Neurasthenia and Arteriosclerosis.—There are many serious conditions that masquerade as neurasthenia. Perhaps the most important is precocious arteriosclerosis. That a man is as old as his arteries is now recognized as an absolutely sure maxim of internal medicine. In many people the arteries wear out before their time and in all there is an inevitable wearing out in the course of years. With the beginning of degeneration of the arteries there are likely to be many symptoms that closely resemble neurasthenia. In the elderly these are nearly always symptoms of defective circulation because of lack of elasticity in the arteries and their failure to accommodate themselves to the variations of pressure in the circulation as the consequence of changes of position, variations in the barometer, heat and cold, and the like.
In these cases a study of the blood pressure will give the differential diagnosis when the actual thickening of the arteries cannot be felt, but it must not be forgotten that nervous excitement may greatly heighten blood pressure on occasions so that a number of observations have to be made.
Neurasthenia and Bright' s Disease.—Other general diseases almost inevitably produce nervous symptoms. It is curious how often a severe exacerbation of Bright's disease, which has been in existence for some time but has given no specific indication, is preceded by a series of neurotic symptoms thought to be due to nothing more than neurasthenia. Men of thirty-five to forty-five, the favorite time for the occurrence of the severe forms of Bright's disease, begin to complain of tiredness, especially on waking in the morning, of inordinate fatigue in the evening, of some stomach symptoms and occasionally a tendency to diarrhea. All of these are ascribed to a neurasthenic condition. Early in these cases an examination of the urine should be made [{558}] as a routine practice, because if there is nothing in it the patient will be just that much more reassured, while if it contains any pathological elements he need know no more about it than his physician deems proper, yet the real nature of the case and its indications will be appreciated. Without this a physician will often find himself suddenly confronted by serious symptoms in a patient when nothing of the kind was anticipated because the condition was thought to be entirely functional.
Occasionally the symptoms of Bright's disease seem to develop suddenly, as it were a storm in the organism out of a clear sky. As a matter of fact, however, there have been for some time before more or less indefinite symptoms pointing to some serious process at work, which if valued at their proper worth might have led to a much earlier diagnosis of the impending nephritis. Such patients are labeled as neurasthenics for months and at times even years before the serious conditions develop which make the recognition of their ailment comparatively easy. One case of this kind has come under my observation that is interesting in its lessons. A medical student had during the first year of his course exhibited every now and then what seemed to be neurotic symptoms. He was inclined to complain of headache for what seemed very slight reasons, and of pains and aches whenever there was a change in the weather and especially a fall in the barometer. He often had stomach symptoms and was anxious about his heart; in general he was looked upon as one of the nervous, complaining kind. During the course of a lesson in clinical pathology in his fourth year, he was asked to furnish a sample of urine which it was supposed would be normal, for comparison with an abnormal sample that was being investigated in the laboratory. To the surprise of the professor and to his own consternation, his urine was loaded with albumin. Up to that time there had been absolutely no objective symptoms and only the vague indefinite subjective symptoms mentioned. The next day his feet swelled. Even this for a time was considered to be rather an index of the neurotic tendency in him to react to very slight causes. It was hoped that the albuminuria was functional, as the examination was made in the full tide of digestion, and that it would pass off. Subsequent examinations, however, showed not only albumin but also casts. There was a slight intermission of symptoms and then an exacerbation. Within a month after the chance examination of his urine and its unexpected result he had a convulsion. Two weeks later, altogether six weeks after the albumin was first discovered, he died in nephritic coma.
Such cases are not so rare as they are thought, though they are seldom so fulminant. There is a story told of a professor at one of our American medical schools who, some twenty years ago, took a sample of his own urine in order to demonstrate the normal characteristics of healthy urine, and to his utter surprise he found albumin and casts in it. Within six months he was dead from Bright's disease.
Nervous Diarrhea and Organic Disease.—Other internal conditions may be called neurotic when they are really due to definite pathological entities. For instance, in three cases I have seen what had been pronounced by several physicians to be chronic diarrhea of nervous origin, proved to be due to quite other and serious pathological conditions of internal organs. In one of them a chronic diarrhea of several years' standing finally culminated in death in [{559}] early middle age from nephritis. After the event, there seemed to be no doubt but that the diarrhea, which no ordinary means of treatment had succeeded in benefiting more than temporarily, was really due to the effort of the intestinal mucosa to supplement the defective work of the kidneys. In this case apparently one of the strongest evidences that the affection was of nervous origin was the fact that whenever the patient was away from home, eating rather plentifully of a varied diet, his intestinal condition was better than when he was eating much more simple and unvaried food at home. The change of scene and surroundings proved a tonic to his kidneys and perhaps also to his skin, thus saving his intestines some of the extra work they had assumed.
Neurasthenia and Diabetes.—Another serious disease that may in its earlier stages be mistaken for neurasthenia is diabetes. There is no doubt that some patients have been passing sugar for a long time before any sure symptom can be noted in their general health, or, indeed, before there is anything to call attention to the possibility of glycosuria. In many of these cases, however, there is a feeling of muscular tiredness and a sense of inadequacy for occupations which were before easy, that may be attributed to neurasthenia. When this muscle tiredness changes to crampy feelings that should be enough to lead to an examination of the urine.
Undoubtedly one of the reasons why neurasthenia is sometimes called the American disease and is thought to be more frequent among us than it is in Europe is this confusion with the beginnings of serious organic disease because of failure to examine patients carefully in order to detect underlying organic conditions. In recent years this neglect has become rarer and the consequence has been a reduction in the numbers of so-called neurasthenia cases. Our morbidity statistics of twenty years ago, for instance, seemed to show that we had only half as much diabetes to the population as they had in Europe. One of the reasons for this was undoubtedly the ease with which the diagnosis of neurasthenia might be made at the beginning of diabetes, and that the terminal stages of the affection were often masked by the development of the tuberculosis so frequent in diabetic conditions or of albuminuria with symptoms pointing to Bright's disease. Even at the present time it would be quite possible to reduce the number of neurasthenia cases by more careful attention to diagnosis.
Simulated Neurasthenia Due to Over-attention.—While there is danger of confusing neurasthenia on the one hand with more serious disease there is a distinct liability on the other hand to exaggerate the significance of certain minor symptoms by employing the word when it is only over-attention of mind to certain portions of the body that constitutes the disease in its literal sense. If something has particularly attracted a patient's attention to some part of his anatomy and if his attention is concentrated on it and allowed to dwell long on it, his feelings may be so exaggerated as to tempt him to think that they are connected with some definite pathological condition and he may even translate them into serious portents of organic disease. If a patient once begins to waste nervous energy on himself because of solicitude with regard to these symptoms then it will not be long before feelings of tiredness, incapacity for work, at times insomnia and certain disturbances of memory are likely to be noted. Then the neurasthenic picture seems to be [{560}] complete. This is the process so picturesquely called "short-circuiting" by which nervous energy exhausts itself upon the individual himself instead of in the accomplishment of external work. Many of the worse cases of so-called neurasthenia have their origin in this process. It is true that this set of events is much more likely to occur among people of lowered nervous vitality, but under certain conditions it may develop in those who are otherwise in good health up to the moment when the attention happened to be particularly called to certain feelings. The physician can start these patients off anew after improving their physical condition, if he can only bring them to see how much their concentration of mind upon themselves is the cause of their symptoms.
It has been well said, though to some it will doubtless seem an exaggeration, that we human beings are a regular boiler factory of sensations which, fortunately for our sanity, mental and physical, we have learned to neglect to a great extent. Wherever our clothing touches us, wherever the air touches us, wherever shoes or belts constrict us, there are definite sensations. These continue, but attract no attention unless they exceed a certain limit to which we are accustomed. Habit in this matter is very different in different individuals. After men and women have grown used to tight shoes or tight corsets these no longer produce disturbance. The chance visitor in a boiler factory or loom room of a cotton mill thinks he could not live in such din. But after a time people get so used to the din that silence and quiet may even become oppressive to them. City dwellers from the slums, especially children, find the peace of the country disturbing when they are first taken for vacations.