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Psychotherapy Of Organic Nervous Diseases





Since we know that the basis of many nervous diseases is an
obliteration of certain cells of the brain or of the spinal cord, or
certain tracts of the central nervous system through which impulses
must pass if they are to be effective as motion, sensation or function
in some other form, we realize that we cannot recreate these portions
of highly organized tissue and that therefore organic nervous diseases
are beyond the action of any remedies we now know or may even hope to
discover.

The development of pathology has shown us that once there has been
serious nephritis or cirrhosis of the liver certain portions of the
glands are destroyed and therefore there cannot be any question of
cure. There is no possibility of redintegration of destroyed tissues
when they are of highly organized character, and so the patient will
always be maimed. One might as well talk of causing an amputated
finger to grow again as talk of curing diseases that involve
destruction of specialized cells. When this first dawned on modern
medicine as the result of the careful study of pathology a period of
therapeutic nihilism developed during which physicians trained in the
pathological schools were prone to distrust drugs entirely, or at
least to a very great degree. The effect of this wave of nihilism has
not entirely disappeared in our time, though we have learned that even
where serious damage to an organ has been done by disease we may still
hope to compensate for defect of tissue by stimulation of other organs
and to replace its function by certain physiological remedies or
biological products; and if we can do nothing more, we can at least
alleviate the symptoms which develop as a consequence of the organic
affection.


Nature's Compensation.--Physicians are prone to forget nature's
wonderful powers of compensation. Apparently even some regeneration
may take place in diseased organs of highly organized type if the
patient's general condition is kept up to its highest point of
nutritive efficiency. How far this may go we do not know, but
observations show some marvelous examples of unexpected regeneration.

These counteracting processes can be stimulated sometimes by drugs,
but oftener they can be best brought into play by keeping the patient
in just as good condition of body and favorable condition of mind as
possible for a prolonged period, so that nature accustoms herself to
the defect and her powers of compensation have full play.



Unfavorable Suggestion.--What is true of organic diseases of all kinds
is especially true of organic nervous diseases, and in spite of the
fact that most of these are essentially incurable, so much can be done
for patients that their condition is made more tolerable and indeed
some of them improved to such an extent that they consider themselves
quite relieved of their organic affection. One of the most serious
burdens that the patient laboring under an organic nervous disease has
to suffer is the consciousness drummed into him by successive
physicians, by his reading, and by every possible means of suggestion,
that his malady is incurable. This makes every symptom as severe in
its effects as it can possibly be. Hope does not buoy up and
discouragement weighs down every effort of the organism to compensate
for the serious defect under which it is laboring. Nothing can be done
for the disease itself, but much can be done for the patient. Many of
the symptoms from which the patient suffers most are really due to his
own discouragement, to that sluggish condition which develops in his
body as a consequence of his lack of hope, to the absence of exercise
and of air and of diversion of mind consequent upon the gloom that
settles over him when he is told that his condition is incurable.


Adventitious Symptoms.--If the adventitious symptoms that are always
present in cases of organic nervous disease are eliminated, if the
conditions which develop from the unhygienic condition in which the
patient lives because of his discouragement and retirement are
removed, as a rule he feels so much better that it is hard to persuade
him that some change has not come in his underlying nervous disease
and that a process of cure is not at work. It is because of this that
irregular practitioners so often succeed in apparently doing much more
for these patients than the regular physician. The irregular does not
insist on the incurability of the disease, but, on the contrary, he
promises a cure. He then proceeds to relieve many bothersome symptoms
that are quite extraneous to the underlying disease, but thus makes
the patient ever so much more comfortable than before, gives a
cheerful air to his life for a time, makes him sleep better as a
consequence and it is not surprising that the patient thinks that his
disease has been bettered, if not cured.


Suggestive Prophylaxis.--While we are optimistic just as far as
possible since genuine nervous disease has declared itself, it must
not be forgotten that we can by suggestion and warning often prevent
or delay the development of nervous degenerations. This, too, is
psychotherapy and must be employed wherever it seems advisable.

Post-syphilitic nervous conditions of so many kinds are likely to
develop that it is important to warn the patients who are sufferers
from this disease from taking up the more strenuous forms of
existence. This may seem an exaggerated view of the condition, but it
is amply justified by the results of the opposite rule of life in
almost any physician's experience in city practice. A man who has had
syphilis must be warned of the danger, one may almost say likelihood,
if he takes up any of the professions in which there is much mental
strain and nervous worry, that he will almost surely not live out the
normal span of life without some serious nervous incident. Locomotor
ataxia, and, above all, general paralysis develop, as a rule, in men
who, having had syphilis, have some occupation in life that calls for
considerable mental strenuosity, and involves excitement and worry.
Actors, brokers, soldiers and sailors, speculators of all kinds,
race-track gamblers, these are the classes from which victims of
paresis and locomotor ataxia are particularly recruited. People who
have suffered from syphilis and who live the ordinary unemotional life
of a teacher, or a merchant, or a writer, do not, as a rule, develop
the postsyphilitic and parasyphilitic conditions.

Precocious apoplexy is especially likely to occur in patients who have
had syphilis and who have then spent themselves at very hard work. I
doubt if hard work alone, without some such antecedent condition, ever
produces this result. Of course, it is not alone syphilis, but other
serious conditions which affect the nervous system that ought to be
guarded against in this same way. If there has ever been any affection
of the kidneys, as a complication, for instance, of scarlet fever,
then it has always seemed to me to be the duty of the family physician
to warn such patients that their kidneys are more prone than those who
have not suffered from such an incident to break down under any severe
strain that may be put upon them by worry, especially worry following
a period of strenuous work. In these cases the affection of the
kidneys nearly always makes itself felt in the nervous system, and
especially in the brain, and so this warning has a proper place here.

Where there has been severe cerebro-spinal meningitis this warning
seems also to be needful, though here our records have not been kept
with sufficient care to enable us to speak positively of the necessity
for the warning.


Treatment.--It is important to remember that as physicians we do not
treat disease but patients. We care for patients, that is the real
etymological significance of the Latin curare, we do not cure
diseases in the modern sense that has come to be given to that term,
of completely removing the materies morbi and setting the patient on
his feet once more just as well as he was before his illness.


Relieving Incurable Disease.--A new cure for locomotor ataxia, for
instance, is announced every now and then, and the evidence for its
beneficial action is the testimony of patients who have been relieved
of many symptoms that they thought connected directly with their
spinal affection. All sorts of remedies have been employed with
announced success. One man builds a particular kind of shoe for them
and has a number of witnesses to his skill in curing them. Another
does some slight operation on their nose or their throat or their
urethra and straightway the patient feels so much better that he talks
confidently about being cured. All the characteristic symptoms of the
affection remain. Their knee-jerks are gone, their pupils do not react
normally, they have some incoordination in their walk, but a number of
other symptoms have disappeared and their walk is probably much
improved because of their confidence and a certain amount of practice
that they have gone through. The new hope born of confident assurance
that they could be relieved gives them an appetite, makes their
digestion better. This lessens the sluggishness of their bowels, gives
them confidence to get out and see their friends, life takes on a new
hope, they sleep better and it is no wonder they talk of having been
helped or even cured.

There is a definite relation between the nervous affection in these
cases and many visceral symptoms. There is no doubt, for instance,
that certain cases of intractable dyspepsia are associated with tabes
and that in nearly the same way obstinate constipation frequently
develops. Notwithstanding the connection of these symptoms with an
incurable condition of the spinal cord that is no reason for
thinking that they cannot be relieved even though no improvement of
the spinal-cord lesions is expected.

Frequently, indeed, gastric dyspepsia is due more to worry over
discomfort somewhere in the stomach region than to any real
disturbance of the digestive functions. It may then be considerably
ameliorated simply by the assurance that the trouble is local and is
localized outside of the stomach itself, though there may be some
sympathetic irritation of the gastric nerve supply. Probably Dr. Head
and those who have studied reflexes so enthusiastically would not
agree with this explanation of the relief of the gastric symptoms in
some of the cases they have described, as due rather to suggestion
than to the local treatment, and, as a matter of fact, we are not
quite sure which factor may be the more important. Counter-irritation
probably plays quite an important role in the relief of discomfort,
but I am sure that the suggestive influence of acute sensory feelings
at the surface produced by counter-irritation serves to divert the
mind from the duller ache or the functional disturbance below.
However, Dr. Head's paragraph should be given in his own words, for it
furnishes a scientific basis for one aspect of these cases.

Throughout the study of cases of nervous diseases, evidence of the
relation between pathological condition of certain viscera and
sensory disturbances in the superficial structures of the body is
constantly manifested. For instance, a man with caries of the spine
suffered from a girdle sensation round the area of the eighth dorsal
segment. At the same time he was greatly troubled by flatulent
dyspepsia which was untouched by drugs. It was, however, greatly
relieved by counter-irritation applied to the maximum tender point
of the eighth dorsal area in the eighth space and mid-axillary line.

Optimistic Suggestions.--Our most prominent neurologists have in
recent years insisted on the necessity for encouraging patients and
for not permitting them to brood upon the worst side of what is to be
expected from their ailment. Patients are entirely too prone to read
up about their disease and the worst symptoms of the extreme cases
impress their minds and are constantly recurring as suggestions of
possible ills to come. Prof. Oppenheim in his "Letters to Nervous
Patients" states in a striking way the optimistic view that it always
seems advisable to give a patient in the initial stages of a serious,
incurable or even progressive nervous disease. That letter is worth
quoting:

I cannot conceal from you the fact, which you have already
ascertained from other sources, that you show the premonitory
symptoms of a disease of the spinal cord. This admission is not,
however, as you fear, synonymous with the sentence "the beginning of
the end." There is no reason for you to despair. We doctors regard
and welcome it as a marked advance in our scientific knowledge that
we are now in a position to diagnose a nervous disease of this kind
in its first commencement. This is undoubtedly a great gain for the
patient, as on account of this knowledge a judicious, experienced
physician may, at least in many cases, by the timely regulation of
the mode of life and the prescription of certain remedies, arrest
the progress of the disease or retard its development. This advice
may, however, and should as a general rule, be given without the
patient himself being made aware of the diagnosis, for the ideas as
to the nature of this disease which prevail in lay circles, and
indeed among many doctors of the old school, arise from the
knowledge of the disease in its advanced and fully established form,
since it was only in this completely developed stage that it was
recognized. Then, indeed, its very noticeable symptoms were obvious
even to the uninitiated. This picture, sad enough indeed in itself,
was rendered still gloomier by the misery and despair which
popular fancy has associated with the conception of locomotor
ataxia.


Arteriosclerosis.--Even with regard to so serious a disease and, of
course, absolutely fatal in its progress as arteriosclerosis, it must
not be forgotten that much can be done for the patients and especially
for the nervous symptoms that develop in connection with the
condition. For the progressive hardening of the arteries on which the
nerve symptoms depend absolutely nothing can be done. A man is as old
as his arteries, and we cannot bring back the years even though the
patient has become prematurely old. For the symptoms so frequently
seen in connection with arteriosclerosis, the paresthesia, the
burnings, the numbness, the pruritus, the pains around joints and the
difficulties in connection with them, even for the intermittent
claudication which develops, much can be done. Above all, the patient
must not be allowed to cherish the notion that his disease is not only
incurable, but that nothing can be done for it. It is inevitable and
progressive, but then according to one definition, life is a
progressive disease and every day brings us nearer death. "Life is a
dangerous thing at best," as an American humorist once said, "and very
few of us get out of it alive."

These patients can be relieved of many physical symptoms, they can be
encouraged, their attention can be diverted from their symptoms, and
it is concentration of mind on them that often makes them intolerable,
while occupation with something, especially if it is interesting, will
often prove an efficient remedy for the discomforts complained of. Old
people who have no interests, who have retired from business, who did
not have the opportunity when young to acquire tastes in art and
literature, above all, those who have no interests in children, no
grandchildren nor close relatives near them, are likely to become
centered on their ills in the midst of their arteriosclerosis, and
this more than the advancing degeneration of arteries itself is at the
root of their symptoms. The ideal old age is that which is passed in
the midst of younger people, with an occasional happy hour during the
day with children in whom one is deeply interested. This is the best
psychotherapeutic factor that we have.

Prof. Oppenheim has given the optimistic side of arteriosclerosis so
suggestively that most patients suffering in this way should have the
opportunity to read it. It occurs in his "Letters to Nervous
Patients":

An eminent physician for whom I have much esteem has told you that
your troubles, especially your vertigo, are caused by calcification
of the arteries. You, sir, heard in this your death sentence, and
since then the encyclopedia has revealed to you all the sufferings
and terrors with which you may expect to be overtaken.

I would, however, explain to you, as the result of the most careful
examination and the most absolute conviction on my part, that your
anxiety is unfounded.

Since you have a certain amount of information and scientific
knowledge, I may speak to you upon this matter almost as a
colleague. One is certainly justified, when a man of your age
complains of vertigo, in suspecting calcification of the arteries to
be the cause of the trouble, since it constitutes the common senile
change, and vertigo forms one of its most frequent symptoms.
But--apart from the fact that in senile calcification of the vessels
this vertigo is frequently a temporary and not always a serious
sign--one is by no means justified in assuming that the appearance
of this symptom in later life is in itself, and without further
evidence, the sign of such a cause. This is an error which in my
experience is far too frequently made, to the detriment of the
patient. It is first of all essential to closely examine and analyze
the symptom in itself. . . . Two years ago, after having overloaded
your stomach, you had a real attack of vertigo, which was repeated
several times during the day, until, by vomiting and diarrhea, the
contents of your stomach were evacuated. Since that time the fear of
vertigo has overpowered you. In my experience it is neither new nor
uncommon to find that a man who has shown his intrepidity and his
contempt of death on many a battlefield, who is a hero in war, may
be overcome by some dread of illness, by some anxiety, or even by
some pain, and may be distressed by it in a way that is in sharp
contrast to his whole personality. Your remembrance of that vertigo
is so lively that the mere idea of it suffices to reawaken the
symptom, or at least an imitation of it which very nearly approaches
the reality. That this idea is present in your case is quite certain
from the consideration of your symptoms. You admit that you almost
never have vertigo at home, but as soon as you leave the house, and
especially if you find yourself alone in the street far from home,
the remembrance of the vertigo comes over you, puts you into a state
of anxiety, and is followed by a sensation of tottering and swaying,
so that you have to stand still; and at last it has gone so far that
you no longer venture to go out alone. And so the hero of X sits
like a timid woman in his arm chair, making life bitter for himself
and for those around him.

Even were I to find that signs of arterial calcification were
present, I should still be satisfied that your vertigo is not due to
this cause, but that it is a vertigo of recollection and of fear.





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Previous: Graves Disease



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