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ists in New York City, all of whom had apparently considered the case as one of neurasthenia, she was likewise treated at the Infirmary for an indefinite period of time as a supposedly neurasthenic patient, until one day the finding of a beginning optic neuritis lead to a further investigation of the case, and a diagnosis of brain tumor was made, which was subsequently confirmed by post-mortem examination. Doubtless there are some present who have known of instances in which individuals suffering from a supposedly functional disorder, later replaced the vague aches, pains and motor weaknesses complained of by symptoms of undoubted organic involvement. In this connection I would refer for the moment to the harmful effects sometimes resulting from failure to diagnose early such cases as tabes dorsalis, and even acute melancholia, in which conditions it is not at all unusual to have a prodromal period of varying length in which the symptomatology presented is largely subjective and neurasthenoid in character. Trauma, likewise, may be a factor in producing nerve fatigue, and by no means today have such disorders as "railway spines" and kindred ailments, passed into oblivion.

The symptoms of neurasthenia are chiefly subjective, and for the sake of convenience can be considered from the following standpoints, motor, sensory, somatic and psychic. The motor symptoms, in brief, are those of muscular exhaustion. The patient complains of tiring easily, and that he cannot undertake any little effort without revealing evidence of ready muscular exhaustion. His grip may be weak, his legs weary easily, even after the shortest of walks, occasionally muscular cramps are present, and sometimes tremors add to the disagreeableness of the situation. There is very commonly an inhibition of the central motor impulses and in consequence the deep tendon jerks, particularly the knee jerks, are found to be in an exaggerated

state.

The sensory phenomena, as a rule, are at first vague and bizarre in character. Headache, backache, and various aches and pains, local and general in character, are sooner or later encountered. Paraesthesias of the hands and feet may be complained of, numbness may be experienced, especially in those parts of the body where the clothing tends to be somewhat restricted, but it is of great importance to note that objective sensory disturbances, such as anesthesia or hypesthesia, are never present.

The somatic or visceral disturbances are likewise the result of a deficient innervation. Owing to the lack of energy of the various viscera, bodily disturbances result. The circulatory apparatus is usually found to be below par in its work, since the cardiac function, as a rule, is weakened by an absence of proper stimuli com

ing over the vagus system. Palpitation of the heart is exceedingly common, feeble circulation in the extremities of the body is by no means unusual, and the various digestive disturbances, indigestion, heaviness in the epigastrum, eructations, constipation, all point to a condition in which undoubtedly there is a deficiency in innervation as well as in inhibition. The clinical picture of the sexual neurasthenic is so well stamped on your memory I dare say, that to attempt to portray the same before this society, I take, is entirely needless. Here, as in the other somatic disturbances, exhaustion is directly responsible for the symptomatology presented.

The psychic phenomena are intensely interesting. There is a pronounced lack of mental tone, the capacity for intellectual work is diminished, there is an absence, as it were, in the spontaniety of thought and the ability of concentration is impaired. Irritability in some cases becomes the order of the day. That a tired man is more apt to be cross than one not wearied in well doing, is well known, giving evidence of a more or less loss of self control, a loss of inhibition. Thus we see that neurasthenia, in the brief outline above presented, may manifest itself as a fatigue neurosis, and the failure thus far to find an organic basis compels us to consider it as functional in character.

Of no less interest, perhaps, is a consideration of psychasthenia. Here due credit must be given to the noted French psychiatrist, Janet, for the introduction of this term, meaning soul weakness. As before stated, psychasthenia is a disease resulting largely from causes arising within the individual himself. Just as neurasthenia is a fatigue neurosis, so in psychasthenia do we likewise find fatigue playing an important role as a causal factor.

Having already spoken somewhat at length regarding the symptomatology of neurasthenia, it is not necessary that your minds be now burdened by a more or less detailed description of the symptoms attending the psychasthenic state, since all the phenomena of nerve exhaustion, such as are present in the neurasthenic states, are to be found in psychasthenia. Suffice it to say that the mental phenomena are the symptoms which especially claim our attention in this disorder and although the psychic field is invaded in some neurasthenic states, there can be no question but that the mental phenomena dominate the clinical picture in the true psychasthenic condition.

It may be of interest to note that psychasthesia requires for its development the combinafatigue neurosis on a neuropathic background. tion of two important factors, the grafting of a It was left to Dercum to point out the duality of the origin of this psychosis, and to this celebrated American alienist belongs the credit of

simplifying our knowledge of the various forms under which the psychasthenic states parade. Any non-neuropathic individual who, for one reason or another, becomes nerve exhausted can be properly classed as a neurasthenic, but in order that a true psychosis be developed, there must be present a previously neuropathic state. As Dercum has well said, "It is only when fatigue symptoms appear in a neuropathic subject, that mental disease results," and it was to this group of mental disorders that he applied the term "neurasthenic-neuropathic insanities."

There is no one, I dare say, who has given even the slightest of attention to mental disorders but has been confronted at times with individuals presenting a mental condition in which the special fears, phobias, obscessions, anxiety psychoses, indecisions, deficiency in inhibition and deficiency in will were present in varying grades and degrees. It is entirely beyond the scope of this paper to even attempt to take up a consideration of these various forms, other than to state that for all practical purposes it would appear that the arrangement of the forms of the neurasthenic-neuropathic insanities is the most applicable one we have today. Here, four special types or groups are considered, namely, The Insanity of the Special Fears, the Insanity of Indecision, the Insanity of Deficient Will, and lastly the Insanity of Deficient Inhibition.

For a clinical study of such cases, it is usually needless for one to look among the inmates of our state institutions and asylums for individuals suffering with some form of this mental disorder, since it is extremely rare for such persons to be committed. On the other hand it is impossible to formulate an idea as to the number of such individuals who are extra-murally situated. Like the proverbial poor, however, they are with us always. Fortunately for society, the psychasthenic is usually one who is harmless, both to himself and to others around about him, but in endeavoring to purge the pathologic associations from such a mind, the physician is confronted with a Herculean task, and not infrequently is he compelled to accept defeat and all that goes with it, due to the fact that neuropathics, like poets, are born and not made.

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tissue. The toxins may be the products of bacterial growth or of disordered metabolism in the tissues themselves brought about by the reaction to invasion with bacteria or in some other way. Thus severe stresses, deprivation, hemorrhage, etc., may result in such an auto-intoxication.

Since nerve tissue has only certain functions to perform it is obvious that intoxications of all kinds can produce only evidences of interference with that function which must be similar in every instance. The only possible differences, apart from those of degree, must depend upon the rapidity of production and duration of the toxin which will influence the course of the disorder, and the particular groups of nerve cells which the toxin is capable of attacking. Upon this last factor will depend the individual differences to be met with in the manifestations of different kinds of intoxication. This last feature, however, does not play a very large part in the bacterial intoxications for the damage is very diffuse and affects especially the higher associative neurons of the brain.

Consequently it is as unnecessary to consider the manifestations of a psychosis resulting from an infection with typhoid separately from those of one arising in the course of pneumonia as it would be to describe separately acute nephritis according to the particular specific fever in which it occurred. The severity and course may differ, but the manifestations are identical.

that there is a widespread tendency to regard This point is here emphasized for the reason psychoses as separate and distinct diseases and

to consider that the addition of mental disorder to the clinical picture of typhoid or pneumonia is a new disease to be combatted. Mind cannot be separated from body and it is even more important to grasp that body cannot be separated from, or treated independently of, mind. We, as physicians, have to deal with human beings and not with mere collections of separate and distinct organs each with existence independent of the others.

From a clinical point of view then the results of diffuse cerebral intoxications may be considered together. It is possible to subdivide them into groups which, as they present certain differences in course, are therefore of practical value. Thus Kraepelin speaks of fever deliria, infection deliria, acute confusion and enfeeblement from infection. The first includes the deliria occurring during the febrile reaction to infections and in which the manifestations run parallel to the fever. It thus would seem that they are dependent upon autointoxications due to the disordered metabolism of the fever reaction.

The second group includes the so-called "initial deliria" met with especial frequency in typhoid and smallpox. Here the disturbance appears before the characteristic manifestations of

the infection and may subside when the disease becomes fully developed. It is apparently due to the sudden invasion of the body with bacterial toxins. Under this same head also come states of delirium which do not run parallel to the fever and may be present even when the temperature is but little raised or has fallen to normal or below. Such are seen, for instance, in the course of influenza, chorea and rheumatism. In some of the especially severe cases of this group there is an actual deposition of bacteria in the brain. The effects seem to be due to the bacterial toxins rather than to autotoxins and hence they are called infection as opposed to fever deliria. Many of this type represent very severe infections and hence the prognosis as to life is always serious. They tend, however, when not fatal, to be of short duration corresponding with the persistence of the toxins plus the time which the damaged brain tissue requires for recovery.

The third group of acute confusion is not very clearly defined from the last but includes a number of severe intoxications appearing after infection, especially with typhoid, acute rheumatism and the puerperium and also in connection with severe exhausting conditions. Death may occur, but it is not so frequent as in the last. When not fatal the condition generally lasts for some time, being given by Kraepelin as from two to six months.

The fourth group again is not very well differentiated from the last as it appears following infection or other exhausting factor. The picture is one of general reduction of psychic activity with easy fatigue, and this usually lasts for some months and may be permanent.

In order to understand the manifestations of these intoxications it is essential to think of the function of nerve tissue. This, in addition to the maintenance of its own nutrition, consists of excitability and the conduction of such states of excitement. It must also be remembered that consciousness is the brain cells in action. Interference with function can take place only in two directions, increase or diminution. In a general way it may be said that lesser degrees of damage to a cell give rise to increased excitability while more severe injury results in diminution and finally loss of excitability. This is perhaps not. universally true, as there may be some toxins which produce lowering of function without the initial excitation. It can readily be understood, however, that in states of generalized intoxication there is a liability to the occurrence of a simultaneous combination between irritative and paralytic phenomena especially during the earlier stages which may later give place to a general and marked lowering of function in which excitability is more or less completely in abeyance.

We have defined consciousness as the brain cells in action and it is obvious that, if this be

granted, the possibility of the stimulation of consciousness must depend upon the degree of excitability possessed by the cells and, since ability to clearly recognize our surroundings depends upon the arousing of a normal degree of activity in the various brain pathways, it is also obvious that any interference with the normal functioning of these pathways must necessarily lead to a disturbance in our grasp of the surroundings.

One of the most prominent features of the infective-exhaustive reactions is such a failure to fully, or correctly, grasp the situations in which the patient may happen to be placed. Consciousness is, as it is said, clouded and the objects and happenings around are more or less misunderstood because incompletely perceived. The consequence is that the behavior and conduct of the patient (which is all that we can observe) seems more or less incongruous and inappropriate to the actual circumstances.

Where there is over-excitability of tissue this clouding is accompanied by confusion and general restlessness. If on the other hand lowering of function is more marked the tendency is to a quieter but at the same time more incoherent state well seen in the so-called “muttering delirium" of severe typhoid states.

But in addition to these misinterpretations or illusions, and consequent disorientation, there is often present a condition of hyperexcitability the cells of the lowest brain levels, that is to say those of the sensory regions of the cortex, with the consequence that stimulations which in health would be insufficient to give rise to sensations may now suffice. There will thus be aroused sensations which do not correspond with any stimulus of the environment-so-called hallucinations. These tend to add to the confusion and apparent disorder of conduct and speech.

These features of clouding of consciousness with more or less disorientation, illusion and hallucination are quite intelligible upon the disorder of function due to the poisoning of the cerebral cells. But it may be difficult to understand why they take the particular forms which we observe clinically. It is easy to see why there may be a hallucination of vision, but why does it take a special form such as that of the devil. a particular face or what not? One can understand that objects or happenings in the surroundings may be misinterpreted. But it is not so obvious why the interpretation made should have some one particular form and this error be repeated over and over again in the same form.

The explanation of these facts depends upon many factors and it is possible here only to indicate briefly certain important points. Firtly, it must be remembered that the direction of one's thoughts is to some extent dependent upon one's mood. When we "feel good" it is difficult to see the dark side of things. When depressed we

find it hard to see the "silver lining" to the cloud. The mood is largely dependent upon the harmonious activity of the various bodily organs. In states of generalized intoxication there is necessarily more or less severe dysharmony and consequently the mood is generally one of depression. Hence one particular trend is at once given to the thoughts aroused by any sense perception. There are especially liable to be aroused those thoughts which fit in with the mood of depression and the patient's erroneous perceptions therefore tend to be unpleasant.

Again, in every individual, some trends of thought are much more habitual than others. This means that those nerve pathways, the activity of which they are, even in health, are more easily stimulated than others. This will give rise to the tendency to misinterpret in the direction of frequent experience and will explain the frequent occurrence of so-called "occupation delirium" in which the patient seems, by his remarks and movements, to be following up his usual avocation.

In states of general excitement with failure to understand the surroundings as the result of clouding together with depressed mood resulting from the general bodily upset and a confused mass of sensations due to hyperexcitability one can then readily understand that the reaction of the patient will be colored by fear and anxiety and that his words and behavior will indicate the most terrible and awful misinterpretations which he is capable of imagining. In other words the particular form which the hallucinations, illusions and the consequent delusions take will depend upon the individual experiences and interests of the patient. Just as the anxious mother when her son fails to return home at the expected hour pictures as having happened all the things she most dreads, the particular dreads being dependent upon her personal experience as to what might happen, so the patient, confused and bewildered by a host of unusual sense experiences (illusions and hallucinations), interprets them in the light of his own personal fears.

The importance of this point lies in the light which it throws upon the fact that in these infective states the actual manifestations, the words and acts which we observe, depend more upon the individuality of the patient than they do upon the particular infection from which he is suffering. No two cases of delirium are alike as regards the particular illusions and consequent delusions which occur. The recognition of the nature of the disorder from which the patient is suffering must therefore depend upon the detection of the basis of disturbance in excitability of brain cells with clouding of consciousness. The manner in which one does this is by attempting to determine how much the individual is able to grasp of his surroundings and the appropriate

ness of his remarks and actions to the situation as the patient grasps it. Since he may be suffering from illustion and hallucination it is obvious that this may differ largely from the situation as the examiner sees it.

To illustrate what is implied by these last remarks suppose that one gathers from the patient's remarks that the sounds in the street are misinterpreted as the voices of her children. One then observes the conduct and contextual remarks with the view of determining whether these are in keeping with such observation.

The fate of the cells which have suffered from such intoxications is obviously an important point in determining the question as to whether recovery of the previous mental capacity will occur. One is quite accustomed to give assurance that these people will fully recover provided life is preserved and fortunately this is generally true. But it must be remembered that if the damage to the cell is sufficiently severe the cell will die and disintegrate. Nerve cells differ from all other cells in the fact that each has a different connection to make from every other. They do not all do exactly the same work as do all liver or kidney cells because they have different anatomical connections. Hence the loss of nerve cells means complete loss of certain possibilities of transfer of energy and consequently lessened mental efficiency.

You are all familiar with the fact that after a severe infectious disease, such as a bad attack of typhoid, patients may remain permanently less active and efficient and more dull and lethargic than before. Such permanently enfeebled states are rarely of sufficient severity to call for more than surprised comments by friends, but occasionally it happens that the loss is more severe as seems to be the case in a patient I have had on my wards in the State Hospital. Such cases are included under the title of enfeeblement from infection used by Kraepelin and mentioned above. Rarely being severe, they require but passing mention and consideration when dealing with severe and prolonged delirium. In this connection do not forget that severely damaged cells. may eventually recover even after several months and that, therefore, rest and hope should be persevered with.

Having thus very cursorily considered the nature and manifestions of these infective-exhaustive psychoses we may turn to the question of the indications for treatment.

It was pointed out that the state of dysharmony and disordered metabolism in the body, due to the infection, resulted in a state of emotional depression. This mood when added to the illusions and hallucinations resulting from local damage to the brain cells gave rise to a still more active disorder in mood. This again as Pawlow, Cannon and others have shown means still fur

ther interruption of bodily metabolism and there thus exists a vicious circle which must militate seriously against the patient's chances of recovery. All such active emotional states imply further a big expenditure of energy as well as a difficulty in digesting and absorbing food. Hence the indications for treatment (apart from those belonging specifically to the treatment of the infection which are not changed by the existence of the psychosis) are fairly clear and may be grouped under two main headings, nutrition and sedation. Of these the former is by far the more important.

It is impossible and unnecessary for me to go into details on these points, but a few features may be emphasized. First a large supply of water, of which the body holds no reserve supply, is essential. If necessary, this must be given by rectum, hypodermically or even intrvenously. Secondly, since digestion is always markedly interfered with, the food must be in readily assimilable form and easily combustible. For this purpose may be mentioned especially the sugars such as glucose, which can, if necessary, be administered hypodermically, and well diluted alcohol. Under this same category also comes the question of alkali. Depletion of the alkali-reserve of the body and even definite acidosis (meaning thereby, of course, not an actual acidity of the blood, but only a diminished alkalinity) are quite frequent and the addition of alkali in any prolonged state of this kind is of importance. The question of sedatives must be weighed by careful consideration of the probable duration and the damage which is apparently resulting from the excitement. Do not rush to drugs which are also toxins and may add to the difficulties with which the body has to contend. Simple quiet and the avoidance of stimulating sights and sounds with adequate water and food will often suffice. In addition, if conditions are suitable, hydrotherapy in the form of baths or packs will often act like magic in securing sufficient rest. Only where such measures fail or where they are impossible of application should resort. be had to drugs.

In thinking of drugs for such purpose do not forget that the stimulation of a lagging heart may result in sufficient improvement in general metabolism to have a general sedative effect. For this purpose we may employ the more powerful but more transient stimulants such as ammonia and camphor (strychnin is a nerve poison and not a cardiac tonic) or those of the digitalis group which produce a milder though more prolonged effect. Finally, in any case, when the dangers of excessive activity lead to the decision to use some sedative drug, careful attention must be paid to its effect upon, and the condition of, the heart. Remember that such patients are usually much more susceptible to the toxic effects of morphine

than persons in more asthenic conditions. Hyoscine may be used with caution and is often of value, but I believe it should not, in these conditions, be combined with morphine. Chloral in small doses is not a cardiac depressant, but large doses should be avoided. I will not bore you with an enumeration of the many such drugs available, but will conclude with the earnest recommendation to attend carefully to water, food and quiet surroundings before deciding to employ them.

REACTION OF THE SEMI-CIRCULAR CANAL TO STIMULI AND DIAGNOSTIC SIGNIFICANCE*

J. B. POTTS, M. D., Omaha, Neb. The announcement of your secretary was, medicine in the present war. that the meeting was to be along the lines of As a member of the examining unit for aviation service in Omaha, it occurred to me that the profession might be interested in the special tests that are required for this service. This was emphasized some days later by the irrelevant question of one of our internists. This man while unusually well posted and having a working knowledge of the caloric and turning tests, flew wide of the mark when inquiring as to the tests necessary for aviators; determine a man's ability to stand being turned his idea being that the tests were intended to round and round with the swooping and sliding that might be experienced in driving aeroplanes. Also the ability to remain cool under unusual conditions and stimuli. This all is very erroneous as will be made plain as the paper proceeds.

The principal interest lies in those tests which are directed to the semi-circular canals. However, previous to testing these, the hearing and

*Read before the Medical Society of the Missouri Valley at Lincoln, Neb., Sept. 21, 1917.

LOYALTY AND SERVICE

Doctor, have you offered your services to your country? Service is the supreme test of loyalty, and true patriotism should inspire every man to do his duty in time of his country's need. Surgeon General Gorgas needs more doctors, and he needs them now. The increasing activities on the western front will intensify the demand for medical men. Now is the golden opportunity for you to serve your own country. And what a glorious thing to be able to say later on that you took an active part in a grand victory! Perhaps you are disqualified for active service: if so, there is ample Opportunity for service in the "Home Guard." Come to Omaha September 19th, and hear these matters discussed. Bring a friend with you. Many of our members are in service. We need new members to fill up the ranks. If you do not receive a program, write me at once.

Fraternally,

CHAS. WOOD FASSETT, Secretary Medical Society of the Missouri Valley. Subscribe to the Fourth Liberty Loan and help hurry the final decision.

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