[Reprint from the St. Louis Courier of Medicine, May, 1886.1 OBSERVATIONS ON FEIGNED AND ARTIFICIAL ERUPTIONS OF THE SKIN. By W. A. Hardaway A. M., M. D., Professor of Diseases of the Skin in the St. Louis Post-Graduate School of Medicine and in the Missouri Medical College. [Bead before the St. Louis Medico-Chirurgical Society, March 23, 1886]. DR. Robert Farquharson has well observed (Quain’s Diet, of Med.) “that no insignificant part of the real difficulty in the practice of our profession depends upon what we may call feigned diseases. ” This is especially true in the department of dermatology, and holds good not only for those where the de- ception is intentional, but equally for those instances in which it is accidental. In this place, however, I wish to put on record briefly the clinical histories of three rather interesting cases that have come under my personal observation. Case I.—T. M., set. about 23 years. I saw this patient about twelve years ago, and, as it was the first case of the sort that I had met, it made a lasting impression on my memory. This young woman was undoubtedly hysterical, and a few months previous to my seeing her had been the subject of a presumed miraculous cure of, I think, some form of abdominal disease. At any rate, some three months after her “cure,” probably find- ing that she was ceasing to be the object of quite the same amount of lively interest as formerly, she determined to revive her waning distinction a little. It was at this time I was called to see her. I found on the left arm between the elbow and wrist an eruption of variously sized and irregularly shaped blebs. She complained very severely of the pain they caused her, the arm was indeed greatly swollen and inflamed. I prescribed for her some soothing application and made the diagnosis of a pem- phigus, although somewhat surprised at some of the features which the case presented. At my next visit, several days later, I found matters in a still worse condition There were now bullse present, and the bases of the older ones, which had been ruptured, were angry and showed evidence of great irritation. Having learned in the meantime the previous history of my pa- tient, and taking into consideration the location and shape of the eruption and the utter failure of any remedial measures to secure even the slightest relief, I began to suspect de- ception. Examining the eruption very closely I discovered marked evidence of traumatism about the sores left by the blisters. I noticed that there were numerous needle or pin scratches, and that these scratches had frequently been care- lessly made, and had, in many instances, invaded the healthy in- tervening skin. In short the whole picture was so unlike that of a pemphigus or any other recognized form of cutaneous trouble that I had no difficulty in convincing myself that the eruption had been caused by the patient herself for the purpose of gaining sympathy and further attention. The agent employed was undoubtedly nitric acid. When I disclosed the facts in the case to the friends of the patient I was promptly dismissed for my pains. Case ll,—This patient was referred to me by Dr. E. M. Nel- son. It is the same woman of whom Dr. Nelson had reported some remarkable occurrences to this Society. Whether she was an honest hysteric or malingerer for gain’s sake I am unable to say. On this occasion she claimed to have acquired syphilis on the little and ring fingers of her left hand by washing the clothes of an infected child. Of course, this patient not being acquainted with the natural history of syphilis, her knowledge of the course and symptoms of the disease was very confused. She merely 3 claimed to have syphilis in the region mentioned. Upon inspe-c tion, I discovered on the little finger a long linear blister occu- pying nearly the length of the member. On the ring finger there had been a large blister, but this had broken down, and left behind it an ugly ulcerated sore. The arm was hot, tumid and acutely sensitive. The glands of the axilla were enlarged and painful; in fact the patient was suffering from an acute lym- phangitis. Here, again, the manner of the patient, her incohe- rent story, the situation and appearance of the lesions, made me suspect at once that her trouble was self-inflicted. I did not know at this time that she was the woman of whom I had heard Dr. Nelson speak. I did not tell her at this visit of my suspicions, but I utterly ridiculed the idea of her skin trouble being “syph- ilis” as see called it; but as I did not fall into the trap which she thought she had so wisely set, I did not have the pleasure of see- ing her again. I believe that Dr. Nelson from subsequent ob- servation, concurred in my view of the case. Case lll.—This was a young girl of sixteen or seventeen, a patient in Dr. Michel’s ophthalmic clinic. She had called Dr. Michel’s attention to a peculiar and very painful affection of the skin of which she was the unhappy possessor, and he very kindly referred her to me. I noticed when she entered my consulting room evidences of considerable perturbation, which taken alone, however, are in no way significant; but when she exhibited her skin lesions to me I made up my mind at once that she had produced them on herself. On the neck, under the chin, were two irregular brown discolorations, about the size of silver half- dollars. They were separated from each other some half an inch or more. The margins of the discolorations were much darker than their centres—a feature of considerable diagnostic import- ance. The color was rather suggestive of nitrate of silver. Upon taking up the patches between the fingers, I detected no evidence of infiltration in the skin. The young girl would moan with agony, and the tears would run from her eyes whenever the parts were handled: these symptoms were evoked even by the slightest pressure, and I observed, which from the situation she could not, that the skin seemed equally sensitive when I pressed upon the uninvaded regions. She had also related that 4 she had an eruption on her arm, not mentioning which arm. I predicted privately to Dr. Michel, who was present at the ex- amination, that it would be found on the left arm. So when she had disrobed we did find a couple of lesions in an accessible posi- tion on the left arm. Here, however, the lesions differed en- tirely in physical characters from those on the neck. We noted in this situation a couple of scratches a few lines wide and about an inch long. They showed signs of previous inflammation, and one had been made sufficiently deep to leave a superficial cica- trix behind it. Being fully satisfied of the nature of the case I determined upon a little experiment. Taking a small gold coin from my pocket I remarked to Dr. Michel, in the presence of the patient, upon the remarkable results obtained in Paris by the local ap- plication of gold and other metals. I explained to the young girl what I wished to do, and assured her of immediate relief to her sufferings. I pressed the coin upon first one and then an- other of the brown spots of the neck (she complained of no symptoms in regard to the places on the arms) spots which, a moment before, whenever touched, caused apparent agony. She not only did not shrink from the application, but in a few mo- ments expressed herself as being entirely free from pain. There- after the spots and the region about could be pinched or freely pressed upon without causing any annoyanceat all. Metallo- therapy was successful. In reviewing this last case my atten- tion was struck by the following points: First, the fact that the eruption corresponded to nothing that I knew off in dermatol- ogy; second, the unusual symptoms of hyperesthesia; third, the absence of infiltration of the skin; fourth, the darker color of the margins of the eruption on the neck, showing that some liquid substance had been employed which, as is often the case, had accumulated most at the periphery; fifth, the presence of two distinct eruptions in the same person, claimed to have been produced by the same cause, and finally the influence of the treatment adopted upon the patient’s imaginary sufferings. Sus- pecting that the stains in the neck had been made with the ni- trate of silver, I made a partial attempt to remove them with a a solution of the cyanide of potassium, but unsuccessfully; the 5 discoloration had perhaps existed too long, or I did not perse- vere sufficiently in the attempt; however, Dr. Michel, who kept the patient under his observation, told me that she experienced no further trouble, and that the stains disappeared not long afterward. It may not be out of place here to call attention to the fre- quency of certain artificial eruptions, acquired innocently enough by the patient, but which, may be very puzzling to the physician. I recall a case of a gentleman who had a vivid red stain upon his chin which a physician had thought to be a nevus, and proposed inserting a hot needle into it. Before consenting to this operation, however, he sought my advice. I certainly found an anomalous red streak some half inch long on his chin, which did not disappear upon pressure. I confess that I was much puzzled by it, but summing up what I knew of skin dis- eases, and recognizing its bizarre character, I proceeded cau- tiously. A few days later the patient informed me that he had discovered the cause of his trouble. It was an aniline stain from a new blanket. Dr. Geo. Henry Fox, of New York, re- lated to me a similar but much more extensive dyeing of the skin which had puzzled a number of physicians. Another case which illustrates these forms of so-called artifi- cial eruption was in the person of a young gentlemen, who pre- sented on his hands, especially the palms, widely diffused punc- tiform brown lesions. To my mind they appeared clearly as the result of an accidental splashing of a nitrate of silver solu- tion, and I had the satisfaction of settling the diagnosis and re- lieving his fears by erasing the supposed eruption with a solu- tion of the iodide of potassium. I remember an instance during the small-pox epidemic in 1872, where a woman was supposed to have variola from having gotten some croton oil on her face and other portions of the body. Similar cases could be multiplied. While hardly pertinent in this connection, it is well to bear in mind the well-known fact that a large number of medicinal sub- stances when ingested produce the most varied manifestations on the skin. In conclusion, I would beg leave to indicate a few of the 6 points which should be borne in mind in making the differential diagnosis between the so-called feigned and artificial eruptions and the substantive diseases of the skin. In the first place, we should ascertain the antecedents of the patient, and take partic- ular note of the present condition. Secondly, we should dis- cover if the patient had ever suffered from any skin disease be- fore, and whether the patient had been or was at the time mak- ing use either locally or internally of any medicinal prepara- tion. We should compare the lesions present with other known eruptions of the skin, make particular note of any anomaly. We should investigate closely the local expressions of the dis- ease, for instance, as regards infiltration, itching, burning, etc. It must be borne in mind that most eruptions produced with in- tent to deceive, generally occupy situations most accessible to the patient, and in the majority of cases, in right handed per- sons, are apt to be on the left side of the body. It would be te- dious to enter into the minute details of the differences between these feigned eruptions and those due to disease, as, for instance, how a pemphigus bleb will have a certain definite outline, and a bleb produced by nitric acid is apt to be jagged and irregular or linear, but I think enough has been given to show in a general way the cautions to be observed in coming to any conclusion in regard to a suspicious eruption. The late Dr, Tilbury Fox has pointed out that so far as the simulated skin affections are con- cerned they generally are of the following forms: The eruption is in erythematous or excoriated patches, such as may be pro- duced by rubbing or by mustard; or bullous, or pustular, or more or less deeply ulcerative, and such as could be caused by the application of cantharides, croton oil, or some corrosive acid; or such an eruption as could be brought about by the con- stant forceful use of the finger nails; or,:it is a pigmentation— e. g., simulating chromidrosis, produced by black lead, candle black, grease, and other compounds.