No great difficulty need be experienced in forming an opinion of this man's mental status after having followed his history thus far, but when we further read that, during his sojourn in the Government Hospital for the Insane, he has evinced the most persistent tendency to weave into his delusional system every important occurrence of local or even national interest, that he sees a clear relationship between his case and the recent change of administration, and is fully convinced that many important officials held over from the last administration owe considerable gratitude to him; when he is seen in his self-assumed most important role of the man of destiny, flooding Congress, the Courts and many high officials with petitions, charges, writs, and proposed investigations; when one sees the criminal code as transformed by him; then one begins to get a proper perspective of the grandiose phase of this man's mental disorder. It is impossible, of course, with the limited space at our disposal, to even give the briefest outline of his activities, but it might be stated that only within the past several months he has succeeded in very ingeniously getting his case before a considerable number of senators and congressmen and many other prominent officials. Among the bills which he proposes to have enacted into law, is one, as has been mentioned, to abolish entirely the Courts of the District of Columbia. Of course, courts which cannot administer justice, as he sees it, must be abolished.

On his admission to the Government Hospital for the Insane, he really welcomed the procedure, stating that at last he had the opportunity to be under the supervision of a trained physician who would soon discover that he was absolutely sane and would render a report to that effect, thus vindicating him. Unfortunately for the physician, he did not see his way clear to render such a report, and Y's amiability soon changed into a very bitter antagonism towards the one who had immediate charge of him, showing a great deal of rancor in his attacks upon him, in spite of the fact that he has been accorded all sorts of privileges. He has, of course, by this time consigned many hospital officials to life imprisonment, and the amount of damages which he expects to collect from them and the Government runs into fabulous sums. He soon began to solicit the grievances of his fellow patients, establishing, so to speak, a law office in miniature upon the ward; and whereas formerly these patients in the criminal department merely aired their grievances as they saw them, they now accompany them with quotations from the statutes concerning these points furnished by this legal missionary. Soon, however, even the insane patients on his ward began to distrust him, and at the present time there is hardly an attendant or patient in the building who cares to associate with Y. He missed no opportunity of playing upon the credulity of the younger and less sophisticated attendants in the criminal building, at first begging and urging them to carry his petitions to their destination in a surreptitious manner, and finding this of no avail threatening them with fines and imprisonment as accomplices in this gigantic crime of keeping him confined in a hospital. When not out walking he keeps himself constantly busy making out documents, briefs, petitions, bills, etc. He is very seclusive, keeping himself aloof from the other patients, as he considers himself very much their superior.

Now this master litigant, this profoundly diseased man, succeeds in making quite a normal impression in a casual interview, and in his writings he frequently succeeds in conveying the idea of being quite normal. Each isolated fact looks plausible enough to the casual observer. He talks quite rationally, shows a remarkably well-preserved memory, has never exhibited hallucinations or those gross disorders of conduct which to the lay mind form the sine qua non of mental disease. It is only after a close study of the entire life history, of the many fine shades of deviation from the normal which this man exhibits, that one discovers that his mind is very seriously affected indeed, and that because of his plausibility he belongs to a rather dangerous type of mentally diseased individuals.

The chief aim of this paper has already been indicated, and we shall adhere to our original intention of rendering it as free from purely didactic considerations as is consistent with clearness. For this reason the case histories given above were considerably abbreviated and only such an account rendered as would suffice to convince even a layman that the two individuals in question are seriously affected mentally. Of this there should not be the slightest doubt in anyone's mind, neither should one encounter here any diagnostic difficulties. The only difficult point, and a point which may become of considerable forensic importance, is the exact estimation of the duration of the illness in each instance. From the available data at hand it would seem that in the case of X——, the disease had its inception in the episode during the late Civil War, though the possibility of retrospective falsification must be kept in mind; while Y seems to have been launched upon his litigious career by his dismissal from the Navy. It is therefore but fair to assume that in both instances the disease has existed for a great number of years. Nevertheless, it was only when these individuals faced the bar as defendants in criminal suits that the disease was recognized in either case. One may readily see, therefore, how easily mental disease may remain undetected, especially if one neglects to take an inventory of the individual's past life. I have already alluded to the difficulty frequently experienced in having evidence of this nature accepted in a court of law, and here, it seems to me, is room for a good deal of reform in procedure. Thus far society's side of this problem has been chiefly emphasized; but what about these unfortunate derelicts, X—— and Y? Both of them are at present confined in the criminal department of the Government Hospital for the Insane with criminal charges pending against them. Assuming that our contentions with respect to their mental status are correct, what possible justification is there to hold them responsible before the law for their acts? Nevertheless, the same sort of procedure is constantly taking place; individuals are being sent daily to hospitals for the insane, presumably for the purpose of giving them the best possible chance for recovery, the best modes of treatment, while at the same time the law persists in carrying them as individuals charged with crime, thus throwing many obstacles in the way of proper care and treatment. With many of these individuals the mere fact that there is still a criminal charge pending against them seems to act in a deleterious manner upon their mentality, while in the great majority of instances, owing to the fact that they must be carried as criminals, unusual precautions have to be resorted to both in their confinement and in the matter of various privileges, thereby vitiating in a great measure all attempts at treatment.

These are some of the problems which present themselves from a study of life histories such as are here reported, a better mutual understanding concerning which between the lawyer and the physician would unquestionably tend to a more enlightened administration of the law.

REFERENCES

[1] MAUDSLEY: "Responsibility in Mental Disease."

[2] KRAEPELIN, E.: "Psychiatrie." Achte Auflage. Leipzig, 1910. Bd. 1.

[3] TANZI: "Mental Disease."

[4] BISCHOFF: "Lehrbuch der Gerichtlichen Psychiatrie." 1912.

[5] SANDER: Quoted by White. "Outlines of Psychiatry." Fourth Edition.



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 aesthetic 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 aesthetic 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'etre. 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.

[A] Intimate contact with members of the legal profession, both professionally and socially, for some years past has convinced me that the average lawyer still looks upon the ideas concerning crime and the criminal expressed by physicians of a forensic bent as totally unpractical and visionary. It would take only a brief visit to a criminal department of any modern, well-conducted hospital for the insane to convince any fair-minded individual that the physician handles the problem of the criminal not only in a more scientific and rational manner than does one not possessed of this particular training, but also in an eminently more practical manner, even so far as dollars and cents are concerned. I have frequently had patients come under my observation who for a great number of years had been oscillating between penal institutions and hospitals for the insane, in whom each additional sentence did not only fail to bring about the hoped-for reformation, but served to render them more depraved and criminally inclined, and who would have undoubtedly continued this checkered career throughout life, had not their true, unreformable nature been discovered and thus caused their permanent isolation from society, not by the jurist but by the physician. Should reformation ever take place in any of these individuals it is safe to assume that the one who was clear-visioned enough to discover the cause of their antisocial existence would likewise be competent enough to know when this cause has disappeared.

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 aesthetic 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 Delbrueck[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 role, 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 Delbrueck 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 role 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 praecox 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 anaemic. 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 praecox 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.

[B] Cited by Penta.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The check:—

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

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

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

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

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

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

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

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

DEAR MR. PRESIDENT:

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

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

DR. W. AND STAFF OFFICERS OF WASHINGTON ASYLUM:

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

Very respectfully, W. W.

Please don't delay this one minute.

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

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

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

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

1. Malingering in the frankly insane;

2. Malingering in those apparently normal mentally; and

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

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