ease most easily pretended. In proportion to the facility of assuming it, must be the vigilance of those whose duty it is to detect the fraud. The inquiry should be made in all suspicious cases, where the disease is seated-what is probably its cause -the nature of the pain-its duration-its symptoms and effects, and what remedies have been already used?

The seat of pain is either the external or the internal parts. Patients will not so readily feign the former, since the deceit is liable to be soon detected; and in addition to this, it is generally of that kind which is deemed a slight disease. Pain in the external parts is, moreover, often accompanied with heat, redness, change of color, or tumor. Gout is sometimes pretended, and, above all, rheumatism, for which the soldier is always ready to assign sleeping on the ground as the cause. Both of these diseases have diagnostic symptoms-redness, etc. in the one; and tumefaction, or diminution of size, with retraction or loss of motion, in the other. But it is equally true, that there are species of severe pain, in which the physician can find no external appearances to found an opinion; and of this description are neuralgic, scorbutic, and venereal pains. Internal pain is accompanied with symptoms which it is impossible to assume, and their absence will of course lead to suspicion. Each organ presents peculiar symptoms, which, if the disease be real, are not periodical or occasional in their manifestations, but incessant, and their severity is generally greater during the night. Inquiry ought also to be made concerning the cause of sickness, and a comparison drawn between it and the violence of the malady. With respect to the species of pain, we should examine whether it be sharp, heavy, or darting, and then compare this with the symptoms. It is, moreover, important to know the duration of the pain complained of; since it is very rare that it is prolonged for any length of time, without exhibiting manifest and unequivocal signs. If violent or persistent pain is stated to be present, and the patient notwithstanding enjoys a good appetite, sleeps well, and does not lose flesh, we have reason to doubt its severity, and even its reality. Much may also be learned from

the remedies employed.

When powerful ones are indicated, the patient will not object to their application if the disease be real. It may also be proper to mix a little opium in the food of the patient; and if sleep be thus readily induced, we may form an opinion as to the magnitude of the disease.

Notwithstanding the above directions, instances have occurred of physicians mistaking real pain for feigned, and feigned for real. "I refused," says Foderé, "for fifteen years, a certificate of exemption to a young soldier, who complained of violent pain, sometimes in one limb, and sometimes in another, and occasionally in the thorax or pericranium, without any external sign to indicate its existence. He died at last in the hospital, from the effects of the malady, which he always insisted was a species of rheumatism. I examined the body after death, viewed all the former seats of disease, but discovered nothing either in the membranes, muscles, nerves, or viscera; and was hence led to believe that life was destroyed solely from the repetition and duration of those pains."* This case induced a determination in our author to be more lenient in future. The result will be seen in the following instances. An artillerist from the garrison of Fort de Bouc, was brought to the hospital at Martigues, with a violent pain in the left leg, which was attributed to sleeping on the damp ground. During the space of eight months, a variety of antimonial preparations, together with mercurials and tonics, when indicated, were administered along with local remedies, but without any relief. The leg, from the repeated use of epispastics and cauteries, became thin, and rather shorter than the other; while from the low diet ordered, there was a general

* Foderé, vol. ii. p. 471. Dr. James Johnson relates the case of a man who complained of inability to move his shoulder-joint without much pain, and yet nothing could be seen externally for a month or six weeks, during which time he was excused from duty. At length the surgeon became suspicious, and finding that he still made the same complaint, reported him, and he was flogged as a skulker. Shortly, however, a deep-seated abscess was discovered in the shoulder-joint, from which large quantities of pus were evacuated. Anchylosis of the joint followed. (Medico Chirurgical Review, vol. iv. p. 596.)

paleness and lankness of the system. Under these circumstances, Foderé could not refuse him a certificate as a real invalid. With the aid of a crutch, he dragged himself to Marseilles, where he obtained the promise of a discharge. He was ordered to return to the fort to await its arrival; but on his way thither, being too overjoyed, he was met by his commander, walking without his crutch. On being put in prison, he avowed the fraud.

A deserter, condemned to hard labor, was conducted from prison to the workshops, marching on two crutches, as being paralytic in the lower part of the body; and from thence to the hospital, where he remained thirteen months. He supported during that time, with the greatest fortitude, the application of epispastics, moxa, and cupping; asked earnestly for the trial of new remedies, and excited the commiseration of all who saw him. At the end of the above period he was dismissed. In a short time he abandoned the use of his crutches, and never employed them except when he expected to be observed.*

It is evident from these cases, that the difficulty of detection is often great. "The imposition is more frequently discovered by the inconsistencies and contradictions which a patient makes in the history of his complaint, than by diagnostic symptoms." There is also often great aversion to the proper modes of cure.

Internal pain, the existence of which it is difficult positively to deny, may be discovered to be feigned by examination during sleep. Thus, a soldier complained of severe pain in the abdomen, and screamed on the slightest touch to that part. He was bled, and afterwards an anodyne exhibited. About midnight he was visited by the medical officer, and found sound asleep. Pressure was made on the abdomen, and afterwards considerable kneading, before he awoke.‡

Lumbago, where the body has been bent nearly double,

* Foderé, vol. ii. pp. 437, 474.

Marshall, p. 118.

† Marshall, p. 115.

has been repeatedly removed in a moment, by Baron Percy, holding the individual in an interesting conversation, while an assistant approached insidiously and pierced him behind with a long needle.

Chronic rheumatism, according to Dr. Cheyne, is distinguished by some disorder of the digestive organs, impaired appetite, a degree of pyrexia in the evening, yielding during the night to perspiration. There is also some emaciation, wasting of the muscles of the affected limbs, and puffiness of the joint. The feigned, on the contrary, do not lose their healthy appearance-have no fever-do not become worse with damp weather, but are complaining at all times-and even allege that they have entirely lost the use of the part affected, which seldom happens in real rheumatism.*

An interesting case of feigned tic douloureux, or facial neuralgia, is mentioned by Dr. A. T. Thomson in his Lectures. It occurred in the person of a girl aged fifteen, who pretended to suffer great pain just back of the symphysis of the lower jaw. It produced her removal from school, the object she had in view. On a subsequent attack, Dr. Thomson resolved to try the effect of a strong mental impression; and understanding that she entertained great antipathy against a dog, informed her that the only remedy remaining was to rub the affected part over the back of that animal. The consequence was, an immediate removal of the disease and its continued absence for eighteen months. This case, according to Dr. Thomson, has been published in the medical journals as an illustration of the effect of mental impressions on the nervous system. Yet, eight years afterwards, when this female bad. become a wife and mother, she wrote to him, stating that the whole course of the disease had been a deception.t

HÆMOPTYSIS is feigned by pretending to cough, and then spitting out the blood which comes from pricking the gums;

* Cheyne, p. 170.

† London Medical and Surgical Journal, vol. vii. p. 101.

or it may be assumed by constantly holding some Armenian bole or vermilion paint under the tongue, which tinge the saliva red. Periodical attacks of this disease are most commonly simulated; but it is difficult to counterfeit the accompanying marks of disease-such as the cough, flushed cheek, and even the florid and coagulated state of the blood. Orfila recommends that they should be made to spit without coughing, when the bloody saliva will be seen.

[Hæmoptysis may also be feigned by scarifying the posterior nares or fauces; the blood trickling over the glottis, excites the secretion of mucus, and cough. When this is suspected, make the patient blow his nose, or draw air forcibly through the nostrils; blood mixed with mucus will be discharged. If the hemorrhage be considerable, ascertain the presence or absence of physical signs of diseased lungs. In hæmatemesis look to the veins for cicatrices, and ascertain whether or not visceral disease be present. Note also the quantity of blood and degree of nausea, which, except in females, when the discharge is vicarious, are usually so great as to cause marked mental and physical depression. When foreign blood is suspected, use the microscope.-R. H. C.]

HÆMATEMESIS, or vomiting of blood, is simulated; and for this purpose, pretenders drink the blood of some animal, use some colored liquid, or swallow their own blood, and then throw it up in the presence of spectators. Sauvages, in his Nosology, mentions of a young lady, who, being unwilling to remain in a convent, had some blood of an ox brought to her, which she drank, and then vomited in the presence of her physician. As no deceit was suspected, he stated that she was really ill, and she thus obtained her liberty.* A similar case is related of a female, who accused a person of having maltreated her. She went to bed, and brought up large quantities of blood without any effort. She could, however, sing, cry, and put herself in a passion, without the disease recur

* Mahon, vol. i. p. 361.