may be the subject of disturbance by a tremor. Since the writing of
the book on Pastoral Medicine, a text-book of medical information
meant to be of assistance to clergymen, [Footnote 43] I have had some
rather interesting tremors associated with the performance of clerical
duties brought to my attention. One of these is a trembling of the
legs which makes standing at a high altar almost impossible. Another
troublesome tremor is that associated with the giving of communion.
{583} Most priests find no difficulty in the performance of the rite.
Some of them are much worried and anxious about it, however, and
develop a slight tremor. Others become so nervous in performing the
ceremony that they cannot succeed in placing the Host on the tongue of
the communicant without certain false movements. These may cause them
to touch the lips or the cheeks of the recipient and after this has
happened a few times the giving of communion becomes practically
impossible for them. Occasionally the men thus affected have no other
nervous symptoms and often they are very intelligent, strong-minded
men.
[Footnote 43: O'Malley and Walsh, "Pastoral Medicine." Longmans, 1906.]
The General Health.--Tremor patients always complain more of this
symptom when they are in a run-down condition. One of them is a
wealthy merchant who, when he can be persuaded to take a vacation,
comes back with nearly all the manifestations of his tremor latent or,
at least, well under control. Another is a broker who at the end of a
long winter of excitement and worry is at his worst, but who after a
vacation in the North Woods is quite well again. Slight symptoms of
this kind are not unusual in teachers, especially women, though I have
seen them also in men, and are much more complained of at the end of
the year when the individuals are in poorer general condition than at
any other time. The symptom itself is annoying because of the notice
that it attracts, but their dread that it may have some serious
significance, indicating the development of a progressive lesion of
the central nervous system, constitutes the worst part of their
ailment. When the intentional tremor is intermittent and occurs only
at times of excitement, or when the patients are under observation,
they can be reassured that it is merely neurotic and that no ulterior
development is to be anticipated.
Treatment.--The treatment of these conditions consists first in
bringing the patient's health up to its normal condition as far as
that is possible. Many of the sufferers from tremors are under weight.
Whenever they are, a definite, determined effort must be made to bring
them up to it. This must be done even though they insist that they
have never been heavier and that to be rather underweight is a family
trait. In many cases it will be found that this family trait, instead
of being due to some inevitable hereditary tendency, is only the
result of family habits in the matter of eating. Many of these people
do not eat substantial breakfasts. Their tremor, too, is likely to be
worse in the early morning than at any other time during the day,
unless, of course, they have become overtired during the day, when the
tremor will reassert itself with vigor. Most of them are much less
disturbed in the afternoon than before. The drug treatment of the
affection consists mainly in the use of nux vomica, but, not in the
small doses of five or ten drops so often employed, but, according to
the size of the individual, beginning with fifteen or twenty minims,
thirty or forty drops, and gradually increased to physiological
tolerance, when the dose should be set somewhat below that.
_Mental Control_.--The main treatment must consist, however, in
enabling the patient to secure psychic control over himself and his
muscles. This is not an easy matter. Most of them are quite
discouraged, but their attitude of mind must be changed and the real
significance of their affection made clear to them. As a rule, they
have either heard or read or been told by a physician that their
intentional tremor is significant of a serious pathological lesion of
the central nervous system. Some of them have heard of multiple
sclerosis {584} and are much disturbed. They must be reassured and it
must be made clear to them that their disease is really due to
over-consciousness and consequent lack of control. A good deal of
reassurance can be given by telling them of patients who suffer from
ailments not unlike theirs, showing how multiform the affection is. A
man who has trouble with his signature may be told about the man who
finds it difficult to drink when under observation, then, as a rule,
he will better realize the neurotic character of his affection. With
hysterical women this method must be used with care or the story of
another patient will act as a suggestion and the physician will
subsequently be treated to an exhibition of the symptoms which he has
described.
_Self-Discipline_.--Persistent quiet discipline is the one thing that
eventually does any good. When patients are first told of this and are
persuaded to attempt it, they make such a determined effort to
overcome the affection that they make themselves more conscious of it
than before with the result that their tremor and spasmodic movements
are emphasized. It is the old story of the man trying to stand so
straight that he falls backwards. It must be made clear to them that
discipline, to be of any value, must be carried out as much as
possible without consciousness of it and with all available artificial
aids. The man who has trouble with his signature may be shown that he
can overcome much of the tendency to tremor and spasm of the forearm
muscles that are at the root of his difficulty by sitting at a higher
chair, so that his arm swings free of the table and so that, in
Gowers' phrase, if a pen were attached to his elbow it would write the
same thing as the pen in his hand. The man who trembles as he drinks
may be taught for a time to raise a cup to his lips while resting his
elbow on the table and bringing his head well down. Nearly always
methods of performing particular actions that require less effort can
be found, until the habit of over-consciousness and loss of control is
overcome.
_Hypnotism and Waking Suggestion_.--Occasionally hypnotism is
effective in these cases, but there is likely to be a relapse unless
there is some discipline before and after its use. Suggestion in the
waking state is often very effective. Patients need to be talked to
and even though intelligent they need to be reminded at regular
intervals for some time that their ailment is merely functional and
not organic. Nearly always it will be found that they trace its
beginning to some pathological event: occasionally there has been a
severe accident, but sometimes only a slight accident seems to them a
sufficient explanation. Sometimes it follows an attack of pneumonia,
oftener still typhoid fever. In these cases the patients become
convinced that this is one of the marks left after the accident or
disease and so it is rather hard to persuade them that they can be
cured. All such impressions, which act as auto-suggestions for the
continuance of their tremor and lack of control, must be combated,
otherwise there is very little hope of improvement. The preceding
disease is not the direct cause, though the weakness consequent upon
it may predispose to the tremor. Overhaste in attempting to resume
their occupations before their strength has returned is often the real
cause. It is the patient's mind more than his body that needs to be
set in order, but this will not be possible unless the physical
condition is normal and thorough reassurance can be given.
{585}
DISORDERS OF THE PSYCHE
SECTION XVII
_PSYCHO-NEUROSES_
CHAPTER I
PSYCHO-NEUROSES (HYSTERIA)
As the derivation of the name indicates, psycho-neuroses are
functional nervous affections dependent on states of mind. They are
not necessarily originated by the mind, though they may be. Their
spontaneous occurrence as pure psychic phenomena, however, is rather
rare. There is practically always some slight physical cause. This may
be severe, for all diseases have neurotic accompaniments that disturb
the nerves involved and exaggerate the original symptoms. In most
cases the patient has no serious interest to divert his or her mind
from this occupation with self, and as a consequence the particular
feeling fills up the whole of consciousness, and as it is painful to
begin with, the pain, following Cajal's law of avalanche, may become
almost intolerable.
It is of primary importance to remember, however, that there is
practically always a physical basis for these curiously interesting
affections which are so difficult to treat and which have so often
proved the despair of physicians. While the attitude of mind must be
changed, the physical state itself must be corrected. These two things
must be secured at the same time, however, for attention to the
physical state without correction of mental attitude will usually only
emphasize the condition by calling further attention to the symptoms.
This is especially true of local treatment. The mind must, above all,
be treated and diversion of attention secured. Psycho-neuroses may
occur in connection with sensory or motor nerves. The patient may
either complain of intense pain in some part of the body for which
there is but a very slight basis, or may be unable to move certain
muscles, or there may be a combination of sensory and motor symptoms
with complaint of pain on movement. The painful conditions are most
important because they prove a source of worry and anxiety to the
patient's friends, as well as often of such annoyance at unsuitable
hours as deprives those near them of rest to a degree that may
undermine health.
{586}
FORMS OF NEUROTIC SIMULATION
Every possible painful condition is simulated by these psycho-neurotic
conditions. They occur probably with more frequency in the abdomen
than elsewhere; they may be thought to be colicky in nature and, as a
rule, some accumulation of gas will be found. This gas is sometimes
swallowed air and sometimes gaseous products that have been diffused
apparently from the blood in the intestinal walls. This always
produces discomfort but nothing like the discomfort that the patient
complains of. The condition if treated by carminatives will nearly
always be emphasized rather than relieved. Local treatment by heat
will help oftener, but may exacerbate it. When chronic constipation is
present, calomel in divided doses is suggestive as well as medicinal.
There may be gastric crises that recall those of tabes, and there may
be vesical and rectal crises of a similar nature. I have seen a
patient complain of every symptom of stone in the kidney. At the
beginning the pains were vague, but after she had been to several
physicians and had been asked certain questions intended to elicit
pathognomonic signs of stone these questions were answered in the
affirmative. Her attacks became strikingly like renal colic. After a
consultation, at which two physicians and a surgeon were present, she
was operated upon for stone in the left kidney. No trace of it was
found. But after this she was well nearly a year. Then she had another
crisis of pain in the early morning hours, a time when her painful
condition always came on, apparently because it attracted more
attention and caused more disturbance at this time, and now all the
symptoms pointed to the right kidney. She was treated on the principle
that it was a neurosis, was made to gain some fifteen pounds in
weight, has since then had no attacks, has not passed any stones, and
there seems no doubt but that the whole case was merely neurotic.
During her attacks instead of having suppression of urine, she had a
free flow of urine and no blood. It is not unlikely that the physical
basis of the attacks was that condition of the kidney which allows
urine to flow through very freely during neurotic conditions and which
somehow got into the sphere of her consciousness and being
over-attended to became extremely painful.
Secretory Neuroses.--Lying between the pain and motor neuroses and
dependent on psychic elements to some extent at least, there is a
series of neuroses that have as their principal symptoms an increase
or decrease of secretion. Occasionally, of course, they are
complicated by motor neuroses, especially in connection with the
viscera. There are various stomach affections, represented by an
increase or decrease in stomach secretion, and accompanied by pain,
discomfort, and decrease or increase of peristalsis. There are biliary
neuroses accompanied by increase or inhibition of biliary secretions.
There are gastric neuroses associated with vomiting, often very
intractable, in which there seems to be sometimes a hypersecretion of
gastric juice and sometimes a lessened secretion. All of these occur,
as is said, spontaneously, but there will usually be found a history
of some exhaustive work or worry during the weeks or months just
before. Apparently nervous control is lost and then the secretory
neurosis manifests itself sometimes in conjunction with painful or
motor affections.
Neurotic Vomiting.--Persistent vomiting occurs in these cases but is
not {587} so serious as it seems and patients do not lose weight, as
might be expected. There is sometimes even a probability that some of
the food ingested finds its way through the pylorus and is used for
nutrition, though the vomiting may come on not long after ingestion.
Practically always nature asserts herself and stops the vomiting when
serious conditions seem about to develop. The solicitude of relatives
may be calmed by this assurance, and just as soon, as a rule, as they
show less anxiety about the patient, the first symptoms of improvement
will be noted. The fasting girls exploited in the newspapers, in
connection with these neurotic conditions are often frauds and
investigation has shown on a number of occasions that they were
obtaining food surreptitiously. It must not be forgotten, however,
that, even though these cases have been discredited, we have a number
of cases on record of men and women who have taken absolutely nothing
nutritious and only water for from ten to forty or even fifty days.
Until at least ten days have passed in one of these gastric neuroses,
then, there is no need for urgent solicitude, and this of itself, when
properly explained, makes an excellent favorable suggestion for these
patients, and, above all, for their friends.
Simulant Appendicitis.--Some of these abdominal psycho-neuroses may
simulate serious pathological conditions that, in recent years, have
come to be looked upon as surgical. I have seen a number of cases,
especially in women who have been constipated for some time, in which
there was considerable discomfort in the right lower abdominal segment
and occasionally surgeons thought that an operation should be
performed. Usually in these cases there is no localized tenderness and
no mass of any kind to be felt in this region. Sometimes tenderness is
complained of, though when the patient's attention is diverted even
deep pressure may be made without their wincing. Whenever there is no
history of an acute attack, no temperature and no increase in pulse
rate, unless there are very definitely localized symptoms, the
question of operation is always to be answered in the negative.
Disturbances of the pulse may mean little. The history must guide. I
have seen these cases operated on, improved for a while, but relapse
afterwards just as soon as there was a resumption of their
constipation. As a rule, when the appendix has been removed, either
because its function has something to do with the inhibition of
putrefactive processes in the lower bowel, or because as the result of
the operation and consequent adhesions, the colon was not so active in
its peristalsis, the constipation seemed to be worse than before,
unless special care was exercised. If there is relapse after an
operation the patients' attacks are almost sure to be more frequent
than before and their discomfort likely to be more pronounced.
Lest it be thought that such cases are mainly confined to women or
that the most striking cases occur only in women, I may say that the
most interesting case of this kind I ever saw was in a young, vigorous
German soldier. He was admitted to Koenig's clinic in Berlin with a
story of abdominal tenderness and pain, the tenderness being located
in the right iliac region. There seemed even to be some distention of
the abdomen after a time and the development of greatly increased
diffuse tenderness. The pulse was considerably disturbed, but there
was only a slight rise in temperature, and for a time it was thought
that this might be a case of appendicitis without fever. A surprising
feature of the case was the presence in the right iliac region of
{588} a scar which, on careful investigation, proved to be double.
Apparently the patient had been opened twice before in this region.
His history was carefully investigated. He had had a fall from a horse
about two years before and afterwards had considerable abdominal
discomfort. He was quite sure that something serious had happened
within his abdominal cavity as the result of the fall and his
attention was concentrated on his right iliac region. At the time of
the accident his symptoms were considered to be a psycho-neurosis or
perhaps an exaggeration of symptoms with malingering tendencies.
Shortly after his term of service expired, however, some acute
symptoms developed and there was swelling, or at least tympanitic
distention of the abdomen with disturbance of the pulse, and he was
operated on in the hospital and his appendix removed. There proved to
be nothing the matter with it and no pathological condition was found
within his abdomen. He seemed to recover completely. After six months
he was admitted to another hospital with the same symptoms. He seemed
to have the habit of swallowing air which found its way beyond his
pylorus, or else gas leaked from the blood vessels in the walls of his
intestines, producing a symptom-complex not unlike the tympanitic
distention consequent upon general peritonitis. Once more this was
taken to mean very probably a ruptured appendix and another operation
was done. This operator went through the old scar, but to his surprise
found no appendix and found everything within the abdomen normal. The
third time the patient came to Koenig's clinic and, owing to his
military record, his hospital experience was available and a third
operation was not done. Instead, according to the story current at the
time, the patient was tattooed with the legend "no appendix here." The
case is interesting as an example of the extent to which an abdominal
psycho-neurosis may simulate a ruptured appendix.
Pseudo Biliary Colic.--A similar state of affairs to that with regard
to the appendix has developed in all that concerns the gall bladder
and the biliary tract generally. Any complaint of discomfort in the
right upper quadrant of the abdomen, if persisted in, is almost sure
sooner or later to be diagnosed as due to a calculus. Now that
operations for gallstones are more common than they used to be, it is
probable that almost as many gall bladders are found without
pathological conditions as appendices without justifiably operative
lesions. In treating individuals who have a history of recurrent
symptoms of intestinal reaction to various foods complicated by
urticaria, it is important to remember that there may probably be
lesions corresponding to those in the skin in portions of the
intestinal tract which may functionally involve either the appendix or
the biliary passages. Some of these cases are extremely difficult to
handle because often there is pain, definite tenderness and some fever
with the attacks, and very localized symptoms. The history, however,
will be helpful. Operation will not relieve the patient from liability
to recurrence. There are, however, other cases where the discomfort is
much more vague, where there is no tenderness, no disturbance after
jolting rides and where there has never been any severe pain. These
should not be set down as biliary calculi without further
developments. The possibility of a stone being present should not be
hinted to the patient until some definite pathognomonic sign is
discovered.
Other Simulated Conditions.--There are many painful conditions of the
{589} head that are psycho-neurotic. Many forms of headache are due to
sensations of pressure or tension or constriction, usually in the
external integuments of the skull, which are dwelt on and then become
painful achy conditions. This is particularly true of so-called
headaches in the back of the head. As we emphasize in the chapter on
Headache, probably most of the headaches of patients who have not much
to occupy themselves with, are due rather to queer feelings in the
head emphasized by the concentration of attention on them than to real
pains. Earache may occur in the same way. Nearly always when one has
been out in the wind, there is likely to be an uncomfortable sensation
in the ear. By attention to it this may readily be exaggerated into an
earache. Occasionally the physical basis of an ache in the region of
the ear seems to be an unconscious performance of Valsalva's
experiment while blowing the nose when catarrhal conditions are
present.
All sorts of painful conditions of the arms and legs may develop in
the same way. Unusual tiredness, or some special exertion of the
muscles, may produce a sense of fatigue readily exaggerated by
attention to it, into severe pain. This condition is not a voluntary
simulation, but is due to lack of diversion and a certain inborn
tendency in these people to pay attention to anything that is the
matter with them. Very seldom does the physical condition need much
treatment, though nearly always something can be done for it with
advantage, but the mental state needs alteration and, above all, the
patient needs to be diverted from over-concentration of mind.
Motor Neuroses.--As has been said, beside painful conditions, various
forms of motor trouble may develop. These usually consist of inability
to move certain groups of muscles. They have sometimes been spoken of
as hysterical palsies or paralyses. The word hysterical, by its
derivation connected with the Greek word for womb, apparently
indicates that these conditions are limited to women. It is well known
now that they are extremely common among men and especially among
young men and have absolutely nothing to do with the genital system.
As with painful psycho-neurotic conditions, there is practically
always a physical basis. This sometimes requires careful questioning
to locate exactly. There is some injury of the muscles of a particular
region, or some over-use of them, or some employment of them under bad
mechanical conditions with over-fatigue, and then attention to this
leads to incapacity to use the muscles or inability to co-ordinate
them properly.
Neurotic palsies, to use a term that carries much less unfavorable
suggestion with it than the word paralysis or the word hysterical, may
occur in any limb or group of muscles. They may occur in the legs with
the production of complete paraplegia. One well-known form,
astasia-abasia, inability to stand or to walk, affects the muscles of
the trunk as well as of the lower limbs. These conditions often remain
for long periods in spite of treatment, frequently recur, are often
called by all sorts of names and continue to be a source of annoyance
to the patient, until a definite successful effort is made to change
the patient's mental state to one of less attention to the particular
part.
There is, it seems to me, an unfortunate tendency to think that our
observations upon these cases are comparatively recent. Sir Benjamin
Brodie, nearly a century ago, insisted that at least four-fifths of
the female patients among the higher classes of society supposed to
suffer from diseased joints were really sufferers from neurotic
conditions, or, as they called them then, {590} hysteria. Sir James
Paget, in his Clinical Lectures and Essays, thinks that Brodie has
exaggerated the proportion, for in his own practice, though, of
course, he includes his hospital cases and the poor as well as the
rich, he found less than one-fifth suffering from neurotic joints. The
hip and the knee, which are the most frequent seats of genuine
pathological conditions, are also most frequently the subject of
neuroses. Next in order, but much more rarely, the metatarsal and
metacarpal joints are affected and then the elbow and shoulder. In Sir
James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a
number of cases which show how clearly psycho-neurotic affections were
recognized in his time. He tells the story of a young man who had been
overworking for examinations and who "after a three-hours'
mathematical cram, fainted and when he rallied set up a very close
mimicry of paraplegia which lasted many weeks." He insists that "such
mimicry is found not only or chiefly in the silly selfish girls among
whom it is commonly supposed that hysteria is rife, but even among the
wise and accomplished, both men and women."
DIFFERENTIAL DIAGNOSIS
For the differential diagnosis of psycho-neuroses from definite
organic conditions, the most important element is the patient's
previous history and a knowledge of the condition of the nervous
system. Where this is known the diagnosis is comparatively easy, but
when the patient is seen for the first time it may often be extremely
difficult. It is, above all, important not to jump to conclusions, for
every nervous specialist knows of cases in which the diagnosis was
considered to be surely a neurosis, yet a fatal termination showed
that a serious organic condition was at work. It must not be forgotten
either that neurotic patients may develop serious organic disease in
the midst of their neurotic symptoms and care must be taken not to
miss the significance of special symptoms. When the patient is not
well known, the presence of certain stigmata, as they have been
called, enable the physician to recognize the probability that a
neurotic condition is present. Patients who are subject to neuroses
are likely to have certain areas of the skin surface and of the
palpable mucous membranes more or less sensitive than normal. There
are likely to be spots of hyperesthesia or hypesthesia or even
complete anesthesia somewhere on the skin. These should be carefully
looked for and in serious cases an examination of the whole skin
surface should be made. Not infrequently anesthesia or a decided lack
of sensitiveness to irritation will be found in the throat or in the
nose. Occasionally the conjunctiva is much less sensitive than usual.
These used to be called hysterical stigmata. The word hysteria carries
an innuendo of imaginativeness or occasionally of affection of the
sexual organs that is unfortunate. It would be better, therefore, not
to use the term in any way. The presence of these areas of
hyperesthesia, hypesthesia and anesthesia indicates that association
fibers are abnormally connected in the brain for the moment at least,
and that as a consequence there is over-attention to certain portions
of the body with lack of ordinary attention to others. This will
account very readily for the occurrence of painful conditions in
certain cases and palsies in others. When over-attention is paid,
there may be a {591} hyperesthesia corresponding to that seen in the
skin in any organ of the body. When, for any reason, there is a
disturbance in a particular part, there may be a lack of motility due
to nervous influences, just as there is a lack of sensation. In all of
these cases the one essential element is to correct the nervous state
through the mind as far as possible. Experience has shown that this
can be done in nearly all cases. It must be the principal effort of
the physician.
TREATMENT
Strong Mental Impression.--In the treatment of these affections two
periods are to be considered, one during, the other after the attacks.
During the attack a strong impression must be made upon the patient's
mind so as to divert the concentrated attention. We have well
authenticated stories of the various expedients resorted to by
physicians who were confident of their diagnosis in order to secure
such a strong mental impression. I once knew an old physician who was
summoned to a childless wife whose adoring husband was in manifest
agonies of solicitude over her and whose mother and mother-in-law had
been caring for her for days with all anxiety, walk into the room of
the patient, take one of her hands in his, slap her on the cheek, tell
her to get up and walk and she would have no more of that supposed
inability to walk which had caused the family so much anxiety. He
succeeded. It can be imagined what would have happened had he not
succeeded. We know of cases where an alarm of fire or a burglar scare
or some sudden emotion has produced a like result. We cannot prescribe
these things, however, and at the most, after one or two successes in
a particular patient, they would fail.
The only thing that we can do as a routine practice is to relieve by
direct treatment the slight physical condition that is usually present
and then try and influence the patient's mind. If a thorough
examination is made in the course of which the physician is able to
show the patient that he understands the condition and that he can
demonstrate for himself and them that there is nothing serious the
matter with important organs, he can make them feel that their pain or
disability is entirely due to concentration of attention on a
particular nerve or set of nerves. With many patients this will
succeed, not at once, but after two or three seances of positive
suggestion, even in the waking state. If the patients are bothering
their relatives very much it may be necessary to give some opium as an
adjuvant. As a rule, the needle had better not be used, but a
suppository given. This is not nearly so attractive to the patient's
mind as the use of the needle and is not likely to be called for so
often. Every physician has had the experience that after giving opium
two or three times, either per rectum or hypodermically, almost
anything can be given, provided the patient is persuaded that the drug
is being given again. A reasonably large dose may be used the first
time, but certainly after the second or third time a much smaller dose
will produce the same effect and often a simple gluten suppository,
provided it looks like the other, will work just as well as an opium
suppository.
After Treatment.--The after treatment of these cases is directed
mainly to such alterations of the mental attitude and physical
condition as shall prevent {592} recurrences. The general condition of
the patient must be improved in every case where there is indication
for this. Many of these patients are under weight for their height.
They must put on weight. Weir Mitchell's success with the "rest cure"
consisted to a great extent in his power to cause these patients to
put on weight. This supplies reserve energy, but, above all, replaces
discouragement by hope and buoyancy. Gain in weight can be
accomplished mainly by two methods. First, by seeing that the patient
gets an abundance of air and, secondly, by dictating how much shall be
eaten. In this matter details are important and it may be necessary to
suggest the actual diet for each meal. This must be liberal and must
consist of simple but particularly nutritious materials. Patients'
dislikes need not be taken into much account, their likes are often
helpful. When there is insistence on lack of appetite and decided
objection to chewing, eggs and milk should be given in increasing
quantities, until five or six eggs and some twelve glasses of milk are
taken every day. Besides this, a good portion of meat should be eaten
at one meal with some vegetables. By firm insistence, day after day,
it will not be hard to get patients whose appetites are seriously
inhibited to take this amount of food. To secure this, a good, firm,
sensible nurse is invaluable. Appetite, as we have emphasized in the
chapter on Appetite, is largely a matter of will, and anything that is
eaten, provided it stays down, will do good unless there is organic
disease.
A certain amount of exercise is important in these cases, but not
nearly so important as an abundance of fresh air. Patients must not be
allowed to overtire themselves. Riding in an open carriage or on the
top of a bus, especially where there are distracting scenes and many
human interests, is particularly beneficial. Automobiling is often
likely to be more tiresome than is good for these patients when they
are run down, though it is one of the best of therapeutic measures for
those who are physically capable, that is, up to weight, even though
they may complain of feeling weak.
_Diversion of Mind_.--It is in these cases particularly that diversion
of mind is of prime importance. Many of these patients have either no
serious interest or at most certain interests with which they may
occupy themselves if they wish, but that are not engrossing and
attention to which may be put off whenever they care to. Duties that
are inevitable and that call for the occupation of so much time that
the patient has little opportunity to think of herself are often the
salvation of these patients. As I mention in the chapters on
Occupation and Diversion of Mind, I have seen a number of cases and I
am sure that every physician of reasonable large experience has seen
similar cases, where women, particularly, who in the midst of
prosperity have been constantly suffering from some form of
psycho-neurosis, great or small, have, after some sudden turn of
fortune, been completely relieved from their nervous symptoms by
having to devote themselves seriously to some occupation for a
livelihood.
Occupation, particularly with children, with the weak and the ailing,
with the poor and those who are unable to help themselves, is
specially likely to be helpful to such patients when they are women.
Such interests affect them deeply and by the sympathy they arouse
through contact with real physical suffering, they prevent
over-attention to themselves. I have seen the care of a cancer
patient, and especially of a relative affected by cancer, do more for
{593} a psycho-neurotic sufferer than all that doctors had been able
to accomplish in years. It is often difficult to find occupation and
diversion of mind for these patients, but this is the therapeutic
problem the physician must solve if he is going to secure relief from
present conditions and prophylaxis against further attacks.
Oldtime Cures.--Many of the remedies for obscure abdominal conditions
show how well the real character of the affection was duly recognized
and appreciated in the past. It is in these cases particularly that
the pillulae micarumpanis, the bread pills, of the olden times, were
so commonly used with good effect. We have quoted examples in other
chapters. Many of the drugs that are employed with reported success
for these affections have a strong suggestive element in them.
Valerian probably is a good tonic and yet there is no doubt that the
suggestive quality of its nauseating smell and the almost inevitable
eructations that occur after to emphasize it, are helpful in curing
certain internal psycho-neuroses. Another drug that has been much used
in the same way is asafetida, whose disgusting taste and odor have
been excellent auxiliaries. Fresh pills of quinine and red pepper
uncoated and therefore producing definite effects on the taste before
swallowing and on the mucous membrane of the stomach after swallowing,
often prove the best remedy for persistent vomiting or for enduring
nausea. A drop of nux vomica, taken every half hour with the definite
warning that the patient must by no means take more, and that the
bottle must be carefully protected lest anyone else should be
poisoned, is often very efficient. These remedies have a slight
physiological action and a large psychic action, but that exactly
corresponds with the etiology of the affection for whose treatment
they are employed.
Dominant Ideas.--During the attack it is often possible to find either
from the patient or from friends that there is some dominant idea
which is bringing about the mental short-circuiting that leads to the
concentration of attention. From the oldest times it has been
recognized that in young women a disappointment in love may prove to
be the occasion for a psycho-neurotic or, as they used to call it,
hysterical attack. This is, however, not a specific cause. It is the
disappointment much more than the sex element in the case, as a rule,
that produces the unfavorable effect. It was easy to conclude that the
sex factor was extremely important in older times when women's sphere
of activity was largely limited to the home, and marriage was the one
legitimate object of their ambition. Now that we have had more
experience with the business woman, we know that serious
disappointments of any kind have a tendency to initiate
psycho-neurotic conditions in susceptible and especially suggestive
individuals. A failure to secure promotion in a store, or to secure
some position that is eagerly sought for, a loss of money in business,
etc., especially when they have been preceded by weeks or months of
solicitude and worry over the event that now happens, may lead to the
development of a psycho-neurosis.
This is particularly notable with regard to educational interests of
various kinds. Young women readily overdo application to study, or,
rather, anxiety over it, and as a result get into a state of mind in
which a failure to pass an examination, or to secure promotion, or
even the failure to win a prize, may give rise to a highly nervous
condition in which tears and laughter come unbidden and in {594} which
further developments may bring on a typical psycho-neurotic attack.
All sorts of pains and aches and motor incapacities may occur in these
states. The supreme occupation with the single idea present in their
minds at all times, waking and sleeping, while they try to study, or
when they read or even when they are supposed to be diverting
themselves, finally precipitates a nervous explosion along nerves that
have been irritated for some reason, though the pathological condition
present may be quite insufficient of itself to explain the affection
that ensues. These are the popular nervous breakdowns, not difficult
to treat once their real character is diagnosed.
Sorrows of various kinds may produce a like effect. Worry or anxiety
about the serious illness of a near relative, especially an inevitably
fatal illness, such as cancer or tuberculosis or the disturbing mental
affections, may have a similar result, but usually not in those who
are occupied with the actual care of the patients. The mental states
constitute the psychic elements underlying the neurotic condition that
develops.
Almost needless to say, successful treatment must include a faithful
attempt to lessen the significance of the mental state that is so
important in the case. Usually the mere obtaining of the patient's
confidence is enough to lessen greatly the irritation produced by the
mental condition. A sorrow shared is halved. It is, above all,
secretive individuals who become depressed over their sorrows. While
the patient who insists on constantly sharing them with everyone
becomes a nuisance, it is always a little dangerous not to have a
confidant to whom worries and anxieties are entrusted. If they are
kept to one's self they are nearly always exaggerated--they are seen
out of proper perspective and have a much more depressing influence.
Calm, judicious reasoning with the patient over the significance of
the condition as presented, is often of great help.
Often these ideas, so potent for mental and bodily disturbance, are
almost entirely unconscious or exist in the patient's subconsciousness
and are recalled only under such special conditions as remove the
bonds of the patient's occupation with himself or herself at the
present time and allow memories to come back without interference.
There are many curious stories of such cases. A child is frightened or
very much disturbed by having a cat kill a favorite bird. The cat
becomes a deterrent object. Gradually this deterrence grows. As a
consequence, there may develop one of those intense dreads of cats
which makes life miserable if near that animal. There may even be
physical effects produced by the continued presence of a cat in the
same room. Often in these cases the beginning of this mental attitude,
or at least its occasion in the incident of the killing of the bird is
forgotten, or at least not consciously referred to as an etiological
element in the dread.
Patients have been known to develop states of mind which made them
object to certain figures or names because of earlier associations
with them that were unpleasant. There is the story of a man who would
never take a car with an odd number though this was sometimes a source
of annoyance and delay and who could not explain to himself or his
physician how this objection had developed, until his memory was
searched and it was found that, years before, he had witnessed the
death of a child under the wheels of a car with an odd number. He had
completely lost the sense of the direct influence of this, but it
existed in subconscious memory and proved the source of much {595}
annoyance to him, for if with a friend he were not able to avoid
taking an odd numbered car he would feel quite miserable during the
ride. Frights of various kinds may produce this same effect. I have in
my notes the case of a man who is unable to sleep at night without a
light in his room, because of a fright. Once while asleep in the dark,
he awoke conscious that someone was in the room and sat up and
demanded who was there. The answer was a revolver shot and a bullet,
passing not far away from him, pierced the head of the bed. As he sank
back the burglar leaped from the window and escaped. He realized that
this was the cause of his fear of the dark, but lesser incidents might
easily become subconscious yet continue their influence.
Psycho-Analysis.--In recent years Freud has suggested that in many
puzzling cases of psycho-neurosis, where, so far as is known, there
seems to be no dominant idea bringing about the concentration of
attention, careful analysis of the patients' memories will bring out
the fact that there is a subconscious idea as the underlying
substratum of these affections. Freud has developed what is called the
process of psycho-analysis in order to bring out these ideas which are
sometimes exerting their influence unconsciously to the patient. The
subconscious is one of the fads of the hour, so that Freud's
announcement attracted much attention. Psycho-analysis, however, is
not advanced so confidently even by its inventor as a positively
curative measure, as it was at the beginning. It has been found that
after the dominant idea in the subconsciousness has been found and
neutralized with a consequent amelioration of the psycho-neurotic
symptoms, there may be a relapse, when another dominant idea will have
to be found, and that there seems to be the possibility, in some cases
at least, of an almost endless succession of such ideas to account for
further and further relapses.
Undoubtedly psycho-analysis has its place in psychotherapy and is of
great value in certain cases. There is no doubt, however, in my mind
that in most of these cases reported as cured after psycho-analytic
methods had been employed, what really happened is that the patient's
mind became diverted to another idea--that of marvelous cure through
mind searching which relieved the previous concentration of mind
underlying the psycho-neurosis. These are the cases that used to be
cured by hypnotism. Before hypnotism was developed they were cured by
mesmerism. Before mesmerism they were cured by magnets or by the
Leyden jar, and during the past century they have been cured by
electrical methods or by osteopathy or by Eddyism. Many of the cures
were effected by stroking and touches, the use of Perkins' tractors,
or Greatrakes' methods, or anything else that attracted attention very
strongly. They were given a new idea which occupied them very much and
so saved them from that preoccupation with themselves and their
feelings and whatever slight ailment might be present that was the
physical occasion for psycho-neurotic symptoms. This happened with
psycho-analysis. When it was absolutely new and the operator had great
confidence in it, this confidence was imparted to the patients, with
the consequent cure or decided amelioration of their psycho-neurosis,
just as that used to be brought about by our previous method of
treating such cases by some strong suggestion.
As I emphasize in the chapter on Dreams, the examination of the dreams
in order to get a hint of the dominant idea, is particularly
interesting, because it represents a return to the oldest methods of
suggestion of which we have record. {596} The fact that sexual ideas
seem to represent a great many of the dominant ideas in these cases is
of interest for a similar reason. It represents the tendency
constantly recurring to refer most nervous ailments, as indeed most
other ailments, to something pathological in the sexual or genital
sphere. The old idea embodied in the word hysterical exemplifies this
very well. The "vapors" or "tantrums" or fits which were supposed to
be due, to some extent at least, to suppressed sexuality by medical
writers of three or four generations ago, have come back to us under
another form and with other terms. Psycho-analysis gives occasion for
instruction in so far as it helps the patient to get rid of old
persuasions and exploded ideas as to disease and diet and the various
functions of the body and the mind that have often almost
unconsciously been acquired and secured a dominance. It is surprising
how often it will be found that people are taking too much or too
little water at meals, too many or too few vegetables, too much or too
little of salt or of other condiments as the result of habits and
notions acquired when they were young and under influences that they
may now forget. In the same way habits of life with regard to bathing,
clothing and the like may be the source of unfavorable conditions in
mind and body that need only to be discovered to be corrected. Their
correction will often bring about the relief of symptomatic conditions
that have proved quite obstinate to treatment. We have emphasized this
in the chapters on the Individual Patient and the necessity for
acquiring just as much knowledge as possible about both his
occupations and his mental attitude in order to be able successfully
to treat chronic disease.
{597}
SECTION XVIII
_DISORDERS OF MIND_
CHAPTER I
MENTAL INCAPACITY (PSYCHASTHENIA)
In recent years we have come to realize that many of the so-called
nervous diseases, or if they do not deserve the serious name of
disease, nervous symptom-complexes, are really due to a deficiency of
vital energy. Some people have a store of energy that enables them to
accomplish many different things successfully. Some become exhausted
from a few trivial occupations. What is noteworthy in the cases to be
discussed in this chapter is that they show always certain symptoms of
mental tiredness or, at least, of lack of capacity for affairs.
Patients complain, for instance, that they cannot make up their minds
so as to reach decisions because they doubt so much whether the
decision they come to will be right or wrong. Others dread the outcome
of any and every act and feel that something is hanging over them.
Slight sources of irritation become so exaggerated by thinking about
them and dwelling on their possibilities that they may even disturb
sleep and appetite and, as a consequence, the general health. Fears
come over patients lest various things should happen and they dread
microbes, or infections, or dirt in general, or the approach of
insanity, and all to such a degree as to incapacitate them for their
ordinary occupations.
Many of these patients become quite incapable of willing effectively.
They not only lose initiative, the power to undertake new enterprises,
but they find it difficult to make up their minds as to details of the
ordinary affairs of life. As we have stated elsewhere in Professor
Grasset's expressive formula, these patients say that they cannot do
things, their friends say "they will not," and the physician, taking
the middle course, which, as usual in human affairs, has much more of
truth than either of the extremes, says "they cannot will."
For these states Janet of Paris suggested the word psychasthenia. It
is formed on the model of the word neurasthenia and unless it is used
with discretion will have all the objections that attach to that other
term. Above all, it shares the tendency pointed out by Sir William
Gowers with regard to neurasthenia of being "too satisfying. Men are
apt to rest on it as they would not on its English equivalent.
Physicians, if they do not actually think that they have found the
malady from which the patient is suffering, have an influence exerted
on them of which they are often unconscious, which lessens the
tendency to go farther in the search for the whole mental state." Much
more can be said in defence of psychasthenia, however, than of
neurasthenia, for the substitution for it of the translation of the
Greek words of {598} which it is composed--"mind weakness" would be
alarming. While it is important, then, to realize that the term may
easily be made too general and prove, as such words as rheumatism has
done in our time and malaria did in the past, a cloak for ignorance
and an excuse for incomplete investigation for diagnostic purposes, it
represents a satisfactory answer to the patient's question as to what
is the matter without committing the physician to such definitely
detailed opinions as to the patient's condition as would surely prove
unfavorably suggestive.
Psychasthenia, Natural and Acquired.--There are two forms of the
mental incapacity that underlies many of the curious symptom-complexes
that have been studied under the term psychasthenia. One is natural,
that is, inherent in the special character of the individual, and the
other acquired through disease or exhausting labor, worry, or anxiety.
Some people are born without sufficient mental energy to do the work
they attempt to accomplish. This is true, also, in the physical order.
It is often pitiable to see young men who have not the physical
strength necessary for athletic exercises, or the dexterity required
for them, faithfully trying to accomplish by effort what others do
with ease. When there is some natural defect in the way they will
usually fail, no matter how much they strive. Just in the same way
some persons are not able to accomplish certain more serious purposes
requiring special mental ability or power which they attempt. Their
brothers, their friends, their schoolmates, may have the ability, and
they cannot understand why they should not have it, but the fact
remains that they are not possessed of it and if they try to make up
for this defect by overwork they simply break down.
Differential Diagnosis.--Each of the two forms of mental incapacity,
congenital and acquired, must be carefully differentiated and treated
from a special standpoint. With regard to congenital lack of mental
control, all that the doctor can do is to counsel against the
assumption of duties and responsibilities that are too heavy for the
patient. Some people have not enough nervous energy to run a business
with many details, and some even find it difficult to try to do things
involving much less responsibility. There is no use for a man five
feet in height, weighing one hundred pounds, to try to be a stevedore.
There is no use for men of delicate muscular build to try to make
their living at heavy manual labor; they simply wear themselves out in
a very short time. This inadaptability is recognized at once. Just the
same thing is true with regard to many nervous systems, but the
recognition is not so easy or immediate. Some cannot stand the strain
of intricate business details or the burden of responsibility in
important transactions. They must be taught to be satisfied, then,
with quiet simple lives without what is for them, excessive
responsibility and without strenuous business worries. A country life
with regular hours, plenty of open air and as little responsibility as
possible, is the ideal for them.
The most difficult problem in this matter is the question of
diagnosis. As a rule, the history is the most helpful for this. The
patient tells of having found difficulty all his life whenever
anything of special significance was placed on his shoulders. He is
one of those who were born tired and remain so all their lives. It has
been the custom to blame these people; they are rather to be pitied.
If they are born in circumstances that allow of their {599} living
quietly in the country, they accomplish a certain amount of work quite
successfully and live happy, contented lives. If they are born in the
city where the hurry and bustle around them and the insistence of
friends that they must take up responsibilities becomes poignant, they
get discouraged and even despondent. It is from this class of patients
that the "ne'er-do-wells" of modern life are recruited. They form the
under-stratum of trampdom, the scions of good families with the
wanderlust, the willing but incapable. Certain of them become vicious
and criminal, either because they do not want to work or because their
mentality is perverted in some way. Such patients cannot be treated
with any hope of their becoming successful exemplars of the strenuous
life, but they may be directed into the less exacting occupations of
country life and so live quiet, useful and happy lives. For the
congenital class we can do little except to prevent them from trying
to do things that are beyond their mental capacity and helping them to
see just what their limitations are.
_Mental Exhaustion_.--Many disturbances of mental energy are acquired.
These may be either functional or organic. For the organic variety we
cannot do much, since it is dependent on changes in organs that are
permanent. We can, however, usually predispose the patient's mind to
the recognition of the fact that he should no longer try to devote
himself to occupations that constitute a special drain on his nervous
energy. The man, for instance, who is already suffering from
arterio-sclerosis must be warned that worry and work will surely
hasten the process and that his nervous symptoms cannot be cured, but
must be palliated. He must be advised to lessen his mental strain and
to take up something which, while occupying his mind, does not make
insistent calls on his vitality. In this matter it must be remembered
that when a man over fifty develops nervous symptoms, as a rule there
is no question of functional trouble but of organic change and usually
heart or arteries or kidneys are at fault.
In recent years we have come to realize that typhoid fever often makes
serious inroads upon a patient's vitality which can only be retrieved
by care, not alone for some months but, if possible, even for some
years, not to put an overstrain on the vital energy. Certain other
diseases produce an even more lasting effect. A sufferer from
well-developed tuberculosis will probably never be able to go back to
the strenuous city life. If he attempts to do so, not only is there
danger of a recurrence of his tuberculosis, but there may even be a
development of neurotic symptoms. Syphilis is another disease that
leaves patients in a condition in which it is dangerous for them to
assume the serious responsibilities of an exacting occupation and
especially anything that involves excitement and worry. Syphilitic
patients should be warned of the danger of pursuing vocations that
make such demands upon them. It is the actor, the broker, the
speculator, and the strenuous business man generally, who is likely to
suffer from parasyphilitic conditions, tabes, paresis and the like,
much more than those who follow occupations that make less demands on
them.
Functional Mental Incapacity.--In a large number of cases the
incapacity to do things because of lack of mental energy is due to
functional disturbances of the nervous system. These are the most
important for the psycho-therapeutist because much can be accomplished
for them. Nearly always the patient can be benefited by advice and
suggestion, and very often some {600} unfavorable factor at work,
using up his mental energy to no purpose, will be discovered. In order
to do good, however, careful study of the individual patient is the
most important element. The most frequent functional disturbance of
the nervous system, leading to exhaustion of mental energy, is
over-attention to one's self and to one's occupations. Men can do many
complicated things quite naturally and easily, but when they carefully
watch themselves doing them, accomplishment is not so ready and the
task is double. They tire much easier, for, as a rule, what they are
doing could be accomplished automatically and they are using up energy
attending to it. This is probably one of the commonest causes for the
rather frequent development of that state called nervous exhaustion in
our time. People watch themselves too closely and by so doing they not
only use up energy unnecessarily in the surveillance, but also they
hamper their powers to do things and so consume additional energy in
overcoming this inhibition.
Morbidly introspective people watch almost ceaselessly everything they
do. They not only watch themselves work and worry about it, but they
watch themselves play and grow solicitous that it will do them good;
they watch themselves divert themselves to see if it is giving them
real recreation and so spoil the diversion; they watch themselves eat
and disturb their appetite, and watch themselves digest and hamper
digestion; they even try at least to watch themselves sleep and so
interfere with sleep. Many of the cases of insomnia are really due to
this over-attention. They fear they will not sleep, they worry about
it, they keep themselves awake hoping that they will sleep, and in the
more serious cases even during sleep itself they are so solicitous
that their dreams become very vivid and a form of unconscious
cerebration goes on with surveillance of themselves. They do not rest
even in sleep. They wake feeling not rested, they get up with a
consciousness that they are beginning a long day without being
properly refreshed and they exhaust enough energy to complete a good
part of the day's work in wondering whether they will be able to go on
with their occupation for the day, whatever it may be.
_Inhibitory Surveillance_.--People become afraid that they cannot or
that they may not do things well and set a guard over themselves. This
is illustrated very well in the doubts about accomplishment because of
which they keep going back to see what they have done and how it was
done, though usually it was accomplished quite well without any
conscious attention. Dreads form another phase of this attitude of
mind. For those who are affected with them they make a thing hard to
do before it is begun, and harder to accomplish after it has been
entered upon because of the suggestion that it may lead to some
serious results, or they even inhibit their activities to a marked
extent by their solicitude with regard to them. They worry about
things before the event and thus consume energy uselessly. Worry has
been defined as anxious solicitude about what we have to do next week
at the same time that we occupy ourselves with what we are doing now
and have to do in the next hour or two. The solicitude about next week
is quite useless, as a rule, until the time comes, and it merely
disturbs what we are doing now, making it harder to do and making
errors in it almost inevitable, and so preparing ourselves for
discouragement because of mistakes that have been made and still
further adding to the difficulty of accomplishment.
{601}
_Inhibition of Automatism_.--These introspective people disturb
themselves by over-attention to things that need no attention, that
are accomplished automatically, and that are not done nearly so well
if they are attended to. Not only is it true that it is harder to do
work that ought to be accomplished automatically if much attention is
given to it, but also nature resents the surveillance. Not only the
brain does not work so well if watched to see whether perhaps it is
working too much, or whether there are too many feelings in our head
while we are doing things, but even the stomach resents being watched
and does not do its work as well. The same thing is probably true for
every one of our organic functions. In the chapters on the heart we
call attention to the fact that surveillance makes a perfectly healthy
though nervous heart miss beats. There is a dual waste of nervous
energy then. We are employing our attention watching things done that
need not be watched, and by that fact we are inhibiting natural
processes and requiring that more energy shall be put into them for
their accomplishment, and even then accomplishing them with
discouraging imperfection.
_Mental Short-Circuit_.--The reflex mental process that particularly
affects many individuals in our time and makes it hard for them to do
their work, has been well described under the figure of a
short-circuit in an electrical dynamo. The short-circuit diverts the
current so that instead of acting outside the dynamo and performing
useful work, it is discharged within the machine, brings about
deterioration of its elements and soon leads to a reduction in the
amount of electrical energy that that particular dynamo can develop.
Association Fibers Diversion.--Prof. Michael Foster in the Wilde
Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote
44] has many valuable suggestions with regard to the mechanism of
mental operations on the neuron theory. He has particularly dwelt on
the function of the association fibers in connection with mental
operations, or with the raising of sensation to the plane of
mentality. A portion of the brain that is originating impulses,
instead of sending them down to the periphery, through the projection
fibers, to lead to the accomplishment of external work, may have its
messages diverted through the association fibers to other portions of
the brain and thus do harm rather than good.
[Footnote 44: _Proceedings of Manchester Literary and Philosophical
Association_, 1898.]
Occurrence of Psychasthenia.--It must not be thought that these
curiously interesting conditions occur only among people of low
intellectual caliber, or in those of narrow intellectual interests,
mere specialists who may have acquired a reputation for doing one
thing well. They are frequent among the most intellectual classes.
Brain workers of all kinds, unless they are careful to vary the
interests of life, unless, as suggested in the chapters on Occupation
of Mind and Diversion of Mind, they have a hobby besides their usual
occupations, are likely to suffer in this way. As a matter of fact,
many intellectual people have had what are called nervous breakdowns
of this kind. A biographical dictionary shows any number of them. Dr.
Gould's Biographic Clinics furnish many documents for the study of
these conditions. A typical instance, told by the sufferer himself,
the distinguished Sir Francis Galton, is of special significance for
the psychotherapeutist. I {602} quote because it illustrates the fact
that such breakdowns do not portend a short or subsequently listless
life, for Sir Francis, a most successful scientific investigator,
lived well beyond fourscore years in the full possession of health of
mind and body.
It was during my third year at Cambridge that I broke down entirely
in health and had to lose a term and go home. I suffered from
intermittent pulse and a variety of brain symptoms of an alarming
kind. A mill seemed to be working inside my head; I could not banish
obsessing ideas; at times I could hardly read a book, and found it
painful to look at even a printed page. Fortunately I did not suffer
from sleeplessness, and my digestion failed but little. Even a brief
interval of mental rest did me good, and it seemed as if a long dose
of it might wholly restore me. It would have been madness to
continue the kind of studious life that I had been leading. I had
been much too zealous, had worked too irregularly and in too many
directions, and had done myself serious harm. It was as though I had
tried to make a steam-engine perform more work than it was
constructed for, by tampering with its safety-valve and thereby
straining its mechanism. Happily the human body may sometimes repair
itself, which the steam-engine cannot.
The physician with experience in such cases would be much more apt to
say, "Happily we can learn to control our mental energy and not let it
go to waste by foolish persistence at one set of ideas constantly, nor
be dissipated in surveillance of functions that work automatically if
left to themselves."
Etiological Factors.--This form of mental incapacity develops
particularly in people after they have gone through a prolonged period
of hard work and then have come to a time when they are much freer
than they were before. They are prone to think that they exhausted
their nerve force during the preceding period of labor and that now
they are paying for it. Almost invariably what is really happening is
that they now have much more time to occupy themselves with themselves
and about themselves and to worry over their ills, real and imaginary.
This is the typical nervous breakdown, as it used to be called, of
elderly retired merchants or bankers. They have looked forward all
their lives to a time when they could enjoy themselves doing nothing.
They retire from business and then their troubles begin. It is no
wonder that the old proverb, "A machine rusts out much sooner than it
wears out" should have been so often quoted with regard to this
condition. A man who has been working busily at something all his life
cannot stop all at once and do nothing. He cannot learn to occupy
himself with trivial things. Commonly, he has few, if any, interests
apart from his business and he very soon wears the novelty off these
and then introspection comes to make him exaggerate the significance
of every feeling that he has, every stiffness that occurs, every
muscle twinge due to change in the weather, until he becomes supremely
miserable.
As a rule, these patients are simple, practical, common-sense,
business men, and it is hard for the physician to think that there is
nothing more than a functional neurosis present. It is even more
difficult for the patient to be made to appreciate that his ills are
mainly due to his own over-attention to himself in this idleness that
he has looked forward to with so much pleasure. Ordinary medicines
fail to relieve and the regular professional man seldom succeeds in
doing these patients much good. They constitute the richest material
for the quack and the charlatan. Much occupied with their ills they
tell their friends all about them. Whenever a strong impression is
produced {603} on their mind by a promise to cure them with some new
wonderful remedy they are favorably influenced, often get better and
then are walking advertisements for the particular quack who has
happened to benefit them. It is this class of people that has given
more trouble to legislative committees of medical societies than any
other. Some of them appeal to legislators whenever a bill for the
admission of some new form of practitioners of medicine comes up with
the story of how much benefit they derived from the treatment. Since
they have been successful business men their word carries weight. It
is curious how little the making of money, though often presumed to be
so, is a test of real intelligence. It is often the man of one idea
with no intellectual breadth who is the best money-getter.
These conditions develop almost entirely in predisposed individuals
who, for some reason, are trying to overdo the energy they possess,
and who, as a consequence, have lost a certain control over
themselves. At times, of course, they occur in persons who have so
little occupation of mind that thoughts of various kinds along these
lines become insistently suggestive and cannot be thrown off because
the patients' interests are not sufficiently deep or sufficiently
varied to occupy their attention. The rational treatment of them,
then, must be founded on a careful study of individual cases, the
recognition of the special cause, and also the occasions at work in
each case, a neutralization of unfavorable suggestion and a provision
of such favorable suggestions and occupation of mind as will enable
the patient to rid himself of the annoyance occasioned by these and
the physical symptoms that so often develop as a consequence. In a
certain number of cases a history of corresponding or equivalent
affections in preceding generations will be found. In many patients,
however, there is no such history, though there is usually the story
of symptomatic mental conditions of one or other of the types
mentioned, earlier in life. When in good health physically the patient
has very little bother from them. When run down in weight or when
worried or anxious about business or from the stress of important
responsibilities these symptoms may become bothersome mentally and
physically. Often it will be impossible to obliterate them entirely,
but always they can be greatly improved and the patient can be made to
realize that they are not seriously significant, that in mild form
they are rather common and that, above all, they are not so peculiar
to the individual as he is likely to think, with consequent increase
of the unfavorable suggestion.
CHAPTER II
HALLUCINATIONS
Hallucinations Differentiated from Illusions and
Delusions.--Hallucinations are vivid impressions on the consciousness
which appeal to their subject as strongly as if they were really the
result of sensory impressions, though those who experience them know,
either at the moment, or on investigation afterwards, that they had no
objective reality, that is, were not due to any external physical
cause. Illusions are deceptions of the senses, due to the imperfection
of the senses or the conditions in which the perception occurs. {604}
Delusions are mental states in which ideas are accepted, or
conclusions drawn, or information assumed to be gained, though the
whole process is mental and has no relation to reality. (For
illustrations of illusions see chapter with that title in the
Appendix.)
Hallucinations lie in between illusions and delusions as a mode of
deception. They are mental occurrences, but they seem to come from the
senses and probably the best explanation for them is that a previous
sensory impression is vaguely aroused and then finds its way into the
consciousness as if it were coming through the senses. It has been
suggested that they might be due to a reversal of the nervous process
by which a sensation reaches the brain. The external object produces
the sensation, this travels along a nerve causing a perception, this
perception is stored in the memory, and then, when very vividly
reawakened, causes impulses to travel backward along the nerve to the
periphery with the production of a feeling very like sensation.
Frequency.--While hallucinations are often supposed to be only
incidents in the life of the insane, or at least of those who are in
the danger zone near mental disequilibration, carefully collected
recent observations show that many perfectly sane people have
experienced them, and some of them have been much disturbed by them
for fear they portended loss of mental control or some developing
pathological condition. A certain number of men and women have seen
things that either had no existence or existed only for them and for
the moment, and that evidently were due to some state of mind rather
than to their senses. They have heard things that were not said or
that were not audible to others, or that were only reproductions of
their memory of previous sounds and quite naturally such mysterious
manifestations disquiet them. It was the rule in the past to dismiss
such phenomena without serious consideration, or at most to consider
that they were only subjective manifestations not worth discussing, or
to go to the opposite extreme and say that they were due to mental
disturbances.
Of course, as a rule, hallucinations are an index of mental
disturbance. No matter how apparently sane the patient, this must be
the first thought and must be carefully excluded before proceeding
with the case. The subject of hallucinations is larger than that,
however, and it is a mistake to brush it aside in every case as if it
were either very serious or of no importance and that in either case
nothing can be done to relieve solicitude about it. Physicians can
often do much, first to prevent hallucinations by getting at the
physical causes of them; second, to prevent them from disturbing
patients seriously by showing them how common are such experiences and
by indicating their possible physical significance; third, by securing
such mental discipline and control as will render their recurrence
much less frequent; and, fourth, they can make the almost inevitable
unfavorable effect upon the mind of the patient and then reflexly upon
his body, much less than it would otherwise be, by sympathetically
discussing and entering into the details of them enough, at least, to
explain their significance or throw some light on their origin in
physical conditions.
Hallucinations of vision, the seeing of things and persons that have
no real existence at the time and place they are seen, are usually
considered to be rather uncommon and to occur only in those whose
mentality is seriously disturbed. Careful studies of the subject,
however, show that at least one in ten {605} of educated people
consulted have had some hallucinations of vision. Either they have
wakened up, or they have dreamt that they waked in the early morning,
and have seen some one whom they knew, but knew to be at the moment at
a distance, standing near them. Such visions have gradually faded away
or suddenly disappeared. Occasionally these persons have in full light
had some appearance, wraithlike or otherwise, some manifestation that
appeals to vision, yet that they knew at the time or learned
afterwards was non-existent.
Many people are backward about confessing that they have had such
experiences, for they fear that it will make them ridiculous or even
cause them to be suspected of disturbed mentality. Just as soon as it
is made clear to them that their admissions will be taken as evidence
for a phenomenon to be discussed seriously, many more than would
otherwise be thought confess to such hallucinations. Most of these, it
may be said at once, are quite sensible people, a great many of them
belong to the educated classes; all of them are trustworthy witnesses
as far as good will goes, and the circumstances of their
hallucinations are such in many cases that there cannot be a mere
mistake, or error of judgment.
The frequency with which hallucinations occur may be appreciated from
the investigation made some years ago at the instance of the Congress
of Experimental Psychology. The following question was put to 17,000
persons, mostly residents of Great Britain, and answers received:
"Have you ever, when believing yourself to be completely awake, had a
vivid impression of seeing or being touched by living beings or
inanimate objects, or of hearing a voice, which impression, so far as
you could discover, was not due to any external physical cause?" The
answers showed that 655 out of 8,372 men and 1,029 out of 8,628 women
had experienced a sensory hallucination at some time in their lives.
Some of them had had a number of them. That is, one out of ten in the
educated classes has had some hallucination, and nearly one out of
every eight women. An analysis of the statistics, however, brings out
some interesting suggestions. There were nearly twice as many
hallucinations related as having occurred during the year before the
question was asked as in the preceding years. There was a definite
reduction in the number that had occurred in all the preceding years,
except the fifth and tenth, and these were evidently due to
uncertainties of memory, so that five- and ten-year periods seemed
about the length of time that had passed since the event.
It is evident then that in spite of the fact that an hallucination
would seem to be very important and surely startling enough to be well
remembered, it is yet easily forgotten, since even a year's interval
made so much difference in the number that were remembered. The
committee, after considering this easy forgetfulness in the matter,
considered that to arrive at the actual total of visual hallucinations
experienced by this group of 17,000 persons during the ten-year period
in question, the numbers in the table should be multiplied by four.
That means that probably very nearly one in three people have had an
hallucination of some kind within ten years. The great majority of the
visual hallucinations consist of apparitions of human figures. Other
forms that are seen are so few, as Mr. Podmore has insisted in his
"Telepathic Hallucinations, The New View of Ghosts," [Footnote 45]
that they are almost negligible. A frank {606} discussion of these
details with a person who is much disturbed by having experienced an
hallucination is the best possible remedy for the physical and mental
disturbance that may result.
[Footnote 45: The Twentieth Century Science Series, New York, 1910.]
Sir Francis Galton, well known for his investigation of many subjects
and who may well be called the father of biometrics or statistical
biology, in his "Memories of My Life" [Footnote 46] tells of his own
investigations of the visions of sane persons. The fact that he
delivered a lecture on this subject at the Royal Institution of London
shows how seriously his studies were made and how much value
scientists placed on them. Galton's well-recognized training in the
careful weighing of evidence and his ability to strip phenomena of
everything that might divert their significance from what they really
were, add to the worth of his conclusions. Those who care to study the
subject further will find his discussion in the _Proceedings of the
Royal Institution_ (London, 1882).
[Footnote 46: New York, 1909.]
There are few people beyond middle age who have not had one or more
curious experiences in the matter of visions or appearances. Mostly
these have been vague and have not proved a disturbing element in the
minds of the subjects. Many more than are thought, however, have seen
visions vividly and with a detail that makes it almost impossible for
them to believe that what they saw was merely an externation of ideas
already in their mind. In this matter it must not be forgotten that
the dreams of many people, especially nervous people, often present
themselves with marvelous vividness of detail. They see people or
places in their dreams and reason about them quite rationally.
Occasionally a dream will bring back details that have been forgotten.
The dreaming state seems in some people to have wonderful power over
the subconscious. Things that are not remembered at all in the waking
state sometimes come back in dreams, and only then are recalled by the
individual as representing past events in his life. He is apt to
wonder where the details could possibly come from, since he had before
no conscious memory of them. This same thing holds for the day-dreams
or sudden visual appearances that come when the attention has been
wrapped in something else.
A typical example of such visual hallucinations is the following
incident told by a prominent London physician of himself:
One afternoon at tea time, before a meeting of the Royal Society,
Sir Risdon Bennett (1809-1891, a well-known physician. President of
the College of Physicians in 1876, and a fellow of the Royal
Society), drew me apart and told me of a strange experience he had
had very recently. He was writing in his study separated by a thin
wall from the passage, when he heard the well-known postman's knock,
followed by the entrance into his study of a man dressed in a
fantastic medieval costume, perfectly distinct in every particular,
buttons and all, who, after a brief time, faded and disappeared. Sir
Risdon says that he felt in perfect health; his pulse and breathing
were normal and so forth, and he was naturally alarmed at the
prospect of some impending brain disorder. Nothing, however, of the
sort had followed. The same appearance recurred; he thought the
postman's knock somehow originated the hallucination. ... I heard
the story at length, very shortly after the event, told me with
painstaking and scientific exactness and in tones that clearly
indicated the narrator's earnest desire to be minutely correct.
Those who are especially interested in this subject will find any
number of similar stories, some apparently rich with meaning, most of
them quite {607} meaningless, in the volumes of transactions of the
English Psychic Research Society, in F. W. H. Myers' "Human
Personality," in Podmore's "Naturalizing the Supernatural," in
Flammarion's "The Unknown," or many other books published in recent
years. It is quite easy to get sufficient material to bring
reassurance to any patient that visual hallucinations, at least, mean
nothing serious for the mind or body of the individual having the
experience.
Hallucinations in the Past.--It must not be thought, however, that
this subject of hallucinations is new. Literature is full of it and
from the earliest times we find traces of it. Egyptian, Babylonian and
Chaldean writers mention them. Nor indeed is the scientific
consideration of the subject new. Aristotle speaks of them and it is
evident that many of the old writers thought of them as psychic
incidents on some physical basis, or at least due to some
predisposition in the individual or in some special state of his
senses. Two generations ago Johann Mueller, the great German
physiologist, discussed the whole subject at length in a monograph,
and considered it of so much importance for physicians that he
introduced a resume of it into his great text-book of physiology. His
explanation of the occurrence of visual hallucinations is not only a
striking illustration of the thoroughly scientific character of his
treatment of the subject, but it serves to show how well men
considered these subjects long before the present fad for the study of
abnormal psychology or mental influence came in. His discussion of the
subject is sufficient of itself to make any patient understand his
hallucinations and keep them from bothering him better than anything
else I know:
The subjective images of which we are speaking have sometimes,
however, both color and light; different particles of the retina, of
the optic nerve, and of its prolongations to the brain, being
conceived as existing in special states of action. This happens
rarely in the state of health, but frequently in disease. These are
the true phantasms which may occur to the sense of hearing and other
senses as well as to that of vision. The process by which
"phantasms" are produced, is the reverse of that to which the vision
of actual external objects is due. In the latter case particles of
the retina thrown into an active state by external impressions, are
conceived in that condition by the sensorium; in the former case,
the idea of the sensorium excites the active state of corresponding
particles of the retina or optic nerve. The action of the material
organ of vision, which has extension in space, upon the mind, so as
to produce the idea of an object having extension, form and relation
of parts, and the action of such an idea upon the organ of vision so
as to produce a corresponding sensation, are both equally wonderful;
and hence the spectral phenomena or visions are not more
extraordinary than the ordinary function of sight. (Vol. II, p.
1393, Eng. transl., 1842.)
Apparitions and their Explanation.--In spite of suggested explanations
on physical grounds, some of these apparitions that appear to people
seriously disturb them. They cannot get them out of their minds. They
are sure that they portend evil. Hence worries, and the more nervous
the people are and the more worried already, the more likely is such a
thing to recur and then to be made much of. Only through their minds
can these people be treated, and it must be made clear to them not
only how common are hallucinations, but that there is an easy psychic
explanation of most of them. Sir Arthur Mitchell, K. C. B., in his
book "About Dreaming, Laughing and Blushing," [Footnote 47] tells a
story and then gives his explanation of it in such a way as to
illuminate many of these occurrences:
[Footnote 47: Longmans, London, 1900, page 21.]
{608}
Perhaps I should illustrate how I think that apparitions may be
nothing more than dream hallucinations. A. B., a gentleman of
culture and strong character, called one hot day, after a hearty
lunch, on an ecclesiastic in a high position, who happened to be
engaged in his library at the time of the call. A. B. was shown into
a room opening off the library, and requested to wait. He sat down
beside a table, and with his elbow resting on it, he leant his head
on his hand. While in this position he saw a man in clerical costume
come through the door communicating with the library, without any
opening of the door. A. B. was absolutely certain that he had seen
an apparition, and was surprised and hurt when I expressed a doubt.
He called on me to explain, and I said that it was at least possible
that he had been asleep for some moments, that if he had slept at
all, however short the dream of the sleep, he must have had a dream,
if I am right in thinking that there is no dreamless sleep, and that
thus what he regarded as an apparition might be nothing more than a
dream hallucination. He assured me persistently that he was
continuously wide-awake, but I assured him that these moments of
sleep often occurred without any consciousness that they had
occurred. He refused to be deprived of his ghost, and I refused to
believe in the supernormal when the normal was sufficient.
Such wraith-like appearances are supposed to occur especially in
connection with the deaths of persons at a distance. Startling stories
are told, particularly of those who are very near relatives, husbands
and wives, mothers and sons, and, above all, twins, who have been very
closely associated with one another during life. There are a large
number of stories of this kind, however, that have been collected by
the Psychic Research Society and other agents with strong evidence in
their favor, in which the appearances have had no ulterior
significance at all and have evidently been mere figments of the
imagination, the externation of images from memory so vividly that
they seem to be the reseen. Reassurances in this matter are the best
possible source of relief from the sense of impending ill for many
patients. The physician who wishes to relieve such symptoms must
familiarize himself with some of the many stories that have been
investigated and that serve to prove that these and like appearances
must not be taken as significant of anything more than a definite
tendency, that exists in human nature at moments of day dreaming or
when one's attention is suddenly turned from a book in which one has
been absorbed, to see externally what is really passing through the
imaginative memory.
A Disappearance.--A very interesting commentary on some of these
appearances is to be found in Mark Twain's story of a disappearance,
which could probably be duplicated many times if experiences in this
line were collected and collated. Mr. Clemens, sitting on the porch of
his residence one day, saw a stranger of rather peculiar appearance
come up the walk toward the front door and he expected to hear him
ring the bell and have the servant come to the door and usher him in,
and then perhaps be called to see him. About the middle of the walk,
however, the stranger disappeared and Mr. Clemens was quite surprised
to come to himself, rub his eyes and conclude that he had had one of
these curious visions or hallucinations, in which the Psychic Research
Society would surely be interested. He had plainly seen the stranger
enter the gate, come up the walk, and then disappear. He was so
impressed by the disappearance that he roused himself to go into the
house to get his notebook, so as to make notes of what had happened
before the details escaped him. To his surprise he found the stranger
in conversation {609} with the servant in the house. There had simply
been a lapse in Mr. Clemen's vision of him. He had had a disappearance
phenomenon instead of an appearance. The story will be found to amuse
patients who complain of appearances disturbing them, though Mr.
Clemens always told his disappearance story very seriously, and it is
as interesting a psychic phenomenon as any told of the wraith-like
appearances.
Treatment.--Considering how frequent are such phenomena, the physician
must be prepared to treat those who are disquieted by them. A
wraith-like appearance, for instance, will disturb many people very
seriously and often for days, sometimes for weeks, make them nervous,
excitable, and impair their appetite, disturb their digestion and
sleep and often such unfortunate occurrences are prone to come just
when they are run down in weight and when they need the help of every
factor that makes for improvement of health. Simply to dismiss such an
appearance as if it were quite imaginary, that is, non-existent in
some form of reality, or quite baseless and trivial, serves no good
purpose, for, as a rule, the persons concerned are deeply impressed
with what they have seen. The only way to remove the unfavorable
impression produced by it is to discuss it straightforwardly on the
basis of what we have come to know as the result of recent
investigations and the collation of the literature which has been
published by the various psychical research societies and authorities
on the subject. We know now that while occasionally such wraith-like
appearances seemed to have a definite significance, because of
something that happened simultaneously or shortly afterwards, this is
mere coincidence and there are literally thousands of such cases in
which a well authenticated wraith-like appearance was followed by no
serious consequence, was never shown to mean anything beyond a curious
psychic phenomenon, and was evidently merely due to some personal
subjective influence, some externation of an image in the memory,
unusual, but not at all unique, or even very rare, and evidently due
to a curious peculiar externalizing power with which certain
intellects are gifted.
Auditory Hallucinations.--Hallucinations of hearing are more common
than those of vision. Many people have had the experience of waking up
thinking that someone was calling them. A great many people are sure
that they have, at some time or other, heard a voice when no one was
near enough to them to have said anything. They have even recognized
the voice. Some people, when thinking deeply about a person, have the
voice of that person occur to them so clearly that they cannot quite
make out whether they have actually heard it or whether it has only
been very vividly reproduced in their memory. Such experiences are so
common as to be well known, though many people hesitate to tell the
stories of them, for hearing voices is rightly looked upon as a
frequent preliminary symptom of insanity.
Hallucinations of hearing are the most common early symptom of
insanity. The hearing of voices must always arouse suspicion at once.
It must not be forgotten, however, that a great many recognizedly sane
people who have remained so for life, have thought that they heard
voices. Of course, we have no definition for insanity, and it is
difficult to draw the line. We have no definition for health either,
yet we have a practical working standard for the recognition of it, as
also for insanity. These hallucinations then, both of vision and
hearing, deserve to be discussed seriously, and in {610} nearly every
case, even though there is some mental disturbance, the physician can
in this way benefit his patients and keep them from being overmuch
distressed by their hallucinations.
There is an expression in such common use that it is evidently the
result of an almost universal experience, according to which men
sometimes explain, after having acted in a particular way, that
"something told them to." What they mean, of course, is that a
conclusion formed in their minds the reasons for which they could not
understand, but which yet had force enough to cause them to follow it
to a practical application. When we hear of Socrates being advised in
life by a demon, a so-called familiar spirit, we are apt to wonder
whether by this term is meant anything more than just this curious
feeling of aloofness from ourselves that we sometimes have when we are
trying to make up our minds, or, indeed, not infrequently when we are
deeply engaged in any intellectual occupation. As discussed in the
chapter on Unconscious Cerebration, our minds seem in a certain way to
act independently of us. Occasionally they draw us to conclusions
quite different from those which we previously expected to reach.
There seems to be a something within us that works quite of itself and
beyond our will. Whether under these circumstances there may not
occasionally come so vivid a feeling of this power within us
impressing itself upon us, that it seems to come from without, must
always be taken into account in the effort to get at the real
significance of these curious hallucinations. Only thus are we able to
come to the relief of patients who are bothered by them.
_Explanation by Sound Reproduction_.--Auditory hallucinations are
probably not more than reproductions of sounds heard before recalled
vividly and apparently heard again at moments when attention is not
attracted to actual auditory sensations and we are in receptive mood.
Some of them are very startling because they are apparently warnings
of future events, as is proved by their fulfillment. These, however,
do not seem to be more than coincidences noted with regard to similar
events connected with Premonitions, Dreads and Dreams (see chapters on
these subjects). There is, for instance, a well authenticated story
published by the English Psychic Research Society of a woman who was
about to take a dose of what she thought was some ordinary home
remedy, when she distinctly heard a voice telling her to taste it. The
dose to be taken was a tablespoonful, and when she tasted it she found
that by mistake she had placed her hands on a bottle containing a
rather strong poison and a tablespoonful of it would almost inevitably
have killed her. Unfortunately, such occurrences are so rare and the
reason for them is so hard to find that their consideration as
anything more than coincidences seems out of the question. Every
medical journal almost brings the story of someone who has taken a
dose of medicine that proves fatal, and there is no warning. If such
warnings came with definite frequency, it would be easier to
appreciate their significance.
There are similar stories with regard to other warnings. There is the
story of the young man who in a storm drove under a shed for
protection. Just as he did so he heard his mother's voice--she had
been long dead--distinctly say "Drive out!" Ho drove out at once in
the teeth of the storm, so deeply impressed was he, and was scarcely
beyond the entrance when the shed fell, crushing everything within it.
Similar warnings of impending {611} accidents are rather frequent in
certain people's minds, yet it is hard to think of them as anything
else than premonitions. These somehow take on the character of
auditory hallucinations in certain sensitive minds. Compared to the
whole number of accidents, however, such incidents are extremely rare
and follow no law, and while there are those who like to think that
perhaps such phenomena are due to the solicitude of some being in the
other world, this is extremely doubtful. In that case, as St.
Augustine suggested, they would be much more frequent and have a
clearer significance than is at present the rule. St. Augustine,
discussing the possibility, was sure that he would have had
communications from his mother. Most men would re-echo his feeling.
Coincidences.--Most of these stories as they have been analyzed by
careful investigators are indeed such trivial unmeaning things that it
would be too bad to let people be bothered by them. They have
occurred, however, from time immemorial. Veridical warnings are a
commonplace in the literature of all countries. Undoubtedly some may
suggest the action of a Higher Power, but the more one knows of the
conditions in which they happened, the people to whom they came and
their ultimate effects, the less will they seem providential. It is
evident that under certain conditions they may be produced even at
moments when men are not particularly excited and when they think that
they are perfectly calm and self-possessed. Each story must be
discussed in its own merits. The only thing to do, then, is not to
make too light of them and, above all, not to treat them as merely
imaginary or as utterly illusory; for they are often natural
phenomena, the reasons for which and the conditions of their
production we do not as yet fully understand. If patients can be
brought to this viewpoint, they may even become interested in
searching out just what it was that caused each particular
hallucination. Over and over again it has been found that a moonbeam
or a peculiar unexpected reflection of the sun, or the light shining
through an unnoted aperture, or any or several of these in connection
with a mirror has been the main cause of the wraith-like appearance.
When they happen during the day it is sometimes at the moment of
passing from very bright light to a darker hall that the occurrence
takes place and evidently there is some physical occasion for the
appearances in the eye itself. Unusual noises of various kinds are
responsible for the auditory hallucinations.
Dangers of Serious Considerations.--There is one serious aspect of
these hallucinations and supposed warnings--they tend to paralyze
action. If a person allows himself to become firmly persuaded that
doubts and premonitory possibilities must be weighed and solved before
he may dare to act with assurance, then action becomes almost
impossible. Premonitions may serve to bring people into danger, or at
least keep people from having such presence of mind as will enable
them to get out of it, as they otherwise would. Doubts lead to
inaction and make a state of mind that is eminently miserable. The
patient's one hope is to put aside resolutely such hallucinations if
they rise to the level of a disturbing doubt or a paralyzing
premonition and to discipline himself against being influenced by
them. In many persons this is a difficult matter, but it represents
the only efficient path to the regaining of mental health and
strength.
{612}
CHAPTER III
DREADS
In any discussion of the influence of mind over body, favorable and
unfavorable, too much emphasis cannot be placed on the hold that
dreads have over a great many people and how much they mean, not alone
for the mental state, but also for the physical sense of well-being or
of ill-feeling in the individual. The expression attributed to the old
hermit who had lived to the age of one hundred and had spent some
sixty years of existence in the solitude of the desert, with all the
opportunities for introspection that this afforded, is the best
illustration even in our day of what dreads signify in life: "I am an
old man," he said to the young solitary who came to him for advice,
"and I have had many troubles, but most of them never happened." We
are nearly all of us, or at least those of us who spend most of our
time in sedentary mental occupations, prone to fear that something
untoward is preparing for us and in many cases to dread lest some
serious ailment or other is just ahead of us. We are afraid that
certain feelings, though we like to call them symptoms, due to some
trivial cause or other as a rule that deserves no notice, may mean the
insidious inroads of a constitutional disease destined to shorten
existence. A little fatigue, over-tiredness of particular muscles, the
straining of joints, the discomforts due to overeating and
undersleeping, that are meant as passing warnings of nature for the
necessity of a little more care in life, are exaggerated into symptoms
that have a more or less serious significance.
DEFINITE DREADS
Besides these rather vague dreads, however, there are certain special
disquietudes peculiar to individuals, even more groundless, if
possible, than the generic apprehension just spoken of and that have
been dignified in recent years by the name of phobias. Phobia means
only "fear" in Greek, but the term is much more satisfying to nervous
people than the shorter but too definite English term, dread, or fear.
There is acrophobia, or the fear of looking down from a height;
claustrophobia, or the fear of narrow places, as the dread of walking
through a narrow street because of the sense of oppression that comes
with the shut-inness of it. Then there is agoraphobia, market-place
dread, or the fear to cross an open space because one has, as it were,
grown accustomed to be near buildings and misses their presence. There
are many others, indeed as many as there are dislikes in human nature,
for any dislike apparently may be exaggerated into a dread. I mention
a few at the beginning of the alphabet and some of special
significance. There is aerophobia, dread of the air, a symptom
sometimes mentioned in connection with hydrophobia; aichmophobia, the
dread of pointed tools; ailurophobia, the dread of cats; anthrophobia
or the dread of men; pathophobia or the fear of disease, microbophobia
or bacillophobia; kenophobia or the dread of emptiness; phthisiophobia
or the dread of consumption; zoophobia or the dread of animals;
sitophobia or the dread of food, and even phobophobia, the dread of
{613} dreading. Neuropsychologists seem to take a special pleasure in
inventing some new phobia or at least giving us a fine long Greek name
for a set of symptoms by no means new and that might well be explained
in simpler terms. The most familiar examples are: the fear of
lightning, which is more frequently brontophobia, the fear of thunder.
These learned words are all formed on the same etymological principle
as hydrophobia, but they are entirely psychic in origin, while
hydrophobia, as it is well to explain to patients who think of the
word phobia in connection with their symptoms, is, of course, a
misnomer for an infectious disease--rabies--which develops as the
consequence of a bite of a rabid animal, and the principal symptom of
which is not fear of water, but the impossibility of swallowing any
liquid because of spasm of the esophageal muscles.
Almost any function of the body may become the subject of a dread or
phobia that may interfere even seriously with it. Any disturbance of
any function is likely to be emphasized by such dreads. The French
have described the basophobia, which makes the patients suffering from
beginning tabes dread so much walking that it becomes a much greater
effort than it would otherwise be and often interferes with walking
rather seriously. Then there is the fear of tremor which exaggerates a
tremor due to some organic cause, but yet not necessarily of grave
import, nor likely to increase rapidly. Many of the hysterical palsies
are really due to dreads, consequent upon some incident, motor or
sensory, which produced a profound effect upon the patient's mind. A
patient who has been surprised by a digestive vertigo while descending
a stairs, even though nothing more happened than the dizziness which
required him to grasp the balustrade, will sometimes develop a fear of
vertigo that will actually make it difficult for him to go down stairs
without such an effort of will as is very exhausting. Even the
slightest functions may be thus disturbed. Pitres and Regis described
some ten years ago what they called the obsession of blushing, or
erythrophobia, the fear of turning red. Patients make themselves
extremely miserable in this way. Only training and self-control will
help them.
These names are long and mouth-filling and consequently satisfying,
and most people who are suffering from a particular phobia are almost
sure to think that they have a very special affliction. When the word
dread is used instead of the word phobia they are less likely to
misunderstand the character of their affection and to realize that it
is not a disease but only an unfortunate mental peculiarity that needs
control and discipline, and not fostering care. Neurasthenia only
means nervous weakness, as we have pointed out, but most people are
rather rejoiced when informed that they have so high-sounding a
disease as neurasthenia, while to be told that they are nervously weak
or suffer from nervous weakness seems quite a come-down from their
interesting Greek-designated affection. Most psychiatrists feel that
it is better not to give the long Greek term, but to state in simple
short Saxon words just what is the matter with the patient. They are
suffering from the dread of a height, or the dread of a narrow street,
or the dread of open spaces, or the dread of dirt, or of cats, or of
whatever else it may be. This makes it easier for them to begin to
discipline themselves against the state of mind into which they allow
themselves to fall with regard to these various objects, and mental
discipline is the only therapeutic adjuvant that is of any avail in
{614} lessening these conditions. With reasonable perseverance most
people can, if not cure themselves of these affections, at least
greatly lessen the discomfort due to them. A consideration of
particular dreads brings out the specific suggestions that may be made
with regard to each and the directions that may be helpful to the
patients. Probably the commonest is acrophobia, so that the detailed
consideration of it shows the indications for other dreads.
Dread of Heights.--Almost without exception men have a sort of
instinctive dread of looking down from a height. In most people this
can be conquered to such a degree that almost anyone, if compelled by
necessity, can learn to work on a skyscraper and continue to do good
work without much bother about the height, though he may have to go up
ten to twenty stories, or even more. When he takes up the work at
first every workman finds it difficult. It gives most of us a trembly
feeling even to sit in our chair and think of looking down from such a
height. To see pictures of men standing on the iron frames of
skyscrapers twenty or thirty stories up in the air looking down 300 to
500 feet below them gives one a series of little chilly feelings in
the back and in many people a goneness or sense of constriction around
the abdomen that is almost a girdle feeling. To sit at a window
opposite where a skyscraper is going up and to see the men lean over
the edge of a beam calling directions of various kinds to workmen
below will give most people, even those who are not nervous or
especially sensitive, creepy feelings with sometimes a little catch in
the breath and an iciness in the hypochondria. It would seem
absolutely impossible that we should ever be able to perform these
feats of looking from a height, yet experience shows that most of us,
after a little training, learn to do it without difficulty.
Even the men who work most confidently have some creepy feelings
return to them whenever they stop and think about this and let their
eyes wander to the distance below them. It is not difficult for us to
walk across a plank raised a foot or two from the ground, though to
walk across the same plank at a height of ten feet may be quite a
trial and at thirty feet may become quite impossible. This is all due
to lack of confidence on our part and there is no reason in the world
why, if the plank is amply wide for us at two feet from the ground, it
should not be just as wide and safe at 30 or 60 or even 100 feet. This
is what the men who have learned to work on skyscrapers have
disciplined themselves to. They have learned to disregard the wide
vacant space around them and the yawning chasm beneath their feet;
they keep their eyes fixed on something in the immediate vicinity,
excluding thoughts of all that might happen if they should lose their
balance.
_Physical Basis_.--There is a physical basis in many of these cases
that constitutes the underlying occasion, at least, for the
development of the psychic dread. Our eyes have grown accustomed to
being fixed on near objects. Whenever they are not so fixed we get a
feeling of trepidation. Even those who have done a little day-dreaming
know that sometimes when they have been looking into space, objects
around them have suddenly seemed to be transferred to a long distance
and at the same time a curious sense of insecurity came over them.
Anyone can get this feeling experimentally by making two large dots on
a piece of paper about two inches apart and then gazing between the
dots into vacancy beyond the paper as it were, until the dots have a
tendency to become four because of the fact that each eye sees {615}
each of the dots on a part of the retina not corresponding to that on
which the other eye sees it (see Fig. 25).
[Illustration: Fig. 25. (Two solid black dots about 1/2 inch
diameter and 4 inches apart.)]
When the experiment is successfully performed the dots begin to float
before the eyes, then they may coalesce into one or become three, but
any number up to four may readily be seen. This will give the sense of
insecurity that comes from the eyes not having any fixed object to
look at and illustrates the discipline of the eyes that must be
learned in order that looking down from a height may not be productive
of the usual dread.
_Dread of Small Heights_.--It is often thought that acrophobia, or the
fear of a height, concerns only great heights and that ordinary
elevations produce no discomfort. I have had patients, however, who,
when compelled by circumstances over which they had no control or at
least by social obligations that were hard to break, to sit on the
front row of even a low balcony, have been extremely uncomfortable.
There was a sense of tightness and oppression about the chest that
made it difficult for them to breathe, that disturbed their heart
action and gave them a general sense of ill-feeling. I have had a
curiously interesting series of cases in clergymen who found it trying
to say Mass or conduct services or to preach from the step of a high
altar. One would be inclined at first to make little of their
description of their utter discomfort. There is no doubt at all,
however, of their real torture of mind and of the extreme effort
required to enable them to support themselves in the trying ordeal.
They are often so exhausted because of the effort required that only
with difficulty can they do anything else during the day.
To most people such a state of mind is inexplicable. There are deeply
intellectual men who, in my experience, are quite disturbed by
apparently so simple a thing as having to say Mass on an altar that
has three or four steps to it and is elevated five or six feet above
the surrounding floor. As for higher altars, like the main altar of a
cathedral, they usually find it quite impossible to conduct services
unless they are in company with others, when their feelings are much
relieved. This same thing is true of agoraphobia in some people. To go
alone across an open place or square is agony, but even the company of
a little child is sufficient to relieve them to a great degree. I told
a distinguished American prelate of this curious dread in priests so
often called to the physician's attention, and he said that he had
never heard of it. To his surprise some of his clergymen present at
the table told him that there were two examples of it in brothers in
his own diocese.
_Mental Discipline_.--The lesson of the many men who, by discipline,
have succeeded in conquering the aversion and the dread of heights
that everyone has to some extent at least, shows the possibility there
is for even those who are extremely sensitive in this matter to so
lessen their timidity and the uncomfortable oppression that comes over
them, as to make it possible to accomplish whatever is in their line
of duty. It is no more difficult for the sensitive clergyman to learn
by practice and discipline to walk with confidence on a reasonably
high altar or platform, than it is for the workman to learn to {616}
walk a beam on the top of a twenty-story building without a thought of
the dangers of his position, or at least putting the thought away from
him so that it does not interfere with his work. At the beginning he
cannot do it, but he disciplines himself to form a habit that makes it
easy. Yielding to his feelings makes it difficult to withstand the
discomforts that come to him. After an accident on a high building, as
a rule, men have to be sent home for the day to get their nerves
settled by the night's sleep before they can work with sufficient
confidence, and yet accomplish their usual amount of work.
So-called Misophobia--Dread of Dirt.--Misophobia, or the fear of dirt,
has grown much more common in recent years, and the spread of the
knowledge of the wide diffusion of bacteria has added to the
unreasoning dread that possesses these people. Some of them wash their
hands forty to fifty times a day, and one young man who was brought to
me with the worst looking hands, because of irritation from soap and
water, that I have ever seen, seemed to be always either just plunging
his hands into water or wiping them dry. These people make themselves
supremely miserable. They do not care to shake hands with friends and,
above all, with physicians, and they invent all sorts of excuses so as
to wait outside of doors till someone else opens them so as to avoid
touching the knob or door pull, "which" with a poignant expression of
repugnance they tell you "is handled by so many people." When the
patients are women, getting on and off cars becomes a nightmare to
them, because they do not want to touch the handle bars and unless
they do they find it difficult to ascend and descend. The curious
excuses they offer for their peculiar actions in avoiding the touch of
objects around them are interesting.
Claustrophobia.--This sort of dread seems quite irrational to most
people and many would probably conclude that individuals thus affected
could not possibly be quite in their right minds, or must surely be
rather weak-minded. On the contrary, many of the people who are
affected by these curious dreads are above the average in intelligence
and sometimes also in their power to do intellectual work. A typical
example, for instance, of claustrophobia, or the fear of closed
spaces, is found in the life of Philip Gilbert Hamerton. He was a
distinguished painter and essayist, editor and novelist. Few men of
his generation were able to do better intellectual work than he. His
book on "The Intellectual Life" was more read perhaps than any work of
its kind in the last generation. He was not a profound thinker, but he
was a very talented practical man. The fact that besides being a
writer whose books sold he was a painter whose works were in demand,
shows a breadth of artistic quality that is quite unusual. His was not
the sort of genius, however, that is so often supposed to be allied to
insanity, for he was rather a worker who obtained his effects by
plodding, than a brilliant genius that got his thoughts by intuition.
In a word, in spite of the fact that he was just the sort of man that
one would not think likely to be affected by a phobia, he had a series
of attacks of claustrophobia, some of which were intensely annoying to
him and seriously disturbing to his friends. His wife has described
some of them in his "Life and Letters." Once after crossing the
English Channel, he had a severe attack in the railroad carriage on
the way up to London. He had not been nervous {617} on the voyage and
had not been seasick. He was returning from a vacation and was in the
best of health and spirits, yet suddenly the feeling of inordinate
dread that he was shut in came over him and he could scarcely control
himself or keep from plunging out of the window in order to get into
the open. His wife says that "His hands became cold, his eyes took on
a far-reaching look, his expression became hard and set and his face
flushed." He seemed "as if ready to overthrow any obstacle in his way;
and indeed it was the case, for, unable to control himself any longer,
he got up and told me hoarsely that he was going to jump out of the
train. I took hold of his hand and said I would follow him, only I
entreated him to wait a short time, as we were near the station. I
placed myself quite close to the door of the railway carriage and
stood between him and it. Happily the railway station was soon
reached, when he rushed from the train and into the fields." His wife
followed him like one dazed, and almost heart-broken. After half an
hour he lessened his pace, turning to her and said, "I think it is
going." For two hours they continued to walk, at the end of which
Gilbert said tenderly in his usual voice, "You must be terribly tired,
poor darling. I think I could bear to rest now. We may try to sit
down."
Dread of Cats.--One of the most interesting of dreads, very frequently
seen and producing much more discomfort than could possibly be
imagined by anyone who had not seen striking cases of it, is the dread
of cats which has been dignified and rendered more suggestively
significant by the Greek designation ailurophobia. While the great
majority of individuals suffering from this unreasoning dread of cats
are women and usually of a delicate nervous organization, it must not
be thought that it is by any means confined to them or has any
necessary connection with hysterical symptoms. One of the most
striking cases of this dread of which I know personally occurs in a
large, rather masculine-looking woman, who cannot abide being in a
room with a cat, and who is quite unable to do anything while one of
these animals is within sight. Yet she is not at all what would be
called timorous and she has more manly than womanly characteristics in
every way. She once proceeded to thrash within an inch of his life a
small burglar who entered her house and she rather prides herself on
being able to protect herself. Nor is this dread necessarily
associated with any other disturbances of mind or nervous system. Some
of the patients I have seen, who confess to suffering from it, were
thoroughly sensible, brave little women, able to stand suffering well,
not at all hysterical in nature, and who in the midst of worries found
time to be thoughtful of others and not to have that selfishness
which, even more than physical symptoms, is so apt to characterize
hysterical patients.
I have had men confess to me their dread of cats, and while, as a
rule, they were of delicate constitution and inclined to be nervous
and did not have the phobia to an inordinate degree, there was no
doubt that they were extremely uncomfortable whenever a cat was near
them. On the other hand, some of them were vigorous, husky men with
strong aversions. One of the most marked cases of ailurophobia that
was ever brought to my attention was in an army officer who had
exhibited bravery in battle on many occasions, and what requires much
more strength of mind, calm fortitude in difficult campaigning, yet
for whom a cat had many more terrors than the battery of an enemy or
even an ambuscade of Filipinos. More cases of this particular {618}
aversion seem to occur in clergymen than in other men, yet one of the
worst cases I ever saw was in a priest of great moral courage, who had
served a pest-house over and over again in smallpox epidemics.
All that can be said about such a dread is that it exists, that it is
unreasoning, that some patients have been known by discipline of mind
to overcome the abhorrence to a great degree but never quite entirely.
In this regard, however, it must not be forgotten that there are many
things abhorrent to human nature that seem impossible to overcome the
aversion for, yet discipline does much to relieve them. For instance,
the handling of dead bodies so familiar to physicians brings with it
an aversion that we never quite get over and which resumes most of its
original strength with disuse, but that can be overcome to such an
extent as to make pathological work produce very little aversion. Even
Virchow, after all his years of occupation with pathological material,
confessed toward the end of his life, that whenever he was away from
his work for a few months his aversion had to be overcome anew.
_The Spectator on Dreads_.--There might be a tendency to think that
these curious dreads came only as the result of the individualistic
over-occupation with self and the introspective sophistication of the
modern time, but the dread is not confined to our time nor special to
it in any way, for we find Shakespeare talking of those who cannot
bear a harmless, necessary cat. A number of other writers of different
periods refer to it. As in so many other things _The Spectator_
reflects his time in this and so we have a letter with regard to the
dread of cats. It would not have been a subject for discussion in one
of these popular communications only that the writer felt that a good
many people would realize how like it was to things that they
themselves knew of. In number 609 the following letter, supposed to be
from a correspondent, seems worth giving in full, because it touches
on other subjects in which uncontrollable, unreasoning feeling plays a
role:
I wish you would write a philosophical paper about natural
antipathies, with a word or two concerning the strength of
imagination. ... A story that relates to myself on this subject may
be thought not unentertaining, especially when I assure you that it
is literally true. I had long made love to a lady, in the possession
of whom I am now the happiest of mankind, whose hand I should have
gained with much difficulty without the assistance of a cat. You
must know then that my most dangerous rival had so strong an
aversion to this species, that he infallibly swooned away at the
sight of that harmless creature. My friend, Mrs. Lucy, her maid,
having a greater respect for me and my purse than she had for my
rival, always took care to pin the tail of a cat under the gown of
her mistress, whenever she knew of his coming; which had such an
effect that every time he entered the room, he looked more like one
of the figures in Mrs. Salmon's wax-work than a desirable lover. In
short, he grew sick of her company, which the young lady taking
notice of (who no more knew why than he did), she sent me a
challenge to meet her in Lincoln's Inn Chapel, which I joyfully
accepted; and have, amongst other pleasures, the satisfaction of
being praised by her for my stratagem.
_Cat Fear and Furs_.--This dread of cats is sometimes exhibited to a
surprising degree under rather unexpected circumstances. For instance,
it is not unusual, since the fashion for the longer-haired furs came
in, to find that some of these patients cannot wear certain supposedly
elegant furs, since they are really dyed catskin. At times this is not
suspected until other possible causes for the discomfort have been
eliminated. Some women cannot even bear to be near catskins in muffs
and other such furs, though the imitation {619} may be so good as to
deceive any but an expert, and they apparently had no suspicion at the
beginning of the presence of cat fur near them. I have been told by a
physician the story of a man, poignantly sensitive to cats, who
purchased a fur-lined coat and found it quite impossible to wear it
because of the sensations it produced in him, though he had no
suspicion of any connection between cats and the fur when he purchased
it.
_Recognition of Presence_.--Why this dread of cats occurs and, above
all, the reason for the ability to know that a cat is near when the
animal is concealed and others are not at all aware of its presence,
or that its fur should produce a disagreeable sensation, is not easy
to decide. Its discussion is suggestive for other forms of dreads, for
there are probably like refinements of sensation, normal and abnormal,
connected with them. Much has been said about this as a reversion to
powers possessed by man in a savage state when there was necessity for
guarding against animal attacks. Unfortunately for any such
supposition as this, these people, who are most fearful of cats, that
is, of the ordinary domestic animal, have no uneasiness in the
presence of the huge cats in the menageries--the lions and the tigers.
It is with regard to these that such a specialization of scent would
be particularly valuable for men. There seems no doubt but that it is
an odor or a sensation allied to an odor, though perhaps below the
ordinary threshold of recognition as such, that enables these people
to detect the presence of a cat. Dr. Weir Mitchell in his article on
"Ailurophobia and The Power to Be Conscious of the Cat as Near While
Unseen and Unheard," in the _Transactions of the Association of
American Physicians_, 1905, discusses odor in this connections as
follows:
To be influenced by an olfactory impression of which (as odor) the
subject rests unconscious, may seem an hypothesis worthy of small
respect and beyond power of proof. Nevertheless it seems to me
reasonable. There are sounds beyond the hearing of certain persons.
If they ever cause effects we do not know. There are rays of which
we are not conscious as light or heat, except through the effects to
which they give rise. There may be olfactory emanations
distinguished by some as odors and by others felt, not as odors, but
only in their influential results on nervous systems unusually and
abnormally susceptible. No other explanation seems to me available,
and this gains value from certain contributory facts.
We must admit that all animals and human beings emit emanations
which are recognizable by many animals and are in wild creatures
protectively valuable.