Chapter IV: The Malingerer: a Clinical Study (2)

Nevertheless, the observation is not uncommon that whenever such method is detected under circumstances where some ulterior motive may be ascribed to it the lay mind, and not infrequently psychiatrically-trained physicians, are at once ready to question the genuineness of the symptoms. It is the more curious that the so-called "insanity dodge" cry is frequently raised under circumstances where it would seem to be the least justifiable, as, for instance, in the case of an individual battling for his life before the bar of justice.

A little inquiry, however, into this phenomenon will help us to understand it better. It has its root primarily in that very common tendency of man to impute to his neighbor a type of behavior, a form of reaction, of which he would gladly avail himself were he in his neighbor's place, and the weapon he would use under the circumstances would very likely be that exquisitely human trait, deceit, malingering. It is a weapon which has played a tremendous part in the evolutionary struggle, not only of man but of all living things; in a broader sense, it may be looked upon as an organic function, as an endowment, thanks to which the weak, inferior being is able to avoid the danger of becoming the prey of the stronger, superior being. This function is very well illustrated in those animals which are able to acquire the color of their immediate surroundings in order to render themselves more difficult of detection. It is common among various insects, reptiles, and amphibians. The chameleon may be especially mentioned in this connection. Even the eggs acquire, in the process of natural selection, the color of the place where they are deposited, and the cuckoo which is about to cheat a couple of another species by placing her eggs in their nest for them to hatch selects that species the color of whose eggs most closely resembles that of her own, in order to assure herself of the success of the deception. The simulation and malingering practiced by the fox is common knowledge. Malingering, an instinctive function originally, has, in the process of evolution, become an act of reason with certain animals. One is forced to believe, from a survey of mythological writings, that primitive man must have had recourse to simulation and all else that this term stands for whenever he was confronted with an especially difficult problem in his struggles for existence. To the gods was attributed, among other special propensities, the ability to assume any shape or form, else how could they have performed all those miraculous escapades? Thus we are told that Jove transformed himself into an eagle when he carried off Ganymede. Achilles, the son of a goddess, sought to avoid the iniquitous fate which drove him to Troy by disguising himself as a woman. Deception is a common weapon of defense with the savage and with the inferior races of today. It is the tool by means of which these individuals render things as they want them to be; it is with them the means for a more direct, less difficult, less tedious solution of the problems of life.

The child in whose development the various steps of phylogeny are recapitulated shows this tendency to deception, to simulation, and dissimulation in a very pronounced degree. Lombroso, who was the first to demonstrate that so-called moral insanity is but a continuation of childhood without the adjunct of education, cites many facts, not excepting his own example, to show that the child is naturally drawn to fraud, to deception, to simulation. The child simulates either because of fear of injury and punishment or because of vanity or jealousy. Ferrari,[3] in his excellent work on juvenile delinquency, discusses the various motives for deception and malingering in the child. According to him, deception is, first of all, instinctive with the child. It malingers because of weakness, playfulness, imitation, egotism, jealousy, envy, and revenge. Deception frequently forms for it the only available weapon of defense against the parents and teachers.

Penta[4] cites many well-authenticated cases of malingering of mental symptoms in children. Of special interest is Malmstein's case of a girl of eight years who, in order to deceive her father and render him less severe in his treatment of her, and in order to gain the sympathy of those in the house who were in the habit of giving her sweets, feigned complete muteness for five months, after which time, no longer able to resist the desire to speak, she went into the woods, where, believing herself unobserved, she began to sing. St. Augustine, in his confessions, speaks of his childhood in the following manner: "I cheated with innumerable lies my teachers and parents from a love of play and for the purpose of being amused."[B] Penta, after a thorough discussion of the subject of malingering in children, comes to the conclusion that children use all the diverse forms of fraud, from simple lying to simulation, much more frequently than is believed or known. It may with them as with some lower animals simply be an instinctive playfulness, a habit or a necessity, as a weapon consciously and voluntarily wielded. This inherent tendency is, of course, modified to a considerable extent by the environment under which the child was brought up. Finally, the independence which the growing human being acquires from this form of reaction is in direct proportion to the ability he has acquired through education and precept to meet life's problems squarely in the face. We will see, later on, how the type of individual who is most likely to malinger has in reality never fully outgrown his childhood; that his reactions to the problems of everyday life are largely infantile in character.

[B] Cited by Penta.

Thus we see that malingering has its _raison d'etre_; that, after all, it is not at all strange that the suspicion of its existence should be so frequently raised by our legal brethren--yes, and medical brethren, too; that in reality it ought to be a very common manifestation. Nevertheless, paradoxical though it may seem, cases of pure malingering of mental disease are comparatively rare in actual practice. Wilmanns,[5] in a report of 277 cases of mental disease in prisoners, cites only two cases of pure malingering, and in a later revision of the diagnoses of the same series of cases the two cases of malingering do not appear at all. Bonhoeffer,[6] in a study of 221 cases, found only 0.5 per cent of malingering. Knecht,[7] in an experience of seven and a half years at the Waldheim Prison, did not observe a single case of true malingering. Vingtrinier[8] claims not to have found a single case of true malingering among the 43,000 delinquents observed by him during his experience at Rouen. Connolly, Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted by Penta as having expressed themselves that pure malingering is extremely rare. Penta, on the contrary, observed about 120 cases during his four years' service in the prison in Naples. He gives as the reason for this unusually high percentage of cases observed by him the fact that two-thirds of the inmates of the prison belonged to the Camorra, an organization whose members are gleaned from the lowest and most degenerate stratum of society, and in whom the tendency for deception and fraud in any form is highly developed.

The question naturally arises, What is the reason for this rarity of cases of malingering? Is it because man has reached a state of civilization where he no longer resorts to deception? Decidedly not. The reason lies almost wholly in our changed attitude of today towards this question. As we acquire more real insight into the workings of the human mind we are prone to become more tolerant towards the human weaknesses, and in our study of the malingerer it is the type of individual, his mental make-up, which interests us most, rather than the malingered symptoms. It is for this reason that today the number of authorities is indeed small who do not look upon malingering _per se_ as a morbid phenomenon, as an abortive attempt at adjustment by an individual who is quite incapable of adequately coping with the vicissitudes of life. In my own limited experience of several years with insane delinquents I have yet to see the malingerer who, aside from being a malingerer, was not quite worthless mentally.

Our discussion of malingering,--_i.e._, of the exhibition of a fictitious mental state by an individual for the purpose of rendering more bearable or more pleasant a particularly painful or difficult situation of life, or for the purpose of entirely annihilating such a situation and of removing it from consciousness by substituting for it a state of affairs wholly created from the individual's fantasy,--would indeed be incomplete if we were to omit from our consideration at least that much of Freud's psychology as pertains to this subject.

Thus far we have considered principally the views of what may be termed the descriptive school of psychiatry, though we have briefly touched upon the instinctive biologic roots of this primitive mode of approach to the problems of life, malingering of mental symptoms.

With the consideration of the Freudian psychology we enter upon the interpretative phase of psychiatry and to a very large extent of mental life in general.

Freud holds that a great part of mental life can either partially or entirely be summarized under two principles, which he terms the "pleasure principle" and the "reality principle" respectively.[9] These two opponents are constantly facing one another in our inner life. The former represents the primary, original form of mental activity, and is characteristic of the earliest stages of human development, both in the individual and in the race; it is, therefore, typically found in the mental life of the infant, and to a less extent in that of the savage. Its main attribute is a never-ceasing demand for immediate gratification of various desires of a distinctly lowly order, and at literally any cost. It is thus exquisitely egocentric, selfish, personal, and antisocial. The activities of this "pleasure principle", however, constantly come into conflict with the "reality principle." The rigid requirements of our environment, of the social system in which we live, deny us the fulfillment of many, if not most, of our most dearly coveted desires, without, however, being able to abrogate these entirely.

There are two ways in which these forbidden desires may become satisfied. On the one hand, the instinctive striving, finding it quite out of the question to gain expression through the desired channels, may become sublimated into a form which is in accord with our social and ethical requirements, or the forbidden strivings and desires may find gratification in the individual's fantasy. We are here particularly concerned with the latter mode of psychic adjustment. This mode of adjustment is the usual way in which conflicts with reality are solved by the child and the savage. For them a rigid recognition of reality, such as is necessitated by the normal adult in his struggles for existence, does not take place. In fact, the evolution from childhood to adult life, from savagery to civilization, consists in nothing else than in the progressive recognition of reality and the adjustment thereto. One of the forms of getting away from reality, or a falsification of conditions as they actually exist, was expressed by one of Freud's patients as the "omnipotence of thought" (_Allmacht der Gedanken_). It is a state of mind in which the individual believes in the omnipotence of his thoughts; that his mere thinking possesses tremendous power; that no sooner he thinks of a certain deed than the same is accomplished; that an enemy, for instance, is actually harmed by merely wishing him harm. This mode of thinking forms the basis for many magic ceremonials. It is this latter mechanism,--_i.e._, the endowment of one's own thoughts with an omnipotent power,--which is also frequently illustrated in malingering. It is sufficient for the type of individual who malingers to merely say the word, and the most fantastic creation of his fancy immediately becomes a reality and is apperceived by him as such. A mere verbal denial of guilt on his part is sufficient to make him believe fully in his innocence and act accordingly. When we inquire into the origin of this facility in transforming fantasy into reality, for this omnipotence of the mere word or thought, we find it in the totally unreasonable overcompensation of these individuals for their feeling of impotence and weakness. This feeling of weakness and helplessness naturally becomes more acute under especially stressful situations of life, and hence it is that the criminal, especially the habitual criminal, who always uses deceit and simulation in his vain attempts at meeting life's difficulties squarely in the face, regularly resorts to malingering when confronted with a serious criminal charge or when life in prison becomes especially unbearable to him. A good illustration of an attempt at falsification of reality for the purpose of annihilating a particularly stressful situation by means of a mere assertion of a state of affairs such as he would wish them to be, with a total disregard for the real facts which constantly stare him in the face, is furnished by the following case:--

M. came from a good family and led a normal life, earning a
substantial livelihood as printer up to the age of about thirty-eight.
At this time one of his children died, and this, together with poor
physical health, is said to have brought on a severe depression,
during which he was actively suicidal and very self-accusatory.
Several months later he lost another child by fire, and at this time
also claimed to have obtained positive proof of his wife's infidelity.
His mental depression became very much more aggravated; he attempted
suicide on a number of occasions, was very suspicious and
apprehensive, developed persecutory delusions, feared he was going to
be burned to death or suffer some other horrible fate. This condition
finally necessitated his admission to the Government Hospital for the
Insane on May 28, 1897, at the age of forty. Here he gradually
improved, and was discharged into the care of his father on
October 22, 1899.

On February 19, 1903, he was readmitted as a D.C. prisoner, having shot and killed a man who seduced one of his daughters. Some idea concerning the type of individual we are dealing with here can be had already when we keep in mind his mode of reaction to the various stressful situations in his life enumerated above. All went well with him so long as he was not called upon to make a difficult adjustment, but with the loss of his child he develops a mental disorder. That he should have reacted to his daughter's injury with murder is quite in line with his general inability and incompetency for proper adjustment, and the development of a mental disorder which has kept him in an institution for the past twelve years and will in all probability keep him there the rest of his life, in reaction to the committed murder, further emphasizes the general vulnerability of his nervous system. Let us see how he attempts to adjust himself to the situation; how he faces reality in his psychosis.

He does just what primitive man has done and what the child of today does. Not being able to face reality, he annihilates it and substitutes for it a world created out of his fantasy, in which he plays every conceivable role but the real one,--_i.e._, that of a patient accused of murder. We will see that he does this by the mere fiat of his word--that magic dexterity which has served so well primitive man in his struggles with reality.

Let me reproduce some of his letters, of which he hands me at least one daily. Here is one addressed to King George V:

DEAR SIR: I wish to return at once to England to the Cissel Hotel. You
told me not to take my wife back after the courts here had granted me
a divorce, so I look to you to just please come on here in person and
have me released, as the United States Senate has given permission for
you to come and release me. I am the young man that rescued you from
drowning at River View, and after telling you my case you advised me
to get a divorce. The guests from the hotel were wishing for me to
return when on here, as also my family.

Please find enclosed check for your expenses and give prompt action.

Very respectfully,
(W. H. M.) HOWARD HALL,
Washington, D.C.

The check:--

U. S. Treasury,
Pa. Ave. and 15th Street.

WASHINGTON, D.C., October 1, 1914.

Please pay to King George of England Ten Thousand Dollars for
professional services.
$10,000 W. H. M.

Thus by the mere stroke of the pen he, a poor mortal accused of murder and indefinitely confined to an institution, succeeds in putting himself in touch with King George, in drawing _ad libitum_ upon the United States Treasury, in ridding himself of the wife whom he accuses of infidelity, and in annihilating old age by styling himself "The young man," when in reality he is fifty-seven years of age at present.

His belief in these statements is absolutely unshakable, notwithstanding the fact that he retains a clear orientation concerning his immediate environment, and thus has the actual state of his affairs constantly forced to his attention.

His grandiose compensation has such dimensions as to gratify every imaginable wish of his. He came here because he was divorced from his wife, not because of any crime he had committed. He is the son of the supervisor in charge of this building. He owns this institution and built it for a place in which he could count his money. He had forty-six wagon-loads of this. He will live 250 years, because he has taken the severest punishment to secure this. He refuses to assist with the ward work, because he pays $1.50 a day for board and is not supposed to do any work. He was brought here to select a woman for his wife. They brought him a lot of blue-eyed blondes and also a lot of Baltimore and St. Louis beauties, etc.

W. H. M., Owner, Washington Asylum, 5000 Branch Hospitals, five
million employees.

ANACOSTIA, D.C., Fri., Nov. 6, 1914.

DEAR MR. PRESIDENT:

I came over here to take out forty-six wagons loaded with greenbacks.
I respectfully had it arranged to have the Senate hold me here on
account of so much wealth until I thought it safe to return. Please
sign this and return it by mail. The Senate ordered me to write it to
you, as there is no crime against me.

WASHINGTON, D.C., Fri., Nov. 6, 1914.

DR. W. AND STAFF OFFICERS OF WASHINGTON ASYLUM:

Please allow Mr. W. H. M. to pass out the gate at once free.

Very respectfully,
W. W.

Please don't delay this one minute.

Thus we see that the entire content of this man's delusional fabric is intended, first, to serve the purpose of annihilating the painful reality, and, second, to substitute for it a beautiful world in which he finds himself free and young again, enjoying his fabulous riches and many blue-eyed beauties. It is the only compromise possible for him, and the fact that it is nothing but a day-dream does not in the least detract from its compensating possibilities for this individual's painful reality. This man's mental disorder has been so obvious ever since its inception that the question of malingering never suggested itself to anyone, and yet the underlying mechanism in this case differs in no particular essential from the cases usually considered as malingerers. In both instances the psychosis represents an attempt to get away from a painful reality by individuals who are quite incapable of meeting such reality face to face.

A more detailed consideration of Freudian psychology, especially such as concerns the subjects of determinism, defense, and compensation, would give one a still clearer insight into the subject under discussion, but to do so would lead us considerably beyond the scope of this paper. From what has been said thus far it will be seen that the mental processes underlying the mental state of malingering differ in no essential from those operative in the human mind generally; that man in his endeavor to reach a satisfactory compromise between the two underlying principles of his conduct,--_i.e._, that of pleasure and reality,--frequently resorts to his fantasy; that malingering in its broader sense,--_i.e._, the attempt to evade reality,--is a common mode of reaction in primitive man, the child of today and in the undeveloped mind, in all of these instances signifying an inability to meet stern reality in the face, and that, therefore, malingering, when it does occur, should at least not be looked upon as an aggravating circumstance, which is not infrequently the case when the malingerer happens to be facing a court of law.

That this mode of reaction is at times resorted to by individuals who had always been looked upon as being far from incompetent only proves that under special stress, especially mental stress, man readily sinks to a lower cultural level and resorts to the defensive means common at this level.

Clinically, malingering is to be considered from three distinct viewpoints:--

1. Malingering in the frankly insane;

2. Malingering in those apparently normal mentally; and

3. Malingering in that large group of border-line cases which should rightly be looked upon as potentially insane and as constantly verging upon an actual psychosis.

It may be difficult to convince the lay mind, and especially the legal mind, that an individual may be suffering from an actual psychosis and at the same time malinger mental symptoms. It is the legal mind especially, working as it does with well-differentiated, sharply-defined, and wholly artificial concepts, that demands a sharp, strict differentiation between the mentally well and the mentally sick. By means of man-made statutes a line has been created, on one side of which they would place all the mentally well and on the other side all the mentally diseased. By the same token they cannot conceive how an individual placed on one side of the line may be able to manifest a type of reaction, a form of conduct, which is by common consent considered as being something essentially characteristic of the man on the other side of the line, losing sight of the fact that in the evolution of the human mind Nature is far from drawing such sharp differentiations as are exemplified by legal statutes. It would certainly be very convenient, and expert testimony would certainly have been spared the disrepute into which it has fallen, were Nature more accommodating in this respect. But Nature does not work in this fashion; differentiation in Nature takes place through infinite gradations, and between the absolutely well mentally and the frankly insane there is a host of individuals concerning whom it is almost next to impossible to state to which of the above two groups they belong. Thus it is that the frankly insane at times manifest conduct which taken by itself differs in no way from normal conduct, and that the so-called normal individual at times exhibits a type of reaction which is essentially of a psychotic nature.

To the psychiatrist it is a matter of common occurrence to see the mentally diseased not only dissimulate very ingeniously and tactfully mental symptoms so that it is frequently impossible to convince a jury of laymen of the existence of mental disorder, but at times, when the necessity arises, they consciously accentuate their symptoms or frankly malinger.

There is nothing strange about this. There is absolutely no reason why the insane, in his desire to gain expression for his wishes and strivings, should not avail himself of the same means that normal man uses.

The following case illustrates this very clearly:--

W. J. C., a well-educated, fairly efficient newspaper reporter, after
a period of indefinite, vague, neurasthenic complaints lasting several
weeks and which brought about his discharge from the staff of a local
newspaper, awoke one July morning, picked up his infant child and,
throwing it against the opposite wall of the room, inflicted fatal
injuries upon it. After this he turned his face to the wall and
remained quietly in bed. There was no ascertainable cause present for
this act. The child was in the habit of entering the patient's room
every morning and playing with him before he arose from bed. It was
apparently on the same errand on this fatal morning. Shortly after
getting up the patient wanted to leave the house in his night clothes,
but was prevented from doing so and held until the police arrived. Six
and one-half hours later,--_i.e._, on July 27, at 12.30 P.M.,--he was
seen by me at the Government Hospital for the Insane.

On admission to the hospital he was very restless and anxious, walked
up and down the room, hands in his pockets, would sit down for a few
minutes, then walked the floor again. Later in the day he was visited
by a newspaper reporter, a friend of his, with whom he conducted a
clear and coherent conversation, and when told by the latter that the
child was dead he assumed a markedly depressed facial expression. In
reply to my questions intended to bring out his attitude towards the
whole affair, he usually stated, "I don't know," and on one occasion
in a very agitated manner said, "So help me God, doctor, I don't know
anything about this." Later in the day he gave a clear and coherent
account of his past life, and a detailed mental examination failed to
bring out any gross mental disorder. He showed, however, considerable
uncertainty about the length of time certain events of the preceding
day consumed. He could not tell exactly when he retired the previous
evening. He remembered, however, going to bed, likewise that his wife
came to his room sometime during the night and asked him to fill the
babe's milk bottle. He didn't remember whether he did this or not. The
next thing he remembered was sitting in the parlor of the house,
sometime in the morning, and was able to describe accurately those who
were present.

During the remainder of the afternoon he was morose and depressed,
refused to eat his supper, and continued in a restless state. He was
again seen by me at 7.30 in the evening in company with two other
physicians. The patient approached one of the physicians, extended his
hand to him, and in a familiar manner said, "Hello, Mr. C." When told
that this was not Mr. C., patient exclaimed "Oh!" in a confused and
astonished manner, said, "Where am I?" and reeled over on the floor as
if in a swoon. He was told to sit up in the chair, which he did.

"What date is this?" "August 26, 1910" (July 27, 1910).

"How long have you been here?" "Since July 25, 1910."

"How long a period would that make?" "One month--oh no, one day; this
is August 10, 1910."

"What were you sent here for?" "Don't know."

"Who brought you here?" "Don't know--oh yes, two policemen."

"What is your babe's name?" "Don't know."

"What is your wife's name?" "Don't know."

He was then given a newspaper clipping in which the whole affair was
fully described. He read the account through, but without exhibiting
the slightest emotion, and said, "Isn't that awful, doctor?"

"How do you feel about this affair of your babe being dead?" "I don't
know anything about it."

"How much is 2 times 3?" After considerable delay and in an absorbed
mood he said, "70."

"How much is 6 times 7?" After a long pause he said, "Don't know."

"Which is the largest newspaper in Washington?" "Don't know." (Patient
was on the staff of a local newspaper.)

When we remember that only several hours before this the patient gave a coherent account of his past life and showed nothing grossly psychotic, the foregoing symptoms, such as the lack of knowledge of his wife's or babe's name, inability to solve problems such as 2 times 3, the fainting spell, etc., must be looked upon as unquestionably malingered. When examined the following day he showed still further signs of malingering, the detailed account of which must, however, be omitted on account of lack of space, and yet this man was unquestionably insane; the act itself (the infanticide) was unquestionably an insane act, as will be shown later. We have mentioned the fact of his neurasthenic symptoms and how as a result of these he lost his position. The physical examination of the patient revealed certain neurological signs, such as exaggeration of the patellar reflexes, lateral nystagmus of both eyes, which determined us to look further into the question of his physical state, especially in view of a history of luetic infection five years before. A spinal puncture was accordingly performed, and the spinal fluid findings were as follows: Fluid clear, pressure moderately increased, Noguchi butyric acid reaction positive, a rather uncommonly heavy granular type of precipitate, cells per cubic millimeter 129. Differential cell count: Lymphocytes, 94 per cent; phagocytes 2.2 per cent; plasma cells, 0.25 per cent; unclassified cells, 2.25 per cent. Wassermann reaction with spinal fluid negative, both active and inactivated. Wassermann reaction with the blood-serum negative. This, however, became positive later on in the disease. The above findings indicate unquestionably that he was suffering from cerebral syphilis.

It is not necessary to enter into further detail concerning the progress of this case. Suffice it to say that with proper treatment he entirely recovered and was so discharged on June 14, 1911.

There can be no doubt that this man malingered mental symptoms, neither need there be the slightest doubt about his having suffered from an actual mental disorder. The motive for his malingering is perfectly obvious. Finding himself suddenly confronted with a charge of infanticide, and rent by the various conflicting emotions which a realization of this carries with it, he resorted to the common weapon of defense, malingering of mental symptoms. We have seen that he deceived no one but himself; that in reality he was a very seriously affected individual. It was fortunate for him that because of some lucky turn of events he landed in a hospital instead of in jail.

A more or less similar case recently received the maximum sentence of life imprisonment for manslaughter. In this instance the case was chiefly observed by jail officials instead of physicians in its early course.

The foregoing case, it seems to me, illustrates very well that, while we are fully justified in assuming a relationship of cause and effect in many cases of malingering, in many others malingering and actual mental disease are concomitant phenomena, having a common root in the same diseased soil. Thus Pelman[10] holds simulation in the mentally normal to be extremely rare, and he always finds himself at a loss to differentiate between that which is simulated and that which represents the actual traits of the individual. My own experience prompts me to agree with Pelman. This confusion and difficulty of differentiation between actual mental disease and malingered symptoms may manifest itself in two ways. The same individual may be suffering at one time from a frank mental disorder, and at some later period, finding himself in a stressful situation, malinger a psychotic state, or, as we saw in the preceding case, malingering of symptoms may manifest itself during the course of a frank mental disorder, as will be further illustrated in succeeding cases. Pelman's statement, however, applies most forcibly to that mass of border-line cases which will be discussed later.

T. W. was admitted to the Government Hospital for the Insane from the
United States Penitentiary, Leavenworth, Kan., on June 16, 1910, at
the age of twenty-nine. He was serving at the time a sentence of eight
years for post-office robbery. His own version of his family and past
personal history is unreliable. He claimed to have suffered from a
paralysis of both arms from March, 1904, until March, 1906, and that
he was at that time confined to a sanitarium. He would not give the
name of that institution, and the whole story may have been
fictitious. At any rate, if he did suffer from this paralysis it was
very likely functional in type, as at the time of his admission here,
four years later, he showed no traces whatever of this. He admitted
having been arrested several times before for drunkenness and
disorderly conduct. His industrial career was very irregular.

The onset of the present attack, as described in the medical
certificate which accompanied him on admission, was as follows:--"On
the evening of April 17, 1910, patient suddenly began to shout, sing,
and pray, claiming that the spirit of God had entered his heart and
that he had a mission to perform. This mission was to go among the
prisoners and preach the Gospel. He then manifested this in a very
erratic manner; ideation was disturbed and disconnected, and there was
present psychomotor restlessness. A probable diagnosis of
manic-depressive psychosis was made by the prison physician."

On admission to this hospital the patient was well nourished
physically, talked readily and coherently, was clear mentally,
although he stated he did not know the nature of this hospital, adding
spontaneously that he knew it was not an insane asylum. His
productivity was chiefly of a religious nature. He stated he was the
real Elijah III, the real prophet; that the vision of Jesus Christ
came to him in his cell, handed him a cross, and told him to pick up
his clothes and follow Him. The warden at the penitentiary was jealous
of his ability to preach the Gospel, and in consequence tried to get
two men to kill him, but these could do him no harm, because he had
the spirit of God in him. The warden also tried to poison him. He
complained of a fever in his stomach from the food the warden gave
him, stated he could see crosses in the corner of his room, and was
continually mumbling something to himself in a low voice. He rested
well on the first night of his sojourn here, and the following morning
told the attendant that he had seen God standing behind him at
intervals during the night. On June 28, 1910, he developed a marked
religious excitement, preached loudly while out in the yard, and
wildly gesticulated in a manner as if he were addressing someone
above. He continued intermittently excited until the early part of
August, 1910. It should be noted here that at this time there were two
other cases confined in the same building, two cases of dementia
praecox, who manifested similar religious excitement. It is of
importance to note this, inasmuch as suggestion plays a considerable
role in the choice of the malingered symptom, and because one of the
characteristics of the type of individuals under consideration is a
high degree of suggestibility.

In his conduct in the ward he was quiet and orderly, frequently talked
in a rational and coherent manner, but invariably brought into the
conversation his delusional ideas. In his demeanor towards me he was
very evasive, suspicious, and showed a marked disinclination to enter
into a protracted interview. Soon after an unsuccessful attempt to
examine him more thoroughly he handed me a letter addressed to Judge
Landis at Chicago, in which he ordered said Judge to remove Voliva
from Zion City and turn the latter over to him, the patient, as the
rightful heir and the only real Elijah III. Following this there was
another tranquil period, during which the patient's conduct was quite
good. About a month later another attempt was made to examine him in
detail, but so soon as he noticed my intention to take notes of the
examination he became very suspicious and evasive and absolutely
refused to cooeperate. This episode was likewise soon followed by a
letter as follows. The letter was addressed to the warden of the
United States Penitentiary at Leavenworth, Kan., and he requested that
it be mailed immediately, as it was very important. It was correctly
dated and read:--

"DEAR SIR: When you receive this letter you will immediately take
steps to have me returned to the penitentiary, where I have a divine
mission to perform. You old ... do you realize that you are fooling
with the prophet Elijah, the Lord's chosen? Have you no fear of the
wrath that God shall bestow on you if you even dare to offend His
divine servant? Don't you ever for a minute think that you can
connive to beat me out of my property in Zion City, you and that
interloper, L. L. Voliva. I shall have it all just as the Lord meant
I should, and I shall carry on the work just as the Divine Master
meant I should. For what matter it if the world is against us, so
long as God is for us? Now, you old reptile, on receipt of this you
will immediately discharge the chaplain; he has no business there.
When I get back I'll take his place, for I am Elijah III, the Lord's
anointed.

(Signed) "T. W. ELIJAH III, Station L, Washington, D.C."

In the meantime it was noted that the patient was very shrewd in his
various schemes for making his escape from the hospital; that he very
ingeniously managed to manufacture all sorts of weapons, and that he
seemed to be especially delusional when in conversation with the
hospital officials.

Soon after the patient planned and executed a very daring escape,
taking with him two other patients, but was soon apprehended and
returned to the hospital. All of this led me to suspect that the
patient was simulating a good many of his symptoms, and that, at any
rate, he was very much exaggerating his psychotic state.

However, there was a certain element of contradiction, a certain lack
of consistency, present in his behavior which is entirely atypical of
the pure malingerer. His explanations of his ideas were flat and
somewhat dilapidated, and resembled to a certain extent the
explanations of a dementia praecox case. In other words, there was no
doubt that the patient malingered, but there was likewise no doubt that
he suffered from a psychosis. On several occasions he refused to take
nourishment for several days at a time in reaction to his delusional
ideas.

Upon his return from his elopement it was felt that, owing to his
dangerous tendencies, a more thorough attempt at evaluating the
relative importance of the genuine and the malingered in his case ought
to be made with a view to returning him to the penitentiary.

He was accordingly again thoroughly examined on April 8, with the
following results: He reiterated his delusional ideas substantially as
given above. He insisted that he was not insane; that he was railroaded
to this hospital because the warden of the penitentiary and other
United States officials are trying to rob him of his property in Zion
City. "God Almighty meant that Zion City should belong to me." This was
decided on the night when he saw the cross.

"How many months in a year?" "Twelve."

"How many days in a week?" "Seven."

"Name the months." "March, April, June, July, August, October,
November, December, January, and February."

"What is the last month of the year?" "October."

"What is the first month of the year?" "March."

"Which is the Christmas month?" "I'm not certain, but I think it's
January."

"How does vinegar taste?" "Sweet."

"How does a lemon taste?" "Sweet."

"What is the color of an orange?" "Blue."

"Count from 1 to 20." Counts very slowly and deliberately, omitting 11
and 15.

"4 x 2 = 8; 8 x 4 = 28; 9 x 3 = 27; 7 x 4 = 24; 6 x 4 = 22; 6 + 7 = 13;
19 + 11 = 30; 7 + 8 = 14; 3 x 3 = 9; 4 x 2 = 12; 6 x 4 = 14;
5 x 2 = 10; 1 + 9 = 10; 9 + 11 = 21; 11 + 9 = 18; 50 + 5 = 11;
8 / 2 = 4; 27 / 9 = 4."

"Name the days of the week." "Tuesday, Wednesday, Thursday, Friday, and
Saturday."

"Name them again." "Monday, Tuesday, Thursday, Friday, Saturday, and
Monday."

In repeating a very simple story he changed the content entirely, and
omitted some of the most important details of it.

When we remember that this man was far from being as ignorant as some
of the above answers would suggest, and that, while he unquestionably
suffered from a psychosis, his state of consciousness was altogether
too clear to justify a degree of lack of touch with his environment
such as his replies would indicate, it becomes quite obvious that he
malingered. This, together with his dangerous tendencies, determined us
to return him to the penitentiary, which was done on April 11, 1911.

He reached the penitentiary on April 13, and on the night of April 20
he began preaching in a loud tone of voice, claiming that he was the
son of David, and that he was called upon to go forth and preach to the
world. He was removed from his cell to the isolation building, where he
refused to take nourishment until April 23. During this period he spent
most of the time preaching and singing religious songs, and at times
would hold long and heated arguments with some imaginary person, always
on religious topics. From the above date until his transfer to the
Government Hospital for the Insane on September 24, 1911, he continued
in a very disturbed and destructive state, refusing food frequently
for several meals in succession, preached, sang, and cursed in turn,
gave voice to the various delusional ideas manifested above, and gave
objective evidence of suffering from hallucinations. Throughout he
strongly maintained that he did not want to return to the hospital at
Washington, as there was nothing wrong with him mentally.

The prison physician who examined the patient at the penitentiary
before his second admission to this hospital made the following
notation in the case: "The mental examination of T. W. reveals
inconsistencies that are strongly suggestive of simulation, and I
believe there is in this case a degree of malingering, frequently
associated with prison psychoses, yet that there is a psychosis, in my
opinion, there is no doubt."

Upon his return to this hospital he became involved in fistic
encounters, on the way to his ward, for which there was very little
provocation. For several weeks following this he was very surly,
dissatisfied, moody, and inaccessible, but showed no other psychotic
symptoms. Four days after admission he subscribed to a local newspaper,
which he read regularly and kept himself well informed on ordinary
topics. He was clear mentally, well oriented in all respects, and
adapted himself readily to his new environment, except that he
absolutely refused to eat the regular food furnished the patients. For
about three weeks he lived practically on fruit and candies which he
purchased, persisting in his determination to starve himself unless he
were given a special diet. This was furnished him, and he had no
further dietetic troubles. No delusions or hallucinations were
manifested, intellectual examination revealed no intelligence defect
(gross), and, aside from his surly mood and his tendency for rather
frequent endogenous depressed periods, he showed no abnormal
manifestations.

In this state he required no special hospital treatment, and, as he
promised to conduct himself properly if he were returned to the
penitentiary, he was transferred back on February 20, 1912.

Upon his return he continued, however, to manifest periodic
excitements, with destructiveness, always, however, in reaction to some
environmental irritation. He nevertheless managed to remain in the
penitentiary until the termination of his sentence.

It is highly doubtful whether proper means will ever be evolved to enable one to differentiate accurately between that which is genuine and that which is malingered in cases like, for instance, the foregoing.

This man unquestionably suffered from a psychosis, and yet there is likewise no doubt that he malingered. The question of the accurate differentiation between the genuine and the shammed seems to me, however, to be strictly an academic one and of very slight practical importance. What is of importance is the recognition that malingering and mental disease are here the expression of the same diseased soil, and that the same source should perhaps be also attributed to this man's criminalistic tendencies. Crime, mental disease, and malingering should perhaps here be looked upon as different phases of a mode of reaction to life's problems which belongs to a lower cultural level, which is largely infantile in character.

That this infantile way of facing reality is dependent upon some constitutional inherent anomaly is attested to by the circumstance that these individuals practically always react in this manner when forced to form new adjustments, new adaptations. This repeated recourse to mental disease as a refuge from a stressful situation is amply illustrated in a series of cases reported elsewhere.

The other form in which malingering may be so intertwined with actual mental disease as to render accurate differentiation quite impossible is where the individual may be suffering from a psychosis at one time, and at some later period, finding himself in a stressful situation, malinger a psychotic state. In these cases the danger of ever committing a habitual criminal to a hospital for the insane is especially apparent.

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 reenlisted 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. Gonorrhoeal 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."