Pseudo Biliary Colic.--A similar state of affairs to that with regard to the appendix has developed in all that concerns the gall bladder and the biliary tract generally. Any complaint of discomfort in the right upper quadrant of the abdomen, if persisted in, is almost sure sooner or later to be diagnosed as due to a calculus. Now that operations for gallstones are more common than they used to be, it is probable that almost as many gall bladders are found without pathological conditions as appendices without justifiably operative lesions. In treating individuals who have a history of recurrent symptoms of intestinal reaction to various foods complicated by urticaria, it is important to remember that there may probably be lesions corresponding to those in the skin in portions of the intestinal tract which may functionally involve either the appendix or the biliary pa.s.sages. Some of these cases are extremely difficult to handle because often there is pain, definite tenderness and some fever with the attacks, and very localized symptoms. The history, however, will be helpful. Operation will not relieve the patient from liability to recurrence. There are, however, other cases where the discomfort is much more vague, where there is no tenderness, no disturbance after jolting rides and where there has never been any severe pain. These should not be set down as biliary calculi without further developments. The possibility of a stone being present should not be hinted to the patient until some definite pathognomonic sign is discovered.

Other Simulated Conditions.--There are many painful conditions of the {589} head that are psycho-neurotic. Many forms of headache are due to sensations of pressure or tension or constriction, usually in the external integuments of the skull, which are dwelt on and then become painful achy conditions. This is particularly true of so-called headaches in the back of the head. As we emphasize in the chapter on Headache, probably most of the headaches of patients who have not much to occupy themselves with, are due rather to queer feelings in the head emphasized by the concentration of attention on them than to real pains. Earache may occur in the same way. Nearly always when one has been out in the wind, there is likely to be an uncomfortable sensation in the ear. By attention to it this may readily be exaggerated into an earache. Occasionally the physical basis of an ache in the region of the ear seems to be an unconscious performance of Valsalva's experiment while blowing the nose when catarrhal conditions are present.

All sorts of painful conditions of the arms and legs may develop in the same way. Unusual tiredness, or some special exertion of the muscles, may produce a sense of fatigue readily exaggerated by attention to it, into severe pain. This condition is not a voluntary simulation, but is due to lack of diversion and a certain inborn tendency in these people to pay attention to anything that is the matter with them. Very seldom does the physical condition need much treatment, though nearly always something can be done for it with advantage, but the mental state needs alteration and, above all, the patient needs to be diverted from over-concentration of mind.

Motor Neuroses.--As has been said, beside painful conditions, various forms of motor trouble may develop. These usually consist of inability to move certain groups of muscles. They have sometimes been spoken of as hysterical palsies or paralyses. The word hysterical, by its derivation connected with the Greek word for womb, apparently indicates that these conditions are limited to women. It is well known now that they are extremely common among men and especially among young men and have absolutely nothing to do with the genital system.

As with painful psycho-neurotic conditions, there is practically always a physical basis. This sometimes requires careful questioning to locate exactly. There is some injury of the muscles of a particular region, or some over-use of them, or some employment of them under bad mechanical conditions with over-fatigue, and then attention to this leads to incapacity to use the muscles or inability to co-ordinate them properly.

Neurotic palsies, to use a term that carries much less unfavorable suggestion with it than the word paralysis or the word hysterical, may occur in any limb or group of muscles. They may occur in the legs with the production of complete paraplegia. One well-known form, astasia-abasia, inability to stand or to walk, affects the muscles of the trunk as well as of the lower limbs. These conditions often remain for long periods in spite of treatment, frequently recur, are often called by all sorts of names and continue to be a source of annoyance to the patient, until a definite successful effort is made to change the patient's mental state to one of less attention to the particular part.

There is, it seems to me, an unfortunate tendency to think that our observations upon these cases are comparatively recent. Sir Benjamin Brodie, nearly a century ago, insisted that at least four-fifths of the female patients among the higher cla.s.ses of society supposed to suffer from diseased joints were really sufferers from neurotic conditions, or, as they called them then, {590} hysteria. Sir James Paget, in his Clinical Lectures and Essays, thinks that Brodie has exaggerated the proportion, for in his own practice, though, of course, he includes his hospital cases and the poor as well as the rich, he found less than one-fifth suffering from neurotic joints. The hip and the knee, which are the most frequent seats of genuine pathological conditions, are also most frequently the subject of neuroses. Next in order, but much more rarely, the metatarsal and metacarpal joints are affected and then the elbow and shoulder. In Sir James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a number of cases which show how clearly psycho-neurotic affections were recognized in his time. He tells the story of a young man who had been overworking for examinations and who "after a three-hours'

mathematical cram, fainted and when he rallied set up a very close mimicry of paraplegia which lasted many weeks." He insists that "such mimicry is found not only or chiefly in the silly selfish girls among whom it is commonly supposed that hysteria is rife, but even among the wise and accomplished, both men and women."

DIFFERENTIAL DIAGNOSIS

For the differential diagnosis of psycho-neuroses from definite organic conditions, the most important element is the patient's previous history and a knowledge of the condition of the nervous system. Where this is known the diagnosis is comparatively easy, but when the patient is seen for the first time it may often be extremely difficult. It is, above all, important not to jump to conclusions, for every nervous specialist knows of cases in which the diagnosis was considered to be surely a neurosis, yet a fatal termination showed that a serious organic condition was at work. It must not be forgotten either that neurotic patients may develop serious organic disease in the midst of their neurotic symptoms and care must be taken not to miss the significance of special symptoms. When the patient is not well known, the presence of certain stigmata, as they have been called, enable the physician to recognize the probability that a neurotic condition is present. Patients who are subject to neuroses are likely to have certain areas of the skin surface and of the palpable mucous membranes more or less sensitive than normal. There are likely to be spots of hyperesthesia or hypesthesia or even complete anesthesia somewhere on the skin. These should be carefully looked for and in serious cases an examination of the whole skin surface should be made. Not infrequently anesthesia or a decided lack of sensitiveness to irritation will be found in the throat or in the nose. Occasionally the conjunctiva is much less sensitive than usual.

These used to be called hysterical stigmata. The word hysteria carries an innuendo of imaginativeness or occasionally of affection of the s.e.xual organs that is unfortunate. It would be better, therefore, not to use the term in any way. The presence of these areas of hyperesthesia, hypesthesia and anesthesia indicates that a.s.sociation fibers are abnormally connected in the brain for the moment at least, and that as a consequence there is over-attention to certain portions of the body with lack of ordinary attention to others. This will account very readily for the occurrence of painful conditions in certain cases and palsies in others. When over-attention is paid, there may be a {591} hyperesthesia corresponding to that seen in the skin in any organ of the body. When, for any reason, there is a disturbance in a particular part, there may be a lack of motility due to nervous influences, just as there is a lack of sensation. In all of these cases the one essential element is to correct the nervous state through the mind as far as possible. Experience has shown that this can be done in nearly all cases. It must be the princ.i.p.al effort of the physician.

TREATMENT

Strong Mental Impression.--In the treatment of these affections two periods are to be considered, one during, the other after the attacks.

During the attack a strong impression must be made upon the patient's mind so as to divert the concentrated attention. We have well authenticated stories of the various expedients resorted to by physicians who were confident of their diagnosis in order to secure such a strong mental impression. I once knew an old physician who was summoned to a childless wife whose adoring husband was in manifest agonies of solicitude over her and whose mother and mother-in-law had been caring for her for days with all anxiety, walk into the room of the patient, take one of her hands in his, slap her on the cheek, tell her to get up and walk and she would have no more of that supposed inability to walk which had caused the family so much anxiety. He succeeded. It can be imagined what would have happened had he not succeeded. We know of cases where an alarm of fire or a burglar scare or some sudden emotion has produced a like result. We cannot prescribe these things, however, and at the most, after one or two successes in a particular patient, they would fail.

The only thing that we can do as a routine practice is to relieve by direct treatment the slight physical condition that is usually present and then try and influence the patient's mind. If a thorough examination is made in the course of which the physician is able to show the patient that he understands the condition and that he can demonstrate for himself and them that there is nothing serious the matter with important organs, he can make them feel that their pain or disability is entirely due to concentration of attention on a particular nerve or set of nerves. With many patients this will succeed, not at once, but after two or three seances of positive suggestion, even in the waking state. If the patients are bothering their relatives very much it may be necessary to give some opium as an adjuvant. As a rule, the needle had better not be used, but a suppository given. This is not nearly so attractive to the patient's mind as the use of the needle and is not likely to be called for so often. Every physician has had the experience that after giving opium two or three times, either per r.e.c.t.u.m or hypodermically, almost anything can be given, provided the patient is persuaded that the drug is being given again. A reasonably large dose may be used the first time, but certainly after the second or third time a much smaller dose will produce the same effect and often a simple gluten suppository, provided it looks like the other, will work just as well as an opium suppository.

After Treatment.--The after treatment of these cases is directed mainly to such alterations of the mental att.i.tude and physical condition as shall prevent {592} recurrences. The general condition of the patient must be improved in every case where there is indication for this. Many of these patients are under weight for their height.

They must put on weight. Weir Mitch.e.l.l's success with the "rest cure"

consisted to a great extent in his power to cause these patients to put on weight. This supplies reserve energy, but, above all, replaces discouragement by hope and buoyancy. Gain in weight can be accomplished mainly by two methods. First, by seeing that the patient gets an abundance of air and, secondly, by dictating how much shall be eaten. In this matter details are important and it may be necessary to suggest the actual diet for each meal. This must be liberal and must consist of simple but particularly nutritious materials. Patients'

dislikes need not be taken into much account, their likes are often helpful. When there is insistence on lack of appet.i.te and decided objection to chewing, eggs and milk should be given in increasing quant.i.ties, until five or six eggs and some twelve gla.s.ses of milk are taken every day. Besides this, a good portion of meat should be eaten at one meal with some vegetables. By firm insistence, day after day, it will not be hard to get patients whose appet.i.tes are seriously inhibited to take this amount of food. To secure this, a good, firm, sensible nurse is invaluable. Appet.i.te, as we have emphasized in the chapter on Appet.i.te, is largely a matter of will, and anything that is eaten, provided it stays down, will do good unless there is organic disease.

A certain amount of exercise is important in these cases, but not nearly so important as an abundance of fresh air. Patients must not be allowed to overtire themselves. Riding in an open carriage or on the top of a bus, especially where there are distracting scenes and many human interests, is particularly beneficial. Automobiling is often likely to be more tiresome than is good for these patients when they are run down, though it is one of the best of therapeutic measures for those who are physically capable, that is, up to weight, even though they may complain of feeling weak.

_Diversion of Mind_.--It is in these cases particularly that diversion of mind is of prime importance. Many of these patients have either no serious interest or at most certain interests with which they may occupy themselves if they wish, but that are not engrossing and attention to which may be put off whenever they care to. Duties that are inevitable and that call for the occupation of so much time that the patient has little opportunity to think of herself are often the salvation of these patients. As I mention in the chapters on Occupation and Diversion of Mind, I have seen a number of cases and I am sure that every physician of reasonable large experience has seen similar cases, where women, particularly, who in the midst of prosperity have been constantly suffering from some form of psycho-neurosis, great or small, have, after some sudden turn of fortune, been completely relieved from their nervous symptoms by having to devote themselves seriously to some occupation for a livelihood.

Occupation, particularly with children, with the weak and the ailing, with the poor and those who are unable to help themselves, is specially likely to be helpful to such patients when they are women.

Such interests affect them deeply and by the sympathy they arouse through contact with real physical suffering, they prevent over-attention to themselves. I have seen the care of a cancer patient, and especially of a relative affected by cancer, do more for {593} a psycho-neurotic sufferer than all that doctors had been able to accomplish in years. It is often difficult to find occupation and diversion of mind for these patients, but this is the therapeutic problem the physician must solve if he is going to secure relief from present conditions and prophylaxis against further attacks.

Oldtime Cures.--Many of the remedies for obscure abdominal conditions show how well the real character of the affection was duly recognized and appreciated in the past. It is in these cases particularly that the pillulae micarumpanis, the bread pills, of the olden times, were so commonly used with good effect. We have quoted examples in other chapters. Many of the drugs that are employed with reported success for these affections have a strong suggestive element in them.

Valerian probably is a good tonic and yet there is no doubt that the suggestive quality of its nauseating smell and the almost inevitable eructations that occur after to emphasize it, are helpful in curing certain internal psycho-neuroses. Another drug that has been much used in the same way is asafetida, whose disgusting taste and odor have been excellent auxiliaries. Fresh pills of quinine and red pepper uncoated and therefore producing definite effects on the taste before swallowing and on the mucous membrane of the stomach after swallowing, often prove the best remedy for persistent vomiting or for enduring nausea. A drop of nux vomica, taken every half hour with the definite warning that the patient must by no means take more, and that the bottle must be carefully protected lest anyone else should be poisoned, is often very efficient. These remedies have a slight physiological action and a large psychic action, but that exactly corresponds with the etiology of the affection for whose treatment they are employed.

Dominant Ideas.--During the attack it is often possible to find either from the patient or from friends that there is some dominant idea which is bringing about the mental short-circuiting that leads to the concentration of attention. From the oldest times it has been recognized that in young women a disappointment in love may prove to be the occasion for a psycho-neurotic or, as they used to call it, hysterical attack. This is, however, not a specific cause. It is the disappointment much more than the s.e.x element in the case, as a rule, that produces the unfavorable effect. It was easy to conclude that the s.e.x factor was extremely important in older times when women's sphere of activity was largely limited to the home, and marriage was the one legitimate object of their ambition. Now that we have had more experience with the business woman, we know that serious disappointments of any kind have a tendency to initiate psycho-neurotic conditions in susceptible and especially suggestive individuals. A failure to secure promotion in a store, or to secure some position that is eagerly sought for, a loss of money in business, etc., especially when they have been preceded by weeks or months of solicitude and worry over the event that now happens, may lead to the development of a psycho-neurosis.

This is particularly notable with regard to educational interests of various kinds. Young women readily overdo application to study, or, rather, anxiety over it, and as a result get into a state of mind in which a failure to pa.s.s an examination, or to secure promotion, or even the failure to win a prize, may give rise to a highly nervous condition in which tears and laughter come unbidden and in {594} which further developments may bring on a typical psycho-neurotic attack.

All sorts of pains and aches and motor incapacities may occur in these states. The supreme occupation with the single idea present in their minds at all times, waking and sleeping, while they try to study, or when they read or even when they are supposed to be diverting themselves, finally precipitates a nervous explosion along nerves that have been irritated for some reason, though the pathological condition present may be quite insufficient of itself to explain the affection that ensues. These are the popular nervous breakdowns, not difficult to treat once their real character is diagnosed.

Sorrows of various kinds may produce a like effect. Worry or anxiety about the serious illness of a near relative, especially an inevitably fatal illness, such as cancer or tuberculosis or the disturbing mental affections, may have a similar result, but usually not in those who are occupied with the actual care of the patients. The mental states const.i.tute the psychic elements underlying the neurotic condition that develops.

Almost needless to say, successful treatment must include a faithful attempt to lessen the significance of the mental state that is so important in the case. Usually the mere obtaining of the patient's confidence is enough to lessen greatly the irritation produced by the mental condition. A sorrow shared is halved. It is, above all, secretive individuals who become depressed over their sorrows. While the patient who insists on constantly sharing them with everyone becomes a nuisance, it is always a little dangerous not to have a confidant to whom worries and anxieties are entrusted. If they are kept to one's self they are nearly always exaggerated--they are seen out of proper perspective and have a much more depressing influence.

Calm, judicious reasoning with the patient over the significance of the condition as presented, is often of great help.

Often these ideas, so potent for mental and bodily disturbance, are almost entirely unconscious or exist in the patient's subconsciousness and are recalled only under such special conditions as remove the bonds of the patient's occupation with himself or herself at the present time and allow memories to come back without interference.

There are many curious stories of such cases. A child is frightened or very much disturbed by having a cat kill a favorite bird. The cat becomes a deterrent object. Gradually this deterrence grows. As a consequence, there may develop one of those intense dreads of cats which makes life miserable if near that animal. There may even be physical effects produced by the continued presence of a cat in the same room. Often in these cases the beginning of this mental att.i.tude, or at least its occasion in the incident of the killing of the bird is forgotten, or at least not consciously referred to as an etiological element in the dread.

Patients have been known to develop states of mind which made them object to certain figures or names because of earlier a.s.sociations with them that were unpleasant. There is the story of a man who would never take a car with an odd number though this was sometimes a source of annoyance and delay and who could not explain to himself or his physician how this objection had developed, until his memory was searched and it was found that, years before, he had witnessed the death of a child under the wheels of a car with an odd number. He had completely lost the sense of the direct influence of this, but it existed in subconscious memory and proved the source of much {595} annoyance to him, for if with a friend he were not able to avoid taking an odd numbered car he would feel quite miserable during the ride. Frights of various kinds may produce this same effect. I have in my notes the case of a man who is unable to sleep at night without a light in his room, because of a fright. Once while asleep in the dark, he awoke conscious that someone was in the room and sat up and demanded who was there. The answer was a revolver shot and a bullet, pa.s.sing not far away from him, pierced the head of the bed. As he sank back the burglar leaped from the window and escaped. He realized that this was the cause of his fear of the dark, but lesser incidents might easily become subconscious yet continue their influence.

Psycho-a.n.a.lysis.--In recent years Freud has suggested that in many puzzling cases of psycho-neurosis, where, so far as is known, there seems to be no dominant idea bringing about the concentration of attention, careful a.n.a.lysis of the patients' memories will bring out the fact that there is a subconscious idea as the underlying substratum of these affections. Freud has developed what is called the process of psycho-a.n.a.lysis in order to bring out these ideas which are sometimes exerting their influence unconsciously to the patient. The subconscious is one of the fads of the hour, so that Freud's announcement attracted much attention. Psycho-a.n.a.lysis, however, is not advanced so confidently even by its inventor as a positively curative measure, as it was at the beginning. It has been found that after the dominant idea in the subconsciousness has been found and neutralized with a consequent amelioration of the psycho-neurotic symptoms, there may be a relapse, when another dominant idea will have to be found, and that there seems to be the possibility, in some cases at least, of an almost endless succession of such ideas to account for further and further relapses.

Undoubtedly psycho-a.n.a.lysis has its place in psychotherapy and is of great value in certain cases. There is no doubt, however, in my mind that in most of these cases reported as cured after psycho-a.n.a.lytic methods had been employed, what really happened is that the patient's mind became diverted to another idea--that of marvelous cure through mind searching which relieved the previous concentration of mind underlying the psycho-neurosis. These are the cases that used to be cured by hypnotism. Before hypnotism was developed they were cured by mesmerism. Before mesmerism they were cured by magnets or by the Leyden jar, and during the past century they have been cured by electrical methods or by osteopathy or by Eddyism. Many of the cures were effected by stroking and touches, the use of Perkins' tractors, or Greatrakes' methods, or anything else that attracted attention very strongly. They were given a new idea which occupied them very much and so saved them from that preoccupation with themselves and their feelings and whatever slight ailment might be present that was the physical occasion for psycho-neurotic symptoms. This happened with psycho-a.n.a.lysis. When it was absolutely new and the operator had great confidence in it, this confidence was imparted to the patients, with the consequent cure or decided amelioration of their psycho-neurosis, just as that used to be brought about by our previous method of treating such cases by some strong suggestion.

As I emphasize in the chapter on Dreams, the examination of the dreams in order to get a hint of the dominant idea, is particularly interesting, because it represents a return to the oldest methods of suggestion of which we have record. {596} The fact that s.e.xual ideas seem to represent a great many of the dominant ideas in these cases is of interest for a similar reason. It represents the tendency constantly recurring to refer most nervous ailments, as indeed most other ailments, to something pathological in the s.e.xual or genital sphere. The old idea embodied in the word hysterical exemplifies this very well. The "vapors" or "tantrums" or fits which were supposed to be due, to some extent at least, to suppressed s.e.xuality by medical writers of three or four generations ago, have come back to us under another form and with other terms. Psycho-a.n.a.lysis gives occasion for instruction in so far as it helps the patient to get rid of old persuasions and exploded ideas as to disease and diet and the various functions of the body and the mind that have often almost unconsciously been acquired and secured a dominance. It is surprising how often it will be found that people are taking too much or too little water at meals, too many or too few vegetables, too much or too little of salt or of other condiments as the result of habits and notions acquired when they were young and under influences that they may now forget. In the same way habits of life with regard to bathing, clothing and the like may be the source of unfavorable conditions in mind and body that need only to be discovered to be corrected. Their correction will often bring about the relief of symptomatic conditions that have proved quite obstinate to treatment. We have emphasized this in the chapters on the Individual Patient and the necessity for acquiring just as much knowledge as possible about both his occupations and his mental att.i.tude in order to be able successfully to treat chronic disease.

{597}

SECTION XVIII

_DISORDERS OF MIND_

CHAPTER I

MENTAL INCAPACITY (PSYCHASTHENIA)

In recent years we have come to realize that many of the so-called nervous diseases, or if they do not deserve the serious name of disease, nervous symptom-complexes, are really due to a deficiency of vital energy. Some people have a store of energy that enables them to accomplish many different things successfully. Some become exhausted from a few trivial occupations. What is noteworthy in the cases to be discussed in this chapter is that they show always certain symptoms of mental tiredness or, at least, of lack of capacity for affairs.

Patients complain, for instance, that they cannot make up their minds so as to reach decisions because they doubt so much whether the decision they come to will be right or wrong. Others dread the outcome of any and every act and feel that something is hanging over them.

Slight sources of irritation become so exaggerated by thinking about them and dwelling on their possibilities that they may even disturb sleep and appet.i.te and, as a consequence, the general health. Fears come over patients lest various things should happen and they dread microbes, or infections, or dirt in general, or the approach of insanity, and all to such a degree as to incapacitate them for their ordinary occupations.

Many of these patients become quite incapable of willing effectively.

They not only lose initiative, the power to undertake new enterprises, but they find it difficult to make up their minds as to details of the ordinary affairs of life. As we have stated elsewhere in Professor Gra.s.set's expressive formula, these patients say that they cannot do things, their friends say "they will not," and the physician, taking the middle course, which, as usual in human affairs, has much more of truth than either of the extremes, says "they cannot will."

For these states Janet of Paris suggested the word psychasthenia. It is formed on the model of the word neurasthenia and unless it is used with discretion will have all the objections that attach to that other term. Above all, it shares the tendency pointed out by Sir William Gowers with regard to neurasthenia of being "too satisfying. Men are apt to rest on it as they would not on its English equivalent.

Physicians, if they do not actually think that they have found the malady from which the patient is suffering, have an influence exerted on them of which they are often unconscious, which lessens the tendency to go farther in the search for the whole mental state." Much more can be said in defence of psychasthenia, however, than of neurasthenia, for the subst.i.tution for it of the translation of the Greek words of {598} which it is composed--"mind weakness" would be alarming. While it is important, then, to realize that the term may easily be made too general and prove, as such words as rheumatism has done in our time and malaria did in the past, a cloak for ignorance and an excuse for incomplete investigation for diagnostic purposes, it represents a satisfactory answer to the patient's question as to what is the matter without committing the physician to such definitely detailed opinions as to the patient's condition as would surely prove unfavorably suggestive.