Landon Carter Gray.

A treatise on nervous and mental diseases: for students and practitioners of ... online

. (page 46 of 84)
Online LibraryLandon Carter GrayA treatise on nervous and mental diseases: for students and practitioners of ... → online text (page 46 of 84)
Font size
QR-code for this ebook


are not sufficient, the sad and suspicious fades^ the hallucinations,
illusions or delusions, the suicidal impulse, the dull cerebral reflex,
or the melancholiac agitation, are amply sufficient signs for a differ-
ential diagnosis.

Commencing subacute mania {vide "Mania"), or the early stage
of general paresis {vide "Paretic Dementia"), are sometimes mis-
taken for hysteria. In subacute mania, however, the accelerated
mental state, the quickened cerebral reflexes, the mental and physical
restlessness, the heavy countenance that contrasts so sharply with
the seeming brightness of retort to an individual question, and
the slight mental confusion, are symptoms that are not seen in any
form of hysteria except hysterical mania. General paresis in its
early stages is sometimes characterized by so much irrationality of
conduct and action as to cause the patient to be suspected of caprice ;
but thie tremor of the tongue and facial muscles, or even of the
body, the inequality of the pupils, the paroxysms of facial flushing,
unsteadiness of gait, and irrational conduct can almost always be
elicited by careful examination or questioning; whilst the diagnosis
is easy in the more advanced stages when the dementia, stupid
delusions — usually of grandeur— general tremor and shuffling gait
have supervened.

Progressive muscular atrophy may be overlooked in some in-
stances where weakness has been complained of, or in the cases that
are probably due to peripheral neuritis, wherein complaint has been
made of the pains. In any suspected cases the patient should be
stripped, and a careful examination mad^ of the different muscular
groups {vide " Progressive Muscular Atrophy ").



Digitized by



Google



THE NEUROSES. 427

Lumbago is not infrequently very persistent and very intractable
to treatment, so that the failure to relieve the patient may be ascribed
to hysteria. But the lumbago following stricture is a curiously
intractable complaint that there is a special danger of confounding
-with hysteria (vide page 169).

That the symptoms of hydrophobia may be purely hysterical is
undoubted. ' In such cases, however, there is a lack of the prodromal
stage of hydrophobia ; and strong assurances of safety, with isolation,
will speedily make the matter plain. In the interests of science, no
injection of the Pasteur virus should ever be made until hysteria has
been excluded, for in an hysterical case the injection of cold water
would probably answer quite as well. In doubtful instances, how- .
ever, where dan^r seems imminent, the patient should be given the
benefit of the doubt, and the proper injection of Pasteur's virus
should be made {vide " Hydrophobia ").

Treatment. The treatment of hysteria will call for the exercise
of much intelligence, tact, and knowledge of human nature, as well
as of medicine. Before entering upon tne task the physician should
disabuse his mind entirely of the idea that hysteria is a caprice, and
not a disease, and should thoroughly imbue himself with the further
idea that although the hysterical individual is exceedingly impression-
able, he or she may yet have the other diseases to which the human
body is subject. The brutal and forcible methods of former days
should never be thought of for a moment. The patient should be
thoroughly studied, and all the circumstances of environment should
be carefully inquired into. For purposes of treatment hysterical
individuals may be divided into two great classes : those who are
suffering from hysteria alone, and those who are afflicted with hysteria
complicated by other diseases. Those who are suffering from hysteria
alone should be treated somewhat differently accordingly as the
hysteria is mild or severe. In the mild cases the confidence of the
patient should be gained by the infinite devices that will suggest
themselves to a physician of experience and knowledge of human
nature. When this has been done, the cure is often effected with
surprising facility, and it is a matter of little consequence what par-
ticular remedial measures are employed. I have had many young
men and girls brought to me who were suffering from slight symp-
toms that their hysterical nature caused them to magnify into enor*
mous ones, so as to produce exactly the same psychical effect as if
they were weighted down with organic disease. The boys have
abandoned their career perhaps, and, aided by the anxiety of well-
meaning relatives who could not be made to understand the true
nature of their symptoms, they have wearied of physicians and
resigned themselves to what they supposed was their destiny of a
lifelong valetudinarianism, overshadowed by vague forebodings of
impending evil. Girls are more prone to fall into a similar hopeless
condition, not only because of the greater impressionability of the
female mind, but also because of their lesser tendency to struggle
against adverse circumstances. Yet I have on my case-book the
histories of many such patients whom I have succeeded in restoring



Digitized by



Google



428 NERVOUS DISEASES.

to energetic participation in the struggles of life without the use of
other measures than gaining their confidence^ gradually and firmly
leading them to exert their self-control, aiding them in this task,
accustoming them to understand that their sensations, however
alarming they^may seem, are really of no importance, and without
the use of drugs further than as placebos. The example of the
quacks through all ages has been too much contemned, I think, by
the r^ular practitioners of medicine, and yet every physician of
experience knows of the startling successes that they occasionally
obtain. Indeed, I believe that if hysteria were to die out from the
human race the fraudulent practitioners of medicine would be moi*e
than half exterminated. Nevertheless, impostors as they are, these
men have done with fraudulent intent what the scientist ought to do
with an honest purpose, namely, recognize that the human mind is a
much more potent instrument to play upon than the nervous system
of the stomach aud intestines. I deal very frankly with this class of
patients. I tell them that their disease is a purely functional one,
and that it can be perfectly cured. Then, bit by bit, I teach them
that they can do many things that they had thought impossible,
taking a special care never to have them enter upon a task that is
too great for them to conduct to a successful issue, because a failure
with an hysteric is apt to be fatal. By this means I gain the prestige
of success with them, and each succeeding task is entered upon with
a feeling of greater confidence. Sometimes I talk kindly, sometimes
I speak very sharply ; but through it all, whether I sympathize with
them or whether I reprove them, I maintain their confidence. For
example, a girl is brought to me who cannot go among crowds, I
gradually get her accustomed to them. A boy cannot take part in
athletic sports. After having gained his confidence, I put him in
charge of someone versed in athletic sports who has good judgment,
and whom I instruct to get him to enter into them by degrees. In
the severer cases of hysteria, however, the patient must be removed
from an unfavorable environment, taken away from home and friends,
and put in charge of a trained nurse who is possessed of good judg-
ment and tact. The selection of this nurse is a matter of consider-
able importance. It would be a fatal mistake to place an old and
worn-out woman in charge of a young and active girl ; or an ill-bred,
coarse, untidy woman in charge of one who is refined and particular
about her person and dress ; or an unkempt, frowzy, ill-conducted,
ill-mannered man in charge of an educated and well-bred gentleman.
If the patient suffering with hysteria is one of that unhappy type
of bedridden individuals of whom neurologists know so many, the
nurse should also be a woman of firmness. Even in these severe
cases, however, the same method of psychical treatment should be
employed. It is supremely ridiculous at times to witness the rudi-
mentary education that must be impressed, detail by detail, upon
these hysterical individuals with an unflinching persistence of pur-
pose. I have put upon their feet and practically cured patients who
had been bedridden for thirty years by means of rigid attention to
these minutise. Day by day they must be taught like a little child



Digitized by



Qoogh



THIS NEUROSES. 429

to do some one thing that they had not done the day before, until,
as the weeks creep by, the accretion of these little things have put
them on their feet. First, they are told to stand for five minutes
each day, then for ten minutes, then for fifteen, and so on. Next,
they are told to take a walk around the room. Next, as mental
control over them is gained, they are suddenly some fine day told to
go out-doors. The heart must, of course, be carefully watched in
these patients who have been bedridden so long, and if it grows
weak and rapid after some exertion of this kind, it is often advisable
to begin the administration of ^ grain of the sulphate of strychnine
three times a day, either in the form, of pill or tablet triturate. If
there is ansemia conjoined with one of these severe cases of hysteria,
the treatment by rest, lai^ quantities of food, and iron should be
instituted, as I have advocated it in the chapter upon "Neurasthenia."
All other sources of bodily discomfort should be sedulously attended
to. True hysterical convulsions need no special treatment further
than the exhibition of some one of the well-known anti-spasmodics
and sedatives, such as the nitrite of amyl in the so-called "pearls"
containing three to five drops, one of which should be broken in a
handkerchief and placed under the nose of the patient ; a dose of
bromide of potash, gr. 15 to 20 ; the inhalation of a small quantity
of ether or chloroform ; a teaspoonful of Hoffmann's anodyne in a
windlass of water; or sometimes a simple hypodermic of cold water.
I have, however, again and again seen these convulsions brought to
an end by firm and judicious psychical treatment and isolation.
Hystero-epilepsy should be treated as is indicated in the chapter
upon "Epilepsy." Hemi-ansesthesia occurring in hysterical indi-
viduals should be treated by a combination of psychical measures
and electricity, the galvanic current being applied to the spinal
column, and the faradic brushed over the affected limbs with two
wire brushes, the current being strong enough to be distinctly felt
by the patient. It should always be remembered, however, that
hysterical individuals are not exempt from the ills that flesh is heir
to, and that they may just as well have neuralgia, neuritis, neur-
asthenia, etc., as individuals who are not hysterical, although they
are apt to respond much more promptly to treatment than the
latter.

To sum up, therefore, the treatment of hysteria should be mainly
by means of psychical measures. If, however, other diseases com-
plicate the hysteria, these should also be carefully looked after.

HYPOCHONDRIA.

Hypochondria is a pseudo-nrental disease that can scarcely be called
an insanity, consisting of a tendency to morbidly exaggerate the vari-
ous sensations of the body and their importance. At times this exag-
geration is so great as to amount to actual delusion. Every physician
is familiar with these cases, for they are the bane of every medical
man. They complain of all sorts of sensations and dwell upon and
recapitulate them ad navseam. One patient thinks that his hair is



Digitized by



Google



430 NERVOUS DISEASES.

falling out; another that he is growing weak in his muscles ; another
that he has this, that, or the other symptom. They all take medi-
cines as a steady diet, and they all fall a ready prey to quacks and
every " ism " that the morbid ingenuity of man can surest. Hypo-
chondria is sometimes met with in conjunction with mental disease ;
and in some cases of mental disease there may be a prodromal period
of hypochondria, and a hypochondriacal insanity has even been de-
scribed, but this latter is certainly rare. Sexual hypochondria, that
is, hypochondria about sexual matters, is a very frequent form, and
is often described under the name of sexual neurasthenia.

The diagnosis of hypochondria is usually very easy. The only
questions that can arise are as to whether the patient is not suffering
from melancholia, or the prodromal stage of some insanity, or from
some actual coexisting disease. From the melancholiac the hypo-
chondriac can be readily distinguished from the fact that the melan-
choliac does not seek relief, is not prone to believe that medicine can
afford him any aid ; and in the slighter forms he also suffers from
the symptoms to which I have elsewhere called attention ("Mel-
ancholia"), namely, insomnia, post-cervical ache, and the suicidal
tendency ; besides which he has a peculiar fades of his own that a
little experience will soon make familiar ; whereas the hypochondriac
readily takes medicine — even eagerly solicits it — has none of the
three cardinal symptoms that have been mentioned above, and has no
peculiar /acies. The hypochondriac prodromal stage of an insanity
is usually not prolonged over a few days or a week, and this fact
alone would distinguish it from the chronic course of hypochondria,
which is often life-long, even if the succeeding mental symptoms of
the insanity were not sufBcient. Any disease that may coexist with
insanity must, of course, be recognized by the general medical knowl-
edge of the physician, and it is useless to catalogue these diseases,
as they embrace almost the whole field of medicine, especially in the
adult.

The treatment of hypochondria is very difficult. I believe that
the most success is to be obtained from the principle of suggestion,
that can only be fully understood after reaaing the chapter upon
" Hypnotism," and, as I have cured several cases of my own by this
method, I can give ftiU credence to the many cures that have been
repoited by the French schools of hypnotism of Nancy and Paris.
It is not always neoe:?sary by any means to induce full hypnotism.
It may be well sometimes in obstinate cases to hypnotize the person
sufficiently to prevent him from opening the eyelids, but in very
many cases even this is not necessary, and it will suffice if the
confidence of the patient is gained by making quiet and dogmatic
assertions and ordering placebos. Any person, however, who
adopts this method of suggestion must be fully acquainted with the
hypnotic methods, so as to be prepared to carry out the treatment
thoroughly. I do not mean to be understood as saying that ftiU
hypnotization of the patient would not be the best, but I merely mean
to advise that it is not usually politic to use the word hypnotism to
the patient, or to let him suppose that hypnotic methods are being



Digitized by



Google



THE NEUROSES. 431

used^ as there is a ^videspread prejudice iu the lay mind against
hypnotism, which is generally thought to be synonymous with
quackery, and anything that aisturbs the confidence of the patient
in the medical attendant will be fatal to the treatment. Occupation
of any kind that will divert the patient's thoughts, or travel, or
change of scene, or great emotions, will often act as temporary palli-
atives and sometimes as cures, and therefore it may be well to make
use of these methods. Of course, it is not always easy to evoke an
emotion, but this can be sometimes done. In one case of mine, for
instance (the patient elsewhere referred to as coming to me with a
specimen of black semen), a cure was effected in this manner : I
requested him to look sharply at the piece of rag upon which he
claimed the black semen was. I then took a black-bound book and
laid it alongside of this piece of rag, and asked him if he thought
the book was of the same color as the stained rag. He said it was.
I then told him that if he thought the rag stained a faint yellow was
of the same color as the black book-bindiug, he must be suffering
from one of two troubles. In the first place, he might have a
delusion, but that involved insanity, and I had treated him long
enough to know that he was not insane. The other was ihat he was
a fool, and I bluntly told him that that was my diagnosis. He,
naturally enough, started back in anger, and aft;er some angry re-
marks, left; my office ; but he came back in the course of a week or
two to tell me that he believed I was right — that my blunt remark
had made him realize how foolish he was ; and since that time —
eight years ha^^ng now elapsed — he has manifested but very slight
symptoms of hypochondria. I do not tell this as a funny story, but
simply to show that emotions can. be evoked at times by the ingenuity
of a physician. Indeed, I believe that in the capacity to play upon
the mind in its various functions, especially those which we now
call emotions, the future therapeutics of hypnotism will lie; for at
present we are stupid enough to think that it is science to play upon
the peripheral terminations of the nerves or the structures in which
they terminate, whilst we deem it quackery to make use of the gray
matter and all its woudrous molecular play. So-called faith-cure,
"Christian science," the great emotions of wars and politics, and love
and anger, and ambition and avarice, aud, finally, the wonderful
but only half understood phenomena of hypnotism, are all neglected
clinical illustrations of the magnificent influence of the mind over
the body ; and in the full day of medicine, into whose dawn we are
now peerii^, we shall make proper application, I have no doubt, of
these therapeutic methods.

NBUBASTHBNIA.

Synonym : Nervous prostration.

History. Functional diseases of the nervous system have been
held largely in contempt unless they were fortunately accompanied
by such startling phenomena as loss of consciousness, convulsions,
epilepsy, the pain of neuralgia, or the often violent muscular



Digitized by



Google



432 NERVOUS DISBASBS.

contractions of chorea. The medical world has no heredity of
training in nervous diseases. For centuries medical writers and
teachers have called attention to the phenomena that could be
studied in the pulse, in the heart, in the tongue, in the feces, in the
temperature of the body ; and within a few generations these and a
few kindred details have been made the language of a more precise
diagnosis of thoracic and abdominal diseases. But nervous diseases
constitute a modern study. We may date them back really to the
fifties, when the great French school began its career; and it is only
within a very few years that the molical schools of the United
States have even thought of having a chair especially devoted to
this branch of medicine. So it is that while tens of thousands will
be prompt in detecting the first signs of deviation from the normal
in the pulse-beat, in the respiration, in the tongue, in the fdcies, in
the urine or feces, there are scarcely tens — and these only with some
special education — who will recognize the primary symptoms of
organic or functional nervous disease, which they are only too ready
to ascribe to hysteria. Yet all attentive observers of disease, more
especially those engaged in neurological study, could not help ob-
serving many phenomena that could. |^t ^e classified; and this, I
think, is the explanation of the enormous success that the writings
of Dr. George M. Beard upon neurasthenia have had in Germany —
indeed, it may be affirmed that he has started a literature in that
country, the contributors to which are such well-known writers
as Arndt, Kraffl-Ebing, Erb, Westphal, Moebius, Seeligmiiller,
Strumpell, and Langstein. As far back as 1828, C. Brown, of
Glasgow, had described what he called spinal irritation, and in 1860,
Bouchut had written fully upon what he termed Fital nerveva:;
each of these writers has had his followers to some extent, but
Beard, it may be said, was the first to boldly formulate the prop-
osition that there was a widespread condition of functional nervous
disease, for which he proposed the name of " neurasthenia" and for
whose inaintenance and prevalence and varied phenomena he battled
with the most alluring and picturesque of pens. It is curious,
nevertheless, that the Germans themselves do not seem to admit that
the malady is frequent among them, but always fall back upon
Beard's assertion that America is its home. In 1874, Murchison,
in his brilliant course of Croonian lectures, delivered before the
Royal College of Physicians, described, under the heading of " Funo-
tioual Diseases of the Liver," a group of symptoms for which he
suggested the name of lithsemia. For the same condition Austin
Flint had some six years before coined the name of uricsemia ; but
Murchison's designation has been the one that has come into vogue
in the time which has since elapsed. Since then contributions to
the subject have been made by JDa Costa, McBride, Lyman, Hud-
son, Potter, and myself. The general feeliug, in this country at
least, is, I think, that the term neurasthenia, as defined by the
writers upon the subject, embraces entirely too much. I share in
that feeling myself The fact seems to have been foi^tten that
there are already a number of well-studied functional nervous dis-



Digitized by



Google



THE NBUBOSES. 433

eases, as well as that each one of these has sjonptoms correlated with
it^ and that no scientific advance is made by jumbling together the
symptoms of these various and differently acting diseases under one
wide name. Then, too, it should not be forgotten that the nervous
system stands preeminently alone among the tissues of the body in
4ie highly important fact that its ramifications carry its influences
into every other tissue, and in turn carry back to it the influences of
every other tissue, so that, much more than is the case with any
other organ, the nervous system is peculiarly at the mercy of reflex
disturbances. Excluding, then, vicious habits, reflexes from non-
nervous organs, and well-recognized functional diseases, the question
arises : Is there such a thing as nervous weakness or neurasthenia?
I believe there is. But I also believe that it is much more limited
in its relative prevalence than is maintained by the eager followers
of Beard.

Clinical History. There are, in my opinion, three forms of
neurasthenia.

1. Beflex neurasthenia ;

2. So-called lithsemic neurasthenia ;

3. Simple neurasthenia.

1. The neurasthenia that results by reflex from non-nervous
organs and vicious habits is, in my experience, the second most fre-
quent form, and can often only be recognized by a very careful ex-
amination of the different organs of the body. The very essence of
a reflex disturbance is its caprice, so that no one set of symptoms
can be relied upon, as a rule, to be indicative of a pure reflex. There
are, to be sure, some seeming exceptions to this statement, as in the
occipital pain of nephritis, the uneasiness at the vertex in uterine
diseases, etc. But clinical experience has taught me that these
vaunted localizations of pain are all of very little practical value.
I know of no shorter way of determining whether a reflex disturb-
ance in a non-nervous organ is the cause of a given neurasthenia
than by an examination of the different organs, especially the kid-
neys, the eyes, the naso-pharynx, the lungs, the heart, the liver, and
the genitalia, and in every case the habits should also be carefully
inquired into.

2. LUhoemic neurasthenia. This form is the most frequent of all,
I think, and its symptoms are vei*tigo, a sense of pressure about the
head, slight insomnia, nervousness, occasional susceptibility to odors,
occasional tinnitus aurium, neuralgia, paraasthesia, rarely slight
anaesthesia, muscular cramp and twitchings, and vasomotor disturb-
ances. It has also been stated by some of the authors that in this
type we may also have fever, a delusional mental condition, even
myelitis of the anterior horns, epilepsy, and disseminated sclerosis ;
and when I wrote my first paper upon the subject in 1886 I was
inclined to think that there was a grain of truth in these statements ;
but an experience since of nine years, ranging over several hundred
patients, has failed to bring to my observation a single undoubted
case with these symptoms, and I think the mistake has lain in over-

28



Digitized by



Google



434 NBBVOUS DISEASES.

looking the fact that the diseases wittr these symptoms may be asso-
ciated with lithaBmic neurasthenia.



Online LibraryLandon Carter GrayA treatise on nervous and mental diseases: for students and practitioners of ... → online text (page 46 of 84)