9 Established 1852
for the
Medical and Biological Student's Outfit
62 THE SPECULUM. May, 1918.
true in the alimentary tract. Recently I attended a meeting of the British Medical Association to hear an able paper on Gastric Fever by Mr. A. B. Devine, and a discussion on its treatment.
The paper was discussed by the leading physicians and surgeons of Melbourne. Diagnosis in particular was considered. To my astonishment no mention was made of what is known to our French brethren as the false gastropath, i.e., the psycho neurotic whose symptoms may mimic accurately a gastric ulcer, or any other organic gastric lesion. This is no rarity. Let me quote you a typical case.
Mrs. B., aged twenty-nine years, complains that for six months she has had severe pains immediately after meals, and frequently vomits her meal. She has lost 42 pounds weight.
Her appetite is very poor. She is constipated. Test meal shows a hyperchlorhydria.
Examination : An emaciated woman with much epi- gastric tenderness. She is treated in hospital by Lenhartz method. There is no improvement. Let us now investigate her Psyche. What do we find ? Her husband for the last six months has neglected her. He spends all his time elsewhere and refuses to let her know what he is doing. She feels this very keenly, and weeps while relating it. She is evidently in a state of extreme and constant misery. Experience has shown that even in the presence of such an exact replica of an organic syndrome the greater probability in such a case is that the ail- ment is a pure neurosis and deserves treatment first on that theory.
The two cases detailed give, I hope, some idea of what we are not taught to observe. From my own experience I would say that at a moderate estimate 25 per cent. of patients are pure psychic neurotics, and the majority of the rest have some psychic neurosis superimposed as an organic lesion.
In seeking to discover a neurosis, the following considera- tions are extremely helpful.
(I) An inquiry as to whether the appearance of symptoms coincided with any important or keenly felt change in the moral, social, financial, spiritual or emotional existence of the patient.
(2) Do the symptoms vary with variations of happiness or fortune?
(3) Are the symptoms illogical?
(4) Are the symptoms superabundant?
(5) Do they closely follow the schenatic syndrome of the klisease?
( 6) Other functional disturbances may always be dis- covered if searched for.
No. 5 happens because the patient often subconsciously creates the symptoms from the doctor's questions.
The consideration of the possibility of such a diagnosis should, I urge, be a routine method with every student and physician. The diligent inquirer will largely increase his know- ledge of human psychology, and so increase tremendously his ability to remedy disabilities and disease. One word of warn- ing is necessary. Do not despise the poor patients because they have no material lesion. Remember that they are ignorant of physiology and pathology. You will find that those most liable to suffer in this way are often excellent people, who will becotne grateful and devoted patients of the man who takes the trouble to understand them and extends sympathy and help.
In this short paper my treatment of the subject is neces- sarily imperfect. Still, T, hope that I have given some insight into the importance -of the subject. My views are based on those of the late Professor J. J. Deferne, of Paris, one of the foremost neurologists of France, a man whose researches into the moral and morbid anatomy of the nervous system, and whose efforts in the classification of nervous diseases, earned him a world-wide renown.
If he were . alive to-day. fresh gratifications would meet him. In England the foremost neurologist of the day, Dr.
F. W. Mott, with whose name all medical students are familiar.
has adopted his definition of neurasthenia. Shell shock. which is declared by Mott to be neurasthenia and no more, is now being treated in England on the lines laid down by Deferne.
I hope that his views will eventually penetrate to Australia.
Further, with this addition to your case-taking you will do more to fit yourself for the successful practice of Medicine.
For in dealing with your patients you have to deal with persons as well as with diseases. In this connection let me quote Jar- dine, who said the other day that in his opinion it was a pity students did not commence hospital practice in their second year as they used to do. For they then took a more direct per- sonal interest in their patients. In their later years they were apt to regard them from the standpoints of anatomy, physiol- ogy, etc.
Finally, there is a great truth in the Frenchman's dictum
"There are no diseases, there are only sick people."
—G. P. O'Day, M.D
'64 THE SPECULUM. May, 1918.
Medical Commentary.
By. Dr. T. P. Noonan.
Mr. J. B., aet. 55, Horse-trainer, on December 12th had a r. ;or lasting about 15 minutes. This was followed (in his own words) by generalised pains and headache, with feverish- ness, loss of appetite, and of energy. He was ill for about 5 days, and remained in bed for that time. Although feeling weak, he resumed his occupation. Two days later he again felt very ill, and took to bed, sending for the doctor. He complained of considerable weakness, and had a troublesome cough, with yellowish expectorations, but no pain. There was some frontal headache.
On examination, the patient was very flushed, and was drowsy. T. 103°, P. 110, R. 30. Pupils equal, and reacting
normally. No strabismus. No neck stiffness.
Patient had always been of aood habits, and there was no history of venereal disease. For seven days, the patient's condition showed little alteration, the evening temperature reaching 103°, with intermissions. ' Pulse varied from no to 126, and the respiratory rate from 28 to 34. There were
some sweats.
Thereafter, until the fourteenth day, the temperature, pulse. and respirations gradually fell until the evening tem- perature reached 99.8°, the pulse ioo, and the respirations
22. There was corresponding improvement in the lung signs.
Two days later the temperature again rose to 103°, and the pulse to 130, the respiratory rate remaining at 26.
Tongue furred and brown in centre.
Both sides of chest moved equally without pain.
Heart showed no alteration of dulness, and the sounds were clear.
There was some dulness at each base, with rise of pitch of respiratory sounds, scattered crepitations, and increase of vocal resonance in parts. These changes were more marked at the right base. Abdomen was clear, except for some ten- derness of the right kidney region.
No abnormalities could be made out on examination of the nervous system.
Urine, clear ; Sp. gr., 1014; trace albumen; no sugar; no pus cells.
Bowels had been open each day since onset of illness.
The lung signs showed little change except that, at the angle of the left scapula, there was a somewhat circumscribed patch about the size of the palm of the 'hand, showing some