An Unusual Form of Bronchiectasis

1898 Boston Medical and Surgical Journal  
develop in public was sufficient to excite them. This apparently capped the climax aud rendered further work exceedingly difficult. As an exciting cause, autosuggestion in the form of apprehension undoubtedly played a part, as I believe. He was in constant apprehension that when he was placed in certain positions the neurosis would strike him. As already explained in the previous cases, this is equivalent to an auto-suggestion, such as, " When I am acting under such circumstances and such a
more » ... g happens, I shall feel so and so." This thing does happen and the neurosis is exploded as an automatic process. When overtired his condition was distinctly worse. The treatment in this case was based upon the above analysis. The idea of neurasthenia was rejected, and the pathology as above outlined was explained at great length to the patient, who recognized its correctness and lent himself heartily to the new plan of treatment. Without this co-operation I believe this would have been a failure. My idea was to artificially create in the patient's mind a fixed idea which should comport with the truth on the one hand, and which should be antagonistic to and therefore would inhibit the morbid idea and its consequences. To this end the following was written on a piece of paper : " These symptoms are only physical processes which by habit have become associated together by a previous pathological mental state. This mental state having subsided, the association will subside and I have nothing to apprehend." This was later changed to : " I know I am the equal of the others. These symptoms are only physical processes which by habit have become associated together by a previous lack of confidence in my ability. Having now regained this confidence and knowing that I am the equal of others, this association will subside." This he was told to learn by heart, and to repeat it constantly to himself on every possible occasion-when he was by himself, and as he walked the streets, the last thing before going to sleep, and especially before undertaking bis professional work in public. The result was decidedly favorable. The psychosis steadily grew less aud in a month or two had substantially subsided. Nevertheless, there has beeu during the past year a tendency to relapse. But the course has been steadily towards improvement, until now his symptoms occur in so moderate a form that he no longer dwells upon them. [Another year has passed since this was written. Although it is not easy to state with absolute accuracy the present condition of this patient, it is well within the truth to say, from my own frequent observations and the patient's own statement, that although not completely free from trouble, yet when we compare his condition with what it was, as shown by my earlier written notes, he is immensely improved. He is still troubled at times, but the attacks are mild, the secondary symptoms have disappeared, he does his professional work without particular discomfort, aud his whole attitude of miud towards his trouble is different.] Sometimes this neurosis does not occur in a pure form by itself, but forms a group of symptoms superimposed upon and complicating another disease of a different nature, perhaps true neurasthenia. For example, I have under observation now a young man who is a neurasthenic of probably a degenerate type, and therefore in certain respects incurable. In him certain habits of mind aud certain peculiarities of body can be recognized, which are undoubtedly due to degenerative processes. Besides symptoms of neurasthenia he exhibits in a very neat way this phobo-neurosis. When brought face, to face with people, particularly women, though the same may happen with men, he has a peculiar set of sensations which develop iu the following order : (1) a feeling of shyness or confusion ; (2) the face flushes ; (3) confusion of thought ; (4) feeling of general weakness. Some palpitation occurs during the attack, but its exact position in the order is uncertain. In extreme attacks, ataxia or clumsiness of gait is added to the above. These symptoms are of such intensity as to be a matter of considerable suffering and to cause the patient to make many sacrifices for relief. They come on with a rush or suddeuuess which does not allow for thought, aud all the circumstances under which this occurs allow of no doubt of the iudependent automatism of the ueurosis. Professor in Medicine in University of Denver; Visiting Physician to Arapahoe County Hospital, etc. Certain features of the following case will be seen to differ markedly from those commonly met with in this affection : Wm. Moeler, age forty-four, laborer, was admitted to the County Hospital March 25, 1897. He gave the following history : At the age of twelve he had " pleurisy." At eighteen he began to suffer from asthma, which continued off aud on in a mild form until twelve years ago, about which time he came to Colorado. It then ceased, and he has since been perfectly well, without cough or other evidence of his former trouble. His present illness begau three months ago as a pain in the region of the left nipple which lasted two hours and was very severe. This was followed immediately by a cough, which still continues. Expectoration was moderate at first, and for a day or two reddish in color ; later it became purulent, increased in quantity up to a pint iu twenty-four hours, its près ent amount, and almost at the outset, he thinks, became offensive in odor. He has not at any time been confined to bed. He speaks of chilly sensations at the first, but does not think he had either fever or dyspnea. He now weighs one hundred and twentyfive pounds aud says his loss of flesh has been very moderate. At the present time his chief complaint is cough, abundant fetid expectoration, soreness in the region of the left nipple, and some general debility. The Physical Examination shows a mau of medium size, rather poorly nourished, faciès pale and somewhat phthisical in appearance. Cough almost constant, with frequent raising of a purulent aud very offensive sputum, necessitating isolation. Patient is up and about; his pulse ranges from 95 to 100, respirations 22 to 28, and temperature normal to 101°, there being daily a rise of at least one degree. The chest presents nothing abnormal on inspection or palpation. Percussion discloses a peculiar coudi-
doi:10.1056/nejm189812221392502 fatcat:kf2zeeknnzcatnlsa63nvwvwrm