Complete Text (Part 6)

happen, it is caused by uremia.^ Paralysis of the palate, except when a part of adynamic bulbar paralysis, is organic. It is especially significant as one pf the earliest symptoms of an oncoming diphtheritic paralysis. Paralysis of laryngieal muscles if bilateral may be either organic or functional, but if unilateral it is al- ways organic. Loss of control of the bladder and rectum ' Genuine cases of hysterical facial paralj^sis are so excessively rare that their possible occurrence may be disregarded in ordinary diagnosis. Glosso-labial spasm is more frequent. THE RECOfiXITrOX OF ORGANIC DISEASE. is generally organic, and paralysis of the sphincters is always so. The mowing gait or steppage gait is proof of organic paralysis. Paralysis, with or without corresponding sen- sory loss, which is definitely limited to the muscles supplied by nerve trunks or spinal segments is organic. Atrophy of muscles with loss of faradic irritability is due either to organic nervous disease or to idiopathic dis- ease of the muscles. Reaction of degeneration or fibnlla- tion in a wasted muscle proves the existence of organic disease of the lower motor segment. Genuine absence of knee-jerk is almost, but not quite absolute proof of organic disease of the nervous system or muscle. It is never a symptom of hysteria or neuras- thenia, but may with extreme rarity be found in apparent health and it has been successfully simulated. Ankle clonus which persists for a considerable time and has a steady rate of five to seven vibrations per second is prob- ably always organic. A clonus of very brief duration or a persistent one at an inconstant rate of two to four vibra- tions per second certainly may be hysterical. A spastic condition of the lower limbs, so extreme that when the examiner lifts one leg from the bed the pelvis and the other leg move with it, is always organic. The allied condition, called spinal epilepsy, in which a paroxysm of tonic spasm of the legs passes into clonic spasm, is also invari- ably organic, Localized convulsions of the Jacksonian type are proof of a correspondingly localized irritation of the cortex which is almost always caused by organic dis- ease. A localized sensory aura is generally caused in the same way but there is a greater possibility of its being merely functional. If no evidence of organic disease is found it is still not to be positively excluded, especially if the symptoms are 72 NERVOUS AND MENTAL DISEASES. equivocal, until the time has elapsed in which organic change would necessarily reveal itself. Thus, if a deli- cate and possibly tubercular child has suffered for a week from headache, with occasional vomiting, the absence of all signs characteristic of organic disease requires the diagnosis of meningitis to be withheld, but does not ex- clude it, for within the next few days, pupillary changes, strabismus or some other conclusive symptom may appear. In the meantime the special diagnosis that would follow in either case must be considered in the light of all the facts already known. Conversely, the longer a disease has lasted without proof of its organic nature the greater the as- surance that it is only functional. If a partial hemiplegia has lasted for months without such proof, and the gait and other symptoms are characteristic of hysteria, organic disease may almost certainly be excluded.^ It will probably be inferred from the foregoing state- ments that the recognition or exclusion of organic disease in general is sometimes very difficult or even, for the time being, impossible ; in fact it is generally this part of the diagnosis which calls for the greatest caution and the highest skill in weighing evidence. The organic nervous diseases are divided into four groups : vascular lesions, including hemorrhage, embolism and thrombosis, inflammations, effects of pressure and morbid growths, and degenerations. These groups are clinically distinguished mainly by the time of onset, that is, the time that elapses between the appearance of the first symptoms and their attaining a considerable degree of intensity. The following table, from Gowers, shows the relation between the time of onset and the nature of the disease. ^ Even then disseminated sclerosis might possibly underlie the hysteria. THE RECOGNITION OF ORGANIC DISEASE. 73 Disease Pressure and growths Onset Sudden (few minutes) Acute (few hours or days) Subacute (one to six weeks) Subchronic (six weeks to six monlhs) Chronic (more than six months) Disease Vascular lesions Inflammation 1 Degeneration From this table it will be seen that, excepting injuries and merely functional disorders, a sudden onset always denotes a vascular lesion, as in a case of apoplexy. An acute onset is most frequently due to an inflammation, but it may be caused by a slowly developing vascular lesion, especially thrombosis or hemorrhage. A subacute onset denotes inflammation or the effect of pressure or morbid growth ; it is too slow for a vascular lesion and too rapid for a degeneration. A subchronic onset denotes chronic inflammation, the effect of pressure or growth, or degener- ation. A chronic onset denotes pressure or growth or a degeneration ; it is too slow for even a chronic inflamma- tion. The pathological diagnosis is carried still further by a consideration of the causes of disease that may be found, the indications afforded by the accompanying symptoms and the seat of the disease, as shown by the localizing symptoms. These indications are applied in the tables which form the main portion of the book. 74 NERVOUS AND MENTAL DISEASES. THE PRINCIPLES OF LOCALIZATION. It has already been said that the kind of organic disease is to be inferred mainly from the time of onset ; the seat of the disease is to be inferred from the part of the body whose function is disturbed and the character of the disturbance. If the hand is paralyzed it is known that the disease at- tacks some part of the motor tract for the hand, either the cortical center, the pyramidal fibers connecting it with the gray matter of the cervical enlargement of the cord, this part of the cord itself or the nerves connecting it with the muscles. A complete knowledge of localization would require a correspondingly complete knowledge of the anatomy and physiology of the nervous system in relation to all the rest of the body. In applying this knowledge to clinical localization it is necessary to distinguish the comparatively limited symp- toms caused by overaction or loss of function at the seat of the lesion alone from the more widespread disturbance which may be caused by pressure or shock transmitted to adjacent and even distant parts of the nervous system. Only the direct symptoms are available for a precise localization, although the indirect ones are important as a general indication. This distinction is made by comparing the extent of the symptoms at different times. Thus, a hemorrhage limited to the cortical center for the right arm, at first not only causes spasm and paralysis of the arm, but, by pressure and shock affecting the entire left hemisphere, it may cause complete hemiplegia, aphasia and unconsciousness. THE PRINCIPLES ALIZATION. 75 NERVOUS AND MENTAL DISEASES. [orizonlaH,. F, of S, THE PRINCIPLES OF LOCALIZATION. 77 After a few days, however, consciousness and speech will have returned, the paralysis of the face and leg will have disappeared and only the paralysis of the arm will remain as a precise indication of the seat of the lesion. Hence, when the symptoms are of sudden onset, the later and more permanent condition is the one on which to base the localization. But, conversely, a rapidly increasing lesion, say a tumor, in the region of the cortical center for the right arm, may at first cause a spasm of the arm which precisely indicates the seat of disease ; later, although the growth still occupies but a small part of the left hemi- sphere, its pressure and irritation may be transmitted to the entire brain, causing hemiplegia, aphasia, general convulsions and coma. Hence, in the case of a gradually increasing lesion the earlier symptoms are the ones avail- able for localization. It will be noticed that while the im- portant symptoms in one case are the late ones and in the other the early ones the time for localization in both cases is when the symptoms are most limited in extent. The problem of localization may be very much confused by the existence of two or more lesions. The only way to solve it is to be thoroughly familiar with the effect of each. Multiple lesions are mostly syphilitic or tubercular. 78 NERVOUS AND MENTAL DISEASES. THE SIGNS OF HYSTERIA. Hysteria is a diseased condition in which perverted ideas and emotions cause the bodily symptoms. In its milder and more familiar forms its mental origin and true nature are generally obvious, but it has a great variety of rarer and more severe manifestations, which, on account of their close superficial resemblance to other diseases, often lead to the most serious errors of diagnosis. Any part of the body, whatever, may be affected in severe hysteria, hence, although it is a purely nervous disease, every practitioner of medicine or surgery must deal with it, and failure to recognize it often leads to treatment that is un- necessary and even disastrous. A trustworthy diagnosis of hysteria must depend first on the absence of the symptoms that would prove the ex- istence of any organic or other functional disease. The signs of organic disease in general have already been dis- cussed ; the special form which is most likely to be mis- taken for hysteria is disseminated sclerosis. The func- tional disorders which it is most important to exclude are epilepsy, migraine, chorea and various effects of uremia. The positive indications of hysteria are of the most varied character and may appear, often quite unexpectedly, at any point in the history or physical examination. The family history is often doubly significant, for the example of an hysterical mother or sister may greatly in- crease whatever predisposition is inherited. The history of the patient's past illnesses may give strong evidence of the abnormal susceptibility to emotional disturbances and THE SIGNS or HYSTERIA. 79 to suggestion which is the primary cause of hysteria. It must be remembered, however, that every one is more or less susceptible to disturbing emotions and ideas ; it is only morbid susceptibility that is to be taken into account. The history of the patient's mental experiences imme- diately preceding the onset is of great importance. If the symptoms closely follow <i strong emotion, or the observa- tion of similar symptoms in others or anxious thought about disease, they are probably hysterical. This is only a probability, however, until other than mental causes have been exxluded by a careful consideration of the age, previous illnesses and present condition ; for the onset of an organic paraplegia may possibly coincide with the shock of bad news, the monoplegia or partial hemiplegia that follows an apparently trivial injury is sometimes due to meningeal hemorrhage or syphilitic thrombosis, a con- vulsion following excitement may be epileptic or toxic, the palpitation that follows a talk about heart-disease may be primarily due to a valvular lesion, the chorea that seems to be an imitation is sometimes genuine, and so on. The character of the paroxysms of which the patient complains often affords conclusive evidence of hysteria. Fits of laughing or sobbing and globus (the feeling of some- thing rising into the throat like that which precedes sobbing) when they follow trivial causes, are proof of hysteria. Convulsions in which consciousness is partially retained and words are uttered, or in which the movements and at- titudes express purpose and emotion and friends vainly try to hold the struggling patient, are always hysterical. Retraction of the head and arching of the body in a con- vulsion whose nature is doubtful, make hysteria probable, but meningitis, tetanus, strychnia poisoning and hydro- phobia must be excluded. The occurrence of a paroxysm whenever a certain definite area (hysterogenic zone) is ir- 8o NERVOUS AND MENTAL DISEASES. ritated, is evidence of hysteria, even when the paroxysm in itself is of doubtful character. States of trance, cata- lepsy and hypnotism are forms of hysteria. Alternating states of consciousness (double consciousness) are gen- erally hysterical, sometimes epileptic. Spasm causing slow, rhythmical oscillation of any part of the body is hysterical, providing that organic disease has been ex- cluded. The state of the reflexes is of minor importance. The knee-jerk and heel-jerk are generally considerably exag- gerated in hysteria while the plantar reflex is often dimin- ished or lost. As this contrast is very rare in other condi- tions it affords probable evidence of hysteria. A nervous start when the knee-jerk is tested, especially if accom- panied by a complaint of peculiar sensations, is also significant. The hysterical character of a paralysis is recognized by the absence of organic disease and the presence of other symptoms of hysteria, rather than by anything peculiar in the motor loss itself. With but rare exceptions (chorea, migraine, occupation neurosis and toxic conditions) any paralysis that is not organic must be regarded as hysterical and symptoms characteristic of hysteria will generally be present. Nevertheless, there are certain forms of par- alysis which are in themselves peculiar to hysteria. In a case of partial hemiplegia, if the paralyzed leg is dragg-ed after the sound one, instead of being swung past it, and the foot is held stiffly at right angles to the leg, in- stead of showing a tendency to drop of its own weight, the paralysis is hysterical. Inability to flex or extend a joint on request, although the same thing can be done automatically when attention is distracted, is proof of hysteria. Restraint, by contraction of the opponents, of a movement which the patient has been urged to make THE SIGNS OF HYSTRRIA. and has actually begun is also hysterical. Paralysis of the adductors of the vocal cords, as indicated by aphonia, is always hysterical when coughing and sneezing are normal. Among the most characteristic stigmata of hysteria are the sensory disturbances. All of these, whether sensory loss, paresthesia, hyperesthesia or pain, are alike in that their location never corresponds definitely to the areas of nerves or spinal segments, but is in areas of a quite dif- ferent shape or in isolated spots. Sensory loss is the most important, although it is probably not so frequent in other countries as in France. It occurs in one of the fol- lowing forms : 1. Hemianesthesia, or loss of sensibility, generally in- cluding all kinds, in one lateral half of the entire body. It is often accompanied by impairnnent of the special senses on the same side, the impairment of sight not being hemi- anopia but amblyopia with contraction of the visual field of the affected eye and perhaps a reversal of the relative size of the color fields. The left side is affected about three times as often as the right. 2. Anesthesia in so-called geometric areas, as in the form of a glove, stocking or sleeve, or in a circle, ellipse or triangle. Such a loss usually includes all kinds of sensibility and is especially apt to be found over a par- alyzed or contractured part. 3- In scattered islets of variable shape. Any of these forms, if the loss is great and well defined, may be confidently regarded as hysterical, even without the variability under suggestion or emotional change which may usually be observed. It is true that on theoretical grounds we might expect organic disease of the cortex to cause sensory loss in similar areas, for the hysterical anesthesia is probably caused by the inhibition of cor- 82 NERVOUS AND MENTAL DISEASES. responding cortical centers, but, as a matter of fact, the sensory loss of cortical organic disease is slight and ill defined compared with that of hysteria. Hemianesthesia may also be caused by organic disease of the internal capsule, but in that case the visual defect, if any be present, is hemianopia and other signs of organic change are generally unmistakable. Hyperesthesia or tenderness in any of the geometric areas just mentioned is almost as significant of hysteria as sensory loss. The pain known as clavus, which is sharply localized in a small area near the vertex, is almost invariably hys- terical, but as a general rule hysterical pains are not to be distinguished bj'^ their character or location. It is rather the circumstances under which they appear and disappear, the absence of certain conditions which accompany ordi- nary pains and the presence of other signs of hysteria that are significant. If a patient complains of severe and long-continued pain, especially if it is said to prevent sleep, and yet there is no loss of weight or disturbance of pulse and the facial expression is not indicative of suffering, the pain is prob- ably hysterical. When a patient complains of intense pain awakened by the lightest touch or slightest change of posture and yet makes no complaint when considerable pressure is indi- rectly applied to the same part, the hysterical character of the pain is certain. For example, in the hysterical imita- tion of hip disease the slightest visible disturbance of the joint may appear to cause great agony, but the foot may be pushed upward so as to press the head of the femur firmly into the cotyloid cavity without causing any sign of pain ; and in the hysterical imitation of Pott's disease there i^ the same superficial tenderness yet the patient may experience THE SIGNS OF HYSTERIA. 83 a sudden jar of the spine or a downward pull on the shoulders without wincing. In many cases of this kind simply calming the fears and diverting the attention of the patient to other things will cause all signs of pain to dis- appear. A visual defect may sometimes be the first convincing sign of hysteria. Dimness of vision which may be cor- rected by