[B]Cited by Penta.
[B]Cited by Penta.
Thus we see that malingering has itsraison d’être; that, after all, it is not at all strange that the suspicion of its existence should be so frequently raised by our legal brethren—yes, and medical brethren, too; that in reality it ought to be a very common manifestation. Nevertheless, paradoxical though it may seem, cases of pure malingering of mental disease are comparatively rare in actual practice.Wilmanns,[5]in a report of 277 cases of mental disease in prisoners, cites only two cases of pure malingering, and in a later revision of the diagnoses of the same series of cases the two cases of malingering do not appear at all. Bonhoeffer,[6]in a study of 221 cases, found only 0.5 per cent of malingering. Knecht,[7]in an experience of seven and a halfyears at the Waldheim Prison, did not observe a single case of true malingering. Vingtrinier[8]claims not to have found a single case of true malingering among the 43,000 delinquents observed by him during his experience at Rouen. Connolly, Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted by Penta as having expressed themselves that pure malingering is extremely rare. Penta, on the contrary, observed about 120 cases during his four years’ service in the prison in Naples. He gives as the reason for this unusually high percentage of cases observed by him the fact that two-thirds of the inmates of the prison belonged to the Camorra, an organization whose members are gleaned from the lowest and most degenerate stratum of society, and in whom the tendency for deception and fraud in any form is highly developed.
The question naturally arises, What is the reason for this rarity of cases of malingering? Is it because man has reached a state of civilization where he no longer resorts to deception? Decidedly not. The reason lies almost wholly in our changed attitude of today towards this question. As we acquire more real insight into the workings of the human mind we are prone to become more tolerant towards the human weaknesses, and in our study of the malingerer it is the type of individual, his mental make-up, which interests us most, rather than the malingered symptoms. It is for this reason that today the number of authorities is indeed small who do not look upon malingeringper seas a morbid phenomenon, as an abortive attempt at adjustment by an individual who is quite incapable of adequately coping with the vicissitudes of life. In my own limited experience of several years with insane delinquents I have yet to see the malingerer who, asidefrom being a malingerer, was not quite worthless mentally.
Our discussion of malingering,—i.e., of the exhibition of a fictitious mental state by an individual for the purpose of rendering more bearable or more pleasant a particularly painful or difficult situation of life, or for the purpose of entirely annihilating such a situation and of removing it from consciousness by substituting for it a state of affairs wholly created from the individual’s fantasy,—would indeed be incomplete if we were to omit from our consideration at least that much of Freud’s psychology as pertains to this subject.
Thus far we have considered principally the views of what may be termed the descriptive school of psychiatry, though we have briefly touched upon the instinctive biologic roots of this primitive mode of approach to the problems of life, malingering of mental symptoms.
With the consideration of the Freudian psychology we enter upon the interpretative phase of psychiatry and to a very large extent of mental life in general.
Freud holds that a great part of mental life can either partially or entirely be summarized under two principles, which he terms the “pleasure principle” and the “reality principle” respectively.[9]These two opponents are constantly facing one another in our inner life. The former represents the primary, original form of mental activity, and is characteristic of the earliest stages of human development, both in the individual and in the race; it is, therefore, typically found in the mental life of the infant, and to a less extent in that of the savage. Its main attribute is a never-ceasing demand for immediate gratification of various desires of a distinctly lowly order, and at literally any cost.It is thus exquisitely egocentric, selfish, personal, and antisocial. The activities of this “pleasure principle”, however, constantly come into conflict with the “reality principle.” The rigid requirements of our environment, of the social system in which we live, deny us the fulfillment of many, if not most, of our most dearly coveted desires, without, however, being able to abrogate these entirely.
There are two ways in which these forbidden desires may become satisfied. On the one hand, the instinctive striving, finding it quite out of the question to gain expression through the desired channels, may become sublimated into a form which is in accord with our social and ethical requirements, or the forbidden strivings and desires may find gratification in the individual’s fantasy. We are here particularly concerned with the latter mode of psychic adjustment. This mode of adjustment is the usual way in which conflicts with reality are solved by the child and the savage. For them a rigid recognition of reality, such as is necessitated by the normal adult in his struggles for existence, does not take place. In fact, the evolution from childhood to adult life, from savagery to civilization, consists in nothing else than in the progressive recognition of reality and the adjustment thereto. One of the forms of getting away from reality, or a falsification of conditions as they actually exist, was expressed by one of Freud’s patients as the “omnipotence of thought” (Allmacht der Gedanken). It is a state of mind in which the individual believes in the omnipotence of his thoughts; that his mere thinking possesses tremendous power; that no sooner he thinks of a certain deed than the same is accomplished; that an enemy, for instance, is actually harmed by merelywishing him harm. This mode of thinking forms the basis for many magic ceremonials. It is this latter mechanism,—i.e., the endowment of one’s own thoughts with an omnipotent power,—which is also frequently illustrated in malingering. It is sufficient for the type of individual who malingers to merely say the word, and the most fantastic creation of his fancy immediately becomes a reality and is apperceived by him as such. A mere verbal denial of guilt on his part is sufficient to make him believe fully in his innocence and act accordingly. When we inquire into the origin of this facility in transforming fantasy into reality, for this omnipotence of the mere word or thought, we find it in the totally unreasonable overcompensation of these individuals for their feeling of impotence and weakness. This feeling of weakness and helplessness naturally becomes more acute under especially stressful situations of life, and hence it is that the criminal, especially the habitual criminal, who always uses deceit and simulation in his vain attempts at meeting life’s difficulties squarely in the face, regularly resorts to malingering when confronted with a serious criminal charge or when life in prison becomes especially unbearable to him. A good illustration of an attempt at falsification of reality for the purpose of annihilating a particularly stressful situation by means of a mere assertion of a state of affairs such as he would wish them to be, with a total disregard for the real facts which constantly stare him in the face, is furnished by the following case:—
M. came from a good family and led a normal life, earning a substantial livelihood as printer up to the age of about thirty-eight. At this time one of his children died, and this,together with poor physical health, is said to have brought on a severe depression, during which he was actively suicidal and very self-accusatory. Several months later he lost another child by fire, and at this time also claimed to have obtained positive proof of his wife’s infidelity. His mental depression became very much more aggravated; he attempted suicide on a number of occasions, was very suspicious and apprehensive, developed persecutory delusions, feared he was going to be burned to death or suffer some other horrible fate. This condition finally necessitated his admission to the Government Hospital for the Insane on May 28, 1897, at the age of forty. Here he gradually improved, and was discharged into the care of his father on October 22, 1899.
M. came from a good family and led a normal life, earning a substantial livelihood as printer up to the age of about thirty-eight. At this time one of his children died, and this,together with poor physical health, is said to have brought on a severe depression, during which he was actively suicidal and very self-accusatory. Several months later he lost another child by fire, and at this time also claimed to have obtained positive proof of his wife’s infidelity. His mental depression became very much more aggravated; he attempted suicide on a number of occasions, was very suspicious and apprehensive, developed persecutory delusions, feared he was going to be burned to death or suffer some other horrible fate. This condition finally necessitated his admission to the Government Hospital for the Insane on May 28, 1897, at the age of forty. Here he gradually improved, and was discharged into the care of his father on October 22, 1899.
On February 19, 1903, he was readmitted as a D.C. prisoner, having shot and killed a man who seduced one of his daughters. Some idea concerning the type of individual we are dealing with here can be had already when we keep in mind his mode of reaction to the various stressful situations in his life enumerated above. All went well with him so long as he was not called upon to make a difficult adjustment, but with the loss of his child he develops a mental disorder. That he should have reacted to his daughter’s injury with murder is quite in line with his general inability and incompetency for proper adjustment, and the development of a mental disorder which has kept him in an institution for the past twelve years and will in all probability keep him there the rest of his life, in reaction to the committed murder, further emphasizes the general vulnerability of his nervous system. Let us see how he attempts to adjust himself to the situation; how he faces reality in his psychosis.
He does just what primitive man has done and whatthe child of today does. Not being able to face reality, he annihilates it and substitutes for it a world created out of his fantasy, in which he plays every conceivable rôle but the real one,—i.e., that of a patient accused of murder. We will see that he does this by the mere fiat of his word—that magic dexterity which has served so well primitive man in his struggles with reality.
Let me reproduce some of his letters, of which he hands me at least one daily. Here is one addressed to King George V:
Dear Sir: I wish to return at once to England to the Cissel Hotel. You told me not to take my wife back after the courts here had granted me a divorce, so I look to you to just please come on here in person and have me released, as the United States Senate has given permission for you to come and release me. I am the young man that rescued you from drowning at River View, and after telling you my case you advised me to get a divorce. The guests from the hotel were wishing for me to return when on here, as also my family.Please find enclosed check for your expenses and give prompt action.Very respectfully,(W. H. M.)Howard Hall,Washington, D.C.
Dear Sir: I wish to return at once to England to the Cissel Hotel. You told me not to take my wife back after the courts here had granted me a divorce, so I look to you to just please come on here in person and have me released, as the United States Senate has given permission for you to come and release me. I am the young man that rescued you from drowning at River View, and after telling you my case you advised me to get a divorce. The guests from the hotel were wishing for me to return when on here, as also my family.
Please find enclosed check for your expenses and give prompt action.
Very respectfully,
(W. H. M.)Howard Hall,Washington, D.C.
The check:—
U. S. Treasury,Pa. Ave. and 15th Street.Washington, D.C., October 1, 1914.Please pay to King George of England Ten Thousand Dollars for professional services.$10,000W. H. M.
U. S. Treasury,Pa. Ave. and 15th Street.
Washington, D.C., October 1, 1914.
Please pay to King George of England Ten Thousand Dollars for professional services.$10,000
W. H. M.
Thus by the mere stroke of the pen he, a poor mortal accused of murder and indefinitely confined to an institution, succeeds in putting himself in touch with King George, in drawingad libitumupon the United States Treasury, in ridding himself of the wife whom he accuses of infidelity, and in annihilating old age by styling himself “The young man,” when in reality he is fifty-seven years of age at present.
His belief in these statements is absolutely unshakable, notwithstanding the fact that he retains a clear orientation concerning his immediate environment, and thus has the actual state of his affairs constantly forced to his attention.
His grandiose compensation has such dimensions as to gratify every imaginable wish of his. He came here because he was divorced from his wife, not because of any crime he had committed. He is the son of the supervisor in charge of this building. He owns this institution and built it for a place in which he could count his money. He had forty-six wagon-loads of this. He will live 250 years, because he has taken the severest punishment to secure this. He refuses to assist with the ward work, because he pays $1.50 a day for board and is not supposed to do any work. He was brought here to select a woman for his wife. They brought him a lot of blue-eyed blondes and also a lot of Baltimore and St. Louis beauties, etc.
W. H. M., Owner, Washington Asylum, 5000 Branch Hospitals, five million employees.Anacostia, D.C., Fri., Nov. 6, 1914.Dear Mr. President:I came over here to take out forty-six wagons loaded with greenbacks. I respectfully had it arranged to have theSenate hold me here on account of so much wealth until I thought it safe to return. Please sign this and return it by mail. The Senate ordered me to write it to you, as there is no crime against me.Washington, D.C., Fri., Nov. 6, 1914.Dr. W. and Staff Officers of Washington Asylum:Please allow Mr. W. H. M. to pass out the gate at once free.Very respectfully,W. W.Please don’t delay this one minute.
W. H. M., Owner, Washington Asylum, 5000 Branch Hospitals, five million employees.
Anacostia, D.C., Fri., Nov. 6, 1914.
Dear Mr. President:
I came over here to take out forty-six wagons loaded with greenbacks. I respectfully had it arranged to have theSenate hold me here on account of so much wealth until I thought it safe to return. Please sign this and return it by mail. The Senate ordered me to write it to you, as there is no crime against me.
Washington, D.C., Fri., Nov. 6, 1914.
Dr. W. and Staff Officers of Washington Asylum:
Please allow Mr. W. H. M. to pass out the gate at once free.
Very respectfully,
W. W.
Please don’t delay this one minute.
Thus we see that the entire content of this man’s delusional fabric is intended, first, to serve the purpose of annihilating the painful reality, and, second, to substitute for it a beautiful world in which he finds himself free and young again, enjoying his fabulous riches and many blue-eyed beauties. It is the only compromise possible for him, and the fact that it is nothing but a day-dream does not in the least detract from its compensating possibilities for this individual’s painful reality. This man’s mental disorder has been so obvious ever since its inception that the question of malingering never suggested itself to anyone, and yet the underlying mechanism in this case differs in no particular essential from the cases usually considered as malingerers. In both instances the psychosis represents an attempt to get away from a painful reality by individuals who are quite incapable of meeting such reality face to face.
A more detailed consideration of Freudian psychology, especially such as concerns the subjects of determinism, defense, and compensation, would giveone a still clearer insight into the subject under discussion, but to do so would lead us considerably beyond the scope of this paper. From what has been said thus far it will be seen that the mental processes underlying the mental state of malingering differ in no essential from those operative in the human mind generally; that man in his endeavor to reach a satisfactory compromise between the two underlying principles of his conduct,—i.e., that of pleasure and reality,—frequently resorts to his fantasy; that malingering in its broader sense,—i.e., the attempt to evade reality,—is a common mode of reaction in primitive man, the child of today and in the undeveloped mind, in all of these instances signifying an inability to meet stern reality in the face, and that, therefore, malingering, when it does occur, should at least not be looked upon as an aggravating circumstance, which is not infrequently the case when the malingerer happens to be facing a court of law.
That this mode of reaction is at times resorted to by individuals who had always been looked upon as being far from incompetent only proves that under special stress, especially mental stress, man readily sinks to a lower cultural level and resorts to the defensive means common at this level.
Clinically, malingering is to be considered from three distinct viewpoints:—
1. Malingering in the frankly insane;
2. Malingering in those apparently normal mentally; and
3. Malingering in that large group of border-line cases which should rightly be looked upon as potentially insane and as constantly verging upon an actual psychosis.
It may be difficult to convince the lay mind, and especially the legal mind, that an individual may be suffering from an actual psychosis and at the same time malinger mental symptoms. It is the legal mind especially, working as it does with well-differentiated, sharply-defined, and wholly artificial concepts, that demands a sharp, strict differentiation between the mentally well and the mentally sick. By means of man-made statutes a line has been created, on one side of which they would place all the mentally well and on the other side all the mentally diseased. By the same token they cannot conceive how an individual placed on one side of the line may be able to manifest a type of reaction, a form of conduct, which is by common consent considered as being something essentially characteristic of the man on the other side of the line, losing sight of the fact that in the evolution of the human mind Nature is far from drawing such sharp differentiations as are exemplified by legal statutes. It would certainly be very convenient, and expert testimony would certainly have been spared the disrepute into which it has fallen, were Nature more accommodating in this respect. But Nature does not work in this fashion; differentiation in Nature takes place through infinite gradations, and between the absolutely well mentally and the frankly insane there is a host of individuals concerning whom it is almost next to impossible to state to which of the above two groups they belong. Thus it is that the frankly insane at times manifest conduct which taken by itself differs in no way from normal conduct, and that the so-called normal individual at times exhibits a type of reaction which is essentially of a psychotic nature.
To the psychiatrist it is a matter of common occurrence to see the mentally diseased not only dissimulate very ingeniously and tactfully mental symptoms so that it is frequently impossible to convince a jury of laymen of the existence of mental disorder, but at times, when the necessity arises, they consciously accentuate their symptoms or frankly malinger.
There is nothing strange about this. There is absolutely no reason why the insane, in his desire to gain expression for his wishes and strivings, should not avail himself of the same means that normal man uses.
The following case illustrates this very clearly:—
W. J. C., a well-educated, fairly efficient newspaper reporter, after a period of indefinite, vague, neurasthenic complaints lasting several weeks and which brought about his discharge from the staff of a local newspaper, awoke one July morning, picked up his infant child and, throwing it against the opposite wall of the room, inflicted fatal injuries upon it. After this he turned his face to the wall and remained quietly in bed. There was no ascertainable cause present for this act. The child was in the habit of entering the patient’s room every morning and playing with him before he arose from bed. It was apparently on the same errand on this fatal morning. Shortly after getting up the patient wanted to leave the house in his night clothes, but was prevented from doing so and held until the police arrived. Six and one-half hours later,—i.e., on July 27, at 12.30P.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 andcoherent 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.)
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 12.30P.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 andcoherent 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 asexaggeration 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 aparalysis 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, statedhe 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 præcox, who manifested similar religious excitement. It is of importance to note this, inasmuch as suggestion plays a considerable rôle 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 coöperate. This episode was likewise soon followed by a letter as follows. The letter wasaddressed 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 præcox 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 × 2 = 8; 8 × 4 = 28; 9 × 3 = 27; 7 × 4 = 24; 6 × 4 = 22; 6 + 7 = 13; 19 + 11 = 30; 7 + 8 = 14; 3 × 3 = 9; 4 × 2 = 12; 6 × 4 = 14; 5 × 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 forseveral 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.
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 aparalysis 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, statedhe 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 præcox, who manifested similar religious excitement. It is of importance to note this, inasmuch as suggestion plays a considerable rôle 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 coöperate. This episode was likewise soon followed by a letter as follows. The letter wasaddressed 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.”
“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 præcox 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 × 2 = 8; 8 × 4 = 28; 9 × 3 = 27; 7 × 4 = 24; 6 × 4 = 22; 6 + 7 = 13; 19 + 11 = 30; 7 + 8 = 14; 3 × 3 = 9; 4 × 2 = 12; 6 × 4 = 14; 5 × 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 forseveral 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 beenchiefly 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.Buffaloas coal-passer; was dishonorably discharged for drunkenness. He then reënlisted and served as fireman, first class, on theMilwaukeefor about three and one-half years. Says he got along well on theMilwaukee, 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. Gonorrhœal 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 moneynot 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 becamemanifest 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 10.30A.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 admissionhad entirely disappeared; pupils slightly dilated. In the forenoon of the 17th he asked for his clothes and to be allowed to go out in thecourtyardfor 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 wasWashington; 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 coöperated 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 performedwell. He described accurately a circle, a square, and triangle in the air with either hand. Movements were steady and accurate. Coördination 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 hyperæmia. 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, hereplied “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.
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 beenchiefly 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.Buffaloas coal-passer; was dishonorably discharged for drunkenness. He then reënlisted and served as fireman, first class, on theMilwaukeefor about three and one-half years. Says he got along well on theMilwaukee, 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. Gonorrhœal 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 moneynot 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 becamemanifest 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 10.30A.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 admissionhad entirely disappeared; pupils slightly dilated. In the forenoon of the 17th he asked for his clothes and to be allowed to go out in thecourtyardfor 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 wasWashington; 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 coöperated 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 performedwell. He described accurately a circle, a square, and triangle in the air with either hand. Movements were steady and accurate. Coördination 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 hyperæmia. 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, hereplied “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 anæsthesia 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 anæmic, 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.
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 régime, 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 penalinstitutions, 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 individualslack 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 excessiveobduracy 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.