Psychotherapy Part 66

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 wis.h.i.+ng 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 authors.h.i.+p 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 a.s.sumed 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 circ.u.mstances, 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 rea.s.sured, 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 antic.i.p.ated 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 alb.u.min. 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 alb.u.minuria was functional, as the examination was made in the full tide of digestion, and that it would pa.s.s off. Subsequent examinations, however, showed not only alb.u.min 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 alb.u.min 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 alb.u.min 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 ent.i.ties. For instance, in three cases I have seen what had been p.r.o.nounced 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 a.s.sumed.

_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 pa.s.sing 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 alb.u.minuria 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 const.i.tutes 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 s.h.i.+n. If we dwell on the subject we have curious p.r.i.c.kly 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 subst.i.tution of one neurotic symptom for another whenever by psychotherapy and mental discipline one condition is overcome. Often the subst.i.tution 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 subst.i.tutions 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

Ch.o.r.eA

This twitching affection, so familiar that it need not be described particularly, is sometimes cla.s.sed 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 p.u.b.erty. 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 ch.o.r.ea. 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 a.s.sociation 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 ch.o.r.ea.

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 ch.o.r.ea 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. Ch.o.r.ea often occurs in bright, intelligent children and always seems worse in them.

Treatment.--The story of the therapeutics of ch.o.r.ea 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 inst.i.tutions 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 ch.o.r.ea, 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 ch.o.r.ea 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 ch.o.r.ea 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 Ch.o.r.ea.--In certain nervous children after the ch.o.r.ea itself has subsided there remains a habit of twitching that often is almost more intractable than the ch.o.r.ea 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 appet.i.tes 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 a.r.s.enic is used over long periods, or any of the salicylates because of the supposed connection of ch.o.r.ea 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 appet.i.tes 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 ch.o.r.eas 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 a.s.sociated 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 p.r.o.ne to manifest itself in the utterance of forbidden words, usually vulgar, sometimes indecent.