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, [{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 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 [{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 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 [{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 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.