_Relieving Incurable Disease_.--A new cure for locomotor ataxia, for

instance, is announced every now and then, and the evidence for its

beneficial action is the testimony of patients who have been relieved

of many symptoms that they thought connected directly with their

spinal affection. All sorts of remedies have been employed with

announced success. One man builds a particular kind of shoe for them

and has a number of witnesses to his skill in curing them. Another

does some slight operation on their nose or their throat or their

urethra and straightway the patient feels so much better that he talks

confidently about being cured. All the characteristic symptoms of the

affection remain. Their knee-jerks are gone, their pupils do not react

normally, they have some incoordination in their walk, but a number of

other symptoms have disappeared and their walk is probably much

improved because of their confidence and a certain amount of practice

that they have gone through. The new hope born of confident assurance

that they could be relieved gives them an appetite, makes their

digestion better. This lessens the sluggishness of their bowels, gives

them confidence to get out and see their friends, life takes on a new

hope, they sleep better and it is no wonder they talk of having been

helped or even cured.

There is a definite relation between the nervous affection in these

cases and many visceral symptoms. There is no doubt, for instance,

that certain cases of intractable dyspepsia are associated with tabes

and that in nearly the same way obstinate constipation frequently

develops. Notwithstanding the connection of these symptoms with an

incurable condition of the spinal cord {511} that is no reason for

thinking that they cannot be relieved even though no improvement of

the spinal-cord lesions is expected.

Frequently, indeed, gastric dyspepsia is due more to worry over

discomfort somewhere in the stomach region than to any real

disturbance of the digestive functions. It may then be considerably

ameliorated simply by the assurance that the trouble is local and is

localized outside of the stomach itself, though there may be some

sympathetic irritation of the gastric nerve supply. Probably Dr. Head

and those who have studied reflexes so enthusiastically would not

agree with this explanation of the relief of the gastric symptoms in

some of the cases they have described, as due rather to suggestion

than to the local treatment, and, as a matter of fact, we are not

quite sure which factor may be the more important. Counter-irritation

probably plays quite an important role in the relief of discomfort,

but I am sure that the suggestive influence of acute sensory feelings

at the surface produced by counter-irritation serves to divert the

mind from the duller ache or the functional disturbance below.

However, Dr. Head's paragraph should be given in his own words, for it

furnishes a scientific basis for one aspect of these cases.

Throughout the study of cases of nervous diseases, evidence of the

relation between pathological condition of certain viscera and

sensory disturbances in the superficial structures of the body is

constantly manifested. For instance, a man with caries of the spine

suffered from a girdle sensation round the area of the eighth dorsal

segment. At the same time he was greatly troubled by flatulent

dyspepsia which was untouched by drugs. It was, however, greatly

relieved by counter-irritation applied to the maximum tender point

of the eighth dorsal area in the eighth space and mid-axillary line.

_Optimistic Suggestions_.--Our most prominent neurologists have in

recent years insisted on the necessity for encouraging patients and

for not permitting them to brood upon the worst side of what is to be

expected from their ailment. Patients are entirely too prone to read

up about their disease and the worst symptoms of the extreme cases

impress their minds and are constantly recurring as suggestions of

possible ills to come. Prof. Oppenheim in his "Letters to Nervous

Patients" states in a striking way the optimistic view that it always

seems advisable to give a patient in the initial stages of a serious,

incurable or even progressive nervous disease. That letter is worth

quoting:

I cannot conceal from you the fact, which you have already

ascertained from other sources, that you show the premonitory

symptoms of a disease of the spinal cord. This admission is not,

however, as you fear, synonymous with the sentence "the beginning of

the end." There is no reason for you to despair. We doctors regard

and welcome it as a marked advance in our scientific knowledge that

we are now in a position to diagnose a nervous disease of this kind

in its first commencement. This is undoubtedly a great gain for the

patient, as on account of this knowledge a judicious, experienced

physician may, at least in many cases, by the timely regulation of

the mode of life and the prescription of certain remedies, arrest

the progress of the disease or retard its development. This advice

may, however, and should as a general rule, be given without the

patient himself being made aware of the diagnosis, for the ideas as

to the nature of this disease which prevail in lay circles, and

indeed among many doctors of the old school, arise from the

knowledge of the disease in its advanced and fully established form,

since it was only in this completely developed stage that it was

recognized. Then, indeed, its very noticeable symptoms were obvious

even to the uninitiated. This picture, sad enough indeed in itself,

was rendered still gloomier by {512} the misery and despair which

popular fancy has associated with the conception of locomotor

ataxia.

_Arteriosclerosis_.--Even with regard to so serious a disease and, of

course, absolutely fatal in its progress as arteriosclerosis, it must

not be forgotten that much can be done for the patients and especially

for the nervous symptoms that develop in connection with the

condition. For the progressive hardening of the arteries on which the

nerve symptoms depend absolutely nothing can be done. A man is as old

as his arteries, and we cannot bring back the years even though the

patient has become prematurely old. For the symptoms so frequently

seen in connection with arteriosclerosis, the paresthesia, the

burnings, the numbness, the pruritus, the pains around joints and the

difficulties in connection with them, even for the intermittent

claudication which develops, much can be done. Above all, the patient

must not be allowed to cherish the notion that his disease is not only

incurable, but that nothing can be done for it. It is inevitable and

progressive, but then according to one definition, life is a

progressive disease and every day brings us nearer death. "Life is a

dangerous thing at best," as an American humorist once said, "and very

few of us get out of it alive."

These patients can be relieved of many physical symptoms, they can be

encouraged, their attention can be diverted from their symptoms, and

it is concentration of mind on them that often makes them intolerable,

while occupation with something, especially if it is interesting, will

often prove an efficient remedy for the discomforts complained of. Old

people who have no interests, who have retired from business, who did

not have the opportunity when young to acquire tastes in art and

literature, above all, those who have no interests in children, no

grandchildren nor close relatives near them, are likely to become

centered on their ills in the midst of their arteriosclerosis, and

this more than the advancing degeneration of arteries itself is at the

root of their symptoms. The ideal old age is that which is passed in

the midst of younger people, with an occasional happy hour during the

day with children in whom one is deeply interested. This is the best

psychotherapeutic factor that we have.

Prof. Oppenheim has given the optimistic side of arteriosclerosis so

suggestively that most patients suffering in this way should have the

opportunity to read it. It occurs in his "Letters to Nervous

Patients":

An eminent physician for whom I have much esteem has told you that

your troubles, especially your vertigo, are caused by calcification

of the arteries. You, sir, heard in this your death sentence, and

since then the encyclopedia has revealed to you all the sufferings

and terrors with which you may expect to be overtaken.

I would, however, explain to you, as the result of the most careful

examination and the most absolute conviction on my part, that your

anxiety is unfounded.

Since you have a certain amount of information and scientific

knowledge, I may speak to you upon this matter almost as a

colleague. One is certainly justified, when a man of your age

complains of vertigo, in suspecting calcification of the arteries to

be the cause of the trouble, since it constitutes the common senile

change, and vertigo forms one of its most frequent symptoms.

But--apart from the fact that in senile calcification of the vessels

this vertigo is frequently a temporary and not always a serious

sign--one is by no means justified in assuming that the appearance

of this symptom in later life is in itself, and without further

evidence, the sign of such a cause. This is an error which in my

experience is {513} far too frequently made, to the detriment of the

patient. It is first of all essential to closely examine and analyze

the symptom in itself. . . . Two years ago, after having overloaded

your stomach, you had a real attack of vertigo, which was repeated

several times during the day, until, by vomiting and diarrhea, the

contents of your stomach were evacuated. Since that time the fear of

vertigo has overpowered you. In my experience it is neither new nor

uncommon to find that a man who has shown his intrepidity and his

contempt of death on many a battlefield, who is a hero in war, may

be overcome by some dread of illness, by some anxiety, or even by

some pain, and may be distressed by it in a way that is in sharp

contrast to his whole personality. Your remembrance of that vertigo

is so lively that the mere idea of it suffices to reawaken the

symptom, or at least an imitation of it which very nearly approaches

the reality. That this idea is present in your case is quite certain

from the consideration of your symptoms. You admit that you almost

never have vertigo at home, but as soon as you leave the house, and

especially if you find yourself alone in the street far from home,

the remembrance of the vertigo comes over you, puts you into a state

of anxiety, and is followed by a sensation of tottering and swaying,

so that you have to stand still; and at last it has gone so far that

you no longer venture to go out alone. And so the hero of X sits

like a timid woman in his arm chair, making life bitter for himself

and for those around him.

Even were I to find that signs of arterial calcification were

present, I should still be satisfied that your vertigo is not due to

this cause, but that it is a vertigo of recollection and of fear.

CHAPTER II

CEREBRAL APOPLEXY

Cerebral apoplexy is an extremely serious organic disease that seems

surely to be an affection for which psychotherapeutics can mean little

or nothing. When an artery has burst in the brain and blood is either

actually flowing out or has flowed out in damaging quantities into the

delicate brain tissues, seriously injuring and perhaps destroying some

of them forever, no amount of mental assurance will do any good for

the organic lesions that have been produced. All that can be hoped is

that the hemorrhage will not prove fatal and that the powers of nature

will be sufficient to deal with it, and though not able to cure it in

the sense of restoring tissues to former conditions, will compensate

for the lesion in some way and dispose of its products so effectually

that but little interference will result with nerve functions within

the skull.

There is no pretence that by psychotherapy or any appeal to mental

powers anything can be done for the underlying pathological process.

And it may be frankly said that no remedy of any kind, physical or

mental, will avail much, while some of those that have been suggested

are just as likely to do harm as good. Position, with the head

elevated and quiet of mind and body are the only remedial measures

that promise definite help. Excitement greatly increases the danger.

Reassurance does more than anything else to lessen blood pressure and

lessen also the danger of a hemorrhage producing fatal effects. In

nervous, excitable people the first stroke is often fatal.

Occasionally the phlegmatic have three or more ruptures of brain

arteries before death supervenes. Psychotherapy, then, has a definite

role even at the time of the apoplexy.

{514}

The Mind Before and After.--Much can be accomplished for the patient

by proper attention to his state of mind both before and after

cerebral hemorrhage. There are many symptoms which point to the

possible occurrence of the rupture of a cerebral artery, and older

people are likely to know something about these and to dread them so

much that to some extent they may by worrying precipitate the evil

they fear. Many people, having read vaguely about apoplexy, having

seen a case or two of it perhaps, and having heard of others, develop

a dread of its occurrence in themselves that makes them miserable.

Finally, the shock of a cerebral hemorrhage is very great and its

after-effects likely to be very disturbing. It affects the whole

personality and often makes a strong, vigorous, healthy man a decided

hypochondriac. All of these associated mental states may be greatly

benefitted by psychotherapy.

A number of neurotic symptoms are always added to whatever

manifestations of mind and the somatic system may develop as a

consequence of the cerebral apoplexy, and these are treated more

effectually by mental reassurance than in any other way. Besides,

apoplexy confines people to the house who have often been vigorous and

active before, and this confinement with deprivation of exercise and

air and consequent disturbance of appetite and digestive functions,

acts as a serious factor in the production of neurotic symptoms. Tears

and hysterical manifestation are not uncommon, and for these

psychotherapy is the most important remedial measure.

In the period preceding true apoplexy there may be such symptoms as

persistent headache with peculiar sensations in one hand. These

sensations are variously described as creepy feelings or as of "pins

and needles," and occasionally as if the fingers and sometimes the arm

were asleep. The group of symptoms known as paresthesia are rather

common as premonitory symptoms of cerebral apoplexy. When these are

combined with headache patients often become seriously disturbed and

begin to dread the occurrence of apoplexy. While these are premonitory

symptoms of cerebral hemorrhage in those whose arteries are

degenerated, patients must be made to understand that just because the

fingers or hand or arm go to sleep occasionally, even though there may

be complaint of headache, these are not indications of impending

apoplexy unless other objective symptoms are present. Subjective

symptoms alone can never mean much as regards organic disease. It is

particularly neurotic individuals who are likely to exaggerate the

significance of their subjective sensations, who are also prone to be

so solicitous about apoplexy that they work themselves into a state of

fear with regard to it. Even children have their hands go to sleep

rather frequently, and at all ages if the arms or legs are placed in

certain positions or under certain conditions of pressure, they are

likely to develop that numbness which ends in the prickly "pins and

needles" feeling that is spoken of as "going to sleep."

Diagnosing Arterial Sclerosis.--Unless, then, some of the arteries at

the periphery of the body show signs of such degeneration as to

indicate advanced arteriosclerosis, any subjective symptoms, no matter

how bothersome, must not be allowed to depress the patient. Usually

they mean nothing at all, and would pass quite unnoticed but for the

patients' nervousness about themselves. If the temporal arteries are

not prominent and visibly thickened and tortuous, and this may be seen

at a glance, the patient may be assured almost without more ado. If

his radial arteries on careful observation show no signs {515} of

degeneration, then it is extremely doubtful if there is sufficient

arterial change in the brain to justify a fear of arterial rupture. In

examining the radial artery it must not be forgotten that the pulse of

nervous people, especially such as have exerted considerable mental

control over themselves in order to come and see a physician about

what they think is a serious condition, is likely to be of high

tension. When the artery is rolled under the finger, then it may seem

that there is some thickening in its walls, though it is only

heightened blood pressure from emotion that causes the feeling. This

high blood pressure may, of course, of itself be an indication of

danger whenever there is heart or kidney disease, but it often occurs

as a passing event in nervous patients whose vasomotor control is so

capricious that arterial tension and blood pressure may change at very

short intervals as the result of excitement.

It may not be easy to obliterate the pulse in the usual way in many of

these cases and as a consequence the illusion of a thickened artery

may remain even when the vessel is quite normal. The important rule is

to ascertain whether the artery is tortuous. Whenever there is

thickening of the arterial wall the artery is lengthened as well as

thickened. If the artery is not lengthened the degenerative changes in

it are so slight, as a rule, as to be negligible. Indeed, the very

beginning of arteriosclerosis may thus be diagnosed. When this cannot

be found, patients may be completely reassured that their suggestive

symptoms have no significance as regards any possibility of cerebral

hemorrhage from the ordinary causes of advancing years and arterial

degeneration.

_Differentiation_.--Occasionally such paresthesiae as have been

described especially when associated with headache, point to an

intracranial growth, or to a developing syphilitic brain lesion, and

these must be carefully eliminated, but they constitute quite separate

problems which always present other accompanying symptoms that make

diagnosis possible once a suspicion as to the nature of the lesion is

aroused. Above all, these occur in much younger patients than are, as

a rule, the subjects of cerebral apoplexy.

Symptoms.--_Dreads--Dizziness_.--There are other symptoms of which

people have heard as preliminary signs of brain hemorrhage which

occasionally disturb them to a great degree and set up a set of dreads

that may be difficult to banish. Probably the one that is spoken

oftenest of is dizziness. There is no doubt that under certain

circumstances this may be a symptom of impending cerebral hemorrhage,

especially if it is accompanied by headache and by objective signs in

the arteries, but dizziness by itself is not enough to justify any

anxiety in even elderly people. If, when a man stoops over and then

straightens up rapidly everything becomes black before him and he must

immediately take hold of something to keep himself from falling, it is

probable that a pathological condition of his cerebral arteries is

present. This interferes with brain circulation and may have seriously

impaired the elasticity of the arteries which is so necessary to

overcome the rapid variations of the influence of gravity on the blood

current when there are sudden changes of position. Fits of dizziness

that come on immediately on rising in the morning, or that attack the

patient when he sits up suddenly in bed may have the same serious

significance. None of these signs are significant, however, unless

there are, as we have said, objective signs in the arteries.

{516}

But dizziness may come from many other causes besides degeneration of

arteries. A very common cause of it is the presence of gas in the

stomach which interferes with the heart action mechanically and so

disturbs the circulation. The column of blood to the head is more

easily affected than the rest of the circulation because it must be

pumped up directly against gravity when we are in a standing position,

and so any, even a slight, interference with the heart action is felt

at once in this portion of the body. Besides, the brain is extremely

sensitive to changes of circulation and even a slight disturbance of

the blood supply to it may cause dizziness. There occurs also

undoubtedly a feeling of dizziness that is entirely subjective. The

patient for some reason loses confidence in himself and has a feeling

of dismay, as if he could not support himself. Such a patient may

complain that when he comes down stairs, at the first step or two,

particularly of a high stairs, he has the dread that he may pitch

forward. Such people have never actually fallen, but they have to

grasp the railing and they have a dread of some accident of this kind.

This is, however, rather a form of akrophobia than a true dizziness.

Prof. Oppenheim has dwelt on vertigo as a dread (see preceding

chapter).

_Vertigo_.--Besides, there are pathological conditions that cause

dizziness yet have no connection at all with the dizziness that is a

premonitory symptom of apoplexy. Meniere's disease, for instance, even

in its milder forms, causes at times a vertigo that is extremely

annoying and that frequently gives rise to the fear that a serious

brain lesion is either actually occurring or is impending. I have seen

even comparatively young patients suffer so much from this dread that

life became miserable to them and they were unable to do their work

properly. A few words of explanation and reassurance literally work

wonders for such patients. In one case the young woman assured me over

and over again that my explanation meant a new lease of life for her.

She still has occasional dizziness, but now she knows that it is due

to her accompanying ear trouble and it does not worry her.

_Motor Symptoms and Over-solicitude_.--Besides dizziness, there are

other symptoms of which patients complain and which may indicate that

an apoplexy is impending or may mean only that a patient is occupying

himself too much with himself and his symptoms. Not infrequently when

there is degeneration of arteries in the brain there will be slight

weaknesses of the limbs or awkwardness in the use of them.

Occasionally women will complain of the fact that they do not button

dresses as they used to. Sometimes men will complain that they do not

button their collar or their suspenders at the back with facility, or

that they are awkward and grow fatigued easily in such strained

positions.

These symptoms may be indicative of some disturbance in the motor

areas of the brain, but it must not be forgotten that all of these may

be simulated by nervousness, especially if the person knows the

meaning that is attached by doctors to these symptoms. In this matter

particularly a little knowledge is a dangerous thing. We are only just

getting a generation of trained nurses to the age when they are likely

to suffer from dread of apoplexy and some of them are over-anxious

patients because of their knowledge without the balance of complete

practical experience with the meaning of such symptoms. Doctors

themselves are prone to be disturbed by such thinking more than {517}

almost anyone else. The delusion of thinking apoplexy is not at all

uncommon in elderly physicians. In men it is important to insist that

objective symptoms are the only details of real value and that

subjective feelings are utterly illusory. If this cannot be brought

home to them they make themselves extremely miserable and may even

help to precipitate through worry the fatal complications they dread.

Prophylaxis.--There is no doubt but that heredity plays an important

role in apoplexy. In certain families most of the members terminate

existence by rupture of an artery in the brain, sometimes at

comparatively early ages. Apparently the resistive vitality of their

arteries is only sufficient to enable them to maintain themselves for

a limited length of time against blood pressure. They are destined to

have arterial degeneration that will predispose to arterial rupture

sometime before they are sixty. Father, grandfather and

great-grandfather had their apoplexies from fifty-five to sixty-five

and the son must realize that he probably will go the same way. Even

the delay of a year or two is important. Anything that will save the

wear and tear of existence may bring about such a delay and it is not

by drugs, nor even by dietetic precautions, so much as by attention to

the patient's state of mind that this decided benefit can be best

secured.

_Over-indulgence_.--People with such an unfortunate heritage should be

made to understand reasonably early in life that they must save

themselves from as much arterial wear and tear as possible. There are

certain occupations involving intense emotion and excitement that are

barred to them if they want to live out their lives, even to the

extent usual in the family. There are three causes that weaken

arterial walls. When the question of causation of aneurism is

discussed it is usually said that it is especially the devotees of

three pagan deities--Venus, Bacchus and Vulcan--who suffer from this

form of arterial trouble. Just this same class suffer particularly

from the tendency to early arterial rupture in the brain. Under the

head of devotees of Vulcan, the hard workers, must now also be placed

the advocates and exemplifiers of the strenuous life, who are

perpetually doing, though often it is hard to see what they

accomplish; the money-getters, who are really overworking as much as

the forced laborers of olden time. People with an apoplectic heredity

should not take up such professions as that of the actor, the broker,

the speculator of any kind, the lawyer absorbed by the strain of trial

work, perhaps not even that of the surgeon. Physicians generally are

not long lived because of the irregularity of their hours of eating

and sleeping and the responsibility of their professional life.

Many men will not be guided by such considerations and insist on

living their lives in their own way in spite of the possibility of the

family inheritance shortening their career in the late fifties. More

than one has said that he would prefer to have the life of the salmon

rather than that of the turtle. The strenuous life alone appeals to

them.

"Better fifty years of Europe than a cycle of Cathay."

This would be an admirable response if what these men accomplished

during their lives amounted to anything. Most of these who run out

their existences in the midst of excitement, however, only do harm by

adding to the swarm of speculators in life, or accomplish very little

because of the intense {518} excitement under which they labor. It is

the quiet lives, doing a few things and doing them well, outside of

the strenuous current of the bustle of existence, that accomplish most

for mankind. The others may attract attention for the moment, but they

soon pass out, often having done rather harm than good.

_Life-direction_.--It is perfectly possible for the physician to make

this clear to a young man with a dangerous heredity and perhaps change

the current of life so as to make it effective in simplicity and

serious patient work. The young man will usually be quite impatient to

think that anything thirty years ahead should be expected to influence

his decision as to how or what he shall do with life, yet this motive

added to others may help to get at least some of this and the next

generation from wasting their lives in an over-strenuous existence

that at most merely accumulates money, often accumulates it only in

order to lose it, with consequent disappointment and worry, and

frequently leaves no real accomplishment but only the problem of the

disposal of accumulated wealth for future generations. Where large

wealth is left to the succeeding generation there is usually little

use to give any advice with regard to the possibility of early

apoplexy, because excitements of other kinds than those of business,

of the heart rather than the mind, are likely to wear out existence

even before the time when the family life of arteries ordinarily,

though precociously, runs itself out.

Certain people have what is called the _apoplectic habitus_, that is,

they are short in stature, rather stout, with short necks and florid

complexions. It seems not unlikely that the mechanical arrangement

within their bodies by which the distance from their heart to their

brain is so much shorter than in ordinary persons is responsible for

the tradition so generally accepted that there is a definite tendency

in such people for apoplexy to occur at a comparatively early age.

Such people should be warned gently but firmly of the danger that they

incur if they subject themselves to a life of excitement or emotional

stress or permit themselves to get into circumstances in which they

will worry much. It may seem as though a warning of this kind would

precipitate the worry of mind that it is meant to ameliorate, but in

present-day publicity such people are likely to have heard of the

meaning of their particular constitution of body and consequently

worry about it, but usually after it is too late to do any good. In

this matter, as in heart disease, the warning must come before there

are any symptoms, or else must not be used at all.

_Certain Abuses_.--In most of these cases definite warnings with

regard to habits of life and indulgence in stimulants and narcotics

should be given. Both Prof. Von Leyden and Prof. Mendel of Berlin

insist that for patients in whom there is any likelihood of the

development of early apoplexy indulgence in alcoholic liquors is

almost sure to be serious, but in addition to this generally accepted

warning, both of them also insist that smoking has a tendency to

produce serious, premature degeneration of arteries, especially in

people who already have tendencies in that direction. Overeating and

high living in general without moderate exercise causes a plethora of

the circulation that must be avoided. On the other hand, violent

exercise, running especially to catch trains or cars, haste in the

ascent of stairs or hills, heavy lifting, straining at stool, and the

like, are particularly prone to have serious consequences for such

people. This warning is all the more needed because many a short,

{519} stout man acquires the idea that gymnastic work and various

exercises indoors may help him to reduce his weight and restore the

activity of his earlier years. This is practically always a delusion

and indoor gymnastic work is always of dubious value.

What these people need is not more muscle and the wearing off of fat

but more air and the burning of it off by increased oxidation. Such

patients must be taught to lead tranquil lives without any of the

excitement and strenuosity that, after all, accomplishes so little.

The sacrifice when first suggested, appears too great a one to make,

but after a few years patients instead of feeling that it was a

sacrifice at all pronounce it to be a blessing in disguise and are

proportionately grateful to their physician. Life for many of these

people may be prolonged not for a few years of hustle-bustle, but for

many years of good work in quiet and peace, without hurting others by

competition, but helping many because there is time in their

considerate lives to see something of the sorrow and suffering around

them and to relieve it.

_Change of Occupation_.--In the matter of prophylaxis it is

particularly important to insist on the fact that when men have worked

at hard manual labor when they are young and then, about middle life,

have turned to intense intellectual labor, such as the management and

administration of important affairs, they are a little more liable

than are the general average of humanity to have an apoplectic seizure

at sixty or a little later. Apparently inurement to a particular kind

of labor when young makes for the capacity to stand it longer than

would otherwise be the case. In this matter, however, the most

important factor is heredity. Men who come from long-lived families

are likely to live long--indeed far beyond the ordinary term of human

life. Even in them, however, certain of these directions are helpful

in securing the full measure of life.

After the Stroke.--After a stroke of apoplexy when it becomes clear

that nature is about to reassert her control over the circulation in

the brain and dispose of the remains of the old hemorrhage,

psychotherapeutics is more important than anything else that we have

for the treatment of these patients. As a rule, they have been active,

vigorous men who are stricken and who suffer more from doing nothing

and waiting to get better than from any pain they have to undergo.

They know that another stroke may come at any time. It is no wonder

that introspection plays its part, that every feeling that they have

becomes exaggerated in significance, that their appetite fails them,

that their bowels become sluggish, that they do not sleep, or that

after having fallen asleep they wake up and then for hours lie awake

thinking.

_Lack of Air and Exercise_.--As they usually have no exercise of any

kind, do not get out into the air, and have very little diversion of

mind, it is easy to understand that neurotic or hysterical symptoms

develop, that they lose all confidence of recovery and make themselves

even worse than they are by dwelling on their condition. The only way

that this group of symptoms can be treated is by favorable suggestion,

by encouragement, by mental reassurance and by occupation of mind.

I have always felt that the condition of affairs which developed in a

family immediately after the occurrence of an apoplexy usually makes a

very unfavorable environment for the treatment of these cases. It is

practically impossible for those who come to visit the patient or for

the members of the {520} family for some time to wear anything but the

resigned air that indicates that they fear the worst.

_Sympathetic Care_.--After the stroke at once when survival is assured

comes the question of the management of the patient. A devoted

daughter seems to be able to do more for an apoplectic father than

anyone else. Somehow her youth appeals to him sympathetically, and he

has not that feeling of sadness mixed with a little envy that comes so

readily to all men when they find themselves slipping out of life

while their contemporaries and friends and relatives are left behind.

It is as if the idea of his daughter being young and strong, even

though he has lost vitality, docs not touch him poignantly because he

has always expected that she should have health and strength after he

was gone. On the other hand, a daughter is not always a good nurse for

a mother. Just why, is hard to say. A hired nurse must take, as a

rule, the place close to the mother which, in the case of the father,

so naturally falls to the daughter. These ideas may be founded on too

few cases to generalize very much about, but I have discussed them

with many physicians, including some women physicians, and they agree

with them, in general principle at least.

_Trained Attendance_.--As a rule, then, the first thing that has to be

done for a patient who has had apoplexy and who is beginning to

recover, is to have trained attendants near him who talk

professionally to him and reassure him and do not make him feel

constantly the possibility of an approaching end. If his improvement

has begun his family must not be allowed to bother him, his affairs

should not be talked over and, as far as possible, some occupation of

mind should be secured for him. He needs new interests at once. These

must be gradually awakened and he must be made to feel as early as

possible that though he may be more helpless than before and most of

his ordinary occupation in life may be cut off, there are still many

interests in life which he may thoroughly enjoy. I shall never forget

hearing Thomas Dunn English, the dear old poet to whom in his earlier

years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the

University of Pennsylvania that he used to think that all the good

things of life were somehow contained in its first eighty years, but

that now since he had past his eightieth birthday (he was at the time

in his eighty-third year) he was beginning to agree with Bismarck, who

declared under similar circumstances that he had found many interests

in the second eighty years of life. At the time English was quite

blind, was almost completely deaf, had been seriously ill for several

months, and had suffered a rather severe stroke some years before; and

yet he made the best speech at the dinner that evening and had the

youngest heart of us all--joyous, uplifting, encouraging, optimistic.

_Outlook_.--Men who have been great workers are prone to think that a

stroke of apoplexy means the end of all serious work. Of course, it

means nothing of the kind for the majority of patients. Many men find

not only enjoyment in life after their recovery from even a serious

stroke, but also possibilities of accomplishment sometimes better than

they had done before. It has even been known that men who had been

occupying themselves with things scarcely worth while, with the mere

accumulation of money without any purpose, were awakened to a sense of

their responsibilities to life and to their fellowmen by a stroke and

planned in the after years institutions or aids to {521} existing

institutions that did much to make life more livable for others.

Nothing makes a man face life in a better mood to do really effective

service for mankind than the prospect of possibly soon having to go

out of life.

_Encouraging Examples_.--On the other hand, many men have been able in

spite even of a severe stroke to go on after a time with the work they

had been at before and, though feeling its effects, accomplish the

best achievements of their lives. A typical example is the case of

Pasteur, the great French bacteriologist, to whom we owe most of our

modern preventive medicine and to whom Lord Lister frankly attributes

the germ idea of the antiseptic theory. When little past fifty,

Pasteur after years of hard work and worry suffered from a severe

stroke of apoplexy followed by several of slighter character. It

seemed absolutely the end of his labors. For more than a year he was

able to do nothing. For all his after life he was seriously lame as a

consequence of his stroke. In spite of this, which would seem to

preclude the possibility of great intellectual work, Pasteur's most

important discoveries were developed after this time and he continued

for over twenty years to be the leader of biological science. Had he

died at the age of fifty or given up his work we would scarcely know

him for the great scientist that he afterwards proved.

It is worth while to be able to tell the stories of such lives as

examples to patients who are dispirited and downhearted after a

stroke. Of course, men must be prevented from doing hard work or from

worrying during the time immediately following the hemorrhage of the

brain, and, indeed, for some months. Work and worry, though worry much

more than work, might easily hasten a recurrence of the seizure. It

has always seemed to me, however, that it is impossible to keep the

human mind utterly unoccupied. Men must think about something during

their waking hours, and if they have not some interests close at heart

they worry about themselves. Of the two things, worry is much harder

on the tissues, raises blood pressure more, disturbs the circulation

of the brain to a greater degree than does work. Anything that a man

will interest himself in, then, should be allowed to him, provided, of

course, that he is kept from getting into the state of mind which

precipitated the rupture of the artery in his brain. It is a change of

mental occupation above all that is needed and this is secured by

deliberate attempts to interest his mind in various ways and keep him

from dwelling on himself and his ills. This injunction cannot be

repeated too often.

_Change of Mental Interest_.--I have already insisted in the chapter

on Diversion of Mind that so far as we know at the present time

different portions of the brain are occupied with different subjects

in which we may interest ourselves. When a man by business worries,

occupation with financial affairs, or with political troubles, has

apparently worn out one portion of his brain, he may still use other

portions to decided advantage. Hence the necessity for finding new

interests for the apoplectic after their attack. The best interests

for them are those associated in some way with their fellows, because

these are accompanied by feelings of consolation, of encouragement, of

desire to live and do good to others. These do more to take men out of

their moodiness, their morbid introspection, and their

self-centeredness, than anything else. With the help of a good nurse,

herself of broad interests, this must become the main purpose of the

physician's treatment.

{522}

_Misplaced Sympathy_.--After the first few days, when the shock is

over, a strong, healthy man who has been suddenly taken down with

apoplexy, then rendered helpless as a consequence of the lesion in his

brain, rather resents the sympathy and, above all, the frequent

expression of the feelings of his friends towards him. Time is needed

for him to recover, there is no way of hastening it, he is already

impatient at the delay and words of sympathy do him very little good

and often add to his impatience. He is to be taken absolutely with

professional calm, made to understand that time is the most important

element in his cure, provided he will not worry and will have patience

to wait and to help as far as he can. I nearly always feel that it is

better for these patients to be away from home as soon as they can be

moved with safety. This enables them to avoid without much difficulty

what they are apt to consider the intrusive and obtrusive sympathy of

friends. Especially is this true of business friends, themselves in

good health, who come to offer their condolences.

Their hysterical condition is largely influenced by the fact that they

are indoors and have so little diversion of mind. Just as soon as

possible they must get out of doors. Over and over again I have found

that patients did not care to expose themselves to the inquisitive

gaze of neighbors and preferred to stay in the house, though the

outing would be of much benefit to them. Hence the necessity for

getting them away from home, among people whom they can observe

without attracting too much attention themselves and, above all,

without being the subjects of such obtrusive pity as will disturb

them. None of us likes to be pitied and least of all the strong,

vigorous man who often has had nothing the matter with him all his

life and is now suddenly stricken. It requires years of experience to

enable one to take sympathy properly and without resenting it.

_Outings and Human Interests_.--When patients care for carriage riding

I have found that the city park is an excellent place for patients

suffering from the effects of apoplexy, who require outdoor air and

diversion of mind, yet without exercise or much exertion. The children

in the park, if they play around, serve as a better diversion of mind

than almost anything else for elderly people thus stricken, for they

seem to renew their youth at the sight of the little ones.

Grandchildren make the best possible consolers even when they seem to

probe deep into old wounds by asking questions and by talking about

death. The talk of death from young lips has not the same disturbing

effect as from older people. The games of children interest the old

once more, and if there is occasional music and the chance to see the

passing throng of carriages and motor cars and the pleasure boats and

all the rest there is refreshment and reinvigoration in it all that

soon brings back to the patient deep, satisfactory, even dreamless

uninterrupted sleep at night, and appetite and strength. At first

there will usually be some objection to being thus treated as an

invalid, but only a few days of experience are needed to convert even

the most morbid to the idea that this outing will do them good. As a

rule, friends must be warned not to spoil the effect of it by fearing

lest the patient should be lonely and so go to the park to entertain

him. If the drive, the lake and the children, as well as the

passers-by, do not suffice to give the patient sufficient diversion of

mind, the visits of friends will not have any favorable effect. As a

rule, it is better for them to see the {523} patient at home and even

that not too often unless they are of his immediate family.

Where people are able to go away and, above all, where they can have

some pleasant companionship, a seaside resort is an ideal place for

those recovering from apoplexy. The long ride in a wheel-chair on the

boardwalk at least several hours in the morning and afternoon soon

acts marvelously. There is constant diversion of mind at any season of

the year, for there are lots of people to be seen in all sorts of

costumes and the shops and the shows and the passing throng all have

their interests. Then the sea air is bracing and tempts to

sleepfulness and just as soon as sleep improves courage comes back. I

have known patients so hysterical that they were crying every day and

that seemed to have given up all hope, improve so much in two weeks at

Atlantic City that it seemed little short of marvelous. What is

needed, however, is not a stay of a few weeks but of several months.

Prognosis of Strokes.--While, of course, any single stroke may be

fatal and no one can tell anything about the prognosis of a rupture of

a brain artery, there are many favorable things that can be said to

patients, and they are so prone to think of all the unfavorable things

that this better side should be presented to them at once. The

physician is tempted to present the worst side of the case lest it

should be thought that he did not realize how serious the condition

was. All the seriousness of it may be impressed upon friends, but the

patient must be told all the possibilities of good. I have always felt

that the tonic quality of hope was worth more in preventing further

damage and in encouraging the beginning of repair than any drug that

we have. If patients have been unconscious, just as soon as

unconsciousness disappears, they should be told that very probably

this is the beginning of recovery and that the great majority of

people who have a stroke recover. The more rapidly the symptoms

disappear the better is the ultimate prognosis. Many a man who has had

a stroke has done years of good work afterwards and very few men who

recover fail to accomplish something that is of supreme satisfaction

to them. They have a new outlook on life as a consequence of the near

vision of death.

Those who have had one stroke usually die in a subsequent one, though,

of course, some intermittent disease such as pneumonia or some organic

complication may anticipate the second stroke. Those who have had two

strokes and survive are often much worried by the old tradition that a

third stroke is always fatal. I am reasonably sure that many old men

have not survived their third stroke when they felt its premonitory

symptoms and knew just what was coming from their previous experience,

because they had given up hope on account of this old tradition.

Ignorant people or those of the lower classes who have not heard this

axiom often survive their third stroke and I have seen a man who had

suffered from seven apoplectic seizures.

Complications.--Occasionally a patient, especially if of the educated

classes, may be much worried by the fact that while one side is

distinctly lamed after his stroke, yet there is also a pronounced

weakness on the other side of the body. This sometimes gives rise to

the rather appalling thought that there was perhaps a simultaneous

rupture on both sides of the brain. It needs to be explained to such

patients that this slight weakness, sometimes quite distinct, however,

on the side opposite that which is most affected is extremely {524}

common. Ordinarily the rupture of an artery on one side of the brain

causes a paralysis on the other side of the body. This paralysis or

loss of control over muscular action is due to disturbance of the

motor tracts of nerves through which muscular action is controlled and

directed by the brain, and these normally cross to the other side on

the way to the periphery. In nearly everyone the tracts remain

uncrossed to some slight extent. In some so much of the pyramidal

tract remains uncrossed that there may be decided weakness on the same

side as the lesion in the brain.

CHAPTER III

LOCOMOTOR ATAXIA

How much can be done for organic nervous disease by attention to the

individual patient and by favorable suggestion is illustrated in

locomotor ataxia. This is, of course, an absolutely incurable disease.

We know definitely that certain tracts of nerves in the spinal cord

are entirely obliterated and their functions can never be restored.

Occasionally the disease gives rise to severe localized pains called

crises, for which even our strongest anodyne remedies are of little

avail. As a rule, the patient grows more and more helpless and though

he may live for twenty or thirty years after the beginning of the

disease, and usually dies from some intercurrent affection rather than

from any direct effect of his disease, the condition is burdensome and

the outlook is most unfavorable and depressing. It is for locomotor

ataxia, however, that the irregular practitioners have succeeded,

apparently, in working wonders. Some of them, indeed, have made quite

a reputation for the cure of the disease. This was not because they

did the impossible and cured genuine cases, but because individual

patients can, in many cases, be so much improved by attention to

particular symptoms, and so much can be done to make life more livable

for them, that it is no wonder that so many of them are ready to

proclaim that they have been cured, though only certain symptoms, are

bettered and their underlying disease remains in essence unchanged.

One thing that constantly happens in the progress of locomotor ataxia

is a yielding of joint capsules and attachments so that there is more

motion permitted in joints than is possible in the normal individual.

As a consequence of this relaxation of tissues around the hip joint

the leg may be stretched up along the trunk when the patient is lying

down, the foot being placed over the shoulder almost as a gun is

placed at carry-arms. Patients often walk with a distinct "back knee"

because of the yielding of the tissues around the knee-joint. The

ankle nearly always yields and a specially severe form of flat foot

develops. This causes muscles to act at a disadvantage and produces

great fatigue and even a painful muscular condition when the patient

stands much on the feet. This form of flat foot is hopeless so far as

cure is concerned, but it can be greatly relieved by the wearing of

flat-foot braces or even, to a greater degree, by the wearing of

specially fitted shoes. This does not seem much to do for a patient

suffering from the serious organic nervous disease of locomotor

ataxia, and yet a lot of patients for whom properly fitting shoes

{525} were made, thought themselves so much improved and relieved by

this simple measure that they allowed themselves to be persuaded that

their locomotor ataxia was cured. In some cases, where the brunt of

the disease was borne by the feet, this relief really did so much to

afford the patients freedom from most symptoms of their affection that

they thought themselves on the road to recovery.

Value of Favorable Suggestion.--If once the idea of the awful

hopelessness of their cases is removed from locomotor ataxia patients

they will suggest their own betterment so powerfully that they easily

persuade themselves that their affection is considerably improved. It

is evident, then, that the regular physician must take advantage of

this wonderful power for the relief of human suffering and depression

that proves so helpful to the irregular. We cannot cure the tabes of

the spinal cord. We cannot re-create the nerve tracts that have been

obliterated. We realize that there is no use trying to do so any more

than there would be in trying to make an amputated finger grow to its

full size again. We can treat the patient, however. We can remove many

symptoms that sometimes bother him more than those necessarily

connected with his spinal affection. We can relieve annoyances of all

kinds that add to his misery and as a consequence we can give him

hope, keep him from brooding about himself and thus perform the proper

function of a physician. We shall not forget that we can only rarely

cure, but we can almost always relieve pain and we can always help the

patient in some way. The ataxic patient needs consolation, and this

can be given without in any way deceiving him. The loss of sight seems

an irreparable ill to those who see, yet the blind are quite happy,

are much more cheerful than many seeing people, and have learned to

stand their affliction not only with equanimity but really without

much depression. In the olden times, before proper care was taken of

the blind, they had little occupation, they had nothing to do with

their hands, the future was blank and they suffered severely from

depression. As a rule, they did not go out enough and their bodily

health suffered and the disturbance of their functions still further

heightened their depression. All of this happens now with the ataxic

patient. A host of symptoms not at all necessarily connected with his

spinal affection develop and prove sources of annoyance. Many of them

can be removed entirely, all of them can be ameliorated. If, while

doing this, we succeed in impressing a discouraged patient's mind with

our power to benefit in spite of an underlying incurable disease, we

have another triumph of psychotherapy.

Removing Unfavorable Suggestions.--The general experience with those

suffering from locomotor ataxia has been that the depression

consequent upon the announcement that they have the disease and the

stigma that is supposed to attach to it in our day leads them to a

great extent to avoid going out into the air. This adds woefully to

their depressed condition. Take a healthy man, let him stay inside a

great part of the time without any exercise, seeing no new faces,

without any interests in life, and at the end of three months he will

have a set of neurotic symptoms on a basis of depression that will

make him supremely miserable. This will be true even though he has not

the threat of an incurable disease hanging over his head. He must be

made to realize that every neglect of any law of health in his

condition is even more serious in its effect upon him than it would be

were he in good health. Above {526} all, it must be made clear to him

that while his neglect of hygiene may perhaps not shorten his life, it

will greatly add to the mental suffering, much more unbearable in its

way than the physical suffering which he will have to endure during

the progress of his disease.

Treating Accessory Symptoms.--Nearly every ataxic patient who is not

directly and almost constantly under the care of a physician, is a

sufferer from two conditions that are so constantly present that they

are sometimes thought to be consequences of the primary affection.

These are loss of appetite with consequent loss of weight and

constipation. Almost without exception neither of these symptoms or

syndromes are at all connected with the locomotor ataxia. They are the

result of the unhygienic life that the patient is living and of the

depressed state of his mind and lack of diversion. They are mutually

connected, for a man who does not eat enough will not have regular

movements of his bowels, and constipation reacts to produce further

depression. A vicious circle in pathogeny is formed and the patient is

likely to get into a very debilitated and depressed condition. Both of

these troublesome symptoms may be corrected to the manifest

improvement of the patient by proper advice and ordinary care for his

well being.

Appetite is largely a function, as the mathematicians say of something

that depends on something else, not of exercise, as is often thought,

but of fresh air. In the tuberculosis sanatoria patients with fever

are not permitted to take exercise, yet if they are out in the air

most of the day and if their rooms are well aired at night, they can

eat heartily and digest their food well. Of course, appetite is

largely a psychic matter and the thoroughly discouraged man will have

no care for food in spite of abundance of air. A little persuasion,

however, of the necessity for making the best of a bad job will

usually arouse even a locomotor ataxia patient in the early stages of

his disease to the necessity for eating a reasonable amount. If he has

suffered from gastric crises and fears that eating normally may

precipitate these, he must be persuaded that this is not the case,

that the presence of food, or its amount, or quality, has nothing to

do with the initiation of these painful attacks so far as we know, and

that even though at the beginning of his affection before his

locomotor ataxia was recognized, his gastralgia may have been declared

by his physicians, as is so often the case, to be connected with some

form of gastritis or indigestion, that idea may now be given up and he

may eat plentifully with confidence that it will not increase his

pains. On the contrary, limitation of food seems to have a distinctly

unfavorable effect in increasing the number and severity of these

attacks.

The same thing must be made clear to him as to intestinal and rectal

crises. It seems likely that tendencies to constipation by irritating

peripheral nerve endings may have some effect in bringing about the

explosion in sensory nerves which have been called intestinal or

rectal crises. In general, however, these are dependent on spinal and

not peripheral conditions, and no thought of any connection must be

allowed to disturb the consumption of a proper amount and variety of

food. It seems clear that when patients are much run down, have lost

considerable in weight and are in a generally depressed condition,

their nervous system is much more irritable than it would otherwise be

and they are likely to suffer more frequently from crises of various

kinds. Once a patient is made to understand that his general {527}

nutrition may affect not only the course but the occurrence of

symptoms in the disease, as a rule it is not difficult to get him to

eat enough and to do so with the definite feeling that it is going to

do him good. Even though it should be necessary to use tonics, and

often they will have to be prescribed, it is clear that this treatment

of the patient's general condition is the physician's first duty,

though it does not and cannot affect the specific disease.

Neurotic Complications.--There can, of course, be no doubt that the

crises of locomotor ataxia represents extremely poignant attacks of

pain. But on the other hand, anyone who has seen many of them is prone

to think that not a few of them are really attacks of pain resembling

those which occasionally develop in hysterical subjects. The pain of a

gastric neurosis may, indeed, so simulate the gastric crises of

locomotor ataxia as to make what is only a case of hysteria seem

beyond doubt one of locomotor ataxic. Locomotor ataxia patients are

prone to think much about themselves and to fear the recurrence of

these painful crises once they have had experience with them. As a

consequence they sometimes suffer from what are pseudo-crises, that

is, from neurotic painful conditions which simulate genuine crises

mainly in the amount of reaction they produce in the patient. True

tabetic crises yield more readily to ordinary anodyne drugs than do

these pseudo-crises. Nearly always the true crises are associated with

and exaggerated by neurotic symptoms due to the depression of the

patient, the yielding to his feelings, the conclusion that his pain is

inevitable and is going to be worse each time, while successive crises

are, as a matter of fact, often milder until they disappear for good,

and this element in the case must always be borne in mind. Much can be

done for the relief by psychotherapy, that is, by making the patient

see the realities of his condition, suggesting to him that succeeding

crises are less painful and that if his general condition is as good

as it should be he becomes better able to stand the pain of his crises

and the shock of them is not so disturbing to his system.

Mental Attitude.--Prof. Oppenheim, in one of his "Letters to Nervous

Patients," advising a patient suffering from an incurable organic

nervous disease, evidently locomotor ataxia, though that is not

explicitly stated, outlines emphatically the favorable side of that

disease. This is absolutely needed. Ever so many unfavorable

suggestions with regard to his affection find their way to the

patient. The very fact that it is pronounced absolutely incurable is

disheartening. Prof. Oppenheim's words, then, may be a precious help

and to have them repeated from time to time renews the suggestion:

Now, however, we neurologists know that that disease frequently runs

a very mild course, that a man showing certain early symptoms of

such a disease may for ten to twenty-five years and even longer

retain his capacity for work and enjoyment. This for a man of thirty

to forty years is almost tantamount to the expectation of a whole

normal lifetime. But on the other hand, what danger to the peace of

mind, what destruction of happiness in life may be caused if the

knowledge that such a disease has begun to develop is imparted to

the patient without being combined with the consoling information as

to the nature and course of the benign forms of this trouble! In

unceasing anxiety and fear, in daily expectancy of some fresh

symptoms, of some increase or aggravation of his troubles, does the

poor man waste his life; and I have frequently found that this

wretched apprehension and excitement cause a nervousness and mental

depression which in their effects are much more momentous than is

the commencing spinal disease.

From this miserable condition I desire to protect you, and I would

ask you to {528} take this advice deeply to heart: do not bear

yourself as one who is condemned; as one who, affected by a

progressive, incurable disease, will soon fall a victim to

paralysis. On the strength of my own experience I give you the

assurance that your condition of health will not necessarily in ten

years' time be essentially different from what it is at present. But

I would also strenuously exhort you to observe all the precautionary

rules laid down for you, to avoid all unaccustomed strain or

indulgence such as can only be undertaken with impunity by a man in

full vigor and absolute soundness of health. I would advise you also

to be thoroughly examined once a year by an experienced physician.

But apart from these restrictions, you should as far as possible

feel yourself and bear yourself like a healthy man, remaining

attached to your work, and not withdrawing yourself from the

pleasures of social intercourse.

Relearning Muscular Movements.--Perhaps the most interesting evidence

of how much may be done for organic nervous disease in spite of the

fact that the underlying lesion is absolutely incurable, may be

obtained from what is accomplished by Frenkel's method of treating

locomotor ataxia. As is well known, by reteaching the movements

necessary for walking, ataxic patients regain control of the movements

of their limbs to a marked extent. As a consequence, bed-ridden

patients are enabled to walk once more even though they may have to

carry a cane and be supported, and patients who have had to use two

canes get along with only one, or may even eventually be able to walk

without any artificial support.

Just how the improvement is brought about we are not quite sure. It

seems probable that the eyes become trained to replace the muscle

sense to a noteworthy degree, but there is in addition apparently a

re-education of the muscle-sense. Perhaps there is also a transfer of

the function of certain degenerated nerves to other tracts than those

in which muscle impulses originally traveled. The improvement in

muscular control originally obtained is a striking illustration of how

much nature is able to compensate for even organic lesions and is a

lesson in the necessity for never ceasing to try to do something even

when the case seems hopeless. Certainly locomotor ataxic patients

would seem the least likely to be benefited by training in movement

and yet this movement therapy for tabes has had some wonderful

results.

The story of how this mode of treatment came into existence is

interesting and instructive as an illustration of how happy chance in

our time, as so often with regard to drugs in the past, came to assist

the rational development of therapeutics. A German professor wished to

demonstrate to his class the varying inco-ordination of a series of

tabetic patients. Some of them had their main inco-ordination in the

legs, others in their hands. He went over the cases in his wards so as

to arrange the demonstration for the next day. He told each patient

that he would ask him to perform a particular set of movements before

the class which would illustrate strikingly a particular phase of

muscular inco-ordination. His patients were interested in the

announced demonstrations and during the afternoon they went over the

movements that they were expected to perform. They practiced them as

assiduously as their condition permitted for the exhibition. As a

consequence the most striking features of their inco-ordination

disappeared. After having practiced the movement for a certain length

of time they could do it ever so much better than before. The special

feature of the professor's demonstration was spoiled, but a great

contribution to our knowledge of nature's compensatory powers {529}

was made and fortunately the hint of its significance for treatment

was taken and developed.

Effect of Favorable Suggestion.--How much can be accomplished for the

relief of the general symptoms of locomotor ataxia and for the placing

of patients in an attitude of mind that makes most of their symptoms

of vanishing importance, can be judged from some recent experiences

with a new cure for the disease. This consisted only of some rather

conventional treatment of the urethra by applications and dilatation,

yet patients were relieved so much of the symptoms of locomotor

ataxia, or at least persuaded themselves that they were, that both in

this country and in Europe the discoverer of the new "cure" soon had

scores of patients. The active therapeutic agent undoubtedly was the

fact that patients who had been told that their disease was incurable

and who had settled down in a state of discouragement and apathy in

which their power over their muscles, their general health and their

strength and vitality were at the lowest ebb, and their tendencies to

discomfort emphasized and made poignant by the supposed hopelessness

of their situation, became aroused to new vitality by the promise of

cure and then, under the repeated suggestion of a treatment said to be

sure to cure them and that had cured others, became so much better,

that is, released so much latent energy, that they felt better, ate

better, walked better, got out more and had their general health

improved, and all to such a degree that their disease seemed cured.

Another interesting illustration of what would seem to be the power of

suggestion over the symptoms of tabes occurs in a recent article in

the Archivos Espanoles de Neurologia Psyqiuatria y Fisioterapia of

Madrid [Footnote 39] on the improvement of tabes dorsalis by

antidiphtheritic serum. It is quite impossible that the serum should

affect favorably any of the underlying lesions of the disease any more

than that these should be ameliorated by the wearing of shoes of

special character or operations on the urethra. The patient in this

case, however, was distinctly improved in many ways _after_ the

antidiphtheritic serum was injected. There were some interesting

sensory manifestations, pains in the arms and legs after the

injection, but these were removed by santonin or methylene blue. Both

of these drugs are eminently suggestive in their action, so that one

would be prone to think the pains rather neurotic than actual. After a

dozen injections had been given, the patient's sensations improved,

his power to pick up small things was better, and the sense of walking

on carpet had disappeared to a marked extent and he was able to walk

much better than before and without support. Probably any attention

given to him to the same degree would have produced like results.

[Footnote 39: Tomo 1 No. 7, July, 1910.]

We have had previous examples of this kind in the history of the

treatment of locomotor ataxia. Certain drugs when given in the past

with the definite promise of cure and pursued for a good while with

frequently repeated favorable suggestions, have often seemed to

benefit patients, though subsequent experience has shown their total

lack of value to modify the disease. Nitrate of silver was one of

these in the old days and many locomotor ataxia patients acquired an

argyria as a consequence of the amount of silver absorbed and

deposited in the skin. Arsenic was another and some of the aluminum

{530} compounds were also used. When we recall the suspension

treatment and its reported good effects--and failure, the

over-extension treatment with the same history and many others in the

past, the real place of the mental in the therapeutics of tabies is

revealed. Once this is practically realized, we find that we have

ready to hand and easy to use, the one really efficient factor in all

these treatments--that is, the influence on the patient's mind. It is

for the physician to devise thoroughly professional ways and means of

using that in each particular case so that his patients may be

benefited as much as possible. Certainly it would be foolish for us to

leave to the irregular practitioner the use of this extremely valuable

remedial measure, when we may do so much good with it, for the relief

of symptoms at least.

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 assurance that my

experience with Fournier in Paris taught me the absolute curability of

the disease, "Well, there are three men of my class 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 pass

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 Reassurance_.--The first point in psychotherapy, then,

is to give just as much reassurance 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 assured 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 constitutional 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 cumulative 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 praecox 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

reassured 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 constitutes 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 attitude of

mind assumed 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 attitude which is so often assumed of

absolute assurance 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 passing 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 reassuring 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 repetitions 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 repetition is likely to be associated 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

assurance 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 Association 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 associated

with extraordinary mental qualities. A study of this subject is

extremely reassuring to the epileptic who is prone 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.--Reassurance 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 attitude 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 attitude 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 prone 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

associated 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 class

of cases so closely related to epilepsy that it is often extremely

difficult to make the differential diagnosis between the two varieties

of seizure. Fifteen years ago, while I was at the 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

associated with falls that resemble fainting spells and seem to be

accompanied by complete loss of consciousness. Usually after them

there is a distinct tired feeling and an inclination to sleep, though,

as a rule, there is a more marked tendency to want to get away from

observation. Some of the cases are much more severe than those

described and the conclusion that they are true epilepsy seems

inevitable, yet they recover so completely that this conclusion is

negatived.

Occasionally such attacks occur only when the patient has been

strenuously exerting mind or body for a much longer period than usual.

In teachers it is likely to occur toward the end of the year or in the

midst of the hard work about examination time. In students this same

period is likely to be a favorite starting point for the attacks and

they recur oftener at this time than at others. Very often there is a

story of some digestive disturbance in connection with the attacks. At

times it seems possible to trace them to some interference with the

cerebral circulation through a distended stomach pressing upward

through the diaphragm and interfering with the heart action. In such

cases stomach resonance will sometimes be found as high as the fifth

rib {539} and the apex beat may be pushed out to the nipple line or

beyond it. This may be true though there are no signs of valvular

lesions and no symptoms or physical signs of dilatation or hypertrophy

of the heart.

_The Suggestive Element_.--Analysis shows the real course of the

trouble in these cases. The sufferer is usually following a sedentary

occupation, not getting much exercise or diversion and prone to

introspection. Many symptoms of themselves of no importance have been

emphasized by concentration of attention on them. Especially is this

true of any heart irregularity. The patient has dreaded for some time

lest the feeling of pressure in the precordia and of discomfort in the

heart might not sometime interfere with him in the midst of his

teaching or preaching duties. Some day when he is feeling much worse

than usual, in the midst of his work, there comes over him the feeling

that now his intellect is going to stop action because there is

something the matter with him. The sudden concentration of his

attention on this with the fear of the consequences and the

uncomfortable feeling that he will not be able to go on with his flow

of ideas, cuts off the thread of what he is thinking about and puts

but one single object before him--this possibility of failure of

mental action. Usually the first attack is only such an interruption

as is thus indicated. The fear of subsequent attacks, the worry over

what has happened, the dread that some serious mental affection or

nervous disease is at work emphasizes introspection and subsequent

attacks are even more likely to be serious, and especially to last

longer than the first.

The more the cases are studied the more the conclusion comes that in

many of these instances it is nothing more than auto-suggestion that

is responsible for the mental lapse. It is true that some physical

condition may be the occasion, though the mental state is the active

immediate cause. Suddenly concentrated attention on the dread of

mental interruption inhibits mental action and what was dreaded

follows almost necessarily. It is a sort of auto-hypnotism in which

the patient's train of thought is interrupted by a momentary or longer

hypnotic state the causes of which can be traced. Even when there is a

real organic lesion of the heart, the lapses of memory and even of

reasoning power that occasionally occur, have often seemed to me to be

due rather to the patient's dread than to any real physical condition.

I cannot think that there is a sufficient interruption of the cerebral

circulation, even though only for a moment, to cause such a lapse. It

is a question of nerve interferences rather than of blood supply. If

the blood were diverted, even though only for a moment, or if there

was a stoppage, the consequences would be more serious and more

lasting than they are.

What evidently happens is some disturbance of neurotic connections

within the brain brought on by sudden dread or emotion. The will has

lost control or has seriously disturbed the conducting apparatus. The

best proof that this is what happens and that it is not the result of

organic change is found in the fact that when the physical occasion,

that is, the digestive disturbance or the heart palpitation which is

the initial factor in these states, is relieved, the attacks do not

take place. Patients in whom they have occurred even for years cease

to have them. This improvement does not begin, however, until their

solicitude over their condition has been lessened by a confident

declaration to them that they are suffering from merely functional and

local reflex conditions apart from the brain itself. Usually it needs

to be made clear {540} to them, too, that their anxiety in the matter

means much more for the continuance of the attacks than any physical

condition.

Almost invariably patients somewhat resent this suggestion. Their

response to this explanation of their ailment usually is that the

attacks come on them when they are not particularly expecting them and

that there is first some physical symptom which might readily be taken

for a sort of aura to a genuine epileptic attack and then the attack

itself comes on. It is this preceding symptom, pain or discomfort, or

whatever else it may be, that provokes the suggestive element and

brings about the state of quasi-hypnosis, which is the main part of

their attack.

Neurotic Syncopal Attacks.--Some of the cases of pseudo-epilepsy are

very mild, though if the word epilepsy has been mentioned there

naturally arises a feeling of dread in patient and friends with

consequent unfavorable suggestion. A type not infrequently seen has

for its main symptom a period, usually of but short duration, in which

there is an intense tired feeling so that even the eyelids droop and

require effort to lift them. During such attacks the respirations may

slow down to fifteen or below, though usually the pulse is inclined to

be rapid. The feeling of fatigue is almost entirely subjective, in the

sense that, if patients are required to do something, they are able to

accomplish it by a little urging, though a moment before they were

sure that they could not. Such attacks are invariably functional, have

no organic basis and do not deserve the name of epilepsy. If called

hysterics this will cause the patient, who is often a woman, to rouse

herself and so gradually overcome them. They are really a loss of

confidence in one's power to do things and a passing astasia-abasia.

The use of the word hysterics may cause the patient to lose the

sympathy of her friends, though she may need it; for often there is an

underlying pathological condition not in the nervous but in the

somatic system. Sometimes the patients are anemic, sometimes they have

an abortive form of Graves' disease, and sometimes they are low in

nutrition.

These conditions give the indication for treatment. What is needed is,

of course, improvement of the general condition, but, above all, a

restoration of the patient's confidence in herself. Once it is made

clear to her that the attacks are largely subjective, that is, are due

to a feeling of prostration because of the fear that she is unable to

do something, then the intervals between the attacks will gradually

grow longer. It is important that long hours of sleep should be

advised with plenty of fresh air, and that whatever disturbances of

the digestive system are present should be carefully treated.

Pseudo-Epilepsy and the Menopause.--A number of these cases of

pseudo-epilepsy occur at the menopause. They seem particularly likely

to occur in women who have not much to occupy themselves with.

Childless women who have no cares and enjoy every luxury sometimes

seem to have these pseudo-epileptic attacks as equivalents for the

flushings of the ordinary menopause. During "a rush of blood to the

head" they lose control of themselves. Occasionally mothers who have

two or three daughters and who get their menopause late in life, that

is, well after fifty, are especially likely to suffer in the same way.

The solicitude of those near them seems to eliminate some of their

power of inhibition and makes them think overmuch of themselves. If

then they keep much at home, as women at this time are prone to do,

have few {541} diversions of mind, little fresh air and exercise,

there is an accumulation of unused nervous energy which dissipates

itself in explosive attacks very like epilepsy. It is with regard to

these that the term hystero-epilepsy almost seems justified. Just as

soon as occupation and diversion of mind and relaxation of the

solicitude of friends for them is secured they begin to get better.

The differential diagnosis of these cases is made from the absence of

certain of the pathognomic signs of true epilepsy. The tongue is not

bitten, involuntary urination does not take place, and when the

patient falls she does not hurt herself as a rule, though occasionally

the fall may result in accidental abrasions or bruises, but these are

quite trivial. If stress is laid upon the fact before these patients

that they do not present any or all of the symptoms of epilepsy, some

of them are likely to occur a little later. Slight abrasions on the

tongue will be noted and the sputum will become a little bloody. Even

very cleanly women will sometimes wet themselves. It is not a

deliberate attempt at deception, but their curious psycho-neurotic

condition causes suggestion to act upon them. Their attacks are really

auto-hypnotic and during these the remarks made by the physician occur

as suggestions and then are accomplished. If the suggestions in this

matter have been carelessly made by previous physicians the attacks

will so closely simulate true epilepsy that it will often be almost

impossible to differentiate them with assurance.

In the preliminary diagnosis of these cases, as well as of all other

cases of pseudo-epilepsy, we must, as far as possible, avoid the use

of the word epilepsy, even of hystero-epilepsy. The unfavorable

suggestion attached to such terms will have the worst possible effect.

There is no need to fear that the patient will be any less taken care

of, if the disease is called by some other name, for instance,

neurotic paroxysms or nervous attacks.

Cure by Suggestion.--Such patients are often cured by remedial

measures of one kind or another that are administered with the

confident declaration that they will get well. A number of cases of

epilepsy which were really of this character have been reported cured

by Eddyism. A number also have been very favorably influenced by

osteopathic treatment. Needless to say, the reports of such cured

cases have not been diminished in significance by the publicity

bureaus of these various cults. Mental healing has relieved a number

more. Usually this relief has been afforded these cases after they had

tried regular physicians who had treated them in the ordinary way with

bromides, without doing anything more than causing them to miss a few

attacks for a temporary period of relief, if even that, giving them

bromism and further increasing their solicitude about themselves by

unconsciously emphasizing their ideas as to how serious epilepsy can

be. The cures of these cases are not due to the various treatments to

which the patients proclaim their debt of gratitude, but to the

confident assurance given them that their condition is not serious,

and will be cured. After analysis of their attacks has shown them to

be neurotic and not genuinely epileptic, the regular medical

practitioner can readily do as much and even more; for psychotherapy

has much more to do in affording relief in these cases than any other

form of treatment. It must be applied with confidence and the results

are often most favorable.

{542}

CHAPTER VI

PARALYSIS AGITANS

This is a chronic affection of the nervous system having for its most

characteristic symptom a tremor, but with marked muscular rigidity and

weakness. It is much more common in men than in women, in almost the

reverse proportion of Graves' disease. It is usually a disease of the

old, but may occur in early middle life and has been known to develop

even early in the twenties. In the old days when malaria was a common

diagnosis for many different conditions, paralysis agitans apparently

followed malaria so often that there was thought to be some connection

between the two diseases. The more we have learned of malaria the less

likely this seems to be. Continuous exposure to cold for long periods

and to dampness during the daily occupation for years, or repeated

severe wettings, have been considered as causative elements. None of

these physical factors, however, has been as directly connected with

the occurrence of the affection as various emotional conditions, and

the thought is suggested that even in cases of severe exposure the

worry and fright and solicitude incident to the fear in an elderly

person that this exposure will have serious consequences, is an

important etiological element.

Psychic Factors.--_Fright_.--Practically all the authorities agree

that mental conditions are prominent factors in the production of the

disease. Serious business cares and worries and anxieties have often

long preceded its development. Fright is mentioned by nearly all those

who write on the subject as at least an occasion for the development

of paralysis agitans if not a cause. One of my own most interesting

cases occurred in the sheriff of a county of the Southwest who had

earned for himself the deep enmity of an Indian by arresting him. Not

long afterwards one Sunday morning when the sheriff quite unarmed came

round a corner he found the Indian just in front of him wildly drunk

and armed with a rifle. At once the rifle went to the Indian's

shoulder, but he did not want to kill his man without having his

revenge by torturing him, so he did not pull the trigger, but

announced to him in vigorous though broken English that he had him now

and was going to kill him. The sheriff tried to parley and for a

moment the Indian permitted him to do so, apparently in order to

prolong the agony. They were not more than two yards apart at the

beginning, and the sheriff took his only chance and jumped and knocked

the gun up. It went off just as he did so, the bullet singeing his

hair. He succeeded in arresting the Indian and throwing him into jail,

but the next day a tremor developed in the arm which had grasped the

rifle. This spread and finally became typical of paralysis agitans. He

was a man only slightly past fifty and there had been no preliminary

symptoms.

Mental Control of Symptoms.--Many similar cases following fright or

vehement emotion have been reported, so that it is easy to understand

the feeling that the affection has a large psychic element in it,

though evidently from its persistency and its continued development,

there is some underlying pathological condition. The tremor may be

controlled in voluntary {543} movements, while emotion exaggerates it.

There is no doubt, however, that concentration of will and the

definite effort to control the symptoms enables the patient to rid

himself of them to a great degree for a time at least. It has been

noted frequently that when a consultant physician is called the

patient will be better for the day of the consultation than he had

been for months before. The visits of particular friends will often

arouse a sufferer to such efforts as greatly lessen his rigidity,

decrease his tremor and make him capable of getting around better than

before. The state of mental depression that commonly develops in these

cases exaggerates the symptoms, adds neurotic and even physical

conditions that develop from lack of exercise and air, and makes the

patient's general state much worse than it would otherwise be.

Pathology.--Our scanty but growing knowledge of the pathology of

paralysis agitans makes it clear that the disease is, in typical

cases, probably due to an overgrowth of connective tissue, the

neuroglia cells, in the central nervous system. Just what causes this

overgrowth of connective tissue is not clear. It is an exaggeration of

a normal senile process. Apparently one of the processes of age in man

is a decadence of the vitality of important higher tissues with a

corresponding increase of vitality in the lower or connective tissues.

When Flourens declared at a meeting of the French Academy of Sciences

that such an overgrowth of connective tissue was natural with

advancing years, he added that this probably accounted for the

slowness with which older men come to conclusions. The old members of

the Academy did not accept this new-fangled doctrine with equanimity.

They were inclined to think that their conservatism and deliberateness

were due to greater poise of intellect.

There seems to be no doubt that at least a comparative overgrowth of

connective tissue is characteristic of the brain in advancing years.

In some people this occurs to a greater extent and is more precocious

than in others. Just what causes are responsible for individual

differences we do not know. Paralysis agitans is seen often in those

who have worked hard most of their lives, but, on the other hand, may

occur in those who have lived sedentary lives, and in people of all

occupations. Over-indulgence in alcohol, though this is often thought

to predispose to the disappearance of the parenchyma of organs and to

the overgrowth of connective tissue, does not seem to have any place

in the etiology of this affection. Its occurrence is a part of that

mystery by which the equilibrium of different kinds of cells in the

body is maintained or diminished. In a mild way paralysis agitans

represents such a change in the central nervous system.

Mental Influences.--With an overgrowth of connective tissue as the

pathology of the disease there would seem to be no question of any

relief of its symptoms or any benefit to be derived from

psychotherapy. Anyone who has much to do with cases of paralysis

agitans, however, knows that they are extremely susceptible to mental

influences. Whenever there is anything that interests them, any

business that they feel they must do, any special event that they look

forward to, they will for days at a time be so much improved in

general symptoms as to be greatly encouraged themselves and make their

friends feel hopeful with regard to them. When they give in to their

condition, however, and make no special effort at self-control and

stimulation their symptoms increase very much. Their rigidity

particularly increases, their {544} tremor becomes more marked and

various inconveniences associated with these two cardinal symptoms are

emphasized.

Methods of Treatment.--_The Vibrating Chair_.--It is interesting to

recall some of the forms of treatment which have been reported as

beneficial in paralysis agitans, because they illustrate how much the

influence of the patient's mind has over his bodily condition and how

much the interest aroused in any new and particularly in any unusual

form of treatment has in mitigating symptoms and how often it seems to

bring about remissions in the progress of the disease. Twenty years

ago Charcot suggested the use of a mechanically vibrating arm-chair.

He had noticed that patients who travelled by rail seemed to have

their symptoms improved for the time at least by the shaking up in the

train. This treatment undoubtedly made patients much less rigid and

much less tremulous. The improvement lasted sometimes for hours and

sometimes for days. It was tried rather extensively and everywhere

with reported good results, when first tried at least. After a time it

was found that it failed to have the desired effect. Apparently

whatever therapeutic value it had was due to the interest aroused in

the patient's mind and the consequent effort that was made to control

his muscles.

_The Suspension Treatment_.--When the method of treatment by

suspension became popular for cases of locomotor ataxia, the idea came

to try the same thing for paralysis agitans. Accordingly suspension

apparatuses of many kinds were used with reported good results.

Patients were suspended by the neck for some minutes and some of them

got used to the treatment and could stand it for a prolonged period.

The effect was always a distinct mitigation of symptoms. The rigidity

particularly became much less marked, but the tremor also was lessened

and besides certain secondary symptoms were bettered. Constipation was

improved, partly because patients were more cheerful, ate more

heartily and, above all, were willing to make some effort in order to

get out regularly into the air. There was a variety in life, different

from the solitary sitting at home into which these patients so often

drift. Sleep was better at night and the subjective sensations of heat

and cold were lessened. Patients were encouraged to think of

improvement and used all their available nervous energy. In the same

way when overstretching of the spinal cord by forcibly bending of the

body at the hips was tried with reported success in tabes it was also

applied to paralysis agitans with similar improvement of symptoms.

Both methods of treatment have gone out for both these affections and

evidently their observed therapeutic efficiency at first was entirely

due to their effect upon the mind.

_Psychic Elements and Other Remedies_.--When organo-therapeutics

became the fad paralysis agitans was treated also by this method. Some

cases were treated with reported good results by thyroid. Later when

the parathyroids attracted attention they were administered with

reported good success in even very severe cases. I think that there is

a report of some cases of paralysis agitans being improved by

injections of diphtheria serum. In other words, anything that was

given to a patient with the promise that he would be better after it

and that produced a definite effect upon his mind was likely to do him

temporary good. If the remedy had some special theory behind it, if

there was a story of some new scientific significance for the material

employed or the method of giving it, then this improvement was sure to

take place. {545} In the drug treatment of the disease the same

principles applied. Earlier, when nitrate of silver was the main

recourse for organic nervous diseases, cases were reported improved by

its administration. When the alterative properties of arsenic became a

therapeutic fad this produced good effects. Atropin had for some time

a reputation of relieving patient's symptoms. After a time all of them

ceased to be used to any extent.

_The Frenkel Method_.--In recent years the application of the Frenkel

directed movement method, modified somewhat from its application in

tabes, has attracted attention in the therapeutics of paralysis

agitans. It is interesting to note how often a mode of treatment that

has been applied successfully to one of these diseases has also proved

successful with the other. The two diseases are, of course, very

different in etiology and pathology; but have one thing in common. The

control over muscles has been lost to some degree in both cases in the

progress of the disease, and a special effort of attention is required

on the part of the patient in order to regulate movement. Anything

that will arouse the patient to make this special effort will relieve

the symptoms for a while and in tabes may bring about a lasting

improvement, because the habit becomes easier after a time, though

apparently this does not occur in paralysis agitans, except perhaps in

the younger patients. It might very well be expected, then, that

Frenkel's method in many cases would do good in paralysis agitans and

it has proved to be another adjunct in the treatment of the affection.

It must be used with great care not to exhaust the patient, but this

is true also in tabes. The real source of its therapeutic quality

seems to be the patient's interest in it and if this cannot be aroused

it usually fails to do good. The success of these various mechanical

methods makes it easy to understand why these patients often improve

for a time under osteopathic treatment.

_Psychotherapy_.--It is clear, then, that the most important aid for

these cases is the arousing of mental interest in some form of

treatment that promises to be of benefit to them. New forms of

treatment cannot always be invented and mental occupation must be

secured by interest in other things. Patients suffering from paralysis

agitans are prone to allow themselves to give up efforts to do things

in which their interest would be aroused. They must be encouraged to

do many things. Carriage riding, automobiling, train excursions,

because of the effort required to resist vibration, are all helpful.

They must not be allowed to drift into vacuous habits in which they

make no effort for themselves. They can thus be made much more

comfortable and most of their symptoms can be relieved to a marked

degree. This requires constant attention and ever-renewed efforts to

arouse the patient's mind and to have him make such efforts as will

overcome rigidity and control the tremor to some extent; but with care

an amelioration of the condition can always be brought about and can

be maintained, at least to the extent of making the patient much more

comfortable than would otherwise be the case.

{546}

CHAPTER VII

HEADACHE

In spite of the improvement in the general health of the community,

due to more hygienic living, more healthy food and better ventilation,

headache, instead of decreasing, has increased to a great degree. Any

number of headache cures are advertised in the daily papers, in the

street cars, on the signboards, even in medical journals, and besides

these nearly every druggist has his own special preparation for

headache, so it would seem as though literally many millions of doses

of these headache cures must be taken every week. It would seem as

though there must be some special unhygienic factor at work to produce

headaches at a time when all other pathological conditions are being

reduced in number and severity.

A study of the patients who are especially affected by headache seems

to furnish evidence as to the special factor that has led to the

increase of the affection. It occurs much more frequently in women

than in men. It is complained of particularly by those who have less

regular occupation, and the notable increase has come with the

opportunity for leisure on the part of large numbers of the community

due to the growth of wealth.