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."
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.