Psychotherapy

Value of Favorable Suggestion.—If once the idea of the awful hopelessness of their cases is removed from locomotor ataxia patients they will suggest their own betterment so powerfully that they easily persuade themselves that their affection is considerably improved. It is evident, then, that the regular physician must take advantage of this wonderful power for the relief of human suffering and depression that proves so helpful to the irregular. We cannot cure the tabes of the spinal cord. We cannot re-create the nerve tracts that have been obliterated. We realize that there is no use trying to do so any more than there would be in trying to make an amputated finger grow to its full size again. We can treat the patient, however. We can remove many symptoms that sometimes bother him more than those necessarily connected with his spinal affection. We can relieve annoyances of all kinds that add to his misery and as a consequence we can give him hope, keep him from brooding about himself and thus perform the proper function of a physician. We shall not forget that we can only rarely cure, but we can almost always relieve pain and we can always help the patient in some way. The ataxic patient needs consolation, and this can be given without in any way deceiving him. The loss of sight seems an irreparable ill to those who see, yet the blind are quite happy, are much more cheerful than many seeing people, and have learned to stand their affliction not only with equanimity but really without much depression. In the olden times, before proper care was taken of the blind, they had little occupation, they had nothing to do with their hands, the future was blank and they suffered severely from depression. As a rule, they did not go out enough and their bodily health suffered and the disturbance of their functions still further heightened their depression. All of this happens now with the ataxic patient. A host of symptoms not at all necessarily connected with his spinal affection develop and prove sources of annoyance. Many of them can be removed entirely, all of them can be ameliorated. If, while doing this, we succeed in impressing a discouraged patient's mind with our power to benefit in spite of an underlying incurable disease, we have another triumph of psychotherapy.

Removing Unfavorable Suggestions.—The general experience with those suffering from locomotor ataxia has been that the depression consequent upon the announcement that they have the disease and the stigma that is supposed to attach to it in our day leads them to a great extent to avoid going out into the air. This adds woefully to their depressed condition. Take a healthy man, let him stay inside a great part of the time without any exercise, seeing no new faces, without any interests in life, and at the end of three months he will have a set of neurotic symptoms on a basis of depression that will make him supremely miserable. This will be true even though he has not the threat of an incurable disease hanging over his head. He must be made to realize that every neglect of any law of health in his condition is even more serious in its effect upon him than it would be were he in good health. Above all, it must be made clear to him that while his neglect of hygiene may perhaps not shorten his life, it will greatly add to the mental suffering, much more unbearable in its way than the physical suffering which he will have to endure during the progress of his disease.

Treating Accessory Symptoms.—Nearly every ataxic patient who is not directly and almost constantly under the care of a physician, is a sufferer from two conditions that are so constantly present that they are sometimes thought to be consequences of the primary affection. These are loss of appetite with consequent loss of weight and constipation. Almost without exception neither of these symptoms or syndromes are at all connected with the locomotor ataxia. They are the result of the unhygienic life that the patient is living and of the depressed state of his mind and lack of diversion. They are mutually connected, for a man who does not eat enough will not have regular movements of his bowels, and constipation reacts to produce further depression. A vicious circle in pathogeny is formed and the patient is likely to get into a very debilitated and depressed condition. Both of these troublesome symptoms may be corrected to the manifest improvement of the patient by proper advice and ordinary care for his well being.

Appetite is largely a function, as the mathematicians say of something that depends on something else, not of exercise, as is often thought, but of fresh air. In the tuberculosis sanatoria patients with fever are not permitted to take exercise, yet if they are out in the air most of the day and if their rooms are well aired at night, they can eat heartily and digest their food well. Of course, appetite is largely a psychic matter and the thoroughly discouraged man will have no care for food in spite of abundance of air. A little persuasion, however, of the necessity for making the best of a bad job will usually arouse even a locomotor ataxia patient in the early stages of his disease to the necessity for eating a reasonable amount. If he has suffered from gastric crises and fears that eating normally may precipitate these, he must be persuaded that this is not the case, that the presence of food, or its amount, or quality, has nothing to do with the initiation of these painful attacks so far as we know, and that even though at the beginning of his affection before his locomotor ataxia was recognized, his gastralgia may have been declared by his physicians, as is so often the case, to be connected with some form of gastritis or indigestion, that idea may now be given up and he may eat plentifully with confidence that it will not increase his pains. On the contrary, limitation of food seems to have a distinctly unfavorable effect in increasing the number and severity of these attacks.

The same thing must be made clear to him as to intestinal and rectal crises. It seems likely that tendencies to constipation by irritating peripheral nerve endings may have some effect in bringing about the explosion in sensory nerves which have been called intestinal or rectal crises. In general, however, these are dependent on spinal and not peripheral conditions, and no thought of any connection must be allowed to disturb the consumption of a proper amount and variety of food. It seems clear that when patients are much run down, have lost considerable in weight and are in a generally depressed condition, their nervous system is much more irritable than it would otherwise be and they are likely to suffer more frequently from crises of various kinds. Once a patient is made to understand that his general nutrition may affect not only the course but the occurrence of symptoms in the disease, as a rule it is not difficult to get him to eat enough and to do so with the definite feeling that it is going to do him good. Even though it should be necessary to use tonics, and often they will have to be prescribed, it is clear that this treatment of the patient's general condition is the physician's first duty, though it does not and cannot affect the specific disease.

Neurotic Complications.—There can, of course, be no doubt that the crises of locomotor ataxia represents extremely poignant attacks of pain. But on the other hand, anyone who has seen many of them is prone to think that not a few of them are really attacks of pain resembling those which occasionally develop in hysterical subjects. The pain of a gastric neurosis may, indeed, so simulate the gastric crises of locomotor ataxia as to make what is only a case of hysteria seem beyond doubt one of locomotor ataxic. Locomotor ataxia patients are prone to think much about themselves and to fear the recurrence of these painful crises once they have had experience with them. As a consequence they sometimes suffer from what are pseudo-crises, that is, from neurotic painful conditions which simulate genuine crises mainly in the amount of reaction they produce in the patient. True tabetic crises yield more readily to ordinary anodyne drugs than do these pseudo-crises. Nearly always the true crises are associated with and exaggerated by neurotic symptoms due to the depression of the patient, the yielding to his feelings, the conclusion that his pain is inevitable and is going to be worse each time, while successive crises are, as a matter of fact, often milder until they disappear for good, and this element in the case must always be borne in mind. Much can be done for the relief by psychotherapy, that is, by making the patient see the realities of his condition, suggesting to him that succeeding crises are less painful and that if his general condition is as good as it should be he becomes better able to stand the pain of his crises and the shock of them is not so disturbing to his system.

Mental Attitude.—Prof. Oppenheim, in one of his "Letters to Nervous Patients," advising a patient suffering from an incurable organic nervous disease, evidently locomotor ataxia, though that is not explicitly stated, outlines emphatically the favorable side of that disease. This is absolutely needed. Ever so many unfavorable suggestions with regard to his affection find their way to the patient. The very fact that it is pronounced absolutely incurable is disheartening. Prof. Oppenheim's words, then, may be a precious help and to have them repeated from time to time renews the suggestion:

Now, however, we neurologists know that that disease frequently runs a very mild course, that a man showing certain early symptoms of such a disease may for ten to twenty-five years and even longer retain his capacity for work and enjoyment. This for a man of thirty to forty years is almost tantamount to the expectation of a whole normal lifetime. But on the other hand, what danger to the peace of mind, what destruction of happiness in life may be caused if the knowledge that such a disease has begun to develop is imparted to the patient without being combined with the consoling information as to the nature and course of the benign forms of this trouble! In unceasing anxiety and fear, in daily expectancy of some fresh symptoms, of some increase or aggravation of his troubles, does the poor man waste his life; and I have frequently found that this wretched apprehension and excitement cause a nervousness and mental depression which in their effects are much more momentous than is the commencing spinal disease.

From this miserable condition I desire to protect you, and I would ask you to take this advice deeply to heart: do not bear yourself as one who is condemned; as one who, affected by a progressive, incurable disease, will soon fall a victim to paralysis. On the strength of my own experience I give you the assurance that your condition of health will not necessarily in ten years' time be essentially different from what it is at present. But I would also strenuously exhort you to observe all the precautionary rules laid down for you, to avoid all unaccustomed strain or indulgence such as can only be undertaken with impunity by a man in full vigor and absolute soundness of health. I would advise you also to be thoroughly examined once a year by an experienced physician. But apart from these restrictions, you should as far as possible feel yourself and bear yourself like a healthy man, remaining attached to your work, and not withdrawing yourself from the pleasures of social intercourse.

Relearning Muscular Movements.—Perhaps the most interesting evidence of how much may be done for organic nervous disease in spite of the fact that the underlying lesion is absolutely incurable, may be obtained from what is accomplished by Frenkel's method of treating locomotor ataxia. As is well known, by reteaching the movements necessary for walking, ataxic patients regain control of the movements of their limbs to a marked extent. As a consequence, bed-ridden patients are enabled to walk once more even though they may have to carry a cane and be supported, and patients who have had to use two canes get along with only one, or may even eventually be able to walk without any artificial support.

Just how the improvement is brought about we are not quite sure. It seems probable that the eyes become trained to replace the muscle sense to a noteworthy degree, but there is in addition apparently a re-education of the muscle-sense. Perhaps there is also a transfer of the function of certain degenerated nerves to other tracts than those in which muscle impulses originally traveled. The improvement in muscular control originally obtained is a striking illustration of how much nature is able to compensate for even organic lesions and is a lesson in the necessity for never ceasing to try to do something even when the case seems hopeless. Certainly locomotor ataxic patients would seem the least likely to be benefited by training in movement and yet this movement therapy for tabes has had some wonderful results.

The story of how this mode of treatment came into existence is interesting and instructive as an illustration of how happy chance in our time, as so often with regard to drugs in the past, came to assist the rational development of therapeutics. A German professor wished to demonstrate to his class the varying inco-ordination of a series of tabetic patients. Some of them had their main inco-ordination in the legs, others in their hands. He went over the cases in his wards so as to arrange the demonstration for the next day. He told each patient that he would ask him to perform a particular set of movements before the class which would illustrate strikingly a particular phase of muscular inco-ordination. His patients were interested in the announced demonstrations and during the afternoon they went over the movements that they were expected to perform. They practiced them as assiduously as their condition permitted for the exhibition. As a consequence the most striking features of their inco-ordination disappeared. After having practiced the movement for a certain length of time they could do it ever so much better than before. The special feature of the professor's demonstration was spoiled, but a great contribution to our knowledge of nature's compensatory powers was made and fortunately the hint of its significance for treatment was taken and developed.

Effect of Favorable Suggestion.—How much can be accomplished for the relief of the general symptoms of locomotor ataxia and for the placing of patients in an attitude of mind that makes most of their symptoms of vanishing importance, can be judged from some recent experiences with a new cure for the disease. This consisted only of some rather conventional treatment of the urethra by applications and dilatation, yet patients were relieved so much of the symptoms of locomotor ataxia, or at least persuaded themselves that they were, that both in this country and in Europe the discoverer of the new "cure" soon had scores of patients. The active therapeutic agent undoubtedly was the fact that patients who had been told that their disease was incurable and who had settled down in a state of discouragement and apathy in which their power over their muscles, their general health and their strength and vitality were at the lowest ebb, and their tendencies to discomfort emphasized and made poignant by the supposed hopelessness of their situation, became aroused to new vitality by the promise of cure and then, under the repeated suggestion of a treatment said to be sure to cure them and that had cured others, became so much better, that is, released so much latent energy, that they felt better, ate better, walked better, got out more and had their general health improved, and all to such a degree that their disease seemed cured.

Another interesting illustration of what would seem to be the power of suggestion over the symptoms of tabes occurs in a recent article in the Archivos Españoles de Neurologia Psyqiuatria y Fisioterapia of Madrid38 on the improvement of tabes dorsalis by antidiphtheritic serum. It is quite impossible that the serum should affect favorably any of the underlying lesions of the disease any more than that these should be ameliorated by the wearing of shoes of special character or operations on the urethra. The patient in this case, however, was distinctly improved in many ways after the antidiphtheritic serum was injected. There were some interesting sensory manifestations, pains in the arms and legs after the injection, but these were removed by santonin or methylene blue. Both of these drugs are eminently suggestive in their action, so that one would be prone to think the pains rather neurotic than actual. After a dozen injections had been given, the patient's sensations improved, his power to pick up small things was better, and the sense of walking on carpet had disappeared to a marked extent and he was able to walk much better than before and without support. Probably any attention given to him to the same degree would have produced like results.

We have had previous examples of this kind in the history of the treatment of locomotor ataxia. Certain drugs when given in the past with the definite promise of cure and pursued for a good while with frequently repeated favorable suggestions, have often seemed to benefit patients, though subsequent experience has shown their total lack of value to modify the disease. Nitrate of silver was one of these in the old days and many locomotor ataxia patients acquired an argyria as a consequence of the amount of silver absorbed and deposited in the skin. Arsenic was another and some of the aluminum compounds were also used. When we recall the suspension treatment and its reported good effects—and failure, the over-extension treatment with the same history and many others in the past, the real place of the mental in the therapeutics of tabies is revealed. Once this is practically realized, we find that we have ready to hand and easy to use, the one really efficient factor in all these treatments—that is, the influence on the patient's mind. It is for the physician to devise thoroughly professional ways and means of using that in each particular case so that his patients may be benefited as much as possible. Certainly it would be foolish for us to leave to the irregular practitioner the use of this extremely valuable remedial measure, when we may do so much good with it, for the relief of symptoms at least.

CHAPTER IV

PARESIS

Paresis would seem to be one of the affections so inevitable in its course, so positively helpless as regards any medication, and so hopeless in its absolutely sure termination in idiocy and death, that nothing can possibly be done for it through the patient's mind, yet it is probably one of the diseases for which most can be accomplished by psychotherapy. Mental treatment for it naturally divides itself into three periods: that of prophylaxis, that of the early stage and that of the severer stage with remissions. Prophylaxis is much more important than is usually thought. It is very generally known at present that paresis is usually a parasyphilitic disease, that is, an affection not due directly to syphilis, but which develops by preference and perhaps exclusively in a soil prepared for it by an attack of syphilis. As a consequence of the diffusion of this knowledge men who have suffered from syphilis sometimes become supremely fatalistic as regards the development of locomotor ataxia or paresis in their cases. Worry is a prominent feature in the causation of paresis, and it is, therefore, extremely important to neutralize this.

I have had university graduates tell me their histories and ask whether I thought they had suffered from syphilis, and when I replied affirmatively have seen a look of despair come into their faces. One of them, a graduate of a large eastern university, said, after hearing my opinion, though it was given with every assurance that my experience with Fournier in Paris taught me the absolute curability of the disease, "Well, there are three men of my class who have already developed paresis, and I suppose I will go the same way." With a persuasion like this haunting him night and day, exhausting nervous energy and making his central nervous system less and less resistive, it would be almost a miracle if paresis did not develop. It is particularly in those who have had nervously exhaustive occupations—brokers, speculators, actors, and the like—that paresis does develop. The strain upon their nervous systems seem to be so great that the syphilitic virus still remaining in their system has a peculiarly degenerative effect upon nervous tissue. A man may be in the least worrisome of occupations, however, and if he is constantly brooding over the possibility of the coming of the hideous specter of paresis, he puts himself in the condition most likely to encourage the development of the pathological changes that underlie the disease.

Prophylaxis.—As a rule patients who have had syphilis and who dread the development of paresis should be warned with regard to their occupations in life. After a patient has had tuberculosis which developed in particular surroundings, if it is at all possible, we no longer permit him to go back into the surroundings in which his disease developed. We are coming, more and more, to apply the principles of preventive medicine and this is as important in paresis as in anything else. Even though there may be many monetary or economic reasons in favor of certain occupations, the danger may overweigh these. Those who have had syphilis should be warned of the risk they run if they continue in occupations that require much mental excitement or the strain of anxiety and the speculative factor of uncertainty with the inevitable occurrence of disappointments. It is unjustifiable to permit a patient whose central nervous system is subjected to the deteriorating influence of the virus of syphilis, still in his body even after ten years, to submit to the nerve-racking irritation of occupations which require all the vigor of a healthy, undisturbed organism to survive their wear and tear.

Sources of Worry .—One of the symptoms which neurotic patients are sure must be a preliminary sign of paresis is a disturbance of memory. Patients have heard that paresis causes memory disturbances and fearing the development of the disease, they disturb themselves very much by finding real or supposed defects of memory. Most of them have had only a very vague idea of the sort of memory they possess and cannot tell whether it is worse than before, but finding a certain difficulty in recalling things they conclude that it is deteriorating. Occasionally their supposed defect of memory is founded on nothing more serious than the fact that they are paying so much attention to themselves, that they cannot concentrate their attention enough on what they wish to remember so as really to impress it on their memories. It is curious how persistent some patients are in making themselves believe they have serious lacunae in their memory when there are only certain conventional disturbances of it. The paretic has defects of memory, but he is, as a rule, quite unconscious of them. He has to have them pointed out to him. Patients who are supremely conscious of their supposed defects, by that very fact show their possession of good intellectual faculties.

Tremor is another symptom that may develop in the midst of the solicitude of those who dread paresis. The power to hold the limbs in a given position is due to a very nice balancing of flexor and extensor muscles. There are many people, especially those a little awkward in the use of their muscles, who lack this power to some extent. To stand without swaying is rather a difficult task in one who is nervous or anxious about himself. Patients who are worrying about paresis and its possible development will almost surely disturb their power over their muscles and cause at least a slight tremor or swaying.

In other words, in all of these cases a series of dreads, or mental obsessions which interfere with various functions which may cause tremor, or some stuttering, or at least some apparent difficulties of speech and which will surely revive any old-time difficulties of this kind, may develop in nervous persons and must not be allowed to pass as signs of developing paresis. The diagnostic tests, of course, consist in the knee-jerks, the pupillary reactions, the difference in disposition, the delusions of grandeur, and, in general, the characteristic symptoms of a physical degeneration running parallel with a mental deterioration.