of the sexual faculty. In many individuals the first sign of their
mental disequilibration noticed by friends is a tendency to sexual
excess. This is true of women as well as of men, and the extent to
which this may manifest itself is almost unlimited. At the beginning
of the disease this symptom is often a source of serious
misunderstanding, and may be the cause of family disruption. Usually,
before {227} there are any open insane manifestations, there are
definite symptoms that would point to a pathological excitement in the
sexual sphere.
One of the most striking characteristics of maniacal patients is the
anaesthesia that often develops and is maintained in spite of the most
serious injury. Because of this, maniacal patients should be guarded
with quite as much care as those suffering from melancholia. I have
seen a patient who, during an attack of acute mania, had put her hand
over a lighted gas jet, holding it there until the tissues were
completely charred. The burner was behind an iron grating, but she
succeeded in reaching it. Neither from this dreadful burning itself,
nor during the after dressings, did she complain of the slightest
pain. Because of this anaesthetic condition and the consequent lack of
complaint, maniacal patients often suffer from severe internal trouble
without the medical attendant having any suspicion of its existence.
There are few conditions that are more painful, for instance, than
peritonitis, yet maniacal patients have been known to suffer and die
from peritonitis, due to intestinal or gastric perforation, without a
single complaint.
Unexpected death frequently occurs in mania because of the failure to
recognise the existence of serious pathological conditions. Pneumonia
may develop, for instance, without the slightest complaint on the part
of the patient and go rapidly on to a fatal termination during the
exhaustion incident to the constant movement, it being utterly
impossible to confine the patient to bed. Meningitis may develop in
the same way and proceed to a fatal issue without the patient's making
any complaint or any sign that will call attention to its existence.
In the meantime, the patient may be constantly in the wildest motion
and so add to the exhausting effect of the organic disease.
The prognosis of acute mania is not unfavourable. Patients suffering
from a first attack will recover completely in eight cases out of ten.
Notwithstanding complete recovery, relapses are prone to occur
whenever the patient undergoes a severe emotional strain. As a rule
not nearly so much mental disturbance is required to produce a second
attack {228} as the first one, so that patients require great care. In
a certain number of cases recovery is incomplete; persistent delusions
remain, and there may even be some weakness of intelligence. Paranoia,
as it is called, mild delusional insanity, may assert itself and then
may persist for the rest of life. Notwithstanding this, patients may
get along in life reasonably well, though their mental condition is
decidedly below the normal.
In a certain number of cases, after the period of excitement
disappears, a certain amount of dementia is noticed. This consists of
a distinct lowering of the intelligence, though without the presence
of any special delusion. This dementia progresses until finally there
is a state of almost complete obliteration of the mental faculties.
The prognosis as to life in cases of mania is very good. Very few
patients die during an attack of acute mania. At times there is a
development of tuberculosis that proves fatal, because of the
restlessness of the individual. Pneumonia or typhoid fever may also
prove fatal.
Besides mania or melancholia, there is a third form of functional
mental disease, which is a combination of these two forms. It is
usually spoken of as circular insanity. The patient has usually first
an attack of melancholia, then an attack of mania, and then after an
interval melancholia and mania once more. We have said that most cases
of mania develop after a distinct stage of depression of spirits, so
that successive attacks of mania take partly the character of circular
insanity. This latter disease, however, is an index of a much more
degenerated mental state of the individual than is either mania or
melancholia alone. When it occurs, the prognosis as to future sanity
for any lengthy interval is unfavourable. A series of attacks
alternately of depression and excitement finally make it necessary to
confine the patient to an institution.
As might be expected in this severer form of mental disturbance,
heredity plays an especially important part in circular insanity. At
least 70 per centum of the patients affected show a family history of
insanity in some forms. In this disease direct inheritance of this
particular form of {229} mental disturbance is noticeably frequent.
The patients who develop this form of insanity usually show marked
signs of degeneration, even before any attack of absolute mental
disturbance has occurred. Wounds of the head, alcoholism, and epilepsy
are prominent factors in the production of circular insanity. This
only means that the predisposition to mental disequilibration is so
strong that but very little is required to disturb the intellectual
equilibrium.
Fortunately, circular insanity is rare. In 40,000 cases of insanity in
New York State, only 96 cases of this form were noted. Mild types of
the disease are not, however, very rare. Many otherwise sane people
have alternating periods of hopeful excitement and of discouraging
depression, not momentary but enduring for weeks at a time, which are
really due to the same functional disturbances that in people of less
stable mentality produce absolute insanity. These cases are of special
interest to the clergyman and to directors of consciences.
JAMES J. WALSH.
{230}
XVIII
NEURASTHENIA
Neurasthenia, or nerve-weakness, "the vapours" of the old novelists
and dramatists, is a very common malady, and it gives the clergyman
trouble by the turmoil it causes in families, religious communities,
in themselves, and elsewhere. Whether the condition is a distinct
disease or not, and that question has been voluminously discussed, is
not altogether an important matter, but that there is such a group of
symptoms is unfortunately a weighty fact. It takes so many forms that
it is bewildering, and therefore not readily reduced to unity.
The cerebral form often exists independently. There is such a thing as
"brain fag," although many complainants may have very little material
for the fag to work on. Often such a patient is robust, even an
athlete, and his assertions meet with ridicule or abuse instead of
treatment. If the patient is a woman she is not seldom called
"hysterical." She is not hysterical. Hysteria, by the way, is as
distinct a trouble as a broken leg, and far more serious, and not a
synonym for perverseness, as the term is popularly used.
In the cerebral form, business, reading, study "go into one ear and
out the other." The patient's memory fails him temporarily just when
he may need it most, say, in a speech or sermon; a fly buzzing on a
pane is a calamity and a source of profanity; a flat note in the
choir-singing is ample reason for doubting the divine origin of the
church, and every petty trouble that whisks its harmless tail across
his floor makes him seek the table-top. I have known a whole convent
of nuns, who were closely shut in, with bad ventilation and a worse
cook, until all were more or less neurasthenic, almost {231}
disintegrated by the presence of a lamb sent in as a pet; not because
of the bleating or any ordinary reason, but solely because of the
hideous incongruity and indecency in the fact that the lamb was a
male.
The cerebral neurasthenic makes rash, impetuous changes in his mode of
life. He leaves a religious order because the coffee is weak, he
resigns an important post in a bank because the president uses snuff,
he abandons medicine for trade because the curate meddled in the
treatment of two of his patients. He takes on anxiety, locks up the
house six times over the same night; meals are eaten in awed silence
by his trembling children; altogether he is an unmitigated nuisance.
He may get religious scruples. If he is a priest he takes an hour to
an hour and a half to say a low mass, and most of that time is spent
in searching the corporal for imaginary particles or in drying the dry
chalice. He rereads his breviary until he is exhausted. Because moral
theologians say that certain scruples are from the devil, he is
convinced that the devil takes a particular interest in his case. The
devil did probably take a special interest in his father's or
grandfather's lack of scrupulosity, for his condition is commonly a
result of alcoholism in an ancestor.
There are three chief types of neurasthenics: in one class is the
person that appears robust, and is really so except in his nervous
system, which lacks a governor. Such patients have little more than a
troubled appearance to draw the attention of a chance observer to
their condition.
A second class is made up of eloquent narrators of their troubles.
They try all the physicians in turn, then the homoeopaths and
osteopaths and similar quacks, and they add patent medicines
prescribed by themselves. They are petulant, capricious, and despite
their apparent energy they accomplish nothing.
The third class are silent, limp, clammy-handed; they are brought
against their will to see the physician; they are sulky; bitter and
unreasoning haters; inclined to melancholy. They may have a tendency
even to suicide, but this is somewhat rare. Neurasthenics are not so
liable to insanity as is popularly supposed, but such an outcome is
possible in certain {232} cases. If their vague fears go on into a
more or less fixed delusion there is cause for anxiety lest insanity
result, but care should be taken here to be sure the delusion is
really irremovable.
Some neurasthenics are afraid to cross an open square or a wide
street, others dread any closed apartment. Vertigo is common; so is
insomnia. Insomnia is almost a constant symptom. The patient may have
naps or he may have uninterrupted vigils. Sometimes there is a heavy
but unrefreshing sleep. Sleepless patients are thrown into distracting
rage by the barking of a neighbour's dog, the howling of cats, or the
cackling of a successful hen, and they haunt the magistrates' courts
in efforts to suppress such noises. They put cotton in their ears,
wear heavy nightcaps, stop clocks, board up windows in search of
sleep, which is not found.
These patients commonly have an enduring feeling of weight or
constriction in the head, especially at the occiput,--a headache that
is not actual pain. They also have vertigo, which is independent of
any aural disease, and this is transient, showing itself on abrupt
changes of position.
Another phase of neurasthenia is spinal. These cases have pain in the
back and their legs give out. The back-pain is a diffuse ache, or it
manifests itself on pressure at certain spots along the spine. There
may be severe pain at the coccyx, especially in women. The walking may
simulate paralytic forms if hysteria is mixed with the neurasthenia.
Cardiac symptoms are often prominent, especially palpitation, but
there is a nervous excitation of the heart rather than any definite
lesion.
The gastro-intestinal symptoms are often important. Pain referred to
the stomach and acidity are common, the tongue is coated, the faeces
scybalous. Digestion is torpid. Sometimes there is nervous diarrhoea.
A list of the belly symptoms described by some neurasthenics is
interminable.
We often find a sexual form, which is the worst of all and the hardest
to cure. It is commonly connected with masturbation. Such
neurasthenics are shameless in the description of their nastiness. It
is better to keep them from marriage unless they are cured, and they
are not to be foisted off on {233} any one as husband or wife to
effect a cure. Allbutt says of them: "I fear that some of our
'criminal psychologists' are encouraging many sorts of prurient
debauchees by dignifying the tales of their vice with the name of
science, a course of conduct which is in the worst interests both of
these persons themselves and of our own profession. It were a curious
inquiry how it comes that sexual perversions are so 'scientific' a
study, while the brutalities of the thieves' kitchen or the wiles of
other pests of society lie in comparative neglect."
Physical, intellectual, or emotional strain can cause neurasthenia
suddenly or gradually. Where it comes on without obvious cause there
is commonly a bad family history of nervousness or alcoholism. Anaemia
makes it worse; eye-strain, too, is a provoking factor. In some cases
a renal congestion is the cause. In many cases a lack of restraint,
bad education, uncontrolled passion, are a marked influence in fixing
the neurasthenic habit. A sedulous parent nags at a neurasthenic child
that is too weak for exertion until the child's susceptibility to
correction is blunted. Instead of treatment and help the child
receives cuffs and abuse, and hell-fire is held up before him until he
deems all religious talk dust and ashes. Encouragement will sometimes
do more good than all the threats in the _via purgativa_. Nagging
never cured anything except a tendency toward virtue, and it always
deepens neurasthenia. Be careful in the selection of a confessor for a
neurasthenic child. Get one that does not believe in kicking a soul
into paradise.
The treatment of neurasthenia is difficult. Traveling about in search
of health is not advisable. The Weir Mitchell Rest Cure is very
effective in many bad cases, but it is costly, and if not correctly
applied it is useless. It is the only cure for some patients. Sea air
helps a certain class of neurasthenics, but it makes others worse--it
is bad for the dyspeptic neurasthenic. A chronic rhinitis, a
refractive error of the eyes, a displacement of the uterus, a
congested kidney, a floating kidney, a tight prepuce, and similar
teasing disorders must be cured before the neurasthenia can be
removed; often the neurasthenia disappears with this cure.
Traumatic neurasthenia is like simple neurasthenia in {234} most
details. It is called also nerve shock, spinal irritation, railway
spine. There is always a causative shock or injury, which is followed
at once or after an interval by the symptoms of neurasthenia. In acute
traumatic neurasthenia there may be, in addition to the symptoms
observed in simple neurasthenia, high fever, and such a fever has been
observed to go as high as 113 degrees Fahrenheit.
AUSTIN OMALLEY.
{235}
XIX
HYSTERIA
The term Hysteria ([Greek text] uterus) has been handed down from the
days when physicians thought there was a connection between
womb-disorders and the set of nervous symptoms grouped under the title
hysteria. It is now etymologically meaningless,--men also grow
hysterical. Briquet found 11 male to 204 female hysterics, and later
statistics increase the number of males.
The disease is not readily definable. The patient is usually a young
emotional woman, oftenest between 15 and 20 years of age. She commonly
has anaesthetic spots on her body, concentric limitations of the field
of vision, and hystero-genetic zones, or tender points, which, when
pressed, appear to inhibit the hysterical fit. The symptoms enumerated
here are not, however, found in every case of hysteria, and it is
difficult at times to diagnose the disease.
The various manifestations of hysteria are (1) apt to come and go
suddenly. A severe paralysis that suddenly disappears for a time is
hysterical; (2) even if they last for years they may be suddenly
cured; (3) they are dominated more by mental and moral influences than
are the symptoms of any other disease; (4) we find no organic lesion
with which we can connect the symptoms.
The conditions that bring about hysteria are hysteria in a parent, or
insanity, alcoholism, or some similar neurotic taint in an ancestor.
There is no direct connection between hysteria and the disorders of
the sexual organs.
Immediate causes are acute depressive emotions, shocks from danger,
sudden grief, severe revulsions of feeling, as from disappointment in
love; and, secondly, cumulative {236} emotional disturbance, as from
worry, poverty, ill treatment, unhappy marriage, or religious
revivals. Certain diseased conditions, as anaemia, chronic
intoxications, pelvic trouble, cause hysteria, or, more exactly, start
it into activity where it is latent. It is also communicated by
imitation and it may become epidemic.
After the great plague, the Black Death, in the fourteenth century,
there were very remarkable epidemics of imitative hysteria in Germany
and elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women
danced together in the streets until they fell exhausted in a
cataleptic state. These dances spread over Holland and Belgium and
went to Cologne and Metz. It is said that in Metz there were 1100 of
the dancers seen at the same time.
The "Dancing Plague" broke out again in 1418 at Strasburg, in Belgium,
and along the Lower Rhine.
"Viel hundert fingen zu Strassburg an
Zu tanzen und springen Frau und Mann,
Am offnen Markt, Gassen und Strassen;
Tag und Nacht ihrer viel nicht assen,
Bis ihn das Wuethen wieder gelag.
St. Vits Tanz ward genannt die Plag."
Beckmann (_Historia des Fuerstenthums Anhalt_. Zerbst. 1710) tells of a
similar outbreak in 1237, wherein nearly a hundred children were
seized by the disease at Erfurt, and they went along the road to
Arnstadt, dancing and jumping hysterically. A number of these children
died of exhaustion. The same infection is often at work in the fury of
a mob, the panic of a beaten army, and it probably was an element in
the Children's Crusade.
The Tarantism so common in Italy from the fifteenth to the eighteenth
century is another example of epidemic hysteria. The Bubonic Plague
ravaged Italy sixteen times between 1119 and 1340, and smallpox was at
work when the black death could find no fresh victims. As a
consequence of economic disturbance and fear the people were generally
neurasthenic, and a slight shock was enough at times to set whole
villages into hysterical convulsions.
{237}
In 1787, at Hodden Bridge in Lancashire, England, a girl in a cotton
mill threw a mouse upon another girl that had a great dread of this
animal. The frightened girl was thrown into a hysterical convulsion
which lasted for hours. The next day three girls that had watched her
were in convulsions, the following day six more, and two days later
fourteen more girls and a man were in fits. American white and negro
camp-meetings result in similar outbreaks, and the French
_Convulsionnaires_, who did outrageous things from 1731 to 1790, were
also afflicted with imitative hysteria. The Cornish Jumpers, founded
in 1760 by Harris Rowland and William Williams, and the American
Barkers were also hysterical. The Barkers in the meetings would run
about on all fours growling, "to show the degeneration of their human
nature," and they would end in almost general fits of imitative
hysteria.
There was an epidemic of hysteria in Tennessee, Kentucky, and a part
of Virginia, which began in 1800 and lasted for a number of years. It
started at revivals. The majority of the cases were in persons from 15
to 25 years of age, although it was observed in every age from 6 years
to 60. The muscles affected were those of the neck, trunk, and arms.
The contractions were so violent that the patients were thrown to the
ground, and their motions there exactly resembled those of a live fish
thrown out of the water upon the land.
There are numerous theories formulated to explain hysteria; some are
ingenious, especially that of Janet, but none is convincing.
Convulsions, tremors, paralyses of various forms and degrees are
common in hysteria. In major hysteria the patient falls into a
convulsion gently. There is checked breathing, up to apparent danger
of suffocation. Then follows a furious convulsion, even with bloody
froth at the mouth, but there is a trace of wilfulness or purpose in
the movements. Next may come a stage of opisthotonos, where the body
is bent back in a rigid arch till the patient rests on her heels and
head only, and this is followed by relaxation and recurrence of the
contortions. An ecstatic phase succeeds this, at times in the
so-called crucifix position, with outbursts of various emotions, and a
final regaining of a {238} normal state. Any of these stages, however,
may constitute the whole fit.
In minor hysteria there is commonly a sensation of a rising ball in
the throat (the _globus hystericus_). There may be uncontrollable
laughter or weeping. Muscular rigidity is frequently found. The
patient, especially if she is a child, may mimic dogs and other
animals. The snarling, biting, and barking of false hydrophobia are
hysterical; these symptoms do not occur in real hydrophobia.
There are almost innumerable physical symptoms of the disease, which
are chiefly of medical interest, but the mental phases are such as to
involve questions of morality. The hysterical character is marked by
an overmastering desire to be an object of general sympathy,
admiration, or interest, rather than by a tendency to baser
indulgence. The will is weak, the emotions explosive, the patient is
impulsive and lacking in self-control. She is a "giggler," who goes
from absurd laughter into floods of tears. The desire for sympathy and
attention makes the patient exaggerate her symptoms or simulate
diseases and conditions that do not exist in her case. Hysterics will
swallow pins or stick them into their flesh to force attention.
Sometimes the simulation of disease is not willed. If there are a
number of hysterical girls in a hospital ward and one develops, say, a
peculiar paralysis, within two or three hours every hysterical woman
in the room will have the same paralysis,--not pretended, but real,
although temporary. It must be remembered that the disease, with all
its perversity, is as much a fact as pneumonia, and the element of
sham is only one of its symptoms. Some authorities go so far as to
hold that a woman who will not lie is not hysterical. They invent most
extraordinary slanders against even their own immediate family, and it
is never prudent to believe an accusation made by an hysterical
patient, no matter how plausible the story.
Acquired hysteria in many cases may be cured, but the congenital
condition is practically hopeless, yet the latter kind may be kept
from violent outbreaks.
We can not prevent drunkards, epileptics, and lunatics from
propagating their kind, and therefore we shall still have the {239}
hysteric with us. The child that has a bad ancestry and shows
hysterical tendencies should be carefully reared. If it has an
hysterical father or mother it should, if possible, be removed from
this evil influence. Keep it from long hours of mechanical work that
leaves opportunity for dreaming. Shut out novels and "art for art's
sake," especially music. Give it a practical education. Teach it
obedience, self-control, and truthfulness. Harden its will by exercise
at things it does not like, and do not coddle it. Do not marry off an
hysterical girl to cure her. Do not inflict her presence upon some
unfortunate young man because he is a good citizen. Marriage will not
cure hysteria,--the worst cases are married women, and they beget
other hysterics in spreading succession.
When the disease shows itself offer no sympathy,--do not try to put
out a fire with oil. When a "good, pious girl" grows hysterical, the
chief obstacles to her cure are untactful and sympathetic visits from
friends, lay and clerical. A visit from the pastor, because of his
importance, is always harmful, and if the bishop drives up in his
carriage so that the neighbours may see him, all the physicians in the
city can not help her. If you wish to keep an hysterical girl in her
vapours, get her a physician that will grow excited over her, take the
dear child out of school and weep above her couch, let the family and
its friends assure the unfortunate attending physician in her presence
that he is heartless, and she will stay hysterical to her soul's
content.