MENINGITIS.  747

search  and  watch  for  symptoms  of  organic  origin  and  allow  these  the  same
weight  as  in  a  case  in  which  there  are  no  hysterical  symptoms,  or  as  in  a
patient  in  whom  hysteria  would  not  be  expected.  Pyrexia  is  of  especial
diagnostic  value  in  these  cases,  and  so  also  are  convulsions  beginning  locally,
and  the  ophthalmic  symptoms.  Strabismus  in  hysteria  is  always  convergent
and  attended  by  spasmodic  contraction  of  the  pupils.  Divergent  strabismus,
or  inequality  of  pupil,  is  certain  evidence  of  organic  disease,  and  as  much  so
if  it  is  transient  as  if  it  is  permanent.  Retention  of  urine  may  be  due  to
hysteria,  but  incontinence  never  is.  The  significance  of  a  tendency  for  the
skin  to  blister  has  been  mentioned ;  signs  of  trophic  lesions  of  the  skin
should  be  carefully  looked  for  in  every  doubtful  case.*

An  illustration  of  the  difficulty  that  sometimes  attends  the  diagnosis,  and
of  the  significance  of  pyrexia,  was  afforded  by  the  case  of  a  servant,  aged
twenty-two,  who  had  had  a  child  three  years  previously,  and  had  suffered
from  some  headache  for  six  weeks.  On  account  of  slight  indisposition,  her
mistress  suspected  another  pregnancy,  and,  without  telling  the  girl,  sent  for
a  medical  man  to  see  her.  Tne  girl  was  intensely  annoyed,  and  refused  to
answer  any  questions.  She  went  up  to  her  room  and  fell,  bruising  her  face.
All  the  rest  of  the  day  she  was  dull  and  lethargic,  occasionally,  however,
throwing  her  arms  about,  screaming,  and  complaining  of  pain  in  her  head.
