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 {355} 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 {356} 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.
{357} 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
apartments[1] or even to separate them by a journey.
[Footnote 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.]
{358} 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 {359} 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 {360} 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 {361} 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.