The Functional Neuroses
( Originally Published 1908 )
As we hope that this book will be of some service to nervous sufferers, we are loath to introduce into it any descriptions of disease. But on the other hand the chief object we have proposed to ourselves is an account of the work undertaken for the benefit of the sick in Emmanuel Church, and to give this without any discussion of the disorders we attempt to treat is impossible. The sick are therefore advised to skip this chapter and they would probably do so without advice.
Every one knows how difficult it is to describe nervousness, partly because its forms are so protean, its phenomena are so rich; partly because they are so elusive. Nor is this to be wondered at when we remember the infinite delicacy and complexity of the nervous system, and its intimate connection with our moral life. On these accounts, nervous affections are apt to be more diffused than others, their symptoms more variable, their forms more fluid and indistinct. The nervous system is general and possesses a great variety of elements, and its diseases also are general and less susceptible than others of definite classification. They may affect one organ or the whole system, sensibility, locomotion, intellect, and character. The difficulty of classifying nervous disorders is shown by the fact that their nomenclature is constantly changing.
A little while ago everyone spoke of nervous prostration. Now almost every form of nervousness is referred to as neurasthenia. The disorder known as psychasthenia is not mentioned in the older books, while hypochondria of which we used to hear so much has become unfashionable. This fact should be carefully borne in mind. Though the several recognized types of nervous disorders present some more or less constant forms and symptoms, yet these forms tend constantly to merge and to blur the picture. They have been compared to the old so-called temperaments, the sanguine, the phlegmatic, the choleric, and the melancholic. No doubt these represent real aspects of human nature. The difficulty is that few human beings possess them in their pure forms. The same is true of nervous disorders. We speak of the neurasthenic temperament, the melancholic, the hysterical, etc., but it is to be remembered that the diagnosis is determined by the dominant note, while the minor symptoms may be identical. Mōbius has prepared a kind of schematic representation of the several neuroses, both functional and organic, in which their types are classified and their general relations indicated by intersecting circles, or by straight lines, e.g., those leading from St. Vitus' dance to epilepsy. The great central circle, Nervousness, it will be observed, intersects all the others, and within this circle lies a smaller one called nervous weakness or neurasthenia, as this lies at the center of all the neuroses without presenting in itself their peculiar phenomena. This scheme is interesting and instructive provided it be remembered that it is only a mechanical device which does not pretend to express everything.
A neurosis is an affection of the nervous system whether it is functional or organic, local or general, in its character.
Functional neuroses or functional nervous disorders are those which involve no change in the form and structure of the elements and organs of the nervous system, or rather, since every effect must have its cause, they are those which involve no change which can be perceived. What we ordinarily call nervousness is less a disease than a condition, the result of overstrain or over stimulation of our nervous system, and here the difficulty of defining nervous disorders appears. The most healthy person may feel the subjective depression, the sense of irritable weakness and exhaustion which we call nervousness. But when this condition is not removed by normal rest, when it becomes acute and gives rise to a general physical debility, it is called neurasthenia.
Neurasthenia, as the name implies, indicates a condition of nervous weakness and irritability. It is the most common and least specialized of the functional neuroses. Mōbius expresses this by placing neurasthenia which he calls nerve weakness at the center of his chart, on the ground that all other nervous disorders are attended by irritability and exhaustion. Persons suffering from neurasthenia are easily excited and they tire easily. They are apt to suffer from depression and from pains in the back and limbs, from headache and insomnia. Their enfeebled condition exposes them to other maladies such as digestional disturbances, vertigo and palpitation of the heart, weakness of vision, and in severe cases it may amount to absolute prostration. Neurasthenia is frequently attended by loss of flesh, which, as Dr. Mitchell points out, is an important symptom in itself and because it is apt to be attended by anaemia. What is the cause of this weakness and exhaustion which cannot be removed by normal rest ? Apart from hereditary predisposition, it is almost invariably psychical in its origin. The patient has been subjected to a nervous strain too great for his powers. He has experienced some moral shock, or has undergone an experience which has given rise to anxiety, worry, or fear, any of which may result in profound depression, the weakening of the normal powers of resistance. In fact all the functional neuroses are to be regarded as diseases of the subconscious mind. By recognizing this we simplify diagnosis, and we are in a position to understand why it is that one form of nervous disorder passes so readily into another. When the psychical poise is established the physical symptoms usually disappear. In many cases this is most readily attained by the admirable system of treatment devised by Dr. Mitchell; but as Dr. Mitchell affirms, no treatment of neurasthenia succeeds which ignores its moral aspects.
2. Hysteria, although pre-eminently an affection of women, has no necessary connection with the reproductive organs (hystera = womb). The interesting characteristic of hysteria is that the thoughts of persons suffering from it create morbid physical and mental conditions, e.g., violent pains and partial paralysis, in short the very conditions which can be produced by suggestion. This fact led Frederic Myers to propose his interesting theory that hysteria is at bottom a disease of the subconscious mind, a theory which is now generally accepted. "It is a striking characteristic of the hypnotic self that it can exercise over the nervous, vasomotor, and circulatory systems a degree of control unparalleled in waking life. Are we aware in practice of any malady or group of maladies in which these functions, these capacities, are the subject of special disturbances? Are there anęsthesię appearing, shifting, and disappearing as rapidly as the suggested anęsthesię of hypnotism? Are there anomalous vasomotor disturbances which seem to follow the patient's mere caprice? The reader will answer with the word hysteria, and meaningless or misleading though that term be, it is in fact our first and obvious reply. Not, indeed, all, but almost all the phenomena which can be induced by suggestion in the hypnotic state occur spontaneously in hysterical patients." Charcot and his disciples also recognized the intimate relation of hysteria to' hypnotic phenomena, but instead of regarding hysteria as a disease of the subconscious mind, they attempted to force all hypnotic phenomena and other evidences of subconsciousness into the category of hysteria. The unanswerable objection to this is that more than ninety per cent of normal men and women can be hypnotized, while real hysteria is comparatively a rare disease. Myers' theory, therefore, that hysteria is a disease of the subconscious mind may be regarded as highly probable. Its phenomena are produced by morbid auto-suggestion over which normal consciousness has little control. The most constant symptom is disturbance of sensibility. The patient may be insensitive on one side of the body, she may become blind in one eye or be affected by mysterious pains and abnormal feelings in various parts of the body. One leg or even both legs may be paralyzed, although this is a mere nervous inhibition as is shown by the fact that the paralyzed limb is able to execute all other movements than those involved in standing and walking. The patient may suddenly lose her voice and as suddenly re-cover it. On the other hand, sensibility may be heightened, certain portions of the body become exquisitely sensitive and the patient keenly perceives her own organic processes. Palpitation of the heart, marked difficulty of breathing, pain in the stomach, strange sensations in the intestines may ensue. In severer cases partial or general convulsions may occur which are frequently mistaken for epilepsy but which produce little if any effect on the personality. The nervous instability of the hysterical is well known. They frequently laugh uncontrollably and their laughter turns to tears with no apparent reason. Persistent vomiting, hiccoughing, etc., frequently occur. In short there is scarcely a functional disturbance which may not be produced by hysteria or an organic disease whose symptoms cannot be counterfeited. A friend of the author was about to operate for the removal of a moderately large abdominal tumor. When the patient was etherized the tumor disappeared a case of hysterical phantom tumor. The very general character of hysterical symptoms leads us to suspect a general cause like the subconscious mind which is able to control all the machinery of the body. The pains, anęsthesię and other phenomena of hysteria are constantly shifting. As they are produced by suggestion, they can be removed by the same means. The underlying cause, however, cannot be so easily analyzed or disposed of, yet suggestion unquestionably is the best method of treatment. I have observed a marked difference, however, in hysterical patients. Some are controlled almost wholly by their own suggestions and are difficult to influence, while others yield much more readily.
The psychical symptoms of hysteria are hardly less pronounced. We observe an increased emotional excitability and rapid changes of mood. Hysterical persons are naturally keenly interested in their own sensations and feelings. They are frequently at the mercy of perverse impulses and deaf to reason. They are capricious, sensitive, and irritable and seldom wish to suffer alone. Although memory sometimes suffers in hysteria, the intelligence is seldom affected. Hysterical traits are found in all nervous disorders, especially in nervous exhaustion, but they usually disappear with the latter.
3. Of late years a third type of nervous disorder has been recognized which is known as psychasthenia. This term is used to designate a form of nervous weakness in which the psychical element is dominant. Its distinctive characteristics are weakness of will and over-scrupulousness, frequently accompanied by episodes of a strange sense of the unreality of all things. Psychasthenic patients find it difficult to come to a decision whether the matter be big or little, and this inability troubles them. They are apt to doubt and to question everything, even their own acts. I once treated a school-teacher who was frequently tormented at night with the apprehension that she had locked up one of her pupils in the school building, and in order to obtain sleep she was obliged more than once to visit the school in the middle of the night and assure herself that no child was con-fined there. Such persons are frequently compelled to perform an act a second time to assure themselves that they have actually done it. They are troubled and anxious about many things and frequently ascribe this to a "New England Conscience." In severer cases they become the victims of morbid fears and so-called fixed ideas, an unspeakably bitter bondage of which the well can form no conception. These phobias may attach themselves to almost any act or situation of life, though as a rule they are pretty well defined. Their victim may recognize their absurdity. He may keenly appreciate the fact that they are limiting his usefulness and cutting him off from every pleasure in life, but such knowledge gives him no power to resist them. I will give a few typical cases from our practice. A woman read of leprosy in the Bible and that one or two Chinese lepers had been discovered in this country. Immediately she conceived a violent dread of leprosy and also the idea that she and her children were exposed to it. She be-came afraid to touch almost every object and spent much of her time in washing her hands until she reflected that the soap might be infected, a thought which drove her to despair, as it seemed to destroy her last refuge. This case was cured by repeated suggestion.
A highly educated gentleman dropped a tin bucket down a well many years ago. In peering down the well he became dizzy and confused. This gave him an aversion to wells and also to tunnels. Dreading the latter he began to avoid traveling and his repugnance toward tunnels extended itself until he became unwilling to allow anything belonging to him to pass through them. Accordingly, if he wished to send a letter to the western part of Massachusetts he would forward his letter to an-other point and have it remailed in order that it might avoid the Hoosac Tunnel. The next development of his phobia was in regard to his own movements. If he set out to go from one part of the city to another, he must return by the same route however circuitous it might be. By the way he went, by the same way he must return, and this applied particularly to entering a room and departing from it. I have seen this gentleman tremble before a door because he could not be sure that it was the way by which he had come in, and because he could not accept my assurance as to the fact. Of course such fears are not developed without much curious reasoning.
A third patient who has come under my care has gradually shut himself off from almost every necessity of life, some morbid fear or thought interdicting one natural and innocent act after another. For years he has drunk no water, nor eaten meat or bread, nor slept in bed, nor taken a proper bath. Sometimes for weeks he cannot remove his clothing as every button gives rise to questions which require hours of anxious thought. The last time he undressed himself he was eight hours in the process, and all this as a result of fears which he feels to be baseless and in consequence of a train of reasoning which he knows to be utterly fallacious.
In such cases the question of sanity becomes very pressing. Fortunately most phobias and fixed ideas are limited in their domain and they require restraint only when they become dangerous to their victim or to others. Unquestionably mental twists of this kind are, like hysteria, to be regarded as diseases of the subconscious personality. Such suggestions do not proceed from reason, which may be unimpaired, since reason resists them and abhors them. They are suggestions issued by the subconscious mind, only in the case of phobia in the form of inhibition. As they are rooted in the subconscious they must be removed from it, and the best means to effect this is by hypnotic suggestion which gradually removes the suggested fear and strengthens the will to resist it. Mere argument is useless, and force and violence are worse than useless.
4. Melancholia. The characteristic trait of melancholia is a morbid depression of self-consciousness, a sadness which is not the result of objective conditions. A sable pall seems to settle upon the world through which the sun cannot shine. Every event is the cause of new sorrow and to avoid pain the melancholic patient turns away from all external happenings and broods upon himself, sometimes refusing to speak for years. Weakness of the will, profound indifference to the ordinary interests of life, and callous insensibility to those he loved are further symptoms of this sad disease which cause fresh sorrow. Sunk in a sea of dark and gloomy thought, the melancholic sufferer often dreams of suicide but is deterred by his enfeebled will. Too much confidence, however, is not to be placed in this protection even in mild melancholia, as many have learned to their sorrow. Sometimes the disease reaches a crisis and explodes in some violent or desperate deed. Melancholia not infrequently alternates with mania.' Two periods of life are especially exposed to it, the stormy period of early manhood and the oncoming of old age. In its severer forms melancholia is regarded as a true mental disease, and as such it is not amenable to psychical treatment. I have recently treated a patient who has undergone periods of more or less acute melancholia for more than forty years, the periods lasting for several months and recurring on an average once a year. In this case suggestion appeared to be very successful, but I am apprehensive that the disease will return as it does in all these periodic cases. The severer cases which have come to my knowledge have been either hereditary or they have consisted in a permanent modification of a temperament and character naturally inclined toward melancholy, and usually this has been attended by delusions and hallucinations of a depressing or dangerous character. These delusions are often of persecution, or they may attach themselves to religion. In the latter case sound and normal religion can hardly be held responsible for them, for it is not the normal conceptions of religion which trouble the minds, but a morbid perversion of thought which religion repudiates and seeks to remove. We all know apparently sane persons of so bitter and morose a disposition that a comparatively slight exaggeration of it would create a condition of true mental disease. These unfortunate beings are often the victims of melancholia, although the fact may not be known. A development of the disease, however, renders them dangerous to them-selves and to society.
Apart from true constitutional melancholia the condition we have described may coexist with epilepsy or hysteria or it may be as a passing psychosis, the result of nervous exhaustion, excess, or painful moral experience. The latter forms are frequently curable by suggestion and moral influence. Indeed Voisin claims to have succeeded with several cases of acute and severe melancholia attended with dangerous delusions, which had been diagnosed as insanity.' Melancholia also is to be regarded as an affection of the subconscious mind. In constitutional cases this is apparent. But even in functional cases there is a dissociation which concentrates attention on a gloom and misery which exists largely in the mind, and which inhibit all joy-giving emotions.
5. Hypochondria is a curious word which has been used time out of mind to describe a form of melancholic disposition in which the attention of the patient is fixed on the conditions of his own organism. If the hypochondriac falls ill, he is confident that his sickness is severe or mortal. He carefully observes his symptoms, and loves to read medical works, referring to himself all the horrors he encounters therein. This introspection makes its -subject and object apprehensive and egoistic. Sometimes he conceals this under a gloomy air, but more often he delights to tell his own woes and to describe his symptoms to the amusement or annoyance of his friends. Nothing vexes him more than the hint that his sufferings are imaginary, and in one sense he is right, for although often purely subjective in origin they may be very real. For not only can our physical functions be deranged by constant attention, but true morbid conditions can be created by fear and strong expectation, e.g., the phenomena of hydrophobia, cholera, yellow fever, etc., which have been frequently observed in persons not actually infected. Hypochondriacal or somatic delusions, if allowed to rise on unchecked, may also result in monomania. Sufferers believe that their heads are made of glass, that they have insects under their skins, or frogs and lizards in their stomachs. Or they believe that the source of their painful feelings lies outside themselves, that they are victims of fiends and demons, that their enemies are trying to poison them, etc. These severe symptoms are fortunately rare. The minor phenomena of hypochondria, however, are very common and they are sufficiently definite to deserve recognition. If they shade insensibly into melancholia on one side, they are frequently produced by the same conditions which cause simple neurasthenia on the other, and in such cases when the nervous exhaustion is overcome the morbid apprehensions disappear. The line of demarcation between hypochondria and hysteria is also frequently vague. This has led some neurologists to drop the unmeaning term altogether, and to substitute for it the more definite and significant psychasthenia which, however, is not of the same content.
6. Chorea or St. Vitus' Dance is characterized by involuntary irregular movements which cease in sleep. Several forms of this disease are recognized, especially the hereditary chorea which affects whole families, and is incurable, and the infectious form which usually appears in children and is curable. In lighter cases of the latter the children are often regarded as mischievous or naughty. They make faces, scratch with their pens, and let things fall to the floor. In severe cases the muscles contract wildly and violently, causing strange movements which were formerly regarded as proofs of possession. Speech is affected or is entirely absent. The disposition is irritable, moody, melancholy, and subject to outbursts of passion. This disease usually attacks weak and delicate children and causes them to appear weak-minded.' The minor chorea is frequently contagious in the sense that one child acquires the habit from another, through conscious or unconscious imitation, or it may follow in-tense fright or an attack of rheumatism. This form of chorea is distinctly amenable to suggestion. Bramwell reports nine cases treated with success, 2 and we are able to add others. The appearance of chorea in later life is unusual, and when it occurs it is apt to be in the incurable form and on a hereditary basis.
7. Mania. Under this ill-omened name are included all those mental disturbances whose fundamental trait is the domination of a morbidly exalted self-consciousness (Möbius). For our purpose it is not necessary to penetrate far into this melancholy field. What leads me to enter it at all is the fact that a condition of stormy excitement known as manic exaltation occurs in the functional neuroses. These states though frequently re-current are usually short-lived. While they persist the patient is completely dominated by a violence of speech, of thought and emotion. He will pour out a flood of excited, sometimes meaningless words. He will utter threats against himself and others, and frequently he is unable to control his movements, but walks violently back and forth like a caged animal. These states can sometimes be checked by moral means at their inception, but when they pass a certain stage they are uncontrollable and must be allowed to wear themselves out. This purely functional disturbance which resembles strong excitement and anger forms one of the intermediate states which lie between the functional neuroses and true mental disease.
The most constant moral symptoms presented by the various functional neuroses are weakness of will, i.e., inability to make a decision, lack of concentration, i.e., in-ability to fix the mind on one subject, weakness of memory, lack of self-control, irritability, rapid exhaustion, apathy, despondency, and fear. It is these moral sufferings and this sense of abject weakness which make the conditions we have described so terrible. Other sufferers hope on to the grave, these are frequently "sunk in despair unfathomably deep." These diseases have found expression in every literature, but no one has described the horrors of melancholia and insomnia with the tragic eloquence of James Thomson with whose writings every neurologist should be familiar. A woman said to me a while ago: "Who could guess that the mind has so many doors leading directly into hell?" Nervous sufferers frequently receive but scant sympathy. Because their maladies rest on no palpable organic basis they are thought to be imaginary. If by imaginary we mean unreal, this is a great mistake. These disturbances are indeed subjective in that they are affections of personality, but in admitting this we do not regard them as unreal. On the contrary, our subjective feelings are the most real things we know. For my part, I would rather break my thigh and be infected with tuberculosis than endure for thirty days even sub-acute melancholia and insomnia, for I know that in the former case I should suffer less and recover my health sooner. By making light of nervous sufferings we simply repel and disgust the sufferers and render ourselves unable to help them. A certain amount of firmness and even of sternness is frequently necessary in dealing with neurotics, but as to our comprehension and sympathy there should be no doubt.