Another patient aged twenty-seven had whooping cough, which lasted six weeks, and was followed by severe pain in the back. For this she consulted various physicians, being treated for Pott's disease and spinal irritation. She, however, continued to grow worse, and every jar and twist gave severe pain. At this time she had lost much flesh, had pain in her back and elsewhere, and was subject to numerous and violent spasms. When first seen by the physician who consulted me she was complaining of pains in her legs, hips, and left shoulder, which she considered rheumatic, and with pain in the abdomen. Examination of the back with the patient on her side showed a slight prominence over the position of the first or second lumbar vertebra. The spot was painful on pressure, and had been so ever since the attack of whooping cough three years before. A tap on the sole of either foot made her complain of severe pain in the back. The same result followed pressure on the head. The patient was unable to stand or walk, but occasionally sat up for a short time, although suffering all the time. There was no muscular rigidity. The limbs and body were quite thin, but, so far as could be detected, she had no loss of motor or sensory power. At times, when the pains were worse, the arms would be flexed involuntarily, and she stated that once the spine was drawn back and a little sideways. The pain in the hips was augmented by pressure. During the application of a plaster bandage she had a sort of fit and fainted, and the application was suspended. She soon recovered consciousness, but refused to allow the completion of the dressing. I diagnosticated the affection as largely hysterical, and a few months later received word that the patient was on her feet and well.
Kemper109 relates the case of a lady who eventually died of sarcoma of the vertebræ, the specimens having been examined by J. H. C. Simes of Philadelphia and myself. She was supposed at first and for some time to be a case of hysteria with spinal irritation. In the case of a distinguished naval officer, who died of malignant vertebral disease after great suffering a short time since, this same mistake was made during the early stages of the disease: his case was pronounced to be one of neurasthenia, hysteria, etc. before its true nature was finally discovered. The absence of muscular rigidity in the back and extremities is the strongest point against vertebral disease in these cases.
109 Journal of Nervous and Mental Diseases, vol. xii., No. 1, January, 1885.
In hysterical hemianæsthesia, ovarian hyperæsthesia, hystero-epileptic seizures, ischuria, and other well-known hysterical symptoms have usually been observed. The anæsthesia in hysterical cases is most commonly on the left side of the body, but it may happen to be so located in an organic case, so that this point is only one of slight value.
Some older observers, as Briquet, who is quoted and criticised by Charcot, believed that hemianæsthesia from encephalic lesions differed from hysterical hemianæsthesia by the fact that in the former case the skin of the face did not participate in the insensibility, or that when it existed it never occupied the same side as the insensibility of the limbs. Recently-reported cases have disproved the accuracy of this supposed diagnostic mark. In his lectures, delivered ten years ago, Charcot observed that up to that period anæsthesia of general sensibility alone appeared to have been observed as a consecutive on an alteration of the cerebral hemispheres, so that obtunding of the special senses would remain as a distinctive characteristic of hysterical hemianæsthesia. He, however, expected that cases of cerebral organic origin would be reported of complete hemianæsthesia, with derangements of the special senses, such as is presented in hysteria. His anticipations have been fulfilled. In the nervous wards of the Philadelphia Hospital is now a typical case of organic hemianæsthesia in which the special senses are partially involved.
Paralysis and contractures, if present, are apt to be accompanied in cases of organic hemianæsthesia, after time has elapsed, by marked nutritive changes, by wasting of muscle, and even of skin and bone. This is not the case in hysteria.
The subsequent history of these two conditions is different. The hysterical patient will often recover and relapse, or under proper treatment may entirely recover; while all the treatment that can be given in a case of organic hemianæsthesia will produce no decided improvement, for there is a lesion in the brain which will remain for ever. Hemianopsia, so far as I know, has not been observed in hysterical hemianæsthesia.
In the monograph of Shaffer, with reference to both true and false knee-joint affections certain conclusions are drawn which I will give somewhat condensed:
Chronic synovitis produces very few if any subjective symptoms; hysterical imitation presents a long train of both subjective and objective symptoms and signs, the former in excess. Chronic ostitis may be diagnosticated if muscular spasm cannot be overcome by persistent effort; when the spasm does not vary night nor day; when it is not affected by the ordinary doses of opium or chloral; when reaction of the muscles to the faradic current is much reduced; when a local and uniform rise of temperature over the affected articulation is present; when purely involuntary neural symptoms, such as muscular spasm, pain, and a cry of distress, are present. Hysterical knee-joint is present, according to this author, when the muscular rigidity or contracture is variable, and can be overcome by mildly persistent efforts while the patient's mind is diverted, or which yields to natural sleep, or which wholly disappears under the usual doses of opium or chloral; when the faradic response is normal; when rise of temperature is absent or a reduced temperature is present over the joint; when variable and inconstant, emotional, and semi-voluntary manifestations are present.
To recognize the neuromimesis of hip disease Shaffer gives the following points: The limp is variable and suggests fatigue; it is much better after rest; it almost invariably follows the pain. Pain of a hyperæsthetic character is usually the first symptom, and it is found most generally in the immediate region of the joint. “In place of an apprehensive state in response to the tests applied will be found a series of symptoms which are erratic and inconstant. A condition of muscular rigidity often exists, but, unlike a true muscular spasm, it can in most cases be overcome in the manner before stated. A very perceptible degree of atrophy may exist—such, however, as would arise from inertia only. A normal electrical contractility exists in all the muscles of the thigh.”