"ONLY NERVOUSNESS." BY HERMAN CANFIELD, M.D., HOPEWORTH SANITARIUM, BRISTOL, R. I. REPRINTED FROM THE Neto Vortt iHeUfcal .SJeutnal for January 11, 1896. Reprinted from, the New York Medical Journal for January 11, 1896. "ONLY NERVOUSNESS.'** By HERMAN CANFIELD, M. D., HOPEWORTH SANITARIUM, BRISTOL, R. I. If any of you are expecting to hear a scientific dis- course upon the subject chosen by me to-night, you will be greatly disappointed, and have my free permission to set- tle yourselves comfortably for a nap, while I impose upon the patience of our good president for the short space of a quarter of an hour. Upon second thought, perhaps, you would better keep awake, as what little I have to say touches one phase of your daily labor, which, if rightly appreciated, proves the biggest little thing among the great mass of little things which together influence your success in your profession. Unfortunately, as we all know, it is not the most learned, the most intellectual, or the most skillful in strictly scien- tific matters who succeeds best in a practical way in our profession. Briefly, it is the one who can " make himself most solid " with his patients; and the real mainstay, the one sure, steady source of income to every doctor is his nervous patients. If he can handle this class, manage and control them, his success is assured. * Read before the Society of Alumni of Bellevue Hospital, Novem- ber 6, 1895. Copyright, 1896, by [>. Appleton and Company. 2 "ONLY NERVOUSNESS." No amount of professional knowledge can compensate for a lack of tact in gaining the confidence and directing the life of a nervous woman. Often I hear young physi- cians say they " do not want to bother with cranks " ; and often, when it is too late, do they find they have thrown away the cream to barely subsist upon skim milk. But there is a far higher consideration, another aspect to the case, which must appeal to every right-minded, gen- erous-souled, and conscientious physician: the distress, the continuous acute suffering, the actual agony physically, and the horrible confusion, unrest, and deep despair of depression mentally, which render the "only nervous" worthy of our study and best care. "It is only nervousness." Yes, so it is; but have you ever for a moment attempted to realize the length, breadth, and depth of suffering so briefly summed up in that glib phrase ? " Only nervous ! " Well, is that not enough t Be- cause it does not kill, because there is no fever to be con- trolled, no cough to be choked down, no abdomen to be opened; because the enemy does not declare himself, does not bid defiance from some vital position, the routine physician shrugs his shoulders, the surrounding friends pocket their fears, and all assume that irritating, patroniz- ing attitude of " Oh, well I you'll come through all right. It is very foolish in you to give way so, but we will stand it." "Only nervousness," and the weary invalid turns her face to the wall and wishes it were only death. For twenty years my daily path of duty has lain among the sick, in hospital, private practice, and sanitarium, to witness all phases and degrees of human suffering, and I say without hesitation, and with perfect confidence in my ability to meet all who may enter the lists to controvert me, that there is no suffering, mental or physical, which "ONLY NERVOUSNESS." 3 can in the slightest degree equal that usually covered by the cant phrase " only nervousness." 1 know it is a great thing to have all your little town buzzing about how you cut off John Smith's leg, how you sewed up Mary Jones's scalp, how you brought Jane Brown out of a lit-all this is something people can see and under- stand, and it seems like coming down a little to turn your thought to the " only nervous." But Alice Buxton will send for you to-night. Her mother will meet you at the door with, " There is not much the matter, doctor, but Alice has been working a lit- tle too hard at school. She ain't got nothing that I know of, only nervousness." I know you are in a hurry, and Mrs. Toner is waiting for you to officiate at the ushering in of the thirteenth little Toner on the list; but off with your greatcoat and draw up your chair beside the pale girl who stretches out a trembling hand, and whose face flushes with the false semblance of health as she bids you good evening. She, too, will tell you, " I don't think there is much the matter with me, doctor. I am only nervous." Look closely. Do you see that strained look in her eyes, that drawn, set mouth, the side of the nose contracted-why, she is driving the very nails into the flesh ; you see that line of perspiration at the roots of the hair upon that clearly cut forehead; one foot rapidly beats the carpet while its mate moves uneasily from time to time. No, she does not sleep. She can not stop thinking. " And such foolish thoughts, too, doctor "-here she laughs in a high-pitched tone-" I know it is all foolish- ness, but I am afraid all the time that something will hap- pen. I am afraid to meet people. I am afraid to be in a crowded room. I feel as though I should suffocate. I can not sit in a pew at church unless I have the end seat. ■'ONLY NERVOUSNESS." 4 I can not take a front seat at the theatre. I can not go anywhere alone. I wouldn't cross that open square for all the gold in the world. I am afraid of thunder. I am afraid I am going to die, and yet I am sure I don't want to live. I know something dreadful will happen "-here come the sobs-" and I don't know what it possibly can be." Now do not tell her that nothing will happen; she knows that as well as you ; but do you see to it that some- thing does happen : that you then and there make a care- ful and thorough study of her case, that you find the cause of this nervousness, that you go to the very bottom of the matter. You will find it no mean task; you have a foe here worthy of your very best skill, and you can have no hope of dislodging the enemy unless you make yourself per- fectly familiar with him in all the multitudinous shapes he is capable of assuming. True, you can cover your laziness or ignorance by diagnosticating " only nervousness "; it will satisfy the friends, and you may ease your conscience by going to Mrs. Toner, who is visibly suffering. But, doctor, the day may come when, take my word for it, you will find it easier to endure a surgical operation every day than to be " only nervous." Listen not to the whispering of the siren voice of a vulgar glory, but do your plain duty. Bring out your brightest, sharpest case of wits, and hunt down the host of devils that are rendering earth a hell for this poor girl. Strike them down one and all, restore her nervous apparatus to a healthy working order, and you will have gained a friend who will never forget you; a measure of gratitude well pressed down, full and running over; and, between you and me, the insane asylum may claim one less victim-one more human being may escape that living death. Half its inmates are there now only be- "ONLY NERVOUSNESS." 5 cause our ignorance or intellectual inertia long ago set the stamp of " only nervous " on the invalid, who was thereby left to time and good luck to survive or to succumb to the awful suffering, fed upon the hard rock of indiffer- ence, instead of being nourished by the milk of human kindness. Many of these cases have no obvious cause, or a num- ber of small items go to make the cause, which the friends will not think worthy of mention. First of all, make friends with your patient; see her often-morning, noon, and night; watch her every action, all her movements, her habits, the trend of her mind, her likes and dislikes, her occupations, her friends. Let nothing seem too small ; ex- amine every point, get inside of her, look out with her eyes, feel with her sensitiveness, move with her motion, think with her thought, know her love and her hatred" Feel her religion, wrestle with her unbelief, feel her abject conscientiousness, enjoy as she enjoys, and descend with her into the blackness of her failures and disappointments. The old Greek philosopher said " Know thyself," but I say to you, Know thy patient as thyself. Do not be discour- aged ; the mystery will resolve itself if you keep at it, and you may well wonder al the simplicity of the problem you have been at so much pains to solve. Always remember that the " only nervous," as a rule, become so from no marked, distinct cause, but usually from dropping one after another of the links in their automatic life, and thus by destroying the unity of the whole throw into prominence symptoms which are really exaggerated traits of the true character or the items that go to make up the natural life. To know how much influence this has in the case before you, you must go far back into family history and infantile life. For her present condition half an hour's quiet obser- vation without your patient's knowing what you are doing 6 "ONLY NERVOUSNESS." will tell you more than a day's direct questioning. In fact, I seldom waste my time in talking directly with nerv- ous people about themselves, but gain my information when they are not expecting examination. Overwork is considered the great cause of American nervousness, but I doubt if there is any such thing as over- work. " It is not the turkey that rests bad, but the fillin'," as a Jersey " schoolmarm " once told me. There is nothing in the world so good for " nerves " as work, and even overwork can be borne for some time without injury ; but the combination of overwork with habits always harmful does the mischief, and overwork, be ing in bad company, bears the blame. Overwork is a myth. It covers more sins than malaria, and outfashions la grippe. No matter how much a man works, but it does matter how many cigars he smokes dur- ing that work, how much thirst must be quenched by the seductive cocktail, " just for a bracer, you know," and then the worry. Ah, there's the rub I One gallon of work, most health-giving; but add one drop of worry, and out with the vile poison ! The late hours, too, the hasty meal, and then Nature's calls. " Oh, my bowels give me no trouble when I am at work. I do not need to have a movement oftener than once weekly " I And then men break down and talk of overwork. Not a bit of it. Over- work has a very small finger in the great " only nervous " pie. Alice Buxton, upon whom we just called, has been sent home from school, suffering from overwork. You question her in regard to her studies and habits, but discern noth ing. She is " only nervous," but that has reduced her to a state of abject unhappiness. You examine this organ and that; true, they are all more or less disordered, but if you are a gynaecologist and find a slight displacement of "ONLY NERVOUSNESS." 7 one of the pelvic organs, and nothing else upon which you can lay your finger as a cause, ten to one you decide that this is a case where unusual sensitiveness causes disturb- ance out of proportion to the displacement. The friends are delighted, and the fond mother loses no time in retail- ing to her neighbors how " Alice is such a sensitive child, you know, and what could not disturb your Minnie, does affect her awfully." Fiddlesticks and bass drums ! Must every woman have a straight nose ? Does it irritate her nervous system to have the tip a little to one side ? And then, too, if you have been a close observer you must have noticed that it is very seldom when we know nervous symptoms to be dependent upon pelvic disease that an operation relieves the nervous symptoms until they have been treated also. Let us try again. She has indigestion, nausea, head- ache, constipation. True, and if you are a general practi- tioner, you will tell her she will be all right when that sen- sitive stomach is relieved ; and pills before, and pepsin afterward, and tonics in between, are expected to perform the miracle. Several months of drug-stuffing find her only worse " How could those doctors have been so stupid ! " says the oculist, and forthwith those eye muscles are cut. A prism gymnasium is introduced into the household; hideous in her dark glasses the victim worries on, while the oversan- guine oculist's bank account swells day by day. Some- times these unfortunates go on for years-now full of hope, now in the depths of despondency, at all events unhappy, and rendering those about them also miserable. The dis- ease outgrows itself and the first cause is lost sight of. Alice has become a classical invalid. Now, how did this happen ? Alice was studying hard, her brain was doing its best, and, kept at a continual high tension, was in a state of abnormal impressionability. A 8 "ONLY NERVOUSNESS." religious movement was going on in the school and Alice became interested. After her work was finished she con- versed with her roommate upon the subject; sleep was lost for a night with thinking of it. She would drop the sub- ject as she must sleep, but the next night, owing to the intense impression made upon the sleep centre by the unusual disturbance, she lost her sleep again. By this time the sleep centre had lost its automatism ; it did not know just what to do ; it had fallen into bad company, had lost its old associations, and had made new acquaintances. Had Alice then and there exerted her will, compelled that sleep centre to do its work at the right time, all would have been well; but she must sleep, and the nurse was called upon for a hypnotic, to the still further confusion of the sleep centre. The next night this was all at sea and, being again aided, began to think such help the proper course, and thereafter refused to respond without assist- ance. I am giving now an extreme case, but one which well illustrates the general principle. Now comes in the element of worry. As I said above, the automatism is destroyed. Alice begins to worry. Keeping up her work, she expends all nerve force supplied by food during the day, and for her insomnia and worry about religious questions she calls upon her reserve nerve force, of which we all have a greater or less supply in health. Soon the hypnotic disturbs her stomach ; her di- gestion fails ; she can manufacture less nerve force during the day, and yet greater calls are made daily upon that reserve force. In the meantime she may have ceased to dwell upon the religious question, but she now has something more to think of; her health is manifestly failing. One day, as she is crossing the large vacant lecture room, a sense of fright seizes upon her, shaking and trembling in great terror with "ONLY NERVOUSNESS." 9 tearless eyes. She does not know what is the matter, only she is " so frightened." Thereafter she will dread to be alone, she will fear all open spaces, and she can not force herself into any large, vacant room. She begins to think how everything will affect her; thoughts of herself now take up a great part of her time. Almost all automatic action is now supplanted by conscious action. " Why, I never used to think anything about myself; now I can think of nothing else. I am in constant fear; a continual apprehen- sion disturbs my sleeping moments." Mark now carefully how, growing up in health, all her nerve centres had come to act in a perfectly automatic way. " I never knew I had a stomach. I did not know what nerves were, and I fell asleep as soon as my head touched the pillow." The chain of association was per- fect, and daily one link after another ran smoothly over the bearings of a well-oiled brain, and her life was pro- pelled gently along as a car upon an endless cable. Now everything is all wrong, and her doctor is unable to tell which of all her disturbed organs is most at fault. If any man should be a gifted man it should be the healer of nerves ; for, without disparagement to his fellow- workers, he continually has problems to unravel such as are not dreamed of by others. Take any case of insanity, trace it back, and you will find the origin in some disturb- ance in the automatic life of the individual. To-day I meet with a loss of money. I spend hours in bewailing my loss and in receiving the commiseration of my friends. For some reason of health I may be just at that time in a particularly impressionable mood. My nerve centres take on an impression of deep sorrow. The next day I do not throw it off. My nerve centre of joy is inhibited, my capacity for feeling grief is increased. I lose more money ; my sleep goes, my appetite becomes capricious; the nerve 10 "ONLY NERVOUSNESS." centres of joy do not respond at all, while those of sorrow are full of life. And so it goes, until the one is so obliter- ated and the other so increased in activity that I become a subject of melancholia for life. Again, to go back to Alice for another illustration. She is just budding into womanhood, full of purity and innocence, and replete with ignorance as to her physical make up. She spends the evening at a concert or the opera, where her senses are played upon until she comes home thrilled through and through, and pleasurably alive throughout every nerve. It is a warm night, and she falls asleep with music ringing in her ears. She is awakened by a dream full of horror to her; she has had feelings un- known to her, such as she would not think of during her waking hours nor breathe a word of even to her mother. No one has told her she is ever to have such an experi- ence. She goes through the day full of terror. She must be bad, she must be different from other girls ; she surely has been guilty of some great sin. Study as she will, her mind steadily returns to the subject during the day, and she retires at night full of fear lest she be subject to a repetition of what has now become most horrible to her. She hates herself. It has never occurred to her before, but she now realizes that her sexual system is an active part of her. Unless her motherly teaching differs from that commonly in vogue, she shares in the too prevalent belief of young women, as well as of those older whose intel- ligence should teach them better, that it must be a low part of her; it can only be abjectly low and degrading. Again there is a repetition of the night before, brought about by an overexcited and violated imagination. She awakens convinced that she has committed " the sin against the Holy Ghost." She imagines she must show it; her face must tell to the world how utterly vile she is; never "ONLY NERVOUSNESS.' 11 more can she claim to be a good girl. And this is no overdrawn picture. Go into any insane asylum and you will find more than one victim of such ignorance, the result of false modesty on the part of parents, where these ex- cited impressions made upon one nerve centre have de- veloped that centre to such an extent as to cause the mental destruction of the poor unfortunate. And now what shall be done for the " only nervous " ? Having discovered the cause, remove it if possible. As I have said, the first cause will more than likely have been lost sight of, and the present condition be the result of ab- normal impressions made upon nerve centres from time to time. It seems easier to impress a nerve cell wrongly than rightly, and the process once begun, the nerve cells simply run riot. Some one organ may be at fault, and be the cause of irritation. If this is manifestly so, restore that organ to its natural state if possible, but at the same time be not over-sanguine, for sooner or later all the nerve centres at fault must be reimpressed, and the simple doing away of the local irritation will not accomplish all. This is the cause of many disheartening failures with the " only nervous." Look deeper for the cause, then set to work to reconstruct and impress the nerve centres. Demonstrate to your patient the futility of depending upon drugs or any external means. Make her understand that the larger part of the treatment falls upon her. You can point out the way, but she must do the work. Regulate her whole course of life, from awaking in the morning to sleeping at night. A nervous patient will do better among strangers than when surrounded by sympathetic friends, who, as a rule, simply deepen false impressions by reiterated expressions of sympathy. Change the environment completely, break up all old associations, and let the patient go among strangers, where she will feel more or less of a moral restraint. 12 "OXLY NERVOUSNESS." Let everything be done to strengthen the physical body and build up the physical side of the nerve centres. See that the patient eats and digests as large a quantity of food as possible; let this amount to stuffing even. Give mas- sage to supply the exercise, and let the patient remain quietly in bed, to store away all the strength gained. That part of the food which goes to the nourishment of nerve tissue must undergo a process of preparation far more complicated than that for any other part of the body. The supply manufactured through the day is necessarily small. lienee it is a part of Nature's plan that we should have a reserve of nerve force. You hear of persons living on their nerves, or doing this or that upon their nerves. This is literally so, and until this reserve gives out they never become " only nervous." Now this reserve force must be renewed. Hence, put all the food possible into the " only nervous," and allow them to expend only the smallest amount compatible with existence. The ways and means of accomplishing this are too numerous and com- plicated to admit of recital here. There is no plain sailing to it, no two days are alike, and where one means fails another must be found to take its place. But doctors and patients have one consolation: success will almost invaria- bly follow their combined efforts. No class of disease is so amenable to treatment, and in none is there so sure a prospect of success. Once the only nervous comprehend the natural physio- logical action of the brain and its adjuncts, they quickly understand how they became "only nervous," and the path of recovery lies open to them. Oh, but the journey over that road 1 That is another matter. Recall again that in the infant nerve centres there are not only undeveloped nerve cells, but material for the formation of numberless other cells; that every new "ONLY NERVOUSNESS." 13 thought, idea, or impression goes to build up one or more of these cells; and that every action is the result of a chain of associated ideas previously formed. Keeping all this in view, it follows that the idea of re- covery must be implanted and encouraged in its growth in the same manner. For example, and we take an extrema case for the clearer illustration : Miss M. was more than "only nervous." She had been suicidal, and thought she had committed "the unpardonable sin," though what that was she did not know. She could not sleep, would not eat, and knew she should harm some one, if not herself, and did not wish to meet anybody. She was told that she would not commit suicide, and whenever the idea came into her mind she was to say to herself that she would not commit suicide. She was to avoid thoughts of death, and read no accounts of it, or of suicide, in the papers. She was continually to say, " I will live; I must live; I want to live." She was to drop the thought of the unpardonable sin in a passive way, not only not to dwell upon it, but to refuse even to think of it. She was to prepare for her sleep in the usual manner, taking it for granted that she was to sleep. When she found she was not sleeping, she was to take no notice of it, but say, "Oh, well, I do not care. I am resting, and I want to think of so and so." She wras not to try to fall asleep, but was to repeat poetry, and to think of one and another pleas- ant thing-of anything but sleep. As for eating, she would do that as she would take medicine. A nutritious diet was selected for her, that the most nourishment might be ob- tained with the least expenditure of energy in digestion, and this she was to take in spite of everything. No notice was to be taken of any resulting symptoms. If she vomited even, the same meal was to be taken next time. A certain number of hours during the day were to be devoted to company, whether she felt inclined or not. There, you see, constant pressure was brought to bear on the nerve centres at fault, and as a consequence a few weeks showed a complete resto- ration to health. 14 "ONLY NERVOUSNESS." Many of the symptoms of the "only nervous" border upon the silly ; but ridicule or scolding only makes a bad matter worse, as it calls attention to them in a most em- phatic manner, and only serves to impress them the more deeply, even if the patients join in the laugh, as they almost always do. When there is apprehension, there is no use in telling patients they are fools, nothing will happen. They know they are not going to have leprosy, die of apoplexy, be- come paralyzed, drop off with consumption; but in some unfortunate way such an impression has been implanted upon their nerve centres, and only time and a steady course of counter impressions, or a dropping out of that line of thought, will obliterate it. Your wife tells you she is go- ing to die. Do not tell her she is a fool, you know better; but say, " Remember how much you have to live for, think how you may enjoy life, and now let us take a drive that you may think of something else." Every symptom must be combated passively and ac- tively by the patient, and that, too, under wise direction, for when the nerve centres are at fault and have lost their automatic guidance they are all at sea, and more often guide wrong than right. In fact, the feelings in an "only nerv- ous" patient are no guide at all. They should seldom be consulted and never relied upon. For instance, in the matter of eating. When one be- gins with "only nervousness," the action of the stomach is usually the first organ to attract attention. Veal was taken at dinner; the distress following must be due to the veal, because that has a bad reputation. The first thought was, "It must have been the veal"; the second, "Yes, veal hurts a great many people, it was that which hurt me"; the third, " I must eat no more veal, I know it hurts me." At the next meal the stomach is still at fault. "Veal "ONLY NERVOUSNESS." 15 hurt me yesterday ; meat can not be good for me. I must stop all meat." At the next meal it is the bread; the vari- ous kinds are tried successively, and the patient settles down to dry, stale bread or none at all. Finally, no solid food will agree without pepsin. One after another article of diet is laid aside, judged at the bar of the feelings, un- til I have seen patients subsisting upon a few teaspoonfuls of beef tea when nothing stood in the way of digesting a good pound of solid beefsteak, except the false idea which had so insidiously crept in and produced so strong an im- pression upon the nerve centres that they would not act until that had been done away with. There is a deal more in the old saw, "You can, if you only think you can," than we give it credit for. Mind acting upon matter has greatly to do with " only nervousness." The mind doctors and faith healers are teaching us a lesson we should not be slow to heed. In closing, let me repeat that the whole treatment of the " only nervous" is based upon two principles: First, the physical restoration of the weakened nerve centres, the manufacture of nerve force to replace the lost reserve power, the reduction of nerve impressionability, and the regulation of nerve impressions. Second, the education and disci- pline of nerve associations, and the development of nerve centres upon a correct basis, with the deadening and de- struction of those nerve centres brought into action by chance impressions and the repetition of unhealthy stimuli. Any treatment based upon these two principles will bring relief to the " only nervous "-to recent cases com- plete cure, and to those chronic so much of comfort that actual cure will not seem so necessary. You, upon whom so much depends in the treatment of this unfortunate class, I beg of you, do not fall into the way of putting off these " cranks " with a placebo, and, above 16 "ONLY NERVOUSNESS." all things, never under any circumstances purchase a dis- honorable respite from their importunities with a narcotic. One hypodermic may be the patient's ruin, and the burden of the dire result is sure to fall upon you. Better give up the case than give a narcotic. Tedious and tiresome these cases always are-at the very best often unsatisfactory ; but when you do cure such a case, consider the sweetness of the victory gained ; and, moreover, if you learn to manage such cases successfully, your professional success is assured, and no class of patients is more grateful, none knows so well what you have really done, and no patient will be so long in forgetting the service you have rendered. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. \ EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a line weekly medical journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. Such a journal fulfills its mission-that of educator-to the highest degree, for not only does it inform its readers of all that is new in theory and practice, but, by means of its correct editing, instructs them in the very important yet much-neglected art of expressing their thoughts and ideas in a clear and correct manner. Too much stress can not be laid upon this feature, so utterly ignored by the " average " medical periodical. Without making invidious comparisons, it can be truthfully stated that no medical journal in this country occupies the place, in these par- ticulars, that is held by The New York Medical Journal. No other journal is edited with the care that is bestowed on this; none contains articles of such high scientific value, coming as they do from the pens of the brightest and most learned medical men of America. A glance at the list of contributors to any volume, or an examination of any issue of the Journal, will attest the truth of these statements. It is a journal for the masses of the profession, for the country as well as for the city practitioner; it covers the entire range of medicine and surgery. A very important feature of the Journal is the number and character of its illustrations, which are unequaled by those of any other journal in the world. 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