Person Under Investigation: Detecting Malingering and a Diagnostics of Suspicion in Fin-de-Siècle Britain

Abstract

In 1889, The British Medical Journal published a piece titled, “Detective Medicine,” which describes feats of medical detection performed by physicians attending malingering prisoners. Though simulating illness had a long history, the medicalization of malingering at the fin de siècle led to a proliferation of such case histories and cheerful records of pathological feigners thwarted.

An 1897 watercolor by H.S. Robert shows two physicians — one lean and mustachioed, another plump and bald, scrutinizing a chamber pot. It reads: “Deux princes de la science furent chargés à leur tour de se rendre exactement compte … de … l’état de l’illustre malade …” and “The Panama Canal: to determine whether he was fit to be extradited, two eminent physicians examine the stools of Dr Cornelius Herz, who had fled France to escape the results of his mismanagement of the canal’s financing.” ¹ The Compagnie Universelle du Canal Interocéanique (French Panama Canal Company) collapsed in 1889, and a few years later a judicial inquiry unearthed bribery, extortion, and government complicity. Among its chief figures was Paris-trained physician and businessman Cornélius Herz (1845-1898), who liaised between the company and fraudulent government officials. Hounded by detectives, Herz fled to England and fought France’s persistent attempts at extradition by claiming that his advanced diabetes was life-limiting. Sequestered in the seaside town of Bournemouth, he soon transitioned from being the poster child for corruption to one for malingering, as jaundiced and antisemitic portrayals in the European press turned his medico-legal struggles into a cause célèbre. Robert’s eleven-watercolor series, titled “Un diabétique,” embraces various aspects of Herz’s alleged medical con-artistry, including: “An English doctor takes Dr Herz’s pulse to see if he is seriously ill” and “Dr Cornelius Herz escapes extradition on the ground that he has a terminal illness, and lives happily in Bournemouth for fifteen years,” augmented by the caption “Ils ne lui donnèrent que quelques heures à vivre et … il y a 15 ans de cela … on n’en parle plus. Mystère !!! …” ² These glib portraits aside, numerous medical practitioners examined Herz to assess his state of health and condition for prosecution. In 1893, Paris physicians Jean-Martin Charcot and Paul Brouardel visited upon the request of the French government and pronounced him too ill for extradition. ³ Though Brouardel returned with Paul Georges Dieulafoy later that year and judged the patient much improved, he was never transported. ⁴ In 1896, the Home Office commissioned British neurologists Thomas Barr and Thomas Buzzard to re-evaluate him. Practically all specialists agreed that Herz was too ill to travel, even to nearby London, and — in contrast to popular media — British clinical accounts were uncharacteristically sympathetic, whether due to inflamed anti-French sentiment or because they were dealing with a fellow physician. ⁵ Herz died in 1898, long before the fifteen-year period archly predicted.

Centering the detection of malingering in Britain from the late nineteenth- to early twentieth-centuries, this paper argues that malingering not only secured distinctly clinical attachments in the fin de siècle, but that those operated in conjunction with its ongoing social and cultural connotations. The Herz case exemplifies this, sitting at the crossroads of medico-legal and forensic issues, and suturing the private and public spheres.

The case of Cornélius Herz is an illuminating episode in fin-de-siècle approaches to malingering, one which highlights the period’s fascination with the meta-diagnosis of the condition, for to expose a malingerer was not only to diagnose along the continuum of illness and health, but to refine individual symptoms and signs into an understanding of how they cohered, organically or artificially. Malingering reverberates through the classical and historical lore: from Odysseus to King David and Hamlet, and military recruits to the working poor, the act of feigning illness to avoid obligations, disrupt boundaries, and unsettle social structures has persisted in the cultural and political realm. ⁶ But a transformation occurred in Western Europe and Britain in the nineteenth century, when malingering came under the purview of the physician, a bio-political power we see evidenced in the procession of eminent doctors who visited Herz. This “medicalization of malingering,” to use Simon Wessely’s phrase, had broad effects upon the cognitive and professional roles of medical practitioners and the diagnostic episteme itself, an effect that I argue has had downstream impact on clinical relationships and health and social policies surrounding diagnosis even today. ⁷ Detecting malingering entered a new forensic and investigative space, and became a way of ordering the social through the clinical. ⁸

Centering the detection of malingering in Britain from the late nineteenth- to early twentieth-centuries, this paper argues that malingering not only secured distinctly clinical attachments in the fin de siècle, but that those operated in conjunction with its ongoing social and cultural connotations. The Herz case exemplifies this, sitting at the crossroads of medico-legal and forensic issues, and suturing the private and public spheres. ⁹ Though feigning illness had a long history, this period witnessed a proliferation in the clinical literature: of sensational case histories and cheerful records of pathological feigners thwarted. Malingering also assumed significance as a node for thinking about diagnosis writ large. Drawing from popular media, fiction, and clinical reports, this paper traces two key prototypes. It shows how the detection of malingering became part of a methodology ascribed to a particular sort of physician: the “malingering detective,” a role bound up with diagnostic proficiency and practitioner skill, existing debates on generalists versus specialists, and the physician investigator model on the rise since the early part of the century. ¹⁰ Malingering was a whetstone. It sharpened competency. Consequently, it bolstered professional authority. ¹¹ At the same time, it generated a secondary phenomenon: as a clinical appraisal, it also informed clinical humility. Diagnosing malingering proved one’s mettle or exposed one’s deficiencies, and shaped constructions of the ideal physician: a clinical, investigative, and ethical being. ¹² To identify it was not only to hone diagnostic technique, but to pit one’s knowledge of the more “subtle signs of disease” against an ingenious adversary, against whom one might readily fail.

Yet it was not all down to investigator skill. If disease was traditionally cast as the criminal, in cases of malingering the patient — especially those viewed as prone to degeneracy such as the incarcerated, working class, neurasthenic, and foreign — was definitively culpable, a “person under investigation.” As such, malingering implanted itself among the “new social diseases” of the end of the century, including contagious and public health threats, neuroses, and childhood ailments, problems which put medical expertise front and center at the intersection of health and policy. ¹³ Out of these interactions emerged a diagnostics of suspicion: distinguishing “legitimate” from “feigned” illness informed not only the identification of so-called fakers, but also the very act of diagnosis even as it pertained to non-factitious disorders. In doing so, it generated debates about practitioner roles and clinical ethics, and produced unease about where clinicians sat in an emergent medico-legal framework. In these fin-de-siècle formations of diagnosis, malingering was central to physicians’ place in a new regime aligning diagnosis with detection and aiming it not merely toward therapeutic discovery, but suspicious surveillance.

The Malingering Detective

The case of Cornélius Herz consumed the Anglo-American imagination. Debates about whether he was malingering were parleyed in the UK Parliament, splashed across newspapers from New York to New Zealand, parodied in cartoon, and scrutinized in medical journals. ¹⁴ Himself a highly skilled physician, Herz was believed to be singularly capable of feigning illness, turning his repeated medical evaluations into a “whodunit” that played out on the public stage. His pathography became the object of collective curiosity, and introduced malingering as a site where medical, criminal, and legal structures intersected on an individual and societal level. In her study on the masculine body, Joanna Bourke argues that it was during World War I that doctors began to assume the overt role of detectives, policing the bodies and behavior of shirking servicemen. She cites an army surgeon’s response when asked if he was a doctor: “No…I am a detective,” as well as Dr. Henry Cohen’s “admission that it was ‘tempting to compare the methods of diagnosis with those of crime detection.’” ¹⁵ I locate this triad of malingering, detection, and diagnosis earlier in the mid-nineteenth century, especially during the fin de siècle where it becomes more fevered. Arising from this moment is a literary example notable for a malingering detective and an exploration of malingering’s clinical, investigative, and cultural facets.

“Malingering is a subject upon which I have sometimes thought of writing a monograph,” remarks Sherlock Holmes after a successful run at it in “The Adventure of the Dying Detective” (1913, His Last Bow). Published twenty years after “The Final Problem,” where the Baker Street sleuth fakes his own death (“The Final Problem,” 1893), “The Dying Detective” bares the ligaments between clinical diagnosis, criminal detection, and malingering. The narrative is reflexive and promiscuously fascinated with these entanglements: a physician (Arthur Conan Doyle) fictionalizes a physician playing detective (John Watson), diagnosing a malingering detective (Holmes), who malingers in order to entrap a criminal (Culverton Smith). At the story’s outset the reader is invited to inhabit the role of the skeptical but baffled Watson, worried physician friend. We are summoned to the bedside of a dying Holmes. The case is plausible. Stigmata are present: “His eyes had the brightness of fever, there was a hectic flush upon either cheek, and dark crusts clung to his lips; the thin hands upon the coverlet twitched incessantly, his voice was croaking and spasmodic.” So alarming is his appearance that his landlady Mrs. Hudson consults Watson (“For three days he has been sinking, and I doubt if he will last the day”). But what Watson sees at a respectable contagious distance is exactly what Holmes wants him to see: a very good piece of method acting. Holmes’ adversary, a British Sumatran planter named Culverton Smith, is equally fooled and — overconfident — confesses his crimes to someone he believes is dying. After duping Smith, Holmes describes his scheme to a shocked Watson: “With vaseline upon one’s forehead, belladonna in one’s eyes, rouge over the cheek-bones, and crusts of beeswax round one’s lips, a very satisfying effect can be produced…A little occasional talk about half-crowns, oysters, or any other extraneous subject produces a pleasing effect of delirium.” ¹⁶

“The Dying Detective” is an unusual Sherlock Holmes adventure. It disrupts the genre formula Conan Doyle burnished, and which his Strand readership had come to expect, opening with the consultation of a doctor, rather than a client approaching the detective. The detective himself, a paragon of stoic vigor, is seemingly debilitated. It is one of the few where the solution turns on a medical diagnosis, even though diagnostic epistemologies are baked into Holmes’ methods via Conan Doyle’s medical training and homage to his professors (i.e. Joseph Bell). ¹⁷ At the same time, it represents a malingering apotheosis. Throughout his repertoire, Holmes establishes himself as a master of disguise and trickery, assuming and shedding identities as varied as sailors, clergymen, and elderly women, and ultimately counterfeiting his own death. Police inspector Athelney Jones tells him in The Sign of Four (1890), “you would have made an actor, and a rare one”; the skill is also bidirectional, with Holmes remarking, “the first quality of a criminal investigator [is] that he should see through a disguise” (The Hound of the Baskervilles, 1901). “The Dying Detective” seems almost inevitable when considering the epidemic of feigning in the rest of the Holmes canon. ¹⁸

Just as the investigator prides himself on being able to “see through a disguise,” a fin-de-siècle physician might view the clinical guise of malingering as a test of diagnostic acumen. “The Dying Detective” is rare in its focus upon Watson’s skill as a doctor, not merely as trusty sidekick, loyal friend, or foil for Holmes’ brilliance. Of chief importance are the twin questions of clinical expertise and ethics — here, where the usual roles are reversed and Holmes is incapacitated, is Watson’s field. The bedside is his stage, just as the consulting room is Holmes.’ Yet when Watson tries to examine him, an apparently delirious Holmes entreats him to keep his distance due to his ailment, “a coolie disease from Sumatra … infallibly deadly and horribly contagious.” Spurred on by a sense of responsibility as both physician and friend, Watson insists: “Do you suppose that such a consideration weighs with me of an instant? It would not affect me in the case of a stranger. Do you imagine it would prevent me from doing my duty to so old a friend?” When threats of contagion fail, and Watson advances undeterred, Holmes turns caustic, undermining his clinical abilities: “If I am to have a doctor whether I will or not, let me at least have someone in whom I have confidence.” Mocking him as a mere generalist — “you are only a general practitioner with very limited experience and mediocre qualifications” — he cites esoteric medical knowledge: “what do you know, pray, of Tapanuli fever? What do you know of black Formosa corruption?” “Shall I demonstrate to you your own ignorance?” he asks brusquely. “There are many problems of disease, many strange pathological possibilities, in the East … I have learned so much during some recent researches which have a medico-criminal aspect.” Holmes identifies himself as a medico-criminal expert, a specialist in contrast to Watson’s humble generalist. Watson knows domestic and quotidian disease; Holmes researches “foreign” and outlandish afflictions, a clear alignment of the consulting detective and the medical specialist. ¹⁹ Despite Holmes’ stinging remarks, Watson offers to seek out tropical disease experts, a convincing example of the character’s subordination of ego to virtue. Later, Holmes tells Watson that he kept him at a distance because of his clinical skills, certain that he would intercept his performance and stymie Culverton Smith’s capture: “Do you imagine that I have no respect for your medical talents? Could I fancy that your astute judgment would pass a dying man who, however weak, had no rise of pulse or temperature?” At the end of this episode, Watson comes through the crucible of malingering as an idealized physician detective: clinically astute (Holmes’ insults notwithstanding), upstanding, and humble. Yet it is Holmes who, as a forensic specialist, intends to write a monograph on the topic.

The traits which Conan Doyle lionizes in “The Dying Detective” appear in contemporary clinical literature about malingering. The word itself appears in 268 Lancet articles between 1800 and 1900. The first time it appears in a title is 1885. Notably, many of the malingering descriptions take the form of a “strange” or “curious” case, highlighting their kinship to the detective genre. ²⁰ Malingerers are often cast as having criminal intelligence, or in many instances, being criminals themselves, with the doctor diagnostician serving as super sleuth. This is exhibited in an 1889 article “Detective Medicine,” reporting from Her Majesty’s Convict Prisons:

There can be no doubt that the variety and multiplicity of devices resorted to by the more confirmed exponents of this imposing art show a remarkable degree of ingenuity, perverted, it is true, and cases arise where special opportunity of gaining knowledge of the more subtle signs of disease have been found, and fully and intelligently turned to account. ²¹

It describes feats of medical detection performed by physicians attending malingering prisoners. ²² By exercising their “diagnostic powers,” they familiarize themselves with the “infinite varieties of physical malingering” and “many forms of assumed insanity.” ²³ They develop a comprehensive nosology of disease across a continuum of legitimate and fictitious, gaining knowledge with each encounter and standing up their expertise against the “expert class of malingerers.” ²⁴ Framing these encounters as competing forms of prowess and virtuosity, the British Medical Journal indexes clinical authority to rooting out malingering and announces an adversarial relationship between physician and patient, where the patient’s body and mind become loci of suspicion. Physicians caution each other to remain vigilant and on multi-sensory alert, aware that penetrating the disguises of malingering indicates superior skill. Writing on feigned insanity, Henry Wentworth Acland (1815-1900) argues that, “if masters of our art, we ought always to detect an imitation of this disease.” ²⁵ Specialists also staked their expertise upon being able to identify malingering within their exclusive ambit, as when English dermatologist F. Parkes Weber (1863-1962) comments on malingerers presenting with esoteric skin conditions, or New Jersey surgeon B.A. Watson discusses central nervous system concussions and lesions. ²⁶ Such differentiation was also viewed as critical to general medical education, wherein the diagnosis of malingering served as a doppelgänger to the diagnosis of legitimate illness, testing the same skills but through inversion. Acland wrote that malingering examples should be presented to advanced medical students, “if a case of supposed feint were offered to him for diagnosis.” ²⁷ Outwitting such tactics was not initially considered part of a garden-variety medical education, nor part of the ethos of a physician, as when Holmes explains why he couldn’t share his secret with Watson: “among your many talents dissimulation finds no place.”

As the century turned, medico-legal pedagogy reinforced unraveling patient artifice and detecting malingering as tricky, yet necessary challenges. For with malingering one was not merely contending with natural histories of disease, but the evasions of the investigated subject themselves. Whether these feints were the “normal” and understandable behavior of “normal” individuals under extraordinary circumstances (as in the case of prisoners of war), the normal and calculated behavior of allegedly abnormal individuals (the avaricious, criminal, or cowardly), or the abnormal behavior of the assuredly and involuntarily abnormal (the insane or otherwise pathological), was a matter of iterative debate and a cardinal feature of the clinical literature. ²⁸ Coterminous with emergent social theories such as Emile Durkheim’s differentiation of the normal and pathological (in The Rules of Sociological Method, 1895), which postulated that even something that seemed intuitively “abnormal,” such as crime, was indisputably “normal” given its presence and frequency in society across numerous contexts, malingering problematized traditional categories of well and ill, suggesting the contingency of the normal and pathological in a way that Canguilhem would articulate some years later. For the “genuine” was not necessarily normal, nor was the counterfeit necessarily pathological. ²⁹ Irreducibly contextual and phenomenological, the “normal” counterfeiter and the “pathological” genuine sufferer could not be reduced to binary heuristics, but existed along a continuum. Indeed, the upending of these categories of illness and wellness was part of what made malingering so epistemologically and affectively challenging for practitioners, and their dissolution triggered uneasiness about how and where physicians ought to intervene, as well as more existential questions about the rightness of such interventions. ³⁰

Malingering narratives went hand in hand with other diagnostic narratives of this period, including those of early detection and systematic clinical approach. Practitioners needed to recognize the tempo and progression of illness and refine their diagnostic method. One could not hope for success without “an analytical mind” and a “carefully arranged system of examination.” ³¹ In the case of infectious diseases in particular such vigilance would be rewarded, as Robert Farquharson, Rugby School medical officer offered in 1869: “to discriminate between trifling complaints and those of a more serious character is at all times desirable, but especially so when the slightest error of judgment may encourage the spread of contagion … ” He argues that it is easy to be a good diagnostician when confronted with florid symptoms, “when the skin, and the throat, and the eyes, and the tongue tell their plain story.” but that detecting subtlety “tries the skill of the most accomplished observer,” and therefore the “value of premonitory symptoms stands in danger of being overlooked amid the more brilliant and exciting investigations of modern medicine.” Unlike many other ailments, for which early detection offered little but a longer duration of illness (in a pre-therapeutic era), infectious diseases could actually be warded off through such attentiveness. The process of distinguishing between “trifling” and “serious” complaints suggests a linked program between the detection of malingering and apprehending infectious disease early, expressing that both crime and disease are epidemic, and that the same techniques which might expose malingering could also detect “the first entrance of infection into our system” and “enable us to state with absolute fidelity whether any group of phenomena indicates serious disease or superficial derangement.” ³²

Above all, malingering offered an exercise in clinical humility. Tracts cautioning against overconfidence, bias, and prejudice come up more frequently with malingering than with non-factitious diagnoses. Some writers warned that such diagnostic hubris would abet the malingerer and reflected poorly upon the profession itself. Here, B.A. Watson: “it is unfortunately too frequently the case that a surgeon commences his examination in medico-legal contests after having fully formed an opinion, or at least a bias or prejudice…[a] serious defect frequently observed in the members of our profession, which sometimes has its origin in laziness, although occasionally in an inordinate greed, where the physician has been accustomed all his life to given an opinion to a patient without either an examination or thought … I have not yet reached the case of the malingerer; but I have thus far merely paid my respects to those who aid and assist the malingerer.” ³³ Another admonishes physicians to develop qualitative aptitudes: “opportunity, discretion, and tact.” Doses of clinical humility delivered, many textbooks of medical jurisprudence and forensic medicine highlighted the juridical role of diagnosing malingering, devoting entire sections to its nosologies and the role of the medical expert in transmitting these diagnoses to the extra-clinical/legal world, for without the medical jurist as a liaison, “avenues of fraud are opened up and capital, lawyers and courts are practically at the mercy of a clever malingerer.” ³⁴ Some viewed the diagnosis of malingering as merely a prelude to the physician’s ethical obligation and an explicitly moral duty: the “task of inducing in such a creature the moral change which shall incline him to return to the ordinary course of the duties and customs of life around him,” for this second, paramount phase tests the true character of a physician, the subtle skills that “no science taught in schools” can aid. ³⁵ They associate a great responsibility with identifying a malingerer, or wrongly accusing an innocent person.

Conan Doyle was evidently preoccupied with contemporary debates on malingering as well, importing them not only into his fictional practice, but his clinical prose. Like Watson, a veteran of the Anglo-Afghan war, Conan Doyle’s military experiences were formative. In 1900, he published on an outbreak of enteric fever during the Boer War, and singled malingering out as something he saw uncommonly among military recruits. Indeed, the piece devotes substantial effort to rescuing the reputation of soldiers, often maligned as “skulkers and shirkers.” He writes, “of the courage and patience of soldiers in hospital it is impossible to speak too highly … I have not had more than two or three cases in my wards which bore a suspicion of malingering, and my colleagues say the same.” ³⁶ Catherine Wynne believes Doyle’s South African experiences to have been determinative, shaping the ways in which Dr. Watson — post Boer War — becomes a more “primary investigative figure” in texts such as The Hound of the Baskervilles and “The Adventure of the Dying Detective.” ³⁷ What is clear is that malingering becomes a way for Conan Doyle to refract contemporary debates around physician authority and virtuosity, diagnostic acumen, vigilance, and surveillance, and draw a clear line from the Baker Street consultation and the medical practices of Harley Street to the specialized medicine practiced by a growing cadre of domestic and colonial physicians. Indeed, “The Dying Detective” pays homage to several such medics when Watson offers to consult them: tropical specialists Dr. Ainstree (an adaptation of William Francis Ainsworth (1807-96), surgeon, cholera specialist, traveler, editor, and one of the founders of the Royal Geographical Society) and Penrose Fisher, likely a portmanteau of a few doctors who trained at Edinburgh with Conan Doyle; even the police officer, Inspector Morton, may have been named for Charles J. Morton, an 1886 Edinburgh medical graduate).

Packing so many doctor investigators into a story about a malingering detective raises the question: what did it mean to be at the receiving end of such scrutiny? What did this generation of malingering detectives mean for patients?

Person Under Investigation

“The Adventure of the Dying Detective” is unorthodox precisely because the detective himself becomes the patient and subject of medical and criminal investigation. ³⁸ As with Cornélius Herz, the expert becomes an object of study. The transformation of patient to person under investigation is a kind of cosmological shift not accounted for in Jewson’s famous ontology of the sick-man, nor in his reappearance at the center of patient-centered medicine toward the end of the twentieth century. ³⁹ David Armstrong has located the “rise of surveillance medicine” in the early twentieth century based on the reconnaissance of normal populations and an extra-corporeal spatialization of diagnosis, reconfiguring the relationship between symptom, sign, and illness into a series of health factors, an “infinite chain of risks.” ⁴⁰ Armstrong carves a sharp boundary between the nineteenth-century diagnostics of hospital medicine, with its lesion-centric pathological approach, and surveillance medicine’s monitoring of healthy populations to “identify the precursors of future illness” and distribution of lifestyle factors. He sees this as medicine’s entrance into the social sphere: no longer content to confine itself to the individual patient in a hospital bed, “medical surveillance would have to leave the hospital and penetrate into the wider population.” ⁴¹ But I posit that these ideas root themselves in the nineteenth century, and that rather than the total dissolution of a somaticist and localizing structure giving way to chains of risk, diagnostic entities such as malingering took on especial relevance at the century’s pivot, reflecting more fluid models integrating discourses of localization, risk and vulnerability, the individual and public, clinical and social. Nineteenth-century precursors like the diagnostics of suspicion as exercised in the work of malingering detectives prototype surveillance ways of thinking. For malingering existed in a liminal space between lesion and symptom, between organic pathology and presentation, and therefore taxed physicians in a very specific way. These continuities suggest that fin-de-siècle formations of diagnosis were negotiating illness semiology, pathological anatomy, and physiology while also veering toward the detection of the “normal,” i.e. the healthy individual feigning illness, a behavior pathologized in association with specific traits, alleged predispositions and susceptibilities, and in many instances a perceived lack of moral and physical fitness.

Holmes’ malingering is aided by the fact that he is mimicking not only a tropical ailment unknown to most European medical practitioners, but an entirely fictitious one. This creates an epistemic rift between himself and Watson. Not only is Holmes is acting, and Watson in earnest, but Holmes’ behavior draws him closer to the marginalized classes and criminals he is devoted to ferreting out. It also associates him with many others, who in the mainstream view, were guilty of such pathological acts. Taxonomies stratifying risk for malingering cropped up around the turn of the century. This surveillance medicine tracked those who made a “career of imposture” versus the unwitting feigners or the mentally ill, and generated probabilities of guilt depending on individual and social factors. The “Detective Medicine” report argues that feigners are found more frequently amongst the “criminal classes,” while in 1890 J.T. Eskridge classes malingerers as “the tramp, criminal, and mercenary.” Unlike many of his colleagues, Eskridge believed that it was less important to generate a differential diagnosis of malingering than it was to classify the malingerer: the “tramp class” try to “‘dead-beat’ their way … to gain sustenance in hospitals, or to eke out a miserable existence by imposing upon the charitably inclined.” The criminal malingerer “hope to escape their deserved punishment,” while the mercenary “feign injury for the hope of gaining remuneration.” ⁴² Such wariness only increased in the setting of the Workmen’s Compensation Act (1898) and the growth of such workers’ compensation schemes in industrializing nations, so that by the early 20th century clinicians across domains maintained a similar administrative roster of offenders: duplicitous workers, “soldiers, prisoners, schoolboys, conscripts … ‘hospital birds,’ hysterical young women, club patients, persons injured or supposed to be injured in railway accidents, and persons who have been accused of some crime,” according to neurosurgeon Byron Bramwell (1847-1931), or as F. Parkes Weber attested, “young women with abnormal psychical states,” and prisoners of war attempting to achieve repatriation. ⁴³

By inhabiting the role of a malingerer suffering from a mysterious tropical disease, Holmes occupies a pathologized identity, one associated with dock workers, global migrants, and colonial subjects. Mrs. Hudson tells Watson that Holmes had been in Southwark, “working at a case down at Rotherhithe, in an alley near the river, and he has brought this illness back with him,” while Holmes himself calls it a “coolie disease from Sumatra.” ⁴⁴ Pablo Mukherjee views Holmes’ malingering as confirmation of the “pathological proximity” between the detective responsible for “the defense of the imperial status quo” with the global laboring class — not only working class English but indigenous laborers everywhere. The allegations of laziness and the racialization of malingering amongst “coolies” (especially in the colonial context) is an “almost reflexive taxonomic move,” harbored in the imperial archive of “official reports, plantation diaries, medical treatises, parliamentary debates, or private correspondences.” Reading “The Dying Detective” through Freudian and Kristevan poetics, Mukherjee argues that Holmes’ physical deterioration (albeit self-imposed) joins him with the abject bodies victimized by Culverton Smith’s horrific medical experiments (collapsing Holmes’ final illness with that of these indigenous subjects, Smith brutally says: “Yes, the coolies used to do some squealing towards the end”). In order to uphold British imperial stability and to contain threats, Holmes must himself become subversive and peripheral. ⁴⁵

Despite being insulated by wealth, education, professional status, and Euro-American caché, Cornélius Herz did not fare much better as a person under investigation, his Jewish heritage making him a ready target in a structurally racist society. A full century later some historians still associate his name with malingering, and his English tenure as a ploy “sheltered under the cloak of invalidism.” ⁴⁶ Accounts of his financial speculations and corruption, dosed with antisemitism, bled into his medical assessment, and it is hard to separate where one begins and the other ends. In the Robert caricatures as well as French political cartoons depicting then Prime Minister Georges Clemenceau as his puppet (or “L’ex copain de Cornelius Herz”), Herz is shown as a “a stereotyped Jewish figure” with a large nose and swarthy features, juggling money bags and tweaking marionette strings. ⁴⁷ Edouard Drumont’s Le Libre Parole is exemplary even among the generally skewed French press for its antisemitism, leveraging the Panama Scandal (Cornelius Herz and Baron Jacques Reinach) and l’affaire Dreyfus of 1894-1906 (Alfred Dreyfus), both featuring prominent Jewish protagonists, toward a surge of French nationalism and religious intolerance. ⁴⁸ As the medico-legal literature suggested qua malingerers, Herz’s criminal intelligence, Jewishness, and foreignness, were thought to enhance his expert counterfeiting. Per Eskridge’s taxonomy, he would exist somewhere between the criminal and the mercenary.

Herz’s reception in England, while still skeptical, was tempered. British physicians, in particular, were more supportive than was their wont. The same qualities undergirding French characterizations of his “pathological proximity” to criminality became their authenticating arguments. They defended Herz as a colleague, an Anglophile (who had spent time in both England and America), and a cosmopolitan global citizen. His status as a French exile fueled more fervent advocacy, as when The British Medical Journal avowed “the French press have never ceased to ridicule the reality of the illness, have published the most fanciful accounts of the patient’s outdoor doings, and generally the most indecent misrepresentations and charges against the patient and his physicians.” ⁴⁹ These accusations of malingering were viewed as an attack on the professional guild itself, for they were dually directed against a fellow practitioner and the acumen of his examining physicians. The media coverage of Herz was also deemed an ethical violation: The Lancet remarked that the intersection of the private, clinical sphere and the politically exigent showed how “the first principle of social ethics may be overborne,” and that this treatment was not only immoral, but dangerous:

The unfortunate object of this legal persecution has been for the past two years confined to his bed by a mortal illness, which has been gradually advancing towards its inevitable termination; and yet during the whole time he has been kept under police surveillance and has been practically condemned unheard. Surely no course could be better calculated to hasten the end of a sufferer from advanced cardiac disease complicated with diabetes. ⁵⁰

Similarly, angina specialist Lauder Brunton (1844-1916) wrote after examining Herz that “unless the strain which is at present weighing upon him is diminished, and his worry and anxiety lessened, the cardiac disease will progress and lead to an utter and irremediable ruin of his health, or even to death itself.” ⁵¹ These characterizations of Herz as a desperately unwell man, condemned “unheard” through ill will and unable to defend himself, a victim of “legal persecution” under a panoptic regime of surveillance, mark him as both person under investigation and martyr to malingering rhetoric. Unlike the anonymous malingerers distributed across contemporary clinical literature, he is regarded with sympathy. I would argue that this operates in tandem with the ideal of the “malingering detective” we have seen elaborated in both medical and cultural sources — a clinically astute, skeptical, and virtuous being. The conjunction of testimonies from well-regarded specialists, iterative clinical examinations, congratulatory rhetoric on the superiority of English good will and ethics, all operate to reconfigure and uplift this professional ideal in response to Herz’s malingering case. As such, the British medical establishment largely viewed the accusations leveled against Herz as violating these principles. When Herz died, The Lancet published a brief but compassionate obituary, remarkable for its eagerness to vindicate British physicians while subtly denouncing colleagues across the Channel: “his death was due to angina pectoris and in its mode of onset sufficiently justified the opinion of the well-known English physicians who refused to take the responsibility of saying that he was in a fit state to appear at the Extradition Court” ⁵²

Many also critiqued the ways in which Herz’s body and suffering were put on display; the cynical disbelief of his symptoms and scrutiny of every physical sign presented on the European stage. As one writer noted, “we have always regretted that it should have been ever deemed necessary to parade before the public the particular details of the malady of Dr. Herz.” ⁵³ Legal proceedings in Paris provoked further outcry across the Channel, as repeated attempts at extradition countervailed what was considered impeccable English medical guidance. In response to this, Malcolm MacDonald McHardy (1852-1913), along with a number of other practitioners who examined Herz, sent “authenticated” clinical impressions to the Cour d’Appel in Paris and the Home Office in London and replicated them in the pages of The Lancet, pointing to the “cruel hardship of the situation,” and the “falseness and indecency of the comments in the lay press of France [which] are as disgraceful as incredible.” ⁵⁴

Despite these calls for privacy and decency, however, even sympathetic British accounts of Herz’s ailments were cast in an explicitly investigative light. In their enthusiasm to refute the malingering allegations, respected medical journals offered competing “authentic statements” upon the “case of Dr. Cornelius Herz.” Thomas Barlow described his visit with Thomas Buzzard: “It is fair to state that Dr Herz bore our investigation of one and a quarter hour’s duration extremely well. We were told by those present that he was at his best and that at previous investigations he had acquitted himself with great success, but that he had suffered much afterwards.” ⁵⁵ Lauder Brunton conducted and publicized a meticulous physical exam, including cardiac auscultation, splenic palpation, and urinoscopic analysis. ⁵⁶ These bedside case histories were arduous and detailed, and evidently taxing for the patient. Because they were iterative, the slightest changes or improvements were noted and tabulated, affixing tiny shifts in constitutional symptom (appetite, weight, fatigue) or sign (auscultation, palpation) to the legal apparatus awaiting Herz.

When Brouardel and Dieulafoy visited Herz, a few months after Brouardel’s initial exam with Charcot, they noted that their subject was significantly improved, notably “dans la plénitude de ses facultés intellectuelles. Il n’est plus l’homme anémié el amaigri du mois de juin; iln’est plus l’homme tombant d’inanition et de faiblesse,” and that as a result he could be extradited. ⁵⁷ For the French press, this was further evidence of a “faux Cornelius Herz,” “montré aux médecins experts lors de leur mission, le vrai, le seul, jouant au crocket, voyageant en France.” When the British raised an outcry, the French responded on medical grounds: “Il semblait que l’on n’avait ja mais vu un malade atteint de diabète, d’albuminurie ou d’affection du cœur, avoir une rémission dans la marche de sa maladie.” ⁵⁸ Perhaps their British counterparts were simply unfamiliar with the natural histories of diabetes and cardiac disease, and not so skilled at detecting malingerers, after all.

Dwelling upon the nineteenth and early twentieth century, this paper has made the case that during this period, malingering transforms into an entity around which the medico-legal establishment constructed an entire clinical, epistemological, and ethical structure. It fixes the fictional and historical case studies of Sherlock Holmes and Cornélius Herz in the broader context of malingering. Framing malingering as an act of detection, its diagnosis becomes part of a methodology ascribed to a certain sort of physician — the “malingering detective” — a figure characterized by clinical acuity, ethical rigor, and a broad forensic sphere of influence bridging the clinic and the courtroom.

A Diagnostics of Suspicion

When Paul Ricœur characterized a “hermeneutics of suspicion” distinguished by skeptical reading, circumventing obvious meanings in favor of occult or unflattering truths, he triggered a half-century debate in literary and historical criticism. ⁵⁹ For isn’t this self-evident? Are we not always panning for meaning amidst the dross? The same can be said for diagnosis; housed in its very etymology is the praxis of sifting truth from appearances. In her landmark study of medical narratology, Kathryn Montgomery identifies a “diagnostic circle” akin to Heidegger’s hermeneutic circle, an iterative process of interpretation where multiple narratives intersect, scaffolding clinical thought and relationships and centering the physician as reader and interpreter. ⁶⁰ Diagnostician and critic share this fascination for the concealed — unearthing profound meanings and mapping relationships between surface and depth — a genealogy of suspicious reading. Diagnosis is also socially constructed, and as Charles Rosenberg famously described, it “structures practice, confers social approval on particular sickness roles, and legitimates bureaucratic relations.” ⁶¹ In this regard, it informs a number of policy frameworks. What then is the meaning of a diagnostics of suspicion, and what ramifications might this have for contemporary social policy?

Dwelling upon the late nineteenth and early twentieth centuries, this paper has made the case that during this period, malingering transforms into an entity around which the medico-legal establishment constructed an entire clinical, epistemological, and ethical structure. It fixes the fictional and historical case studies of Sherlock Holmes and Cornélius Herz in the broader context of malingering. Framing malingering as an act of detection, its diagnosis becomes part of a methodology ascribed to a certain sort of physician — the “malingering detective” — a figure characterized by clinical acuity, ethical rigor, and a broad forensic sphere of influence bridging the clinic and the courtroom. Alongside we witness the mutation of the patient into a person under investigation, a term which still carries epidemiological heft, signaling both contagious danger and medicalized surveillance in recent outbreaks from Ebola (2014-2016) to the ongoing SARS-CoV-2 pandemic (2019-). ⁶² As such, it is even attached to diagnostic and billing codes, as when the Centers for Disease Control updated ICD-10 taxonomies to reflect the category of COVID-19 “PUI.” ⁶³ This interaction between diagnosis in the clinic, classificatory schemes, public health policy, and business and legal apparatus mirror the networks of malingering in the fin de siècle.

For the late Victorians, the person under investigation was often pathologized, racialized, and distanced from the investigator due to alleged predispositions and susceptibilities. Simultaneously, the practitioner developed a sense of social and ethical responsibility beyond the clinical, to address a condition thought to present risk to the population and medico-legal system at large. The interplay between these figures contributed, in turn, to a diagnostics of suspicion. In contemporary biomedicine on the individual and population health scale, such dynamics operate in subtle, but pervasive ways. Though malingering was expunged from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) but remains a “V” code (a numeric code used for visits to a health care professional for purposes other than for illness), its afterlives continue and have ramifications for almost all forms of diagnosis. Doctors are coached to be skeptical of patients or to distrust their reports — before the advent of patient-centred medicine in the last few decades of the twentieth century, this was overt and endemic in published clinical literature, even as late as a 1979 Journal of the American Medical Association piece which counsels physicians to model themselves on the “detective prototype” in order to “detect deception on the part of a patient.” ⁶⁴ Such deception, writes the author, is not just deliberate malingering but anything that threatens the physician’s authority, from subconscious undermining to non-compliance. Since the 1980s, a growing body of literature has addressed physician distrust of patients, including major works in the health humanities and bioethics, such as Jay Katz’ The Silent World of Doctor and Patient (1984), Susan Sherwin’s No Longer Patient: Feminist Ethics and Health Care (1992), and health communications and health equity scholarship addressing distrust mediated by racial, gender, and cultural bias. ⁶⁵ Nevertheless, the legacy of the malingering detective endures in the medical “hidden curriculum,” that cues trainees to doubt patients, though such language might never appear in overt form. ⁶⁶ Such a diagnostics of suspicion is embedded even in the seemingly benign aspects of quotidian medicine, such as the conventional “SOAP” note (Subjective/Objective/Assessment/Plan) which assigns subjectivity to the patient’s story and symptoms, but objectivity and primacy to diagnostic and laboratory data and physician impression. Medical care is billed according to this fault line, practically effacing the patient’s account from the critical/billable portion of the chart. These social and cultural views of diagnosis therefore have substantive clinical, epidemiological, and policy effects, tied to diagnostic error and bias, insurance models and compensation, and global health outcomes.⁶⁷ This framing of doctors as suspicious readers and patients as evasive or untrustworthy subjects, whether actively cynical toward patient reports and motivations or more subtly undermining of them, carries forward from the long nineteenth century a consequential paradigm: that of virtuous doctor and unvirtuous patient. One to be believed and trusted, the other to be investigated.