45MALINGERY.

The issue of this unfortunate marriage, says Dr. Grinker,comprised three children whose conditions illustrate the

various hereditary sequelae of syphilis in a striking way.The eldest, a male, was born in May, 1878, and developedinto=a, typical case of juvenile tabes dorsalis ; the second,also a male, born in October, 1880, manifested generalparalysis during adolescence; and the third, a female,showed signs of infantile cerebral syphilis soon after shewas born in 1882. The woman not only brought forth

these hereditarily degenerate children but in thecourse of years developed into a case (rare in women)of tabes dorsalis herself. Her illness began 12 years agowith numbness and tingling of the feet and a sensation asthough she was walking on a" stuffed cushion." Thenfollowedparaesthesis ("pins and needles" and dull sensations of

pain) in the legs. "During the last ten years she had theclassical lightning pains of tabes, which were mostly at

night." For the past five years similar shooting pains hadoccurred in the upper extremities. Vision was gradually ’lost in the right eye and subsequently in the left eye, so thatthe patient became at length totally blind. For seven yearsshe had had the abdominal pains or " crises of tabes-"twisting and grinding of the stomach and intestines," asshe described them. Gastric crises with vomiting and intenseagonising pain in the epigastrium lasting from 12 to 24 hourswere also experienced. At present (1903), says Dr. Grinker, sheis "a small, poorly nourished old lady of apparently 65 or 70years, though her real age is 57." She is the subject of chroniclocomotor ataxy, with absent knee-jerks, ataxia of stationand of gait, and numerous peripheral areas of cutaneousanalgesia. Complete optic atrophy is present. Intelligenceand memory are good. The sphincters are beginning to showslight incontinence. The lightning pains, Westphal andRomberg symptoms, optic atrophy, gastric crises, par-aestbesias, and absence of motor involvement make this anundoubted case of tabes dorsalis, while the children of thewoman illustrate various pathogenic aspects hereditarilytransmitted. This patient died in April, 1904, from coma.

THE medical officer of health of the Cape Colony statesthat for the week ending Dec. 10th, 1904, the condition ofplague in the colony was as follows. At Port Elizabeth 2

cases were discovered during the week, both being of

European females. Of 153 rodents bacteriologically ex-

amined 4 rats and 11 mice were found to be plague-infected. Plague-infected rodents continued to be found inEast London. Elsewhere in the colony no plague infectionin man or other animals was noted. As regards theMauritius a telegram from the Governor to Mr. Lytteltonreceived at the Colonial Office on Dec. 30th state? that

for the week ending Dec. 29th there were 19 cases of

plague and 11 deaths from the disease.

THE opening lecture of the spring session of the North-East London Post-Graduate College will be given at the

Tottenham Hospital, N., on Jan. 10th, at 4.30 P.M., by Mr.John Langton, consulting surgeon to the hospital and toSt. Bartholomew’s Hospital. The subject of the lecture,which is open to all medical practitioners, is "Points whichshould be considered in Determining the Prospects of the

Operation for the Radical Cure of Hernia."

Major Robert Bird, I.M.S., surgeon to His Excellency theViceroy and Governor-General of India, has been appointeda Companion of the Most Eminent Order of the Indian

Empire. -

OUR Special Sanitary Commissioner, who recently visitedthe St. Louis Exhibition, took the opportunity while in theneighbouring State to investigate thoroughly the famous

Chicago stockyards and the condition of the celebrated

abattoirs. It will be seen that our representative, speakingfrom a wide experience of such matters in all countries, wasnot favourably impressed with the sanitary regulations inforce for the slaughter of the animals.

THE annual dinner of the Laryngological Society ofLondon will take place at the Imperial Restaurant, Regent-street, London, W., on Friday, Jan. 13th, at 7.30 for 8 P.M.

Mr. W. H. Cross, who has retired from the post of clerk ofSt. Bartholomew’s Hospital after 38 years’ service, has beenplaced upon the commission of the peace for Middlesex.

MALINGERY.

THE art of shamming disease has reached a high level ofperfection. This is mainly to be attributed to the fact

that the rewards of proficiency are great. Fresh in theminds of all is the recent case of a professional beggar inthe City of London whose voluntarily paretic limbs stirredup the lively compassion of the passers-by, even of the

poor, so that charitable gifts flowed into his ready palm.This case has excited some little attention chiefly becausethe police have prosecuted him successfully but he is onlyone of very many. So remunerative are these attempts onthe charity of the benevolent that there is great dangerthat the publication of the details of the case that we havementioned will rather induce others to follow his examplethan that his punishment will act as a deterrent. In one partof London it is said that ready-made ulcers on pieces ofadhesive plaster can be obtained at a reasonable priceand these are greatly in vogue with professional mendicants,for an outward and visible sign, such as an obvious ulcer, isfar more efficacious in exciting the almsgiving propensitiesof the tender-hearted than any amount of internal pains.Paralysis, too, is a fairly good argument in favour ofcharitable assistance, for the giver contrasts his powers ofmovement with the weakness of the afflicted one, and as

paralysis of a kind is readily counterfeited it is much infavour with the begging fraternity, though a great deal ofof it will not. stand a careful medical examination.Many are the motives which incite a man to pretend to

be suffering from a disease with which he is not afflicted.Probably the commonest motive is the wish to obtaincontributions from the charitable and thus to prevent thenecessity for working which is extremely distasteful tothese professional beggars. Ulcers and paralysis are theusual forms in which this motive manifests itself andto these we have already alluded. Fits of all kinds are,however, frequently simulated, especially fits of an

epileptiform nature, and in cases where the malingererhas had opportunities of observing someone afflicted withepilepsy the resemblance to the true epileptic seizure

may be extraordinarily great ; the frothing of the mouthis usually brought about by means of a small pieceof soap, the discovery of which in a "patient’s" mouthwould, to say the least, cause the fits to be looked uponwith grave suspicion. The fits are usually also ratheroverdone and it is a common failing of the malingererthat he is not satisfied with a reasonable amount ofdisease. Another motive nowadays for simulating disease isto obtain admission into a hospital. The comfort, therest, and the luxuries to be obtained in hospital makea deep impression on many patients, so that they leavewith regret to return to their former work. Can wewonder, then, that some of them, lamenting the fleshpotsof Egypt, should wish to return ? All that is necessaryis to possess some severe manifestations of disease andevery resident medical officer of a hospital musthave met with many cases of patients endeavouringto obtain admittance on account of some wonderful

pain or spasm and doubtlessly many a time has he beendeceived. This form of malingering is especially likely tobe successful when there is some obvious lesion which mayform a basis for the superstructure derived from the patient’simagination. In one case a young man a few years ago

46 MALINGERY.

received a severe blow on the head and even now someirregularity can be detected on the skull. He describesattacks of Jacksonian epilepsy and as the lesion issituated over the motor area of the corresponding sideof the body he readily gains admission into a surgicalward. He will even agree to have an operation performedfor the removal of the damaged portion of the cranial bonewhich is supposed to be causing his fits, though curiously henever has a satisfactory fit except when alone. His customis to decline the operation when the day fixed for its per-formance arrives and on leaving the hospital he attempts,generally successfully, to repeat the performance elsewhere.One of the most inveterate of these malingerers is, or ratherwas, a man who had a genuine paralysis of the left arm withsome weakness of the leg on the same side. He hadtasted the delights of hospital life and as nearly everysojourn iri the hospital was followed by two or threeweeks at a convalescent home in the country or atthe seaside he had an extra inducement to endeavourto be readmitted into a hospital. It was his customwhen he felt inclined for hospital treatment to enter a

tavern not far from a hospital. Here after a short timehe would be seized with a "fit," and then he would becarried in an apparently unconscious or semiconscious stateinto the receiving room of the neighbouring hospital. Thehouse surgeon would immediately detect the unilateral

paralysis and would not unnaturally diagnose cerebral

haemorrhage or some other sudden interference with thecirculation of the brain. The patient would be admitted atonce and in a few weeks part of the paralysis would passoff leaving, however, some definite permanent loss of power,especially in the arm. Then would follow the convalescenthome and later a return to the hard outer world wherethe unpleasant necessity of working would tend to obtrudeitself on his mind. Then would come a visit, similarlyinaugurated, to another hospital, with the same cycle ofevents. The number of hospitals in London being limited,it happened more than once that he returned to a hospitalbefore the remembrance of his previous visit had quite diedaway. Some former clinical clerk who had become a housephysician remembered his face or his history, which con-scientiously he never varied, and then his well-plannedenterprise was liable to come to a sudden and untimelyend.

It is, however, in connexion with the naval and militaryservices that the art of malingery finds its chief exponents.Indeed, the word " malinger" was first applied to the

attempts of soldiers to evade arduous or unpleasant duty.It is of interest to notice the difference that exists betweencountries in which conscription prevails and those in whichonly voluntary service exists. In the former the moststrenuous exertions are sometimes made to escape serviceand since most deformities disqualify for admission recruits,or rather those who were liable to serve in the army, havenot hesitated to inflict on themselves the most severe injuriesin order to avoid service. In the days when it was

necessary for a soldier to bite off the end of the cartridgein loading his musket it was no uncommon event for aman to have one or more teeth extracted or filed downso as to obtain exemption. In countries such as our

own at the present time, where voluntary service exists,we are more likely to find applicants for enlistmentwho attempt to hide diseases. In all countries, however,many soldiers, whether they have been called to the serviceby conscription or have entered it voluntarily, earnestlydesire to leave it. There is an old tale, in all probabilitytrue, that illustrates well the trouble which such a man willtake to escape from military service. A soldier was seizedwith paralysis of the right arm ; the loss of power came onsuddenly and without obvious cause. Malingering was sus-pected but all the efforts of the surgeon of the regiment wereunavailing; no proof could be obtained that the paralysiswas feigned. The man was examined by two medicalboards and ultimately he was given his discharge. As hewent off from the barracks on the top of the coach (it wasin the days before railways) he waved a hearty good-byeto his comrades with his paralysed arm. Probably thebest example of the perseverance which men will displayin the attempt to leave a service which they detest is tobe found in a case under the care of Cline. The patientwas a sailor in the British Navy and it is worthy of notethat he was a " pressed" man. He fell on to his head anda slight depression of the skull was produced. He imme-diately became unconscious and all efforts to rouse him

failed. He lay quietly in his hammock and never moved.He seemed deaf to all sounds and at no time uttered anyword. He was able to swallow food, both solid and liquid,and indeed he made signs with his lips and tongue when hewanted nourishment. He was brought back to England butno improvement followed and the unconsciousness" " lastedfor 13 months. Then it was resolved to raise the depressedportion of bone. Flaps were made, a trephine was applied,and the bone was cut through. An elevator was thenintroduced to raise the bone and as the bone was liftedup consciousness suddenly returned to the patient andhe spoke. At the time of the operation most of theonlookers accepted the case as genuine but no one

would nowadays venture to support the idea that thepatient really lay unconscious for 13 months, suddenlyregaining consciousness on removal of the depressed bone.There can be no doubt that the man was a malingererand adopted this arduous method of leaving a service intowhich he had been forced. The amount of pain and dis-comfort which malingerers are willing to endure to obtaintheir discharge is almost incredible but the facts are wellattested. A limb has been held in a fixed position for manymonths and not even the application of the actual cauteryhas suinced to move it. Many men have chopped off somefingers and have claimed that it was an accident. Mentalderangement of one sort or another is a favourite form ofmalingery but the results usually resemble the popular orstage idea of insanity rather than the true products ofmental alienation. It is not uncommon for the malingererto combine two forms of insanity and this may be of valuein detection. Still, it is often very difficult to be certainthat a patient is shamming. There are, however, somephenomena which cannot be simulated. It is impossiblefor a sane man to imitate successfully the persistentinsomnia which often occurs in the insane; the impostorcannot put off sleep beyond the second or third day.Another frequent motive for malingering is to attract

attention not for the purpose of obtaining money but

merely to gain notice. This motive is most frequently seenin young unmarried women. The most common mani-festation is to be found in the skin, where ulcers, bullse, andother lesions suddenly appear. Simulated joint affectionsare also not rare and there are many other forms. Thesecases merge imperceptibly into hysteria and indeed in

many hysteria is combined with the wish to deceive. It isnot improbable that in some of these patients there is acertain degree of cutaneous anaesthesia which renders theself-mutilation more easy of accomplishment. There areother causes for simulating disease or injury. Sometimes itis done to avoid punishment, sometimes to wreak vengeanceon another person who is accused of having inflicted theinjury. To obtain compensation for injury in a railwayaccident several lesions may be simulated and especiallythose obscure and ill-defined conditions which have beenattributed to " spinal concussion." These latter form a

large and very important class the detection of thefraud of which is often most difficult. Sad to relate,many of the attempts to imitate disease have led toserious and irreparable results and even to death itself.A man excited an ulcer in his leg by means of a coppercoin and later gangrene appeared and required amputa-tion below the knee In endeavouring to excite haemo-

ptysis a man swallowed a cork into which pins had beeninserted. He spat up blood and became very emaciated andthen suddenly died from hemorrhage. At the necropsy itwas found that the cork and pins had lodged at the junctionof the pharynx and cesophagus and that the pins hadulcerated through the aesophageal walls and had openedinto the common carotid artery on both sides. Childrenare great adepts at feigning maladies and they frequentlydisplay a surprising acquaintance with the symptoms ofdisease. A little boy, five years old, complained that hisurine was bright red, and so indeed it was, but it wasfound to be due, not to any blood colouring matter but tothe red dye of his flannel shirt, a portion of which he hadsoaked in it. In another case a little girl vomited faecalmatter and this symptom only ceased when she was toldthat such methods were not allowed in the hospital.The detection of malingering is often no easy matter and

no general rule can be laid down which will be applicableto all cases. The mere threatening of severe methods oftreatment is sometimes successful but frequently fails. Thethreat of the application of the actual cautery has curedparalysis but cases have been recorded where malingerers

47ASYLUM REPORTS.

have endured the cautery on several occasions. A man who

simulated blindness was placed on the edge of a jetty andtold to walk straight forward. He stepped out and fell intothe water, for he knew that those who were testing himdared not let him drown. In another case, however, a manwho seemed to have paralysis of an arm allowed the

amputating knife to be placed close to it without flinchingbut when thrown into the river he struck out with both armsand swam. A very useful method of detection is the sug-gesting of new signs and symptoms to the patient. The

surgeon remarks-say in the case of a paralysed arm-in the hearing of the malingerer that it is strange that thelittle finger is flexed, it ought to be straight. In all

probability at the next visit the little finger will haveassumed the suggested position. The more o?ttr6 and irre-gular the fresh symptoms suggested by the surgeon themore definite is the detection. In general anaesthesia wepossess a valuable means of discriminating in certain casesbetween true and false paralysis or contractures. Whilethe patient is just going under or recovering from anaes- Ithesia the "paralysed" limb may be seen to move freely.It is well always to remember the possibility of a dis-order being feigned, especially when a strong motive exists,for by this vigilance cases may be detected which wouldotherwise escape notice. In the detection, however, ofcases which we imagine to be examples of malingery it is

important that no methods should be adopted which can doharm, should our supposition be groundless, for it is farbetter that many impostors should succeed than that onereal sufferer should be condemned uselessly to undergofurther pain. It is no more than a mistake to be deceived

by a malingerer, it is almost a crime to deal harshly withone who is really afflicted with disease.

ASYLUM REPORTS.

London County AS.1llmn, Hanitell (report for the yearending March 31st, 1904).-The average number of patientsresident during the year was 2555, comprising 998 males and1557 females. The admissions during the year amounted to614-viz., 265 males and 349 females. Of these 518 werefirst admissions. Dr. R. R. Alexander, the medicalsuperintendent, states in his report that the three chiefcauses which operated in the production of insanity amongthe admissions were alcoholic intemperance (21 per cent. of

’ males and 12 per cent. of females), heredity (19 per cent. ofmales and 23 per cent. of females), and previous attacks (12per cent. of males and 23 per cent. of females). 17 per cent.of the men and 2’ 5 per cent. of the woman were afflictedwith general paralysis, as against 18 per cent. and 3 percent. respectively in 1902. The number of cases dischargedas recovered during the year amounted to 209-viz.,90 males and 119 females, or 8’2 2 per cent. of the

average number resident. The deaths during the yearamounted to 258, or 10’ 1 per cent. as calculated on thesame basis. Of the deaths eight each were due to colitisand renal disease, 18 each to pneumonia and cancer, 20each to cardiac disease and cerebral softening, 39 tosenile decay, 39 to pulmonary and other forms of tuber-culosis, 47 to general paralysis, and the rest to other causes.’’ The most remarkable feature of the general health of theasylum was the unprecedentedly high death-rate during thefirst quarter of the year. In that period we had 99 deaths(42 males and 57 females), or 38 per cent. of the totalnumber of deaths of the year....... I am quite unable," addsDr. Alexander, "to account for this death wave. It

may have been partly owing to an irregular form ofinfluenza, as we then had some undoubted cases ofthat disease ...... but most of the deaths had no apparentrelationship to influenza and there was certainly no

inclemency oE the weather to account for the highmortality." The deaths included 33 patients (12 malesand 21 females) over the age of 70 years. It is gratifyingto add that a decline has been observed to occur in the mor-

tality-rate of colitis during the past three years. The Commis-sioners in Lunacy have not visited the asylum during the yearand there is no report. Owing to the uncommonly heavyrainfall of the year 1903 and the incapacity of the drains tocarry off the suddenly produced and torrential volumes ofrain water on May 30th and July 18th, two of the femalewards were submerged. The flood invaded the female in-

firmary ward No. 7 to the depth of about 18 inches. All

the patients (45 in number) had to be carried into otherwards and retained there until the damage to the floor wasrepaired. The flood caused considerable damage also to otherparts of the asylum. The committee of management statesin its report that further measures have been taken to securethe safety of the inmates in the event of an outbreak of fire,including the provision of alternative exits for five femaleand four male wards, the formation of an additional firestation on each side of the asylum, and improvements inthe fire-alarm system. Improvements in the boiler planthave been made and the cost of repairs, alterations, andimprovements has amounted to f:.6982.

COCOA CHEMICALLY AND PHYSIO-LOGICALLY CONSIDERED.

I.

ALTHOUGH cocoa was introduced into this country somefive centuries ago and several years before either tea or coffeewas known, it enjoyed but little popularity until compara-tively recent days. It is an important fact, however, thatcocoa is now in very great demand and official returns showthat its consumption has increased enormously in this

country in particular, the demand for it having given riseto a very considerable expansion of trade. There must,however, be some more special reason for this selection ofcocoa as a beverage than can be explained by mere com-mercial enterprise. The present popularity of cocoa as abeverage and the fact that so many give it preference to teaand coffee raise some important physiological questions whichclaim more attention than they have hitherto received.

All three beverages-tea, coffee, and cocoa-contain well-known and well-defined stimulating principles, but there aremarked and important differences of chemical composi-tion between the three substances as might be expectedconsidering that coffee and cocoa have their origin in theseeds of a plant while tea consists of a leaf. Moreover, allthese undergo considerable modification during their manu-facture. Coffee is roasted, tea is fermented and dried, andcocoa goes through a process of fermentation and roasting,and besides is submitted to a further treatment by which aconsiderable quantity of its fat is expressed. Thus the de-velopment of the flavour and the peculiar character of coffeeis brought about by merely roasting, but in tea and cocoaboth a fermentative process and a species of roasting areemployed to the same end. These processes, thoughdirected chiefly to the development of aesthetic qualities,are, of course, not without effect upon the chemical

composition of the product and this effect has probablya dietetic significance. In coffee there are a loss of caffeine,the stimulating alkaloid, and a development of oil; in teathere is reason for believing that the tannin or astringentprinciples are rendered less soluble by the fermentative

process (green tea is not fermented and yields muchmore tannin than does black tea); and in cocoa theinitial bitterness of the bean is considerably reduced

and its colouring is deepened, while roasting the cocoa

according to the degree to which the process is carriedi intensifies the colour still more, and develops at the samel time an oil of pleasing character much in the same way ass does roasting coffee. In cocoa also some of the tannin isj apparently changed into a colouring matter termed cocoa, red." Even in their original form, however, the proportionz of theine and tannin differs widely in tea, coffee, and cocoa,5and it is improbable that the tannin in the finished) products is identical in kind. The tannins are a veryi numerous class of bodies, varying widely in character,and it is probable that coffee, tea, and cocoa contain each a different tannin or astringent principle, presenting not only- different chemical but different physiological characteristics- also. Tea certainly gives the most powerful astringent in-r fusion, coffee coming next, while cocoa appears to possess quite a feeble astringency. It may be easily surmised that3 it is to this latter property that cocoa owes its negativef effect upon digestive functions. Tea contains 10 per cent.e and upwards of tannin, and coffee and cocoa contain 4 per- cent. As regards their content of alkaloid, tea yields from1 3 to 4 per cent. of caffeine, coffee 1 per cent., and cocoa