Essays In Pastoral Medicine Part 21

Unexpected death frequently occurs in mania because of the failure to recognise the existence of serious pathological conditions. Pneumonia may develop, for instance, without the slightest complaint on the part of the patient and go rapidly on to a fatal termination during the exhaustion incident to the constant movement, it being utterly impossible to confine the patient to bed. Meningitis may develop in the same way and proceed to a fatal issue without the patient's making any complaint or any sign that will call attention to its existence.

In the meantime, the patient may be constantly in the wildest motion and so add to the exhausting effect of the organic disease.

The prognosis of acute mania is not unfavourable. Patients suffering from a first attack will recover completely in eight cases out of ten.

Notwithstanding complete recovery, relapses are p.r.o.ne to occur whenever the patient undergoes a severe emotional strain. As a rule not nearly so much mental disturbance is required to produce a second attack {228} as the first one, so that patients require great care. In a certain number of cases recovery is incomplete; persistent delusions remain, and there may even be some weakness of intelligence. Paranoia, as it is called, mild delusional insanity, may a.s.sert itself and then may persist for the rest of life. Notwithstanding this, patients may get along in life reasonably well, though their mental condition is decidedly below the normal.

In a certain number of cases, after the period of excitement disappears, a certain amount of dementia is noticed. This consists of a distinct lowering of the intelligence, though without the presence of any special delusion. This dementia progresses until finally there is a state of almost complete obliteration of the mental faculties.

The prognosis as to life in cases of mania is very good. Very few patients die during an attack of acute mania. At times there is a development of tuberculosis that proves fatal, because of the restlessness of the individual. Pneumonia or typhoid fever may also prove fatal.

Besides mania or melancholia, there is a third form of functional mental disease, which is a combination of these two forms. It is usually spoken of as circular insanity. The patient has usually first an attack of melancholia, then an attack of mania, and then after an interval melancholia and mania once more. We have said that most cases of mania develop after a distinct stage of depression of spirits, so that successive attacks of mania take partly the character of circular insanity. This latter disease, however, is an index of a much more degenerated mental state of the individual than is either mania or melancholia alone. When it occurs, the prognosis as to future sanity for any lengthy interval is unfavourable. A series of attacks alternately of depression and excitement finally make it necessary to confine the patient to an inst.i.tution.

As might be expected in this severer form of mental disturbance, heredity plays an especially important part in circular insanity. At least 70 per centum of the patients affected show a family history of insanity in some forms. In this disease direct inheritance of this particular form of {229} mental disturbance is noticeably frequent.

The patients who develop this form of insanity usually show marked signs of degeneration, even before any attack of absolute mental disturbance has occurred. Wounds of the head, alcoholism, and epilepsy are prominent factors in the production of circular insanity. This only means that the predisposition to mental disequilibration is so strong that but very little is required to disturb the intellectual equilibrium.

Fortunately, circular insanity is rare. In 40,000 cases of insanity in New York State, only 96 cases of this form were noted. Mild types of the disease are not, however, very rare. Many otherwise sane people have alternating periods of hopeful excitement and of discouraging depression, not momentary but enduring for weeks at a time, which are really due to the same functional disturbances that in people of less stable mentality produce absolute insanity. These cases are of special interest to the clergyman and to directors of consciences.

JAMES J. WALSH.

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XVIII

NEURASTHENIA

Neurasthenia, or nerve-weakness, "the vapours" of the old novelists and dramatists, is a very common malady, and it gives the clergyman trouble by the turmoil it causes in families, religious communities, in themselves, and elsewhere. Whether the condition is a distinct disease or not, and that question has been voluminously discussed, is not altogether an important matter, but that there is such a group of symptoms is unfortunately a weighty fact. It takes so many forms that it is bewildering, and therefore not readily reduced to unity.

The cerebral form often exists independently. There is such a thing as "brain f.a.g," although many complainants may have very little material for the f.a.g to work on. Often such a patient is robust, even an athlete, and his a.s.sertions meet with ridicule or abuse instead of treatment. If the patient is a woman she is not seldom called "hysterical." She is not hysterical. Hysteria, by the way, is as distinct a trouble as a broken leg, and far more serious, and not a synonym for perverseness, as the term is popularly used.

In the cerebral form, business, reading, study "go into one ear and out the other." The patient's memory fails him temporarily just when he may need it most, say, in a speech or sermon; a fly buzzing on a pane is a calamity and a source of profanity; a flat note in the choir-singing is ample reason for doubting the divine origin of the church, and every petty trouble that whisks its harmless tail across his floor makes him seek the table-top. I have known a whole convent of nuns, who were closely shut in, with bad ventilation and a worse cook, until all were more or less neurasthenic, almost {231} disintegrated by the presence of a lamb sent in as a pet; not because of the bleating or any ordinary reason, but solely because of the hideous incongruity and indecency in the fact that the lamb was a male.

The cerebral neurasthenic makes rash, impetuous changes in his mode of life. He leaves a religious order because the coffee is weak, he resigns an important post in a bank because the president uses snuff, he abandons medicine for trade because the curate meddled in the treatment of two of his patients. He takes on anxiety, locks up the house six times over the same night; meals are eaten in awed silence by his trembling children; altogether he is an unmitigated nuisance.

He may get religious scruples. If he is a priest he takes an hour to an hour and a half to say a low ma.s.s, and most of that time is spent in searching the corporal for imaginary particles or in drying the dry chalice. He rereads his breviary until he is exhausted. Because moral theologians say that certain scruples are from the devil, he is convinced that the devil takes a particular interest in his case. The devil did probably take a special interest in his father's or grandfather's lack of scrupulosity, for his condition is commonly a result of alcoholism in an ancestor.

There are three chief types of neurasthenics: in one cla.s.s is the person that appears robust, and is really so except in his nervous system, which lacks a governor. Such patients have little more than a troubled appearance to draw the attention of a chance observer to their condition.

A second cla.s.s is made up of eloquent narrators of their troubles.

They try all the physicians in turn, then the h.o.m.oeopaths and osteopaths and similar quacks, and they add patent medicines prescribed by themselves. They are petulant, capricious, and despite their apparent energy they accomplish nothing.

The third cla.s.s are silent, limp, clammy-handed; they are brought against their will to see the physician; they are sulky; bitter and unreasoning haters; inclined to melancholy. They may have a tendency even to suicide, but this is somewhat rare. Neurasthenics are not so liable to insanity as is popularly supposed, but such an outcome is possible in certain {232} cases. If their vague fears go on into a more or less fixed delusion there is cause for anxiety lest insanity result, but care should be taken here to be sure the delusion is really irremovable.

Some neurasthenics are afraid to cross an open square or a wide street, others dread any closed apartment. Vertigo is common; so is insomnia. Insomnia is almost a constant symptom. The patient may have naps or he may have uninterrupted vigils. Sometimes there is a heavy but unrefres.h.i.+ng sleep. Sleepless patients are thrown into distracting rage by the barking of a neighbour's dog, the howling of cats, or the cackling of a successful hen, and they haunt the magistrates' courts in efforts to suppress such noises. They put cotton in their ears, wear heavy nightcaps, stop clocks, board up windows in search of sleep, which is not found.

These patients commonly have an enduring feeling of weight or constriction in the head, especially at the occiput,--a headache that is not actual pain. They also have vertigo, which is independent of any aural disease, and this is transient, showing itself on abrupt changes of position.

Another phase of neurasthenia is spinal. These cases have pain in the back and their legs give out. The back-pain is a diffuse ache, or it manifests itself on pressure at certain spots along the spine. There may be severe pain at the coccyx, especially in women. The walking may simulate paralytic forms if hysteria is mixed with the neurasthenia.

Cardiac symptoms are often prominent, especially palpitation, but there is a nervous excitation of the heart rather than any definite lesion.

The gastro-intestinal symptoms are often important. Pain referred to the stomach and acidity are common, the tongue is coated, the faeces scybalous. Digestion is torpid. Sometimes there is nervous diarrhoea.

A list of the belly symptoms described by some neurasthenics is interminable.

We often find a s.e.xual form, which is the worst of all and the hardest to cure. It is commonly connected with masturbation. Such neurasthenics are shameless in the description of their nastiness. It is better to keep them from marriage unless they are cured, and they are not to be foisted off on {233} any one as husband or wife to effect a cure. Allb.u.t.t says of them: "I fear that some of our 'criminal psychologists' are encouraging many sorts of prurient debauchees by dignifying the tales of their vice with the name of science, a course of conduct which is in the worst interests both of these persons themselves and of our own profession. It were a curious inquiry how it comes that s.e.xual perversions are so 'scientific' a study, while the brutalities of the thieves' kitchen or the wiles of other pests of society lie in comparative neglect."

Physical, intellectual, or emotional strain can cause neurasthenia suddenly or gradually. Where it comes on without obvious cause there is commonly a bad family history of nervousness or alcoholism. Anaemia makes it worse; eye-strain, too, is a provoking factor. In some cases a renal congestion is the cause. In many cases a lack of restraint, bad education, uncontrolled pa.s.sion, are a marked influence in fixing the neurasthenic habit. A sedulous parent nags at a neurasthenic child that is too weak for exertion until the child's susceptibility to correction is blunted. Instead of treatment and help the child receives cuffs and abuse, and h.e.l.l-fire is held up before him until he deems all religious talk dust and ashes. Encouragement will sometimes do more good than all the threats in the _via purgativa_. Nagging never cured anything except a tendency toward virtue, and it always deepens neurasthenia. Be careful in the selection of a confessor for a neurasthenic child. Get one that does not believe in kicking a soul into paradise.

The treatment of neurasthenia is difficult. Traveling about in search of health is not advisable. The Weir Mitch.e.l.l Rest Cure is very effective in many bad cases, but it is costly, and if not correctly applied it is useless. It is the only cure for some patients. Sea air helps a certain cla.s.s of neurasthenics, but it makes others worse--it is bad for the dyspeptic neurasthenic. A chronic rhinitis, a refractive error of the eyes, a displacement of the uterus, a congested kidney, a floating kidney, a tight prepuce, and similar teasing disorders must be cured before the neurasthenia can be removed; often the neurasthenia disappears with this cure.

Traumatic neurasthenia is like simple neurasthenia in {234} most details. It is called also nerve shock, spinal irritation, railway spine. There is always a causative shock or injury, which is followed at once or after an interval by the symptoms of neurasthenia. In acute traumatic neurasthenia there may be, in addition to the symptoms observed in simple neurasthenia, high fever, and such a fever has been observed to go as high as 113 degrees Fahrenheit.

AUSTIN oMALLEY.

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XIX

HYSTERIA

The term Hysteria ([Greek text] uterus) has been handed down from the days when physicians thought there was a connection between womb-disorders and the set of nervous symptoms grouped under the t.i.tle hysteria. It is now etymologically meaningless,--men also grow hysterical. Briquet found 11 male to 204 female hysterics, and later statistics increase the number of males.

The disease is not readily definable. The patient is usually a young emotional woman, oftenest between 15 and 20 years of age. She commonly has anaesthetic spots on her body, concentric limitations of the field of vision, and hystero-genetic zones, or tender points, which, when pressed, appear to inhibit the hysterical fit. The symptoms enumerated here are not, however, found in every case of hysteria, and it is difficult at times to diagnose the disease.

The various manifestations of hysteria are (1) apt to come and go suddenly. A severe paralysis that suddenly disappears for a time is hysterical; (2) even if they last for years they may be suddenly cured; (3) they are dominated more by mental and moral influences than are the symptoms of any other disease; (4) we find no organic lesion with which we can connect the symptoms.

The conditions that bring about hysteria are hysteria in a parent, or insanity, alcoholism, or some similar neurotic taint in an ancestor.

There is no direct connection between hysteria and the disorders of the s.e.xual organs.

Immediate causes are acute depressive emotions, shocks from danger, sudden grief, severe revulsions of feeling, as from disappointment in love; and, secondly, c.u.mulative {236} emotional disturbance, as from worry, poverty, ill treatment, unhappy marriage, or religious revivals. Certain diseased conditions, as anaemia, chronic intoxications, pelvic trouble, cause hysteria, or, more exactly, start it into activity where it is latent. It is also communicated by imitation and it may become epidemic.

After the great plague, the Black Death, in the fourteenth century, there were very remarkable epidemics of imitative hysteria in Germany and elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women danced together in the streets until they fell exhausted in a cataleptic state. These dances spread over Holland and Belgium and went to Cologne and Metz. It is said that in Metz there were 1100 of the dancers seen at the same time.

The "Dancing Plague" broke out again in 1418 at Strasburg, in Belgium, and along the Lower Rhine.

"Viel hundert fingen zu Stra.s.sburg an Zu tanzen und springen Frau und Mann, Am offnen Markt, Ga.s.sen und Stra.s.sen; Tag und Nacht ihrer viel nicht a.s.sen, Bis ihn das Wuthen wieder gelag.

St. Vits Tanz ward genannt die Plag."

Beckmann (_Historia des Furstenthums Anhalt_. Zerbst. 1710) tells of a similar outbreak in 1237, wherein nearly a hundred children were seized by the disease at Erfurt, and they went along the road to Arnstadt, dancing and jumping hysterically. A number of these children died of exhaustion. The same infection is often at work in the fury of a mob, the panic of a beaten army, and it probably was an element in the Children's Crusade.

The Tarantism so common in Italy from the fifteenth to the eighteenth century is another example of epidemic hysteria. The Bubonic Plague ravaged Italy sixteen times between 1119 and 1340, and smallpox was at work when the black death could find no fresh victims. As a consequence of economic disturbance and fear the people were generally neurasthenic, and a slight shock was enough at times to set whole villages into hysterical convulsions.

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In 1787, at Hodden Bridge in Lancas.h.i.+re, England, a girl in a cotton mill threw a mouse upon another girl that had a great dread of this animal. The frightened girl was thrown into a hysterical convulsion which lasted for hours. The next day three girls that had watched her were in convulsions, the following day six more, and two days later fourteen more girls and a man were in fits. American white and negro camp-meetings result in similar outbreaks, and the French _Convulsionnaires_, who did outrageous things from 1731 to 1790, were also afflicted with imitative hysteria. The Cornish Jumpers, founded in 1760 by Harris Rowland and William Williams, and the American Barkers were also hysterical. The Barkers in the meetings would run about on all fours growling, "to show the degeneration of their human nature," and they would end in almost general fits of imitative hysteria.

There was an epidemic of hysteria in Tennessee, Kentucky, and a part of Virginia, which began in 1800 and lasted for a number of years. It started at revivals. The majority of the cases were in persons from 15 to 25 years of age, although it was observed in every age from 6 years to 60. The muscles affected were those of the neck, trunk, and arms.

The contractions were so violent that the patients were thrown to the ground, and their motions there exactly resembled those of a live fish thrown out of the water upon the land.

There are numerous theories formulated to explain hysteria; some are ingenious, especially that of Janet, but none is convincing.

Convulsions, tremors, paralyses of various forms and degrees are common in hysteria. In major hysteria the patient falls into a convulsion gently. There is checked breathing, up to apparent danger of suffocation. Then follows a furious convulsion, even with b.l.o.o.d.y froth at the mouth, but there is a trace of wilfulness or purpose in the movements. Next may come a stage of opisthotonos, where the body is bent back in a rigid arch till the patient rests on her heels and head only, and this is followed by relaxation and recurrence of the contortions. An ecstatic phase succeeds this, at times in the so-called crucifix position, with outbursts of various emotions, and a final regaining of a {238} normal state. Any of these stages, however, may const.i.tute the whole fit.