sent to the hospital with a diagnosis of erysipelas of the face; but, the absence of a chill or fever, the general condition of the patient and absence of swollen glands (inguinal or submaxillary) at once brings the subject under suspicion. The surface involved bleeds readily, resembling acute eczema. One of these patients was evacuated at Troyon with a diagnosis of erysipelas, and, in another base hospital, at Ambly, as having eczema. The rapid evolution of the condition is significant. In from two to four days, the eruption has fully declared itself and in from four to six it is completely healed, once the patient is hospitalized. With the disappearance of the eruption, the skin tends at once to return to a normal state; this being quite contrary to the spongy, furfuraceous desquamation, glistening surface, and tender condition that follows eczema. Still, despite all this, the condition is difficult to diagnose. If it is possible to eliminate erysipelas, it is less easy to exclude eczema. When one is convinced that the condition is the result of some irritating agent, the nature of it can be determined only by the confession of the patient and here comes an important point. In case of simulation, the patient will persistently deny all knowledge, hiding carefully the agent employed; whereas, if it was accidental and not purposely provoked, it is possible to discover that some lotion or hair-dye or a sublimate solution made use of by the subject as a cosmetic or therapeutic preparation is the causative agent. This form of eczematous dermatitis is rare, because it is not easily produced, and requires a certain skin susceptibility to produce artificially. The only agent I know of that can produce the condition is automobile-essence (gasolin), which it is not difficult for a soldier to procure. So far I do not know of a single instance where a confession has been secured as to the agent and manner in which the eruption was brought about. Edemas Certain of the simpleminded men tie a band about the lower extremity of the arm at night, tight enough to impede the circulation, but, not so tight as to be unbearable. In the morning, the members presents a white and swollen aspect, quite edematous; but, it is at once recognized by the sharp mark around the arm or leg where the constriction was made. False Leg Ulcers Simulations of ulcer are more likely to deceive than any other form of induced disease, for the reason that there is nothing about the lesion to mark it as being selfinduced. The following is an ordinary case. A soldier is brought to the hospital with a bandaged leg and which has been treated at one of the first-line stations. He relates that he fell and skinned his shin or was wounded by a grenade, or had a blind boil, or anything that would leave a wounded surface, and that this had been treated for two or three weeks without being cured. For the time, the unsuspecting surgeon accepts the explanation. He sees one or more rounded ulcers, often profound, varying in size from a 10-cent coin to that of a silver dollar that, from their simple appearance and sharply defined extent, with proper applications and dressings may be expected to heal promptly. tration; but, from time to time, one finds clinging to the dressing an eczematiform liquid, the result of the irritating agent that has been employed. (Fig. 4.) The suppuration, as a rule, is abundant, thick, and of a greenish-yellow color. The ulcers are almost always situated at a point easily accessible to the right hand; the inferior third of the right tibia, outer surface of the left leg, and inner surface of the superior third of the right leg. In one case reported, it was the inner surface Fig. 4. Ulcers produced on the Calf of the Leg (Milian). Time passes, the regular dressings are carefully made, but, the sores do not show the slightest tendency toward a cure. After three weeks, they are in practically the same state as at the date of entrance, sometimes somewhat enlarged, some new abrasions may appear, until at last these sores, that have resisted treatment for six weeks, arrest the attention. The doctor no longer can refer their cause to traumatism and he begins to review the various conditions that could give rise to the existing state, think-pearing at the same time. ing, mayhap, of varicose ulcer and syphilis. He redoubles the minutia of his treatment, uses antiseptics in abundance, et cetera, but, the result is the same; weeks and months pass, yet, the patient still is there. It can be set down, as a rule, that the majority of leg-sores resulting from traumatism, if they do not respond to ordinary hospital treatment and persist for three months, are induced and artificially kept active. These provoked ulcers are, generally, round and very regular in contour, simulating in a marked degree the gummas of syphilis. They will have a depth of 4 to 5 millimeters, with borders sharp-cut and slightly elevated, the base bright-red and inflamed; there is absence of the filiform amorphous breaking-down of material accompanying infection and absence of infil of the left arm. They never appear at the classic point for varicose ulcer, just above the malleolus, a point of which the ordinary soldier of the kind with whom we have to deal, is ignorant; but, are higher up, where more readily reached. It is rare that the subject does not cause more than one sore to appear, the rule being two or three, or even four, and, mark! all ap A characteristic point in the diagnosis is, that these sores are evolved very slowly. In spite of the various applications and rest in bed, besides the perfectly healthy appearance of the surrounding parts, they show not the slightest sign of a varicose condition; they gradually deepen, but, they rarely enlarge. Sometimes a new point will be started, and then, if the doctor is alert, he will find some very significant signs. The new ulcer starts in one of two forms, either as a vesi-. cle, as the result of the application of some vesicant, or as a discolored gangrenouslooking spot, the result of a caustic application, such as caustic potassa. In the presence of a newly forming spot presenting either of these characteristics, every hypothesis of syphilis, to which may have been attributed the trouble, is nullified; for, never has an ulcerous gumma started as a vesicle or an escar. The Differential Diagnosis The diagnosis of provoked ulcers of this character is extremely difficult, unless one can witness it in its first stages, seeing it start as a vesicle or an escar. The differentiation from an ulcerated syphilitic gumma is rendered extremely difficult when the patient gives a history of previous syphilitic manifestations and, because of his acquaintance with the characteristic shape and appearance of the gummous syphilide, he causes his provoked ulcer to appear as like that as possible. Milian relates a case sent to him at the base hospital, with a diagnosis of syphilitic gumma, in which the characteristic appearance of the ulcers substantiated the same. This diagnosis was accepted and the patient put under treatment with neosalvarsan in progressive doses, starting with 0.45 Gram and gradually increase amount to 0.9 Gram. However, the ulcer remained the same, the treatment produced no effect. The effectlessness of the medication and the appearance of a new ulcer starting with a vesicle opened the surgeon's eyes, for, never has a syphilide commenced with a vesicle. ar The antisyphilitic treatment with senic is an excellent diagnostic expedient. The skin- and the mucous lesions of syphilis so readily and rapidly yield to this remedy that the persistence of suspected ulcer, in face of an intensive course of treatment, always is significant. The Wassermann test is of uncertain value in these cases and often disappointing. With a syphilitic history of the patient, the test will vary, but, it is only rarely that it does not show negative at the close of an arsenical cure. However, the Wassermann test is of decided value when negative in presence of what is supposed to be an ulcerated gumma, for, rarely, if ever, will the test be other than positive when the ulcer is a syphilide. The provoked ulcer is readily differentiated from the chronic ulcer of ecthyma. The latter starts with a swelling and elevation to a point or apex, which becomes pustulous. When established, it shows a fungoid base of infiltration, with mamelon eminences. The entire denuded surface is covered with these vegetations, which are characteristic. Moreover, they become covered with crusts. Neither of these charac teristics are present in the induced ulcer. The constant reapplication of the caustic destroys these vegetations and crusts never appear. Chronic ulcers of spontaneous origin and syphilitic gummas have been met with frequently since the outbreak of the war, and they are the two conditions to be distinguished from induced ulcer. It hardly is necessary to point out the distinguishing features between a varicose ulcer and one provoked and kept in a state of irritation. An additional point in the diagnosis is found in the vague hesitant and oftentimes embarrassed statements of the patients, frequently farfetched and but little likely to be true. However, the decisive factor is, the final test of an occlusive dressing, either by means of collodion, which the patient cannot remove, or, if the doctor will apply the dressing himself and note the pleating of the bandage about the foot and exact neat manner in which it is applied and closed, he can usually discover when his dressing has been tampered with. But, an occlusive dressing, regularly applied, will see the ulcer rapidly progress to a cure in a few days. In very rare cases, a confession can be secured of the means employed to produce the primary lesion and to keep it in a state of irritation. In France, the provocative agent most frequently is a plaster named "vésicatoire Bidet," which is advertised in all the popular journals. Its action is very violent, blistering the skin in a very short time. The erosion thus made is kept in an aggravated state by applications of tobacco-juice or croton-oil. An explanation of the ulceration can sometimes be found through some happy coincidence. Thus, a soldier with an ulcer on the internal aspect of the left arm came into the service. It was a small wound, rather deep, which had persisted for weeks, and which the man averred had resulted from a shell splinter. It had but one opening, but, the x-ray disclosed no foreign body either in the soft parts or the bone. After a short period of observation, the original wound was suspected to be self-inflicted; so, after a thorough preparation, the arm was covered with an occlusive dressing. In twelve days, the ulcer was completely cicatrized. The patient, knowing that the wound would readily heal when cause. Induced Blenorrhagia protected from further interference, applied evident as to admit of no mistake as to the croton-oil to his left cheek, which produced a pustulous eruption; however, when categorically accused, he confessed, also that the first lesion had been produced in the He was subject to a form of punishment that most likely would prevent his ever attempting a like ruse in the future. same manner. False Mucous Plaques A soldier presents himself and, in reply to the question as to his trouble, says: “I am syphilitic, I left the hospital two weeks ago, where they gave me injections, and now these sores have come in my mouth." Upon examination, one finds one or two plaques, red, inflamed, looking like fresh wounds. Further, the papulous projections the surrounding leukoplasia, the peripheral ulceration, the tenacious yellow infiltrationbase of the mucous patch of syphilis are absent-conditions that are of the greatest importance in making the differential diagnosis. Concomittant with this, it will be found that the sores are almost always located back in the mouth about two-thirds the distance of the length of a cigarette, on the borders of the palate, on the cheeks, rarely on the tongue, sometimes on the inside of the lips themselves; the reason being that the lighted end of a fresh cigarette is the ordinary means employed to produce these escars. Naturally, they are usually on the left side. The wound rarely is larger than a cigarette end, often a little less, the whole end of the cigarette not having been applied. When found upon the soft palate, they are invariably situated at a point reached by a cigarette held at the end by two fingers. The frequency of regularity of these signs is remarkably exemplified if, by chance, two soldiers with the same history happen to be in the service and are examined side by side. Left to themselves, these abrasions rapidly heal, showing no tendency to the progressive extension, eccentric or radiating, so characteristic of syphilis. If, on the contrary, there is an extension of the ulcer, suddenly one sees, in the morning, a violent renewal of inflammatory signs at the base of the sore, possibly at the healthy border (if the lighted cigarette happened to be applied outside), a blister or a whitened, cooked border where part of the burning cigarette overlapped or, if applied in a fresh spot, the signs of a burn are so Induced blenorrhagia had not occurred to me as a means of escaping military service, until one day one of my blenorrhagia-patients confided to me that, at the solicitation of one of his comrades, he per-mitted him to take pus from his meatus on the point of a knife, who then introduced it into his own healthy meatus. Sure enough, I found the soldier in question with a beginning gonorrhea. Once started, there are various practices by which the subject delays his cure, the most certain being, the daily imbibing of a certain quantity of some alcoholic beverage. When deprived of this aid, they resort to the inordinate use of condiments or drinking vinegar or anything else designed to render the urine acid or irritating. False Symptoms Given by Culprits The patient having provoked troubles often will complain of symptoms having no relation to or with the trouble induced. A soldier coming with an ulcer the size of a quarter dollar will complain of lancinating pains, that he can not sleep, that he can not walk or stand erect, and, when pressed to locate his pain, often will refer it to the neighboring bone. Besides these discrepancies in history and subjective symptoms, it is possible to establish indubitable proof of the simulation by means of the occlusive dressing and subsequent rapid cure. Often, also, it is possible to persuade the subject by suggestion, to induce a new wound, somewhat as follows. When examining the patient in the presence of the nurses, aids or visitors or other patients, say to the suspected man: "I recognize perfectly that disease. I have seen it a number of times since the beginning of the war, but, I am surprised to find this ulcer in this location; for, it invariably is 6 inches higher (or lower)-it always has been there in the cases I have observed, and this is very well explained in an article by Dr. So-andSo. It does not heal easily". In general, the next day or day after, there will appear a new lesion at the exact point indicated as the ordinary site of this lesion, and this is instant proof of the self-production of the trouble. Or, if convinced of the fraud, the surgeon can size up his subject and say brutally: "My friend, I am perfectly well acquainted with this ulcer. I have seen a number of them since the war began, it is a false ulcer, you brought it on yourself. Don't deny it. I will give you the friendly advice to let it be cured in the next week. If you do not, I shall turn you over to the provost marshal". As a rule, this patient will be cured in the regulation period, without further trouble. a To get the patient to confess, is a difficult matter; first, because he is ashamed and once having committed himself to a given cause he is unwilling to change his story, second, he is afraid of the consequences of his misdeed, should he confess the truth. Never can an admission be secured in the presence of third person, nurse or other patient. It must be alone, away from any possible listener, and then in a perfectly friendly manner. If the physician asks the question and promises, on his honor, not to expose the soldier and to help him back to duty without suspicion, it may be possible to learn the truth, for, many of these men are ashamed and would willingly repair their fault if a way were opened to them. Another course that has had success is, to call the soldier into the office of the surgeon, alone. He stands before the officer who interrogates him about his name, profession, place of birth, date of birth, name of father, name of mother, their profession and residence, as also of any brothers or sisters. Under this category of questions and the stern visage of the questioner, the culprit begins to show uneasiness, especially when questioned relative to his father and mother. As soon as he shows any signs, sternly charge him with his fault and promise him immunity and your aid if he confesses, when frequently he will give in. It is unnecessary to say that these poor devils get no punishment other than their humiliating sense of shame; however, it is of value to the doctor to learn by what agent and in what manner the trouble was induced, for, this is valuable in aiding him in detecting the next case. The question naturally arises as to the responsibility of the surgeon of reporting the case to the military authorities and it is rather a delicate one. Before a court martial, the doctor can produce no evidence except history of treatment and diagnosis. The patient will solemnly deny all culpability and in nine out of ten cases will be acquitted, leaving the surgeon in the wrong. The result of this spreads through the regiment, to the detriment of the surgeon, and lends encouragement to others to practice similar simulations. Moreover it can not but be repugnant to the doctor to denounce one of his regiment even when rigorous discipline makes it his duty-when he is convinced that the man is not really bad, but, has succumbed to an impulse resulting from ennui, impatience or fear. It is a situation where the surgeon has a perfect right to exercise his judgment. However, in order to discourage and prevent any repetition by this patient or the multiplication of his kind, it is wise, when convinced of the self-produced nature of a man's complaint, to call him aside at the moment of his discharge and say quietly to him: "I have not been duped. I am perfectly well satisfied that the eruption with which you were troubled was self-inflicted. I shall send you directly back to your regiment, without the customary leave that follows a period in the hospital, and I warn you not to appear again with this complaint." The soldier will salute, without protest, too abashed and too pleased to get off so easily. In additon, it is well to send a letter to the captain of the soldier's company, marked "Confidential", in which you say: "I wish to bring to your knowledge that the soldier N. has been in my hospital for a skin affection which I believe was provoked by the man himself. I call your attention to this man, in order that he shall not present himself again under like circumstances." |