Views & Reviews Between the lines

On the detection of fakes

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39192.664583.94 (Published 26 April 2007) Cite this as: BMJ 2007;334:905
  1. Theodore Dalrymple, writer and retired doctor

    Medical books these days don't have such good titles as they once had. The other day, for example, I came across a book that I had long wanted to possess, published in 1843: On Feigned and Factitious Diseases Chiefly of Soldiers and Seamen, On the Means Used to Simulate or Produce Them, and On the Best Modes of Discovering Impostors. It was by Hector Gavin MD, who at the time was surgeon to the London Orphan Society and to the British Penitent Female Refuge. These days, of course, no British female is penitent.

    The book was the prize essay in military surgery in the University of Edinburgh for 1835-6, written when Gavin was 20 years old. We mature physically earlier these days, but it seems they matured intellectually earlier in those days. At 20 I had hardly ever seen a sick person, let alone one feigning sickness.

    Feigned sickness was particularly common among soldiers and sailors because, in the days before so many insurances, only they had much to gain by the practice (those whom the author calls “indulged females,” and slaves on the plantations, are the other classes the author regards as peculiarly susceptible to feigned sicknesses). Gavin was at pains to be fair to men in the armed services, for he recognised that to declare a sick man fit was cruel in its consequences and sometimes led to death. On the other hand, he is eloquent on the dangers of allowing malingerers to get away with it; but at a time when medicine was so underdeveloped, it must often have been difficult to distinguish the real from the fake.

    He says something that has a certain resonance today in a land such as ours in which the numbers of sick people have so overtaken the numbers of the unemployed, to the delight of government statisticians, doctors, and the unemployed themselves: “Medical certificates must not be compared as a practice (as they have been) to that of alms-giving; in the best hands they are liable to great abuse; and however pure and disinterested the motives, much evil not infrequently results from them—none more than the inevitable depreciation of the medical character, which cannot fail to follow from their being given in a careless or lax manner.” This is enough to make one blush.

    A passage concerning the detection of fakes brought a memory back to my mind: “Flying or migratory pains are very common among soldiers and sailors, and are known by the cant name of the all-overs.” And one method of detecting a fake is to ask him whether he has such and such a physiologically impossible symptom.

    I recall a professor using this technique to demonstrate the false nature of a woman's complaints. He got her to say that she suffered from pain, even in her hair. QED. The story didn't have a happy ending, though. The next ward round was interrupted by the sight of her falling from the roof of the hospital past the ward windows. She killed herself.

    Gavin himself had an unhappy ending. He became an associate of Edwin Chadwick and the other sanitary reformers and went out to the Crimea to bring a little sanitation to the British troops. His younger brother, a veterinary surgeon, was also there. As Gavin gave his brother his revolver to look after one evening, it went off and wounded him fatally in the stomach. His brother died from cholera 18 days later.

    “Medical certificates must not be compared as a practice (as they have been) to that of alms-giving; in the best hands they are liable to great abuse”