Hysteria, neurasthenia, neurosis...

CHAPTER XIII
HYSTERIA, NEURASTHENIA, NEUROSIS, TRAUMATIC NEURITIS, MALINGERING

THE line between organic and functional lesions is difficult to draw in cases such as those alluded to near the end of the last chapter. Yet the distinction should be made. In a book it is easy to do this by changing the title of a chapter, but in practice there are cases in which wise men disagree.
I have nothing particularly original to contribute to the subject suggested in the heading of this chapter. My work has been that of a surgeon, and while I have always been interested in the phenomena of surgical conditions involving the various distributions of the motor and sensory nerves, I have had no particular experience in handling cases of functional nervous disorders. Every surgeon and practitioner unavoidably sees cases in which the hysterical or nervous element is involved, although it is rare for any one not engaged in neurological work, particularly, to see and to treat cases which are purely functional in character. Unavoidably, the question of the nervous element is frequently presented in cases of lesions in the shoulder. In fact, it seems to me that it is normal in the average individual to present a certain percentage of this complication after injuries of any kind, especially if the question of justice or of compensation is under consideration. It would seem to me that a twenty-five per cent allowance for exaggeration might be fairly given to any normal patient when there are Medico-Legal questions involved. Furthermore, it is also true that the longer a patient is laid up as the result of an injury, the more his mental state is involved in relation to the physical side. His mind becomes riveted on the injured part; he notices every little point of soreness, and marks it deeper and deeper on his mentality in order to use it to strengthen his case. He goes to bed thinking of his troubles and thinks of them when he wakes—perhaps he dreams of them. Often in industrial cases, he is insufficiently fed; his general condition deteriorates; he talks to every one who will listen, and describes the details of the accident, the character of his suffering, and his feeling that injustice has been done him. Prom a life in which his whole mind has been filled by his occupation, he is thrown into idleness and has nothing to do but dwell on his misfortunes. Such a man is not abnormal, in my opinion, and cannot be considered hysterical or malingering, until he passes from the twenty-five per cent class into the fifty or seventy-five per cent class. One of the strongest arguments against our Workman's Compensation Laws is, that they so often result in producing this state of mind.
After all, what are the conditions named in the title of this chapter? The following definitions are given in Dorland's Medical Dictionary :

Hysteria: Disease mainly of women, characterized by lack of control over emotions and acts.
Neurasthenia:   Depression due to exhausted nerve energy.
Neurosis:  A nervous disease, especially a functional disease.
Traumatic neuritis: Inflammation of a nerve caused by an injury.
Malingering:   Feigning illness.

Doubtless, by consulting textbooks on Neurology, these definitions might be made more satisfactory—certainly much greater detail would be given and therefore more confusion. To the ordinary surgeon or practitioner, these definitions would suffice, and yet when one comes to apply them to individual cases, they are not so far apart that it is easy to label our patients. All five diagnoses might be applied correctly to one case at different times. Even the two extremes, hysteria and malingering, are not easy to separate. We can readily picture an hysterical woman quite unconsciously simulating any kind of disease, or we can picture a husky, shrewd, healthy man feigning an illness merely to get a few hundred dollars compensation. Between these extremes, we find the ordinary man I have described above, who takes a trivial lesion too seriously, will not endure a degree of pain with which a brave man would work, and prefers to associate himself with those who blame the rich for all the misfortunes of the poor.
In industrial work, one often sees that a quarrel with a foreman tends to make a healthy man exaggerate his injury. His sense of injustice from the behavior of the foreman predominates over his common sense, and he uses his illness as a method of discrediting the foreman. He perhaps has more zeal to have a doctor support his contentions, in order that the foreman will be put in wrong with his employer, than he does to obtain compensation for an injury, the pain of which he would have endured if there had been no quarrel about it.
It sometimes seems to me that it might be easier for an Industrial Accident Board, in questioning experts about the relative amount of the nervous to the physical element after a given injury, to ask for a statement as to whether, in the doctor's opinion, the hysterical or neurasthenic, or malingering element formed a twenty-five, fifty or seventy-five per cent basis in the case—freely allowing twenty-five per cent for the average man. The individual who is one hundred per cent physically injured, could only be a dead one. There are men who will endure physical injuries and continue to work in spite of pain, sleepless nights and overbearing foremen, but we cannot judge the average by these truly brave individuals. When it comes to the patient in whom we believe the nervous element is one hundred per cent, it will have to be shown that prior to the injury he had always been one who complained in an exaggerated way about other trivial experiences in his life. It is hardly possible that a sound-minded, sound-bodied man will be turned by an injury into a malicious, cowardly individual, who would allow his self-respect to fall so low as to present extreme hysterical symptoms. In those cases in which the nervous element and the physical element combine in such degree that they fall into the twenty-five to seventy-five per cent class, we are more likely to make mistakes. The same individual, as the months pass, may descend from the twenty-five to the seventy-five per cent class.

I have the feeling that some neurologists, who have seen many mental cases and the extreme forms of hysteria, are too ready to pin the label of hysteria to symptoms which may possibly be due to physical conditions of which they are ignorant. It is no easy matter for a neurologist to keep accurately in his mind, the areas of peripheral distribution of the sensory nerves, nor the paths of these nerves as they pass through the different portions of the brain, through the spinal cord and through the canals of exit between the vertebra and outward through the planes of fascia. Physicians having had experience with many mental cases, and having seen that hysteria in extreme cases can mimic almost any physical condition, are ready to believe that the phenomena, in an individual case in which the symptoms consist in areas of unexplained anaesthesia, are due entirely to the mental condition. Surgeons, on the other hand, dealing with concrete anatomic structures, rather than with functions, err on the opposite side. Not infrequently they even neglect to test for anaesthesia at all. If they can conceive a possible anatomic basis to explain the areas of anaesthesia, they prefer to accept that explanation, rather than to assume a functional disorder. The neurologist and surgeon will, therefore, come to agree on those cases in which their combined knowledge of anatomy and pathology is unable to interpret a group of symptoms.
Yet they both may be ignorant of the true cause, for it has been my experience to have seen patients with rupture of the supraspinatus who have had the misfortune to be classed as neurasthenics, malingerers, or hysterics, because the signs and symptoms which I have alluded to in previous chapters have not been recognized by the doctors in attendance.
I am afraid there are still many doctors who have never even heard of rupture of the supraspinatus, and many of our teachers in our medical schools will be astonished at the statistics of Dr. Akerson, that this lesion is as common as demonstrated by his finding evidence of it in nearly forty per cent of his autopsies. As I look back on my own experience, I find that even for years after I had recognized the existence of this lesion, I made the mistake in some cases of attributing the patient's unwillingness to raise the arm to his tendency to malinger.
Before one makes a diagnosis of hysteria or its allied conditions, the following four points should be taken into consideration especially.
(1) The age of the patient. It is generally admitted that if a patient is to have serious hysterical phenomena, these signs appear in youth. It is most unusual for a healthy individual in adult life who has previously been normal to exhibit a sudden attack of hysteria.
(2) The industrial record of the patient. If a suspected patient has been in continuous employment and given satisfaction at his work for a long period of years prior to his injury, it strongly influences me to consider that the neurotic element in his case is not large.
(3) The length of the period, from the time of the accident to the time of the examination, must be taken into account. I have already explained that a normal individual, forced out of employment for many months by a painful injury, may present a pitiable mental condition. The wolf is at his door and his family's door, and the elements of worry and sleeplessness, insufficient food, and self-concentration, bring about what I should consider a normal high percentage of the nervous element.
(4) The degree of fright received at the time of the accident, especially as evidenced by the behavior of the patient within the first few weeks after the accident. There is no question in my mind that a healthy man may be reduced to a pitiable condition of "nerves" by a single accident, and I am inclined to believe that the brain may register a local fear complex, following an accident to any given part of his body. It seems to me possible that the brain may receive such a shock from the supposed loss of the use of one limb, that the corresponding portion of the brain may be in a helpless condition, while the rest of the patient, so far as his fear for the rest of his body goes, may be normal. Such a condition may be a "traumatic neurosis."
The three cases alluded to at the end of the last chapter as possible instances of trauma to the sensory roots of the brachial plexus were all in healthy, physically strong, adult males, who had worked steadily and had exhibited their symptoms immediately after the accident—and persisted in their claims of the same symptoms for many months afterwards. To my mind, these facts are strong evidence that the lesions were of a true physical nature. That the anatomic injury is hard to explain, from what we know of the connections of the sensory nerves at the ganglia near the nerve roots, may be attributed to our ignorance. It seems to me side-stepping to assume either a conscious or a subconscious effort to imitate such peculiar conditions, especially as the three cases do offer a pretty close resemblance in the areas of distribution to the known areas supplied by certain peripheral nerves.
The diagnosis of true hysteria should not be made lightly in cases of cutaneous anaesthesia about the shoulder. One should be very sure that the limits of the field do not correspond to the known anatomic distributions of the different nerves and their branches. Even this is not enough, however, for the areas of anaesthesia must be looked at also from the segmental point of view.
One of my cases, for instance, had an area of sensation on the inner side of the upper arm corresponding with the area supplied by the nerve of Wrisberg, which comes from the third and fourth dorsal segments, yet the skin all about this area was anaesthetic down to the ulnar distribution in the hand, which also comes from about the fourth dorsal segment.
It is out of place here to go into the fine diagnosis of peripheral nerve lesions. It would take too large a proportion in a book which is intended to have its focus on the subacromial bursa, which gets its sensory nerve supply from only two nerves. These are the suprascapular and the circumflex in the deep tissues. The skin nerve supply comes from the cervical plexus.
A true hysteric anaesthesia has the boundaries which the patient thinks should be there, as, for instance, the classic "glove anaesthesia," bounded by a ring around the arm entirely at variance with the anatomic nerve supply. But complete hemianesthesia is usually considered a very sure proof of hysteria, although it is anatomic in distribution.
While I was writing this chapter (March, 1930), an industrial accident case was referred to me. He was a dull-looking Portuguese laborer of 43, who had fallen twenty-five feet from a staging on December 21, 1927, and had been unable to work since. His main symptoms were in the back and sacroiliac region. His case had been under discussion for over two years, and four doctors had given their opinions without agreement being reached. No one had suggested hysteria. On examining the shoulder, I found that he was anaesthetic over the whole right shoulder and arm, but further investigation proved that he also had a complete hemianesthesia. The muscles were well developed, and there was no asymmetry of his body. The diagnosis of hysteria was made and was later confirmed by a neurologist.
The following case illustrates the difficulty of diagnosis between traumatic neuritis, traumatic neurosis and hysteria, in an injury to the shoulder. Possibly the case furnishes an example of all three diagnoses.

CASE REPORT

R. S. An Italian of 43 was helping to lift a huge rock on Sept. 15, 1922. The rock slipped and the man injured his shoulder. His arm became useless and swollen. A local doctor bandaged his arm to his side with a Velpeau bandage. He had been incapacitated ever since. I saw him nearly two years after the injury. The following is my report in full:
"I examined this employee at my office on July 24, 1924. He is an Italian laborer, undersized, quick, nervous and voluble, but very difficult to understand.
"With the request from the Board to examine this patient, I also received copies of the reports of the following physicians who had previously examined him: Dr.- Dr. -, Dr.- , Dr.- , Dr.-, Dr.- .  There seems to be a fair unanimity of opinion that the condition is hysteria.
" I hesitate very much to offer a contrary opinion, but my belief, which amounts to a conviction, is that this condition is not hysterical, certainly not wholly hysterical. I will grant that this man presents a picture of imperfect self-control and is evidently obsessed with the idea that it is impossible to use the arm. To him that arm and shoulder are two-thirds or more of his whole mental horizon. Yet I believe that extreme physical pain from a true injury is the basis of his trouble.
"My explanation of the condition is this. He had an injury of more or less severity to his shoulder—perhaps a dislocation, perhaps a ruptured capsule or tendon. Following this a bandage was misapplied—too tight—the circulation in the extremity, particularly in the nerve trunks, was impeded. The arm 'went to sleep' in the bandage. Brachial neuritis of a degree just short of total paralysis resulted. Instead of a complete 'drunkard's paralysis,' with a flaccid condition of the muscles, a condition of paresthesia and imperfect muscular control resulted. The pain, which would have been destroyed by a little greater pressure, was on the contrary aggravated, because a little circulation persisted in the nerve trunks. The paresthesia and hyperesthesia caused by the neuritis extended up and down the brachial plexus and even to the subsidiary anastomosing nerves. Pain and hypersensitiveness are after all protective processes. Nature demanded rest for that brachial plexus and obtained it in this old, hereditary way. I believe that in this case she has succeeded in saving a set of damaged nerves which were all but permanently destroyed.
"I am aware that this explanation has little of direct proof to support it, being founded more on personal opinion than on demonstrable points. However, there are certain facts that support it and others that might be obtained. First: Sudden onset of hysteria in a man of this age is very unusual, but it is not at all unusual for doctors to diagnose hysteria when a real lesion is present. The burden of proof is on the one diagnosing hysteria. Second: Atrophy has been a striking feature since the first examination. I have never seen hysterical paralysis produce marked atrophy. Third: This patient presents a peculiar spasm of the muscles of the forearm, which is inimitable in hysteria, but is the rule in the 'fish fin hand' accompanying injuries of the nerve trunks of the arm. It is felt on the tendons of the wrist while one attempts to extend the fingers.
"Great light would be thrown on this case if we could obtain a reliable record of the first few days after the injury.   What record has the -- Hospital of the first aid?   Did he have extreme pain after the first bandage was applied? How long was it left on? Was he given opiates? Did the hand swell after the bandage was applied? Was it purple? I think an Italian interpreter should see the family and get a matter-of-fact answer to these questions. The ultimate prognosis I believe to be good. He has, I think, passed the turning point now. He is clearly still disabled."

One of the doctors who saw this case was a prominent neurologist, and he believed it was a case of hysteria. It was easy for him to believe that an Italian laborer of 43, in good condition, from merely straining his arm while helping to lift a large stone could have an hysterical attack which resulted in such a serious condition two years later. If the injury had come from a runaway railroad engine, from which the patient in great fright barely escaped, I would be more likely to agree to hysteria; but to suppose an Italian laboring man in lifting a rock would receive adequate emotional cause for a true hysteric attack lasting two years, is more than my mind can follow. It is easier for me to believe that the patient really did strain his arm—perhaps ruptured his supraspinatus or biceps—had hemorrhage in the tissues (there was note of immediate swelling). After this he was put up in a tight dressing by his local doctor. It is easy for me to believe that a swollen arm, bandaged tightly to the chest with a Velpeau bandage, can cause all the symptoms shown by this man. Under these conditions I have several times seen the hand swell, the fingers become crippled, the shoulder joint become fixed, the forearm flattened where it lay in contact with the chest distally, and swollen near the elbow where it was not in contact. Indications of disturbance of the median and ulnar nerves in the hand from pressure from bandages are only too common. Two years after the injury, this patient presented symptoms in accordance with the later effects of such restriction. I believe that if we could have had sections of different parts of the nerves of the shoulder and arm at times during the course of this trouble, we should have found evidence of anaemia, necrosis, and inflammation at various points in the course of the nerves. We should have probably found an anaemic necrosis of the muscles of the forearm of mild degree. The diagnosis in this case would have been traumatic neuritis. If the question had been one of neurosis, should we have found decided atrophy two years after the injury? I think not. Yet the neurologist who made the diagnosis of hysteria accepted atrophy, for hysterical contractures, after several years, have been alleged to bring about atrophy.  I have never seen such a case.

Strongly in favor of the hysterical origin was a test made by the neurologist. He gave an anaesthetic and says in his report: "Under an anaesthetic, rigidity completely disappeared and he was able to move the arm in every direction. When he recovered from the anaesthetic, however, he immediately assumed his former attitude and would not perform, any movement of the arm." The neurologist was unable to effect any improvement by suggestive treatment.
To my mind, even this strong statement does not counterbalance the fact that the X-ray expert reported that the bones of the affected side were markedly atrophied. It is easier for me to believe that the neurologist's examination of the patient under ether was inexact in stating that the rigidity completely disappeared, than it is to believe that atrophy of muscle and of bone of such duration (a year) would not be accompanied by some rigidity in the shoulder joint.
This case is presented more because it illustrates the definitions of the words which head our chapter, than because it is a case in which a conclusion has been reached.  I wanted to illustrate the point of view which the neurologist will usually take, compared to the point of view of a surgeon. I had no opportunity to treat this patient, but I may say now that my own mind is so occupied with rupture of the supraspinatus tendon as the most common cause of obscure shoulder injuries, that I am prejudiced in favor of its being the primary factor in this case, and I should have explored his bursa. The case offers a text for preaching that the application of a Velpeau bandage, after an acute injury to the shoulder or arm, is a serious procedure. Medical students enjoy the triumph of applying their first Velpeau. It is a beautiful bandage which the teacher enjoys teaching, and the pupil enjoys learning, but applied in acute injuries, it is as dangerous as it is beautiful.

Neurasthenia. We use the words hysterical and neurasthenic too loosely. Neurasthenia does not imply loss of function without consciousness of the patient. It implies a relative loss of nervous energy, such as comes from worry and overwork in a normal individual whose resistance becomes lowered, or from congenital or nutritional lack of proportionate control over mind and body. It does not seem necessary to me to discuss this condition, which is so apparent in every sort of post-traumatic lesion. The term should not be used as a definite diagnosis after a given shoulder injury. It is a word to be applied to most long-standing post-traumatic conditions if the nervous element is somewhat in excess. Hysteria, on the other hand, is a definite diagnosis, the name of a subconscious, functional disease. The terms traumatic neuritis and traumatic neurosis, also loosely used, should be distinguished. I think that neurologists feel that traumatic neurosis is a local form of hysteria; that is, a local functional disease, due to a traumatic origin, accompanied by no demonstrable—even microscopic—signs of inflammation in the nerves. Traumatic neuritis, on the other hand, would show under the microscope signs of inflammation somewhere in the course of the nerve. A typical instance might be the adherent nerve caught in the callus of a spiral fracture of the humerus. Such forms of neuritis are, in my mind, very common, and associated with most cases of subacromial bursitis and rupture of the tendons of the short rotators. The myositis in the substance of the supraspinatus muscle, and the anaemic necrosis in its tendon, must have an effect on the finer branches of the suprascapular nerve. Every case of periarthritis following an injury would, therefore, be complicated by some traumatic neuritis.
 
Traumatic neurosis is a term which I think the neurologists use with much the same meaning as I have alluded to as a local fear complex.
I believe malingering per se in Industrial Accident cases must be rare, but I do not think it is unusual for a case, which originally was a disability from bona fide trauma, to become one of typical malingering. The most important reason that this sequence is rare, is, of course, that the benefits received are small.
If we take the five terms used in the heading of this chapter as a whole, including even the malicious element of malingering and the wholly involuntary phases of hysteria, we may at least differentiate this whole group of "nervous conditions" from true cases of injury to the bursa and its adjacent structures. I would certainly not be likely to use any of the above diagnoses in cases which presented atrophy of the supra- and infra-spinatus muscles. Practically every long-standing case of rupture of the tendons of these muscles results in atrophy, and this atrophy persists for many, many months—even after the local lesion in the tendon has been repaired by surgery. It is noteworthy, however, that the deltoid as contrasted to the spinati may be hypertrophied, or at least equivalent to the muscle on the opposite side, because the deltoid is overworked to replace the supra-spinatus.
True lesions in this neighborhood also almost invariably present some limitation of motion in the extremes of the arcs of external rotation and abduction. After a little experience, one can tell at once whether these limitations are due to voluntary efforts on the part of a patient. There is a peculiar feeling about the limitation due to actual adhesions. Limitation due to the patient's unwillingness to allow the arm to be lifted up is quite different. He exerts a voluntary downward pull on one's hand. One may lift the patient's arm with one hand, and feel his opposing muscles contract, with the other.
If the patient has no limitation of motion, and has a jog in that motion, with a disturbance of the scapulo-humeral rhythm, it is very unlikely that the nervous element is predominant. It is scarcely possible for those who have not given attention to lesions in this region to appreciate the amount of pain and disability which may be present in a patient, who, to a superficial examiner, appears to have no decided signs of any lesion. I cannot too strongly recommend a search for atrophy, limitation, and irregular scapulo-humeral rhythm. It is due to the fact that these symptoms have been ignored that the diagnosis of rupture of the supraspinatus has been so long delayed in attaining publicity. Do not laugh at a display of "nerves" when these signs are present. Instruction about them does not receive its fair share of a medical student's time. We were taught in detail the rarer forms of fracture and dislocation which are obvious to any one who has learned his anatomy, but nothing is said of this truly more important lesion. This chapter may seem to have been written to belittle its title, but I have tried to give due proportion to the ever-interesting effects of the mind on the body, so far as the shoulder is concerned. I do think that there is usually a physical basis for complaints of pain after shoulder injuries, and that injuries of the supraspinatus should be carefully considered in every case.

REFERENCES

I know of no articles which relate to hysterical manifestations in lesions of the shoulder.