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.
DISORDERS OF THE PSYCHE
SECTION XVII
PSYCHO-NEUROSES
CHAPTER I
PSYCHO-NEUROSES (HYSTERIA)
As the derivation of the name indicates, psycho-neuroses are functional nervous affections dependent on states of mind. They are not necessarily originated by the mind, though they may be. Their spontaneous occurrence as pure psychic phenomena, however, is rather rare. There is practically always some slight physical cause. This may be severe, for all diseases have neurotic accompaniments that disturb the nerves involved and exaggerate the original symptoms. In most cases the patient has no serious interest to divert his or her mind from this occupation with self, and as a consequence the particular feeling fills up the whole of consciousness, and as it is painful to begin with, the pain, following Cajal's law of avalanche, may become almost intolerable.
It is of primary importance to remember, however, that there is practically always a physical basis for these curiously interesting affections which are so difficult to treat and which have so often proved the despair of physicians. While the attitude of mind must be changed, the physical state itself must be corrected. These two things must be secured at the same time, however, for attention to the physical state without correction of mental attitude will usually only emphasize the condition by calling further attention to the symptoms. This is especially true of local treatment. The mind must, above all, be treated and diversion of attention secured. Psycho-neuroses may occur in connection with sensory or motor nerves. The patient may either complain of intense pain in some part of the body for which there is but a very slight basis, or may be unable to move certain muscles, or there may be a combination of sensory and motor symptoms with complaint of pain on movement. The painful conditions are most important because they prove a source of worry and anxiety to the patient's friends, as well as often of such annoyance at unsuitable hours as deprives those near them of rest to a degree that may undermine health.
FORMS OF NEUROTIC SIMULATION
Every possible painful condition is simulated by these psycho-neurotic conditions. They occur probably with more frequency in the abdomen than elsewhere; they may be thought to be colicky in nature and, as a rule, some accumulation of gas will be found. This gas is sometimes swallowed air and sometimes gaseous products that have been diffused apparently from the blood in the intestinal walls. This always produces discomfort but nothing like the discomfort that the patient complains of. The condition if treated by carminatives will nearly always be emphasized rather than relieved. Local treatment by heat will help oftener, but may exacerbate it. When chronic constipation is present, calomel in divided doses is suggestive as well as medicinal.