Malingering in its various forms is by no means uncommon, and by many is
regarded as a disease in itself. It is necessary, however, to
distinguish between those cases in which it is feigned for some definite
purpose--for example, to escape punishment or avoid public service--and
those in which there is adequate motive, and the patient shams simply
with the view of exciting sympathy, or from the mere delight of giving
ouble. It is not uncommon for individuals summoned on a jury, or to
give evidence in the law courts, to apply to their doctor for a
certificate, assigning as a cause of exemption neuralgia, or some
similar complaint unattended with objective symptoms. In such cases it
is well to remind the patient that in most courts such certificates are
received with suspicion, and are often rejected, and that the personal
attendance of the medical man is required to endorse his certificate on
Malingering has become much more common since the National Health
Insurance Act has been passed. The possibility of obtaining a fair sum
each week without the necessity of working for it induces many persons
either to feign disease or to make recovery from actual disease or
accident much more tedious than it ought really to be.
The feasibility of successfully malingering is greatly enhanced by the
possession of some chronic organic disease. An old mitral regurgitant
murmur is useful for this purpose.
It is not flattering to one's vanity to overlook a case of malingering,
but should this occur little harm is done. It is a much more serious
matter to accuse a person of malingering when in reality he may be
suffering from an organic disease.
Here are some of the diseases which are most frequently feigned:
=Nervous Diseases=, as headache, vertigo, paralysis of limbs, vomiting,
sciatica, or incontinence or suppression of urine, spitting of blood;
others, again, simulate hysteria, epilepsy, or insanity.
On the other hand, the malingerer may actually produce injuries on his
person either to excite commiseration or to escape from work. Thus, the
beggar produces ulcers on his legs by binding a penny-piece tightly on
for some days; the hospital patient, in order to escape discharge,
produces factitious skin diseases by the application of irritants or
It is much more difficult to decide whether certain symptoms are due to
a real disease which is present, or whether they are merely
exaggerations of slight symptoms or simulations of past ones. The miner,
after an injury to his back, recovers very slowly, if at all. He is
suffering from 'traumatic neurasthenia'--a condition only too often
simulated, and a disease very difficult to diagnose accurately. The
miner takes advantage of our ignorance, and continues to draw his
compensation. A workman during his work receives a fracture; instead of
being able to resume work in six weeks, he asserts that the pain and
stiffness prevent him, and this disability may persist for months. Such
cases as these frequently come before the courts when the employer has
discontinued to pay the weekly compensation for the injury. Medical men
are called to give evidence for or against the injured workman.
=Epilepsy= is often simulated. The foaming at the mouth is produced by a
piece of soap between the gums and the cheek. The true epileptic,
especially if he suspects that a fit is imminent, takes his walks abroad
in some secluded spot, whilst the impostor selects a crowded locality
for his exertions. The epileptic often injures himself in falling, his
imitator never; one bites his tongue, but the other carefully refrains
from doing so. The skin of an epileptic during an attack is cold and
pallid, but that of the exhibitor is covered with sweat as the result of
his exertions. In epilepsy the urine and fæces are passed involuntarily,
but his colleague rarely considers it necessary to carry his deception
to this extent. In true epilepsy the eyes are partly open, with the
eyeballs rolling and distorted, whilst the pupils are dilated and do not
contract to light; the impostor keeps his eyes closed, and he cannot
prevent the iris from contracting when a bicycle-lamp is flashed across
his face. A useful test is to give the impostor a pinch of snuff, which
promptly brings the entertainment to an end.
=Lumbago= is often feigned, and the imposture should be suspected when
there is a motive, and when physical signs, such as nodes and tender
spots, are absent. A simple test is to inadvertently drop a shilling in
front of him, when he will promptly stoop and pick it up. The same
principles apply to spurious sciatica.
=Hæmorrhages= purporting to come from the lungs, stomach, or bowels,
rarely present much difficulty. The microscope is of use in all cases of
bleeding. Possibly the gums or the inside of the cheeks may have been
scratched or abraded with a pin.
=Skin Diseases= are excited artificially, especially those which may be
produced by mechanical and chemical irritants. The most commonly
employed are vinegar, acetic acid, carbolic acid, nitric acid, and
carbonate of sodium; but tramps frequently use sorrel and various
species of ranunculus. The lesions simulated are usually inflammatory in
character, such as erythema, vesicular and bullous eruptions, and
ulceration of the skin. They may be complicated by the presence of
pediculi and other animal and vegetable parasites. Chromidrosis of the
lower eyelids in young women often owes its origin to a box of paints.
Factitious skin diseases are seen most commonly on the face and
extremities, especially on the left side--in other words, on the most
accessible parts of the body.
Feigned menstruation, pregnancy, abortion, and recent delivery are
common, and should give rise to no difficulty. The same may be said of
feigned insanity, aphonia, deaf-mutism, and loss of memory.
The following hints may be useful to a medical man when called to a
supposed case of malingering: Do not be satisfied with one visit, but go
again and unexpectedly; see that the patient is watched between the
visits; make an objective examination, compare the indications with the
statements of the patient, noting especially any discrepancies between
his account of his symptoms and the real symptoms of disease; ask
questions the reverse of the patient's statements, or take them for
granted, and he will often be found to contradict himself; have all
dressings and bandages removed; suggest, in the hearing of the patient,
some heroic methods of treatment--the actual cautery, or severe surgical
operation, for example; finally, chloroform will be found of great use
in the detection of many sham diseases.