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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