A system of practical medicine. By American authors. Vol. 5

by Unknown

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.