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PART I.

(CONTINUED.)

MALINGERING AND THE FEIGNED DISORDERS.

FROM the beginning of the human race affections of a surgical nature have been simulated-by cowards, to avoid the dangers of combat; by beggars, to excite compassion; by rogues, to attain their ends; and by others, for purposes as varied as they are sometimes obscure. Even children are not exempt. The little boy who suddenly acquires a lame knee and cannot attend school, and the little girl who sprains her wrist in time to avoid an hour's practice on the piano, are as certainly malingerers as is the soldier who feigns contractured fingers in order to escape military service. Animals are often skilled in deception. The woodcock, in order to draw attention from her young, will simulate a broken wing; and the painful limp of an unwilling horse will miraculously disappear when his head is turned toward home.

Feigned surgical affections, with the exception of such as are due to hysteria, are comparatively so rare in private practice, and real ones so common, that we are apt to be caught off our guard and do not recognize the fraudulent symptoms when they appear. Hence the necessity for the surgeon to acquire an idea not only of diseases which may be feigned, but of the motives and characters of those who are most likely to feign them. He should be familiar with every form of surgical trouble in all its variations in order to avoid mistaking a real disease for one which is simulated, which is far more culpable than overlooking a simulation. It is better that many spurious affections be regarded as genuine than that one genuine case should be declared spurious. If we could pass in review the legion of unfortunate wretches whose real sufferings have given rise to neglect and maltreatment under the impression that they were feigned, we should employ more time and care before coming to conclusions in similar cases in the future. It is also well to remember that many instances of simulation occur in those who, from some cause or other, are not in good physical condition.

Opportunities for fraud in the domain of surgery are far fewer than in that of medicine. It is easier to simulate a colic, for instance, than a hernia. Nevertheless, deceptions are commonly enough met with, particularly in the army and navy and in hospitals and prisons; while pension examiners and physicians to accident-insurance companies are constantly harrassed by the most obscure forms of fraud.

In former times feigning of surgical diseases was much more prevalent than now. For this there were various reasons. Beggars were more numerous and importunate; in fact, begging assumed almost the dignity of an industry, and deception was practised as an art. Apparent

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deformities, nauseous sores, and frightful tumors, draped by the rags of filthy mendicants, were seen in profusion on the streets, and there were even those who made a business of manufacturing cripples.

Most of these things, however, were mere stage tricks which required only close observation for their detection, and were calculated to deceive the passer-by rather than the surgeon.

In the army and navy there were formerly many more malingerers than there are to-day, malingering becoming so common at times that the most stringent laws were enacted for its suppression. This was particularly true when conscription was in vogue. Individuals resorted to all sorts of deception and self-mutilation in order to escape entering the service or to obtain a discharge. So-called "epidemics of incontinence of urine appeared among young men. Teeth were

filed off and extracted by the wholesale in order that men should become unfitted to bite off the ends of the old-fashioned cartridges. Many resorted to the cutting or shooting off of fingers and the severing of tendons. Simulations of hernias, hydroceles, contractures of joints, ulcers, and swellings of various kinds were often seen.

A reason for the lessened prevalence of such frauds is the marked improvement in the service. Men enter voluntarily instead of being impressed, and they are treated more like human beings and less like slaves. The food and hygienic surroundings are better, and personal liberty is greater. In fact, where much malingering is found, there is generally a cause, which should in justice be removed if possible.

Another reason is that malingering has been rendered easier of detection by such instruments of precision as the clinical thermometer, the microscope, the laryngoscope, the ophthalmoscope, etc. Surgical anesthesia is also of immense value in the diagnosis of obscure cases.

It is often better to reserve judgment for a time until opportunity can be gained to study the case in all its bearings. It may be useful to appear to believe all that is said until the patient, secure in the apparent success of the fraud, finally commits himself. If he can be convinced of the hopelessness of gaining his ends, he may sometimes be inclined to give up the deception. In order to accomplish this most effectively it is better that the examination be conducted privately, for the larger the audience, the more stubborn the subject. Sometimes the mere threat of severe treatment, such as amputation or the cautery, will effect a cure. Violent measures should, as a rule, be avoided, as they often do little good and it is always possible that the trouble may be real. A soldier has been known to walk for eighteen months with his back bent double and his fingers within two inches of the ground, in spite of the most severe treatment, rather than give in; and, on the other hand, the writer has seen a stoker on an ocean-steamer, who refused to work on account of real weakness and pain, killed by a ducking, followed by exposure, under the impression that he was a malingerer.

The simulator is apt to give an incorrect history of his disease, or couple with it some ridiculous symptom, especially if such things be cleverly suggested by the examiner. Care is requisite, however, in

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