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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 discomfort 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."





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