The Organic Origin of Apparent Functional Nervous Disease

THE ORGANIC ORIGIN OF APPARENT FUNCTIONAL NERVOUS DISEASE

LERoy H.

SLOAN,

M.D.*'

CASE I

OUR first patient, a white male aged 45 years, was first seen in January complaining of weakness, easy perspiration, loss of a slight amount of weight, ready flushing, hot flashes, restlessness and tremor of the hands together with palpitation -of the heart. This symptom complex was not constant but canle-lfi attacks or waves. During such waves the patient was compelled to sit down. After resting for a few minutes the symptoms and signs would disappear and the patient would return to his duties. On some days the spells were frequent while on others they came only occasionally. There was loss of weight, loss of appetite, increasing frequency of bowel movement, moderate vertigo and insomnia. The patient had always lived with his mother. He had never married. He had never been able to mix well with people and as a result had isolated himself from practically all social contacts and given himself over to the care of his mother. The mother died during the preceding April. Some three or four months afterward the above train of symptoms put in their appearance. Several clinical syndromes come to mind. Does the patient have hyperthyroidism? While the symptoms suggest such a diagnosis, the wavelike character of the cycle does not. Also, the basal metabolic rates which were taken many times were extremely labile-one day up and the next down, inconsistent and not dependable. The pulse during the attacks would be rapid and at rest, afterward, would be normal. It was our impression that the patient did not have either a toxic adenoma or hyperplastic thyroid to account for h~s difficulties. There was no palpable enlargement of the thyroid at any examination. A second clinical syndrome for passing consideration is the currently popular male climacteric. This patient had to all ordinary study no evidence of a male menopausal status. True, he had never experienced any real sexual urge but his present gonadal status" varied little from that of his past years. From the Illinois Central Hospital, Chicago. • Professor of Medicine, University of Illinois School of Medicine; Director of the Medical Service, Illinois Central Hospital; Adjunct Staff, St. Luke's Hospital. 30

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A third syndrome suggested by the easy palpitation, flushing, rapid alteration in pulse rate, variation in blood pressure, and weakness, was postural hypotension. But here again there was no finding to clinch such a thought. The pressure, while very labile, did not conform to the pattern of postural drop. The syndrome of hyperirritable carotid sinus could not be confirmed. During the period of the last war this case would undoubtedly have been labeled as neurocardiac asthenia or effort syndrome. Blushing, flushing, sweating, palpitation, nervousness, tremor, irritability, apprehension and loss of confidence with labile blood pressure and more labile pulse-what more could be needed? During his first sojourn in the hospital there was relatively li~de change in his status. He continued to be a very apprehensive, ea'$ily irritated, anxious type constantly interrogating all who came near him and at all times asking questions about his physical and laboratory findings, his future status in his work, and in society in general. Several capable internists saw him from time to time and all came to the same conclusion: that this patient aside from a mess of infected teeth was suffering from a functional condition conforming more to an anxiety neurosis than to any other syndrome or classification. This impression was confirmed by psychiatric consultation. So our patient was discharged from the hospital with the advice to have his teeth cared for, to keep with other people, to obtain and consume a generally nutritious and balanced diet, to engage in the usual and currently considered normal functions of existence, and to report from time to time for further study and check up. The patient returned in November almost eleven months after his initial admission to the hospital. About six months after his previous discharge he first began to have pain in the left arm. He had gained a little weight prior to this time, had received attention to his teeth with the extraction of most, had thought that he was fairly well. His failure to gain much weight he al$ributed to his inability to procure sufficient food because he stilled lived alone, still ate wherever he happened to be. His friends had been very cooperative and his employers more than kind. A much easier job had been assigned to him. On 'examination in November the patient showed all of the symptoms and signs mentioned above-the waves of flushing, of sweating, of palpitation, and so forth-hut-there was beginning atrophy of the small muscles of the hand, there was numbness of the small and ring fingers, and the complaint of pain which began in the arm, advanced to the left shoulder and subscapular area and into the c;:ubital space.

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LgROY H. SLOAN

In the supraclavicular area on the left there was a small gland. This gland was removed and microscopic examination showed it to be metastatic adenocarcinoma. Here then was the organic origin of our patient's difficulties. Away went the anxiety neurosis, away the cardiac asthenia, away the male climacteric. The blood pressure remained the same, the heart rate the same, the weight decreased, atrophy advanced, pain became much more severe, more glands appeared. The blood Wassermann and Kahn tests were, as one might expect, entirely negative and the spinal fluid showed no block. It was clear, with only six cells and 29 mg. of total protein, a negative Wassermann reaction and a flat gold chloride curve. When the carcinomatous gland was found, repeat x-rays of the lung and chest cage were made. In the apex of the left upper lobe was an increased soft tissue density. A classical Horner's syndrome made its appearance on the left with enophthalmos, miosis, ptosis. Gradually the pain spread to the right side. Roentgen therapy was given to the area of the left supraclavicular fossa, cervical vertebrae, and the lung. There was a consistently downward course and the patient expired sixteen months after his initial complaints. Autopsy showed an adenocarcinoma involving the apex of the left lung, the left cervical and supraclavicular soft tissues, the cervical fifth, sixth and seventh and the first dorsal vertebrae. CASE 11

Our second patient was a clerical worker 57 years of age who had been under treatment in the outpatient department at irregular intervals. The history obtained therein was chiefly of pain in the right shoulder and right arm. This pain had come on following a night of bowling after which he went out into zero weather before he had had an opportunity to cool off. The next morning he developed sharp pain beneath the right shoulder blade. The pain was quite constant and not affected by any motion of the shoulder, the elbow, the wrist or the neck. The pain was worse in cold weather, much worse in very cold weather, relieved in part by heat, either moist or dry, very slightly relieved by salicylates and similar antineuralgic medication. The patient insisted that the pain was now limited to a small area of the arm and elbow region, appeared to originate above the clavicle but was most marked at or near the elbow. From February on the difficulty persisted until he became extremely nervous and took to heavy drinking to relieve the distress. All laboratory examinations were negative except for a slight clouding of the right apex of the

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lung which was interpreted after much discussion as probably tuberculosis of minimal extent. The patient became increasingly difficult to manage, increased the length of his alcoholic sprees, refused hospitalization, became more and more apprehensive but, apart from the slight clouding of the right apex, showed no single pathological or clinical finding of any moment. He was therefore regarded as a high grade psychoneurotic patient with an anxiety state. The alcoholic factor was given due consideration and felt to be just one more added factor in the clinical picture and perhaps the important one. However, he was given a few injections of sodium salicylate and iodide of sodium intravenously. Radiant heat was advised and administered to him at irregular intervals along with medication by mouth and the usual topical applications for nonspecific neuralgic pain. However, in the minds of all who contacted him there was the settled feeling that here was a high grade psychoneurotic patient trading on a functional difficulty and bathing his depressed spirits in alcoholic libations far and beyond the therapeutic dosage. In October he finally came into the hospital. Ten days before this admission he had developed pain across the right chest from the midline and referred up to the arm and the muscles of the neck. General examination at this time was again negative. The laboratory examinations were normal throughout. There was no pain of any sort on any motion of the shoulder, elbow, wrist, neck or body. Yet the patient complained bitterly of pain down the right arm and especially along the medial border of the triceps and ulnar border of the lower arm. Of great importance to all of us should be the continued complaint of the patient of pain in one general area, in this instance in the right arm, shoulder and I,leck. This insistence points to an organic lesion and not to a functional one. In the functional patient other areas are sooner or later incriminated. Rarely does he stick to one portion of his anatomy. The paucity of physical findings may be present in both. Why did we regard the patient as a psychoneurotic? Chiefly I expect because we could find no other explanation for his distress. Here was a patient who had been divorced, who had a background of unhappiness as the soil for his anxiety state, who had taken to alcohol to cure his difficulties and who continued to bowl right along even up to the time when he came into the hospital. His stubborn and uncooperative nature just added that much more evidence that our patient was suffering from a functional state. But, let us follow him a bit longer. Within a few days after admis-

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LEROY H. SLOAN

sion to the hospital the lesion in the apex of the right lung had spread until there was now an area of opacity very suggestive not of tuberculosis, not of an apical cap, but of malignancy. Here, then was the organic basis for his supposedly functional state. Shortly after this the patient began to show atrophy of the muscles of the lower right arm and hand, the right pupil became smaller than the left, the palpebral fissure narrowed and the bulb retracted-all indicating a Horner's syndrome produced by compression or infiltration of the tissues of the sympathetic system. This patient began to have symptoms after bowling for several hours and then going out into the bitter cold-a perfect setting for a refrigeration neuralgia or neuritis or whatever onc might wish to call it. But, the lesion in the right apex spread, involved the cervical vertebrae, compressed the brachial plexus, comprised the esophagus and the trachea, finally led to a paralysis of peripheral type of the entire right arm with glossy skin, atrophy and weakness. The patient terminated his earthly sojourn eighteen months after his initial complaint. For exactly a year from the time of his first complaint there were no demonstrable bony changes even of minor degree. Now what was found at autopsy on this patient? A carcinoma of the apex of the right lung beginning in the bronchial structures and extending into the superior sulcus area, invading the ribs, the cervical vertebrae, and the soft structures at the base of the neck on the right side. In my experience the tumors of the apex of the lung have been more often on the right side, have produced pain at some stage in their course, and have originated in the great majority of instances in the bronchial tissues and not in the tissues of the nervous system. In other words, superior sulcus tumors are usually bronchogenic carcinomas. SUMMARY

We have presented as examples two patients both regarded as suffering from functional nervous disease over a period of weeks and months. Both were shown on further examination to have tumors of the lung, one in the right apex and the other in the left apex. Both were examined by competent internists and neurologists. The one exhibited many of the symptoms and signs seen in panic reactions of anxiety neurosis; the other, consistent pain in the right arm. One lived sixteen months and the other eighteen months after the initial complaints began. Both were shown at autopsy to have sufficient organic, neoplastic disease to explain all of the symptoms presented throughout the long course of their illnesses.

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The consistent segmental distribution of pain is assumed to be of organic origin until proved by long observation not so to be. Pain in the upper chest or arm associated with slight percussion dullness over the apex and linked with a history of even slight hemoptysis is highly suggestive of apical carcinoma. Persisting pain in the arm with atrophy or weakness or numbness of the extremity calls for x-ray study of the apical portions of the lung. A palpable gland in the supraclavicular area should be removed for microscopic study. Most of the apical tumors giving the above symptoms and signs have been shown at autopsy to be bronchogenic carcinomas. Occasionally, as in one seen previous to the case described and showing much the same clinical picture, they are from nervous tissue of the sympathetic system.