BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT FUND THE GIFT OF X891 pn^zo ?.////jm 3081 3 1924 031 260 296 Cornell University Library The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031260296 ON THE SIMULATION OF HYSTERIA BY ORGANIC DISEASE OF THE NERVOUS SYSTEM. HY THOMAS BUZZARD, M.D.Lond., Fellow of the Royal College of Physicians in London; Fellow of King's College, London; Physician to the National Hospital for THE Paralysed and the Epileptic. LONDON : & A. CHURCHILL n, NEW BURLINGTON STREET. '1 891. PREFACE. A Presidential Address, which was delivered by the author before the Neurological Society of London in January 1890, forms the substance of this work. In publishing the address in book form the opportunity has been taken of adding materially to it, and thereby, it is hoped, of in- creasing its interest. The title, it is acknowledged, is open to criticism ; but, after consideration, it has been retained as representing, perhaps as well as could be done in a few words, the object aimed at in the publication. That object is to draw attention to the frequency with which symp- toms liable to be looked upon as hysterical are found to be really due to structural changes in the nervous system. To illustrate how apt this error is to occur the author contributes the results of experience extending over many years. He trusts that the discussion of the iv. Preface, subject may tend in some measures to facilitate the diagnosis of certain obscure conditions, and so render it less likely for patients affected with organic disease of the cerebro-spinal nervous system to be considered and treated as ex- amples of hysteria or nerve prostration. The work is entirely clinical in character. A considerable number of cases are narrated, in- cluding, in the majority of instances, their after- history, and much of what value the book may possess depends upon this feature. London, November, 1891. SYNOPSIS. PAGE Introduction... ... ... ... ... ... i Paraplegia dependent upon Atrophy of Ilio- psoas Muscle ... ... ... ... ... 5 Illustrative Cases OF this Affection ... ... 5-22 Important Signification of absence of Knee- jerk in Young Females ... ... ... 23 Cases of Friedreich's Ataxy ... ... ... 23-29 Case of Hysterical Paraplegia ... ... ... 29 Case of Secondary Cancer in a Patient sup- posed to be Hysterical 32 The Behaviour of the Bladder in Functional and Organic Disease 35 Urinary Trouble in a Case of Hysterical Para- plegia ... ... ... ... ■•• ••■ 38 Trophic Disorders occurring in Hysterical Paralysis 41 vi. Synopsis. PAGE Adhesions in Joints and Contracture of the Skin ... ... ... ... ... ... 42 Total Absence or Great Weakness of Plantar Reflex IN Hysterical Paraplegia ... .. 43 Illustrative Case showing return of Plantar Reflex on the Patient's Recovery ... 44 Plantar Reflex may be absent in the Affected Limb ALONE : Examples ... ... ...46-48 Case of Hysterical Paraplegia, with absent Plantar Reflexes and Contraction of Visual Fields 48 Some Points of Diagnosis in Hysterical Para- plegia ... ... ... ... ... ... 50 Disseminated Sclerosis ... ... ... ... 51 Frequent absence of Characteristic Symptoms 52 Case of Disseminated Sclerosis which had been supposed to be an example of Hysteria ... 53 Lengthy Remissions occurring in Disseminated Sclerosis ... ... ... ... ... 58 Case of Disseminated Sclerosis which had been treated as Hysterical — Fatal Termination 59 Cases of Disseminated Sclerosis diagnosed as Hysterical ... ... ... ... ... 62-95 Many Symptoms of Disseminated Sclerosis have LONG been referred TO HySTERIA ... ... 96 Synopsis. vii. PAGE. Value of the Absence of Plantar Reflex as a Symptom OF Hysterical Paraplegia ... g8 Cases of Combined Organic and Functional Disease ... ... ... ... ... ... loo Contraction of the Visual Field in Hysteria 102 Case of Disseminated Sclerosis in a Male Patient ... ... ... ... ... ... 104 Characters of Hysterical Paraplegia ... ... 106 Loss OF Sight in the Hysterical, and in Cases OF Disseminated Sclerosis ... ... ' ... 108 Value OF THE Symptom Nystagmus ... ... log Value of the Symptom Tremor on Voluntary Exertion ... ... ... ... .. 109 Localised Atrophy in Disseminated Sclerosis may BE temporary and shifting ... ... Ill On the probable Organic Origin of many Symp- toms accounted Hysterical ... ... ... 112 Instances of Recurring Amblyopia in Dissem- inated Sclerosis 60, 71, 72, 80, 83 Changes in the Optic Disc in Disseminated Sclerosis 60,63,65,69,70,80,88 ON THE SIMULATION OF HYSTERIA BY ORGANIC DISEASE OF THE NERVOUS SYSTEM. In our practice as physicians we are very frequently meeting with cases which suggest the presence of organic lesion of the nervous system, whilst, at the same time, circumstances occur to make us doubt whether the symptoms present may not be dependent upon what, for want of a better term, is styled "functional" disorder. It is unnecessary here to attempt to define what is meant by the term, nor tO' insist upon the importance, both as regards;^ prognosis and the treatment of the condition,, that our diagnosis should be correct. The field occupied by cases of this descrip- 2 THE SIMULATION OF HYSTERIA tion is extensive, and I propose to limit my observations to the consideration of cases in which some loss of power in a limb or limbs is the dominating feature. In a previous work* I discussed the differential diagnosis between certain hysterical conditions and mye- litis, and the present is in some measure an extension of the same subject. It is not my intention to dwell at any length upon the more common forms of so- called " hysterical " paralysis, the recognition of which the surrounding circumstances may render easy, although it will be necessary by way of comparison or contrast to quote some instances of this class. One difficulty in connection with the class of cases to which I refer, lies in the fact that under the term " functional " we probably have often to include (because of our inability to differentiate them) examples of various forms. There is, in the first place, involuntary simula- tion of organic disease associated with some morbid psychical condition — to which the term * " Clinical Lectures on Diseases of the Nervous System," Lecture V., 1882. BY ORGANIC DISEASE. 3 hysterical is usually applied. Next, there are examples of functional inability dependent probably upon a temporary malnutrition of certain parts of the nervous centres. There appears reason to believe that this local im- perfection may sometimes exist for a long while without giving rise to destructive changes in the parenchyma, but that in most instances it represents but a stage of actual change in tissue, which eventually becomes permanent and irrecoverable. How far we may reckon that there is a point in this pro- gressive deterioration at which treatment may be successfully applied must still be considered doubtful, although evidence tends rather to the idea that this is the case at an early stage. The cases of this class present peculiar diffi- culty in their diagnosis, because, combined with evidence of local troubles of nutrition in the nerve centres, there are often so many symptoms of hysterical or emotional character as to greatly obscure and confuse the pic- ture. To this category especially it is proposed to draw attention on the present occasion. It is possible that my remarks may apparently 4 THE SIMULATION OF HYSTERIA tend even more to expose than to solve the difificulties which we are liable to encounter in dealing with cases of this description, but it will not be denied that a clear recognition of the points of doubt is an important step towards solution of the problem. As far as possible the sequel of cases to which reference is made will be related. This will often decide a question which has been a puzzling one. Owing to the kindness of Dr. Playfair, with whom I have examined during the last ten or twelve years many cases in which a serious question of diagnosis has arisen, I shall be able to refer to the results of the Weir Mitchell treatment applied with his well-known skill. This form of systematic treatment is so remarkable in its effect upon the economy that it may fairly be likened in some measure to one of those experiments which enable us to decide , some question in natural science. In some cases to which re- ference will be made, the disappearance under improved nutrition of the symptoms which gave rise to the doubt has resolved the diffi- culty in the happiest way. possible. In others the question has been determined by failure of BY ORGANIC DISEASE. time or treatment to interrupt the course of the malady, or by a fatal issue. (^ ($• f^ <^ 1^ 1^ There is a form of paraplegia hitherto, so far as I am aware, undescribed, of which I have seen several examples, and in nearly all of them important questions have arisen as to the functional or organic nature of the condition. Although the lesion probably concerns in some of these the muscular rather than the nervous system, circumstances make it advisable that I should class these cases together, and include a brief account of them in the present collection. Case i. — A young lady, cet. twenty-one, was seen by me in consultation with Dr. Playfair on November ist, 1886. Since the age of fifteen she had been observed by her friends to have a peculiar gait, and this was noticed two years later by a surgeon who was consulted on account of some pain in her joints. At that time she walked with a stifif and stilted gait, which was chiefly 6 THE SIMULATION OF HYSTERIA noticeable in going upstairs, and varied very much. There appeared, however, I was told, to be no want of muscular power. She could walk well, and dance. From time to time she sufifered from a variety of typical hysterical symptoms, including an aversion from food, under which she had greatly lost flesh and strength at the time that I saw her. It was especially during several preceding months that she had gradually failed in her walking powers, and on several occasions had fallen down. The question to be determined was whether the condition was an hysterical one, as it had been pronounced to be by more than one medical authority, and likely therefore to yield to a course of Weir Mitchell treatment, for which purpose she had been taken to Dr. Play- fair. On examination I observed that the girl was highly anaemic. She could stand or walk without support, but slowly and laboriously, inclining the trunk to the side opposite to that from which depended the limb which was being advanced. When in the recumbent position she could flex the thighs upon the trunk with a fair amount of force, but when seated she had BY ORGANIC DISEASE. 7 little or no power of lifting either knee. Ex- tension at the knee joint was only moderately well performed, whilst the power of flexion at the same joint, and extension and flexion at the ankle joint, appeared to be normal. When standing it was with great difficulty that she could place her right foot upon a chair, and only by adopting a swinging movement. She could not even swing the left foot on to it. With her right foot on the chair, she could not lift herself up so as to stand upon it. As a necessary con- sequence of this inability, the ascent of a stair- case was accomplished only with the greatest difficulty and labour. With all this, the muscles of the lower extremities were to all appearance well developed, and showed no sign of atrophy. There were no sensory symptoms. No com- plaint was made of the upper extremities. The wrist jerks were exaggerated ; the knee jerks, on the other hand, were decidedly feeble. This contrast in the state of the deep reflexes, when taken in conjunction with the other symp- toms, gave important evidence. I have often referred to the fact that the knee jerk is not, according to my observation, lost in cases of hysteria ; on the contrary, it is almost always ■8 THE SIMULATION OF HYSTERIA •increased. Its marked diminution in this case, alongside of greatly exaggerated wrist jerk, pointed in the circumstances to impaired nu- trition of the second lumbar segment of the spinal cord. The complete loss of power in the ilio-psoas muscle, as shown by the examin- ation of the patient's movements, appeared to indicate that the first lumbar segment was still more severely affected. An opinion to this effect was given. As regards the Weir Mit- chell treatment, it was. agreed that the general health was likely to receive benefit from it, but no promise could be made that the local symp- toms would be removed. The patient went through a course of syste- matic treatment conducted by Dr. Playfair, who at the end of six weeks was kind enough to let me again examine her. She: was no longer anaemic, and had greatly improved in appear- ance. She had gained fifteen pounds. in weight. The knee jerks were now well marked, but there was still considerable difficulty in the move- ments performed by the ilio-psoas muscle. She could "fling" her foot on to a low chair — it could scarcely be called lifting it — and could then drag herself up, holding on to the back of BY ORGANIC DISEASE. 9 the chair, so as to stand upon the seat. This was only when the right foot was employed ; she could not do this with the left. I am informed that this lady still shows a certa.in peculiarity of gait, but that she can dance, run about quite actively, ascend stairs quickly, and appears to have full muscular power. She was recently married. Postponing for a time consideration of the nature of this case, let me refer to some others, possibly belonging to the same class. Case 2. — Some four years previous to this I had been consulted in the case of a well- nourished healthy-looking young woman, set. twenty-four, who had failed in her walking powers, and a similar question had arisen as regards the nature of her disability. It is no- torious that when a girl of highly neurotic tem- perament complains of difficulty in walking, the suggestion of an hysterical cause is very apt, and in many cases justly, to arise. The patient, whom I saw in 1882, had been observed by her mother in 1879 to be walking in a laboured way, which was at first attributed to the wearing of high-heeled boots, and the 10 THE SIMULATION OF HYSTERIA presence of chilblains. But the difficulty con- tinued and only increased as time went on. It appeared that in the winter of 1876-77 she had undergone great fatigue in " rinking," and it was not long after this that she had begun to feel unduly tired in walking. I found on examination that those muscles of the lower extremities the condition of which it was possible to examine by the eye, and by electrical testing, were well developed, and that the only defect in movement was in the action of the ilio-psoas group. There appeared to be absolutely no power of flexing the thigh upon the knee, all the other movements being well performed. The knee jerks were normal. The patient was sent to bed, fed, rubbed, and fired in the lower dorsal region of the spine, but without any effect. In December 1883 she could still walk, but required first to be set upon her feet. I learned last year that she had lost all power of movement in her lower extremities. There was no wasting of the limbs, which were sound and indeed unduly firm. Case 3. — Last year a sister of this patient, set. twenty-eight, was brought to me suffering BY ORGANIC DISEASE. II in her turn from a somewhat narrowly locaHsed loss of power. This patient could run upstairs two steps at a time, and mount easily upon a chair without the aid of her arms, but she had no power of dorsal flexion of the right foot, and almost none in the left. The leg itself was very firm and plump. Electrical examination showed complete absence of reaction to induced currents in the anterior tibial muscles. The patient, I learned, had enjoyed very good health, but her walk had been observed to be peculiar for eight or nine months. This was due, no doubt, to the dropping of her feet necessitating high action. Besides the patient with ilio-psoas paralysis above described (Case 2) this girl has two other sisters, one whom I have not seen, who is thirty-two years old and married, and is described as walking in the same fashion. She is unable to walk fast. The other sister, twenty-five years of age, shows no pecu- liarity of gait. It is evident that in the first of these three sisters' cases no question as between the organic or functional nature of the affection could have arisen, had the muscles affected (the flexors of the thigh upon the trunk) been in a position to be explored by electric currents. 12 THE SIMULATION. OF HYSTERIA They would doubtless have shown an absence of reaction to' induced currents, such as was dis- covered in the anterior tibial muscles of the second sister. But although in very emaciated persons it may, though very rarely, be possible to apply a rheophore in the situation of the iliacus muscle, the pain caused by electric cur- rents in this situation is intolerable to most persons, and renders exploration impracticable. I suppose it can hardly be doubted that the condition of the anterior tibial muscles, in the second sister, gives the clue to that of the ilio- psoas muscle in the first, and from the de- scription given of the married sister (whom I have not seen) it seems likely that she is also affected in some of her muscles in a similar manner. It seems probable that these are cases of idiopathic muscular atrophy — a primary myo- pathy, which is apt to occur in several mem- bers of the same family, and is not of central origin. The unnaturally firm condition of the limbs, coupled with the results of electrical examination, seems to point to overgrowth of interstitial tissue. In this family I could hear of no other instance of a like affection, and BY ORGANIC DISEASE. 1 3 the only peculiarity in the history that could be ascertained was that the father and mother were first cousins. Case 4. — Some years ago I saw with Dr. Playfair another lady who had been affected for more than ten years with a similar powerlessness which was confined to the ilio-psoas muscle. This was said to have ensued upon a moral shock, and in her case the condition was sup- posed to be hysterical. The Weir Mitchell treatment was adopted without success. She was probably an example of the same condi- tion. Case 5. — In 1885, a military man, set. sixty- eight, consulted me on account of inability to flex the hip joints — the other movements of the lower extremities being perfect, and the elec- trical reactions of the muscles which could be reached, normal. There was no loss of sen- sation. The knee jerks were perfect, and there was no difficulty in the action of the bladder. The want of power first showed itself at the close of the Crimean campaign, during which the patient had enjoyed good health. He was 14 THE SIMULATION OF HYSTERIA affected with peculiar nervous sensations. In this case there was a history of syphilis, but specific treatment had produced no effect. Case 6. — A lady, aet. thirty-six, was sent to me by a physician as a case of hysteria, in Febuary of last year. It appeared that in 1883 she had begun to feel weakness in her legs, shown es- pecially by difficulty in going upstairs — a diffi- culty which had been more or less constantly increasing. Examination showed that although the left lower extremity was that which was almost alone complained of by the patient, the right had but little the advantage in power. She rose from a sitting position with difficulty, and could not lift either foot on to a chair, but only by adopting a swinging movement of the leg could she accomplish the position. With the foot on a chair, she could only lift up the other foot to the same level by pulling at something high above her. It was not sufficient to grasp the chair-back. The other movements of the lower extremities appeared to be normal — that only in which the ilio-psoas muscles are con- cerned was affected. The muscles which were in a position to be tested responded normally BY ORGANIC DISEASE. 15 to electrical currents. It appeared, from her account, that a brother rather older than her- self was similarly afflicted, and later I had the opportunity of examining him. Case 7. — The brother of the lady whose case I have just described, consulted me in May, 1890. He was thirty-nine years of age, and was actively engaged in business. From childhood, according to his account, he was always supposed to be weak upon the legs, but he played football, and it was only, he thought, for about ten years that he had ex- perienced difficulty in getting upstairs, and in mounting on horseback. He thought the diffi- culty had increased, and he had felt it especially whilst grouse shooting during the last season. When stripped, it was found that the muscles of the lower extremities were more than com- monly developed, the quadriceps extensor standing out like that of an acrobat. He could manage to lift either foot on to a chair, but only in a sort of roundabout way, and ap- parently by the employment of the tensor vaginae femoris muscle. The foot being so placed, he was unable to pull himself up so as l6 THE SIMULATION OF HYSTERIA to Stand with the two feet on the chair. The knee jerks were present, but not very well marked. The right was stronger than the left. He told me that, if he caught his foot in an obstacle he was unable to bring the other foot rapidly enough forward to save himself, and would consequently pitch forward upon the ground. The tensor vaginae femoris on each side was hyperptrophied. The electrical re- action of the muscles that were tested was found to be normal. This patient told me that his general health was excellent, and that he could walk all day on the level. He had four brothers, all remark- ably strong. One of them had walked eighty- two miles in twenty-two hours. The family was a long-lived one, and with the exception of the sister (Case 6), no instance of muscular atrophy had been known in it. It is to be noted that both this patient and his sister appear to have displayed symptoms of weakness in the ilio-psoas muscle at about the age of twenty-nine. Case 8. — Last autumn I examined a lady ^t. forty-two, who showed great difficulty in lifting BY ORGANIC DISEASE. 17 her foot on to a chair, and complained much of trouble in going upstairs. Her gait resembled that of the other patients affected with incap- acity of the ilio-psoas muscle. In walking, as she puts forward the right foot, the left shoulder sinks remarkably, and the same with the left in its turn. The knee jerks were present and well marked, and the muscles of the lower extremities did not appear wasted. f^ Wl w www The occurrence of localised want of power in the ilio-psoas muscle in more than one member of a family coincidently, points rather distinctly, I think, to muscular atrophy as the cause of the incapacity. And this view, as will have been seen, is confirmed by the occurrence of muscular atrophy in a situation patent to the eye and to electrical testing, in Case 3, the sister of a patient affected with loss of power in the ilio- psoas district. It would appear from these cases that there is a form of progressive muscular atrophy which commences in the ilio-psoas muscle, which may 2 1 8 THE SIMULATION OF HYSTERIA attack more than one member of a family, and is probably a primary myopathy. i$> 1^ <^ w «9^ i$< Atrophy of the ilio-psoas muscle occurring in a young female, accompanied by hysterical symp- toms, would seem to be peculiarly liable to be wrongly interpreted. The patient complains of difficulty in walking, but the knee jerks are preserved, and the electrical condition of all the muscles of the lower extremity that can be tested is strictly normal. One is naturally dis- posed to expect in such a case that if there be a central lesion in the cord, either the muscles innervated from the lumbar enlargement will be found atrophied and their electrical reactions abnormal, or if the lesion be above the enlarge- ment, that symptoms of spasticity will be ob- served, the knee jerks will be exaggerated, and more or less ankle clonus present. I think that the cases which I have described may serve a useful purpose in drawing attention, in a doubtful case, to the fact that there may be isolated atrophy of the ilio-psoas muscle, giving BY ORGANIC DISEASE. 19 rise to that form of paraplegia which is charac- terised by the patient being unable to mount stairs without dragging at the banister, and, one foot being placed upon a chair, inability to lift the body up so as to stand upon it with both feet. w w w f^ w iw JF T n: 'F T * The successful result of systematic treatment by high feeding and massage in the case first related is probably to be explained by the fact that the patient was anaemic and much reduced. It seems possible that in her case the condition was not one of congenital muscular atrophy, but that there was a temporary state of mal-nutrition of the cord, which recovered. I remember another instance of the kind in a young woman profoundly affected with anaemia, who regained power under appropriate treatment. Case 9. — A governess, set. twenty-three, came to me on Oct. i8th, 1884, on account of diffi- culty in walking. She had been delicate in childhood, but had usually enjoyed good health. 20 THE SIMULATION OF HYSTERIA For the last fortnight she had been unable to carry on her occupation. Five weeks previously she had felt her breath very short in going up stairs, and had kept in bed for a few days. Every time she left the bed she fainted. A fortnight since she experienced great difficulty in walking, as though her legs gave her no support, and there was a great aching at the bottom of the back. She could only just hobble about from one room to the other. There was great vesical irritability. The catamenia had been suspended for three months. The patient was suffering from marked chloro-ansemia ; the cardiac sounds were normal ; the urine contained no albumen or sugar. There was some tender- ness on pressure on the first lumbar vertebra ;: the spinal column showed no deformity. The movements of the lower extremities were feeble, especially flexion of the thigh upon the hip, which could scarcely be performed. The knee, jerks were rather in excess. Iron and arsenic were prescribed for her. After a fortnight she had greatly improved in colour, and was able to walk better. The trouble with the bladder, however, still continued. She was unable to lift the left knee, but could lift. BY ORGANIC DISEASE. 21 the right. There was no affection of sensibility. In three weeks more she felt quite well in her- self, and the vesical trouble had ceased. She was able to lift the right knee against a certain amount of pressure, but the left not at all. She could straighten the left leg, flex and extend the foot, and in fact do anything but lift the knee. In going up stairs she would put her right foot down first, and then draw the left after her ; in descending the left was put down first. She still suffered from palpitation and breathlessness. About six weeks later, when I saw her again, the legs had quite recovered ; she was able to walk more than a couple of miles, and could lift her knee on either side in normal fashion. Case io. — In 1889, a married lady, aet thirty- four, applied to me on account of impairment in the power of walking, from which she had suffered for one and a half years. She had given birth to children very quickly, and her last was ten months old. For three months before the birth of this, she was at her worst and had to be carried about, nor was there very marked improvement after her confinement, 22 THE SIMULATION OF HYSTERIA though she contrived to walk a little. She had a very "waddling" walk. There was no per- ceptible muscular atrophy. The spinal column appeared normal. The weakness appeared to be entirely in the action of the ilio-psoas mus- cles, so that she could not mount a chair, and had to pull herself up stairs by the banisters, i|^ «^ «|^ 1^ ^ ($1 It will be remembered that the late Dr. Moxon, in his Croonian Lectures before the Royal College of Physicians in i88i, called at- tention to the great length and obliquity of the spinal arteries which supply the lower third of the spinal cord, as a probable cause of tem- porary anaemia in that region. It would seem that where there is general anaemia this anato- mical arrangement may explain the localisation of disturbed nutrition in this part. I suppose that in the case first related, where the knee jerks, which were at first small, became well pronounced as the patient recovered, it was to the anaemic condition of the cord at the second lumbar segment that the imperfection of the BY ORGANIC DISEASE. 23 reflex action was due. One can conceive it possible that in a given case anaemia might even be so extreme as to cause a temporary disappearance of this reflex. It is necessary to bear this in mind, as the absence of knee jerk is a symptom which, if the illness has been long continued, is more suggestive of permanent damage than of a condition capable of being treated successfullv. 1^ 1^ 1^ »^ I^W #^ The absence of knee jerk in a young female, so far as my experience goes, is a matter always requiring very careful examination. I need not mention the obvious conditions which usually explain the absence, but would refer to cases of a less common kind, which are occasionally met with. One of these I saw with Dr. Playfair in 1884. The patient, a young lady, set. twenty- six, had begun to get weak in walking eight or nine years previously. The difficulty had gra- dually increased until she had an attack of tyhoid fever, since when she had been unable to walk at all. 24 THE SIMULATION OF HYSTERIA Examination showed the following condition. — Her speech is ataxic, the words being slurred. The hands possess a good grasp, but are rather wildly moved about when directed to touch an object — a condition of marked ataxy. This is the case with each hand. It is not the tremor of disseminated sclerosis, but the movement of a person suffering from tabes dorsalis. There is no wrist jerk on either side. She cannot sit up. When two persons tried to make her stand and walk between them, she could do nothing ; her legs and feet disappeared and were mere appendages to her frame. There was no power whatever of standing ; she sank "in a heap " to the ground. Lying on the couch, she failed to lift the right foot which was on the ground. The sensibility of the limbs appeared good. The knee jerks were absolutely want- ing ; the plantar reflex was preserved. There was enormous lateral curvature of the spine. This, she informed me, had not been observed to begin until she was ten years of age. There had never been any pains. The powerlessness of the muscles of the trunk and lower extremi- ties was very great. With all this the action of the bladder and bowels was described as BY ORGANIC DISEASE. 2$ normal, although there had been occasional in- continence. The patient had a fairly good colour, with a face not markedly unhealthy looking. Her manner was highly nervous and hysterical. The pupils responded well to light. It appeared that her condition had been ascribed to hysteria, and that in an earlier stage of her illness she had been forced to try and walk up stairs under the impression that the disability was due to want of " will." She managed this only by the aid of the banisters, never without. At that time {three years previously) she could get about a room with the help of a chair. The general health was good. I was of opinion that the case was one of Friedreich's ataxy and that it was not fitted for the Weir Mitchell treatment. Her mother told me that she had two sons and one daughter besides the patient. They were in very good health, able to play lawn tennis and take long walks. She herself en- joyed good health, and so did the father of the patient. Neither in her family nor in her hus- band's was there any case of paralysis or nervous disorder so far as she knew. 26 THE SIMULATION OF HYSTERIA As is well known, Friedreich's ataxy is usually not confined to one member of a family, so that in this instance the exceptional limitation in- creased the likelihood of the case being referred, as indeed it had been positively, to hysteria ; but there can be no question of its nature. Another case of this kind, lately under my care in hospital, had been previously considered to be one of hysterical paralysis. The follow- ing account is taken from the notes of Dr. May, resident medical officer. Patient is a young woman, aet. twenty-four, who complained of some difficulty in walking eight years ago. There were aching pains in the legs constantly, but increased now and again. At times she complained of " girdle sensation." She never suffered from lightning pains. Five years ago she became unable to walk, and her hands were noticed to be unsteady for fine movements. For four years the articulation has become in- distinct. Her mental condition is fair, but she is a little depressed, and cries somewhat easily. The eyes show nystagmoid jerkings on looking to either side. Her speech is slow, jerky, and indistinct. The movements of the arms are BY ORGANIC DISEASE. 27 distinctly ataxic. Sensation is normal. There are no wrist or elbow jerks. The legs are very ataxic. The patient cannot stand, even with support. There is no wasting. There is slight tendency to contracture in the feet. The knee jerks are absent, there is no ankle-clonus. The plantar reflex is active. The spine presents a lateral curvature. There is weakness in the muscles of the spine and of the neck. There is some unsteadiness in the head when it is unsupported. This patient is not, like the last, an isolated example of Friedreich's ataxy. An elder sister now thirty-nine years of age, became affected with similar symptoms when about fifteen years old. She has four brothers who are quite well. A year or two ago a young man, set. twenty- four, was brought to me on account of difficulty in walking, the cause of which had given rise to difference of opinion. He had a staggering gait, with hesitating and slurring speech. The knee jerks were absent. It appeared that up to fourteen months old he had been liable to " spasmodic croup," and he was two and a-half years old before he began to 28 THE SIMULATION OF HYSTERIA Stand upon his feet. As a school boy he would tumble about at times and never could learn to dance. He did well, however,- in his school work and carried off prizes, the mental develop- ment being good. He went to one of the universities, but had to quit it after two years, the proctors accusing him of intoxication owing to his gait. This was, evidently, a case of Friedreich's ataxy, but here again I could obtain no history of a family proclivity to the disease. There was an elder brother and a younger sis- ter, both of whom I was informed were free from disease, and I could not hear of any other mem- ber of the family having been affected in a like manner. I cannot remember (and my very imperfect notes say nothing upon the point) whether either of these patients presented the deformity of foot which has been specially described by Ruti- meyer, Burg and Ormerod. My attention was first drawn to the symptom by Dr. Ormerod, who thus describes the development of the kind of club foot which is apt to occur in cases of Friedreich's ataxy. " The instep becomes pro- minent, and the meta-tarsals appear to be shortened; at the- metatarso-phalangeal joints BY ORGANIC DISEASE. 29 the toes become over-extended, and at the first inter-phalangeal joints flexed. The foot looks humpy and shortened. Below, the plantar arch (at least as seen from the inner side), is abnor- mally high, and the balls of the toes are very prominent. The foot also tends to assume the position of equino-varus."" I remember seeing a case many years ago (which I do not now doubt was one of Frie- dreich's ataxy, although I failed to diagnose it at the time), in which the only complaint made by the patient was of this club foot, to which was attributed the difficulty in gait. The knee jerks were absent. It may be well to mention this, as there is always the possibility of the disease being overlooked from the attention being directed to one prominent symptom. I$> 1^ 1^ >^ (^ !$• There is no doubt that as a rule the fact that a patient has been observed on some occasion when she thought herself alone, to perform some ' Brain, January, 1888. 30 THE SIMULATION OF HYSTERIA movement which she has previously alleged to be impossible, lends us very important aid in coming to the conclusion that the case is not one of organic disease. This circumstance oc- curred in a case which I will briefly relate. A lady, st. thirty-three, was seen by me at Dr. Playfair's request on June i6th, 1884. She had been for nearly eighteen years confined to her bed on account of loss of power in her lower extremities. The patient had fallen down a flight of steps at the age of fourteen or fifteen, and shortly afterwards began to walk with difficulty and only with the help of sticks and crutches. She was seen by an eminent surgeon, who thought that she might have injured her spine and ad- vised that she should rest. She took to her bed, and shortly afterwards completely lost the use of her lower extremities. The patient when I visited her lay on a couch with her legs semi-flexed at the knees and turned on their side. The feet were dropped and toes pointed. She said that she was unable to move her legs voluntarily in the least, but that they moved sometimes of themselves. She knew how they were lying without looking at them. BY ORGANIC DISEASE. 3 1 The muscles when examined electrically were found to contract normally to induced currents. There was complete anaesthesia of both legs from just above the knee downwards — in fact of that portion of the lower extremity which would be covered by a stocking. The limbs were emaciated, the muscles being small and flabby, but there was no " picked-out " atrophy. The knee jerk was good on each side, and the tendo achillis jerk well marked ; there was no ankle clonus. The plantar reflex could scarcely be evoked. The spinal column was free from deformity ; there was superficial tenderness in the mid-dorsal region, and also in the nape of the neck. The patient gave me her left hand saying that the right was somewhat weak. The muscles of that arm contracted normally to induced currents. The cutaneous anaesthesia was entirely confined to the legs. The patient did not suffer from any pains in the extremities ; there were no bed sores. She was liable to severe dysmenorrhoea. The sight was perfect, the intelligence high, the general health very good. I was informed that on two or three occasions the urine had been passed in the bed apparently 32 THE SIMULATION OF HYSTERIA without the patient's knowledge. On one occa- sion when she had been laid up on her couch for about ten years, her maid, coming unexpectedly into her room, found her standing at the window, whence she walked to bed again. Even with- out this incident, the case, it will be seen, pre- sented but little difficulty in diagnosis. A confident opinion was given that the case was one of hysteria, and the patient was put through a course of systematic treatment. She perfectly recovered. Dr. Playfair informs me that she has remained well ever since, and leads a very busy and energetic life. A recent experience shows that great cau- tion should be observed in drawing inferences from some behaviour of the patient which appears inconsistent with other symptoms. I saw not long ago in consultation a lady, aet. fifty-five, of highly nervous temperament, with hysterical antecedents, who had been suffering for several days past from attacks of violent colic-like abdominal pain, extending at times to the lower extremities. She described the at- tacks as commencing with a " creeping " up the spine. In the course of time there would BY ORGANIC DISEASE. 33 be a state of intense excitement, with convul- sive movements of the arms. It appeared that one of her breasts had been removed in the early part of the year on account of malignant disease, and the patient was under so fixed a belief that the present illness signified a reappearance of this disease, that she could not be pacified. The patient looked thin, but not emaciated. She lay in bed and appeared to have especially great difficulty in flexing the thighs upon the trunk ; dorsal flexion of the feet was performed more easily. The muscles were very flabby. The knee jerks were absent, and there was no plantar reflex. She complained of numbness over both lower extremities from about the level of the tenth dorsal vertebra downwards, and in this district touches were felt imperfectly. She told me that a fortnight previously numb- ness had commenced in the right lower ex- tremity and also rather to the left of the spine. At the same time there was weakness of the right leg. This had gradually within the last few days invaded the left lower limb, but the right was still the worst. She was sure that •the loss of power and the numbness both com- 3 34 THE SIMULATION OF HYSTERIA menced together in the right hmb. Nothing wrong was to be detected about the spine nor in the abdomen. The nurse said that the patient when by her- self walked about the room quite actively, in strong contrast to the feebleness of movement shown when she was observed. In view of this circumstance, the patient's manner and history, and the absence of any sign of growth under the most careful examination, opinions had been expressed that the symptoms were probably functional, and it was with a view of helping to clear up this initial difficulty that my opinion was asked. From the fact that, whilst the wrist jerks were strongly m.arked (as is common in hysterical women), the knee jerks were quite absent, I had no difficulty in coming to a conclusion that the symptoms depended upon organic lesion. The opinion was expressed that she was suffering from neuritis, and this was assigned to the cauda equina. It might be due either to rheuma- tism, gout, syphilis, or the presence of a ma- lignant growth. The latter contingency was the one to be feared in the circumstances. Large doses of iodide were, however, advised to be given tentatively. BY ORGANIC DISEASE. 35 On Nov. 20th, there was still further loss of power, but the attacks of colic-like pain had ceased. The vasti muscles did not respond to induced currents. On Dec. 6th there was abso- lute paraplegia except that she could just move the toes of the right foot. The bladder was not affected. There was difficulty in swallowing and dangerous choking. Her condition became more and more grave, and on Dec. 9th she died, after an attack of choking. There can be no doubt that she succumbed to secondary deposits of cancer. '$''$''$' "^ ^ ^ In the case preceding that which has just been related, it will be noted that the patient had occasionally suffered from unconscious dis- charge of urine. The behaviour of the bladder has sometimes been made a crucial test in the question between functional and organic disease. There are conditions of the urinary system which admit of no doubt that they are connected with organic lesion of the spinal cord. In a patient, for instance, with loss of power in the lower 36 THE SIMULATION OF HYSTERIA extremities, ammoniacal purulent urine is con- stantly dribbling away, whilst the patient is unconscious of its discharge. In such circum- stances we should not hesitate to diagnose organic disease. But there may be organic disease of the cord whilst the behaviour of the bladder gives no such definite evidence. In spastic paraplegia from sclerosis of the lateral columns the patient may be quite conscious of the desire to discharge urine, and fully aware of its passing, at the same time that he is unable to restrain its evacuation when the desire arrives. A tumour pressing upon the cord in the upper part of the dorsal region may, as its first effect, cause simply an inability to empty the bladder. This may be followed, shortly afterwards, by increasing loss of power in the lower extremities, going on to complete paraplegia, with dribbling of ammoniacal and purulent urine. But the urine may, in some cases of organic disease, remain acid for a considerable time, whilst it is constantly dribbling in small quantities. In hysterical paraplegia retention of urine is not an uncommon symptom, and in some cases it is occasionally discharged involuntarily, the patient apparentlynot possessingthe power of restraining BY ORGAISTIC DISEASE. , 37 the evacuation when the bladder is distended. This is not a true "incontinence" of urine, such as is apt to occur from organic disease of the cord. In this latter the bladder is never distended, but the urine constantly runs away as soon as it is secreted. On the other hand, one often sees in organic disease of the cord a condition indistinguishable from that which oc- curs sometimes in hysteria. There is a kind of spasmodic incontinence. The urine gradually accumulates until the bladder is distended. Then, if it be not drawn off it is suddenly ex- pelled, the patient having no control over it. The fact is that the subject is a very compli- cated one, and I would here only point out that neither retention of urine nor apparent (though not real) incontinence are of them- selves, without other symptoms, evidence either of organic disease of the cord or of hysteria. <|^ ^ ^ 1^ <^ ^ An instructive illustration of urinary troubles occurring in the course of a case which was evidently hysterical will be' found in the nar- rative which follows. 38 THE SIMULATION OF HYSTERIA A female patient, set. thirty-three, was ad- mitted into the National Hospital for the Paralysed and the Epileptic on May 26th, 1886, on account of loss of power in both legs and the left arm, of five years' duration. In the autumn of 1879 the patient had suffered from " inflammation of the lungs," and after- wards from general weakness with "weak heart" and faintness. In 1881 her legs became very weak, and at the end of the year she could not move them. In 1883 the legs began to get stiff, and since then they had gradually become worse. In 1864 she had fallen downstairs and hurt the left side of the head. This was followed by a discharge from the left ear, and about a year later an abscess formed behind it, and there had been more or less discharge from the abscess or the ear ever since. In 1878 she had broken "her left arm and wrist and finger," so she described it, and the hand had been useless ever since. The arm, however, and the elbow and shoulder had only been helpless since last July. She never had severe pain in the back or limbs, and had never suffered from bedsore. BY ORGANIC DISEASE. 39 There had been occasional inability to retain the urine for some months during the last year, but there had not been any loss of control over the sphincter ani. The patient had suffered from scarlet fever at twelve, and diphtheria at seventeen. As regards her family history, the father as well as two of his sisters and two of his brothers and many other relations had died of consumption. Her mother has cancer ; many of her relations have had paralysis. On admission the following note was taken by the house physician. There is complete left facial paralysis ; a foul discharge comes from the left ear, copious in amount, with tenderness on pressure over the mastoid process, where there is a mark of an old scar. A short distance inside the external auditory meatus a pale poly- poid mass is seen. In the left eye corneal opacities are seen in the lower half There is no paralysis of the tongue, no difficulty in articulation or deglutition. There is aphonia : attempts to examine the larynx failed. The left hand lies in a position of rigid flexion, the joints cannot be voluntarily moved. The patient cannot stand ; there is rigidity of the ■ 40 THE SIMULATION OF HYSTERIA legs in the extended position. Both ankles are extended, and the toes over-extended on the meta-tarsus. There is no voluntary power over the joints of the lower extremities. Knee jerks are equal ; no ankle clonus can be produced, possibly on account of mechanical impediment ; the wrist jerks are equal. There is no affection of sensation anywhere. The plantar reflexes can only be evoked with great difficulty. There is a little tenderness of the spine be- tween the scapulae ; some tenderness is com- plained of in the iHac fossae, especially the left. Nothing is found wrong in the cardiac and respiratory systems. As it appeared likely, from the history and circumstances, that the case was one of hysteria, a few days after admission I forcibly extended the left fingers, which had been rigidly flexed. In doing so the skin was- torn at the roots of the fingers. A splint was then applied. Next morning, when the splint was removed, the patient was able to move her fingers to a con- siderable extent. The legs were now also for- cibly moved at the knees, and the feet actively dorsal-flexed as far as was possible. There were evident adhesions in the ankle joints, which BY ORGANIC DISEASE. 4 1 obstructed flexion. Some of these were broken down. Two days afterwards the patient could move all the joints of her legs a little. There was still aphonia. Although the grasp of the left hand still measured o on the dynamometer, she was found to be using the fingers of this hand nimbly enough for knitting. After three weeks it is noted she has now very good move- ments in the left hand and arm, and has con- siderable grasping power with it. She can move the toes very well, and bend the knees consider- ably, but the feet are extended at the ankle joints and cannot be flexed on the legs. There is still aphonia, but she can close her glottis for the purpose of coughing. About six weeks later the patient was dis- charged, able to walk fairly well, though a little awkwardly, without help. She could use her left hand and arm perfectly well. The voice had entirely returned. There was no rigidity of any of the limbs. This was in my opinion a case of hysterical paraplegia, and is important as illustrating be- sides the " incontinence " of urine some of the trophic disorders which may result simply from long disuse of limbs. The formation of 42 THE SIMULATION OF HYSTERIA adhesions in joints, requiring forcible disrup- tion, I have seen in other cases which were proved by the sequel to be of hysterical origin. There was no real muscular contracture in this case, although the dropped position of the feet suggested over-pulling of the sural muscles. As soon as the adhesions were all torn through, the feet could be dorsal-flexed into a normal position. I have reason to think that this condition of joints is often regarded as strong evidence against the diagnosis of an hysterical condition, but I have convinced myself that this is an error. Nor was there any real muscular contracture in the left forearm, although the prima facie resemblance to the late rigidity so often seen in hemiplegia, was remarkable. In true hemiplegic contracture it will be observed that you cannot by any amount of force straighten the whole limb at one moment. If you straighten out the fingers, the wrist remains rigidly flexed. Bring the metatarsus into a line with the forearm by extending the wrist, the fingers will ipso facto become rigidly flexed. But in this case I found, as I have often seen in other cases of apparent BY ORGANIC DISEASE. 43 contracture of hysterical origin, that I could ex- tend the fingers and wrist at the same moment, thus bringing the forearm and hand and fingers into the same plane. In doing this, however, the skin at the roots of the fingers gave way, so that there was a transverse tear at each meta- tarso-phalangeal joint, showing that there had been an adapted contracture of the skin from long disuse of the member. 1^ <^ (^ 1^ (^ 1^ It is a rule of almost universal application, according to my experience, that the plantar reflex is either entirely absent or very feebly indeed expressed in cases of hysterical para- plegia. Sometimes by perseverance in a very elaborate titillation of the foot-sole the reflex is produced, and occasionally also it is easy to see that a good deal of voluntary action is expended in restraining the muscular contraction. But usually there is a simple absence of the plantar reflex, the stimulus being felt as touch only, even in persons who are naturally very ticklish. 44 THE SIMULATION OF HYSTERIA In May, 1883, a young married lady, the mother of three children, was brought up from the country and placed under my care by her medical attendant. When I first saw her she lay in bed, unable, according to her account, to do more than slightly flex each knee joint. She could not lift either foot off the bed, or dorsal- flex it in the least. There was no loss of cuta^ neous sensibility. The knee jerk was in ex- cess on both sides, the plantar reflex entirely abolished, although she could feel perfectly well the pencil point with which it was tested. With all this want of power in the lower ex- tremities she could yet raise herself in bed from the recumbent to the sitting posture with moderate aid from her hands. She could not stand even with help, but dropped "in a heap" on the floor. I applied strong faradaic currents to the foot- soles (the muscles of the legs shewed normal reaction) and I talked in a private interview with the patient, explaining to her that she was not paralysed, but that her legs had "gone to sleep." She appeared much relieved by the explanation. When I saw her two days after- wards she was able to walk with the aid of a BY ORGANIC DISEASE. 45 nurse's arm. She told me she had "pins and needles " in her legs. I now found the plantar eflex perfectly restored.* Faradaism was again applied, and she was instructed to make various movements of the legs and feet against resis- tance. Next day she walked without aid, and had lost the "pins and needles " feeling in the legs. The patient presented an emaciated appearance, and told me that she had been losing flesh for six months. She was en- couraged to take a liberal dietary, and soon quite recovered her health. ^ t$> ^ 1^ ^ w> The absence of plantar reflex is, as I have mentioned, so much the rule in cases of hysterical paraplegia, that the presence of this reflex affords rather strong presumptive evidence, in a doubt- ful case, of the affection being of organic and =■= To the behaviour of the plantar reflex in hysterical paraplegia I first drew attention several years ago {Clinical Lectures on Diseases of the Nervous System, 1882, p. 118; many cases illustrating this symptom are related in Lecture 5.) 46 THE SIMULATION OF HYSTERIA not simply functional character. It is interesting to observe in this connection that the plantar reflex will sometimes be observed to be absent only on the side affected with hysterical para- lysis, where this is confined to one lower ex- tremity. A young woman aet. twenty-one was admitted into hospital under my care in May, 1890, af- fected with loss of power and alleged shortening of the left leg. It seemed that she had com- plained of pain in the back in October, 1889, for which, after a time, she had been sent to bed. In March, 1890, after lying in bed for three months, the left leg was found to be partially paralysed. We found the movements of the left leg very weak, attended, it was said, with pain. Tenderness about the left hip was complained of. The limb was kept extended, and to superficial observation appeared considerably shortened, but careful examination showed this to be illusory, and due to the position in which the girl kept her pelvis. There was no anaesthesia. The knee-jerk was more active on the left side than on the right, and at times ankle-clonus could be elicited on the affected side. On the BY ORGANIC DISEASE. 47 Other hand, whilst the plantar reflex was very active indeed on the right side, it was entirely- absent on the left. The patient was discharged in September not materially improved, but I understand from Dr. Rivers, resident medical officer, that she came to the hospital some months afterwards quite well, having recovered suddenly on the occasion of a great shock caused by her mother's death. In another case — that of a male — a similar condition was present, and assisted me, in con- junction with other circumstances, in coming to a diagnosis of hysteria. A man eet. forty, was admitted in June, 1890, with pain in the back and inability to walk with- out much support. Three months previously he had sustained a fall on the back and left hip, and his symptoms dated from the accident. There was apparent weakness of his lower extremities, but far more in the left than in the right. The muscles of the left lower extremity were some- what wasted, but the electrical reactions were perfect. Both knee jerks were exaggerated, but especially the left, and there was ankle clonus on the left side. There was no anaesthesia. 48 THE SIMULATION OF HYSTERIA The plantar reflex on the right side was active, that on the left entirely absent. Patient alleged that he could only flex the left knee joint if he turned on one side. He could then do it readily. There was no surgical lesion to ex- plain this anomaly, which on the other hand is not a symptom, so far as I have observed, of paraplegia from disease of the spinal cord. The patient was an extremely emotional man, and whilst in hospital was subject to emotional attacks with tremor. I am unable to give the sequel of this case, as the patient quitted the hospital after a time in much the same state as on admission. In the following case both plantar reflexes were completely absent. A girl, set. sixteen, was admitted in April, 1 890, with complete loss of power in both lower ex- tremities. In January, 1888, she had complained of pain in the right side, constipation, and reten- tion of urine. She is described as squinting at the same time. In February it was discovered that she had lost feeling all over the body, and there was besides loss of taste and smell. There was complete loss of power in the lower BY ORGANIC DISEASE. 49 extremities, and great weakness in the arms; In July, 1888, she had recovered common sensa- tion, taste, smell, and the power of her arms, but the legs remained powerless. On admission flaccid paralysis of both lower extremities was noted, complete except for very slight movement of some of the toes. Her legs lay motionless in bed quite helplessly in what- ever position placed. The muscles were wasted and flabby ; the electrical reactions normal. There was no affection of sensation, including sense of position. The knee jerks were active. There was no ankle clonus. The plantar rer flexes were completely absent. The field of vision in each eye was greatly contracted ; there was no loss of colour vision. Under systematic treatment by high feeding, massage, and later by induced electrical currents, she slowly im- proved, and was discharged in December able to walk by herself. •^ "^ "^ •$• "^ "^ The behaviour of the reflexes in hysterical paraplegia is almost always the converse of that which usually obtains in tabes dorsalis — the knee 4 so THE SIMULATION OF HYSTERIA jerks are exaggerated, and there may be ankle clonus — the plantar reflexes absent. The ex- aggeration of knee jerks occurs even when there is no tendency to spasticity in the limb, the muscles of which may, indeed, be abnor- hially lax. In tolerably recent cases of hysterical para- plegia the limbs may be firm and round, the skin- healthy looking, and the knee jerks well marked. If in these circumstances total inability to extend the knee joint and dorsal-flex the foot is alleged, whilst the muscles respond normally to induced currents, the knee jerks are present, and there is no spasticity, the diagnosis is not usually difficult, because one can exclude the presence of structural lesion in and above the lumbar en- largement But given a partial loss of power in a limb with a tendency to rigidity, and the diffi- culty of diagnosis is often enormous. 1^ i$i i$> nally be the leg of one side and the arm of the other which would be coincidently affected. The patient walked in a tottering way. The muscles flexing the thigh appeared to be stronger on the left than on the right side. She could get up on to a chair with either leg first, but with the left better than with the right. BY ORGANIC DISEASE. jg The muscles appeared to be well nourished. Her power had varied very much from time to time. Soon after her attack of powerlessness in the left leg she had a manifest squint, with double vision, which lasted for several months. It was on account of the squint that she was taken to an eminent physician, who expressed an unfavourable opinion of the case. The knee jerks were exaggerated and ankle clonus was said to have occurred, but I did not elicit any. An opinion was given that the condition as then observed was apparently of functional character, and systematic treatment was advised. Dr. Playfair treated her, and she apparently got so far well, that when treatment was discontinued there was only a slight difficulty in walking. From recent enquiry, however, it appears that now, three years later — she remains in statu quo, and is evidently affected with organic dis- ease. A lady, aet. thirty-nine, the mother of one child, was sent to me by Dr. Playfair on July 9th, 1888. She complained of loss of power in walking. In Scotland, four years previously, 80 THE SIMULATION OF HYSTERIA she could walk six miles, and gradually after that she lost power^ so that she staggered in her walk on looking up, and was obliged to hold on to something. At the same time, she said, a touch was not felt on the left side of the fore- head and cheek, and the mouth was pulled on one side — she thinks the left. When examined it was noted that her hand was steady for hold- ing things or for writing. She said that the ends of her fingers tingled. Her articulation was of a hesitating, clipped character, but this, it seems, she had had since the age of fourteen. Her sight began to fail in 1882 ; the failure in her walking powers a year or two later. The knee jerks were well marked ; there was no ankle clonus. She picked up anything from the table easily and without tremor. Three years previously she could not see to read and write, but recovered the power, and for two years she could read fairly small print. Now she could hardly read minion (No. 4) at all. Both optic discs were found to be distinctly atrophic. Dr. Playfair informed me that this patient ap- parently made a good recovery under systematic treatment^ and went abroad with her nurse. For two and a-half months her condition remained. BY ORGANIC DISEASE. 8 1 quite satisfactory. Then one day after unusual fatigue she had a cerebral attack, the precise nature of which is left in doubt. She appears to have been quite unconscious for a consider- able time, perhaps some days, and was supposed to be dying. Eventually she recovered from this and came back to England. I saw this patient in May, 1889, and ex- amination showed distinct symptoms of dis- seminated sclerosis. The cerebral attack was probably of the apoplectiform character, de- scribed by Charcot as occurring in cases of disseminated sclerosis. A lady, aet. twenty-four, was seen by me with Dr. Playfair^ in May, 1884, when the following notes were made : — She has a good colour, large pupils, and is not unhealthy looking. She is rather, but not very thin. She rises from a chair with difficulty and stands tottering, glad to put her hand on any- thing to support her, and elects to have the feet wide apart, so as to enlarge the base. In walking, the gait is somewhat ataxic, with a slight tendency to over-action. There is but little power in the flexors of the thighs. The 6 82 THE SIMULATION OF HYSTERIA knee jerk is much in excess on both sides, and there is ankle clonus. The plantar reflex is present and not abnormal. Complaint is made of considerable ansesthesia of the lower ex- tremities. A touch is felt, but dimly and less distinctly on the right than on the left leg, and she cannot distinguish by the touch of her foot a Turkey carpet from one of another kind. In reply to a suggestion, she says that her legs feel as if asleep. She does not know where they are in bed without kicking against something. There is slight cutaneous anaesthesia in the fingers. She cannot pick up small things without looking. She has had cutaneous anaesthesia of the left side of the face, and indeed more or less all over her body. No bladder trouble is reported, except rather frequent micturition. There is no nystagmus. The patient's illness dates from three years. First there was deafness, or, to use her own description, sounds were heard as though at a great distance. Then followed diplopia ; there was no strabismus perceptible, according to her sister's account. A surgeon said there was paralysis of a nerve, but an ophthalmic au- thority is reported to have said that it was of BY ORGANIC DISEASE. 83 no consequence. In a week or two or more she lost the sight of the left eye almost entirely, but after some little time it returned. Now nothing abnormal is to be detected with the ophthalmoscope. She says that now the sight of the right eye is not so keen as that of the left. It seems that at one time she had lost the use of both her arms. Now there is good grasp with each hand ; no increased reflex is to be observed at the wrists. There are no tremors in the arms. An opinion had been given by two eminent physicians three years previously that this patient had disease of the spinal cord, but two equally distinguished authorities who had more recently seen the case (one of whom indeed sent it to Dr. Playfair) said that it was an example of hysterical paralysis. Having been informed that three years pre- viously the anterior muscles of the left leg had been found by a high authority to give no response to induced currents, whilst those of the right contracted well, I submitted the patient to a careful examination with electrical currents. §4 THE SIMULATION OF HYSTERIA The application of currents to the legs gave rise to a good deal of reflex muscular action in the muscles moving the" thighs. The faradaic excitability was everywhere quite normal in the lower extremities, as also in the forearms and hands. With the galvanic current K S Z > A S Z. I gave the opinion that all the symp- toms observed at that time could be explained by functional trouble, but some reserve must be felt owing to the past history. The patient underwent a course of syste- matic treatment for nerve prostration, but with- out satisfactory result as regards her power of walking. At her mother's request I saw her nearly four years afterwards, February 27th, 1888. She was then a good deal more helpless, but could lift the right knee a few inches, and the left, perhaps, one inch. She could not dorsal- flex either foot. With a stick and an arm she walked in a laboured manner, but the exertion to do this caused her great fatigue. Her eyes now presented nystagmus, both horizontal and vertical. There was a little waviness in the movement of the hands. Speech and hearing were good. Patient suffered from great fre- BY ORGANIC DISEASE. 85 quency of micturition, the bladder requiring to be relieved every few minutes. She had no trouble with the bowel. She slept well, and her general health was good. Tested by induced currents the anterior tibial muscles of the left leg showed more defective response than those of the right, but on both sides the reaction was distinctly lowered. It does not need to be said that symptoms of dis- seminated sclerosis were now strongly pro- nounced. In the case which follows a diagnosis of hysteria had been made before it came under my observation, and the girl certainly presented very much the aspect of an hysterical patient. It seeftis worth recording because of the sequel. A young woman; aet. twenty- two, was ad- mitted into the National Hospital, for the Para- lysed and the Epileptic on August 3rd, 1887, on account of loss of power in the hands, and also in the lower extremities. There was no history of injury. She had suffered from mea- sles when a child. About five years previous to admission she began to suffer from pains in both hip joints and weakness in the legs. 86 THE SIMULATION OF HYSTERIA Nine months ago her knees gave way, and she complained of severe pains in the lower limbs. For three months she was able to go about with the aid of sticks, but for the last four months had been confined to bed. For the last three years she had had attacks of loss of power in the hands, accompanied by semi-flexion of the fingers and pains. The condition had been considered hysterical. On admission it was found that she could perform all movements of the upper limbs. No wasting or rigidity was present. She stated that she had occasional numbness and a ' pins-and-needles ' sensation in the fingers of both hands, and that she often had loss of power in the hand for a short time. No loss of sensation was observed. When asked to take hold of a pen held at a distance, there was marked tremor and inco-ordination. This was present in both upper limbs. It was with diffi- culty that she could drink from a cup without spilling the contents. The wrist jerks were present on both sides, not exaggerated. She could perform all movements of the right lower limb as she lay in bed, but they were feeble. The left lower limb was flexed BY ORGANIC DISEASE. 87 at the hip and knee, and patient was unable to extend fully at these joints. She was able to dorsal-flex the foot to a slight extent, also to flex and extend to a very slight degree the left hip and knee, but was unable to perform any other movements of the left lower limb. There was drooping of the toes of both feet, especially the left, but the patient was able to extend them. There was great rigidity in both lower limbs, especially in the left, which resisted all attempts at passive movements. The plantar reflexes were present on both sides, ankle clonus present on both sides, espe- cially marked on the left. The knee jerks were exaggerated ; there was knee clonus on the right side. The right lower limb was subject to attacks of great rigidity in a position of extension ; the left to attacks of rigidity in a flexed position. Formerly, according to her account, the left limb was apt to fall into a rigid posture in the position of extension. There was no loss of sensation anywhere, but the patient complained that she suffered from twitchings and drawing up of the legs, especially of the left. She also had pain in the thighs and 88 THE SIMULATION OF HYSTERIA knees. She had been unable to walk for the last three months. When examined she was unable- to stand without help, and could not put the left foot to the ground on account of the contracture de- scribed. There was slight nystagmus, and tremor of the head and neck was observed when the patient was asked to fix her eyes on any object. Her speech was rather slow, and there was a tendency to pronounce the words in syllables ; there was very slight tremor in the lips and tongue. She suffered occasionally from pain in the head, in the vertex, and also in the forehead. She de- scribed having frequently suffered from dip- lopia. The pupils reacted to light and to accommodation. There was no spinal deformity and no tender spot on percussion of the spine. There was no vesical trouble, and nothing wrong in the re- spiratory and circulatory systems. The optic discs were very pale. On sus- tained convergence there was well marked quick nystagmus, occurring simultaneously in both eyes, but generally better marked in one than in the other. The pupils were not ob_ BY ORGANIC DISEASE. 89 served to vary consentaneously with the nys- tagmus. The patient having been attacked with scar- let fever, was sent to the Fever Hospital, where she died. Dr. Barlow, under whose care she was admitted, was good enough to let me ex- amine a hardened specimen of the spinal cord, which showed characteristic evidence of dis- seminated sclerosis. During the first week or two of the following patient's stay in hospital I could not make up my mind as to the nature of her case, and I dis- tinctly inclined to the belief that it was of func- tional character. She was highly hysterical ; there was a history of long-continued vomiting, and of loss of voice. But further observation convinced me that it was one of disseminated sclerosis — as was proved by the sequel. A female patient, set. forty-two, was admitted into the National Hospital for the Paralysed and the Epileptic, Queen Square, on December 3rd, 1884, complaining of stiffness of both legs, being unable to walk without aid ; also of pain, especially in the back, which seemed to radiate go THE SIMULATION OF HYSTERIA down both legs, shooting in character. The left leg appeared worse than the right. The pains were better when the patient was up and walking about. For the last twenty years the patient had been subject to attacks of sickness after every meal (sometimes only after one meal in the day), the longest interval of freedom from sick- ness at any time being fourteen days. During this time the patient used to be readily tired, the legs would ache, but she did not have any special pains. Four and a half years before admission the aching and weariness of the limbs began to get worse, and the patient complained of the weight of her dress. The calves of both legs used to swell, and become shiny and hard. This disappeared in about a fortnight or so, but would occasionally recur. After this she began to suffer much from sharp shooting pains in the head and neck, relieved by lying down. The toes also at that time became very tender, and the tenderness continued for about two months, but had not returned. Twelve months previously the patient noticed the legs begin to get stiff, but even before this BY ORGANIC DISEASE. 9 1 her legs had occasionally drawn up when she was in bed. On two occasions during the last fifteen months, the urine had had to be drawn off. It is noted on admission that the patient is fairly well nourished. The hands tend to turn over, and she would drop things unless very careful ; the grasp is fairly good. She is not able to do fine needlework. Occasionally there is a 'pins-and-needles' sensation in all the fingers of the right hand. She has difficulty in touch- ing the nose with the fingers, her eyes being closed, but there are no tremors. She is able to localise touch and pain correctly in the arms ; the wrist jerks are not increased. There is no nystagmus. She has a feeling of tightness around the waist ; the whole leg from the knee to the ankle feels tight "as if it were going to burst." Tactile and painful sensibility is much impaired all over the legs and thighs. The plantar reflex is well marked in both legs ; both legs are very stiff. Knee jerk is well marked when the legs are not too rigid, but it is impossible to get ankle clonus because of the stiffness of the legs. She is able to direct each foot pretty well to an object. 92 THE SIMULATION OF HYSTERIA As regards the sickness from which she used to suffer, she says that she never felt sick, but food would come up at once. There was no pain in her stomach. The smell of fish would make her sick. Eight years ago for about three months she lost her voice. Her manner is highly hysterical. No particular change occurred in the symp- toms during her stay in the National Hospital. This patient died in 1885 in Guy's Hospital, under the care of the late Dr. Carrington. The notes of the autopsy, for which I am indebted to Dr. Gay, are as follows : — Large bed sores over the sacrum extending down to the bone, and one over the great trochanter of the left side. Abscess in each thigh, which had been opened. Brain weighed forty - one ounces. Meninges and arteries at the base presented nothing abnormal. The left temporo-sphenoidal lobe showed yellow softening on the surface and interior, extending to the corpus striatum. The whole brain was very carefully cut into fine sections, but no sclerotic patches were found. The spinal column was normal. A patch of purulent lymph was found on the pos- terior surface of the spinal cord in the lumbar BY ORGANIC DISEASE. 93 region. The cerebro-spinal fluid was rather in excess. Patches of sclerosis began in the pons varolii, at the centre of which there was a patch on either side, and one also on the surface. They were raised, hard, semi-translucent, and glistening. There was a patch on the surface of the medulla oblongata, spindle shaped, half-an- inch long, and extending inwards to the white matter. There was no softening of the cord, but many patches of sclerosis on the surface or more deeply. The dorsal region of the cord was the least affected, the lumbar most. The posterior columns were most diseased, many parts be- tween the posterior cornua and commissure being, completely sclerosed. In some parts of the lumbar enlargement the whole transverse area, including the grey matter, was affected. All the other organs were healthy, A case which was recently under care in hospital furnishes so good an illustration of the difficulty in diagnosis that may be caused where a moral shock forms part of the history that, although incomplete, it appears to be worth recording. 94 THE SIMULATION OF HYSTERIA Ann B , set. thirty-one, • widow, was ad- mitted into the National Hospital for the Para- lysed and the Epileptic, on October 26th, 1889. The following notes were taken by Dr. Taylor, then resident medical officer. Nine years ago, two or three weeks after the death of her husband (after a fortnight's illness), which had been a very great shock to her, she suddenly in one night lost power in her legs, and was unable to stand or walk for several weeks. She had previously been in good health. She gradually recovered, but has never been as she was before — has never been able to run or to walk fast. During the last six months she has gradually . lost ground, not suddenly, but she is now worse than she has been during the last seven years. Her difficulty is to get her legs to separate from each other, and also in going up stairs. For the last four years there has been at times great difficulty in passing water, and sometimes she has suffered from inability to retain it. Patient was a strong healthy woman previous to her husband's death. On admission she complained of difficulty in walking. The con- dition of the arms was normal, except that a BY ORGANIC DISEASE. 95 slight tremor showed itself at the end of the act in attempting to touch an object with the left hand. In the lower extremities all move- ments were carried out, though rather feebly and with some tremulousness, especially to be noted on bending the knees. There was a peculiar condition of the skin, of ichthyotic character, which appeared to be sufficient to account for any blunting of sensi- bility observed. This has been present, accord- ing to the patient's account, all her life. The knee jerks were greatly exaggerated. Ankle clonus was present in the right leg, and a ten- dency to it was evident in the left. The patient appeared well nourished. The gait was that of a person with functional paraplegia, but the legs showed notable stiffness. When standing the legs were widely separated and became tremulous, whilst the body swayed to and fro. Whilst under observation in hospital this patient continued much in the same state. There was no peculiarity of articulation, and no nystagmus. The ophthalmoscope showed no change in the optic discs. I believe that this woman is affected with organic disease of the spinal cord, and possibly g6 THE SIMULATION OF HYSTERIA in the form of disseminated sclerosis, but the difficulty of pronouncing an opinion upon this point will, I think, be manifest. •f" # ^ i" •t # There can be but little doubt that of all organic diseases of the nervous system, dis- seminated sclerosis in its early stages is that which is most commonly mistaken for hysteria. This would appear to be due especially to the following circumstances. The disease is par- ticularly common in young females — symptoms frequently showing themselves about the period of puberty. There is very often a history of some moral shock or strain, preceding or accom- panying the first symptoms. It is a question worthy of consideration whether sudden strong emotion or long-continued mental worry may not be found to be etiological factors in the disease, but this is not the occasion for discus- sion of the point. In addition, there are few cases of disseminated sclerosis in females in which hysterical symptoms are not mixed up with those incident upon the recognised patho- BY ORGANIC DISEASE. 97 logical changes. Obviously this combination of itself causes a peculiar liability to mistakes of diagnosis. But there is another great source of error in the fact that many of the symptoms of disseminated sclerosis are just those which have long been looked upon as hysterical. An alleged sudden loss of power in a limb of an apparently healthy young female, a localised numbness, or ' pins-and-needles ' sensation, or complaint of loss of sight in one eye, are symp- toms familiar enough as expressions of functional trouble. But they are no less modes in which, organic disease of the kind which we are dis- cussing is very apt to make its first appearance. These local symptoms may clear off after a short time, just as would be the case if they were of hysterical origin. The girl recovers her sight, or the use of her limb, and nothing more is heard of the numbness. A little later perhaps loss of sight in the other eye is com- plained of; a 'pins-and-needles' sensation is described in some other part ; another limb is said to be very weak. The opinion that the symptoms are due to hysteria may very pos- sibly appear to be confirmed by this re-appear- ance of trouble in other situations. Or the 7 0"8. THE SIMULATION OF HYSTERIA patient perhaps complains of weakness and stiffness in both legs, which increase so that in six or eight weeks she cannot stand. Then comes a rather rapid improvement, and she recovers her power completely. Sooner or later — in some cases after an interval of years — the failure of power recurs. After recoveries and relapses of this kind, the characteristics of confirmed disseminated sclerosis show them- selves. Reference has been already made to a symp- tom which I have observed to be exceedingly common, to be the rule, indeed, in hysterical paraplegia — absence of plantar reflex. This has been dwelt upon rather fully, as it has not, to my knowledge, been described by other writers, and in my experience its value is con- siderable. It would be still more valuable, of course, if it were quite constant, but this is not the case. Every now and then one meets with exceptions to that which, however, is distinctly the rule. It becomes of importance to inquire as to the behaviour of the plantar reflex in those cases of disseminated sclerosis which are accom- panied by emotional characteristics of a kind to which the term hysterical is commonly appliedi BY ORGANIC DISEASE. 99 I have been much interested in observing that in these it is a rare exception for the plantar reflex to be absent. It is not, perhaps, press- ing the point too much to say that in a case of doubtful character the persistence of plantar reflex should distinctly weigh in the direction of a diagnosis of organic disease — its absence lending support to the view that the affection is functional. But I cannot sufficiently insist that reliance must not be placed upon the evi- dence afforded by one symptom alone. It is obvious that absence of reflex from the foot-sole may be dependent upon myelitis or neuritis, the existence of which may be left in no doubt by the presence of corroborative symp- toms. It will have been observed, I think, that in all the cases described in this work in which the sequel has shown the disease to be of organic character, the plantar reflex has been preserved ; in all but one in which the result has given evidence of functional disease the plantar reflex has been absent. A patient has lately been in hospital whose case would seem to furnish an exception to this rule. lOO THE SIMULATION OF HYSTERIA A young woman, set. twenty-three, has suf- fered on and off for eight years from weakness and occasionally numbness in the legs. On one occasion she lost her voice for some time. Her knee jerks are active ; there is no ankle clonus. 'The plantar reflex is not obtained on either side. The field of vision in each eye is contracted to a marked extent. Such a history points strongly as far as it goes in the direction of functional disorder. But, on the other hand, the patient has suffered from attacks of giddiness, with double vision, and her gait is unsteady. There is slight tremor of the arms on voluntary movement, and, most important of all, there is nystagmus. She therefore presents, at the same time, marked symptoms both of functional and organic disease, and the case must certainly be included in the latter category. My colleague. Dr. Bastian, has kindly al- lowed me to refer to a case of his lately in hospital, in which the presence of marked symptoms of functional character might easily tend, without careful observation, to render a case of organic disease — probably disseminated BY ORGANIC DISEASE. 10 r sclerosis — liable to be set down as one of hysteria. I am indebted to Dr. Rivers for the notes. The patient, twenty-one years old, about four years ago suffered from diplopia, and a few months later, after going through a course of cold baths for the cure of obesity, from weak- ness and shaking of the left arm. She would frequently fall when out for a walk. There has been occasional retention of urine, and some- times inability to restrain the action of the bladder. On two occasions lately her motion passed unconsciously. The utterance has be- come slower, and she has lost the power of singing. Her gait is very unsteady, and she cannot walk without support. There is tremor of the left arm on voluntary movement. There is weakness of the right external rectus muscle, with resulting diplopia, and nystagmus, which is principally seen during the upward move- ment of the eyes. The knee jerks are exag- gerated and there is ankle clonus, most marked on the left side. The plantar reflexes are present. The visual fields are contracted in both eyes, most in the right. Whilst the colour vision of the left eye is normal that of 102 THE SIMULATION OF HYSTERIA the right is very defective, especially for red and green. The optic discs are normal. Vision : R. -/f, L, nearly il. On the left side of the body there is hemi- anaesthesia to touch, pain, and temperature, complete on the arm and leg, whilst the sensa- tion on the trunk is impaired. With this the sense of position is quite absent in the left arm and leg. Whilst in hospital the patient had some very severe fainting attacks. She quitted the hospital unimproved. The girl exhibits the modifications of vision which have been insisted upon by Charcot as of very frequent occurrence in hysteria. There is great retraction of the field of vision in each eye. This symptom, it will have been ob- served, was noted in a girl affected with what was certainly hysterical paraplegia, whose case is described on page 48. Besides the retraction of the field there is great diminution also of the acuteness of vision, and on the right side con- siderable loss of the notion of red and green. It is true that- these phenomena accompanying hemiansesthesia are not absolutely peculiar to hysteria, but may be observed in cases where there is a lesion in a certain part of the in- ternal capsule. BY ORGANIC DISEASE. 103 Cases such as these two last are very impor- tant, as showing that in examining a patient the mere presence of what are supposed to be marked symptoms of hysteria is quite insuffi- cient to enable us to refer the disease to that category. A single symptom of organic disease outweighs even a number of these, and we must be careful to exclude, if we can, the presence of anything, however slight, pointing distinctly to organic disease ere we can venture to diagnose the case as of functional character. ^ ^ ^ !$• 1^ <5^ It is well known that hysteria is not confined to women. Hence the difficulty of diagnosis in affections of the class under consideration may occur in the case of persons of the male sex. The following is an important illustration of this. In 1882 I examined, in consultation, a young man with sallow complexion, large pupils, and very nervous manner. He was lying on a couch, and said that he was not able to walk I04 THE SIMULATION OF HYSTERIA much, because walking brought on a queer sensation in his legs, especially in the left leg, a ' pins-and-needles ' numbness being described. There did not appear to be any anaesthesia below the knee of the left leg. His symptoms were entirely subjective. It appeared that at Easter, 1881, he had got a rhill. Later there was a feeling of numbness, especially in the left leg. Since then, with intervals of good health, he had had several breakdowns, which had occurred after walking too long a distance, jumping, riding, some physical strain. There had been no moral strain. I tested the muscular power, which seemed perfect in all the groups of muscles of both lower extremities. The knee jerk on each side was much exaggerated, and there was a slight attempt at ankle clonus, more on the right than on the left side. There was, how- ever, considerable excess of reflex in the triceps and wrist also, whilst there was no complaint of anything being wrong with the arms, so that I thought the excess in the knees might be "discounted." There were no tremors. Plantar reflex was not very strong. The pupils contracted readily to light ; the BY ORGANIC DISEASE. 105 ophthalmoscope showed nothing abnormal. There was a strong neurotic history on the mother's side. The disorder was thought to be functional, and the patient was advised to go for a voyage and then resume his studies. I saw this patient about fifteen months later. It appeared that after seeing me he went for a time to the seaside, and thence to one of the Universities, where he took his degree satis- factorily, and appeared to be quite well. Soon afterwards he walked in Scotland as well as ever. He only complained of a little numbness about the knees, equally on each side. I con- gratulated myself on a successful diagnosis, but this, as the result showed, was premature. Not to weary the reader with details, it is enough to say that this patient now — seven or eight years having elapsed — presents charac- teristic symptoms of disseminated sclerosis. 1^ 1^ <^ w» i$> ^ In view of this publication I have looked through a large number of notes of cases both of hysterical paralysis and of disseminated I06 THE SIMULATION OF HYSTERIA sclerosis which have been under my care, and in many of which I have been able to learn the issue. As regards the value of individual symptoms in enabling us to differentiate or^ ganic disease from functional disorder, I find that whilst there is still much to be desired, there are points in which experience appears to speak with a fair amount of distinctness. As a rule — though this is not without some notable exceptions — the class of hysterical para- plegia is not very difficult of diagnosis by those well acquainted with the symptoms and course of organic disease of the spinal cord, the surrounding circumstances, and especially the contradictions palpable in the symptoms leaving one usually in but little doubt. I need not dwell upon these on the present occasion, but would remark that the attitude and condi- tions of the lower limbs in such cases may vary exceedingly. The limbs are most often in a state of perfect flaccidity, a condition of spas- ticity being comparatively rare. The feet are frequently " dropped." After long disuse it will not unfrequently happen that there are strong adhesions in the joints. I have already referred to this, and to the pseudo-contracture due partly BY ORGANIC DISEASE. 1 07 to this fibrous ankylosis and partly to contrac- ture of the skin — not of the muscles. Hysteri- cal paralyses are most often complete. The loss of power in disseminated sclerosis is very rarely (except in advanced stages) more than moderate. I cannot help thinking that the view still generally held that a shifting of loss of power from one limb to another (such as that which I have described) is characteristic of hysteria is quite an error. The hysterical woman who has lost all power in her legs, will, it is true, very often later on (whilst still para- plegic) lose the power of one arm, usually the left ; but I have not found that she is prone to lose the power in a limb, then recover it, and then lose it in another. It seems to me that the idea of this shifting powerlessness being strongly confirmative of hysteria has arisen from mistakes in diagnosing as hysteria cases of disseminated sclerosis. Such mistakes must have been continually occurring before the latter disease had been differentiated. No doubt the hysterical are prone to changes of disorder ; at one time, for example, losing the use of a limb or limbs, with or without pro- found anaesthesia, at another time losing the I08 THE SIMULATION OF HYSTERIA voice, or closing one eyelid, or contracting a limb, but the shifting about of a state of more or less powerlessness, which we see in dis- seminated sclerosis, appears to me to be sui generis, and should, I am disposed to think, save us from error. And equally so with the occurrence of numbness or ' pins-and-needles ' sensation, sometimes at one part and some- times at another, which, if my notes do not betray me, points with considerable distinctness to disseminated sclerosis. There would appear to be a little more diffi- culty in regard to the impairment of sight in one eye to which I have referred. The ophthal- moscope perhaps shows no change. But we shall find, I think, that the hysterical patient, as a rule, when loss of sight of one eye is in question, is quite blind on that side, and has usually become suddenly blind, whilst the patient with sclerosis has only more or less obscurity of vision which has come on some- what gradually. I cannot call to mind, since I have been better acquainted with dissemi- nated sclerosis, any case of simple hysteria in which first one eye lost some amount of vision for a time and recovered, and afterwards BY ORGANIC DISEASE. 109 the Other eye behaved in a similar fashion. So that this symptom I should now take to point with considerable force to disseminated sclerosis. When the ophthalmoscope shows atrophy of disc (and it is remarkable in what a large proportion of cases of disseminated sclerosis some atrophy is to be found — in some a stage of hypersemia preceding it) my experience would teach me that a diagnosis of functional disorder must be discarded. The same must be said of nystagmus, a symptom of peculiar value when combined with others about which there might otherwise be some doubt. It is necessary, of course, to remember the possibility of chronic alcoholism producing a temporary nystagmus, but this chance of error ought not to be difficult to avoid. We next come to the tremor on intentional movement, upon which I am disposed to place a diagnostic value higher than that possessed by any other symptom of disseminated sclero- sis. Looking back many years I can remember observing numerous cases which presented this symptom at a time when I used to feel very great difficulty in the differential diagnosis no THE SIMULATION OF HYSTERIA which we are considering. I cannot call to mind one which the sequel proved was simply functional. It is true that in the hysterical we not unfrequently see a clumsiness of move- ment of the hand when directed towards an object, which is somewhat liable to deceive, but observed carefully it will be found that this is rather of the nature of ataxy than a rhythmical tremor such as is found in sclerosis, and would appear to result from a temporary loss of mus- cular sense. There is also another variety which is worth noting. The patient asked to touch an object with her finger, does so without difficulty or hesitation, but when the finger has rested upon the object for two or three seconds the arm becomes affected with somewhat rude tremors. This is in striking contrast with the tremor which affects the arm in disseminated sclerosis, as the patient brings the finger near the object, tending to cease when it is attained. On the coarser semi-convulsive movements, twitchings, jerkings, and grimacings not rarely met with in hysteria I do not dwell. They could not for a moment deceive anyone ac- quainted with the subject. BY ORGANIC DISEASE. Ill Localised atrophy of muscles with loss of electrical reaction is well known to occur some- times in the course of disseminated sclerosis, and in a case otherwise open to doubt its presence is undoubtedly of the highest value in determining the organic nature of the disease. But I do not think it is generally known that localised atrophy may behave like the tem- porary powerlessness of a limb or limbs, or the shifting numbness. I have seen several cases of disseminated sclerosis in which atrophy of some muscles, with loss of electrical reaction, has cleared off entirely, to be succeeded some time afterwards by a similar lesion in another or the same part. It is exceedingly improbable that dissem- inated sclerosis is a new disease. Little more than half a century has elapsed since it was figured by Cruveilhier in his Atlas d' Anatomie Pathologique, and twenty-three years ago Char- cot expressed his belief — a well-founded belief, I have reason to think — that the disease was not known, that is to say, not recognised, in England. It is practically indeed to Charcot that we owe our acquaintance with the disease, from the admirable summary of its clinical and 112 THE SIMULATION OF HYSTERIA pathological features published by him in his earlier lectures. Now we all know what a length of time it takes for a disease, however excellently pictured, to fix its features so firmly in the minds of medical men generally, as to make the diagnosis of it come readily to those who have not gone out of their way to seek examples of it. And this, which is true of most forms of organic disease, is from the nature of things most marked in reference to dissem- inated sclerosis. In that disease the infinite, irregularity in the situation of the essential pathological lesions creates difficulties of re- cognition beyond those to be met with in any other exam.ple. This being the case it is not surprising that the symptoms, characterised as they are by frequent remissions, should, in the absence of other explanation, be set down to the vagaries of hysteria. The almost constant admixture of circupstances pointing to an emotional origin or accompaniment of these symptoms greatly increases the likelihood of this confusion occurring. As I have before remarked, it appears to me reasonable to con- clude that many symptoms which have come to be considered characteristic of hysteria will, if BY ORGANIC DISEASE. II3 examined by the light of improved knowledge and experience, be relegated to disseminated sclerosis. The figure of Hysteria shrinks in proportion as the various forms of organic dis- ease acquire greater solidity and sharper defini- tion.