Cohwttbia ^niber^ftp IS^tfnmct ilibrarg A PRACTICAL TREATISE ON Neea^ous Exhaustion (NEURASTHENIA) ITS Symptoms, Xature, Sequences, 'I'l'catmeiit BY GEORGE M. BEARD, A.M., M D. FELLOW l)F THE NKW YORK A(rADEMY OF MEDICINE ; OK THE NEW YORK ACADEMY OF BCIENCES; VICE-PRESIDENT OF THE AMERICAN ACADEMY OF MEDICINE; MEMBER OF THE AMERICAN NECKOLOOICAL ASSOCIATION; OF THE AtlERICAN MEDI- CAL association; THE NEW YORK NKUROLOOICAL SOCIETY, ETC. KDITKD. AVITII NOTES AND ADDITIONS, BY A. \). ROCKWELL, A.M., M.D. PROFESSOR OF ELECTRO THERAPECTICH IN THE NEW YORK POST GRADl'ATE MEDICAL SCHOOL AND HOSPITAL; FELLOW OF THE NEW YORK ACADEMY; MEMBER liF THE AMERICAN NKlHOUMilCAL ASSOCIATION; OF THE NEW YORK NEl'KUlAKilCAI. Sp<>v nerve, « privative, and ffSevo^ strength], and literally interpreted means lack of nei^ve strength. My first paper on this subject, based on the study of thirty cases, was prepared in 1868, was read before the New York Medical Journal Association, and was published in the Boston Medical and Surgical Jour- nal, April 29th, 1869, and subsequently appeared in the first edition of Beard and Rockwell's " Electricity." This was, so far as I know, the first systematic treat- ise on neurasthenia ever pubhshed. At first the subject excited absolutely no interest in the profession of this country. In Europe the effect was somewhat different. In England, Dr. Hugh CampbeU shortly after published PREFACE. " y a work on Nervous Exhaustion, largely, if not entirely, based on my writings on that subject, and containing little additional matter; it was clear that, although in- terested in this functional nervous disease, his oppor- tunities for observation had not been abundant, and that he was not fully capable of analyzing and formu- lating his o^vn material. In England, his work has passed through many editions. In Germany, how- ever, where the above-mentioned work on Electricity became widely known through the translation of Vater, of the University of Prague, that section of it devoted to neurasthenia met, for the first time, with a criticism and comment at once sympathetic, intelli- gent, and scientific. In the volume of Ziemssen's "Cyclopaedia" that treats of diseases of the spinal cord, which was pre-/ y^ pared by Professor Erb, of Heidelberg, one of the very ablest of tlje Gei-man neurologists, and one of the most oiiginal and i)hilosophical of recent medical writere, is found a chapter on spinal exhaustion, wherein he not only confirms the description and analysis and nomen- clature of neurastlienia which I gave several years ago, but adds some judicious and valuable observations of his own. Erb, after giving a correct atialysis, in a very general way, of some of the more prominent symptoms of this disease, details a typical case, and observes that he has seen over two dozen similar cases. This observation is of value as showing that this malady is not confined to the Unit(;d States, where it was first systematically described, and where it is ceitainly far O PREFACE. more common than in all the world besides, and that the symptoms, behavior, and clinical history are the same in both countries. At the time when my first article on this subject was prepared (1868), I used the general term neurasthenia to cover all forms and types of nervous exhaustion, the symptoms coming from the brain and from the spinal cord being described to- gether and indiscriminately. This imperfection Pro- fessor Erb has repeated, and, to that extent, the value of his essay is impaired, since, in strictness, the disease neurasthenia should appear both in the volume on the brain and on the spinal cord, in the former as cerehras- thenia, or exhaustion of the brain, in the latter as fnyelasthenia, or exhaustion of the spinal cord. It is this latter form, or myelasthenia, that Erb attempts to describe in his volume under the term neurasthenia spinalis; but of necessity many of the symptoms con- nected with the brain are included in his description. Erb makes the fm-ther mistake, but one in which he is sustained by a large body of writers on the nervous system, of treating of spinal irritation as a separate and special disease instead of one of the many symp- toms of myelasthenia, or spinal exhaustion, which it really is; and he further overlooks the existence of cerebral irritation, which is just as real, though not quite so frequent as spinal irritation; and he evidently fails to recognize the fact that the general irritation or tenderness of the whole body, to which he gives the name hyperaesthesia, is in scientific analysis a condition to be accounted for just as much as spinal irritation. PREFACE. 9 Many important symptoms he does not mention, and no attempt is made to explain in detail the diagnosis, pathology, or rationale of the disease. It is due, how- ever, to Professor Erb to say that he evidently suspects the justness of his analysis, and in one place clearly intimates that he has doubts whether spinal irritation should be considered as a distinct disease; and he con- fesses that it is impossible to draw the hues between spinal exhaustion and spinal irritation, ' So far as I know, none of the recent standard works on nervous diseases, in any language, have any chap- ter on neurasthenia, with the exception of that of Erb, above noted, and the Maladies du Systeme Nerveux (Paris, 1879), by Dr. J. Grasset, Professor in the Fac- ulty of Medicine, Montpellier, France; and "Diseases of the Nervous System," ' by Rosenthal, of Viemia. Prof. Grasset, however, unlike Erb, makes no addi- tion to our knowledge of neurasthenia, but simply epitomizes the facts and reasonings of my earlier es- say. In attempting to point out the relation of neu- rasthenia to the special symptom, spinal irritation, he falls into the same confusion as Erb, without appar- ently suspecting that confusion. Under the general heading Spinal Irritation, various phases of neuralgia, " cerebro-cardiac neuropathia " and agoraphobia— fear 'During the past suiiinier I had the pleasure of meeting Prof. Erl) in Heidelberg, and <>f conversing with him in some detail on this subject. He stated tliat his exj)erienee with ncMir.-isthenia had much widened since the publication of his oliaptcr in the CyelopiL'dia. In most respects 1 believe he would accept the criticisms nnd suggestions aliove ofTered. ' This work has been translated by Dr. Putzel, of New York. 10 PREFACE. of open places — are promiscuously gathered. Dr. Julius Althaus, of London, in the third edition of his work on Electricity (1S73), has a short chapter on "Spinal Exhaustion," among the symptoms of which he men- tions " nervousness, impaired digestion, and increased elimination of urea; " and cites two or three cases, giving the results of electrical treatment. April 4th, 1878, I read before the New York Acad- emy of Medicine a paper on certain symptoms of nerv- ous exhaustion, designed to he supplementary to the original paper on neurasthenia, prepared ten years be- fore, describing a number of new symptoms, or those but partially noticed heretofore, and yet further dif- ferentiating the disease. This paper, which was based on a study of several hundred cases of neurasthenia, in its different forms and phases, was subsequently published in the Virginia Medical Monthly for June, 1878. Since that time, I have continued the discussion of the subject in a number of papers, delivered before the scientific societies of New York and vicinity, be- fore the American Neurological and American Medical Associations, the New York Neurological Society, and in a lecture before the Baltimore Medical and Surgical Society. These papers have been published in the various medical journals. Although the first systematic indorsement and con- firmation of what had been written on neurasthenia was obtained in Germany, yet these later writings have both awakened interest and inspired activity, on the part of scientific men in this country, so that already PREFACE. 11 we have a number of independent workers in the same field, among whom are to be mentioned Drs. Jewell, Mitchell, and Goodell, who have made, and are still making, thoughtful and suggestive contributions to this subject. In England, Mr. Jonathan Hutchinson,' approach- ing this subject from the side of ophtlialmology, has by his own observations confirmed, though not in a systematic fomi, some of the facts and reasonings of this treatise. It would, therefore, appear that the general doc- trines tauglit in this work have already passed the test which every claim in science must meet — verification by a number of experts in the branch t(^ which it be- longs, and that the time has come to present the sub- ject in a i)ermaneut form. Although neurasthenia had not been systematically studied, yet that there was a morbid c( )ndition of the nervous system, for which the ordinary names and de- scriptions of the books would not suffice, had been suggested by various writers. Tims, Dr. Flint, in the first edition to liis work on " Practice," devotes a page to what he calls " nervous asthenia," acknowledging the indebtedness for that term to Dr. Fordyce Barker. Dr. Flint defines the disease as "functional debility, induced by excessive and luiduly prolonged activity of the brain functions." In spite of the imperfections of this definition, which ■See the London Medical Times and Gazette, June 2l8t and August 23d, 1879. 12 PREFACE. by no means covers the facts of neurasthenia, Dr. Flint's few sentences on this subject are, so far as they go, scientific, suggestive, and verifiable, and those who are interested would do well to refer to them. He states, for example, that it occui's without anaemia, that it is especially frequent in this country, and in cities. In regard to the special symptoms, the differ- ential diagnosis, or the treatment, he says but little, and concludes that " a full consideration of nervous asthenia would require much more space than can be accorded to it in this work." In his last work on " CHnical Medicine," the author repeats substantially the views of the earher treatise, and adopts the term neurasthenia. In the older edi- tions of Dunglison's Medical Dictionary the word neu- rasthenia ai)pears. Dr. Jewell, of Chicago, in a series of lectures on neu- rasthenia, now being published in the Journal of Nerv- ous Disease^ refers to the following terms that have been employed by writers: — Nervosime (Bouchut); etat nerveux (Sandra s and Boui'gignon); nervopathie pro- teiforme (Cerise); nervospasmie (Brachet); nerven- erethismus (Henle); neurcemie (Laycock). Benjamin M. Richardson, of London, in his valuable treatise on the " Diseases of Modern Life," also refers to some of the symptoms of neurasthenia, such as ir- ritable heart, and roaring in the ears, and hopelessness; taking, however, a more pessimistic view of such symptoms than is consisterit with the facts as observed in bhe majority of the cases. PREFACE. 13 The propriety of publishing these researches is yet further inculcated by the consideration of the very im- portant progress that has been made in the treatment of neurasthenia and allied affections, especially during the last decade — cases which formerly were allowed to suffer for years, and perhaps to develop special and more serious diseases, are now, -uith our more abun- dant remedies, and, more than aU, with our better knowledge of the dosage and action of remedies, and of the laws of their combination, speedily relieved, and, in time, substantially cm-ed. In no department of therapeutics has there been, even in this most active age, so rapid and so useful an advance as in the man- agement of nervous exhaustion, and the diseases that result from and are related to it; and hence a subject the interest of which was originally and mainly scien- tific and philosophic, is now of direct and practical and personal concern, not only to specialists in the diseases of the nervous system, but to practitioners," and to sufferers everywhere. To describe with thoroughness, if not exhaustively, the symptoms of neurasthenia — those hitherto assigned to the other affections, or regarded as special and dis- tinct diseases themselves; to show their relations and interdependence ; to distinguisli them from tlie often times closely resembhng symptoms of organic disease on the one hand and the symptoms of hysteria and hypochondria on the other hand; to unify and harmo- nize the complex developments and manifestations of this malady; to indicate its pathology and rationale, 14 PREFACE. and trace out in detail its prognosis, sequences, treat- ment, and hygiene — tliis is the task I have undertaken in the present volume. In regard to the nomenclature adopted in this work, this may, perhaps be admitted, that it is at first annoy- ing and apparently unnecessary to introduce new terms for even frequently occurring symptoms. At the be- gimiing, however, I may say that the nomenclature is the least important part of the subject, and the one that is the least insisted upon. It is the fact — the idea —the truth behind the nomenclature that demands our attention. Names, however, are necessary in science; simply, if for no other reason, for the sake of economy of time and labor in expressing thought; and where a subject is much discussed, this matter of economy be- comes a matter of not a little consideration. The ht- erature of ophthalmology has a very extensive nomen- clature, which has been made necessary by the advances of science in that direction, and by which communication and converse among ophthalmolo- gists are made easier. New terms are necessary to new sciences, although it is not necessary that all persons should remember them, or try to bear them in mind, so long as they understand the conditions which they are designed to express. In devising new nomenclature, certain hberties are allowed when anything is thereby gained for brevity or euphony. Cerebrasthenia, derived from a Latin and a Greek word, is preferable to encephalasthenia, which would be the term if made up purely from PREFACE. 16 Greek. In naming the morbid fears, certain elisions and abbreviations are required in order to simplify and shorten the words, which at best are unpleasantly long. There is a proper repugnance to new terms which can only be met by showing theii' necessity or convenience, or by making them as brief and as euphonious as pos- sible. It is designed that this work shall be exclusively practical, and for that reason the causes of neurasthe- nia here receive no consideration. In a work on Amer- ican Nervousness which is now in preparation and nearly completed, and which will be, in a measure, supplementary to the present treatise, it is expected to supi)ly this want and discuss both the causes and the consequences of the rise and increase in motlern times, not only of neurasthenia, but of the general nerve- sensitiveness of which neui'asthenia, with all its vast array of symptoms and se^juences, is but a result and expression. A philosophic and thorough analysis of American nei'vousness nmst be a contribution to soci- ology of which it is a part, and will require a discus- sion of many questions of race, of climate, of institu- tions, and of social customs, that, however interesting they may Ix) to the general reader and inquirer, and however imix>rtant for a full and strictly scientific apprehension of all sides of our theme, are of less im- mediate concern to the physician or the patient than a knowledge of the symi)toms, the diagnosis, the se- quences, and the treatment of neurasthenia. What IC PREFACE. practical physicians above all things want is, to have a book which should be as a mirror held up before disease and reflecting the symptoms and history, not as they logically might be or ought to be, or are sup- posed to be, but as they are in actual experience. This ideal the present work aims to fulfill. Already the leading principles to be taught in the work on American nervousness has been made pubhc in various lectures and essays, and incident- ally and fragmentarily also in some of my pubhshed volumes. During the past summer (1879), I brought the sub- ject before the British Medical Association, in Cork, in a paper on the Nervous Diseases of America. During this last visit to Europe, as well as in 1869, I investi- gated the comparative nervousness of Americans and Europeans with especial reference to neurasthenia. These topics have also been discussed in a popular way in essays in the North American Beview, Atlantic Monthly, and Appleton'^s Journal. The facts and reasonings in these publications have aroused considerable criticism, notably in England, in the London Times and Spectator and other journals, and to a certain degree also in this country. When the work is published, these criticisms will receive proper consideration. Meanwhile this may be stated in advance, that the prime cause of modem nervous- ness is modern civilization with its accompaniments; all other accredited influences, however important and interesting, as indulgence of appetites and passions, PREFACE. 11 and even climatic conditions and the nervous diathe- sis, being only secondary or tertiary. I improve this opportunity to express my obliga tions to many, in my own and in other professions, patients, correspondents and friends, who, m various ways, have given me important aid through the long period during which these difficult researches have been conducted. The study of neurasthenia, from its very nature, re- quires an acquaintance, not only with the forms of functional and structural diseases of the nervous sys- tem in general, but with disorders of special organs, as the eye, the ear, the throat, of the digestive and re- productive systems, as well as of psychology, and the phenomena of the involuntary life in health and dis ease. In the evolution of recent science and art, a complete knowledge of these several departments is not possible to a single human mind; specialties are built upon other specialties; experts must lean on other experts; we cannot walk a single step alone. The task of excluding organic disease— the chief fact in making tlie differential diagnosis — demands in some cases diagnostic skill of the very highest order, since it is far easier to see a coarse lesion when it exists than to make sure that there is no lesion or objective condi- tion within the range of the aided or imaided senses. From the beginning of my study of the subject, es- pecially of late years, I have been called upon to diag- nosticate and to carry out the details of treatment for cases of neurasthenia among veiy many of the mem- 1 8 PREFACE. bers of my own profession, students of medicine, and men of science; with many of these cases it has been one of the means of cure to have them study in a scien- tific way — through the intellect rather than through the emotions — not only their own experience, but the general subject in its various relations. Some of these professional patients have been men of large practical experience, superior skill, and high authority in their respective departments, from whose general observa- tions and suggestions and special co-operation as ex- perts I have derived incalculable benefit, which, as it is hoped, this contribution to the scientific study of neurasthenia may partially repay. G. M. B. CONTENTS. CHAPTER I. Introduction. PAOB Why the Study of Neurasthenia has been neglected. — The Symp- toms of a Subjective Character. — Reasoning vs. Observa- , tion. — Less Frequent in Europe. — More Medicine used in America 25-35 CHAPTER n. Symptoms of Nervous Exhaustion. How to Study Cases. — Tenderness of the Scalp. — Cerebral Irrita- tion.— Dilated Pupils. — Sick Headache and Various Forms of Head Pain. — Pain, Pressure, and Heaviness in the Head. — Changes in the Expression of the Eye. — Congestion of the Conjunctiva. — Disturbances of the Nerves of Special Sense. — Neurasthenic Asthenopia. — Muscce. Volitantes. — Noises in the Ears. — Atonic Voice. — Deficient Mentiil Control. — Mental Irritability. — Hopelessness. — Morbid Fears. — Astraphobia or Fear of Lightning. — Topophobia or Fear of Places. — Agora- phobia or Fear of Open Places. — Claustrophobia or Fear of Closed Places. — Anthropophobia or Fear of Society. — Mono- phobia or Fear of being Alone. — Phobophobia or Fear of Fears. — Mysophobia or Fear of Contamination. — Pantapho- bia or Fear of Everj'thing. — Symptomatic Merely. — Morbid Fears Rarely E.xist Alone. Flushing and Fidgetiness. — Frequent Blusbing. »^ Sleeplessness. — Bud Dreams. — In- somnia. — Drowsin^s. — Tenderness of the Teeth and Gum.s. — Nervous Dyspepsia (/>y.s;v7)«iV Asth^nujtte). — Deficient Thirst and Citpacity for Assiniiliiling Fluids. — Desire for Stimulants and Narcotics. — Dryness of the Skin. — Abnormalilies of the Secretions. — Abnormal Dryness of the Skin, Joints, and 20 CONTENTS. / PAGE Mucous Membranes. — Sweating Hands and Feet with Red- ness (Palmar Hyperidrosis). — Salivation. — Tenderness of the Spine (Spinal Irritation) and of the whole Body (General Hypereesthesia). — Coccyodynia. — Peculiarities of Pain in the Back. — Heaviness of the Loin and Limbs.— Shooting Pains simulating those of Ataxy. — Podalgia (Pain in the Feet).— Tremulous and Variable Pulse and Palpitation of the Heart (Irritable Heart). — Local Spasms of Muscles (Tremors). — Dysphagia (Difficulty of Swallowing). — Convulsive Move- ments, especially' on going to Sleep. —Cramps. — Special Idio- syncrasies in regard to Food, Medicine, and external Ii-ri- tants. — Sensitiveness to Weather. — Sensitiveness to Cold or Hot Water. — Sensitiveness to Changes in tlie Weather. — Sunstroke brings on many Symptoms of Neurasthenia. — Localized Peripheral Numbness and Hyperiestliesia. — A Feeling of Profovmd Exhaustion Unaccompanied by Positive Pain. — Ticklishness. — Vague Pains and Flj'ing Neuralgias. — General or Local Itching (Pruritus). — General and Local Chills and Flashes of Heat. — Cold Feetand Hands. — Nei'vous Chills. — Sudden giving way of General or Special Func- tions. — Temporary Paralysis. — Diseases of Men (Involuntary Emissions, Partial or Complete, Impotence, Irritability of the Prostatic Urethra). — Diseases of Women. — Oxalates, Urates, Phosphates, and Spermatozoain the Urine.— Gaping and Yawning. — Appearance of Youth. — Rapid Decay and Irregularities of the Teeth. — Hemi-neurasthenia. — Course and Caprice of the Symptoms. — Time of Life at which Neurasthenia is most Frequent. — Frequency of these Diseases. — How such Cases are usually diagnosticated. — Multitude of tlie Symptoms. — Correlation of Nervous Symp- toms 36-117 CHAPTER III. Nature and Diagnosis of Nervous Exhaustion. Distinguished from Organic or Structural Nervous Disease. — 1. Symptoms of Organic Diseases fixed and stable. — -2. Neuras- thenia has some Symptoms peculiar to itself. — 3. In Neu- rasthenia reflex Activity increased. — Reflexes from Brain, Digestion, and Reproductive Apparatus. — Relation of Geni- tal Troubles in both Sexes to Neurasthenia. — 4. Neuras- thenia most common where Nervous Diathesis predominates. CONTENTS. 21 PAGE — Characteristics of Nervous Diathesis. — Distinguished from Hypochondriasis or Pathophobia. — General Hopelessness. — Groundless Fear of Disease. — Distinguished from Cerebral and Spinal Anaeraias and Hypertemias. — Distinguished from Anajniia. — Distinguished from Hysteria. — Distinguished from SN'philis. — Distinguished from common Cold and Rheumatism. — Differential Diagnosis of Cerebrasthenia (Bi-ain Exhaustion) and Myelasthenia (Spinal Exliaustion). — Pathology and Rationale. — Vaso-Motor Reflexes. — Func- tional as distinguished from Organic Disease, — Recapitula- tion ... 118-159 CHAPTER IV. Prognosis and Sequences of Nervous Exhaustion, Recent Progress made in the Treatment of Neurasthenia and Allied Affections.— Relief and Recovery of Special Symp- toms. — Prognosis depending on the hereditary Character of the Disease. — Working Order. — Sequence of Neurasthenia. — Insanity (Melancholia). — Hysteria and Hystero-Epilepsy. — General Neuralgia. —Inebriety. — Meconism (Opio-Mania). — Disea.se of the Reproductive Organs. — Hay Fever. — Writer's Cramp. — Trance. — Paralysis and Organic Diseases of the Spinal Cord. — Certain Stages of Bright's Disease (Albuminuria) 160-175 CHAPTER V. Treatment and Hygiene of Nervous Exhaustion. Each case of Neurasthenia is a study of itself. — Digestive Hygiene. — Milk Diet.— Rectal Alimentation.— Rest Cure vs. Work Cure.— Rest and Isolation. — A New Impression Needed. — Seclusion and Non-seclusion. — Brain-work in Nervous Dis- ea.ses.— The Psycholf>gy of Patients to be .studied. — Enume- ration of Priniipal Remedies. — Ai-senic. — Cannabis Indica. — UafTeine.- Tea Tasting.— Caffcinism.— Coca.— Zinc Combina- tions. — Duboisia. — Cimicifugin. — Traihng Arbutus. — Eucalyptus. — Hydrastis. — Bromides. — Chloral. — Chloral Asthenopia.— Strychnia.— Opium.— Alcohol. — Mineral Acids. — Cod-Liver Oil.— Phos|)hafes. — Koumiss.— External Modes of Tn-alment. — Electricity.— Massage.— Mftalloscopy and Metal Therapeutics. — Recent Experiments in that Line.— 22 CONTENTS. PAGE Nitrous Oxide, — Philosophy of the Plan of Treatment. — Nerve Alteratives. — Local Treatment of Uterus and Prostate and Prostatic Urethra. — Effects of Self -Abuse. — Pei-sistence in Treatment. — Treatment of Sequences. — General and Special Effects of this Combined Treatment. — Improvement in Sleep. — Mental and Physical Sedation. — Increase in Fat and Weight of the Body. — Improvement in Appetite and Digestion. — Relief of Pain and Exhaustion. — Increased Capacity for Muscular and Cerebral Toil. — Travelling as Medicine often injurious. — Horse-back Riding, when to be avoided. — Clothing should be warm. — Climatology of Nerv- ous Diseases. — Neurasthenics benefited by a warm Climate. — Sea Air vs. Mountain Air. — Nervous Diseases of America and Europe compared 176-249 NERVOUS EXHAUSTIOK. (NEURASTHENIA.) CHAPTER I. INTRODUCTION. WHY THE STUDY OF NEURASTHENIA HAS BEEN NEG- LECTED. There is a large family of functional nervous dis- orders that are increasingly frequent among the in-door classes of civilized countries, and that are especially frequent in the northern and eastern parts of the United States, but of which our standard works of medicine and our lecture-rooms give little or no infor- mation. The sufferers from these maladies are counted in this country by thousands and hundreds of thousands; in all the Northern and Eastern States they are found in nearly every brain-working household; and yet one might graduate at all of our colleges, read all of our most-used medical treatises, and converse with the majority of our ablest practitionei-s, without obtaining any just ideas in regard to the nature or treatment of these maladies. Even when these affections are treated of at all, it is, as a rule, one-sidedly, i)artially, and erroneously. Thus, neurasthenia is confounded 24 NERVOUS EXHAUSTION. with general anaemia; cerebrasthenia (exhaustion of the brain) is assigned to cerebral anaemia or hyperaemia. Myelasthenia (exhaustion of the spinal cord) or spinal irritation is confounded with spondylitis or spinal con- gestion, or is attributed to mere circulatory irregulari- ties, as anaemia or hyperaemia; sick headache is re- garded as a disease of the stomach, and treated with antacids and purgatives; physical hysteria is stigma- tized as a malady of the imagination; hay fever is sup- posed to be parasitic or infectious; inebriety is mistaken for drunkenness; while cerebral irritation and the dif- ferent varieties of morbid fear are not mentioned at all. Conversing on the subject, not long since, with a very intelligent interne of one of our largest hospitals, I found that neither in the medical school nor in the hospital had he received any suggestions relating to any of these functional diseases of the nervous system, although, if he should ever engage in private practice among the better classes of any of our larger cities, he will meet these diseases every day and every hour, and his success will depend to a considerable extent on his skill in managing them. These disorders are transmissible oftentimes, tak- ing the place of each other. They run in famihes more demonstrably than scrofula, or cancer, or consumption. Indeed, one great cause of the rapid increase of these disorders during the first quarter of the century has been inheritance. It is not difficult to find families in which all these diseases are represented; and there are individuals who at different times, or at the same time, suffer from all or nearly all of them. I have said that in Europe these affections are but little known; but, in liability to them, all the Euro- pean countries are not alike. They appear to be least common in Germany and Russia, Italy and Spain; INTRODUCTION. 25 considerably more frequent in France, and more fre- quent still in England. Although these difficulties are not directly fatal, and so do not appear in the niortahty tables; although, on the conti-ary, they may tend to prolong hfe and to protect the system against febrile and inflammatory diseases, yet the amount of suffering that tliey cause is enormous. Volumes ai-e written on typhoid and other fevers; but m this country these neuroses, al- though not fatal, cause more distress and annoyance than all forms of fever combined, excepting perhaps those of a malarious origin. Fevei*s kill, it is true, while these neuroses do not; but to many death is by no means the most disagi*eeable of the many^ symp- toms of disease. A cyclopaedia of medicine, adapted to the wants of the practitioner in the northern and east- ern pai-ts of this country, should contain a full volume devoted to these diseases; and yet, so blind is our def- erence to Europe, so fearful are we of making our own independent, original observations of the maladies peculiar to this land, and so completely are we tethered to hosi)ital and dispensaiy experience, that up to the present time there is no monograph even on these diseases, and all attempts to study them, or to diffuse a knowledge in regard to them, are met, or have until recently been met, at every step with inai)preciation or positive opposition. These diseases I bring into one family, because they have a common pathology, a connnon prognosis, a common history, and a common treatment. They all occur under similar conditions, and in similar tempera- ments. They are all diseases of civilization, and of modem civilization, and mainly of tlie nineteenth cen- tury, and of the United States. They are to l)e dis- tinguished from certain other nervous diseases, aa 26 NERVOUS EXHAUSTION. epilepsy, and psychical or mental hysteria, and espe- cially are they to be distinguished from unquestioned structural or congestive diseases, such as locomotor ataxy, progressive muscular atrophy, tetanus, and apoplexy, all of which diseases are probably thousands of years old, are not restricted to civihzation, though more frequent in civilized countries, and are as com- mon in Europe as in America, if not more so. These organic or structm-al nervous diseases also occur chiefly in the strong or comparatively strong; they are not diseases of nervous debility, and abound more among the muscle -working than among the brain-working classes. The centre and type of this family of functional nervous diseases is neurasthenia, or nervous exhaus- tion. To understand this disease is, therefore, to be prepared to miderstand all the members of the family to which it belongs. For this reason it is that to the study of neurasthenia in its varied forms and phases this work is devoted. Why is it that this important field of science has been so little studied? Why has a disease which is more frequent than any other nervous disease, indeed may be regarded as the king of the neuroses, succeeded so successfully in escaping the attention of men of sci- ence? The answer to this query is somewhat complex: First of all, the symptoms of neurasthenia are largely of a subjective character, and to one who does not suffer them, appear trifling and unreal; many of them do not appeal directly to the senses of the scientific ob- server: the physician can only know of their existence through the statements of the patient, or through his conduct. Uuhke the existence of surgical and acute and inflammatory diseases, the phenomena of which the physician can see and feel, and for the study of INTRODUCTION. 27 which he is httle, if at all, dependent on the patient's intelligence or honesty, they do not appeal directly to the eye or ear or touch, and are in fact quite out of the range of aU modern appUances to suplement the defects of the senses, as the ophthalmoscope and laryn- goscope, or even the spectroscope. It is the tendency of the partially trained mind everywhere to reject or doubt what cannot be confirmed by the eyes or ears; forgetting that the capacities of the five senses of man are so meagre that tliey practically shut him out from nature; forgetting that the gi'eat natural forces, as light, lieat, electricity, magnetism, gi-avity, are quite beyond the reach of any one of the senses, or all of them combined, scientific men have allowed them- selves to ignore and despise some of tlie most remark- able, interesting, and insti"uctive phenomena of the nervous system both in health and disease, for the only reasons that they cannot be seen and heard and felt.' Then again, many of these indefinite symptoms of nem-asthenia, considered alone and by themselves, are so small, and feeble, and unimportant to those who do ' Dr. Jewell, in a recent lecture, remarks as follows: " In the physic^al science of to-day, there is clearly too little dependence on, liecause there is so much ijjnorance of, the nature >ind cf)n that in (Tenuany, as in this oountry, it ha» been tlie fu^hiuu to diagnose ueurastheuia as hypochondria. 32 NERVOUS EXHAUSTION. European authorities would be the pioneers either in the study of its nature or treatment. Neurasthenia, indeed, hke the decay of the teeth, which in some cases is really one of the symptoms of the neurasthenic tendency, was first made of special consequence in this country. Within recent years, various statistics have been pub- lished on the subject of the disproportion of doctors of medicine to population. It is said, and truthfully, that in this country there are more physicians in proportion to the people than in any other country. These statis- tics have been brought up mainly by those who seek in some way to limit the graduation of doctors; but the figures have been used in such a way as to give an im- pression not entirely correct. The fallacy in them is this, that Americans need more doctoring than any other people; they have more illnesses of various kinds —major and minor— than any of the European nations. A hundred well-to-do families in our large cities would send for a doctor to treat them very many more times than a hundred equally conditioned famihes in Eng- land, France, or Germany. This fact, taken in con- nection with the fact that our population extends over a wide teritory, makes it possible to support a larger number of physicians than in any other country of equal population. What is true of doctors is equally true of drug stores; the meagreness of the apothecary shops strikes one immediately on visiting Europe. The A^mericans take very much more medicine, both prescribed and unprescribed, than Europeans; they take a larger variety, they take finer qualities; hence it is that very many of our drug stores are palaces ' 'The past summer (1879) I had much difficulty in procuring from the best drug stores of London, Paris, and Brussels such remedies as bromide of sodium and citrate of caffeine, in quanti- ties sufficient for the treatment of the sea-sick on my return voyage. INTRODUCTION. 33 containing an immense quantity of medicinal prepara- tions, including not only all that are used in Europe, but many that are peculiar to this country, or at least but very Uttle known abroad. Neurasthenic patients and neurasthenic famihes, even when they have no febrile and inflammatory dis- ease, are subject to numberless symptoms of disease that invite, if they do not absolutely require, medical advice and medical treatment. They keep our physi- cians constantly on the alert to advise and suggest for them new remedies and modes of treatment; hence it is that the treatment of disease in this country among the leading physicians is more satisfactory in all respects than in Europe; Germany, that leads the world in science, being far behind in the art of thera- peutics. CHAPTER II. SYMPTOMS OF NERVOUS EXHAUSTION. The symptoms of neurasthenia have never yet been fuUy described. In my first paper on this subject, I indicated only a minority of the signs and evidences of this many- sided and fluctuating disorder, although the general philoso- phy of this morbid condition was precisely the same as that advocated in this volume. The present chapter, in the form here given, is an evolution from a few independent observations, to which others have been added little by little, by suc- cessive and slowly appearing increments. From medical literature, for reasons already given, only inconsiderable assistance could be obtained. In order to learn the nature and symptoms of this mal- ady, it was necessary to closely study the cases by themselves, taking notes of their histories and progress, with no other guidance than that obtained from my own preceding observations of similar cases, and oc- casional hints from physicians with whom I saw the patients, or by whom they were referred to me. Some of the symptoms that I shall here describe are somewhat famihar to aU medical men everywhere; though usually under different headings, and without any definite relation to any definite morbid state ; others are familiar only to those who give their time chiefly to the nervous system, and others still are here described for the first time. Some of the symptoms herein detailed, when they are SYMPTOMS OP NERVOUS EXHAUSTION. 35 mentioned at all in works on diseases of the nervous system, have been and are now reJteiTed to under such headings as cerebral anaemia or hyperaemia, or general anaemia, or hysteria, or hypochondriasis, or oxaluria; and some of them, as will be seen, are mentioned in connection ^ith structural lesions, as ataxy and mus- cular atrophy, and by many are regarded as essential parts of the clinical image of these grave disordei^s. Neurasthenia attacks or is Hable to attack all functions and organs. Hence, a description of the disorder, to be complete, must include the varied modifications that many parts and functions experience under the influ- ence of a neurasthenic invasion. Hovj to Study Cases. — One reason why neurasthe- nia has been so long neglected is, that the symptoms are, in some instances, so subtle, illusory, and difficult of analysis and classification. One who has never seen and carefully examined a large number of cases of this disease would not believe it possible that it could manifest itself in so many different ways. The usual custom of giving an opinion in cases of this sort, after slight, partial, incomplete examinations, including very short conversations with the patient, or perhaps only with friends of the i)atient, never leads to good results. Both physicians and patients have for years, if not for ages, encouraged the custom of calling upon the physician for the symptoms here described, and expecting that a brief conversation, more or less, will suffice to establish a diagnosis and lay out a course of treatment. Now, as ai-ule, it requires more than a few minutes' conversation to make clear the diagnosis in tliis disorder, and the euro is not usually to be wrought by a single carelessly prepared prescription. Tliese symptoms of neurastlienia, cerel)rasthenia, and myelasthenia, as has been stated in the introduc- 36 NERVOUS EXHAUSTION. tion, do not appeal, many of them, directly to the senses; we only learn of their existence, in many cases, by close cross-examination of the patient and the pa- tient's friends, or of the physician who brings the pa- tient for consultation. Before entering upon a study of this class of cases, it is well to examine the princi- ples of the evidence derived from human testimony, so as to know what to accept and what to reject; else we may be misled at every step. Many of these cases, in a first interview with me, give a history of their life, and their disease and symp- toms, in all sincerity and Avith very great care, which on a further examination and at subsequent interviews I have found to be not only untrue in many important respects, but even quite the reverse of the truth ; while symptoms and facts which, when known, determine the diagnosis, are kept back, or altered, or denied^ not usually so much through intentional deception as through f orgetf ulness, or perhaps through a misunder- standing or misapprehension of the purjjort or impor- tance of the questions that were asked. I have had patients of high intelligence, thorough education, and good mental discipline, give me a history, at the first interview, of the nervous diseases in their family which has misled me, and was only corrected perhaps after I had seen them a number of times. In very many cases it has happened to me that patients denied that there was nervous disease in their family or even among their distant connections, when on subsequent examinations I have found there had been epilepsy, neuralgia, hysteria, sick headache, hay fever, and even insanity — or perhaps all these disorders rumiing through many generations. I have had patients come to me with some one symptom — say sick headache or neuralgia or spinal irritation — who have said to me in SYMPTOMS OF NERVOUS EXHAUSTION. 37 reply to questions, and also voluntarily, that in all their Uves they had never suffered from any other symptom of nervous diseases than that one; whereas, on further examination, I have found that the symptoms which sent them to me was only one of a large family or army of troubles which had annoyed and followed them for years. To study these cases successfully, one must, therefore, give much time and thought, and either by correspondence or personal interview — preferably, of course, the latter — obtain accurate, and as far as possi- ble complete, knowledge of all their symptoms, includ- ing those even the most seemingly trifling and unim- portant, and even fanciful. The effect of this scientific analysis of cases is not to make our patients hypochondriacal, but to remove their hypochondria. The worst enemy of the emotions is the intellect, and by getting a patient intellectually interested in his own case, by assisting him to face the enemy, we can put him in a position to understand that his troubles, serious as they may be, are not so serious as he had feared. It is very often necessary to ascertain the condition of all or nearly all of the important organs and func- tions. The eyes, the ears, the spinal cord, the diges- tion, the reproductive organs should be inquired into with more or less detail. Many of these cases, when we see them for the first time, have passed through certain stages of the disease, symptoms wliicli tliey have forgotten, and the existence of which they will deny, for the sole reason that they have forgotten them, and not from any desire to deceive us. Experiences of this kind are most suggestive illus- trations of the limitations of the human memory — a subject which I have discussed elsewhere. It is one of the blessed orderings of nature that we can and do 38 NERVOUS EXHAUSTION. lose remembrance of our miseries — the physical pains and sufferings of the past, instead of accumulating like pent-up waters, pass silently away into the caverns of forgetfulness; like certain streams, of which it is said that they sink into the earth, remain quite out of sight, and appear to view only at long intervals. It is this forgetfulness of physical pain and discomfort that makes existence possible or endurable. All per- sons would want to die, all persons would die, if they were obliged to remember and keep before the mind at all times, or were even able to recollect all the physical sufferings of the past; but this very forgetful- ness of symptoms and sickness makes it harder for the physician to diagnosticate functional nervous diseases. Some cases of this kind illustrate this principle in a most remarkable way. I lately cured a very remarkable case of neurasthenia complicated with astigmatism, where the patient took pains to write out and give me in detail a history of the symptoms. I treated him for a long time, saw him many times, conversed with him freely about his case, in which I felt a special interest, as he well knew, both on account of its peculiar history and the special results of the treatment, and towards the close of the treatment presented him before the American Neuro- logical Association; but even after all that I learned from him of symptoms that he had suffered, various forms of morbid fear that he had experienced and re- covered from, but which he had never Ijefoi'e, during all the treatment, mentioned to me. Symptoms of Nervous Exhaustion. — Exact logical order is impossible, but for convenience sake and for ease of reference, I begin with the head and l^rain and go downwards. Tenderness of the Scalp (Cerebral Irritation). — This SYMPTOMS OF NERVOUS EXHAUSTION. 39 is a phenomenon which is to the head what spinal irri- tation is to the spine. As in spinal irritation, the whole spine may be tender all the way from the first cervical vertebra to the coccyx; or the tenderness may be confined to the middle dorsal and middle lumbar vertebra?; so, in cerebral irritation there may be ten- derness over the entire scalp, or it may be confined to the vertex, or to certain points in the forehead. Some- times the scalp is so tender that biTishing the hair causes pain; even touching the tips of the hair is dis- agreeable. At the vertex, the tenderness is sometimes accompanied by a feeling of heat and burning, that may be somewhat relieved by fu^m pressure. This cerebral tenderness, hke spinal tenderness, is superficial and peripheral, not deep-seated nor central, as some have supposed. It is, in many if not in all cases, ten- derness of the ramifications of the occipital and other nerves that supply the scalp, just as spinal irritation is tendemess of the superficial nerves of the bones of the spinal column. A frequent spot of tenderness is found over the eye- brow and in the left temple. This is found in sick headache, and in connection with it there may be tendemess of the nape of the neck. A sudden jar, as when one slips in going down-staire, may, in these cases of cerebral irritation, cause temporary pain, as thougli the head itself had been struck. Emotional disturbance of any sort may bring on an attack of this symptom, as also may confinement in heated rooms, or in bad air, or over mental labor. These symptoms, indeed, are not constant, but come and go according to the exciting causes. Sometimes they last but for an hour or two, or for a day or part of a day. The same is true of all analogous states, as spinal tender- ness and general hyperiesthesia. 40 NERVOUS EXHAUSTION. Dilated Pupils. — Dilatation of the pupils is so often seen in neurasthenia that it may be considered as an important fact to be noted in the study of a case. Abnormal activity of the pupil — sudden and frequent alternations between contraction and dilatation — is a sign of neurasthenia, or, at least, of nervous irritabil- ity, of perhaps more importance than mere dilatation, just as in organic diseases of the cord, sluggishness of the pupils, slowness to contract or dilate, has been recently suggested as a better diagnostic sign than mere contraction of one or both pupils. Temporary inequality of the pupils — one being at times more dilated than the other — I have seen in neurasthenia. Permanent inequality of the pupils is a sign of organic disease; but this neurasthenic inequal- ity is inconstant, varying with the general condition. Sick Headache and Various Forms of Head Pains. — Sick headache is both a symptom and a safety-valve. If one must be nervous, an occasional attack of sick headache, if it be not too severe, is an excellent way for this nervousness to manifest itself, and, no doubt, saves other and worse affections. When sick head- aches suddenly and permanently leave us, there may be reason to beware, though not probably in all cases. Some years ago, I had under my care, for a short time, a case of shaking palsy that had followed a sudden and apparently causeless cessation of sick headache. When sick headache leaves us as a result of improvement of the nervous system through treatment or hygiene, it is so far forth a good sign. Like most of the symptoms of nervous exhaustion I am here describing, sick headache is experienced mostly between the ages of fifty and fifteen. Earely, or never, do young children have it, and it usually stops before old age. It is a symptom that belongs to SYMPTOMS OF NERVOUS EXHAUSTION. 41 the perturbable and active years, and may quickly show itself when, from any cause, the nervous system is de- pleted of its force. Pain, Pressure and Heaviness in the back of the head and over the vertex and through the whole head, very commonly attend the neurasthenic state, especially when the brain is congested; but many also appear where there is no evidence of an excess of blood on the brain. Lightness of the head is also a common com- plaint; also a symptom usually defined as " I cannot teUhowIfeel." Changes in the Expression of the Eye. — The mere expression of the eye is modified by disease in a way that it is hard to analyze or describe. In chronic nervous exhaustion from any cause or combination of causes, this expression of debility may become chronic — a permanent state that is revealed at once on meet- ing and addressing the sufferer. In the exhaustion that precedes death, the eye, as has been observed, sometimes protrudes far more than is natural. It is believed that this i)henomenon takes place through the sympathetic. A lady whom I once treated for numerous neiwe difficulties, and wlio entirely recovered, told me that as she got better the whites of her eyes were of a clearer blue, and consequently, to her delight, more attractive. This fact was observed by several of her friends as well as myself. It is a matter of disi)ute with Darwin and others, who have written on the ex- pression of the emotions, whether the eyeljalls can or cannot express feeUng indei)endent of the lids. The affirmative view is verifiable. Congestion of the Conjunctiva. — One of the many ways in which neurastlionia affects the eyes is, by congestion of the conjunctiva. This passive conges- 42 NERVOUS EXHAUSTION. tion comes and goes, like all the other symptoms, being very bad in the morning, and almost disappear- ing by night, or perhaps in the course of an hour or two, I have now under care a i^atient in ^vhom this symptom is a very striking one. When at its worst, he looks as though he had been drinking heavily, or as though he were suffering from a v^ery severe cold in his eyes. The condition, or rather the tendency to the condition, is a chronic one, and increases and dis- appears in proportion to the improvement in his nervous system. Disturbances of the Nerves of Special Sense. — A malady of the eye is what I may call neurasthenic asthenopia, or the irritable eye, from nervous exhaus- tion, not depending solely on any muscular or accom- modative trouble, but mainly symptomatic, revealing nothing very satisfactory to the ophthalmoscope or other tests of modeni ophthalmology, but none the less painful, distressing, and sometimes exceedingly obsti- nate. This disease of the eye, symptomatic of nervous exhaustion, I observed a number of years ago, but could find no formal recognition of it in the standard text-books of ophthalmology. Dr. Mathewson, in conversation on the subject, tells me that this third form of asthenopia is now, however, under various names, coming into recognition in the journals and societies devoted to diseases of the eye. For a time it was supposed that Donders had solved all the problems of asthenopia; but it is now known that there are many cases that cannot be cured by glasses. These cases are common in this country, and. Dr. Roosa tells me, were first observed by our ophthalmologists. An attack of this neurasthenic asthenopia — which is oftentimes so severe that reading or writing or sewing are accomplished only with great pain, and the eyes are SYMPTOMS OF NERVOUS EXHAUSTION. 43 painful and tender on pressure even when not used— may last half an hour, or three houi-s, or three months; and, hke analogous states in other parts of the body, with which it is often accompanied, may come and go very suddenly. Sometimes there is dimness of vision. In looking at the eye when in one of these attacks, we may observe a passively venous congested state of the conjunctiva. This congestion is a result— not the cause — the effect of the nervous irritation, and comes and goes under exciting causes. Such, without question, is the jjathology of cerebral irritation, of spinal irrita- tion, of irritation of the mammae, the ovaries and testes, and of sick headaclie and many other forms of nem-al- gia. The notion which has been advocated — that this neurasthenic asthenopia, or irritable eye, is pecuhar to women, and therefore to be called uterine asthenopia, is but an adumbration of the truth ; for the malady, though most common in women, like all this family of symptoms, is found in both sexes; the very worst cases I have ever seen have been in males. Several of my cases have been examined by our best experts in oph- thalmology. Jonathan Hutchinson, of London, in a recently published lecture, has confirmed the position here taken. In these cases there may be insufficiency of the internal recti or hypermetropia, etc., but not enougli to account for tlie symptoms, and glasses do not cure them. This form of eye weakness is quite susceptible to the influence of physical contagion. A number of years ago it spread through many of the colleges and seminaries of the country — in some in- stances com J jelling young men to abandon their plans of a liberal education. Mnscw Volitantes, or floating specks before the eyes, often annoy even the slightly nervously exhausted; in these cases, the ophtbalmoscope is only of negative as- 44 NERVOUS EXHAUSTION. sistance. Under exciting causes, the specks suddenly appear and disapj)ear. The UabiUty to them may be a habit of one's life. They come and go Hke other nervous systems. Noises in the Ears in the shape of sudden explosions or pulsations, to say nothing of other varieties of tin- nitus aurium, are quite common in cerebral exhaustion, especially when attended with congestion. Tliese ex- plosions may come on without any warning, while one is sitting quite still, and there is no apparent exciting cause. These symptoms may occur even when there is no perceptible disease of the auditory apparatus, and may disappear as suddenly as they appear. A feehng of fullness and opi^ression in the head sometimes at- tends these symptoms. Subjective odors of various kinds— as of ozone or phosphorus; also abnormal sub- jective tastes — bitter or sour, with other fleeting symp- toms of cerebral exhaustion, are observed. Sometimes there is a pumping sound in one or both ears, synchronous with the movements of the heart, worse usually dming or after exertion, as going up- stairs; and it may be very annoying when one is very still, as when lying down in bed in the night; it is apt to be worse when stooping, or when worried or annoyed or flurried by any mental emotion. If this symptom were a constant one, and were always associated with demonstrable disease of the drmn or middle ear, it might not perhaps be so gTeat a mystery; but appear- ing as it sometimes does in those whose hearing is clearly perfect or nearly so, and coming and going al- ternate with other symptoms of neurasthenia, without oftentimes any exciting cause being traced, it is prob- ably due to the hyperaesthesia of the auditory nerve and analogous to that of the retina; and, Uke the retinal hyperaesthesia, it is inconstant, variable, and SYMPTOMS OF NERVOUS EXHAUSTION. 45 capricious. My friend Dr. Schell, of Philadelphia, tells me that he has seen a number of cases where there were attacks of pain and aching in the ear, analogous to the pain and aching of the neurasthenic eye; but to account for which no objective appearances can be found. Atonic Voice. — When neurasthenia lays its hands on a man, it is Hable to leave its impress on every or- gan and function of the body; from the crown to the toe there is not a fibre that is safe from attack. If some parts escape in one individual, they suffer in others. If at one stage of the malady certain regions are unaffected, it may be only that they may be at- tacked ^vith all the gi'eater violence at another stage. Thus the hair, the scalp, the eyes, the ears, the nasal and respiratoiy passages, the brain, in whole or in part, the cranial nerves, the heart, the spinal cord in any portion, the sensory and motor nerves, the stom- ach and bowels, the reproductive system, the skin, the nails, the secretions, the excretions, the absorbents — all are objects of assault. It is not strange, therefore, that there should be a neurasthenic voice, just as there is a neurasthenic eye, a neurasthenic stomach. Tlie chief peculiarity of the neurasthenic voice is softness, faintness, want of cour- age and clearness of tone. These terms, though vague, express perhaps, as well as it is possible to do in words, how this voice deviates from the normal voice, but at best verbal descriptions are faulty, and far inferior to even a single living illustration. To a physician accus- tomed to see these cases and to obsei've the voice, there is but little difficulty in at least suspecting the diagno- sis by this symptom alone. This nem-asthenic voice somewhat resembles the peculiar voice of the deaf; and yet it is not precisely Uke that, and can usually be 46 NERVOUS EXHAUSTION. distinguished from it. A neurasthenic sufferer may have the muscles of an athlete, and be so strong that a hard day's toil is but play, and yet speak in a voice which in quality and volume of sound suggests the be- girming of convalescence from a severe fever. "The voice," says Emerson, *'is a delicate index of the soul," and with scientific truth the same philoso- pher asserts, that the orator can often tell by the qual- ity of his own speech, at the beginning of an oration or sermon, whether he is or not in a mood of speaking, whether he is to be eloquent or will utterly fail. A dissolute life, especially in women, always regis- ters itself in the voice, impressing a coarseness that in its quahty is almost diagnostic. The queens of song are never grossly impure. There are a number of cases of various forms of dis- eases of the larynx, which have been reported by Dr. Elsberg, Dr. Cutter, and others, that are clearly re- flected from the reproductive orgaDS, and which yield to treatment directed to these organs, when no local treatment in the lar3aix is employed.' My friend, Dr. Morrell Mackenzie, of London, told me this summer that he did not see these cases. The answer wliich I gave was, that in this country nervous irritability was far more frequent than in England, and that there is far more liabihty to reflex irritations of this kind. Deficient Mental Control. — Inability to concentrate the intellect on any task, as in writing or thinking, is a notable symj)tom. The mind wanders away in every direction, and when brought back by an effort of the will, is hable to be soon again lost in reverie. In some cases, the exercise of concentration, or even ' Dr. Cutter's paper on this subject was read at the meeting of the American Laryngological Association, and pubhshed in the St. Louis Medical and Surgical Journal., November, 1879. SYMPTOMS OF NERVOUS EXHAUSTION. 47 slight attention, is exceedingly irksome and painful, causing distress sometimes in the head, sometimes in the back or extremities, or other parts of the body. Inability to control the mind shows itself in various ways. An individual may take up a newspaper or book and read over a paragraph a half-dozen times, without knowing anything about that paragraph, without being able even in a general way to tell what he has been reading. Sometimes, in discouragement, they throw down the book; in despair they may at- tempt to write a letter, and find that they must give it up before a single page is completed, the mind wanders in a sort of day dream as far as possible from the sub- ject to which they would direct their thoughts; they find that their brains are masters and not themselves. Such a person often finds himself absorbed in a kind of dream, perhaps sitting quite still and forgetful of the work to which he has directed himself. A cler- gyman who consulted ine in the past year for cere- brasthenia, or brain exhaustion, tells me that, although he can read even profound treatises, and converse on difficult themes, yet if he should attempt even to dic- tate and systematize a sermon he would bo obHged to give up; the very idea of sustained, directed thought at once takes away all his power. Closely allied to this deficient mental control, and indeed a part of it, is what a layman, Mr. Richard Grant White, calls " Heterophemy, " that is, saying one thing and meaning another, saying oftentimes directly the opposite to what we meant to say; saying precisely what we w^ish to avoid; the word we wish shps in ahead of the one that we would bring to the front. Persons in health are frequently guilty of this very interesting blunder; but in disease of the brain it becomes a very bad sometimes very amusing as well 48 NERVOUS EXHAUSTION. as very annoying symptom. One of my old patients (the wife of a patient just referred to), who has both brain exhaustion and spine exhaustion, sometimes is compelled to mention a number of different words before she strikes the word she wishes. If, for exam- ple, she would have a book, perhaps she would say chair or sofa. She was not troubled in this way until she became neurasthenic, and since that time she has been troubled constantly. Mental Irritability. — A man comes home at night specially tired, and finds himself, or his friends find him, in a condition to fret and worry and become iras- cible over trifles which, when feeUng well and calm, would have no influence upon him. The flurries of domestic life, the cares of the house, disappointments and vexations, the noise of play of children, become a source of great distress, and he expresses this distress in his words and actions. This behavior may be either physiological or patho- logical — the habit of a perfectly healthy man or a symptom of neurasthenia; appearing in one previously good-tempered, and associated with other neurasthenic symptoms, it becomes of diagnostic value. Hopelessness. — When a patient is dying, in the last stages of consumption or cancer, he is often, if not usually, hopeful; and sometimes he does not abandon the expectation of recovery even when on the edge of the grave. After friends have given up utterly, and the physician only comes to relieve, the patient him- self is full of hope. In functional nervous disorders, that are relievable if not curable, the reverse phenomenon is observed. The patient, even in the earlier and milder stages, is without hope, while the friends laugh at his fears and ridicule him for talking or thinking of his symptoms. SYMPTOMS OF NERVOUS EXHAUSTION. 49 A good example is found in an attack of sick headache, but nearly all the neuroses exhibit this phenomenon, in greater or less degree. In organic, structural, and incurable disease, such as cerebral paralysis, paraplegia, etc., the sufferer is far less Hkely to despair of relief. The philosophy of this symptom of hopelessness ap- pears to be similar to that of morbid fear — an instinc- tive consciousness of inadequacy for the task before us. We are hopeless because our nerve force is so reduced that the mere holding on to hfe seems to be a burden too heavy for us. A certain amount of nerve strength is necessary to supply the courage requisite for simple existence. Abstaining from dying demands a degree of force just as the mere keeping in an erect position — standing up without taking a single step— is only possible to those who have a certain quantity of strength. Abstaining from dying, hke abstaining from falling, is in one respect a negation only, but neither is possible without an expenditure of force. In our half-awakened moments at midnight, a slight noise causes the heart to beat rapidly, for we are conscious of not having full possession of our powers to meet any attack or danger. The nervously-exhausted man is always in this state, physically insolvent, and unequal to the task of living. The despair of sea-sickness well illustrates this phe- nomenon. In the short space of an hour, or less, one can be reduced from a state of perfect bliss to perfect misery, simply from the perturbations caused by the motion of the vessel. One time, when returning from England, our steamer collided ^vith a sailing vessel in such a way and under such circumstances as to give just reason for the belief that we might be in serious peril. In the height of 4 50 NERVOUS EXHAUSTION. the excitement and alarm a seasick passenger came out from his room, where he had been shut up ever since oar departure, and inquired what the trouble was all about. He was informed that our steamer was leaking and that we were fast sinking. " If that's all, I'll turn in again," he replied, and went back to his berth, whence he did not emerge until we all landed in New York. In some cases of neurasthenia, this hopelessness is intermittent, periodic, hke attacks of inebriety or neuralgia, and these attacks are quite independent of all external conditions, although they may be excited and modified more or less by the environment. Hope- lessness, as has been said, is quite distinct from hypo- chondria, defined and described elsewhere. (See Chap- ter III.) Morbid Fear. — The emotion of fear is normal to the human mind. It is as natural and as necessary to be afraid as to be courageous. Fear is, indeed, a part of the first law of nature, self-existence. This emotion is, therefore, physiological, varying both in degree and kind, with race, sex, age, and the individual. In neuropathology, especially in the pathology of func- tional nervous diseases, the difference between health and disease is of degree rather than of kind; the phe- nomena that belong to what we call health passing, by indefinite and not distinctly defined gradations, into the phenomena of what we call disease; j)athology being, in truth, as has been said, but the shady side of physiology. Morbid fears are the result of various functional dis- eases of the nervous system, and imply a debility, a weakness, an incompetency and inadequacy, as com- pared with the normal state of the individual. A healthy man fears; but when he is functionally dis- SYMPTOMS OF NERVOUS EXHAUSTION. 51 eased in his nervous system he is hable to fear all the more; to have the normal, necessary fear of his physio- logical condition descend into an abnormal pathological state, simply from a lack of force in the disordered nei'vous system. The debihty of the brain — the nerve impoverishment — renders it impossible to meet respon- sibility, just as paraplegia makes it difficult or impossi- ble to walk; morbid fear is indeed but a psychical paralysis, but of a functional rather than of an organic nature. Patients of this kind will walk up and down before a physician's office many times before venturing to enter. In a number of instances, patients of mine have told me that they have come to the office and gone away without being able to summon the courage to ring the bell, and have gone away and have waited for weeks before again making the attempt. These confessions come oftentimes from men in middle life who are actively engaged m most important business enteii:>rises, where they are compelled all the time to meet and deal with large numbers of people. This timidity becomes a serious matter in business, making success very difficult. One of my patients troubled with cerebral exliaustion (cerebrasthenia), of veiy large wealth and great business exi^^rience, tells me that, desiring once to borrow, on perfect security, some money for a certain business i)urpose, he walked several times up and down the front of the office of the capitalist whose aid he sought, before he could summon tlie strength to go in. Responsibility of any kind, without any labor, even when unconscious, may powerfully affect the system, and in various ways. A very eminent theologian and [)reacher, who con- sulted me three or four years ago, told me that when 52 NERVOUS EXHAUSTION. he had charge of a parish, the responsibihty of sitting in his pulpit and Hsfcening to a traveUing agent ex- hausted him more than preaching himself, for the reason that he continually feared that the stranger would say or do some indiscreet thing. Thus it comes to pass that with the development of functional nervous diseases in modern times, particu- larly with the increase of neurasthenia in its various phases, there has been an increase in the forms of mor- bid fears, and in the number of their manifestations. When any special phase of morbid fear assumes a con- siderable frequency and consistency, so as to allow of classification, it is proj^er and convenient to give it a special name by which it can be known, described, and referred to. With the understanding that these mor- bid fears are symptoms of diseases, rather than diseases of themselves, simply belonging to a large family of symptoms, it is a very important convenience to be able to recognize them, to interpret their meaning, to understand their relations to the other members of the same family of symptoms, and to be familiar with their diagnosis and treatment. It would probably be a cor- rect statement to say that no symptom of functional nervous disease is so likely to be overlooked, or slighted, or misinterpreted, or improperly named, as this one symptom of morbid fear; it is diagnosticated as hys- teria, hypochondria, dyspepsia, imagination, bilious- ness, and actual insanity. Insanity has, it is true, its morbid fears, but they are associated with delusions or hallucinations. There are quite a number of varieties of morbid fear associated with cerebrasthenia, or brain exhaustion, without any hallucinations or delusions. The patient knows that there is no just, objective ground for his fear, but his emotional nature, under the influence of SYMPTOMS OF NERVOUS EXHAUSTION. 63 his exhausted nei-vous condition, overcomes his reason and will. A number of years ago, I described a form of mor- bid fear under the term astixiphohiciy or fear of light- ning, from the Greek astrape and phobos, fear. Of this disease I have seen quite a number of cases, and have nothing to say in regard to it beyond what has been already published. The leading symptoms are headache, numbness and pain in the back of the head, nausea, vomiting, diarrhoea, and, in some cases, con- vulsions. Tliese symptoms are preceded and accom- panied by great dread and fear. One of my patients tells me she is always watching the clouds in summer, fearing that a storm may come. She knows and says that this is absurd and ridiculous, but she declares she cannot help it. In this case the symptom was inherited from her grandmother; and even in her cradle, as slie is informed by her mother, she suffered in the same way. A lady now under my care, the wife of a clergyman, was first attacked with these symptoms six years ago, in comiection witli other symptoms of general neurasthe- nic and uterine difficulties. Her husband tells me that on the approach of a thunder-storm he is obliged to close the doors and windows, darken the room, and make things generally inconvenient for himself and family. After the reading of a paper on this subject by me at the meeting of the American Neurological Associa- tion, in June, 187l>, Dr. Webster, of New York, related a case of fear of storms, simply as storms, without referi'uce to liglitning. A woman forty yeai-s of age, whose mother, during pregnancy, had been frightened by a storm, suffered severely during the progress of a storm, walking up and down, in great distress, and arousing the whole house -at times appearing almost insane from terror. 54 NERVOUS EXHAUSTION. Westphal more recently has described a form of morbid fear under the term agoraj^hobia, or fear of places. This title, however, is quite inadequate to express the many varieties of morbid fear which the expression fear of places covers. The Greek word agora, from which Westphal derives his term, means an open square — a market place, a public place where assemblies were held — and as applied to the cases first described by him, the term is practically, though not etymologically, a correct one, for the fear of going across open squares or j^laces, at a distance from houses to shoj^s, was the chief feature in all of those cases.' This fear of open squares or places is, however, but one of a large number of phases that the fear of places assumes, as I have elsewhere described. In strictness, fear of places should be derived from the Greek word topos, place, a generic term, while agora is a special kind of place; agorapliohia would, therefore, be a species of topophohia. or a general fear of places, which symptom seems to be capable of infinite variety. Thus one of my cases, a gentlemnn of middle life, could walk up Broadway without difficulty, because shops and stores, he said, ofi'ered him an opportunity of retreat, in case of peril. He could not, however, walk up Fifth Avenue, where there are no stores, nor in side streets, unless they w^ere very short. He could not pay a visit to the country in any direction, but was hopelessly shut up in the city during the hot weather. One time, in riding in the stage up Broadway, on turning into Madison Square, he shrieked with terror, to the astonishment of the j)assengers. The man who jdos- sessed this interesting symptom was tall, vigorous, ' In etymological strictness agoraphobia means fear of large as- semblies of human beings, and not of the place where the people meet. SYMPTOMS OP NERVOUS EXHAUSTION. 55 full-faced, and physically and mentally capable of en- durance. He had, however, other symptoms of cere- brasthenia. These fears take opposite phases; thus, with one it is impossible to go to a certain place, where he was perliaps first attacked with the evil symptoms. And another finds it impossible or very difficult to go out of his house to any distance where business calls. I have now under care a patient who for a long time has been shut up in his house, unable to go anywhere, simply from fear of going anywhere. For a long time he was unable to come to consult me; but now I see him regularly; but he did not, mitil lately, since he has improved, go anywhere else. Quite a number of persons I have seen who find it difficult to go on long journeys, and if they do go, must have company. A person wrote me from a distant city in the West, ex- pressing a desire to come and consult me, but upon reaching a city at some distance, was compelled to return home without reaching New York. All these forms of morbid fear — fear of leaving home, fear of going to any locality or in any direction, fear of travel — are properly varieties of topophobia, the fear of open squares or places being expressed, though not quite correctly, by cujoraphohia. I have known four persons who were unable to cross the Brooklyn Ferry, and all got well in a few weeks or months. My friend, Dr. D. E. Smith, of Bronxville, N. Y., tells me of a lady who is unable to cross Harlem River on the cai"s, and consequently cannot visit New York City. I have now under my care a lady in whom the topo- l)hobia takes the form of inability to go to church. It was in churcli that she was first taken with a ]>eculiar and hard-to-be- described lightness of the head; and she 56 NERVOUS EXHAUSTION. now feels that she could do almost anything else rather than attend church. Ability to do that she would regard as the best and strongest sign of recovery. A young business man, who was first attacked with bad symptoms in his factory, dreaded to enter the building, until, under various treatment, he recovered. Some of the phases of this morbid fear are very in- teresting and surprising, even to those who are most famihar with the caj^rices of the diseased nervous sys- tem. I have elsewhere published a brief account of the physician who consulted me in regard to himself for long-standing cerebrasthenia, one of the symptoms of which was inabihty to go away from his home or office, or place where he was stopping, to any consider- able distance in a direct hne. He had the muscular strength to walk twenty miles, but when summoned to a patient was often obhged to decline to attempt to go even half a mile, which was a great astonishment to his patients, who were aware that even when un- able to visit them he could work all day in his garden. Like many of these cases he had a morbid fear of visiting the place where he was fii'st attacked by any of his ill feelings; thus he had been at one time pros- trated in Kew York City, and felt incompetent to come here to consult me; accordingly I met him by appoint- ment in a distant city. In walking out with him one morning, I observed that he continually turned off to the side streets, so as to keep at a httle distance from the hotel where he was stopping for the day, and, on my questioning liim, he said that he could not go more than half a mile in a straight hne, and that therefore he turned into the side streets so as to keep the hotel near at hand; the result was that we walked arm in arm, circumnavigating the hotel at a moderate distance —although not always keeping it in sight. The patient SYMPTOMS OF NERVOUS EXHAUSTION. 57 •was not at all wearied, although the walk was a long one — in a direct line perhaps a mile or two. I have now under care a patient whose morbid fear takes just the opposite phase: he cannot go to a certain locaUty, but can go very near to it, and beyond that point liis own will is often powerless to urge him for- ward. He was first attacked while in a lithographic establishment, working at his trade; and from that hour he has found it hard or actually impossible to enter any building devoted to that business. One day he re solved that he would conquer what seemed to him and his friends a foohsh whim, and started out for the shop, but on arriving within sight — about the distance of a block — he was compelled to stop; a cordon of police- men could not have been a more effective blockade; re- solved not to be beaten, he retired a short distance, and approached the building from another direction, but was again brought up against the imaginary barrier, and so in succession all the points of the compass were tried with absolute failure. He had a chance to work in Syracuse, and went to the depot to take the train for that city, but on enter- ing the station and going up to the office, he burst into teare and could not buy his ticket; he tried and tried, and finally gave up and returned home. He could have walked to Syracuse, but he could not reach out his liand and purchase the ticket for his fare. At an- other time he succeeded in reaching Cincimiati in (juest of employment, and was directed to a lithographic establishment where he expected to be employed; but in spite of all his rei)eated trials he could only come within sight of the building, and he was forced to return to New York. T have just been consulted by a ]>hysician who, as one of the effects and signs of cerebrasthenia, cannot 58 NERVOUS EXHAUSTION. at times undertake any slight responsibility; thus he has sometimes allowed a large number of horse-cars to pass him before he could bring up the resolution to jump on board one of them; and yet his muscular strength at the time was excellent. Dr. Meschede brought to the attention of the physi- cians at Cassel, in Germany, a form of morbid fear quite the opposite of what is known as agoraphobia, or fear of open places. In his case the symptom was fear of close^ narroiv places. The patient, a young man twenty years of age, was seized wnth a feeling of giddiness and confusion when in a small, narrow room. In the summer he could not sleep in a room at all, but was obliged to camp out; in winter he slept in a large, airy room. He was obliged to give up his studies and become a farmer. This symptom camiot be classed as agoraphobia at all, for it is the reverse condition. It belongs properly to what I call topopliohia, fear of places; and is, like agoraphobia, a species of which topophobia is the genus. At the late meeting of the British Medical Associa- tion (IS 79), I listened to a very interesting paper en- titled " Claustrophobia," by Professor Ball, of Paris. This term he applied to this morbid fear of narrow places— inabihty to stay within doors. Dr. Ball related a number of cases illustrative of this phase of nervous disease, and referred to Meschede and others, who had studied the same subject. The term Claustrophobia, fear of close places, as its derivation implies, seems to be an excellent one and may well be accepted. A form of morbid fear that I have lately described, and of which I have seen a large number of cases, is Anthropopliohia, derived from the Greek anthropos, man, and phohos, fear. This term applies to aversion to society, a fear of seeing, encountering, or mingUng I SYMPTOMS OF NERVOUS EXHAUSTION. 59 with a multitude, or of meeting auy one besides our- selves. This phase of morbid fear has different varie- ties. In quite a number of cases, this fear of man is so severe as to compel patients to give up business en- tirely; and I know a number of cases where men of strong muscles and having the appearance of great physical strength have been compelled, through this symptom alone, to withdraw from the occupations in which they were engaged; they could not face men, deal with them, persuatle them to buy or sell, or have any influence over them; they dreaded to meet a human being. This form of morbid fear is often ac- companied with turning away of the eyes and hanging down of the head, but not necessarily so, and usually so only in the severer cases. The world over, aversion of the eyes with a tmuiing away of the face is an ex- pression of the emotion of humihty and bashfulness, that is, of a feeling of weakness as com[)ared with the person in whose presence we stand — an instinctive and involuntaiy recognition of the fact that, for the mo- ment, our force is inferior to his. In neurasthenia this same principle appears as a pathological symptom— an expression of debility, of inadequacy, of incompetence. This avei-sion of tlie eyes is so constant a symptom in these neurasthenic patients that I often make the diag- nosis as soon as they enter the office, l)efore a word has been spoken by eitlier party, and even liefore the patient has had time to be seated. T have now under my care a young man wlio is so badly anthiopoj)liobic that, even when I take his hea/1 in my hands and hold it up, it is impossible to keep his eyes fixed on mine for more tlian an instant. A very intelligent and able friend, once imder my professional care, displayed this same characteristic, and I liave often talked with him in regard to it. This phase of morbid fear is a very 60 NERVOUS EXHAUSTION. good barometer of the condition of the system. From this alone we can often judge whether the patient is improving or growing worse. It is a very interesting symptom. In some cases I have loiown it to come on suddenly, or at least with very little warning, save the other associated nervous symptoms. This phase of morbid fear also has its opposite. In some persons there exists what may be called mono- phobia, or fear of being alone. Some of these persons camiot travel alone, but have no difficulty in travelling if they are in company with some one. Sometimes they cannot walk the street alone, or leave the house, except in company. Dr. C. L. Mitchell tells me of a gentleman who was so badly topophobic that he was unable to leave his house without company, and ac- cordingly he paid a man $20,000 to be his constant companion. There have been men who, by this symp- tom, have been kept as close prisoners as though within the walls of a penitentiary A form of morbid fear that has long been known to the profession is pathophohia, or fear of diseases — more commonly known as hypochondriasis. This form of morbid fear seldom exists alone, but is found in company with other symptoms — some real disorder of the nervous S3^stem, The pathophobic sufferer, with brain or stomach, or both, exhausted for some reason, may fear disease of the heart, of the stomach, or of the brain, or of the reproductive system, even when there is no sign of disease except his fear. The mis- take usually made in the study of these cases is to assume that this fear of disease is the only symptom which the patient has, and that it is the cause of the disease; whereas, usually, it is the result of the disease of cerebral exliaustion, like the other forms of morbid SYMPTOMS OF NERVOUS EXHAUSTION. 61 fear, whatever the cause may be; and as such it should be studied and treated. (See Chapter III.) There is a manifestation of morbid fear which is not uncommon, and to which we might perhaps give the ievia pantaphobia, or fear of everything; all responsi- bility, every attempt to make a change of movement being the result of dread and alarm. The wife of one of my patients has a morbid fear in reference to one of her sons, a lad of about fifteen years of age; and so distressed is she by it that she cannot allow him to go out of the house, or out of her sight, fearing lest he may be kidnapped, or some harm may come to him, as in the case of Charlie Ross. The poor fellow is thus ♦ kept a prisoner most of the time, and the whole family is disturbed and annoyed. He must remain in the city during the summer, as she cannot allow him to leave town; and at no season can he go anywhere unless accompanied by his tutor. A lady now under my treatment, who is also astra- phobic, tells me that she is afraid to go into the street, to do any shopping, or attend to any business; that it is an affliction for her to see a physician; eveiything is a dread to her, even when there is no draft mad«^ uj)on her physical strength. The expi'ession, phobophobia, fear of fears, might possil)ly apply to a certain class of nervous patiejits who fear they may feai-, provided they make an at- tempt to move or go in any direction where their mor- bid ear is in the way; they are afraid even when they do and say nothing. These persons fear when they aie entirely still and inactive, from a fear that if they attemj)t to do anything they will be attacked with their especial morbid fear. One of my patients — a stout and largo man — in addition to topoi)hobia (fear of places) had at one time a fear of committing 62 NERVOUS EXHAUSTION. some crime that would disgrace him. He was ashamed of his fear; he could not help it, although he has now entirely recovered. Mifsopliohia, fear of contamination, lately described by Dr. Hammond, comes under this head; the results of the treatment showing very clearly that it is symp- tomatic of a similar or analogous condition of the brain. In those cases there were no hallucinations or delusions. In one of the cases, there was an iiTesistible desire to wash the hands; the patient spent a large part of her time in that occupation. One of the patients gashed her hands as many as two Imndred times a day. I lately saw, in consultation with Dr. Cai'penter, a lady who was fuU of morbid fears, some of them of the most absurd character; she feared storms and was in apprehension of earthquakes, and, in certain crises, when at her worst, she could not let her husband set out on a short journey on a matter of business. In this case, the tendency to morbid fear was hereditary: her father being a most striking instance of mysopho- bia, having such dread of dust that he never sits down in a cl^ir until he has well dusted it, no matter in whose presence he may be. He will even get up in the night and dust all his clothes with great thorough- ness, holding them out of the window so that the room may not be defiled. Siderodromopliohia. — "This is a form of intense spinal irritation, described by Rigler of Germany, coupled with a hysterical condition, and morbid disin- clination for work, which is the result of shock, and occurs among railroad men; most commonly seen in cases of railway-engine mechanics who hav^e some altered nerve condition, or irritation of the nerve- centres. It is the perpetual jarring, shaking, and noise SYMPTOMS OP NERVOUS EXHAUSTION 63 which lead by degi'ees to this change, and which under the influence of some unexpected shock completely breaks up the nervous equilibrium." I have very lately seen two cases where the morbid fear was directed against diTinken men. I have had under care a young man of intelligence and culture, who is neurasthenic in many important features; and, indeed, has been an unusual sufferer from this trouble, who is so afraid of meeting or coming in contact with a drimken man in the street, that he will stay in the house, even when necessary for him to be out, rather than go out and run the risk of meeting such a person. On the feny boat, if lie sees a drunken man, he goes to the extreme end of the boat, to get as far as he can from the object of ten-or. He tells me that, one time, getting on a street car, there was a man only shghtly intoxicated; he could not remain on the car, but was obhged to leave it before he had nearly an-ived at his destination. This fear seems to be a fear of a row— of some trouble which the drunken man may cause, rather than any fear of the man himself. In the case of this young man, the difficulty is periodic. There is a certain street down-town, in the vicinity where intoxicated men are often found, where his business sometimes compels him to go. He can go tln-ough this street before three o'clock in the after- noon, but not after that time. In regard to all these different forms of morbid fear, by whatever name they are known or described, these general pro])ositions are tiiie and verifiable: First. — Tlieso morbid fears are symptomatic of func- tional, never, or rarely, of organic diseases. Tlie ex- istence of any of tliose symptoms, in a doubtful rase of diagnosis, would alone almost establish the nature of the disease, or enable us to give the casting vote. 64 NERVOUS EXHAUSTION. The best test of skill in the practice of neurology is in making a differential diagnosis between functional and organic diseases in their early stages; for this cause alone morbid fears demand close attention. While it is possible for hysterical and neurasthenic symptoms to appear and maintain themselves, more or less, in organic diseases, yet these symptoms of morbid fear are not found, according to my observa- tion, in what we call organic or structural diseases of the brain or spinal cord; it is strange that they are not, but the fact as here related is verifiable. They are not found in insanity itself, save as delu- sions or hallucinations, and the habit of calling them forms of mania or delusion is not based on fact or a right study of these cases. I observe that, even now, some forms of morbid fears are classed under insanity, or mania of some kind, even when there are no delu- sions or hallucinations. When the insane have morbid fears, such as I have described, or very many others which they may have, and do have, as we all know, they are delusions out of which they cannot be rea- soned, and are a part of, and in harmony with other delusions of the insane. But in all the cases to which I have here referred, there are no delusions and no hallucinations whatever; the patient is as well aware of his troubles as his friends are, and is as anxious to get rid of them as he would be of a sick headache, fever, or paralysis; but he is unable to shake them off until the exhausted brain, of which they are the du'ect result, is strengthened by hygiene and time and treat- ment. Second. — These symptoms may come on suddenly, in some cases almost instantaneously, and when once they appear, they may exist for months and years, varying in intensity at different times, Hke other symp- SYMPTOMS OF NERVOUS EXHAUSTION. 65 toms of cerebrasthenia, with which they are often as- sociated. Third. — These morbid fears are very frequently, though not always or necessarily, the result in whole or part of disorder of the reproductive system. Excess in the male in the natural or unnatural ways, or prolonged and teasing continence united with sexual excitation, and in the female, various slight and super- ficial uterine erosions, or displacements or lacerations, are the common provoking causes of these morbid fears, especially in constitutions where the nervous diathesis predominates. These fears may exist long after the local difficulty has been cured; in this respect these symptoms follow the law of the nervous symptoms witli which they are so often associated. Some of these cases are anaemic, but the majority are not so, and many are models of physical strength. Fourth. — The morbid fears rarely exist alone. They almost always appear in connection with other symp- toms of neurasthenia, either myelasthenia, exliaustion of the spine, or cerebrasthenia, exhaustion of tlio brain; most frecjuently the latter. I think, indeed, tliat I liave never seen a case of morbid fear, such as I have liere described, that existed alone, without some one accompanyijig neurasthenic symjttom, or many such symptoms. In some cases, I admit, these accompany- ing symptoms are few and slight, and can be ascer- tained only by careful study. Among those associated symptoms may be men- tioned palmar hyperidrosis, flushing of the face, a feel- ing of profound exhaustion, insonmia, hopelessness, shooting pains in the extremities, excess of oxalates and urates in the urine, heaviness of the loins and hmbs, dilated pupils, local spasms of muscles. Only 66 NERVOUS EXHAUSTION. rarely, however, is there a complete picture in which all these symptoms are represented. Like all these symptoms of neurasthenia, morbid fears very often occur in those of great, even enormous muscular strength and endurance; many of them can walk and work all day with muscle and with brain; but in the presence of their special fears they are as infants. A very frequent accompanying symptom is dizziness. Many of these cases, when they approach the object of dread, or even think of approaching it, are seized with vertigo— sometimes with less defined abnormal sensations. I have seen three cases where an epigas- tric spasm appears on attempting or even thinking of doing anything which is a dread. I have now under care a patient who tells me that he has a spasm in the stomach whenever he thinks of doing anything where he fears a failure. He describes it as a sudden sinking — a falling, somewhere between the base of the lungs and the navel. This patient has also a large array of correlated nervous symptoms, such as sweating of the hands, twitching of the eyelids, mental depression, etc. One of these cases had this phase of spasm — sinking in of the stomach; while at school it would come upon him whenever he was called upon, or feared he might be called upon, to read; even the thought of responsi- bility, though it might be in the remote future, brought on the attack. For convenience of reference, this classification of morbid fears may be thus tabulated: AsTRAPHOBiA— Fear of lightning. ToPOPHOBiA — Fear of places; a generic term, with these subdivisions: Agoraj)hobia — Fear of open places. Claustrophobia — Fear of naiTow, closed places. SYMPTOMS OF NERVOUS EXHAUSTION. 67 Anthropophobia — Fear of man; a generic term, in- cluding fear of society. Gynephobia — Fear of woman. Monophobia— Fear of being alone. Pathophobia — Fear of disease, usually called hypo- chondriasis. Pantaphobia — Fear of everything. Phobophobia — Fear of being afraid. Mysophobia— Fear of contamination. Flush imj and Fidget hies.s.—Vaimnis of this class oftentimes easily flush and easily faint; the inhibitory action of the symi)athetic is readily interfered with by any slight emotion. Fidgetiness and nervousness, in- ability to keep still — a sensation that amounts to pain — is sometimes unspeakably distressing. Although it cannot be defined, it may be an accompaniment of growing pains, and is one of the myriad results of spinal irritation. Sometimes in writing, the hand and arm become so nervous and fidgety that to continue writing would be the severest torture. When the legs feel this way, the sufferer nuist get uj) and walk or run, even though he be debilitated and is made worse by severe exercise. A gentleman once under my care could not sit still in the chair long enough to take an application of electricity. Freqiiciif Blnshiny — A very common effect of nerv- ous exhaustion, in both sexes, is frecpient and severe blushing from the sligbest i)ossil)l(^ mental or physical causes, and extending sometimes, not ()nly over the face, forehead, and ears, but down the neck, and ap- ])anMitly over other portions of the body. Suddenly meeting any onC; a stranger or acquaintance, the bear- ing of an unexi)ected noise, the taking of food or diink into the stomach, esi)ecially when rapidly swallowed, any stooping, or straining, or any slight muscular or 68 NERVOUS EXHAUSTION. mental exertion, may bring on this unpleasant, per- plexing, and annoying symptom. In some cases the symptom appears without any objective cause what- ever; the person may be sitting all alone, and the face, under some thought, or fear, or anxiety, or feehng of responsibility, may become as red as though suddenly entering company. This blushing is accompanied sometimes by blinking of the eyes, smarting or stinging of the eyelids, twitch- ing of some of the muscles of the face, confusion of mind and stammering of speech, which, like the red- dening of the face, are beyond the control of the will. Infants under one year never blush, for they do not feel that sensitiveness in regard to what others think of them, that is needful to excite blushing. Some of the peculiarities of blushing are very inter- esting. A lady patient of mine, who is of a very sensi- tive organization, tells me that when she blushes, little red spots, resembhng measles, first appear on the cheeks, and then extend down over the neck; in a moment these coalesce into a diffused redness. Sir James Paget, while examining the spine of a girl, noticed that a big splash of red appeared on lier cheek; this was followed by others over her neck and face. On questioning her mother in regard to it, she said that the peculiarity Avas inherited from her, and in answer- ing this question she blushed like her daughter. Blushing is a physiological phenomenon; but, like many other physiological phenomena, may become pathological, both causes and results of disease. When it becomes excessive, as in the above description, it may be regarded as pathological. As a symptom of neurasthenia, it is more common and more distressing than is generally believed. I have seen very strong, vigorous men, who have large muscular power and SYMPTOMS OF NERVOUS EXHAUSTION. 69 great capacity for physical labor, who, while in a neurasthenic state, would blush like young girls. Some young men are so harassed by this symptom that they cannot meet young ladies in the street or go into any company of their own sex without blushing ex- cessively; and on this account they frequently keep away from society altogether. This symptom does not occur in the modest, diffi- dent, and retirmg alone; the bold, the energetic, and the determined — those who can and do push their way in hf e — may become victims of this disorder. It is said that Tliomas Brown, the author of Religio Medici, was a sufferer in this way, \'Miile this veiy paragraph is being constructed, I am consulted by a young physi- cian of intelligence, ability, and education, who, al- though suffering from otlier neurasthenic symptoms of at least disagreeable cliaracter, yet complains more of this blushing than of all other symptoms combined, and for this, chiefly, came to ask my advice. Like many of the other phenomena of neurasthenia, this blushing may come and go — lasting for months and years, and disappearing as suddenly as it came. Like sick headache, it has a tendency to disappear as we advance in life. It is, also, as amenable to treat- ment as other symptoms of neurasthenia. Insomnia. — The different phases of insomnia in neurasthenic patients are exceedingly interesting. One man finds no difficulty in getting to sleep on re- tiring, but soon awakes, and nnist remain awake for the rest of the night. Another man rolls and tumbles for horn's before he falls into oblivious slumber, but when once asleep does not usually wake until morning. I was recently consulted for a case of insonmia of many years' duration, where there had never been any difficulty in sleeping after getting to sleej). 70 NERVOUS EXHAUSTION. Other sufferers report that they sleep in fragments — oases of repose in a desert of dreary wakefulness— but bad dreams constantly harass them so that in the morning they are less rested than they should be. Why a bad dream should be a bad symptom is not quite clear. Vn.ij a man disturbed by indigestion, or exhausted nervously by excitement late in the even- ing, should dream of snakes and monsters instead of green fields and gardens, of death and murder instead of deUghtful society and experiences, has perliaps only this general explanation, that the normal action of the cerebral cells is designed to be, in the main, pleasura- ble, and that mental, hke physical pain, is a symptom of something abnormal. It is also a question how far dreams are pathological. It would seem tliat in per- fect health — if there be such a state — one might dream even unpleasantly; and yet there is no doubt that sav- ages, and farmers, and, in general, those who live out- doors, depending on their muscles for their subsistence, dream far less than the in door brain-workers My guide in the woods of Maine and northern New Hamp- shire teUs me that he very rarely dreams, and one cool, phlegmatic maJi, whom I met in that region last sum- mer, assui'ed me again and again that he never, in aU his hfe, had a dream that he could recall; and with that class, as a rule, dreams of any kind, good or bad, are exceptional. Some neurasthenic patients can only sleep by night — never by day, however wearied. Others can sleep by day; often faU to sleep when they especially desire to keep awake, but at night toss in painful ac- tivity. Physical exercise also acts very capriciously with dif- ferent persons. Thus one of my patients tells me that if he takes a long walk in the evening, he is more restless SYMPTOMS OF NERVOUS EXHAUSTION. 71 than usual that night; and yet he is a very strong man, capable of much physical and mental toil. One peculiarity of sleeplessness is, that the mind is intensely and painfully active in many directions, or in some one direction, very often over the events of the day, and all the efforts of the sufferer to slow down the wheels of thought are inoperative; the patient dozes all night, or a good portion of the night, living over again in a most distressing way the experiences of waking liours. Nervously exhausted patients often wake up in the moniing, feeling almost as tired as wlien they went to bed in the night; may have slept perhaps several hours, but they have not rested by the sleep; they get up tired and discouraged. All patients of this kind generally sleep more than they believe; they say that they get no sleep, when they do perhaps lose themselves several hours every night; it is impos- sible, as a rule, to convince such people that they sleep at all. It is, however, one of the interesting facts of the human constitution, tliat these sufferers can go so long, can live so many years, be active in business and social life, with so little sleep. Drowsiness is the opposite symptom, and is experi • enced by persons whose symptoms in other respects are very much the same as those of the sl(Y'i)less, One of my patients, a clergyman, long suffering from cerebrastlienia, tells me that at one time, if he imdertook to read, lie would very soon feel sleepy, lemain so for half an hour, wake uj), attemi)t to read, and again feel sleepy; this symptom more than any other comp('ll(!(l bim to n'sign his charge. In som(^ cases this drowiiiess does not come to positive sleep; the patient is simply dull, heavy, sleepy, without hav- ing the ability to get asl«'ep. It has been supposed that this drowsiness was a symptom of amemia of the 72 NERVOUS EXHAUSTION brain, while wakefulness was a symptom of hyperae- mia of the brain; but the truth is, that both conditions may be relieved oftentimes by the same treatment. On this subject, my friend Dr. Lente gives me this experience: He was in consultation with the late Dr. George T. Elliott, of this city, over a case of severe hemorrhage, which caused the patient to be very sleep- less from profound ana3mia. Dr. Lente suggested the use of bromide of potassium. Dr. Elhott objected, on the theory that the bromides tended to diminish the quantity of blood in the brain; bromide, however, was used, and it made the patient sleep in spite of anaemia. All close observers must have had experience very much the same. Tenderness of the Teeth and Gums. — Attacks of ten- derness of all the teeth, accompanied by a whitish appearance of the gums, I have noticed in nervous exhaustion. In these attacks, which may result from over- work, or excess, all the teeth may be very tender OQ pressure, although none of them are decayed. Here, then, is another opportunity to study with the naked eye the pathology of spinal irritation. In nervous exhaustion, whether complicated with anaemia or not, there may be tender uess of any part of the body or of the whole body. Tenderness of the head is cerebral irritation; of the spine, spinal irritation; of the tip of the spine, coccyodynia; of the breast, irrita- ble mammae; of the ovaries, irritable ovaries; of the teeth here described, dental irritation ; and so on of the womb; and the jDathology of any one of these symp- toms is probably the pathology of all. Nervous Dyspepsia {Dyspepsie Asthenique). — In cases — not a few — nervous dyspepsia is the first notice- able symptom of nervous exhaustion — the earliest sign that the body is giving way; and for years, the SYMPTOMS OF NERVOUS EXHAUSTION. 73 stomach may be fmictionally disordered before the brain, or spinal cord, or other parts or organs, show signs of yielding. The tine philosophy is, that ner- vous dyspepsia is a symptom of the same general pathological condition as all the orders of symptoms here noted, and it may follow or accompany as well as lead this multitudinous army. A literary gentle- man whom I once met gave a history of nervous ex- haustion from over-confinement, that after some years broke out through the pneumogastiic nerve, causing profound and obstinate dyspepsia that for a long time made him a complete invalid; the symptoms were al- most as bad as those of cancer of the stomach, and yet the disturbance was entirely functional, and the patient improved. Flatulence, with annoying rumb- ling in the bowels, these patients complain of very frequently; also nausea and diarrhoea. I am accustomed to diagnosticate nervous dyspepsia from other forms of nervous dyspepsia depending on inflammation or other chronic disturbances, by the following considerations: First, in nervous dyspepsia, the patients feel woi'se when the stomach is empty, and are relieved by eat- ing. Patients of this class have the greatest distress before meals, or when a meal is long delayed; even over-eating is a relief to them. With these persons, mental or physical labor on a perfectly empty stomach is very apt to cause distress— pain in the eyes, pain in the head, general nervous distress all over the body, and j)ain in the stomach itself; indeed, there is no jiart of the organism that will not suffer when mind or body is much exercised on a i)erfectly empty stomach. Secondly, the symptoms of nervous dyspepsia are very capricious, coming and going without traceable cause. 74 NERVOUS EXHAUSTION. Thirdly, nervous dyspepsia is most commonly found with the nervous diathesis, and is apt to be associated with other nervous symptoms in other parts of the body. In some cases, nervous dysiDepsia is a forerun- ner of a long list of nervous symptoms through all the different organs, as the eyes, the ears, the bi-ain, the spine, and reproductive apparatus. In some cases, it takes the place of many of these symptoms, being better when they are worse, and worse when they are better. Fourthly, nervous dyspeptics are relieved by reme- dies that have a sedative and tonic effect in general, without any special reference to the stomach. Elec- tricity is one of the very best for all forms of this dys- pepsia. The bromides, that have no special effect upon the stomach so far as we are informed, are very well adapted to relieve nervous dyspepsia. Deficient Thirst, and Capacity for Assimilating Fluids. — Quite recently, a physician who consulted me in regard to himself, called my attention to the highly interesting fact that he rarely drank water either at meals or between meals; and he stated that the aver- age quantity of liquid that he consumed was far below the normal standard. Investigation of other cases of neurasthenia has convinced me that this deficiency of thirst is one of the symptoms of that state, and it would appear that it is not an unusual symptom, but exists in not a few cases; there are many who for years have a poor appetite for fluids, as they have a poor appetite for solid food; they live on a small quan- tity of liquid, and, perhaps, without suspecting it, until their attention is directed to the fact. There are those who find that, if they take much liquid, the stomach suffers, even when little or no solid food is mingled with it. One advantage, with some disadvantages, of SYMPTOMS OF NERVOUS EXHAUSTION. 75 the free use of beer with our German friends is in the quantity' of fluid that they thereby imbibe — the water of the drink more than the alcohol. Drinking milk has a similar advantage. "VVTien we remember that the body is composed mostly of water, we can easily see that there is a dan- ger of starving for want of simple liquid, just as, under the influences of our civilizatiou, we are starving for want of fatty food. There is no question that the Europeans, who are far less nei^ous than the Americans, use far more liquid nourishment; and it is a fact, more and more impressed on my mind, that many neui'asthenic patients are very temperate, if not total abstainers, and some abstain even from tea and coffee. Desire for Stimulants and Narcotics. — When the nervous system loses, through any cause, much of its jiei-vous force, so that it cannot stand upright with ease and comfort, it leans on the nearest and most convenient artificial support that is capable of tempo- rarily i^ropping up the enfeebled frame. Anything that gives ease, sedation, oblivion, such as chloral, chloroform, opium, or alcohol, may be resorted to at first as an incident, and finally as a habit. Such is the philosophy of many cases of opium or alcohol ine- briety. Not only for the relief of pain, but for the relief of exliaustion, deeper and more distressing tban pain, do Ijoth men and women resort to the drug shop. I count this as one of the great causes of the recent increases of oj)inin and alcohol inebriety among women. Fi-equently an inlierited tend(>ncy to inel)riety is utterly latent, and does not break out until affliction, or some form of wony or distress, robs the brain of its nerve- force. Very many cases illustrative of this hav(? been published by my friend Dr. T. D. Crothei*s, of Hart- ford, Ct. 76 NERVOUS EXHAUSTION. One sign of neurasthenia, especially of an acute at- tack, is inability to bear certain kinds of stimulants and narcotics to which patients have been accustomed; thus patients have told me, that during illness of any kind, they were obliged to suspend smoking; they say that tobacco makes them sick. This happens to those who have been accustomed to use large quantities, both chewing and smoking. As they regain their strength, they also regain their power of using stimu- lants. The opposite condition is also found; and a person when depressed can sometimes bear immense quanti- ties of alcohol, who in health is capable of drinking but veiy little. It happens sometimes in hysteria, for example, that alcoholic drinks can be consumed very freely indeed, although the patient is very weak and nervous in every respect. A hay-fever patient of mine — a frequent sufferer from that disease — who was accustomed to take sev- eral large doses of stimulants before an attack to pre- vent nervous exhaustion, told me that, while in that state, he would drink almost any amount of alcoholic hquors without being affected thereby. This form of idios3^ncrasy against alcohol would appear to be a dan- gerous state, as it may lead to inebriety. Ahnormalities of the Secretions. — In nervous ex- haustion, the eyes may become moistened more read- ily than in health, and under a very slight emotion of f)leasure or of pain. The flood-gates seem, as it were, to stand ajar; and on trifling agitation the tears flow forth. In grave cerebral disease, this symptom is common enough, but in functional disease — simple nervous exhaustion — it is even more common; and " softening of the brain " is feared. In nervous debility, also, the sebaceous glands may SYMPTOMS OF NERVOUS EXHAUSTION. 77 refuse to do their duty; the hair and beard become dry and stiff, and much pomade is needed. The hair then falls off or becomes gray in patches. Abnormal dryness of the Skin, Joints, and Mucous Membranes. — In sonxe cases of neurasthenia the skin of the whole body is unnaturally dry; this is especially and most reacHly noticed in the hands, but all parts of the surface may present this peculiarity. A scaliness or scui-finess may accompany this dryness, as though there were a deficiency of fluids and of sebaceous secretion. There would also appear to be a relation between this condition and a disinchnation to drink, or use fluids freely. A young lady of twenty-one, in addition to many other neurasthenic symptoms, had dryness of the scalp, eyes and ears, especially in the moraing; her eyes and ears would be dry and hot, and in the ears a thin skin would form, and fine scales would be thrown off. These s>^nptoms were not constant; they would leave entirely for a number of days, and then, without any apj)arent cause, return — tlius following the law of all other symptoms of neurasthenia Dryness of the joints is also observed in the nei-v- ously exhausted. How the joints may suffer in grave spinal diseases, sucli as ataxy, is well known; but in these functional maladies, of wliich neurasthenia is a type, tlie joints may suffer, though in a less severe mamier. Deficiency of the secretion, with dryness and cracking sound on movement, I have noticed in a number of cases; in one striking case of nnisician's cramp, cracking of the joints is noticed in the affected fingers. Sweating Hands and Feet, tvifh Redness {Palmar Hyjieridrosis).— SweatinQ of the hands— of the palmar surface, or of the entire hand — palmar hyperidi'osis — 78 NERVOUS EXHAUSTION. is a symptom of neurasthenia at once so interesting and so frequent that I wonder that the hterature of the subject is so meagre. This phenomenon — abnormal perspiration of the hands — is certainly more common in males than in females, although it occurs, as, indeed, all forms of hyperidrosis occur, in both sexes. The milder phases are common enough, but there are severe manifesta- tions that this symptom may assume, which seem well-nigh beyond behef. Thus a young man now under my care is so distressed thereby that he threatens suicide unless he is permanently cured. In his case, there are various evidences of a bad inheri- tance, a poor constitution, although this palmar sweat- ing is just now the only very annoying expressioji of the depraved diathesis. A young lady in the northern part of the State is compelled to take a number of handkerchiefs with her when she goes to school, and on her retm^n they are aU saturated from the excessive perspiration of her hands. My friend. Dr. Josiah Koberts, of this city, teUs me that in a similar case, lately brought to his attention, there was clear proof of uterine disease. The intimate relation of this symptom to the nervous system is shown in many striking facts. Thus one young man who consulted me would be attacked peri- odically — at ten and four o'clock — and whenever he was at sea the symptom would utterly leave him. In one of my cases, the slightest emotion would instantly satui'ate the hands as thoroughly as dipping them in a pail of water. The effort to shake hands is sufficient to produce this effect. Eedness of the whole hand- erythema — sometimes attends this palmar sweating, and in one of my cases the ears are as red as the hands. SYMPTOMS OF NERVOUS EXHAUSTION. 7{) One of my patients, now restored to health, tells nie that his luind-sweating was so prof use that, in writing, he was forced to kee}) blotting paper beneath his hand to absorb the moisture. I have been consulted by a physician who is so mucli affected with palmar hyperidrosis that a pair of gloves will not List him more than ten days, and his shoes also wear out rapidly. Sdl ivat iuH . — Dvyness of tlie mouth, through sup- pression of the salivaiy secretion, is often noticed, both as an effect of emotion and as an effect of nervous substitution: the opposite condition, salivation, is not so common. A year ago, an intelligent physician informed me that, at one time, while in a neurasthenic state, he went to bed, and l)y an effort of the will, as he ex- pressed it, brought on free salivation. Subsequent nights the same effect occui-red, contrary to his wishes, and it was some time before he was restored to his normal, original condition. Teudrnicss of tlio Spine {Sphial Trrifafioii), and of the v'liolc Body {Cknicral llijpord'sthi'sia). — When the spine is so tender as to become an important and per- maueut afllirlion, and to overshadow other symptoms of the neurasthenic state, it is called spinal irritation; but, strictly, it is a symptom, like cerebral irritation, not proi>erly a disease as such, although, as a matter of convenience, there can be no harm practically in describing it as a disease. In regard to tliis symptom of nervous exhaustion, these i)oints are noticeable: First, its great frcMpiency in the higher classes, espec- ially among women. I suppose if one should go through Fifth Avenue, of New York City, and exam- ine the spines of all the ladies between fifteen and forty-five years of age, he would find in qmte a per- 80 NERVOUS EXHAUSTION. centage of cases that, at times, there would be tender- ness either of the whole length of the spine, or, more likely, at certain points, as the nape of the neck, and between the shoulder-blades, and on the middle lum- bar vertebrae. Crawling, creeping, and burning sensa- tions often accompany this tenderness. This condition would be found at times in those who do not call themselves invalids, and who are not under medical treatment. It would furthermore be found that, with some of these cases, there would be tenderness of the scapula or hip bones, of the breast bone, and, indeed, of the whole surface of the body. This general hyper- sesthesia, like the local hyperaesthesia of the spine, appears and disappears under any subjective or objec- tive exciting causes, and is attended usually by a feel- ing of debility, and oftentimes, though not always, by backache, headache, insomnia, and mental depression. The transient nature of this symptom of spinal and general irritation is shown by the fact that it may disappear often after a single application of electricity. Many women always have spinal irritation during the period of menstruation. Spinal irritation — tenderness on pressure — is not the only symptom of spinal ex- haustion; it is but one of many symptoms of that state. In some cases of spinal exhaustion, also, there is no tenderness of the spine on pressure. Coccyodynia. — A very common and sometimes most distressing form of spinal irritation is what is caUed coccyodynia — that is, tenderness with pain, and some- times severe neuralgia at the tip of the spine, what is called the coccyx. This is far more common with women than with men; indeed, in man it very rarely occurs. It almost always accompanies irritations of other portions of the spine. One of the symptoms of this form of spinal irritation SYMPTOMS OF NERVOUS EXHAUSTION. 81 is a feeling as though the spine were too long; when sitting, this feeUng is a distressing one. Peculiarities of Pain in the Back. — In neurasthenia, all parts of the back may be the seat of pain, although certain districts are more affected than others. There may be tenderness when there is no pain, and con- versely pain, even severe pain, when there is no ten- derness. There may be much distress in the loins and over the hips, when careful examination shows no tenderness anywhere. Tliis pain in the hips and loins is something quite different from ordinary neuralgia or sciatica; it rather resembles muscular rheumatism or a common cold, and is, indeed, often confounded with one or both of these diseases, even by able diagnosticians. The ha- bility to confound initation of the upper part of the spine at the nape of the neck with rheumatism is very great; the symptoms, indeed, are quite the same — pains, stiffness, aching, inability to move the head with- out discomfort. Sometimes this condition perfectly simulates wry-neck, and is mistaken for it. One of the very ablest neurologists in Germany, on being con- sulted by a case of irritation in the upper part of the spine, made diagnosis of rheumatism, and treated the patient accordingly. This back pain, and the tender- ness that may or may not accompany it, fluctuates hke all these neurasthenic symptoms: to-day they are present in fuU force, to-morrow they are all gone, but, on any provocation, are liable to return. They fly about in every direction; now just below tlie shoulder- blade; now in the centre of the spine; and at another time between the shoulder-blades, or in the middle lumbar region; sometimes with heat and burning, at others with biting penetrating sensations, or a feeling as though ants were crawling just under the skin. 82 NERVOUS EXHAUSTION. Heaviness of the Loins and Limbs. —One of the most frequent complaints among the neurasthenic (myelasthenic form) is heaviness and vague aching of the loins and limbs, and sometimes of the whole body. This is a symptom hard to defiae in exact words, but it is very common, and it is a cause of great distress. This symptom is quite apt to follow over physical exertion, as in walking or standing, but may come on without any apparent or special exciting causes. This feeling so closely resembles rheumatism that it is often confounded with that affection by those who are un- familiar with neurasthenia, and even one well ac- quainted with nervous exhaustion in all its forms, might, on first being called to a patient, mistake this heaviness and aching for a common cold, or for a rheumatic attack.' I have lately been consulted by a gentleman suffering from myelasthenia, where this aching of the lower part of the back and loins is almost the only subjective symptom. In sexual exhaustion, pains in the loins and limbs, not amounting to neu- ralgia, but sufficient to be a severe annoyance, are frequent enough, but they are not restricted to the sexual variety of neurasthenia. There would seem to be a degree of truth in the suggestion, which has often occurred to me in study- ing these cases of pain in the back and loins and the lumbar region, that they were to men what so-called spinal irritation is to women. It may be said that this condition is to spinal irritation what hypochondri- asis is to hysteria. The distinction is not absolute, for both sexes have the same group of symptoms. There would appear to be more cases of men who have these symptoms — pain in the back and loins, from neuras- ' How the symptoms of ataxy have been, and are, mistaken for rheumatism is well known to the physician. SYMPTOMS OP NERVOUS EXHAUSTION. 83 thenia, without any tender points, any irritation of the spine— than of women. When females have pain and weakness in the back, they are more hkely to have great tenderness on pressure. This distinction is, I beHeve, verifiable. Erb, in his chapter on this subject, raises the same query. Shooting Pains simulating those of Ataxy. — If there be any difference between the familiar shooting, light- ning-like pains in the extremities, that have so long been considered as peculiar to ataxy, and the shooting pains of neurasthenia, I have not been able as yet to find it out. Generally, these neurasthenic pains are milder than those of ataxy, but this average fact does not interfere with the fact of observation, that this difference in degree is not of itself sufficient to make it possible to establish the differential diagnosis; for the shooting pains of ataxy are by no means always severe, and in many cases of the disease do not exist at all. The mistake of writers in so strenuously insist- ingi on the diagnostic importance of these shooting pains has been, and is, the source of terri1)le annoyance to physicians, especially who hai)pen to be themselves sufferers from these neurasthenic symptoms. The same remark api)lies to fibrillaiy contractions, which have been looked upon as indicating muscular atrophy, but whicli, as I have elsewhere stated, may exist as one of the many symptoms of neurasthenia. Fodalgia (Pdiu- iti the Feet). — One of the symptoms of ataxy in the early stages is a feeling of numbness of the feet. Sometimes there is a feeling as tliough straw were at the bottom of their feet, or as of walking on velvet, or rubber, or wool. A feeling of heat and burning is also noticed; and both in neurasthenia and in ataxia it comes from the spine. It has, however, a very 84 NERVOUS EXHAUSTION. different significance; in one case it means an organic, and in the others a nervous, functional disease. In some cases, there are painful spots on the feet, either on the sides or at the bottoms. These spots are more painful from pressure of the boot or shoe; they are felt even when in bare feet or in slippers. Pains of the feet may be observed in persons not specially nervous, but they are to be found also as symptoms and results of neurasthenia. There is little question but that in some cases they are reflected from the stomach or genital apparatus. Tremulous and Variable Pulse and Palpitation of the Heart {Irritable Heart).— In the nervous, the rapidity and quality of the pulse-beats may vary in many ways during the process of counting. Fre- quently the pulse of the nervously exhausted is com • pressible, and almost always it is more rapid than normal, ranging between 75 and 90, frequently going up to 95, 100, or 110 and more. In exceptional in- stances, nervous exhaustion has a very slow puis©, in the neighborhood of -10 or less, or there may be alter- nations between a very high and a very low pulse. The heart is quite apt to be very irregular and irrita- ble in many of these cases. It beats perceptibly and painfully, not only under excitement, but upon even a thought of responsibihty— of undertaking anything which requires exertion: even when sitting quite still. It is so powerfully affected by the mind, so intimately under the influence of the emotions, that I have almost abandoned the habit of examining the pulses of my patients, on a first visit, for the reason that I learn almost nothing by such examinations. The ex- citement of seeing a stranger always puts the pulse up so much that I can hardly tell what the actual condi- tion is. Those affected thus often suppose that they SYMPTOMS OF NERVOUS EXHAUSTION. 85 have organic disease of the heart, and sometimes worry more over this symptom than all of the other symptoms combined. In some cases, noises in the ears rise and fall with the beating of the heart, and when the pulse is veiy high the noises are very loud and distressing. In some cases, also, the pulse, a part of the day, will be very high indeed, and again, in a few hours, very slow. There is pain and oppression in the region of the heart. [Dr. S. (t. Webber' has recently made some interest- ing observations on the use of the sphygmograph in neurasthenic patients, and divides them into three classes: " First, those in which the vascular tension is nearly or quite normal. There are a few such, who seemingly have been only temporarily run down, and quickly recover. "Another class may be formed of those who, at first, show a decid