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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