EPILEPSY, HYSTERIA, AND NEURASTHENIA
THEIR CAUSES, SYMPTOMS, & TREATMENT
BY ISAAC G. BRIGGS A.R.S.I.
METHUEN & CO. LTD. 36 ESSEX STREET W.C. LONDON
First Published in 1921
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TO ALBERT E. WOODRUFF OF STOKE PRIOR NR. BROMSGROVE MY OLD SCHOOLMASTER
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I. MAJOR AND MINOR EPILEPSY 1
II. RARER TYPES OF EPILEPSY 7
III. GENERAL REMARKS 15
IV. CAUSES OF EPILEPSY 20
V. PREVENTION OF ATTACKS 25
VI. FIRST-AID TO VICTIMS 28
VII. NEURASTHENIA 30
VIII. HYSTERIA 39
IX. ADVICE TO NEUROPATHS 46
X. FIRST STEPS TOWARD HEALTH 53
XI. DIGESTION 56
XII. INDIGESTION 60
XIII. DIETING 63
XIV. CONSTIPATION 67
XV. GENERAL HYGIENE 71
XVI. SLEEPLESSNESS 76
XVII. THE EFFECTS OF IMAGINATION 79
XVIII. SUGGESTION TREATMENT 82
XIX. MEDICINES 86
XX. PATENT MEDICINES 90
XXI. TRAINING THE NERVOUS CHILD 98
XXII. DANGERS AT AND AFTER PUBERTY 109
XXIII. WORK AND PLAY 115
XXIV. HEREDITY 118
XXV. CHARACTER 123
XXVI. MARRIAGE 131
XXVII. SUMMARY 140
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I hope this book will meet a real need, for when one considers how prevalent epilepsy, hysteria and neurasthenia are, among all ranks and ages of both sexes, it seems remarkable some such popular book was not written long ago.
I add nothing to our knowledge of these ills, my object being to put what we know into simple words, and to insist on the necessity for personal discipline being allied to expert aid. The book aims at helping, not ousting, the doctor, who may find it of use in getting his patient to see—and to act on—the obvious.
"Nervous Disease", as here used, includes only the three diseases treated of; "Neuropath"—victims of them.
"Advice" to a neuropath is usually a very depressing decalogue of "Thou Shalt Nots!" If it be made clear why he must not do so-and-so, the patient endeavours to obey; peremptorily ordered to obey, he rebels. Much sound advice is wasted for lack of an interesting, convincing, "Reason Why!" which would ensure the hearty and very helpful co-operation of a patient who had been taught that writing prescriptions is not the limit of a doctor's activities.
Many folk, with touching belief in his own claims, regard the quack as a hoary-headed sage, who from disinterested motives devotes his life to curing ailments, by methods of which he alone has the secret, at low fees. To fight this dangerous idea I have tried to show in an interesting way how science deals with nerve ills, and to prove that qualified aid is needed. Suggestions and criticisms will be welcomed.
I. G. BRIGGS THE UNIVERSITY, BIRMINGHAM, June, 1921
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"Lette than clerkes enditen in Latin, for they have the propertie of science, and the knowing in that facultie: and lette Frenchmen in their Frenche also enditen their queinte termes, for it is kyndely to their mouthes; and let us showe our fantasies in soche wordes as we lerneden of our dames tongue."
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EPILEPSY, HYSTERIA, AND NEURASTHENIA
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MAJOR AND MINOR EPILEPSY
(Grand and Petit Mal)
"My son is sore vexed, for ofttimes he falleth into the fire, and ofttimes into the water."—Matthew xvii, 15.
"Oft, too, some wretch before our startled sight, Struck as with lightning with some keen disease, Drops sudden: By the dread attack o'erpowered He foams, he groans, he trembles, and he faints; Now rigid, now convuls'd, his labouring lungs Heave quick, and quivers each exhausted limb.
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"He raves, since Soul and Spirit are alike Disturbed throughout, and severed each from each As urged above, distracted by the bane; But when at length the morbid cause declines, And the fermenting humours from the heart Flow back—with staggering foot first treads Led gradual on to intellect and strength."—Lucretius.
Epilepsy, or "Falling Sickness", is a chronic abnormality of the nervous system, evinced by attacks of alteration of consciousness, usually accompanied by convulsions.
It attacks men of every race, as well as domesticated animals, and has been known since the earliest times, the ancients imputing it to demons, the anger of the gods, or a blow from a star.
It often attacks men in crowds, when excited by oratory or sport, hence the Roman name: morbus comitialis (crowd sickness).
In mediaeval times, sufferers were regarded with awe, as being possessed by a spirit. Witch doctors among savages, and founders and expounders of differing creeds among more civilized peoples, have taken advantage of this infirmity to claim divine inspiration, and the power of "seeing visions" and prophesying.
Epilepsy has always interested medical men because of its frequency, the difficulty of tracing its cause, and its obstinacy to treatment, while it has appealed to popular imagination by the appalling picture of bodily overthrow it presents, so that many gross superstitions have grown up around it.
The description in Mark ix. 17-29, is interesting:
"Master, I have brought Thee my son, which hath a dumb spirit. And wheresoever he taketh him, he teareth him: and he foameth, and gnasheth with his teeth, and pineth away: ... straightway the spirit tare him; and he fell on the ground, and wallowed foaming.
"And He asked his father, How long is it ago since this came unto him? And he said, Of a child. And ofttimes it hath cast him into the fire, and into the waters, to destroy him.
"And he said unto them, This kind can come forth by nothing, but by prayer and fasting."
Up to the present, epilepsy can be ascribed to no specific disease of the brain, the symptoms being due to some morbid disturbance in its action. Epilepsy is a "functional" disease.
GRAND MAL ("Great Evil")
An unusual feeling called an aura (Latin—vapour), sometimes warns a patient of an impending fit, commonly lasting long enough to permit him to sit or lie down. This is followed by giddiness, a roaring in the ears, or some unusual sensation, and merciful unconsciousness. In many cases this stage is instantaneous; in others it lasts some seconds—but an eternity to the sufferer. This stage is all that victims can recall (and this only after painful effort) of an attack.
As unconsciousness supervenes, the patient becomes pale, and gives a cry, which varies from a low moan to a loud, inhuman shriek. The head and eyes turn to one side, or up or down, the pupils of the eyes enlarge and become fixed in a set stare, and the patient drops as if shot, making no effort to guard his fall, being often slightly and sometimes severely injured.
The whole body then becomes stiff. The hands are clenched, with thumbs inside the palms, the legs are extended, the arms stiffly bent, and the head thrown back, or twisted to one side. The muscles of the chest and heart are impeded in their action, breathing ceases, the heart is slowed, and the face becomes pale, and then a livid, dusky blue.
The skin is cold and clammy, the eyebrows knit; the tongue may be protruded, and bitten between the teeth. The eyeballs seem starting from their sockets, the eyes are fixed or turned up, so that only the sclerotic ("whites") can be seen, and they may be touched or pressed without causing blinking. The stomach, bladder, and bowels may involuntarily be emptied.
This tonic stage only lasts a few seconds, and is followed by convulsions. The head turns from side to side, the jaws snap, the eyes roll, saliva and blood mingle as foam on the lips, the face is contorted in frightful grimaces, the arms and legs are twisted and jerked about, the breathing is deep and irregular, the whole body writhes violently, and is bathed in sweat.
The spasms become gradually less severe, and finally cease. Deep breathing continues for some seconds; then the victim becomes semi-conscious, looks around bewildered, and sinks into coma or deep sleep.
"...As one that falls, He knows not how, by force demoniac dragg'd To earth, and through obstruction fettering up In chains invisible the powers of Man; Who, risen from his trance, gazeth around Bewilder'd with the monstrous agony He hath indured, and, wildly staring, sighs: ..."
In a few hours he wakes, with headache and mental confusion, not knowing he has been ill until told, and having no recollection of events just preceding the seizure, until reminded of them when they are slowly, and with painful effort, brought to mind. He is exhausted, and often vomits. In severe cases he may be deaf, dumb, blind, or paralysed for some hours, while purple spots (the result of internal hemorrhage) may appear on the head and neck. Victims often pass large quantities of colourless urine after an attack, and, as a rule, are quite well again within twenty-four hours.
This is the usual type, but seizures vary in different patients, and in the same sufferer at different times. The cry and the biting of the tongue may be absent, the first spasm brief, and the convulsions mild. Epilepsy of all kinds is characterized by an alteration (not necessarily a loss) of consciousness, followed by loss of memory for events that occurred during the time that alteration of consciousness lasted.
Attacks may occur by day only, by day and by night, or by night only, though in so-called nocturnal epilepsy, it is sleep and not night that induces the fit, for night-workers have fits when they go to sleep during the day.
Victims of nocturnal epilepsy may not be awakened by the seizure, but pass into deeper sleep. Intermittent wetting of the bed, occasional temporary mental stupor in the morning, irritability, temporary but well-marked lapses of memory, sleep-walking, and causeless outbursts of ungovernable temper all suggest nocturnal epilepsy.
Such a victim awakes confused, but imputes his mental sluggishness to a hearty supper or "a bad night". A swollen tongue, blood-stained pillow, and urinated bed arouse suspicion as to the real cause, suspicion which is confirmed by a seizure during the day. He is more fortunate (if such a term can rightly be used of any sufferer from this malady) than his fellow victim whose attacks occur during the day, often under circumstances which, to a sensitive nature, are very mortifying.
Epileptic attacks are of every degree of violence, varying from a moment's unconsciousness, from which the patient recovers so quickly that he cannot be convinced he has been ill, to that awful state which terrifies every beholder, and seems to menace the hapless victim with instant death. Every degree of frequency, too, is known, from one attack in a lifetime, down through one in a year, a month, a week, or a day; several in the same periods, to hundreds in four-and-twenty hours.
PETIT MAL ("Little Evil")
This is incomplete grand mal, the starting stages only of a fit, recovery occurring before convulsions.
Petit mal often occurs in people who do not suffer from grand mal, the symptoms consisting of a loss of consciousness for a few seconds, the seizure being so brief that the victim never realizes he has been unconscious. He suddenly stops what he is doing, turns pale, and his eyes become fixed in a glassy stare. He may give a slight jerk, sway, and make some slight sound, smack his lips, try to speak, or moan. He recovers with a start, and is confused, the attack usually being over ere he has had time to fall.
If talking when attacked, he hesitates, stares in an absent-minded manner, and then completes his interrupted sentence, unaware that he has acted strangely. Whatever act he is engaged in is interrupted for a second or two, and then resumed.
A mild type of petit mal consists of a temporary blurring of consciousness, with muscular weakness. The victim drops what he is holding, and is conscious of a strange, extremely unpleasant sensation, a sensation which he is usually quite unable to describe to anyone else. The view in front is clear, he understands what it is—a house here, a tree there, and so on—yet he does not grasp the vista as usual. Other victims have short spells of giddiness, while some are unable to realize "where they are" for a few moments.
Frequent petit mal impairs the intellect more than grand mal, for convulsions calm the patient as a good cry calms hysterical people. After a number of attacks of petit mal, grand mal usually supervenes, and most epileptics suffer from attacks of both types. Some precocious, perverse children are victims of unrecognized petit mal, and when pushed at school run grave risks of developing symptoms of true epilepsy. The "Little Evil" is a serious complaint.
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RARER TYPES OF EPILEPSY
If it be true that: "One half the world does not know how the other half lives", how true also is it that one half the world does not know, and does not care, what the other half suffers.
Epilepsy shows every gradation, from symptoms which cannot be described in language, to severe grand mal. Gowers says: "The elements of an epileptic attack may be extended, and thereby be made less intense, though not less distressing. If we conceive a minor attack that is extended, and its elements protracted, with no loss of consciousness, it would be so different that its epileptic nature would not be suspected. Swiftness is an essential element of ordinary epilepsy, but this does not prevent the possibility of deliberation."
In Serial Epilepsy, a number of attacks of grand mal follow one another, with but very brief intervals between. Serial epilepsy often ends in
Status Epilepticus, in which a series of grand mal attacks follow one another with no conscious interval. The temperature rises slowly, the pulse becomes rapid and feeble, the breathing rapid, shallow and irregular, and death usually occurs from exhaustion or heart-failure. Though not invariably fatal, the condition is so very grave that a doctor must instantly be summoned. Nearly all victims of severe, confirmed epilepsy (25 per cent of all epileptics) die in status epilepticus.
Jacksonian Epilepsy, named after Hughlings Jackson, who in 1861 traced its symptoms to their cause, is not a true epilepsy, being due to a local irritation of the cortex (the outermost layer) of the brain.
There is usually an aura before the attack, often a tingling or stabbing pain. The chief symptoms are convulsions of certain limbs or areas of the body, which, save in very severe cases, are confined to one side, and are not attended by loss of consciousness.
The irritation spreads to adjacent areas, as wavelets spread from a stone thrown into a pond, with the result that convulsions of other limbs follow in sequence, all confined to one side.
As every part of the brain is connected to every other part by "association fibres", in very violent attacks of Jacksonian epilepsy the irritation spreads to the other side of the brain also, consciousness is lost, the convulsions become general and bilateral, and the patient presents exactly the same picture as if the attack were due to grand mal.
All degrees of violence are seen. The convulsions may consist only of a rapid trembling, or the limb or limbs may be flung about like a flail.
Jackson said: "The convulsion is a brutal development of a man's own movements, a sudden and excessive contention of many of the patient's familiar motions, like winking, speaking, singing, moving, etc." These acts are learned after many attempts, and leave a memory in certain groups of brain cells; irritate those cells, and the memorized acts are performed with convulsive violence.
The convulsions are followed by temporary paralysis of the involved muscles, but power finally returns. As we should expect, this paralysis lasts longest in the muscles first involved, and is slightest in the muscles whose brain-centres were irritated by the nearly exhausted waves. If the disease be untreated, the muscles in time may become totally paralysed, wasted, and useless.
Friends should very carefully note exactly where and how the attack begins, the exact part first involved, and the precise order in which the spasms appear, as this is the only way the doctor can localize the brain injury. The importance of this cannot be overrated.
The consulting surgeon will say if operation is, or is not, advisable, but operation is the sole remedy for Jacksonian epilepsy, for the causes that underly its symptoms cannot be reached by medicines.
Patients must consult a good surgeon; other courses are useless.
Psychic or Mental Epilepsy is a trance-state often occurring after attacks of grand or petit mal, in which the patient performs unusual acts. The epileptic feature is the patient's inability to recall these actions. The complaint is fortunately rare.
The face is usually pale, the eyes staring, and there may be a "dream state". Without warning, the victim performs certain actions.
These may be automatic, and not seriously embarrassing—he may tug his beard, scratch his head, hide things, enter into engagements, find the presence of others annoying and hide himself, or take a long journey. Such a journey is often reported in the papers as a "mysterious disappearance". Yet, had he committed a crime during this time, he would probably have been held "fully responsible" and sentenced.
The actions may be more embarrassing: breaking something, causing pain, exhibiting the sexual organs; the patient may be transported by violent rage, and abuse relatives, friends or even perfect strangers; he may spit carelessly, or undress himself—possibly with a vague idea that he is unwell, and would be better in bed.
Finally the acts may be criminal: sexual or other assault, murder, arson, theft, or suicide.
In this state, the patient is dazed, and though he appreciates to some extent his surroundings, and may be able to answer questions more or less rationally, he is really in a profound reverie. The attack soon ends with exhaustion; the victim falls asleep, and a few moments later wakes, ignorant of having done or said anything peculiar.
We usually think of our mind as the aggregate of the various emotions of which we are actually conscious, when, in reality, consciousness forms but a small portion of our mentality, the subconscious—which is composed of all our past experiences filed away below consciousness—directing every thought and act. Inconceivably delicate and intricate mind-machinery directs us, and our idlest fancy arises, not by chance as most people surmise, but through endless associations of subconscious mental processes, which can often be laid bare by skilful psycho-analysis.
Our subconscious mind does not let the past jar with the present, for life would be made bitter by the eternal vivid recollection of incidents best forgotten. Every set of ideas, as it is done with, is locked up separately in the dungeons of subconsciousness, and these imprisoned ideas form the basis of memory. Nothing is ever forgotten, though we may never again "remember" it this side the grave.
In a few cases we can unlock the cell-door and release the prisoner—we "remember"; in some, we mislay the key for awhile; in many, the wards of the lock have rusted, and we cannot open the door although we have the key—we "forget"; finally, our prisoner may pick the lock, and make us attend to him whether we wish to or not—something "strikes us".
Normally, only one set of ideas (a complex) can hold the stage of consciousness at any one time. When two sets get on the boards together, double-consciousness occurs, but even then they cannot try to shout each other down; one set plays "leading lady", the other set the "chorus belle" and so life is rendered bearable.
This "dissociation of consciousness" occurs in all of us. A skilled pianist plays a piece "automatically" while talking to a friend; we often read a book and think of other things at the same time: our full attention is devoted to neither action; neither is done perfectly, yet both are done sufficiently well to escape comment.
Day-dreaming is dissociation carried further. "Leading lady" and "chorus belle" change places for a while—imaginary success keeps us from worrying about real failure. Dissociation, day-dreaming, and mental epilepsy are but few of the many milestones on a road, the end of which is insanity, or complete and permanent dissociation, instead of the partial and fleeting dissociation from which we all suffer. The lunatic never "comes to", but in a world of dreams dissociates himself forever from realities he is not mentally strong enough to face.
The writing of "spirits" through a "medium" is an example of dissociation, and though shown at its best in neuropaths, is common enough in normal men, as can be proved by anyone with a planchette and some patience.
If the experimenter puts his hands on the toy, and a friend talks to him, while another whispers questions, he may write more or less coherent answers, though all the time he goes on talking, and does not know what his hand is writing. His mind is split into two smaller minds, each ignorant of the other, each busily liberating memory-prisoners from its own block of cells in the gaol of the subconscious. The writing often refers to long-forgotten incidents, the experiment sometimes being of real use in cases of lost memory.
Dreams are dissociations in sleep, while the scenes conjured up by crystal-gazing are only waking dreams, in which the dissociation is caused by gazing at a bright surface and so tiring the brain centres, whereupon impressions of past life emerge from the subconscious, to surprise, not only the onlookers to whom they are related, but also the gazer herself, who has long "forgotten them".
It is childish to attach supernatural significance to either dreams or crystal-gazing, both of which mirror, not the future, but only the past, the subject's own past.
It is noteworthy that women dream more frequently and vividly than men. When a dreamer has few worries, he usually dreams but forgets his dream on waking; when greatly worried, he often carries his problems to bed with him, and recent "representative dreams" are merely unprofitable overtime work done by the brain. Occasionally, dreams have a purely physical basis as when palpitation becomes transformed in a dream into a scene wherein a horse is struggling violently, or where an uncovered foot originates a dream of polar-exploration; in this latter type the dream is protective, in that it is an effort to side-track some irritation without breaking sleep.
Since Freud has traced a sex-basis in all our dreams, many worthy people have been much worried about the things they see or do in dreams. Let them remember that virtue is not an inability to conceive of misconduct, so much as the determination to refrain from it, and it may well be that the centres which so determinedly inhibit sexual or unsocial thoughts in the day, are tired by the very vigour of their resistance, and so in sleep allow the thoughts they have so stoutly opposed when waking to slip by. The man who is long-suffering and slow to wrath when awake, may surely be excused if he murders a few of his tormentors during sleep.
Epileptiform Seizures are convulsions due to causes other than epilepsy, and only a doctor can tell if an attack be epileptic or not and prescribe appropriate treatment. To give "patent" medicines for "fits", to a man who may be suffering from lead poisoning or heart disease, is criminal.
Convulsions in Children often occur before or after some other ailment. Such children need careful training, but less than 10 per cent of children who have convulsions become epileptic. Epilepsy should only be suspected if the first attack occurs in a previously healthy child of over two years of age. There are many possible causes for infantile convulsions, and but one treatment; call in a doctor at once, and, while waiting for him, put the child in a warm bath (not over 100 deg. F.) in a quiet, darkened room, and hold a sponge wrung out of hot water to the throat at intervals of five minutes. Never give "soothing syrups" or "teething powders".
The "soothing" portion of such preparations is some essential oil, like aniseed, caraway or dill, and there are often present strong drugs unsuitable for children. According to the analyses made by the British Medical Association, the following are the essential ingredients of some well-known preparations for children:
Mrs. Winslow's Soothing Potassium Bromide, Syrup. Aniseed, and Syrup (sugar and water).
Woodward's Gripe Sodium Bicarbonate, Water. Caraway, and Syrup.
Atkinson and Barker's Pot. and Magnesium Royal Infant Bicarbonate, several Preservative. Oils, and Syrup.
Mrs. Johnson's American Spirits of Salt, Common Soothing Syrup. Salt, and Honey.
Convulsions During Pregnancy. Send for a doctor instantly.
Feigned Epilepsy is an all-too-common "ailment". The false fit, as a rule, is very much overdone. The face is red from exertion instead of livid from heart and lung embarrassment, the spasms are too vigorous but not jerky enough, the skin is hot and dry instead of hot and clammy, the hands may be clenched, but the thumb will be outside instead of inside the palm, foam comes in volumes but is unmixed with blood, and the whole thing is kept up far too long. Almost before a crowd can gather an epileptic seizure is over, whereas the sham sufferer does not begin seriously to exhibit his questionable talents until a crowd has appeared.
Pressure on the eye, which will blink while the "sufferer" will swear; bending back the thumb and pressing in the end of the nail, when the hand will be withdrawn in feigned but not in true epilepsy; blowing snuff up the nose, which induces sneezing in the sham fit alone, or using a cold douche will all expose the miserable trick.
It is, unfortunately, far easier to suggest than to apply these tests, for anyone foolish enough to try experiments within reach of the wildly-waving arms will probably get such a buffet as will damp his ardour for amateur diagnosis for some time.
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"Do not muse at me, my most worthy friends; I have a strange infirmity, which is nothing To those that know me." "Macbeth," Act III.
Starr's table shows that combinations of all types of epilepsy are possible, and that mental epilepsy is rare:
Grand mal 1150 Grand and petit mal 589 Petit mal 179 Jacksonian 37 Mental 16 Grand mal and Jacksonian 10 Grand mal, petit mal and Jacksonian 8 Grand mal and mental 3 Grand mal, petit mal and mental 6 Petit mal and mental 2 Fits by day only 660 Fits day and night 880 Fits by night only 380
The majority of victims have attacks both by day and by night. Of 115,000 seizures tabulated by Clark, 55,000 occurred during the day (6 a.m. to 6 p.m.) and 60,000 by night.
The usual course of a case of epilepsy is somewhat as follows: the disease begins in childhood, the first convulsion, about the age of three, being followed some twelve months later by a second, and this again by a third within a few months. Then attacks occur more frequently until a regular periodicity—from one a day to one a year—is reached after about five years, and this frequently persists throughout life.
The effect of epilepsy on the general health is not serious, but it has a more serious effect on the mind, for epileptic children cannot go to school (though special schools are now doing something towards removing this serious disability), and grow up with an imperfect mental training. They become moody, fretful, ill-tempered, unmanageable, and at puberty fall victims to self-abuse, which helps to lead to neurasthenia. Then they may drift slowly into a state of mental weakness, and often require as much care as imbeciles. If the fits are severe from an early age, arrest of mental development and imbecility follow. If the disease be very mild in character, and especially if it be petit mal, the victim may be very precocious, get "pushed" at school, and later become eccentric or insane.
Adult victims necessarily lead a semi-invalid life, often cut off from wholesome work and from the pleasures of life, and become hypersensitive, timid, impulsive, forgetful, irritable, incapable of concentration, suspicious, show evidences of a weakened mind, have few interests, and are difficult to manage.
About 10 per cent—the very severe cases—go on to insanity; either temporary attacks of mania, calling for restraint, or permanent epileptic dementia with progressive loss of mind. Some victims are accidentally killed in, or die as a result of a fit; about 25 per cent—severe cases again—die in status epilepticus, but the majority after being sufferers throughout life are finally carried off by some other disease.
There are many exceptions to this general course. Some patients have attacks very infrequently, and are possessed of brilliant talent, though apt to be eccentric. Others may have a number of seizures in youth, and then "outgrow" the complaint.
A few victims are attacked only after excessive alcoholic or sexual indulgence, some women only during their menses, while other women are free from attacks during pregnancy, which state, however (contrary to popular belief), commonly aggravates the trouble. Victims may be free from attacks during the duration of, and for some time after, an infectious disease; while Spratling says that a consumptive epileptic may have no fits for months, or even years.
Some epileptics are normal in appearance, but many show signs of degeneration. This is common in the insane, but less frequent and pronounced in neurasthenics. An abnormal shape of the head or curvature of the skull, a high, arched palate, peculiarly-shaped ears, unusually large hands and feet, irregular teeth from narrow jaws, a small mouth, unequal length and size of the limbs, a projecting occiput, and poor physical development may be noted.
These are most pronounced in intractable cases, in whom mental peculiarities are most frequently seen—either dullness, stupidity and ungovernable temper, or very marked talent in one direction with as marked an incapacity in others. In all epileptics, the pupils of the eye are larger than normal, and, after contracting to bright light soon enlarge again.
The facial expression of most epileptics indicates abnormal mentality. When the seizures have been so frequent and severe as to cause mental decay, the actions are awkward, and the gait slouching and irregular. Progressive poor memory is one of the first signs of intellectual damage consequent upon severe epilepsy.
Though the disease may occur at any age, most cases occur before the age of twenty, there being good reason to look for other causes (often syphilis) in cases which occur after that age. Of 1,450 of Gowers' cases, 30 per cent commenced before the age of ten; 75 per cent before twenty. In Starr's 2,000 cases, 68 per cent commenced before the patient was twenty-one.
According to Turner, the first epoch is from birth to the age of six, during which 25 per cent of all cases commence, usually associated with mental backwardness, and some due to organic brain trouble. The second epoch is ten to twenty-two, the time of puberty and adolescence, during which time no less than 54 per cent of all cases commence. This is, par excellence, the age of onset of genuine epilepsy, the mean age of maximum onset being fourteen in men and sixteen in women. The remaining 21 per cent of cases occur after the age of twenty-two.
In 430 cases of epilepsy in children, Osler found that 230 were attacked before they reached the age of five, 100 between five and ten, and 100 between ten and fifteen.
Epilepsy, then, is a disease of early youth, coming on when the development and growth of the nervous and reproductive systems is taking place. During this period, causes, insignificant for stable people, may light up the disease in those of unstable, nervous constitution, a fact which explains the importance of training the child.
Both sexes are attacked. If we consider only cases of true idiopathic epilepsy female patients are probably in excess, but in epilepsy in adults, from all causes, males predominate. In females, the menopause may arrest the disease.
In days gone by, epilepsy more rarely commenced after the age of twenty, but in these days of nerve stress it commences more frequently than formerly in people of mature age. A victim who has a fit for the first time after the age of twenty, however, should consult a nerve specialist immediately.
In its early stages there are no changes of the brain due to, or the cause of, epilepsy, but in long-standing, severe cases, well-marked, morbid changes may be found. These are the effects, not the cause, of the disease, and they vary in intensity according to the manner of death and the length and severity of the malady. They probably cause the mental decay and slouching gait mentioned before.
Fits may suddenly cease for a long time, but they usually recur, and most patients have them more or less regularly through life.
The fact that recovery is rare should not be hidden from patients and friends. Perhaps 8 per cent of all classes recover—and "recovery" may only be a long interval—but 4 per cent of these are Jacksonian, syphilitic or accident cases. Only one victim in every thirty recovers from true epilepsy; and these are very mild cases, in which the fits are infrequent, there is no mental impairment, and bromides are well borne. The earlier the onset, the more severe and frequent the attacks, the deeper the coma, and the worse the mental decay, the poorer the outlook.
Cure is exceptional, but by vigorous treatment the severity of the malady may be much abated. Petit mal is no more hopeful than grand mal; less so in cases with severe giddiness; in all cases, the better the physical condition and digestive powers of the patient, the brighter the outlook.
To sum up, epilepsy is a chronic abnormality of the higher nervous system, characterized by periodic attacks of alteration of consciousness, often accompanied by spasms of varying violence, affecting primarily the brain and secondarily the body, based on an abnormal readiness for action of the motor cells, occurring in persons with congenital nerve weakness, and leading to mental decay of various types and degrees of severity.
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CAUSES OF EPILEPSY
"Find out the cause of this effect, Or rather say, the cause of this defect, For this effect defective comes by cause." "Hamlet," Act II.
THE MECHANISM OF THE FIT
The brain consists of cells of grey matter, grouped together to form centres for thought, action or sensation, and white matter, consisting of nerve strands, which act as lines of communication between different parts of brain and body. The wrinkled surface (cortex) of the brain, is covered with grey matter, which dips into the fissures. There are also islands of grey matter embedded in the white.
The front part of the brain is supposed, with some probability, to be the seat of intelligence, while a ribbon three inches wide stretched over the head from ear to ear would roughly cover the Rolandic area, in which are contained the motor cells through which impulse is translated to action. These motor cells are controlled by inhibitory cells, which act as brakes and release nerve energy in a gentle stream; otherwise our movements would be convulsive in their violence, and life would be impossible through inability usefully to direct our energy.
That is how inhibition acts physically; mentally it is the power to restrain impulses until reason has suggested the wisest course.
Irritation of the cortex, especially the motor area, causes convulsions, and experiment has shown that epilepsy may be due to a disease or instability of certain inhibitory cells of the cortex. The motor cells of epileptics are restrained, with some difficulty, by these cells in normal times. When irritation from any cause throws additional strain on the motor cells, the defective brakes fail, and the uncontrolled energy, instead of flowing in a gentle stream through the usual channels, bursts forth in a tidal wave through other areas of the brain, causes unconsciousness, and exhausts itself in those violent convulsions of the limbs which we term a fit.
The Primary Cause of epilepsy is an inherent instability of the nervous system.
Secondary Causes are factors which cause the first fit in a person with predisposing nervous instability; later, the brain gets the fit habit, and attacks recur independently of the secondary cause. In most cases no secondary causes can be discovered, and the disease is then termed idiopathic, for want of an explanation.
Injuries to the brain may cause epilepsy, and many cases date from birth, a difficult labour having caused a minute injury to the brain.
Some accident is often wrongly alleged as the cause of fits, for most victims come of a bad stock, and when the first fit occurs, their relatives recollect an injury or a fright in the past, which is said to be the cause.
Great fright may cause epilepsy, as in the case of a nervous girl whose brother entered her room, covered with a sheet, as a "ghost", a "joke" that was followed by a fit within an hour.
Sunstroke may cause fits, and a few cases follow infectious diseases.
Alcoholism is a strong secondary factor, fits often occurring during a drinking-bout and in topers, but in many cases, drunkenness, instead of being the cause, is only the result of a lack of self-control following epilepsy.
Pregnancy may be a secondary cause of the malady: it may lead to more frequent and severe seizures in women who are already victims; bring on a recurrence of the malady after it has apparently been cured; or, very rarely, induce a temporary or permanent cure.
Epilepsy may be due to abortives. These drugs wreck the constitution of the undesired children, who contract epilepsy from causes which would not so have affected them had they started fairly. In many families, the first child, who was wanted, is normal; some or all the others, who were not desired and on whom attempts were probably made to prevent birth, are neuropaths, as are many illegitimate children. It cannot too emphatically be stated that there is no drug known which will procure abortion without putting the woman's life in so grave a danger as to prevent medical men using it; legal abortion is always procured surgically. Dealing in abortifacients would be a capital offence under the laws of a rational community.
Self-abuse may perhaps play some part in epilepsy commencing or recurring after the age of ten.
The onset of menstruation often coincides with the onset of epilepsy, and in some cases irregularity of the menses seems to be a secondary or exciting cause.
Exciting Causes aggravate the trouble when present, causing more frequent and severe seizures. The chief are irritation of stomach and bowels (from decaying teeth, unchewed, unsuitable, or indigestible food, constipation, or diarrhoea), exhaustion, work immediately after a meal, passion or excitement, fright, worry, mental work, alcoholism, sexual excess, nasal growths, eye-strain; in short, anything that irritates brain or body.
Theories as to Cause. Epilepsy is usually classed as a functional disorder; that is, the brain cells are physically normal, but, for some unknown reason, they act abnormally at certain times. This term is a very loose one, and there is reason to believe that the basis of epilepsy is some obscure disease of the brain which has not been detected by present methods.
The new school of psychologists regard the malady as a mental complex—a system of ideas strongly influenced by the emotions—the convulsions being but minor symptoms.
Fits are most frequent between 9-10 p.m. the hours of deepest repose. One school says this is due to anaemia of the brain during sleep. Clark traces the cause to lessened inhibitory powers owing to the higher brain centres being at rest, while Haig claims to have explained the high incidence at this hour by the fact that uric acid is present in the system in the greatest amount at this time.
Some doctors have thought, on the contrary, that excess of blood in the head was the cause, but results of treatment so directed did not bear out the sanguine hopes built on the theory.
The fact that convulsions occur in diabetes and alcoholism, suggested that epilepsy was due to poisons circulating in the blood, and thus irritating the brain. Every act uses up cell material and leaves waste products, exactly as the production of steam uses up coal and leaves ashes. Various waste products have been found in more than normal quantities in the blood of epileptics, but it is uncertain whether accumulation of waste products causes the seizure.
A convincing theory must satisfactorily account for all the widely diverse phenomena seen in epilepsy, and the problem must remain largely a matter of speculation, until research work has given us a far deeper insight into the biochemistry of both the brain cells, and the germ-plasm than we have at present.
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PREVENTION OF ATTACKS
In health matters, prevention is nine points of the law.
Some patients are obsessed by a peculiar sensation (the "aura") just before a fit. This warning takes many forms, the two most common being a "sinking" or feeling of distress in the stomach, and giddiness. The character of the aura is very variable—terror, excitement, numbness, tingling, irritability, twitching, a feeling of something passing up from the toes to the head, delusions of sight, smell, taste, or hearing (ringing, or buzzing, etc.), palpitation, throbbing in the head, an impulse to run or spin around—any of these may warn a victim that a fit is at hand. Some patients "lose themselves" and make curious mistakes in talking.
The warning is nearly always the same each time with the same patient, and is more common in mild than in severe cases. Rarely, the attack does not go beyond this stage.
When the patient becomes conscious of the aura he should sit in a large chair, or lie down on the floor, well away from fire, and from anything that can be capsized. He must never try to go upstairs to bed. Some one should draw the blind, as light is irritating.
If the warning lasts some minutes, the patient should carry with him, a bottle of uncoated one-hundredth-grain tabloids of
Nitroglycerin, replacing the screw cap with a cork, so that they can quickly be extracted. When the warning occurs, one—or two—should be taken, and the head bent forward. The arteries are dilated, the blood-pressure thus lowered, and the attack may be averted.
The use of nitroglycerin is based on the theory that seizures are caused by anaemia due to vasomotor constriction. Success is only occasional, but this is so welcome as to justify the habitual use of the method.
If the aura be brief, buy a few "pearls" of Amyl Nitrite, crush one in your handkerchief, and sniff the vapour. This has the same affect as nitroglycerin, but the action occurs in 15 seconds and only persists 7 minutes. A headache occasionally follows the use of these drugs, and they should not be employed without professional advice.
When the warning is felt in the hand or foot, a strap should be worn round the ankle or wrist, and pulled tight when the aura commences. This sometimes aborts a fit, as biting a finger in which the aura commences may also do.
If a victim feels unwell after a meal, he must never eat the next meal at the usual time, simply because it is the usual time.
Should a patient feel unwell between, say, dinner and tea, instead of eating his tea he must empty his bowels by an enema, or croton oil (see chemist), and his stomach by drinking a pint of warm water in which has been stirred a tablespoonful of mustard powder and a teaspoonful of salt. After vomiting, drink warm water.
Never attempt to empty the stomach at the onset of a definite aura, for if the seizure occurs, the vomit will probably obstruct the trachea, and suffocate the victim.
After the stomach has been empty ten minutes, the patient should take a double dose of bromides (Chapter XIX) and go to bed. Next morning he will be well, whereas if he eats but a single piece of bread-and-butter he will probably have a fit within five minutes.
Unfortunately, in 60 per cent of cases, there is no warning at all, while in those cases which do exhibit an aura, the measures mentioned above more often fail than succeed.
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FIRST-AID TO VICTIMS
"First-aid is the assistance which can be given in case of emergency by those who, with certain easily acquired knowledge are in a position, not only to relieve the sufferer, but also to prevent further mischief being done pending the arrival of a doctor."—Dickey.
Never try to cut short a fit. Placing smelling-salts beneath the nose, together with all other remedies for people who have "fainted", are useless in epilepsy.
Lay the patient on his back, with head slightly raised; admit air freely; remove scarf or collar and tie, unfasten waistcoat, shirt, stays or other tight garments, and if it be known or observed that the victim wears artificial teeth, remove them.
If five people are at hand, let two persons grasp each a leg of the victim, holding it above the ankle and above the knee; two others should each hold a hand and the shoulder; the fifth supports the head. Do not kneel opposite the feet or you may receive a severe kick. Prevent the limbs from striking the floor, but allow them full play. If the victim rolls on his face gently turn him on his back.
Roll a large handkerchief up from the side (not diagonally) and holding one end firmly, tie a knot in the other end, and place it between the teeth to protect the tongue; or slide the handle of a spoon or a piece of smooth wood between the teeth, and thus hold the tongue down. Soft articles like cork and indiarubber should not be used, for if they are bitten through, the rear portion will fall down the throat and choke the victim.
After the fit, lower the head to one side to clear any vomitus which, if left, might be drawn into the windpipe, lift the patient on to a couch, cover him warmly, and let him sleep. An epileptic's bed should be placed on the ground floor; if his bed be upstairs, it is difficult to get him there after an attack, while he may at any time fall downstairs and be killed.
Any effort to rouse him will only make the post-epileptic stupor more severe, but whether he sleeps or not, he must carefully be watched, for patients in this state are apt to slip away, often half-clothed, and travel towards nowhere in particular at a wonderfully rapid rate.
If several fits follow one another, or if one is very long or severe, send for a doctor.
When a seizure occurs in public, a constable should be summoned, who, being a "St. John" man, will be of far more use than bystanders brimming over with sympathy—and ignorance. If some kindly householder near by will allow the victim to sleep for an hour or two—a boon usually denied more from fear of recurrence than lack of sympathy, it is better than taking him home. If not, let someone call a cab, and deliver the victim safely to his friends.
Every epileptic should carry always with him a card stating his full name and address, with a request that some one present at any seizure will escort him home.
If the victim wakes with a headache, give him a 10-grain Aspirin powder, or a 5-grain Phenalgin tablet; never patent "cures".
If possible, the patient should lie abed the day after a fit, undisturbed, taking only soda-and-milk and eggs beaten up in hot milk.
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"Some of your hurts you have cured, And the worst you still have survived; But what torments of mind you endured From evils which never arrived." —Lowell.
To-day, the need to eat forces even sensible men to live—and die—at a feverish rate. In bygone days the world was a peaceful place, in which our forefathers were denied the chance of combining exercise with amusement dodging murderous taxis; knew not the blessings of "Bile Beans", nor the biliousness they blessed either; they did not fall victims to "advert-diseases"; and they left the waters beneath to the fishes, and the skies above to the birds.
Withal they were sound trenchermen, who called their few ailments "humours" or "vapours" and knew what peace of mind meant. Sixty years ago there was one lunatic in every six hundred people; to-day there is one in every two hundred.
At the same time, the "neurasthenic temperament" is not altogether a modern product, for Plato described it with great precision, and declared such people to be "undesirable citizens" for his ideal republic.
Neurasthenia is due to exhaustion and poisoning of the nervous system, the chief symptoms of which is persistent neuro-muscular fatigue with general irritability. Its minor symptoms are almost as numerous as the various activities possible in mind and body.
The Predisposing Cause of neurasthenia is inherited nervous instability, but among nervous diseases, neurasthenia seems the least dependent on heredity, this factor playing a less important part than
Exciting Causes which are the sparks that fire explosive trains laid by the living, and often by the dead.
Worry in any form (especially when accompanied by excess of brain-work), Accident-shock, Sexual abuse, Abuse of drink, drugs or tobacco, Lack of exercise, Exhausting diseases, Menopause, and diseases of the womb, "Society life", Retirement,
are the commonest exciting causes of neurasthenia; hard brain-work, unless accompanied by worry, not being injurious.
The disease is more common in men than women (because of the more active part played by them in the struggle for existence), in cities than in the country, in mental than in manual workers, in the "idle rich", and in races which live feverishly, like the Americans. It is rare in old age.
Ambition, the race for "success", the struggle to carry out projects beyond the reasonable capacity of one man, and the ceaseless work and worry with little sleep and no real rest which mark life to-day are responsible for this disease.
Competition has increased in all conditions of life; free course is given to ambition, individuals impose on their brains a work beyond their strength; and then comes care and perhaps reverse of fortune; and the nervous system, under the wear and tear of incessant excitation, at last becomes exhausted,
The basic symptom is an inability to stand a normal amount of mental or physical strain, and shows itself in seven marked ways:
1. Muscular Fatigue, which is often most marked in the morning. The patient rises reluctantly, feeling as if he had not slept, is listless and "lazy", and can neither work nor play much without getting unduly tired. This weariness may pass off as the day wears on.
2. Backache is often constant and annoying. It may be a pain, or a general discomfort, and may be felt anywhere in the back, the nape of the neck and down the spine being common places. The legs often "give way", and, in severe cases, patients believe they cannot stand, and become bed-ridden. Under sudden excitement they may walk again, becoming "miracles of healing". These spinal symptoms are common in neurasthenia following accident.
3. Headache is more often an abnormal sensation than an intense pain. Pulsations, feelings of distress, of lightness, fullness, heaviness and pressure are common, or a band may seem to be drawn tightly round the head across the forehead.
The sensations are usually located in the back of the head, and may be accompanied by dizziness, noises in the ears, or dimness of sight. There may be a feeling of unsteadiness when walking, or a sense of being in motion when at rest. The headache varies in intensity; it is worst in the morning, is increased by thinking, diminished after eating, often improves at night, and never keeps the patient awake.
4. Stomach and Bowel Disorders. The victim is indifferent to food, though dainties often tempt him, when he cannot face a square meal. He has a feeling of general well-being after a meal, but within an hour signs of imperfect digestion arise; he feels oppressed, and has flatulence. Later, there are flushes of heat, palpitation, drowsiness, and a craving for food. Constipation is usually obstinate, while diarrhoea may cause great weakness.
5. Sleeplessness. Some patients go to sleep readily, but after some instants wake suddenly, in a state of excitement that persists despite their efforts to calm themselves, and only at an early hour in the morning do they sleep again. Other patients go to bed with the conviction they will not sleep, and are kept awake by incessant cogitation, their minds being harassed by a rapid flow of images, ideas and memories. In some cases the person is calm, his mind is at rest, yet he cannot sleep.
6. Circulatory Disturbances. More blood flows to an organ at work than to one at rest. In health we do not notice these changes, but in neurasthenia these internal tides are exaggerated as rushes of blood to the head, flushings of various parts, and coldness of hands and feet.
Heart palpitation is alarming but not dangerous, and the distended blood-vessels of the ears may set up vibrations in the drum, so that at night when the head is on the pillow, every beat of the heart is heard as a thump, which banishes sleep, and works the victim into a state of high tension. A pain in the chest, arms and elbows is often felt, limbs may swell (shown by the tightness of rings, collars, etc.) while the hands and feet are usually moist and clammy. The patient may have to empty the bladder every half-hour. Disorders of menstruation are common.
7. Mental Fatigue. Hundreds of pages would be needed to describe all the symptoms due to mental fatigue, the morbid belief that the victim has a fatal disease being very common, though his "disease" rarely makes him lie up; in the day he works, at night describes his symptoms to the home circle.
The inability of most men to apply themselves steadfastly to any one set of ideas is seen in the immense popularity of music halls, cinemas, and short-story magazines, which offer a change of interest every few minutes.
In normal people there is a slight consciousness of mental processes, but the mind rarely watches itself work; the neurasthenic is unable to concentrate, and gets charged with inconstancy and shiftlessness.
His ideas are restive, continuous thought is impossible, and when talking he has to be "brought back to the point" many times. Memory and attention flag, and he listens to a long conversation, or reads pages of a book without grasping its import, and consequently he readily "forgets" what in reality he never laboured to learn. Trembling of limbs is common.
He lacks initiative, and whatever course he is forced to take—after much indecision—he is convinced, a moment later, it would have been wiser to have taken the opposite one.
All his acts are done inattentively. He goes to his room for something, but has forgotten what when he gets there; later, he wonders if he locked the drawer, and goes back to see. At night he gets up to make sure he bolted the door, put out the gas, and damped the fire.
Regret for the past, dissatisfaction with the present, and anxiety for the future are plagues common to most people, but they become acute in a neurasthenic, who reproaches himself with past shortcomings of no moment, infuriates himself over to-day's trivialities, and frets himself over evils yet unborn.
Such a patient is often greatly upset by a trifle, yet little affected by a real shock, which by its very severity arouses his reactive faculties which lay dormant and left him at the mercy of the minor event. He will fret over a farthing increase in the price of a loaf, but if his bank fails he sets manfully to.
Duty that should be done to-day he leaves to be shirked to-morrow; he is easily discouraged, timid, and vacillating. Extremely self-conscious, he thinks himself the observed of all observers. If others are indifferent toward him, he is depressed; if interested, they have some deep motive; if grave, he has annoyed them; if gay, they are laughing at him; the truth, that they are minding their own business, never occurs to him, and if it did, the thought that other people were not interested in him, would only vex him.
He is extremely irritable (slight noises make him start violently), childishly unreasonable, wants to be left alone, rejects efforts to rouse him, but is disappointed if such efforts be not made, broods, and fears insanity. The true melancholic is convinced he himself is to blame for his misery; it is a just punishment for some unpardonable sin, and there is no hope for him in this world or the next. The neurasthenic, on the contrary, ascribes his distress to every conceivable cause save his own personal hygienic errors.
A neurasthenic, if epileptic, fears a fit will occur at an untoward moment. He dreads confined or, maybe, open spaces, or being in a crowd. When he reaches an open space (after walking miles through tortuous byways in an endeavour to avoid it) he becomes paralysed by an undefinable fear, and stops, or gets near to the wall.
He fears trains, theatres, churches, social gatherings, or the office.
Other victims fear knives, canals, firearms, gas, high places, and railway tracks, when the basic fear is of suicide. Many patients have sudden impulses—on which the attention is focussed with abnormal intensity—to perform useless, eccentric, or even criminal actions; to count objects, to touch lamp-posts, to continually reiterate certain words, and so on.
The victim is fully aware that there are no grounds for his panic or impulse, but though his reason ridicules, it cannot disperse, his fear, and the wretched man finds relief in sleep alone, which adds to his woes by being a coy lover.
An almost invariable stage is that wherein the patient studies a patent-medicine advertisement and finds that a disease, or collection of diseases, is the root of his troubles. This alarms but interests him; he studies other advertisements, sends for pamphlets, and so becomes familiar with a few medical terms. He then takes a "treatment", and talks of his "complaint" and how he "diagnosed" it. He has become hypochondriac.
He borrows a book on anatomy from the public library to discover in what part of the body his ailment is located.
He draws up (or copies) a special diet-sheet, and talks of "proteids", notices a slight cloudiness in his urine, and underlines "The Uric-Acid Diathesis" in one of his pamphlets. Then his heart bumps, he diagnoses anew, and so goes on, usually ending by taking phosphorus for his "brain fag". Then he finds he has a disease unknown to the faculty, which discovery interests him as intensely as it irritates his unfortunate friends.
This prince of pessimists has a conviction that, compared with him, Job was a happy man, and that he will go insane. He does not know that it is only when there are flaws in the brain from inheritance or organic disease that mental worry leads to lunacy; a sound brain never becomes unhinged from intellectual stress alone.
Books and friends are daily questioned about his "diseases", and in spite of reassuring replies, he continues to doubt, re-question and cross-examine endlessly, feeding his hopes on the same assurances, consoling himself with the same sympathies, and worrying himself with the same fears.
Other folk may be "nervy", he is seriously ill; he knows it because he feels it. He expects the greatest consideration himself, denies it to others, and then complains he is "misunderstood".
"Every symptom becomes magnified; the trifling ache or pain, the trivial flatulence, the disinclination or mere hesitation of the bowels to adhere to a strict schedule, all minor events such as occur to the majority of healthy men from time to time unheeded, come to be of vast importance to the psychasthenic individual."
He keeps a record of hourly changes in his condition, and pesters his family doctor to death. He goes from physician to physician, from hospital to hospital. Having been induced by his friends to see a specialist, he bores that good man—who knows him all too well—with a minute description of his symptoms, presenting for inspection carefully preserved prescriptions, urinary examination records, differential blood counts, and the like. Coming away with precious advice, he feels he omitted to describe all his symptoms, begins to doubt if the specialist really understands his case, and so the pitiful farce goes on—for years.
The extraordinary fact is that while he is suffering (sic) from cancer, or heart disease, or Bright's disease, and spasmodically from minor affections like tuberculosis, arterio-sclerosis, and liver-fluke, he is probably running a successful business. While making money he forgets his ills; the moment his attention is diverted from the "root of evil" he proceeds to further "diagnosis".
In the end, he makes a pleasant hobby of his imaginary maladies, trying each patent nostrum, and giving herbalists, electric-belt men, Christian Scientists, and dozens of other weird "specialists" a chance to cure him.
Sexual Neurasthenia occurs chiefly in young men given to self-abuse or sexual excesses. Erections and emissions are frequent, first at night with amorous dreams, then in the day as a result of sexual thoughts; weakness and pain in the back follow, and the sexual act may become impossible. The patient usually studies a quack advertisement, and passes into the hands of men who make a living by bleeding such wretches dry. Cold baths and the treatment outlined in Chapter IX will cure him.
Course and Outlook. Neurasthenia is very curable. If the cause be removed, and vigorous treatment instituted, the victim may be well in a couple of months, but in most cases there are obstacles to radical treatment, and the disease drags on indefinitely.
Egoism, moral cowardice, and sexual excess play a part in much neurasthenia, but relatives must not forget, in their indignation at these laxities, that the patient really is ill; it is unkind, unjust and useless to tell an ailing man the unpalatable truth that it is his own fault.
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"Diseased nature oftentimes breaks forth In strange eruptions; ..." "King Henry IV."
Hysteria, recorded in legend and law, in manuscript and marble, in folk-lore and chronicle, right from history's dawn, is still a puzzle of personality, and only equalled by syphilis in the protean nature of its manifestations.
The sacred books of the East said delayed menstruation due to a devil was its cause; the thrashing-out of the devil its cure. Chinese legends describe it, and its symptoms were ascribed by the Inquisition to witchcraft and sorcery.
Old Egyptian papyri tell how to dislodge the devil from the stomach, and there were hysteria specialists in 450 B.C. All old theories fix on the womb as the seat of the disease. The name hysteria is the Greek word for womb, and 97 per cent of patients are women.
A few of the very numerous modern theories may be noticed.
The unconscious (or the subconscious) and the conscious are only parts of one whole. Our "conscious" activities are those which have developed late in the history of the race, and which develop comparatively late in the history of the individual. The "conscious" is the product of the racial education of the "unconscious"; the first is the man, the modern, the civilized; the last is the child, the primitive, the savage. Between the two there is no gulf fixed, and the Oxford metaphysician need not go to Timbuctoo to seek a superstitious savage; he may find one within himself.
In hysteria, Janet says, the field of consciousness is narrowed, and the patient lives through subconscious experiences, which she forgets when she again "comes to". She journeys back into the past, back a few years individually, back centuries or aeons racially, and becomes a savage child again.
Normally, when anything goes wrong, or we suffer from excessive emotion, we give vent to our feelings by tears, abuse, anger, or impulsive action; in some way we "hit back", and relieve ourselves of the feeling of oppression. Then we forget, which heals the sore, and closes the experience.
If, at the moment, we bottle up our emotions, they obtrude later at inconvenient times until we "get them off our mind" by confiding in some one, when we get peace of mind. Open confession is good for the soul, and it is better to "cry your eyes out" than to "eat your heart out".
There are some experiences, however, to which we cannot react by anger or confidence, and so we imprison our emotions, and try to obtain peace of mind by forgetting the irritation.
Freud thinks perverted sex ideas are thus repressed, and cause hysteria by coming into conflict with the normal sex life. If these old sores can be laid bare by psycho-analysis, and the mental abscess drained by confession and contrition, cure follows.
The biologists consider hysteria as an adult childishness, a primitive mode of dodging difficulties. Victims cannot live up to the complicated emotional standard of modern life, and so act on a standard which to us seems natural only in children and uncivilized races.
Savill gives the following differences between neurasthenia and hysteria:
Sex Both sexes equally. 97 per cent females.
Age Any age. First attack before page of 25.
Mental Intellectual weakness; Deficient will power, peculiarities bad memory Want of control and attention. over emotions.
Causes Overwork; dyspepsia; Emotional upset or accident; shock. nervous shock.
Course Fairly even. Paroxysms. Vary from hour to hour.
Mental Mental exhaustion; Emotional; wayward; Symptoms unable to study; no self-analysis, restless; sad; living by irritable; not rule or reading equal to medical books; amusement. May Fond of gaiety; be suicidal. sad and joyous by turns. Never suicidal.
General Occasional giddiness; Flushing; convulsions Symptoms fainting rare; and fainting convulsions; common; no headache; backache; symptoms between sleeplessness; no attacks; local loss of feeling. anaesthesia or hyperaesthesia.
Termination Lasts weeks or Lasts lifetime in months. spasms. CURABLE. TEMPORARILY CURABLE.
Hysteria is a disease of youth, usually ceasing at the climacteric. Social, financial and domestic worries are exciting causes, a happy marriage often curing, and an unhappy one greatly aggravating the complaint. It is most common among the races we usually deem "excitable", the Slavs, Latin races and Jews, and is often associated with anaemia and pelvic disorders.
Symptoms. Changeability of mood is striking. "All is caprice. They love without measure those they will soon hate without reason."
Sensationalism is manna to them. They must occupy the limelight. Pains are magnified or manufactured to attract sympathy; they pose as martyrs—refusing food at table, and eating sweets in their room, or stealing down to the larder at night—to the same end. If mild measures fail, then self-mutilation, half-hearted attempts at suicide, and baseless accusations against others are brought into play to focus attention on them.
Minor attacks usually commence with palpitation and a "rising" in the stomach or a lump in the throat, the globus hystericus, which the patient tries to dislodge by repeated swallowing. This is followed by a feeling of suffocation, the patient drags at her neck-band, throws herself into a chair, pants for breath, calls for help, and is generally in a state of great agitation. She may tear her hair, wring her hands, laugh or weep immoderately, and finally swoon. The recovery is gradual, is accompanied by eructations of gas, and a large quantity of pale, limpid, urine may be passed later.
Major attacks have attracted attention through all ages, ancient statues showing the same poses as modern photographs. The beginning stage—which may last a few moments or a few days—is one of mental unrest, the victim being irritable and depressed. In some cases a warning aura then occurs; clutchings at the throat, or the globus hystericus, palpitation, dizziness, sounds in the ears, spots dancing before the eyes, or feelings of intense "tightness" as if the skin is about to tear or the stomach to burst.
The victim throws herself on a chair or couch, from which she slides to the floor, apparently senseless, the head being thrown back, the arms extended, the legs held straight and stiff. The face is that of a dreamer, and the crucifix position is not uncommon. This stage is a gigantic sexual stretch.
Next comes the convulsive stage, but the convulsions are not the true jerky movements of epilepsy, but are bilateral tossing, kicking, and rolling movements, interspersed with various irregular passionate attitudes. There is great alteration but not loss of consciousness. The patient struggles with those about her, bites them, but never her own tongue, shrieks and fights, but never passes urine, throws things about, and arches the back until the body rests on head and feet (opisthotonos). The stretching and convulsive stages alternate, and the attack lasts a long time, being stopped by pain or by the departure of onlookers. During this stage the face may reflect the various emotions passing through the mind—with a fidelity that would rouse the envy of an Irving.
The patient gradually calms down, and a fit of tears or a scream ends the attack, after which the worn-out victim is depressed but not confused, though memory for the events of the attack may only be partial. The patient sometimes passes into the "dream state", described in Chapter II, for some hours or occasionally for far longer; these are the women described with much gusto in the local Press as being in a trance—"the living dead".
The victim of these attacks is suffering from a disease, for she shows many temporary mental symptoms which could not possibly be feigned, while there is often a genuine partial forgetfulness of the incidents of an attack. She says she cannot help it; candid friends say she will not. The truth is that she cannot will not to help it; for though intelligence and memory are often good and sometimes abnormal, the judgment and will are always weak—indecision, obstinacy, and doubt being common.
Treatment. A thorough examination by a doctor is absolutely essential, to prove that the patient is merely hysterical, and not the victim of unrecognized organic disease. In a few cases, skilled attention to some minor ailment will result in an apparently miraculous cure.
Many who habitually "go into hysterics", are merely grown-up "spoiled children", and in all cases, the basic factor is a lack of control and self-discipline.
Unfortunately, these tainted individuals who are so exquisitely sensitive that any reproof brings floods of tears, turn with mercurial rapidity from passionate fury to passionate self-reproach, and assuage by impassioned protestations of affection the distress they have carelessly inflicted, and, as a consequence of their momentary but undoubtedly sincere contrition, escape blame and punishment.
Harmful sympathy is thus substituted for helpful discipline, and the more stable members of the family are often made slaves to the whims and caprices of the hysterical member.
The usual home treatment of the victim passes through various stages, and lacks persistence. Violent methods are succeeded by studied indifference; and that again by reproaches and recriminations.
Greene's remarks are very pertinent: "The condition must be regarded as an acquired psycho-neurosis to be ameliorated, and perhaps removed, by suggestion and a complete control, which, though kind, is firm, persistent, insistent, and lacking in every element that enters into the upbuilding of the hysterical temperament."
For anaemic patients, the following is a useful prescription:
R. Quininae valerianatis gr. xx Ferri valerianatis gr. xx Ammon. valerianatis gr. xx Misce et fiant pilulae no. xx Sig.: One or two three times a day, after meals.
As far as the minor symptoms are concerned, the disease is usually chronic, for as soon as one symptom has been overcome another takes its place, and there is little hope of cure save when the case is taken vigorously in hand in childhood, treatment being best given in a home or hospital. Home treatment consists in an attempt to inculcate the lost or never-acquired habit of self-control, and in the hygienic measures laid down for neuropaths in general in the rest of this book.
In a major attack, show no sympathy. Let every one leave the room, save one attendant, whom the victim knows to be of firm character, and calm but determined disposition. This attendant should get a jug of water, and threaten to douche the victim unless she makes vigorous efforts to control herself. If she cannot, or will not, douche her, then hold a towel over her nose and mouth, and she will perforce cease her gymnastics to breathe, though the attendant must be prepared for an outburst of abuse when she has recovered her breath. Between attacks, all who are brought into contact with the victim, must adopt a tolerant but unsympathetic attitude, while efforts are made to inculcate habits of control.
* * * * *
ADVICE TO NEUROPATHS
"Great temperance, open air, Easy labour, little care."
The above quotation epitomizes the cure for neurasthenia, for as Huxley said:
"Our life, fortune, and happiness depend on our knowing something of the rules of a game far more complicated than chess, which has been played since Creation; every man, woman and child of us being one of the players in a game of our own. The board is the world, the pieces the phenomena of the universe, while the rules of the game are the laws of nature. Though our opponent is hidden, we know his play is fair, just and patient, but we also know to our sorrow that he never overlooks a mistake or makes the slightest allowance for ignorance. To the man who plays well, the highest stakes are paid with that overflowing generosity with which the strong show their delight in strength. The one who plays badly is checkmated; without haste, but without remorse. Ignorance is visited as sharply a as wilful disobedience; incapacity meets with the same punishment as crime."
In many cases some real trouble is the best medicine for a neurasthenic, for though disaster may crush him, it is more likely to act as a spur, by diverting his thoughts from his woes, and making him fight instead of fret.
Since such blessings in disguise cannot be booked to order, first see a doctor. Though little be physically wrong, the sense of comfort and relief from fear, which a clear idea of what is wrong brings, goes a long way towards cure by giving the patient hope and confidence.
Having seen the doctor, assist him by carrying out the following advice as far as real limitations—not lazy inclinations—permit. Do not say after reading this chapter, "I know all that"; you have to do "all that", for medicine alone, whether patent or prescribed, is useless.
* * * * *
Go for a long sea voyage, if possible.
If not, get a long holiday in a quiet farmhouse, or, better still, get to the country for good, be it in never so humble a capacity, for a healthy cowman is happier than a neurasthenic clerk. The rural worker has no theatres, but he can walk miles without meeting another; he has woods to roam in, hills to climb, trees to muse under: he has ample light and air, and his is a far happier lot than that of a vainglorious but miserable, sedentary machine in a great city.
The rural districts round Braemar, the Channel Islands, Cromer, Deal, Droitwich, Scarborough, and Weston-super-Mare are, in general, suitable holiday resorts for neuropaths.
Avoid alcohol, tea, coffee, much meat, all excitement, anger and worry. Take tickets only for comedy at the theatre, and leave lectures, social gatherings and dances alone.
Nerve-starvation needs generous feeding with easily digested food. Drink milk in gradually increasing amounts up to half a gallon per day. If more food is needed, add eggs, custard, fruit, spinach, chicken, or fish, but do not forgo any milk. Avoid starchy foods and sweets.
Eat only what you can digest, and digest all you eat. Chew every mouthful a hundred times. This is one of the few sensible food fads.
Drink water copiously between meals, and take no liquid (save the milk) with them. Keep the bowels open.
If you must "occupy your mind", take up some very simple, quiet hobby. Gardening, fretwork, photography and gymnastics are not necessarily quiet hobbies. Chess, billiards, and contortions with gymnastic apparatus are not to be recommended.
If you must read, peruse only humorous novels. Never study, and leave exciting fiction and medical work alone. Symptoms are the most misleading things in a most misleading world.
After your evening meal, take a quiet walk, go to bed and sleep. You should occasionally spend from Saturday midday to Monday morning in bed, with blinds drawn, living on milk, seeing nobody and doing nothing. The deepest degradation of the Sabbath is to fill it with odd jobs which have accumulated through the week.
Do not get out of bed too early in the morning, but rise in time to eat your breakfast slowly, attend to the toilet, and catch the car without haste. If your occupation be an indoor one, rise an hour earlier, and walk or cycle quietly to work.
Take a warm bath followed by a cold douche on rising. If no warm after-glow follows, use tepid water. Keep your body warm; your head cool.
Be continent. Nerve-tone and sexual delights are not compatible. Matrimony, while a convenient cloak, is no excuse for lust.
Try suggestion for fears and impulses (see Chapter XVIII), for it is useless to try to "reason them out", though it is useful for a brief period each day to try deliberately to turn the mind away from the obsession, by singing or whistling, gradually prolonging the attempts.
Rest, to prevent the manufacture of more waste products, the elimination of those present, and the generation of nerve-strength from nourishing food are the things that cure. Chapters XIX and XX deal with the drug treatment.
Do not Worry. Whatever your trouble is, it is useless to
"Look before and after, and sigh for what is not"
for the future cannot be rushed nor the past remedied. All patients reply promptly that they "can't help" worrying, when in truth they do not try.
Work never hurt anyone, but harassing preoccupation with problems which no amount of thought will solve drives many thousands to early graves. Anger exhausts itself in a few minutes, fatigue in a few hours, and real overwork with a week's rest, but worry grows ever worse. Ponder Meredith's lines:
"I will endure; I will not strive to peep Behind the barrier of the days to come."
"Look on the bright side!" said an optimist to a melancholy friend.
"But there is no bright side."
"Then polish up the dull one!" was the sound advice tendered.
Learn to forget!
One cannot open a periodical without being exhorted to train one's memory for a variety of reasons. The neuropath needs a system of forgetfulness. Lethe is often a greater friend than Mnemosyne.
To brood on disappointments, failures and griefs only wastes energy, sours temper, and upsets the general health. Resolve beforehand that when unhappy ideas arise you will not dwell on them, but turn your thoughts to pleasant trifles; take up a humorous book, or take a turn in the fresh air, and you will soon acquire the habit of laughing instead of whining at Fate.
To sum up: Go slow! Your neurons have been exhausted in your foolish attempt to "live this day as if thy last" in a wrong sense; feverish activity and unnecessary work must be abandoned to enable the nerves to recuperate.
When the doctor says "rest", he means "rest", not change your bustle from work to what you are pleased to regard as play.
So much is absolute rest recognized as the foundation of treatment, that severe cases undergo the "Weir-Mitchell Treatment". The patient is utterly secluded; letters, reading, talking, smoking and visits from friends are forbidden. He is put to bed, not allowed even to sit up, sees no one save nurse and doctor, is massaged, treated electrically, grossly overfed, fattened up, and freed from every care.
In leaving his habitual circle, the patient escapes the too-attentive care of his relatives, and the incessant questions about his complaint with which they overwhelm him. The results of this regime with semi-insane wrecks are marvellous. It is a very drastic but very successful "rest-cure", and while it cannot be undergone at home, neurasthenics will benefit by following its principles as far as they can in their own homes.
High-frequency or static electricity sometimes works wonders in the hands of a specialist, but the electric batteries, medical coils, finger-rings and body-belts so persistently advertised are useless.
When the patient has in some measure recuperated, he may try the following exercises in mental concentration. Vittoz claims good results from them, but they must be done quite seriously.
1. Walk a few steps with the definite idea that you are putting forward right and left feet alternately. Go on by easy stages until you concentrate on the movement of the whole body.
2. Take any object in your hand, and note its exact form, weight, colour, etc.
3. Look in a shop-window while you count ten, and as you walk on, try to recall all the objects therein exhibited.
4. Accustom yourself to defining the sounds you hear, and concentrating on a special one, as that of a passing tram, or a ticking watch.
5. Make a rapid examination several times daily of your feelings and thoughts, and try to express them definitely.
6. Concentrate on the mental reproduction of a regular curve: a figure 8 placed on its side.
7. Listen to a metronome, and, a friend having stopped it, mentally repeat the ticking to time.
8. Whenever you handle anything, try to retain the impression of that object and its properties for several minutes, to the exclusion of other ideas.
9. Concentrate on ideas of calm, and of energy controlled.
10. Place three objects on a sheet of white paper. Remove them one by one, at the same time effacing the impression of each one as it is removed, until the mind, like the paper, is blank.
11. Efface two of the objects, and retain the impression of one only.
12. Replace the impressions in your mind, but not the objects on the paper, one by one.
The object of these exercises is to get your wandering mind daily a little more under control; do not exhaust yourself.
After some months of treatment, ask yourself—
Am I able to walk ten miles with ease? when introduced to a stranger of either sex or any age, to converse agreeably, profitably and without embarrassment? to entertain visitors so that all enjoy themselves? to read essays or poetry with as much pleasure as a novel? to listen to a lecture, and be able afterwards to rehearse the main points? to be good company for myself on a rainy day? to submit to insult, injustice or petulance with dignity and patience, and to answer them wisely and calmly? When you are able to answer, "Yes!" to these queries, your nerves are sound.
* * * * *
FIRST STEPS TOWARDS HEALTH
"All sick people want to get well, but rarely in the best way. A 'jolly good fellow' said: 'Strike at the root of the disease, Doctor!' And smash went the whisky bottle under the faithful physician's cane."
In neuropaths, all irritation to the nervous system is dangerous, and must be eliminated, and to this end, eyes, ears, nose and teeth, all in close touch with nerves and brain, must be put and kept in perfect order.
The Eye. Only 4 per cent, of people have perfect sight. Errors in refraction—common in neuropaths—mean that the unstable brain-cells are constantly irritated. Dodd corrected eye-errors in 52 epileptics, 36 of whom showed improvement.
You take your watch to a watchmaker, not a chemist; take your eyes to an oculist, and if you cannot afford to see one privately, get an eye-hospital note. (To allow a chemist or "optician" to try lenses until he finds a pair through which you "see better" is very dangerous.)
Then you go to a qualified optician, who makes a proper frame, and inserts the lenses prescribed. Patients should inquire if the glasses are to be worn continually, or only when doing close work or reading.
The Ears. Giddiness and other unpleasant symptoms may be due to ear trouble. If there is any discharge, buzzing or ringing, see a doctor, for if ear disease gains a firm hold it is usually incurable.
The Nose. Neuropaths often suffer from moist nasal catarrh, or from a dry type in which crusts of offensive mucus form, the disagreeable odour of which is not apparent to the patient himself. He must pay careful attention to the general health, take nourishing food, and wash out the nose three times a day with:
1 oz. Bicarbonate of Soda, 1 oz. Common Salt, 1 oz. Borax, Dissolved in 1 pint hot water.
For obstinate nasal trouble, consult an aural surgeon.
"Most men dig their graves with their teeth."—Chinese Proverb.
Serious ills are caused by defective teeth, for microbes decompose the food left in the crevices to acid substances which dissolve the lime salts from the teeth, and this process continues until the tooth is lost.
Faulty teeth are common in neuropaths, and at the risk of being wearisome—and good advice is wearisome to people—patients must get proper aid, privately or at a dental hospital, from a registered dentist, who, like a doctor, does not advertise.
Teeth gone beyond recall will be painlessly extracted, those going, "stopped", and tartar or scale scraped off. If necessary, have artificial teeth, but remember that the comfort of a plate depends upon skilled workmanship, not on gold or platinum. Everyone should visit the dentist as a matter of routine once a year.
Buy 3 ozs. Precipitated Chalk, 1 oz. Chlorate of Potash,
and brush the teeth with this mixture ere going to bed; use tepid water after meals. Do not brush across, but, holding the brush horizontally, brush with a circular motion, cleaning top and bottom teeth at once. Use a moderately hard brush with a curved surface which fits the teeth.
After each meal, it is essential to cleanse the interstices between the teeth with a quill toothpick or dental floss, never with a pin, for it is the decomposition of tiny particles that starts decay; a tooth never decays from within.
11/2 fl. oz. Glycerine, 1 fl. oz. Carbolic Acid, 1/2 fl. oz. Methylated Chloroform.
With ten drops of this mixture in a wineglassful of tepid water, wash out your mouth and gargle your throat after every meal, sending vigorous waves between the teeth, and so removing any particles left by toothpick and brush.
Children should be taught these habits as soon as they can eat, for the custom of a lifetime is easy.
* * * * *
"We may live without poetry, music and art; We may live without conscience, and live without heart; We may live without friends, we may live without books, But civilized man cannot live without cooks."
The human digestive system consists of a long tube, in which food is received, nutriment taken from it as it passes slowly downwards, and from which waste is discharged, in from sixteen to thirty hours afterwards.
Six glands pour saliva into the mouth, where it should be—but how rarely is—mixed with the food, causing chemical changes, and moistening the bolus to pass easily down.
The acid Gastric Juice, of which a quart is secreted daily, stops the action of the saliva, and commences to digest the proteins, which pass through several stages, each a little more assimilable than the last.
The lower end of the stomach contracts regularly and violently, churning the food with the juice, and gradually squirting it, when liquified to Chyme, into the small intestine. If food is not chewed until almost liquified, the gastric juice cannot act normally, but has to attack as much of the surface of the food-lump as possible, leaving the interior to decompose, causing dyspepsia and flatulence.
Most people suppose the stomach finishes digestion, but it only initiates the digestion of those foodstuffs which contain nitrogen, leaving fats, starches and sugars untouched.
By an obscure process, the acid chyme stimulates the walls of the bowel to send a chemical messenger, a Hormone through the blood to the liver and pancreas, warning them their help is needed, whereupon they actively secrete their ferments.
The secretion of the pancreas is very complex. It carries on the work of the saliva, and also splits insoluble fats into a soluble milky emulsion.
Fats are unaffected in the mouth and stomach, which explains why hot, buttered toast, and other hot, greasy dishes are so indigestible. The butter on plain bread is quickly cleared off, and the bread attacked by the gastric juice, but in toast or fatty dishes, the fat is intimately mixed with other ingredients, none of which can properly be dealt with. Always butter toast when cold.
To continue: The secretion of the pancreas also contains a very active ferment, which, on entering the bowel, meets and mixes with another ferment four times as powerful as gastric juice, which completes the digestion of the proteids.
Meantime, the secretions of Lieberkuehn's glands (of which there are immense numbers in the small intestine) are further aiding the digestion of the chyme, while the liver (the largest and most important gland in the body) sends its ferments, and the gall-bladder its bile, which further emulsifies the fatty acids and glycerin until they are ready to be absorbed.
The chemically-changed chyme is now termed Chyle, and is ready to be absorbed by the minute, projecting Villi.
The fatty portion of the chyle is absorbed by minute capillaries and ultimately mingles with the blood, which may look quite milky after a fatty meal.
The remaining food is absorbed by the blood capillaries in the villi, and passes to the liver for filtration and storage.
The large bowel has Lieberkuehn's glands, but not villi, and is relatively unimportant, though most of the water the body needs is absorbed from here.
How food becomes energy and tissue we do not know. The tissues are continually being built up from assimilated food, and as constantly being burnt away, oxygen for this purpose being extracted from the air we inhale, and carried via the blood to every corner of the body. The ashes of this burning are expelled into the blood and lymph, and carried out of the body by the kidneys, lungs, skin and bowels. The product of the burning is the marvel—Life; the extinction of the fire is the terror—Death.
Energy is obtained almost solely from the combustion of fats and sugars, proteids being reconverted into albumin, and then broken down to obtain their carbon for combustion, the nitrogen being expelled, but proteids are essential for the building of the tissues themselves, the stones of the furnaces which burn up carbohydrates and fats.
The time taken in the digestion of foods was first studied through a wound in the stomach of St. Martin, a Canadian. Experiments were made with various well-masticated foods, and with similar foods placed unchewed, into the stomach through the wound, the latter experiment being carried out by millions of people at every meal, by a slightly different route.