Diseases Of The Nose Throat And Ear

THE LABYRINTH AND THE EIGHTH NERVE 399

voluntary attention is in abeyance, as in a person who has to sit through a
long, dull sermon. The individual does not listen, but he does not try not to
listen; he hears, but does not attend. In the true malingerer, on the other
hand, not only is voluntary attention withdrawn, but the patient is in opposi-
tion and damps down even the spontaneous attention. The true malingerer
listens intently, but tries hard not to respond. He is attempting to act the part
of a deaf man, and is consequently under great mental strain, from which
he desires to be relieved. Time is therefore on the side of the examiner, who
should never hurry. When the patient imagines the examination is finished,
he lets himself go, and may often be readily caught out.

Experience has shown that when hysterical (functional) deafness is associ-
ated with mutism it requires no special treatment, as hearing almost invariably
returns spontaneously when speech is restored. It is advisable to let the
patient know that directly he speaks he will hear his own voice and that then
he will hear everything clearly. There is rarely any difficulty in curing the
mutism by simple explanation and persuasion. Uncomplicated deafness is
much more difficult to treat. Hypnosis is seldom of any use, as the patient
remains deaf while hypnotized. 'Fake' operations on the ear are not invariably
successful, and cannot be regarded as desirable. Most cases can be cured by
explanation with persuasion and re-education. The patient is made to under-
stand by a written statement why he is deaf, and that the original cause of his
deafness long ago disappeared. Since at first the deafness was organic, he
could not hear, however much he listened, and consequently after a time he
ceased to listen at all. He is next persuaded to listen intently, and is taught
that listening is just as active a process as moving, and requires a conscious
effort on his part until it becomes automatic once more. Sounds are generally
heard before words can be recognized. Even when a man has apparently
recovered his hearing, if caught unawares he often fails to hear.

TESTS FOR SIMULATED DEAFNESS

There are two classes of malingerers—those who complain of: (1) unilateral,
and (2) bilateral deafness. Simulation of bilateral deafness requires very
considerable intelligence and hardihood, and consequently its detection
becomes increasingly difficult. It is only by constant observation that people
who simulate bilateral deafness can be detected and it is wise to admit the
suspected case to hospital where he will more easily be caught off his guard,
e.g. he may be awakened from sleep by a loud noise, or he may be observed
listening to the radio. A possible motive should be sought for. Before com-
mencing the tests for malingering in unilateral cases, it is as well to blindfold
the patient.

1. If the hearing has been entirely lost on the right side, a tuning-fork
placed upon the vertex of the skull should be heard on the left side. If the
suspected malingerer is now told to place the finger in his left or hearing ear,
he should hear the tuning-fork in that ear even louder than before; but he
will more probably say that he does not hear it at all, in which case of course,
the fraud is detected.

2. Place two speaking-tubes, one in each ear of the patient. Two people
now speak, one into each tube, on different subjects and at different rates. If
the patient hears with both ears, he will confuse the voices and be unable to