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

On admission to this hospital the patient was well nourished physically, talked readily and coherently, was clear mentally, although he stated he did not know the nature of this hospital, adding spontaneously that he knew it was not an insane asylum. His productivity was chiefly of a religious nature. He stated he was the real Elijah III, the real prophet; that the vision of Jesus Christ came to him in his cell, handed him a cross, and told him to pick up his clothes and follow Him. The warden at the penitentiary was jealous of his ability to preach the Gospel, and in consequence tried to get two men to kill him, but these could do him no harm, because he had the spirit of G.o.d in him. The warden also tried to poison him. He complained of a fever in his stomach from the food the warden gave him, stated he could see crosses in the corner of his room, and was continually mumbling something to himself in a low voice. He rested well on the first night of his sojourn here, and the following morning told the attendant that he had seen G.o.d standing behind him at intervals during the night. On June 28, 1910, he developed a marked religious excitement, preached loudly while out in the yard, and wildly gesticulated in a manner as if he were addressing someone above. He continued intermittently excited until the early part of August, 1910. It should be noted here that at this time there were two other cases confined in the same building, two cases of dementia praec.o.x, who manifested similar religious excitement. It is of importance to note this, inasmuch as suggestion plays a considerable role in the choice of the malingered symptom, and because one of the characteristics of the type of individuals under consideration is a high degree of suggestibility.

In his conduct in the ward he was quiet and orderly, frequently talked in a rational and coherent manner, but invariably brought into the conversation his delusional ideas. In his demeanor towards me he was very evasive, suspicious, and showed a marked disinclination to enter into a protracted interview. Soon after an unsuccessful attempt to examine him more thoroughly he handed me a letter addressed to Judge Landis at Chicago, in which he ordered said Judge to remove Voliva from Zion City and turn the latter over to him, the patient, as the rightful heir and the only real Elijah III. Following this there was another tranquil period, during which the patient's conduct was quite good. About a month later another attempt was made to examine him in detail, but so soon as he noticed my intention to take notes of the examination he became very suspicious and evasive and absolutely refused to cooperate. This episode was likewise soon followed by a letter as follows. The letter was addressed to the warden of the United States Penitentiary at Leavenworth, Kan., and he requested that it be mailed immediately, as it was very important. It was correctly dated and read:--

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

When I get back I'll take his place, for I am Elijah III, the Lord's anointed.

(Signed) "T. W. ELIJAH III, Station L, Washington, D.C."

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

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

However, there was a certain element of contradiction, a certain lack of consistency, present in his behavior which is entirely atypical of the pure malingerer. His explanations of his ideas were flat and somewhat dilapidated, and resembled to a certain extent the explanations of a dementia praec.o.x case. In other words, there was no doubt that the patient malingered, but there was likewise no doubt that he suffered from a psychosis. On several occasions he refused to take nourishment for several days at a time in reaction to his delusional ideas.

Upon his return from his elopement it was felt that, owing to his dangerous tendencies, a more thorough attempt at evaluating the relative importance of the genuine and the malingered in his case ought to be made with a view to returning him to the penitentiary.

He was accordingly again thoroughly examined on April 8, with the following results: He reiterated his delusional ideas substantially as given above. He insisted that he was not insane; that he was railroaded to this hospital because the warden of the penitentiary and other United States officials are trying to rob him of his property in Zion City. "G.o.d Almighty meant that Zion City should belong to me." This was decided on the night when he saw the cross.

"How many months in a year?" "Twelve."

"How many days in a week?" "Seven."

"Name the months." "March, April, June, July, August, October, November, December, January, and February."

"What is the last month of the year?" "October."

"What is the first month of the year?" "March."

"Which is the Christmas month?" "I'm not certain, but I think it's January."

"How does vinegar taste?" "Sweet."

"How does a lemon taste?" "Sweet."

"What is the color of an orange?" "Blue."

"Count from 1 to 20." Counts very slowly and deliberately, omitting 11 and 15.

"4 2 = 8; 8 4 = 28; 9 3 = 27; 7 4 = 24; 6 4 = 22; 6 + 7 = 13; 19 + 11 = 30; 7 + 8 = 14; 3 3 = 9; 4 2 = 12; 6 4 = 14; 5 2 = 10; 1 + 9 = 10; 9 + 11 = 21; 11 + 9 = 18; 50 + 5 = 11; 8 2 = 4; 27 9 = 4."

"Name the days of the week." "Tuesday, Wednesday, Thursday, Friday, and Sat.u.r.day."

"Name them again." "Monday, Tuesday, Thursday, Friday, Sat.u.r.day, and Monday."

In repeating a very simple story he changed the content entirely, and omitted some of the most important details of it.

When we remember that this man was far from being as ignorant as some of the above answers would suggest, and that, while he unquestionably suffered from a psychosis, his state of consciousness was altogether too clear to justify a degree of lack of touch with his environment such as his replies would indicate, it becomes quite obvious that he malingered. This, together with his dangerous tendencies, determined us to return him to the penitentiary, which was done on April 11, 1911.

He reached the penitentiary on April 13, and on the night of April 20 he began preaching in a loud tone of voice, claiming that he was the son of David, and that he was called upon to go forth and preach to the world. He was removed from his cell to the isolation building, where he refused to take nourishment until April 23. During this period he spent most of the time preaching and singing religious songs, and at times would hold long and heated arguments with some imaginary person, always on religious topics. From the above date until his transfer to the Government Hospital for the Insane on September 24, 1911, he continued in a very disturbed and destructive state, refusing food frequently for several meals in succession, preached, sang, and cursed in turn, gave voice to the various delusional ideas manifested above, and gave objective evidence of suffering from hallucinations. Throughout he strongly maintained that he did not want to return to the hospital at Washington, as there was nothing wrong with him mentally.

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

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

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

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

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

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

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

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

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

J. E. M., aged twenty-seven on admission, June 15, 1912. Family history obtained from the patient four days after admission is quite unreliable. He knew nothing of his grandparents, who died in Ireland.

Father was living when last heard from, four or five years ago. He is moderately alcoholic; a stableman by occupation. Mother died at fifty-five in Bellevue Hospital, New York City, from some unknown cause. One brother was drowned. One sister died of tubercular adenitis. No instance of epilepsy, insanity, or nervous disorder in any form is known to have existed among his relatives.

Patient stated that he was born in Ireland on October 12, 1884. He never attended school, but has learned to read and write a little.

Childhood was uneventful, so far as known. He came to this country at the age of four, and at twelve or thirteen years of age began selling newspapers in the streets of New York. His occupational career since then has been chiefly that of a steamboat and longsh.o.r.eman laborer along the docks of New York City. He said he enlisted in the Navy in 1907 or 1908, was not quite certain as to which year, at San Francisco, Cal. He served on the U.S.S. _Buffalo_ as coal-pa.s.ser; was dishonorably discharged for drunkenness. He then reenlisted and served as fireman, first cla.s.s, on the _Milwaukee_ for about three and one-half years. Says he got along well on the _Milwaukee_, until he got into his present trouble. He was convicted of sodomy and sentenced to prison for ten years, January 15, 1911. Patient did not see the discrepancies in the dates as given by him, but, as stated before, the history is quite unreliable.

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

He had measles and mumps during childhood, from which he made good recoveries. Gonorrhal and syphilitic infection were denied.

(Wa.s.sermann with the blood-serum negative.) During a bar-room brawl in Panama he was struck on the head with a table leg and rendered unconscious for fifteen or sixteen hours. This was some time in 1908.

He thinks there was nothing more than a scalp wound, requiring no treatment beyond a simple dressing. For about a year after, headaches were present almost continually, occipital in location and of a tingling sensation. There was likewise a reduction of tolerance for alcoholics, since then two gla.s.ses of whisky being sufficient to intoxicate him. He does not know whether there was any change in his mental make-up or faculties following this injury, as he paid no attention to this. He commenced to indulge in alcoholics at the age of eighteen or nineteen. He cannot give a detailed account of the extent, but, as a rule, he spent all his money not needed for living expenses for whisky. He would become intoxicated every time he went ash.o.r.e, stating that there was nothing else to do and no place to which he could go. Practice of onanism was denied. He claimed to have begun normal s.e.xual intercourse at about the usual age. Strenuously denied s.e.xual perversions, in spite of the fact that he is now serving a ten years' sentence for sodomy. He denied the guilt of this offense; insisted that he was never arrested before in his life, and believed the present conviction to have been a trumped-up affair because they must have gotten sore on him, although he cannot figure out why.

Following his conviction for the above offense he was sent to the State Penitentiary at Concord, N.H. For a short while after he got there he got along well; was kept continually at work in the chair factory. He did not like this work, as he was subjected to the inhalation of the dust and shavings, and feared he would develop tuberculosis from this, and asked to be transferred to some other place. This request was finally granted him, and he was put to work in the kitchen. He states he did not get along well there; very soon got into some sort of trouble and was put into a dark dungeon, where he thinks he remained for about twelve months, strapped to the bed. He never saw the daylight during this time. He does not know why these strict measures were taken with him, but it is a fact that he was tied down. He had no idea of the onset of the present trouble, but stated that he complained frequently to the doctor of headaches and vomiting.

The headaches were occipital in nature and severe at times. He could not recall his transfer to this inst.i.tution nor the events which transpired during the first two or three days after his arrival here.

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

Patient was admitted to this inst.i.tution June 15, 1912, at 10.30 A.M.

On admission he was carried in by two employees. His legs were shackled and he had wristlets on his hands. He was apparently unable to stand una.s.sisted, and, when support was removed, fell to the floor.

Pupils were widely dilated; internal strabismus of the right eye was present. Facial musculature was distorted, and he mumbled to himself in a low, indifferent tone of voice, over and over again, "Give me something to eat. I can't do it. Give me something to eat," etc., in a rapid monotone. He appeared to be in a deep stupor. He did not seem to realize his whereabouts, and attention could not be gained. He was totally inaccessible. When put to bed he became quite restless, rolled out on the floor, and was unable to a.s.sist himself back into bed.

Musculature of legs was in a constant mild clonus, and the right foot was kept in position of talipes equinovarus. Pins pushed deeply into the skin all over the body caused no reaction. When food was brought to him he leaped upon it and finished the meal with extreme rapidity, stuffed his mouth full, never taking sufficient time for mastication or swallowing, and food was frequently expelled forcibly, probably from irritation of the air-pa.s.sages. Questions addressed to him remained unheeded, but he kept up a constant mumbling in a low monotone, as described above. He was totally unable to stand on his feet unsupported, but when lying down his legs were moved about quite freely in an indifferent manner. When alone in the room he remained quietly in bed, head and face covered up with a blanket, but as soon as the room was entered he became restless, grabbing to those about him and holding on tenaciously. During his first night in the inst.i.tution he slept well and was clean in habits. The following morning he was still inaccessible. He ate his breakfast quite voraciously, mumbling to himself all the time, "Give me something to eat" or "Give me something to drink." When water was brought to him he would endeavor to gulp the entire contents of the vessel at one effort.

During the day of June 16, the day following his admission, he was frequently seen sitting on the side of the bed with quite a pleasant facial expression, rubbing his arms and legs. When his room was entered, however, he at once began mumbling to himself similar phrases as those given above, became quite restless, grabbing at those about him and not paying any attention to questions put to him. The following day, June 17, he showed marked improvement; was very much quieter in behavior when approached; walked back and forth in his room quite una.s.sisted and in quite a steady manner; was seen looking out of the window into the yard for about fifteen or twenty minutes. Upon being approached by any one his gait seemed to become definitely less steady, and diffused twitchings of the thigh and leg were noted. The strabismus which was present on the day of admission had entirely disappeared; pupils slightly dilated. In the forenoon of the 17th he asked for his clothes and to be allowed to go out in the courtyard for a walk. A few questions addressed to him were answered coherently and relevantly. He said, in answer to direct questions, that his name was J. E. M.; that he did not know his age; that he came off some ship. Said the name of the ship was _Washington_; that he did not know how long he was on that ship, but thought it was a good long time.

Asked where he was now, he said he was in the brig. "Where?" "Don't know." Asked if he were crazy, he said, "No, sir." When he came here?

"A year ago." Asked what was the matter with him. "Nothing, sir. They kept me tied up too much." Asked when his bowels moved last, he said, "About a week ago."

On June 19 he gave a coherent and connected account of his past life.

He talked freely and cooperated in every way with the interviewer.

Requests were obeyed promptly and intelligently. Physical examination on that date showed him to be a well-built, well-developed white male.