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Bernard Glueck, M.D. (1916)
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CHAPTER IV
THE MALINGERER: A CLINICAL STUDY

I

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

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

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

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

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

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

II

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

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

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

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

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

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

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

The extent to which lying and allied behavior depend  upon unconscious motives has never been so well illustrated as in recent psychoanalytic literature, especially in a paper by Brill.[1] This author is so thoroughly convinced of the value of conscious lying as an indicator of unconscious strivings and motives that he frequently asks his patients to construct—artificially—dreams which he finds to be of valuable aid in the analysis of the patient’s unconscious. After citing a number of examples Brill states: “These examples suffice to show that these seemingly involuntary constructions have the same significance as real dreams, and that as an instrument for the discovery of hidden complexes they are just as important as the latter. Furthermore, they also demonstrate some of the mechanisms of conscious deception. The first patient deliberately tried to fool me by making up what he thought to be a senseless production, but what he actually did was to produce a distorted wish. He later admitted to me that for days he was on his guard lest I should discover his inverted sexuality, but it never occurred to him that I could discover it in his manner. That his artificial dreams have betrayed him is not so strange when one remembers that no mental production, voluntary or involuntary, can represent anything but a vital part of the person producing it.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In reproducing it he said:—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This brings us to the subject of malingering proper.

 III

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

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

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

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

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

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

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

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

Thus we see that malingering has its raison 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 half  years at the Waldheim Prison, did not observe a single case of true malingering. Vingtrinier[8] claims not to have found a single case of true malingering among the 43,000 delinquents observed by him during his experience at Rouen. Connolly, Ball, Krafft-Ebing, Jessen, Siemens, Mittenzweig, and Scheule are quoted by Penta as having expressed themselves that pure malingering is extremely rare. Penta, on the contrary, observed about 120 cases during his four years’ service in the prison in Naples. He gives as the reason for this unusually high percentage of cases observed by him the fact that two-thirds of the inmates of the prison belonged to the Camorra, an organization whose members are gleaned from the lowest and most degenerate stratum of society, and in whom the tendency for deception and fraud in any form is highly developed.

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

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

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

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

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

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

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

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

He does just what primitive man has done and what  the child of today does. Not being able to face reality, he annihilates it and substitutes for it a world created out of his fantasy, in which he plays every conceivable 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.

The check:—

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

Washington, D.C., October 1, 1914.

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

W. H. M.

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

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

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

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

Anacostia, D.C., Fri., Nov. 6, 1914.

Dear Mr. President:

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

Washington, D.C., Fri., Nov. 6, 1914.

Dr. W. and Staff Officers of Washington Asylum:

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

Very respectfully,

W. W.

Please don’t delay this one minute.

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

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

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

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

1. Malingering in the frankly insane;

2. Malingering in those apparently normal mentally; and

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

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

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

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

The following case illustrates this very clearly:—

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

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

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

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

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

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

“What were you sent here for?” “Don’t know.”

 “Who brought you here?” “Don’t know—oh yes, two policemen.”

“What is your babe’s name?” “Don’t know.”

“What is your wife’s name?” “Don’t know.”

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

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

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

“How much is 6 times 7?” After a long pause he said, “Don’t know.”

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

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

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

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

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

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

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

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

On admission to this hospital the patient was well nourished physically, talked readily and coherently, was clear mentally, although he stated he did not know the nature of this hospital, adding spontaneously that he knew it was not an insane asylum. His productivity was chiefly of a religious nature. He stated he was the real Elijah III, the real prophet; that the vision of Jesus Christ came to him in his cell, handed him a cross, and told him to pick up his clothes and follow Him. The warden at the penitentiary was jealous of his ability to preach the Gospel, and in consequence tried to get two men to kill him, but these could do him no harm, because he had the spirit of God in him. The warden also tried to poison him. He complained of a fever in his stomach from the food the warden gave him, stated  he could see crosses in the corner of his room, and was continually mumbling something to himself in a low voice. He rested well on the first night of his sojourn here, and the following morning told the attendant that he had seen God standing behind him at intervals during the night. On June 28, 1910, he developed a marked religious excitement, preached loudly while out in the yard, and wildly gesticulated in a manner as if he were addressing someone above. He continued intermittently excited until the early part of August, 1910. It should be noted here that at this time there were two other cases confined in the same building, two cases of dementia 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 was  addressed to the warden of the United States Penitentiary at Leavenworth, Kan., and he requested that it be mailed immediately, as it was very important. It was correctly dated and read:—

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

(Signed) “T. W. Elijah III,

Station L, Washington, D.C.”

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

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

 However, there was a certain element of contradiction, a certain lack of consistency, present in his behavior which is entirely atypical of the pure malingerer. His explanations of his ideas were flat and somewhat dilapidated, and resembled to a certain extent the explanations of a dementia 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 for  several meals in succession, preached, sang, and cursed in turn, gave voice to the various delusional ideas manifested above, and gave objective evidence of suffering from hallucinations. Throughout he strongly maintained that he did not want to return to the hospital at Washington, as there was nothing wrong with him mentally.

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

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

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

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

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

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

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

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

Finding, as these individuals do, a successful and convenient refuge in a psychosis, it is but natural for them to again seek this refuge when they find themselves in conflict with the law. But that which was at one time a spontaneous, unconsciously motivated mental reaction may later become a conscious volitional act, an only available means of escape—malingering of mental symptoms.

J. E. M., aged twenty-seven on admission, June 15, 1912. Family history obtained from the patient four days after admission is quite unreliable. He knew nothing of his grandparents, who died in Ireland. Father was living when last heard from, four or five years ago. He is moderately alcoholic; a stableman by occupation. Mother died at fifty-five in Bellevue Hospital, New York City, from some unknown cause. One brother was drowned. One sister died of tubercular adenitis. No instance of epilepsy, insanity, or nervous disorder in any form is known to have existed among his relatives.

Patient stated that he was born in Ireland on October 12, 1884. He never attended school, but has learned to read and write a little. Childhood was uneventful, so far as known. He came to this country at the age of four, and at twelve or thirteen years of age began selling newspapers in the streets of New York. His occupational career since then has been  chiefly that of a steamboat and longshoreman laborer along the docks of New York City. He said he enlisted in the Navy in 1907 or 1908, was not quite certain as to which year, at San Francisco, Cal. He served on the U.S.S. Buffalo as coal-passer; was dishonorably discharged for drunkenness. He then reënlisted and served as fireman, first class, on the Milwaukee for about three and one-half years. Says he got along well on the Milwaukee, until he got into his present trouble. He was convicted of sodomy and sentenced to prison for ten years, January 15, 1911. Patient did not see the discrepancies in the dates as given by him, but, as stated before, the history is quite unreliable.

A letter received from the War Department on June 28 requested identification of J. E. M. for the purpose of detecting whether or not he is the same man who under the name of Lee deserted from the Army, January 14, 1909. The photograph accompanying the letter was that of the patient.

He had measles and mumps during childhood, from which he made good recoveries. 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 money  not needed for living expenses for whisky. He would become intoxicated every time he went ashore, stating that there was nothing else to do and no place to which he could go. Practice of onanism was denied. He claimed to have begun normal sexual intercourse at about the usual age. Strenuously denied sexual perversions, in spite of the fact that he is now serving a ten years’ sentence for sodomy. He denied the guilt of this offense; insisted that he was never arrested before in his life, and believed the present conviction to have been a trumped-up affair because they must have gotten sore on him, although he cannot figure out why. Following his conviction for the above offense he was sent to the State Penitentiary at Concord, N.H. For a short while after he got there he got along well; was kept continually at work in the chair factory. He did not like this work, as he was subjected to the inhalation of the dust and shavings, and feared he would develop tuberculosis from this, and asked to be transferred to some other place. This request was finally granted him, and he was put to work in the kitchen. He states he did not get along well there; very soon got into some sort of trouble and was put into a dark dungeon, where he thinks he remained for about twelve months, strapped to the bed. He never saw the daylight during this time. He does not know why these strict measures were taken with him, but it is a fact that he was tied down. He had no idea of the onset of the present trouble, but stated that he complained frequently to the doctor of headaches and vomiting. The headaches were occipital in nature and severe at times. He could not recall his transfer to this institution nor the events which transpired during the first two or three days after his arrival here.

The medical certificate which accompanied him here stated: “Patient has been convicted of sodomy and is at present serving sentence for same. First symptoms became  manifest about February 6, 1912. Came under the care of prison physician at Concord, N.H., State Prison with severe headaches. Previous to above date it is said there were the following records at above prison in regard to this patient: April 15, 1911, and August 10, 1911, he had convulsions. These are not described in detail. The prison physician at the time noted that patient showed symptoms of organic brain disease. On February 26, 1912, he became violent, and has had to be restrained since then. For some time previous to that he had acted peculiarly. The symptoms immediately preceding his transfer to this institution are as follows: Has to be restrained to prevent violence to himself and others. Frequently suspicious when food and drink are offered him. At times noisy when he desires food and it is not given to him at once. Probable cause unknown. There is a vague history of head injury aboard ship in the tropics. Homicidal tendencies were present when the disease first became manifest.”

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

During the day of June 16, the day following his admission, he was frequently seen sitting on the side of the bed with quite a pleasant facial expression, rubbing his arms and legs. When his room was entered, however, he at once began mumbling to himself similar phrases as those given above, became quite restless, grabbing at those about him and not paying any attention to questions put to him. The following day, June 17, he showed marked improvement; was very much quieter in behavior when approached; walked back and forth in his room quite unassisted and in quite a steady manner; was seen looking out of the window into the yard for about fifteen or twenty minutes. Upon being approached by any one his gait seemed to become definitely less steady, and diffused twitchings of the thigh and leg were noted. The strabismus which was present on the day of admission  had en