Chapter IV: The Malingerer: a Clinical Study (3)

Patient was admitted to this institution June 15, 1912, at 10.30 A.M.
On admission he was carried in by two employees. His legs were
shackled and he had wristlets on his hands. He was apparently unable
to stand unassisted, and, when support was removed, fell to the floor.
Pupils were widely dilated; internal strabismus of the right eye was
present. Facial musculature was distorted, and he mumbled to himself
in a low, indifferent tone of voice, over and over again, "Give me
something to eat. I can't do it. Give me something to eat," etc., in a
rapid monotone. He appeared to be in a deep stupor. He did not seem to
realize his whereabouts, and attention could not be gained. He was
totally inaccessible. When put to bed he became quite restless, rolled
out on the floor, and was unable to assist himself back into bed.
Musculature of legs was in a constant mild clonus, and the right foot
was kept in position of talipes equinovarus. Pins pushed deeply into
the skin all over the body caused no reaction. When food was brought
to him he leaped upon it and finished the meal with extreme rapidity,
stuffed his mouth full, never taking sufficient time for mastication
or swallowing, and food was frequently expelled forcibly, probably
from irritation of the air-passages. Questions addressed to him
remained unheeded, but he kept up a constant mumbling in a low
monotone, as described above. He was totally unable to stand on his
feet unsupported, but when lying down his legs were moved about quite
freely in an indifferent manner. When alone in the room he remained
quietly in bed, head and face covered up with a blanket, but as soon
as the room was entered he became restless, grabbing to those about
him and holding on tenaciously. During his first night in the
institution he slept well and was clean in habits. The following
morning he was still inaccessible. He ate his breakfast quite
voraciously, mumbling to himself all the time, "Give me something to
eat" or "Give me something to drink." When water was brought to him he
would endeavor to gulp the entire contents of the vessel at one
effort.

During the day of June 16, the day following his admission, he was
frequently seen sitting on the side of the bed with quite a pleasant
facial expression, rubbing his arms and legs. When his room was
entered, however, he at once began mumbling to himself similar phrases
as those given above, became quite restless, grabbing at those about
him and not paying any attention to questions put to him. The
following day, June 17, he showed marked improvement; was very much
quieter in behavior when approached; walked back and forth in his room
quite unassisted and in quite a steady manner; was seen looking out of
the window into the yard for about fifteen or twenty minutes. Upon
being approached by any one his gait seemed to become definitely less
steady, and diffused twitchings of the thigh and leg were noted. The
strabismus which was present on the day of admission had entirely
disappeared; pupils slightly dilated. In the forenoon of the 17th he
asked for his clothes and to be allowed to go out in the courtyard
for a walk. A few questions addressed to him were answered coherently
and relevantly. He said, in answer to direct questions, that his name
was J. E. M.; that he did not know his age; that he came off some
ship. Said the name of the ship was _Washington_; that he did not know
how long he was on that ship, but thought it was a good long time.
Asked where he was now, he said he was in the brig. "Where?" "Don't
know." Asked if he were crazy, he said, "No, sir." When he came here?
"A year ago." Asked what was the matter with him. "Nothing, sir. They
kept me tied up too much." Asked when his bowels moved last, he said,
"About a week ago."

On June 19 he gave a coherent and connected account of his past life.
He talked freely and cooeperated in every way with the interviewer.
Requests were obeyed promptly and intelligently. Physical examination
on that date showed him to be a well-built, well-developed white male.
Face slightly asymmetrical. Skin was soft and smooth, free from
eruption, and covered with numerous elaborate tattoo marks. Linear
depressed scar in the occipital region. Muscle tone was good. Muscular
power was good in upper extremities. On first being tested in the
lower extremities said he could not resist very much passive
movements; upon suggestion, however, the muscular power of the lower
extremities became much stronger and equal to that of the upper
extremities. Grip was strong and equal on both sides. Station and gait
were unimpaired when a steady and erect attitude and firm gait were
suggested to the patient; left alone, he was inclined to be slightly
unsteady on his feet. With eyes closed and feet together, there was
considerable swaying present; said he felt like falling over.
Voluntary movements were performed well. He described accurately a
circle, a square, and triangle in the air with either hand. Movements
were steady and accurate. Cooerdination was slightly impaired in f-f
and f-n tests; the termination of the act was accompanied by a slight
tremor. The musculature of thighs showed a more or less constant
clonic twitching. When attention was called to this he was able to
control it to a certain extent. Upon assuming a sitting posture the
twitchings ceased. He said it was due to weak ankles. There was no
tremor of protruded tongue or lips when showing teeth; fine tremor of
the extended fingers and forearm when extended; no tremor of facial
musculature. There was no paralysis, but there seemed to be a slight
weakening of the lower extremities. No atrophies or hypertrophies
noted. The triceps and radial reflexes were definitely exaggerated.
Upon tapping, the quadriceps tendon caused a brisk marked contraction
of thigh muscles, followed by mild clonus. Tapping of one knee tended
to set musculature of opposite knee in mild clonus of short duration.
Knee kicks were definitely exaggerated. Tendo Achillis exaggerated. No
ankle clonus. Muscular irritability to mechanical stimulation
increased. Superficial reflexes were normal, except plantar defense
reaction was slight. Cutaneous sensibility was unimpaired: heat and
cold readily distinguished. Light touches of pin pricks were felt and
localized all over the body. Sense of position normal. No
astereognosis in either hand. No excessive sweating. Eyes clear;
irides brown; pupils round and regular, moderately dilated, reacted
readily to all tests; eye movements well performed in all directions;
no nystagmus nor strabismus. Vision--20/30 in each eye, improved by
glasses. Skin of vitreous clear; slight weakness of external recti;
cornea clear; field of vision normal for white; both fundi normal
except for slight hyperaemia. Smell, taste, audition, and speech
unimpaired.

Mentally the patient was clear. He comprehended readily what was said
to him, and his replies were prompt and relevant. He was disoriented
for time. He stated that he knew the nature of this place; that he was
told it the day before by a patient. Claimed to have total or almost
total amnesia for several months past during the year he was confined
in the dungeon of the Concord Penitentiary. He had no idea of the trip
from there down to this hospital. He did not remember his arrival, nor
how he acted the first two days here. Stated that on June 17 he first
began to notice things about him and to realize faintly where he was.
Delusions or hallucinations could not be elicited as having existed at
that time. He spoke of having been bothered at the penitentiary; of
having been chloroformed; that they put stuff in his food, tried hard
to get him out of the way, and because they could not do it sent him
down here. Said the doctor poured ether down his neck. He does not
know the doctor's name, but he knew it was ether, he smelt it, and
that is the reason he could not use his legs on arrival. He had no
idea why he should have been treated thus, but thought perhaps they
had it in for him. Auditory hallucinations could not be elicited. When
asked if he ever saw anything, he said it was pitch dark in the
dungeon and no one could see anything. Said the food tasted bad all
the time, and sometimes made him vomit. On one occasion he noticed
some powder in the beans. No electricity, no shocks, no outside
influence was used on him. He did not know how long he was tied down
in the dungeon, as half the time he did not know anything at all. Said
they put needles in him, and pointed to some marks on his arm as a
result of hypodermics. Facial expression denoted perfect satisfaction;
said he felt fine and did not worry about anything, as he is not of
the worrying kind. Said he had been treated well here. Insight was
imperfect. When asked directly if he had been insane, he replied
"No." When the various symptoms which he manifested on admission were
described to him he was inclined to agree that if he did show these
symptoms he must have been out of his head. Remote memory was not
impaired, so far as could be determined. There was an ill-defined
amnesia extending over several months past, and up to June 17, when he
claimed to have first realized his whereabouts. Attention was
unimpaired. He reacted well to the intellectual tests, with the
exception of the arithmetical problems, which he did poorly. Replies
to ethical questions showed a rather low grade of morality, perhaps
due somewhat to ignorance more than to anything else. In his conduct
on the ward he was absolutely normal following June 17. He spent his
time reading and in conversation with the other patients. He was
perfectly satisfied in his surroundings, frank in his conversation
with those about him, and gradually gained more and more insight into
his condition. He still persisted, however, in his statements that
ether was poured down his back. Said he remembered this distinctly as
having taken place while confined in the dungeon. He was then,
however, inclined to think that probably they did not have it in for
him, and probably they did what they thought was best. In conversation
with him today, on June 19, four days after admission, he showed
perfectly normal behavior in every respect. Was frank in his
statements, spoke of the amnesia mentioned above, and no delusions or
hallucinatory experiences or physical symptoms present on admission
could be detected.

When finally confronted with the picture sent from the War Department
for his identification he showed some degree of emotional reaction,
stated that the picture was his, but persistently denied ever having
been a recruit in the army. On the whole, he took the matter rather
lightly and good-naturedly.

The history of this attack illustrates a typical case of hysterical psychosis. The marked stupor and confusion, the numerous and varied neurological symptoms, the sensory disturbances, especially the profound anaesthesia to pin pricks, the amnesia and rapid recovery after change of environment, all point to this diagnosis. It is a form of reaction frequently seen in prisoners, and has been designated, for want of a better term, as prison psychosis. At any rate, there can be no doubt as to the genuineness of the symptoms presented by the patient.

If we keep in mind that such a type of psychotic reaction is the result of the mutual interaction between an unstable, highly vulnerable psyche and an unfavorable environmental situation--in this instance prison environment--we understand the more readily the later history of this case.

On July 16, 1912, he was discharged recovered and turned over to the naval authorities to be returned to prison. Soon after his return to prison he was noted to be melancholy, uncommunicative, was not interested in condition of self or surroundings, had unsystematized delusions of persecution. Physically he was noted to be anaemic, showed general tremors when undergoing examination, reflexes were exaggerated, positive Romberg was present. The physician who accompanied patient to the Government Hospital for the Insane on his second admission stated that on the trip from Portsmouth Prison M. tried to assault a waiter in a restaurant in Boston, accusing the latter of following him. To the physician he said, while on the train, "Take your d---- eyes off me, or I'll brain you."

He was readmitted to the Government Hospital for the Insane on February 6, 1913. Physical examination on this admission was negative, except for some impairment of vision, for which he was given eye-glasses. Mentally he was found to be disoriented for time, though perfectly clear mentally, as was shown later in the examination; he said he did not know the name of the institution, though a minute later he gave correctly the name of the building in which he was located. He spoke in a very vindictive manner of the naval officials, who he said were persecuting him in various ways, and who he reckoned were then working to send him to some other d---- prison. On February 7, the day after admission, he wrote the following letter to the Secretary of the Navy:

HOWARD HALL, January 29, 1913.

MR. SECRETARY OF THE NAVY: _Rev. Sir_.--Will you kindly have some
investigating, as I cannot have my life endangered. It is continually
in my food, and times I have found the compounded powders in the air
of my room choking me. Please let me know if you will do so, and I
shall close.

Respectfully yours,
J. E. M., H. H. 5, Station L.

No hallucinations could be elicited, and his delusional ideas were confined to the naval officials. These, he said, were persecuting him; they sentenced him unjustly in the first place, and threatened to get even with them. He answered the intelligence tests fairly well, but the examining physician noted that frequently he gave expression of consciously giving erroneous replies to questions put to him. Emotionally he was at first somewhat depressed, but later this disappeared. In his conduct he was inclined to be very troublesome, easily irritated, and fault-finding.

This disorder of conduct, however, became consistently more aggravated whenever he was in the presence of the physician. While he gradually became quite friendly with the attendants and willingly assisted with the ward work, he became quite abusive whenever an attempt was made to examine him by the physician. This became especially evident in December, 1913, when the physician who had him in charge during his first sojourn at the hospital again assumed charge of him. At that time the patient had been on excellent behavior for a number of months, and in his daily conduct showed no evidence of a psychosis. He continued, however, to air his delusional ideas whenever the physician attempted to examine him.

Everything went well upon the return of his former physician until December 22, 1913, when the latter attempted to examine him. The patient became very abusive and threatening in his attitude, began to air all sorts of bizarre persecutory ideas, and for about a month he continued in an excited and destructive state. At the expiration of this period he apologized to the physician for his conduct, said that he could not help going on a rampage once in a while, as it is all due to his mean disposition, and promised to conduct himself in an excellent manner if he were not returned to prison. This was early in January, 1914, since which time he has been a model patient in every respect. It is needless to say that he has not been given, since that time, any occasion for the development of another tantrum, and accordingly he remained free from psychotic manifestations.

He was a model patient after this, assisted willingly with the ward work, and on one occasion prevented the successful culmination of a daring plot on the part of several patients to escape from the institution.

Upon the recommendation of the hospital authorities and Dr. Sheehan, the naval officer stationed at this hospital, the remainder of this man's sentence was commuted, and he was accordingly discharged on June 29, 1914. For about six months prior to this his conduct was exemplary, and, though through a considerable part of this period he enjoyed freedom of the grounds, he never showed the slightest inclination to abuse these privileges.

The salutary effect of the commutation of this man's sentence is quite obvious. On the other hand, I am equally certain that had this particular individual been returned to prison we would have had him again before long as a very seriously ill patient.

This case is extremely interesting from many points of view. In the first place, it gives us some insight into that highly inflammable, hair-trigger, emotional type of individual who, when thrown into a stressful situation, is very likely to go to pieces mentally. It is a type which is always very difficult to manage under a prison regime, and which in my estimation requires some intermediary place between a hospital for the insane and a penal institution. It is likewise quite irrational in our judicial disposition of these cases to impose a definite sentence. If our prisons are to function as reformatory institutions, it is quite clear that in this particular case no one can possibly foretell how long a period it would take to bring about a reformation. It is as if a man suffering from pulmonary tuberculosis were told that he must go to a place set aside for such as he and stay there, say, five years, irrespective of whether he is well at the end of that time, or whether he might have recovered long before the expiration of that period.

In this particular instance we were led to recommend a commutation of the unexpired term of the sentence by the following considerations: First of all, I cannot consider sodomy a crime punishable by imprisonment, unless the act was performed on a subject who either is incapable of giving his consent or becomes a party to the act against his will, by force. Anomalies of the sexual function are not crimes, but diseases, and as such should come under the purview of the physician, and not the agents of the law. In the second place, this man served in the navy with an excellent record for about two years, and, so far as we know, is not inclined to habitual criminality, and therefore deserved at least another chance. But these considerations are somewhat beside the issue under discussion. The case, to my mind, illustrates very well how closely malingering of mental symptoms is related to actual mental disease, how both manifestations are expressions of the same underlying diseased soil, and how difficult, nay even impossible, it is to tell in a given case which of the symptoms are real and which shammed. On his first admission this man suffered from a grave mental disorder, from which, so far as anybody could determine, he made a complete recovery. Thrown back into the same stressful situation, he again finds himself unable to cope with it, becomes melancholy, suspicious, and mildly delusional. There is, however, considerable doubt in my mind as to the genuineness of these symptoms; unquestionably genuine is only the psychopathic make-up of this individual, which under stress permitted the development in one instance of a grave psychosis, in another of malingering.

Cases like the foregoing are by no means exceptions in criminal departments of hospitals for the insane. It is on account of this type of prison population that penal institutions furnish us with ten times as many insane as free communities.

Whatever convictions I possess concerning the subject of malingering were gained from a fairly extensive experience with insane delinquents at the Government Hospital for the Insane, and when I assert that I have yet to see a malingerer who, aside from being a malingerer, was likewise normal mentally, I do so with the full consciousness that my experience has been a more or less one-sided one. I mean to say that the material observed by me came to my notice within the confines of a hospital for the insane, and that my failure, therefore, to see the so-called pure malingerer is probably due to this circumstance. I shall not argue this point further, but merely state that it is true I have not had experience with the detected and convicted malingerer in the jail and court-room. I have had ample opportunity to study this same genus later as a patient in the hospital.

It would be an extremely interesting study to follow up the later careers of the so-called detected malingerers who are sent to prison and see how many of them later find their way to hospitals for the insane. A setting forth of these figures--and I doubt not for one second that the number is not at all inconsiderable--would not in the least have to be construed as a criticism of the diagnostic acumen of the original investigator. It would simply substantiate the truth of our contention that in the malingerer we see a type of individual who is far from normal, and in whom malingering as well as frank mental disease is not at all a rare phenomenon.

I have no doubt whatever that a considerable number of suspected malingerers are annually sent to penal institutions, there to be later recognized in their true light and transferred to hospitals for the insane; else it would be difficult to account for the fact that mental disease, according to many authors, is at least ten times as frequent among prisoners as it is among a free population. Certainly this cannot be attributed to environment alone, especially not to that of our modern, well-conducted prisons. The reason lies chiefly in the type of individual who populates our prisons. A number of them are either insane when sent to prison or potentially so, and when thrown into a more or less difficult situation, such as imprisonment, readily develop a mental disorder. We see this illustrated very well in the highly beneficial effect which transfer to a hospital for the insane has upon these individuals. I am convinced that one would not be wrong in agreeing with the opinions quoted below, that malingering, as such, is a morbid phenomenon and always the expression of an individual inferior mentally. It may be looked upon as a psychogenetic disorder, the mere possibility of the development of which is, according to Birnbaum[11] and others, an indication of a degenerative make-up, a defective mental organization. Siemens[12] says: "The demonstration of the existence of simulation is not at all proof that disease is simulated; it does not exclude the existence of mental disease." Pelman 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. Melbruch[13] holds that simulation is observed solely in individuals more or less decidedly abnormal mentally, because in the great majority of cases, if there does not actually exist a frank mental disorder, these individuals lack in a marked degree psychic balance and are constantly on the verge of a psychosis. Penta, in a most thorough study of the subject of malingering, likewise comes to the conclusion that it is always a morbid phenomenon. It is a tool almost always resorted to by the weak and incompetent whenever confronted with an especially difficult or stressful situation. It is, therefore, almost exclusively seen in hysterics, neurotics and other types of psychopaths, in the frankly insane, and in grave delinquents.

With these remarks concerning malingering in the supposedly mentally normal, we may turn to a discussion of that large group of borderland cases which furnishes, outside of the frankly insane, the great majority of malingerers. I am tempted here to borrow Bornstein's classic description of the type of personality to which I am referring. According to him, these individuals come into the world with the stamp of a hereditary taint, with certain somatic anomalies (ears, palate, formation of skull, growth of hair, etc.), and already as children show those psychic characteristics which are decisive for their individuality. They are, above all, characterized by a marked hypersensitiveness and by a lack of harmonious relationship between the various psychic functions. This disharmony finds its expression chiefly in the predominance of the emotional element over the intellectual and in the entire subordination of the latter to the former. Their feelings, furthermore, express themselves in an abnormal manner, both as regards their intensity and duration. The emotional reaction is either excessively strong or, on the other hand, disproportionately weak compared with the stimulus, and in spite of the extravagance of the expression it quickly passes over or remains with an excessive obduracy for a disproportionately long time. Notwithstanding the apparent intensity of the outbreak in the former and its tediousness in the latter case, these emotional upsets almost always lack real depth. They are usually very superficial, insufficiently grounded, rather dependent upon accident; transitions from one extreme to the other make up the daily experiences of these individuals--from intense love to burning hatred, from deepest reverence to an irreconcilable disgust, from unshakable loyalty to brutal treachery. They lack energy and initiative, are undecided, vacillating, and inclined to self-reproach. The domination of the emotional sphere and the frequent incongruity and discord between the various forms of emotional expression frequently lead to the development of morbid doubts, morbid fears, a morbidly exaggerated egotism, and sensitiveness which leads them to scent everywhere personal injury and insult. Finally, they frequently show an overdevelopment of the sexual instincts and various deviations from normal sexual development. Many of them seem to lack totally in the power of reason, but act entirely upon impulse, upon the mere feeling that this or that proposition is true. Many others show a pronounced tendency to a metaphysic brooding and day-dreaming and to the transformation into fact of the dreamed air castles, without any regard to the iron logic of life which they cannot satisfy, with which they either will not or do not know how to reckon. Turning their backs upon the demands of life, centered in self, given up to the kaleidoscopic play of their emotions, which are of short duration, imperfect as to depth, varying in intensity, and depending upon any and every external influence, these individuals are very uncertain in their opinions, judgments, and motives for action. They go through life without any direction, without any guiding idea, without initiative, and without will, incapable of any kind of systematic labor, yet at times ready, under the influence of a temporary affect, to sacrifice everything in order to carry out what later on proves worthless and vain. Lacking in sure criteria and guides, they are slavishly dependent upon momentary external influences, and under unfavorable conditions of life suffer want and misery and give way to temptation, frequently falling into a life of vagabondage, drunkenness, and crime. In prison they often develop mental disorders, are looked upon as malingerers, and oscillate between prison and the insane asylum, only to begin the old game over again so soon as they again come in contact with life.

It is little wonder, then, that the psychiatrist in dealing with these unfortunates frequently finds himself at a loss to tell where health leaves off and disease begins. The psychoses which these individuals develop are in the great majority of instances purely psychogenetic in character, one of the many distinguishing features of which is a marked susceptibility of the symptoms to be influenced by external occurrences. This tendency of the symptoms to shape themselves in accordance with occurrences in the immediate environment frequently leads to the suspicion of malingering, because there seems to be altogether too much discretion displayed by these alleged insane.

I have elsewhere[14] reported a series of these cases and entered into a detailed discussion both of the personality and the nature of the psychoses from which these individuals suffered. Most of my cases had been both in prison and in hospitals for the insane on more than one occasion, every arrest and imprisonment having been apparently sufficient to bring out a fresh attack of mental disease.

The following case is fairly illustrative of this type:--

J. H., white male, age twenty-seven on admission, November 13, 1913.
While serving a year's sentence at the Portsmouth Naval Prison for
fraudulent enlistment the patient told the authorities there that on
August 7, 1909, he had murdered a girl in Rochester, N.Y. He described
the murder in great detail, stated that he met the girl in one of the
Rochester cemeteries, attempted a sexual assault upon her, and when
she resisted he choked her to death. He stated that he did not mean to
kill his victim, but that he had inflicted the fatal injury before he
was aware of it. It was remorse, he said, and the desire to expiate
his crime which prompted his confession. He persisted in this
confession until the naval authorities were persuaded to discharge him
and turn him over to the civil authorities of Rochester, N.Y. Upon
arriving there an alibi was easily established, freeing the patient of
all suspicion of the murder, whereupon it took a good deal of
investigation on the part of the authorities to establish the
patient's real legal status. It was finally decided that he belonged
to the naval authorities, and he was accordingly returned to prison
and was given an additional sentence of a year for this fraud, which
he began to serve on December 13, 1909. While awaiting this new
sentence he assaulted a master-at-arms, who he claimed abused him, and
for this offense he received an additional five years' sentence. He
served this sentence until his first admission to this hospital on
July 16, 1913, on the following medical certificate: First symptoms
became manifest in 1910. The patient manifested fixed delusions of
having murdered a girl on August 7, 1909. Present symptoms: Fixed
delusions of a self-accusatory nature, delusions of persecution;
accused a medical officer whom he had never seen before as being among
those who were hounding him. Becomes excited, violent, profane,
incoherent and obscene in speech, and attempted to assault the
officer. He attempted suicide on February 15, 1910, while at Concord,
N.H., State Prison.

During the patient's first sojourn at this hospital he conducted
himself in an orderly manner, and, aside from the expression of mild
persecutory ideas with reference to the prison personnel, he was free
from psychotic manifestations. On only one occasion was he involved in
some trouble while here, which was entirely his own fault. He was
discharged on September 23, 1913, diagnosis "Not insane, psychopathic
constitution," and returned to the U.S.S. _Southery_ Prison Ship. Upon
his return there it was noted that he was suffering from a double
benign, tertiary, malarial infection, which it was maintained he had
contracted in this hospital.

He was readmitted here on March 15, 1914, on a medical certificate
which stated that the patient said he snuffed cocaine prior to
admission to the navy; that the murder he believes he committed was
due, according to his statement, to the refusal of the victim to
permit sexual intercourse. The patient has at present the same fixed
delusion of having committed this murder in 1909. He wants to expiate
his crime to escape those who are continually hounding him. When
irritated he flies into a rage, cries, tries to do himself injury, and
talks incoherently. For no cause, while working in the yard, he struck
a fellow prisoner and pursued him with a shovel. During maniacal
attacks he can be restrained only with much difficulty, smashes
furniture in his cell, and is slovenly in habits. Complains constantly
of numbness and needle-like pains in vertex. As a probable cause,
prison routine was given. It will thus be seen that the same fraud
about the murder, which served at one time to bring him an additional
sentence of a year, was considered at another time one of the symptoms
which justified his return to this hospital. The patient's version of
the reason for his return is as follows: Soon after his transfer to
Portsmouth the guards began to annoy him, calling him crazy guy, hard
guy, etc. He also got into trouble with the sergeant because the
latter cursed him, began to express the same ideas about the murder,
and thought this was the reason they sent him back.

The mental examination and physicians' notes made during his second
admission showed no gross psychotic symptoms. The patient still
maintained that he actually committed this crime in Rochester, and
related it in great detail. He stated that when he was confined in
Portsmouth Prison he became remorseful over this crime and decided to
confess. His conduct during his second sojourn here was exemplary. He
appeared at conference on April 20, 1914, and a diagnosis of
psychopathic character was made. The opinion was expressed that it was
extremely difficult to pick out the truth from the abnormal elements
in the patient's story, and that there were a great many things in the
general emotional reaction of the patient that fitted into the story.
It was believed that the patient had a sort of determination to get
into difficulties for the sake of posing as a martyr and all that fits
in with the grandiose element of his character. Being oppressed, he is
taking it in a way that is very satisfying to his feelings of
importance. Later during his sojourn here the patient became rather
anxious to be returned to the penitentiary, stating that he had given
up all the ideas which he had expressed on admission, and assured the
physician that he was malingering on both occasions of his transfer to
the hospital. He stated that his chief anxiety which led him to
malinger was that he might be given additional sentences for his
inability to get along in the penitentiary, and he thought the only
way to avoid this would be to be pronounced insane. Patient was
discharged from here to be returned to the penitentiary on July 9,
1914.

The patient was readmitted to this hospital on November 13, 1914, on a
medical certificate which states: Diagnosis--Constitutional
psychopathic state, not in line of duty, existed prior to enlistment.
He was in the Government Hospital for the Insane in Washington for
about four months this year. His condition is not improving. A sudden
outburst occurred two days ago and he has been under close confinement
since. He struck a recruit and after confinement in a cell destroyed a
chair and had to be restrained. His retention in the prison in these
barracks is not deemed desirable.

Nothing essentially new has developed in the case during this
admission. The patient has from the first been quiet, well behaved, a
willing worker in our industrial department, and free from signs of
mental disorder. Of course, he again blamed the guards at the prison
for the trouble which he became involved in and which necessitated his
third admission to this hospital. A letter received from the naval
medical officer stationed at the marine barracks, Norfolk, Va., the
place of the patient's last confinement, was to the effect that while
under observation there the patient made the impression of being a
good worker, and normal in every way, except that he had a quick
temper, and that the only difficulty they had noted was on the
occasion when he assaulted the man at the prison, who appeared against
him at the mast, and that after this scene he was put in the brig,
where he threatened to kill any ---- ---- man who came near him. The
medical officer was impressed with the fact that the patient was
feigning insanity.

The patient's version of the circumstances which led to this last
admission is as follows: He was reported to the commanding officer by
a guard for some alleged minor infraction of discipline, of which he
claims not to have been guilty. After the guard was through making
his report the patient asked the commanding officer whether this
alleged offense would prevent his release in July of this year, as he
had been promised if he conducted himself well. The officer replied
that it certainly would, upon hearing which he could not restrain
himself, became quite overwhelmed with anger, and struck the guard who
reported him. His behavior which necessitated his readmission took
place following this episode. The patient dwells upon the fact that
prior to this episode he behaved in an excellent manner under the
prison regime for about four months, and that during his sojourn there
he was practically a model prisoner, which was true.

He certainly has manifested no signs of mental disorder during his
present admission, and still insists that he malingered all of the
symptoms which led to his former two admissions because he feared more
punishment at the hands of the naval authorities unless he was
considered insane.

_Anamnesis._--The patient comes from a family of farmers in mediocre
circumstances. Grandparents are in Bohemia, and he knows nothing
concerning them. Father died of Bright's disease; was alcoholic.
Otherwise family history negative.

Patient is uncertain about the time and place of birth, but believes
he is about thirty years of age at present. He entered school at seven
or eight, but proved to be a confirmed truant, and his father finally
had to take him out of school entirely. He was in the habit of running
away from home and school, to wander about the country, where he would
stop at different farm houses, claiming he was an orphan and without a
home, until his father would discover him and bring him back home.
After giving up school definitely he worked as a farm hand, earning
the ordinary wages paid for this labor. He changed places frequently,
was a spendthrift, and assisted his parents financially very little.
This mode of existence he led until 1904, when he forged his father's
name to a $25 check and received a five-year term of imprisonment,
part of which he spent in the Minnesota State Reformatory and part at
the State Penitentiary. In the fall of 1907 he was paroled, but broke
his parole by enlisting in the army, under the name of Kimlicka, at
Fort Snelling, Minn. About a month later the fraud was discovered
through his father. He was given a dishonorable discharge and sent
back to the penitentiary, where he remained about six months. At the
end of this time (December, 1907) he was granted another parole, and
went to work for a man named George Hall, on a farm in Minnesota. He
was there nearly two months, when he cut his foot while chopping wood.
He says that after this accident he was not able to do much work, and
his employer did not seem to like to have him hanging around, so he
went back to prison, which he says paroled prisoners were supposed to
do when they lost their jobs. As his time was up in two months, the
prison authorities made no effort to get him a new job, but kept him
there until his sentence expired. He left the penitentiary in March,
1908, and went home for a couple of weeks. He then went to Minneapolis
and enlisted in the navy under the name of James Hall, but did not
tell the recruiting officer about his prison or army experiences.
About four months after he enlisted he was caught with another sailor
in civilian's clothes in Newport, R.I. This was against the navy
regulations. Patient says he did this because they did not allow him
in dance halls, theaters, etc., in sailor's clothes. He used to keep
his civilian's clothes in the Y. M. C. A. building in town, and would
change there. He received a dishonorable discharge for this escapade.
He says he had one court-martial before that, in July, 1908. He then
went to Providence, R.I., and enlisted in the army under the name of
Herman Hanson. In Fort Andrews, Boston Harbor, patient was caught in
civilian's clothes again, and got into a brawl with a sergeant.
Patient says the sergeant was drunk and provoked the quarrel. As a
result the patient was put in the guard-house, receiving a sentence of
six months and dishonorable discharge. Two months of this sentence he
served at Fort Andrews, and the rest at Governor's Island. After being
discharged, he hung around New York City for a week, and then went to
Rochester, N.Y. This was in May, 1909. Here he worked on a farm for
Mrs. McCale, and the following month, June, 1909, he enlisted in the
Marine Corps under the name of Vilt. He was sent to the Brooklyn Navy
Yard, but after a week's sojourn there he got into trouble on account
of not having his rifle cleaned. He feared that he would be reported
for this and his previous frauds might be discovered, and he decided
to desert. He returned to Rochester, worked for Frank Little and Roy
Fritz. Soon after he enlisted in the army, this time under the name of
James Hall, but was rejected on account of some nasal defect. This was
at Columbus Barracks. After being rejected in the army he enlisted in
the navy and was sent to Norfolk, Va. He was here likewise rejected on
account of this defect, and while awaiting his discharge papers it was
discovered that he had fraudulently enlisted. He was court-martialed
and given a year. This was on November 20, 1909. His career following
this has already been outlined.

If one takes into consideration the entire life history of this individual he will have little cause for surprise at the resort to malingering by this man when he found himself under an especially stressful situation. That he malingered every frank psychotic symptom which he manifested is beyond doubt a fact, even though he would not have admitted so much himself. But one would commit a serious error if on this account he would consider the man normal mentally. From childhood on this man has manifested traits of character which are absolutely psychopathic in nature. Among these may be especially emphasized the confirmed truancy and running away from home, the aimless, constantly-changing industrial career, the inability to pursue any line of endeavor towards a definite goal, the early criminalistic tendencies, the repeated commission of military offenses in spite of the frequent punishments, and, lastly, his total inability to adjust himself to the prison regime, resulting in serious mental upsets which necessitated his admission to a hospital for the insane on three different occasions. It is perfectly natural that he should resort to malingering of mental disease in his last attempt at evading a stressful situation. Malingering is frequently the only means of escape for such as he, unable as they are to meet life's problems squarely in the face.

It is of no particular value to add more cases illustrative of the type of mental make-up which leads to malingering, especially since there exists a more or less complete unanimity of opinion on the subject among present-day psychiatrists.

CONCLUSIONS

The conclusions which may safely be drawn from the study of malingering as it is manifested in criminal departments of hospitals for the insane are as follows:--

1. The detection of malingering in a given case by no means excludes the presence of actual mental disease. The two phenomena are not only not mutually exclusive, but are frequently concomitant manifestations in the same individual.

2. Malingering is a form of mental reaction manifested for the purpose of evading a particularly stressful situation in life, and is resorted to chiefly, if not exclusively, by the mentally abnormal, such as psychopaths, hysterics, and the frankly insane.

3. Malingering and allied traits, viz., lying and deceit, are not always consciously motivated modes of behavior, but are not infrequently determined by motives operative in the subconscious mental life, and accordingly affect to a marked extent the individual's responsibility for such behavior.

4. The differentiation of the malingered symptoms from the genuine ones is, as a rule, extremely difficult, and great caution is to be exercised in pronouncing a given individual a malingerer.

REFERENCES

[1] BRILL, A. A.: "Artificial Dreams and Lying," _Journal of Abnormal Psychology_, vol. ix, No. 5.

[2] DELBRUeCK, ANTON: "Die Pathologische Luege," Enke, Stuttgart, 1891.

[3] FERRARI, L.: "Minorenni Delinquenti," Milano, 1895.

[4] PENTA, PASQUALE: "La Simulazione della Pazzia," Napoli, Francesco Perrella, 1905.

[5] WILMANNS: "Ueber Gefangnispsychosen," Halle, S. 1908.

[6] BONHOEFFER: "Degenerationspsychosen," Halle, S. 1907.

[7] KNECHT: Quoted by Penta.

[8] VINGTRINIER: "Des Alienes dans les Prisons," _Annales d'hygiene et de med.-legale_, 1852-53.

[9] JONES: Introduction to "Papers on Psycho-analysis."

[10] PELMAN: "Beitrag zur Lehre von der Simulation," Irrefreund, 1874, and _Arch. de Neurolog._, 1890.

[11] BIRNBAUM, K.: "Zur Frage der psychogenen Krankheitsformen," _Zeitsch. f. d. ges. Neur. u. Psych._, 1910.

[12] SIEMENS: "Zur Frage der Simulation von Seelenstoerung," _Arch. f. Psych. und Nerv._, xiv, 1883.

[13] MELBRUCH: Quoted by Penta.

[14] GLUECK, BERNARD: "Catamnestic Study of Juvenile Offender," _Journal of Am. Inst. Crim. Law and Crimin._, viii, No. 2.