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MEDICAL SOCIETY OF THE MISSOURI VALLEY, OMAHA, SEPTEMBER 19-20

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307 NEW ENGLAND BUILDING

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Refer by permission to the editor of this journal.

When Writing to Our Advertisers, Please Mention Tho Medical Herald

= Incorporating
Kansas City Medical Index-Lancet

An Independent Monthly Magazine

Vol. XXXVII.

SEPTEMBER, 1918

No. 9

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m
mmmmmmmmmmm m mmment be called but to two of the three chief neuroses,

namely, neurasthenia and psychasthenia. HysOriginal Contributions

teria, for reasons obvious to the society, cannot

and should not be considered at this time. In ( EXCLUSIVELY FOR THE MEDICAL HERALD.)

this connection also, it might be well to add mmg Commitmondotcommitmeg Combinadamu that the occupation neuroses, the traumatic neuFATIGUE NEUROSES*

roses, migraine and epilepsy are likewise ex

cluded from consideration, although in some inTOM BENTLEY THROCKMORTON, B. Sc., M. D., stances fatigue may be a causative factor. to a Des Moines, Iowa.

more or less degree, in producing or promulIn presenting the subject “Fatigue Neuroses,” gating the symptoms arising from such disorit is quite natural that one's mind be turned to a ders. With these preliminary remarks, let us consideration of such conditions as are capable of now turn our attention to a consideration of producing changes in the nervous system which neurasthenia. While this disorder is in reality are not organic in type. It has been the custom

a neurosis due to exogenous causes, we find that for many years to arbitrarily divide all nervous psychasthenia, in its essence, is the result of disorders into so-called functional and organic causes arising largely within the human economy classes. For clinical purposes, it must be con

itself. For years a popular and fashionable disfessed that such a division is not entirely with

ease, of more recent time we find that it is with out merit, for it has perhaps served as a means reluctance that a diagnosis of neurasthenia, or for better fixing some of the all too hazy ideas nerve exhaustion, is made. Pardoning a personal of neurology in the medical students' mind. To

reference, I recall the time when in the absence day, however, we are brought face to face with of frank organic changes, a case was considered the fact that theoretically, at least, it is impos

neurasthenic until proven to be otherwise. Tosible to have a perverted function of an organ

day, I believe the pendulum has swung in the or tissue without there first being an underlying

opposite direction, and no case is considered one cause, some pathologic change present some

of just plain "nerves" until every known means where within the animal structure. All too well for detecting organic changes in the nervous do we realize that the boundary line between the system has been utilized and a negative result neuroses on one hand and the organic nervous obtained. diseases on the other hand is entirely imaginary. The commonest cause in the production of the To consider a neurosis simply as a nervous dis- disorder now under consideration is overstrain, ease devoid of anatomical changes is inade- mental or physical. True it is also that alcoquate, for who can conceive of disease or per- holism, cocainism, tobaccoism, and allied subverted function without there being also the stances may play at times an important role as presence of some underlying abnormal physical etiologic factors, and indeed one must not lose or chemical basis? Yet I feel that the time is sight of the part played by toxins elaborated hardly at hand for us to erase the line which at during the process of the various infective distimes so narrowly divides the functional disor- eases, but these factors by no means invalidates ders from the truly organic ones, but we must the assertion that mental or physical exhaustneeds be content to look upon the neuroses as ion are the commonest causes. Again, it must functional in character until a more definite not be forgotten that an overlapping of symppathology is established.

toms, supposedly neurasthenoid in origin, with In order that the subject may be given proper those emanating from a purely organic basis, consideration in the brief space of time allotted, can and do occur. I recall yet quite vividly the it is necessary that the scope of this paper be case of a young nurse, who came into the service well understood, and to this end, attention will of Dr. Francis Sinkler, at the Philadelphia

Orthopedic Hospital and Infirmary for Nervous *Contributed to the Symposium on the Diseases of Diseases, some years ago. After having passed kuk, Iowa, March 22, 1917.

through the hands of several eminent special

xhaustion, Medical Society of the Missouri Valley, Keo

ists in New York City, all of whom had appar- ing over the vagus system. Palpitation of the ently considered the case as one of neurasthenia, heart is exceedingly common, feeble circulation she was likewise treated at the Infirmary for an in the extremities of the body is by no means indefinite period of time as a supposedly neu- unusual, and the various digestive disturbances, rasthenic patient, until one day the finding of indigestion, heaviness in the epigastrum, eruca beginning optic neuritis lead to a further in- tations, constipation, all point to a condition in vestigation of the case, and a diagnosis of brain which undoubtedly there is a deficiency in innertumor was made, which was subsequently con- vation as well as in inhibition. The clinical firmed by post-mortem examination. Doubtless picture of the sexual neurasthenic is so well there are some present who have known of in- stamped on your memory I dare say, that to atstances in which individuals suffering from a tempt to portray the same before this society, supposedly functional disorder, later replaced the I take, is entirely needless. Here, as in the other vague aches, pains and motor weaknesses com- somatic disturbances, exhaustion is directly replained of by symptoms of undoubted organic sponsible for the symptomatology presented. involvement. In this connection I would refer

I would refer The psychic phenomena are intensely intermoment to the harmful effects sometimes esting. There is a pronounced lack of mental resulting from failure to diagnose early such tone, the capacity for intellectual work is dimincases as tabes dorsalis, and even acute melan- ished, there is an absence, as it were, in the sponcholia, in which conditions it is not at all un

nich conditions, it is not at all un- taniety of thought and the ability of concentrausual to have a prodromal period of varying tion is impaired. Irritability in some cases belength in which the symptomatology presented comes the order of the day. That a tired man is is largely subjective and neurasthenoid in char- more apt to be cross than one not wearied in acter. Trauma, likewise, may be a factor in well doing, is well known, giving evidence of a producing nerve fatigue, and by no means today more or less loss of self control, a loss of inhihave such disorders as “railway spines” and kin- bition. Thus we see that neurasthenia, in the dred ailments, passed into oblivion.

brief outline above presented, may manifest itself The symptoms of neurasthenia are chiefly as a fatigue neurosis, and the failure thus far to subjective, and for the sake of convenience can

ce, of convenience can find an organic basis compels us to consider it be considered from the following standpoints, as functional in character. motor, sensory, somatic and psychic. The motor Of no less interest, perhaps, is a considerasymptoms, in brief, are those of muscular ex- tion of psychasthenia. Here due credit must be haustion. The patient complains of tiring easily, given to the noted French psychiatrist, Janet. and that he cannot undertake any little effort

ne cannot undertake any little effort for the introduction of this term, meaning soul without revealing evidence of ready muscular

weakness. As before stated, psychasthenia is a exhaustion. His grip may be weak, his legs

disease resulting largely from causes arising weary easily, even after the shortest of walks, within the individual himself. Just as neurasoccasionally muscular cramps are present, and thenia is a fatigue neurosis, so in psychasthenia sometimes tremors add to the disagreeableness of do we likewise find fatigue playing an important the situation. There is very commonly an in- role as a causal factor. hibition of the central motor impulses and in

Having already spoken somewhat at length consequence the deep tendon jerks, particularly the knee jerks, are found to be in an exaggerated

regarding the symptomatology of neurasthenia,

it is not necessary that your minds be now burdstate.

ened by a more or less detailed description of The sensory phenomena, as a rule, are at the symptoms attending the psychasthenic state, first vague and bizarre in character. Headache, since all the phenomena of nerve exhaustion, such backache, and various aches and pains, local and

as are present in the neurasthenic states, are to general in character, are sooner or later encoun- be found in psychasthenia. Suffice it to say tered. Paraesthesias of the hands and feet may that the mental phenomena are the symptoms be complained of, numbness may be experienced, which especially claim our attention in this disespecially in those parts of the body where the order and although the psychic field is invaded clothing tends to be somewhat restricted, but it in some neurasthenic states, there can be no is of great importance to note that objective sen- question but that the mental phenomena dominate sory disturbances, such as anesthesia or hypes- the clinical picture in the true psychasthenic conthesia, are never present.

dition. The somatic or visceral disturbances are like- It may be of interest to note that psychaswise the result of a deficient innervation. Owing thesia requires for its development the combinato the lack of energy of the various viscera, tion of two important factors, the grafting of a bodily disturbances result. The circulatory appa- fatigue neurosis on a neuropathic background, ratus is usually found to be below par in its It was left to Dercum to point out the duality of work, since the cardiac function, as a rule, is the origin of this psychosis, and to this celeweakened by an absence of proper stimuli com- brated American alienist belongs the credit of simplifying our knowledge of the various forms tissue. The toxins may be the products of bacunder which the psychasthenic states parade. terial growth or of disordered metabolism in the Any non-neuropathic individual who, for one tissues themselves brought about by the reaction reason or another, becomes nerve exhausted can to invasion with bacteria or in some other way. be properly classed as a neurasthenic, but in order Thus severe stresses, deprivation, hemorrhage, that a true psychosis be developed, there must be etc., may result in such an auto-intoxication. present a previously neuropathic state. As Der- Since nerve tissue has only certain functions cum has well said, “It is only when fatigue symp- to perform it is obvious that intoxications of all toms appear in a neuropathic subject, that mental kinds can produce only evidences of interference disease results,” and it was to this group of men with that function which must be similar in every tal disorders that he applied the term “neuras- instance. The only possible differences, apart thenic-neuropathic insanities."

from those of degree, must depend upon the rapThere is no one, I dare say, who has given idity of production and duration of the toxin even the slightest of attention to mental disorders which will influence the course of the disorder, but has been confronted at times with individuals and the particular groups of nerve cells which the presenting a mental condition in which the spe- toxin is capable of attacking. Upon this last cial fears, phobias, obscessions, anxiety psy- factor will depend the individual differences to choses, indecisions, deficiency in inhibition and be met with in the manifestations of different deficiency in will were present in varying grades kinds of intoxication. This last feature, howand degrees. It is entirely beyond the scope of ever, does not play a very large part in the bacthis paper to even attempt to take up a consid- terial intoxications for the damage is very diferation of these various forms, other than to fuse and affects especially the higher associative state that for all practical purposes it would ap- neurons of the brain. pear that the arrangement of the forms of the Consequently it is as unnecessary to consider neurasthenic-neuropathic insanities is the most the manifestations of a psychosis resulting from applicable one we have today. Here, four spe- an infection with typhoid separately from those cial types or groups are considered, namely, The of one arising in the course of pneumonia as it Insanity of the Special Fears, the Insanity of In- would be to describe separately acute nephritis decision, the Insanity of Deficient Will, and according to the particular specific fever in which lastly the Insanity of Deficient Inhibition.

it occurred. The severity and course may differ, For a clinical study of such cases, it is usu- but the manifestations are identical. ally needless for one to look among the inmates

This point is here emphasized for the reason of our state institutions and asylums for indi

that there is a widespread tendency to regard viduals suffering with some form of this mental

psychoses as separate and distinct diseases and disorder, since it is extremely rare for such per

to consider that the addition of mental disorder sons to be committed. On the other hand it is to the

to the clinical picture of typhoid or pneumonia impossible to formulate an idea as to the num

is a new disease to be combatted. Mind cannot ber of such individuals who are extra-murally

be separated from body and it is even more imsituated. Like the proverbial poor, however,

portant to grasp that body cannot be separated they are with us always. Fortunately for so- Fr

from, or treated independently of, mind. We, ciety, the psychasthenic is usually one who is

as physicians, have to deal with human beings harmless, both to himself and to others around

and not with mere collections of separate and about him, but in endeavoring to purge the patho- distinct organs each with existence independent logic associations from such a mind, the physi

of the others. cian is confronted with a Herculean task, and not infrequently is he compelled to accept defeat and

From a clinical point of view then the results

of diffuse cerebral intoxications may be considall that goes with it, due to the fact that neuro

ered together. It is possible to subdivide them pathics, like poets, are born and not made.

into groups which, as they present certain dif

ferences in course, are therefore of practical THE INFECTIVE-EXHAUSTIVE PSY value. Thus Kraepelin speaks of fever deliria, CHOSES*

infection deliria, acute confusion and enfeebleH. DOUGLAS SINGER, M. D., M. R. C. P., ment from infection. The first includes the deDirector, Illinois State Psychopathic Institute.

liria occurring during the febrile reaction to inSpringfield, Ill.

fections and in which the manifestations run The mental disorders grouped under this title

parallel to the fever. It thus would seem that

pal constitute a fairly clear-cut clinical picture with

they are dependent upon autointoxications due to a readily intelligible etiological basis. They

the disordered metabolism of the fever reaction. represent the results of intoxication of brain

The second group includes the so-called “in

itial deliria” met with especial frequency in ty*Symposium on the Exhaustion Diseases, Medical phoid and smallpox. Here the disturbance apSociety of the Missouri Valley, Keokuk, Iowa, March 21,

pears before the characteristic manifestations of

1917.

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