medulla oblongata, the involuntary movements of the thorax. When this upper part of the cranio-spinal axis becomes involved in the disease, and its reflex power ceases, the breathing stops also, and the patient is presently dead.'

On being called to a case of deep coma there will often be experienced great difficulty in deciding whether this condition is due to apoplexy, or to a large dose of opium, or to a poisonous quantity of alcohol. All physicians engaged in hospital practice have seen cases in which they have been placed in this dilemma, a most unhappy one, since the life of the sufferer may depend upon the correctness of the diagnosis. The points which will assist the practitioner in forming an opinion are, the history of the patient, his general appearance, and such other circumstances as can be gleaned from his friends, or those persons who picked him up in the street; the smell of his breath, the odor of tobacco, of spirits, or of wine, being often easily detected; his condition in life; and the state of his mind for the previous few days. In cases of poisoning by opium, however, the pupils are almost invariably contracted, sometimes to the size of a pin's point; in deep intoxication they are often dilated, but sometimes contracted; and so in apoplexy. When house physician to King's College Hospital I saw more than one case of profound coma caused by dead-drunkenness, which was quickly relieved by having recourse to the stomach-pump, administering two or three ounces of the liquor ammoniæ acetatis, and afterwards employing cold affusion. The diagnosis of intoxication is often difficult, for though the odor of the breath is one of the best means of throwing light on the case, yet it must be remembered that a fit of apoplexy or epilepsy is very likely to occur in a plethoric predisposed person after a glass or two of spirits.

Dr. Watson, op. cit. vol. i, p. 481.

CHAPTER VI.

ON THE DIAGNOSIS OF NATURAL FROM
FEIGNED DISEASE.

IN every age and in every country disease has been simulated by all classes of society. Numerous examples to prove the truth of this assertion might be quoted from the Scriptures as well as from ancient and modern history, but such instances would prove more entertaining than useful. Suffice it to say that the monarch, the statesman, the priest, the soldier, and the criminal have alike feigned mental and bodily infirmities for the advancement of their own ambitious or nefarious designs. In the present day the majority of these impostors are found amongst persons suspected of crime, vagrants, sailors, soldiers-a soldier feigning illness is said to be malingering— members of benefit societies, children, and such hysterical and capricious women as, having no healthy occupation, amuse themselves by simulating cardiac, pulmonary, spinal, or uterine disease.

In the investigation of this class of cases great discrimination and ingenuity will be required, since the actors in these deceits generally play their parts with considerable skill, and often with a total disregard to trouble or even physical suffering. There are four modes in which disease may be said to be simulated:-1. Disease may be altogether feigned, the person being in a state of health. 2. It may be exaggerated; that is to say, there being a certain amount of disease, the patient may pretend that it exists in a greater degree and causes more disturbance and suffering than it truly does. 3. Disease may be artificially excited, sickness being actually produced either by the patient, or with his concurrence.' And, 4. Disease may be artificially increased or aggravated during

its course.

The accompanying table exhibits the diseases which are most frequently simulated, the mode in which they are feigned, and the means to be adopted for their detection.

Robertson, in his History of Charles the Fifth (Book xi), tells us of Pope Julius III, who feigned sickness to avoid holding a consistory, and, in order to give greater color to his imposture, confined himself to his apartment, and changed his usual diet and manner of life. So effectually, however, did he play his ridiculous part, that he contracted a real disease, of which he died in a few days.

DISEASE.

13. Convul-
sions.

14. Cutaneous

Eruptions.

15. Death.

MODE OF SIMULATION.

characterize this disease. It requires good acting to imitate this
affection closely. Baglivi, who states that symptoms similar to those
of chorea arise from the bite of the tarantula or venomous spider,
asserts that women frequently counterfeited this affection in order
to enjoy the music and dancing provided for those really afflicted
with it

In the west of Scotland, in 1742, attacks of convulsions-occa-
sioned by religious excitement and enthusiasm-became almost
epidemic. Such was also the case in Cornwall, in 1813 and 1814.
Many of the Jansenists-the Methodists of France-who made pil-
grimages to the grave of Deacon Paris during their persecution in
1724, and were there seized with fits, were doubless impostors; but
it cannot be denied that many credulous zealots actually worked
themselves into convulsions by the force of their imaginations.
Nervous convulsive movements of the muscles of the face and other
parts of the body are often feigned.

An ointment of tartar emetic, croton oil, &c., will give rise to a
pustular eruption, which, after a few days, will slightly resemble
impetigo. A young woman in King's College Hospital, during the
time I was house physician, produced a very good imitation of pom-
pholyx by the inunction of powdered cantharides. Urticaria will
often arise from eating shell-fish, bitter almonds, &c.

Carden tells us of a priest who could simulate death at will, with
no sign of respiration, and in whom no appearance of sensation
could be produced by pricking, tickling, or burning. Dr. Cheyne,
in his "English Malady," states that the Hon. Colonel Townsend
was able voluntarily, so to retard or stop the functions of respira-
tion and circulation, that the action of neither could be perceived.
In the "Memoirs of Vidocq," mention is made of a prisoner who
counterfeited death so well and so often, that when he actually ex-
pired, two days elapsed before the jailers were convinced and would
remove his iron collar.

By the deficiency of the respiratory move-
ments, the cessation of the motions of the
heart, and by the complete loss of tone and
irritability. In doubtful cases, therefore, hold
a fine feather, or the flame of a candle, before
the nose and mouth, auscultate the heart, and
try if blood will flow on opening a vein. Irri-
tants, moreover, will not redden the skin in
the dead. Dr. Josat (De la Mort et de ses Ca-
racteres) concludes from his researches, that
there is no single sign of death which can be