery. He was admitted on a
medical certificate which stated that his father was supposed to have
died from pulmonary tuberculosis. The patient gave a history of
epilepsy until fourteen years of age, likewise of having been a
patient in a Vienna hospital for the insane for one and a half years,
in 1900 and 1901. So far as was known to the prison authorities, he
was mentally depressed and had delusions since his arrival at the
Minnesota State Prison on October 11, 1913. The present symptoms were
described as mental depression; says that everybody is persecuting
him; also has the delusions that he has or can invent a wonderful
electric machine which he wants to sell to the government for a
hundred million dollars; said he would shoot himself and die in
prison. Physical condition was not good. Patient suffered from
obstinate constipation, peculiar shuffling gait, suggesting partial
loss of control of legs and feet. Complained of constant headache on
the top of his head. No fever.

On admission to this hospital the patient was in poor physical health
and very anaemic. He was quite slender in stature and somewhat
effeminate in manners and speech. He walked with a very marked limp of
the right leg, stating that he had been afflicted in this manner ever
since his first attack of mental trouble at the age of nineteen.
Patellar reflexes were markedly exaggerated on both sides, the left
more so than the right, and ankle clonus was present on the left side.
Babinski phenomenon was absent. While the reflexes were being tested
he volunteered the information that his left patellar reflex was very
much stronger than the right. He was a very glib talker and spoke
fluently in five foreign languages. He gave his name as E. J. B.,
Count de C., the son of the chamberlain to the Austrian Emperor and of
a famous Austrian countess. In the official papers which accompanied
him to the hospital the above name was followed by several aliases. He
talked in an affected, whining manner, constantly complained of
various bodily ailments, and showed a marked tendency to
hypochondriasis. He spoke of himself as a poor, down-trodden, and
persecuted unfortunate who is being constantly misunderstood. The
whole "white slavery" episode for which he is unjustly made to suffer
ten years' imprisonment was a trumped-up affair on the part of the
sheriff, who was bound to make a case out of it. He married the girl
with the best of intentions, and when arrested was with her on the way
to the Atlantic coast, preparatory to sailing for Paris, where he
intended to give her a splendid time. She testified against him at the
trial because she was scared into it by the officials, and, being
naturally of a weak nervous organization, she gave in. He was certain
he was going to die if he had to serve out his sentence, because
prison life is so different from the life he has led in the past. He
is entirely too refined to be able to stand the rough life of
imprisonment. Referred the examiner to the Austrian Embassy, which
could readily establish his noble descent and get him out of this
terrible predicament. When, later in his sojourn here, he was
interviewed by several gentlemen from the Austrian Embassy he
maintained the same attitude of wronged innocence, notwithstanding the
fact that these gentlemen confronted him with an undoubtedly genuine
photograph of himself, obtained from the Austrian police. It seems
that he was quite a famous character in Austria, and had served a
sentence there under a different name for a similar offense (white
slavery). Soon after his arrival at the Government Hospital for the
Insane he began to scheme for his escape, and on one occasion
attempted to saw the guards in his room with an improvised saw. He
likewise began to associate freely with the more dangerous element of
the criminal department of this hospital, quite likely with a view
towards getting assistance for his escape. He spoke with reluctance of
his ideas concerning the inventions, adding that he had decided to
quit talking about these things, because, although he is quite
convinced of the extreme value of these original ideas of his, people
have told him he was crazy wherever he expressed them. As an
illustration of some of these extremely valuable original ideas the
following may be mentioned. It concerns a bed-bug trap which he
invented, and which he described as a paper pocket which is placed in
the bed and scented with oil of pine so as to attract the bed-bugs.
These make their home in this paper pocket and lay their eggs there,
after which it is removed and burned. In the course of time (about two
months) he fully recovered from that serious leg affliction from which
he stated he had been suffering since the age of nineteen.

When an attempt was made to obtain his past history it was soon
discovered that it was so fantastically colored with fabrications as
to be entirely worthless, so far as a reliable account of his past
life is concerned. As an instance of pathological lying, however, it
was a masterpiece. He was requested to write out briefly his past life
history, and in this abbreviated form it covered twelve
closely-typewritten pages. We will not burden the reader with a
complete reproduction of his story, although I assure you it makes
very interesting reading material, but will simply review it briefly.

He speaks of the confession made to him several years ago by the lady
whom he had always looked up to as his mother. She told him that she
was only his foster-mother, and that in reality he was the son of the
Austrian chamberlain and a famous countess. The latter turned him over
into this lady's care when he was quite young, following her divorce
from the chamberlain. She furnished him with the authenticated proof
of the fact that he was entitled to a fabulous fortune left by his
parents. Unfortunately the lady died after a brief illness, during
which he practically sacrificed his life to save her, and thus his
most important witness is forever inaccessible. The papers which could
readily prove his noble descent were, most unfortunately, taken from
him when he was arrested and are probably destroyed by this time.

His foster-mother, he states, was regularly supplied with funds by his
real mother, gave him an excellent education and traveled with him
extensively. In a plea for clemency he dwells upon the fact that his
father died insane, that he himself suffered from epilepsy in his
youth, and that at the age of twenty he spent a year in an insane
asylum in Austria.

As an instance of his tendency to dramatization, of the part his ego plays in the recital of his past exploits and of the tendency to crave sympathy and compassion, a characteristic quite common to these pathological swindlers, the following, his own description of the circumstances which brought about his admission to the Vienna Insane Asylum may be quoted:--

"While on vacation, I met at Wertersee, which is a fashionable summer
resort, a girl with the name L. Adle von D. I had left my tutor
behind. She was the first girl I met, and my romantic character, my
easily-excited nervous system, overpowered me and I fell in love, in
love as deep as a man can fall. A few months after that I was engaged
to her, and we should have been married on the 23d of April, 1899. On
the 22d of April my beautiful beloved bride was riding horseback with
me in the park, when at once her horse frightened, threw her off,
dragged her for a distance and then left her behind, a motionless,
bleeding mass. I saw right away that she was dead, lost to me, lost
forever; there was but one way not to lose her, and that was to follow
her soul, and that as quickly as possible. There in the park beside
her I took my pistol and shot myself. The public had gathered and
stopped me, and then I don't know what happened. I only remember that
I was ill for a long time, and then I was ill again, and they told me
L. was alive, and then I found out that she was not alive and I was
ill again."

Of course, the entire episode is a fabrication. The patient admitted quite as much, but the interesting thing in this episode is the fact that it illustrates how rigidly dependent lying is upon unconscious motives. Had this episode really taken place, the patient, because of his particular make-up, would have acted, in all likelihood, just the way he behaved in his fantastic adventure.

After his year's confinement in the insane asylum his foster-mother traveled with him in France, England, Egypt, and Turkey, in order to divert his mind. Finally arriving at Transylvania, he became infatuated with a poor girl named P., whom he christened L. in memory of his former love, and married. The highly dramatic adventures of this second matrimonial venture are altogether too numerous to describe in detail. He describes in a very dramatic style how this lady was kidnapped from him by a family of New York artists and spirited away across the ocean; how after awakening from his unconsciousness, induced by some dope administered to him in a tea which he had with these artist-friends the night before, he at once made for the dock, arriving there just as the ship carrying his wife was disappearing from sight; how he pursued them across the Atlantic, to England, the continent, and so on, finally locating them in Cape Town, South Africa; how upon arriving there he was mortally wounded to find his beloved wife performing upon the stage of a cheap, dirty place. An excerpt from his description of this eventful voyage is as follows: "We passed Las Palmas, Asuncion, and St. Helena. Christmas and New Year's were celebrated on board the ship, but I did not care much for it. I was too much in distress. Would I find her there? Would I reach her in time? How would I find her? Would she be alive? My excitable fantasy awakened in me the most terrible suspicions. I suffered dreadfully, and it seemed to me we would never arrive. But we did at last, and some time in the beginning of January, 1906, I landed in Cape Town." This is how he discovered her: "I knew I was going to see something terrible, but I remained there--I had to. There were the rope dancers, the clowns, and the music, but I had no interest in them. I was waiting for L., my wife, and she came. On a small, mean stage L., my beloved wife, appeared with painted cheeks and shining eyes, dressed up in tights. She was dancing a mean dance and singing an obscene song before an audience consisting mostly of drunken sailors. So I found my wife L. and the music played. It was surely wonderful that I could control myself at such a moment. At once it seemed to me that I had no reason to be astonished. I was quiet and decided and waited until the show was over, and after the show I went behind the stage, and when my wife came out, laughing and happy, with a couple of other girls, I stepped near her and said simply 'L.' She gazed at me and fainted." Thus he finishes another tableau in his adventurous career. Several other similarly dramatic adventures follow in his history, the last of which landed him, wholly unjustifiably, in prison for ten years. When asked why all his love adventures ended so disastrously, he replied: "Doctor, all my life I have been suffering from a 'superaltruistic monomania to help girls in distress,' and that is how I'm repaid."

Any discussion on "freedom of will" and responsibility in connection with an individual of this type is, of course, quite futile and really of no practical importance. This man ought to be permanently isolated from the community, but not because he happens to have violated a given statute, but because his grave mental defect--in all probability an incurable defect--tends to express itself in criminal traits.

Back of this fantastic lying we see again that instinctive craving for compensation by means of a resort to the imagination and fantasy, a subterfuge rendered easy by those inherent defects enumerated in connection with the preceding case.

All the frankly psychotic manifestations, such as his delusional ideas and his grave affection of the lower extremity which served to put him in a hospital for the insane, were, of course, entirely malingered.

This brings us to the subject of malingering proper.

III

In malingering we see the application of deceit and lying to a definite situation. That which is a habitual type of reaction in some individuals, as was illustrated in the foregoing cases, comes to the fore in others only under certain stressful situations of life. While in the habitual fabricator the most prominent motives are those of an egotistic nature, a craving for self-esteem as compensation for an inherent defect, in the malingerer we see a resort to this form of reaction as a means of self-preservation, as a means of escape from a particularly painful situation.

There was a time in the history of psychiatry when malingering was a frequent subject of discussion in psychiatric literature. This was due not so much to any inherent practical importance of the phenomenon of malingering as such as to the faulty conception that this phenomenon was something which by its very existence ruled out the existence of mental disease. More scientific studies of personality which led to a direction of our attention to the malingerer rather than to malingering as an isolated mental phenomenon brought with it a complete change of attitude towards the entire subject.

Today, far from harboring the notion that malingering and mental disease are mutually exclusive, we are beginning to look upon malingering itself as the expression of an abnormal psychic make-up. Furthermore, far from believing, as of old, that the proverbially insane is supposed to be totally devoid of discretion in his conduct, we know that there may be a good deal of method in madness, and that even the frankly insane malinger mental symptoms when the occasion requires it. No experienced psychiatrist would today, for instance, consider the oft-quoted story of the alleged madness of Ulysses as evidence of malingering.

The story is told that Ulysses, in order to escape the Trojan war, feigned insanity. He yoked a bull and a horse together, plowed the seashore, and sowed salt instead of grain. Palamedes detected this deception by placing the infant son of the King of Ithaca in the line of the furrow and observing the pretended lunatic turn the plow aside, an act of discretion which was considered sufficient proof that his madness was not real. Without attempting to pass upon the case of Ulysses, we may say without fear of contradiction that no one would today depend upon such criteria. Experience teaches us that an individual may be very seriously mentally affected and at the same time show sufficient discretion of conduct to avoid threatening danger and to seek those means which best subserve his immediate needs and wants. Not only is this true, but we have arrived at a stage where we are prone to look upon a great many of the psychoses as the direct expressions of the individual's wish--as a haven sought out by himself within which he seeks shelter from the tempests of life. One of my patients tells me that the gun which he used in the alleged homicide was not loaded with bullets, but with paper wadding put there by his enemies, hence his alleged victim could not have been killed; in fact, he knows that this man is alive and having a good time on the money furnished him by his, the patient's, enemies. Another instance is that of a colored man who is serving a life sentence for murder. Among the many symptoms which this fairly advanced dementia praecox case shows is the one that he considers himself a white man; that his dark color is due to some paint which he used in order to disguise himself; and that, inasmuch as the murder with which he is charged was supposed to have been committed by a colored man, he is not guilty of it. The motives here are quite obvious. Both these individuals find life much more bearable believing, as they do, in their innocence of the crimes imputed to them. Many other examples could be cited to prove that symptoms in mental disease do serve a definite purpose; that there may be indeed considerable method in madness.