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CENTRAL LIBRARY . 1 1 1 1 1 III I • 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 )• 1 1 1 1 Toronto Public I.ibrary (Pamphlet Collection) .(LA--T I I • I I I I 1 1 I I I I 1 1 I I I I I I I • I I I i I I I NEI'RASTJIHNIA liV 1) R. DA N I K L (' I, A R K, Mtilic;;! Sii|MMiiiieii • • • 1 ■ 1 1 1 ■ • • • 1 1 1 ■ 1 1 1 1 1 > 1 I._K. Hkvavc 8: i"<>.. PtiVilisliLTs. Toronto.' ("rmada. ■ 2^" m T^; 'V;.^l-' I NEURASTHENIA. The name neurasthenia^ or neuratropia, is as good as any term we can use to describe this nervous disorder. The class of patients to which this formidable word can be applied js very large, and is growing larger day by day in this nerve-exhausting age. 'I'he patient's mind is " centred all in self." I'he woes and aches and pains such endure — real or imaginary — and which are recited to the physician with weari- some reiteration, are legion. The old story is to such ever new. The history of these multi- form afflictions becomes an old friend in its familiarity. The weary doctor in his rejoinder can only encore his previous homily to relieve the recurrmg distress. This sad recital is re- peated from week to week, and from month to month, until recovery or insanity has taken place. The concentration of thought on ail the varied moods and feelings which the patient may possess intensifies the mental pain and aggravates the nervous condition. We know in our own experience how much mental anxiety or anguish depresses physical function. Fear is more distressing than pain, and tugs at the heart-strings with greater intensity. Out of this class come the many suicides who are not insane, and who leave behind them sensible but woeful epistles to friends or acquaintances. In medical literature this condition has been given many names, such as cerebrasthenia, brain exhaustion, general debility, nerve starvation, " run down," jjoverty of blood, spinal irritation, and other terms " too numerous to mention." This disease is not to be confounded with hypochondria, hysteria, or insanity, l^^ach of these conditions is well marked and easily dis- cerned by any observant physician. The morbid fears of insanity are usually definite and per- manent, and accompanied by delusions, which are fixedly believed in by the insane patient. The neurasthenic, on the other hand, will tell you how unfounded are their extravagant ideas, and that they can temporarily banish these vagaries, but only to return again, like the swing of a pendulum. These ever-recurring whims pull down the physical energy, and the bodil) depreciation reacts on the mental until the nerve masses and the physical activity are mutually i)ut out of gear for the time. 'I'he functional want of harmony is bordering on the pathological. The morl)id fears of people thus nervously unstrung are as varied as are the individuals. The list of their fancies and wild imaginings is endless. All are based on some groundless alarm in respect to themselves or in their rela- tion to others. Men full of energy and push succumb to the depression. " Enterprises of great pith and moment," which in their best estate they would have gloried, without waver- ing, to have carried through successfully, now paralyze them in mere contemplation. The brain debility conjures up lions in the way, or mountains too high to climb over. The fears and forebodings of indefinable evil about to come, the unnatural and morbid dread of impending adverse circumstances have been the means of bringing about commercial or busi- ness disaster before friends see that worry of months, and it may be of years, has been drawing on the pat'ent's stock. The re- serves of the nervous system, which we all have in store for emergencies, have been con- sumed, and the fagged-out system has no alternative but capitulation, which it never does without a struggle. The neurasthenic may be divided into three classes : ist. Those who complain of general weari- ness, becoming easily tired, having poor or capricious appetites, being restless, yet look fairly nourished and healthy. 2nd. Those who are evidently feeble. They are usually pale, thin, and show generally a waste of tissue and a breaking-down without any evident local disease. 3rd. This class contains those in which we find a. hysterical condition and anaemia, especi- ally in chlorotic females. It is well, however, in all such cases not to jump too hastily at conclusions, lest organic and local disease should exist, and the nerve conditions only prove to be symptoms indi- cating permanent trouble, which may need special and direct treatment. I have made mistakes myself in this direction, and many cases have come under my care in which my professional brethren have been guilty of the same sins of omission. Be thorough in your examinations. All these jihenomena are defects, outside of brain disease, of a permanent character. 'I'he identity is not present, but the family resem- blance is striking in this brood of evils which border on insanity. 'J 'he want of sleep, fol- lowed by a low power of thinking in the pursuit of daily business ; the weakening of the jjowe r of attention and a desire to wander from necessary thought ; a shrinkage from doing a business which heretofore was a delight : be- coming abnormally wearied in mind when doing routine and ordinar}' work ; not the natural facility to put ideas into words, and an unnatu- ralness of temper in respect to small matters and on small occasions ; and change of manners and feelings to near friends and relatives without any just reason, are cardinal character- istics. - --. ,.^ ■, - . ,-■.-.:.. -,^v ■ Wc often meet with the other |)sychical extremes, such as unusual and constant buoy- ancy of spirits, mental exhilaration not natural, loijuacity and rtightiness, which are observed by everyone except by the individual himself. So marked are these changes of character, that many such are accused of having become drunkards. The accusers do not know that these symptoms are signals of distress. The indecision of will, the bewildered judgment, the lack of self-control and of di.scretion, the ex- citement alternating with unaccountable mental depression may be only temporary and evanes- cent, or they may be " coming events casting their shadows before." If there is any hereditary taint of insanity, or any serious neurosis existing, then these evi- dences of physical and mental deterioration are not to be lightly thought of, for any such con- dition may evoke from latent tendencies avlive diseases of an alarming character. The defi- cient mental control of sane people thus afflicted is a psychological study of great interest. They know how al)surd are their fears and fore- bodings, yet no reasoning can shake them off or remove the general nervousness. The hope- lessness, the silly fancies, the unnatural dread of being in company or of being alone, the fear of contamination in many ways undreamed of when well, the undefined terror on walking certain streets or living in isolated houses, and the general sense of ill-being with a dread of something vague about to happen, are only a few of the many psychical conditions found in the neunsthenic. 'i'he most pro- nounced manifestations underlying these mor- bidly tinged concepticnis and misconceptions are timidity, irresolution, and constant irritability of manners and speech not natural to the person. This state of feeling has a defined period of in- vasion, and has not been gradually acquired through daily experience and repetition, nor is it a congenital trait of character. 'I'his abnor- mal condition is often the primary stage of in- sanity. It is interesting to note how conversely , we often find insane convalescents show merely this modification of mental weakness in the last stages before recovery. Just as the colors of the rainbow, or those of the spectrum analysis, blend into one another so imperceptibly that no boundary between each shade can be located, so it is often difficult to know by observation, or to define in language, where the dividing line is m many cases, between that disease we call insanity and nerve-starvation. It is not, however, a fixed physical disease^ and does not affect and con- trol abfiormally the language and conduct of an individual^ as in insanity. The physical con- dition is not to be overlooked. We often find abnormal dryness of the skin and mucous mem- branes, tenderness of the spine in circumscribed places, as, we often find in hysterical women. A 7 i ( ' Coinpljunts of fcclini; heaviness of the loins and limbs ; shooting pains simulating those of ataxy, irritable heart-action, best known by a tremulous, variai)le i)ulse ateompanied by pal- pitation and it may be intermissions of beats, mostly the third and fifth beats. (.Convulsive movements, especially on going to sleep, which have often been mistaken for nocturnal epilepsy ; localized hyper-iesthesia ; sudden giving out of general or special functions ; temporary paresis, or it may be |)aralysis, and .v pent-up Utica." The usual diagnostic and differential skill will enable an;/- onc readily to distinguish this disease froiii either hysteria or ordinary anaemia. It is not chietiv found to exist in naturallv nervous iier- sons. A patient may be plethoric and muscular -not necessarily anaemic, and yet have impoverishment of the nervous system. Neuratropia exists chiefly in patients between the ages of 25 and 50 years. Its presence does not depend on any important recognizable organic disease. I have found in a 8 majority of case-' a full, normal pulse, but some- times it is very rapid, or abnormally slow, with a '^.uttering feeling under the finger. There is no cardiac disease present in most cases, and the face may look the picture of health. The patients will often apologize for their satisfactory appearance. In spite of apparent strength, such are easily fatigued by mental exertion, and complain o^ giving out long before the usual time of resting. The memory is often tempor- arily weakened ; consecutive thinking, intense attention, or sustained mental activity of any kind, is found to be impossible, even when there is no muscular fatigue. It is at this stage, when insomnia is complained of, usually to be followed by mental depression i^nd by distress- ing forebodings of some impending calamity, which they cannot define. It is a general sense of ill-being and ill-happening. It is common to both sexes, but is more common in the male sex. A frequent mistake is made by medical men in attempting to lecture such patients out of their notions about themselves. This will only deepen the morbidity and intensify the evil. It is best to accept the evil as a fact, but to raise hopes for the future in a sunshiny way. This is mental therapeutics. No two cases can be treated alike. If it is a case merely of brain exhaustion, then our main reliance must be upon vigorous out-door exer- cise and light mental exertion. The muscular 1 9 and organic life can do much through activity in bracing up the nerve centres. If we have an anaemic case, or one in which there is evi- dently exhaustion of the cord, especially in chlorotic women, then absolute rest and quiet are indicated. Digestive power and hygiene are our auxiliaries. 1 am a great believer in the " gospel of fatness," or alimentation — not over- feeding, but what the system can fully assimilate. It is nerve nutrition which we have to do with, hence the necessary pabulum must be provided. Such usually recover but gradually, and so slowly as to discourage patient, friends and i)hy- sician. The fact is, that all nerve deterioration needs a i)rotracted time to recuperate, and it is well to set out in treatment with this under- standing Ijy all, that tl is depressing condition has invaded the nervous system by slow ap- proaches, and that it will leave the seat of disease with reluctance, under the most favor- able circumstances. It is necessary to start out with a large stock of patience in treating such cases. A close catechising of a number of young persons has led me to believe that this abnormal condition is often brought about, or at least inten- sified, by worry, the vicious habit of self-abuse, or from syphilis. It is also well to make minute enquiry as to the existence of the mild form of epilepsy, especially of the nocturnal or larvated or masked variety, which is often overlooked, lO yet by its enervating shocks not only does it pull the system down, but also keeps it prostrated when the mischief is done. A rigid enquiry on these points is of paramount importance in diagnosis of many cases. I am inclined to think that the abnormal mental conditions are always secondary, and that the primary trouble is in the sympathetic and spinal systems. The constant complaints of unusual sensa- tions in one or more of the abdominal organs are evidences of this. The heart's irregularity, the atonic dyspei)sia, the obstinate costiveness, the kidney derangement, and the temporary dysp- noea, all point to these great nerve centres as the eflficient causes of these derangements. If we keep in mind that in the neurasthenic we have mostly to do with reflexes of the sym- pathetic and spinal cord, including all the organs to which nerve stimulation is given from these centres of influence and control, we can under- stand how varied must be the symptomology of this generic disease. If we add to these dis- turbing causes a tendency to insanity, or at least find a nervous diathesis predominating, then, of necessity must our progno;.is be less favorable. I have found that those who usually complain of pain in the back, show that the spinal nerve function is temporarily deranged. This fact is evident when we find the oxalates, the urates, and uric acid in excess. These are present only as results, and are not pathognomonic, as 1 1 in oxaluria, because on a return of tonicity in the nervous system these ahnormahties disap- pear. They are at first only signals of distress, which warn us of graver evils should the disease intensify and continue. 'I'he i)athology of the disease is not yet fully determined. It may be a change in the quality or (juantity of blood supply to the nervo\ system, it may be an impoverish- ment of nerve force, it may be bad nutrition fiom low power of assimilation, one or all of these causes, or others yet unknown, would account for the exhaustion, the positive pain, the unsteadiness, the fluctuating character of the morbid sensations and phenomena. Whatever may be the cause or causes, the result is nerve starvation, the cry is for more food and for uiore reserve energy. Let me summarize the treatment . ist. Rest and cheerfulness for the anaemic. 2nd. Outdoor exercise and work for the ])lethoric and sedative. 3rd. Fresh air, substantial food and absolute cleanliness for both classes, as a rule. 4lh. No chloral, no opium, no alcohol ; in short, no artificial stimulant, soporific or nar- cotic, of any kind. Three hours of natural sleep or rest have in them more recuperative power than nine hours of stupor or drugged (juietude. Such short cuts to rest only murder natural sleep and strangle the heroic efforts of nature to come back to normal conditions. 1 IS Even when these stilts are used, it must be after serious and thorough deHberation. 5th. Any employment which will have a tendency to divert the mind away from self- contemplation and, m chort, seeking relief by the law of substitution. 6th. I find the best remedies are such as the arsenites, cod liver oil, zinci phosphidi, ferri pyrophosphate, nux vomica, bromides with caffeine, zinc oxide with ergot, and such like. These tonics and calmatives assist nature to seek again ihe old paths. Allow me to add a word of w. --ning to the younger members of our profession. If sedatives, or narcotics, or stimulants are administered, it is well to mask them as much as possible. We all know their seductive power, and I have been told by dozens of victims to the alcohol, chloral or opium habit, that the first knowledge they had of the pleasurable potency of such drugs was received from the family physicians. After their visits ceased the remedy became a luxury, and the druggist was, api)lied to for the material to inflict infinite injury to many a valuable life. My method has been to use some menstruum which would disguise the taste and smell of these drugs and to maintain a stubborn silence as to their presence in my prescriptions. This warning is given here, ;is there is a great temp- tation to use them in neurasthenic cases, in which arc found insomnia, local pain, and mental distress. ■IWlin IW.IIII I .^mmmik.,M^'^-^^'' r : %:. .^A^ :m ssf .«; L^'.-'^'tRfittl