{230}
Neurasthenia, or nerve-weakness, "the vapours" of the old novelists and dramatists, is a very common malady, and it gives the clergyman trouble by the turmoil it causes in families, religious communities, in themselves, and elsewhere. Whether the condition is a distinct disease or not, and that question has been voluminously discussed, is not altogether an important matter, but that there is such a group of symptoms is unfortunately a weighty fact. It takes so many forms that it is bewildering, and therefore not readily reduced to unity.
The cerebral form often exists independently. There is such a thing as "brain fag," although many complainants may have very little material for the fag to work on. Often such a patient is robust, even an athlete, and his assertions meet with ridicule or abuse instead of treatment. If the patient is a woman she is not seldom called "hysterical." She is not hysterical. Hysteria, by the way, is as distinct a trouble as a broken leg, and far more serious, and not a synonym for perverseness, as the term is popularly used.
In the cerebral form, business, reading, study "go into one ear and out the other." The patient's memory fails him temporarily just when he may need it most, say, in a speech or sermon; a fly buzzing on a pane is a calamity and a source of profanity; a flat note in the choir-singing is ample reason for doubting the divine origin of the church, and every petty trouble that whisks its harmless tail across his floor makes him seek the table-top. I have known a whole convent of nuns, who were closely shut in, with bad ventilation and a worse cook, until all were more or less neurasthenic, almost{231}disintegrated by the presence of a lamb sent in as a pet; not because of the bleating or any ordinary reason, but solely because of the hideous incongruity and indecency in the fact that the lamb was a male.
The cerebral neurasthenic makes rash, impetuous changes in his mode of life. He leaves a religious order because the coffee is weak, he resigns an important post in a bank because the president uses snuff, he abandons medicine for trade because the curate meddled in the treatment of two of his patients. He takes on anxiety, locks up the house six times over the same night; meals are eaten in awed silence by his trembling children; altogether he is an unmitigated nuisance.
He may get religious scruples. If he is a priest he takes an hour to an hour and a half to say a low mass, and most of that time is spent in searching the corporal for imaginary particles or in drying the dry chalice. He rereads his breviary until he is exhausted. Because moral theologians say that certain scruples are from the devil, he is convinced that the devil takes a particular interest in his case. The devil did probably take a special interest in his father's or grandfather's lack of scrupulosity, for his condition is commonly a result of alcoholism in an ancestor.
There are three chief types of neurasthenics: in one class is the person that appears robust, and is really so except in his nervous system, which lacks a governor. Such patients have little more than a troubled appearance to draw the attention of a chance observer to their condition.
A second class is made up of eloquent narrators of their troubles. They try all the physicians in turn, then the homoeopaths and osteopaths and similar quacks, and they add patent medicines prescribed by themselves. They are petulant, capricious, and despite their apparent energy they accomplish nothing.
The third class are silent, limp, clammy-handed; they are brought against their will to see the physician; they are sulky; bitter and unreasoning haters; inclined to melancholy. They may have a tendency even to suicide, but this is somewhat rare. Neurasthenics are not so liable to insanity as is popularly supposed, but such an outcome is possible in certain{232}cases. If their vague fears go on into a more or less fixed delusion there is cause for anxiety lest insanity result, but care should be taken here to be sure the delusion is really irremovable.
Some neurasthenics are afraid to cross an open square or a wide street, others dread any closed apartment. Vertigo is common; so is insomnia. Insomnia is almost a constant symptom. The patient may have naps or he may have uninterrupted vigils. Sometimes there is a heavy but unrefreshing sleep. Sleepless patients are thrown into distracting rage by the barking of a neighbour's dog, the howling of cats, or the cackling of a successful hen, and they haunt the magistrates' courts in efforts to suppress such noises. They put cotton in their ears, wear heavy nightcaps, stop clocks, board up windows in search of sleep, which is not found.
These patients commonly have an enduring feeling of weight or constriction in the head, especially at the occiput,—a headache that is not actual pain. They also have vertigo, which is independent of any aural disease, and this is transient, showing itself on abrupt changes of position.
Another phase of neurasthenia is spinal. These cases have pain in the back and their legs give out. The back-pain is a diffuse ache, or it manifests itself on pressure at certain spots along the spine. There may be severe pain at the coccyx, especially in women. The walking may simulate paralytic forms if hysteria is mixed with the neurasthenia. Cardiac symptoms are often prominent, especially palpitation, but there is a nervous excitation of the heart rather than any definite lesion.
The gastro-intestinal symptoms are often important. Pain referred to the stomach and acidity are common, the tongue is coated, the faeces scybalous. Digestion is torpid. Sometimes there is nervous diarrhoea. A list of the belly symptoms described by some neurasthenics is interminable.
We often find a sexual form, which is the worst of all and the hardest to cure. It is commonly connected with masturbation. Such neurasthenics are shameless in the description of their nastiness. It is better to keep them from marriage unless they are cured, and they are not to be foisted off on{233}any one as husband or wife to effect a cure. Allbutt says of them: "I fear that some of our 'criminal psychologists' are encouraging many sorts of prurient debauchees by dignifying the tales of their vice with the name of science, a course of conduct which is in the worst interests both of these persons themselves and of our own profession. It were a curious inquiry how it comes that sexual perversions are so 'scientific' a study, while the brutalities of the thieves' kitchen or the wiles of other pests of society lie in comparative neglect."
Physical, intellectual, or emotional strain can cause neurasthenia suddenly or gradually. Where it comes on without obvious cause there is commonly a bad family history of nervousness or alcoholism. Anaemia makes it worse; eye-strain, too, is a provoking factor. In some cases a renal congestion is the cause. In many cases a lack of restraint, bad education, uncontrolled passion, are a marked influence in fixing the neurasthenic habit. A sedulous parent nags at a neurasthenic child that is too weak for exertion until the child's susceptibility to correction is blunted. Instead of treatment and help the child receives cuffs and abuse, and hell-fire is held up before him until he deems all religious talk dust and ashes. Encouragement will sometimes do more good than all the threats in thevia purgativa. Nagging never cured anything except a tendency toward virtue, and it always deepens neurasthenia. Be careful in the selection of a confessor for a neurasthenic child. Get one that does not believe in kicking a soul into paradise.
The treatment of neurasthenia is difficult. Traveling about in search of health is not advisable. The Weir Mitchell Rest Cure is very effective in many bad cases, but it is costly, and if not correctly applied it is useless. It is the only cure for some patients. Sea air helps a certain class of neurasthenics, but it makes others worse—it is bad for the dyspeptic neurasthenic. A chronic rhinitis, a refractive error of the eyes, a displacement of the uterus, a congested kidney, a floating kidney, a tight prepuce, and similar teasing disorders must be cured before the neurasthenia can be removed; often the neurasthenia disappears with this cure.
Traumatic neurasthenia is like simple neurasthenia in{234}most details. It is called also nerve shock, spinal irritation, railway spine. There is always a causative shock or injury, which is followed at once or after an interval by the symptoms of neurasthenia. In acute traumatic neurasthenia there may be, in addition to the symptoms observed in simple neurasthenia, high fever, and such a fever has been observed to go as high as 113 degrees Fahrenheit.
AUSTIN ÓMALLEY.
{235}
The term Hysteria (uterus) has been handed down from the days when physicians thought there was a connection between womb-disorders and the set of nervous symptoms grouped under the title hysteria. It is now etymologically meaningless,—men also grow hysterical. Briquet found 11 male to 204 female hysterics, and later statistics increase the number of males.
The disease is not readily definable. The patient is usually a young emotional woman, oftenest between 15 and 20 years of age. She commonly has anaesthetic spots on her body, concentric limitations of the field of vision, and hystero-genetic zones, or tender points, which, when pressed, appear to inhibit the hysterical fit. The symptoms enumerated here are not, however, found in every case of hysteria, and it is difficult at times to diagnose the disease.
The various manifestations of hysteria are (1) apt to come and go suddenly. A severe paralysis that suddenly disappears for a time is hysterical; (2) even if they last for years they may be suddenly cured; (3) they are dominated more by mental and moral influences than are the symptoms of any other disease; (4) we find no organic lesion with which we can connect the symptoms.
The conditions that bring about hysteria are hysteria in a parent, or insanity, alcoholism, or some similar neurotic taint in an ancestor. There is no direct connection between hysteria and the disorders of the sexual organs.
Immediate causes are acute depressive emotions, shocks from danger, sudden grief, severe revulsions of feeling, as from disappointment in love; and, secondly, cumulative{236}emotional disturbance, as from worry, poverty, ill treatment, unhappy marriage, or religious revivals. Certain diseased conditions, as anaemia, chronic intoxications, pelvic trouble, cause hysteria, or, more exactly, start it into activity where it is latent. It is also communicated by imitation and it may become epidemic.
After the great plague, the Black Death, in the fourteenth century, there were very remarkable epidemics of imitative hysteria in Germany and elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women danced together in the streets until they fell exhausted in a cataleptic state. These dances spread over Holland and Belgium and went to Cologne and Metz. It is said that in Metz there were 1100 of the dancers seen at the same time.
"Dancing Plague" broke out again in 1418 at Strasburg, in Belgium, and along the Lower Rhine.
"Viel hundert fingen zu Strassburg anZu tanzen und springen Frau und Mann,Am offnen Markt, Gassen und Strassen;Tag und Nacht ihrer viel nicht assen,Bis ihn das Wüthen wieder gelag.St. Vits Tanz ward genannt die Plag."
Beckmann (Historia des Fürstenthums Anhalt. Zerbst. 1710) tells of a similar outbreak in 1237, wherein nearly a hundred children were seized by the disease at Erfurt, and they went along the road to Arnstadt, dancing and jumping hysterically. A number of these children died of exhaustion. The same infection is often at work in the fury of a mob, the panic of a beaten army, and it probably was an element in the Children's Crusade.
The Tarantism so common in Italy from the fifteenth to the eighteenth century is another example of epidemic hysteria. The Bubonic Plague ravaged Italy sixteen times between 1119 and 1340, and smallpox was at work when the black death could find no fresh victims. As a consequence of economic disturbance and fear the people were generally neurasthenic, and a slight shock was enough at times to set whole villages into hysterical convulsions.
{237}
In 1787, at Hodden Bridge in Lancashire, England, a girl in a cotton mill threw a mouse upon another girl that had a great dread of this animal. The frightened girl was thrown into a hysterical convulsion which lasted for hours. The next day three girls that had watched her were in convulsions, the following day six more, and two days later fourteen more girls and a man were in fits. American white and negro camp-meetings result in similar outbreaks, and the FrenchConvulsionnaires, who did outrageous things from 1731 to 1790, were also afflicted with imitative hysteria. The Cornish Jumpers, founded in 1760 by Harris Rowland and William Williams, and the American Barkers were also hysterical. The Barkers in the meetings would run about on all fours growling, "to show the degeneration of their human nature," and they would end in almost general fits of imitative hysteria.
There was an epidemic of hysteria in Tennessee, Kentucky, and a part of Virginia, which began in 1800 and lasted for a number of years. It started at revivals. The majority of the cases were in persons from 15 to 25 years of age, although it was observed in every age from 6 years to 60. The muscles affected were those of the neck, trunk, and arms. The contractions were so violent that the patients were thrown to the ground, and their motions there exactly resembled those of a live fish thrown out of the water upon the land.
There are numerous theories formulated to explain hysteria; some are ingenious, especially that of Janet, but none is convincing. Convulsions, tremors, paralyses of various forms and degrees are common in hysteria. In major hysteria the patient falls into a convulsion gently. There is checked breathing, up to apparent danger of suffocation. Then follows a furious convulsion, even with bloody froth at the mouth, but there is a trace of wilfulness or purpose in the movements. Next may come a stage of opisthotonos, where the body is bent back in a rigid arch till the patient rests on her heels and head only, and this is followed by relaxation and recurrence of the contortions. An ecstatic phase succeeds this, at times in the so-called crucifix position, with outbursts of various emotions, and a final regaining of a{238}normal state. Any of these stages, however, may constitute the whole fit.
In minor hysteria there is commonly a sensation of a rising ball in the throat (theglobus hystericus). There may be uncontrollable laughter or weeping. Muscular rigidity is frequently found. The patient, especially if she is a child, may mimic dogs and other animals. The snarling, biting, and barking of false hydrophobia are hysterical; these symptoms do not occur in real hydrophobia.
There are almost innumerable physical symptoms of the disease, which are chiefly of medical interest, but the mental phases are such as to involve questions of morality. The hysterical character is marked by an overmastering desire to be an object of general sympathy, admiration, or interest, rather than by a tendency to baser indulgence. The will is weak, the emotions explosive, the patient is impulsive and lacking in self-control. She is a "giggler," who goes from absurd laughter into floods of tears. The desire for sympathy and attention makes the patient exaggerate her symptoms or simulate diseases and conditions that do not exist in her case. Hysterics will swallow pins or stick them into their flesh to force attention. Sometimes the simulation of disease is not willed. If there are a number of hysterical girls in a hospital ward and one develops, say, a peculiar paralysis, within two or three hours every hysterical woman in the room will have the same paralysis,—not pretended, but real, although temporary. It must be remembered that the disease, with all its perversity, is as much a fact as pneumonia, and the element of sham is only one of its symptoms. Some authorities go so far as to hold that a woman who will not lie is not hysterical. They invent most extraordinary slanders against even their own immediate family, and it is never prudent to believe an accusation made by an hysterical patient, no matter how plausible the story.
Acquired hysteria in many cases may be cured, but the congenital condition is practically hopeless, yet the latter kind may be kept from violent outbreaks.
We can not prevent drunkards, epileptics, and lunatics from propagating their kind, and therefore we shall still have the{239}hysteric with us. The child that has a bad ancestry and shows hysterical tendencies should be carefully reared. If it has an hysterical father or mother it should, if possible, be removed from this evil influence. Keep it from long hours of mechanical work that leaves opportunity for dreaming. Shut out novels and "art for art's sake," especially music. Give it a practical education. Teach it obedience, self-control, and truthfulness. Harden its will by exercise at things it does not like, and do not coddle it. Do not marry off an hysterical girl to cure her. Do not inflict her presence upon some unfortunate young man because he is a good citizen. Marriage will not cure hysteria,—the worst cases are married women, and they beget other hysterics in spreading succession. When the disease shows itself offer no sympathy,—do not try to put out a fire with oil. When a "good, pious girl" grows hysterical, the chief obstacles to her cure are untactful and sympathetic visits from friends, lay and clerical. A visit from the pastor, because of his importance, is always harmful, and if the bishop drives up in his carriage so that the neighbours may see him, all the physicians in the city can not help her. If you wish to keep an hysterical girl in her vapours, get her a physician that will grow excited over her, take the dear child out of school and weep above her couch, let the family and its friends assure the unfortunate attending physician in her presence that he is heartless, and she will stay hysterical to her soul's content.
If you wish to control the attack, or even remove the disease under certain conditions, call in an experienced physician, leave the treatment to him, and pay no attention to her. Do not make light of the disease, do not speak of it at all. There are attacks that may be cured by the razor-strop or a bucket of cold water, but these are exceptional. They are new cases or old professional offenders. Rough treatment is not so good as patient tact, but at times roughness is the only cure.
AUSTIN ÓMALLEY.
{240}
Menstruation is a periodic discharge of blood from the uterus and the Fallopian tubes. It occurs every twenty-eight or thirty days, and it lasts from puberty to the menopause, or the cessation of the menses,—about the forty-fifth year of age.
There is a connection between menstruation and the production of the human ovum. During the first stage of menstruation the mucous membrane lining the uterus swells to twice or thrice its normal thickness, and this growth is a preparation for the reception of the ovum, which, as a rule, is given off by one of the ovaries at this time and passes out into the uterus. Menstruation and ovulation ordinarily occur simultaneously, but they may be independent and take place at different times. If, during this stage, the ovum is impregnated, pregnancy begins, and menstruation ceases until some time after childbirth. In married women conception is more likely to be effected during the first stage of menstruation than during the interval of quiescence; the contrary is almost the exception. Impregnation, however, is likely to occur in the spring more than at other seasons, and this fact coincides with the advent of spring in various latitudes.
If the ovum is not impregnated, the material that made the uterine mucous membrane thick during the first week of menstruation degenerates and passes off, constituting the menstrual flow. This stage lasts about five days. A reparative period of about four days follows, and then a period of quiescence until the next menstruation commences.
Menstruation is first observed about the fourteenth year, but it may start earlier or later. In general, it comes on{241}earlier in warm climates, and later in the extreme north. The menstruation, too, is likely to show sooner in the labouring classes than in girls who do not work.
Even in normal menstruation there is often a marked physiological excitation which affects the entire person. Very commonly a nervous disturbance and sensitiveness are observed, and in women that are not robust there may be mental depression and irritability. The temperature will rise a half degree, and drop to the normal height on the day preceding the flow.
There are derangements of menstruation which are symptoms of various diseases. Amenorrhoea is an absence of menstruation in conditions other than pregnancy or lactation. Absolute amenorrhoea is a complete absence of menstruation for several months; relative amenorrhoea is delayed, scant menstruation.
Amenorrhoea is common during convalescence from acute diseases; it is also a result of chronic diseases of the liver, stomach, intestines, kidneys, and especially of the lungs; it complicates anaemia, malaria, rheumatism, and other general pathological conditions. Fright, grief, great anxiety, mental shock cause amenorrhoea; so do homesickness and many forms of insanity.
There are also local causes of this condition: imperfect development of the uterus or the organs connected therewith, and inflammations of these organs or of the pelvic wall.
Opposed to amenorrhoea is menorrhagia, or an excessive menstrual flow. Metrorrhagia, or hemorrhage from the uterus at any time, is a term confounded with menorrhagia, which is an inordinate menstrual loss of uterine blood, but the distinction is not important. Menorrhagia and metrorrhagia commonly have an identical cause and they frequently coexist. They are found in chronic diseases of the heart, lungs, liver, and other organs; they are an outcome of prolonged lactation, and of local affections of the uterus and its appendages. Any condition also that deranges the blood may cause menorrhagia or metrorrhagia; so do malignant tumours of the uterus, uterine displacements, lacerations that{242}occur in childbirth, and psychical influences, as fright, anxiety, and other strong emotions.
Dysmenorrhoea, difficult or obstructed menstruation, is a term used for menstruation accompanied by pain. This is a common menstrual derangement, and it may be neuralgic or inflammatory in origin, or it may be caused by obstruction to the menstrual flow. There is another variety of dysmenorrhoea, called membranous, in which the superficial layer of the uterine lining is cast off partly or wholly.
In the neuralgic form the uterus and its appendages are normal in appearance, but the pain recurs monthly, and it may have degrees from mere discomfort to agony. This form is characterised by reflex headache, sympathetic nausea or vomiting; and the pain may not be confined to the uterus and its appendages. The irritation often brings out latent hysterical phenomena, spinal irritation, and neurasthenia. Rheumatism and gout are predisposing causes, so are indolence, lack of physical exercise, light clothing in cold weather, forced school work and similar depressing agents.
In the neurotic variety of dysmenorrhoea pain often persists after the menstrual flow has set in, but in inflammatory dysmenorrhoea the flow relieves the pain or removes it. Marriage commonly removes the neurotic form of dismenorrhoea.
In obstructive dysmenorrhoea the menstrual fluid is retained by narrow or tortuous outlets, flexions of the uterus, and similar causes. The prognosis is good in all forms of dysmenorrhoea, but frequently long and skilful treatment is required to cure such conditions, especially the membranous form. Inflammatory, obstructive, and membranous dysmenorrhoea are commonly made worse by marriage.
At the end of the childbearing period menstruation gradually ceases. In temperate climates this menopause occurs about the forty-fifth year, but it may come earlier or considerably later. Work that keeps a woman in a heated atmosphere, as cooking, washing, and baking, disturbs menstruation and tends to advance the menopause. Workers in chemical factories, in badly ventilated rooms, or women that do heavy labour in the open air, are apt to age prematurely, and have{243}an early menopause or "change of life." This premature climacteric is found also in women that bear many children in rapid succession.
At the menopause there may be various physical or mental disturbances which are probably due more to the somewhat abrupt advent of old age, at the cessation of the childbearing part of life, rather than to the menopause itself. It is a fact, however, that often profound disturbances coincide with the climacteric, and we know no sufficient cause for them if the menopause itself may not be deemed such.
There are numerous disorders of the nervous system in women which are dependent directly or indirectly upon a derangement of the pelvic organs. Distant parts of the body are affected pathologically through sympathetic irritation when the primary disease is in the pelvic organs, and direct treatment of the pelvic trouble alone cures these reflex conditions. The very common disorders of pregnancy, the marked physiological changes in women at the beginning of menstruation with puberty, and its cessation with the menopause, are among the first proofs of this assertion that occur. Menstruation may aggravate goitre, uterine fibroid tumours, skin diseases, and affections of the blood vessels. Disordered menstruation causes sleeplessness, melancholy, dementia, and mania, by affecting the brain; it may bring on local paralysis; start up latent epilepsy; excite reflex cough and difficulty in breathing; make the heart irritable; cause nausea, vomiting, dyspepsia, flatulence, diarrhoea, skin-inflammations, pain in the joints, and many other symptomatic phenomena.
Chorea ("St. Vitus's Dance") is caused by various irritatations, and dysmenorrhoea can be such a cause. If a person is disposed to hysteria by neurotic inheritance, idleness, sedentary habits, vicious practices, excessive development of the emotions, any affection of the uterus or its appendages will greatly aggravate the outbreaks. The same is true in neurasthenia; and uterine disorders can directly cause neurasthenia, a condition described in another chapter. Migraine is an extremely severe form of headache which arises from various excitations, and uterine disturbances are among the causes.
{244}
Insanity frequently appears in women at puberty, soon after marriage, during pregnancy or lactation, and at the menopause; at these periods disposed women are especially prone to outbreaks of insanity. Irritation and exhaustion from diseases of the pelvic organs are potent factors in bringing on insanity, although these conditions may coexist independently of each other. Symptoms should not be mistaken for causes, but pelvic diseases at least aggravate a tendency toward mental unbalance.
In an article like this it is not expedient to speak of treatment, but the conditions are described in outline so that the spiritual adviser may recognise the need of medical aid and suggest its employment. A woman suffering from pelvic disorders should be relieved from a labourious or responsible office until she has been cured of her disease, in her own interest and especially in the interest of those affected by her condition.
AUSTIN ÓMALLEY.
{245}
It is often of great practical importance to bear in mind that a number of affections, commonly not serious in themselves at the beginning, and sometimes giving very few external symptoms, may make the mental condition of the individual suffering from them utterly incapable of meeting grave responsibilities. This is especially true with regard to such positions as that occupied by the Superior of a religious community who may, during the course of an ailment that has a tendency to affect the mental condition, do things that involve the community financially, or make life so uncomfortable for their subjects as to cause them to abandon the religious life. Some of these ailments are very insidious and may develop utterly apart from all anticipation in persons that were previously healthy. The weight of responsibility itself may, by impairing the general health, bring on an aggravation of a previously mild chronic condition that will cause distinct mental deterioration, yet without the absolute production of such disturbance of intellection as will be readily recognised by those that are not brought intimately in contact with the individual.
Such cases are not uncommon in history. A distinguished specialist in mental diseases called attention, in the LondonLancetnot long ago, to the case of Nicias, the Greek general who was in charge of the Athenian expedition against Syracuse. Nicias undoubtedly had a genius for war and for politics when in normal health. Some of the mistakes committed by him, though, are of an order that indicate a lapse of mental control at certain times. Details given by a number of Greek historians point to the existence in Nicias of{246}symptoms of chronic nephritis, which at periods of great responsibility became exacerbated with consequent interference with normal intellection. The same authority points to certain otherwise inexplicable political mistakes in the life of Napoleon III. as due to the existence in him of a low-grade nephritis, consequent upon the presence of stone in the kidney. After his abdication, during his life in England, he had to be operated upon for this condition, and the calculi found had manifestly been in existence for many years.
Even more important for the sake of the individual himself than for those he is in contact with is the recognition of his pathological condition. Nothing is more likely to cause kidney disease to grow rapidly worse than responsibilities heavier than the individual is accustomed to. When, then, there are symptoms of nephritis it is inadvisable for the patient to be made Superior, and if the symptoms develop after his appointment or election he should be relieved of his responsibilities, at least to a considerable degree. There are a number of cases on record in which failure to realise the necessity for this mode of action has been a cause of great unhappiness in religious communities, and not infrequently a shortening of a very precious life that might otherwise have been spared for long years of usefulness in some less demanding position. It is not impossible that paresis should develop in the Superior of a religious community. The disease is extremely rare among clergymen generally, and the statistics of asylums show that it is rarest of all among Catholic clergymen. Should it occur, however, it must constitute a quite sufficient reason either for a change of Superiors, or for the institution of such other safeguards as may, according to the special religious institute, be provided in order to prevent serious evil.
In the religious communities of women, particularly, it has seemed to us that the occurrence of Graves' disease (the affection is three times more frequent in women than in men) in a Superior should always be the signal for relieving her of the responsible duties of her position. This action is quite as necessary for the patient's own health as for the peace and happiness of the community. The disease may exist in a{247}latent form and only develop strikingly after the assumption of the serious responsibilities of the position of Superior. When, however, the eyes are prominent, the pulse rapid, and the goitre, or swelling of the front of the throat, characteristic of the disease, is present, there are practically always mental symptoms that make it extremely inadvisable for her continuance in a position of serious responsibility. Professor Church of Chicago (Professor of Nervous and Mental Diseases and of Medical Jurisprudence, in the Northwestern University Medical School), in the last edition of his book onNervous and Mental Diseases, [Footnote 5] has this to say with regard to the mental disturbances of Graves' disease:
[Footnote 5: Nervous and Mental Diseases. Church and Peterson, 4th edition. Saunders, Phila., Pa., 1903.]
"From the beginning, and often for a long period antecedent to the appearance of cardiac symptoms, the subjects of Graves' disease present a considerable mental erethism. There is an indefinable and tormenting agitation, marked by mental and motor restlessness and an imperative and impulsive tendency to be doing. Their emotions are too readily excited, and they are unusually impressionable and irritable, reacting in an exaggerated manner to all the incidents of daily life. In more pronounced cases they become voluble and manifest the greatest mobility of ideas, but have no persistent concentration of logical order. Their affections are likely to undergo modifications, and they become irascible, fault-finding, inconsiderate, ungrateful, and hard to live with. In some instances this disturbance of mentation carries them over the border into active mania, marked, perchance, by delusions of fear, due to the cardiac symptoms of sensations of heat. Insomnia is often added and the fitful sleep is disturbed by horrifying dreams that are likely to be projected into the waking moments and woven into delusions which are usually unsystematised, and constantly changing, furnishing the analogue of the motor restlessness. Hallucinations of sight and hearing are not uncommon.
"The mental perturbance only rarely reaches the degree of actual mania, and then is, perhaps, equally dependent upon numerous other causes acting in a neurotic individual. But{248}a condition of abnormal mental stimulation is characteristic of the malady, and is as important an index as any of the cardinal triad." [Footnote 6]
[Footnote 6: Of physical symptoms, namely, the rapid heart, the prominent eyes, and the enlargement of the thyroid gland in the neck.]
Dr. Church considers, then, that the mental symptoms of the disease are as important a concomitant, and as little likely to be absent in any given case, as are any of the three or four well-known physical symptoms characteristic of the disease. Under these circumstances the necessity for the exercise of care in permitting such a patient to continue in the office of Superior must be manifest. It is a question not for religious authorities to decide but for physicians, and they are to be experts in mental diseases. There are many physicians who have had experience with cases in which Graves' disease has been a source of unfortunate conditions in religious life, owing to the failure to understand the relations of the physical affection to mental disturbances. At times unfortunate consequences follow that are irretrievable in the destruction of vocations and the impairment of the religious spirit in communities.
As a rule it may be said that the development of serious disease is almost sure to incapacitate a Superior from fulfilling the functions of office. This is true, however, not only for physical disease but for the so-called neuroses. These are maladies which have their basis in some disturbance of the physical constitution, though this is not always easy to find. We prefer to speak of them as neuroses rather than neurasthenia, because this latter name has somehow come to have an unwelcome sound and to carry with it the idea of imaginary rather than real ailments. A true neurasthenic, however, is supremely to be pitied.
It has often been noticed that such individuals, while perfectly capable of judging properly for others, are not able to form right judgments with regard to their own conditions. This principle, however, should not be taken as a rule, and it must not be forgotten that neurasthenics are often the subjects of compulsory ideas—so-called obsessions, in which they are not entirely responsible for actions performed. At such{249}times they are prone to be irritated by very trivial faults, and what is worse, to exaggerate slight defects into serious infractions of rule or of obedience. With regard to such persons, therefore, constant care has to be exercised to control their statements by those of others and not to take them at their full value without due substantiation. In this matter the subject is quite as likely to suffer as the Superior, and information obtained from them should not be acted upon without consultation with others who know the details of the case.
As a rule neurasthenic individuals become, as is well known, worse as far as the mental condition is concerned when they are asked to assume new responsibilities. This physical side of the choice of Superiors, and of those to be elected by members of the community, should always receive due attention, though sometimes it is entirely lost sight of. Not a few communities, however, have suffered in their usefulness and in the fulfilment of the design of their institute by the selection of Superiors whose neurotic conditions sometimes seemed to proclaim a high degree of piety, which was, however, rather emotional than practical. The physician's view of some of these cases would add materially to the knowledge of the character of such individuals.
It should in general be very clear that the development of any serious nervous disease, which is not likely to be cured by ordinary remedies or which requires freedom from responsibility as the first requisite for improvement, should be the signal for consideration as to a change of Superiors. Physicians see much more of the evil that may be worked in this way, and realise the true significance of what is often a sad state of affairs, much better than those who have not the secret of the cause of the unfortunate condition. It is almost needless to say that the question of obedience to some one whose responsibility is not complete, but is influenced by neurotic disturbance, becomes an extremely difficult problem for the subject, and one in which there is apt to be the feeling that it was not the original intention of his obligation of obedience to bind him under such circumstances.
With regard to women especially, it must be remembered that there is for them a period between the ages of forty{250}and fifty, during which for several years they are extremely unsuited for the responsibilities and exacting duties of a Superior. These years prove even to mothers of families, surrounded only by their own children and the ordinary circumstances of home life, a time of worry and irritation that plays sad havoc even with the best of dispositions. Mothers constantly complain to their physicians of an irritability of temper which they can scarcely account for, and which makes them do and say things which they are extremely sorry for afterwards. It is easy to understand, then, that a Superior with still more insistent duties when brought in contact with a number of persons, some of whom are almost sure not to be entirely sympathetic, is likely to suffer from irritation that is not a sign of absence of a fitting religious disposition, but only a physical manifestation of the physical strain through which she has to pass at this time of life. The years of the menopause, to be very plain, should not be allowed to make a Superior's life miserable and to add to the difficulties that a religious community always has to face in its relations to its Superior and to one another. Charcot, the distinguished French neurologist, used to say that women should never be asked to assume special responsibilities during the days of their monthly period, for their judgments are often warped by their physical condition. It is doubtful whether, in the majority of normal women, this is quite true, though the expression deserves to be remembered. There is no doubt, however, that the years of the change of life do bring on very serious modifications of the character of the individual, and occasionally these changes are lasting.
JAMES J. WALSH.
{251}
From the very earliest times epilepsy has been looked upon as a mysterious and in many ways an inexplicable disease. The Romans spoke of it as themalum comitiale, the comitial disease, because if an attack of it occurred during the meeting of the Roman people known as thecomitia, in which municipal officers were elected and other city business transacted, an adjournment was at once moved, and no further proceedings were considered valid. During more modern times, especially during the middle ages, and almost down to our own time, those affected by the disease frequently came to be looked upon as the subjects of possession by the devil. Hysterical manifestations were even more frequently considered signs of possession (diabolical manifestations) but even in our time it is not always easy to make the distinction between certain forms of hysteria and epilepsy. Many of these sufferers were considered as not responsible for their actions. In this respect, at least, the advance of modern medical science has only served to confirm the popular impression of less sophisticated times, and it has come to be recognised that quite a large number of the sufferers from epilepsy must be deemed lacking in responsibility.
There are few nervous diseases that have been more studied than epilepsy, and yet, because the ailment involves so intimately the relations of the nervous system and the bodily function, there are few diseases of which less definite opinions can be given. This is especially true as regards prognosis and the question of mental deterioration in any given case. As a matter of fact the extension of our knowledge of epilepsy, far from making the question of the responsibility of the{252}epileptic under trying circumstances more easy of solution, has rather served to show how difficult this problem must ever remain.
There are many forms of the disease,—the frank epileptic convulsion in which patients fall down, are seized with certain convulsive movements, become pale and lose consciousness for a time and then come to with an intense feeling of weariness which usually prompts them to sleep for some hours—too familiar to need further description. There are forms of epilepsy, however, quite different from these. In some cases, the attacks occur only at night, and unless the patient happens to be watched for some reason, there may be no trace of their occurrence, except perhaps a sore tongue where it has been bitten, or an intense feeling of weariness and depression in the morning. In still other cases, the physical signs are lacking almost entirely. There may be only a momentary loss of consciousness. A distinguished professor of medicine in this country used to have a momentary attack of confusion, during which he lost the thread of his discourse, and always within a minute, with a somewhat flushed face, he was able to go on, though he had to begin with another idea. The so-called psychic epilepsy, in which the symptoms are entirely mental and consist of some marked change of disposition for a time, are now universally conceded as constituting well-marked phases of the disease. Curiously enough it is with regard to these obscure cases, uncomplicated by serious physical manifestations, that there is most mystery; and they seem to affect the mentality and to disturb volition and responsibility more than the supposedly severer forms which cause convulsive attacks and are so easy of recognition.
Certain forms of masked or psychic epilepsy constitute the most puzzling problem that the expert in nervous and mental disease has to deal with where criminal acts are performed, apparently without sufficient motive, and yet where the limits of responsibility must if possible be determined. It is easy to dismiss these cases and to consider that because a certain amount of intelligence has been displayed in the performance of the act, and because the patient ordinarily understands perfectly the distinction between good and evil.{253}that therefore the will must have been entirely free in the accomplishment of the criminal action and the intellect must have understood what it was doing. As yet the general public refuses to take the standpoint of the expert in mental diseases in many of these cases; and only when clergymen also shall come to a realisation of the pathological elements undermining free will in these cases, that justice will be properly tempered, not by unworthy or misplaced charity, but by the mercy which, knowing all, has learned duly to appreciate what is and what is not criminal.
Epilepsy, in certain of its obscurer forms, is responsible for many conditions in which there is a sudden access of insane excitement of a violent, often very impulsive, character, though sometimes of very short duration. During this state the patient is practically irresponsible, and yet he may have sufficient control over his actions to enable him to work serious harm. Such a stage of excitement may last not more than an hour or two; usually all trace of it passes off in a day or two; before and after it the patient may be in perfectly sound sense and in apparently good health. One of our best authorities here in America, Berkley, in his treatise onMental Diseases, gives the following striking opinion on this subject.
"The subject of masked epilepsy and the consequent mania is replete with interest to the physician and the jurist, since such patients are prone to impulsive acts of violence and automatic states in which the most complicated, but entirely unconscious, actions and crimes may be carried out without premeditation on the part of the sufferer, being also out of all accord with his character during his intervals of mental health. Besides the irritability, impulsiveness is an equally characteristic feature. No form of insanity more frequently gives rise to assaults and murder than epilepsy, and in no form of alienation is the physician so frequently called to the witness stand to determine the responsibility of the criminal."
One of the most prominent features of all epilepsy is the well known tendency to irritability that characterises sufferers from the disease. This of itself is an index of the fact that{254}their responsibility is somewhat lessened, since they are unable to withstand even the petty annoyances of life without exaggerated reaction. Friends of epileptics know very well that it is a preliminary symptom of the coming on of an attack of epilepsy for the patients to become even more irritable than usual. Just after the comatose condition which follows an attack of epilepsy patients are also prone to be very irritable. An attack of epilepsy is really an explosion of nerve force, for no rational purpose, along motor nerves. This same tendency to an unwarranted explosion of energy is liable to occur along other nerve tracts that rule the patient's disposition.
The main symptom of importance in the case, and the one on which depends the recognition of the existence of the epileptic condition, is the actual occurrence of typical epileptic seizures. These do not always occur. Sometimes the periodic attacks take the form of what are called epileptic equivalents, that is, certain anomalous states of consciousness or disposition, which can be accounted for only on the supposition that there is some more or less latent explosion of nerve force in progress. At times even so simple a condition as migraine so nearly simulates epilepsy of the psychical type, because of its complications and sequelae and the regularity with which it occurs, that it has been spoken of as an epileptic equivalent. There is no doubt that, in successive generations, epilepsy and migraine may have a relation to one another that is something more than merely a coincidence.
A very interesting feature of epilepsy for confessors and spiritual directors is the tendency to religious emotionalism which so often accompanies what is called idiopathic epilepsy. This means epilepsy that develops without a direct cause, and which is evidently dependent on some essential defect of the nervous system of the individual. In asylums epileptics that have become irrational are known for their religious manifestations, and very often for perversion of their religious tendencies. As has been well said, an epileptic may carry his Bible under his arm, read passage after passage from the Scriptures, sing psalms continuously, and yet be so{255}ungovernable as to be a nuisance, and so irritable towards his fellow patients and attendants as to be a constant source of worriment. He may read just those passages which have reference to love and charity for one's neighbour and dwell on them until they become a bore by repetition, and yet in a moment of irritation implore to be allowed to get hold of some deadly weapon in order to kill the usually inoffensive person who has done him some imaginary injury.
This last is a marked feature of the disease, for epileptics are prone to foster fancied grudges, and to consider without due reason that they have been ill treated. This is especially true with regard to their relatives or to those in attendance on them, and must be always borne in mind when the subjects of epilepsy bring tales of woe and persecution, which they pour out to anyone who will listen to them, and especially to anyone whom they think will set them right. These fancied wrongs are as real to the patients themselves as if they had suffered from actual maltreatment. The idea of revenge may easily obtrude itself. It can be kept under control, as a rule, during ordinary health, between attacks, but just preceding or after an attack it may very well become of the imperative character that sets an uncontrollable impulse at work.
On the other hand, no class of patients is apt to exhibit the low cunning of the insane in so marked a degree as the epileptic. Not only this, but even during ordinary health between attacks they may, owing to their disposition, plan cunningly to simulate some of the symptoms of an attack and then accomplish a really malicious purpose with deliberation. In a word, these patients present to the alienist the most serious problem in the calculation of responsibility that can possibly be imagined. As an expert has declared, "It is ofttimes impossible to decide whether an assault has been committed with full consciousness, or in a transient but blind epileptic fury."
There are a series of attacks that occur in which there are some almost typical convulsive movements followed by loss of consciousness that simulate epilepsy very closely, yet are not true epilepsy. These attacks are usually due to some{256}cerebral affection or perhaps to some injury of the brain. Chronic intoxications, that is, the long continued presence in the body in noxious quantities of some poisonous substance, are especially liable to cause these attacks, which are called from their character epileptiform. Characteristic epileptiform convulsions occur as the result of lead poisoning or from alcohol or syphilis. Lead poisoning, for instance, may very well occur in others than those engaged directly in the manufacture or handling of lead. Certain persons are extremely susceptible to the influence of lead. In them such small amounts as are contained in a hair-dye, or even in water that is being used by others without any bad effect, may cause particularly the nervous symptoms of lead poisoning.
Chronic alcoholism is also a relative term in this regard. Some persons are able to stand very large amounts of alcohol without serious consequences, even though it is taken for long periods. Others succumb to its influence very rapidly; some especially susceptible people are liable to suffer from epileptiform convulsions almost whenever they take alcohol to excess. This masked epilepsy may take on an anomalous form. The story is told of a student of a Catholic college in the eastern part of this country, who, during one vacation, was given as a joke by some friends a rather strong dose of liquor in a glass of ginger ale. He was very thirsty at the time and did not notice the presence of the alcohol until he had swallowed the whole glass. As he was well aware himself he was extremely susceptible to the influence of alcohol. During the course of half an hour he became almost wildly drunk, and going down the street with an open pocket-knife he murdered the first person whom he met, who happened to be an entire stranger to him. The occurrence took place in New Jersey, and, in spite of every influence that could be brought to bear—the incident took place some thirty years ago—Jersey justice would have its way and the young fellow of less than twenty was hanged.
The epileptiform attacks that occur in the midst of these intoxications are quite as likely to be accompanied by various forms of mental disturbance as are attacks of true{257}epilepsy. Only one feature with regard to them is more favourable, and that is that the ultimate prognosis is not bad. The neutralisation of existing poison in the system, and the prevention of further ingestion of the toxic material, puts an end to the tendency to epileptiform convulsions, as a rule, and also to the mental symptoms associated with them.
Epilepsy remains, notwithstanding all the advance in modern nervous pathology, quite as mysterious a disease as it has ever been. It matters not what its cause, or how slight it may be, sooner or later it is almost sure to be followed by mental disturbance and deterioration of intellectual and will power. At times there are periodic attacks of mental perturbation that may become true insanity. Even the mild form of epilepsy known as Jacksonian epilepsy, and consisting not of general convulsive movements, but of convulsive movements in only one member or one side of the body, are, if allowed to continue, followed by some mental disturbance. It would seem as if the explosion of nerve force in the brain centres,—which, physiologically speaking, an attack of epilepsy evidently is,—causes eventual deterioration of the physical basis of mind and will, so that mental operations can no longer be performed with their wonted expertness or accuracy, nor decisions made as rationally as before.
In general, it is well understood that the more serious the epilepsy the more liability there is of the development of permanent mental disturbance. The earlier in life the epilepsy declares itself, too, the more unfavourable is the prognosis as to the enduring retention of complete mental sanity. In people in whom the epilepsy commences late in life, the process of mental deterioration does not begin to be noticeable so soon as when it occurs in younger years, and besides, it practically never runs a rapid course. Epilepsy, however, developing late in life, unless for some special cause, as injury or the development of syphilitic tumours in the brain, is an extremely rare affection. Idiopathic epilepsy, that is, epilepsy for which no definite cause can be discovered, is usually dependent on hereditary instability of the nervous system and is typically a disease of early years, of childhood{258}and adolescence. According to the best authorities, about one-fourth of the cases of epilepsy make their appearance before the age of 7 years. Over 50 per centum of all cases develop before puberty. About one-third of all the cases develop between 14 and 20. And even of the remaining, less than 20 per centum, over 12 per centum develop between 20 and 25, leaving scarcely more than 5 per centum for all the remaining years of life.
Of course, even in severer forms of epilepsy, mental disturbances do not appear at once. It sometimes takes many years for the constantly recurring manifestation of explosive nerve force to produce the deterioration that gives rise to lowered rationality. Distinct mental deterioration is eventually inevitable, though modern experience with epileptic colonies, in which patients are enabled to live a quiet life, most of it in the open air and under conditions of nutrition and restfulness especially favourable for their physical well-being, shows that the development of insanity may be put off almost indefinitely.
There are many advertised cures for epilepsy. None of them is successful, and all of them may do harm. The bromides have a distinct effect in lessening the number and frequency of seizures, but if taken to excess they have a serious depressing effect upon the patient. There have been more cases of mental disturbance among epileptics, and intellectual degeneration sets in earlier, since the introduction of the bromides, than before. It is the abuse of the drug, however, not its use, that does harm. More important than any drug is the care of the patient's general health. The digestion must be kept without derangement; the bowels made regular; all sources of worry and emotional strain must be removed. Patients should as far as possible live in the country, and farm life has been found especially suitable. Relatives are often a source of irritation rather than consolation to these patients, and the life in epileptic colonies has been found eminently helpful.
JAMES J. WALSH.