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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
sexual 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 association
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 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 principal 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 rectum 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 attitude and physical
condition as shall prevent 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 Mitchell'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 appetite and decided
objection to chewing, eggs and milk should be given in increasing
quantities, until five or six eggs and some twelve glasses 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 appetites are seriously
inhibited to take this amount of food. To secure this, a good, firm,
sensible nurse is invaluable. Appetite, as we have emphasized in the
chapter on Appetite, 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
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 sex element in the case, as a rule,
that produces the unfavorable effect. It was easy to conclude that the
sex 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 pass 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 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
constitute 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 attitude,
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 associations
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
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,
passing 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-Analysis.--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 analysis 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-analysis 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-analysis, 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-analysis 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-analytic
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-analysis. 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. The fact that sexual 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 sexual 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 sexuality by medical
writers of three or four generations ago, have come back to us under
another form and with other terms. Psycho-analysis 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 attitude in order to be able successfully
to treat chronic disease.





Next: Mental Incapacity Psychasthenia

Previous: Forms Of Neurotic Simulation



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