PSEUDO-EPILEPSY
There is a large and important field of psychotherapeutics in a class of cases so closely related to epilepsy that it is often extremely difficult to make the differential diagnosis between the two varieties of seizure. Fifteen years ago, while I was at the Salpêtrière, there was much discussion of a variety of attack called hystero-epilepsy, in which the patients' symptoms were such that it was difficult if not practically impossible to decide whether the case was true epilepsy or merely hysteria. Personally I do not think there is any third, intermediate variety deserving a separate term. The attacks are either hysterical, or, to use a less objectionable name, neurotic, or they are genuinely epileptic, that is, due to some as yet not well-defined change in the brain, and therefore not likely ever to be completely relieved. To decide whether a given case is neurotic or epileptic, however, is sometimes quite out of the question until long and careful study of it has been made. It is true that such signs as full loss of consciousness, biting of the tongue, the so-called epileptic cry, involuntary urination, dangerous falls and the like in the midst of an attack, have often been declared to be signs of true epilepsy, but there are cases in which one or other of these signs has been present, yet the subsequent course of the affection has shown them to be functional and not organic in origin.
Neurotic Simulation of Epilepsy.—Nearly every physician who has reasonably large experience with neurotic patients has seen cases in which there were recurrent attacks of loss of consciousness that came on sometimes at most inopportune moments, that rendered the patient quite incapable of caring for himself for the moment, yet lacked many of the signs of true epilepsy. Teachers sometimes complain of a complete lapse of memory that begins without warning and then recurs at intervals, making their work very difficult. Preachers sometimes bring the story of having lost the thread of their discourse and forgetting absolutely what they were talking about, there being a complete blank for some seconds at least. Occasionally such lapses are associated with falls that resemble fainting spells and seem to be accompanied by complete loss of consciousness. Usually after them there is a distinct tired feeling and an inclination to sleep, though, as a rule, there is a more marked tendency to want to get away from observation. Some of the cases are much more severe than those described and the conclusion that they are true epilepsy seems inevitable, yet they recover so completely that this conclusion is negatived.
Occasionally such attacks occur only when the patient has been strenuously exerting mind or body for a much longer period than usual. In teachers it is likely to occur toward the end of the year or in the midst of the hard work about examination time. In students this same period is likely to be a favorite starting point for the attacks and they recur oftener at this time than at others. Very often there is a story of some digestive disturbance in connection with the attacks. At times it seems possible to trace them to some interference with the cerebral circulation through a distended stomach pressing upward through the diaphragm and interfering with the heart action. In such cases stomach resonance will sometimes be found as high as the fifth rib [{539}] and the apex beat may be pushed out to the nipple line or beyond it. This may be true though there are no signs of valvular lesions and no symptoms or physical signs of dilatation or hypertrophy of the heart.
The Suggestive Element.—Analysis shows the real course of the trouble in these cases. The sufferer is usually following a sedentary occupation, not getting much exercise or diversion and prone to introspection. Many symptoms of themselves of no importance have been emphasized by concentration of attention on them. Especially is this true of any heart irregularity. The patient has dreaded for some time lest the feeling of pressure in the precordia and of discomfort in the heart might not sometime interfere with him in the midst of his teaching or preaching duties. Some day when he is feeling much worse than usual, in the midst of his work, there comes over him the feeling that now his intellect is going to stop action because there is something the matter with him. The sudden concentration of his attention on this with the fear of the consequences and the uncomfortable feeling that he will not be able to go on with his flow of ideas, cuts off the thread of what he is thinking about and puts but one single object before him—this possibility of failure of mental action. Usually the first attack is only such an interruption as is thus indicated. The fear of subsequent attacks, the worry over what has happened, the dread that some serious mental affection or nervous disease is at work emphasizes introspection and subsequent attacks are even more likely to be serious, and especially to last longer than the first.
The more the cases are studied the more the conclusion comes that in many of these instances it is nothing more than auto-suggestion that is responsible for the mental lapse. It is true that some physical condition may be the occasion, though the mental state is the active immediate cause. Suddenly concentrated attention on the dread of mental interruption inhibits mental action and what was dreaded follows almost necessarily. It is a sort of auto-hypnotism in which the patient's train of thought is interrupted by a momentary or longer hypnotic state the causes of which can be traced. Even when there is a real organic lesion of the heart, the lapses of memory and even of reasoning power that occasionally occur, have often seemed to me to be due rather to the patient's dread than to any real physical condition. I cannot think that there is a sufficient interruption of the cerebral circulation, even though only for a moment, to cause such a lapse. It is a question of nerve interferences rather than of blood supply. If the blood were diverted, even though only for a moment, or if there was a stoppage, the consequences would be more serious and more lasting than they are.
What evidently happens is some disturbance of neurotic connections within the brain brought on by sudden dread or emotion. The will has lost control or has seriously disturbed the conducting apparatus. The best proof that this is what happens and that it is not the result of organic change is found in the fact that when the physical occasion, that is, the digestive disturbance or the heart palpitation which is the initial factor in these states, is relieved, the attacks do not take place. Patients in whom they have occurred even for years cease to have them. This improvement does not begin, however, until their solicitude over their condition has been lessened by a confident declaration to them that they are suffering from merely functional and local reflex conditions apart from the brain itself. Usually it needs to be made clear [{540}] to them, too, that their anxiety in the matter means much more for the continuance of the attacks than any physical condition.
Almost invariably patients somewhat resent this suggestion. Their response to this explanation of their ailment usually is that the attacks come on them when they are not particularly expecting them and that there is first some physical symptom which might readily be taken for a sort of aura to a genuine epileptic attack and then the attack itself comes on. It is this preceding symptom, pain or discomfort, or whatever else it may be, that provokes the suggestive element and brings about the state of quasi-hypnosis, which is the main part of their attack.
Neurotic Syncopal Attacks.—Some of the cases of pseudo-epilepsy are very mild, though if the word epilepsy has been mentioned there naturally arises a feeling of dread in patient and friends with consequent unfavorable suggestion. A type not infrequently seen has for its main symptom a period, usually of but short duration, in which there is an intense tired feeling so that even the eyelids droop and require effort to lift them. During such attacks the respirations may slow down to fifteen or below, though usually the pulse is inclined to be rapid. The feeling of fatigue is almost entirely subjective, in the sense that, if patients are required to do something, they are able to accomplish it by a little urging, though a moment before they were sure that they could not. Such attacks are invariably functional, have no organic basis and do not deserve the name of epilepsy. If called hysterics this will cause the patient, who is often a woman, to rouse herself and so gradually overcome them. They are really a loss of confidence in one's power to do things and a passing astasia-abasia. The use of the word hysterics may cause the patient to lose the sympathy of her friends, though she may need it; for often there is an underlying pathological condition not in the nervous but in the somatic system. Sometimes the patients are anemic, sometimes they have an abortive form of Graves' disease, and sometimes they are low in nutrition.
These conditions give the indication for treatment. What is needed is, of course, improvement of the general condition, but, above all, a restoration of the patient's confidence in herself. Once it is made clear to her that the attacks are largely subjective, that is, are due to a feeling of prostration because of the fear that she is unable to do something, then the intervals between the attacks will gradually grow longer. It is important that long hours of sleep should be advised with plenty of fresh air, and that whatever disturbances of the digestive system are present should be carefully treated.
Pseudo-Epilepsy and the Menopause.—A number of these cases of pseudo-epilepsy occur at the menopause. They seem particularly likely to occur in women who have not much to occupy themselves with. Childless women who have no cares and enjoy every luxury sometimes seem to have these pseudo-epileptic attacks as equivalents for the flushings of the ordinary menopause. During "a rush of blood to the head" they lose control of themselves. Occasionally mothers who have two or three daughters and who get their menopause late in life, that is, well after fifty, are especially likely to suffer in the same way. The solicitude of those near them seems to eliminate some of their power of inhibition and makes them think overmuch of themselves. If then they keep much at home, as women at this time are prone to do, have few [{541}] diversions of mind, little fresh air and exercise, there is an accumulation of unused nervous energy which dissipates itself in explosive attacks very like epilepsy. It is with regard to these that the term hystero-epilepsy almost seems justified. Just as soon as occupation and diversion of mind and relaxation of the solicitude of friends for them is secured they begin to get better.
The differential diagnosis of these cases is made from the absence of certain of the pathognomic signs of true epilepsy. The tongue is not bitten, involuntary urination does not take place, and when the patient falls she does not hurt herself as a rule, though occasionally the fall may result in accidental abrasions or bruises, but these are quite trivial. If stress is laid upon the fact before these patients that they do not present any or all of the symptoms of epilepsy, some of them are likely to occur a little later. Slight abrasions on the tongue will be noted and the sputum will become a little bloody. Even very cleanly women will sometimes wet themselves. It is not a deliberate attempt at deception, but their curious psycho-neurotic condition causes suggestion to act upon them. Their attacks are really auto-hypnotic and during these the remarks made by the physician occur as suggestions and then are accomplished. If the suggestions in this matter have been carelessly made by previous physicians the attacks will so closely simulate true epilepsy that it will often be almost impossible to differentiate them with assurance.
In the preliminary diagnosis of these cases, as well as of all other cases of pseudo-epilepsy, we must, as far as possible, avoid the use of the word epilepsy, even of hystero-epilepsy. The unfavorable suggestion attached to such terms will have the worst possible effect. There is no need to fear that the patient will be any less taken care of, if the disease is called by some other name, for instance, neurotic paroxysms or nervous attacks.
Cure by Suggestion.—Such patients are often cured by remedial measures of one kind or another that are administered with the confident declaration that they will get well. A number of cases of epilepsy which were really of this character have been reported cured by Eddyism. A number also have been very favorably influenced by osteopathic treatment. Needless to say, the reports of such cured cases have not been diminished in significance by the publicity bureaus of these various cults. Mental healing has relieved a number more. Usually this relief has been afforded these cases after they had tried regular physicians who had treated them in the ordinary way with bromides, without doing anything more than causing them to miss a few attacks for a temporary period of relief, if even that, giving them bromism and further increasing their solicitude about themselves by unconsciously emphasizing their ideas as to how serious epilepsy can be. The cures of these cases are not due to the various treatments to which the patients proclaim their debt of gratitude, but to the confident assurance given them that their condition is not serious, and will be cured. After analysis of their attacks has shown them to be neurotic and not genuinely epileptic, the regular medical practitioner can readily do as much and even more; for psychotherapy has much more to do in affording relief in these cases than any other form of treatment. It must be applied with confidence and the results are often most favorable.
CHAPTER VI
PARALYSIS AGITANS
This is a chronic affection of the nervous system having for its most characteristic symptom a tremor, but with marked muscular rigidity and weakness. It is much more common in men than in women, in almost the reverse proportion of Graves' disease. It is usually a disease of the old, but may occur in early middle life and has been known to develop even early in the twenties. In the old days when malaria was a common diagnosis for many different conditions, paralysis agitans apparently followed malaria so often that there was thought to be some connection between the two diseases. The more we have learned of malaria the less likely this seems to be. Continuous exposure to cold for long periods and to dampness during the daily occupation for years, or repeated severe wettings, have been considered as causative elements. None of these physical factors, however, has been as directly connected with the occurrence of the affection as various emotional conditions, and the thought is suggested that even in cases of severe exposure the worry and fright and solicitude incident to the fear in an elderly person that this exposure will have serious consequences, is an important etiological element.
Psychic Factors.—Fright.—Practically all the authorities agree that mental conditions are prominent factors in the production of the disease. Serious business cares and worries and anxieties have often long preceded its development. Fright is mentioned by nearly all those who write on the subject as at least an occasion for the development of paralysis agitans if not a cause. One of my own most interesting cases occurred in the sheriff of a county of the Southwest who had earned for himself the deep enmity of an Indian by arresting him. Not long afterwards one Sunday morning when the sheriff quite unarmed came round a corner he found the Indian just in front of him wildly drunk and armed with a rifle. At once the rifle went to the Indian's shoulder, but he did not want to kill his man without having his revenge by torturing him, so he did not pull the trigger, but announced to him in vigorous though broken English that he had him now and was going to kill him. The sheriff tried to parley and for a moment the Indian permitted him to do so, apparently in order to prolong the agony. They were not more than two yards apart at the beginning, and the sheriff took his only chance and jumped and knocked the gun up. It went off just as he did so, the bullet singeing his hair. He succeeded in arresting the Indian and throwing him into jail, but the next day a tremor developed in the arm which had grasped the rifle. This spread and finally became typical of paralysis agitans. He was a man only slightly past fifty and there had been no preliminary symptoms.
Mental Control of Symptoms.—Many similar cases following fright or vehement emotion have been reported, so that it is easy to understand the feeling that the affection has a large psychic element in it, though evidently from its persistency and its continued development, there is some underlying pathological condition. The tremor may be controlled in voluntary [{543}] movements, while emotion exaggerates it. There is no doubt, however, that concentration of will and the definite effort to control the symptoms enables the patient to rid himself of them to a great degree for a time at least. It has been noted frequently that when a consultant physician is called the patient will be better for the day of the consultation than he had been for months before. The visits of particular friends will often arouse a sufferer to such efforts as greatly lessen his rigidity, decrease his tremor and make him capable of getting around better than before. The state of mental depression that commonly develops in these cases exaggerates the symptoms, adds neurotic and even physical conditions that develop from lack of exercise and air, and makes the patient's general state much worse than it would otherwise be.
Pathology.—Our scanty but growing knowledge of the pathology of paralysis agitans makes it clear that the disease is, in typical cases, probably due to an overgrowth of connective tissue, the neuroglia cells, in the central nervous system. Just what causes this overgrowth of connective tissue is not clear. It is an exaggeration of a normal senile process. Apparently one of the processes of age in man is a decadence of the vitality of important higher tissues with a corresponding increase of vitality in the lower or connective tissues. When Flourens declared at a meeting of the French Academy of Sciences that such an overgrowth of connective tissue was natural with advancing years, he added that this probably accounted for the slowness with which older men come to conclusions. The old members of the Academy did not accept this new-fangled doctrine with equanimity. They were inclined to think that their conservatism and deliberateness were due to greater poise of intellect.
There seems to be no doubt that at least a comparative overgrowth of connective tissue is characteristic of the brain in advancing years. In some people this occurs to a greater extent and is more precocious than in others. Just what causes are responsible for individual differences we do not know. Paralysis agitans is seen often in those who have worked hard most of their lives, but, on the other hand, may occur in those who have lived sedentary lives, and in people of all occupations. Over-indulgence in alcohol, though this is often thought to predispose to the disappearance of the parenchyma of organs and to the overgrowth of connective tissue, does not seem to have any place in the etiology of this affection. Its occurrence is a part of that mystery by which the equilibrium of different kinds of cells in the body is maintained or diminished. In a mild way paralysis agitans represents such a change in the central nervous system.
Mental Influences.—With an overgrowth of connective tissue as the pathology of the disease there would seem to be no question of any relief of its symptoms or any benefit to be derived from psychotherapy. Anyone who has much to do with cases of paralysis agitans, however, knows that they are extremely susceptible to mental influences. Whenever there is anything that interests them, any business that they feel they must do, any special event that they look forward to, they will for days at a time be so much improved in general symptoms as to be greatly encouraged themselves and make their friends feel hopeful with regard to them. When they give in to their condition, however, and make no special effort at self-control and stimulation their symptoms increase very much. Their rigidity particularly increases, their [{544}] tremor becomes more marked and various inconveniences associated with these two cardinal symptoms are emphasized.
Methods of Treatment.—The Vibrating Chair.—It is interesting to recall some of the forms of treatment which have been reported as beneficial in paralysis agitans, because they illustrate how much the influence of the patient's mind has over his bodily condition and how much the interest aroused in any new and particularly in any unusual form of treatment has in mitigating symptoms and how often it seems to bring about remissions in the progress of the disease. Twenty years ago Charcot suggested the use of a mechanically vibrating arm-chair. He had noticed that patients who travelled by rail seemed to have their symptoms improved for the time at least by the shaking up in the train. This treatment undoubtedly made patients much less rigid and much less tremulous. The improvement lasted sometimes for hours and sometimes for days. It was tried rather extensively and everywhere with reported good results, when first tried at least. After a time it was found that it failed to have the desired effect. Apparently whatever therapeutic value it had was due to the interest aroused in the patient's mind and the consequent effort that was made to control his muscles.
The Suspension Treatment.—When the method of treatment by suspension became popular for cases of locomotor ataxia, the idea came to try the same thing for paralysis agitans. Accordingly suspension apparatuses of many kinds were used with reported good results. Patients were suspended by the neck for some minutes and some of them got used to the treatment and could stand it for a prolonged period. The effect was always a distinct mitigation of symptoms. The rigidity particularly became much less marked, but the tremor also was lessened and besides certain secondary symptoms were bettered. Constipation was improved, partly because patients were more cheerful, ate more heartily and, above all, were willing to make some effort in order to get out regularly into the air. There was a variety in life, different from the solitary sitting at home into which these patients so often drift. Sleep was better at night and the subjective sensations of heat and cold were lessened. Patients were encouraged to think of improvement and used all their available nervous energy. In the same way when overstretching of the spinal cord by forcibly bending of the body at the hips was tried with reported success in tabes it was also applied to paralysis agitans with similar improvement of symptoms. Both methods of treatment have gone out for both these affections and evidently their observed therapeutic efficiency at first was entirely due to their effect upon the mind.
Psychic Elements and Other Remedies.—When organo-therapeutics became the fad paralysis agitans was treated also by this method. Some cases were treated with reported good results by thyroid. Later when the parathyroids attracted attention they were administered with reported good success in even very severe cases. I think that there is a report of some cases of paralysis agitans being improved by injections of diphtheria serum. In other words, anything that was given to a patient with the promise that he would be better after it and that produced a definite effect upon his mind was likely to do him temporary good. If the remedy had some special theory behind it, if there was a story of some new scientific significance for the material employed or the method of giving it, then this improvement was sure to take place. [{545}] In the drug treatment of the disease the same principles applied. Earlier, when nitrate of silver was the main recourse for organic nervous diseases, cases were reported improved by its administration. When the alterative properties of arsenic became a therapeutic fad this produced good effects. Atropin had for some time a reputation of relieving patient's symptoms. After a time all of them ceased to be used to any extent.
The Frenkel Method.—In recent years the application of the Frenkel directed movement method, modified somewhat from its application in tabes, has attracted attention in the therapeutics of paralysis agitans. It is interesting to note how often a mode of treatment that has been applied successfully to one of these diseases has also proved successful with the other. The two diseases are, of course, very different in etiology and pathology; but have one thing in common. The control over muscles has been lost to some degree in both cases in the progress of the disease, and a special effort of attention is required on the part of the patient in order to regulate movement. Anything that will arouse the patient to make this special effort will relieve the symptoms for a while and in tabes may bring about a lasting improvement, because the habit becomes easier after a time, though apparently this does not occur in paralysis agitans, except perhaps in the younger patients. It might very well be expected, then, that Frenkel's method in many cases would do good in paralysis agitans and it has proved to be another adjunct in the treatment of the affection. It must be used with great care not to exhaust the patient, but this is true also in tabes. The real source of its therapeutic quality seems to be the patient's interest in it and if this cannot be aroused it usually fails to do good. The success of these various mechanical methods makes it easy to understand why these patients often improve for a time under osteopathic treatment.
Psychotherapy.—It is clear, then, that the most important aid for these cases is the arousing of mental interest in some form of treatment that promises to be of benefit to them. New forms of treatment cannot always be invented and mental occupation must be secured by interest in other things. Patients suffering from paralysis agitans are prone to allow themselves to give up efforts to do things in which their interest would be aroused. They must be encouraged to do many things. Carriage riding, automobiling, train excursions, because of the effort required to resist vibration, are all helpful. They must not be allowed to drift into vacuous habits in which they make no effort for themselves. They can thus be made much more comfortable and most of their symptoms can be relieved to a marked degree. This requires constant attention and ever-renewed efforts to arouse the patient's mind and to have him make such efforts as will overcome rigidity and control the tremor to some extent; but with care an amelioration of the condition can always be brought about and can be maintained, at least to the extent of making the patient much more comfortable than would otherwise be the case.
CHAPTER VII
HEADACHE
In spite of the improvement in the general health of the community, due to more hygienic living, more healthy food and better ventilation, headache, instead of decreasing, has increased to a great degree. Any number of headache cures are advertised in the daily papers, in the street cars, on the signboards, even in medical journals, and besides these nearly every druggist has his own special preparation for headache, so it would seem as though literally many millions of doses of these headache cures must be taken every week. It would seem as though there must be some special unhygienic factor at work to produce headaches at a time when all other pathological conditions are being reduced in number and severity.
A study of the patients who are especially affected by headache seems to furnish evidence as to the special factor that has led to the increase of the affection. It occurs much more frequently in women than in men. It is complained of particularly by those who have less regular occupation, and the notable increase has come with the opportunity for leisure on the part of large numbers of the community due to the growth of wealth.
A feeling of discomfort in the head to which much attention is paid will become such a painful condition as to deserve the name of ache, if it develops in those who have no serious occupation in life and no interests that demand peremptory attention. With the noise of many children around them in the olden times women suffered comparatively little from headaches. Most of our grandmothers scarcely knew what it was to have a headache. Now most business men are likely to say the same thing. Very rarely do they suffer from headache. When they do, there is some specific reason and when this is removed the headache disappears. There are many women of leisure who have regular headaches for which they must have some remedy at hand or the pain becomes intolerable, but there are few women strenuously occupied with business affairs or with interests in which their attention is absorbed who find themselves under any such necessity.
It is evident that certain conditions predispose to headache. The principal of these is having sufficient time to advert to certain uncomfortable feelings in or around the head. Few people who stop to think of what their head feelings are but will find there is some unusual sensation somewhere in or outside the head which if dwelt upon becomes emphasized into an ache. If the mind can be diverted it disappears. If there has been some injury of the head or some pathological conditions set up by congestion or anemia, the feelings may become emphasized and occupy the center of attention, and even after the injury has disappeared or the pathological condition been ameliorated some sensations remain which with advertence produce achy feelings of discomfort. This is the history of a great deal of the increase of headache in our time. There are, of course, real headaches due to definite pathological conditions, but the great majority of headaches complained of [{547}] are the result of over-attention to certain sensations, some of them normal, some of them only slightly abnormal, which are emphasized by concentration of attention on them until they become a torment.
Two main classes of headaches come to the physician for treatment. One class is seen in patients who suffer from real and even acute pain that cannot be distracted by diversion of mind, that is usually worse when they try to sleep, as toothache is, and is evidently due to definite physical disturbance. In the second class are the many queer feelings about the head called headaches, though the patient suffers rather from annoyance than from pain. It is said that the Chinese in olden times put criminals to a lingering death by fastening them in such a way that a drop of water fell every minute on their heads. It was impossible to avoid the falling drop, and its constant recurrence became an awful torture. Any feeling that engrosses consciousness will be followed by the same sense of torment. The constant exercise of function of any nerve without rest is of itself physically disturbing to a serious degree. This must be realized with regard to many forms of headache which, though trivial in origin, are the source of bitter complaint.
Attention Headaches.—Professor Oppenheim, in his "Letters to Nervous Patients," has a paragraph with regard to headache that is worth recalling for the benefit of patients who suffer from low-grade headaches. Doubtless these were at the beginning real aches due to some local condition. They are now due merely to exaggeration of more or less normal feelings within the head which have come into the realm of the conscious because of the attention attracted to them when the intracranial affection was first noted. Professor Oppenheim says:
Your headache also I ascribe to this source. Originally it may have been a real headache, the result of your nervous shock. There is no one who has not at some time had a transient feeling of pain in the head or in some other part of the body, quite apart from those caused by injuries or painful diseases. Out of a thousand various kinds of causes I will mention only an extremely common one: the pains which result from straining muscles or nerves. Every sudden awkward movement may in this way cause pain in different parts of the body, but very specially so in nervous persons, in whom the mechanical excitability of the nerves—that is, their sensitiveness to pressure and strain—is usually exaggerated. As a rule, however, this pain is quite transient. But here again the law of which I have been already speaking comes into force: under the stimulating influence of introspection the tiny, perishable seed-grain of pain grows into the firm, strong, enduring tree of neuralgia or psychalgia.
The first condition for the successful treatment of headache, then, must include the recognition of the possibility of some rather simple pathological condition being exaggerated by over-attention to a disturbing affection, or of some affection, now past, having produced a suggestion that, in a mind given to introspection, continues to have influence even to the inveteration of sensations for which there is no longer a physical cause.
These patients insist that their medical status is that of real pain. Hysterical patients describe a sensation as if a nail were being driven into the forehead—the so-called clavus hystericus. In nervous people the sense of pressure increases from one of mere discomfort to a positive pain, as a consequence of attention to it. In most cases of headache, however, what is most needed is a distraction of the attention from the ailment. Over and over [{548}] again I have found that when all remedies failed the deliberate search for an occupation of mind that would interest the patient during many hours of the day was the only thing that promised relief and in many cases the relief afforded was so complete that patients were effusive in their gratitude.
Power of Distraction.—The proof that these so-called headaches are really not aches is found in the comparative ease with which many of them may be suppressed. Almost any interesting occupation will make the sufferer forget them entirely and they will not return immediately after the occupation ceases, but usually only when the patient is alone and attention is once more directed to this symptom. These queer feelings about the head that are often raised to the dignity of headaches by attention and auto-suggestion may be distracted away completely. That they are not pain is shown by the fact that the ordinary remedies which ease pain so promptly often fail to relieve these or soon cease to have any effect on them.
Lack of Distractions.—The apartment hotel system has multiplied the victims of headaches. When a woman has nothing in the world to do except get her clothes fitted and attend to what she calls her "social duties," it is no wonder that her head bothers her. Blood is constantly going to the brain and interchange of nutritive elements is taking place, yet there is no real function of cells and no consumption of material, or at least function is so slight that consumption of material must be trivial. There is no reason why these women should get up in the morning. Their breakfast is brought to their rooms, and some of them do not get around until eleven o'clock. Women used to have a morning occupation in going out to market or else in planning the household day with housekeepers, but of course there is no more of that. In olden times, too, many of them had religious practices. Now women are likely to be unemployed until the afternoon, which must be occupied at most with so-called social duties that may be done if one wishes to do them, but that may be put off for many reasons and there are constantly recurring reasons for not making any special exertion. Also, the rooms these women live in must be kept at a high temperature because the poorer the air that we breathe the higher must be its temperature for comfort, while stimulating fresh air may be quite low in temperature and yet produce only a brisk reaction instead of chilly feelings.
Children used to be the best possible remedy for these non-occupation headaches, but either there are no children any more or there are but one or two and these are largely cared for by bonnes at home and by various schools once they have reached the age of three. The old idea that children should not leave home until six put upon the mother the burden of their early education, but since the coming of the kindergarten she is relieved of responsibility of this and the mother of one or two children might now almost as well be childless as far as any serious occupation from care of her children is concerned.
If patients are told all this bluntly there will be a vigorous protest from most of them, for to them their pains are very real. It must not be forgotten that a pain in the mind is often worse than in the body. Some of these women save themselves from having their unused mental faculties disturb them from very lack of something to do, by becoming interested in charities, in clubs, in social movements of various kinds, in art and in literature. It is [{549}] not to these that I refer. On the contrary, if women have nothing else to do I would insist that they find some cause or movement in which they may become deeply interested. Their interest will save them from self-annoyance, though it may not exactly add to the gayety of nations in its effect upon other people. As a physician, however, I am only interested for the moment in the good of particular patients.
Source of Pain.—I would not be understood as saying that all headaches are not real aches nor pains in the most literal sense of the word, for some of them are agonizing tortures. With regard to all headaches, however, even the most genuine variety, there are certain considerations that are of value from the standpoint of psychotherapeutics. The most important of these is assurance as to the source or location of the pain. Most people think that it is the brain itself that is suffering pain and not a little of their suffering is due to the fact that they dread the effect of such pain upon the cerebral tissues and its possible consequences upon their mental state. These people will be much relieved to be told at once that the brain tissue itself is not sensitive, that when exposed it may be touched with impunity without causing any pain. It is the structures surrounding the brain that are sensitive. As a rule the lesion that causes pain is not progressive and all dreads with regard to serious after effects may be put aside.
Pressure Headaches.—It is important to insist on the fact that, as a rule, headaches and pains in the head are not due to the brain, but to extraneous structures within the skull. It is true that brain tumors, gliomatous and cystic and, above all, the overgrowth of the pituitary body in acromegaly give rise to agonizing pains. The cause of these headaches is undoubtedly pressure. It is not the pressure upon the brain tissue itself, however, that is the underlying cause of the pain, but pressure upon the sensitive structures connected with the brain. The same thing is true with regard to congestive headaches. Pain is produced not because vascular congestion presses on sensitive brain tissues, for we have no reason to think that any such exist, but because the congested brain exerts pressure upon sensitive filaments in its integuments. Neuralgia may be unbearable and yet it is borne with more equanimity, and less dread of results, because it is felt to be in a comparatively unimportant structure. One of the most serious elements in severe headache is the fear of lasting results in the brain tissues, that may lead to disturbance of mentality or to injury affecting mental processes. Patients find their pain much more bearable as soon as they are assured that headaches do not lead to mental disturbances and that, as a rule, even the growth of a tumor does not disturb mentality.
In the relation of the brain to the intellectual faculties that are so closely associated with it, we must remember that direct connection between the two has not been demonstrated and that the relations of the brain and the mind are almost as mysterious as they ever were. There are some who still think that the frontal convolutions are especially concerned in carrying out mental operations. All that we know about them in pathology, however, is that they are the silent convolutions. When a lesion occurs in other portions of the brain we see the effect of it practically always without delay, in some way, either in the sensory or motor functions of the body. Large lesions in the frontal region, however, often give no sign. Large tumors have been found [{550}] pushing frontal convolutions from their ordinary positions without any noticeable effect upon the individual.
Hard Study and Headache.—It is worth while to impart this knowledge to patients who suffer from headaches, because it at once improves their outlook on life. I have known hard students—men who had spent twenty or thirty years in work at a special subject—live in constant dread that sometime their minds would give way because they frequently suffered from headaches, or at least from some uncomfortable sensations in their heads, which they feared as a portent of ultimate mental breakdown. The assurance that such a thing is utterly unlikely and quite apart from the physician's ordinary experience, not only relieved their anxiety and made their headaches more bearable, but in a dozen of cases in my note-books the headache has gradually disappeared as certain habits of life were corrected and modified, as their habits of eating were varied, as bodily functions were controlled and as diversions of mind were introduced into lives that had before been too unvaried for healthy functions.
I do not think that I have ever seen a case, and I have been closely in touch with hard students for over twenty years, where I felt that the cause of a headache was mental overwork. I have known men who at the age of seventy or over have taken but four or five hours of sleep and who have worked at their favorite subjects for the better part of half a century. They never complained of headaches. Of course, there are others whose physical and mental power is less and who cannot be expected to stand a strain that for large-minded men is only the normal exercise of function. It has not been the mental work that they were doing, however, that was the source of whatever central nervous disturbance was to be found in lesser minds, but worry and anxiety and dread over what they were doing, anxiety as to what they were going to do that constituted the real pathological agents at work.
Local Conditions.—A striking case that impresses patients much more than the physician's declaration and is more likely to be remembered and is therefore of psychotherapeutic value, is that of Von Bülow, the German musician. He suffered for many years from excruciating headaches. They were so severe as almost to drive him crazy. His only relief was morphine and he and his friends lived in the midst of no little dread that sometime or other either the pain or the process which caused it would bring about a deterioration of mentality. After his death an autopsy was made. It was found to be a small nerve fiber pinched by a scar in the dura as a consequence of an injury received when Von Bülow was very young. Many other stories of this kind have been told.
It must not be forgotten that in many cases the pain is not within the skull itself or at least its cause is not and other sources should be carefully looked for. The connection of the eyes with headache has been so well worked out, owing to the initiative of S. Weir Mitchell, that nothing more need be said of it. One feature perhaps deserves to be mentioned. While strain of accommodation is a frequent source of headache and is at once looked for by ophthalmologists, there seems no doubt that some headaches, much fewer than accommodation cephalalgias, are due to muscle difficulties, that is, a lack of balance among the external muscles of the eye, whose full pathological significance has perhaps not yet been worked out. Headaches are [{551}] frequently due to sinus troubles, especially to disturbances in the frontal sinus and to intranasal difficulties. These must be eliminated before the patient can be helped. Sometimes these nasal and sinus difficulties are signs of a deeper constitutional disturbance, due to lack of fresh air and exercise and are relieved promptly by the establishment of hygienic habits.
Congestion Headaches.—Some headaches require changes of habit and persuasion of the necessity for arranging the day's work so as to give proper intervals for relaxation. Much experience with persons whose absorption in their work causes them to miss a meal or delay taking it for seven or eight hours from the last time of eating has shown me that this disturbance of the routine of vegetative life is particularly likely to be followed by headache. This headache is not a mere dull ache and is much more than a sense of discomfort; it is often an excruciatingly painful condition that usually does not come on until toward the end of the day and then may seriously disturb sleep. An interesting thing about this class of headaches is that nearly always they are increased by lying down. Often only a faint preliminary symptom of it is apparent when the patients go to bed, though they may be wakened after two or three hours of disturbed slumber by a headache that prevents further sleep, and pass the remainder of the night in painful wakefulness.
Usually it becomes impossible to continue lying down. The head must be raised and much relief is afforded by sitting up. The headache does not disappear at once but it will gradually pass away and sleep may be resumed after a half an hour of sitting up, though the sleeper will have to be in a sitting posture. Older people get up and sit in an arm-chair. I have found that placing a chair with a rather long back beneath the mattress, the mattress slanting along the chair back at an angle of about forty-five degrees and then an arrangement of three or four pillows above that, will enable these patients to get to sleep better than anything else. The ordinary remedies for headache afford some relief, but even very large doses of the coal-tar products will not relieve the pain entirely unless some arrangement is made for keeping the head quite high and immovable.
The headache is evidently due to congestion. The reason for it is perhaps the failure of the blood to be recalled from the brain to do its usual physiological work at the digestive tract, with a consequent distention of arterioles in the brain so that a little later they do not react to prevent congestion. Usually with the headache there is some digestive disturbance, a feeling of unrest, flatulency with perhaps acid eructations. Accordingly the headache is often attributed to digestive disturbance. But both would rather seem to be effects of the same cause—the failure to supply the digestive apparatus with the proper amount of material to work on at the time when it expects it, while the mental absorption naturally attracts blood to the head. We know from delicate experiments made in physiological laboratories that at times of mental work there is an appreciably larger amount of blood in the head. A proof of the connection between the lack of a meal and the headache seems to be the fact that with most people even a glass of milk and a cracker, taken at the time when the meal is normally eaten, is sufficient to prevent the otherwise inevitable headache.
Whenever some such simple explanation as this for a headache is found and the patient made to realize its truth on his own observation, the [{552}] significance of the headache at once dwindles and it becomes much easier to bear it. Before the very real pains of it were emphasized by the dread of the consequences that would result from it. If it was really a brain ache patients would find it hard to understand how under its influence even serious changes might not take place in the brain. This is only a rational suggestion, but it is mental healing of the best kind.
Many of the aches which are spoken of as headaches are really forms of tenderness associated with the integuments of the skull. Certain of the muscles particularly are likely to suffer from achy feelings which are spoken of as headaches. This is true of certain feelings of discomfort in the frontal region and also of those that occur on the occipital region. External applications of many kinds relieve headaches in these regions, particularly in the frontal region. It is easy to understand that such applications do not affect the contents of the skull.
Some Occipital Aches.—Occasionally I have found that people who complained of a sense of weight at the back of the head, with some muscular tenderness, were sleeping on pillows that were too high. They were over-exerting these muscles and this gave a sense of fatigue, which when much attention was paid to it, became such an ache or at least discomfort as is often found in the occupation neuroses. I have seen schemata according to which headache complained of at the top of the head meant digestive disturbance, headache in the anterior portion of the head was referred to the eyes or the brain, and headache at the back of the head spinal exhaustion or severe neurasthenia, but these are at most very uncertain and I do not think that the tabulation of cases justifies any such diagram of absolute causes and effect. Usually there is some local condition that calls particular attention to a special part of the head and then the attention being concentrated complaint is made of that part.
Local Head Discomfort.—Usually a headache, accompanied by a localized sense of pressure or weight or constriction, occurs in highly neurotic people or those inclined to think much of themselves and whose attention becomes concentrated on some part. At all times we have sensations streaming up to our consciousness from every portion of the body and anyone who wants to think about them, or a particular set of them, can make them sources of considerable discomfort by concentration of attention. Sometimes there are special conditions that predispose to these localized sensory disturbances. I have known tight hats to produce such effects. It is sometimes surprising how tightly hats are worn. Nervous people are prone to overdo everything, and they overdo the pulling down of their hats. At times the wearing of a heavy hat will be the root of the trouble. I have known nervous men accustomed to wearing high hats all their lives who began to complain of headache when they were in the midst of busy worries and troubles of late life, find considerable relief by abandoning their high hats.
Toxic Headaches.—There are headaches that are due to the taking of stimulants, as is well known from common experience. The mistake is often made, however, of thinking that only alcoholic stimulation will cause a severe headache. Tea and coffee headaches may be quite as severe. Whenever people complain much of headache it is important to revise their dietary as to the consumption of tea and coffee. Of course, the headaches following [{553}] alcoholic stimulation are usually recognized as such, though occasionally a man accustomed to taking much alcohol without any such after effects is surprised in the midst of the worry incident to business stresses to find that he is having headaches. These are due to the combination of stimulants and congestion consequent upon an excess of alcohol with the increased brain work that is demanded, or even with the same amount of brain work from a tired brain. Gradually stopping the alcohol will do more to relieve these headaches than anything else. To advise the sudden stoppage of regular quantities of spirits that have been taken for some time, will sometimes produce an anemic headache and defeat the purpose of the advice.
When for some other reason tea or coffee or alcoholic stimulants are suddenly omitted after they have been taken to excess for some time, patients' complain of a headache. Some of this is probably imaginary, or at least is due to the idea that their craving for the stimulant, whatever it may be, must have a local manifestation, and the head sensation is exaggerated as a consequence. Tea and coffee cravings may here give more trouble than the longing for alcohol. Sometimes there may be a real disturbance of the circulation from the lack of the heart stimulant to which the system is accustomed and therefore an uncomfortable feeling in the head from brain anemia. This can be overcome by not cutting off the stimulant, whatever it may be, all at once, but by bringing about its gradual cessation. These patients, however, are very prone, even with the best of good will in the matter, to deceive themselves and find an excuse for not having their favorite tipple, be it tea or coffee or alcohol, taken from them, so that they readily create symptoms by auto-suggestion.
Direct Mental Treatment.—For both congestive and anemic headaches mental treatment is important. For those suffering from the congestive kind the physicians's business is not so much the cure of any one attack of headache (for this can be accomplished by various now rather familiar anodyne drugs as a rule), but the discovery and removal of the cause for the recurring attacks. These will be found in some habit of the patient which must be corrected. Drugs are seldom needed for the underlying condition which occasions the headache, for when it is due to such organic affections as brain tumors or other intracranial lesions, drugs can accomplish very little. In less serious conditions benefit may be obtained by having the patient change his attitude towards certain important details of his life, such as eating, sleeping, attention to business or to study and the like, so as to prevent the mistakes of daily habit that predispose to headache.
With regard to anemic headaches, especially those which occur in persons who are very much run down in weight, the most important element of treatment is to bring about an increase in weight. This can be accomplished much better through the mind than in any other way. Appetite is a function of the will, and patients should have an increase of diet dictated to them and then be persuaded to follow that. I have seen many a headache disappear among teachers, and religious workers particularly simply as the result of this measure.
As regards headaches for which no definite cause can be found mental treatment is the only efficient remedy. Practically nothing but a change of mental attitude towards the affection and its underlying causes, whether these [{554}] be neurotic or psychic, will bring about relief, and each patient is a problem quite distinct from any other.
There is no pretense that this use of mental healing for headache is new or even modern. Many stories show that in olden times headaches were often relieved by this means, and that suggestion was looked upon as an important element in the treatment for their relief. In the chapter on [Great Physicians in Psychotherapy] the quotation from Plato with regard to Socrates curing the headache of his young friend Charmides illustrates this very well.
In the old stories of Greek medicine there are a number of references to headaches cured by suggestion or at least by mental influence. Miss Hamilton, in her book on "Incubation," [Footnote 40] tells the story of Agestratos and his headaches and how they were cured at Epidaurus. Agestratos had a combination of headache and insomnia, the description of the ailments having a strangely modern air. Just as soon as he came to the Temple at Epidaurus he fell asleep and had a dream. The God of Medicine, AEsculapius, whose cult was practiced assiduously at Epidaurus, came to him in his sleep and promised him the cure of his headache and at the same time taught him wrestling and advised its practice. When day came he departed cured, and continued to practice wrestling. Not long after he competed at the Nemean Games and was victor in the racing. The suggestion that his headache would get better had come to him and at the same time he had been given a suggestion that provided him with occupation of mind and body. Many of the people who suffer from persistent headaches need this advice more than anything else. Probably every physician has had the experience of headaches being cured by some interesting exercise, especially if taken in the open air. The important factor is the change of mental attitude, though changes in exercise, diet, amount of sleep and the like are helpful auxiliaries.
[Footnote 40: London, 1906.]
SECTION XVI
NEUROSES
CHAPTER I
NERVOUS WEAKNESS (NEURASTHENIA)
Neurasthenia, from the Greek roots, neur, meaning nerve, and sthenos, strength, joined by the negative particle a, turning strength into weakness, means nothing more than nervous weakness. To tell a patient that he or she is nervously weak, or is suffering from nervous weakness is usually not satisfactory, but it may be absolutely true and may represent the limit of our knowledge with regard to the particular case. To tell them that they are sufferers from neurasthenia is satisfying as a rule, because then they have a nice, long, and imposing word with which to talk to their friends about their ailment. To discuss with friends one's own nervous weakness is just a little absurd; to talk over neurasthenia and its symptoms, however, adds importance to those symptoms and makes them seem manifestations of some interesting underlying condition.
The discussion of symptoms always does harm, but the internal complacency with its constant auto-suggestion of the underlying nervous disease is still more harmful. Neurasthenia seems to most people to signify a new and serious disease of the nervous system which has developed as the result of our high-pressure civilization and the modern strenuous life, and, therefore, has a special interest and an exaggerated importance. All of this makes for an unfavorable attitude of mind towards the affection and encourages the intensification of symptoms by attention to them. The opposite state of mind in which symptoms would be given their proper value by the term nervous weakness would act as a constant source of favorable suggestion. I believe that if the word neurasthenia must be used, it should be translated for the patient and the absolutely functional character of the affection insisted on in order to neutralize its suggestive influence.
Probably the most serious objection to the use of the word neurasthenia comes from the number of organic affections having vague nervous symptoms, including especially tiredness, a certain incapacity to do what was readily done before with tired feelings and a general feeling of unfitness, that have come to be grouped under this head. In this it resembles the word rheumatism rather strikingly. The diagnostic general principles seem to be: tired feelings equal neurasthenia; achy feelings (especially if worse on rainy days) equal rheumatism. So whenever either word is used, patients are apt to think of cases they have known which were labeled by one of these two terms, [{556}] rheumatism or neurasthenia and ended by developing some serious condition. The unfavorable suggestion consequent upon this has made many patients miserable and has prevented them from using their nervous energy to relieve their condition.
The use of the word neurasthenia has another decided disadvantage in that the facile recourse to it often keeps the physician from examining his patient sufficiently to detect an underlying pathological condition. The term can be made to cover so much that it has done great harm in this way. I feel, therefore, that in the discussion of what can be done for patients suffering from nervous weakness we should first of all describe and set aside a number of forms of disease that have sometimes masqueraded as "neurasthenia" and that have given the affection stronger unfavorable suggestiveness. Sir William Gowers, whom no one would suspect of either minimizing the significance of the word or of the affections that have come to be grouped under it, nor of wishing to attract attention by differing from others, has in one of his recent smaller medical works [Footnote 41] emphasized both of these unfortunate connotations of the word. Because his expressions as applied to other medical terms that are too general in their significance, will help physicians to get at the real meaning of them I venture to quote his opinion at some length:
[Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy and Other Lectures," Philadelphia, 1904.]
The history of the word "neurasthenia" is noteworthy. ... I have to confess to the authorship of two words. One, "myotatic," was always a puny infant, and I doubt whether it still maintains an independent existence. The other, "knee-jerk," instantly attained universal use, and indeed, I think has seemed to most persons to have sprung spontaneously from the thing itself, without suggestion—perhaps the greatest compliment a word can pay its author. But the general use at once achieved by "neurasthenia" was in spite of a strong objection to it which was felt by many. The Royal College of Physicians of London could not include it in their "Nomenclature of Disease," and yet it is now one of the most common of medical words in every language. It would be instructive in more than one way to have a careful study of the forces which have influenced its career, but that I cannot attempt. We must, I think, admit that not only is it a satisfying word to those who suffer, but it has a certain convenience which has also compelled many to employ it who at first objected. If I may be pardoned for a partial paradox, its convenience is not the less real because this rests on features that are illusory. Remember that the word is a name which should have little meaning, even to those who use it. You may employ it to collect the symptoms of the case under a general designation, but do not let it cover them as a cloak.
Neurasthenia and Melancholia.—A serious mistake of diagnosis, though it is often not a mistake of knowledge but of medical judgment, is the confusion, apparent or real, of neurasthenia with melancholia. The word melancholia has come to have a definite serious significance, as it should, in the minds of many persons and as a consequence physicians sometimes hesitate to use it, and employ instead the all-embracing term neurasthenia, or neurasthenic depression. It is popularly well known that melancholies are likely to commit suicide if their condition is serious, while neurasthenia is not at all connected with the idea of suicide. As a consequence, patients are often not guarded as they otherwise would be and so we have suicides every [{557}] month of so-called neurasthenics who were really sufferers from melancholia. This sad state of affairs reflects in two ways to the detriment of medicine. First, it leaves melancholies without due protection. Second, it leads many of the neurotic patients whose ailments have been labeled neurasthenia and who read the stories of these supposed neurasthenics, to think that they, too, are tending toward suicide and so they are less capable of reacting against their neurotic condition and in general are much worse for the unfortunate dread of some such fatal termination.
Neurasthenia Simulation by Organic Disease.—Neurasthenia is especially a dangerous term since, like other words of this kind with wide connotation, many quite disconnected diseases may in early stages simulate it and give rise to the thought that there is only a functional nervous disease present, when the symptoms are really a manifestation of an underlying organic disease, heightened somewhat by a nervous organization or by worry on the patient's part. So-called neurasthenia in the old must always be looked upon with suspicion. Neurasthenia in the young may be a purely functional nervous disease, though it is probable that in most cases the nervous system is congenitally defective, or at least is unable to perform the functions which have been assumed by the patient. If a nervous organization has stood the strain of the trials of early and middle life, which are usually severe enough to try out individuals from the physical side, if they are in moderate circumstances, or from the mental side if they are wealthy, it will not, as a rule, be overborne by the burdens put upon it by age unless some organic disease has come to seriously disturb it.
Neurasthenia and Arteriosclerosis.—There are many serious conditions that masquerade as neurasthenia. Perhaps the most important is precocious arteriosclerosis. That a man is as old as his arteries is now recognized as an absolutely sure maxim of internal medicine. In many people the arteries wear out before their time and in all there is an inevitable wearing out in the course of years. With the beginning of degeneration of the arteries there are likely to be many symptoms that closely resemble neurasthenia. In the elderly these are nearly always symptoms of defective circulation because of lack of elasticity in the arteries and their failure to accommodate themselves to the variations of pressure in the circulation as the consequence of changes of position, variations in the barometer, heat and cold, and the like.
In these cases a study of the blood pressure will give the differential diagnosis when the actual thickening of the arteries cannot be felt, but it must not be forgotten that nervous excitement may greatly heighten blood pressure on occasions so that a number of observations have to be made.
Neurasthenia and Bright' s Disease.—Other general diseases almost inevitably produce nervous symptoms. It is curious how often a severe exacerbation of Bright's disease, which has been in existence for some time but has given no specific indication, is preceded by a series of neurotic symptoms thought to be due to nothing more than neurasthenia. Men of thirty-five to forty-five, the favorite time for the occurrence of the severe forms of Bright's disease, begin to complain of tiredness, especially on waking in the morning, of inordinate fatigue in the evening, of some stomach symptoms and occasionally a tendency to diarrhea. All of these are ascribed to a neurasthenic condition. Early in these cases an examination of the urine should be made [{558}] as a routine practice, because if there is nothing in it the patient will be just that much more reassured, while if it contains any pathological elements he need know no more about it than his physician deems proper, yet the real nature of the case and its indications will be appreciated. Without this a physician will often find himself suddenly confronted by serious symptoms in a patient when nothing of the kind was anticipated because the condition was thought to be entirely functional.
Occasionally the symptoms of Bright's disease seem to develop suddenly, as it were a storm in the organism out of a clear sky. As a matter of fact, however, there have been for some time before more or less indefinite symptoms pointing to some serious process at work, which if valued at their proper worth might have led to a much earlier diagnosis of the impending nephritis. Such patients are labeled as neurasthenics for months and at times even years before the serious conditions develop which make the recognition of their ailment comparatively easy. One case of this kind has come under my observation that is interesting in its lessons. A medical student had during the first year of his course exhibited every now and then what seemed to be neurotic symptoms. He was inclined to complain of headache for what seemed very slight reasons, and of pains and aches whenever there was a change in the weather and especially a fall in the barometer. He often had stomach symptoms and was anxious about his heart; in general he was looked upon as one of the nervous, complaining kind. During the course of a lesson in clinical pathology in his fourth year, he was asked to furnish a sample of urine which it was supposed would be normal, for comparison with an abnormal sample that was being investigated in the laboratory. To the surprise of the professor and to his own consternation, his urine was loaded with albumin. Up to that time there had been absolutely no objective symptoms and only the vague indefinite subjective symptoms mentioned. The next day his feet swelled. Even this for a time was considered to be rather an index of the neurotic tendency in him to react to very slight causes. It was hoped that the albuminuria was functional, as the examination was made in the full tide of digestion, and that it would pass off. Subsequent examinations, however, showed not only albumin but also casts. There was a slight intermission of symptoms and then an exacerbation. Within a month after the chance examination of his urine and its unexpected result he had a convulsion. Two weeks later, altogether six weeks after the albumin was first discovered, he died in nephritic coma.
Such cases are not so rare as they are thought, though they are seldom so fulminant. There is a story told of a professor at one of our American medical schools who, some twenty years ago, took a sample of his own urine in order to demonstrate the normal characteristics of healthy urine, and to his utter surprise he found albumin and casts in it. Within six months he was dead from Bright's disease.
Nervous Diarrhea and Organic Disease.—Other internal conditions may be called neurotic when they are really due to definite pathological entities. For instance, in three cases I have seen what had been pronounced by several physicians to be chronic diarrhea of nervous origin, proved to be due to quite other and serious pathological conditions of internal organs. In one of them a chronic diarrhea of several years' standing finally culminated in death in [{559}] early middle age from nephritis. After the event, there seemed to be no doubt but that the diarrhea, which no ordinary means of treatment had succeeded in benefiting more than temporarily, was really due to the effort of the intestinal mucosa to supplement the defective work of the kidneys. In this case apparently one of the strongest evidences that the affection was of nervous origin was the fact that whenever the patient was away from home, eating rather plentifully of a varied diet, his intestinal condition was better than when he was eating much more simple and unvaried food at home. The change of scene and surroundings proved a tonic to his kidneys and perhaps also to his skin, thus saving his intestines some of the extra work they had assumed.
Neurasthenia and Diabetes.—Another serious disease that may in its earlier stages be mistaken for neurasthenia is diabetes. There is no doubt that some patients have been passing sugar for a long time before any sure symptom can be noted in their general health, or, indeed, before there is anything to call attention to the possibility of glycosuria. In many of these cases, however, there is a feeling of muscular tiredness and a sense of inadequacy for occupations which were before easy, that may be attributed to neurasthenia. When this muscle tiredness changes to crampy feelings that should be enough to lead to an examination of the urine.
Undoubtedly one of the reasons why neurasthenia is sometimes called the American disease and is thought to be more frequent among us than it is in Europe is this confusion with the beginnings of serious organic disease because of failure to examine patients carefully in order to detect underlying organic conditions. In recent years this neglect has become rarer and the consequence has been a reduction in the numbers of so-called neurasthenia cases. Our morbidity statistics of twenty years ago, for instance, seemed to show that we had only half as much diabetes to the population as they had in Europe. One of the reasons for this was undoubtedly the ease with which the diagnosis of neurasthenia might be made at the beginning of diabetes, and that the terminal stages of the affection were often masked by the development of the tuberculosis so frequent in diabetic conditions or of albuminuria with symptoms pointing to Bright's disease. Even at the present time it would be quite possible to reduce the number of neurasthenia cases by more careful attention to diagnosis.
Simulated Neurasthenia Due to Over-attention.—While there is danger of confusing neurasthenia on the one hand with more serious disease there is a distinct liability on the other hand to exaggerate the significance of certain minor symptoms by employing the word when it is only over-attention of mind to certain portions of the body that constitutes the disease in its literal sense. If something has particularly attracted a patient's attention to some part of his anatomy and if his attention is concentrated on it and allowed to dwell long on it, his feelings may be so exaggerated as to tempt him to think that they are connected with some definite pathological condition and he may even translate them into serious portents of organic disease. If a patient once begins to waste nervous energy on himself because of solicitude with regard to these symptoms then it will not be long before feelings of tiredness, incapacity for work, at times insomnia and certain disturbances of memory are likely to be noted. Then the neurasthenic picture seems to be [{560}] complete. This is the process so picturesquely called "short-circuiting" by which nervous energy exhausts itself upon the individual himself instead of in the accomplishment of external work. Many of the worse cases of so-called neurasthenia have their origin in this process. It is true that this set of events is much more likely to occur among people of lowered nervous vitality, but under certain conditions it may develop in those who are otherwise in good health up to the moment when the attention happened to be particularly called to certain feelings. The physician can start these patients off anew after improving their physical condition, if he can only bring them to see how much their concentration of mind upon themselves is the cause of their symptoms.
It has been well said, though to some it will doubtless seem an exaggeration, that we human beings are a regular boiler factory of sensations which, fortunately for our sanity, mental and physical, we have learned to neglect to a great extent. Wherever our clothing touches us, wherever the air touches us, wherever shoes or belts constrict us, there are definite sensations. These continue, but attract no attention unless they exceed a certain limit to which we are accustomed. Habit in this matter is very different in different individuals. After men and women have grown used to tight shoes or tight corsets these no longer produce disturbance. The chance visitor in a boiler factory or loom room of a cotton mill thinks he could not live in such din. But after a time people get so used to the din that silence and quiet may even become oppressive to them. City dwellers from the slums, especially children, find the peace of the country disturbing when they are first taken for vacations.
Over-attention to sensations, often scarcely abnormal, is indeed the real source of many of the symptoms that can so readily be exaggerated into pathological portents when attention is directed to them. Every portion of our body is connected with the central nervous system. Every square inch of surface touched either by clothing or the movement of the air producers a sensation at every moment of our waking life. Ordinarily we pay no attention at all to these sensations. We can recognize their presence by turning our attention for the moment to any portion of the body and recognizing at once that there are sensations coming from it, though the moment before we did not notice them. If we think of the point of our big toe on the right foot we find, though we were totally unaware of it a moment before, that a certain pressure is being exerted in it. If we continue to think of it queer feelings develop in it. We may get a sense of numbness that proceeds up along the tendons that lead to it. We can follow them up to the insertion of the muscles in the shin. If we dwell on the subject we have curious prickly sensations and numb feelings, all of which were there and were neglected a minute before but now are acutely felt.
This same thing is true of all the manifold sensations that come streaming into the brain. We learn almost to enjoy them though we are paying no attention to them. To be without them would mean very often a fright lest there should be something the matter. Usually we think of the outside of our body as the main source of sensation. It must not be forgotten, however, that our viscera have also certain sensitive nerves and while these are not as closely distributed as those on the surface they are there and their presence is often a source of pleasure or at least of satisfaction, but may be the source [{561}] of poignant discomfort. We are constantly disregarding ordinary messages from these, too. Something may easily call our attention to these sensations, however, and then we may translate them into pathological terms though they are really only physiological. Ordinarily man may put a couple of pounds of food and drink into his stomach and not feel it at all. If anything particularly calls attention to our stomachs, however, and we dwell on it, then this weighty feeling may seem to indicate serious indigestion because of the discomfort that is produced. This is what nervously weak persons, the so-called neurasthenics, are constantly doing. It is this habit that by suggestion and training they must be taught to break.
There is a tendency to the substitution of one neurotic symptom for another whenever by psychotherapy and mental discipline one condition is overcome. Often the substitution is of something just as bad or even worse. I have known cases where people when properly persuaded gave over paying too much attention to their stomachs and then proceeded to pay too much attention to their sleep with the result that insomnia developed. On the other hand, I have known patients to get over insomnia and then develop a series of complaints of queer feelings in their head which they usually spoke of as headache, though when asked to describe them carefully they confessed that they were at most a sense of pressure or of unusual feeling in some part of the head.
These curious substitutions take place particularly if for any reason special attention is called to another part of the body, either by accident or by some therapeutic manipulation or remedial measure. I have known a patient who complained of headache and was advised to take up exercise in the open air, do much stooping and lifting while cleaning snow from the sidewalk, develop a tired condition in the lumbar muscles and straightway this was thought to be rheumatic. Liniment was employed and the counter-irritation which developed attracted the patient's attention to that portion of the body for a week. The headache was no longer complained of, but lumbago was considered to have developed. I have known a person who suffered from headache develop what seemed to be a retention of urine for which unfortunately the doctor thought it necessary to use a catheter and after this there was no complaint of the headache, but the patient became almost unable to hold any amount of urine in her bladder and could not go out for social or other duties because of the fear of imperative urination.
CHAPTER II
CHOREA
This twitching affection, so familiar that it need not be described particularly, is sometimes classed as a pure neurosis, sometimes as a nervous disease with perhaps some organic basis and sometimes is placed among the ailments related to rheumatism and attributed to some pathological condition of the circulation.
Etiology.—Two elements must be considered in the problem of the etiology [{562}] of the disease—the predisposition and the direct occasion. The affection occurs particularly in nervous children who are made to occupy their intellects too much while their muscular systems are kept quiet for long hours. Often a preceding running down in weight is noticed, though sometimes the child only fails to increase in weight as it should in proportion to its growth. It occurs quite frequently among chlorotic girls just before or about the time of puberty. Anemia generally seems to predispose to it, but the affection may occur among children who seem to be in excellent physical health, though usually a distinct nervous heredity is found.
Immediate Causation.—Fright is one of the most frequent immediate causes or occasions of the development of chorea. Mental worry of any kind may have the same effect. Scolding has produced it; a sudden grief has seemed to be the occasion; a slight injury, and still more, a severe injury, or a surgical operation, even a slight one, may be the forerunner of it.
Pathology.—No definite lesions have been found to which the disease can be attributed, though a careful search has been made for them. Endocarditis is an extremely common accompaniment. It is probably present in three-fourths of the cases that have come to autopsy. Osler found it in sixty-two out of seventy-three cases in the literature. The association of the affection with rheumatism is insisted on by the French and English particularly, and certainly in a considerable number of cases there is a history of preceding or coincident rheumatism, that is, an acute rheumatic arthritis. Often these attacks are concealed under such names as "growing pains" or "colds in the joints" but it is not hard to elicit a history of a red and swollen joint with some fever. In children mild cases may occur of genuine acute rheumatism with the involvement of but a single joint and that not severely. These mild forms are often found in the history of cases of chorea.
It seems likely that the heart affection is often responsible for the symptoms and it is probably through the endocarditis that whatever connection there is between chorea and rheumatism exists.
All the elements in the disease point to the influence of the mind over it. The predisposition is caused by over-use of the mind at a time when many claims are being made on the nervous system because of the growth of muscles. There must, as a rule, be a pathological basis, natural or acquired, that is, something that tends to produce a defect in the circulation, but even without this certain children suffer from the affection. If the patient is an object of solicitude or of curiosity at home or at school, the symptoms rapidly become worse. At any time the consciousness of observation makes them worse. The symptoms do not occur during sleep, or at times when the patient's mind is much occupied with some absorbing interest. They lessen just to the degree that the patient's own attention is not called to them or the consciousness not allowed to be concentrated on them. Chorea often occurs in bright, intelligent children and always seems worse in them.
Treatment.—The story of the therapeutics of chorea in recent years strongly confirms the idea of the place of mental influence in the cure of the disease. We have had a whole series of remedies, introduced with a promise of cure by distinguished authorities, used for a time with apparent success by many physicians, and then gradually falling into innocuous desuetude. It was recognized that any remedy would have to be used over a rather [{563}] prolonged period, at least from five to ten weeks. It was appreciated, also, that the patient must be kept quiet, both in mind and body, emotional disturbances especially being avoided, that all physical functions have to be set right and that the nutrition particularly must be corrected if in anything it is abnormal. Where all this is done patients recover without any remedy quite as promptly in most cases as with any of the supposed specifics. Expectant treatment, supplemented by symptomatic treatment, has proved in many institutions to give excellent results without the necessity of troubling the patients with more or less dubious drugs. It was important that the patient should be given certain medicine and impressed with the idea that this medicine was expected to do them good, a suggestion automatically emphasized at every dose, but it is probable that few men of considerable clinical experience now hold the notion that we have any genuinely curative remedy for chorea, though we have certain tonic, alterative remedies which, in conjunction with the setting of the mind at rest, help to put the patient in a condition where the affection is gradually overcome.
The most important object in the treatment of chorea must be its prevention or its early recognition, and its immediate treatment; then there is little likelihood of relapses and, above all, the condition does not last long. Children who have had an attack of acute articular rheumatism or who have suffered from growing pains or any other of the rheumatic simulants of childhood should be watched carefully during their growing period and at certain critical times in early life. They should be especially regarded immediately after being sent to school. The first sign of involuntary twitchings should be taken to mean that the children are overborne and a period of rest from anxiety and study and over-exercise should be afforded them. Of course, all this watchful care must be exercised without attracting the little patient's attention, or the very purpose of the care will be defeated and the mind disturbed.
Rest does not mean that patients should be kept absolutely in bed even after chorea has frankly developed, but that there should be hygienic rest. Long hours of sleep, interesting occupations without much exercise, a period of lying down in the afternoon, but, above all, such occupation of mind with simple pleasant things as keeps their attention from themselves. Visitors should not be allowed to see them; above all, they should not be conscious objects of over-solicitous care on the part of father and mother or the relief of symptoms will be delayed and the condition will be made worse. As a rule, children do not worry about themselves nor their physical ailments, but they can be made to do so by seeing the over-anxiety of others. A good nurse of sympathetic nature with power to interest the child, is better than its mother for a constant companion, though family life, the playing with brothers and sisters and the regular routine of home is the best possible mental solace and occupation. Grandmothers are useful adjuvants in the treatment late in the affection. At the beginning their over-solicitude nearly always does harm.
Habit Following Chorea.—In certain nervous children after the chorea itself has subsided there remains a habit of twitching that often is almost more intractable than the chorea itself. This is particularly likely to be manifest in children who have an unfortunate nervous heredity or in those whose [{564}] nervous systems have been impaired by preceding infections disease as anterior polio-myelitis, syphilis or one of the forms of meningitis. Occasionally it is seen in children without nervous heredity, but they are usually children surrounded by solicitous relatives, made the centre of pathological interest and constantly fussed about. The habit is not surprising and would remind the observant physician of the whoop that by habit sometimes clings to children in any cough that they may have for months after they have had whooping cough. Often it will be found that these children are capricious eaters, that they take tea and coffee, that their diet instead of being the simple nutritious food that they should have consists of many things that their mothers obtain to tempt their appetites and that the children can really have anything they crave for and get it much oftener than is good for them. To continue any form of presumedly specific treatment in these cases does no good. If arsenic is used over long periods, or any of the salicylates because of the supposed connection of chorea and an underlying rheumatic diathesis they will certainly do harm. The patients' diet can be regulated, nerve stimulants of all kinds must be denied them, and their appetites must be brought into order by the proper care of a nurse who will not yield too readily to their caprices, and then the solicitous environment must be changed. These cases represent a good many of the so-called prolonged choreas and are really habits or tics due to concentration of mind and a certain hysterical tendency to continue to attract attention which may be noted.
CHAPTER III
TICS
Without any good reason in the etymology or the history of the word, the term "tics" has now been generally accepted to signify certain involuntary movements, frequently recurrent, of which, by habit, certain persons usually of diminished nervous control, become the victims. For the psychotherapeutist, however, they have an interest quite beyond that which they have for the ordinary student of nervous diseases. They represent the possibility of the formation of habits in the nervous system, originally quite under the control of the will, but which eventually become tyrannously powerful and quite beyond management by the individual. They deserve to be studied with particular care because it is probable that they represent objectively what occurs also on the sensory side of the system, but which not being manifest externally, is spoken of as entirely subjective. If nerve explosions of motor character can, through habit, get beyond the control of the patient, it is not unlikely that sensations, primarily of little significance, may, in persons of low nervous control, become by habit so likely to be repeated as to make the patient miserable. Hence the study of tics as here presented.
As a result of the studies of Gilles de la Tourette, we realize that there is an essential distinction between involuntary movements of various kinds, and that spasms and tics must be separated from one another. Tics consist of various movements of the voluntary muscles. Probably the most familiar [{565}] is that of winking. Everybody winks both eyes a number of times a minute quite unconsciously, though the unconscious movement accomplishes the definite and necessary purpose of keeping the conjunctiva free from irritant particles. When this same movement is done more frequently than is necessary, or is limited more to one eye than to the other, or is repeated exaggeratedly in both eyes, then it is a tic. There are many other facial tics. Most of them represent movements of the lips or of the nose or of the skin of the forehead and all of them are identical with movements that are occasionally performed quite voluntarily. There are movements of the lips as in sucking, or smacking sounds may be made, or such movements of the features as are associated with sensations of taste or smell. Sometimes changes of facial expression may be tics and without any reason there may be recurring expressions of emotion, of joy, or grief, or fright, or even pain. Sometimes the tics affect structures that are internal, as various motions of the larynx accompanied by the production of grunting or sighing sounds or sometimes even of particular words. In children the tendency is prone to manifest itself in the utterance of forbidden words, usually vulgar, sometimes indecent.
Besides these facial and throat tics any of the voluntary muscles of the body may be affected. There may be the gestures that accompany certain mental states, or there may be twisting or turning movements as if the patient were in an awkward position and wanted to get out of it, or as if the clothes were hampering movement and there was an effort to relieve some discomfort. The head may be lifted and lowered, or may be twisted from one side to the other and, indeed, various nodding tics are extremely common. Almost any ordinary movement may, in nervous people, come to be repeated so frequently as to be a tic.
Practically all of the convulsive or quasi-convulsive movements associated with respiration are likely to become the subject of tics. Yawning, for instance, involuntary to some degree, usually a reflex with a physical cause, but so readily the subject of imitation, may become so frequent as to be repeated a couple of times a minute and this repetition kept up for many days. Sneezing may also become a tic, though it is usually a definite reflex due to palpable physical causes. Hiccoughs may easily become the subject of a tic. The occurrence of a persistent hiccough is in popular medicine a sign of unfavorable prognosis in serious diseases, especially such as involve the abdominal region. In connection with neurotic affections of the abdomen, however, hiccoughs are not uncommon and are of no serious significance.
Varieties of Tics.—There are many more tics than are ordinarily supposed. Indeed, there are few of us who escape them entirely. Nearly all the curious phrases that people interlard so frequently into their conversation, usually quite unconscious of them, or of the ridiculous significance they often have, must be placed under the tics. Some men cannot say a dozen words without interpolating "don't you know." Others use some such expression as "in that way." I once knew a distinguished professor of elocution who by actual count used this phrase forty times in an hour. Some say "hum" or "hem" every sentence or so. Whenever there is a bit of obscurity in their thought these voluntary but unconscious expressions are sure to pop out. No one who has had much experience in public speaking ever succeeds in keeping entirely out of such bad habits. It is curious how phrases will insist on repeating [{566}] themselves. One year one set of words, or a pet phrase, or mode of expression, creeps unconsciously here and there into an address. Then either because the speaker has been reading dictated copy, or because some good friend has the courage to tell him of it, he finds out the bad habit and suppresses it.
Word formulas senselessly repeated are only one of many forms of tics that public speakers are prone to indulge in. Gesture which begins as an artificial adornment of speech, very appropriate in itself, after a while may settle down into certain forms that not only often lack elegance but that are really disturbing to an audience. Of these gestures and movements men are often quite unconscious. They have become habitual and in the absorption of mind with the thought and the words, they are reproduced quite involuntarily though they are all originally voluntary movements. Nearly every public speaker needs a mentor to correct him of such faults. It is rather difficult to break some of these habits and it requires no little concentration of effort and attention to be successful in eradicating them. It can be done, however, provided the habit is not too inveterate, and this is the best evidence that tics of other kinds can also be eradicated if the patient really takes the matter in hand and is not of a weakened will.
Teachers' Habits.—Indeed it is almost impossible for public speakers and teachers not to acquire certain habits irritating to their auditors at first but amusing as they grow used to them, and students particularly learn to look kindly at the ridiculous side of many of them. I remember an old professor of literature who used to lecture at some length on each of the important contributors to English prose and poetry. We soon observed that whenever he came to their deaths he took out his handkerchief and blew his nose. This was as inevitable and as invariable a rule as the laws of the Medes and the Persians. It was, as it were, his tribute of sympathetic condolence with humanity for the loss of a brilliant contributor to English literature.
Occasionally the effort to break up these habits will seriously interfere with modes of thought and habits of expression, for the time being at least. A professor at a certain university had a habit every now and then of plucking at a button on his coat. His students could tell when his hand was going to find this object of its occupation and knew from experience that he would twist it a certain number of times. He was not what would ordinarily be called a nervous person. One day he happened to take off his coat shortly before a lecture and one of the students surreptitiously removed the button. At the end of the first few minutes of his lecture his hand went up to find the button as usual but failed. For the moment there was a hesitancy in his speech; then he tried again. A little later his hand went up unconsciously and was disappointed; then he stammered and lost the thread of his discourse. The last half hour of that lecture was seriously impaired because of the absence of that button.
Tricks of Speech.—There are many other curious tricks of speech that are really tics. Women often indulge in them and sometimes even pretty women spoil their appearance by bad habits. All of us know the pretty woman who talks very fast, but who every now and then projects her tongue a little beyond her teeth. Occasionally there is a tendency to wrinkle the nose or the forehead. Most of us have seen the woman who sets her face into a definite smile of a particular kind whenever her company manners are in [{567}] use, though there is a vacancy behind the smile that is rather disturbing. Some people have habitual movements of the fingers that are really tics, and even positions assumed on sitting down that are very ungraceful, or that are very noticeable, sometimes partake of this character.
Fussiness.—A very common form of tic that is quite difficult to control is that tendency to be doing something with some of their muscles which characterizes many men. They must handle a pencil or a knife, or they must swing on their chair or tilt back on it, or keep one of their limbs swinging over the other, or twirl their moustaches or stroke their beards, or rumple their hair, and they cannot find it quite possible to sit still. The difference between men and women in this regard is remarkable. Women are conceded to be much more nervous than men, but men are ever so much more fidgety than women. The author of "The Life of a Prig" in his book "The Platitudes of a Pessimist" has some striking paragraphs with regard to this subject. He says:
To look nearer home, the British bar affords splendid examples of nervous fidget. Observe barristers pleading a cause. How they torture a piece of red-tape, how they twirl their eye-glasses or spectacles, and how they hitch at their garments, as if they momentarily expected them to desert their finely proportioned figures. But worse than the Queen's Counsellors, and even worse than the domestic peripatetic, is the villain who is abandoned to a performance vulgarly known as "the devil's tattoo"—drumming with the fingers.
Writers' Tics.—Writers, and above all writers for the daily press and such as have to do their writing in a rush and therefore get nervous and anxious about it, are especially prone to develop tics, though others who write leisurely may do so. Some of these are curious and others are only expressions of nervousness common to all people. Many of them chew their nails, some of them bite at their fingers round the nails and make them sore, many of them chew the ends of their pens and find it practically impossible to keep a pen with a long handle to it. Some of them run their hands through their hair until it is in a greatly rumpled condition, some of them pluck at their eyebrows. I have one patient who when he is going through a particular nervous strain plucks out the middle portion of his right eyebrow so that he has a distinct bald spot at this point.
The tradition in newspaper offices is that these curious expressions of the tendency of the body to occupy itself with something while the mind is occupied are more or less inevitable in nervous people. They continue for many, many years. They are only habits, however, that it would have been rather easy to break in the beginning, though they become extremely difficult to modify after they have once secured a firm hold. Occasionally I have fastened a piece of adhesive plaster over a much battered eyebrow, but that made it difficult for the man to go on with his work. His hand would go up involuntarily time after time and while plucking at his eyebrow would not disturb in the slightest his train of thought, just as soon as his fingers touched the unusual object a serious distraction occurred and work was not only slower, but much more difficult.
In Games.—The tendency to the formation of curious habits of associated movements can be seen very well in most games where skill is combined [{568}] to a certain degree with chance. It is most noticeable, perhaps, in bowling. Few men are able to restrain themselves from making some special movement just as the ball strikes the pin. This is sometimes a motion of the head, oftener it is a jerk of the trunk, sometimes it is an associated movement of the arms, occasionally it is a kick or a stamp. In billiards the same movements are noticeable if a man is much interested in making a difficult shot. Usually there is some movement of the body or of the hands or of the head that would indicate his desire to move the ball in a particular direction. Women who play these games do not usually have these associated movements to such a marked degree and this may be due either to their better restraint to movement in general, for as we have said men do not acquire the habit of self-restraint in small matters of deportment as women do, or to the fact that such associated movements might disarrange their clothes. Perhaps, also, they are not as much interested in the games as a rule as are the men. Of course, similar associated movements may be seen in outdoor sports that require skill yet have an element of chance in them. For it is, as it were, to overcome this that the additional movement is made.
Children's Tics.—Some tics consist of some very curious habits. Occasionally children hear some obscene or vulgar expression and repeat it. The repetition of it produces such a look of shock to propriety on the part of some of the other little ones who happen to be present that they repeat it in the spirit of bravado and then continue to utter it until it becomes a habit that is hard for them to break. After all, the use of blasphemy later on in life is really a tic, a habit of uttering words no longer expressive of any particular feeling, as a rule, unless in exceptional circumstances but just the result of a tendency for the speech organs to repeat certain words. They tell a good story of the Rev. Sydney Smith who, wishing to break an acquaintance of the habit of indulging in expletives, interlarded his speech with "fire tongs and sugar tongs" every ten words or so and when his auditor protested that that added nothing to the significance of what he said the Rev. Sidney suggested that that was also true of various blasphemous expressions that his acquaintance was accustomed to use.
At the Salpêtrière they tell the story of a little boy who had the habit of saying the French word which the corporal in Victor Hugo's "Les Miserables" made use of when anyone told him that it was because Wellington was a greater general than Napoleon that the French Emperor was defeated at Waterloo. Nothing seemed to be able to break the boy of the habit of interjecting this word into conversations sometimes in which he had no part and sometimes toward which he was expected to take only a respectful and childlike attitude of silence. He was sent to the Salpêtrière. The ordinary remedies had failed entirely. One day he was allowed to go outside of the hospital, or rather stole out of the gate and played marbles with some street gamins in front of it. During the game he used the word in question and they proceeded to give him a good thrashing. It is Charcot who tells that this broke him effectually of the habit.
One of the childish customs that sometimes disturbs parents very much because it seems to be such an unaccountable lapse into barbarism, though it is really nothing more than a tic in the strict sense of the word, is the habit that some children acquire of removing portions of hardened material [{569}] from their nose and then putting it into their month. Refined parents are apt to be so seriously disturbed by this that they fear for the child's mentality. Really the habit is not nearly so rare as is usually thought by some grown-ups who have forgotten about their own and others' childhood. In country places the habit is very common. It is not alone the dull children who do it but some very bright ones. Indeed, the tendency to the habit is so common that one wonders whether there is not something in nature that tempts to it. Parents who are fearful lest their children may be seriously hurt in health by the awfully insanitary habit may be reassured that after all a certain amount of the drainage of the nose is normally carried off through the posterior nares to the stomach and that no danger to health seems ever to have resulted from the practice. As a rule, the habit can be broken rather easily by a little judicious care and insistence, though I know of cases where relapses occurred and the habit continued surreptitiously.
Motor Tics.—Motor tics frequently develop as a consequence of some injury to a nerve or some intense overuse of it. Winking habits follow an herpetic involvement of the superior branch of the fifth nerve. Bell's palsy is sometimes followed in the face by a tendency to twitching on the unaffected side that makes the patient quite uncomfortable. Herpes zoster is sometimes followed by a catching of the breath, probably due to a little spasm in the muscles supplied by the nerve thus affected. Some of the yawning tics have this origin. Any neuritis may in the course of its betterment be followed by this curious tendency to explosion along the nerve that has been affected, as if the pathological process had more seriously interfered with inhibition than with the actual function of the nerve. Examples of over-exertion followed by twitchings are not rare. A scrubwoman who has seen better days and now has to carry a heavy bucket and use her right hand much with the brush may develop a twitching of the right arm. A janitor's wife who sweeps much may have a tendency to twitchings of the fingers as a consequence of the unusual exertion of holding the broom. Twitchings in the limbs of men who work at a foot lathe or other machine requiring foot power are not unusual though they are more often seen in the leg on which the workman habitually stands than in the other one and it seems to be oftener a strain on muscles than actual over-exercise that precedes the development of these tics.
Heredity.—Heredity plays as large a role in tics as it does in stuttering and other functional nervous disturbances. Occasionally the direct inheritance of some habit will be found, though there is nearly always more than a suspicion that a trick of speech or of act, which constitutes the tic, was learned by imitation rather than transferred directly. Besides, it is a case of a similarly constituted nervous system reacting in the same way to a similar environment, rather than any definite tendency existing by heredity in the nervous system. It is surprising what close observers children are and how easily they learn to imitate any habitual action of father or mother or, for that matter, of nurses or those who are close to them.
Mental Treatment.—The most important element in the psychotherapy of tics is their prophylaxis. They run in families, not by any inevitable hereditary influence, but as a consequence partly of imitation and of corresponding tendencies resulting from certain weaknesses in the family. Wherever they are known to be likely to occur, parents should be warned of the [{570}] possibility and the first symptom of any motor habit should be considered the beginning of a tic. As we have said, they are likely to begin in muscles that have been overstrained for any reason, especially when patients are run down. They are often seen after herpes and certain facial neuralgias.
There is probably no tic, no matter how long or how serious, that can not be eradicated, or greatly modified, if the patient will take the trouble and if the treatment is conducted so as gradually to get rid of it. Peculiar movements cannot be done away with at once. They can be lessened in intensity and in frequency and then gradually the patient will be encouraged by their becoming less noticeable than before to make renewed efforts. The habit must be gradually undone and this will take as long as it did to form it originally. The exercise of contrary muscular movements carefully carried out, and of gentle repression with definite times of exercise during the day, gradually increasing the length of the intervals of repression, in the end proves successful. Only a determined struggle will effect a cure. It depends on the patient's will. Like a drug addiction, or a tendency to overeat, or a craving for alcohol, it must be gradually overcome and then care must be exercised to prevent relapses; for when the condition is somewhat better, to relax vigilance and give up effort will allow the old condition to reassert itself with startling rapidity. People suffering from severe tics will often give up. Without the patient's hearty co-operation cure is impossible. With good will its gradual diminution gives the patient a confidence in self and an uplift in character that is extremely valuable, not only for physical but for mental conditions.
CHAPTER IV
STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC.
The difficulty of speech called stuttering has usually been considered rather as an unfortunate lack of control over the organs of articulation, somewhat corresponding to muscular awkwardness of any other kind, than as a pathological condition deserving the physician's attention. If anything was done for it formally, the first effort of the parents or the teacher was to correct the supposed bad habits and this failing the affection was relegated to someone who claimed to produce wonderful results by some special method. Perhaps, even oftener, stuttering was considered one of those affections, fortunately decreasing in number, that the child may be expected to outgrow. Often there was noted an hereditary element which was supposed to indicate incurability.
Stuttering deserves special treatment in a work on psychotherapy because it illustrates very strikingly one phase at least of mental influence over bodily function. While in the study of the etiology of the disease much has been made of anatomical features, nerves and muscles and anatomical anomalies of the speech organs and the respiratory tract, the sufferers from stuttering are certainly quite up to the average both in the physiology and anatomy of these regions. They are of all ranks and conditions of life, of all sizes and build, and it is evident that the trouble is not physical, but mental. They [{571}] pay too much attention to their speech and to the co-ordination of the many muscles engaged in speech production and the consequence is that they impair their power to use these organs. Practically all the cures recommended contain some element which distracts the attention from the speech to something else and so permits the function of the speech organs to proceed undisturbed.
A number of conditions develop in nervous individuals that resemble stuttering. There are disturbances of swallowing, disturbances of walking (astasia abasia), neurotic disturbances of writing, and of other uses of the hands and of the legs.
State of Mind.—It is perfectly clear to anyone who has closely observed the ways of stutterers that the state of mind is extremely important in these cases and indeed probably constitutes the underlying factor in the speech disturbance. Stuttering and all speech defects are much worse when the patient is laboring under excitement. This is so amusingly true that the impotence of a stutterer to say a word when he wants very much to say it is a commonplace in the cheap drama and never fails to raise a laugh. In ordinary conversation with friends the stutterer may have little difficulty. As soon, however, as he begins to talk with those with whom he is unfamiliar his speech defect becomes noticeable. When the others present are entire strangers and, above all, strangers whom he wishes to impress favorably, then his stuttering becomes pronounced. The mental element is the most important factor. Just as soon as consciousness of the task supervenes his power of co-ordination fails and stuttering begins.
Stuttering in Complex Activities.—There are many actions that become habitual and people are thus saved from the necessity of constantly performing them under the control of the will and the consciousness. Walking is a typical illustration of this and is seldom disturbed by consciousness, but there may be a stuttering in the gait of sensitive persons if they become overconscious when passing people who are watching them. Talking is even a more striking example of elaborate co-ordination without conscious effort. We have to bring into play more than a score of muscles whose movements are nicely and accurately co-ordinated, or else the effort at articulate speech is a failure. We have to change the positions of most of these muscles many times every minute, yet we do it without a thought of how it is done and most of us accomplish it with ease and perfection.
Stuttering Walk.—Stuttering, after all, comes most naturally under the head of dreads in the classification of the psychoses. Stuttering is not a physical difficulty so much as a nervous apprehension, and there may be a stuttering in any co-ordination as in speech. I have a patient under observation who, if people are looking at her, finds so much difficulty in walking because of a trembling that comes over her that she fears she may not be able to keep from falling. Boys at school whistle a certain air that requires a little halt in the gait to keep time with it, as their schoolgirl friends go by, and it is impossible for these not to drop into the peculiar gait indicated by the time of the tune.
Stuttering Writing.—There are many men who become so nervous about writing their signatures that they cannot sign while anyone is present. There are others whose penmanship becomes very irregular, or at least exhibits many signs of nervousness, whenever they think someone is watching them. Most of [{572}] the difficulties seen in speech may, indeed, be exhibited in writing. The same difficulty in beginning, the same elision of letters under stress of excitement, may occur.
Writer's cramp is, after all, much more of the nature of a stuttering in writing than a real cramp. Over-action, added motions, and, finally, incomplete power to act as desired are seen in both cases. It might be expected that this would not affect so simple and familiar a set of motions as those required for a personal signature, but it does, as many cases illustrate. A typical example was the treasurer of a large trust company who had to sign a number of bonds, some thirty thousand. At the rate of 200 an hour, over three a minute, as he did the first day with others making it easy for him, it looked as though he could complete the task, huge as it was, in a month. At the end of a week, however, the rate had fallen to 120 an hour and, toward the end of the second week, one a minute on the average was all that could be accomplished. At the end of the month his signature, while retaining certain of its original characteristics, had become very different from what it was at the beginning and signing had become an extremely difficult matter. He had to take a rest from business for several weeks after accomplishing this apparently mechanical procedure.
Emotional Ataxia.—Dr. S. Weir Mitchell in his article on "Motor Ataxia from Emotion" in the May number (1910) of The Journal of Nervous and Mental Disease, discusses some cases in which inability to write even a signature came as a consequence of nervousness and emotional disturbance.
In one of Dr. Mitchell's patients, other manifestations of ataxia occurred as the result of the consciousness that people were watching the patient. At times he is compelled to leave a dinner table, since with strangers it is almost impossible for him to eat. If there are two or three at the table with him, however, and especially if he is worried about himself, he may become almost helpless, requiring both hands to get a cup of coffee or a glass of water to his mouth. A patient of mine with like symptoms has described to me equivalents of various kinds to his own difficulties in his sisters. One of them cannot play the piano before strangers, though an excellent musician. The other cannot crochet with any success if any but intimate friends are present. How much of this family trait is due to suggestion or psychic contagion would be hard to say. The state that comes over amateur actors and which makes them forget their lines, stammer in their speech, walk awkwardly, and trip easily, are really manifestations of this same incapacity to control even familiar sets of actions when there is great self-consciousness and over-attention.
Mental Influence.—The correction of these conditions comes through soothing the mind of the patient and getting him or her not to be so self-conscious as to disturb action by thought about it. It is easy to say this and extremely difficult to do it. In certain nervous organizations it is quite impossible to overcome the tendency to this ataxia or inco-ordination of voluntary movements. Much can be accomplished, however, by proper training and discipline in all cases, and, while the patient can never be completely cured, great improvement may be brought about by patient habituation under favorable circumstances. In Dr. Mitchell's cases the taking of a glass of whiskey or of wine sometimes stimulated the patient so that co-ordination became possible where it was impossible before. In nearly all cases of writer's cramp [{573}] and writing difficulties the power to write is restored for a time by such stimulation. Strong coffee will sometimes serve the purpose as well as alcohol. It is easy to understand, however, how dangerous is the resort to such stimulation.
Practice in Self-Control.—The excitement and nervousness incident to appearance before an audience which make thought and speech so difficult and action so awkward and so exaggerated gradually disappear as the individual becomes habituated to appearing in public. In most people there is never a complete loss of self-consciousness with entire freedom from nervousness, but the conditions are much improved so that there is no noticeable interference with ordinary actions and speech. Whenever there is some reason for additional excitement, however, as when a new play is being put on, or when some special audience is being entertained, there is a reappearance of many of the old symptoms due to a self-consciousness.
Stuttering in the Young.—The prognosis of stuttering when it develops at a certain period is much better than at others. The stuttering of the very young can usually be overcome by a little careful training, if it is taken early and treated patiently by a competent teacher. Not infrequently a certain amount of stuttering develops at puberty when the voice changes, partly due to the inability of muscles and nerves to co-ordinate so easily as before upon the rapidly-enlarging vocal chords and larynx, and partly to that greatly increased self-consciousness amounting almost to painful bashfulness which develops in boys about this time. Breathing exercises and especially slow expiration is an excellent thing in these cases and distracts their attention from themselves and their speech.
The chest has usually developed rather rapidly at this time and the muscles have to some extent lost control over it, and it will be found on careful observation that the breathing is particularly superficial, that the descent of the diaphragm is quite limited and that the use of this important muscle of respiration requires practice in order that it may be controlled properly.
In Women.—Perhaps the most interesting thing about stuttering is that it is ever so much rarer in women than it is in men. Something less than one-fourth as many women suffer from it as men and this is true for all periods of life. Women are usually more bashful and self-conscious than men, but this rarely goes to the extent of disturbing their speech faculties. Ungallant observers have suggested that the sex quality of ready speech is too profoundly seated in nature to be disturbed by mere bashfulness, but there seems to be no doubt that the breathing of women has much to do with the difference between them and men in the matter of speech defects.
When stuttering occurs in women the defect is much less tractable and is usually dependent on a more serious disturbance of the psyche or of the central nervous system. The prognosis of cases of stuttering in women is not so good as in men, but remarkable cures are sometimes effected by mental treatment of the self-consciousness which causes the speech defect.
Correction of Respiratory Defects.—This last point, the correction of all pathological conditions in the respiratory tract, is especially important. Many stutterers are for one reason or another mouth breathers. If they are mouth breathers because they have adenoids, these must be removed. This must [{574}] be done early in life, certainly not later than the third or fourth year, or else there will come a serious deformation of the chest and that chicken-breastedness, which is not undesirable in itself, but which hampers to some extent the action of the diaphragm because that muscle cannot act as well in the deformed as in the natural chest. Not all who are chicken-breasted have any defect of speech, nor any tendency to stutter, but when there is a natural tendency to a lack of inco-ordination because of sub-normal nervous ability the presence of such a deformity makes the prospect of cure much less favorable than would otherwise be the case. If the mouth-breathing is due to stoppage of the nostrils, this must be relieved.
Realization of Allied Conditions.—A helpful suggestion for stutterers is found in the recognition of the fact that there are so many conditions allied to stuttering and so many people afflicted with them. Under the heading Neurotic Esophageal Stricture stuttering in swallowing is treated of. In the chapters on urinary symptoms stuttering in urination is discussed. Any set of muscles requiring careful co-ordination may thus be disturbed. The stutterer is apt to look upon his affliction as a very special individual annoyance. When he learns that in practically every set of muscles requiring nice adjustment for function like difficulties may occur, that in every action requiring careful co-ordination of muscles there may be a similar disturbance, and yet that in most of them careful mental discipline, especially training in self-control, proves a source of relief, he takes new courage to face the struggle necessary to overcome the self-consciousness which is the root of most of these troubles.
A striking form of inability to co-ordinate muscles so as to enable them to perform their ordinary function is aphonia, or mutism, sometimes spoken of as hysterical mutism. After some sudden emotion or fright or accident a neurotic person proves to be quite unable to talk. He cannot utter a sound. In Prof. Raymond's clinic at the Salpêtrière I once saw the classical case described by Charcot and presented at his clinics several times. It was a man whose wife had run away from him and been taken back three times. Each time on her disappearance he had an attack of aphonia, inability to utter a sound of any kind. It lasted for from several weeks to a few days. The cases are much commoner in women. After a disappointment in love or a scare the patients become unable to speak. Sometimes they can whisper but cannot phonate. The affection is entirely functional or neurotic, and if the patient's mind is properly predisposed speech returns without difficulty or delay. A little massage of the muscles of the throat or of the tongue by means of a tongue depressor or the use of Politzer's bag in the nose with the assurance that after proper swallowing movements the ability to speak will return, have proved successful. Occasionally hypnotism is recommended for these cases, but many of them are too highly neurotic to be readily susceptible to hypnotism and, besides, suggestion in the waking state proves just as effective.
After several days of speechlessness it seems little short of marvelous to make a patient talk readily after a little massage of the throat. It is all dependent, however, upon confident assurance and the suggestion to talk. The physician himself must possess absolute confidence in his power to bring this about, for the slightest sign of doubt or hesitation will make it impossible [{575}] to influence the patient and will completely destroy his psychotherapeutic efficiency.
Neurotic Esophageal Stricture.—A rare but interesting form of neurosis, which should be studied in connection with stuttering because of the light shed on both by their relations to each other, is that seen in the sufferers from so-called neurotic esophageal stricture. These patients are unable to swallow solids except after determined deliberate effort and occasionally the discomfort caused by this effort leads them to eat much less than is sufficient for their nutrition. The physician is sometimes tempted to overcome the spasmodic closure or partial closure of the esophagus by bougies and dilators, and these the patients learn to pass by themselves. I have never known any of these cases to be benefited more than temporarily by this treatment and I have seen two that were made distinctly worse. Forcible dilatation by concentrating attention on the affected parts hampers the proper flow of nervous impulses and the ordinary reaction to these which should occur.
To appreciate how closely related to stuttering this spasmodic closure of the esophagus is, it is necessary to see these patients swallow when they do not know that they are under observation. For when they are on exhibition for the physician, when their condition is intensified by the excitement of the occasion and by the definite purpose to make the doctor appreciate how serious is their case, they swallow with more difficulty. Nearly always they have more difficulty in eating in public than with friends, and it is only with those with whom the patient is on a footing of perfect familiarity that the best swallowing power is obtained.
In sufferers from esophageal stricture of the neurotic type the muscles by an unfortunate perversion of nerve force contract in front of the bolus instead of behind it. This contraction may be so complete as to prevent even the swallowing of liquids. Usually, however, liquids can be swallowed without much difficulty. Such patients, then, if they become much run down in weight, must be fed on milk and eggs and ice cream and the gruels and soups until they gain in weight. While they are much under weight their condition is distinctly worse and their power of co-ordination much less. It is, however, not hard to make them gain in weight. This gain in weight acts as a strong suggestion which persuades them that they are getting better and this of itself soon helps them to control their muscles. Local treatment does harm rather than good. Ice in small pieces swallowed shortly before a meal seems in some patients to have the effect of making the muscles less prone to follow the inco-ordinate nervous action and thus renders swallowing much easier. In some, and especially in nervous people, warm liquids have the same effect, while ice produces further irritation. Acids nearly always increase the spasmodic condition. Sucking a piece of hard candy for some time before a meal, especially if it is not too sweet nor flavored with acid, helps some people.
Nearly all of them when carefully questioned prove to have special foods that are more difficult of deglutition than others. Not infrequently these idiosyncrasies for food are found to follow ideas with regard to their digestibility. If the patient is hurrying for any reason and suddenly becomes conscious that he is not masticating sufficiently, swallowing at once becomes much more difficult.
The main element in the treatment, however, must be as far as possible to get the patient's mind off his condition. The more attention he gives to it the worse it will be. No treatment that we have will cure it any more than stuttering can be cured, though a deliberate effort to form a habit for the control of the swallowing muscles will often do much to lessen the discomfort and the inability to swallow.
It is important in all these cases to be sure that there has been no incident in childhood which might have caused the production of scar tissue in the esophagus with a consequent stricture. Sometimes it is many years before this manifests itself and, as in the case of the urethra, even ten to twenty years may pass before serious trouble comes. When the first symptoms are noticed, the actual stricture may be so slight as scarcely to be possible of diagnosis by the bougie. Occasionally the first symptom of a cancer of the esophagus is an inability to swallow, and cancers of the esophagus have been known to occur in quite young people, especially young men. I remember seeing a case at autopsy in Vienna where the first symptom had been the difficulty of swallowing and the man, at the recommendation of friends, swallowed a glass of beer with some black peppers in it and these stuck in his esophagus and produced death. Such cases are exceptional but must not be forgotten. Neurotic esophageal stricture is entirely benignant and its prognosis altogether favorable.
Treatment.—The treatment of stuttering presents the best example that we have of the influence of the mind over neurotic difficulties of any and every kind. Many forms of treatment have been announced as successful, most frequently in the hands of men who have themselves been stutterers and who have helped themselves by them. This would seem to make it clear beyond all doubt that discoveries in direct therapeutics had been found. As a matter of fact, however, when a review of all the methods is made, they are seen to be so different from one another and founded on such essentially diverse principles that the only common connecting link to be found is in the occupation of mind with something else besides speech which all these methods recommend. We have had successful cures announced by surgery, by discipline, by making speech more difficult by obstacles of various kinds, by special positions of the tongue—up against the palate or down against the floor of the mouth—by associated movements, by rhythmic speech, by special control of the muscles of respiration, and of many other structures much less related to speech. The interesting phase of all this is the uniform success claimed by different specialists using many different methods.
From the beginning of history cures have been suggested. That idea, still held among the non-medical, that the sufferer from a difficulty of speech is tongue-tied and needs to have the frenum cut, is as old as the history of medicine. Galen suggested cauterization of the tongue. Aetius, the first prominent Christian physician of whom we have any record, divided the frenum of the tongue. So did Paul of AEgina. Of course, in the Renaissance, when the old medical classics were revived, this became a favorite method of treatment. Hildanus is sure that it accomplishes great things. This idea has never been entirely given up, and recurs from time to time in the practice of those who do not reason much, but who look for some ready explanation and, above all, some direct method of treatment. Much more [{577}] serious surgical intervention has been suggested from time to time, however. Velpeau advised division of the extensor muscles of the tongue. Of course a number of surgeons have quite properly insisted on the removal of the tonsils, uvula, polyps in the nose and other obstructions of respiration.
Singing in Treatment.—A number of the stuttering cures employ singing as a method of training in forthright utterance. Few people stutter when they sing. Most people can be given confidence in themselves and their power to talk right on by being shown that as soon as they try to follow a set of notes there is little or no difficulty in utterance. The teaching of singing, then, is of distinct value in many cases. Taking advantage of this a number of those who correct stuttering endeavor to introduce a certain rhythm into speech. So long as the rhythm can be maintained stuttering does not occur. As Kussmaul has pointed out the rhythmus acts as an efficient will-regulator, so that nerve impulses go down regularly and are not interrupted by consciousness and by the sudden starts and stoppages due to fear and tremor and mental uneasiness. Undoubtedly the lesson of this method of teaching is extremely important as an index of how stuttering may be relieved.
Regulation of Respiration.—A number of systems to correct stuttering depend on the regulation of breathing. It has been shown over and over again, and notably by Prof. Gutzman of Berlin, [Footnote 42] that one of the most important differences between stutterers and those who talk naturally is that the normal individual talks during expiration as may be seen in Fig. 23, while the stutterer begins at the end of inspiration or at least where normally on the respiratory curve expiration is just about to begin, but instead of permitting his diaphragm to go up as in ordinary expiration, the stutterer makes it sink lower and lower in a forced inspiration.
[Footnote 42: See my translation of one of his clinical lectures In The International Clinic for July, 1899.]
Fig. 23.—Normal Diaphragm Curve in Normal Breathing. Expiration as we Talk Normally.
Fig. 24.—Curve in Diaphragm Before and During Talking by a Stutterer.
Attention to Something Besides Speech.—The attention must be centered on something besides speech itself. This is the important element in any method of treating stuttering. If it is allowed to occupy itself with that [{578}] nothing will save the individual from getting tangled in the efforts that he makes to co-ordinate the complex movements necessary, though if he would only allow them to proceed automatically, as do the rest of mankind, there would be no difficulty at all. Washington Irving, so ready with the pen, could not utter two successive sentences at a banquet without having to sit down, with expression absolutely inhibited from excitement. Expression, thought, utterance—all may be inhibited by overconscious attention, which may also disturb all other complex activities.
The most interesting methods of treatment for stuttering are those which involve the use of various hindrances to speech and which would seem to be least likely to make it possible for a person already laboring under speech difficulties to talk with more ease. The secret is, of course, that the added impediments so distract the attention of the patient that he is unconscious of the co-ordination necessary for speech and so accomplishes it without difficulty. It is because of over-attention to himself that the disturbance occurs. These methods developed very early in history. We all know the tradition of Demosthenes overcoming his impediment by placing pebbles in his mouth. One of the most earnest advocates of a similar method, who had himself suffered very seriously from stuttering was the Rev. Charles Kingsley, one of the most distinguished of English literary men. He cured himself, or at least greatly relieved his symptoms, by keeping a cork fast between his back teeth.
There have been many other curious suggestions for the cure of stuttering. What was known as the American method had great vogue in the early part of the nineteenth century. It was probably invented by Yeats of New York, though it came to be known as the Leigh method. Yeats, himself a physician, seemed to fear that he might fall into professional disrepute if he advertised the method in any way, so he had his daughter's governess, a Mrs. Leigh, open an institute for the cure of stuttering in which this method was practiced and it proved to be very successful. The entire secret of it was to have the patient raise the tip of the tongue to the palate and hold it there while speaking.
Another mode of treatment that attracted considerable attention consisted mainly of just exactly the opposite maneuver, that is, keeping the tongue as far as possible firmly placed on the floor of the mouth during speech. It is evident that neither of these suggestions does anything more than occupy the patient's attention with an additional activity, so that his speech function may be allowed to proceed automatically of itself, as it will if not disturbed by attention to it and by conscious attempts to regulate the various activities of it. Instruments were invented to help the patients to secure various positions of the tongue. Itard, for instance, during the second decade of the nineteenth century invented a golden or ivory fork to be placed beneath the tongue, so as to support it.
After the various methods of managing the tongue, the most popular curative maneuver has been that of regulating the breathing. During the nineteenth century there were at least a dozen different methods, all of which had a number of reported successes, of treating stuttering by means of breathing exercises.
Very simple methods of diverting the attention from speech are quite [{579}] sufficient in many cases to bring improvement. For instance, the insertion of extra letters that are themselves easy to say between words or preceding consonants that are hard to utter has been a favorite method among the specialists in stuttering. Johann Müller, as I said, suggested an e. Others have suggested an n. Occasionally stutterers themselves form the habit of using an m or a to and find that it aids their facility in uttering difficult sounds over which they would otherwise halt and stutter. A combination of these methods, as, for instance, an e between all words and the placing of an easy n before the most difficult sounds, has been repeatedly revived as an infallible method of treatment.
All this serves to show that in patients whose functions are being interfered with by over-attention diversion of mind must be the main remedy. If this can be secured, the function they are disturbing will be allowed to proceed unhampered. What will prove effective for one patient will fail with another, however. After the patient gets used to a particular form of diversion another must be tried. Simple methods are sometimes sufficient to secure good results. The one thing is not to be discouraged and to proceed from one effort to another, satisfied even if relief is obtained for a while, for after relapse another method of treatment may always be tried.
Suggestion for Stuttering.—There are many systems to train people out of the spasmodic inco-ordination that constitutes stuttering. All of these systems have their successes, but, as is well known, all of them have their failures. When the patient has confidence in the teacher and his method there is practically always quite a remarkable improvement, at the beginning. This improvement is more noticeable during the first month than at any other time. Not infrequently after this there is a tendency for patients to drop back into old habits, apparently discouraged, as a consequence of loss of confidence. It is the mental element that means more than anything else. It is the old, old story that we have to repeat with regard to every chronic ailment.
Distraction of Mind.—Each inventor is sure that his method is the best and his "cured cases" support his claim. Others who try his method, however, never succeed as well as he does and those who are interested invent methods of their own. I have on my desk, as I write, six different, infallible—to their authors—methods of treating stuttering. I am sure that none of them succeed absolutely, that is, none of them will cure every case and most of them will not succeed beyond a moderate degree, except where the enthusiasm and the confidence of the inventor or an immediate disciple of his is behind them to make them efficient. There are all sorts of elements in these cures, but most of them depend on their power to distract the patient from his over-attention to himself and what he is doing when he talks, so as to permit without hindrance the automatic movements which are so necessary for the complex function we call speech. Those who have spent most time in treating stutterers confess that the effect produced upon the patient's mind is an extremely important part of the treatment and that, if this cannot be secured, failure is almost certain. If the patient has no confidence that he can be cured and by this particular method, failure is inevitable from the very beginning and just as soon as a patient loses confidence improvement ceases.
CHAPTER V
TREMORS
Two types of tremors come to us for treatment: those that are quite involuntary and occur when muscles are at rest, and those that are associated with voluntary movements. The most common type of involuntary tremor is that seen in paralysis agitans to which a [special chapter] is devoted. After this, though coming for treatment much less frequently, is senile tremor which may, however, also be increased by voluntary movement. The tremors associated with voluntary movements are spoken of as intentional tremors. They may occur as the result of organic disease of the nervous system and the most characteristic type is that seen in multiple sclerosis. They are more frequent, however, with functional diseases of the nervous system and with emotional disturbances of various kinds. They are especially frequent as the result of dreads. Usually the idea of tremor is associated only with the head and the hands. Tremors may occur in other parts of the body, however, and tremors of the legs are particularly important. A familiar type is the tremor and unsteadiness of the legs which occur as a consequence of the dread of heights when a person unused to such situation attempts to walk across a narrow path a great distance above the ground.
Senile Tremor.—The most common of the involuntary tremors is that associated with old age. It develops in practically all very old people, but it comes to some who are comparatively young. Its occurrence at the age of fifty-five usually gives the sufferer a severe shock which is emphasized by the attitude of mind of friends toward the affection. They seem to be always sure that it is the index of rapidly advancing age and that it is practically a signal of approaching dissolution. As a matter of fact, when unassociated with gross pathological lesions, the senile tremor has no such significance. When associated with definite lesions it is the prognosis of the special condition and not any supposed significance of this particular symptom of tremor that expresses the genuine outlook in the case. Many people who live to a very old age develop tremor before they are threescore. Most of those who live to be eighty or more have some tremor that develops about or just after the age of seventy.
Significance.—Senile tremor is supposed to be due to, and in most cases probably is the result of, an overgrowth of connective tissue in the central nervous system which disturbs the ordinary conduction of nerve impulses, rendering them wavering and uncertain. This seems to indicate that it will not be long before the advancement of this sclerotic process will make serious inroads on the vigor of the individual. As a matter of repeated observation, however, the ordinary involuntary tremor of old people may last twenty years.
Reassurance.—The main principle in the treatment of tremors of the old is to make the patients realize that the symptom has no such bad prognosis as is usually attributed to it. Of course, they will find this out for themselves after a few years, but what they need is assurance at the beginning lest during the period of depression consequent upon the conclusion that the end is not far [{581}] off, which seems to be forced on them by their fears and the foolish sympathy of friends, their resistive vitality should be so lowered as to permit the invasion of some serious disease. In spite of apprehensions on the part of themselves and friends, tremor is rather a good sign than a bad one. It indicates the formation of connective tissue in the central nervous system, but this is always a slow process and is usually quite benign. As a matter of fact, most sclerotic processes are so chronic as to be compensatory in their action for many other degenerations. Those in whom tremor develops early often seem to be better protected against rupture of cerebral arteries, as if the growth of connective tissue was a conservative process here also. Information of this kind helps patients not to borrow trouble because of their condition.
Intention Tremors.—The tremors that occur in association with voluntary movements are often very troublesome and may be difficult to manage. The worst cases are entirely functional. They are typical neuroses and often develop as a consequence of some serious crisis through which the nervous system has passed. In older people they sometimes pass over into paralysis agitans or a close simulant of that affection. The incident of the Texas sheriff and the Indian related in the chapter on [Paralysis Agitans] illustrates how these tremors may be induced.
Tremors from Fright.—Frequently the tremors have no direct connection with any action, though they may be the result of fright. A little girl bitten by a dog and much shocked may, for some time afterwards, be quite unable to stand when she sees a dog on the street, so disturbing is the tremor that comes over her. Tremors of the same kind have been connected with horses after the patient had been run down in the street, and, in one case that I saw even when the patient was only thrown out of a carriage during a runaway. Occasionally fright by a burglar may cause a distinct tremulousness that supervenes whenever the patient thereafter is wakened suddenly at night.
Influence of Dread.—Tremors of all kinds can be made worse by the dread of them. In the chapter on [Dreads] we discuss the disturbance of function by dreads and especially the tendency to exaggeration of pathological conditions of any kind when the patient's mind becomes concentrated on it. Steadiness in any position is due to a nice balancing of extensor and flexor muscles requiring the sending down of a continuous stream of impulses. The equilibrium is attained and maintained in spite of the fact that, as a rule, the flexor muscles are stronger than the extensors and better situated to exert their mechanical force. If anything happens to disturb this balance even to a slight degree, the mind becomes attracted to it and there is a corresponding result as in stuttering, or other complex function when surveillance is too great. It is important to remember this at the beginning of all cases of tremor, for the patient nearly always exaggerates his tremor by attention to it and can be made so much better by reassurance and diversion of mind that he is much encouraged and his general health usually improves, making him feel, even though his affection is organic, that he is being cured.
Tremors may occur in connection with almost any set of actions requiring special co-ordination of muscles, but they are especially likely to occur when a feeling of dread disturbs the control over muscles. A typical example of this is noted in shaving. There are many men who cannot shave without trembling so as to cut themselves. The feeling that they have a sharp instrument in their [{582}] hand with which they may cut themselves sets up the tremor. There are others who cannot shave because they dread that while using the instrument over the important organs of the neck, and especially the blood vessels, they may be tempted to cut their throats. This is, of course, purely a dread and not a tremor. Some men find both the dread and the tremor much worse at times when they are tired and worried, and can shave very well at other times. Some men can shave very well when they are not under observation, but if anyone is looking at them they tremble and cut themselves. The safety razor usually does away with these troubles, large or small, but if it should happen that by particularly inexpert use they cut themselves even with a safety razor, especially in the throat region, the old dread and tremor reassert themselves and shaving becomes almost as difficult as before.
Self-consciousness.—Almost any position or action in which a man feels himself under observation may cause one of these tremors. As a consequence this particular set of actions may become the source of so much discomfort as to produce an intense sense of fatigue. It may, indeed, become quite impossible of accomplishment. Some teachers cannot do demonstrating work on a blackboard before a large unfamiliar class, at least not without serious efforts to control themselves, though they may be facile demonstrators before a small class. I have known men, however, who practically could not do blackboard work at all because of nervousness. Their writing went all askew and very often their thoughts would not follow one another in such order as to make demonstrations possible. Sometimes they were good talkers, so long as they did not turn their backs to the class and feel the eyes of all on them. The same thing is true of such religious services as Mass in the Catholic Church, where some of the clergymen have this feeling. I know of priests who have not said Mass publicly for years and others who can only say it in a small chapel before a few people because of the intense discomfort of the fatigue caused by this state of mind.
Stage Fright.—It is not alone the hands and the arms that tremors are likely to affect, for they may also occur in the legs. A typical and familiar case is the tremor that occurs upon the first appearance before large audiences of orators or actors or clergymen. Owing to excitement, they are unable to make flexor and extensor muscles exactly balance each other and the consequence is a tremulous movement that may be complicated by some swaying. Some people never lose this in spite of long experience in public appearance. Young people may have it upon being introduced to persons of whom they think a great deal. This passes off with years, as a rule, but in some it persists, and any excitement causes tremor of the legs and swaying movements. The effort to control this is often severe and causes intense fatigue.
Any set of movements requiring even slight co-ordination of muscles may be the subject of disturbance by a tremor. Since the writing of the book on Pastoral Medicine, a text-book of medical information meant to be of assistance to clergymen, [Footnote 43] I have had some rather interesting tremors associated with the performance of clerical duties brought to my attention. One of these is a trembling of the legs which makes standing at a high altar almost impossible. Another troublesome tremor is that associated with the giving of communion. [{583}] Most priests find no difficulty in the performance of the rite. Some of them are much worried and anxious about it, however, and develop a slight tremor. Others become so nervous in performing the ceremony that they cannot succeed in placing the Host on the tongue of the communicant without certain false movements. These may cause them to touch the lips or the cheeks of the recipient and after this has happened a few times the giving of communion becomes practically impossible for them. Occasionally the men thus affected have no other nervous symptoms and often they are very intelligent, strong-minded men.
[Footnote 43: O'Malley and Walsh, "Pastoral Medicine." Longmans, 1906.]
The General Health.—Tremor patients always complain more of this symptom when they are in a run-down condition. One of them is a wealthy merchant who, when he can be persuaded to take a vacation, comes back with nearly all the manifestations of his tremor latent or, at least, well under control. Another is a broker who at the end of a long winter of excitement and worry is at his worst, but who after a vacation in the North Woods is quite well again. Slight symptoms of this kind are not unusual in teachers, especially women, though I have seen them also in men, and are much more complained of at the end of the year when the individuals are in poorer general condition than at any other time. The symptom itself is annoying because of the notice that it attracts, but their dread that it may have some serious significance, indicating the development of a progressive lesion of the central nervous system, constitutes the worst part of their ailment. When the intentional tremor is intermittent and occurs only at times of excitement, or when the patients are under observation, they can be reassured that it is merely neurotic and that no ulterior development is to be anticipated.
Treatment.—The treatment of these conditions consists first in bringing the patient's health up to its normal condition as far as that is possible. Many of the sufferers from tremors are under weight. Whenever they are, a definite, determined effort must be made to bring them up to it. This must be done even though they insist that they have never been heavier and that to be rather underweight is a family trait. In many cases it will be found that this family trait, instead of being due to some inevitable hereditary tendency, is only the result of family habits in the matter of eating. Many of these people do not eat substantial breakfasts. Their tremor, too, is likely to be worse in the early morning than at any other time during the day, unless, of course, they have become overtired during the day, when the tremor will reassert itself with vigor. Most of them are much less disturbed in the afternoon than before. The drug treatment of the affection consists mainly in the use of nux vomica, but, not in the small doses of five or ten drops so often employed, but, according to the size of the individual, beginning with fifteen or twenty minims, thirty or forty drops, and gradually increased to physiological tolerance, when the dose should be set somewhat below that.
Mental Control.—The main treatment must consist, however, in enabling the patient to secure psychic control over himself and his muscles. This is not an easy matter. Most of them are quite discouraged, but their attitude of mind must be changed and the real significance of their affection made clear to them. As a rule, they have either heard or read or been told by a physician that their intentional tremor is significant of a serious pathological lesion of the central nervous system. Some of them have heard of multiple sclerosis [{584}] and are much disturbed. They must be reassured and it must be made clear to them that their disease is really due to over-consciousness and consequent lack of control. A good deal of reassurance can be given by telling them of patients who suffer from ailments not unlike theirs, showing how multiform the affection is. A man who has trouble with his signature may be told about the man who finds it difficult to drink when under observation, then, as a rule, he will better realize the neurotic character of his affection. With hysterical women this method must be used with care or the story of another patient will act as a suggestion and the physician will subsequently be treated to an exhibition of the symptoms which he has described.
Self-Discipline.—Persistent quiet discipline is the one thing that eventually does any good. When patients are first told of this and are persuaded to attempt it, they make such a determined effort to overcome the affection that they make themselves more conscious of it than before with the result that their tremor and spasmodic movements are emphasized. It is the old story of the man trying to stand so straight that he falls backwards. It must be made clear to them that discipline, to be of any value, must be carried out as much as possible without consciousness of it and with all available artificial aids. The man who has trouble with his signature may be shown that he can overcome much of the tendency to tremor and spasm of the forearm muscles that are at the root of his difficulty by sitting at a higher chair, so that his arm swings free of the table and so that, in Gowers' phrase, if a pen were attached to his elbow it would write the same thing as the pen in his hand. The man who trembles as he drinks may be taught for a time to raise a cup to his lips while resting his elbow on the table and bringing his head well down. Nearly always methods of performing particular actions that require less effort can be found, until the habit of over-consciousness and loss of control is overcome.
Hypnotism and Waking Suggestion.—Occasionally hypnotism is effective in these cases, but there is likely to be a relapse unless there is some discipline before and after its use. Suggestion in the waking state is often very effective. Patients need to be talked to and even though intelligent they need to be reminded at regular intervals for some time that their ailment is merely functional and not organic. Nearly always it will be found that they trace its beginning to some pathological event: occasionally there has been a severe accident, but sometimes only a slight accident seems to them a sufficient explanation. Sometimes it follows an attack of pneumonia, oftener still typhoid fever. In these cases the patients become convinced that this is one of the marks left after the accident or disease and so it is rather hard to persuade them that they can be cured. All such impressions, which act as auto-suggestions for the continuance of their tremor and lack of control, must be combated, otherwise there is very little hope of improvement. The preceding disease is not the direct cause, though the weakness consequent upon it may predispose to the tremor. Overhaste in attempting to resume their occupations before their strength has returned is often the real cause. It is the patient's mind more than his body that needs to be set in order, but this will not be possible unless the physical condition is normal and thorough reassurance can be given.