Neurotic Complications.—There can, of course, be no doubt that the crises of locomotor ataxia represents extremely poignant attacks of pain. But on the other hand, anyone who has seen many of them is prone to think that not a few of them are really attacks of pain resembling those which occasionally develop in hysterical subjects. The pain of a gastric neurosis may, indeed, so simulate the gastric crises of locomotor ataxia as to make what is only a case of hysteria seem beyond doubt one of locomotor ataxic. Locomotor ataxia patients are prone to think much about themselves and to fear the recurrence of these painful crises once they have had experience with them. As a consequence they sometimes suffer from what are pseudo-crises, that is, from neurotic painful conditions which simulate genuine crises mainly in the amount of reaction they produce in the patient. True tabetic crises yield more readily to ordinary anodyne drugs than do these pseudo-crises. Nearly always the true crises are associated with and exaggerated by neurotic symptoms due to the depression of the patient, the yielding to his feelings, the conclusion that his pain is inevitable and is going to be worse each time, while successive crises are, as a matter of fact, often milder until they disappear for good, and this element in the case must always be borne in mind. Much can be done for the relief by psychotherapy, that is, by making the patient see the realities of his condition, suggesting to him that succeeding crises are less painful and that if his general condition is as good as it should be he becomes better able to stand the pain of his crises and the shock of them is not so disturbing to his system.
Mental Attitude.—Prof. Oppenheim, in one of his "Letters to Nervous Patients," advising a patient suffering from an incurable organic nervous disease, evidently locomotor ataxia, though that is not explicitly stated, outlines emphatically the favorable side of that disease. This is absolutely needed. Ever so many unfavorable suggestions with regard to his affection find their way to the patient. The very fact that it is pronounced absolutely incurable is disheartening. Prof. Oppenheim's words, then, may be a precious help and to have them repeated from time to time renews the suggestion:
Now, however, we neurologists know that that disease frequently runs
a very mild course, that a man showing certain early symptoms of
such a disease may for ten to twenty-five years and even longer
retain his capacity for work and enjoyment. This for a man of thirty
to forty years is almost tantamount to the expectation of a whole
normal lifetime. But on the other hand, what danger to the peace of
mind, what destruction of happiness in life may be caused if the
knowledge that such a disease has begun to develop is imparted to
the patient without being combined with the consoling information as
to the nature and course of the benign forms of this trouble! In
unceasing anxiety and fear, in daily expectancy of some fresh
symptoms, of some increase or aggravation of his troubles, does the
poor man waste his life; and I have frequently found that this
wretched apprehension and excitement cause a nervousness and mental
depression which in their effects are much more momentous than is
the commencing spinal disease.
From this miserable condition I desire to protect you, and I would
ask you to {528} take this advice deeply to heart:
do not bear yourself as one who is condemned; as one who, affected
by a progressive, incurable disease, will soon fall a victim to
paralysis. On the strength of my own experience I give you the
assurance that your condition of health will not necessarily in ten
years' time be essentially different from what it is at present. But
I would also strenuously exhort you to observe all the precautionary
rules laid down for you, to avoid all unaccustomed strain or
indulgence such as can only be undertaken with impunity by a man in
full vigor and absolute soundness of health. I would advise you also
to be thoroughly examined once a year by an experienced physician.
But apart from these restrictions, you should as far as possible
feel yourself and bear yourself like a healthy man, remaining
attached to your work, and not withdrawing yourself from the
pleasures of social intercourse.
Relearning Muscular Movements.—Perhaps the most interesting evidence of how much may be done for organic nervous disease in spite of the fact that the underlying lesion is absolutely incurable, may be obtained from what is accomplished by Frenkel's method of treating locomotor ataxia. As is well known, by reteaching the movements necessary for walking, ataxic patients regain control of the movements of their limbs to a marked extent. As a consequence, bed-ridden patients are enabled to walk once more even though they may have to carry a cane and be supported, and patients who have had to use two canes get along with only one, or may even eventually be able to walk without any artificial support.
Just how the improvement is brought about we are not quite sure. It seems probable that the eyes become trained to replace the muscle sense to a noteworthy degree, but there is in addition apparently a re-education of the muscle-sense. Perhaps there is also a transfer of the function of certain degenerated nerves to other tracts than those in which muscle impulses originally traveled. The improvement in muscular control originally obtained is a striking illustration of how much nature is able to compensate for even organic lesions and is a lesson in the necessity for never ceasing to try to do something even when the case seems hopeless. Certainly locomotor ataxic patients would seem the least likely to be benefited by training in movement and yet this movement therapy for tabes has had some wonderful results.
The story of how this mode of treatment came into existence is interesting and instructive as an illustration of how happy chance in our time, as so often with regard to drugs in the past, came to assist the rational development of therapeutics. A German professor wished to demonstrate to his class the varying inco-ordination of a series of tabetic patients. Some of them had their main inco-ordination in the legs, others in their hands. He went over the cases in his wards so as to arrange the demonstration for the next day. He told each patient that he would ask him to perform a particular set of movements before the class which would illustrate strikingly a particular phase of muscular inco-ordination. His patients were interested in the announced demonstrations and during the afternoon they went over the movements that they were expected to perform. They practiced them as assiduously as their condition permitted for the exhibition. As a consequence the most striking features of their inco-ordination disappeared. After having practiced the movement for a certain length of time they could do it ever so much better than before. The special feature of the professor's demonstration was spoiled, but a great contribution to our knowledge of nature's compensatory powers {529} was made and fortunately the hint of its significance for treatment was taken and developed.
Effect of Favorable Suggestion.—How much can be accomplished for the relief of the general symptoms of locomotor ataxia and for the placing of patients in an attitude of mind that makes most of their symptoms of vanishing importance, can be judged from some recent experiences with a new cure for the disease. This consisted only of some rather conventional treatment of the urethra by applications and dilatation, yet patients were relieved so much of the symptoms of locomotor ataxia, or at least persuaded themselves that they were, that both in this country and in Europe the discoverer of the new "cure" soon had scores of patients. The active therapeutic agent undoubtedly was the fact that patients who had been told that their disease was incurable and who had settled down in a state of discouragement and apathy in which their power over their muscles, their general health and their strength and vitality were at the lowest ebb, and their tendencies to discomfort emphasized and made poignant by the supposed hopelessness of their situation, became aroused to new vitality by the promise of cure and then, under the repeated suggestion of a treatment said to be sure to cure them and that had cured others, became so much better, that is, released so much latent energy, that they felt better, ate better, walked better, got out more and had their general health improved, and all to such a degree that their disease seemed cured.
Another interesting illustration of what would seem to be the power of suggestion over the symptoms of tabes occurs in a recent article in the Archivos Españoles de Neurologia Psyqiuatria y Fisioterapia of Madrid [Footnote 39] on the improvement of tabes dorsalis by antidiphtheritic serum. It is quite impossible that the serum should affect favorably any of the underlying lesions of the disease any more than that these should be ameliorated by the wearing of shoes of special character or operations on the urethra. The patient in this case, however, was distinctly improved in many ways after the antidiphtheritic serum was injected. There were some interesting sensory manifestations, pains in the arms and legs after the injection, but these were removed by santonin or methylene blue. Both of these drugs are eminently suggestive in their action, so that one would be prone to think the pains rather neurotic than actual. After a dozen injections had been given, the patient's sensations improved, his power to pick up small things was better, and the sense of walking on carpet had disappeared to a marked extent and he was able to walk much better than before and without support. Probably any attention given to him to the same degree would have produced like results.
[Footnote 39: Tomo 1 No. 7, July, 1910.]
We have had previous examples of this kind in the history of the treatment of locomotor ataxia. Certain drugs when given in the past with the definite promise of cure and pursued for a good while with frequently repeated favorable suggestions, have often seemed to benefit patients, though subsequent experience has shown their total lack of value to modify the disease. Nitrate of silver was one of these in the old days and many locomotor ataxia patients acquired an argyria as a consequence of the amount of silver absorbed and deposited in the skin. Arsenic was another and some of the aluminum {530} compounds were also used. When we recall the suspension treatment and its reported good effects—and failure, the over-extension treatment with the same history and many others in the past, the real place of the mental in the therapeutics of tabies is revealed. Once this is practically realized, we find that we have ready to hand and easy to use, the one really efficient factor in all these treatments—that is, the influence on the patient's mind. It is for the physician to devise thoroughly professional ways and means of using that in each particular case so that his patients may be benefited as much as possible. Certainly it would be foolish for us to leave to the irregular practitioner the use of this extremely valuable remedial measure, when we may do so much good with it, for the relief of symptoms at least.
Paresis would seem to be one of the affections so inevitable in its course, so positively helpless as regards any medication, and so hopeless in its absolutely sure termination in idiocy and death, that nothing can possibly be done for it through the patient's mind, yet it is probably one of the diseases for which most can be accomplished by psychotherapy. Mental treatment for it naturally divides itself into three periods: that of prophylaxis, that of the early stage and that of the severer stage with remissions. Prophylaxis is much more important than is usually thought. It is very generally known at present that paresis is usually a parasyphilitic disease, that is, an affection not due directly to syphilis, but which develops by preference and perhaps exclusively in a soil prepared for it by an attack of syphilis. As a consequence of the diffusion of this knowledge men who have suffered from syphilis sometimes become supremely fatalistic as regards the development of locomotor ataxia or paresis in their cases. Worry is a prominent feature in the causation of paresis, and it is, therefore, extremely important to neutralize this.
I have had university graduates tell me their histories and ask whether I thought they had suffered from syphilis, and when I replied affirmatively have seen a look of despair come into their faces. One of them, a graduate of a large eastern university, said, after hearing my opinion, though it was given with every assurance that my experience with Fournier in Paris taught me the absolute curability of the disease, "Well, there are three men of my class who have already developed paresis, and I suppose I will go the same way." With a persuasion like this haunting him night and day, exhausting nervous energy and making his central nervous system less and less resistive, it would be almost a miracle if paresis did not develop. It is particularly in those who have had nervously exhaustive occupations—brokers, speculators, actors, and the like—that paresis does develop. The strain upon their nervous systems seem to be so great that the syphilitic virus still remaining in their system has a peculiarly degenerative effect upon nervous tissue. A man may be in the least worrisome of occupations, however, and if he is constantly brooding over the possibility of the coming of the hideous specter of paresis, {531} he puts himself in the condition most likely to encourage the development of the pathological changes that underlie the disease.
Prophylaxis.—As a rule patients who have had syphilis and who dread the development of paresis should be warned with regard to their occupations in life. After a patient has had tuberculosis which developed in particular surroundings, if it is at all possible, we no longer permit him to go back into the surroundings in which his disease developed. We are coming, more and more, to apply the principles of preventive medicine and this is as important in paresis as in anything else. Even though there may be many monetary or economic reasons in favor of certain occupations, the danger may overweigh these. Those who have had syphilis should be warned of the risk they run if they continue in occupations that require much mental excitement or the strain of anxiety and the speculative factor of uncertainty with the inevitable occurrence of disappointments. It is unjustifiable to permit a patient whose central nervous system is subjected to the deteriorating influence of the virus of syphilis, still in his body even after ten years, to submit to the nerve-racking irritation of occupations which require all the vigor of a healthy, undisturbed organism to survive their wear and tear.
Sources of Worry.—One of the symptoms which neurotic patients are sure must be a preliminary sign of paresis is a disturbance of memory. Patients have heard that paresis causes memory disturbances and fearing the development of the disease, they disturb themselves very much by finding real or supposed defects of memory. Most of them have had only a very vague idea of the sort of memory they possess and cannot tell whether it is worse than before, but finding a certain difficulty in recalling things they conclude that it is deteriorating. Occasionally their supposed defect of memory is founded on nothing more serious than the fact that they are paying so much attention to themselves, that they cannot concentrate their attention enough on what they wish to remember so as really to impress it on their memories. It is curious how persistent some patients are in making themselves believe they have serious lacunae in their memory when there are only certain conventional disturbances of it. The paretic has defects of memory, but he is, as a rule, quite unconscious of them. He has to have them pointed out to him. Patients who are supremely conscious of their supposed defects, by that very fact show their possession of good intellectual faculties.
Tremor is another symptom that may develop in the midst of the solicitude of those who dread paresis. The power to hold the limbs in a given position is due to a very nice balancing of flexor and extensor muscles. There are many people, especially those a little awkward in the use of their muscles, who lack this power to some extent. To stand without swaying is rather a difficult task in one who is nervous or anxious about himself. Patients who are worrying about paresis and its possible development will almost surely disturb their power over their muscles and cause at least a slight tremor or swaying.
In other words, in all of these cases a series of dreads, or mental obsessions which interfere with various functions which may cause tremor, or some stuttering, or at least some apparent difficulties of speech and which will surely revive any old-time difficulties of this kind, may develop in nervous persons and must not be allowed to pass as signs of developing paresis. The {532} diagnostic tests, of course, consist in the knee-jerks, the pupillary reactions, the difference in disposition, the delusions of grandeur, and, in general, the characteristic symptoms of a physical degeneration running parallel with a mental deterioration.
Prophylactic Reassurance.—The first point in psychotherapy, then, is to give just as much reassurance as can be given. Probably not one out of a thousand of those who have suffered from syphilis afterwards develops paresis. Nearly always there is something in the history besides syphilis that seems to be an essential etiological factor. A great many of the people who develop this disease have some hereditary taint of mental incapacity at least, if not of actual insanity. Very often there is a personal or family history that indicates some mental unevenness or at least some lack of intellectual vigor. When people are sanely intellectual and have no unfortunate hereditary tendencies they can be almost completely assured as to the possibility of the development of paresis, provided they take reasonable care of themselves.
Alcohol.—It is still an unsettled question whether alcoholism has anything to do, even in a subsidiary capacity, with the etiology of paresis. Probably it helps to predispose nerve tissues to degeneration by lowering their resistive vitality to the direct pathogenic action of the virus of syphilis. It seems clear, besides, that men who have acquired syphilis sometimes take to over-indulgence in alcohol, at least to a greater degree than would otherwise be the case, because of the discouraging dread that develops as a result of their worry over this constitutional taint. A warning in this matter of indulgence in intoxicants is important because there are many nerve specialists who insist that alcoholism is probably one of the prime factors in paresis.
Unconclusive Diagnosis.—When the first symptoms of paresis have developed so that the physician is almost certain that the disease is present—the cumulative experience of recent mistakes on the part of the most careful experts seems to show that he can never be entirely certain—then it is important not to announce the worst to the patient, but to let him learn the reality of his condition gradually, so that all the awfulness of it does not overwhelm him. What have seemed typical cases of paresis, so diagnosed by excellent authorities, have occasionally proved to be something else, or, at least, to be wayward and very irregular forms of that disease with a long course and marked remissions. There are forms of paranoia in the middle-aged which sometimes exhibit symptoms so strongly simulant of paresis as to deceive even the expert. There are forms of nervous weakness—neurasthenia—some of which are really cases of mental exhaustion or incapacity—the modern psychasthenia—which often lead even experienced physicians to think of and sometimes to diagnose paresis. There are cases of dementia praecox that only time can differentiate.
Prognosis.—Seeing the Worst.—There is a tendency in most physicians to see the worst side of the story rather than the better. This is not because of any desire to be a harbinger of evil tidings, nor, as is sometimes said, to show the patient, should he get better, from what a depth of affliction he has been rescued, but it is rather due to the very natural tendency existing in most of us to look on the worst side of things. Besides, we have found by experience that if patients are to be aroused to the necessity of care for themselves they must be scared a little, and so we have formed the habit, not of consciously {533} and deliberately telling the worst, but of stating the unfavorable possibilities of a group of symptoms, in order that a patient may take due precautions and that he may realize, if the worst does happen, that we were not ignorant of it. If he gets better he is correspondingly grateful for this. If the unfavorable happens and we had not warned him, he is more or less justifiably resentful.
Consoling Hesitancy of Final Judgment.—Patients suspected of suffering from paresis can then without any violation of truth be reassured that their cases may not be incurable until the epileptiform incidents of the disease bring on that happy obscuration of mentality, that either takes away all the terror of the disease or lessens so much its awful significance that the patient is spared the worst. There are cases of reported cures in the literature even after what seemed to be characteristic epileptiform attacks had occurred.
We cannot be sure, in any case, of the future course of an affection exhibiting symptoms resembling paresis. The patient can always be given the advantage of this doubt then and the awful word incurable or even the diagnosis paresis need not be mentioned to him. It is perfectly possible, as a rule, to take other means to prevent unfortunate incidents from tendencies to violence or serious loss from foolishness, without overwhelming the patient with an absolutely unfavorable prognosis, and the diagnosis of paresis, involving as it does, now that so much more is popularly known of the disease than before, the dread of inevitable idiocy. In this way much of the depression that constitutes so large a part of the really sane period of the early stage of paresis and which inevitably hastens the course of the disease may be avoided. On the other hand, failure to announce absolutely the diagnosis of paresis until there can be no particle of doubt, can do no harm and will do good to the patients themselves, as well as save their anxious friends from the trial of having to think of the awful possibilities of the disease. A single sensible member of the family may be selected as the confidant and the situation saved.
Rôle of Psychotherapy.—While it is important that someone closely connected with the patient should know the doctor's suspicions, he should be bound to absolute secrecy as regards the patient himself and especially as regards women friends and relatives. The attitude of mind assumed by women relatives, and especially those nearest and dearest, is sure to be communicated to the patient, if not directly at least indirectly and inadvertently, and makes for anything but relief from the depression that is sure to be his if he has any gleam of understanding of his condition. Indeed, so much of pain and suffering is needlessly inflicted on relatives of paretic patients in the early stages of the disease by a premature announcement of the diagnosis that it is especially important to insist on care in this matter. The family will usually clamor to know just what is the matter, but it is the physician's duty to care for his patient and save the sufferings of the patient's family, regardless of their unwitting insistence. Once the disease has developed and the patient's mind becomes affected it may be thought that psychotherapy is no longer of value. As a matter of fact, these patients as a rule become more childlike and are much more affected by suggestion than in their normal states. All this is worthy of careful attention on the part of the physician who feels that it is his duty to treat patients and not merely their disease.
The psychic care of the patient is the most important element in any {534} scheme of therapeutics during the longer remissions of paresis, which are sometimes so complete that it is difficult to understand that the patient, who is now as sensible as he ever was, only a few months before was doing the most foolish things under the influence of his delusions of grandeur and probably within a few months will be quite as insane as before and perhaps hopelessly demented. The brevity of these remissions in most cases seems to depend directly on how much the patient is persuaded that his disease will return without fail and run its inevitable course. It is well worth while to lengthen these remissions by setting the patient's mind just as much at rest as possible. Instead of the attitude which is so often assumed of absolute assurance on the part of the physician that the old condition will inevitably return, it is advisable always to give the opinion that the previous mental derangement was paranoiac rather than paretic, or was perhaps only a passing syphilitic condition and that the ultimate outlook is not as hopeless as might be thought. This opinion is thoroughly justified by certain surprising results in a number of recently reported cases. Some patients whose symptoms have been diagnosed as paresis by excellent diagnosticians, have, after a time, experienced a cessation of their symptoms which looked very much like a remission occurring in the midst of the inevitably progressive paretic degeneration and then to the surprise of their physicians have not exhibited any further symptoms of the affection. Syphilis of the nervous system sometimes simulates paresis to such an extent as to deceive the most expert, and proper antisyphilitic treatment will sometimes produce results that are little short of marvelous. It is beyond all question, then, for the good of the patient suspected of paresis that his physician should give him the benefit of every doubt.
With regard to the major neuroses generally, very much more therapeutic benefit can be secured than in any other way that we know by reassuring the patient's mind, by careful regulation of his life and by such modifications of his occupation as will take him out of a strenuous existence, so likely to be harmful to a nervous system laboring under these serious handicaps. In recent years we have come to realize that epilepsy, for instance, is more favorably influenced by a simple outdoor life in the country without worries and cares, with carefully regulated exercise in the open air and special attention to the digestive tract, than by any formal remedial measures or drug treatment. The fewer the emotional storms the less likelihood of repetitions of attacks of epilepsy. No medicine is so effective in prolonging the intervals between attacks as this placing of the patient in favorable conditions of mind and body. Our experience with the colony system has emphasized the fact that drug treatment is quite a subsidiary factor in this general care for the patient. The most important element in this treatment is the effect on the {535} patient's mind and the consequent gain in poise and in resistive vitality against emotional explosions which are so often the immediate occasion of attacks. This lessens their number and it is well known that frequent repetition is likely to be associated with that deterioration of the physical nature and mental condition which is most to be dreaded.
Mental Influences.—When living a quiet placid life without worry about himself or his concerns, the number of the epileptic attacks goes down in a noteworthy degree and the intervals between them become longer and longer. After years of quiet country living epileptics who had two or three attacks a week have scarcely more than one a month, if, indeed, that often, and their general condition is greatly improved. We have had many remedies for the affection, only a few of which have proved to be really therapeutic. The remainder have had their effect through the mental influence that went with them, the assurance of relief and the confidence that it aroused.
First attacks of epilepsy are not infrequently the result of an immediately preceding fright or sudden emotion of some kind or other. Gowers tells the story of a sentinel posted near a graveyard who was very much disturbed by his proximity to the dead and who, during the night, saw a white goat run past him, jump over a low wall and disappear. He was sure it was a ghost. He had his first attack of epilepsy shortly after. Children not infrequently have their first attack after a scare from a dog or a rough-looking stranger who has come near them. After the affection has established itself attacks of epilepsy follow vehement mental disturbances of any kind. Sometimes after a long interval of freedom from attacks a sudden strong emotion is followed by a fit and then the epileptic habit is reestablished. In order to be as free as possible from the affection patients must be protected from emotional storms.
Power of Suggestion.—-A strong proof of the favorable influence of suggestion upon epilepsy was given when operations for epilepsy became common about twenty years ago. A number of patients were operated on by trephining, even though almost nothing else was done except to open the dura and examine the brain, for often no definite pathological condition to justify surgical intervention was found. But these patients did not suffer from attacks of epilepsy for months and sometimes years afterwards. Many surgeons reported these cases as cured, as they apparently were when discharged from the hospitals, for no attacks had recurred; but physicians had to treat them later when their epilepsy redeveloped. The surgical procedure, as indeed might have been expected from the findings, had given only temporary betterment. The real therapeutic factor at work had probably been not any definite change within the skull, but the suggestive influence of the operation, the period of rest with favorable suggestion constantly renewed, and the confidence of recovery inspired during convalescence. Even in cases where adhesions were found between the dura and calvarium and these were broken up, the relief afforded was usually but temporary. The succession of events, the relief afforded and subsequent relapse, probably represented the same influence of suggestion as in the preceding cases with perhaps a slight physical betterment in addition.
An important factor in the psychotherapeutics of epilepsy is to relieve the patient as far as possible from the haunting dread of insanity, which, especially if he has read much of the disease, is so likely to hang over him as {536} a pall because of the absolutely bad prognosis which often occupies so prominent a place in older text-books and articles on epilepsy. There is no doubt that in a great many cases epilepsy is a progressive degenerative disease and that a state of lowered mentality will eventually develop. There are many cases, however, in which epilepsy is only a series of incidents which does not seem to affect the intellectual life and which is quite compatible not only with prolonged existence, but with mental achievements of a high order and, above all, with a personality that may be commanding in its power over others. This knowledge, which unfortunately is not usually given in text-books because they are studies in the pathology rather than in the psychology of epilepsy, is extremely important for the epileptic. This view is of special significance for those sufferers from the disease who are well educated and in whom mentality means so much.
The Individual in Epilepsy.—In epilepsy, indeed, the individual counts much more than his ailment, and even in severe cases of epilepsy there are individuals to whom the recurring convulsions are only annoying occurrences of life, somewhat dangerous because of the risks encountered during unconsciousness, but without any ulterior significance for degeneration of character or intellectual power. As a matter of fact, there are many men in history who were epileptics and who yet succeeded in great work of many kinds, even purely intellectual, unhampered by this condition, and some of them have proved to be leaders in achievement. In his paper read before the National Association for the Study of Epilepsy and the Care and Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew Woods discussed what certain famous epileptics had accomplished in spite of epilepsy. He takes three typical examples—Julius Caesar, Mohammed and Lord Byron—the founders, respectively, of an empire, a religion and a school of poetry—with regard to whom there is convincing evidence that they were epileptics. A fourth name, that of Napoleon, might easily have been added. Greater accomplishments than these epileptics made in their various departments are not to be found in the history of the race.
Many other names of epileptics distinguished for achievement might well have been added to the list. The argument that would be founded on their lives is not that epileptics are necessarily or even usually of high intelligence, but that some of them, at least, retain in spite of the major neurosis, or even serious brain disorder, whichever it may be, all their intellectual qualities undisturbed. Lombroso, arguing from the other standpoint, has pointed out that there is a close relation between genius and insanity, and he sets down epilepsy as one of the forms of insanity (mental un-health) often associated with extraordinary mental qualities. A study of this subject is extremely reassuring to the epileptic who is prone to think from traditions with regard to the disease that his fate is almost sure to be a gradual lapse into imbecility. No epileptic is likely to be at all worried over the suggestion that epilepsy and genius are allied, for since he has the one he is quite willing that the other shall follow.
Treatment.—Reassurance is especially important when patients develop epilepsy in adult life. There is an unfortunate social stigma attached to the disease which adds to the unfavorable suggestions that are likely to run with it. This probably cannot be overcome, for it is a heritage, not alone of many {537} generations, but of many centuries. Our better knowledge of epilepsy, however, should gradually take the disease out of the sphere of suspected mystery in which it has been popularly placed and set it among the diseases to which human nature is liable, but which is surely as physical in its character as any other. If a favorable attitude of mind on the patient's part can be secured there is less necessity for many of the disturbing drugs that are used and there seems to be no doubt that even in producing the effect of these, such as it is, suggestion of a favorable character plays a large role. Over and over again in the history of the affection we have had remedies introduced which have seemed to be quite efficient in producing longer intervals between attacks, making the patient less nervous and putting him in better physical health. After a time, however, these have proved to be quite useless, or at most of but very slight value. It was suggestion that gave them their apparent value, and this suggestion must be used without the drugs whenever possible.
The bromides have done good in the treatment of epilepsy, but they are the only drugs that maintain the reputation they first had. All the others accomplished whatever benefit they conferred on the patient, and some of them for a time seemed to excellent authorities of large experience to give marvelous results, through their influence over the patient's mind. Nothing can produce more confidence in the physician who is using suggestion for epilepsy than this fact. Even the bromides, unless used carefully, easily do more harm than good and they have often worked mischief. Favorable suggestion cannot do harm. At the present time those of largest experience in the treatment of epileptics, the directors of farm colonies, as Dr. Shanahan of Craig Colony, insist that diet, hygiene, especially hydrotherapy, are of much more importance than drugs, but that the patient's attitude of mind towards himself and his malady and the future of it is even more important. He must have occupation of mind so as not to worry about himself. He must have recreation so as to relieve the gloom so likely to come in the disease. He must have outdoor air and proper exercise, which these patients are so prone to neglect.
Those who have studied the subject most in recent years agree that the great majority of cases of epilepsy are not primarily due to acquired causes, but to some congenital defect, so that there is an inherent instability of the nervous system. This makes the patient liable to explosions of nerve force, figuratively represented as boilings over of nervous energy, when not properly inhibited. Once such a paroxysm occurs it is likely to happen again, and very often it brings on gradual degeneration of the nervous system and of mentality. In many cases, however, this degeneration can be delayed or even completely kept off by putting the patient under favorable conditions. These patients need, above all, to realize that they cannot live the strenuous life nor even the ordinary busy life of most people. They are as cripples compelled to limit the sphere of their activities. If they will but take this to heart, however, and not attempt too busy occupations, they may live quite happy lives for many years, and if mentally content and without worrying anxieties they will have so few attacks as to incur only to a slight degree the dangers inevitably associated with fits of unconsciousness. To get the epileptic's mind into a condition of satisfaction with his condition must be the main portion of the treatment.
There is a large and important field of psychotherapeutics in a class of cases so closely related to epilepsy that it is often extremely difficult to make the differential diagnosis between the two varieties of seizure. Fifteen years ago, while I was at the Salpêtrière, there was much discussion of a variety of attack called hystero-epilepsy, in which the patients' symptoms were such that it was difficult if not practically impossible to decide whether the case was true epilepsy or merely hysteria. Personally I do not think there is any third, intermediate variety deserving a separate term. The attacks are either hysterical, or, to use a less objectionable name, neurotic, or they are genuinely epileptic, that is, due to some as yet not well-defined change in the brain, and therefore not likely ever to be completely relieved. To decide whether a given case is neurotic or epileptic, however, is sometimes quite out of the question until long and careful study of it has been made. It is true that such signs as full loss of consciousness, biting of the tongue, the so-called epileptic cry, involuntary urination, dangerous falls and the like in the midst of an attack, have often been declared to be signs of true epilepsy, but there are cases in which one or other of these signs has been present, yet the subsequent course of the affection has shown them to be functional and not organic in origin.
Neurotic Simulation of Epilepsy.—Nearly every physician who has reasonably large experience with neurotic patients has seen cases in which there were recurrent attacks of loss of consciousness that came on sometimes at most inopportune moments, that rendered the patient quite incapable of caring for himself for the moment, yet lacked many of the signs of true epilepsy. Teachers sometimes complain of a complete lapse of memory that begins without warning and then recurs at intervals, making their work very difficult. Preachers sometimes bring the story of having lost the thread of their discourse and forgetting absolutely what they were talking about, there being a complete blank for some seconds at least. Occasionally such lapses are associated with falls that resemble fainting spells and seem to be accompanied by complete loss of consciousness. Usually after them there is a distinct tired feeling and an inclination to sleep, though, as a rule, there is a more marked tendency to want to get away from observation. Some of the cases are much more severe than those described and the conclusion that they are true epilepsy seems inevitable, yet they recover so completely that this conclusion is negatived.
Occasionally such attacks occur only when the patient has been strenuously exerting mind or body for a much longer period than usual. In teachers it is likely to occur toward the end of the year or in the midst of the hard work about examination time. In students this same period is likely to be a favorite starting point for the attacks and they recur oftener at this time than at others. Very often there is a story of some digestive disturbance in connection with the attacks. At times it seems possible to trace them to some interference with the cerebral circulation through a distended stomach pressing upward through the diaphragm and interfering with the heart action. In such cases stomach resonance will sometimes be found as high as the fifth rib {539} and the apex beat may be pushed out to the nipple line or beyond it. This may be true though there are no signs of valvular lesions and no symptoms or physical signs of dilatation or hypertrophy of the heart.
The Suggestive Element.—Analysis shows the real course of the trouble in these cases. The sufferer is usually following a sedentary occupation, not getting much exercise or diversion and prone to introspection. Many symptoms of themselves of no importance have been emphasized by concentration of attention on them. Especially is this true of any heart irregularity. The patient has dreaded for some time lest the feeling of pressure in the precordia and of discomfort in the heart might not sometime interfere with him in the midst of his teaching or preaching duties. Some day when he is feeling much worse than usual, in the midst of his work, there comes over him the feeling that now his intellect is going to stop action because there is something the matter with him. The sudden concentration of his attention on this with the fear of the consequences and the uncomfortable feeling that he will not be able to go on with his flow of ideas, cuts off the thread of what he is thinking about and puts but one single object before him—this possibility of failure of mental action. Usually the first attack is only such an interruption as is thus indicated. The fear of subsequent attacks, the worry over what has happened, the dread that some serious mental affection or nervous disease is at work emphasizes introspection and subsequent attacks are even more likely to be serious, and especially to last longer than the first.
The more the cases are studied the more the conclusion comes that in many of these instances it is nothing more than auto-suggestion that is responsible for the mental lapse. It is true that some physical condition may be the occasion, though the mental state is the active immediate cause. Suddenly concentrated attention on the dread of mental interruption inhibits mental action and what was dreaded follows almost necessarily. It is a sort of auto-hypnotism in which the patient's train of thought is interrupted by a momentary or longer hypnotic state the causes of which can be traced. Even when there is a real organic lesion of the heart, the lapses of memory and even of reasoning power that occasionally occur, have often seemed to me to be due rather to the patient's dread than to any real physical condition. I cannot think that there is a sufficient interruption of the cerebral circulation, even though only for a moment, to cause such a lapse. It is a question of nerve interferences rather than of blood supply. If the blood were diverted, even though only for a moment, or if there was a stoppage, the consequences would be more serious and more lasting than they are.
What evidently happens is some disturbance of neurotic connections within the brain brought on by sudden dread or emotion. The will has lost control or has seriously disturbed the conducting apparatus. The best proof that this is what happens and that it is not the result of organic change is found in the fact that when the physical occasion, that is, the digestive disturbance or the heart palpitation which is the initial factor in these states, is relieved, the attacks do not take place. Patients in whom they have occurred even for years cease to have them. This improvement does not begin, however, until their solicitude over their condition has been lessened by a confident declaration to them that they are suffering from merely functional and local reflex conditions apart from the brain itself. Usually it needs to be made clear {540} to them, too, that their anxiety in the matter means much more for the continuance of the attacks than any physical condition.
Almost invariably patients somewhat resent this suggestion. Their response to this explanation of their ailment usually is that the attacks come on them when they are not particularly expecting them and that there is first some physical symptom which might readily be taken for a sort of aura to a genuine epileptic attack and then the attack itself comes on. It is this preceding symptom, pain or discomfort, or whatever else it may be, that provokes the suggestive element and brings about the state of quasi-hypnosis, which is the main part of their attack.
Neurotic Syncopal Attacks.—Some of the cases of pseudo-epilepsy are very mild, though if the word epilepsy has been mentioned there naturally arises a feeling of dread in patient and friends with consequent unfavorable suggestion. A type not infrequently seen has for its main symptom a period, usually of but short duration, in which there is an intense tired feeling so that even the eyelids droop and require effort to lift them. During such attacks the respirations may slow down to fifteen or below, though usually the pulse is inclined to be rapid. The feeling of fatigue is almost entirely subjective, in the sense that, if patients are required to do something, they are able to accomplish it by a little urging, though a moment before they were sure that they could not. Such attacks are invariably functional, have no organic basis and do not deserve the name of epilepsy. If called hysterics this will cause the patient, who is often a woman, to rouse herself and so gradually overcome them. They are really a loss of confidence in one's power to do things and a passing astasia-abasia. The use of the word hysterics may cause the patient to lose the sympathy of her friends, though she may need it; for often there is an underlying pathological condition not in the nervous but in the somatic system. Sometimes the patients are anemic, sometimes they have an abortive form of Graves' disease, and sometimes they are low in nutrition.
These conditions give the indication for treatment. What is needed is, of course, improvement of the general condition, but, above all, a restoration of the patient's confidence in herself. Once it is made clear to her that the attacks are largely subjective, that is, are due to a feeling of prostration because of the fear that she is unable to do something, then the intervals between the attacks will gradually grow longer. It is important that long hours of sleep should be advised with plenty of fresh air, and that whatever disturbances of the digestive system are present should be carefully treated.