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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,
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
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.


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
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 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 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.

Over-attention to sensations, often scarcely abnormal, is indeed the
real source of many of the symptoms that can so readily be exaggerated
into pathological portents when attention is directed to them. Every
portion of our body is connected with the central nervous system.
Every square inch of surface touched either by clothing or the
movement of the air producers a sensation at every moment of our
waking life. Ordinarily we pay no attention at all to these
sensations. We can recognize their presence by turning our attention
for the moment to any portion of the body and recognizing at once that
there are sensations coming from it, though the moment before we did
not notice them. If we think of the point of our big toe on the right
foot we find, though we were totally unaware of it a moment before,
that a certain pressure is being exerted in it. If we continue to
think of it queer feelings develop in it. We may get a sense of
numbness that proceeds up along the tendons that lead to it. We can
follow them up to the insertion of the muscles in the shin. If we
dwell on the subject we have curious prickly sensations and numb
feelings, all of which were there and were neglected a minute before
but now are acutely felt.

This same thing is true of all the manifold sensations that come
streaming into the brain. We learn almost to enjoy them though we are
paying no attention to them. To be without them would mean very often
a fright lest there should be something the matter. Usually we think
of the outside of our body as the main source of sensation. It must
not be forgotten, however, that our viscera have also certain
sensitive nerves and while these are not as closely distributed as
those on the surface they are there and their presence is often a
source of pleasure or at least of satisfaction, but may be the source
of poignant discomfort. We are constantly disregarding ordinary
messages from these, too. Something may easily call our attention to
these sensations, however, and then we may translate them into
pathological terms though they are really only physiological.
Ordinarily man may put a couple of pounds of food and drink into his
stomach and not feel it at all. If anything particularly calls
attention to our stomachs, however, and we dwell on it, then this
weighty feeling may seem to indicate serious indigestion because of
the discomfort that is produced. This is what nervously weak persons,
the so-called neurasthenics, are constantly doing. It is this habit
that by suggestion and training they must be taught to break.

There is a tendency to the substitution of one neurotic symptom for
another whenever by psychotherapy and mental discipline one condition
is overcome. Often the substitution is of something just as bad or
even worse. I have known cases where people when properly persuaded
gave over paying too much attention to their stomachs and then
proceeded to pay too much attention to their sleep with the result
that insomnia developed. On the other hand, I have known patients to
get over insomnia and then develop a series of complaints of queer
feelings in their head which they usually spoke of as headache, though
when asked to describe them carefully they confessed that they were at
most a sense of pressure or of unusual feeling in some part of the
head.

These curious substitutions take place particularly if for any reason
special attention is called to another part of the body, either by
accident or by some therapeutic manipulation or remedial measure. I
have known a patient who complained of headache and was advised to
take up exercise in the open air, do much stooping and lifting while
cleaning snow from the sidewalk, develop a tired condition in the
lumbar muscles and straightway this was thought to be rheumatic.
Liniment was employed and the counter-irritation which developed
attracted the patient's attention to that portion of the body for a
week. The headache was no longer complained of, but lumbago was
considered to have developed. I have known a person who suffered from
headache develop what seemed to be a retention of urine for which
unfortunately the doctor thought it necessary to use a catheter and
after this there was no complaint of the headache, but the patient
became almost unable to hold any amount of urine in her bladder and
could not go out for social or other duties because of the fear of
imperative urination.





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