Diseases of the nervous system / edited by Archibald Church.

Date:
1908
Catalogue details

Licence: In copyright

Credit: Diseases of the nervous system / edited by Archibald Church. Source: Wellcome Collection.

    1159/1256 (page 1117)
    pupils, pallor of the optic disc, absence of the patella reflex, degenerative muscular atrophy, a lead line, sugar or albumin in the urine, extreme ar- teriosclerosis, or similar conditions, the most obvious inference is that no neurosis is present. Of course traumatic neuroses are somewhat more apt to be accompanied by organic disease than the non-traumatic—as I tried to explain when discussing the symptomatology—and only when the compli- cated organic symptoms are subordinate to the entire pathologic picture may we conclude that a neurosis is present. This is the case when there is slight arteriosclerosis after injury in a person who shows chiefly the general ob- jective and subjective symptoms of the neurosis or similar conditions. If the organic symptom present is pupillary rigidity or something of like importance, we must have other and cogent reasons for believing a neurosis to be present before we can make such diagnosis, or can believe that symp- toms of two different natures, one of a neurosis and one of organic disease, coexist. In practice this generally occurs when the organic sequels of chronic alcoholism (disturbance of pupillary reaction or optic atrophy) or of an old syphilitic infection are joined to neurotic symptoms. Among the organic diseases of the nervous system which must be con- sidered in the differential diagnosis are a few which, especially at the onset of the affection, may completely simulate a neurosis. Chief among these are progressive paralysis and brain tumor. A case of the latter proved most instructive to me. The patient was a man with a severe injury of the head. He presented marked symptoms of a neurosis, but under any psychical influence there was such a conspicu- ous variation in his condition and complaints (uncertainty in gait) that we seriously considered a diagnosis of hysteria, and thought certain symptoms to be feigned. While under observation, however, objective signs rapidly appeared which permitted the diag- nosis of brain tumor, and autopsy revealed a tumor in the anterior portion of the brain. In a pathologic condition like that just described the decision whether the affection is functional or organic may not always at first be possible; nevertheless, after an examination, especially after several such or after clinical observation, it can be made with great certainty. But there are con- ditions in which such a diagnosis, or even a differential diagnosis, cannot be made; I refer to the cases in which, following severe injuries to the head, there is mental depression, inhibition, general psychical dulness, vertigo, headache, general adynamia, etc. This symptom-complex, as Friedmann demonstrated, is often due to the multiple but slight organic changes in the cerebral vascular apparatus and its surroundings. It is no doubt true that Friedmann’s findings are observed in only a few of the cases with this clin- ical picture, and that others with exactly the same clinical phenomena are purely functional. But Friedmann’s investigations and similar ones make it appear likely that in the future many other symptom-pictures following trauma, which have so far been regarded as functional, will be proven to be due to an underlying organic condition. Assuming that examination has revealed no organic change in our pa- tient, even this does not certainly prove a neurosis, and our object has been only partially attained. For in the preceding consideration we always as- sumed the presence of distinctly objective pathologic symptoms. If the