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.





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