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 trouble. 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 oath.

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 caustics.

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.