A feeling of discomfort in the head to which much attention is paid

will become such a painful condition as to deserve the name of ache,

if it develops in those who have no serious occupation in life and no

interests that demand peremptory attention. With the noise of many

children around them in the olden times women suffered comparatively

little from headaches. Most of our grandmothers scarcely knew what it

was to have a headache. Now most business men are likely to say the

same thing. Very rarely do they suffer from headache. When they do,

there is some specific reason and when this is removed the headache

disappears. There are many women of leisure who have regular headaches

for which they must have some remedy at hand or the pain becomes

intolerable, but there are few women strenuously occupied with

business affairs or with interests in which their attention is

absorbed who find themselves under any such necessity.

It is evident that certain conditions predispose to headache. The

principal of these is having sufficient time to advert to certain

uncomfortable feelings in or around the head. Few people who stop to

think of what their head feelings are but will find there is some

unusual sensation somewhere in or outside the head which if dwelt upon

becomes emphasized into an ache. If the mind can be diverted it

disappears. If there has been some injury of the head or some

pathological conditions set up by congestion or anemia, the feelings

may become emphasized and occupy the center of attention, and even

after the injury has disappeared or the pathological condition been

ameliorated some sensations remain which with advertence produce achy

feelings of discomfort. This is the history of a great deal of the

increase of headache in our time. There are, of course, real headaches

due to definite pathological conditions, but the great majority of

headaches complained of {547} are the result of over-attention to

certain sensations, some of them normal, some of them only slightly

abnormal, which are emphasized by concentration of attention on them

until they become a torment.

Two main classes of headaches come to the physician for treatment. One

class is seen in patients who suffer from real and even acute pain

that cannot be distracted by diversion of mind, that is usually worse

when they try to sleep, as toothache is, and is evidently due to

definite physical disturbance. In the second class are the many queer

feelings about the head called headaches, though the patient suffers

rather from annoyance than from pain. It is said that the Chinese in

olden times put criminals to a lingering death by fastening them in

such a way that a drop of water fell every minute on their heads. It

was impossible to avoid the falling drop, and its constant recurrence

became an awful torture. Any feeling that engrosses consciousness will

be followed by the same sense of torment. The constant exercise of

function of any nerve without rest is of itself physically disturbing

to a serious degree. This must be realized with regard to many forms

of headache which, though trivial in origin, are the source of bitter

complaint.

Attention Headaches.--Professor Oppenheim, in his "Letters to Nervous

Patients," has a paragraph with regard to headache that is worth

recalling for the benefit of patients who suffer from low-grade

headaches. Doubtless these were at the beginning real aches due to

some local condition. They are now due merely to exaggeration of more

or less normal feelings within the head which have come into the realm

of the conscious because of the attention attracted to them when the

intracranial affection was first noted. Professor Oppenheim says:

Your headache also I ascribe to this source. Originally it may have

been a real headache, the result of your nervous shock. There is no

one who has not at some time had a transient feeling of pain in the

head or in some other part of the body, quite apart from those

caused by injuries or painful diseases. Out of a thousand various

kinds of causes I will mention only an extremely common one: the

pains which result from straining muscles or nerves. Every sudden

awkward movement may in this way cause pain in different parts of

the body, but very specially so in nervous persons, in whom the

mechanical excitability of the nerves--that is, their sensitiveness

to pressure and strain--is usually exaggerated. As a rule, however,

this pain is quite transient. But here again the law of which I have

been already speaking comes into force: under the stimulating

influence of introspection the tiny, perishable seed-grain of pain

grows into the firm, strong, enduring tree of neuralgia or

psychalgia.

The first condition for the successful treatment of headache, then,

must include the recognition of the possibility of some rather simple

pathological condition being exaggerated by over-attention to a

disturbing affection, or of some affection, now past, having produced

a suggestion that, in a mind given to introspection, continues to have

influence even to the inveteration of sensations for which there is no

longer a physical cause.

These patients insist that their medical status is that of real pain.

Hysterical patients describe a sensation as if a nail were being

driven into the forehead--the so-called clavus hystericus. In nervous

people the sense of pressure increases from one of mere discomfort to

a positive pain, as a consequence of attention to it. In most cases of

headache, however, what is most needed is a distraction of the

attention from the ailment. Over and over {548} again I have found

that when all remedies failed the deliberate search for an occupation

of mind that would interest the patient during many hours of the day

was the only thing that promised relief and in many cases the relief

afforded was so complete that patients were effusive in their

gratitude.

_Power of Distraction_.--The proof that these so-called headaches are

really not aches is found in the comparative ease with which many of

them may be suppressed. Almost any interesting occupation will make

the sufferer forget them entirely and they will not return immediately

after the occupation ceases, but usually only when the patient is

alone and attention is once more directed to this symptom. These queer

feelings about the head that are often raised to the dignity of

headaches by attention and auto-suggestion may be distracted away

completely. That they are not pain is shown by the fact that the

ordinary remedies which ease pain so promptly often fail to relieve

these or soon cease to have any effect on them.

_Lack of Distractions_.--The apartment hotel system has multiplied the

victims of headaches. When a woman has nothing in the world to do

except get her clothes fitted and attend to what she calls her "social

duties," it is no wonder that her head bothers her. Blood is

constantly going to the brain and interchange of nutritive elements is

taking place, yet there is no real function of cells and no

consumption of material, or at least function is so slight that

consumption of material must be trivial. There is no reason why these

women should get up in the morning. Their breakfast is brought to

their rooms, and some of them do not get around until eleven o'clock.

Women used to have a morning occupation in going out to market or else

in planning the household day with housekeepers, but of course there

is no more of that. In olden times, too, many of them had religious

practices. Now women are likely to be unemployed until the afternoon,

which must be occupied at most with so-called social duties that may

be done if one wishes to do them, but that may be put off for many

reasons and there are constantly recurring reasons for not making any

special exertion. Also, the rooms these women live in must be kept at

a high temperature because the poorer the air that we breathe the

higher must be its temperature for comfort, while stimulating fresh

air may be quite low in temperature and yet produce only a brisk

reaction instead of chilly feelings.

Children used to be the best possible remedy for these non-occupation

headaches, but either there are no children any more or there are but

one or two and these are largely cared for by _bonnes_ at home and by

various schools once they have reached the age of three. The old idea

that children should not leave home until six put upon the mother the

burden of their early education, but since the coming of the

kindergarten she is relieved of responsibility of this and the mother

of one or two children might now almost as well be childless as far as

any serious occupation from care of her children is concerned.

If patients are told all this bluntly there will be a vigorous protest

from most of them, for to them their pains are very real. It must not

be forgotten that a pain in the mind is often worse than in the body.

Some of these women save themselves from having their unused mental

faculties disturb them from very lack of something to do, by becoming

interested in charities, in clubs, in social movements of various

kinds, in art and in literature. It is {549} not to these that I

refer. On the contrary, if women have nothing else to do I would

insist that they find some cause or movement in which they may become

deeply interested. Their interest will save them from self-annoyance,

though it may not exactly add to the gayety of nations in its effect

upon other people. As a physician, however, I am only interested for

the moment in the good of particular patients.

Source of Pain.--I would not be understood as saying that all

headaches are not real aches nor pains in the most literal sense of

the word, for some of them are agonizing tortures. With regard to all

headaches, however, even the most genuine variety, there are certain

considerations that are of value from the standpoint of

psychotherapeutics. The most important of these is assurance as to the

source or location of the pain. Most people think that it is the brain

itself that is suffering pain and not a little of their suffering is

due to the fact that they dread the effect of such pain upon the

cerebral tissues and its possible consequences upon their mental

state. These people will be much relieved to be told at once that the

brain tissue itself is not sensitive, that when exposed it may be

touched with impunity without causing any pain. It is the structures

surrounding the brain that are sensitive. As a rule the lesion that

causes pain is not progressive and all dreads with regard to serious

after effects may be put aside.

Pressure Headaches.--It is important to insist on the fact that, as a

rule, headaches and pains in the head are not due to the brain, but to

extraneous structures within the skull. It is true that brain tumors,

gliomatous and cystic and, above all, the overgrowth of the pituitary

body in acromegaly give rise to agonizing pains. The cause of these

headaches is undoubtedly pressure. It is not the pressure upon the

brain tissue itself, however, that is the underlying cause of the

pain, but pressure upon the sensitive structures connected with the

brain. The same thing is true with regard to congestive headaches.

Pain is produced not because vascular congestion presses on sensitive

brain tissues, for we have no reason to think that any such exist, but

because the congested brain exerts pressure upon sensitive filaments

in its integuments. Neuralgia may be unbearable and yet it is borne

with more equanimity, and less dread of results, because it is felt to

be in a comparatively unimportant structure. One of the most serious

elements in severe headache is the fear of lasting results in the

brain tissues, that may lead to disturbance of mentality or to injury

affecting mental processes. Patients find their pain much more

bearable as soon as they are assured that headaches do not lead to

mental disturbances and that, as a rule, even the growth of a tumor

does not disturb mentality.

In the relation of the brain to the intellectual faculties that are so

closely associated with it, we must remember that direct connection

between the two has not been demonstrated and that the relations of

the brain and the mind are almost as mysterious as they ever were.

There are some who still think that the frontal convolutions are

especially concerned in carrying out mental operations. All that we

know about them in pathology, however, is that they are the silent

convolutions. When a lesion occurs in other portions of the brain we

see the effect of it practically always without delay, in some way,

either in the sensory or motor functions of the body. Large lesions in

the frontal region, however, often give no sign. Large tumors have

been found {550} pushing frontal convolutions from their ordinary

positions without any noticeable effect upon the individual.

Hard Study and Headache.--It is worth while to impart this knowledge

to patients who suffer from headaches, because it at once improves

their outlook on life. I have known hard students--men who had spent

twenty or thirty years in work at a special subject--live in constant

dread that sometime their minds would give way because they frequently

suffered from headaches, or at least from some uncomfortable

sensations in their heads, which they feared as a portent of ultimate

mental breakdown. The assurance that such a thing is utterly unlikely

and quite apart from the physician's ordinary experience, not only

relieved their anxiety and made their headaches more bearable, but in

a dozen of cases in my note-books the headache has gradually

disappeared as certain habits of life were corrected and modified, as

their habits of eating were varied, as bodily functions were

controlled and as diversions of mind were introduced into lives that

had before been too unvaried for healthy functions.

I do not think that I have ever seen a case, and I have been closely

in touch with hard students for over twenty years, where I felt that

the cause of a headache was mental overwork. I have known men who at

the age of seventy or over have taken but four or five hours of sleep

and who have worked at their favorite subjects for the better part of

half a century. They never complained of headaches. Of course, there

are others whose physical and mental power is less and who cannot be

expected to stand a strain that for large-minded men is only the

normal exercise of function. It has not been the mental work that they

were doing, however, that was the source of whatever central nervous

disturbance was to be found in lesser minds, but worry and anxiety and

dread over what they were doing, anxiety as to what they were going to

do that constituted the real pathological agents at work.

_Local Conditions_.--A striking case that impresses patients much more

than the physician's declaration and is more likely to be remembered

and is therefore of psychotherapeutic value, is that of Von Buelow, the

German musician. He suffered for many years from excruciating

headaches. They were so severe as almost to drive him crazy. His only

relief was morphine and he and his friends lived in the midst of no

little dread that sometime or other either the pain or the process

which caused it would bring about a deterioration of mentality. After

his death an autopsy was made. It was found to be a small nerve fiber

pinched by a scar in the dura as a consequence of an injury received

when Von Buelow was very young. Many other stories of this kind have

been told.

It must not be forgotten that in many cases the pain is not within the

skull itself or at least its cause is not and other sources should be

carefully looked for. The connection of the eyes with headache has

been so well worked out, owing to the initiative of S. Weir Mitchell,

that nothing more need be said of it. One feature perhaps deserves to

be mentioned. While strain of accommodation is a frequent source of

headache and is at once looked for by ophthalmologists, there seems no

doubt that some headaches, much fewer than accommodation cephalalgias,

are due to muscle difficulties, that is, a lack of balance among the

external muscles of the eye, whose full pathological significance has

perhaps not yet been worked out. Headaches are {551} frequently due to

sinus troubles, especially to disturbances in the frontal sinus and to

intranasal difficulties. These must be eliminated before the patient

can be helped. Sometimes these nasal and sinus difficulties are signs

of a deeper constitutional disturbance, due to lack of fresh air and

exercise and are relieved promptly by the establishment of hygienic

habits.

Congestion Headaches.--Some headaches require changes of habit and

persuasion of the necessity for arranging the day's work so as to give

proper intervals for relaxation. Much experience with persons whose

absorption in their work causes them to miss a meal or delay taking it

for seven or eight hours from the last time of eating has shown me

that this disturbance of the routine of vegetative life is

particularly likely to be followed by headache. This headache is not a

mere dull ache and is much more than a sense of discomfort; it is

often an excruciatingly painful condition that usually does not come

on until toward the end of the day and then may seriously disturb

sleep. An interesting thing about this class of headaches is that

nearly always they are increased by lying down. Often only a faint

preliminary symptom of it is apparent when the patients go to bed,

though they may be wakened after two or three hours of disturbed

slumber by a headache that prevents further sleep, and pass the

remainder of the night in painful wakefulness.

Usually it becomes impossible to continue lying down. The head must be

raised and much relief is afforded by sitting up. The headache does

not disappear at once but it will gradually pass away and sleep may be

resumed after a half an hour of sitting up, though the sleeper will

have to be in a sitting posture. Older people get up and sit in an

arm-chair. I have found that placing a chair with a rather long back

beneath the mattress, the mattress slanting along the chair back at an

angle of about forty-five degrees and then an arrangement of three or

four pillows above that, will enable these patients to get to sleep

better than anything else. The ordinary remedies for headache afford

some relief, but even very large doses of the coal-tar products will

not relieve the pain entirely unless some arrangement is made for

keeping the head quite high and immovable.

The headache is evidently due to congestion. The reason for it is

perhaps the failure of the blood to be recalled from the brain to do

its usual physiological work at the digestive tract, with a consequent

distention of arterioles in the brain so that a little later they do

not react to prevent congestion. Usually with the headache there is

some digestive disturbance, a feeling of unrest, flatulency with

perhaps acid eructations. Accordingly the headache is often attributed

to digestive disturbance. But both would rather seem to be effects of

the same cause--the failure to supply the digestive apparatus with the

proper amount of material to work on at the time when it expects it,

while the mental absorption naturally attracts blood to the head. We

know from delicate experiments made in physiological laboratories that

at times of mental work there is an appreciably larger amount of blood

in the head. A proof of the connection between the lack of a meal and

the headache seems to be the fact that with most people even a glass

of milk and a cracker, taken at the time when the meal is normally

eaten, is sufficient to prevent the otherwise inevitable headache.

Whenever some such simple explanation as this for a headache is found

and the patient made to realize its truth on his own observation, the

{552} significance of the headache at once dwindles and it becomes

much easier to bear it. Before the very real pains of it were

emphasized by the dread of the consequences that would result from it.

If it was really a brain ache patients would find it hard to

understand how under its influence even serious changes might not take

place in the brain. This is only a rational suggestion, but it is

mental healing of the best kind.

Many of the aches which are spoken of as headaches are really forms of

tenderness associated with the integuments of the skull. Certain of

the muscles particularly are likely to suffer from achy feelings which

are spoken of as headaches. This is true of certain feelings of

discomfort in the frontal region and also of those that occur on the

occipital region. External applications of many kinds relieve

headaches in these regions, particularly in the frontal region. It is

easy to understand that such applications do not affect the contents

of the skull.

Some Occipital Aches.--Occasionally I have found that people who

complained of a sense of weight at the back of the head, with some

muscular tenderness, were sleeping on pillows that were too high. They

were over-exerting these muscles and this gave a sense of fatigue,

which when much attention was paid to it, became such an ache or at

least discomfort as is often found in the occupation neuroses. I have

seen schemata according to which headache complained of at the top of

the head meant digestive disturbance, headache in the anterior portion

of the head was referred to the eyes or the brain, and headache at the

back of the head spinal exhaustion or severe neurasthenia, but these

are at most very uncertain and I do not think that the tabulation of

cases justifies any such diagram of absolute causes and effect.

Usually there is some local condition that calls particular attention

to a special part of the head and then the attention being

concentrated complaint is made of that part.

Local Head Discomfort.--Usually a headache, accompanied by a localized

sense of pressure or weight or constriction, occurs in highly neurotic

people or those inclined to think much of themselves and whose

attention becomes concentrated on some part. At all times we have

sensations streaming up to our consciousness from every portion of the

body and anyone who wants to think about them, or a particular set of

them, can make them sources of considerable discomfort by

concentration of attention. Sometimes there are special conditions

that predispose to these localized sensory disturbances. I have known

tight hats to produce such effects. It is sometimes surprising how

tightly hats are worn. Nervous people are prone to overdo everything,

and they overdo the pulling down of their hats. At times the wearing

of a heavy hat will be the root of the trouble. I have known nervous

men accustomed to wearing high hats all their lives who began to

complain of headache when they were in the midst of busy worries and

troubles of late life, find considerable relief by abandoning their

high hats.

Toxic Headaches.--There are headaches that are due to the taking of

stimulants, as is well known from common experience. The mistake is

often made, however, of thinking that only alcoholic stimulation will

cause a severe headache. Tea and coffee headaches may be quite as

severe. Whenever people complain much of headache it is important to

revise their dietary as to the consumption of tea and coffee. Of

course, the headaches following {553} alcoholic stimulation are

usually recognized as such, though occasionally a man accustomed to

taking much alcohol without any such after effects is surprised in the

midst of the worry incident to business stresses to find that he is

having headaches. These are due to the combination of stimulants and

congestion consequent upon an excess of alcohol with the increased

brain work that is demanded, or even with the same amount of brain

work from a tired brain. Gradually stopping the alcohol will do more

to relieve these headaches than anything else. To advise the sudden

stoppage of regular quantities of spirits that have been taken for

some time, will sometimes produce an anemic headache and defeat the

purpose of the advice.

When for some other reason tea or coffee or alcoholic stimulants are

suddenly omitted after they have been taken to excess for some time,

patients' complain of a headache. Some of this is probably imaginary,

or at least is due to the idea that their craving for the stimulant,

whatever it may be, must have a local manifestation, and the head

sensation is exaggerated as a consequence. Tea and coffee cravings may

here give more trouble than the longing for alcohol. Sometimes there

may be a real disturbance of the circulation from the lack of the

heart stimulant to which the system is accustomed and therefore an

uncomfortable feeling in the head from brain anemia. This can be

overcome by not cutting off the stimulant, whatever it may be, all at

once, but by bringing about its gradual cessation. These patients,

however, are very prone, even with the best of good will in the

matter, to deceive themselves and find an excuse for not having their

favorite tipple, be it tea or coffee or alcohol, taken from them, so

that they readily create symptoms by auto-suggestion.

Direct Mental Treatment.--For both congestive and anemic headaches

mental treatment is important. For those suffering from the congestive

kind the physicians's business is not so much the cure of any one

attack of headache (for this can be accomplished by various now rather

familiar anodyne drugs as a rule), but the discovery and removal of

the cause for the recurring attacks. These will be found in some habit

of the patient which must be corrected. Drugs are seldom needed for

the underlying condition which occasions the headache, for when it is

due to such organic affections as brain tumors or other intracranial

lesions, drugs can accomplish very little. In less serious conditions

benefit may be obtained by having the patient change his attitude

towards certain important details of his life, such as eating,

sleeping, attention to business or to study and the like, so as to

prevent the mistakes of daily habit that predispose to headache.

With regard to anemic headaches, especially those which occur in

persons who are very much run down in weight, the most important

element of treatment is to bring about an increase in weight. This can

be accomplished much better through the mind than in any other way.

Appetite is a function of the will, and patients should have an

increase of diet dictated to them and then be persuaded to follow

that. I have seen many a headache disappear among teachers, and

religious workers particularly simply as the result of this measure.

As regards headaches for which no definite cause can be found mental

treatment is the only efficient remedy. Practically nothing but a

change of mental attitude towards the affection and its underlying

causes, whether these {554} be neurotic or psychic, will bring about

relief, and each patient is a problem quite distinct from any other.

There is no pretense that this use of mental healing for headache is

new or even modern. Many stories show that in olden times headaches

were often relieved by this means, and that suggestion was looked upon

as an important element in the treatment for their relief. In the

chapter on Great Physicians in Psychotherapy the quotation from Plato

with regard to Socrates curing the headache of his young friend

Charmides illustrates this very well.

In the old stories of Greek medicine there are a number of references

to headaches cured by suggestion or at least by mental influence. Miss

Hamilton, in her book on "Incubation," [Footnote 40] tells the story

of Agestratos and his headaches and how they were cured at Epidaurus.

Agestratos had a combination of headache and insomnia, the description

of the ailments having a strangely modern air. Just as soon as he came

to the Temple at Epidaurus he fell asleep and had a dream. The God of

Medicine, AEsculapius, whose cult was practiced assiduously at

Epidaurus, came to him in his sleep and promised him the cure of his

headache and at the same time taught him wrestling and advised its

practice. When day came he departed cured, and continued to practice

wrestling. Not long after he competed at the Nemean Games and was

victor in the racing. The suggestion that his headache would get

better had come to him and at the same time he had been given a

suggestion that provided him with occupation of mind and body. Many of

the people who suffer from persistent headaches need this advice more

than anything else. Probably every physician has had the experience of

headaches being cured by some interesting exercise, especially if

taken in the open air. The important factor is the change of mental

attitude, though changes in exercise, diet, amount of sleep and the

like are helpful auxiliaries.

[Footnote 40: London, 1906.]

{555}

SECTION XVI

_NEUROSES_

CHAPTER I

NERVOUS WEAKNESS (NEURASTHENIA)

Neurasthenia, from the Greek roots, _neur_, meaning nerve, and

_sthenos_, strength, joined by the negative particle _a_, turning

strength into weakness, means nothing more than nervous weakness. To

tell a patient that he or she is nervously weak, or is suffering from

nervous weakness is usually not satisfactory, but it may be absolutely

true and may represent the limit of our knowledge with regard to the

particular case. To tell them that they are sufferers from

neurasthenia is satisfying as a rule, because then they have a nice,

long, and imposing word with which to talk to their friends about

their ailment. To discuss with friends one's own nervous weakness is

just a little absurd; to talk over neurasthenia and its symptoms,

however, adds importance to those symptoms and makes them seem

manifestations of some interesting underlying condition.

The discussion of symptoms always does harm, but the internal

complacency with its constant auto-suggestion of the underlying

nervous disease is still more harmful. Neurasthenia seems to most

people to signify a new and serious disease of the nervous system

which has developed as the result of our high-pressure civilization

and the modern strenuous life, and, therefore, has a special interest

and an exaggerated importance. All of this makes for an unfavorable

attitude of mind towards the affection and encourages the

intensification of symptoms by attention to them. The opposite state

of mind in which symptoms would be given their proper value by the

term nervous weakness would act as a constant source of favorable

suggestion. I believe that if the word neurasthenia must be used, it

should be translated for the patient and the absolutely functional

character of the affection insisted on in order to neutralize its

suggestive influence.

Probably the most serious objection to the use of the word

neurasthenia comes from the number of organic affections having vague

nervous symptoms, including especially tiredness, a certain incapacity

to do what was readily done before with tired feelings and a general

feeling of unfitness, that have come to be grouped under this head. In

this it resembles the word rheumatism rather strikingly. The

diagnostic general principles seem to be: tired feelings equal

neurasthenia; achy feelings (especially if worse on rainy days) equal

rheumatism. So whenever either word is used, patients are apt to think

of cases they have known which were labeled by one of these two terms,

{556} rheumatism or neurasthenia and ended by developing some serious

condition. The unfavorable suggestion consequent upon this has made

many patients miserable and has prevented them from using their

nervous energy to relieve their condition.

The use of the word neurasthenia has another decided disadvantage in

that the facile recourse to it often keeps the physician from

examining his patient sufficiently to detect an underlying

pathological condition. The term can be made to cover so much that it

has done great harm in this way. I feel, therefore, that in the

discussion of what can be done for patients suffering from nervous

weakness we should first of all describe and set aside a number of

forms of disease that have sometimes masqueraded as "neurasthenia" and

that have given the affection stronger unfavorable suggestiveness. Sir

William Gowers, whom no one would suspect of either minimizing the

significance of the word or of the affections that have come to be

grouped under it, nor of wishing to attract attention by differing

from others, has in one of his recent smaller medical works

[Footnote 41] emphasized both of these unfortunate connotations of the

word. Because his expressions as applied to other medical terms that

are too general in their significance, will help physicians to get at

the real meaning of them I venture to quote his opinion at some

length:

[Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy

and Other Lectures," Philadelphia, 1904.]

The history of the word "neurasthenia" is noteworthy. ... I have to

confess to the authorship of two words. One, "myotatic," was always

a puny infant, and I doubt whether it still maintains an independent

existence. The other, "knee-jerk," instantly attained universal use,

and indeed, I think has seemed to most persons to have sprung

spontaneously from the thing itself, without suggestion--perhaps the

greatest compliment a word can pay its author. But the general use

at once achieved by "neurasthenia" was in spite of a strong

objection to it which was felt by many. The Royal College of

Physicians of London could not include it in their "Nomenclature of

Disease," and yet it is now one of the most common of medical words

in every language. It would be instructive in more than one way to

have a careful study of the forces which have influenced its career,

but that I cannot attempt. We must, I think, admit that not only is

it a satisfying word to those who suffer, but it has a certain

convenience which has also compelled many to employ it who at first

objected. If I may be pardoned for a partial paradox, its

convenience is not the less real because this rests on features that

are illusory. Remember that the word is a name which should have

little meaning, even to those who use it. You may employ it to

collect the symptoms of the case under a general designation, but do

not let it cover them as a cloak.

Neurasthenia and Melancholia.--A serious mistake of diagnosis, though

it is often not a mistake of knowledge but of medical judgment, is the

confusion, apparent or real, of neurasthenia with melancholia. The

word melancholia has come to have a definite serious significance, as

it should, in the minds of many persons and as a consequence

physicians sometimes hesitate to use it, and employ instead the

all-embracing term neurasthenia, or neurasthenic depression. It is

popularly well known that melancholies are likely to commit suicide if

their condition is serious, while neurasthenia is not at all connected

with the idea of suicide. As a consequence, patients are often not

guarded as they otherwise would be and so we have suicides every {557}

month of so-called neurasthenics who were really sufferers from

melancholia. This sad state of affairs reflects in two ways to the

detriment of medicine. First, it leaves melancholies without due

protection. Second, it leads many of the neurotic patients whose

ailments have been labeled neurasthenia and who read the stories of

these supposed neurasthenics, to think that they, too, are tending

toward suicide and so they are less capable of reacting against their

neurotic condition and in general are much worse for the unfortunate

dread of some such fatal termination.

Neurasthenia Simulation by Organic Disease.--Neurasthenia is

especially a dangerous term since, like other words of this kind with

wide connotation, many quite disconnected diseases may in early stages

simulate it and give rise to the thought that there is only a

functional nervous disease present, when the symptoms are really a

manifestation of an underlying organic disease, heightened somewhat by

a nervous organization or by worry on the patient's part. So-called

neurasthenia in the old must always be looked upon with suspicion.

Neurasthenia in the young may be a purely functional nervous disease,

though it is probable that in most cases the nervous system is

congenitally defective, or at least is unable to perform the functions

which have been assumed by the patient. If a nervous organization has

stood the strain of the trials of early and middle life, which are

usually severe enough to try out individuals from the physical side,

if they are in moderate circumstances, or from the mental side if they

are wealthy, it will not, as a rule, be overborne by the burdens put

upon it by age unless some organic disease has come to seriously

disturb it.

_Neurasthenia and Arteriosclerosis_.--There are many serious

conditions that masquerade as neurasthenia. Perhaps the most important

is precocious arteriosclerosis. That a man is as old as his arteries

is now recognized as an absolutely sure maxim of internal medicine. In

many people the arteries wear out before their time and in all there

is an inevitable wearing out in the course of years. With the

beginning of degeneration of the arteries there are likely to be many

symptoms that closely resemble neurasthenia. In the elderly these are

nearly always symptoms of defective circulation because of lack of

elasticity in the arteries and their failure to accommodate themselves

to the variations of pressure in the circulation as the consequence of

changes of position, variations in the barometer, heat and cold, and

the like.

In these cases a study of the blood pressure will give the

differential diagnosis when the actual thickening of the arteries

cannot be felt, but it must not be forgotten that nervous excitement

may greatly heighten blood pressure on occasions so that a number of

observations have to be made.

_Neurasthenia and Bright' s Disease_.--Other general diseases almost

inevitably produce nervous symptoms. It is curious how often a severe

exacerbation of Bright's disease, which has been in existence for some

time but has given no specific indication, is preceded by a series of

neurotic symptoms thought to be due to nothing more than neurasthenia.

Men of thirty-five to forty-five, the favorite time for the occurrence

of the severe forms of Bright's disease, begin to complain of

tiredness, especially on waking in the morning, of inordinate fatigue

in the evening, of some stomach symptoms and occasionally a tendency

to diarrhea. All of these are ascribed to a neurasthenic condition.

Early in these cases an examination of the urine should be made {558}

as a routine practice, because if there is nothing in it the patient

will be just that much more reassured, while if it contains any

pathological elements he need know no more about it than his physician

deems proper, yet the real nature of the case and its indications will

be appreciated. Without this a physician will often find himself

suddenly confronted by serious symptoms in a patient when nothing of

the kind was anticipated because the condition was thought to be

entirely functional.

Occasionally the symptoms of Bright's disease seem to develop

suddenly, as it were a storm in the organism out of a clear sky. As a

matter of fact, however, there have been for some time before more or

less indefinite symptoms pointing to some serious process at work,

which if valued at their proper worth might have led to a much earlier

diagnosis of the impending nephritis. Such patients are labeled as

neurasthenics for months and at times even years before the serious

conditions develop which make the recognition of their ailment

comparatively easy. One case of this kind has come under my

observation that is interesting in its lessons. A medical student had

during the first year of his course exhibited every now and then what

seemed to be neurotic symptoms. He was inclined to complain of

headache for what seemed very slight reasons, and of pains and aches

whenever there was a change in the weather and especially a fall in

the barometer. He often had stomach symptoms and was anxious about his

heart; in general he was looked upon as one of the nervous,

complaining kind. During the course of a lesson in clinical pathology

in his fourth year, he was asked to furnish a sample of urine which it

was supposed would be normal, for comparison with an abnormal sample

that was being investigated in the laboratory. To the surprise of the

professor and to his own consternation, his urine was loaded with

albumin. Up to that time there had been absolutely no objective

symptoms and only the vague indefinite subjective symptoms mentioned.

The next day his feet swelled. Even this for a time was considered to

be rather an index of the neurotic tendency in him to react to very

slight causes. It was hoped that the albuminuria was functional, as

the examination was made in the full tide of digestion, and that it

would pass off. Subsequent examinations, however, showed not only

albumin but also casts. There was a slight intermission of symptoms

and then an exacerbation. Within a month after the chance examination

of his urine and its unexpected result he had a convulsion. Two weeks

later, altogether six weeks after the albumin was first discovered, he

died in nephritic coma.

Such cases are not so rare as they are thought, though they are seldom

so fulminant. There is a story told of a professor at one of our

American medical schools who, some twenty years ago, took a sample of

his own urine in order to demonstrate the normal characteristics of

healthy urine, and to his utter surprise he found albumin and casts in

it. Within six months he was dead from Bright's disease.

_Nervous Diarrhea and Organic Disease_.--Other internal conditions may

be called neurotic when they are really due to definite pathological

entities. For instance, in three cases I have seen what had been

pronounced by several physicians to be chronic diarrhea of nervous

origin, proved to be due to quite other and serious pathological

conditions of internal organs. In one of them a chronic diarrhea of

several years' standing finally culminated in death in {559} early

middle age from nephritis. After the event, there seemed to be no

doubt but that the diarrhea, which no ordinary means of treatment had

succeeded in benefiting more than temporarily, was really due to the

effort of the intestinal mucosa to supplement the defective work of

the kidneys. In this case apparently one of the strongest evidences

that the affection was of nervous origin was the fact that whenever

the patient was away from home, eating rather plentifully of a varied

diet, his intestinal condition was better than when he was eating much

more simple and unvaried food at home. The change of scene and

surroundings proved a tonic to his kidneys and perhaps also to his

skin, thus saving his intestines some of the extra work they had

assumed.

_Neurasthenia and Diabetes_.--Another serious disease that may in its

earlier stages be mistaken for neurasthenia is diabetes. There is no

doubt that some patients have been passing sugar for a long time

before any sure symptom can be noted in their general health, or,

indeed, before there is anything to call attention to the possibility

of glycosuria. In many of these cases, however, there is a feeling of

muscular tiredness and a sense of inadequacy for occupations which

were before easy, that may be attributed to neurasthenia. When this

muscle tiredness changes to crampy feelings that should be enough to

lead to an examination of the urine.

Undoubtedly one of the reasons why neurasthenia is sometimes called

the American disease and is thought to be more frequent among us than

it is in Europe is this confusion with the beginnings of serious

organic disease because of failure to examine patients carefully in

order to detect underlying organic conditions. In recent years this

neglect has become rarer and the consequence has been a reduction in

the numbers of so-called neurasthenia cases. Our morbidity statistics

of twenty years ago, for instance, seemed to show that we had only

half as much diabetes to the population as they had in Europe. One of

the reasons for this was undoubtedly the ease with which the diagnosis

of neurasthenia might be made at the beginning of diabetes, and that

the terminal stages of the affection were often masked by the

development of the tuberculosis so frequent in diabetic conditions or

of albuminuria with symptoms pointing to Bright's disease. Even at the

present time it would be quite possible to reduce the number of

neurasthenia cases by more careful attention to diagnosis.

Simulated Neurasthenia Due to Over-attention.--While there is danger

of confusing neurasthenia on the one hand with more serious disease

there is a distinct liability on the other hand to exaggerate the

significance of certain minor symptoms by employing the word when it

is only over-attention of mind to certain portions of the body that

constitutes the disease in its literal sense. If something has

particularly attracted a patient's attention to some part of his

anatomy and if his attention is concentrated on it and allowed to

dwell long on it, his feelings may be so exaggerated as to tempt him

to think that they are connected with some definite pathological

condition and he may even translate them into serious portents of

organic disease. If a patient once begins to waste nervous energy on

himself because of solicitude with regard to these symptoms then it

will not be long before feelings of tiredness, incapacity for work, at

times insomnia and certain disturbances of memory are likely to be

noted. Then the neurasthenic picture seems to be {560} complete. This

is the process so picturesquely called "short-circuiting" by which

nervous energy exhausts itself upon the individual himself instead of

in the accomplishment of external work. Many of the worse cases of

so-called neurasthenia have their origin in this process. It is true

that this set of events is much more likely to occur among people of

lowered nervous vitality, but under certain conditions it may develop

in those who are otherwise in good health up to the moment when the

attention happened to be particularly called to certain feelings. The

physician can start these patients off anew after improving their

physical condition, if he can only bring them to see how much their

concentration of mind upon themselves is the cause of their symptoms.

It has been well said, though to some it will doubtless seem an

exaggeration, that we human beings are a regular boiler factory of

sensations which, fortunately for our sanity, mental and physical, we

have learned to neglect to a great extent. Wherever our clothing

touches us, wherever the air touches us, wherever shoes or belts

constrict us, there are definite sensations. These continue, but

attract no attention unless they exceed a certain limit to which we

are accustomed. Habit in this matter is very different in different

individuals. After men and women have grown used to tight shoes or

tight corsets these no longer produce disturbance. The chance visitor

in a boiler factory or loom room of a cotton mill thinks he could not

live in such din. But after a time people get so used to the din that

silence and quiet may even become oppressive to them. City dwellers

from the slums, especially children, find the peace of the country

disturbing when they are first taken for vacations.

Over-attention to sensations, often scarcely abnormal, is indeed the

real source of many of the symptoms that can so readily be exaggerated

into pathological portents when attention is directed to them. Every

portion of our body is connected with the central nervous system.

Every square inch of surface touched either by clothing or the

movement of the air producers a sensation at every moment of our

waking life. Ordinarily we pay no attention at all to these

sensations. We can recognize their presence by turning our attention

for the moment to any portion of the body and recognizing at once that

there are sensations coming from it, though the moment before we did

not notice them. If we think of the point of our big toe on the right

foot we find, though we were totally unaware of it a moment before,

that a certain pressure is being exerted in it. If we continue to

think of it queer feelings develop in it. We may get a sense of

numbness that proceeds up along the tendons that lead to it. We can

follow them up to the insertion of the muscles in the shin. If we

dwell on the subject we have curious prickly sensations and numb

feelings, all of which were there and were neglected a minute before

but now are acutely felt.

This same thing is true of all the manifold sensations that come

streaming into the brain. We learn almost to enjoy them though we are

paying no attention to them. To be without them would mean very often

a fright lest there should be something the matter. Usually we think

of the outside of our body as the main source of sensation. It must

not be forgotten, however, that our viscera have also certain

sensitive nerves and while these are not as closely distributed as

those on the surface they are there and their presence is often a

source of pleasure or at least of satisfaction, but may be the source

{561} of poignant discomfort. We are constantly disregarding ordinary

messages from these, too. Something may easily call our attention to

these sensations, however, and then we may translate them into

pathological terms though they are really only physiological.

Ordinarily man may put a couple of pounds of food and drink into his

stomach and not feel it at all. If anything particularly calls

attention to our stomachs, however, and we dwell on it, then this

weighty feeling may seem to indicate serious indigestion because of

the discomfort that is produced. This is what nervously weak persons,

the so-called neurasthenics, are constantly doing. It is this habit

that by suggestion and training they must be taught to break.

There is a tendency to the substitution of one neurotic symptom for

another whenever by psychotherapy and mental discipline one condition

is overcome. Often the substitution is of something just as bad or

even worse. I have known cases where people when properly persuaded

gave over paying too much attention to their stomachs and then

proceeded to pay too much attention to their sleep with the result

that insomnia developed. On the other hand, I have known patients to

get over insomnia and then develop a series of complaints of queer

feelings in their head which they usually spoke of as headache, though

when asked to describe them carefully they confessed that they were at

most a sense of pressure or of unusual feeling in some part of the

head.

These curious substitutions take place particularly if for any reason

special attention is called to another part of the body, either by

accident or by some therapeutic manipulation or remedial measure. I

have known a patient who complained of headache and was advised to

take up exercise in the open air, do much stooping and lifting while

cleaning snow from the sidewalk, develop a tired condition in the

lumbar muscles and straightway this was thought to be rheumatic.

Liniment was employed and the counter-irritation which developed

attracted the patient's attention to that portion of the body for a

week. The headache was no longer complained of, but lumbago was

considered to have developed. I have known a person who suffered from

headache develop what seemed to be a retention of urine for which

unfortunately the doctor thought it necessary to use a catheter and

after this there was no complaint of the headache, but the patient

became almost unable to hold any amount of urine in her bladder and

could not go out for social or other duties because of the fear of

imperative urination.

CHAPTER II

CHOREA

This twitching affection, so familiar that it need not be described

particularly, is sometimes classed as a pure neurosis, sometimes as a

nervous disease with perhaps some organic basis and sometimes is

placed among the ailments related to rheumatism and attributed to some

pathological condition of the circulation.

Etiology.--Two elements must be considered in the problem of the

etiology {562} of the disease--the predisposition and the direct

occasion. The affection occurs particularly in nervous children who

are made to occupy their intellects too much while their muscular

systems are kept quiet for long hours. Often a preceding running down

in weight is noticed, though sometimes the child only fails to

increase in weight as it should in proportion to its growth. It occurs

quite frequently among chlorotic girls just before or about the time

of puberty. Anemia generally seems to predispose to it, but the

affection may occur among children who seem to be in excellent

physical health, though usually a distinct nervous heredity is found.

_Immediate Causation_.--Fright is one of the most frequent immediate

causes or occasions of the development of chorea. Mental worry of any

kind may have the same effect. Scolding has produced it; a sudden

grief has seemed to be the occasion; a slight injury, and still more,

a severe injury, or a surgical operation, even a slight one, may be

the forerunner of it.

Pathology.--No definite lesions have been found to which the disease

can be attributed, though a careful search has been made for them.

Endocarditis is an extremely common accompaniment. It is probably

present in three-fourths of the cases that have come to autopsy. Osler

found it in sixty-two out of seventy-three cases in the literature.

The association of the affection with rheumatism is insisted on by the

French and English particularly, and certainly in a considerable

number of cases there is a history of preceding or coincident

rheumatism, that is, an acute rheumatic arthritis. Often these attacks

are concealed under such names as "growing pains" or "colds in the

joints" but it is not hard to elicit a history of a red and swollen

joint with some fever. In children mild cases may occur of genuine

acute rheumatism with the involvement of but a single joint and that

not severely. These mild forms are often found in the history of cases

of chorea.

It seems likely that the heart affection is often responsible for the

symptoms and it is probably through the endocarditis that whatever

connection there is between chorea and rheumatism exists.

All the elements in the disease point to the influence of the mind

over it. The predisposition is caused by over-use of the mind at a

time when many claims are being made on the nervous system because of

the growth of muscles. There must, as a rule, be a pathological basis,

natural or acquired, that is, something that tends to produce a defect

in the circulation, but even without this certain children suffer from

the affection. If the patient is an object of solicitude or of

curiosity at home or at school, the symptoms rapidly become worse. At

any time the consciousness of observation makes them worse. The

symptoms do not occur during sleep, or at times when the patient's

mind is much occupied with some absorbing interest. They lessen just

to the degree that the patient's own attention is not called to them

or the consciousness not allowed to be concentrated on them. Chorea

often occurs in bright, intelligent children and always seems worse in

them.

Treatment.--The story of the therapeutics of chorea in recent years

strongly confirms the idea of the place of mental influence in the

cure of the disease. We have had a whole series of remedies,

introduced with a promise of cure by distinguished authorities, used

for a time with apparent success by many physicians, and then

gradually falling into innocuous desuetude. It was recognized that any

remedy would have to be used over a rather {563} prolonged period, at

least from five to ten weeks. It was appreciated, also, that the

patient must be kept quiet, both in mind and body, emotional

disturbances especially being avoided, that all physical functions

have to be set right and that the nutrition particularly must be

corrected if in anything it is abnormal. Where all this is done

patients recover without any remedy quite as promptly in most cases as

with any of the supposed specifics. Expectant treatment, supplemented

by symptomatic treatment, has proved in many institutions to give

excellent results without the necessity of troubling the patients with

more or less dubious drugs. It was important that the patient should

be given certain medicine and impressed with the idea that this

medicine was expected to do them good, a suggestion automatically

emphasized at every dose, but it is probable that few men of

considerable clinical experience now hold the notion that we have any

genuinely curative remedy for chorea, though we have certain tonic,

alterative remedies which, in conjunction with the setting of the mind

at rest, help to put the patient in a condition where the affection is

gradually overcome.

The most important object in the treatment of chorea must be its

prevention or its early recognition, and its immediate treatment; then

there is little likelihood of relapses and, above all, the condition

does not last long. Children who have had an attack of acute articular

rheumatism or who have suffered from growing pains or any other of the

rheumatic simulants of childhood should be watched carefully during

their growing period and at certain critical times in early life. They

should be especially regarded immediately after being sent to school.

The first sign of involuntary twitchings should be taken to mean that

the children are overborne and a period of rest from anxiety and study

and over-exercise should be afforded them. Of course, all this

watchful care must be exercised without attracting the little

patient's attention, or the very purpose of the care will be defeated

and the mind disturbed.

Rest does not mean that patients should be kept absolutely in bed even

after chorea has frankly developed, but that there should be hygienic

rest. Long hours of sleep, interesting occupations without much

exercise, a period of lying down in the afternoon, but, above all,

such occupation of mind with simple pleasant things as keeps their

attention from themselves. Visitors should not be allowed to see them;

above all, they should not be conscious objects of over-solicitous

care on the part of father and mother or the relief of symptoms will

be delayed and the condition will be made worse. As a rule, children

do not worry about themselves nor their physical ailments, but they

can be made to do so by seeing the over-anxiety of others. A good

nurse of sympathetic nature with power to interest the child, is

better than its mother for a constant companion, though family life,

the playing with brothers and sisters and the regular routine of home

is the best possible mental solace and occupation. Grandmothers are

useful adjuvants in the treatment late in the affection. At the

beginning their over-solicitude nearly always does harm.

Habit Following Chorea.--In certain nervous children after the chorea

itself has subsided there remains a habit of twitching that often is

almost more intractable than the chorea itself. This is particularly

likely to be manifest in children who have an unfortunate nervous

heredity or in those whose {564} nervous systems have been impaired by

preceding infections disease as anterior polio-myelitis, syphilis or

one of the forms of meningitis. Occasionally it is seen in children

without nervous heredity, but they are usually children surrounded by

solicitous relatives, made the centre of pathological interest and

constantly fussed about. The habit is not surprising and would remind

the observant physician of the whoop that by habit sometimes clings to

children in any cough that they may have for months after they have

had whooping cough. Often it will be found that these children are

capricious eaters, that they take tea and coffee, that their diet

instead of being the simple nutritious food that they should have

consists of many things that their mothers obtain to tempt their

appetites and that the children can really have anything they crave

for and get it much oftener than is good for them. To continue any

form of presumedly specific treatment in these cases does no good. If

arsenic is used over long periods, or any of the salicylates because

of the supposed connection of chorea and an underlying rheumatic

diathesis they will certainly do harm. The patients' diet can be

regulated, nerve stimulants of all kinds must be denied them, and

their appetites must be brought into order by the proper care of a

nurse who will not yield too readily to their caprices, and then the

solicitous environment must be changed. These cases represent a good

many of the so-called prolonged choreas and are really habits or tics

due to concentration of mind and a certain hysterical tendency to

continue to attract attention which may be noted.

CHAPTER III

TICS

Without any good reason in the etymology or the history of the word,

the term "tics" has now been generally accepted to signify certain

involuntary movements, frequently recurrent, of which, by habit,

certain persons usually of diminished nervous control, become the

victims. For the psychotherapeutist, however, they have an interest

quite beyond that which they have for the ordinary student of nervous

diseases. They represent the possibility of the formation of habits in

the nervous system, originally quite under the control of the will,

but which eventually become tyrannously powerful and quite beyond

management by the individual. They deserve to be studied with

particular care because it is probable that they represent objectively

what occurs also on the sensory side of the system, but which not

being manifest externally, is spoken of as entirely subjective. If

nerve explosions of motor character can, through habit, get beyond the

control of the patient, it is not unlikely that sensations, primarily

of little significance, may, in persons of low nervous control, become

by habit so likely to be repeated as to make the patient miserable.

Hence the study of tics as here presented.

As a result of the studies of Gilles de la Tourette, we realize that

there is an essential distinction between involuntary movements of

various kinds, and that spasms and tics must be separated from one

another. Tics consist of various movements of the voluntary muscles.

Probably the most familiar {565} is that of winking. Everybody winks

both eyes a number of times a minute quite unconsciously, though the

unconscious movement accomplishes the definite and necessary purpose

of keeping the conjunctiva free from irritant particles. When this

same movement is done more frequently than is necessary, or is limited

more to one eye than to the other, or is repeated exaggeratedly in

both eyes, then it is a tic. There are many other facial tics. Most of

them represent movements of the lips or of the nose or of the skin of

the forehead and all of them are identical with movements that are

occasionally performed quite voluntarily. There are movements of the

lips as in sucking, or smacking sounds may be made, or such movements

of the features as are associated with sensations of taste or smell.

Sometimes changes of facial expression may be tics and without any

reason there may be recurring expressions of emotion, of joy, or

grief, or fright, or even pain. Sometimes the tics affect structures

that are internal, as various motions of the larynx accompanied by the

production of grunting or sighing sounds or sometimes even of

particular words. In children the tendency is prone to manifest itself

in the utterance of forbidden words, usually vulgar, sometimes

indecent.

Besides these facial and throat tics any of the voluntary muscles of

the body may be affected. There may be the gestures that accompany

certain mental states, or there may be twisting or turning movements

as if the patient were in an awkward position and wanted to get out of

it, or as if the clothes were hampering movement and there was an

effort to relieve some discomfort. The head may be lifted and lowered,

or may be twisted from one side to the other and, indeed, various

nodding tics are extremely common. Almost any ordinary movement may,

in nervous people, come to be repeated so frequently as to be a tic.

Practically all of the convulsive or quasi-convulsive movements

associated with respiration are likely to become the subject of tics.

Yawning, for instance, involuntary to some degree, usually a reflex

with a physical cause, but so readily the subject of imitation, may

become so frequent as to be repeated a couple of times a minute and

this repetition kept up for many days. Sneezing may also become a tic,

though it is usually a definite reflex due to palpable physical

causes. Hiccoughs may easily become the subject of a tic. The

occurrence of a persistent hiccough is in popular medicine a sign of

unfavorable prognosis in serious diseases, especially such as involve

the abdominal region. In connection with neurotic affections of the

abdomen, however, hiccoughs are not uncommon and are of no serious

significance.

Varieties of Tics.--There are many more tics than are ordinarily

supposed. Indeed, there are few of us who escape them entirely. Nearly

all the curious phrases that people interlard so frequently into their

conversation, usually quite unconscious of them, or of the ridiculous

significance they often have, must be placed under the tics. Some men

cannot say a dozen words without interpolating "don't you know."

Others use some such expression as "in that way." I once knew a

distinguished professor of elocution who by actual count used this

phrase forty times in an hour. Some say "hum" or "hem" every sentence

or so. Whenever there is a bit of obscurity in their thought these

voluntary but unconscious expressions are sure to pop out. No one who

has had much experience in public speaking ever succeeds in keeping

entirely out of such bad habits. It is curious how phrases will insist

on repeating {566} themselves. One year one set of words, or a pet

phrase, or mode of expression, creeps unconsciously here and there

into an address. Then either because the speaker has been reading

dictated copy, or because some good friend has the courage to tell him

of it, he finds out the bad habit and suppresses it.

Word formulas senselessly repeated are only one of many forms of tics

that public speakers are prone to indulge in. Gesture which begins as

an artificial adornment of speech, very appropriate in itself, after a

while may settle down into certain forms that not only often lack

elegance but that are really disturbing to an audience. Of these

gestures and movements men are often quite unconscious. They have

become habitual and in the absorption of mind with the thought and the

words, they are reproduced quite involuntarily though they are all

originally voluntary movements. Nearly every public speaker needs a

mentor to correct him of such faults. It is rather difficult to break

some of these habits and it requires no little concentration of effort

and attention to be successful in eradicating them. It can be done,

however, provided the habit is not too inveterate, and this is the

best evidence that tics of other kinds can also be eradicated if the

patient really takes the matter in hand and is not of a weakened will.

_Teachers' Habits_.--Indeed it is almost impossible for public

speakers and teachers not to acquire certain habits irritating to

their auditors at first but amusing as they grow used to them, and

students particularly learn to look kindly at the ridiculous side of

many of them. I remember an old professor of literature who used to

lecture at some length on each of the important contributors to

English prose and poetry. We soon observed that whenever he came to

their deaths he took out his handkerchief and blew his nose. This was

as inevitable and as invariable a rule as the laws of the Medes and

the Persians. It was, as it were, his tribute of sympathetic

condolence with humanity for the loss of a brilliant contributor to

English literature.

Occasionally the effort to break up these habits will seriously

interfere with modes of thought and habits of expression, for the time

being at least. A professor at a certain university had a habit every

now and then of plucking at a button on his coat. His students could

tell when his hand was going to find this object of its occupation and

knew from experience that he would twist it a certain number of times.

He was not what would ordinarily be called a nervous person. One day

he happened to take off his coat shortly before a lecture and one of

the students surreptitiously removed the button. At the end of the

first few minutes of his lecture his hand went up to find the button

as usual but failed. For the moment there was a hesitancy in his

speech; then he tried again. A little later his hand went up

unconsciously and was disappointed; then he stammered and lost the

thread of his discourse. The last half hour of that lecture was

seriously impaired because of the absence of that button.

_Tricks of Speech_.--There are many other curious tricks of speech

that are really tics. Women often indulge in them and sometimes even

pretty women spoil their appearance by bad habits. All of us know the

pretty woman who talks very fast, but who every now and then projects

her tongue a little beyond her teeth. Occasionally there is a tendency

to wrinkle the nose or the forehead. Most of us have seen the woman

who sets her face into a definite smile of a particular kind whenever

her company manners are in {567} use, though there is a vacancy behind

the smile that is rather disturbing. Some people have habitual

movements of the fingers that are really tics, and even positions

assumed on sitting down that are very ungraceful, or that are very

noticeable, sometimes partake of this character.

_Fussiness_.--A very common form of tic that is quite difficult to

control is that tendency to be doing something with some of their

muscles which characterizes many men. They must handle a pencil or a

knife, or they must swing on their chair or tilt back on it, or keep

one of their limbs swinging over the other, or twirl their moustaches

or stroke their beards, or rumple their hair, and they cannot find it

quite possible to sit still. The difference between men and women in

this regard is remarkable. Women are conceded to be much more nervous

than men, but men are ever so much more fidgety than women. The author

of "The Life of a Prig" in his book "The Platitudes of a Pessimist"

has some striking paragraphs with regard to this subject. He says:

To look nearer home, the British bar affords splendid examples of

nervous fidget. Observe barristers pleading a cause. How they

torture a piece of red-tape, how they twirl their eye-glasses or

spectacles, and how they hitch at their garments, as if they

momentarily expected them to desert their finely proportioned

figures. But worse than the Queen's Counsellors, and even worse than

the domestic peripatetic, is the villain who is abandoned to a

performance vulgarly known as "the devil's tattoo"--drumming with

the fingers.

_Writers' Tics_.--Writers, and above all writers for the daily press

and such as have to do their writing in a rush and therefore get

nervous and anxious about it, are especially prone to develop tics,

though others who write leisurely may do so. Some of these are curious

and others are only expressions of nervousness common to all people.

Many of them chew their nails, some of them bite at their fingers

round the nails and make them sore, many of them chew the ends of

their pens and find it practically impossible to keep a pen with a

long handle to it. Some of them run their hands through their hair

until it is in a greatly rumpled condition, some of them pluck at

their eyebrows. I have one patient who when he is going through a

particular nervous strain plucks out the middle portion of his right

eyebrow so that he has a distinct bald spot at this point.

The tradition in newspaper offices is that these curious expressions

of the tendency of the body to occupy itself with something while the

mind is occupied are more or less inevitable in nervous people. They

continue for many, many years. They are only habits, however, that it

would have been rather easy to break in the beginning, though they

become extremely difficult to modify after they have once secured a

firm hold. Occasionally I have fastened a piece of adhesive plaster

over a much battered eyebrow, but that made it difficult for the man

to go on with his work. His hand would go up involuntarily time after

time and while plucking at his eyebrow would not disturb in the

slightest his train of thought, just as soon as his fingers touched

the unusual object a serious distraction occurred and work was not

only slower, but much more difficult.

_In Games_.--The tendency to the formation of curious habits of

associated movements can be seen very well in most games where skill

is combined {568} to a certain degree with chance. It is most

noticeable, perhaps, in bowling. Few men are able to restrain

themselves from making some special movement just as the ball strikes

the pin. This is sometimes a motion of the head, oftener it is a jerk

of the trunk, sometimes it is an associated movement of the arms,

occasionally it is a kick or a stamp. In billiards the same movements

are noticeable if a man is much interested in making a difficult shot.

Usually there is some movement of the body or of the hands or of the

head that would indicate his desire to move the ball in a particular

direction. Women who play these games do not usually have these

associated movements to such a marked degree and this may be due

either to their better restraint to movement in general, for as we

have said men do not acquire the habit of self-restraint in small

matters of deportment as women do, or to the fact that such associated

movements might disarrange their clothes. Perhaps, also, they are not

as much interested in the games as a rule as are the men. Of course,

similar associated movements may be seen in outdoor sports that

require skill yet have an element of chance in them. For it is, as it

were, to overcome this that the additional movement is made.

_Children's Tics_.--Some tics consist of some very curious habits.

Occasionally children hear some obscene or vulgar expression and

repeat it. The repetition of it produces such a look of shock to

propriety on the part of some of the other little ones who happen to

be present that they repeat it in the spirit of bravado and then

continue to utter it until it becomes a habit that is hard for them to

break. After all, the use of blasphemy later on in life is really a

tic, a habit of uttering words no longer expressive of any particular

feeling, as a rule, unless in exceptional circumstances but just the

result of a tendency for the speech organs to repeat certain words.

They tell a good story of the Rev. Sydney Smith who, wishing to break

an acquaintance of the habit of indulging in expletives, interlarded

his speech with "fire tongs and sugar tongs" every ten words or so and

when his auditor protested that that added nothing to the significance

of what he said the Rev. Sidney suggested that that was also true of

various blasphemous expressions that his acquaintance was accustomed

to use.

At the Salpetriere they tell the story of a little boy who had the

habit of saying the French word which the corporal in Victor Hugo's

"Les Miserables" made use of when anyone told him that it was because

Wellington was a greater general than Napoleon that the French Emperor

was defeated at Waterloo. Nothing seemed to be able to break the boy

of the habit of interjecting this word into conversations sometimes in

which he had no part and sometimes toward which he was expected to

take only a respectful and childlike attitude of silence. He was sent

to the Salpetriere. The ordinary remedies had failed entirely. One day

he was allowed to go outside of the hospital, or rather stole out of

the gate and played marbles with some street gamins in front of it.

During the game he used the word in question and they proceeded to

give him a good thrashing. It is Charcot who tells that this broke him

effectually of the habit.

One of the childish customs that sometimes disturbs parents very much

because it seems to be such an unaccountable lapse into barbarism,

though it is really nothing more than a tic in the strict sense of the

word, is the habit that some children acquire of removing portions of

hardened material {569} from their nose and then putting it into their

month. Refined parents are apt to be so seriously disturbed by this

that they fear for the child's mentality. Really the habit is not

nearly so rare as is usually thought by some grown-ups who have

forgotten about their own and others' childhood. In country places the

habit is very common. It is not alone the dull children who do it but

some very bright ones. Indeed, the tendency to the habit is so common

that one wonders whether there is not something in nature that tempts

to it. Parents who are fearful lest their children may be seriously

hurt in health by the awfully insanitary habit may be reassured that

after all a certain amount of the drainage of the nose is normally

carried off through the posterior nares to the stomach and that no

danger to health seems ever to have resulted from the practice. As a

rule, the habit can be broken rather easily by a little judicious care

and insistence, though I know of cases where relapses occurred and the

habit continued surreptitiously.

_Motor Tics_.--Motor tics frequently develop as a consequence of some

injury to a nerve or some intense overuse of it. Winking habits follow

an herpetic involvement of the superior branch of the fifth nerve.

Bell's palsy is sometimes followed in the face by a tendency to

twitching on the unaffected side that makes the patient quite

uncomfortable. Herpes zoster is sometimes followed by a catching of

the breath, probably due to a little spasm in the muscles supplied by

the nerve thus affected. Some of the yawning tics have this origin.

Any neuritis may in the course of its betterment be followed by this

curious tendency to explosion along the nerve that has been affected,

as if the pathological process had more seriously interfered with

inhibition than with the actual function of the nerve. Examples of

over-exertion followed by twitchings are not rare. A scrubwoman who

has seen better days and now has to carry a heavy bucket and use her

right hand much with the brush may develop a twitching of the right

arm. A janitor's wife who sweeps much may have a tendency to

twitchings of the fingers as a consequence of the unusual exertion of

holding the broom. Twitchings in the limbs of men who work at a foot

lathe or other machine requiring foot power are not unusual though

they are more often seen in the leg on which the workman habitually

stands than in the other one and it seems to be oftener a strain on

muscles than actual over-exercise that precedes the development of

these tics.

Heredity.--Heredity plays as large a role in tics as it does in

stuttering and other functional nervous disturbances. Occasionally the

direct inheritance of some habit will be found, though there is nearly

always more than a suspicion that a trick of speech or of act, which

constitutes the tic, was learned by imitation rather than transferred

directly. Besides, it is a case of a similarly constituted nervous

system reacting in the same way to a similar environment, rather than

any definite tendency existing by heredity in the nervous system. It

is surprising what close observers children are and how easily they

learn to imitate any habitual action of father or mother or, for that

matter, of nurses or those who are close to them.

Mental Treatment.--The most important element in the psychotherapy of

tics is their prophylaxis. They run in families, not by any inevitable

hereditary influence, but as a consequence partly of imitation and of

corresponding tendencies resulting from certain weaknesses in the

family. Wherever they are known to be likely to occur, parents should

be warned of the {570} possibility and the first symptom of any motor

habit should be considered the beginning of a tic. As we have said,

they are likely to begin in muscles that have been overstrained for

any reason, especially when patients are run down. They are often seen

after herpes and certain facial neuralgias.

There is probably no tic, no matter how long or how serious, that can

not be eradicated, or greatly modified, if the patient will take the

trouble and if the treatment is conducted so as gradually to get rid

of it. Peculiar movements cannot be done away with at once. They can

be lessened in intensity and in frequency and then gradually the

patient will be encouraged by their becoming less noticeable than

before to make renewed efforts. The habit must be gradually undone and

this will take as long as it did to form it originally. The exercise

of contrary muscular movements carefully carried out, and of gentle

repression with definite times of exercise during the day, gradually

increasing the length of the intervals of repression, in the end

proves successful. Only a determined struggle will effect a cure. It

depends on the patient's will. Like a drug addiction, or a tendency to

overeat, or a craving for alcohol, it must be gradually overcome and

then care must be exercised to prevent relapses; for when the

condition is somewhat better, to relax vigilance and give up effort

will allow the old condition to reassert itself with startling

rapidity. People suffering from severe tics will often give up.

Without the patient's hearty co-operation cure is impossible. With

good will its gradual diminution gives the patient a confidence in

self and an uplift in character that is extremely valuable, not only

for physical but for mental conditions.

CHAPTER IV

STUTTERING, ATAXIA IN TALKING, WALKING, WRITING, ETC.

The difficulty of speech called stuttering has usually been considered

rather as an unfortunate lack of control over the organs of

articulation, somewhat corresponding to muscular awkwardness of any

other kind, than as a pathological condition deserving the physician's

attention. If anything was done for it formally, the first effort of

the parents or the teacher was to correct the supposed bad habits and

this failing the affection was relegated to someone who claimed to

produce wonderful results by some special method. Perhaps, even

oftener, stuttering was considered one of those affections,

fortunately decreasing in number, that the child may be expected to

outgrow. Often there was noted an hereditary element which was

supposed to indicate incurability.

Stuttering deserves special treatment in a work on psychotherapy

because it illustrates very strikingly one phase at least of mental

influence over bodily function. While in the study of the etiology of

the disease much has been made of anatomical features, nerves and

muscles and anatomical anomalies of the speech organs and the

respiratory tract, the sufferers from stuttering are certainly quite

up to the average both in the physiology and anatomy of these regions.

They are of all ranks and conditions of life, of all sizes and build,

and it is evident that the trouble is not physical, but mental. They

{571} pay too much attention to their speech and to the co-ordination

of the many muscles engaged in speech production and the consequence

is that they impair their power to use these organs. Practically all

the cures recommended contain some element which distracts the

attention from the speech to something else and so permits the

function of the speech organs to proceed undisturbed.

A number of conditions develop in nervous individuals that resemble

stuttering. There are disturbances of swallowing, disturbances of

walking (astasia abasia), neurotic disturbances of writing, and of

other uses of the hands and of the legs.

State of Mind.--It is perfectly clear to anyone who has closely

observed the ways of stutterers that the state of mind is extremely

important in these cases and indeed probably constitutes the

underlying factor in the speech disturbance. Stuttering and all speech

defects are much worse when the patient is laboring under excitement.

This is so amusingly true that the impotence of a stutterer to say a

word when he wants very much to say it is a commonplace in the cheap

drama and never fails to raise a laugh. In ordinary conversation with

friends the stutterer may have little difficulty. As soon, however, as

he begins to talk with those with whom he is unfamiliar his speech

defect becomes noticeable. When the others present are entire

strangers and, above all, strangers whom he wishes to impress

favorably, then his stuttering becomes pronounced. The mental element

is the most important factor. Just as soon as consciousness of the

task supervenes his power of co-ordination fails and stuttering

begins.

Stuttering in Complex Activities.--There are many actions that become

habitual and people are thus saved from the necessity of constantly

performing them under the control of the will and the consciousness.

Walking is a typical illustration of this and is seldom disturbed by

consciousness, but there may be a stuttering in the gait of sensitive

persons if they become overconscious when passing people who are

watching them. Talking is even a more striking example of elaborate

co-ordination without conscious effort. We have to bring into play

more than a score of muscles whose movements are nicely and accurately

co-ordinated, or else the effort at articulate speech is a failure. We

have to change the positions of most of these muscles many times every

minute, yet we do it without a thought of how it is done and most of

us accomplish it with ease and perfection.

_Stuttering Walk_.--Stuttering, after all, comes most naturally under

the head of dreads in the classification of the psychoses. Stuttering

is not a physical difficulty so much as a nervous apprehension, and

there may be a stuttering in any co-ordination as in speech. I have a

patient under observation who, if people are looking at her, finds so

much difficulty in walking because of a trembling that comes over her

that she fears she may not be able to keep from falling. Boys at

school whistle a certain air that requires a little halt in the gait

to keep time with it, as their schoolgirl friends go by, and it is

impossible for these not to drop into the peculiar gait indicated by

the time of the tune.

_Stuttering Writing_.--There are many men who become so nervous about

writing their signatures that they cannot sign while anyone is

present. There are others whose penmanship becomes very irregular, or

at least exhibits many signs of nervousness, whenever they think

someone is watching them. Most of {572} the difficulties seen in

speech may, indeed, be exhibited in writing. The same difficulty in

beginning, the same elision of letters under stress of excitement, may

occur.

Writer's cramp is, after all, much more of the nature of a stuttering

in writing than a real cramp. Over-action, added motions, and,

finally, incomplete power to act as desired are seen in both cases. It

might be expected that this would not affect so simple and familiar a

set of motions as those required for a personal signature, but it

does, as many cases illustrate. A typical example was the treasurer of

a large trust company who had to sign a number of bonds, some thirty

thousand. At the rate of 200 an hour, over three a minute, as he did

the first day with others making it easy for him, it looked as though

he could complete the task, huge as it was, in a month. At the end of

a week, however, the rate had fallen to 120 an hour and, toward the

end of the second week, one a minute on the average was all that could

be accomplished. At the end of the month his signature, while

retaining certain of its original characteristics, had become very

different from what it was at the beginning and signing had become an

extremely difficult matter. He had to take a rest from business for

several weeks after accomplishing this apparently mechanical

procedure.

Emotional Ataxia.--Dr. S. Weir Mitchell in his article on "Motor

Ataxia from Emotion" in the May number (1910) of _The Journal of

Nervous and Mental Disease_, discusses some cases in which inability

to write even a signature came as a consequence of nervousness and

emotional disturbance.

In one of Dr. Mitchell's patients, other manifestations of ataxia

occurred as the result of the consciousness that people were watching

the patient. At times he is compelled to leave a dinner table, since

with strangers it is almost impossible for him to eat. If there are

two or three at the table with him, however, and especially if he is

worried about himself, he may become almost helpless, requiring both

hands to get a cup of coffee or a glass of water to his mouth. A

patient of mine with like symptoms has described to me equivalents of

various kinds to his own difficulties in his sisters. One of them

cannot play the piano before strangers, though an excellent musician.

The other cannot crochet with any success if any but intimate friends

are present. How much of this family trait is due to suggestion or

psychic contagion would be hard to say. The state that comes over

amateur actors and which makes them forget their lines, stammer in

their speech, walk awkwardly, and trip easily, are really

manifestations of this same incapacity to control even familiar sets

of actions when there is great self-consciousness and over-attention.

Mental Influence.--The correction of these conditions comes through

soothing the mind of the patient and getting him or her not to be so

self-conscious as to disturb action by thought about it. It is easy to

say this and extremely difficult to do it. In certain nervous

organizations it is quite impossible to overcome the tendency to this

ataxia or inco-ordination of voluntary movements. Much can be

accomplished, however, by proper training and discipline in all cases,

and, while the patient can never be completely cured, great

improvement may be brought about by patient habituation under

favorable circumstances. In Dr. Mitchell's cases the taking of a glass

of whiskey or of wine sometimes stimulated the patient so that

co-ordination became possible where it was impossible before. In

nearly all cases of writer's cramp {573} and writing difficulties the

power to write is restored for a time by such stimulation. Strong

coffee will sometimes serve the purpose as well as alcohol. It is easy

to understand, however, how dangerous is the resort to such

stimulation.

_Practice in Self-Control_.--The excitement and nervousness incident

to appearance before an audience which make thought and speech so

difficult and action so awkward and so exaggerated gradually disappear

as the individual becomes habituated to appearing in public. In most

people there is never a complete loss of self-consciousness with

entire freedom from nervousness, but the conditions are much improved

so that there is no noticeable interference with ordinary actions and

speech. Whenever there is some reason for additional excitement,

however, as when a new play is being put on, or when some special

audience is being entertained, there is a reappearance of many of the

old symptoms due to a self-consciousness.

Stuttering in the Young.--The prognosis of stuttering when it develops

at a certain period is much better than at others. The stuttering of

the very young can usually be overcome by a little careful training,

if it is taken early and treated patiently by a competent teacher. Not

infrequently a certain amount of stuttering develops at puberty when

the voice changes, partly due to the inability of muscles and nerves

to co-ordinate so easily as before upon the rapidly-enlarging vocal

chords and larynx, and partly to that greatly increased

self-consciousness amounting almost to painful bashfulness which

develops in boys about this time. Breathing exercises and especially

slow expiration is an excellent thing in these cases and distracts

their attention from themselves and their speech.

The chest has usually developed rather rapidly at this time and the

muscles have to some extent lost control over it, and it will be found

on careful observation that the breathing is particularly superficial,

that the descent of the diaphragm is quite limited and that the use of

this important muscle of respiration requires practice in order that

it may be controlled properly.

In Women.--Perhaps the most interesting thing about stuttering is that

it is ever so much rarer in women than it is in men. Something less

than one-fourth as many women suffer from it as men and this is true

for all periods of life. Women are usually more bashful and

self-conscious than men, but this rarely goes to the extent of

disturbing their speech faculties. Ungallant observers have suggested

that the sex quality of ready speech is too profoundly seated in

nature to be disturbed by mere bashfulness, but there seems to be no

doubt that the breathing of women has much to do with the difference

between them and men in the matter of speech defects.

When stuttering occurs in women the defect is much less tractable and

is usually dependent on a more serious disturbance of the psyche or of

the central nervous system. The prognosis of cases of stuttering in

women is not so good as in men, but remarkable cures are sometimes

effected by mental treatment of the self-consciousness which causes

the speech defect.

Correction of Respiratory Defects.--This last point, the correction of

all pathological conditions in the respiratory tract, is especially

important. Many stutterers are for one reason or another mouth

breathers. If they are mouth breathers because they have adenoids,

these must be removed. This must {574} be done early in life,

certainly not later than the third or fourth year, or else there will

come a serious deformation of the chest and that chicken-breastedness,

which is not undesirable in itself, but which hampers to some extent

the action of the diaphragm because that muscle cannot act as well in

the deformed as in the natural chest. Not all who are chicken-breasted

have any defect of speech, nor any tendency to stutter, but when there

is a natural tendency to a lack of inco-ordination because of

sub-normal nervous ability the presence of such a deformity makes the

prospect of cure much less favorable than would otherwise be the case.

If the mouth-breathing is due to stoppage of the nostrils, this must

be relieved.

Realization of Allied Conditions.--A helpful suggestion for stutterers

is found in the recognition of the fact that there are so many

conditions allied to stuttering and so many people afflicted with

them. Under the heading Neurotic Esophageal Stricture stuttering in

swallowing is treated of. In the chapters on urinary symptoms

stuttering in urination is discussed. Any set of muscles requiring

careful co-ordination may thus be disturbed. The stutterer is apt to

look upon his affliction as a very special individual annoyance. When

he learns that in practically every set of muscles requiring nice

adjustment for function like difficulties may occur, that in every

action requiring careful co-ordination of muscles there may be a

similar disturbance, and yet that in most of them careful mental

discipline, especially training in self-control, proves a source of

relief, he takes new courage to face the struggle necessary to

overcome the self-consciousness which is the root of most of these

troubles.

A striking form of inability to co-ordinate muscles so as to enable

them to perform their ordinary function is aphonia, or mutism,

sometimes spoken of as hysterical mutism. After some sudden emotion or

fright or accident a neurotic person proves to be quite unable to

talk. He cannot utter a sound. In Prof. Raymond's clinic at the

Salpetriere I once saw the classical case described by Charcot and

presented at his clinics several times. It was a man whose wife had

run away from him and been taken back three times. Each time on her

disappearance he had an attack of aphonia, inability to utter a sound

of any kind. It lasted for from several weeks to a few days. The cases

are much commoner in women. After a disappointment in love or a scare

the patients become unable to speak. Sometimes they can whisper but

cannot phonate. The affection is entirely functional or neurotic, and

if the patient's mind is properly predisposed speech returns without

difficulty or delay. A little massage of the muscles of the throat or

of the tongue by means of a tongue depressor or the use of Politzer's

bag in the nose with the assurance that after proper swallowing

movements the ability to speak will return, have proved successful.

Occasionally hypnotism is recommended for these cases, but many of

them are too highly neurotic to be readily susceptible to hypnotism

and, besides, suggestion in the waking state proves just as effective.

After several days of speechlessness it seems little short of

marvelous to make a patient talk readily after a little massage of the

throat. It is all dependent, however, upon confident assurance and the

suggestion to talk. The physician himself must possess absolute

confidence in his power to bring this about, for the slightest sign of

doubt or hesitation will make it impossible {575} to influence the

patient and will completely destroy his psychotherapeutic efficiency.

_Neurotic Esophageal Stricture_.--A rare but interesting form of

neurosis, which should be studied in connection with stuttering

because of the light shed on both by their relations to each other, is

that seen in the sufferers from so-called neurotic esophageal

stricture. These patients are unable to swallow solids except after

determined deliberate effort and occasionally the discomfort caused by

this effort leads them to eat much less than is sufficient for their

nutrition. The physician is sometimes tempted to overcome the

spasmodic closure or partial closure of the esophagus by bougies and

dilators, and these the patients learn to pass by themselves. I have

never known any of these cases to be benefited more than temporarily

by this treatment and I have seen two that were made distinctly worse.

Forcible dilatation by concentrating attention on the affected parts

hampers the proper flow of nervous impulses and the ordinary reaction

to these which should occur.

To appreciate how closely related to stuttering this spasmodic closure

of the esophagus is, it is necessary to see these patients swallow

when they do not know that they are under observation. For when they

are on exhibition for the physician, when their condition is

intensified by the excitement of the occasion and by the definite

purpose to make the doctor appreciate how serious is their case, they

swallow with more difficulty. Nearly always they have more difficulty

in eating in public than with friends, and it is only with those with

whom the patient is on a footing of perfect familiarity that the best

swallowing power is obtained.

In sufferers from esophageal stricture of the neurotic type the

muscles by an unfortunate perversion of nerve force contract in front

of the bolus instead of behind it. This contraction may be so complete

as to prevent even the swallowing of liquids. Usually, however,

liquids can be swallowed without much difficulty. Such patients, then,

if they become much run down in weight, must be fed on milk and eggs

and ice cream and the gruels and soups until they gain in weight.

While they are much under weight their condition is distinctly worse

and their power of co-ordination much less. It is, however, not hard

to make them gain in weight. This gain in weight acts as a strong

suggestion which persuades them that they are getting better and this

of itself soon helps them to control their muscles. Local treatment

does harm rather than good. Ice in small pieces swallowed shortly

before a meal seems in some patients to have the effect of making the

muscles less prone to follow the inco-ordinate nervous action and thus

renders swallowing much easier. In some, and especially in nervous

people, warm liquids have the same effect, while ice produces further

irritation. Acids nearly always increase the spasmodic condition.

Sucking a piece of hard candy for some time before a meal, especially

if it is not too sweet nor flavored with acid, helps some people.

Nearly all of them when carefully questioned prove to have special

foods that are more difficult of deglutition than others. Not

infrequently these idiosyncrasies for food are found to follow ideas

with regard to their digestibility. If the patient is hurrying for any

reason and suddenly becomes conscious that he is not masticating

sufficiently, swallowing at once becomes much more difficult.

{576}

The main element in the treatment, however, must be as far as possible

to get the patient's mind off his condition. The more attention he

gives to it the worse it will be. No treatment that we have will cure

it any more than stuttering can be cured, though a deliberate effort

to form a habit for the control of the swallowing muscles will often

do much to lessen the discomfort and the inability to swallow.

It is important in all these cases to be sure that there has been no

incident in childhood which might have caused the production of scar

tissue in the esophagus with a consequent stricture. Sometimes it is

many years before this manifests itself and, as in the case of the

urethra, even ten to twenty years may pass before serious trouble

comes. When the first symptoms are noticed, the actual stricture may

be so slight as scarcely to be possible of diagnosis by the bougie.

Occasionally the first symptom of a cancer of the esophagus is an

inability to swallow, and cancers of the esophagus have been known to

occur in quite young people, especially young men. I remember seeing a

case at autopsy in Vienna where the first symptom had been the

difficulty of swallowing and the man, at the recommendation of

friends, swallowed a glass of beer with some black peppers in it and

these stuck in his esophagus and produced death. Such cases are

exceptional but must not be forgotten. Neurotic esophageal stricture

is entirely benignant and its prognosis altogether favorable.

Treatment.--The treatment of stuttering presents the best example that

we have of the influence of the mind over neurotic difficulties of any

and every kind. Many forms of treatment have been announced as

successful, most frequently in the hands of men who have themselves

been stutterers and who have helped themselves by them. This would

seem to make it clear beyond all doubt that discoveries in direct

therapeutics had been found. As a matter of fact, however, when a

review of all the methods is made, they are seen to be so different

from one another and founded on such essentially diverse principles

that the only common connecting link to be found is in the occupation

of mind with something else besides speech which all these methods

recommend. We have had successful cures announced by surgery, by

discipline, by making speech more difficult by obstacles of various

kinds, by special positions of the tongue--up against the palate or

down against the floor of the mouth--by associated movements, by

rhythmic speech, by special control of the muscles of respiration, and

of many other structures much less related to speech. The interesting

phase of all this is the uniform success claimed by different

specialists using many different methods.

From the beginning of history cures have been suggested. That idea,

still held among the non-medical, that the sufferer from a difficulty

of speech is tongue-tied and needs to have the frenum cut, is as old

as the history of medicine. Galen suggested cauterization of the

tongue. Aetius, the first prominent Christian physician of whom we

have any record, divided the frenum of the tongue. So did Paul of

AEgina. Of course, in the Renaissance, when the old medical classics

were revived, this became a favorite method of treatment. Hildanus is

sure that it accomplishes great things. This idea has never been

entirely given up, and recurs from time to time in the practice of

those who do not reason much, but who look for some ready explanation

and, above all, some direct method of treatment. Much more {577}

serious surgical intervention has been suggested from time to time,

however. Velpeau advised division of the extensor muscles of the

tongue. Of course a number of surgeons have quite properly insisted on

the removal of the tonsils, uvula, polyps in the nose and other

obstructions of respiration.

_Singing in Treatment_.--A number of the stuttering cures employ

singing as a method of training in forthright utterance. Few people

stutter when they sing. Most people can be given confidence in

themselves and their power to talk right on by being shown that as

soon as they try to follow a set of notes there is little or no

difficulty in utterance. The teaching of singing, then, is of distinct

value in many cases. Taking advantage of this a number of those who

correct stuttering endeavor to introduce a certain rhythm into speech.

So long as the rhythm can be maintained stuttering does not occur. As

Kussmaul has pointed out the rhythmus acts as an efficient

will-regulator, so that nerve impulses go down regularly and are not

interrupted by consciousness and by the sudden starts and stoppages

due to fear and tremor and mental uneasiness. Undoubtedly the lesson

of this method of teaching is extremely important as an index of how

stuttering may be relieved.

_Regulation of Respiration_.--A number of systems to correct

stuttering depend on the regulation of breathing. It has been shown

over and over again, and notably by Prof. Gutzman of Berlin,

[Footnote 42] that one of the most important differences between

stutterers and those who talk naturally is that the normal individual

talks during expiration as may be seen in Fig. 23, while the stutterer

begins at the end of inspiration or at least where normally on the

respiratory curve expiration is just about to begin, but instead of

permitting his diaphragm to go up as in ordinary expiration, the

stutterer makes it sink lower and lower in a forced inspiration.

[Footnote 42: See my translation of one of his clinical

lectures In _The International Clinic_ for July, 1899.]

[Illustration: Fig. 23.--Normal Diaphragm Curve in Normal Breathing.

Expiration as we Talk Normally.]

[Illustration: Fig. 24.--Curve in Diaphragm Before and During Talking

by a Stutterer.]

_Attention to Something Besides Speech_.--The attention must be

centered on something besides speech itself. This is the important

element in any method of treating stuttering. If it is allowed to

occupy itself with that {578} nothing will save the individual from

getting tangled in the efforts that he makes to co-ordinate the

complex movements necessary, though if he would only allow them to

proceed automatically, as do the rest of mankind, there would be no

difficulty at all. Washington Irving, so ready with the pen, could not

utter two successive sentences at a banquet without having to sit

down, with expression absolutely inhibited from excitement.

Expression, thought, utterance--all may be inhibited by overconscious

attention, which may also disturb all other complex activities.

The most interesting methods of treatment for stuttering are those

which involve the use of various hindrances to speech and which would

seem to be least likely to make it possible for a person already

laboring under speech difficulties to talk with more ease. The secret

is, of course, that the added impediments so distract the attention of

the patient that he is unconscious of the co-ordination necessary for

speech and so accomplishes it without difficulty. It is because of

over-attention to himself that the disturbance occurs. These methods

developed very early in history. We all know the tradition of

Demosthenes overcoming his impediment by placing pebbles in his mouth.

One of the most earnest advocates of a similar method, who had himself

suffered very seriously from stuttering was the Rev. Charles Kingsley,

one of the most distinguished of English literary men. He cured

himself, or at least greatly relieved his symptoms, by keeping a cork

fast between his back teeth.

There have been many other curious suggestions for the cure of

stuttering. What was known as the American method had great vogue in

the early part of the nineteenth century. It was probably invented by

Yeats of New York, though it came to be known as the Leigh method.

Yeats, himself a physician, seemed to fear that he might fall into

professional disrepute if he advertised the method in any way, so he

had his daughter's governess, a Mrs. Leigh, open an institute for the

cure of stuttering in which this method was practiced and it proved to

be very successful. The entire secret of it was to have the patient

raise the tip of the tongue to the palate and hold it there while

speaking.

Another mode of treatment that attracted considerable attention

consisted mainly of just exactly the opposite maneuver, that is,

keeping the tongue as far as possible firmly placed on the floor of

the mouth during speech. It is evident that neither of these

suggestions does anything more than occupy the patient's attention

with an additional activity, so that his speech function may be

allowed to proceed automatically of itself, as it will if not

disturbed by attention to it and by conscious attempts to regulate the

various activities of it. Instruments were invented to help the

patients to secure various positions of the tongue. Itard, for

instance, during the second decade of the nineteenth century invented

a golden or ivory fork to be placed beneath the tongue, so as to

support it.

After the various methods of managing the tongue, the most popular

curative maneuver has been that of regulating the breathing. During

the nineteenth century there were at least a dozen different methods,

all of which had a number of reported successes, of treating

stuttering by means of breathing exercises.

Very simple methods of diverting the attention from speech are quite

{579} sufficient in many cases to bring improvement. For instance, the

insertion of extra letters that are themselves easy to say between

words or preceding consonants that are hard to utter has been a

favorite method among the specialists in stuttering. Johann Mueller, as

I said, suggested an e. Others have suggested an n. Occasionally

stutterers themselves form the habit of using an m or a to and find

that it aids their facility in uttering difficult sounds over which

they would otherwise halt and stutter. A combination of these methods,

as, for instance, an e between all words and the placing of an easy n

before the most difficult sounds, has been repeatedly revived as an

infallible method of treatment.

All this serves to show that in patients whose functions are being

interfered with by over-attention diversion of mind must be the main

remedy. If this can be secured, the function they are disturbing will

be allowed to proceed unhampered. What will prove effective for one

patient will fail with another, however. After the patient gets used

to a particular form of diversion another must be tried. Simple

methods are sometimes sufficient to secure good results. The one thing

is not to be discouraged and to proceed from one effort to another,

satisfied even if relief is obtained for a while, for after relapse

another method of treatment may always be tried.

_Suggestion for Stuttering_.--There are many systems to train people

out of the spasmodic inco-ordination that constitutes stuttering. All

of these systems have their successes, but, as is well known, all of

them have their failures. When the patient has confidence in the

teacher and his method there is practically always quite a remarkable

improvement, at the beginning. This improvement is more noticeable

during the first month than at any other time. Not infrequently after

this there is a tendency for patients to drop back into old habits,

apparently discouraged, as a consequence of loss of confidence. It is

the mental element that means more than anything else. It is the old,

old story that we have to repeat with regard to every chronic ailment.

_Distraction of Mind_.--Each inventor is sure that his method is the

best and his "cured cases" support his claim. Others who try his

method, however, never succeed as well as he does and those who are

interested invent methods of their own. I have on my desk, as I write,

six different, infallible--to their authors--methods of treating

stuttering. I am sure that none of them succeed absolutely, that is,

none of them will cure every case and most of them will not succeed

beyond a moderate degree, except where the enthusiasm and the

confidence of the inventor or an immediate disciple of his is behind

them to make them efficient. There are all sorts of elements in these

cures, but most of them depend on their power to distract the patient

from his over-attention to himself and what he is doing when he talks,

so as to permit without hindrance the automatic movements which are so

necessary for the complex function we call speech. Those who have

spent most time in treating stutterers confess that the effect

produced upon the patient's mind is an extremely important part of the

treatment and that, if this cannot be secured, failure is almost

certain. If the patient has no confidence that he can be cured and by

this particular method, failure is inevitable from the very beginning

and just as soon as a patient loses confidence improvement ceases.

{580}

CHAPTER V

TREMORS

Two types of tremors come to us for treatment: those that are quite

involuntary and occur when muscles are at rest, and those that are

associated with voluntary movements. The most common type of

involuntary tremor is that seen in paralysis agitans to which a

special chapter is devoted. After this, though coming for treatment

much less frequently, is senile tremor which may, however, also be

increased by voluntary movement. The tremors associated with voluntary

movements are spoken of as intentional tremors. They may occur as the

result of organic disease of the nervous system and the most

characteristic type is that seen in multiple sclerosis. They are more

frequent, however, with functional diseases of the nervous system and

with emotional disturbances of various kinds. They are especially

frequent as the result of dreads. Usually the idea of tremor is

associated only with the head and the hands. Tremors may occur in

other parts of the body, however, and tremors of the legs are

particularly important. A familiar type is the tremor and unsteadiness

of the legs which occur as a consequence of the dread of heights when

a person unused to such situation attempts to walk across a narrow

path a great distance above the ground.

Senile Tremor.--The most common of the involuntary tremors is that

associated with old age. It develops in practically all very old

people, but it comes to some who are comparatively young. Its

occurrence at the age of fifty-five usually gives the sufferer a

severe shock which is emphasized by the attitude of mind of friends

toward the affection. They seem to be always sure that it is the index

of rapidly advancing age and that it is practically a signal of

approaching dissolution. As a matter of fact, when unassociated with

gross pathological lesions, the senile tremor has no such

significance. When associated with definite lesions it is the

prognosis of the special condition and not any supposed significance

of this particular symptom of tremor that expresses the genuine

outlook in the case. Many people who live to a very old age develop

tremor before they are threescore. Most of those who live to be eighty

or more have some tremor that develops about or just after the age of

seventy.

_Significance_.--Senile tremor is supposed to be due to, and in most

cases probably is the result of, an overgrowth of connective tissue in

the central nervous system which disturbs the ordinary conduction of

nerve impulses, rendering them wavering and uncertain. This seems to

indicate that it will not be long before the advancement of this

sclerotic process will make serious inroads on the vigor of the

individual. As a matter of repeated observation, however, the ordinary

involuntary tremor of old people may last twenty years.

_Reassurance_.--The main principle in the treatment of tremors of the

old is to make the patients realize that the symptom has no such bad

prognosis as is usually attributed to it. Of course, they will find

this out for themselves after a few years, but what they need is

assurance at the beginning lest during the period of depression

consequent upon the conclusion that the end is not far {581} off,

which seems to be forced on them by their fears and the foolish

sympathy of friends, their resistive vitality should be so lowered as

to permit the invasion of some serious disease. In spite of

apprehensions on the part of themselves and friends, tremor is rather

a good sign than a bad one. It indicates the formation of connective

tissue in the central nervous system, but this is always a slow

process and is usually quite benign. As a matter of fact, most

sclerotic processes are so chronic as to be compensatory in their

action for many other degenerations. Those in whom tremor develops

early often seem to be better protected against rupture of cerebral

arteries, as if the growth of connective tissue was a conservative

process here also. Information of this kind helps patients not to

borrow trouble because of their condition.

Intention Tremors.--The tremors that occur in association with

voluntary movements are often very troublesome and may be difficult to

manage. The worst cases are entirely functional. They are typical

neuroses and often develop as a consequence of some serious crisis

through which the nervous system has passed. In older people they

sometimes pass over into paralysis agitans or a close simulant of that

affection. The incident of the Texas sheriff and the Indian related in

the chapter on Paralysis Agitans illustrates how these tremors may be

induced.

_Tremors from Fright_.--Frequently the tremors have no direct

connection with any action, though they may be the result of fright. A

little girl bitten by a dog and much shocked may, for some time

afterwards, be quite unable to stand when she sees a dog on the

street, so disturbing is the tremor that comes over her. Tremors of

the same kind have been connected with horses after the patient had

been run down in the street, and, in one case that I saw even when the

patient was only thrown out of a carriage during a runaway.

Occasionally fright by a burglar may cause a distinct tremulousness

that supervenes whenever the patient thereafter is wakened suddenly at

night.

Influence of Dread.--Tremors of all kinds can be made worse by the

dread of them. In the chapter on Dreads we discuss the disturbance of

function by dreads and especially the tendency to exaggeration of

pathological conditions of any kind when the patient's mind becomes

concentrated on it. Steadiness in any position is due to a nice

balancing of extensor and flexor muscles requiring the sending down of

a continuous stream of impulses. The equilibrium is attained and

maintained in spite of the fact that, as a rule, the flexor muscles

are stronger than the extensors and better situated to exert their

mechanical force. If anything happens to disturb this balance even to

a slight degree, the mind becomes attracted to it and there is a

corresponding result as in stuttering, or other complex function when

surveillance is too great. It is important to remember this at the

beginning of all cases of tremor, for the patient nearly always

exaggerates his tremor by attention to it and can be made so much

better by reassurance and diversion of mind that he is much encouraged

and his general health usually improves, making him feel, even though

his affection is organic, that he is being cured.

Tremors may occur in connection with almost any set of actions

requiring special co-ordination of muscles, but they are especially

likely to occur when a feeling of dread disturbs the control over

muscles. A typical example of this is noted in shaving. There are many

men who cannot shave without trembling so as to cut themselves. The

feeling that they have a sharp instrument in their {582} hand with

which they may cut themselves sets up the tremor. There are others who

cannot shave because they dread that while using the instrument over

the important organs of the neck, and especially the blood vessels,

they may be tempted to cut their throats. This is, of course, purely a

dread and not a tremor. Some men find both the dread and the tremor

much worse at times when they are tired and worried, and can shave

very well at other times. Some men can shave very well when they are

not under observation, but if anyone is looking at them they tremble

and cut themselves. The safety razor usually does away with these

troubles, large or small, but if it should happen that by particularly

inexpert use they cut themselves even with a safety razor, especially

in the throat region, the old dread and tremor reassert themselves and

shaving becomes almost as difficult as before.

Self-consciousness.--Almost any position or action in which a man

feels himself under observation may cause one of these tremors. As a

consequence this particular set of actions may become the source of so

much discomfort as to produce an intense sense of fatigue. It may,

indeed, become quite impossible of accomplishment. Some teachers

cannot do demonstrating work on a blackboard before a large unfamiliar

class, at least not without serious efforts to control themselves,

though they may be facile demonstrators before a small class. I have

known men, however, who practically could not do blackboard work at

all because of nervousness. Their writing went all askew and very

often their thoughts would not follow one another in such order as to

make demonstrations possible. Sometimes they were good talkers, so

long as they did not turn their backs to the class and feel the eyes

of all on them. The same thing is true of such religious services as

Mass in the Catholic Church, where some of the clergymen have this

feeling. I know of priests who have not said Mass publicly for years

and others who can only say it in a small chapel before a few people

because of the intense discomfort of the fatigue caused by this state

of mind.

_Stage Fright_.--It is not alone the hands and the arms that tremors

are likely to affect, for they may also occur in the legs. A typical

and familiar case is the tremor that occurs upon the first appearance

before large audiences of orators or actors or clergymen. Owing to

excitement, they are unable to make flexor and extensor muscles

exactly balance each other and the consequence is a tremulous movement

that may be complicated by some swaying. Some people never lose this

in spite of long experience in public appearance. Young people may

have it upon being introduced to persons of whom they think a great

deal. This passes off with years, as a rule, but in some it persists,

and any excitement causes tremor of the legs and swaying movements.

The effort to control this is often severe and causes intense fatigue.