Forms Of Neurotic Simulation

Every possible painful condition is simulated by these psycho-neurotic

conditions. They occur probably with more frequency in the abdomen

than elsewhere; they may be thought to be colicky in nature and, as a

rule, some accumulation of gas will be found. This gas is sometimes

swallowed air and sometimes gaseous products that have been diffused

apparently from the blood in the intestinal walls. This always

produces disco fort but nothing like the discomfort that the patient

complains of. The condition if treated by carminatives will nearly

always be emphasized rather than relieved. Local treatment by heat

will help oftener, but may exacerbate it. When chronic constipation is

present, calomel in divided doses is suggestive as well as medicinal.



There may be gastric crises that recall those of tabes, and there may

be vesical and rectal crises of a similar nature. I have seen a

patient complain of every symptom of stone in the kidney. At the

beginning the pains were vague, but after she had been to several

physicians and had been asked certain questions intended to elicit

pathognomonic signs of stone these questions were answered in the

affirmative. Her attacks became strikingly like renal colic. After a

consultation, at which two physicians and a surgeon were present, she

was operated upon for stone in the left kidney. No trace of it was

found. But after this she was well nearly a year. Then she had another

crisis of pain in the early morning hours, a time when her painful

condition always came on, apparently because it attracted more

attention and caused more disturbance at this time, and now all the

symptoms pointed to the right kidney. She was treated on the principle

that it was a neurosis, was made to gain some fifteen pounds in

weight, has since then had no attacks, has not passed any stones, and

there seems no doubt but that the whole case was merely neurotic.

During her attacks instead of having suppression of urine, she had a

free flow of urine and no blood. It is not unlikely that the physical

basis of the attacks was that condition of the kidney which allows

urine to flow through very freely during neurotic conditions and which

somehow got into the sphere of her consciousness and being

over-attended to became extremely painful.





Secretory Neuroses.--Lying between the pain and motor neuroses and

dependent on psychic elements to some extent at least, there is a

series of neuroses that have as their principal symptoms an increase

or decrease of secretion. Occasionally, of course, they are

complicated by motor neuroses, especially in connection with the

viscera. There are various stomach affections, represented by an

increase or decrease in stomach secretion, and accompanied by pain,

discomfort, and decrease or increase of peristalsis. There are biliary

neuroses accompanied by increase or inhibition of biliary secretions.

There are gastric neuroses associated with vomiting, often very

intractable, in which there seems to be sometimes a hypersecretion of

gastric juice and sometimes a lessened secretion. All of these occur,

as is said, spontaneously, but there will usually be found a history

of some exhaustive work or worry during the weeks or months just

before. Apparently nervous control is lost and then the secretory

neurosis manifests itself sometimes in conjunction with painful or

motor affections.





Neurotic Vomiting.--Persistent vomiting occurs in these cases but is

not so serious as it seems and patients do not lose weight, as

might be expected. There is sometimes even a probability that some of

the food ingested finds its way through the pylorus and is used for

nutrition, though the vomiting may come on not long after ingestion.

Practically always nature asserts herself and stops the vomiting when

serious conditions seem about to develop. The solicitude of relatives

may be calmed by this assurance, and just as soon, as a rule, as they

show less anxiety about the patient, the first symptoms of improvement

will be noted. The fasting girls exploited in the newspapers, in

connection with these neurotic conditions are often frauds and

investigation has shown on a number of occasions that they were

obtaining food surreptitiously. It must not be forgotten, however,

that, even though these cases have been discredited, we have a number

of cases on record of men and women who have taken absolutely nothing

nutritious and only water for from ten to forty or even fifty days.

Until at least ten days have passed in one of these gastric neuroses,

then, there is no need for urgent solicitude, and this of itself, when

properly explained, makes an excellent favorable suggestion for these

patients, and, above all, for their friends.





Simulant Appendicitis.--Some of these abdominal psycho-neuroses may

simulate serious pathological conditions that, in recent years, have

come to be looked upon as surgical. I have seen a number of cases,

especially in women who have been constipated for some time, in which

there was considerable discomfort in the right lower abdominal segment

and occasionally surgeons thought that an operation should be

performed. Usually in these cases there is no localized tenderness and

no mass of any kind to be felt in this region. Sometimes tenderness is

complained of, though when the patient's attention is diverted even

deep pressure may be made without their wincing. Whenever there is no

history of an acute attack, no temperature and no increase in pulse

rate, unless there are very definitely localized symptoms, the

question of operation is always to be answered in the negative.

Disturbances of the pulse may mean little. The history must guide. I

have seen these cases operated on, improved for a while, but relapse

afterwards just as soon as there was a resumption of their

constipation. As a rule, when the appendix has been removed, either

because its function has something to do with the inhibition of

putrefactive processes in the lower bowel, or because as the result of

the operation and consequent adhesions, the colon was not so active in

its peristalsis, the constipation seemed to be worse than before,

unless special care was exercised. If there is relapse after an

operation the patients' attacks are almost sure to be more frequent

than before and their discomfort likely to be more pronounced.



Lest it be thought that such cases are mainly confined to women or

that the most striking cases occur only in women, I may say that the

most interesting case of this kind I ever saw was in a young, vigorous

German soldier. He was admitted to Koenig's clinic in Berlin with a

story of abdominal tenderness and pain, the tenderness being located

in the right iliac region. There seemed even to be some distention of

the abdomen after a time and the development of greatly increased

diffuse tenderness. The pulse was considerably disturbed, but there

was only a slight rise in temperature, and for a time it was thought

that this might be a case of appendicitis without fever. A surprising

feature of the case was the presence in the right iliac region of

a scar which, on careful investigation, proved to be double.

Apparently the patient had been opened twice before in this region.

His history was carefully investigated. He had had a fall from a horse

about two years before and afterwards had considerable abdominal

discomfort. He was quite sure that something serious had happened

within his abdominal cavity as the result of the fall and his

attention was concentrated on his right iliac region. At the time of

the accident his symptoms were considered to be a psycho-neurosis or

perhaps an exaggeration of symptoms with malingering tendencies.



Shortly after his term of service expired, however, some acute

symptoms developed and there was swelling, or at least tympanitic

distention of the abdomen with disturbance of the pulse, and he was

operated on in the hospital and his appendix removed. There proved to

be nothing the matter with it and no pathological condition was found

within his abdomen. He seemed to recover completely. After six months

he was admitted to another hospital with the same symptoms. He seemed

to have the habit of swallowing air which found its way beyond his

pylorus, or else gas leaked from the blood vessels in the walls of his

intestines, producing a symptom-complex not unlike the tympanitic

distention consequent upon general peritonitis. Once more this was

taken to mean very probably a ruptured appendix and another operation

was done. This operator went through the old scar, but to his surprise

found no appendix and found everything within the abdomen normal. The

third time the patient came to Koenig's clinic and, owing to his

military record, his hospital experience was available and a third

operation was not done. Instead, according to the story current at the

time, the patient was tattooed with the legend "no appendix here." The

case is interesting as an example of the extent to which an abdominal

psycho-neurosis may simulate a ruptured appendix.





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 passages. 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

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 classes of society supposed to

suffer from diseased joints were really sufferers from neurotic

conditions, or, as they called them then, 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."