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.
The officer who could not kick.
Case 454. (Mills, January, 1917.)
An officer had had a bullet in the right calf, of which nothing was evident months later but small scars of entrance and exit. Nevertheless he complained of pain, especially after walking, and of inability to dorsiflex the foot beyond a certain point. No wasting could be found and no impairment of sensation. The muscles were faradically normal. Mills thought the symptoms were exaggerated and so remarked to the officer.
Under anesthesia, however, the dorsiflexion also proved to be impossible, and after exerting considerable force, Dr. Dunhill was able to rupture a massive fibrous band of adhesions that had prevented extension. The officer made a good recovery.
Dr. Mills confessed his error to the officer who had naturally resented the suggestion of malingering. The officer forgave him.
Re malingering, Moore states that no diagnosis of malingering should be made without the most careful examination and consideration of the individual as such, on account of the fact that the erroneous diagnosis dejects the patient and postpones recovery. It is particularly unwise to term the trouble “imaginary,” or to talk about “suggestion” or use similar terms in the presence of the patient.