Essays In Pastoral Medicine Part 22

In minor hysteria there is commonly a sensation of a rising ball in the throat (the _globus 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 a.s.sure 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 oMALLEY.

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XX

MENSTRUAL DISEASES

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 p.u.b.erty 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 pa.s.ses 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 lat.i.tudes.

If the ovum is not impregnated, the material that made the uterine mucous membrane thick during the first week of menstruation degenerates and pa.s.ses off, const.i.tuting 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 cla.s.ses 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 p.u.b.erty, and its cessation with the menopause, are among the first proofs of this a.s.sertion 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.

Ch.o.r.ea ("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.

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Insanity frequently appears in women at p.u.b.erty, soon after marriage, during pregnancy or lactation, and at the menopause; at these periods disposed women are especially p.r.o.ne 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 oMALLEY.

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XXI

CHRONIC DISEASE AND RESPONSIBILITY

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 antic.i.p.ation 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 London _Lancet_ not 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 const.i.tute a quite sufficient reason either for a change of Superiors, or for the inst.i.tution of such other safeguards as may, according to the special religious inst.i.tute, 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 a.s.sumption 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 on _Nervous 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 p.r.o.nounced 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 a.n.a.logue 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 circ.u.mstances 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 const.i.tution, 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 p.r.o.ne 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.