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 inst.i.tution, 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 inst.i.tution 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 a.s.sist 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 pa.s.s 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 subst.i.tute 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 circ.u.mstance, which is not infrequently the case when the malingerer happens to be facing a court of law.

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

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

1. Malingering in the frankly insane;

2. Malingering in those apparently normal mentally; and

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

It may be difficult to convince the lay mind, and especially the legal mind, that an individual may be suffering from an actual psychosis and at the same time malinger mental symptoms. It is the legal mind especially, working as it does with well-differentiated, sharply-defined, and wholly artificial concepts, that demands a sharp, strict differentiation between the mentally well and the mentally sick.

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

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

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

The following case ill.u.s.trates 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 a.s.sumed a markedly depressed facial expression. In reply to my questions intended to bring out his att.i.tude towards the whole affair, he usually stated, "I don't know," and on one occasion in a very agitated manner said, "So help me G.o.d, 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, "h.e.l.lo, 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 s.p.a.ce, 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; uncla.s.sified cells, 2.25 per cent. Wa.s.sermann reaction with spinal fluid negative, both active and inactivated. Wa.s.sermann 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, ill.u.s.trates very well that, while we are fully justified in a.s.suming 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 ill.u.s.trated in succeeding cases. Pelman's statement, however, applies most forcibly to that ma.s.s 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 inst.i.tution, and the whole story may have been fict.i.tious. 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.