SECTION XVI
NEUROSES
CHAPTER I
NERVOUS WEAKNESS (NEURASTHENIA)
Neurasthenia, from the Greek roots, neur, meaning nerve, and sthenos, strength, joined by the negative particle a, turning strength into weakness, means nothing more than nervous weakness. To tell a patient that he or she is nervously weak, or is suffering from nervous weakness is usually not satisfactory, but it may be absolutely true and may represent the limit of our knowledge with regard to the particular case. To tell them that they are sufferers from neurasthenia is satisfying as a rule, because then they have a nice, long, and imposing word with which to talk to their friends about their ailment. To discuss with friends one's own nervous weakness is just a little absurd; to talk over neurasthenia and its symptoms, however, adds importance to those symptoms and makes them seem manifestations of some interesting underlying condition.
The discussion of symptoms always does harm, but the internal complacency with its constant auto-suggestion of the underlying nervous disease is still more harmful. Neurasthenia seems to most people to signify a new and serious disease of the nervous system which has developed as the result of our high-pressure civilization and the modern strenuous life, and, therefore, has a special interest and an exaggerated importance. All of this makes for an unfavorable attitude of mind towards the affection and encourages the intensification of symptoms by attention to them. The opposite state of mind in which symptoms would be given their proper value by the term nervous weakness would act as a constant source of favorable suggestion. I believe that if the word neurasthenia must be used, it should be translated for the patient and the absolutely functional character of the affection insisted on in order to neutralize its suggestive influence.
Probably the most serious objection to the use of the word neurasthenia comes from the number of organic affections having vague nervous symptoms, including especially tiredness, a certain incapacity to do what was readily done before with tired feelings and a general feeling of unfitness, that have come to be grouped under this head. In this it resembles the word rheumatism rather strikingly. The diagnostic general principles seem to be: tired feelings equal neurasthenia; achy feelings (especially if worse on rainy days) equal rheumatism. So whenever either word is used, patients are apt to think of cases they have known which were labeled by one of these two terms, [{556}] rheumatism or neurasthenia and ended by developing some serious condition. The unfavorable suggestion consequent upon this has made many patients miserable and has prevented them from using their nervous energy to relieve their condition.
The use of the word neurasthenia has another decided disadvantage in that the facile recourse to it often keeps the physician from examining his patient sufficiently to detect an underlying pathological condition. The term can be made to cover so much that it has done great harm in this way. I feel, therefore, that in the discussion of what can be done for patients suffering from nervous weakness we should first of all describe and set aside a number of forms of disease that have sometimes masqueraded as "neurasthenia" and that have given the affection stronger unfavorable suggestiveness. Sir William Gowers, whom no one would suspect of either minimizing the significance of the word or of the affections that have come to be grouped under it, nor of wishing to attract attention by differing from others, has in one of his recent smaller medical works [Footnote 41] emphasized both of these unfortunate connotations of the word. Because his expressions as applied to other medical terms that are too general in their significance, will help physicians to get at the real meaning of them I venture to quote his opinion at some length:
[Footnote 41: "Subjective Sensations of Sight and Sound, Abiotrophy and Other Lectures," Philadelphia, 1904.]
The history of the word "neurasthenia" is noteworthy. ... I have to confess to the authorship of two words. One, "myotatic," was always a puny infant, and I doubt whether it still maintains an independent existence. The other, "knee-jerk," instantly attained universal use, and indeed, I think has seemed to most persons to have sprung spontaneously from the thing itself, without suggestion—perhaps the greatest compliment a word can pay its author. But the general use at once achieved by "neurasthenia" was in spite of a strong objection to it which was felt by many. The Royal College of Physicians of London could not include it in their "Nomenclature of Disease," and yet it is now one of the most common of medical words in every language. It would be instructive in more than one way to have a careful study of the forces which have influenced its career, but that I cannot attempt. We must, I think, admit that not only is it a satisfying word to those who suffer, but it has a certain convenience which has also compelled many to employ it who at first objected. If I may be pardoned for a partial paradox, its convenience is not the less real because this rests on features that are illusory. Remember that the word is a name which should have little meaning, even to those who use it. You may employ it to collect the symptoms of the case under a general designation, but do not let it cover them as a cloak.
Neurasthenia and Melancholia.—A serious mistake of diagnosis, though it is often not a mistake of knowledge but of medical judgment, is the confusion, apparent or real, of neurasthenia with melancholia. The word melancholia has come to have a definite serious significance, as it should, in the minds of many persons and as a consequence physicians sometimes hesitate to use it, and employ instead the all-embracing term neurasthenia, or neurasthenic depression. It is popularly well known that melancholies are likely to commit suicide if their condition is serious, while neurasthenia is not at all connected with the idea of suicide. As a consequence, patients are often not guarded as they otherwise would be and so we have suicides every [{557}] month of so-called neurasthenics who were really sufferers from melancholia. This sad state of affairs reflects in two ways to the detriment of medicine. First, it leaves melancholies without due protection. Second, it leads many of the neurotic patients whose ailments have been labeled neurasthenia and who read the stories of these supposed neurasthenics, to think that they, too, are tending toward suicide and so they are less capable of reacting against their neurotic condition and in general are much worse for the unfortunate dread of some such fatal termination.
Neurasthenia Simulation by Organic Disease.—Neurasthenia is especially a dangerous term since, like other words of this kind with wide connotation, many quite disconnected diseases may in early stages simulate it and give rise to the thought that there is only a functional nervous disease present, when the symptoms are really a manifestation of an underlying organic disease, heightened somewhat by a nervous organization or by worry on the patient's part. So-called neurasthenia in the old must always be looked upon with suspicion. Neurasthenia in the young may be a purely functional nervous disease, though it is probable that in most cases the nervous system is congenitally defective, or at least is unable to perform the functions which have been assumed by the patient. If a nervous organization has stood the strain of the trials of early and middle life, which are usually severe enough to try out individuals from the physical side, if they are in moderate circumstances, or from the mental side if they are wealthy, it will not, as a rule, be overborne by the burdens put upon it by age unless some organic disease has come to seriously disturb it.