Psychotherapy Part 63

CHAPTER IV

PARESIS

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

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

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

_Sources of Worry_.--One of the symptoms which neurotic patients are sure must be a preliminary sign of paresis is a disturbance of memory.

Patients have heard that paresis causes memory disturbances and fearing the development of the disease, they disturb themselves very much by finding real or supposed defects of memory. Most of them have had only a very vague idea of the sort of memory they possess and cannot tell whether it is worse than before, but finding a certain difficulty in recalling things they conclude that it is deteriorating.

Occasionally their supposed defect of memory is founded on nothing more serious than the fact that they are paying so much attention to themselves, that they cannot concentrate their attention enough on what they wish to remember so as really to impress it on their memories. It is curious how persistent some patients are in making themselves believe they have serious lacunae in their memory when there are only certain conventional disturbances of it. The paretic has defects of memory, but he is, as a rule, quite unconscious of them. He has to have them pointed out to him. Patients who are supremely conscious of their supposed defects, by that very fact show their possession of good intellectual faculties.

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

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

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

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

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

Prognosis.--_Seeing the Worst_.--There is a tendency in most physicians to see the worst side of the story rather than the better.

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

_Consoling Hesitancy of Final Judgment_.--Patients suspected of suffering from paresis can then without any violation of truth be rea.s.sured that their cases may not be incurable until the epileptiform incidents of the disease bring on that happy obscuration of mentality, that either takes away all the terror of the disease or lessens so much its awful significance that the patient is spared the worst.

There are cases of reported cures in the literature even after what seemed to be characteristic epileptiform attacks had occurred.

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

Role of Psychotherapy.--While it is important that someone closely connected with the patient should know the doctor's suspicions, he should be bound to absolute secrecy as regards the patient himself and especially as regards women friends and relatives. The att.i.tude of mind a.s.sumed by women relatives, and especially those nearest and dearest, is sure to be communicated to the patient, if not directly at least indirectly and inadvertently, and makes for anything but relief from the depression that is sure to be his if he has any gleam of understanding of his condition. Indeed, so much of pain and suffering is needlessly inflicted on relatives of paretic patients in the early stages of the disease by a premature announcement of the diagnosis that it is especially important to insist on care in this matter. The family will usually clamor to know just what is the matter, but it is the physician's duty to care for his patient and save the sufferings of the patient's family, regardless of their unwitting insistence.

Once the disease has developed and the patient's mind becomes affected it may be thought that psychotherapy is no longer of value. As a matter of fact, these patients as a rule become more childlike and are much more affected by suggestion than in their normal states. All this is worthy of careful attention on the part of the physician who feels that it is his duty to treat patients and not merely their disease.

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

CHAPTER V

EPILEPSY AND PSEUDO-EPILEPSY

EPILEPSY

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

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

First attacks of epilepsy are not infrequently the result of an immediately preceding fright or sudden emotion of some kind or other.

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

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

Even in cases where adhesions were found between the dura and calvarium and these were broken up, the relief afforded was usually but temporary. The succession of events, the relief afforded and subsequent relapse, probably represented the same influence of suggestion as in the preceding cases with perhaps a slight physical betterment in addition.

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

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

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

Treatment.--Rea.s.surance is especially important when patients develop epilepsy in adult life. There is an unfortunate social stigma attached to the disease which adds to the unfavorable suggestions that are likely to run with it. This probably cannot be overcome, for it is a heritage, not alone of many {537} generations, but of many centuries.

Our better knowledge of epilepsy, however, should gradually take the disease out of the sphere of suspected mystery in which it has been popularly placed and set it among the diseases to which human nature is liable, but which is surely as physical in its character as any other. If a favorable att.i.tude of mind on the patient's part can be secured there is less necessity for many of the disturbing drugs that are used and there seems to be no doubt that even in producing the effect of these, such as it is, suggestion of a favorable character plays a large role. Over and over again in the history of the affection we have had remedies introduced which have seemed to be quite efficient in producing longer intervals between attacks, making the patient less nervous and putting him in better physical health.

After a time, however, these have proved to be quite useless, or at most of but very slight value. It was suggestion that gave them their apparent value, and this suggestion must be used without the drugs whenever possible.

The bromides have done good in the treatment of epilepsy, but they are the only drugs that maintain the reputation they first had. All the others accomplished whatever benefit they conferred on the patient, and some of them for a time seemed to excellent authorities of large experience to give marvelous results, through their influence over the patient's mind. Nothing can produce more confidence in the physician who is using suggestion for epilepsy than this fact. Even the bromides, unless used carefully, easily do more harm than good and they have often worked mischief. Favorable suggestion cannot do harm.

At the present time those of largest experience in the treatment of epileptics, the directors of farm colonies, as Dr. Shanahan of Craig Colony, insist that diet, hygiene, especially hydrotherapy, are of much more importance than drugs, but that the patient's att.i.tude of mind towards himself and his malady and the future of it is even more important. He must have occupation of mind so as not to worry about himself. He must have recreation so as to relieve the gloom so likely to come in the disease. He must have outdoor air and proper exercise, which these patients are so p.r.o.ne to neglect.

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

{538}

PSEUDO-EPILEPSY

There is a large and important field of psychotherapeutics in a cla.s.s 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 Salpetriere, 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 a.s.sociated 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.