Part 52

A man enlisted September, 1914, went to France after six months’ training, immediately put himself on sick list, and was admitted to a base hospital: Diagnosis, sciatica. Later, he ceased complaining of sciatica and developed spastic torticollis. He was sent back to England, was treated with radiant heat and so on, and was eventually sent to the Royal Bath Hospital at Harrowgate.

He recovered from torticollis after six weeks’ treatment; but then developed a spasmodic contracture of the right shoulder and forearm. He was massaged for this and also given high frequency treatment. Then came two transfers (massage).

Early in December, 1915, he came under Collie’s observation. He then showed right wrist bent at right angles to the forearm; hand tightly clenched, so firmly that it seemed as if the wrist were ankylosed. The case was obviously a functional one. The man refused to enter hospital at Collie’s suggestion. He was sent to the Maida Vale Hospital. Previously he tried to persuade the medical officer that further hospital treatment was unnecessary, stating that he was now able to straighten his arm and that he was applying a splint to keep it straight. He progressed slowly in the institution. Told, if he would recover within fourteen days, he would be classified “for home service only”--before the fourteen days were up, he had suspended his weight on a trapeze and pulled himself up to his chin on it; had also lifted a 28-lb. weight with his paralyzed hand. In short, he wholly recovered. He is now doing duty with his unit.

Collie says this is not deliberate malingering but a mixture of functional disease and an obvious desire to avoid active service. When he appeared before the board for a final decision, there was a tendency to assume the old paralyzed position until he was sharply called to order, when his arm assumed normal position.

_Conclusion_: The direct personal treatment of his mental condition and an appeal to his lower instincts were immediately curative and of much more value than the radiant heat or high frequency treatment.

_Re_ Collie’s case, Russel finds surprisingly large numbers of malingerers; he found many at the time of the battles at Loos. It was particularly easy in cases of epilepsy to demonstrate a close relation between hysteria and malingering. In the psychogenesis of these conditions, Russel emphasizes the initial element of deception, which soon enormously increases either through the patient’s convictions of his ability to deceive or through a process of autosuggestion. Cases of semi-malingering are not uncommon. In England, Russel found more cases of a clearly psychogenic nature; yet in these, also, there was always primarily an element of deception.

Yes-No test of value _re_ anesthesia.

=Case 459.= (MILLS, January, 1917.)

The “Yes-No” test proved of special value in the case of an Australian private. Shortly after landing at Gallipoli this man had a bullet graze his ankle and fell some thirty feet over the bow of a ridge. He was picked up unable to move his legs and insensitive therein.

The paraplegia and anesthesia lasted three months. “Fracture dislocation of the dorsal spine” was the diagnosis made, and laminectomy was even contemplated. The sphincter reflex was normal and there was no atrophy, no rigidity and no reflex disorder. Asked to say “no” when he could not feel a pin-prick and “yes” when he did feel it, he replied “no” to each prick to the anesthetic area and changed his reply to “yes” when the sensitive parts of the body were examined. At another time the answers were found not to correspond with those given before.

The soldier was assured that he would get well and that as soon as he could walk he would be boarded and returned to Australia.

After a number of weeks he became able to walk.

Arabian fever.

=Case 460.= (ROUSSY, April, 1915.)

An Arab fell on his knee, one day in the trenches. A contracture of the left arm, with great pain, and a temperature of 38 to 40 degrees, with hemoptysis, developed. This man had been considered tuberculous. One day, however, the thermometer went up to 41 degrees. It was discovered that he took artificial means to push the mercury up, and that the spitting of blood was voluntary. All these phenomena disappeared after he was put in the guardhouse for 24 hours.

Shrapnel scratch of head: Hysterical amaurosis “?” On isolation in a dark room, the patient began to see light!

=Case 461.= (BRIAND and KALT, February, 1917.)

A man may seek to exaggerate an anomaly of his eye which had existed before the war, in order to live comfortably far from the front.

A soldier sustained a slight scratch from a shrapnel bullet in front of the left ear, which scarred over in a few days. The soldier said, however, that the bullet had gone through his skull and a few hours after his wound said he could not see. Sent to the hospital he continued to say he was blind and finally brought up in an asylum for the blind near Lyons where he was taught to cane chairs and to write in Braille. This happened in July, 1915.

In October he was sent to the Hospital at Quinze-Vingt where a diagnosis of hysterical amaurosis was made with a large interrogation point. He was then sent to Brequet where there was a section reserved for disciplinary cases and very nervous cases not wanting to get well, a service under the charge of Roubinowitch.

The soldier escaped with a comrade and eventually reached Val-de-Grâce where the diagnosis of hysterical amaurosis was again made. Examinations several times showed that there was nothing abnormal about the eyes except that the eyelids presented habitual fibrillary movements (antebellum).

The eyelids passively opened, would remain open for a few minutes and then close. There was no winking of the eye to a light, yet the pupil preserved its reflex power.

Vision was abolished, however, the soldier said. He was without any other motor or sensory disorder. Much sympathy was given to the poor blind soldier. People were much astonished when the chief of the ophthalmological service had the man isolated in a dark room. Three weeks later the man had begun to see the light a little. A week later the eyes remained open without the necessity of having the lids raised by the fingers, and vision returned.

_Re_ amaurosis, Parsons explains the blindness which may remain after consciousness returns following Shell-shock, as a condition in which the lower visual paths are carrying on their functions normally. For example, the pupillary reactions are preserved. The condition is not unlike that found in amaurosis of uremia, and Parsons has found it in children with posterior basic meningitis. For Parsons, therefore, the block occurs in the higher centers above the thalamus, possibly in the synapses of the optic radiation fibers. Ormond states that the true cases of concussion blindness invariably pass through phases of great discomfort; whereas the malingerers are without such discomfort. Medical suggestion, also, has a powerful effect here, and may actually retard recovery.

A newspaper cure.

=Case 462.= (SICARD, October, 1915.)

Sicard read in a French newspaper a story to the effect that, at two o’clock in the afternoon, a soldier had fallen on the sidewalk between Nos. 40 and 42 Boulevard de Liberté, in a nervous crisis. The people ran and picked him up. When he came to, he was very joyful, perceiving that the shock had given him back his speech, which he had lost the August previous. This soldier, the newspaper continued, became deafmute through the explosion of a bomb in a fight in Upper Alsace. “The brave soldier is most happy over the unexpected result.” The newspaper went on, “We congratulate him sincerely, as well as the people who assisted him.” He was the more contented that he had gotten well because, the soldier said, he would now be able to go back among his comrades to fight with the Boches!

Now, in point of fact, Sicard had dealt with this soldier the morning of the day in question. He had been simulating mutism for ten months, and finally told Sicard that he would like to leave that afternoon as he felt cure coming. Sometime after, he wrote a letter of profuse thanks for the benefits received, and said he did not deserve to avoid court-martial. He also said that he was going to do everything he could to justify himself. Incidentally, he kept his word and an officer in his regiment later gave him an enthusiastic recommendation.

_Re_ malingering, see discussion concerning _simulateurs de création_ and _simulateurs de fixation_ under Case 453.

Deafmutism: Explained by patient as malingering.

=Case 463.= (MYERS, September, 1916.)

A pure malingerer, of set purpose, initiates a quasipathological condition which he will discard when he has gained his end or when he is assured that he is unobserved. Malingering in the field of speech is rare. A private, 26, one year in service, three months in France, entered a base hospital, deafmute for nine weeks. He wrote: “I should be very happy if you can do anything for me. I cannot give a very clear account of what happened, as it is sometime since. I remember retiring from Hill ---- with some more to some trenches, and in the open we were shelled and I lost touch with our chaps or else they were killed. I remember a great concussion and finding myself on the ground, and a soldier dragged me up and we ran for the trench. I was very thirsty and I ran down the trench to get some water. I met one of our chaps and tried to ask him for some, and I could not make him understand. He only smiled at me. The man who picked me up took me to an officer who was sitting on the edge of the trench and tried to make me understand, and then he sent me with this man to a dressing station, and from there I have been to different places, the names of which I do not know, except the last place, No. -- Convalescent Camp. I have been there about two months----”

He seemed anxious to get well. He could not understand what was said. Induced anesthesia caused no phase of excitement, and the patient failed to regain his speech. He was evacuated to England. Three months later the patient thence wrote the following confidential letter from a Convalescent Home. “Sir,--I regret very much to inform you that I was imposing upon you.----I may state that I was physically unfit for the Front.----During the whole time of training my pay was chiefly spent in tonics and drugs, but I kept going as I was determined to see what it was like at the Front.----I have written this----that your ‘notes’ on cases will not suffer any detrimental effect through my imposture.----I have not got my discharge yet, but shall stick out for it. I ‘speak’ but do not ‘hear’ very well.--” He was in two hospitals for functional nervous disorders in England, but in neither institution was he regarded as a malingerer.

_Re_ hysteria explained by the patient as malingering, Chavigny discusses what he calls _sursimulation_. The physician must not fall into a permanent state of suspicion, and especially must not reveal his suspicions to the accused or to the bystanders. Chavigny quotes a French soldier whose letter to his wife was intercepted, stating that he was going to feign deafmutism to secure his discharge. Before he had succeeded in doing so, however, he suffered Shell-shock, and got a true hysterical deafmutism, which showed no signs of malingering whatever.

Deafmutism: Appearance of malingering.

=Case 464.= (MYERS, September, 1916.)

A stretcher bearer was seen by Lt.-Col. Myers two days after admission to a base hospital. Stolid looking and mute, he had nevertheless talked in his sleep, had written a few words about “shells coming over,” and understood what was said to him. Lt.-Col. Myers’ notes run, “He puts out his tongue and closes his eyes and holds out one hand when I ask him to do so, but gets stupid (as if sulky) when I ask for the other hand. He _will_ not hear any more. Next day quite deaf, and the following day light anesthesia with ether caused a return of hearing and of speech, with repetition of syllables to request on the way to deeper anesthesia. On awaking he cried as he was induced to resume his speech, and complained of pains in the head.

“Two days later, he seemed normal and said that he could have spoken on the second day, but that his eyes and ears had begun to swim, that he had felt dizzy, and was afraid to talk. He did not want to be sent back to the trenches. There had been severe shelling. He had lost consciousness until he awoke in a hospital at Y--. He recalled, little by little, how he had been taken back by a corporal to a cellar. He said he wanted to go back, but wanted a rest first. He went back to his unit and was reported as having done well for four months.”

There was a certain suggestion of malingering about the admission of the lad that he could have spoken before he was induced to do so. According to Lt.-Col. Myers, a number of patients upon recovery of speech are apt falsely to believe that they have been malingering. Functional disorders may simulate malingering.

Lannois and Chavanne warn against the suggestions given to malingerers and to hysterics by the statements on the tickets of admission borne by the patients for transfer, _e.g._ “incurable deafness.” These authors found 11 per cent malingerers amongst 262 cases of labyrinthine shock.

Simulation of deafmutism.

=Case 465.= (GRADENIGO, March, 1917.)

A soldier in the mountain artillery acted like a deafmute. He was unable to read or write. It was reported that he had been wounded, but no evidence of wound could be found. The man had a low forehead and a furtive glance, his whole impression being that of a criminal.

The only evidence of disease found was inflammation with perforation of the tympanic membrane of the left ear. Deep in the left auditory meatus was found _a grain of crushed oats_! The man’s speech difficulty was of a stuttering nature, but he stuttered in a different way at every test. He was unwilling to be narcotized. Finally by a process of scolding and cajoling, the man was made to confess that he could both hear and speak well. The peculiar stuttering early led to the diagnosis of simulation, but the fact that the tympanic membrane was not anesthetic, and that there was no anesthetic zone in the body strengthened the suspicion--to say nothing of the refusal of narcosis and the general behavior of the somewhat criminal-looking soldier.

A lame rascal.

=Case 466.= (GILLES, April, 1917.)

An infantryman, 28, had an equinovarus, for which he was evacuated, hospitalized, given treatment, sent home for convalescence, and declared unfit for service. He was, however, sent back to the front, and on arrival, went lame; whereupon the regimental surgeon sent him to a nerve center. The equinovarus was there but it was nothing but a simple contracture without pain, atrophy, sensory, reflex, electrical, or X-ray disorders.

The abductor muscles were stimulated by electricity and the foot straightened. He was kept under observation for a time, was lame no longer, and was sent back to his regiment.

However, sometime later he was evacuated again to the same neurological center, stating that he did not know why. There was no longer any varus or anything abnormal. The rascal had enjoyed the game of going lame and had prevailed upon his officers to evacuate him. He then saw that he was found out and pretended that he had been forcibly evacuated.

Mother love and jaundice.

=Case 467.= (BRIAND and HAURY, January, 1916.)

A soldier, 19½, entered the central psychiatric service at Val-de-Grâce, having been evacuated from a hospital in Paris, _suspect_ of having brought about a picric acid jaundice. He had been undergoing treatment in this hospital, when the physician who had isolated him found that he was getting picric acid in packages secreted in his képi.

It seems that the soldier lived with his mother, and enlisted when he was not yet 18. He proved to be as good a soldier as he was workman, and came through the campaign without wound or disease. Accordingly, in December, 1915, he got a six-day leave. His mother, who loved him well, and of whom he was the sole support, had much regretted his enlisting. She was sick with some stomach disease and, after he enlisted, she told everybody that she was going to die and that it was his fault. So, when he came on leave the next day, she asked him to take a powder so he might stay a fortnight. She did not tell him the name of the drug; only told him how to take it in a small paper, swallowing it with a little water. She said he would become yellow and that he would get a supplementary leave. Three days after his return to the front, the boy took three of the ten powders; took the same number three or four days later; and the others five or six days later. He soon had jaundice with colic and diarrhea, and apparently was exempted from service for a few days. He had returned to the front hardly a month when his mother died and the boy got another six-day leave for the funeral. He took ten fresh doses of picric acid while at Paris, and was put into hospital by a physician without suspicion. His relatives thought he was suffering from a recurrent jaundice. When the story was told, the boy confessed to the family, and said that he had taken the drug in the first place only to please his mother. It is harder to explain the second trial, since he talked about the compassion and sense of obedience he felt to his dead mother. It is probable that he simply wanted a prolonged leave at Paris.

_Re_ malingering, Blum speaks of fictitious jaundice as having received the name of _La Carotte_ (the carrot) from the soldiers. Blum gives a partial list of instances of simulation as follows:

SIMULATION

(BLUM, DECEMBER, 1916)

_False angina_, from irritating solution.

_Gastric disorder._ Oil and tobacco (with tachycardia or jaundice) (use ipecac).

_Diarrhea._ (Isolate.)

Diarrheal stools imitated by a mixture of urine and water.

Dysenteric stools imitated by the addition of fat pork and bits of raw meat.

_Appendicitis._ Complaint of pain at the well-known McBurney point.

_Tape worm._ Carriers supply others.

_Jaundice._ (Smoke mixture of antipyrin and tobacco; drink tobacco juice. Ingest picric acid.)

_Hemoptysis._ Irritation of throat surfaces with a needle.

_Albuminuria._ Eat kitchen salt to excess in a bowl of milk. Edema and albumin disappear on surveillance. Albumin injected into bladder.

_Diabetes._ Phloridzin, or oxalate of ammonia. Glucose added to urine.

_Incontinence._ (Difficult to prove fraudulent. True incontinence in middle of night. Simulated, just before waking.)

_Skin diseases_:

_Erythema._ Herbs.

_Eruptions._ Mercury, arsenic, iodine, bromide.

_Herpes._ Euphorbiacae.

_Eczema._ Rubbing with slightly warmed thapsia. Rubbing excoriated skin with acids, Croton oil, bark of garou, sulphur, oil of cade, mercurial pomade.

_Impetigo._ With cantharides plaster and _pomade stibiée_.

_Intertrigo._ (In the infantry.)

_Hyperidrosis of feet._ Prolonged hot baths. Hot foot baths with excoriation, followed by scratching and covering with linen soaked in urine.

_Edema of legs._ Constriction.

(In Lombardy, cases due to introduction of equisetum arvense, an astringent herb, by fingers and toes, followed by energetic rubbing.)

_Recurrent wounds._ (Cover with wax sealed bandages.)

_Abscesses._ Introduction of septic material. A thread soiled with tartar from teeth is drawn through the skin. Characteristic odor of resulting abscess.

_Phlegmons._ Subcutaneous introduction of turpentine or petrol.

_Paraffine tumors._ (Apply heat.)

_Sprain._ A stopper is put under the heel; or compress the leg with bandages to stop circulation and knock below repeatedly and forcibly. Edema and ecchymosis follow.

_Conjunctivitis._ Ipecac, pepper, septic or fecal materials. Pupillary dilatation has been produced by introduction of a belladonna grain under the eyelid daily.

_Ears._ Running at the ears produced by placing urine or chemical product in the ear.

_Emaciation and pallor._ Ingestion of a large amount of vinegar. Abuse of strong tobacco.

_Muscular weakness._ Arsenious acid in eggs. Voluntary lead and mercurial intoxications.

_Epilepsy._ Absence of pupillary reflex to light and pupillary dilatation, insensibility of nasal mucosa and modifications of pulse persistent after the attack is over cannot be imitated.

_Fever._ Striking elbows against walls to elevate the mercury in the thermometer. Take temperature by rectum.

_Bites._ One simulator had a fork with twisted teeth to produce the effect.

_Intra-abdominal projectiles._ Bullet swallowed.

Swelling of hand and forearm, seven months.

=Case 468.= (LÉRI and ROGER, September, 1915.)

A soldier was wounded September 22, 1914, at Charleroi by a bullet in the forearm. He came under observation May 14, 1915, with a huge edema of forearm and hand, suddenly stopping at the elbow, an elastic edema, especially marked in the palm, which was restored to its smooth contour very quickly after being compressed by the fingers, and very like an elephantiasis. The hand was in a position of moderate extension on the forearm, with fist clenched. There was a linear ecchymotic line at the upper edge of the zone of edema, especially on the antero-internal face.

According to the soldier’s own story, the swelling had begun a fortnight after the injury. He said that a very tight moist dressing had been applied during the first few days.

The patient was cared for by massage, and then by local baths. He was anesthetized in December and several drains were inserted; no result. In January he was chloroformed again and two long incisions were made along the internal border of the supinator longus and along the ulnar border of the forearm. He was better for two weeks after this second operation, but then grew worse.

The diagnosis of syringomyelia was now made, based upon the appearance of the arm and upon some ill-defined hypesthesia. This diagnosis was not entertained by Léri and Roger who, when they obtained the patient, put him into a plaster cast up to the shoulder. The edema went down rapidly to normal. In short, it was here a question of a simulator, who was even willing to undergo surgical operations with general anesthesia.

_Re_ evading service, Gleboff’s classification is as follows: 1. False assertion of disease of (_a_) internal organs, (_b_) vision, (_c_) hearing, (_d_) joints. 2. Simulation of temporary disease of organs. 3. Mutilation of limbs.

_Re_ swelling of hand and forearm, see remarks on hysterical edema under Cases 407 and 456.

A German shell-shy.

=Case 469.= (GAUPP, April, 1915.)

Gaupp’s simulator had not been under shell fire. He said to his captain that he wanted to see his badly wounded brother (he had in fact no brother), and got a furlough on this ground. He then fled as far as possible from the front, into the interior, roved about for some days, falsely asserting that he was under dentist’s treatment.

He was brought to Tübingen on the ground of mental derangement, on a hospital train, and was delivered to the clinic as a case of Shell-shock. This man’s state of excitement soon ended. As Gaupp could not make out his case clinically, he applied to the regiment and received in return court-martial papers. The man confessed that he had made false statements and fled because he was afraid of shells. Reproached with simulation, he preserved a shameful silence.

A fair exchange no robbery: France gets a simulator in an exchange with Germany of prisoners “unfit for service.”

=Case 470.= (MARIE, April, 1915.)