SOME OBSERVATIONS ON NEURASTHENIA AND ITS TREATMENT. WHEN, thirty-five years ago, the writer first made the acquaintance of what is now called neurasthenia, it was known as spinal irritation, and the best of modern researches have been unable to give a better definition beyond a functional disturbance of the spinal and cerebral nerves, dependent on a morbid process, for which “irritation” is as proper a term as any.

WHEN, thirty-five years ago, the writer first made the acquaintance of what is now called neurasthenia, it was known as spinal irritation, and the best of modern researches have been unable to give a better definition beyond a functional disturbance of the spinal and cerebral nerves, dependent on a morbid process, for which “irritation” is as proper a term as any.

As deaths do not occur, autopsies throw no light on the subject. Briefly stated, neurasthenia, when observed from the beginning through its chronic course, has a period of prodromal symptoms followed by a protracted acute, and succeeded by a still more protracted chronic, state, between the end of which and the beginning of convalescence there is a very vague, often indiscernible, boundary line.

The prodromal symptoms are quite indefinite and very variable, pointing to nothing in particular. Loss of appetite, irregular sleep, excitability alternating with lassitude, etc., are often overlooked, especially when the second stage-display of unusual mental and physical energy without subsequent fatigue- becomes apparent. This is often mistaken for a sign of unusually good health. When a young girl or mature woman, married or unmarried, feels that she can study ten hours a day and devote half of her night to pleasure or business; when besides much mental occupation she begins to rejoice in long walks without fatigue, that is the time when the mischief is going on without exciting timely suspicion.

Relief is at last sought when the functional disorder of the nerves has gone to the opposite extreme, and becomes manifest in what is properly and popularly termed “nervous prostration,” when instead of having no sense of fatigue, the best bodily or mental effort seems intolerable, in grave cases rendering the patient a helpless being, completely dependent on the unremitting assistance of others whom she )it is usually a woman) rules with the inexorable power of the vis inertiae.

During this usually very protracted period of the disease convalescence usually sets in, but so imperceptibly that the physician alone can sometimes estimate its progress, which is unnoticeable to others towards whom the patient acts as she has for months or years. This is the time for action, too often delayed from motives of misplaced sympathy on the part of relatives and friends.

The affections is in many instances limited to the spine, the mind becoming only secondarily tired. In other cases it is spinal and cerebral; in others again chiefly cerebral. The line between this and insanity is always clearly definable. Though a neurasthenic patient may become insane, and probably the reverse, yet both are distinct conditions.

Books speak of this disease at common to men and women. Yet in this region in small towns as well as in large cities the cases of neurasthenia in women are preponderatingly great.

Hypochondriacs and hysteria stand in peculiar relation to neurasthenia. They maybe regarded as different species of the same genus; that is, more or less deeply seated disturbances of the cerebro-spinal system in which the sympathetic system is probably indirectly involved, as many functional disturbances presided over by the great sympathetic system often testify. Hypochondriasis, pure and simple as occurring in men, is easily distinguishable by its striking characteristic of introspection and despondency, occasioned by abnormal sensations, without marked physical weakness and tiredness.

Pure hypochondriacs are often energetic, conscientious workers. In hysteria there is neither great tiredness nor tendency to introspection, but a paroxysmal or prolonged absence of the power of self control, in grave cases associated with tonic or clonic muscular spasm and loss of consciousness. While neurasthenia in its uncomplicated forms is free from these symptoms, but, as ample experience teaches, often complicated with both of the preceding forms to such an extent that it is often very difficult to tell which is primary and which secondary. The symptoms known as introspection, hysterical aberrations of the emotions, and neurasthenic sense of exhaustion are in their distinctive manifestations most important and constitute indications in the selection of remedial and dietetic measures.

The following are some observation of peculiarities observed in a large number of cases and peculiar to all:.

Introspection.-The neurasthenic patient in variably expresses her desire for relief, not so much in a direct appeal as in a supplicating, subdued tone of voice and manner. She rarely asks, “What can you do to relieve me?” but almost invariably, “What is the cause of” this or that sensation? If she is introspective, that is, hypochondriacal, she becomes a nosomaniac, watching acutely every one of her numerous distressing sensation, on the unremitting analysis of which her mind dwells.

In marked cases she is quite unable to think of anything outside of herself, and in many cases dislikes to do so, preferring to river her attention on herself. Attempts to divert her annoy or anger her. Friends and relatives implore the physician to divert the patient, but all their attempts are in vain because quite misdirected.

Positive and Negative Will.-It seems sometimes as if the patient delights in her self-inspection, and that she prefers her condition to speedy recovery. This is not the case, for the patient will always assure the physician of her wish to get well. During the acute stage-a long yet definable period-this wish and longing cannot well be utilized, but the long and ill-defined period of convalescence must first be awaited.

Here we shall always discover that the wish and the will of the patient are two very different mental conditions. The desire or wish for recovery is entirely unattended by any will effort to accomplish the desired end. The injunctions and directions of the physician are resisted by the same unconquerable power of negative power, or vis inertiae. The patient having been unable to exert her will, now thinks herself unable to use it.

Numerous Symptoms of Patients.-To physicians in search of indications for medicines each statement of patient concerning a sensation is apt to be considered as a symptom. Many years ago, when resolved to get at the keynote of a patient’s case, the writer determined to allow the patient to detail all her symptoms as long as she chose and to take accurate notes of each one till the right one should be disclosed; and this was to be done regardless of time and exertion.

The patient, one who needed no urging to describe her “symptoms,” began in an almost inaudible voice, detailing one sensation after another with an unrivalled degree of clearness and vividness of expression; as she proceeded the voice became stronger, her face slightly flushed, and the most perfect descriptive language flowed in an endless stream. Each word was written down, page after page was filled; still she went on with unmistakable signs of satisfaction at being able to pour her pent-up emotions into willing and sympathetic ears. If, for a moment, the flow of language was interrupted, a simple question would re-animate her to proceed with renewed energy.

Feelings seemed to beget feelings; their complexity gave the patient no trouble; her intellect was equal to the action of unraveling the most complicated sensation, separating them into their component parts and spreading them out before the mind of the listener. A glance at the watch showed that nearly two hours had passed, during which the feeblest of neurasthenic patients had talked incessantly. The note-book was full, the keynote was found. It was this: neurasthenic patients have innumerable sensation and exhibit no sings of fatigue after talking incessantly for nearly two hours.

Great Endurance of Neurasthenics.-The instance just related, which is one of many, illustrates two things. One is, that it is not the kind of sensation described but the fact that neurasthenics have innumerable sensations, that constitute the symptoms. The other thing is that many neurasthenics are capable of great exertion without suffering disagreeable after- effects from fatigue.

This is illustrated by other cases of which I have notes. A highly neurasthenic young lady consented to camp out for her health near a lake. She was induced to join a party for a short walk along the lake. By trying what they thought a shorter road the party lost their way and took a very long walk of about four hours, through bogs and over forces. The neurasthenic was less fatigued than some of the others. The interesting observation was subsequently made that the patient had become interested in a young man of the party. She recovered her health within a year from that time. Other cases of this kind will appear under the head of therapeutic suggestions.

Neurasthenic Patients Crave Sympathy.-This is one of the most formidable obstacles to the curative management of such cases, for the kind of sympathy such patients crave is expressions of condolence and more or less deep affliction at so much suffering as the patient expresses. Such sympathy is most natural and does honor to the feelings of parents, sisters, brothers and husbands, but it is unfortunate that the deeper their expression of affliction so much the more profound will be the mental dejection and weakness of the patient.

Almost every case which has come under the writer’s observation has been much hampered if not made hopeless by this condition of things, against which no remedy suggests itself that would not be construed as “unkind”.

The origin of this very formidable and refractory nervous disease, like that of most diseases usually termed chronic, is either hereditary or acquired, as the histories of every observed case plainly testify. Either the father was a hypochondriac or the mother neurasthenic, or both parents were of unsound nervous constitution. Dipsomania on the part of parents produces neurasthenia in the children, as readily as it will be followed by any other form of nervous disease, according to the individual predisposition of the offspring.

The excessive use of tea and coffee is another very active factor in the history of neurasthenics. Where fathers inclined to alcohol, mothers are addicted to tea and coffee, which, while its immediate effects do not obtrude themselves upon our notice, are none the less insidious in their more remote consequences.

The acquired forms of neurasthenia are of utmost interest to the therapeutist, and the sources of acquisition are readily stated. They are much brain-work with insufficient food and sleep. Such conditions obtain chiefly in women (less frequently in men) of fine intellectual ability, conscientiousness and ambition. Physical overwork with unintellectual women has no such effect.

Quite analogous to the above are the conditions of care and sorrow, especially in women who are able for a long time to conceal and control their emotions. The usual consequence of such states of mind is disregard of food and insufficient sleep. Instances of acquired neurasthenia are presented in families of several girls and boys, where one or more of the former are Neurasthenic while the latter are vigorous and athletic. Boys delighting in vigorous exercise do not, as is the case with girls, lose appetite and sleep.

The effects of nervous exhaustion in boys are usually much less grave than in girls; as a rule such effects are manifested in mental, not muscular, tiredness, and they are relieved by air and exercise, while in girls and women those influences are shunned because they seem to increase the tiredness.

Predisposition-The temperament, or what in modern pharaseology is called the personal equation, plays a visible but uncontrollable part in the progress of neurasthenia, as temperament greatly determines the other imperfectly known condition known as predisposition. Where the disease is hereditary, it is easy to say that the predisposition is due to that source; where there is no history of heredity and where neurasthenia exists in the last members of a generation, it may be attributed to acquired predisposition which needed only the exciting cause to establish the disease in its most typical form.

One of the most common forms of neurasthenia, often quite intractable, results from a serious defect in our public school system, one which affects chiefly girls from twelve to fourteen years of age. The following is a brief example: The child rises late with no appetite for breakfast and no time to eat it if so inclined. The lessons, however, have been learned the evening before, and the school work is begun with an ambitions will and a crammed mind, and continues with one intermission of often not more than ten minutes or three of four hours. The pupil arrives at home ravenously hungry, eats too fast, and too much of injudiciously prepared food, too long in digesting to leave room for an appetite for even a light evening meal, or even for a breakfast the next morning.

In another case the girl or boy grows desperately hungry while at school, but being unprovided with food (lunch), goes on with the school exercises, at the end of which the sense of hunger has vanished and has been replaced by an aversion to normal food, with a possible craving for something pungent and indigestible. This observation can easily be made in many instances, and will, in as many cases, be seen to lead to nervous prostration, which is then treated by vile, patented concoctions consisting largely of whiskey, under the name of “tonics,” while the patient needs only the best that a legitimate market affords prepared in a sensible manner.

Typical Cases Ending in Rapid Recovery.-Curative results have already been indicated in what has been said above, and further indications for treatment may be gathered from a few cases of extremely rapid recovery of apparently incurable cases, to which brief allusion will here be made. A woman of forty had been a victim of grave neurasthenia for five years. In the absence of an inclination to exert himself, she had, during that period, been mostly confined to her bed or lounge, in the meantime giving birth to two children, going through gestation and confinement normally, without recovering from neurasthenic prostration which, in the course of some years more, rendered her entirely helpless.

Her condition was associated with a feeling of dropping to pieces unless supported and braced by a harness of wood, iron and leather, in which she “sat up” for several hours each day, spending the rest of the time in bed. Having left the patient in this condition, it was reported before the writer’s next professional visit that Mrs.-had been cured, and that she was able to go out like other people. A visit to the house confirmed the report. The patient came to the door herself, and in a quiet manner, entirely without the least expression of joy or wonder at her release, stated, that having heard of a famous “magnetic physician,” she summoned him, was ordered by him to arise and stand; protesting that it was impossible, she was raised to her feet and again ordered to stand, then to walk.

Fearing that she would fall, she begged the magnetic doctor to support her, which he peremptorily refused, saying she might fall if she liked. Instead of falling, she had to walk about the room, was then placed upon a lounge and subjected to a severe treatment of rolling and pummelling, and then ordered to dress and sit up until tired, to remain up and about like other people, and to call on the doctor in future, as he would not come so far to the patient again.

This happened about twenty-five years ago, and the patient has been in very fair health arrested by insisting that all professional visits by the writer or any other physician to whose sympathy the patient could appeal must cease. This injunction was carried out conscientiously with the best results by the husband of the patient. Perhaps we may learn from this that sometimes, at least, the familiar motto is reversed, and angels rush in where fools fear to tread.

Profiting by this experience, another neurasthenic woman, unmarried, but of most intractable, antagonistic temperament, confined to her bed, in and out of hospitals, for years, wearing out the strength and means of her relatives and the patience of many physicians, was at length abandoned by them. It was a case of spinal and cerebral neurasthenia complicated with hypochondriasis in its most trying form of introspective maunderings and endless description of symptoms.

She tormented her advisers by her endless tirades, the indulgence of which invariably aggravated her condition, and were there fore avoided, until once her physician yielded to the patient’s importunities for a visit, when be found her in her usual abject state of prostration. Guided by experience derived from cases like the one first described, he assisted the patient to her feet and marched her, will you nil you, up and down the room until he, at least, was thoroughly tired, and then departed with the promise never to do so again. The patient, on her part, made a number of her unnameable promises, but kept on her feet and let the doctors alone.

Though not cured of deeply-rooted morbid mental faults, the neurasthenic phase of her condition had yielded to the change of the antagonistic element of her character from passive to very practical activity. A third very serious case of this kind occurred in the person of a girl of fifteen, of selfish character, who gradually became bed-ridden with spinal and cerebral neurasthenia, and tormented with the usual multifarious painful sensations, none of which, on the most pains-taking physical examination, resulted from demonstrable organic disease of genital or abdominal organs. The patient was most tenderly cared for by her mother, who, in the course of years, became so imbued with the idea of yielding to every wish and whim of the patient, that at length remonstrance became useless.

The mother, though recognizing the importance of persuading or urging her daughter to depend more on herself, admitted that she had yielded so long that now she must continue to feed, dress and assist her charge in the most trivial things. Her food had to be placed in her mouth, the position of a hand or foot changed by some one else, although patient did so spontaneously when she chose. This went on for fifteen years, when the mother, growing old and feeble, died. Her maternal support being gone, the patient at once proved her ability to walk, to dress, to feed herself, and to seek light employment. Though far from well, she is equally far fro being a helpless, bed-ridden invalid.

A fourth case, still very vividly impressed on the writer’s mind, was one of a healthy, romping girl of 14, who, as happen in this remarkably capricious disease, in the midst of perfect health, one day took to her bed and remained there with all the symptoms of neurasthenia, involving first the spinal and finally the cerebral nerves. This patient was very amiable, conscientious, and sensible, never loquacious, and not troubled with hypochondriacal thoughts or sensations. Tiredness was the only expression she used in describing her feelings. There was literally no variation from this condition, which confined her to her bed for years, till she grew from a girl to a woman.

Eating and sleeping well, and improving perceptibly in personal appearance and character, yet she lay on her couch tired and watched over with unremitting care by a most anxious mother, showing her solicitude and sympathy in every feature. Once, in the second year of the disease, a favorable interruption occurred. The mother, still a young woman, gave birth to another child. During her confinement the neurasthenic patient was in charge of her mother’s nurse, assisted by other servants. The nurse, while devoted to the daughter, agreed with the writer that excess of sympathy was injurious, and used her best and judicious endeavors gradually to persuade the patient to make some physical effort at walking and standing.

In this she was so successful that in two weeks she accompanied the girl on half-mile walks up and down hill, finally without assistance. Thus, recovery seemed assured, and everything was favorable progressing towards it when the mother, having fully recovered, again took charge of her daughter, with the result that she at once took to her lounge and remained there two years longer. About that time other advice was urged and gladly acceded to, with the result that the case was diagnosed by an eminent surgeon as spinal paralysis in consequence of concussion, though it could never be shown when and where it occurred.

Salves, plasters, anodynes, nervines, and electricity did no good, but effectually destroyed appetite and digestion, which higher to had been normal. So this adviser resigned in favor of a third, who, being a younger and less prejudiced man, agreed perfectly with the writer’s original opinion. He advised return to moderate exercise, avoidance of drugs, and less display of sympathy. This, though formerly rejected as “unkind,” was now acceded to as coming from a nerve- specialist, fresh from Europe, at that time very rare.

Still attending the other members of the family, the writer had sample opportunity of observing the course of the case. Improvement was very slow and uncertain till financial misfortune overtook the family. Almost with a bound our patient left her cough, and, organizing a kindergarten, strove energetically in supporting herself and assisting her mother. The change came about in less than three weeks, and resulted in perfect recovery.

At this point another very instructive case of very speedy recovery, after six or seven years of neurasthenic prostration, deserves to be mentioned. A woman of 35 had been in bed and on the lounge most of the time for nearly seven years, at the end of which time she became my patient, her regular medical attendant having gone to Europe. She was of very amiable disposition and as sensitive as she was weak. Her symptoms, as in the other cases, were instantaneous exhaustion on the least physical exertion.

Conrad Wesselhoeft