War Strain; Shell-shock: Hysteria (question of malingering).
Case 453. (Myers, March, 1916.)
A sergeant, 32, with 11 years’ service and eight months’ service in France, was admitted to a base hospital for inquiry as to possible malingering. It seems that he had taught in an army school for seven years before the war. He found heavy marches in France too much for him and fainted in the retreat from Mons and during the fighting on the Aisne, where he had reported sick for dysentery. The field ambulance where he was treated was near the shell fire, and a shell knocked him into a ditch. The ambulance had to move to a cave. Thereafter the patient suffered from tremor when spoken to or when watched. After discharge, he was employed as a dispatch rider on a motor cycle, but after three months lost his nerve for this work and took charge of fatigue parties. He found the work too much for him. He had been a total abstainer. Finally the malingering charge was brought up.
The patient was nervous, delicate-looking, with widely dilated pupils, prominent eyeballs, tremor of right arm, and pulse of 102. The tremor was markedly lessened when he was alone, and was somewhat under control. He felt that his memory was defective, and tests demonstrated the defect.
In hospital patient slept better, the pupils grew smaller, the pulse rate diminished. There was a reduction in sensibility to pain over the right side of the head and body and over the right limbs. A prick of the right arm or leg was described as a finger touch. There was also almost complete hemi-anosmia and complete hemi-ageusia on the right side. Visual acuity was diminished on the right, and there was general limitation of right field; left-sided vision and field normal.
After a month in hospital at home and two months’ leave, the patient was discharged no longer physically fit for service. He is now weak physically and mentally, subject to severe headaches, and tremulous, especially in the right arm, when tired.
Re malingering, Sicard denies the existence of unconscious malingerers (presumably regarding this phrase as a figure of speech in relation to hysteria), and divides malingering into a creative and an acquired form. The simulateur de création assumes attitudes and symptoms to attract attention or pity; the simulateurs de fixation having been sick in the beginning, perpetuate their disease, in brief, crystallize their neuroses. The fixateur may be very realistic in all this, seeing that he has known from his own experience what a real disease is. The formula runs: The simulateur de création improvises; the simulateur de fixation repeats.
According to Mott, malingering in the form of an assumed Shell-shock is not uncommon amongst soldiers, and is rather hard to distinguish from a neurosis developing on the basis of an idée fixe.
Ballet’s definition of simulation is “a subjective or objective disorder which the patient invents with the idea of voluntarily and consciously misleading the observer.” Closely related to simulation is exaggeration or prolongation, conscious or intentional, of a real disorder. Babinski states that cases of genuine simulation are very rare, and that the subject under suspicion should be given the benefit of the doubt. Especially the word simulation, or similar words, should not be uttered in the presence of the patient. Practically speaking, psychotherapy applied as in cases of hysteria may often cure the simulator and the exaggerator.