Psychotherapy / Including the History of the Use of Mental Influence, Directly and Indirectly, in Healing and the Principles for the Application of Energies Derived from the Mind to the Treatment of Disease

by James J. Walsh

NURSING

The attitude of mind of a woman toward her milk supply is important, as the flow of milk is closely subject to mental influence. The presence of the child and the consequent exercise of maternal instinct does more to bring about the prompt, healthy flow of milk than anything else. Sometimes women in the later months of their first pregnancy upon seeing a mother nursing her child have felt the flow of milk to their breasts not rarely with such painful overdistention of the milk ducts as to require artificial relief. On the other hand, a fright may stop the flow of milk or make it scanty and a mother's aversion to a child may prevent her being able to nurse it. The sight of the father of the child in a state of intoxication may have a similar result.

How much milk supply may be dependent on the state of mind, or at least the state of the nervous system, can be realized from the animals from which we obtain milk. Any serious disturbance is likely to interfere with the milk supply. When a cow's calf is taken away the animal will often refuse for a time to give milk. If a cow is scared, as by the attack of a wild animal, or by being hit though only slightly injured by an engine, it will often not have milk for several days or even longer. There is an impression prevalent among farmers that if a cow takes a dislike to a particular person they are not likely to "give down" as much milk as would otherwise be the case. This may be only a curious farmer tradition, that has no basis in fact, although it is supported by so many observations reported from many different countries that it is apparently to be taken as of scientific value.

In modern times many fashionable women do not nurse their children because they have not the proper supply of milk. It is easy to see how this can be brought about through suggestion from many sources and the sight of others neglecting their duty in this matter. Most fashionable women would rather not nurse their children, and yet many of them feel a bounden duty in the matter. Some of these, however, having heard that many mothers of the better class are not capable of nursing their children, easily persuade themselves that they come in this category, and so their whole attitude of mind toward nursing is one of extreme doubt. Knowing as we do how the mental state influences nursing we are not surprised when these women prove not to have sufficient milk in the early days of the nursing. If they are to have it they must look forward with confidence to nursing their children and they must be ready and willing to take such food and secure such fresh air as will put them in the best possible condition for this function, always with the thought that nothing can be better for a child than to be nursed by its own mother. Nature has made exactly the form of food suited for the particular child, and it matters not how healthy a wet nurse may be, her milk is not likely to be so suitable. Much depends on the nutrition of the child during this early susceptible period of its life and there is more that passes over with the milk than merely the food elements. It is well recognized now that the reason why nurslings are protected from most of the so-called children's diseases and the contagious diseases generally, is that, as a rule, their mothers [{461}] have had these diseases, have acquired an immunity to them and this immunity is transferred to the child so long as the nursing process is continued. This has been shown to be true over and over again in animals and holds good for human beings.

Professor Von Leyden, the distinguished professor of medicine at the University of Berlin, points out that we are not quite sure as yet just what may happen to the human race from the very general refusal of mothers to nurse their children and the almost universal substitution of the bovine mother; whether in times to come certain bovine traits, at least as regards susceptibility to disease, may not be stamped upon the human race, cannot be determined until this experiment in ethnology, now being conducted on so large a scale, has been carried to some definite conclusion.

Perhaps this view is groundless, but there is no doubt that milk is more than merely a food and that during the period after birth when the child's nervous system is being formed, the perfectly adapted mother's milk is more likely to be the proper food than anything that human ingenuity can elaborate. We have heard much in recent years of the tendency of education and civilization to lower the birth-rate and to make women less fitted for maternity and for such maternal duties as nursing, but stronger than any deterioration of the physical constitution by the mental development is the unfortunate unfavorable effect of mental suggestion upon such functions, by which the preparation of the organism for their fulfillment is greatly influenced. It is in this respect that the women of to-day differ from the woman of the past much more than in mere physical development.

CHAPTER II
MATERNAL IMPRESSIONS

"Maternal impression" is accepted as a specific designation to signify the real or supposed influence of emotion and especially serious trouble, which may affect the mother's mind during pregnancy and be transferred to the child in utero, with the production of deformities or mother's marks. There used to be an almost superstitious belief in the power of the maternal impressions to influence unfavorably the child in utero. With the newer developments as to the influence of the subconscious and subliminal there might well occur in some minds an exaggeration of these ideas with the production of much mental suffering at least, if not of more serious results.

Maternal Impressions in Old Literature.—The belief in the influence of maternal impression on the child in utero is so strongly fixed that to most people it will seem paradoxical to question the whole subject. The evidence for it, however, is quite trivial, and none of it rises above the grade of what may be explained by coincidence. But there are many apparently insuperable difficulties, from the standpoint of our modern scientific knowledge, with regard to the whole subject. If we take up the medical books and the popular science, or rather pseudo-science, and the folk stories of a century ago we find overwhelming evidence for the belief in maternal impressions. More recent [{462}] literature has but few examples, and the more the details are studied the less is the evidence of any kind that the mother's mind influences her unborn child. There is really no more reason why a child should he marked within its mother's womb than that it should be marked while nursing at the breast if something should happen to the mother at that time. This latter effect strikes one at once as absurd; the former, as we shall see, is exactly of the same nature.

Many of the older stories of maternal impressions are reported on no better grounds than the vomiting of snakes and the like, even live mice, which used to be found in old-time medical literature. It is true that there was usually no such morbidity about the stories of maternal impressions, but men wanted to find some explanation for the problem of the occurrence of deformities and markings and the maternal impression idea seemed satisfactory and inviting by its very mystery. The belief that animals could live for some time in human stomachs is now relegated to the limbo of old-time credulous traditions. Maternal impressions are on the same path and in twenty-five years they will be as great curiosities in serious medical literature as the gastric fauna of two generations ago. Under these circumstances prospective mothers who are anxious over possibilities and who have dreads of all kinds about their unborn children should be reassured and informed as to the scientific status of this important question.

Mother and Child Distinct Beings.—There is no direct connection between the mother and her unborn babe. No nerves run in the cord and none pass from the uterine tissues to the placenta. It is easy to understand the influence of mind on body under ordinary circumstances, at least the mystery has a rational explanation. The central nervous system rules the nutrition of the body. To cut off the nerve supply has as serious an effect as to cut off the blood supply. Owing to the existence of a chain of neurons, that is, a succession of nervous elements, instead of one continuous nerve fiber from center to periphery, it is possible for one of the neurons of the chain to be so disturbed that the conducting apparatus is interrupted and impulses do not flow. Hence, if a strong impression is produced on the mind with regard to a particular part of the body the neurons leading to it may be so disturbed that trophic nerve impulses do not flow down, the blood supply of the part may be disturbed through the vaso-motor system and consequent changes may take place.

Absence of Circulatory Connection.—Since no nerves pass, as we have said, from mother to babe, disturbances acting on the mother's mind can at most only influence the blood supply to the baby. Most people think that there is a direct blood supply from mother to child and that the mother's blood literally flows in the baby's veins. This is not true. The baby's blood is an entirely independent structure, originating in the child's own body, and always maintaining a distinct and quite different composition from that of the mother. The baby's blood has a higher specific gravity, and it has, in normal condition, nearly double as many red corpuscles to the cubic millimeter as the mother's blood. If the blood supply is disturbed by mental influences, then it is not the baby's blood nor its circulation that is disturbed, but only the circulation through the maternal part of the placenta where an exchange of gases and nutrient elements between mother's and baby's blood takes place. It is [{463}] impossible to conceive that during this passage through a membrane of nutrient elements, soluble proteids, gases, etc., mental influences should also pass over.

Supposed Examples of Maternal Impression.—The stories that are told would lead us to believe that somehow definite changes in the mother are reproduced in the babe. One case, which in a circle of friends that I knew very well made many a convert to the idea of maternal impressions, was that of a young woman at whom, during an early stage of her first pregnancy, her husband playfully threw a tiny frog. He did not know that she had a mortal dread of frogs. She was seriously frightened and put up her hand to ward off the animal, and as the clammy thing struck her palm she felt a shiver go through her. When her baby was born a curious growth that had some pigment in it and that, by a stretch of the imagination, might be considered to resemble a frog was in the baby's hand—the same hand, by the way, as that which the mother used to ward off the animal. The lack of any nervous connection and of any direct blood connection between mother and child makes the story simply absurd as an illustration of maternal impression.

In recent years such stories have come from more and more distant parts of the country. Kansas was the principal source of them until a generation of great editors arose there. Texas was then their favorite location, but Texas has in recent years become so progressive and so closely connected with the rest of the world that, in spite of its size, it does not produce so many of these wonders. A generation ago the announcement of the birth of six children at once in Austria, or somewhere else in Central Europe, would usually be followed by a report from Texas announcing seven at a birth. Maternal impression stories grew luxuriantly for the benefit of the news-gatherer in dull seasons. A standing type of them is that of the farmer cutting hay on his farm who puts his fingers too far into the hay cutter and has them taken off. His wife binds up the bleeding stump. She is pregnant at the time. When her baby is born—usually two or three months later—just the same fingers are missing on the same hand of the child. Now the mechanism by which such maternal impression could be transferred to the child is incomprehensible. There is no connection between the two, and the old metaphysical axiom (actio in distans repugnat) that all action between bodies at a distance from one another, that is without some connecting link between them, is absurd, holds as good in modern times as it did in the Middle Ages. Surely a tendency-to-amputation is not carried over from mother's blood to baby's blood through the membrane in the placenta just as are the gases for respiration and the nutrient elements for food. If it is, we have a greater mystery than ever to solve.

Period of Occurrence.—The infant in the uterus is fully formed before the tenth week of pregnancy and at a time when women are usually almost unconscious of the fact that they are pregnant. Such impressional changes as we have referred to, if produced after this, must be in the nature of backward growth or an inversion of trophic influences or a great perversion of embryonic life. They have nothing to do with the formation of the child, since that is completed. They are as much accidents as if the child should fall after it was born. We know how fetal limbs are amputated through the formation of amniotic bands, but that maternal impressions should influence the formation of these bands is of itself ridiculously absurd. That it should [{464}] influence them in a directive and selective way so that certain limbs may be amputated at a certain point reaches a climax of absurdity. A distinguished physician of our generation once said that one might as well hope to absorb a pencil case in one's vest pocket by medicine as to try to bring about absorption of fully formed connective tissue by drugs. We cannot think of any mental influence bringing about such absorption, yet to credit maternal impressions with the production of fetal amputations not only supposes the directive formation of connective tissue within the uterus, quite beyond the domain of the influence of the mother's nervous system, but also assumes the direction of the anomalous action of that connective tissue in its mutilating procedures in a very exact and definite way.

Some curious things have been explained on the score of maternal impressions and it is this very exaggeration that is perhaps the best proof of how coincidence, imitation, and other factors play a role that has exaggerated the idea of maternal impressions into a causative factor. A typical illustration is the case cited years ago, half in joke, perhaps, half in earnest, by a distinguished professor of obstetrics. It occurred in the days when the elder Sothern was playing Lord Dundreary to crowded houses and when Dundrearyisms were the current witticisms and Dundreary ties and Dundreary clothes and Dundreary whiskers were all the rage. A young woman who was recently married became much taken with the actor and went to see him over and over again, secured an introduction to him, and showed the liveliest interest in him and the performance. Their acquaintance, however, remained merely that of chance friends. Some months after it began, not more than five or six at the most, a boy was born to her. According to the story this boy, when he began to walk some years later, developed that little skip in his gait which proved so taking to those who crowded the theaters to see Sothern as Lord Dundreary.

By this time the play had lost something of its vogue and most people did not recognize the curious halt in the gait, but it was very clear to the mother and her friends. It was set down as due to a maternal mental impression. Mental transfer seems ludicrous in this case. It is much more likely that the mother was hysterical, and, wishing in a morbid way to attract attention to herself and her child, taught the boy the little skip, or perhaps some curious little skip once taken by the child attracted the mother's attention because of her memory of Sothern, and her surprise at the act impressed the peculiar action upon the boy's mind, who proceeded to attract further attention by repeating it. It is cases like this with their reductio ad absurdum of the whole process that have quite discredited the belief in maternal impressions.

Some Figures and Coincidences.—The occurrence of mothers' marks in connection with various external incidents of pregnancy are only coincidences. Most young mothers dread lest something should happen to their children. About once in a thousand times an infant is marked in some way. Nine hundred mothers rejoice over the fact that their baby is not marked in spite of the fact that they feared it might be, ninety-nine of them never gave the matter any thought and one of them finds to her sorrow that her foreboding has come true. Occasionally a mother who has not dreaded such a result finds that her offspring is marked. Then she recalls all the happenings of her pregnancy and picks out something to which she thinks she may attribute the accident. [{465}] There must be some reason for it and she finds it. Sometimes she begins by saying that it must be because she was frightened at such a time, or fell down at such a place, or saw such a thing, and then a week later she tells the story with circumstantial additions which make it very clear to her friends that she knows exactly the reason and that she had thought about it before and feared it might be so, though the whole matter was hazy until it had been talked over a number of times.

Coincidences have been the most serious detriment in drawing scientific conclusions in every department of medicine. Most of our diseases are self-limited and any medicine that was given being followed by recovery seemed to be the cause of that recovery and the more strictly self-limited a disease the greater the number of remedies. When stories of maternal impressions are analyzed it is found that a great many mothers have had forebodings as to their children being marked and their dreads have not come true. A few have feared and have realized their worst fears. Many women whose children are marked can recall no event in the course of their pregnancy which could have marked their child and they ask the doctor what he thinks must have been the reason. But unintelligent mothers can always find some cause by searching out unpleasant details of their experience during pregnancy.

Intrauterine Nutrition and Nursing.—To explain the occurrence of a frog-like appearance or a mousey patch on a baby as due to its mother having been frightened by one of these little animals while nursing would be the height of absurdity. But it is no more absurd than the supposition that mental impressions in the late months of pregnancy can have the effects that are popularly ascribed to them. If a mother suffers from severe fright, or even if she has a fit of intense anger or other profound mental disturbance, her milk may disagree with her infant. Every physician has seen nursing infants made sick by the change in the milk superinduced by strong mental emotions in the mother. This, however, could have nothing to do with the production of a special lasting physical mark on the outside of the body.

Maternal Solicitude and Superstition.—The wonderful stories that are told are nearly all in the older literature and are much more reasonably explained on the score of coincidence than on that of any possible direct connection of cause and effect. Mothers, then, may be reassured and made to understand that the better their own health, the less they worry about their condition, the more likely is their pregnancy to terminate favorably with a perfectly healthy offspring. This is the source of so much concern in the little world of child-bearing that it is worth while taking it seriously and making mothers understand that the old notions in this matter are but superstitions. Superstitions are not always nor exclusively religious, they are survivals from a previous state of knowledge, the reasons for which are now known to be false. Maternal impression, that is, the belief in the power of the mother's mind over the unborn child, is a superstition that we must now dismiss.

Favorable Maternal Influences.—Every now and then a sensational newspaper has an article on how mothers will tend to make their children physically handsomer by gazing at beautiful works of art, beautiful scenes in nature, and seeing only handsome (one feels like inserting well-dressed in the category, also) people during pregnancy. The reading of good books [{466}] containing moral lessons of the highest quality are supposed to have something of the same influence on the child's character. There is no doubt at all that the more carefully and simply and beautifully and healthily the mother lives, and the more her mind possesses itself in peace and happiness, the better will be her own nutrition and consequently that of her offspring, and, all things considered, this will contribute to the perfection of the infant's body and so give the best instrument for the expression of its soul. That these supposed favorable influences have any more direct power than this over the state of the infant that is to be is doubtful. It is worth trying for, but if the indefinite influence for good emphasizes, as it apparently does in many minds, the presumed direct and definite influence for evil, then it is not worth dwelling on.

Etiology of Deformities.—But if these curious deformities and markings are not due to maternal impressions, what, then, is their cause? To the question for many of the minor marks and slight deformities—naevi vascular and pigmentary, extra fingers, slight overgrowths, special peculiarities of bone and soft tissues—no satisfactory answer can be given. We must simply say that as yet we do not know. It is a good thing to say we do not know. Long ago Roger Bacon declared that the principal reason why man did not advance in knowledge more in spite of the amount of their work was that they were afraid to say "I do not know," and accepted inadequate reasons and insufficient authority in order to avoid this humiliating expression. On the other hand, there are many deformities and markings, the reasons for which have been found, and the more important they are the more we know about them, as a rule. Besides, with the advance of our knowledge of embryology we are getting to know more and more about these difficult problems and many things that were mysteries before are now clear. In addition to observation we have experiment and this is making observation more thoroughly scientific.

The more we know of the intricacies of the development of animals and human beings, the greater is our surprise that deformities do not occur even more commonly than they do. All the openings of the human as of the animal body gradually close in with the production of the finished form. The slightest interference with growth in the neighborhood of these openings, which involve nearly all of the front of the body, leaves various deformities. Nature has surrounded the developing embryo with fluid so that it is saved from jars of all kinds and from contact with other tissues that would disturb growth. Cell is laid on cell as brick is laid on brick in the building of a house, and the predetermined plan in the immense majority of cases is followed without accident to the minutest detail. That more mishaps do not occur, considering the delicacy of the process and the perfection of the finished structure, is hard to understand.

There are many factors likely to intrude in every pregnancy that may lead to the production of unfortunate results. Literally millions of cells are growing with apparent freedom from constraint in many portions of the fetus, yet all are directed with definite purpose corresponding to other cells and are destined to meet in due course of time. Each one of them or at least each group seems to be independent in its growth. Each growing cell doubles by dividing every few hours, yet all are co-ordinated to a definite end. We admire the men who begin at the two ends of a tunnel far distant from one another and work without any communication except through the engineer's plans [{467}] made long before, and yet make two bores that can be depended on to meet with but a few inches of divergence. The bridges of tissue that are built across the openings of the body jut out to meet one another in this way and in more than ninety-nine out of every one hundred cases there is not the slightest divergence. Many things may occur to disturb conditions—not connected with mental influences, but with distinctly physical factors—missteps, trips, jars on stairs or getting off and on cars, on the sidewalk, etc. These, and not the mythical factors that make up so-called maternal impressions, are the causes of deformities and mothers' marks.

[{468}]

SECTION XII
GENITO-URINARY DISEASES
CHAPTER I
PROSTATISM

It may seem impossible to include prostatic hypertrophy, or the train of symptoms connected with it, among those affections likely to be benefited by mental treatment. The history of this affection, however, and especially of its treatment in recent years since it has come to be the subject of special study, has furnished many examples of the value of suggestion in the relief of many of its symptoms. Many forms of treatment have been exploited for a time, attracting attention because of the cures attributed to them, and have then been relegated to the limbo of unsuccessful remedial measures. A striking example of the place of suggestion came with the development of organo-therapy some fifteen years ago. The succession of events illustrated well how much persuasion and a favorable attitude of mind might mean even in so purely physical an affection as interference with urination by enlargement of the prostate.

It was at a time when thyroid medication for myxedema having proved successful the medical journals were full of reports of other successful phases of organo-therapy. The spleen and the bone marrow were being used in the anemias, the ductless glands in various nutritional diseases and even extract of heart for heart disease. Just on what general principle it was assumed by some German investigator that possibly extract of prostate from animals might be of benefit in the treatment of prostatic hypertrophy is hard to understand. The German physician, however, gave an order to the butcher to send him prostates and as furnished they were administered to the patients. A number of patients began at once to improve on the treatment. They were able to empty their bladders much better than before, the residual urine was decreased, the tendency to fermentation was diminished and, above all, the patients' general symptoms were much improved.

The success was so marked that the German investigator published his cases and, with the public mind interested in organotherapy, they attracted wide-spread attention. He was asked how to obtain the material and only then did he take the trouble to investigate just what the butcher had been sending him. The description furnished the butcher by the doctor was that he wanted an organ lying below and somewhat in front of the bladder of the bull. It was found on careful inquiry that the abattoir attendants following these directions had supplied not prostates but seminal vesicles. As soon as this was found out some of the therapeutic suggestions failed. A number of cases, [{469}] however, continued to improve. German medical journals made fun of the whole proceeding and most people will consider the ridicule deserved.

Shortly before this time, however, we had had a very similar experience with another pair of organs. In spite of the fact that whatever we know about Graves' disease would seem to indicate that that affection is due to an increased thyroid secretion in the system, at the time of the organo-therapeutic fads, thyroid extract was reported as having been used successfully in the treatment of this affection. The name signed to the report was that of a trustworthy English clinical observer. A few practitioners of medicine got similar results, but most of them failed entirely to get his successes and some of them were sure that their patients were rather harmed than helped by the new medication. An investigation of just what material was being employed in the English cases showed that the butcher was supplying thymus and not thyroid glands. Suggestion did the rest, for thymus has proved to be quite ineffective, and the treatment was entirely expectant but acted on a favorable state of mind. Anyone who has had much experience with Graves' disease knows how amenable to suggestion the patients are. It would seem evident from the foregoing story of organo-therapy for prostatic hypertrophy that sufferers from prostatism are probably as prone to suggestion as patients with Graves' disease. This is all the more surprising as the two affections are so different in their etiology. Graves' disease being undoubtedly a ductless gland disease, while prostatism is due entirely to mechanical obstruction.

We have abundant additional evidence of the role of psychotherapy in prostatism. Some years ago a well-known American surgeon suggested that removal of the testicles would reduce the enlarged prostates. And much improvement was seen after castration in those who previously suffered from prostatism. The subject was carefully studied. Experiments were made on animals and the results seemed to prove that castration in them constantly produced prostatic atrophy. The fallacy probably came from the fact that at the time so little was known about the prostate in comparative anatomy and, above all, with regard to the prostate in dogs, that it was impossible to come to any sure conclusion as to reduction in weight and size after removal of the testicles. A number of prostatic cases were treated by different surgeons and with excellent results. Then after a time the number of supposed successes dwindled or proved to be failures and now no one does the operation. The only explanation that is at all satisfactory in these cases, is that the rest in the hospital, the favorable suggestion of reported cures and of an experimental demonstration on animals led many patients, some of them even physicians, to secure a better control over their bladders.

It took a good deal of persuasion as a rule to bring men, even men well beyond seventy, to consent to the sacrifice of their testicles, but once they did, the sacrifice brought a favorable suggestion to work and so it was not long before they were able to make their bladder act much more efficiently against the obstacles presented to its contraction. Some could be persuaded more easily to sacrifice a single testicle, but in these cases the mental influence was less and the reported cures fewer. After a time the operation of vasectomy was suggested as a substitute for the removal of the testicles. For a time even this in the hands of certain operators gave excellent results. Almost any other operation in the genito-urinary tract performed with the definite persuasion [{470}] on the part of the patient that he would be better after it would probably have acted just as favorably. The whole story of these series of incidents in the surgery of the last decade of the nineteenth century ought to be a clear demonstration of how valuable for therapeutic purposes is mental influence oven in prostatism, and how much we should try to secure its favorable effects.

Unfavorable Suggestion.—Since enlargement of the prostate has become a familiar subject of discussion and men know and hear much about it every now and then, one has to reassure a man but little beyond fifty that he is not suffering from this affection. Just as soon as a man begins to urinate frequently during the day and to have to got up once at night he begins to wonder how soon he will be likely to suffer from further symptoms of enlarged prostate. If he is of the nervous kind his worrying will soon give him additional symptoms that will confirm his suspicions. Probably one of the most familiar of phenomena, even to the non-medical man, is the ease with which worry and excitement causes frequent urination. Probably no system of organs in the body is so likely to be disturbed by the mind as the urinary system with the exception, of course, of the allied tract, the genital system, but the two are so one in union and sympathy that they cannot be separated in practice. The prostate is rather a genital than a urinary organ.

Urinary Worries.—When a man begins to worry about the possibility of bother from enlarged prostate and recalls that frequent urination is one of the symptoms of it, it will not be long before this symptom develops. Occasionally his first wakings to urinate at night or in the early morning are only due to passing conditions, either he drank freely shortly before bedtime or perhaps he did not drink enough. In the one case the bladder is rather full; in the other a concentrated urine, especially with the patient lying on his back, makes itself felt over the sensitive area at the base of the bladder, waking him up. The rest of the symptoms may develop as a consequence of solicitude over a few such incidents.

Practically all men who reach sixty have some tendency to more frequent urination than before. Their bladder does not hold as much fluid with comfort and they are likely to have to get up in the early morning. This does not necessarily mean any enlargement of the prostate nor any pathological change. The physiological change that takes place seems to be rather conservative than otherwise. Old muscles are less capable of extension and thorough reaction than they were earlier in life and in order that the bladder may not be over-distended nature makes it more sensitive than before.

Emptying the Bladder.—In the study of these cases individual peculiarities in the emptying of the bladder must be remembered. There are some men who cannot urinate if anyone is near them, and who even have to step into a closed toilet if they are to succeed in emptying their bladders when others are in the room. Some who find no difficulty in the presence of others in open urinals find it difficult or impossible to urinate when it is expected of them. Under worry and excitement urination may become urgent or imperative, but on the other hand some men find it very difficult to empty their bladders under an emotional strain. Now that much more is written publicly with regard to symptoms from enlarged prostate and much more is heard of the affection, many old men got worried and lose some of the power that they had over their bladder before, not so much because of their enlarged prostate as from the [{471}] psychic loss of control over their bladder. The viscus consists of a series of muscles, the fibres of which must be rather nicely coordinated and controlled in order to secure that complete contraction necessary for thorough emptying. A certain amount of residual urine occurs occasionally at least in many other persons besides those who have prostatic obstruction.

The Question of Operation.—In recent years there has been a tendency to suggest operation even on comparatively small prostates when symptoms referable to them are noted. Operations on the prostate have become much more easy and successful, and there has been the same sort of feeling about them among surgeons as there was when operations for affections, real or supposed, of the ovaries came into general vogue twenty years ago. I have seen patients in whom an operation for the removal of the prostate had been suggested, though the only symptoms were somewhat increased frequency of urination during the day and the necessity for rising two or three times at night. Such a suggestion, by calling the patient's attention strongly to his condition, emphasizes the irritability of the vesical tissues and is almost sure to bring about a considerable increase in the symptoms. The first principle of any treatment of irritability of the bladder should be the setting of the patient's mind as free as possible from solicitude. Any over-attention is sure to lead to reflexes and often to what seems to be even imperative urination, though with a little care and discipline much can be done for the relief of such symptoms.

The necessity for operation must be judged entirely from the symptoms of the individual patient and not from any hard and fast rule with regard to the size of the prostate. Prostates are eminently individual organs, at least as individual as the human nose, and their projection into the rectum is dependent on the relations of other tissues in the neighborhood as well as on mere size. Men have been known to live with comparatively few or no symptoms for many years, though at autopsy they proved to have what would ordinarily be considered a pathologically enlarged prostate.

Operations upon the prostate are valuable and indeed often afford the only avenue of relief from an intolerable condition. The results are not so encouraging in all cases, however, as to make recourse to operation advisable until a thorough trial of palliative measures has been made. It is surprising how often the confident suggestion of assured relief when accompanied by the same amount of rest in bed and the special care that is required for an operation, brings about a disappearance of symptoms that seemed inevitably to demand surgical intervention. There may be much residual urine, there may even be, as a consequence of this, some fermentation with cystitis, and yet a course of rather simple remedial measures may serve to bring about a period of prolonged freedom from vesical symptoms. If these patients, however, have heard much of the trials and sufferings of a catheter life, the solicitude aroused with regard to their condition is sufficient of itself to disturb their urination to a marked degree. Unfavorable suggestion is particularly serious in its effects in these cases, while favorable suggestion frequently repeated will enable the patient very often to regain bladder control when the developments present might seem to put that almost out of the question.

Position Suggestions.—An important suggestion for treatment in prostatism with residual urine seems to be to teach the patient to urinate lying down, [{472}] especially with the hips somewhat elevated. This seems to be the element that proved capable of making many different operations, castration, the removal of one testicle, vasectomy, and other suggestions appear curative. My own experience is too limited to make my opinion of much weight; but I have seen certain patients greatly relieved of prostatic symptoms and their residual urine much diminished by the advice to urinate leaning well out of bed, lying prone with the head lower than the body. A small stool is brought to the side of the bed, a pillow placed on it and the patient leans over face down on this with the shoulders considerably lower than the pelvis. This allows gravity to assist rather than hamper the emptying of the bladder and after men have become a little used to it they are quite satisfied to take the trouble. Personally I feel sure that more generally applied this would put off the necessity for using a catheter a good deal and even save some cases from operation that now seem to need it. The principle is exactly the same as that by which patients suffering from bronchiectasis avail themselves of the help of gravity and get rid of the nocturnal accumulation of material in their dilated bronchi. They can thus be saved much trouble and exhausting effort.

So much, as we have said, is written in recent years with regard to prostatic symptoms that a body of unfavorable suggestion has been created. This must be neutralized as far as possible by calling the attention of patients who have initial symptoms of vesical disturbance to the ease with which mental influences act upon the urinary functions. Solicitude and anxiety will add to symptoms and may even bring about their continuance when the original, local and passing condition which has caused them has ceased. Very often if the patient's mind can be properly disposed a marked relief of symptoms will follow, especially if, at the same time, remedial measures of other kinds are employed to lessen the irritation that is being set up. While prostatism seems to be due to such purely mechanical difficulties that mental influences can mean very little, the history of the therapeutics of the condition for the last twenty years shows us clearly that if strong mental influences are aroused they bring so much relief that many patients consider themselves cured. This psychotherapy will not do away with the necessity for operation in many cases, but it will cure many of the sufferers from milder symptoms and will in not a few cases bring such relief as will prepare the patients to undergo operation, if it should be necessary, with more assurance of favorable results.

CHAPTER II
SEXUAL NEUROSES

Anything that disturbs the sexual sphere in either sex, no matter how trivial it may be, becomes a source of worry and depression quite beyond its real importance. It is not unusual for men and women to become so worried over some trifling affection of their sexual organs that they become convinced that serious pathological conditions are developing and that there is little hope of anything like a complete cure. This is particularly true of young patients, but holds also for those of older years. Slight discomforts are exaggerated into nagging aches and pains which produce extreme depression of spirits.

[{473}]

It is important, then, for the physician to recognize this and to treat the patient's mind by reassurance while conducting whatever other therapeutics may be required. There is danger always in these cases of either making too little or too much of the affection. If too much is made of it, an unfavorable influence is produced in the patient's mind and the discouragement leads to so much inhibition or even actual physical disturbance that the affection will not improve. If too little is made of it, patients get discouraged and are prone to think that the physician does not understand their cases. Then they go to the advertising specialist in men's diseases who works upon their fears and makes them feel much worse than before, though in the end he may lift the cloud of anxiety from their minds and pretend to have cured them. He always leaves them, however, with the impression that something serious has been the matter, and this acts as a nightmare and a source of dread in after time.

In men the unfavorable suggestions occur particularly as a consequence of affections of the external organs. In women the same suggestions are likely to make themselves felt with regard to the internal genital organs. We all recognize the exaggeration of feeling and even physical reaction that takes place with regard to slight sexual ailments in the male, because it is easy to recognize just exactly what pathological conditions are present and how trivial they may be and yet produce serious depression and all kinds of symptoms, reflexly referred to many other organs. There is a tendency to listen to the complaints from women more seriously because the actual pathological condition cannot be determined and there is always the fear that some serious affection may be at work. It must not be forgotten, however, that the complaints of pains and aches, the disturbance of sleep, of digestion and of the intestinal function, the mental and physical lassitude and the over-reaction to irritation which occur in both sexes as a consequence of sexual affections may be due entirely to mental solicitude and not to any real pathological change.

Trivial Afflictions—Varicocele.—It is curious what a little thing will sometimes set off the explosion of a train of sexual symptoms. Every physician has probably had some young man come to him with the look and the tone that there was something the matter that he knew was serious and would affect all his after life. The patient then goes on to say that he wants to know all and is brave enough to face it, and, though he has lost sleep for two or three nights and is not looking well for the present moment because his health has been disturbed by the loss of sleep, still he has the strength to know the worst and it is to be told him and he will bravely battle on in spite of the suffering that must come. Or he will submit to a serious operation if it is necessary for his relief. With a prelude like this, the inexperienced physician might expect strangulated hernia or some preliminary symptoms of brain tumor, but what he usually finds is a varicocele, and a small one at that. By chance the patient has discovered it and slept none the following night, went round in an agony of dread next day meaning to go to a physician, but too fearful to be told the worst, losing another night's sleep and then finally coming to a friend to be told all the ill that is in store for him.

There is no need for alarm in these cases; they merely illustrate the role of the mind disturbing the body. Nearly one-fourth of the male world carries its [{474}] varicocele around with it and never bothers about it. A few sensitive individuals are annoyed by a sense of weight and a feeling of distention from congestion in connection with it. In a few, because of special pathological conditions or congenital defects, the varicocele becomes so large that it has to be supported by a special bandage. In people who ride horseback, in athletes, and those who indulge in severe exercise, this sort of a bandage may be necessary or at least may make the wearer more comfortable even in slighter forms of the affection. Severe cases may be much relieved by it.

On first discovery of his varicocele nearly every young man, because of concentration of attention on it, is so much annoyed that he thinks he must wear a bandage. After a time, however, he often finds that the bandage itself is a source of more annoyance than the varicocele, and then he learns to forget it and its feelings—and that is all about it.

I have dwelt on this succession of events that takes place so often with regard to varicocele, because it is typical of the effect that an affection of the sexual organs has upon the mind. It exerts an unfavorable influence entirely disproportionate to the physical cause that is at work. If, as sometimes happens, a young man hesitates to confide in some one capable of undeceiving him with regard to the supposed significance of his affection, he may work himself into a decided nervous condition and lose much weight before he discovers his mistake. This physical running down confirms his exaggerated notion of the significance of the affection. He is sure that it constitutes the reason why he is losing weight and declining in health and he rather congratulates himself on the fact that he discovered the cause so shortly before the serious effects began.

If under these conditions he places himself in the hands of any of the men who advertise themselves as curing "men's diseases," or as relieving the "awful" symptoms that are likely to follow varicocele, instead of being reassured he will be told that he has come just in time and that while his cure will require a long time and will cost a great deal of money, yet it can surely be effected. In nothing can men or women be more easily imposed upon than with regard to affections involving their sex organs. They lose their power of judgment and their control over their feelings and so plunge sometimes into profound depression. Every year we have a number of suicides among young men, the most important element in whose depression is due to unrelieved occupation of mind with the thought that they are suffering from some incurable sexual disease which will unsex them, and that even death is to be preferred to the alternative of being recognized generally—as they are sure they will be—as sexual defectives.

As a rule, these young men are suffering from only some slight ailment that could be easily cured if they were frank about their state of mind and described their symptoms to a reputable physician. Oftener than not their supposed ailment is something so common as to be of no significance, so far as any serious results may possibly be anticipated, and their only real ailment is the mental condition which has developed because of concentration of mind on this one phase of organic life and the consequent inevitable exaggeration of symptoms and feelings. It is sometimes not easy to disabuse them of their unfortunate notions, but there is probably no set of cases in medicine where psychotherapeutics means more than it does with regard to the curious [{475}] neurotic and psychic conditions which develop in those who are suffering from any sexual ailment, real or imaginary.

Long Prepuce.—Much has been said in recent years about the influence of a long prepuce in the male in producing various reflexes the effects of which may be seen in serious disturbance of even distant organs. The kidneys are sometimes said to be thus reflexly affected, and occasionally the digestion and the bowels—even, sometimes, mental processes are said to be influenced unfavorably by the diffusion of reflexes from the irritation consequent upon this sensitive structure being too long. A whole system of nosology exists in some minds due to an over-long prepuce. There are, of course, cases in which circumcision should be performed. There is a larger number of others, however, in which the redundant prepuce is neither adherent nor constricted and is only slightly longer than it should be. Occasionally something arouses the attention of the possessor of the redundant tissue and he gets the idea that it is the source of reflex irritation even for distant parts of his organism. It is an interesting study in suggestion to see how symptoms develop in various organs as a consequence of the cultivation of this thought. Urination becomes frequent, the patient even wakes at night to urinate and the urine, as in many neuroses, becomes more abundant and of lower specific gravity—the typical nervous urine of the hysterical, and there may be much worry and emotional disturbance.

These symptoms, however, are not effects of the long prepuce, but are results of the neurotic influence of concentration of mind on it. It will often be advisable, in young men particularly, to have circumcision performed, but in most cases this is unnecessary, and if the patient can be made to understand how the symptoms have developed he will learn a precious lesson in not interfering with his functions by over-attention to them. Of course, there are many surgeons who will continue to hold, as they seem to now, that nature was quite at fault in the production of this organ and that it should be removed in nearly every human being. The majority of men, however, have lived their lives quite well and happily without such intervention and there are certain inconveniences attached to the condition which remains after operation that may in their way be quite as bothersome as the symptoms due to the long foreskin.

Psychic Impotence.—An important sexual neurosis, at least in the eyes of sufferers from it, is what physicians have come to know as psychic impotence. Young married men, because of over-anxiety with regard to themselves for a number of reasons, but without any physical factor to disturb them, find it impossible to complete the sexual act. Naturally this creates a serious disturbance of mind. The patient will either hurry to a physician at some place on his wedding tour, or his wedding tour will be shortened and he will return to consult a friend. He presents a lively picture of despair. He has not been sleeping, his appetite is disturbed, he feels lassitude and weakness, and if he has a lively imagination he is inclined to think that the fatal termination of some serious nervous disease of which he has heard, and which is accompanied by the symptom of sexual impotence, is impending over him. His condition is quite pitiable, though largely imaginary.

Reassurance.—The treatment of the condition is not so difficult as it might seem if the patient has a reasonable confidence in his physician. If he [{476}] goes to an advertising "specialist," as occasionally happens, because he concludes that the ordinary physician cannot know all the details of these intricately complex nervous diseases, he is sure to suffer severely in general health before cure is obtained. His morbid ideas will be fostered because he is ready to pay any amount of money in order to stop the progress of the presumed serious disease. An investigation of these "specialists" in New York, made a few years ago by a committee of the New York County Medical Society, showed to what an extent the terrors of these unfortunate patients are exploited for monetary reasons.

A physician of even a little experience in these matters, however, recognizes at once the entirely neurotic character of the case and by reassurance soon enables the young man to dispel many of his worst terrors. His general health can be regulated, his constipation, which so frequently exists, is relieved, and he can be told, what is very true, that the excitement consequent upon the preparations for his wedding and the exhaustion due to the overwork so frequently necessary in order to enable him to take the time off for his wedding journey, have made him so nervously irritable that the ordinary mechanism of the sexual act, which is extremely delicate and requires nice co-ordination for proper function, has been disturbed. Just as soon as this fatigue and the over-excitement of mind consequent upon the unfortunate experience are mitigated his potency will return. This assurance can be given almost at once.

His fears, however, will delay his recovery. His dread of incapacity will become an obsession. Probably the most effective means of treating this is to forbid him to attempt the sexual act for a definite length of time, say two or three weeks. This must be impressed upon him. There is a good reason for insisting that he shall not irritate his already excited sexual system by such attempts. Usually at the end of a week or ten days he will come back with a smiling look of confidence in himself and his physician, to confess that he has violated the injunction, but that he was not disappointed as before.

Subconscious Obsession.—In most of these cases the young men have been victims of sex habits of some kind or of drug addictions, and they have heard that occasionally individuals who have had such experiences may suffer from sexual impotence later in life. This is a strong suggestion to them and in some cases becomes a haunting obsession, and produces the unfavorable effect upon the organism. It is necessary to remove this obsession before a cure can be effected. The patient's confidence must be obtained and the physician's personality and persuasive powers used to change his point of view. Occasionally I have seen cases in which the patients themselves seem to be scarcely aware of this strong suggestion or obsession at work in them. It seemed to be more or less subconscious. An idea with regard to the evil effects of the old habit had been implanted and remained in their minds, occasionally making itself felt but more often apparently lying dormant. In these cases it is important that the physician should make this underlying factor clear to the patient. In some of these cases hypnosis is necessary. Usually the hypnoidal condition, with suggestions in the waking state, is all that is necessary and ordinary suggestions will often effect the purpose completely.

Organic Impotence.—Certain forms of sexual impotence are really preliminary signs of serious organic nervous disease. Sometimes it is the first [{477}] symptom of paresis or of locomotor ataxia. Oftener it is a very early symptom of syphilitic spinal myelitis. In practically all of these cases, however, there is a history of syphilis and the presence of this should always be a warning not to think of functional or psychic impotence until the possible influence of the syphilis itself or of some of the parasyphilitic diseases is thoroughly excluded. Unfortunately, not a few people who have had syphilis are nervous and anxious about themselves and by their very anticipation of possible developments may auto-suggest themselves into a state in which these symptoms will develop. It is cases of neurasthenia that develop after secondary syphilis in persons who have been studying syphilis and its possible effects, which present the most difficult problems in diagnosis that come to the nerve specialist. Many simulated symptoms are unconsciously developed and this makes differential diagnosis extremely hard. As a rule, the psychic impotence is merely functional and patients need reassurance more than anything else.

Nocturnal Emissions.—One of the sexual neuroses that gives rise to a high degree of solicitude centers around the question of involuntary seminal emissions. Young men who are living normal healthy lives and who are in robust health with no indulgence of sexuality are likely to experience more or less regular involuntary emissions. If for any reason they become nervous or anxious about their sexual functions, especially at times when they are under much mental strain, these phenomena of emptying the seminal vesicles may occur rather frequently. If they have been reading some of the literature, or hearing some of the exaggerated notions that are often expressed with regard to the evil effects that may come from this, they are likely to suffer much mental anxiety over it. Occasionally they lose sleep, frequently they feel so wearied and worried the day after the occurrence as to be disturbed at their work, sometimes they are sure they are so tired that they are unable to fulfill their ordinary duties, and I suppose every physician has known young men who were even sure that the loss of the seminal fluid was seriously interfering with health, hampering many physical functions and bringing them to an untimely grave. They had no appetite and in consequence of not eating enough they were constipated and then a whole round of physical troubles, headache, lassitude, over-fatigue, to which they are almost sure to add loss or disturbance of memory, began to annoy them.

In those cases it is not the physical effect of any loss of seminal fluid that is the disturbing factor of their health, but their worry over the losses. Just as soon as their minds can be taken off the subject, the supposed physical effects begin to disappear. So long as the solicitude continues the emissions themselves increase in number and the condition is made worse. These patients must be taught that in every normal healthy man in whom there is no regular occasion for the emptying of the seminal vesicles, nature provides for an evacuation about every ten days or two weeks. In some it is more frequent than this. In those who are much indoors and in whom oxidation processes are low this emptying takes place more frequently. In those who lead a sedentary life with the consumption of much proteid food the same thing seems to be true. Any anxiety about it is sure to cause frequent repetition of the evacuation processes. Over-solicitude about the bladder will have just the same effect. If the patient will take his mind off the subject, will eat normally, will get out in the air more than before, tiring himself thoroughly [{478}] if he is young and vigorous, and will not allow the sexual side of his being to be excited by stories or pictures, plays or voluntary thoughts, his affliction will soon disappear.

Prophylaxis.—Certain directions are helpful and by occupying the patient's mind will overcome certain physical factors that underlie the affection. It is important that the bladder should not be allowed to be full, above all, not to be over-distended at night. Some care should be exercised in not taking too much to drink shortly before going to bed and the bladder should be faithfully emptied before retiring. The weight of a large amount of urine in the bladder pressing down upon the seminal vesicles situated below and behind it causes them to contract rather easily. This is particularly true if the patient sleeps on his back and occasionally in certain over-irritable patients for a time at least an arrangement may have to be made by means of small pillows that will prevent him from sleeping on his back. On the other hand, it must not be forgotten that too great abstinence from fluid will cause the urine to be more concentrated and this will irritate the bladder and either wake the patient up at night, which of itself is undesirable, or else will cause congestion in the prostatic region which will irritate the seminal vesicles to the point of evacuation. While five or six glasses of water a day should be taken besides the ordinary fluid taken at meals, the only regulation necessary is of the amount of fluid taken in the evening after the last meal, that is, if more than three hours intervene before retiring for the night.

Besides the physical conditions in the bladder, an accumulation of fecal material in the rectum may cause irritation of the seminal vesicles. It is important, moreover, to remember that thoroughly free movements of the bowels, by preventing to a great extent the reabsorption of material from the intestines which may prove irritant when excreted through the kidneys and when present in the bladder, is of itself an excellent therapeutic measure in cases of irritability of the genital organs. The setting of the patient's mind to thinking about his rectum, his bowels, and his bladder instead of his genital tract is an excellent psychotherapeutic measure that will soon bear fruit.

The consumption of various foods, condiments and drinks enters into the underlying condition which produces frequent emissions. We have already suggested that the use of a large amount of proteid materials, especially in people who live a sedentary life, often predisposes to this condition. An abundance of the carbohydrates, however, by supplying more heat than is necessary may have a like effect. Certain spices seem to predispose to irritability of the sexual system. Red pepper has always seemed to those who saw much of these cases to be particularly at fault. Mustard, curries, peppers generally, however, and even other spices seem to have a corresponding effect. As a rule, young folks suffering from this disturbance or from the tendency to eroticism in other ways should be warned about this irritation of spices. In neurotic individuals tea and especially coffee has the same effect. Probably this is only an indirect influence of tea upon the nerve centers, making them more irritable, but coffee, by raising the blood pressure, seems to have a direct unfavorable effect.

All alcoholic drinks are contraindicated in these cases and must be forbidden. Certain of them seem to be more harmful than others. According to French tradition warm wine or mulled ale as it is used in England is [{479}] especially likely to excite sexuality. Warm alcoholic drinks of any kind are absorbed more rapidly than are cool drinks, which is the main reason in modern times for having these liquids cooled so that they will not be absorbed too rapidly and disturb the equilibrium. Champagne also has, by tradition, a special effect, sometimes said to be due to the increased hyperemia of the stomach induced by the carbonic acid gas and the consequent more rapid absorption.

The prohibition of spices and alcoholic drinks has a good effect in itself. It acts constantly as a suggestion to the necessity for care and guard over one's self. Besides the exercise of self-denial necessary to keep away from the use of such substances, especially under present social conditions, is of itself a good training that strengthens the will against certain tendencies to indulgence in sexual thoughts which predispose to the frequent emptying of the seminal vesicles.

Erotic Dreams.—Very often these nocturnal seminal emissions are associated with erotic dreams. Patients are inclined to attribute the occurrence of these dreams to some fault of their own or to consider that they are at least in some way responsible for them. This thought often becomes a source of serious worry, making their condition worse. A study of this question has convinced me that in most cases there is practically no responsibility in the matter. Pressure on the seminal vesicles by an over-full bladder, or a distended rectum, leads to the production of nervous stimuli around which the erotic dream-ideas gather. A straightforward explanation of this will relieve many patients' minds, and keep them from bothering about the subject in such a way as to make their genital tract even more sensitive than it is because of their concentration of attention on it.

Sexual Mental Troubles.—In our generation sex occupies a great deal of attention. Sexual tendencies are emphasized by suggestive reading of all kinds and by forced attention to sex matters. Most of the successful novels deal with the so-called sex problem, our plays are to a great extent sex problem plays and our newspapers are full of sex crimes and sexual divagations of many kinds. This acts as a strong incitement to sexuality and represents exactly the opposite of what nature intended in the matter. As a consequence, all the tendencies to over-solicitude with regard to sexual affections and all that instability of mind and over-reaction to all forms of irritation that comes in the midst of sexual excitation are noted. This seriously disturbs the minds of many patients and makes their health as well as their morals worse than they should be. The neurotic conditions seen in those who occupy their leisure with erotic subjects are fostered by this unfortunate over-attention to sexual matters. For general prophylaxis the physician needs to throw all the weight of his influence toward the correction of unfortunate tendencies in our present-day life and healthier subjects of thought should be encouraged.

We often hear it said in our time that the great fact of life is sex. Indeed, this has been insisted on ad nauseam in recent years. There is no doubt that without the sex element the race would not continue under the present dispensation. If sexual feelings did not mean so much to the generality of men and women it is doubtful whether marriage would be the success that it is, though so much is said nowadays about its failure. The analogy with all the beings lower in the scale than man shows how imperative and prominent [{480}] in life this instinct is and how much it signifies. Those who insist so much, however, on sex as the one great fact of life seem to forget that there are many other natural functions of quite as much importance to the individual at least, if not to the race. Without eating neither the individual nor the race could go on. Neither would the race go on without eliminating waste products. If there is one thing that our consideration of the problems of psychotherapy has made clear it is that whenever any of these animal facts of life is made much of and occupies attention to the exclusion of higher ideas, there is sure to be trouble. It matters not how apparently automatic and completely spontaneous a function may be, if exaggerated attention is given to it, it is sure to be disturbed in its functions and cause serious troubles in the organism.

There is no need further to illustrate this with regard to such physiological necessities as feeding and excretion. At present the world is much occupied with sex problems because, unfortunately, its attention has been focused on this subject. Physicians, particularly if they are paying attention to nervous patients, are likely to know many individuals who have food problems, diet problems, digestion problems, bowel problems, and many others of similar nature because they have been focusing their attention on these functions of their being.

The most distinguished psychiatrist of our generation, certainly the man whose works have done most to open up new vistas for us in mental diseases and who has added not only new knowledge but new possibilities of development, visited this country not long since and said, "Oh! here in America you are sex mad." He added, "I knew that we were madly following sex problems in Europe, but I thought that in this country, with so many other things to occupy the minds of men and women, you were not bothered so much with sex problems." What he said represents the impression of nearly every thoughtful foreigner who is surprised to find that wealth and luxury have brought to us this same degenerate interest in things sexual that occupies the so-called upper classes and their imitators in Europe.

Livy, the Roman historian, said long ago, "Whenever women become ashamed of the things they should not be ashamed of, it will not be long before they will begin not to be ashamed of the things they should be ashamed of." Whenever in history men and women have occupied themselves, not with the rearing of families, but with the suppression of families to as great an extent as possible, sex problems have always become emphasized. The woman who is a mother, and especially many times a mother, usually has no trouble at all about sex problems and no tendency to have "affinities." With her there is usually no question of sex as the central factor of life nor of any other of the curious nonsense that has been talked about this matter as the result of giving sex a place of importance that it does not deserve. Until there is a reform in this matter we can look for many "neurotic, erotic and tommy-rotic" tendencies, as they have been called, due to over-attention to one set of organs. Any organic system in the body would be disturbed by such attention, but the sexual system is particularly susceptible to suggestion.

The state of affairs thus emphasized is the result of interfering with an animal instinct. It will make itself felt properly and secure the due exercises of function if allowed to pursue the even tenor of its way under reasonable [{481}] control, but if it is fostered, thought about, discussed, excited in various ways, pampered by indulgence and perversion, it runs away with nature. The gourmet who constantly thinks about food, plans new modes of exciting the appetite, studies savors and odors in order to satisfy a palate that has been artificially stimulated, gets a certain animal enjoyment out of his food that other people do not; but he usually overeats, loses his appetite, and with it any real satisfaction in eating, and suffers from indigestion as a consequence of indulgence, so that the suffering much more than compensates for any slight additional pleasure that he has enjoyed. Besides, man is an essentially intellectual being, and occupation with the things of sense, that will manage themselves very well if let alone, takes up just so much of the precious time that should be devoted to other things to attain that satisfaction that makes life well worth living. Sexuality cultivated with the degree of attention that certain people devote to feeding, becomes a pest, ruins intellectual effort, hurts initiative, leads to the most serious disappointments in life and is the most fruitful cause of despondency and suicide that we have besides being the origin of many social evils that still further complicate life.

One great modern nation has debauched its literature to such an extent that probably the major portion of its books treat of sex and sex problems. Practically all of its esthetic expression has been seriously hurt by the same fault. Its painting, its sculpture, its dramatics, its art of all kinds, have all gone the same road. The result is seen in the lowered moral fiber of its people. A recent census report showed that the nation has reduced some 20,000 in numbers and that this was only the beginning of the race suicide. They have been thinking, talking, writing, painting, chiseling, acting sex problems, but in the only phase of life in which sex really counts it has been so pushed into the background or perverted that there it is failing utterly to accomplish its one legitimate purpose. The younger generation as they grow up are given the idea that they are missing the most wonderful thing in life unless they have memorable sex experiences. These experiences must be varied in order to satisfy the artificial appetite that has been created. As a consequence, family life and the real meaning of love and the affection of man for woman rooted in the depths of their nature is spoiled by mere animal passion and its passing expression.

Nature's own attitude with regard to over-attention to sex matters must not be forgotten. The purely sexual organs have been pushed into the background to as great an extent as possible and are intimately associated in both sexes with one of the two ugly excretory functions, urination, and placed in close relationship with the structures which subtend the other—defecation. Evidently nature intended that they should be the subject of as little attention as possible. Unfortunately, the paying of attention to them to any great extent lessens somewhat of the disgust naturally aroused by the excretory functions with which they are associated. Nature has provided as far as possible for deterrence from over-interest. One might expect that cleanliness and the cultivation of the feelings of refinement would serve as auxiliaries in the repression of sex indulgence. The lessons of history are that usually the great bathing nations have been most sexually divagant. Among the Greeks and the Romans the ugliest sex habits and proclivities found a place—among peoples who devoted themselves to the cleanliness of the body. The classes [{482}] who bathe most are often those with the strongest tendency to sexuality. Refinement instead of lessening the tendency to sexual indulgence rather increases it.

Education and the development of intellectuality, far from being a barrier to sexual divagations, seem to predispose to the exaggeration of the significance of sex in life, unless the individual has a well-balanced character or has been thoroughly grounded in ethical principles. The ugly stories of Greek love at a time when the Greeks were at the climax of culture, as well as what we know about the relations of the freedmen to their masters among the Romans during the classical period, is all confirmed by the revelations of corresponding tendencies in recent generations among the intellectual classes even at the universities. Development of mind apparently does not neutralize to any extent these sexual tendencies. Evidently the rule of life for health's sake must be to push sexuality as much into the background of the mind as nature has put the sex organs in the human body. Reason does not protect knowledge but increases suggestion. Only absorbing occupation of mind with other subjects that will bring about neglect of these functions, as of all other physiological functions, leaving them to nature, serves to keep them in their proper place and condition.

CHAPTER III
SEXUAL HABITS

As was emphasized in the preceding chapter, sexual symptoms are usually the subject of so much worry and disturbance of mind and become the center of so much unfavorable suggestion, that the only way to ameliorate the conditions which develop is by securing relaxation of the attention and diversion of mind. Mental influence is much more important than any other remedies that we have at our command in these cases, not only for their relief but for their ultimate cure.

A state of depression of mind similar to that which develops in patients frightened by seminal emissions is often seen in those who have for some time indulged in the habit of self-abuse. Rather frequently a physician, especially if he is known to be interested in nervous diseases, has to listen to the story of a patient who is sure that his health is completely undermined and that his future is the darkest possible, because of this habit in younger days. Usually the patient is a young man who has been reading some of the literature of the advertising "specialists" who distribute reading matter which pictures appalling and almost irretrievable effects from such sexual habits. The consequence is that the patient is in highly nervous condition, has lost his appetite, is not sleeping well, is avoiding society, because he fears that some one may recognize his condition and its cause, and he is really in a pitiable state. Such patients are usually sure that little can be done for them. Sometimes they have already been through the hands of several "specialists," particularly of the mail-order variety, and the literature provided for them and the letters written to them have all helped to make them worse and much more solicitous about themselves.

[{483}]

Unfortunately some of the exaggerated notions with regard to the effect of these habits that are so widely diffused by the exploiters of the young have been adopted by moralists with the idea that they can thus deter youth from certain practices and scare the victims of such habits out of them. It is extremely doubtful, however, whether self abuse of itself, unless practiced in very early years or indulged in to a degree that is possible only in those of unbalanced mind, ever works anything like the serious harm that is claimed. Certainly physicians who are most familiar with its results are not ready to confirm the opinions usually advanced as to the awful harmfulness of the practice. Personally, I have had a number of patients confess to me that they had indulged in the habit to some extent for twenty years and longer and yet had never suffered anything more than passing physical discomfort. It is unfortunate, then, that the exaggerations of the quack should by receiving the approval of the well-intentioned moralists, be emphasized so as to add to the neurotic disturbance of mind which makes these patients so miserable and for a time may seriously interfere with their health. Occasionally even suicides are reported in which the underlying motive seems to have been the dread on the part of a young man that a sexual habit has so undermined his health that cure is impossible and that physical and mental deterioration to a marked degree is inevitable. The opinions of conservative physicians tend to show that there is no good reason for thinking that in normal healthy persons such habits ever have the serious effects thus set forth.

Patients can be assured that whatever evil effects follow the practice will not remain after it has been given up. There are no serious enduring sequelae, with one or two exceptions in very special cases, that perhaps should be noticed. Most men of considerable experience in the matter are now decidedly of the opinion that self-abuse does not produce any more serious consequences than the same amount of ordinary sexual intercourse. It is possible for sexual intercourse indulged in excessively, as it sometimes is in early marital life, to produce the same feelings of exhaustion, lack of control over the vasomotor system and disturbance of the gastro-intestinal tract which are noted in self-abuse. In both cases the symptoms promptly disappear upon proper regulation of life. This is a very different opinion from that which used to be expressed in this matter and it is given only after due deliberation and consultation of many authorities both in writing and orally. Its expression, far from taking away one of the best deterrent motives against the practice, rather forces an appeal to the manliness of the individual. The motive of fear never accomplishes much, while a frank statement of the real condition may be greatly helpful.

While the habit of self-abuse as indulged in by the ordinary individual practically never has the awful consequences that have been sometimes pictured as resulting from it even long after its cessation, there is no doubt that it is productive of many physical symptoms during the time of its indulgence. There is almost sure to be a discouraging lassitude and a tendency to exhaustion after even comparatively small efforts. While this is true for ordinary muscular efforts it is also true for other bodily functions that involve muscular activity. In recent years we have learned that of the stomach functions the motor is more important than the chemical. In the bowels the motor function is extremely important. There are likely to be disturbances, then, in the gastro-intestinal tract as a consequence of the muscular condition that [{484}] develops in those patients. Probably more important even than the physical, however, are the psychic results of the habit. The patient feels discouraged and cast down at his inability to conquer himself and is likely to avoid such exercise and diversion of mind as would make normal healthy function possible.

Mental Disturbances.—It is the custom to say that mental deterioration almost surely follows the habit. Those familiar with mental cases often see self-abuse practiced with serious results by young folks whose mentality is deteriorated. In these cases the practice was indulged in with great frequency and with direct physical consequences, such as loss of sleep, of appetite and the like. It is not the habit, however, that has caused the mental deterioration. The young patients are going crazy, but not because of self-abuse. Their habit of self-abuse had originated and become exaggerated because they were already mentally unbalanced. Their extreme indulgence in it is especially due to their lack of control over themselves, because they are not possessed of strong will power with regard to any thing. A vicious circle is formed and the insane young man gradually deepens his insanity by hurting his physical condition through over-indulgence in the habit and all this further lessens his self-control; but were it not for the original mental weakness the habit would not have been indulged in to so great an extent.

Effect on Prostate.—There is one phase of the ill effects of self-abuse that it is well to recall as having the confirmation of men of large experience and conservative views. There is a definite impression among specialists in genito-urinary diseases that enlargement of the prostate in some cases is due to the frequently repeated irritation and the prolongation of that irritation of the prostate during the practice of self-abuse. When such men as Bangs and Keyes are agreed on a subject of this kind, then even though in a certain number of cases the changes in the prostate leading to its enlargement are evidently inflammatory, it is well to consider that the functional over-activity of the gland superinduced by the practice may lead at least to an enlargement of the glandular elements with the consequent interference with urination which so frequently comes in old age.

Physical Factors.—Besides mental elements that predispose to the formation of sexual habits there are physical factors that are important in these cases. They must be particularly looked for and treated carefully if found, or there can be little hope of relief for the conditions. The most prominent of these is the existence of a long foreskin, especially if its opening is small, thus leading to the retention of urine, the deposition of urinary salts with the formation of preputial concretions or so-called calculi. These are intensely irritant, cause frequent itching and thus predispose to these sexual habits. Even where the preputial opening is free and allows egress of urine without residue, the accumulation of smegma often causes considerable irritation and if the most scrupulous cleanliness with cleansing at least once a day is not maintained, irritative conditions arise, especially in hot weather, that may give occasions for sex habits.

Under these conditions the habit is sometimes seen in extremely early years. The youngest case I ever saw occurred in a child not quite nineteen months old whose mother said that for several months she had noticed certain curious actions that she could scarcely understand until finally the truth dawned on her. Then she was morbidly sensitive about it, sure that the habit was due [{485}] to a fault of her own and it was some time before she consulted a physician. This was her fourth child and, strange as it may seem, it was only at the conception of this child that she first knew what sexual pleasure was. She feared that her feeling had been in some way sinful and that as a consequence of her sin this curious habit had developed in such early years in her baby boy. As is usually the case in these instances, I found that the prepuce was very tight indeed, having scarcely more than a pinhole opening in it. During urination this ballooned and there remained in the pouch-like process at the end of the penis a certain amount of residual urine after every urination. From this urinary salts had been precipitated and had formed scaly concretions which remained in the preputial pouch and were extremely irritant. As a consequence of this irritation the baby had been very itchy and it was in the endeavor to relieve the itching by the natural process of scratching that the pleasure of the sensations aroused had been discovered and the sexual habit had been formed.

Not infrequently in young men a condition resembling this to some degree at least is found and then, of course, the question of its removal must be taken up at once. It is surprising how often in youths in their late teens concretions are seen. The constant irritation makes it practically impossible for the patient to keep his hands from the parts, and so circumcision is absolutely necessary. Not infrequently when the preputial condition is not nearly so bad this operation may also be at least advisable if not necessary. The matter of cleanliness must be attended to, preferably after getting up in the morning and not before going to bed at night, for the reaction after cold water may cause congestion of the organ. After a time the frequent use of cold water seems to make the parts much less reactive to irritation of any kind.

Physical Effects.—The super-excitation of nerves consequent upon the more or less general erethism that is induced, lessens resistive vitality. Victims of the habit are more liable to colds, to various infectious diseases, and are subject to fatigue and lassitude, with incapacity to work to their full power. They lose control over their vasomotor system to some extent as a result of this systemic erethism. They blush easily, they perspire easily, there is a tendency in many of them to flash as if of heat and cold, they become pale under excitement or anger more than formerly, they are likely to suffer from cold hands and feet, and the surface of the body is inclined to be cold and as a consequence patients are tremulous. This represents a waste of nervous energy and as a consequence sleep may be disturbed and digestion interfered with.

It is important, therefore, to consider these cases as really needing medical care. For their treatment the most important consideration is prophylaxis, not alone of the habit itself, but of each of the acts. Prophylaxis of the habit is an ethical question that we can scarcely do justice to here. Prophylaxis of the acts requires consideration of the physical and moral factors that predispose to their commission. While the habit may have secured such deep control that the patient almost despairs of relief from it, when care is taken to remove physical and moral predispositions the conquest of the habit becomes comparatively easy. Over and over again I have seen cases that have lasted for years in which the patients were surprised at the ease with which they were able [{486}] to drop the habit just as soon as they took the measures necessary to prevent predisposing conditions.

Breaking the Habit.—Once physical factors predisposing to it are removed, the habit is not so hard to break as it would seem to be from the suggestions to that effect made in sensational literature. It is neither so deleterious in its physical effects nor so deteriorating as regards character as is usually stated. Anyone with a reasonable amount of firmness can break it off if he really resolves to. Over and over again I have seen patients quite surprised at the ease with which they were able to avoid the practice for weeks once they made up their minds in the matter. Indeed this is one of the unfortunate features in completely conquering the habit. It is comparatively so easy to break it off when the mind is made up that there comes the feeling that now it must be absolutely facile to keep away from it. This is, however, never true. Relapses are extremely easy. If the patient allows himself to read vicious books, or suggestive literature of any kind, or permits himself an indulgence in the reading of several columns of the account of a sex murder trial, or goes to see a sex problem play with its suggestions, or exposes himself to sexually exciting conditions of any kind, he will be almost sure to lapse into the old habit.

Relapses are almost inevitable. But it is easier to break the habit the second time than it was the first and it becomes increasingly easy if the patient keeps up the effort of regulating his life so as to avoid the occasions of the habit. Relapses are quite as sure to occur as with regard to alcoholism if occasions for the taking of liquor are not sedulously avoided. The patient always seems to need a confidant—someone to whom he can go for help and who assures him of the ability that he has to overcome himself if he only will. The practice of confession in the Roman Catholic Church makes it comparatively easy for serious people of that faith to overcome the habit. The physician must be taken into confidence in the same way and for a time, at least once a week, the patient may have to be perfectly frank with regard to his condition in order to have the help afforded by such confidences. The physician can often, particularly at the beginning, make the physical conditions such as to help in the breaking of the habit. Bromides taken to the extent of a dram or more a day are almost a specific for superirritability of the nervous system, and if taken for two or three weeks the patient will usually have little or no difficulty in overcoming the habit. They are not of much avail after this time unless the patient's character has been aroused to determined helpfulness in the matter.

In obstinate cases it may be necessary to have a patient come every day, or at least every second day, for some time and give an account of how he has succeeded in resisting his habit in the interval. At least he must be asked to report whenever there is a lapse. It is surprising how much the anticipation of having to tell someone else of a drop back into the habit means in helping the patient eventually to overcome it. Very slight motives serve to cause relapses, but almost any external personal aid, if pursued with confidence, will avail effectually to break it. I talk from an experience of many cases and know how much can be accomplished even though patients insist that they have tried all the resources of their will power and of prayer without avail. They have really not tried, they have not willed in reality; sometimes they [{487}] have reached a point where they cannot will without the moral support of another personality. This can be readily supplied to them by a firm, sympathetic physician whom they respect. It will take time to overcome the tendency to relapse whenever the will is relapsed, but the habit itself can be broken without much difficulty in a few days.

Certain times are particularly dangerous for relapses into the habit. These are just before going to sleep at night and before getting out of bed in the morning. At these times the mind must be occupied or else the patient will almost surely find his habit recurring. Often the habit of reading in bed, properly supported by pillows and with abundant light at an angle that makes reading easy, seems to be good for these patients, because they may read until their eyelids get heavy, then pull the chain of their light to extinguish it and turn over to sleep. In the morning prompt rising after waking is important. Bed clothes that are too heavy and too great warmth of clothing predispose to sexual excitation and must be avoided. The room should be cool rather than warm and the mattress rather hard.

The more tired the patient is the less liability will there be to difficulty in these matters. But air is even more important than exercise in giving the tiredness which superinduces deep sleep. A lessening of the normal amount of oxygen seems to relax the inhibitory power of the higher centers over the sexual centers in the cord. People who are drowned, those who are hanged, and those whose supply of oxygen is shut off by the inhalation of the heavier gases are likely to have involuntary seminal emissions. These are probably consequent upon the shutting off of the air.

The important element in the treatment is to make the patient feel that, if he really wants to, he can conquer in this matter. The old motives of fear, and especially fear of physical consequences, were quite unworthy, and inasmuch as they had any effect rather produced a deterioration of character than a strengthening of it. The patient must understand that if he is a man he can overcome it. Religious motives will help much. I do not know that I have ever seen a case where religious motives were not the most important element in the cure, but that may be due to the conditions in which I have been placed. I have seen a number of these cases in men and women because clergymen have sent them to me in order that they might be helped in the work of reform, and while there are many relapses and some had apparently given up the effort in despair of their power to overcome themselves, nine out of every ten of those who have seriously faced the problem have succeeded in overcoming themselves, and as a result have a better knowledge of their own characters and more respect for themselves. They are better men in every way than if their improvement had come about through selfish fear of physical consequences.

After Cure.—After the habit of self-abuse has been conquered the seminal vesicles will have a tendency to evacuate themselves rather more frequently than before and as a consequence they will nag at certain sexual nerve endings. They are used to having their contents emptied and distention is followed by rather ready evacuation. During the course of this evacuation sexual thoughts are awakened in dreams and this may lead to dream states in which there seem to be lapses into the old habit. This constitutes a serious difficulty in getting rid of the habit entirely in young and vigorous men. They may even become disheartened by it. It should be explained to them that they must let [{488}] contrary habits form gradually and permit nature to accommodate herself to the new state of affairs. The bromides are a useful adjunct for body and mind.

Supposed After-effects.—At times a patient suffering from some exhausting or serious disease, consumption, heart disease or the various forms of Bright's disease, will be discouraged by remembrance of the fact that in earlier years he allowed himself for some time to fall into the habit of self-abuse. If he has read, and very few men have not, some of the literature issued by the advertising "specialists" and has heard the unfortunately exaggerated ideas commonly entertained with regard to the influence on health of this habit, he will become more or less disheartened by the idea that he thus undermined his constitution and that one reason why he is not able to react better against his affection is that he seriously diminished his resistive vitality. This idea must, of course, be overcome or it will act as a constant source of unfavorable suggestion, lessening appetite, tending to disturb sleep, banishing peace of mind to some extent and thus inhibiting the patient from releasing such stores of vital energy for his recovery as would surely be in his power under favorable conditions.

Female Habits.—The habit is more rare in women than in men, but when it occurs is a little harder to break. In men it usually develops in youth, but oftenest in women who are past thirty-five and unmarried. In these cases it is much harder for the patient to regain self-control, because the class of women patients who acquire such a habit have less character, as a rule, than the men who fall into the same condition. In all sex matters, once passion is aroused or habit formed, the woman is likely to lose control of herself more than is the man. Even in women, however, it is not only possible, but under favorable circumstances, quite easy to secure a break in the habit, though relapses are more frequent than in men. Certain occupations seem particularly to favor the development of the habit. These are mainly sedentary occupations that can be followed without the necessity for such attention as to prevent the mind from wandering off into thoughts that may prove provocative of sexual sensation. Dressmakers seem particularly likely to suffer from the affection, and those who run sewing-machines are predisposed by the movements involved in their occupation to the development or, at least, to the persistence of the habit.

For women even more than men religion and the motives it supplies are the most efficient factors for the ultimate cure of the habit. In general, the greater difficulty of overcoming it in them is due in no small degree to the fact that they live indoors much more than men, often have sedentary occupations, and are more frequently alone. These afford opportunities for introspection and for the harboring of thoughts that lead to relapses into the habit. Besides, women are more prone to read novels and stories relating to sex problems and the details of sex murder trials and the like which constitute ever-recurring sources of mental erethism. If their habits can be modified, especially if they can be made to realize the necessity for being out in the air as much as possible, and for keeping their windows open at night, as well as for thorough cleanliness—for every gynecologist notes the necessity for this and how frequently it happens that neglect of it leads to irritability of the external organs that is of itself a serious factor—then it would be no more difficult for women to overcome the habit and get beyond the relapses than it is for men. [{489}] Sometimes we have to overcome a morbid dread of touching themselves even for cleansing purposes which allows the accumulation of irritant material and predisposes to relapse.

Sexual Perversion.—Sexual perversions are sometimes considered as different from sexual neuroses, but such they really are. They are oftener due to habit than to anything deeper. Much has been said about the unfortunate natural inclination of some people to indulge in sexual perversion, but such talk partakes of the nature of similar remarks with regard to habits of other kinds. The alcohol habit, for instance, is formed by many men as the result of their environment and a weakness of character, with lack of resolution to support themselves in self-denial when they are tempted to drink. In recent years it has been only too often the custom to excuse or to justify many of these cases. There are a few persons in whom, owing to weakness of character, alcoholism is more or less inevitable if occasions for indulgence occur. And in the same way there has been much maudlin sentimentality wasted on sexual perverts, as if most of these men could not avoid the actions that the rest of humanity abominates. There are, perhaps, a few individuals who because of a failure on the part of nature to define sex in them properly—as if she had not quite made up her mind which sex they should belong to—are more to be pitied than held to account for their delinquencies in this matter. Compared to the whole number of sexual perverts, however, these are very few. Under the protection of the pity awakened for these, a large number of others find quasi-justification for their acts.

Anyone who knows much about these patients realizes that their story is, as a rule, very different from what it would be if they were inevitably impelled to the commission of the acts in question. Many of them had the greatest abhorrence for it at the beginning, were attracted to it out of curiosity and morbid sexualism, because they had allowed themselves to think and read and dream about sex matters overmuch. They are usually idle people who do not take life seriously and who have an inordinate curiosity about sex subjects. At the beginning the commission of the perverted sexual act was associated with an intensely deterrent rather than an attractive feeling, but gradually this was overcome and a contrary habit has been formed. It is difficult to break this habit and to get away from the morbid sexual ideas that have been allowed to develop and grow strong in connection with it.

This opinion is somewhat different from that held by many men who are recognized as authorities on this subject and who find many excuses in the nature of their patients for these perversions. If it is recalled, however, that whenever wealth has brought luxury to a people and luxury has brought over-refinement, such sex perversions have been particularly noted, it will be realized that not nature, but the ways of men are responsible for their development. Whenever men pay much attention to their bodies, exercise for the sake of their muscles, bathe not for cleanliness but for luxury, sex perversions become common in history. The story of Greek love is well known. Corresponding conditions developed at Rome under similar circumstances. According to good authorities, the English universities became tainted with it a generation ago. Our athletic clubs in this country have rightly or wrongly fallen under suspicion in this matter, though the tendency to exaggeration with regard to such things, and popular credulity in such matters must be recalled. [{490}] Some confirmatory evidence undoubtedly there was. Sexual perversions then would seem to be due in most cases to definite conditions and our knowledge suggests readily what should be the prophylaxis.

In the course of some studies with Professor Magnan at L'Asile Ste Anne in Paris I saw a number of these curious cases of sexual divagations, exhibitionism, sex perversions and similar conditions. Some of his cases were clearly curious examples of natural tendency, at least, to mental hermaphroditism. Occasionally men of normal development otherwise have a woman's waist and woman's torso above the waist, and many womanly coquettish ways that point to this curious mixture of sexes. Occasionally women are lacking in all the sex characteristics of the upper portion of the body, have no breasts and have the hirsute characteristics of men on the face and even on the chest. In such cases one may be tempted to let one's pity override one's better judgment and feel that resistance to the temptations to indulge in perverted sexual feelings may be so difficult for these people as to be almost impossible. Even in such cases, however, under Magnan's gentle tutelage, under his faithful care and sympathy, men and women lost most of the tendency to commit unnatural acts and certainly found it easier to live normal lives than before.

For the majority of these sexual perverts, however, it is as with regard to drug addictions, alcoholism, and obesity, just a question of willing not to indulge in certain appetites that serves to help them. There is no doubt that it is a difficult matter to break a habit that has become a second nature, and it is almost impossible that it should be accomplished without a number of relapses. If the patient really wishes to correct the evil habit, however, this is perfectly possible.

The talk of a third sex with homo-sexual inclinations is quite beside the mark. Certain of this class have a weakness of intellect and of will that is at the root of their trouble, but not a few of them pride themselves on their intellect and will power in most other things and must not be permitted to deceive themselves as to their weakness and its significance. It is not nature but self that is at fault and the disease can be completely eradicated.

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SECTION XIII
SKIN DISEASES
CHAPTER I
PSYCHOTHERAPY IN SKIN DISEASES

The place of mental influence in the treatment of skin diseases will be best realized from the role that we know the mind plays in the production of various skin manifestations. There is a whole series of skin affections which depend to a considerable extent on mental conditions, worries, anxieties, shocks, frights and the like, and a number of skin affections that have been labeled hysterical which occur in nervous persons, due to over-attention to self and their conditions. It has been well said that it is possible to make the feet warm by thinking about them. Certainly attention to any part of the skin surface causes a tingling and hyperemia may follow. Blushing is an illustration of mental influence on the skin, and anything that would tend to make this endure for some time would give rise to erythematous conditions. We know the creepy, uncomfortable, hot feelings that come over us in times of suppressed excitement when we are waiting for something to happen; and, on the other hand, there is a pallor and tremor that accompanies fright or fear, which points to mental influences over the vasomotor system in the skin.

Urticarias.—Certain skin diseases, especially those allied to the urticaria group, are prone to occur in connection with excitement and worry. In the chapter on [Neurotic Intestinal Affections] attention is called to the fact that many patients who suffer from intestinal idiosyncrasies and have excessive reactions to special kinds of food, as cheese, strawberries, or the like, sometimes also suffer from skin lesions and intestinal disturbance through worry or excitement. While preparing for examinations or undergoing some physical trial or suffering from worry or anxiety such persons may have urticaria or even wheals on the skin. There may be some dietary disturbance to account for them, but they would not occur, or at least would not be so serious and annoying, but for the disturbed mental condition. Under these circumstances dermatographia is a common manifestation. It used to be considered a symptom of many physical conditions, but will occur in almost any nervous person during the course of an examination by a strange physician or when some important medical decision is pending.

Eczema.—Not only these passing conditions of the skin, however, but more lasting affections have been connected with mental disturbance. Probably every skin specialist has noted in a number of his cases that a first attack of eczema came after a period of worry or excitement, or sometimes followed directly on a fright. When relief from the condition has been brought about [{492}] by treatment, relapses occur during periods of business worry or family anxiety or mental stresses of one kind or another. Cabinet crises in England are found to be likely to be followed by the recurrence of eczematous conditions in older members of the Cabinet or by first attacks in some of those whose skin has been irritated by some internal condition. Unless business worries can be removed or family anxieties allayed the cure of eczema becomes a difficult matter. Men or women who worry about their eczematous condition apparently prolong it. This is particularly true if they have little to do and are likely to be much occupied with themselves and their condition.

Herpes.—Herpetic conditions resemble urticaria in their response to mental conditions. Herpes preputialis and herpes progenitalis occur particularly in people who worry over the possibility of some infection of the genitals. The lesions are likely to be indolent until the state of mind with regard to them is relieved by reassurance as to their comparatively innocuous character. Even herpes zoster is prone to come on after a period of worry and anxiety. It is due to infection, but the infection becomes more possible after a lowering of resistive vitality in the nervous system. This is particularly true as regards herpes facialis. It has been noted again and again that facial neuralgia is most likely to occur after fright, deep emotion, or prolonged anxiety. Treatment of these cases will only be successful if the mental state is set right. This is particularly true with regard to Bell's palsy. Patients who worry much about it and who fear that it may have lasting results are likely to prolong its course and to put off complete cure for a good while.

Vasomotor Disturbance.—There is a series of skin affections connected directly with the vasomotor system of the skin which are largely under the influence of emotional or mental factors. These represent particularly the milder forms of Raynaud's disease and the parallel forms of Weir Mitchell's disease. In the one case there is a spasm of the arterioles causing what the French call "dead fingers," and in the other paralysis of the vasomotor system with venous congestion in the parts. They are seen particularly in persons of highly nervous organization and especially after periods of emotional strain or stress. There is a series of affections related to these, characterized by numbness, paresthesiae, going to sleep of the fingers or members, tingling, and even milder forms of itchiness—sometimes dignified as pruritus—which are largely due to mental factors. Some physical condition will need to be corrected, but they will only disappear if the mind is set at rest and if the patient is kept from occupying his attention much with them. Concentration of attention will make them chronic.

Scurvy.—Scurvy is not usually thought of as a skin disease, though it has many local manifestations on the skin and mucous membrane. It is a deep nutritional disturbance of such nature that it would seem the mind could have but little influence over it. When scurvy was common, however, it was often noticed that any change of attitude of mind in affected persons brought amelioration or deterioration of condition. Scurvy develops with special virulence during discouragement; it gets better with the dawn of hope. It has been known to be much improved by the prospect of a naval engagement when all the sick men wanted to get into the fighting. The famous case of the Siege of Breda in 1625 is often quoted. The city was about to capitulate because so many of the soldiers were suffering from the disease. The Prince of Orange, [{493}] however, sent word that a new and powerful remedy had been discovered that was sure to cure the affection, and that he had secured some of it and it would not be long before they would all be well. What he sent was a remedy that had been used with indifferent success for scurvy when taken in large doses. He could send only enough to give a few drops to each patient. This small dose was wonder-working in its effect and proved to have the healing virtue of a gallon of the liquor. Most of the patients got better and surrender was put off.

Warts.—A striking evidence of the influence of the mind upon the skin is given by what we know of warts. All sorts of charms have been not alone suggested for them but found to work in certain cases. Lord Bacon in his "Natural History" tells the story of the charming away of warts and exemplifies it by his own experience. When he was about sixteen a number of warts—at least 100—came out upon his hands. One of these had been there from childhood. The manner of their cure he details as follows:

The English Ambassador's lady, who was a woman far from superstition, told me one day she would help me away with my warts; whereupon she got a piece of lard with the skin on, and rubbed the warts all over with the fat side; and amongst the rest that wart which I had from my childhood. Then she nailed the piece of lard, with the fat towards the sun, upon a post of her chamber window, which was to the south. The success was that within five weeks' space all the warts went away, and that wart which I had so long endured for company. But at the rest I did not marvel, because they came in a short time, and might go away in a short time again; but the going away of that which had stayed so long doth yet stick with me.

Lucian, the Greek satirist, tells that warts were cured by magic in his time. Carpenter in his "Human Physiology," page 984, says: "The charming away of warts by spells of the most vulgar kind belonged to those cases which are real facts, however they may be explained." Dr. Hack Tuke in his "Influence of the Mind Upon the Body" says: "In visiting a county asylum some years ago my attention was directed to several of the patients who were pestered with warts and I solemnly charmed them away within a specified period. I had quite forgotten the circumstance until on revisiting the institution a few months afterwards I found that my practice had been followed by the desired effect and that I was regarded as a real benefactor." This feature of the method of removing warts, setting a date before which they shall disappear, is noted in most of the successful charms. Dr. Tuke tells of a case in which a gentleman on shaking hands with a young lady noticed that she had many warts. He asked her how many she had; she replied about a dozen, she thought. "Count them, will you," said the caller; and taking out a piece of paper he solemnly took down her counting, remarking: "You will not be troubled with your warts after next Sunday." Now it is fact that by the day named the warts had disappeared and did not return.

Neurotic Pigmentation.—Pigmentation occurs very commonly as the result of neurotic conditions. Dr. Champneys, in his article on "Pigmentation of the Face and Other Parts, Especially in Women," in St. Bartholomew's Hospital Reports, Volume XV, has illustrated this very thoroughly. The pigmentations of women during the phases of genital life, menstruation, pregnancy, the menopause and the fact that eunuchs are usually fair and fat, while deep pigmentation in the white race is usually associated with sexual irritability, all make interesting studies in this subject. From comparative [{494}] anatomy and physiology the influence of the nervous system over pigmentation has been very well illustrated. Brücke in 1851 established the influence of the nerves on the color of the chameleon and of the frog, and there have been many confirmations of his work. Pouchet, in 1876, in the Journal de l'Anatomie et de Physiologie proved that fish gained the power of changing color by practice and lost it by disuse. The influence in most cases, animal and human, which produces pigmentation is exerted by the nervous system through the vascular supply. The duskiness that sometimes comes with emotion, the pallor that accompanies strong mental disturbance, as well as the blushing states, show that the vasomotor system can be influenced in every part. Pigmentation often seems only a consequence of local continuance of such disturbance. Many of the feminine patients in whom even deep discolorations around the eyes occur in connection with menstruation are typical neurotic individuals. It is worry in combination with the physical disturbance that produces the pigmentation. There are some cases on record where emotional states have caused loss of pigment in the negro or other colored races, or in the hair, as when, in well-substantiated cases, people's hair has become white in a single night. In every case of pigmentary disturbance, then, the individual must be carefully studied and as far as possible all emotional disturbance must be eliminated. Without this other treatment usually fails.

Pruritus.—Pruritus in the old is often a bothersome symptom. All sorts of remedies, internal and external, are recommended for it and successes are reported with them. Whenever there are many remedies for a symptom complex, it usually means that the suggestive element in all of them is large. For pruritus the influence of the patient's mind is extremely important. Often it will be found that these old patients are getting out scarcely at all, but are living in close confinement in their rooms, the air of which is scarcely ever changed. I have known even the keyholes to be stuffed and arrangements made by which the cracks between the door and the frame were rendered impervious to air. In these cases the most important feature of any treatment is to secure a proper amount of air. Sir Henry Thompson, the great English surgeon, in his advice how to grow old successfully, written when he himself was over 80, suggested that the cells of the skin needed an air bath every day. He advised that men should make all their toilet arrangements for the day without any garments on. Washing, the preparation of clothing, shaving, and whatever else was done in the early morning was to be accomplished after the night clothes were taken off and before other clothes were put on. He lived to be well above eighty and was sure that this practice had been of help to him. Stimulating rubbings, if done gently and without the production of too much reaction, will always benefit these people.

If old people have no interest, nothing that attracts their attention, and if they once develop pruritus their mind gets concentrated on their cutaneous sensations and it will be impossible to relieve them by any treatment until their minds get occupied with something else. Anyone who wants to sit in a chair for a few minutes and think about his cutaneous sensations will soon realize how vividly these can be brought to mind and how annoying they can become. To sit and think of a portion of the body is to want to scratch it before long. Scratching produces a flow of blood to the surface that adds to the itchy feeling. The only way to get away from it is to get the mind [{495}] occupied with something else. Of course, where circulation is weak because of failing heart or disturbed because of arteriosclerosis, treatment directed to these conditions should be employed, but the influence of the mind on blushing and skin feeling must not be forgotten.

When pruritus develops in the old in connection with phases of arterial degeneration—its most intractable form—it is important to remember that diversion of mind is the most important therapeutic agent that we have. The old have few diversions. They have given up their ordinary occupations, they are often no longer interested in reading, friends whom they used to know have died, and they are left a great deal to themselves. Under these circumstances anything the matter with them brings about a concentration of attention. This is even more true if they have been very well in earlier life and have had practically no experience with sickness.

Hysterical Cutaneous Conditions.—There are certain cracks of the skin with ulcerative lesions which occur in hysterical patients in the neighborhood of the knuckles that represent a phase of unfavorable influence of the mind. When these patients begin to worry or be anxious they know that these skin lesions will follow. Expectancy seems to make it certain that the lesions will come and attention adds to their chronicity. It has been noted that "chapped hands," especially when accompanied by deep cracks in cold weather, are made worse by anxiety or worry. In many neurotic patients it is impossible to treat such conditions satisfactorily unless the patient's mind can be put at ease. It is surprising how intractable these conditions can be, but that is usually because all the physician's attention is devoted to the skin instead of a considerable portion of it being given also to the patient's mental and nervous condition.

Artefact Skin Lesions.—Of course artefact skin lesions produced by the application of carbolic acid or nitric acid or ammonia or some other chemical irritant, or by rubbing with pumice stone, or with the thumb as schoolboys make what in my schooldays were called "fox bites," are skin lesions connected with a special state of mind and so deserve a mention here. The physician finds them under the most unexpected circumstances at times and in patients apparently above all suspicion of their self-infliction. They can only be prevented by changing the patient's state of mind, though this is scarcely what is ordinarily thought of in psychotherapy. Where skin lesions are atypical it is well to bear in mind the possibility of this curious condition.

The Mind in Dermatotherapy.—I have had old dermatologists assure me that they felt that the mind influenced materially the course of many forms of skin disease. Younger dermatologists are prone to be localists; as they get older the treatment of the patient's general condition is felt to be more important; after twenty years of experience they realize the place of psychotherapy in the treatment of their cases. What is said here is only meant to be suggestive, but certainly sufficient data are supplied to make it quite sure that the mind greatly influences skin conditions and must always be treated if success, especially in chronic cases, is to be secured. I have seen confidence in a particular physician or remedy do much for even the most sloughing and obstinate psoriases. Eczema follows the same law. If psychotherapy can help in the treatment of conditions that are so often intractable, it must surely not be neglected in other cases.

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SECTION XIV
DISEASES OF DUCTLESS GLANDS
CHAPTER I
DIABETES

Diabetes is an affection of metabolism definitely recognized as due to serious organic changes, though existing in several forms. We are not as yet absolutely sure whether there may not be quite different organic diseases in the various forms. Of one thing clinical experience has given us assurance, that the condition of the patient's nervous system is extremely important. While certain forms of diabetes are due to pancreatic changes and others perhaps to changes in the liver or other abdominal organs, the nervous system itself can affect the consumption and excretion of sugar within the body. Certain injuries, especially, as pointed out by animal experiments, irritation of the floor of the fourth ventricle may produce passing diabetes. The symptom may also occur in connection with states of the nervous system. Glycosuria, or the passage of sugar in the urine, may occur simply as alimentary glycosuria; and while this is usually due to an excess of sugar in the diet, the glycosuria itself is predisposed to by neurotic conditions in the patient. Diabetic patients are made worse by worry of any kind and particularly by solicitude about themselves and their ailment. Hence, the place that psychotherapy has in the treatment of the disease.

Unfavorable Suggestion.—In most cases of diabetes, however, probably the most important factor in the production of symptoms is the serious disturbance of mind. The patient has an incurable disease and is frankly told so. For the physician the word "incurable" means only that his remedies are as yet inefficient in preventing certain nutritional or metabolic disturbances, and that these will be likely to continue in spite of all he can do. For the patient "incurable" means that he has a disease for which the doctor confesses that he can do nothing—which is not true—and that it is almost surely progressive, while the many reports of death from diabetes of which he hears only confirm the impression that he has not long to live and that most of the time remaining will have to be spent in irksome care of himself and almost superhuman self-denial.

As a consequence of this train of unfavorable suggestions, the history of practically every case of the milder form of diabetes in older people contains a period in which, shortly after the discovery that they had the disease, they suffered more severely from it than at any other time. As a rule, the discovery was accidental. The occurrence of a succession of boils, the development of a [{497}] carbuncle, occasionally an intractable eczema or a great itchiness of the skin, or an irritation of the external urinary organs, the occurrence of cramps at night, or neuralgia pains, have led to an examination of the urine and the finding of a considerable quantity of sugar. As a rule, the patients are at once put on a diet containing little starch and no sugar, and after a short time most of the bothersome symptoms of the diabetes have ceased. Their own worry, however, the strictness of the regimen, the craving for starches, the decrease in weight from the limitation of diet, have made them profoundly miserable. Their feelings have been translated into the definite conclusion that the disease must still be making progress since they feel so miserable, and they have suffered more from their mental state than from their diabetes.

This is as true of physicians themselves when they are sufferers from diabetes as of ordinary patients. Indeed, it seems that physicians make themselves more profoundly miserable because of their supposed knowledge of the disease than other people do. I have had the confidences of more than a dozen physicians who were sufferers from diabetes, and all of them admitted that they had suffered more from their scare over the disease and from trying to maintain a sugar-free diet than from the effects of their ailment. The lowering of nutrition reacts upon the nervous system, already laboring under the strain of the persuasion that an incurable disease is present, and the consequence is a whole series of nervous and often mental symptoms, especially of the depressive kind, that still further disturbs digestion, interferes with peristalsis, causes constipation or alternate constipation and diarrhea, leads to wakefulness at night, inability to concentrate attention and a constant state of worry. All this reacts upon the system and further increases the diabetes, that is, the inability to use sugar properly, and adds to its elimination through the urine.

Favorable Suggestion.—Just as soon as these patients realize that people have often had considerable quantities of sugar—two per cent. or more—in their urine for years without serious consequences and that most diabetics die, not from the affection itself, but from intercurrent disease, the reassurance of mind which ensues makes their nervous system cease to be a factor in the further disturbance of metabolism and they are able to consume more starch and sugar without increasing the amount of sugar in their urine. This is not true, of course, for the severe diabetes that attacks young people. These run a rather rapid course and usually end in from one to two years in diabetic coma or some complication connected directly with the diabetes.

Danger of Over-treatment.—To strive to keep the urine of diabetic patients free or nearly free from sugar is practically always sure to produce a serious effect upon general nutrition and to disturb the patient's mind and nervous system. Very often, however, an attempt of this kind is made. Doctors who suffer from diabetes are too prone to watch their urine carefully from day to day and this only emphasizes their solicitude about themselves, impairs their digestion, and produces such preoccupation of mind that all their functions are sure to be disturbed. After a time they learn that their general condition is a more important question than the amount of sugar in their urine. If they can maintain their weight with reasonable freedom from the secondary symptoms of diabetes, then the primary symptom—the amount of sugar in the urine—may be almost or quite neglected.

[{498}]

Interval Treatment.—Van Norden has pointed out that if diabetic patients are occasionally made to observe for a couple of weeks at a time an absolute diet, these intervals seem to form a new starting-point for metabolism and enable the patient to increase his power of utilizing sugar and consequently to diminish his pathological elimination of it. Patients look forward with interest to these periods, provided that in the intervals they are allowed a certain amount of starch; and each one of them seems a landmark on the road to recovery. There is a strong element of suggestion in this that acts very favorably and greatly influences the actual power of such intermissions to help nature recover her lost metabolic faculties. This is certainly a better method of treatment than the attempt to keep up an absolute diet which so easily produces the other evil of nervousness that adds to the diabetes, so that there is question of choosing between two evils, and the lesser evil includes particularly the reassurance of the patient.

The Individual in Diabetes.—While diabetes is a question of glycosuria and usually of hyperglykemia, and the consumption of any form of cane sugar or of starch convertible into it, will usually increase the diabetic tendency, not all the forms of starch which may change into cane sugar have the same effect in all individuals or undergo the same modifications. Some patients, for instance, stand milk better than others and may take large quantities of it so that there is less craving for starchy foods. Most patients can take potatoes better than bread even when there is the same equivalent of starch in each. Those who have been accustomed to potatoes from their early years sometimes stand them well and may be able to take them almost with impunity. I have noted in several cases that the Irish and Scotch, accustomed to oatmeal from their early years, seem to be able to take notable quantities of this food when suffering from diabetes without having a marked increase of sugar in the urine.

There are forms of sugar that satisfy the craving of patients for sweets and may be taken in considerable quantities without seriously disturbing metabolism. Honey is one of these, its sugar occurring in the form of mannite, and there are other substances related to it that probably can be employed to advantage. It must not be forgotten that what seems to be sugar in the urine of certain patients, that is, grape sugar, has proved on more careful investigation to be one of the other chemical forms of sugar. We have a number of cases of pentosuria on record in which patients were excreting penatomic sugar, but had not glycosuria, though their urine responded to the ordinary tests for this. It seems well not only to be sure of the diagnosis in these cases, but to use what we have learned to make patients feel that their condition though not curable is by no means hopeless. Care must be exercised to take advantage of every possible individual peculiarity for reassurance, for the extension of the diet in any possible way, and for the satisfaction of the cravings which are so likely to come to these patients. Some of their craving is really due to the suggestion that they cannot have a particular article of diet. Whenever any human being knows that he cannot have a thing, the liking for it grows by suggestion and then it may become an obsession. To be allowed even small quantities of it is often enough to enable patients to overcome this and at least put them in a better state of mind.

Physical Condition.—The most important element in the treatment of [{499}] the less severe cases of diabetes is exercise in the open air. Whatever the ultimate solution of the mystery of diabetes may be, there is no doubt but that the muscles are an important factor in our disposal of sugar within the body. The material which is burned up in the muscles during movement is a form of sugar derived directly from the starch and sugar ingested. When diabetics exercise freely much more of their sugar is consumed within the body and much less of it eliminated through the kidneys than when very little or no exercise is taken. It is interesting to note the difference in the amount of sugar in the urine when patients are taking abundant exercise and when they are taking practically none. Even on a much more liberal diet the percentage of sugar is likely to be less in the exercising patient. One of the results of the diabetic scare is likely to be almost a cessation of muscular exercise. This is partly due to the fact that one of the results of diabetes in many cases is a sense of fatigue in the muscles on comparatively little exertion. Indeed, this is sometimes the first symptom that is noted and that calls the attention of the patient to the fact that there is something seriously wrong with him.

This occurs when there is a serious disturbance of sugar metabolism so that the patient who consumes large amounts of starch and sugar is excreting most of it. Just as soon as the diet is made a little more rigid and the sugar metabolism improves, then exercise can be taken and will benefit the patient. This is particularly true of women suffering from diabetes whose depression on being told that they are suffering from an incurable disease tempts them to remain within doors; the frequent tendency to urination further adds to their disinclination to go out. Under these circumstances they lose their appetites, do not sleep well, and become highly nervous, thus increasing their diabetic tendency. If they are required to go out and take exercise in the open air and rather long riding or walking periods every day, their general health will at once improve and the diabetes will become more manageable. I have seen this happen without exception even in patients well beyond middle age, and I am convinced that it is the diversion of mind as well as the salutary tiredness and thorough oxidation consequent upon outdoor exercise that is the best possible remedial measure for these cases.

Solicitude.—It is important that diabetic patients should not be bothered by frequent reports upon their urine. Their improvement and the reduction of the amount of sugar excreted is at best but slow, and is subject to many variations. While improvements, especially at the beginning, are sources of great encouragement, the deteriorations that are likely to be rather more frequent are prone to overweigh the good effects and eventual discouragement results. It is not from the urine but from the general condition that the improvement in the diabetic condition is to be judged. So long as the patient feels strong, gains in weight (when they do not belong to the obesity type of diabetes), the diabetes itself is almost sure to be improving, even though there may be discouraging periods as regards the amount of sugar eliminated.

Dangers of Rigid Diet.—There are more dangers in a rigid diet than in a certain amount of liberty in the consumption of starches and sugars. The craving for these becomes so strong as to make life intolerable to many people unless a certain amount of these substances is allowed. It is rather easy to manage limitation while it is almost impossible to be sure that [{500}] patients will practice absolute denial. Besides, the almost complete absence of starches and sugars, even though their place is supplied by the fats, always seems to predispose patients to the development of the acid intoxication which results in the coma often so serious an incident of diabetes. It is for this reason particularly that mild diet regulations are clinically more judicious than the absolute denial which on chemical and physiological grounds seems to be the scientific ideal. A rather good therapeutic method is to have the patients maintain a rigid diet for some ten, fifteen or twenty days and then leave them practically without restrictions for the rest of the month. Continuous restriction of diet becomes appalling. Looking forward to a period when they can eat as other people do relieves the tedium, and makes it much easier to keep the restrictions. The mental influence of this moderate treatment is very favorable and encourages the patients in the thought that after all their disease is not so serious. This is the most important element in psychotherapy.

CHAPTER II
GRAVES' DISEASE

Graves' disease, sometimes called Basedow's disease, though the Irish physician has a right to the name by priority, is often called exophthalmic goitre, because this term is descriptive of the two most marked symptoms. It must not be forgotten, however, that there are cases in which there is no exophthalmos and even no goitre, at least no enlargement of the thyroid gland that can be demonstrated externally. It is said that in these cases there must be an enlargement of the thyroid bound down by fascia and concealed by other structures of the neck so that it does not appear externally. It is probable, however, that there are cases of true Graves' disease without enlargement of the thyroid yet with the characteristic tremor, rapid heart and the mental symptoms of the affection.

Etiology.—The symptoms of the affection often develop after a period of excitement or worry, or at critical times in life, if sorrow or misfortune proves a burden. Responsibility sometimes has a like effect. I have seen a woman patient on several occasions in the last fifteen years develop marked symptoms of Graves' disease when she was placed in a position of responsibility involving worry, while in the intervals when pursuing a simple ordinary life without trouble of mind no symptoms were present. Occasionally a fright seems to be at least a predisposing cause for the development of the symptoms. Emotional strains, mental stresses, play a large part in occasioning Graves' disease, though the cause of it is probably deeper in some structural defect. In recent years nearly all the medical attention has become concentrated on the idea that the disease is primarily due to hyperthyroidization. More detailed study, however, has shown that other ductless glands are probably also concerned in the etiology. The adrenals particularly seem to be associated closely with the thyroid and Graves' disease may be due to some disturbance of the co-ordination between these glandular systems. The thymus gland is usually [{501}] persistent in these cases and this must represent something in the affection and at one time the use of thymus substance for therapeutic purposes seemed to confirm this idea. The parathyroids have also been called into question and their use in therapeusis seems to justify this to some extent, though probably we know too little about them to be able to say anything definite in the matter.

Even though the affection may be due directly to hypersecretion of the thyroid, it is possible that the mental and nervous state may be closely concerned in the etiology. Some patients have had an enlarged thyroid for years, without any symptoms of Graves' disease. Then during a time of stress and worry or anxiety and responsibility symptoms of the affection develop. The circulation of the thyroid is under the control of the cervical sympathetic. It is possible that this may be affected by states of mind to such an extent as to cause an increase of the circulation in the thyroid and as a consequence more of the thyroid secretion may get into the blood stream and produce its effect. Under these circumstances anything that would allay the excited mental condition and thus neutralize the unfavorable effect of the cervical sympathetic would cure or at least relieve Graves' disease.

The affection is about five times as frequent among women as it is among men. This has sometimes been attributed to the fact that there seems to be some more or less direct correlation between the sex organs in women and the ductless gland systems. It has often been pointed out that the thyroid is likely to be engorged at the time of menstruation and, indeed, there are those who have attributed some of the symptoms of tremulousness, irritability, and tiredness at this time to over-functioning of the gland. In women who have borne a child the thyroid is usually somewhat enlarged. Good authorities in obstetrics have insisted that they could pick out of a group of women in evening dress, those who had borne children, from the appearance of their necks. Probably this is an exaggeration, but there is no doubt that the thyroid is intimately related to the genital functions in women. It has been said that a direct connection could be traced between disappointments in love or in sexual matters and the development of Graves' disease. To put much stress on this would easily lead to mistaken conclusions, though it represents a principle that should be recalled in certain cases of the affection. The frequency with which slighter disturbances of the thyroid occur in connection with the common genital incidents of female life and their comparative insignificance for health or strength, should make for the holding of a not too serious prognosis in the affection.

Symptomatology.—There are four cardinal symptoms of the disease: rapid heart action, tremor, enlargement of the thyroid, and exophthalmos. At least two of these are largely dependent on mental influences. There are certain accompanying symptoms that are of importance and supposed to be connected directly with the disease, though oftener they can be traced to the influence of the state of the patient's mind upon the organism. Emaciation is common. It is due to the fact that the appetite is likely to be seriously disturbed by anxiety and solicitude. Anemia develops as a consequence and there may be slight fever which is sometimes inanition fever. Attacks of vomiting and diarrhea occur intermittently and sometimes there is constipation. The disturbance of eating consequent upon the affections seems largely [{502}] responsible for these. The disturbance of the vascular system gives rise to flashes of heat and cold and often to profuse perspiration. Certain of the symptoms of the menopause can be compared rather strikingly with those of Graves' disease and have been attributed to the disturbance of the external secretion of the ovaries which are now known to act as ductless glands as well as genital organs.

With the exception of the enlargement of the thyroid and the exophthalmos, all of the symptoms of Graves' disease are of a kind that can be produced in states of excitement with nothing more present than a functional neurotic condition. It is true that the tremor is characteristic and differs from that of hysterical patients, being finer and at the rate of a little more than eight to the second. The rapid heart action, however, and the disturbance of the general circulation which causes flushing and pruritus and the sense of nervousness, as if the patients were in a constant state of fright, are always characteristically neurotic. The changes in disposition, often in the line of irritability, sometimes with severe mental depression, seem in many cases to be only a mental reaction to the patient's solicitude. The weakness of the limbs which sometimes amounts to a giving away of the legs, is connected with the tremor, but seems to be neurotic rather than of any more serious character. In spite of all our study of the affection its place among the neuroses must still be reserved for it, at least as regards many cases, and its treatment must be conducted with that idea in mind.

Diagnosis.—The disease is easy to recognize when fully developed. At the beginning of cases, however, and in certain abortive types of the affection which the French have called formes frustes, the diagnosis may be difficult. Usually the first symptom is tremor and this of itself will often serve, especially in association with general symptoms of nervousness, to make the diagnosis. Tremor with tachycardia puts the case beyond doubt, as a rule, though of course it must not be forgotten that hysteria may simulate rather closely this much of the disease.

The abortive types of the affection are important because they masquerade as forms of psychoneurosis, hysteria, and the like, though the patients are not suggestible, have very definite, not variable, symptoms and get better and worse according to the variations in the underlying affection. Occasionally they seem to be associated with certain other forms of neurotic conditions, especially those with vascular disturbances. There may be tinglings in the ends of the fingers, occasionally with suffusion, erythromelalgia—Weir Mitchell's disease—and even a tendency to the white "dead fingers" as the French call them, of Raynaud's disease. It seems not unlikely that further study will show that many of these affections involving disturbances of the vasomotor system are connected in some special way.

Prognosis in Young Patients.—Some of the cases, especially in young people, are likely to seem quite discouraging and apparently to justify even a serious operation. I have in mind a young woman seen some fifteen years ago when she was about seventeen. The prominence of the eyes, the enlargement of the thyroid, the tremor and the rapid heart were all marked. The symptoms had been growing worse for over a year and the outlook was serious. Ten years later I saw her in another city in perfectly normal health, married and happy and the mother of two healthy children. The only trace [{503}] apparently of the disturbance of the thyroid to be noted in the family was that her children got their teeth very late, her first child, a boy, not cutting his first tooth until after he was fifteen months old. In every other way, however, the boy was perfectly well, rugged and strong, having passed through his summers without any serious disturbance and not being a particularly nervous or excitable child. Such complete relief from symptoms after the condition had been so grave would ordinarily have seemed quite out of the question. It emphasizes the fact that for Graves' disease as it occurs among young growing people, where perhaps the thyroid does not grow in proper proportion to the rest of the body, but for some reason overgrows, the prognosis of the case may seem to be much worse than it really is.

Treatment.—The story of the various methods of treatment that have been reported as successful for Graves' disease serve to show very well how much the affection must depend upon psychic and neurotic conditions, for most of them have been positive in action at the beginning when their suggestive influence was strong, and quite inert after they had lost their novelty and their power to influence the mind. Sometimes even slight operations as on the nose, the removal of polyps, or of a spur on the septum, or an enlarged turbinate, have been found to bring relief of the symptoms of Graves' disease even in marked cases. Operations upon the tonsils have had a like effect and even shortening of the uvula has been reported as curative. A generation ago applications of iodin to the goiter were reported to have good effects. In lancing the goiter, sometimes evidently a cyst was punctured, but sometimes the lance was only followed by a slight issue of blood, yet the affection was favorably modified. More serious operations have followed by complete relief of symptoms for a time, though relapses are not infrequent and occasionally the patient was not relieved, though apparently all the conditions present were similar to those of other patients in whom the operation produced excellent results.

The medical treatment of Graves' disease demonstrates interestingly the power of suggestion. About fifteen years ago a distinguished English observer announced that he was getting good results in the treatment of Graves' disease by the administration of thyroid substance. At that time our present theories with regard to hyperthyroidization as the etiology of the affection had not been formulated, though some vague connection between the thyroid secretion and the symptoms had been accepted. A number of patients were improved by taking thyroid. Other observers found, however, that not only were their patients not improved, but they seemed to be worse as the result of the thyroid feeding. The English physician therefore was asked to say exactly how he obtained his material and prepared it for his patients. Organo-therapy was then new and it was found that the orders given to the butcher for thyroid had been filled by him according to the directions by furnishing portions of a large gland situated in the neck of the calf. This was the thymus, and not the thyroid. Thymus was then deliberately used for a while and there were some reported good successes while the treatment was new and strongly suggestive. After a time it proved to be of no avail.

A number of biological remedies were tried after this. Personally, after having made some studies of the parathyroids while in Virchow's laboratory, I resolved to try material from those glands. The first two patients to whom [{504}] the material was given, with a careful explanation of the theory on which it was administered, proceeded to obtain relief from their symptoms and an intermission in their disease. Just as soon as I purposely omitted to explain to patients how much might be expected from this new remedy and failed to make suggestions founded on the parathyroids, no improvement was noted. In the first two cases this had been more or less necessary in order to determine whether the patients could stand the doses suggested, which began very low and were gradually increased. The material seemed to have no ill effects, however, and a definite dosage could be used without the necessity of taking patients into one's confidence.

A number of serums of one kind or another were reported as beneficial for Graves' disease. It was admitted that they did not benefit all the cases, but that in certain cases they did much good. Practically all of these were strikingly more efficient in their discoverers' hands than when used by anyone else. Thyroids were removed from animals and after some time serum from these animals, supposed to be of lower thyroid content, was injected into human beings with the idea of reducing the hyperthyroidization or perhaps neutralizing it by some substance present in the serum. One very interesting observation on most of these cases deserves remark. The animals deprived of their thyroids, such as goats and sheep, lived on absolutely unhurt by the operation, and as one experimenter expressly noted, sold for more money after being kept for a year under observation than they had cost him before dethyroidization.

Most of our biological remedies for Graves' disease then are strongly reminiscent of the therapy of the affection in older times. It was particularly for Graves' disease, or at least for nervous symptoms closely resembling Graves' disease—those of fright, nervousness, irritability and tremor—that various more or less terrifying procedures and particularly deterrent substances were employed in medicine. These patients, for instance, were cured by the touch of a hanged criminal, and particularly by the touch of their goiter to the mark on his neck. It was especially for them that Usnea, the moss gathered from the skull of a criminal who had been hanged, was of benefit when administered internally. Mummy as a remedial substance remained in common use until well on into the latter half of the eighteenth century in England.

In older times a dead snake wrapped around the neck was said to be an excellent remedy for goiter and especially those cases of goiter that caused symptoms of fright and nervousness. Evidently anything that produces a strong effect upon the patient's mind may prove helpful. Perhaps the suggestion enables the mind to control the cervical sympathetic and by that means the circulation in the thyroid gland, thus lessening the amount of blood that flows through and therefore the amount of secretion that is carried out. There is no doubt but that the sympathetic is largely under the influence of the emotions and that through it very important effects may be worked out in various structures. There seems no other possible explanation for the uniformly reported success of remedies when their suggestive power is strong and their failure quite as invariably later even in the same cases.

Operations.—In recent years operations for the removal of portions of the enlarged thyroid have become popular and some very successful results have been reported. Those of us who know how easy it is to influence the minds of [{505}] patients in Graves' disease favorably hesitate as yet to pronounce definitely with regard to the indication for operation except under such conditions of pressure in the neck or projection of the eyeballs as may lead to serious symptoms. Not all the operators have been as successful as some who made a specialty of the affection. I have personal information which shows a number of unsuccessful cases after operation and the records of conservative surgeons as published indicate this. Unfortunately, a great many cases have been reported within a few months as cured; if they were comparatively without symptoms, surgical intervention is considered to have been eminently successful. For, be it noted, very few are entirely without symptoms, even after operation.

Dr. William H. Thompson in his book on "Graves' Disease" points out that even so good an operator and so thoroughly conservative a surgeon as Kocher reports cases of Graves' disease as cured, which are still exhibiting symptoms that would make the medical clinician hesitate to agree with him and, indeed, rather lead him to expect that under the stress of worry and excitement there may be redevelopment of the symptoms. As the number of cases operated upon has increased there has been a growing feeling that relapses might be expected in certain cases even after removal of large portions of the thyroid gland. The fact of the matter is that we do not understand as yet what is the underlying pathological significance of the symptoms grouped under the term Graves' disease. When there are severe symptoms, as extreme exophthalmos, greatly enlarged thyroid pressing upon the important neck structures, or serious disturbance of nutrition, an operation is always needed; but as yet we cannot be sure that it will produce even complete or lasting relief.

Many patients have been greatly benefited by operation, some of them perhaps permanently, but we need more of the after-history of these patients covering a long period of time, to be sure that the results flow entirely from the operation. There was a time when operations were reported as doing quite as much good for epilepsy as they are now for Graves' disease. As we have pointed out, a number of operative procedures that had nothing to do with the underlying basic pathology of the disease have proved the occasion for considerable improvement or sometimes what might be called a cure for a prolonged period. We can be sure, as a rule, that patients will be benefited immediately after operations. The rest, with care, the strong suggestion, the aroused feeling of expectancy, the confidence in the surgeon, all this would do much of itself. It remains to be seen how much more than this the operation does.

General Condition.—The treatment of patients suffering from Graves' disease consists largely in having them take up some occupation that, while reasonably absorbing, does not make too great a demand upon them. Often when they complain most of their symptoms they are below normal weight and the first indication is to have them brought back to it. I have seen such cases over and over again almost entirely without symptoms when they were up to normal weight and with a good many symptoms when they were below normal. It would be easy to theorize as to why this is so, but the observation is the most important consideration for practical purposes, and we are not yet in possession of enough scientific knowledge with regard to the thyroid or [{506}] its possible connection with other organs that have an internal secretion, to be able to say anything definite about it.

After weight and nutrition the most important indication is sleep. It is impossible for patients to get along with less than eight or nine hours of sleep. Most of them are much better if they have nine or ten every night. Late hours are particularly prejudicial to them. They are tired if they have been on their feet all day and they should be encouraged to take more sleep than others. Sleep is one of the most important considerations for sufferers from the abortive forms of Graves' disease and they must be encouraged to take it in the quantity that they need. This can only be decided by their feeling.

Diversion of Mind.—Much more than other nervous people these patients need encouragement and require diversion of mind. They are prone to be discouraged, rather tired, and easily tempt themselves into a routine in which there is little recreation and no diversion. For them more than for most other patients it is necessary to prescribe that twice every week they shall have some engagement different from their ordinary routine to which they look forward for several days. This looking forward to a break in the routine does much to make life more livable for them and must be encouraged in every way. As to what the diversion is to be must depend entirely on the character of the individual. Some find complete diversion of mind in the theater or even in vaudeville. Others are bored by this after a while and need other recreations. I have known people who were bored by the theater find an evening a week spent in helping a poor person or an afternoon devoted to a visit to a hospital ward or to an ailing friend an excellent diversion. Some of those who do not care for the theater like music and are helped by it. As a rule, however, one must be careful about the indulgence of music for neurotic people since it seems to exert a serious emotional strain on many of them and as the phrase goes "takes a good deal out of them." This is particularly true for younger people who have a passion for music. Older people may be trusted more in this matter and the attendance on concert and opera, which is looked upon as a social duty by some, giving them an opportunity to greet friends and to display their gowns and jewels, is a harmless diversion of mind.

Mental Treatment.—Graves' disease is, then, as we have said, especially likely to be influenced by the patient's state of mind. Nothing disturbs patients more than the declaration sometimes made by physicians that their condition is incurable or that they will have to doctor for it for many years. This must be avoided because our present knowledge does not justify any such positive declarations. Most cases of Graves' disease, while not particularly amenable to treatment by specific drugs, are very much improved if the patient's general health is brought up to the best standard and if all sources of worry and emotion are eliminated, as far as possible. Nothing is more serious for them, however, than the suggestion that they will not get well. Probably no one has ever seen a mild case of Graves' disease that did not improve so much as to be practically well after the lapse of some time. Recurrences take place, but if all sources of worry and irritation of the digestive tract and over-tiredness are removed, then patients will stay free from their symptoms for surprisingly long periods. Old people do not have these [{507}] favorable remissions so much as the young, but under twenty there can be, as a rule, definite promise of decided improvement and sometimes of results that seem like complete cure. For patients under thirty there is every reason to think that if they are in a run-down condition when the disease is first noted remissions of symptoms can be looked for lasting for long periods, during which they will be comparatively well.

Diet Suggestions.—The changes in diet necessary to bring improvement in Graves' disease are different for individual patients. Prof. Mendel, in Berlin, found in his extensive experience that meat does not seem to be disposed of well by these patients and acts somewhat as an irritant. He reduces the meat taken and usually allows it at but one meal. If patients get on well as vegetarians, meat is gradually eliminated from their diet. On the other hand, there are patients who seem to develop Graves' disease during a vegetarian diet. Very often it will be found that there is an intermittent constipation and diarrhea in these cases, and that the bowels will act much better if a certain amount of meat is given, and then the symptoms of Graves' disease remit, as a rule. As in most of the major neuroses, as is known so well in epilepsy, any irritative condition of the digestive tract will surely revive neurotic manifestations and make many of the major neuroses much worse than they were before.

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SECTION XV
ORGANIC NERVOUS DISEASES
CHAPTER I
PSYCHOTHERAPY OF ORGANIC NERVOUS DISEASES

Since we know that the basis of many nervous diseases is an obliteration of certain cells of the brain or of the spinal cord, or certain tracts of the central nervous system through which impulses must pass if they are to be effective as motion, sensation or function in some other form, we realize that we cannot recreate these portions of highly organized tissue and that therefore organic nervous diseases are beyond the action of any remedies we now know or may even hope to discover.

The development of pathology has shown us that once there has been serious nephritis or cirrhosis of the liver certain portions of the glands are destroyed and therefore there cannot be any question of cure. There is no possibility of redintegration of destroyed tissues when they are of highly organized character, and so the patient will always be maimed. One might as well talk of causing an amputated finger to grow again as talk of curing diseases that involve destruction of specialized cells. When this first dawned on modern medicine as the result of the careful study of pathology a period of therapeutic nihilism developed during which physicians trained in the pathological schools were prone to distrust drugs entirely, or at least to a very great degree. The effect of this wave of nihilism has not entirely disappeared in our time, though we have learned that even where serious damage to an organ has been done by disease we may still hope to compensate for defect of tissue by stimulation of other organs and to replace its function by certain physiological remedies or biological products; and if we can do nothing more, we can at least alleviate the symptoms which develop as a consequence of the organic affection.

Nature's Compensation.—Physicians are prone to forget nature's wonderful powers of compensation. Apparently even some regeneration may take place in diseased organs of highly organized type if the patient's general condition is kept up to its highest point of nutritive efficiency. How far this may go we do not know, but observations show some marvelous examples of unexpected regeneration.

These counteracting processes can be stimulated sometimes by drugs, but oftener they can be best brought into play by keeping the patient in just as good condition of body and favorable condition of mind as possible for a prolonged period, so that nature accustoms herself to the defect and her powers of compensation have full play.

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Unfavorable Suggestion.—What is true of organic diseases of all kinds is especially true of organic nervous diseases, and in spite of the fact that most of these are essentially incurable, so much can be done for patients that their condition is made more tolerable and indeed some of them improved to such an extent that they consider themselves quite relieved of their organic affection. One of the most serious burdens that the patient laboring under an organic nervous disease has to suffer is the consciousness drummed into him by successive physicians, by his reading, and by every possible means of suggestion, that his malady is incurable. This makes every symptom as severe in its effects as it can possibly be. Hope does not buoy up and discouragement weighs down every effort of the organism to compensate for the serious defect under which it is laboring. Nothing can be done for the disease itself, but much can be done for the patient. Many of the symptoms from which the patient suffers most are really due to his own discouragement, to that sluggish condition which develops in his body as a consequence of his lack of hope, to the absence of exercise and of air and of diversion of mind consequent upon the gloom that settles over him when he is told that his condition is incurable.

Adventitious Symptoms.—If the adventitious symptoms that are always present in cases of organic nervous disease are eliminated, if the conditions which develop from the unhygienic condition in which the patient lives because of his discouragement and retirement are removed, as a rule he feels so much better that it is hard to persuade him that some change has not come in his underlying nervous disease and that a process of cure is not at work. It is because of this that irregular practitioners so often succeed in apparently doing much more for these patients than the regular physician. The irregular does not insist on the incurability of the disease, but, on the contrary, he promises a cure. He then proceeds to relieve many bothersome symptoms that are quite extraneous to the underlying disease, but thus makes the patient ever so much more comfortable than before, gives a cheerful air to his life for a time, makes him sleep better as a consequence and it is not surprising that the patient thinks that his disease has been bettered, if not cured.

Suggestive Prophylaxis.—While we are optimistic just as far as possible since genuine nervous disease has declared itself, it must not be forgotten that we can by suggestion and warning often prevent or delay the development of nervous degenerations. This, too, is psychotherapy and must be employed wherever it seems advisable.

Post-syphilitic nervous conditions of so many kinds are likely to develop that it is important to warn the patients who are sufferers from this disease from taking up the more strenuous forms of existence. This may seem an exaggerated view of the condition, but it is amply justified by the results of the opposite rule of life in almost any physician's experience in city practice. A man who has had syphilis must be warned of the danger, one may almost say likelihood, if he takes up any of the professions in which there is much mental strain and nervous worry, that he will almost surely not live out the normal span of life without some serious nervous incident. Locomotor ataxia, and, above all, general paralysis develop, as a rule, in men who, having had syphilis, have some occupation in life that calls for considerable mental strenuosity, and involves excitement and worry. Actors, brokers, soldiers and sailors, speculators of all kinds, race-track gamblers, these are the classes from [{510}] which victims of paresis and locomotor ataxia are particularly recruited. People who have suffered from syphilis and who live the ordinary unemotional life of a teacher, or a merchant, or a writer, do not, as a rule, develop the postsyphilitic and parasyphilitic conditions.

Precocious apoplexy is especially likely to occur in patients who have had syphilis and who have then spent themselves at very hard work. I doubt if hard work alone, without some such antecedent condition, ever produces this result. Of course, it is not alone syphilis, but other serious conditions which affect the nervous system that ought to be guarded against in this same way. If there has ever been any affection of the kidneys, as a complication, for instance, of scarlet fever, then it has always seemed to me to be the duty of the family physician to warn such patients that their kidneys are more prone than those who have not suffered from such an incident to break down under any severe strain that may be put upon them by worry, especially worry following a period of strenuous work. In these cases the affection of the kidneys nearly always makes itself felt in the nervous system, and especially in the brain, and so this warning has a proper place here. Where there has been severe cerebro-spinal meningitis this warning seems also to be needful, though here our records have not been kept with sufficient care to enable us to speak positively of the necessity for the warning.

Treatment.—It is important to remember that as physicians we do not treat disease but patients. We care for patients, that is the real etymological significance of the Latin curare, we do not cure diseases in the modern sense that has come to be given to that term, of completely removing the materies morbi and setting the patient on his feet once more just as well as he was before his illness.

Relieving Incurable Disease.—A new cure for locomotor ataxia, for instance, is announced every now and then, and the evidence for its beneficial action is the testimony of patients who have been relieved of many symptoms that they thought connected directly with their spinal affection. All sorts of remedies have been employed with announced success. One man builds a particular kind of shoe for them and has a number of witnesses to his skill in curing them. Another does some slight operation on their nose or their throat or their urethra and straightway the patient feels so much better that he talks confidently about being cured. All the characteristic symptoms of the affection remain. Their knee-jerks are gone, their pupils do not react normally, they have some incoordination in their walk, but a number of other symptoms have disappeared and their walk is probably much improved because of their confidence and a certain amount of practice that they have gone through. The new hope born of confident assurance that they could be relieved gives them an appetite, makes their digestion better. This lessens the sluggishness of their bowels, gives them confidence to get out and see their friends, life takes on a new hope, they sleep better and it is no wonder they talk of having been helped or even cured.

There is a definite relation between the nervous affection in these cases and many visceral symptoms. There is no doubt, for instance, that certain cases of intractable dyspepsia are associated with tabes and that in nearly the same way obstinate constipation frequently develops. Notwithstanding the connection of these symptoms with an incurable condition of the spinal cord [{511}] that is no reason for thinking that they cannot be relieved even though no improvement of the spinal-cord lesions is expected.

Frequently, indeed, gastric dyspepsia is due more to worry over discomfort somewhere in the stomach region than to any real disturbance of the digestive functions. It may then be considerably ameliorated simply by the assurance that the trouble is local and is localized outside of the stomach itself, though there may be some sympathetic irritation of the gastric nerve supply. Probably Dr. Head and those who have studied reflexes so enthusiastically would not agree with this explanation of the relief of the gastric symptoms in some of the cases they have described, as due rather to suggestion than to the local treatment, and, as a matter of fact, we are not quite sure which factor may be the more important. Counter-irritation probably plays quite an important role in the relief of discomfort, but I am sure that the suggestive influence of acute sensory feelings at the surface produced by counter-irritation serves to divert the mind from the duller ache or the functional disturbance below. However, Dr. Head's paragraph should be given in his own words, for it furnishes a scientific basis for one aspect of these cases.

Throughout the study of cases of nervous diseases, evidence of the relation between pathological condition of certain viscera and sensory disturbances in the superficial structures of the body is constantly manifested. For instance, a man with caries of the spine suffered from a girdle sensation round the area of the eighth dorsal segment. At the same time he was greatly troubled by flatulent dyspepsia which was untouched by drugs. It was, however, greatly relieved by counter-irritation applied to the maximum tender point of the eighth dorsal area in the eighth space and mid-axillary line.

Optimistic Suggestions.—Our most prominent neurologists have in recent years insisted on the necessity for encouraging patients and for not permitting them to brood upon the worst side of what is to be expected from their ailment. Patients are entirely too prone to read up about their disease and the worst symptoms of the extreme cases impress their minds and are constantly recurring as suggestions of possible ills to come. Prof. Oppenheim in his "Letters to Nervous Patients" states in a striking way the optimistic view that it always seems advisable to give a patient in the initial stages of a serious, incurable or even progressive nervous disease. That letter is worth quoting:

I cannot conceal from you the fact, which you have already ascertained from other sources, that you show the premonitory symptoms of a disease of the spinal cord. This admission is not, however, as you fear, synonymous with the sentence "the beginning of the end." There is no reason for you to despair. We doctors regard and welcome it as a marked advance in our scientific knowledge that we are now in a position to diagnose a nervous disease of this kind in its first commencement. This is undoubtedly a great gain for the patient, as on account of this knowledge a judicious, experienced physician may, at least in many cases, by the timely regulation of the mode of life and the prescription of certain remedies, arrest the progress of the disease or retard its development. This advice may, however, and should as a general rule, be given without the patient himself being made aware of the diagnosis, for the ideas as to the nature of this disease which prevail in lay circles, and indeed among many doctors of the old school, arise from the knowledge of the disease in its advanced and fully established form, since it was only in this completely developed stage that it was recognized. Then, indeed, its very noticeable symptoms were obvious even to the uninitiated. This picture, sad enough indeed in itself, was rendered still gloomier by [{512}] the misery and despair which popular fancy has associated with the conception of locomotor ataxia.

Arteriosclerosis.—Even with regard to so serious a disease and, of course, absolutely fatal in its progress as arteriosclerosis, it must not be forgotten that much can be done for the patients and especially for the nervous symptoms that develop in connection with the condition. For the progressive hardening of the arteries on which the nerve symptoms depend absolutely nothing can be done. A man is as old as his arteries, and we cannot bring back the years even though the patient has become prematurely old. For the symptoms so frequently seen in connection with arteriosclerosis, the paresthesia, the burnings, the numbness, the pruritus, the pains around joints and the difficulties in connection with them, even for the intermittent claudication which develops, much can be done. Above all, the patient must not be allowed to cherish the notion that his disease is not only incurable, but that nothing can be done for it. It is inevitable and progressive, but then according to one definition, life is a progressive disease and every day brings us nearer death. "Life is a dangerous thing at best," as an American humorist once said, "and very few of us get out of it alive."

These patients can be relieved of many physical symptoms, they can be encouraged, their attention can be diverted from their symptoms, and it is concentration of mind on them that often makes them intolerable, while occupation with something, especially if it is interesting, will often prove an efficient remedy for the discomforts complained of. Old people who have no interests, who have retired from business, who did not have the opportunity when young to acquire tastes in art and literature, above all, those who have no interests in children, no grandchildren nor close relatives near them, are likely to become centered on their ills in the midst of their arteriosclerosis, and this more than the advancing degeneration of arteries itself is at the root of their symptoms. The ideal old age is that which is passed in the midst of younger people, with an occasional happy hour during the day with children in whom one is deeply interested. This is the best psychotherapeutic factor that we have.

Prof. Oppenheim has given the optimistic side of arteriosclerosis so suggestively that most patients suffering in this way should have the opportunity to read it. It occurs in his "Letters to Nervous Patients":

An eminent physician for whom I have much esteem has told you that your troubles, especially your vertigo, are caused by calcification of the arteries. You, sir, heard in this your death sentence, and since then the encyclopedia has revealed to you all the sufferings and terrors with which you may expect to be overtaken.
I would, however, explain to you, as the result of the most careful examination and the most absolute conviction on my part, that your anxiety is unfounded.
Since you have a certain amount of information and scientific knowledge, I may speak to you upon this matter almost as a colleague. One is certainly justified, when a man of your age complains of vertigo, in suspecting calcification of the arteries to be the cause of the trouble, since it constitutes the common senile change, and vertigo forms one of its most frequent symptoms. But—apart from the fact that in senile calcification of the vessels this vertigo is frequently a temporary and not always a serious sign—one is by no means justified in assuming that the appearance of this symptom in later life is in itself, and without further evidence, the sign of such a cause. This is an error which in my experience is [{513}] far too frequently made, to the detriment of the patient. It is first of all essential to closely examine and analyze the symptom in itself. . . . Two years ago, after having overloaded your stomach, you had a real attack of vertigo, which was repeated several times during the day, until, by vomiting and diarrhea, the contents of your stomach were evacuated. Since that time the fear of vertigo has overpowered you. In my experience it is neither new nor uncommon to find that a man who has shown his intrepidity and his contempt of death on many a battlefield, who is a hero in war, may be overcome by some dread of illness, by some anxiety, or even by some pain, and may be distressed by it in a way that is in sharp contrast to his whole personality. Your remembrance of that vertigo is so lively that the mere idea of it suffices to reawaken the symptom, or at least an imitation of it which very nearly approaches the reality. That this idea is present in your case is quite certain from the consideration of your symptoms. You admit that you almost never have vertigo at home, but as soon as you leave the house, and especially if you find yourself alone in the street far from home, the remembrance of the vertigo comes over you, puts you into a state of anxiety, and is followed by a sensation of tottering and swaying, so that you have to stand still; and at last it has gone so far that you no longer venture to go out alone. And so the hero of X sits like a timid woman in his arm chair, making life bitter for himself and for those around him.
Even were I to find that signs of arterial calcification were present, I should still be satisfied that your vertigo is not due to this cause, but that it is a vertigo of recollection and of fear.

CHAPTER II
CEREBRAL APOPLEXY

Cerebral apoplexy is an extremely serious organic disease that seems surely to be an affection for which psychotherapeutics can mean little or nothing. When an artery has burst in the brain and blood is either actually flowing out or has flowed out in damaging quantities into the delicate brain tissues, seriously injuring and perhaps destroying some of them forever, no amount of mental assurance will do any good for the organic lesions that have been produced. All that can be hoped is that the hemorrhage will not prove fatal and that the powers of nature will be sufficient to deal with it, and though not able to cure it in the sense of restoring tissues to former conditions, will compensate for the lesion in some way and dispose of its products so effectually that but little interference will result with nerve functions within the skull.

There is no pretence that by psychotherapy or any appeal to mental powers anything can be done for the underlying pathological process. And it may be frankly said that no remedy of any kind, physical or mental, will avail much, while some of those that have been suggested are just as likely to do harm as good. Position, with the head elevated and quiet of mind and body are the only remedial measures that promise definite help. Excitement greatly increases the danger. Reassurance does more than anything else to lessen blood pressure and lessen also the danger of a hemorrhage producing fatal effects. In nervous, excitable people the first stroke is often fatal. Occasionally the phlegmatic have three or more ruptures of brain arteries before death supervenes. Psychotherapy, then, has a definite role even at the time of the apoplexy.

[{514}]

The Mind Before and After.— Much can be accomplished for the patient by proper attention to his state of mind both before and after cerebral hemorrhage. There are many symptoms which point to the possible occurrence of the rupture of a cerebral artery, and older people are likely to know something about these and to dread them so much that to some extent they may by worrying precipitate the evil they fear. Many people, having read vaguely about apoplexy, having seen a case or two of it perhaps, and having heard of others, develop a dread of its occurrence in themselves that makes them miserable. Finally, the shock of a cerebral hemorrhage is very great and its after-effects likely to be very disturbing. It affects the whole personality and often makes a strong, vigorous, healthy man a decided hypochondriac. All of these associated mental states may be greatly benefitted by psychotherapy.

A number of neurotic symptoms are always added to whatever manifestations of mind and the somatic system may develop as a consequence of the cerebral apoplexy, and these are treated more effectually by mental reassurance than in any other way. Besides, apoplexy confines people to the house who have often been vigorous and active before, and this confinement with deprivation of exercise and air and consequent disturbance of appetite and digestive functions, acts as a serious factor in the production of neurotic symptoms. Tears and hysterical manifestation are not uncommon, and for these psychotherapy is the most important remedial measure.

In the period preceding true apoplexy there may be such symptoms as persistent headache with peculiar sensations in one hand. These sensations are variously described as creepy feelings or as of "pins and needles," and occasionally as if the fingers and sometimes the arm were asleep. The group of symptoms known as paresthesia are rather common as premonitory symptoms of cerebral apoplexy. When these are combined with headache patients often become seriously disturbed and begin to dread the occurrence of apoplexy. While these are premonitory symptoms of cerebral hemorrhage in those whose arteries are degenerated, patients must be made to understand that just because the fingers or hand or arm go to sleep occasionally, even though there may be complaint of headache, these are not indications of impending apoplexy unless other objective symptoms are present. Subjective symptoms alone can never mean much as regards organic disease. It is particularly neurotic individuals who are likely to exaggerate the significance of their subjective sensations, who are also prone to be so solicitous about apoplexy that they work themselves into a state of fear with regard to it. Even children have their hands go to sleep rather frequently, and at all ages if the arms or legs are placed in certain positions or under certain conditions of pressure, they are likely to develop that numbness which ends in the prickly "pins and needles" feeling that is spoken of as "going to sleep."

Diagnosing Arterial Sclerosis.—Unless, then, some of the arteries at the periphery of the body show signs of such degeneration as to indicate advanced arteriosclerosis, any subjective symptoms, no matter how bothersome, must not be allowed to depress the patient. Usually they mean nothing at all, and would pass quite unnoticed but for the patients' nervousness about themselves. If the temporal arteries are not prominent and visibly thickened and tortuous, and this may be seen at a glance, the patient may be assured almost without more ado. If his radial arteries on careful observation show no signs [{515}] of degeneration, then it is extremely doubtful if there is sufficient arterial change in the brain to justify a fear of arterial rupture. In examining the radial artery it must not be forgotten that the pulse of nervous people, especially such as have exerted considerable mental control over themselves in order to come and see a physician about what they think is a serious condition, is likely to be of high tension. When the artery is rolled under the finger, then it may seem that there is some thickening in its walls, though it is only heightened blood pressure from emotion that causes the feeling. This high blood pressure may, of course, of itself be an indication of danger whenever there is heart or kidney disease, but it often occurs as a passing event in nervous patients whose vasomotor control is so capricious that arterial tension and blood pressure may change at very short intervals as the result of excitement.

It may not be easy to obliterate the pulse in the usual way in many of these cases and as a consequence the illusion of a thickened artery may remain even when the vessel is quite normal. The important rule is to ascertain whether the artery is tortuous. Whenever there is thickening of the arterial wall the artery is lengthened as well as thickened. If the artery is not lengthened the degenerative changes in it are so slight, as a rule, as to be negligible. Indeed, the very beginning of arteriosclerosis may thus be diagnosed. When this cannot be found, patients may be completely reassured that their suggestive symptoms have no significance as regards any possibility of cerebral hemorrhage from the ordinary causes of advancing years and arterial degeneration.

Differentiation.—Occasionally such paresthesiae as have been described especially when associated with headache, point to an intracranial growth, or to a developing syphilitic brain lesion, and these must be carefully eliminated, but they constitute quite separate problems which always present other accompanying symptoms that make diagnosis possible once a suspicion as to the nature of the lesion is aroused. Above all, these occur in much younger patients than are, as a rule, the subjects of cerebral apoplexy.

Symptoms.—Dreads—Dizziness.—There are other symptoms of which people have heard as preliminary signs of brain hemorrhage which occasionally disturb them to a great degree and set up a set of dreads that may be difficult to banish. Probably the one that is spoken oftenest of is dizziness. There is no doubt that under certain circumstances this may be a symptom of impending cerebral hemorrhage, especially if it is accompanied by headache and by objective signs in the arteries, but dizziness by itself is not enough to justify any anxiety in even elderly people. If, when a man stoops over and then straightens up rapidly everything becomes black before him and he must immediately take hold of something to keep himself from falling, it is probable that a pathological condition of his cerebral arteries is present. This interferes with brain circulation and may have seriously impaired the elasticity of the arteries which is so necessary to overcome the rapid variations of the influence of gravity on the blood current when there are sudden changes of position. Fits of dizziness that come on immediately on rising in the morning, or that attack the patient when he sits up suddenly in bed may have the same serious significance. None of these signs are significant, however, unless there are, as we have said, objective signs in the arteries.

[{516}]

But dizziness may come from many other causes besides degeneration of arteries. A very common cause of it is the presence of gas in the stomach which interferes with the heart action mechanically and so disturbs the circulation. The column of blood to the head is more easily affected than the rest of the circulation because it must be pumped up directly against gravity when we are in a standing position, and so any, even a slight, interference with the heart action is felt at once in this portion of the body. Besides, the brain is extremely sensitive to changes of circulation and even a slight disturbance of the blood supply to it may cause dizziness. There occurs also undoubtedly a feeling of dizziness that is entirely subjective. The patient for some reason loses confidence in himself and has a feeling of dismay, as if he could not support himself. Such a patient may complain that when he comes down stairs, at the first step or two, particularly of a high stairs, he has the dread that he may pitch forward. Such people have never actually fallen, but they have to grasp the railing and they have a dread of some accident of this kind. This is, however, rather a form of akrophobia than a true dizziness. Prof. Oppenheim has dwelt on vertigo as a dread (see preceding chapter).

Vertigo.—Besides, there are pathological conditions that cause dizziness yet have no connection at all with the dizziness that is a premonitory symptom of apoplexy. Menière's disease, for instance, even in its milder forms, causes at times a vertigo that is extremely annoying and that frequently gives rise to the fear that a serious brain lesion is either actually occurring or is impending. I have seen even comparatively young patients suffer so much from this dread that life became miserable to them and they were unable to do their work properly. A few words of explanation and reassurance literally work wonders for such patients. In one case the young woman assured me over and over again that my explanation meant a new lease of life for her. She still has occasional dizziness, but now she knows that it is due to her accompanying ear trouble and it does not worry her.

Motor Symptoms and Over-solicitude.—Besides dizziness, there are other symptoms of which patients complain and which may indicate that an apoplexy is impending or may mean only that a patient is occupying himself too much with himself and his symptoms. Not infrequently when there is degeneration of arteries in the brain there will be slight weaknesses of the limbs or awkwardness in the use of them. Occasionally women will complain of the fact that they do not button dresses as they used to. Sometimes men will complain that they do not button their collar or their suspenders at the back with facility, or that they are awkward and grow fatigued easily in such strained positions.

These symptoms may be indicative of some disturbance in the motor areas of the brain, but it must not be forgotten that all of these may be simulated by nervousness, especially if the person knows the meaning that is attached by doctors to these symptoms. In this matter particularly a little knowledge is a dangerous thing. We are only just getting a generation of trained nurses to the age when they are likely to suffer from dread of apoplexy and some of them are over-anxious patients because of their knowledge without the balance of complete practical experience with the meaning of such symptoms. Doctors themselves are prone to be disturbed by such thinking more than [{517}] almost anyone else. The delusion of thinking apoplexy is not at all uncommon in elderly physicians. In men it is important to insist that objective symptoms are the only details of real value and that subjective feelings are utterly illusory. If this cannot be brought home to them they make themselves extremely miserable and may even help to precipitate through worry the fatal complications they dread.

Prophylaxis.—There is no doubt but that heredity plays an important rôle in apoplexy. In certain families most of the members terminate existence by rupture of an artery in the brain, sometimes at comparatively early ages. Apparently the resistive vitality of their arteries is only sufficient to enable them to maintain themselves for a limited length of time against blood pressure. They are destined to have arterial degeneration that will predispose to arterial rupture sometime before they are sixty. Father, grandfather and great-grandfather had their apoplexies from fifty-five to sixty-five and the son must realize that he probably will go the same way. Even the delay of a year or two is important. Anything that will save the wear and tear of existence may bring about such a delay and it is not by drugs, nor even by dietetic precautions, so much as by attention to the patient's state of mind that this decided benefit can be best secured.

Over-indulgence.—People with such an unfortunate heritage should be made to understand reasonably early in life that they must save themselves from as much arterial wear and tear as possible. There are certain occupations involving intense emotion and excitement that are barred to them if they want to live out their lives, even to the extent usual in the family. There are three causes that weaken arterial walls. When the question of causation of aneurism is discussed it is usually said that it is especially the devotees of three pagan deities—Venus, Bacchus and Vulcan—who suffer from this form of arterial trouble. Just this same class suffer particularly from the tendency to early arterial rupture in the brain. Under the head of devotees of Vulcan, the hard workers, must now also be placed the advocates and exemplifiers of the strenuous life, who are perpetually doing, though often it is hard to see what they accomplish; the money-getters, who are really overworking as much as the forced laborers of olden time. People with an apoplectic heredity should not take up such professions as that of the actor, the broker, the speculator of any kind, the lawyer absorbed by the strain of trial work, perhaps not even that of the surgeon. Physicians generally are not long lived because of the irregularity of their hours of eating and sleeping and the responsibility of their professional life.

Many men will not be guided by such considerations and insist on living their lives in their own way in spite of the possibility of the family inheritance shortening their career in the late fifties. More than one has said that he would prefer to have the life of the salmon rather than that of the turtle. The strenuous life alone appeals to them.

"Better fifty years of Europe than a cycle of Cathay."

This would be an admirable response if what these men accomplished during their lives amounted to anything. Most of these who run out their existences in the midst of excitement, however, only do harm by adding to the swarm of speculators in life, or accomplish very little because of the intense [{518}] excitement under which they labor. It is the quiet lives, doing a few things and doing them well, outside of the strenuous current of the bustle of existence, that accomplish most for mankind. The others may attract attention for the moment, but they soon pass out, often having done rather harm than good.

Life-direction.—It is perfectly possible for the physician to make this clear to a young man with a dangerous heredity and perhaps change the current of life so as to make it effective in simplicity and serious patient work. The young man will usually be quite impatient to think that anything thirty years ahead should be expected to influence his decision as to how or what he shall do with life, yet this motive added to others may help to get at least some of this and the next generation from wasting their lives in an over-strenuous existence that at most merely accumulates money, often accumulates it only in order to lose it, with consequent disappointment and worry, and frequently leaves no real accomplishment but only the problem of the disposal of accumulated wealth for future generations. Where large wealth is left to the succeeding generation there is usually little use to give any advice with regard to the possibility of early apoplexy, because excitements of other kinds than those of business, of the heart rather than the mind, are likely to wear out existence even before the time when the family life of arteries ordinarily, though precociously, runs itself out.

Certain people have what is called the apoplectic habitus, that is, they are short in stature, rather stout, with short necks and florid complexions. It seems not unlikely that the mechanical arrangement within their bodies by which the distance from their heart to their brain is so much shorter than in ordinary persons is responsible for the tradition so generally accepted that there is a definite tendency in such people for apoplexy to occur at a comparatively early age. Such people should be warned gently but firmly of the danger that they incur if they subject themselves to a life of excitement or emotional stress or permit themselves to get into circumstances in which they will worry much. It may seem as though a warning of this kind would precipitate the worry of mind that it is meant to ameliorate, but in present-day publicity such people are likely to have heard of the meaning of their particular constitution of body and consequently worry about it, but usually after it is too late to do any good. In this matter, as in heart disease, the warning must come before there are any symptoms, or else must not be used at all.

Certain Abuses.—In most of these cases definite warnings with regard to habits of life and indulgence in stimulants and narcotics should be given. Both Prof. Von Leyden and Prof. Mendel of Berlin insist that for patients in whom there is any likelihood of the development of early apoplexy indulgence in alcoholic liquors is almost sure to be serious, but in addition to this generally accepted warning, both of them also insist that smoking has a tendency to produce serious, premature degeneration of arteries, especially in people who already have tendencies in that direction. Overeating and high living in general without moderate exercise causes a plethora of the circulation that must be avoided. On the other hand, violent exercise, running especially to catch trains or cars, haste in the ascent of stairs or hills, heavy lifting, straining at stool, and the like, are particularly prone to have serious consequences for such people. This warning is all the more needed because many a short, [{519}] stout man acquires the idea that gymnastic work and various exercises indoors may help him to reduce his weight and restore the activity of his earlier years. This is practically always a delusion and indoor gymnastic work is always of dubious value.

What these people need is not more muscle and the wearing off of fat but more air and the burning of it off by increased oxidation. Such patients must be taught to lead tranquil lives without any of the excitement and strenuosity that, after all, accomplishes so little. The sacrifice when first suggested, appears too great a one to make, but after a few years patients instead of feeling that it was a sacrifice at all pronounce it to be a blessing in disguise and are proportionately grateful to their physician. Life for many of these people may be prolonged not for a few years of hustle-bustle, but for many years of good work in quiet and peace, without hurting others by competition, but helping many because there is time in their considerate lives to see something of the sorrow and suffering around them and to relieve it.

Change of Occupation.—In the matter of prophylaxis it is particularly important to insist on the fact that when men have worked at hard manual labor when they are young and then, about middle life, have turned to intense intellectual labor, such as the management and administration of important affairs, they are a little more liable than are the general average of humanity to have an apoplectic seizure at sixty or a little later. Apparently inurement to a particular kind of labor when young makes for the capacity to stand it longer than would otherwise be the case. In this matter, however, the most important factor is heredity. Men who come from long-lived families are likely to live long—indeed far beyond the ordinary term of human life. Even in them, however, certain of these directions are helpful in securing the full measure of life.

After the Stroke.—After a stroke of apoplexy when it becomes clear that nature is about to reassert her control over the circulation in the brain and dispose of the remains of the old hemorrhage, psychotherapeutics is more important than anything else that we have for the treatment of these patients. As a rule, they have been active, vigorous men who are stricken and who suffer more from doing nothing and waiting to get better than from any pain they have to undergo. They know that another stroke may come at any time. It is no wonder that introspection plays its part, that every feeling that they have becomes exaggerated in significance, that their appetite fails them, that their bowels become sluggish, that they do not sleep, or that after having fallen asleep they wake up and then for hours lie awake thinking.

Lack of Air and Exercise.—As they usually have no exercise of any kind, do not get out into the air, and have very little diversion of mind, it is easy to understand that neurotic or hysterical symptoms develop, that they lose all confidence of recovery and make themselves even worse than they are by dwelling on their condition. The only way that this group of symptoms can be treated is by favorable suggestion, by encouragement, by mental reassurance and by occupation of mind.

I have always felt that the condition of affairs which developed in a family immediately after the occurrence of an apoplexy usually makes a very unfavorable environment for the treatment of these cases. It is practically impossible for those who come to visit the patient or for the members of the [{520}] family for some time to wear anything but the resigned air that indicates that they fear the worst.

Sympathetic Care.—After the stroke at once when survival is assured comes the question of the management of the patient. A devoted daughter seems to be able to do more for an apoplectic father than anyone else. Somehow her youth appeals to him sympathetically, and he has not that feeling of sadness mixed with a little envy that comes so readily to all men when they find themselves slipping out of life while their contemporaries and friends and relatives are left behind. It is as if the idea of his daughter being young and strong, even though he has lost vitality, docs not touch him poignantly because he has always expected that she should have health and strength after he was gone. On the other hand, a daughter is not always a good nurse for a mother. Just why, is hard to say. A hired nurse must take, as a rule, the place close to the mother which, in the case of the father, so naturally falls to the daughter. These ideas may be founded on too few cases to generalize very much about, but I have discussed them with many physicians, including some women physicians, and they agree with them, in general principle at least.

Trained Attendance.—As a rule, then, the first thing that has to be done for a patient who has had apoplexy and who is beginning to recover, is to have trained attendants near him who talk professionally to him and reassure him and do not make him feel constantly the possibility of an approaching end. If his improvement has begun his family must not be allowed to bother him, his affairs should not be talked over and, as far as possible, some occupation of mind should be secured for him. He needs new interests at once. These must be gradually awakened and he must be made to feel as early as possible that though he may be more helpless than before and most of his ordinary occupation in life may be cut off, there are still many interests in life which he may thoroughly enjoy. I shall never forget hearing Thomas Dunn English, the dear old poet to whom in his earlier years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the University of Pennsylvania that he used to think that all the good things of life were somehow contained in its first eighty years, but that now since he had past his eightieth birthday (he was at the time in his eighty-third year) he was beginning to agree with Bismarck, who declared under similar circumstances that he had found many interests in the second eighty years of life. At the time English was quite blind, was almost completely deaf, had been seriously ill for several months, and had suffered a rather severe stroke some years before; and yet he made the best speech at the dinner that evening and had the youngest heart of us all—joyous, uplifting, encouraging, optimistic.

Outlook.—Men who have been great workers are prone to think that a stroke of apoplexy means the end of all serious work. Of course, it means nothing of the kind for the majority of patients. Many men find not only enjoyment in life after their recovery from even a serious stroke, but also possibilities of accomplishment sometimes better than they had done before. It has even been known that men who had been occupying themselves with things scarcely worth while, with the mere accumulation of money without any purpose, were awakened to a sense of their responsibilities to life and to their fellowmen by a stroke and planned in the after years institutions or aids to [{521}] existing institutions that did much to make life more livable for others. Nothing makes a man face life in a better mood to do really effective service for mankind than the prospect of possibly soon having to go out of life.

Encouraging Examples.—On the other hand, many men have been able in spite even of a severe stroke to go on after a time with the work they had been at before and, though feeling its effects, accomplish the best achievements of their lives. A typical example is the case of Pasteur, the great French bacteriologist, to whom we owe most of our modern preventive medicine and to whom Lord Lister frankly attributes the germ idea of the antiseptic theory. When little past fifty, Pasteur after years of hard work and worry suffered from a severe stroke of apoplexy followed by several of slighter character. It seemed absolutely the end of his labors. For more than a year he was able to do nothing. For all his after life he was seriously lame as a consequence of his stroke. In spite of this, which would seem to preclude the possibility of great intellectual work, Pasteur's most important discoveries were developed after this time and he continued for over twenty years to be the leader of biological science. Had he died at the age of fifty or given up his work we would scarcely know him for the great scientist that he afterwards proved.

It is worth while to be able to tell the stories of such lives as examples to patients who are dispirited and downhearted after a stroke. Of course, men must be prevented from doing hard work or from worrying during the time immediately following the hemorrhage of the brain, and, indeed, for some months. Work and worry, though worry much more than work, might easily hasten a recurrence of the seizure. It has always seemed to me, however, that it is impossible to keep the human mind utterly unoccupied. Men must think about something during their waking hours, and if they have not some interests close at heart they worry about themselves. Of the two things, worry is much harder on the tissues, raises blood pressure more, disturbs the circulation of the brain to a greater degree than does work. Anything that a man will interest himself in, then, should be allowed to him, provided, of course, that he is kept from getting into the state of mind which precipitated the rupture of the artery in his brain. It is a change of mental occupation above all that is needed and this is secured by deliberate attempts to interest his mind in various ways and keep him from dwelling on himself and his ills. This injunction cannot be repeated too often.

Change of Mental Interest.—I have already insisted in the chapter on Diversion of Mind that so far as we know at the present time different portions of the brain are occupied with different subjects in which we may interest ourselves. When a man by business worries, occupation with financial affairs, or with political troubles, has apparently worn out one portion of his brain, he may still use other portions to decided advantage. Hence the necessity for finding new interests for the apoplectic after their attack. The best interests for them are those associated in some way with their fellows, because these are accompanied by feelings of consolation, of encouragement, of desire to live and do good to others. These do more to take men out of their moodiness, their morbid introspection, and their self-centeredness, than anything else. With the help of a good nurse, herself of broad interests, this must become the main purpose of the physician's treatment.

[{522}]

Misplaced Sympathy.—After the first few days, when the shock is over, a strong, healthy man who has been suddenly taken down with apoplexy, then rendered helpless as a consequence of the lesion in his brain, rather resents the sympathy and, above all, the frequent expression of the feelings of his friends towards him. Time is needed for him to recover, there is no way of hastening it, he is already impatient at the delay and words of sympathy do him very little good and often add to his impatience. He is to be taken absolutely with professional calm, made to understand that time is the most important element in his cure, provided he will not worry and will have patience to wait and to help as far as he can. I nearly always feel that it is better for these patients to be away from home as soon as they can be moved with safety. This enables them to avoid without much difficulty what they are apt to consider the intrusive and obtrusive sympathy of friends. Especially is this true of business friends, themselves in good health, who come to offer their condolences.

Their hysterical condition is largely influenced by the fact that they are indoors and have so little diversion of mind. Just as soon as possible they must get out of doors. Over and over again I have found that patients did not care to expose themselves to the inquisitive gaze of neighbors and preferred to stay in the house, though the outing would be of much benefit to them. Hence the necessity for getting them away from home, among people whom they can observe without attracting too much attention themselves and, above all, without being the subjects of such obtrusive pity as will disturb them. None of us likes to be pitied and least of all the strong, vigorous man who often has had nothing the matter with him all his life and is now suddenly stricken. It requires years of experience to enable one to take sympathy properly and without resenting it.

Outings and Human Interests.—When patients care for carriage riding I have found that the city park is an excellent place for patients suffering from the effects of apoplexy, who require outdoor air and diversion of mind, yet without exercise or much exertion. The children in the park, if they play around, serve as a better diversion of mind than almost anything else for elderly people thus stricken, for they seem to renew their youth at the sight of the little ones. Grandchildren make the best possible consolers even when they seem to probe deep into old wounds by asking questions and by talking about death. The talk of death from young lips has not the same disturbing effect as from older people. The games of children interest the old once more, and if there is occasional music and the chance to see the passing throng of carriages and motor cars and the pleasure boats and all the rest there is refreshment and reinvigoration in it all that soon brings back to the patient deep, satisfactory, even dreamless uninterrupted sleep at night, and appetite and strength. At first there will usually be some objection to being thus treated as an invalid, but only a few days of experience are needed to convert even the most morbid to the idea that this outing will do them good. As a rule, friends must be warned not to spoil the effect of it by fearing lest the patient should be lonely and so go to the park to entertain him. If the drive, the lake and the children, as well as the passers-by, do not suffice to give the patient sufficient diversion of mind, the visits of friends will not have any favorable effect. As a rule, it is better for them to see the [{523}] patient at home and even that not too often unless they are of his immediate family.

Where people are able to go away and, above all, where they can have some pleasant companionship, a seaside resort is an ideal place for those recovering from apoplexy. The long ride in a wheel-chair on the boardwalk at least several hours in the morning and afternoon soon acts marvelously. There is constant diversion of mind at any season of the year, for there are lots of people to be seen in all sorts of costumes and the shops and the shows and the passing throng all have their interests. Then the sea air is bracing and tempts to sleepfulness and just as soon as sleep improves courage comes back. I have known patients so hysterical that they were crying every day and that seemed to have given up all hope, improve so much in two weeks at Atlantic City that it seemed little short of marvelous. What is needed, however, is not a stay of a few weeks but of several months.

Prognosis of Strokes.—While, of course, any single stroke may be fatal and no one can tell anything about the prognosis of a rupture of a brain artery, there are many favorable things that can be said to patients, and they are so prone to think of all the unfavorable things that this better side should be presented to them at once. The physician is tempted to present the worst side of the case lest it should be thought that he did not realize how serious the condition was. All the seriousness of it may be impressed upon friends, but the patient must be told all the possibilities of good. I have always felt that the tonic quality of hope was worth more in preventing further damage and in encouraging the beginning of repair than any drug that we have. If patients have been unconscious, just as soon as unconsciousness disappears, they should be told that very probably this is the beginning of recovery and that the great majority of people who have a stroke recover. The more rapidly the symptoms disappear the better is the ultimate prognosis. Many a man who has had a stroke has done years of good work afterwards and very few men who recover fail to accomplish something that is of supreme satisfaction to them. They have a new outlook on life as a consequence of the near vision of death.

Those who have had one stroke usually die in a subsequent one, though, of course, some intermittent disease such as pneumonia or some organic complication may anticipate the second stroke. Those who have had two strokes and survive are often much worried by the old tradition that a third stroke is always fatal. I am reasonably sure that many old men have not survived their third stroke when they felt its premonitory symptoms and knew just what was coming from their previous experience, because they had given up hope on account of this old tradition. Ignorant people or those of the lower classes who have not heard this axiom often survive their third stroke and I have seen a man who had suffered from seven apoplectic seizures.

Complications.—Occasionally a patient, especially if of the educated classes, may be much worried by the fact that while one side is distinctly lamed after his stroke, yet there is also a pronounced weakness on the other side of the body. This sometimes gives rise to the rather appalling thought that there was perhaps a simultaneous rupture on both sides of the brain. It needs to be explained to such patients that this slight weakness, sometimes quite distinct, however, on the side opposite that which is most affected is extremely [{524}] common. Ordinarily the rupture of an artery on one side of the brain causes a paralysis on the other side of the body. This paralysis or loss of control over muscular action is due to disturbance of the motor tracts of nerves through which muscular action is controlled and directed by the brain, and these normally cross to the other side on the way to the periphery. In nearly everyone the tracts remain uncrossed to some slight extent. In some so much of the pyramidal tract remains uncrossed that there may be decided weakness on the same side as the lesion in the brain.

CHAPTER III
LOCOMOTOR ATAXIA

How much can be done for organic nervous disease by attention to the individual patient and by favorable suggestion is illustrated in locomotor ataxia. This is, of course, an absolutely incurable disease. We know definitely that certain tracts of nerves in the spinal cord are entirely obliterated and their functions can never be restored. Occasionally the disease gives rise to severe localized pains called crises, for which even our strongest anodyne remedies are of little avail. As a rule, the patient grows more and more helpless and though he may live for twenty or thirty years after the beginning of the disease, and usually dies from some intercurrent affection rather than from any direct effect of his disease, the condition is burdensome and the outlook is most unfavorable and depressing. It is for locomotor ataxia, however, that the irregular practitioners have succeeded, apparently, in working wonders. Some of them, indeed, have made quite a reputation for the cure of the disease. This was not because they did the impossible and cured genuine cases, but because individual patients can, in many cases, be so much improved by attention to particular symptoms, and so much can be done to make life more livable for them, that it is no wonder that so many of them are ready to proclaim that they have been cured, though only certain symptoms, are bettered and their underlying disease remains in essence unchanged.

One thing that constantly happens in the progress of locomotor ataxia is a yielding of joint capsules and attachments so that there is more motion permitted in joints than is possible in the normal individual. As a consequence of this relaxation of tissues around the hip joint the leg may be stretched up along the trunk when the patient is lying down, the foot being placed over the shoulder almost as a gun is placed at carry-arms. Patients often walk with a distinct "back knee" because of the yielding of the tissues around the knee-joint. The ankle nearly always yields and a specially severe form of flat foot develops. This causes muscles to act at a disadvantage and produces great fatigue and even a painful muscular condition when the patient stands much on the feet. This form of flat foot is hopeless so far as cure is concerned, but it can be greatly relieved by the wearing of flat-foot braces or even, to a greater degree, by the wearing of specially fitted shoes. This does not seem much to do for a patient suffering from the serious organic nervous disease of locomotor ataxia, and yet a lot of patients for whom properly fitting shoes [{525}] were made, thought themselves so much improved and relieved by this simple measure that they allowed themselves to be persuaded that their locomotor ataxia was cured. In some cases, where the brunt of the disease was borne by the feet, this relief really did so much to afford the patients freedom from most symptoms of their affection that they thought themselves on the road to recovery.

Value of Favorable Suggestion.—If once the idea of the awful hopelessness of their cases is removed from locomotor ataxia patients they will suggest their own betterment so powerfully that they easily persuade themselves that their affection is considerably improved. It is evident, then, that the regular physician must take advantage of this wonderful power for the relief of human suffering and depression that proves so helpful to the irregular. We cannot cure the tabes of the spinal cord. We cannot re-create the nerve tracts that have been obliterated. We realize that there is no use trying to do so any more than there would be in trying to make an amputated finger grow to its full size again. We can treat the patient, however. We can remove many symptoms that sometimes bother him more than those necessarily connected with his spinal affection. We can relieve annoyances of all kinds that add to his misery and as a consequence we can give him hope, keep him from brooding about himself and thus perform the proper function of a physician. We shall not forget that we can only rarely cure, but we can almost always relieve pain and we can always help the patient in some way. The ataxic patient needs consolation, and this can be given without in any way deceiving him. The loss of sight seems an irreparable ill to those who see, yet the blind are quite happy, are much more cheerful than many seeing people, and have learned to stand their affliction not only with equanimity but really without much depression. In the olden times, before proper care was taken of the blind, they had little occupation, they had nothing to do with their hands, the future was blank and they suffered severely from depression. As a rule, they did not go out enough and their bodily health suffered and the disturbance of their functions still further heightened their depression. All of this happens now with the ataxic patient. A host of symptoms not at all necessarily connected with his spinal affection develop and prove sources of annoyance. Many of them can be removed entirely, all of them can be ameliorated. If, while doing this, we succeed in impressing a discouraged patient's mind with our power to benefit in spite of an underlying incurable disease, we have another triumph of psychotherapy.

Removing Unfavorable Suggestions.—The general experience with those suffering from locomotor ataxia has been that the depression consequent upon the announcement that they have the disease and the stigma that is supposed to attach to it in our day leads them to a great extent to avoid going out into the air. This adds woefully to their depressed condition. Take a healthy man, let him stay inside a great part of the time without any exercise, seeing no new faces, without any interests in life, and at the end of three months he will have a set of neurotic symptoms on a basis of depression that will make him supremely miserable. This will be true even though he has not the threat of an incurable disease hanging over his head. He must be made to realize that every neglect of any law of health in his condition is even more serious in its effect upon him than it would be were he in good health. Above [{526}] all, it must be made clear to him that while his neglect of hygiene may perhaps not shorten his life, it will greatly add to the mental suffering, much more unbearable in its way than the physical suffering which he will have to endure during the progress of his disease.

Treating Accessory Symptoms.—Nearly every ataxic patient who is not directly and almost constantly under the care of a physician, is a sufferer from two conditions that are so constantly present that they are sometimes thought to be consequences of the primary affection. These are loss of appetite with consequent loss of weight and constipation. Almost without exception neither of these symptoms or syndromes are at all connected with the locomotor ataxia. They are the result of the unhygienic life that the patient is living and of the depressed state of his mind and lack of diversion. They are mutually connected, for a man who does not eat enough will not have regular movements of his bowels, and constipation reacts to produce further depression. A vicious circle in pathogeny is formed and the patient is likely to get into a very debilitated and depressed condition. Both of these troublesome symptoms may be corrected to the manifest improvement of the patient by proper advice and ordinary care for his well being.

Appetite is largely a function, as the mathematicians say of something that depends on something else, not of exercise, as is often thought, but of fresh air. In the tuberculosis sanatoria patients with fever are not permitted to take exercise, yet if they are out in the air most of the day and if their rooms are well aired at night, they can eat heartily and digest their food well. Of course, appetite is largely a psychic matter and the thoroughly discouraged man will have no care for food in spite of abundance of air. A little persuasion, however, of the necessity for making the best of a bad job will usually arouse even a locomotor ataxia patient in the early stages of his disease to the necessity for eating a reasonable amount. If he has suffered from gastric crises and fears that eating normally may precipitate these, he must be persuaded that this is not the case, that the presence of food, or its amount, or quality, has nothing to do with the initiation of these painful attacks so far as we know, and that even though at the beginning of his affection before his locomotor ataxia was recognized, his gastralgia may have been declared by his physicians, as is so often the case, to be connected with some form of gastritis or indigestion, that idea may now be given up and he may eat plentifully with confidence that it will not increase his pains. On the contrary, limitation of food seems to have a distinctly unfavorable effect in increasing the number and severity of these attacks.

The same thing must be made clear to him as to intestinal and rectal crises. It seems likely that tendencies to constipation by irritating peripheral nerve endings may have some effect in bringing about the explosion in sensory nerves which have been called intestinal or rectal crises. In general, however, these are dependent on spinal and not peripheral conditions, and no thought of any connection must be allowed to disturb the consumption of a proper amount and variety of food. It seems clear that when patients are much run down, have lost considerable in weight and are in a generally depressed condition, their nervous system is much more irritable than it would otherwise be and they are likely to suffer more frequently from crises of various kinds. Once a patient is made to understand that his general [{527}] nutrition may affect not only the course but the occurrence of symptoms in the disease, as a rule it is not difficult to get him to eat enough and to do so with the definite feeling that it is going to do him good. Even though it should be necessary to use tonics, and often they will have to be prescribed, it is clear that this treatment of the patient's general condition is the physician's first duty, though it does not and cannot affect the specific disease.

Neurotic Complications.—There can, of course, be no doubt that the crises of locomotor ataxia represents extremely poignant attacks of pain. But on the other hand, anyone who has seen many of them is prone to think that not a few of them are really attacks of pain resembling those which occasionally develop in hysterical subjects. The pain of a gastric neurosis may, indeed, so simulate the gastric crises of locomotor ataxia as to make what is only a case of hysteria seem beyond doubt one of locomotor ataxic. Locomotor ataxia patients are prone to think much about themselves and to fear the recurrence of these painful crises once they have had experience with them. As a consequence they sometimes suffer from what are pseudo-crises, that is, from neurotic painful conditions which simulate genuine crises mainly in the amount of reaction they produce in the patient. True tabetic crises yield more readily to ordinary anodyne drugs than do these pseudo-crises. Nearly always the true crises are associated with and exaggerated by neurotic symptoms due to the depression of the patient, the yielding to his feelings, the conclusion that his pain is inevitable and is going to be worse each time, while successive crises are, as a matter of fact, often milder until they disappear for good, and this element in the case must always be borne in mind. Much can be done for the relief by psychotherapy, that is, by making the patient see the realities of his condition, suggesting to him that succeeding crises are less painful and that if his general condition is as good as it should be he becomes better able to stand the pain of his crises and the shock of them is not so disturbing to his system.

Mental Attitude.—Prof. Oppenheim, in one of his "Letters to Nervous Patients," advising a patient suffering from an incurable organic nervous disease, evidently locomotor ataxia, though that is not explicitly stated, outlines emphatically the favorable side of that disease. This is absolutely needed. Ever so many unfavorable suggestions with regard to his affection find their way to the patient. The very fact that it is pronounced absolutely incurable is disheartening. Prof. Oppenheim's words, then, may be a precious help and to have them repeated from time to time renews the suggestion:

Now, however, we neurologists know that that disease frequently runs a very mild course, that a man showing certain early symptoms of such a disease may for ten to twenty-five years and even longer retain his capacity for work and enjoyment. This for a man of thirty to forty years is almost tantamount to the expectation of a whole normal lifetime. But on the other hand, what danger to the peace of mind, what destruction of happiness in life may be caused if the knowledge that such a disease has begun to develop is imparted to the patient without being combined with the consoling information as to the nature and course of the benign forms of this trouble! In unceasing anxiety and fear, in daily expectancy of some fresh symptoms, of some increase or aggravation of his troubles, does the poor man waste his life; and I have frequently found that this wretched apprehension and excitement cause a nervousness and mental depression which in their effects are much more momentous than is the commencing spinal disease.
From this miserable condition I desire to protect you, and I would ask you to [{528}] take this advice deeply to heart: do not bear yourself as one who is condemned; as one who, affected by a progressive, incurable disease, will soon fall a victim to paralysis. On the strength of my own experience I give you the assurance that your condition of health will not necessarily in ten years' time be essentially different from what it is at present. But I would also strenuously exhort you to observe all the precautionary rules laid down for you, to avoid all unaccustomed strain or indulgence such as can only be undertaken with impunity by a man in full vigor and absolute soundness of health. I would advise you also to be thoroughly examined once a year by an experienced physician. But apart from these restrictions, you should as far as possible feel yourself and bear yourself like a healthy man, remaining attached to your work, and not withdrawing yourself from the pleasures of social intercourse.

Relearning Muscular Movements.—Perhaps the most interesting evidence of how much may be done for organic nervous disease in spite of the fact that the underlying lesion is absolutely incurable, may be obtained from what is accomplished by Frenkel's method of treating locomotor ataxia. As is well known, by reteaching the movements necessary for walking, ataxic patients regain control of the movements of their limbs to a marked extent. As a consequence, bed-ridden patients are enabled to walk once more even though they may have to carry a cane and be supported, and patients who have had to use two canes get along with only one, or may even eventually be able to walk without any artificial support.

Just how the improvement is brought about we are not quite sure. It seems probable that the eyes become trained to replace the muscle sense to a noteworthy degree, but there is in addition apparently a re-education of the muscle-sense. Perhaps there is also a transfer of the function of certain degenerated nerves to other tracts than those in which muscle impulses originally traveled. The improvement in muscular control originally obtained is a striking illustration of how much nature is able to compensate for even organic lesions and is a lesson in the necessity for never ceasing to try to do something even when the case seems hopeless. Certainly locomotor ataxic patients would seem the least likely to be benefited by training in movement and yet this movement therapy for tabes has had some wonderful results.

The story of how this mode of treatment came into existence is interesting and instructive as an illustration of how happy chance in our time, as so often with regard to drugs in the past, came to assist the rational development of therapeutics. A German professor wished to demonstrate to his class the varying inco-ordination of a series of tabetic patients. Some of them had their main inco-ordination in the legs, others in their hands. He went over the cases in his wards so as to arrange the demonstration for the next day. He told each patient that he would ask him to perform a particular set of movements before the class which would illustrate strikingly a particular phase of muscular inco-ordination. His patients were interested in the announced demonstrations and during the afternoon they went over the movements that they were expected to perform. They practiced them as assiduously as their condition permitted for the exhibition. As a consequence the most striking features of their inco-ordination disappeared. After having practiced the movement for a certain length of time they could do it ever so much better than before. The special feature of the professor's demonstration was spoiled, but a great contribution to our knowledge of nature's compensatory powers [{529}] was made and fortunately the hint of its significance for treatment was taken and developed.

Effect of Favorable Suggestion.—How much can be accomplished for the relief of the general symptoms of locomotor ataxia and for the placing of patients in an attitude of mind that makes most of their symptoms of vanishing importance, can be judged from some recent experiences with a new cure for the disease. This consisted only of some rather conventional treatment of the urethra by applications and dilatation, yet patients were relieved so much of the symptoms of locomotor ataxia, or at least persuaded themselves that they were, that both in this country and in Europe the discoverer of the new "cure" soon had scores of patients. The active therapeutic agent undoubtedly was the fact that patients who had been told that their disease was incurable and who had settled down in a state of discouragement and apathy in which their power over their muscles, their general health and their strength and vitality were at the lowest ebb, and their tendencies to discomfort emphasized and made poignant by the supposed hopelessness of their situation, became aroused to new vitality by the promise of cure and then, under the repeated suggestion of a treatment said to be sure to cure them and that had cured others, became so much better, that is, released so much latent energy, that they felt better, ate better, walked better, got out more and had their general health improved, and all to such a degree that their disease seemed cured.

Another interesting illustration of what would seem to be the power of suggestion over the symptoms of tabes occurs in a recent article in the Archivos Españoles de Neurologia Psyqiuatria y Fisioterapia of Madrid [Footnote 39] on the improvement of tabes dorsalis by antidiphtheritic serum. It is quite impossible that the serum should affect favorably any of the underlying lesions of the disease any more than that these should be ameliorated by the wearing of shoes of special character or operations on the urethra. The patient in this case, however, was distinctly improved in many ways after the antidiphtheritic serum was injected. There were some interesting sensory manifestations, pains in the arms and legs after the injection, but these were removed by santonin or methylene blue. Both of these drugs are eminently suggestive in their action, so that one would be prone to think the pains rather neurotic than actual. After a dozen injections had been given, the patient's sensations improved, his power to pick up small things was better, and the sense of walking on carpet had disappeared to a marked extent and he was able to walk much better than before and without support. Probably any attention given to him to the same degree would have produced like results.

[Footnote 39: Tomo 1 No. 7, July, 1910.]

We have had previous examples of this kind in the history of the treatment of locomotor ataxia. Certain drugs when given in the past with the definite promise of cure and pursued for a good while with frequently repeated favorable suggestions, have often seemed to benefit patients, though subsequent experience has shown their total lack of value to modify the disease. Nitrate of silver was one of these in the old days and many locomotor ataxia patients acquired an argyria as a consequence of the amount of silver absorbed and deposited in the skin. Arsenic was another and some of the aluminum [{530}] compounds were also used. When we recall the suspension treatment and its reported good effects—and failure, the over-extension treatment with the same history and many others in the past, the real place of the mental in the therapeutics of tabies is revealed. Once this is practically realized, we find that we have ready to hand and easy to use, the one really efficient factor in all these treatments—that is, the influence on the patient's mind. It is for the physician to devise thoroughly professional ways and means of using that in each particular case so that his patients may be benefited as much as possible. Certainly it would be foolish for us to leave to the irregular practitioner the use of this extremely valuable remedial measure, when we may do so much good with it, for the relief of symptoms at least.

CHAPTER IV
PARESIS

Paresis would seem to be one of the affections so inevitable in its course, so positively helpless as regards any medication, and so hopeless in its absolutely sure termination in idiocy and death, that nothing can possibly be done for it through the patient's mind, yet it is probably one of the diseases for which most can be accomplished by psychotherapy. Mental treatment for it naturally divides itself into three periods: that of prophylaxis, that of the early stage and that of the severer stage with remissions. Prophylaxis is much more important than is usually thought. It is very generally known at present that paresis is usually a parasyphilitic disease, that is, an affection not due directly to syphilis, but which develops by preference and perhaps exclusively in a soil prepared for it by an attack of syphilis. As a consequence of the diffusion of this knowledge men who have suffered from syphilis sometimes become supremely fatalistic as regards the development of locomotor ataxia or paresis in their cases. Worry is a prominent feature in the causation of paresis, and it is, therefore, extremely important to neutralize this.

I have had university graduates tell me their histories and ask whether I thought they had suffered from syphilis, and when I replied affirmatively have seen a look of despair come into their faces. One of them, a graduate of a large eastern university, said, after hearing my opinion, though it was given with every assurance that my experience with Fournier in Paris taught me the absolute curability of the disease, "Well, there are three men of my class who have already developed paresis, and I suppose I will go the same way." With a persuasion like this haunting him night and day, exhausting nervous energy and making his central nervous system less and less resistive, it would be almost a miracle if paresis did not develop. It is particularly in those who have had nervously exhaustive occupations—brokers, speculators, actors, and the like—that paresis does develop. The strain upon their nervous systems seem to be so great that the syphilitic virus still remaining in their system has a peculiarly degenerative effect upon nervous tissue. A man may be in the least worrisome of occupations, however, and if he is constantly brooding over the possibility of the coming of the hideous specter of paresis, [{531}] he puts himself in the condition most likely to encourage the development of the pathological changes that underlie the disease.

Prophylaxis.—As a rule patients who have had syphilis and who dread the development of paresis should be warned with regard to their occupations in life. After a patient has had tuberculosis which developed in particular surroundings, if it is at all possible, we no longer permit him to go back into the surroundings in which his disease developed. We are coming, more and more, to apply the principles of preventive medicine and this is as important in paresis as in anything else. Even though there may be many monetary or economic reasons in favor of certain occupations, the danger may overweigh these. Those who have had syphilis should be warned of the risk they run if they continue in occupations that require much mental excitement or the strain of anxiety and the speculative factor of uncertainty with the inevitable occurrence of disappointments. It is unjustifiable to permit a patient whose central nervous system is subjected to the deteriorating influence of the virus of syphilis, still in his body even after ten years, to submit to the nerve-racking irritation of occupations which require all the vigor of a healthy, undisturbed organism to survive their wear and tear.

Sources of Worry.—One of the symptoms which neurotic patients are sure must be a preliminary sign of paresis is a disturbance of memory. Patients have heard that paresis causes memory disturbances and fearing the development of the disease, they disturb themselves very much by finding real or supposed defects of memory. Most of them have had only a very vague idea of the sort of memory they possess and cannot tell whether it is worse than before, but finding a certain difficulty in recalling things they conclude that it is deteriorating. Occasionally their supposed defect of memory is founded on nothing more serious than the fact that they are paying so much attention to themselves, that they cannot concentrate their attention enough on what they wish to remember so as really to impress it on their memories. It is curious how persistent some patients are in making themselves believe they have serious lacunae in their memory when there are only certain conventional disturbances of it. The paretic has defects of memory, but he is, as a rule, quite unconscious of them. He has to have them pointed out to him. Patients who are supremely conscious of their supposed defects, by that very fact show their possession of good intellectual faculties.

Tremor is another symptom that may develop in the midst of the solicitude of those who dread paresis. The power to hold the limbs in a given position is due to a very nice balancing of flexor and extensor muscles. There are many people, especially those a little awkward in the use of their muscles, who lack this power to some extent. To stand without swaying is rather a difficult task in one who is nervous or anxious about himself. Patients who are worrying about paresis and its possible development will almost surely disturb their power over their muscles and cause at least a slight tremor or swaying.

In other words, in all of these cases a series of dreads, or mental obsessions which interfere with various functions which may cause tremor, or some stuttering, or at least some apparent difficulties of speech and which will surely revive any old-time difficulties of this kind, may develop in nervous persons and must not be allowed to pass as signs of developing paresis. The [{532}] diagnostic tests, of course, consist in the knee-jerks, the pupillary reactions, the difference in disposition, the delusions of grandeur, and, in general, the characteristic symptoms of a physical degeneration running parallel with a mental deterioration.

Prophylactic Reassurance.—The first point in psychotherapy, then, is to give just as much reassurance as can be given. Probably not one out of a thousand of those who have suffered from syphilis afterwards develops paresis. Nearly always there is something in the history besides syphilis that seems to be an essential etiological factor. A great many of the people who develop this disease have some hereditary taint of mental incapacity at least, if not of actual insanity. Very often there is a personal or family history that indicates some mental unevenness or at least some lack of intellectual vigor. When people are sanely intellectual and have no unfortunate hereditary tendencies they can be almost completely assured as to the possibility of the development of paresis, provided they take reasonable care of themselves.

Alcohol.—It is still an unsettled question whether alcoholism has anything to do, even in a subsidiary capacity, with the etiology of paresis. Probably it helps to predispose nerve tissues to degeneration by lowering their resistive vitality to the direct pathogenic action of the virus of syphilis. It seems clear, besides, that men who have acquired syphilis sometimes take to over-indulgence in alcohol, at least to a greater degree than would otherwise be the case, because of the discouraging dread that develops as a result of their worry over this constitutional taint. A warning in this matter of indulgence in intoxicants is important because there are many nerve specialists who insist that alcoholism is probably one of the prime factors in paresis.

Unconclusive Diagnosis.—When the first symptoms of paresis have developed so that the physician is almost certain that the disease is present—the cumulative experience of recent mistakes on the part of the most careful experts seems to show that he can never be entirely certain—then it is important not to announce the worst to the patient, but to let him learn the reality of his condition gradually, so that all the awfulness of it does not overwhelm him. What have seemed typical cases of paresis, so diagnosed by excellent authorities, have occasionally proved to be something else, or, at least, to be wayward and very irregular forms of that disease with a long course and marked remissions. There are forms of paranoia in the middle-aged which sometimes exhibit symptoms so strongly simulant of paresis as to deceive even the expert. There are forms of nervous weakness—neurasthenia—some of which are really cases of mental exhaustion or incapacity—the modern psychasthenia—which often lead even experienced physicians to think of and sometimes to diagnose paresis. There are cases of dementia praecox that only time can differentiate.

Prognosis.—Seeing the Worst.—There is a tendency in most physicians to see the worst side of the story rather than the better. This is not because of any desire to be a harbinger of evil tidings, nor, as is sometimes said, to show the patient, should he get better, from what a depth of affliction he has been rescued, but it is rather due to the very natural tendency existing in most of us to look on the worst side of things. Besides, we have found by experience that if patients are to be aroused to the necessity of care for themselves they must be scared a little, and so we have formed the habit, not of consciously [{533}] and deliberately telling the worst, but of stating the unfavorable possibilities of a group of symptoms, in order that a patient may take due precautions and that he may realize, if the worst does happen, that we were not ignorant of it. If he gets better he is correspondingly grateful for this. If the unfavorable happens and we had not warned him, he is more or less justifiably resentful.

Consoling Hesitancy of Final Judgment.—Patients suspected of suffering from paresis can then without any violation of truth be reassured that their cases may not be incurable until the epileptiform incidents of the disease bring on that happy obscuration of mentality, that either takes away all the terror of the disease or lessens so much its awful significance that the patient is spared the worst. There are cases of reported cures in the literature even after what seemed to be characteristic epileptiform attacks had occurred.

We cannot be sure, in any case, of the future course of an affection exhibiting symptoms resembling paresis. The patient can always be given the advantage of this doubt then and the awful word incurable or even the diagnosis paresis need not be mentioned to him. It is perfectly possible, as a rule, to take other means to prevent unfortunate incidents from tendencies to violence or serious loss from foolishness, without overwhelming the patient with an absolutely unfavorable prognosis, and the diagnosis of paresis, involving as it does, now that so much more is popularly known of the disease than before, the dread of inevitable idiocy. In this way much of the depression that constitutes so large a part of the really sane period of the early stage of paresis and which inevitably hastens the course of the disease may be avoided. On the other hand, failure to announce absolutely the diagnosis of paresis until there can be no particle of doubt, can do no harm and will do good to the patients themselves, as well as save their anxious friends from the trial of having to think of the awful possibilities of the disease. A single sensible member of the family may be selected as the confidant and the situation saved.

Rôle of Psychotherapy.—While it is important that someone closely connected with the patient should know the doctor's suspicions, he should be bound to absolute secrecy as regards the patient himself and especially as regards women friends and relatives. The attitude of mind assumed by women relatives, and especially those nearest and dearest, is sure to be communicated to the patient, if not directly at least indirectly and inadvertently, and makes for anything but relief from the depression that is sure to be his if he has any gleam of understanding of his condition. Indeed, so much of pain and suffering is needlessly inflicted on relatives of paretic patients in the early stages of the disease by a premature announcement of the diagnosis that it is especially important to insist on care in this matter. The family will usually clamor to know just what is the matter, but it is the physician's duty to care for his patient and save the sufferings of the patient's family, regardless of their unwitting insistence. Once the disease has developed and the patient's mind becomes affected it may be thought that psychotherapy is no longer of value. As a matter of fact, these patients as a rule become more childlike and are much more affected by suggestion than in their normal states. All this is worthy of careful attention on the part of the physician who feels that it is his duty to treat patients and not merely their disease.

The psychic care of the patient is the most important element in any [{534}] scheme of therapeutics during the longer remissions of paresis, which are sometimes so complete that it is difficult to understand that the patient, who is now as sensible as he ever was, only a few months before was doing the most foolish things under the influence of his delusions of grandeur and probably within a few months will be quite as insane as before and perhaps hopelessly demented. The brevity of these remissions in most cases seems to depend directly on how much the patient is persuaded that his disease will return without fail and run its inevitable course. It is well worth while to lengthen these remissions by setting the patient's mind just as much at rest as possible. Instead of the attitude which is so often assumed of absolute assurance on the part of the physician that the old condition will inevitably return, it is advisable always to give the opinion that the previous mental derangement was paranoiac rather than paretic, or was perhaps only a passing syphilitic condition and that the ultimate outlook is not as hopeless as might be thought. This opinion is thoroughly justified by certain surprising results in a number of recently reported cases. Some patients whose symptoms have been diagnosed as paresis by excellent diagnosticians, have, after a time, experienced a cessation of their symptoms which looked very much like a remission occurring in the midst of the inevitably progressive paretic degeneration and then to the surprise of their physicians have not exhibited any further symptoms of the affection. Syphilis of the nervous system sometimes simulates paresis to such an extent as to deceive the most expert, and proper antisyphilitic treatment will sometimes produce results that are little short of marvelous. It is beyond all question, then, for the good of the patient suspected of paresis that his physician should give him the benefit of every doubt.

CHAPTER V
EPILEPSY AND PSEUDO-EPILEPSY
EPILEPSY

With regard to the major neuroses generally, very much more therapeutic benefit can be secured than in any other way that we know by reassuring the patient's mind, by careful regulation of his life and by such modifications of his occupation as will take him out of a strenuous existence, so likely to be harmful to a nervous system laboring under these serious handicaps. In recent years we have come to realize that epilepsy, for instance, is more favorably influenced by a simple outdoor life in the country without worries and cares, with carefully regulated exercise in the open air and special attention to the digestive tract, than by any formal remedial measures or drug treatment. The fewer the emotional storms the less likelihood of repetitions of attacks of epilepsy. No medicine is so effective in prolonging the intervals between attacks as this placing of the patient in favorable conditions of mind and body. Our experience with the colony system has emphasized the fact that drug treatment is quite a subsidiary factor in this general care for the patient. The most important element in this treatment is the effect on the [{535}] patient's mind and the consequent gain in poise and in resistive vitality against emotional explosions which are so often the immediate occasion of attacks. This lessens their number and it is well known that frequent repetition is likely to be associated with that deterioration of the physical nature and mental condition which is most to be dreaded.

Mental Influences.—When living a quiet placid life without worry about himself or his concerns, the number of the epileptic attacks goes down in a noteworthy degree and the intervals between them become longer and longer. After years of quiet country living epileptics who had two or three attacks a week have scarcely more than one a month, if, indeed, that often, and their general condition is greatly improved. We have had many remedies for the affection, only a few of which have proved to be really therapeutic. The remainder have had their effect through the mental influence that went with them, the assurance of relief and the confidence that it aroused.

First attacks of epilepsy are not infrequently the result of an immediately preceding fright or sudden emotion of some kind or other. Gowers tells the story of a sentinel posted near a graveyard who was very much disturbed by his proximity to the dead and who, during the night, saw a white goat run past him, jump over a low wall and disappear. He was sure it was a ghost. He had his first attack of epilepsy shortly after. Children not infrequently have their first attack after a scare from a dog or a rough-looking stranger who has come near them. After the affection has established itself attacks of epilepsy follow vehement mental disturbances of any kind. Sometimes after a long interval of freedom from attacks a sudden strong emotion is followed by a fit and then the epileptic habit is reestablished. In order to be as free as possible from the affection patients must be protected from emotional storms.

Power of Suggestion.—-A strong proof of the favorable influence of suggestion upon epilepsy was given when operations for epilepsy became common about twenty years ago. A number of patients were operated on by trephining, even though almost nothing else was done except to open the dura and examine the brain, for often no definite pathological condition to justify surgical intervention was found. But these patients did not suffer from attacks of epilepsy for months and sometimes years afterwards. Many surgeons reported these cases as cured, as they apparently were when discharged from the hospitals, for no attacks had recurred; but physicians had to treat them later when their epilepsy redeveloped. The surgical procedure, as indeed might have been expected from the findings, had given only temporary betterment. The real therapeutic factor at work had probably been not any definite change within the skull, but the suggestive influence of the operation, the period of rest with favorable suggestion constantly renewed, and the confidence of recovery inspired during convalescence. Even in cases where adhesions were found between the dura and calvarium and these were broken up, the relief afforded was usually but temporary. The succession of events, the relief afforded and subsequent relapse, probably represented the same influence of suggestion as in the preceding cases with perhaps a slight physical betterment in addition.

An important factor in the psychotherapeutics of epilepsy is to relieve the patient as far as possible from the haunting dread of insanity, which, especially if he has read much of the disease, is so likely to hang over him as [{536}] a pall because of the absolutely bad prognosis which often occupies so prominent a place in older text-books and articles on epilepsy. There is no doubt that in a great many cases epilepsy is a progressive degenerative disease and that a state of lowered mentality will eventually develop. There are many cases, however, in which epilepsy is only a series of incidents which does not seem to affect the intellectual life and which is quite compatible not only with prolonged existence, but with mental achievements of a high order and, above all, with a personality that may be commanding in its power over others. This knowledge, which unfortunately is not usually given in text-books because they are studies in the pathology rather than in the psychology of epilepsy, is extremely important for the epileptic. This view is of special significance for those sufferers from the disease who are well educated and in whom mentality means so much.

The Individual in Epilepsy.—In epilepsy, indeed, the individual counts much more than his ailment, and even in severe cases of epilepsy there are individuals to whom the recurring convulsions are only annoying occurrences of life, somewhat dangerous because of the risks encountered during unconsciousness, but without any ulterior significance for degeneration of character or intellectual power. As a matter of fact, there are many men in history who were epileptics and who yet succeeded in great work of many kinds, even purely intellectual, unhampered by this condition, and some of them have proved to be leaders in achievement. In his paper read before the National Association for the Study of Epilepsy and the Care and Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew Woods discussed what certain famous epileptics had accomplished in spite of epilepsy. He takes three typical examples—Julius Caesar, Mohammed and Lord Byron—the founders, respectively, of an empire, a religion and a school of poetry—with regard to whom there is convincing evidence that they were epileptics. A fourth name, that of Napoleon, might easily have been added. Greater accomplishments than these epileptics made in their various departments are not to be found in the history of the race.

Many other names of epileptics distinguished for achievement might well have been added to the list. The argument that would be founded on their lives is not that epileptics are necessarily or even usually of high intelligence, but that some of them, at least, retain in spite of the major neurosis, or even serious brain disorder, whichever it may be, all their intellectual qualities undisturbed. Lombroso, arguing from the other standpoint, has pointed out that there is a close relation between genius and insanity, and he sets down epilepsy as one of the forms of insanity (mental un-health) often associated with extraordinary mental qualities. A study of this subject is extremely reassuring to the epileptic who is prone to think from traditions with regard to the disease that his fate is almost sure to be a gradual lapse into imbecility. No epileptic is likely to be at all worried over the suggestion that epilepsy and genius are allied, for since he has the one he is quite willing that the other shall follow.

Treatment.—Reassurance is especially important when patients develop epilepsy in adult life. There is an unfortunate social stigma attached to the disease which adds to the unfavorable suggestions that are likely to run with it. This probably cannot be overcome, for it is a heritage, not alone of many [{537}] generations, but of many centuries. Our better knowledge of epilepsy, however, should gradually take the disease out of the sphere of suspected mystery in which it has been popularly placed and set it among the diseases to which human nature is liable, but which is surely as physical in its character as any other. If a favorable attitude of mind on the patient's part can be secured there is less necessity for many of the disturbing drugs that are used and there seems to be no doubt that even in producing the effect of these, such as it is, suggestion of a favorable character plays a large role. Over and over again in the history of the affection we have had remedies introduced which have seemed to be quite efficient in producing longer intervals between attacks, making the patient less nervous and putting him in better physical health. After a time, however, these have proved to be quite useless, or at most of but very slight value. It was suggestion that gave them their apparent value, and this suggestion must be used without the drugs whenever possible.

The bromides have done good in the treatment of epilepsy, but they are the only drugs that maintain the reputation they first had. All the others accomplished whatever benefit they conferred on the patient, and some of them for a time seemed to excellent authorities of large experience to give marvelous results, through their influence over the patient's mind. Nothing can produce more confidence in the physician who is using suggestion for epilepsy than this fact. Even the bromides, unless used carefully, easily do more harm than good and they have often worked mischief. Favorable suggestion cannot do harm. At the present time those of largest experience in the treatment of epileptics, the directors of farm colonies, as Dr. Shanahan of Craig Colony, insist that diet, hygiene, especially hydrotherapy, are of much more importance than drugs, but that the patient's attitude of mind towards himself and his malady and the future of it is even more important. He must have occupation of mind so as not to worry about himself. He must have recreation so as to relieve the gloom so likely to come in the disease. He must have outdoor air and proper exercise, which these patients are so prone to neglect.

Those who have studied the subject most in recent years agree that the great majority of cases of epilepsy are not primarily due to acquired causes, but to some congenital defect, so that there is an inherent instability of the nervous system. This makes the patient liable to explosions of nerve force, figuratively represented as boilings over of nervous energy, when not properly inhibited. Once such a paroxysm occurs it is likely to happen again, and very often it brings on gradual degeneration of the nervous system and of mentality. In many cases, however, this degeneration can be delayed or even completely kept off by putting the patient under favorable conditions. These patients need, above all, to realize that they cannot live the strenuous life nor even the ordinary busy life of most people. They are as cripples compelled to limit the sphere of their activities. If they will but take this to heart, however, and not attempt too busy occupations, they may live quite happy lives for many years, and if mentally content and without worrying anxieties they will have so few attacks as to incur only to a slight degree the dangers inevitably associated with fits of unconsciousness. To get the epileptic's mind into a condition of satisfaction with his condition must be the main portion of the treatment.

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