NEURASTHENIA.
BY H. C. WOOD, M.D.
INTRODUCTION.—The term neurasthenia, signifying nervous weakness, and not rarely paraphrased by nervous exhaustion, indicates by its very derivation that it denotes not a distinct disease, but a condition of the body. The relations of the nervous system to the functions of organic and animal life are so intimate that almost all forms of exhaustion might well be discussed under the present heading. A further difficulty in attempting to decide the exact limitations of this article is to be found in the fact that hysteria, insanity, chorea, and various other nervous diseases are very closely connected with nervous exhaustion. Indeed, many of the cases which are considered by authorities as instances of neurasthenia would be more appropriately classed with one or other of the especial diseases. Thus, the nervous fears discussed in such detail by George M. Beard in his work upon neurasthenia plainly belong with the monomaniacal insanities, and, although they usually are associated with nervous depression, may coexist with great physical and mental power.
Further, very many chronic diseases produce neurasthenia. It has not been many years since general debility was a common inscription upon records of diagnosis. In very many cases the general debility afflicted the diagnostic powers or zeal of the physician rather than the body of the patient, and it is to be feared that neurasthenia not rarely at present replaces it. Malarial poisoning, chronic Bright's disease, chronic diarrhœa, lithæmia, and various other affections may be readily overlooked, and patient and physician satisfied with the diagnosis of neurasthenia; indeed, in my own experience in a very considerable proportion of the cases which had been diagnosed as nervous exhaustion the patient was really suffering from definite disease.
The folly of attempting to make neurasthenia a distinct affection is strongly brought out whenever it is attempted to give sharp diagnostic differences between it and other diseases. As examples may be noted the flat contradictions which exist in the different diagnostic tables given in the elaborate work of the late George M. Beard.
It is necessary, therefore, in the outset, to recognize that neurasthenia is a bodily condition which is very frequently associated with various chronic disorders, or not rarely coexists with perverted functional activity of the nervous centres, which perverted nerve-functions may, however, exist independently of any perceptible neurasthenia, and are not simply the outcomes of the neurasthenia. Under these circumstances an apology for devoting an article in this work to the consideration of neurasthenia may seem necessary to readers. The justification of the present discussion is to be found in the facts that neurasthenia often exists without the presence of definite disease, and that still more frequently it is a bodily condition which dominates in its therapeutic importance the manifestations of perverted functions, so that the patient is to be treated for it rather than for the disease with which it is associated.
ETIOLOGY.—There are various chronic diseases which may lead directly to nervous exhaustion. Neurasthenia may, moreover, be the result of disease which is long past; neglected diarrhœas, bleeding piles, and other affections with exhausting discharges, when they have been cured, may leave behind them conditions whose source and nature it is most important to recognize.
Overwork, excessive mental emotion, need only to be alluded to as capable of producing a pure neurasthenia. As Samuel Jackson was accustomed to say, in his lectures at the University of Pennsylvania thirty years ago, “Whenever the expenditure of nerve-force is greater than the daily income, physical bankruptcy sooner or later results.” It is to be remembered that the nerve-capital of persons differs almost as widely as does their moneyed capital. There are numerous families many of whose members are neurasthenics from birth—i.e. who are born with less power of creating nervous energy than is necessary to meet the requirements of the ordinary duties of life. There is every grade of natural endowment between the most feeble person, scarcely able to produce more nervous energy than is necessary for breathing, eating, and drinking, and the organism that is capable of enduring incessant toil. The development of neurasthenia is therefore not so much the result of a strain which is absolutely great as of a strain which is excessive in its relations to the organism which has to bear it.
SYMPTOMS.—The onset of neurasthenia is always gradual, although at times the condition appears to develop with great suddenness. Under these circumstances, however, the explosion has been preceded by a long train of more or less overlooked phenomena: thus, in a case that just now occurs to me a gentleman had long suffered from the premonitory symptoms of neurasthenia, to which he had paid but little attention until he was one day seized with violent vertigo, accompanied by such prostration of strength that he had to be taken home from the street in a carriage. The symptoms vary very much according to the portion of the nervous system which is especially affected, and also to some extent according to the etiology of the attack. Nervous exhaustion may in the beginning affect the whole of the nervous system, or it may be at first purely local and coexist with general nervous strength. Many cases of spermatorrhœa are instances of the local form of neurasthenia, the sexual centres being primarily affected; but as in these cases, sooner or later, the whole of the nervous system becomes implicated, so in other forms of the disorder the exhaustion, at first local, finally, if neglected, implicates the whole organism. There are not rarely cases of brain exhaustion in which the symptoms are at first purely local. Almost always the cause of a local neurasthenia is excessive use of the part; thus, cerebral asthenia is usually the result of mental overwork, sexual asthenia of sexual excesses, etc. When to the intellectual fatigue is added the depressing effects of excessive anxiety or allied emotions, the symptoms usually from the first are more general. The exhaustion may affect chiefly a single function of the brain. As an instance may be cited the case of a postal clerk now under my care, who has been accustomed to distribute five to eight thousand letters every day from a general mass into three hundred pigeon-holes representing as many post-office districts scattered over a large territory. As soon as the address is read there must be an instantaneous automatic recognition of the district to which the letter goes. It is at this place where, in the case now under consideration, the symptoms manifest themselves. Reading the address fails to produce immediate recognition of the locality to which the letter is to be assigned. Asked in what district such a post-office is, the clerk answers instantly, but seeing the address himself he hesitates, and sometimes balks so that he can distribute only about one-third as many letters as when in health. As in most cases of local nerve exhaustion, in this patient some evidences of general implication exist, there being decided disturbance of the sexual organs.
Another form of local neurasthenia which is frequently associated with brain exhaustion is that of writer's cramp. I have repeatedly seen it come on as the herald of a general breakdown; but under such circumstances the symptoms have usually not been those of typical writer's cramp: there have usually been not so much marked spasms as loss of power and distress in the arm on attempting to write.
In pure brain exhaustion loss of the disposition to work is usually the first symptom, the sufferer finding that it constantly requires a more and more painful effort of the will to perform the allotted task. The basis of this difficulty is largely loss of the power of fixing the attention, and this by and by is accompanied with weakness of the memory. Disturbances of sleep are frequent. Various abnormal sensations in the head are complained of. In most cases there is not absolute headache, but a feeling of weight or fulness or an indescribable distress, usually aggravated by mental effort.
It is true that in some cases of very dangerous brain-tire cerebration is performed with extraordinary vigor and ease; the power of work is for the time markedly increased, and even the quality of the product may be raised; the patient may even glory in a wild intellectual exaltation, a sense of mental power, with an almost uncontrollable brain activity. It is probable, however, that these cases are not instances of pure neurasthenia, but that there is an active congestion of the cortical gray matter. It is certain that they are very prone to end in serious organic brain trouble. In some cases of cerebral asthenia there are disturbances of the special senses, tinnitus aurium, flashes of light, and even the seeing of visions. Under these circumstances it is again probable that active congestion of the affected centres exists.
Severe cerebral neurasthenia may be associated with good spirits, but usually there is marked depression, and this perversion of function may finally go on to decided melancholy. The will-power, as all other functional activities of the brain, is prone to be weakened; morbid fears may finally develop themselves; and at last that which was at the beginning a simple brain exhaustion may end in hypochondriasis or insanity. In my own experience such ending is very rare unless there have been from the beginning marked symptoms of hypochondriasis or melancholy; in other words, unless there be the inborn tendency to distinct mental disorders, cerebral neurasthenia rarely produces them, but in a person who inherits such tendency the brain exhaustion may become an exciting cause of insanity.
The symptoms of brain-tire may be very largely existing in the individual who still has muscular strength and is capable of enduring much physical labor; but in most cases, sooner or later, the more general symptoms of neurasthenia manifest themselves.
Amongst the earliest of these symptoms may be disorder of the special senses. For reasons which are not very evident it is the eye which is generally affected. Although existing deafness is often greatly intensified by the coming on of nervous exhaustion, I cannot remember ever to have seen severe deafness entirely neurasthenic. The nature of the optical trouble is to be recognized by the fact that vision is at first good, but fails when the eye is steadily used for a few minutes, although the organ is physically perfect. This weakness of the eye may long be the most troublesome manifestation of the disorder.
In some instances, before any loss of muscular strength is marked, vaso-motor weakness is prominent. Excessive blushing on the slightest provocation, great flushing of the face after the use of alcohol or other stomachic irritant, waves of heat passing over the body, occasional pallors provoked by exertion or apparently causeless, and cold extremities, are some of the phenomena which mark the lack of power in the centres that control the blood-vessels. Closely allied to these disturbances are those of secretion. In my own experience the most marked of these is a tendency to night-sweats, but in some cases the hands, and more rarely the palms of the feet, are perpetually bathed in perspiration, which may be greatly increased by any emotional disturbance. In some patients there is a very great tendency to serous diarrhœa, which in its turn of course increases the nervous exhaustion.
In many neurasthenics the heart as well as the vaso-motor system sympathizes in the weakness, so that palpitation and shortness of breath not rarely follow even slight exertion: a more characteristic symptom is, however, a peculiar dropping of the heart's beat, which is to the patient at first very alarming, but which is entirely independent of any lesion of the heart itself. The true nature of this cardiac intermission is to be recognized by the existence of other symptoms of neurasthenia, and by the fact that it is not constant, and that it is very prone to follow eating or gastric irritation of any kind. Not rarely it is relieved at once by the belching up of wind. When tobacco has been very freely used the cardiac symptoms of neurasthenia usually come on very early, and may be very severe. Under these circumstances it is really a mixture of neurasthenia and tobacco-poisoning with which we have to deal.
The muscular strength may finally fail almost altogether. It is almost characteristic that the patient should be capable of much exertion under excitement, and should suffer from the results of such exercise not immediately, but after one or two days.
In many cases of neurasthenia atonic dyspepsia exists, but it is always a question for careful consideration how far a nervous condition is due to the dyspepsia and how far the dyspepsia is caused by the nervous condition.
Disturbances of sensation are common in neurasthenia, these disturbances taking the form in many instances of itchings or formication or other similar minor ills. Neuralgia is often severe and its attacks frequent, but I am convinced that something more than simple nervous exhaustion is responsible for its production. I believe that there is a neuralgic diathesis or temperament which is often associated with neurasthenia, but may exist without it, and which probably has, at least on many occasions, relations to a gouty ancestry. When such temperament exists the neuralgic attacks are greatly aggravated by the coming on of neurasthenia. Hyperæsthesia and anæsthesia mark the line where simple neurasthenia passes into hysteria. The same also is true of the peculiar tenderness over the spinal processes of the vertebræ, which is especially frequent in women, and is the chief symptom of the so-called spinal irritation or spinal anæmia—an affection which I believe to be a form of neurasthenia allied to hysteria.
In neurasthenia disturbances of the sexual organs are very common; in women great pain on menstruation, ovarian irritation, the so-called irritable uterus of Hodge, are closely connected with a general nerve weakness. In not a small proportion of the cases of uterine disorders which are often locally treated I believe the local disease is largely the expression of the general condition. It is well known that masturbation and sexual excess in the male may produce an exhaustion of the nerve-centres especially implicated and also a general nervous exhaustion. This is the common history of spermatorrhœa. It is no less true that a general neurasthenia may produce a local weakness of the sexual centres, with symptoms at least resembling those of spermatorrhœa—namely, great irritability of the sexual organs, with a practical impotence due to immediate seminal discharge whenever coition is attempted. I have certainly seen this condition result from excessive intellectual labor when there has been no sexual excess, and at a time when the muscular strength was still good. Such cases may, perhaps, be distinguished by the fact that unprovoked emissions are not nearly so apt to occur as in true spermatorrhœa.
TREATMENT.—The natural cure for neurasthenia is rest, and my own experience coincides with the logical inferences to be drawn from an etiological consideration of the subject—namely, that medicines are only of limited value, and unless very judiciously administered may readily do harm. Disturbing symptoms should be met and tonics may be used, especially strychnine and arsenic, but all drugs hold a secondary position in the relief of a pure neurasthenia. In using remedies the practitioner must be guided by general principles, and I shall not engage in any detailed consideration of the subject, but employ the space at my disposal with a discussion of rest.
When nervous exhaustion has been produced by over-use of any one organ or system of organs, absolute rest of such organ is a primary necessity. Thus, when there has been sexual excess absolute avoidance of use of the sexual organs must be enjoined, and in married Americans it is often essential to insist upon man and wife occupying distinct apartments1 or even to separate them by a journey.
1 Because in this country man and wife habitually occupy one bed. Sexual continence under these circumstances can only be obtained at the cost of a suppressed sexual excitement worse than moderate indulgence.
Again, in cases of brain-tire it is the brain which should be rested. To rest an overwearied, excited brain is often not an easy task. In attempting it the effort should be to obtain the following results: 1st. The removal of all cares, anxieties, and all brain-work, especially those of such character as have been connected with the breakdown. 2d. The maintenance of the interest of the patient, so that the past shall for the time being be forgotten, and the present not overweighted with irksomeness. 3d. Invigoration of the physical health of the whole body, and especially of the nervous system. In order to obtain the first of these measures of relief, isolation of some sort is essential; for the second mental occupation is usually required; for the third fresh air, exercise, or some substitute is to be superadded to abundant food and rest.
The proper method of meeting these indications varies greatly, not only with the varying physical conditions and idiosyncrasies of patients, but also with their diverse domestic and pecuniary relations. To give detailed directions for every case is impossible, and I shall therefore limit myself first to simple cases of brain-tire in which the muscular strength is preserved; second, to cases of profound general neurasthenia.
In brain-tire travel is usually recommended, and travel affords, when properly directed, separation from old cares and thoughts, a maintenance of interest by a succession of novel sights and experiences, and the physical stimulation of fresh air and exercise. In bad cases general travel is too stimulating, and ocean-voyaging is much better. Upon the ocean is to be found nothing provocative of thought, only complete isolation, fresh air, enjoyment if the patient be fond of the sea, and a sufficient exercise, especially if the sufferer in any large measure works in the management of a sailing vessel. Hence prolonged yachting affords in many cases our best method of relief. The isolation of the North Woods or any other large primeval wilderness may be complete, the air most fresh, and the exercise to be had also boundless, but at the same time controllable; the man may, according to his will, lie in his tent and be fed by his guide or be unceasingly active. If the life be agreeable to the sufferer, and sufficient care against undue exposure be exercised, the camp-cure is most efficient. European travel may serve almost equally well, provided hard journeying, sight-seeing, and even cities are avoided. The quiet of Switzerland or the Tyrol may bring restoration when the bustle of London and Paris might complete the ruin.
To those who cannot travel extensively the seashore, mountains, or lowlands of the United States are open, and the best way of meeting the indications in any individual case must be determined by a joint consultation between doctor and patient.
There are cases of neurasthenia in which the slightest exercise does harm, and in which even the unconscious effort of company and conversation is an injury. Between the extremely exhausted and the slightly brain-tired is every grade of case, and much tact is often required in properly regulating the treatment of the individual case.
It is only the most severe forms of neurasthenia which require the use of the so-called rest-cure. For such, however, it is a very valuable method of treatment. It finds its most brilliant application undoubtedly in neurasthenic women, but, more or less modified according to circumstances, it has a wide scope in the treatment of both sexes. When the bodily condition is developed by prolonged lactation, nursing, grief, overwork, acute disease, or other temporary or removable cause, the rest-cure may give permanent relief; and even when the cause of the neurasthenia is largely inherited feebleness of constitution, it is a valuable though a more temporary remedy. This method of treatment has long been used in this city, and was especially dwelt upon in its general scope by Samuel Jackson, but in its modern form it has become a very valuable method of treatment, essentially different in its details from what it was formerly, and far more potent in its influence. To S. Weir Mitchell is due a great debt of gratitude, for by him has this improvement been made.
The principles of the rest-cure are absolute rest, forced feeding, and passive exercise. Absolute rest is often prescribed by the physician without being sufficiently definite and insisted upon. When it is desired to apply it most strictly, it should be clearly explained that the patient is not to be allowed to get out of bed even to pass urine or feces, not to feed himself or herself, or perform any act of the toilet whatsoever. The rest also must be for the mind as well as for the body, and it is essential that the patient be isolated. Separation from friends should especially be insisted upon in the case of women. It may be possible to separate a man in his own house completely from his daily cares, but a woman in her own house is in the midst of her daily business, and is like a man placed in the corner of his factory. In obstinately severe cases of neurasthenia complete and absolute isolation is a sine quâ non, and especially when there is a decidedly hysterical element is it necessary to separate the patient entirely from her friends. Under these circumstances there must be a well-trained nurse who is personally agreeable to the patient. The confinement would be very irksome to any except the most exhausted patient were it not for the daily visit of those engaged in the treatment; to further provide against ennui the nurse should be a good reader, so that under the definite instructions of the physician she can occupy a certain portion of the time in reading to the patient.
In order to maintain the functions of the skin the patient should be well sponged in bed every morning after breakfast. A strong solution of salt, or, better, sea-brine, is to be preferred to simple water, and frequently it may be followed by the use of alcohol. In very feeble cases the alcohol may be employed alone. I have seen very good effects from momentarily rubbing each portion of the skin with ice just after the bathing.
The question of feeding is one of great importance, and requires the utmost care and attention from the physician. The end to be attained is to feed the patient as much as can be digested, but not to overdo and derange the digestion. Food should be given at intervals of two or three hours, and must be both light and nutritious. It should, at least at first, largely consist of milk, except in those rare cases in which that fluid does really disagree, and not merely is thought to do so. The milk should be skimmed or given in the form of koumiss. Beef and other concentrated meat-essences are valuable as stimulants, and may be used, especially as the basis of soups. Various farinaceous articles of food may be added to them, or if an egg be broken into the concentrated bouillon or beef-essence just as it ceases boiling a nutritious, and to many persons palatable, dish is obtained. When constipation exists, oatmeal porridge, Graham bread, fresh or dried fruits may be allowed if readily digested by the patient. In order to give an idea of the general plan of the dietary, the following schedule of the daily life is given. Such a schedule should always be put into the hands of the nurse, who should be required to follow it strictly. It must be altered from day to day, so as not to weary the patient with monotony. It is especially important to remember that the diet must be carefully studied for each patient, and be adapted to the individual requirements of the case. Success will in a great measure depend upon the practical skill and tact of the physician in this adaptation:
| 8 | A.M. | Rolls or toast; cocoa or weak coffee, or roasted wheat coffee; beefsteak tenderloin or mutton chop. |
| 9 | A.M. | Bathing. |
| 11 | A.M. | Oatmeal porridge, with milk, or else a pint of koumiss. |
| 12 | M. | Massage. |
| 2 | P.M. | Dinner: Bouillon with or without egg; beefsteak; rice; roast white potatoes; dessert of bread pudding, blanc mange, or similar farinaceous article of diet. |
| 4 | P.M. | Electricity. |
| 5 | P.M. | Milk toast. |
| 9 | P.M. | Half pint of skimmed milk or koumiss. |
In many cases the patient at first can take very little food, and it is very frequently best to begin the treatment with an entirely liquid diet, giving milk every two hours, or using Liebig's raw-meat soup, with milk or plain farinaceous food, and only after a time gradually accustoming the patient to solid food. Not rarely a prolonged treatment by the so-called milk diet is of avail. The rest-cure is indeed largely based upon a careful regulation of the food; but a full discussion of the various dietaries to be used would require a treatise upon dietetics.
Passive exercise is to be obtained by the use of electricity and massage, the object being to get the effects of exercise upon the nutrition and circulation without the expenditure of the patient's nerve-force. By the use of electricity muscular contractions are secured which simulate those which are voluntary and more or less thoroughly replace them. By the general application of the current to the whole body we probably affect the tone of all of the minute blood-vessels, and certainly in this or some other way stimulate the general nutrition, and, as has been shown by S. Weir Mitchell, for the time being elevate the bodily temperature.
The faradic current is alone used. It is applied in two ways: first, to the individual muscles; second, to the whole body. The séances should be daily, the operator beginning at the hand or foot, and systematically faradizing each muscle of the extremities and trunk.
The slowly-interrupted current is generally preferable, but advantage is sometimes gained by varying the rapidity of the interruptions. The general rule is to select that current which produces most muscular contraction with the least pain. The poles should be applied successively to the motor points of the muscles, so as to contract each firmly and thoroughly. This process should occupy from thirty to forty minutes. The electrodes are then to be replaced by large sponges well dampened with salt water: one of these should be put at the nape of the neck and the other against the soles of the feet, and a rapidly-interrupted current, as strong as the patient can bear, should be sent through the body for twenty minutes or half an hour. It is not necessary for the operator to remain during this time. In some cases the electrical programme may be varied so as to get a local stimulant action from the general current; thus, when digestion is enfeebled and the bowels costive for a portion of the time one of the sponges may be placed upon the epigastric region. In women when there is great abdominal and pelvic relaxation one pole may be placed high up in the vagina. I have seen old-standing prolapses cured in this way. Some electro-therapeutists claim great advantage from galvanization of the cervic sympathetic ganglia, but I do not myself believe that they ever succeeded in reaching these ganglia with the current.
Massage, like electricity, affects greatly the peripheral circulation, empties the juice-channels, and gives tone to the muscular system. It must be clearly distinguished from rubbing of the skin. It consists in manipulations of such of the muscles as are not too deep to be reached, and of the cellular tissue: in order to lessen as much as may be the skin friction by these manipulations, it is often well to anoint the surface with cocoanut or other bland oil. As sold in the drug-stores, cocoanut oil is very often rancid, and at any time it is well substituted by the cheaper cottonseed oil. In practising massage it is essential to remember that the natural course of the venous blood and the juices of the cellular tissue is toward the centre of the body; therefore, all general movements should be practised in this direction.
The manipulations are percussion, rolling, kneading, and spiral. They consist of movements made with the pulpy ends of the fingers and thumbs, and spiral movements with the whole hand so folded as to adapt its palm to the limb. In percussion the strokes should be from the wrist, and should be quick and short. It is probably not possible, even by long strong strokes, to affect deep muscles. In the rolling manipulation the effort is to roll the individual muscles beneath the pulps of the fingers. This manipulation may be varied by pinching the muscles, not the skin, and kneading. In each case it is intermittent pressure upon the muscles which is aimed at. The circular movements are to be in opposite directions with both hands simultaneously, the limb being grasped by one hand a little above the other, and a spiral sweep made up the limb, the ball of the thumb and the palm of the hand resting upon the patient, and the pulpy parts of the thumb and the fingers grasping the limb. It is especially such motions as these which affect the circulation of the flesh-juices.
The length of time the patient is to be kept in bed and treated in the manner described varies of course with the individual case, but usually less than four weeks is not sufficient, and rarely are more than six weeks required. In getting up, the patient should begin by sitting up one or two hours a day, increasing daily, but not too rapidly, the time of being out of bed and the amount of exertion made. The electrical treatment should be gradually intermitted: in many cases massage twice a week seems to be of service even after the patient is about. In the going back to ordinary daily life great care is to be exercised to proportion the amount of exertion to the newly-obtained strength, so as not to lose what has been gained. In cases of natural or of long-standing acquired severe neurasthenia the mode of life must be arranged to correspond with the small daily product of nervous energy.
In dismissing this subject I desire to caution against a routine employment of this so-called rest-cure, which might readily degenerate into a species of quackery; and, again, to call attention to the widespread value of the principles which underlie it, and the importance of the physician applying those principles with endless modifications of detail.