TYPES OF HABIT NEURO-PSYCHOSES. By EDWARD W. TAYLOR, M.D. OF BOSTON. Read at the Annual Meeting of the Massachusetts Medical Society, June 8, 1898. TYPES OF HABIT NEURO-PSYCHOSES. The excuse for bringing to your notice a subject by no means new, is its extreme but too often unrecognized im- portance. In the same sense that habit forms so essential a part in the normal conduct of our daily lives must we look upon it in those conditions which, while bordering on health, often lead to disturbances of nervous equilibrium, which are distinctly pathological. It is the transitional pe- riod which is important, and demands our special attention, that critical period when a neural process once gone slightly astray is as likely to go on to the formation of a confirmed morbid habit as to return to the bounds of what we com- monly term a normal state. Our attitude toward the vic- tims of such perverted nervous habits is often tolerant, but rarely truly sympathetic and analytical as toward the less subtle forms of disease. The object of this paper is to bring to your notice a number of conditions, illustrated by certain typical eases, which deserve our profound study and closest analysis. In attempting this we are repeating what has already been ad- mirably done in Boston by Dr. Morton Prince* and Dr. Russell Sturgis,f whose papers, in great measure, have afforded the stimulus for this reiteration of the general prin- ciple involved. Prince’s paper on "Association Neuroses ” * Prince: Association Neuroses, etc. Jour. Ment. and Nerv. Dis. 1891, XVI. p. 257. tSturgis: Use of Hypnotism to the First Degree, etc. Med. Record, Feb. 17, 1894. 4 TYPES OF HABIT NEURO-PSYCHOSES'. appeared in 1891. It is an altogether convincing presen- tation of the significance of association or habit—to use a less technical word—in the genesis of many affections which, when established, have the traits of independent diseases. Dr. Sturgis has approached the subject from a somewhat different point of view, but likewise offers much that is suggestive. It is evident to the most superficial student that in the genesis of the common neuroses we are dealing with mat- ters, whose proper interpretation demands the exercise of our most critical judgment. Neurasthenia, for example, has far outgrown the interpretation put upon it by Beard. Fatigue is by no means always an adequate explanation ; the sympathetic nervous system is demanding a recognition not yet accorded it; the subtle problems of food supply to the neuron, and nutrition, in the broadest sense, are claiming their share of attention. The mental factor is again becoming prominent. The time has, in fact, come, when our conceptions must be remodelled on compara- tively new lines. It is, however, not at all our purpose to attempt the discussion of any of these disputed mat- ters, but simply to limit ourselves to the interpretation of certain symptoms by means of an appeal to habit. In doing this we shall try to avoid the use of psychological terms, and modes of expression which are foreign to common ex- perience. There is no doubt a general willingness to admit that habit constitutes the very essence of a well organized and effectual life. As children we are taught to make as many as possible of the commonplace acts of life habitual, and as we grow older we become more and more subservient to the power of continually repeated acts, until finally w'e be- come, in great measure, automatic. This is regarded as an unmitigated good so long as the continually forming habits subserve the general welfare of the individual, and that edu- TYPES OF HABIT NEURO-PSYCHOSES. 5 Nation is regarded as successful, which best brings this end to |)ass. As Prof. William James admirably puts it: "The ■great thing then, in all education, is to make our nervous system our ally instead of our enemy. It is to fund and 'capitalize our acquisitions, and live at ease upon the interest of the fund. For this we must make automatic and habit- ual as early as possible, as many useful actions as tee can, and guard against the growing into ways that are likely to be disadvantageous to us as we should guard against the plague.”* It requires no elaborate argument to see and Realize the essential correctness of this point of view. We all of us recognize, in a more or less thoughtful way, that we are bundles of habit, and that so far as these habits are good they ate serviceable to us, and so far as they are bad they are more or less harmful. In persons physically well the mixture of good and bad habits is regarded as inevitable, and certainly not noteworthy. When, however, through any cause the nervous system is, or has become unstable, it must happen that the tendency to the formation of a mor- bid habit is increased. It is, no doubt, just at this point ’that so many persons begin a life of partial nervous in- validism, brought about by the persistence of certain per- nicious associations. Leaving aside all other questions then, our purpose in what follows is simply to draw atten- tion to, and attempt to analyze some of the morbid con- ditions in which habit plays a predominant role. It is not difficult to make a rough but practical classifi- cation into three divisions ': 1. That in which without apparent cause a morbid as- sociation is aroused, and persists through repetition. 2. That in which an association is formed as the result -of an imperfect interpretation of physiological processes. 3. That in which an association persists after its ex- citing cause has been removed. * .Jaiftes : Principles of Psychology. Vol. I. p. 122. 6 TYPES OF HABIT NEURO-PSYCHOSES. In the first category may be placed a very large number of so-called neurasthenic conditions, whose source is often most difficult to determine. These are the patients who tell you they have been ailing for months or years. Their symptoms are often vague but annoyingly persistent; they know of no cause; they are not overworked. They are not neurasthenic in Beard’s sense. A rest cure is just what they should not have. A persistent attempt to analyze the conditions brings us no further than to a settled conviction, that a fixed habit of experiencing certain morbid sensations has grown up, has fed upon itself, has finally so dominated the individual both mentally and physically that he is quite as likely to experience pain and discomfort in the various situations in which a normal person would experience .only pleasure. These are difficult cases ; their troubles are often temperamental, and an integral part of their charac- ter. They are, in great measure, the victims of perverted habit; their cure lies evidently not in drugs, but in a correc- tion of their point of view, through a substitution of help- ful for harmful trains of association. There is, no doubt, such a thing as a habit of health ; and an equally definite habit of illness. Each day fixes the morbid habit, as in the healthy person each succeeding day brings a completer assurance of the health of the next. There are many of these border line cases; they merge on the one hand into what would generally be called the normal, and on the other into what every one would acknowledge as pathologi- cal. Not long since I saw a young girl who was afflicted with an attack resembling hay fever, whenever she looked for any length of time at a cat. When I saw her she had been playing with a kitten for perhaps half an hour, and as a result was undergoing a marked conjunctivitis. Her eye was suffused; her nasal mucous membrane was discharging; in a typical fashion, her throat was affected, and altogether TYPES OF HABIT NEURO-PSYCHOSES. 7 she presented a perfectly characteristic appearance of a hay fever victim. She is not a sufferer from hay fever ordi- narily, and nothing but a cat produces this effect. On questioning she was absolutely unable to give a reason for the peculiarity. She was fond of cats, and could not re- call the circumstances of her first attack. This affection is evidently a nuero-psychosis of the habit type, owing its origin to some unknown association, and its persistence to habit. A friend of mine who is a sufferer from hay fever, is annoyed in a similar way by contact with horses; his cure has been partially effected by a breaking up of the as- sociation, through wearing blue glasses. Prince narrates cases of a similar sort, in which the origin of the associa- tion is evident, and in which cure was affected by counter- suggestion. These are merely examples of a very general principle which, undoubtedly, plays an important part in the per- sistence of many neuroses. The second class is of much importance, not only theo- retically, but also in view of the excellent results of treat- ment, when the condition is properly analyzed and inter- preted. These are cases, who through ignorance of physi- ological laws form morbid habits, which result in distinct neuroses or psychoses. The commonest source of these disturbances is undoubtedly the sexual sphere. Both men and women are ignorant to an extraordinary degree of the normal function of the sexual organs. Everything is done by the charlatans in medicine to profit to their own gain by this ignorance, with the result that associations of a most pernicious sort are aroused, which grow in the usual ways to the discomfort and possible ruin of the individual. Cases of this sort are most familiar to us all, but their pro- per interpretation and successful treatment are far less com- mon experiences. The following is an example of this type of neuro-psy- TYPES OE IIABiT JVEtrRO-tSYCiiOSfcS. chosis. A student of perfectly clean venereal history brings this report: For over four years he has been wor- ried regarding a purely physiological matter, which in his ignorance he has thought abnormal. In consequence he has formed the habit of waking with regularity at three in the morning, which has added to his anxiety and annoys unce. He went to college and through his entire course grew gradually worse, inasmuch as his head also began to trouble him. He studied psychology, and learned some- thing of cerebral localization, which he naturally inter- preted to fit his own case. He associated his supposed sexual difficulty with his head sensation, and in the light 'of his acquired knowledge put the two together as cause and effect. His reasoning was, if the arms and legs have cortical Centres, the sexual apparatus must also ; hence all my symptoms. For years he had been taking drugs, turally without effect. He graduated from college and was anxious to take up his life work, but felt absolutely income potent. Plis confidence failed, he was nervous, and on the Verge of a break-down. With a feeling of desperation and With small hope of relief, he again sought medical advices, His cure consisted in the assurance that he had formed a tnorbid habit through ignorance of certain physiological laws, which later study had fostered. No hypnotism was ne- 'cessary; and the new point of view offered brought about the desired result. The following night he slept until about five instead of waking at three, and a letter several months later stated the permanence of the cure. This case is a perfectly typical one* and extremely Vasy of analysis. The onset of the affection was due to the false interpretation of a physiological event; it was fostered by a constantly more elaborated scheme of associa- tion ; it led finally to a complex neurosis or more properly phychosis, which was rapidly undermining the nervous con- stitution of the patient. Treatment consisted in a substi- TYPES OF HABIT NEURO-PSYCHOSES. 9 tution of a true for a false conception, and the habit of years’ standing was immediately cheeked. Had the case been properly understood at the outset, those years of worry and unhappiness might easily have been avoided; had the condition persisted many more years the habit might aa easily have become permanently fixed, to the lasting detri- ment of the nervous system. There are many cases of a similar sort to this, some of them much less clear; but that this element of morbid association based on ignorance, is an almost constant factor in certain neuro-psychoses, no one who has observed will be disposed to deny. In many of the nervous disorders of women this factor is at work. It is sometimes encouraged and sometimes allayed, by efforts directed to the local treat- ment of the pelvic organs. Th6 absolutely important point to bear in mind is, that however conspicuous the subjective symptoms may be, and at times the objective signs as well, we should all the more direct our attention to the possibility of habit as a fundamental factor in the production of the final morbid condition. Could we intelligently forewarn our patients of the ills of certain habits into which they unwittingly fall, a step of the utmost value in prophylactic medicine would be taken, and the whole group of wretched hypochondriacal states be at least limited in their possibility of harm. A realization of this fact, we are convinced, is much needed by practitioners of medicine in every field. We have taken the sexual system as a characteristic example, but we do not wish • therefore to be understood that the significance of this type of neurosis is confined to this sphere. On the contrary it is very general in its manifestation, and is to be considered under manifold conditions. Further examples are the association of colds with damp feet and draughts in certain individuals, leading so often to a help- less slavery, or digestive disturbances following the eating of ordinarily harmless articles of food. 10 TYPES OF HABIT NEURO-PSYCHOSES. The third class which we have marked out is that in which a disturbed nervous state persists long after its excit- ing cause has been removed. In general, that large and constantly more important group of psychoses or neuroses following trauma is to be included in this class. In this connection we shall confine ourselves only to those results of trauma which are not connected with legal proceedings. We need offer no argument to prove that various nervous disorders do follow trauma; that is generally accepted. Our purpose is merely to trace one of the ways in which such disorders are perpetuated, following out the principle already outlined. An illustrative case will best demonstrate our point. A man previously healthy falls on his shoulder, thereby sus- taining an injury to the joint and its neighboring structures. His arm is temporarily disabled. His chief complaint is of pain in and about the joint, which is so severe that the arm is held practically immovable. He gives up doing any work which requires the use of the shoulder muscles, on the ground that the pain is too severe to permit it. The arm hangs helpless at the side. At the end of three months the patient presents himself at the hospital. Examination then shows, in other respects, a healthy man who holds his arm flaccidly at his side as if through an injury to the brachial plexus. There is, however, no marked muscular atrophy. On attempts to move the arm each effort is vigorously resisted by the patient with incessant complaint of pain. It is quite impossible for this reason, and on account of muscular spasm, to raise the arm to the horizontal, or in fact to move it freely in any direction. Voluntary movements of any magnitude on the part of the patient are not possible. From the history and physical appearances there was in this case no great hesitation in making a diagnosis of peri- arthritis, which subsequent events proved to be wrong. By way of instruction to the patient certain passive movements TYPES OF HABIT XEURO-PSYCIIOSES. 11 of the affected arm were made, which no less to his than to my surprise were brought about with more freedom and less pain than either had expected. In a few moments the patient could move the previously helpless arm almost as well as the sound one. His astonishment was extreme. He left the hospital temporarily cured and returned a few days later with the same disability, in spite of his efforts to help himself. He was again easily relieved, and has not since been seen. Here again is a typical and exceedingly important type of disturbance. Its genesis is perfectly clear. A man falls and receives a definite injury, from which follows an actual disability, associated with pain. As the mechanical effects of the injury pass off, the pain persists in spite of the fact that its cause has been removed, and to the patient this idea of pain is as real as was the original pain. He has, in other words, formed a definite habit, which persists and tends to increase; the arm therefore remains helpless until the association is violently broken in upon; and even then tends to recur. It is a mere begging of the question to call such an affection hysterical, a term too much and too loosely used. Whether hysterical or not, the process remains to be explained. Its explanation lies in the line we have suggested, at least in part, in veiy many cases. The failure to recognize such conditions is a just reproach to the physi- cian . By such failure many psycho-neuroses are engendered and propagated, until finally the association becomes so firmly engraved in a nervous system, that relief is difficult if not impossible. A case, for example, comes to my mind in which a head- ache has persisted for fifteen or more years as the result of a trifling injury to the head, so firmly has the association of pain with a fancied fracture of the skull become fixed in the patient’s mental life. The duty and the opportunity of the physician are clear in such cases. 12 TYPES OF HABIT NEURO-PSYCHOSES. Without further multiplying examples, we have seen, if the foregoing be accepted, that habit is an enormously important element in the perpetuation of certain morbid states. It all seems clear enough if we may only realize that a pathological habit is, in one sense, as physiological as a normal habit. To live always with a sense of well- being and health is accepted as natural; to be continually dragged down by pain and discomfort is looked upon as abnormal, but the two are, after all, simply habitual reac- tions of the nervous system to certain conditions, and the one is quite as natural as the other. The nervous system does its work well in either case; the fault lies with the unfortunate tendencies which determine the character of the neural associations. The nervous system is at first plastic, and easily moulded into right channels, but none the less easily, when certain strains are brought to bear upon it, into wrong ones. Some of those strains we have consid- ered, and their power for harm when directed against an unstable nervous system. It is often possible for the physi- cian to bring just that quality to his patient, which will permit him "to make of his nervous system his ally instead of his enemy.”