THE PAINS OF HYPOCHONDRIASIS.
There is perhaps nothing, in the whole range of practical medicine, more
difficult to seize with clear comprehension, and picture to the mind
with accuracy, than the group of pseudo-neuralgiae which belong to the
domain of hypochondriasis. They are among the most indefinable, and at
the same time the most intractable, of nervous affections.
To understand what hypochondriac pains are, we must first be familiar
with the general character of the hypochondriacal temperament, for the
pains are only a subordinate and ever-varying phenomena of the general
disease.
Hypochondriasis is not insanity, if by insanity we mean intellectual
perversion dependent mainly or entirely on the state of the higher
nervous centres. But it is closely allied to insanity in its phenomena,
only that these are, as it were, manifested in a scattered form,
unequally distributed over the whole central nervous system, and
especially affecting the spinal sensory centres. And its radical
relationship to true insanity is strongly indicated by the fact that the
sufferers from hypochondriasis are nearly, if not quite, always members
of families in which distinct insanity has shown itself; indeed, more
often than not, of families which have been strongly tainted in this
way. In the majority of instances there are psychical peculiarities of a
marked kind which accompany or precede the development of the abnormal
sensations which form the especial torment of hypochondriacs. Without
apparent cause, they begin to evince a heightened self-feeling and an
anxious concentration of their thoughts upon the state of one or more of
their bodily organs. Or it may be that, before any such definite bias is
given to their thoughts, they simply become less sociable and more
self-centred, and are subject to fits of indefinite and inexplicable
depression, or at least to great variability of spirits. But before long
they begin to experience definite morbid sensations, most commonly
connected with the digestive organs, and very often accompanied by
positive derangement of digestion of an objective character; such as
flatulence, sour eructation, spasmodic stomach-pain, etc. Along with
these phenomena, or soon afterward (and not unfrequently before the
patient has acquired that intensity of morbid conviction of his having
some special disease which is afterward so marked a peculiarity of his
mental state), he very often becomes the subject of the kind of pains
which it is the special purpose of this chapter to describe.
The pains of hypochondriasis, when they assume any more definite form
than that of mere dyspeptic uneasiness, present many analogies with
neuralgia. They are not, usually, periodic in any regular manner, but
they have the same tendency to complete intermission, and they
frequently haunt some one or more definite nerves for a considerable
period of time. Of all nerves that are liable to this kind of affections
the vagus is undoubtedly the most susceptible; hypochondriac patients
very frequently complain of pseudo-anginoid and pseudo-gastralgic pains;
next in frequency are nervous pain in the region of the liver, or in the
rectum or bladder. The main distinctions by which they are separable
from true neuralgia are two: in the first place, the character of the
pain nearly always is more of the boring or burning kind than of the
acutely darting sort which is most usual in true neuralgia; and,
secondly, the influence of mental attention in aggravating the pain is
far more pronounced than in the latter malady; indeed, it is often
possible, by merely engaging the patient in conversation on other
topics, to cause the pain to disappear altogether for the time. But in
hypochondriasis it is not often that we are left, for any long time, to
these means of diagnosis only; the special character of the disease is
that the morbid sensations shift from one place to another, in a manner
that is quite unlike that of the true neuralgias. The patient who to-day
complains of the most severe gastralgia, or liver-pain, will to-morrow
place all his sufferings in the cardiac region, or in the rectum, or
will complain of a deep fixed pain within his head; and these changes
are often most rapid and frequent. Frequently there are also peculiar
skin sensations, which usually approach formication in type, and these,
like the pains, are apt to shift with rapidity from one part of the body
to another. Later on in the disease, especially in those worst cases
which approach most closely to the type of true insanity, there are
often hallucinations of a peculiar and characteristic nature, such as
the conviction of the patient that he has some animal inside him gnawing
his vitals, that he is made of glass and in constant danger of being
broken, and a variety of similar absurdities. In short, it is not the
fully-developed cases of hypochondriasis that need puzzle us, these are
usually distinct enough; but the earlier and less characteristic stages
in which pain may be nearly the only symptom that is particularly
prominent.
In hypochondriasis, as in hysteria, there is often great sensitiveness
of the surface; and, as in hysteria, this sensitiveness is found to be
very superficial, so that a light touch often hurts more than firm, deep
pressure. As in hysteria, too, the tenderness is a phenomenon so greatly
affected by the mind, that, if we can divert the patient's attention for
a moment, he will let us touch him anywhere, without noticing it at all.
It is a marked peculiarity of hypochondriasis that it is far more common
in men than in women; a relation which is precisely the opposite to that
which rules in neuralgia. Hypochondriasis is also pre-eminently a
disease of adult middle life; it is scarcely ever seen in youth, except
as the result of excessive masturbation acting on a temperament
hereditarily predisposed to insanity.
The results of treatment frequently assist our diagnosis in difficult
cases. Almost any medicine will relieve the pains of the hypochondriac
for a time, and it is generally far easier to do him good, temporarily,
than it is to relieve a neuralgic patient; but, _en revanche_, every
remedy is apt to lose its affect after a little while. The only chance
of producing permanent benefit in hypochondriasis is by the judicious
combination of remedies that remove symptoms (especially dyspepsia,
flatulence, etc.), which mischievously engage the patient's mind, with
general tonics, and, above all, which such alterations in the patient's
habits of daily life as take him out of himself and compel him to
interest himself in the affairs of the world around him. And, after all,
our best efforts will frequently lead to nothing but disappointment.
It is notoriously the fact that hypochondriasis especially affects the
rich and idle classes; but it would be a great mistake to suppose that
it never attacks the poor or the hard-worked: only, in the latter
instances, it apparently needs, for it development, the existence of
strong family tendencies to neurotic disease, and especially to
insanity. Among the numerous debilitated persons who attend the
out-patient rooms of our hospitals we every now and then encounter as
typical a case of hypochondriasis as could be found even among the rich
and gloomy old bachelors who haunt some of our London clubs. I have one
such patient under my care now, who has been a repeated visitor at the
Westminster Hospital during many years: he has had pseudo-neuralgic
pains nearly everywhere at different times; but his most complaint has
been of pain in the groin and scrotum of the right side. The existence
of what seemed, at first, like the tender points of lumbo-abdominal
neuralgia, at one time led me to believe it was a case of that
affection; but I was soon undeceived by finding that the tenderness did
not remain constant to the same points, but shifted about. This man has
professed, by turns, to derive benefit from nearly all the drugs in the
Pharmacopoeia; but the only remedies that have done him good, for
more than a day or two at a time, have been valerian and assafoetida,
with the prolonged use of cod-liver oil. He will never be really cured;
and I suspect that the secret of his maladies is an inveterate habit of
masturbation acting on a nervous system hereditarily predisposed to
hypochondriasis.
Sometimes it happens that the starting-point of hypochondriac pains,
simulating neuralgia, is a blow, or other bodily injury acting on a
predisposed nervous system. Another of my patients at the Westminster
Hospital was a policeman, who had received a severe kick in the groin;
he suffered pains which at first seemed to wear all the characters of
true neuralgia in the pudic nerve, but afterward shifted to other places
and exhibited all the intractability of hypochondriasis; the patient
also developed the regular appearance and the characteristic
hallucinations of the latter disease. On the last occasion when I saw
him, he struck me as likely to become really insane, in the melancholic
form; and the probability is that the casualty which he suffered was
only accidentally the starting-point of a malady which was inherent in
him since birth, and would have been developed, in any case, at some
period of his life.