This brings us to the question of the relationship between hysteria and malingering. Opinions differ as to when a diagnosis of hysteria should be made and when one of malingering would be justified. Yet even those who hold opposite views are agreed as to there being a close similarity in the clinical manifestations of the two conditions and as to there being great difficulty in establishing the differentiation in practice. "Nothing, it may be said, resembles malingering more than hysteria; nothing hysteria more than malingering. In both alike we are confronted with the same discrepancy - between fact and statement, between objective sign and subjective symptom - the outward aspect of health, seemingly giving the lie to all the alleged functional disabilities. . . . We may examine a hysterical person and a malingerer - using exactly the same tests - and get precisely the same results in one case as in the other. The finer the methods that we employ to test the genuineness of their complaints, the reality of their objective phenomena, the more do they - in hysterical individuals - yield results which in a non-hysterical person would be held as proof of positive deceit.
In short, anyone who has had much experience of hysteria comes inevitably to the following conclusion: tests for malingering holding valid with reference to organic diseases are invalid in reference to hysteria." l
1 Disciplinary Treatment of Shell Shock. (Notes from German and Austrian Journals.) Brit. Med. Journ., Dec. 23, 1916.
2 F. X. Dercum. Rest, Suggestion in Nervoxts and Mental Disease: Philadelphia, 1917.
The motives enumerated above as constituting the mainspring of hysterical conduct are the same as those which students of malingering have uniformly reported as actuating their cases.2 Also the manifestations . described by students of malingering are exactly the same as those observed daily in hysteria. Jones and Llewellyn, for instance, describe the following: pain, hyperesthesia, anaesthesia, analgesia, limping gait, tremor, contractures, paralysis, epileptiform seizures, amaurosis or amblyopia, contractions of the visual field, deafness, aphonia, stuttering, mutism, deaf-mutism, etc.
A search through the literature reveals but one point to which the differentiation is fastened almost unanimously, namely, the conscious or unconscious quality of the motivation. Yet even on this point writers have shown much inconsistency; for it is admitted that malingering, as well as hysteria, may be subconscious or unconscious.1 But there is more to add to the confusion. A case, it is said, may begin with conscious deception and end with unconscious self-deception; or vice versa; or there may be a mixture of unconscious and conscious simulation, i.e., hysteria complicated with malingering; or there may be a condition half-way between conscious and unconscious simulation.2
1 A. B. Jones and L. J. Llewellyn. Malingering. Philadelphia, 1918.
2 Pearce Bailey. Malingering in U. S. Troops. The Military Surgeon, March and April, 1918. - Jones and Llewellyn. Loc. cit.
It is strange that so futile a consideration, one so obviously belonging to the domain of metaphysics and not science, as the question of degree of consciousness of a mental process, should become the preoccupation of scientific men and should be chosen as a criterion of clinical diagnosis! When we are dealing with weak-minded, emotionally unstable, morally defective individuals, such as hysterics and malingerers are; and when, moreover, the question is one of "conscious" or "unconscious" deception, it is all the more amazing that a criterion, which is, in the first place, vague, and, in the second place, purely subjective, should seriously occupy the professional mind as a guide in practical work.
Among other points of differentiation between hysteria and malingering which have been suggested are: (1) Results of treatment by persuasion, i.e., if persuasion fails to cure the case is not hysteria but malingering (Babinski). (2) A desire to be cured speaks for hysteria; the opposite indicates malingering. (3) The malingerer dreads examination; the hysteric welcomes it. (4) Hysterical manifestations bear the stamp of a certain genuineness which those of malingering lack. These points merit somewhat detailed discussion.
1B. Glueck. The Malingerer; a Clinical Study. International Clinics, Vol. Ill, Series 25, 1915. - R. Sheehan. Malingering in Mental Disease. U. S. Naval Med. Bull., Oct., 1916.
2 H. Campbell. War Neuroses. Practitioner, May, 1916. - W. Harris. Nerve Injuries and Shock. (Oxford War Primers.) London, 1915. - A. B. Jones and L. J. Llewellyn. Malingering. Philadelphia, 1918. - Pearce Bailey. Malingering in U. S. Troops. The Military Surgeon, Mar. and Apr., 1918.
As regards results of treatment by persuasion, it is very generally recognized that in many cases which are by all diagnosed as typical hysteria persuasion fails to cure - so-called refractory hysterics. In other cases, also refractory, a cure is, indeed, obtained by persuasion, but only when it is reinforced with painful electrical treatment (Kaufmann method), isolation on liquid diet, threat of operation or of court martial, etc.
It is true, of course, that many cases of hysteria have readily yielded to persuasion; but the conditions under which that has happened should be taken into account. When the danger was removed of being returned to the front, especially, as already stated, after the signing of the armistice, many cases were not only easily "persuaded," but were cured by any method that happened to be tried, though they had previously proved refractory. The cure in these cases is obviously to be attributed not so much to persuasion as to the removal of the danger, the presence of which had given rise to the symptoms. Some cases have remained refractory even since the signing of the armistice; in these cases the actuating motive is to gain government compensation; that is the reason why the "persuasion" that has cured thousands of others is doing them no good.
Moreover, proved malingering has also in many cases yielded to persuasion, while other cases have proved refractory; in other words, the experience with malingering, in that respect, has been exactly like the experience with hysteria. Of great interest in this connection are the observations of Sicard.1
Babinski's differentiating test of cure by persuasion is based on his general conception, according to which the essential feature of the hysterical personality is abnormal suggestibility. But a close scrutiny of the facts does not support this conception. An equally plausible case might be made out for abnormal lack of suggestibility.
1 J. A. Sicard. Simulateurs sourds-muets. Paris med., Oct. 23, 1915. Abstracted in English by M. W. Brown and F. E. Williams, in Neuro-Psychiatry and the War, published by The National Committee for Mental Hygiene, New York, 1918.
Under certain conditions the hysteric is, indeed, remarkably receptive to certain suggestions; he is at the same time refractory to others. When he has to play sick in order to avoid dangerous duty he will not only be readily influenced by suggestions unwittingly made by the examining physician in testing for disorders of sensation, etc., but will actually seek suggestions by observing cases of real disease and will develop by auto-suggestion such symptoms as he may imagine to be appropriate for a "dead nerve," "stoppage of circulation," etc. At the same time he is apt to resist any suggestion of cure.
But a time comes, when, upon removal of danger, the situation changes. What was previously a life-saving disability now becomes a nuisance. Although many are, in the new situation, cured spontaneously, others feel that a sudden cure without treatment would but betray the false nature of the trouble. Nothing is more natural than that they should again seek the cooperation of the medical profession to assist them in making a seemly and plausible exit from an awkward situation. And so, after taking electricity, hypnosis, re-education, vocal exercises, or what not, accompanied by "suggestion," they are pronounced cured: this carries with it not only relief from a no longer serviceable disability, such as mutism, paralysis, contracture, etc., but also, by implication, added certification by duly constituted medical authority that a disease had existed.
Turning now to the next point of differentiation, according to which a desire to be cured speaks for hysteria, while the opposite indicates malingering, I am forced to judge from the war experience that no such generalization is possible; in a given case everything depends on special circumstances. This is, in fact, the view held by many competent students of hysteria: "Every practitioner knows the service a nervous illness often is to a patient in dealing with relatives, over whose head the patient holds it almost as a threat; this process may be consciously or unconsciously carried out. Under such circumstances the patient's deep-rooted objection to getting better may defy all therapeutic measures." l I have seen cases in which stubborn resistance to treatment gave way, following the signing of the armistice, to an impatient longing to get well.
The next alleged differentiating point, according to which the malingerer dreads examination, while the hysteric welcomes it, is, as far as my experience is concerned, also untrustworthy. In the one case of proved malingering observed by me, in which conviction and sentence by general court martial was obtained, the patient willingly at all times reiterated his story, gave written statements, submitted to neurological examinations in which the areas of anaesthesia were repeatedly mapped out, etc. He was, of course, not told that these examinations had for their object the dstec-tion of simulation. Under similar conditions hysterics, too, welcome examination. But I have many times seen hysterics cease to cooperate and become resistive to examination upon a suspicion arising in their minds that the object of the exami nation was to test the genuineness of the symptoms. This was especially noted in cases of convulsions, in which patients by turning away, biting, struggling, and fighting resisted an examination of the pupils, knee jerks, plantar reflexes, etc.
The last above mentioned differentiating point, according to which hysterical manifestations bear the stamp of a certain genuineness which those of malingering lack, is also not to be relied on. All that can be said is that in both hysteria and malingering one meets with various degrees of adroitness in simulation, various degrees of determination and persistence. "Macdonald tells of a man, feigning epilepsy, who during a fit suffered without flinching knives thrust under his nails, the insufflation of irritating powders into his eyes, and one day fell 30 feet to convince the expert, though finally he acknowledged his deceit." l
1 E. Jones. Papers on Psycho-Analysis. London, 1918.
To sum up: My own experience, much discussion with other medical officers, and a study of the literature, all lead me to the conclusion that what some have described under the name of hysteria and what others have described under the name of malingering are one and the same thing. The difference seems to be entirely one of viewpoint. Hysteria is an expression which would stress a medical viewpoint. Malingering is one which would stress a legal viewpoint.