Ex Libris C. K. OGDEN THE NEW LIBRARY OF MEDICINE EDITED BY C. W. SALEEBY, M.D., F.R.S.E. FUNCTIONAL NERVE DISEASES FUNCTIONAL NERVE DISEASES A. T. SCHOFIELD, M.D HON. PHYS., FRIEDENHEIM HOSPITAL LIFE IS NOT FORCE, IT IS COMBINING POWER. ' IT IS THE PRODUCT AND PRESENCE OF MIND ' " PROFESSOR BASCOM WITH THREE DIAGRAMS METHUEN & CO. 36 ESSEX STREET W C. LONDON First Published in igo8 PREFACE THE subject of Functional Nerve Diseases has been here approached from a somewhat novel standpoint. Hitherto these diseases have been treated pretty much after the same method as all other diseases, and only the most casual allusions have been made to Psychic treatment in connection with them. Once we recognise that the description "functional" really means "psychic," just as "organic" means "physical," we shall agree that diseases in this former cate- gory stand in close and necessary connection with the relation of mind to disease. It is quite certain that mind has taken a large share in the causation of many of these Functional Nerve Diseases ; and it is therefore not unreasonable to expect that it should play a considerable part in their cure. A. T. S. 19 HARLEY ST., LONDON, W. January, 1908 CONTENTS CHAPTER PAGE I. INTRODUCTORY . . . . i II. PSYCHOLOGY OF THE BRAIN. . . 17 III. GENERAL ^ETIOLOGY OF FUNCTIONAL NERVE DISEASES . . . . 55 IV. ^ETIOLOGY OF HYSTERIA . . .73 V. PHYSICAL SYMPTOMS OF HYSTERIA . , 93 VI. PSYCHICAL SYMPTOMS OF HYSTERIA . . in VII. ETIOLOGY OF NEURASTHENIA . . 126 VIII. SYMPTOMS OF NEURASTHENIA . . . 135 IX. DIAGNOSIS IN FUNCTIONAL NERVE DISEASES 156 X. PSYCHOTHERAPY .... 169 XI. THE REST CURE % . . . 199 XII. GENERAL TREATMENT . . . 234 XIII. NERVES IN CHILDHOOD , . . 258 XIV. OTHER FUNCTIONAL NERVE DISEASES . 270 XV. QUACKERY . * , 2 9 6 INDEX . . . . 317 DIAGRAMS PAGE SENSORI-MOTOR ARCS . 2I COURSE OF NERVE CURRENT 28 SUGGESTION . . .... . -193 FUNCTIONAL NERVE DISEASES CHAPTER I INTRODUCTORY U NOTIONAL nerve diseases occupy a -L vague, ill-defined and unscientific territory. No two writers can agree upon what they mean by the phrase, or arrive at the same conclusions on the diseases to be included, while many take refuge in avoiding the subject altogether. The word " disease " is vague enough in itself. It is defined as " a deviation from the standard of health in any of the functions or component materials of the body," but this is surely misleading, for we all experience countless deviations in function and component materials that do not constitute disease. " Disease," says H. Campbell, "is an abnormal mode of life." There is not much help here, for there are many abnormal modes of life that do not constitute disease. Clifford Allbutt, in despair, takes 2 FUNCTIONAL NERVE DISEASES refuge in a remarkable simile and says, " To define disease is to build a wall round a stick, round nothing, in fact, that needs definition." There can be no doubt that in disease there is a deviation from the normal state, though this cannot be taken as its definition, and to measure any deviation from health, the bounds of the latter must first be known ; and here we encounter one of the first practical difficulties met with by the student of functional nerve diseases. It is easy, of course, to diagnose deviations from health when you have before you a case of small-pox with a copious eruption or croupous pneumonia with a high temperature ; but when a patient enters your room with a nervous, jerky manner and complains of weak- ness and loss of memory, how is it possible to measure the departure from health, or even diagnose the condition as abnormal without knowing the normal ? It is essential in dealing with functional disease that some conception be first formed of what the patient regards as health, for in no two people is the standard alike, nor can it be fixed by the doctor ; and amongst none does it vary so much as with nerve sufferers. 1 1 Carlyle, in a letter dated February 25, 1859, sa Y s on health : "It is curious to remark that ' Heilig ' in our old INTRODUCTORY 3 To return to disease. The gradations between health and disease are not infinite in number, nor are they all equally well marked ; and though as a fact Natura nihil facit per saltum, nevertheless in clinical medicine the saltus is often sufficiently well marked for diagnosis, which otherwise would be impossible. Disease is a perturbation that contains no elements (save an invading germ) essentially different from health, but elements presented in a new form and in disorder ; hence diseases are frequently called disorders. They cannot be classified into genera and species. Certain morphological groups are found with sufficient connecting links for broad classification, but intermediate types are always cropping up. When there is any distinct proclivity to any special group of diseases we speak of a diathesis, which signifies any bodily condition, however induced, in virtue of which the individual is, through a long period or his whole life, prone to suffer from some special type of disease. A diathesis is generally hereditary, but may be acquired. Teutonic speech is both holy and also healthy j that the words holy and healthy, as our antique fathers understood them, are one and the same. " We, sure enough, have completely contrived to divorce holiness (as we call it) from health, and have been reaping the fruits very plentifully during these fifteen hundred years." 4 FUNCTIONAL NERVE DISEASES Temperament is another old but useful con- cept that sums up the combined psychical and physical peculiarities of an individual, exclusive of any definite tendency to disease. Diathesis may therefore be called the pathological temperament. Temperaments have been classed in various ways. One of the most useful is into four bilious, sanguine, lymphatic, and nervous. There is no need to describe these here, especially as they rest on no scientific basis, but I may briefly sum up the classical features of the one with which we have to do here the nervous. In this temperament the nervous and psychic element so prevails over the somatic and physical that full control over the former is difficult. The skin may be dark and earthy, or pale, or delicately tinted ^with colour in fact, of any shade and is often hot and dry. The skull may be large in proportion to the face, the features small, the eyes quick, large, and lustrous, the muscles spare, the veins large, the face characterised by energy and intensity of thought and feeling, the movements hasty, often abrupt and violent, or else languid. The hands and feet are small, the frame slender and delicate. Insomnia is common, and also addiction to some form of stimulant tea, coffee, or alcohol. This class is specially prone to functional nervous disorders. They always seem either to be able to do more than they are INTRODUCTORY 5 doing or to be doing more than they are able. There is a general want of balance as well as of control. The character on one side is often admirable for its powers of mind, depth of emotion, and lofty imagination ; while on the other it may be disfigured by some vice or unruly passion. To this class belong the most intellectual of the race, the wittiest, the cleverest, the most attractive the leaders of mankind. These are the poets, the men of letters, the students, the professors, and the statesmen. Their great danger is loss of self-control. They feel pain acutely ; nevertheless they can at times endure long fatigue and privation. Before leaving diseases we must glance at one more conception of it which was well stated by Sir F. Treves at Edinburgh in 1905. He says, " The prevailing idea of disease is something evil in origin, evil in intention, evil in effect. The popular view is that it is a calamity, and such is the attitude of the medical man." " Disease," he proceeds, " is not one of the ills the flesh is heir to, but one of the good gifts ; for its motive is benevolent and protective. If it were not for ' disease ' in the popular sense, the human race would soon be extinct " (!). Such a view is, of course, not only wildly paradoxical, but, without a good deal of explana- tion, extremely incorrect. It is quite evident that 6 FUNCTIONAL NERVE DISEASES what Sir Frederick speaks of is not disease itself at all (whatever that may be), but its symptoms. For, as most diseases are now zymotic, it is abundantly clear that the germs are neither benevolent nor protective, but the reverse. It is the symptoms set up by their presence which are, as Sir Frederick points out, the result of good motives (implying mind) that are beneficent ; and few people absolutely confuse the one with the other. Sir Frederick would be more intelligible if he had used the French word " mal-adie," which does imply evil rather than disease (French des, without, aise, ease), which expresses no opinion. My object in quoting this view is not only to show the purposive character of symptoms as recognised ; but I may also point out that while their beneficial character is seen even in Neuras- thenia, it is absent, and for a very special reason, in Hysteria. We shall see why this is so when we come to consider these diseases. To sum up, then. Disease is the correlative of health, and both words are incapable of accurate definition. To know the presence of the former, one must be acquainted with the " norm " of the body, which is the same in no two cases ; and this knowledge is especially essential in functional nerve disease. If the definition of disease be so unsatisfactory and indefinite, I fear we shall find the words INTRODUCTORY 7 " functional nerve" still more so. In the first place they constitute the most recent additions to our great family of benefactors (Treves), and their features are as yet unformed and hard to recognise. Nervous sufferers undoubtedly are a numerous class, and this from two causes, one of which is not fully recognised. Modern civilisa- tion has not only destroyed for ever the leisure and quiet of simple country life, but on the one hand, by its perpetual hustle and competition, has put an ever-increasing strain on the nervous system, while on the other (and it is this that requires to be recognised) it always tends to preserve and propagate the weak stock by a care of the unfit that was formerly unknown. Func- tional nerve sufferers are thus the direct and indirect products of our age in increasing numbers. This class of disease is indeed sweeping over civilised society like a plague. Dr. Goodhart even ten years ago, remarked : "as the world grows older it tends to grow more nervous." I do not see how it can well be otherwise. It is brain pitted against brain, and ever increasingly so. It is not liver against liver, or heart against heart, or only indirectly so. Of course, medical men, accustomed to hypertrophied hearts and similar instances of adaptation to meet increased 1 Dr. Goodhart, Lancet, October 30, 1897. 8 FUNCTIONAL NERVE DISEASES strain, argue, and rightly, that the brain of man is quietly evolving to higher powers, and becoming better and better able to resist the pressure of its environment. This may be so, but still break-downs must be most frequent where the strain is greatest, and the battlefield of life is increasingly on a psychic rather than a physical plane. Functional nerve diseases, ranging in their effects from slight physical defects to severe mental disturbances, are at any rate increasing by leaps and bounds ; and there is scarcely a family in this country but has suffered in some of its members from this trouble in one way or another. In classification, functional nerve diseases labour under the disadvantage that, no organic change being known, they must be grouped by their symptoms, and no clear definition can be given of any disease until its pathological basis is known. All diseases are either organic or functional that is, classed according to physical or psychic signs : for all structural changes are materialistic, or changes of physique ; whereas all functional changes are vital, psychic, and connected with life. Organic changes exist when life has passed, but functional changes have then all disappeared. This distinction is profound, and INTRODUCTORY 9 obviously bears radically on the true under- standing and treatment of this entire class. The diseases I here speak of are necessarily grouped according to their psychic phenomena, and not according to physical changes. The ego, or personality, is psychic, and the mind is one, and hence in these diseases the person himself is ill in a sense often not found in other diseases, and it is in functional nerve disease where that saying "If one member suffer, all the members suffer with it," is profoundly true in a way it is not in many organic diseases. There can, of course, be no change in functional activity, by increase, diminution, or perversion, without coincident changes in the plasmode. Hence, strictly speaking, there can be no such thing as pure functional disease as distinct from structural disease, any more than there can be any expression of mind apart from the body. Disease, au fond, has always a material basis, whether recognisable or not, and " functional " and " organic " are but expressions of our ignorance that will one day be superfluous. It is important to see this, and that, inasmuch as our propositions regarding diseases are but tentative and provisional, if they are prematurely crystallised into laws and dogmas they cramp all thought and obscure the truth. This is especially true in functional nerve diseases. io FUNCTIONAL NERVE DISEASES In dealing with these we must be equipped with a due sense of proportion between physio- logical and psychological action, and above all other requirements possess an abundant supply of that rare sense miscalled " common." Doctors are so impressed with their role as physicians of the body that they are often at a loss when they have to deal with these diseases, that so combine the physical with the psychic. The study of these nerve diseases requires reasoning as well as observing powers, and it is a curious fact that while the former are but little cultivated in our modern schools, the latter are fostered to an amazing extent. It is impossible in any case to be a physician for the body alone, and yet Professor Drummond (Durham University) is still (1906) able to make this remarkable statement : " Instruction con- cerning these matters (psycho-physical) forms no part of the curriculum of medical students nor of the training of the nurse. We examine a patient from head to foot with instruments of precision, but often forget to cast a glance at the combined psycho-physical personality. In functional nerve disease such an omission is fatal to success. Indeed, the difference between the veterinary art and medicine is only that of the clientele, once the mind is left out." All functional nerve diseases have a psychic INTRODUCTORY 11 element that requires recognition and psychic treatment. There are pure psychoses or insanities neuro- psychoses, such as hysteria, and neuroses, such as neurasthenia. Insanities were formerly thought to be possessions of evil spirits, to be cast out, and only slowly were classed as diseases ; and in the same way nerve diseases have been since supposed, not unfrequently by medical men, to be possessions of lying and evil spirits which friends have tried in vain to cast out, and are now being classed as diseases. The Middle Ages drove away these evil spirits by exorcisms ; the most modern method is to cast out the pathogenic idea by suggestion. Before the present recognition of functional nerve diseases as a distinct class, the various symptoms now grouped under Neurasthenia, Hysteria, &c., were treated as distinct diseases, and labelled cephalgia, rachialgia, dyspepsia, &c. Now the mental link that binds them all together is discovered, and this makes the unity. Of course, there is always variety of type. When we consider that no two nervous systems are ever alike, it must specially be so in functional nerve diseases. If one hundred children taught in the same school by the same schoolmaster write a hundred different hands, and if no two of their finger-tips are alike in their marking, it is 12 FUNCTIONAL NERVE DISEASES evident that, whether the disease be more psychic or physical, in either case the varieties will be endless, and all that can be done is to classify loosely without rigid boundaries. There can be no doubt of the great importance of this class of disease. In the first place, the personality itself of the individual is ever more or less profoundly affected. In the second place, the central nervous organism whereby the psychic expresses itself physically is diseased ; and thirdly, inasmuch as this nervous organism presides over every system in the body, and especially over the cardiac-vascular, on which life itself depends, this and other systems become deranged, though, fortunately, not often to the extent of causing a fatal end. It must not be imagined for a moment, because functional nerve diseases have not long been known as such, that " nerves " are, as is some times supposed, a modern invention. They have flourished under many names, in all ages, and amongst all peoples. What we now call neurasthenia has been variously termed vapours, nervous fever, nervous debility, general neuralgia, neurospasm, nervous wasting, cerebro-cardiac neuropathy, nervous cachexia, general neurosis, and, if partial, topoalgia, rachialgia, &c. When we come down to the present time and INTRODUCTORY 13 attempt to make a list of what are Functional Nerve Diseases and what are not, we find our- selves in inextricable confusion. In the nomen- clature of diseases by the London Royal College of Physicians I find a list of one hundred and thirty-nine nervous diseases given. When I say, however, that amongst them are included bedsores, convulsions, hypersesthesia, anaesthesia, stammering, hiccough, &c., it is evident our list may be of less dimensions. The other extreme is perhaps reached by Dr. Clouston, who says that clinically there are four types of Functional Nerve Disease : 1. Feigned disease, malingering, &c. 2. Functional disease dependent on obvious organic origin. 3. Neurasthenia. 4. Hysteria. With regard to even these four the ground is not clear ; for the first is surely not a disease at all, but a fraud, the appropriate treatment being a cell in a prison rather than a bed in a hospital. The second includes a large class open to question as to their right to be classed as Func- tional Nervous Diseases. Nos. 3 and 4 are, of course, the two diseases that by universal consent belong to the category. Another list includes twenty or more arranged as follows : FUNCTIONAL NERVE DISEASES FUNCTIONAL NERVE DISEASES. i. Neuroses of primary de- generation. 2. Acquired neuroses. a. Primary neurasthenia, hy pochondria. b. Epilepsy. c. Hysteria major. d. Hereditary chorea. e. General spasmodic tic. / i. Chorea, ii. Tetany. iii. Rabies, iv. Tremors. v. Neuralgia, i. Neurasthenia, ii. Hysteria, iii. Exophthalmic goitre, iv. Occupation neuroses. c. Acquired de- ( i. Tic doloureux. generation I ii. Local spasmodic neuroses. | tics. I iii. Paralysis agitans. d. Muscle, vasomotor, trophic and sleep disorders. a. From infec- 1 tion and -I poisons. b. Exhaustion and nerve shocks. This list appears to me a sample of the evil of attempting to accurately tabulate this class of disease, of which in most instances the pathology is too obscure to justify any such arrangement. Who, for instance, can accurately distinguish the two hysterias, the two neurasthenias, or the pathology of general and local tics ? A list of functional nerve diseases of doubtful organic origin (mostly spinal) is as follows : INTRODUCTORY 15 Tetanus. Ideal paralysis. Tetany. Chorea. Torticollis. Spinal neurasthenia. Hydrophobia. Toxic spinal paraplegia. Paralysis agitans. General paralysis of the Writer's cramp. insane. Functional spinal paralysis. Tetanus and hydrophobia and general paralysis of the insane must obviously be excluded, both going beyond mere disturbance of function, and as far outside the category of functional nerve disease as angina pectoris. Tetany and paralysis agitans occupy a doubt- ful position and might be included ; others are mere varieties of neurasthenia or hysteria. After due consideration of this perplexing subject I have decided to include twelve func- tional neuroses in my list, six of which are more or less doubtful. The first six are : Hysteria. Neurasthenia. Hypochondria. Occupation neuroses. Paralysis agitans. Neuralgia. And the six doubtful are : Migraine, selected as the headache that can be classed as a disease and not only a symptom. 16 FUNCTIONAL NERVE DISEASES Chorea. Torticollis a doubtful disease. Tetany. Vertigo (not true Meniere's disease). Exophthalmic goitre, whose increasingly obscure pathology entitles it to be classed among Functional Nerve Diseases. This list makes no claim whatever to scientific accuracy, and probably no one else would make the same list. But as so far I have found no two writers who agree in their lists, which include all numbers of diseases from 4 to 139, I am not peculiar in this. CHAPTER II PSYCHOLOGY OF THE BRAIN IT has been well said that, as a rule, the brain only concerns the ordinary physician on its physiological and anatomical side, as in the case of anaemia, hypersemia, hemorrhages, new growths, inflammations, and lesions of all sorts, its func- tional disorders being mostly handed over to the alienist ; though we must be quite clear that our present subject of functional nerve disease forms no part of the domain of the specialists in lunacy. It will, indeed, soon be found that not only pre-eminently in nerve diseases, but in all other classes of disease, the study of the functions of the mind connected with them becomes more and more the province of the general physician. I have said " functions of the mind" pur- posively, though I well know how very difficult it is to draw the line between mind and brain in their actions. The intelligible connection of the two is well expressed by Dr. Browne : "The great character of current opinion appears to be that wherever there is nerve there is psychical function, actual i8 FUNCTIONAL NERVE DISEASES or potential, which may rise within the range of consciousness. Not only is there apparently inseparable connection during life between the nervous structures and mental phenomena, but the latter are clearly dependent on the former. The ordinary condition of the nervous system is like that of a moderately-charged battery that can be discharged by the completion of the circuit and recharged by the blood. The will can complete the charged circuit. Mental causes can produce physical effects and physical causes mental effects." I would here point out, however, that though we may be absolutely certain that (as Professor Bain puts it) with all our mental processes there is an unbroken natural physical succession, it by no means necessarily follows, as Dr. Browne suggests, 1 that with every physical change in the brain there is a necessary mental change. It may be so, but this sequence has not so far been generally recognised or proved, and it is probable that vast numbers of minor vasomotor, nutritive, functional, and other changes of the brain do not affect the mind ; whereas, on the other hand, it is perfectly certain that there is no mind action, however slight, that does not produce (I do not say arise from) some physical change. 1 Dr. W. A. F. Browne, in Journal of Mental Science, vol. xii. p. 321. PSYCHOLOGY OF THE BRAIN 19 Herbert Spencer says : " No thought, no feeling, is ever manifested save as the result of a physical force. This principle may now almost be said to be a scientific commonplace." l Having thus marked the intimate connection and interdependence of mind and brain, we must, to keep the balance of truth, equally insist on the radical distinction between the two. " The intelli- gence of men," says Calderwood, "as known in personal consciousness, is of a nature entirely dis- tinct from any sensory apparatus. Mind is not a mere product of cerebral evolution." 2 Again Herbert Spencer sounds a timely note of warning : " Here, indeed, we arrive at the barrier which needs to be perpetually pointed out alike to those who seek materialistic explanations of mental phenomena and to those who are alarmed lest such explanations may be found. The last class prove by their fears, almost as much as the first prove by their hopes, that they believe that mind may possibly be interpreted in terms of matter, whereas . . . there is not the remotest possibility of so interpreting it. For the concept or form of matter is but the symbol of some form of power absolutely and for ever unknown to us. Mind is also unknowable, and 1 Herbert Spencer, " First Principles of Psychology." 2 Professor Calderwood, "Relations of Mind and Body," P- 307- 20 FUNCTIONAL NERVE DISEASES the simplest form under which we can think of its substance is but a symbol of something that can never be rendered into thought. Never- theless, were we compelled to choose between translating mental phenomena into physical phenomena or translating physical phenomena into mental phenomena, the latter alternative would seem the most acceptable." I This again, like so many utterances, is much more correct in what it affirms than in what it denies. Truth is so much greater than our- selves that it is well for the most profound philosopher to remember the maxim, "Affirm, and deny not," and especially " Never prophesy." Already Herbert Spencer's assertion that the power of which matter is the symbol must be "absolutely and for ever unknown" is partially disproved by Lord Kelvin, who has rendered it reasonably certain that the force of which it is the symbol is electricity, and that elec- trons seem as clearly the meeting-point of force and matter as neurons are of mind and brain. For our purpose of considering the function of mind, besides the obvious divisions of the brain into greater and lesser, or cerebrum and cerebellum, and into two halves, right and left, 1 Herbert Spencer, " First Principles of Psychology," 2nd edition p. 63. I.CORTEXOR UPPER BRAIN CO RTEX r cs"s | o \j /no t or ^ ^ r T U ^SPIRIT A .enjory nen* current proceeding from