Diseases of the nervous system / edited by Archibald Church.

Date:
1908
Catalogue details

Licence: In copyright

Credit: Diseases of the nervous system / edited by Archibald Church. Source: Wellcome Collection.

    1161/1256 (page 1119)
    The perfect simulation of an entire symptom-complex, none of the symp- toms actually existing, is so exceedingly rare as to be seen but a few times among several hundred cases. For obvious reasons a few symptoms are often simulated, and these are interwoven with difficulties actually existing, there- fore etched into a real pathologic condition. Prominent among these is an apparent diminution or absence of sensory functions and those of the special senses. Hemianesthesia which actually exists in no small proportion of these cases is knowp. to many patients (perhaps owing to the indiscretion of the physicians during their frequent examinations, their accompanying questions not being always cautiously framed) as a sign of disease, hence is often simulated. Among motor symptoms those adynamias and pareses are simu- lated which are generally limited to an extremity or a portion of an extremity. Arthritic and muscular rigidity are often feigned. In discussing Romberg's sign I called attention to the fact that swaying on closure of the eyes is a favorite method by which the accident patient attempts to prove the severity of his disease, but the movements of stooping and subsequent rising also furnish an opportunity for exaggeration, the in- jured either declaring themselves absolutely unable to stoop or that on doing so they sway or even fall. In eliciting the patella tendon reflexes we occasionally note that the pa- tients try to increase the jerk by their own efforts, or they produce all sorts of muscular contractions such as drawing up or drawing away the legs and the like, in order to show the active reflex effect upon the nervous system. In the course of objective investigation, attempted simulation in regard to sleep, appetite, and other subjective difficulties is much more common. After having enumerated the principal factors which incite the injured to feign, I must state that the recognition of simulation is one of the most difficult parts of the investigation of these patients. For, since actual sim- ulation as well as hysterical and hypochondriacal exaggeration originates psychically from the pathologic nature of the disease, and is therefore a psychically congenital phenomenon, it is not remarkable that simulation and pathologic exaggeration are often closely akin. Only a most experienced physician who understands the nature and the phenomena of the great neu- roses will attempt to diagnosticate simulation from any of the aforesaid symptoms, and cases occur which even baffle an expert, as has been repeat- edly emphasized by Strümpell and other authors. The demonstration of simulation is usually of greater practical than sci- entific import; and in practice one law must chiefly be our guide. We must always prove that the actual difficulty, the definite symptom-complex, or the individual symptom which has always been paramount, is simulated. There- fore evidence that the patient has a general tendency, even in other matters, to simulate does not .warrant us in declaring that a suspicious individual symptom is feigned. For example, if a patient has paralysis of the arm which is difficult to explain, and we find upon investigating sensation or testing his visual field that he makes incorrect reports (therefore shows a tendency to feign) this is not sufficient to prove that the paralysis of the arm is also feigned. The fact that the patient at every investigation tries to deceive us will naturally strengthen our suspicions that the paralysis of the arm is simulated, but this presumption becomes certainty only when by some method