flower-makers, turners, watchmakers, knitters, engravers, masons in using the trowel, sailors from pulling on ropes, treadlers, compositors, enamelers, cigarette-makers, shoemakers, milkers, money-counters, letter-sorters, and players on various musical instruments, including drummers, comprise the list given by Gowers. It has been noted in a shoe salesman from the stooping position needed in putting on shoes, in gum-chewers, affecting the masticatory muscles, and in various factory employees who incessantly use the same movement in feeding or attending some machine. Clergymen and other public speakers, from a faulty use of the vocal apparatus, may acquire a laryngeal neurosis that is manifest every time the voice is strained, causing a sudden loss of modulation, which may end in continuous vocal disability. A spasm of a similar nature, involving the lumbar muscles, has been seen in physicians, due to continuous riding in carts or buggies. CHAPTER V. IN 1869 Beard, of New York, directed general attention to a nervous state or condition marked by irritable weakness, and adopted for it the name of neurasthenia. It is familiarly known as nervous prostration or nervous exhaustion, and is a fatigue neurosis. In Europe. it was at first somewhat derisively called the American disease or Beard's disease. It is now recognized the world over as a morbid state; as one of all time, and not a product of modern life or of American conditions. It is marked by a host of subjective symptoms and a very few objective phenomena, all more or less variable, and most of them inconstant. As a rule, all forms of nervous energy-psychic, motor, and organic are reduced, so that fatigue is more quickly occasioned than in health. There is less endurance, and consequently greater irritability, which most shows itself in the mental sphere. The whole state is summed up in the classical term "irritable weakness.” Etiology. Neurasthenia seldom occurs before twenty years of age or after fifty. It is essentially a disorder of the energetic, productive, troubled period of life. Both sexes suffer, and perhaps in equal proportion, but in females a more common association with hysteria frequently carries these cases into that list. In this country the high altitudes of the Western plateaus and the extremes of climatic conditions in the Northern, and particularly the Northwestern, States apparently account for the greater frequency of neurasthenia in these localities than on the seaboard and in the Southern States. All races present the disorder. Hebrews and Slavs are said to be very subject to it, and Scandinavians, at least in this country, furnish a large contingent. A neuropathic heredity is less common than in hysteria or epilepsy, but neurasthenics are very commonly found at the head of a neuropathic strain. Debilitating conditions in the antecedents of neurasthenics are very common. Gout, rheumatism, tuberculosis, syphilis, excesses, dissipation, malaria, and all the cachexias in parents are likely to discount the stamina of offspring and favor the early limitation of endurance and vigor demonstrated in neurasthenia. A defective education that omits discipline and the cultivation of self-control, poorly fitting the child for the rude shocks of later life, may be a predisposing cause. Educational methods that overtrain and overstrain may directly induce the neurosis. Occupations of all varieties furnish neurasthenics. It is only requisite that the element of overwork come in, whether the labor be mental or physical. Overwork, moreover, is a variable quantity, relative to the forces and endowments of the individual. Among the inciting causes overwork is the most common, and associated with it we usually encounter anxiety, worry, or excitement, which depress the patient's forces, often at the same time impelling him to greater efforts. The business man, anxious for his ventures, works doubly hard to secure success. The sleepless mother, worn with care and nursing, does double and treble duty, and finally "goes to pieces" when the strain is over. The overtrained athlete goes "stale." Excesses, by their debilitating effects, are frequent sources of neurasthenia. Alcohol, tobacco, venery, masturbation, either as onanism or withdrawal, unnatural stimulation of sexual responses, and, very rarely, sexual continence may result in the general depression we call neurasthenia. Trauma, both physical and mental, may induce neurasthenia, and is likely to do so in proportion as the psychic shock is well developed. Railway accidents may breed neurasthenia in those who do not receive a scratch. The fright is often worse than the blow. Together they may cause a double injury. A muscular strain from overexertion, as in lifting, may start neurasthenia, particularly if the back be hurt and there is suggestion or fear of serious harm having been done. The more neurasthenia is studied, the more prominent will its mental side become. Exhausting illness, either from acute or chronic disease, may cause neurasthenia. Various toxic states, such as lithemia and syphilis, are prone to produce it. It is usually difficult, and often impossible, to determine the exact cause of neurasthenia in a given case. Ordinarily, there are a number of both predisposing and exciting causes. In a large number of instances neurasthenia is secondary to and symptomatie of organic conditions, such as phthisis, Bright's disease, diabetes, gout, rheumatism, uremic and toxic states generally. Pathology. Although we know no pathological anatomy of the disorder, its manifestations are those best explained by a diminished dynamic energy and lessened recuperative power in the cerebrospinal axis, and especially in its cellular elements. This may be a nutritional defect. The very constant factor of persistent overwork, overstrain, and overfatigue in the causation of neurasthenia, coupled with Hodge's findings in the motor cells after an expenditure of energy, leads to the opinion that we have to do with a fatigue neurosis, general in distribution and comparatively slight in degree. With this view in mind, we will be the better able to understand the symptomatology and the requirements for treatment. ous. Symptoms. The symptoms of neurasthenia are extremely numerSome of these are essential, most are adventitious. Charcot considered headache, backache, gastro-intestinal atony, neuromuscular weakness, cerebral depression, mental irritability, and insomnia as the fundamental symptoms of the disorder, the true stigmata of the neurosis. Secondarily and inconstantly arise a host of complaints that are of less importance and significance. It will be necessary to take up the symptoms seriatim. It may be said of them all that they indicate a deficiency of function, never an absolute want of it. The reduction is one of quantity rather than of quality, but is never absolute in degree. Motor Disorders.-A constant condition in neurasthenia is muscular weakness. The patients complain that muscular efforts are promptly fatiguing. They can only walk a few squares, standing a long time is exhausting, and exercise or use of the back and upper extremities prostrates them. They often show a remarkable diminution of strength as registered on the hand-dynamometer or in lifting, but occasionally a patient can put forth one or two fairly forcible efforts, and then the strength quickly subsides. Sustained effort is impossible. As another manifestation of the generalized myasthenia, tremor is frequently observed, and can usually be provoked by comparatively slight muscular efforts. Lamarcq1 found it in eighty-five per cent. of neurasthenics. Many patients complain of their trembling knees and shaking hands, or the tremor may appear in the handwriting, especially toward the end of a long letter, where the firmness of the strokes is also likely to be reduced. Tremor in the lips and face is sometimes noticed. Muscular twitchings in the face and extremities are not rare. The tendon reflexes, ordinarily, are increased. This is customarily the case with the knee-jerk. A tendency to widely distributed responses is frequently present, so that a tap on the patellar tendon causes starting of both lower limbs or of all four extremities, and sometimes gives rise to a complaint of pain in the back. If the knee-jerk be repeatedly produced, the intensified response first elicited may gradually subside and even disappear, giving another evidence of the early fatigue of the nervous apparatus. In some instances a tap on muscle or nerve-trunk will call forth a similar response. Ankle-clonus is sometimes present, but is spurious in character, and only a few vibrations of the foot can be elicited. Repetitions. of the test may fail to produce it. Paralysis or abolished knee-jerks are not found in neurasthenia unless due to other coincidental disease. Sensory Disturbances.-Neurasthenia never causes anesthesia. When this is present we have a condition of actual deficit, to which limit. neurasthenia does not go. The vague subjective disturbances of sensation, on the other hand, are limitless. Among them a feeling of general tiredness and fatigue is almost constant, and the recumbent posture tends to become habitual. 1 "Revue Neurol.," August 15, 1896. Headache is one of the most common symptoms; it is practically never wanting and often is described in striking terms. In some instances it is slight and constant, more often it is produced by any muscular or mental effort, and occasioned by any disturbing emotion. Usually it is occipital, "at the base of the brain," as these patients are fond of saying; but it may be frontal, temporal, or vertical. One describes a sensation as if the head were splitting or the skull lifting; another has a terrible weight or a severe constriction about the head. This lead-cap headache is very common. Heaviness, throbbing, buzzing, a sensation of wind blowing or of water running under the scalp, and many others are perhaps indicative of the vasomotor disturbances within the skull. Backache is equally common with headache. It is probably a fatigue symptom for the most part, though sometimes referable to gastro-intestinal disturbances. The small of the back is its usual seat, whence it streaks up between the shoulders or through the loins and down the limbs. Very commonly it is associated with a "drawing" sensation at the back of the neck, and the occipital pain is then usually complained of. By lying down or by padding a chair with pillows, some relief is obtained. The advanced case customarily assumes one of these expedients. In milder cases the backache is occasioned by any effort or disturbing circumstances and subsides upon rest. Tenderness is usually found over the spine and is rather superficial in character, but occasionally is intensified by deep pressure. Rarely the spine is tender its entire length; usually only small sensitive spots are present. The upper cervical spine near the occiput, over the vertebra prominens, opposite the lower angle of the scapula, at the waistline, at the top of the sacrum, and over the coccyx are the favorite locations. Sometimes the tenderness is diffuse and the skin over the entire dorsum is painfully over-sensitive. Sometimes this sensitiveness prevents the dorsal decubitus or interferes with sitting up. It is likely to be aggravated by anything which disturbs the patient or increases the other symptoms. Sensitiveness on the head, limbs, or other portions of the trunk is not rare, and is usually associated with spontaneous pain in the same location. The outlines of these sensitive areas are never sharply defined, and they may shift position or vary in intensity within a few hours or days, but sometimes remain practically stationary for months. All manner of vague sensations of heat, cold, prickling, tightness, numbness, stiffness, weakness, fatigue, soreness, pain, pressure, etc., referred to this or that part of the body or limbs are constantly encountered. In addition there are a host of abnormal feelings referred to the thoracic, abdominal, pelvic, and generative organs. Visual Disturbances.-The neurasthenic commonly complains that reading has grown difficult because it causes headache and vague distress, and states that the letters blur or run together after a few minutes. In other instances they can not maintain attention. Careful examination will usually demonstrate that the accommodative apparatus and the retinal sensitiveness are promptly fatigued. One is a motor loss, the other a sensory deficiency. The first is shown by the rapidly diminishing ability to clearly make out the test-type; the second, by the quickly narrowing visual field, due to impaired sensitiveness in the retinal periphery. Both may be regained after a slight rest. A high and oscillating degree of muscular asthenopia is usually due to neurasthenia, and commonly subsides as the nervous state improves. Deficiency of the interni is the usual finding. Photophobia may be encountered of sufficient intensity to keep patients in dark rooms or wearing colored glasses. In lessened degree retinal hyperesthesia is not uncommon, and is similar to the cutaneous sensitiveness. Misty obscurities and a veiling of vision are sometimes described, or everything looks strange and unreal. The pupils are usually very mobile, contracting and expanding excessively, sometimes sluggishly, sometimes very actively and even independently of light or accommodative efforts. Inequalities, both transient and persistent for days, are rarely encountered. Permanent inequality is due to organic disease. Disorders of Hearing, Smell, and Taste.—Hearing is apparently frequently disordered. Thus, patients start at the slightest sound, and often tie up the door-bell and seek seclusion to avoid all such irritation. This is as much mental as aural, perhaps, but tinnitus in various forms and throbbings in the ears are due to the irritable weakness that spares no nerve. Complaints of peculiar or bad smells and tastes have a similar significance. Di Gastro-intestinal Disorders.-Nervous indigestion is one of the commonest features of neurasthenia. The appetite is often capricious, and may be excessive or greatly diminished. The mere thought of food may be repugnant. In milder cases there are complaints of the food lying heavy or of gaseous eructations, which may or may not be attended by heart-burn. The gaseous gastric distention may suggest dilatation, and often provokes cardiac palpitation and precordial and epigastric distress. In more aggravated cases dilatation actually occurs, and hydrochloric acid may disappear from the gastric secretion. gestion is retarded and deficient, but the tongue may remain clean and nutrition still be inadequate to maintain the body-weight. The small intestine is usually affected in the same atonic fashion, causing constipation. In the severe cases of neurasthenia all these conditions are aggravated. The eructations of gas become frequent, noisy, and distressing; meteorismus, colicky pains, alternating constipation and mucous diarrhea, intestinal fermentation, and the passage of undigested food mark the atonic and irritable state of the gastro-intestinal tract. Cases present great variations, and the same case is rarely consistent in regard to these features. Circulatory Disorders.-Cardiac palpitation due to digestive disturbance is one of the common symptoms in neurasthenia, but may result from other causes, as muscular or mental efforts, sudden starts or embarrassments of any sort. In some instances it reaches a high degree and is attended by precordial pain, a tumultuous heart's action, throbbing arteries, and generalized distress. In other cases it may occasion |