CERTAIN SYMPTOMS 
OF 
NERVOUS EXHAUSTION. 
GEORGE M. BEfVRD, M. D., 
Fellow of the New York Academy of Medicine, Member of the American Neu- 
rological Association, etc. 
(Read before the New York Academy of Medicine, April 4th, 1878.) 
[Reprint from Virginia Medical Monthly, June, iSySl] 
Under tlie term, Neurasthenia, (vsopov, nerve; a, pri- 
vative; and strength (lack of nerve strength), I 
described a number of years ago* a functional nervous 
disease of modern, and largely, though not entirely, of 
American origin. It is a malady that has developed mainly 
during the last half century, although scattering cases ap- 
peared before that time. At present, in the Northern part 
of this country, this disorder is ■ exceedingly frequent, and is 
the cause of much distress; and yet, like many other impor- 
tant and interesting phenomena of the nervous system, it has 
been neglected by the profession, and abandoned utterly to 
tenth-rate popular medical treatises, and the advertisements 
of charlatans. 
Neurasthenia—poverty of nerve force—is to be distinguished 
from simple anaemia—poverty of blood—with which it is fre- 
quently combined; and also from hysteria to which it often 
leads. One may be nervously exhausted without being anae- 
mic. Some of the worst sufferers are full-blooded and fleshy, 
ami of considerable muscular development; indeed, some of 
our noted athletes have been afflicted in this way. 
•:ln a paper read before the New York Medical Journal Association, in 1869, 
and subsequently published in Beard & Rockwell’s Medical and Surgical Elec- 
tricity, first edition. 2 
NERVOUS EXHAUSTION. 
Neurasthenia is also to be distinguished from the numer- 
ous organic diseases with which it is so often, though not 
necessarily, associated. It is a type of a very numerous class 
of functional nervous diseases—that is, diseases, the patholo- 
gy of which cannot be directly studied by the senses, but 
must be reasoned out deductively. The nervously exhausted 
state may, indeed, both follow and precede numerous other 
maladies, not only of the nervous system, but of special or- 
gans, and may accompany other diseases; but it is none the 
less a disorder of itself, and has an array of symptoms pecu- 
liar to itself. 
Electricity in the general and central methods of applica- 
tion, is one of the very best of remedies for this form of ner- 
vous disease; consequently, the cases, so to speak, drift to- 
ward those who use this method of treatment. From the 
first year of my practice, I have seen this class of cases, and 
treated them, and, as the course of treatment is usually some- 
what protracted—at least requiring a number of visits—the 
opportunity afforded me for the investigation of the symp- 
toms and course of the malady in different varieties of con- 
stitutions has been universally good. 
I soon found that the literature of this disease was of little 
worth—in fact, that it had little or no literature at all.* In 
order, therefore, to learn its nature and its symptoms, it was 
necessary to 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 occasional hints from physicians with whom I saw 
the patients in consultation, or by whom they were referred 
to me. 
Some of the symptoms that I shall here describe, are some- 
what familiar to all medical men everywhere; others are fa- 
miliar only to those who give their time chiefly to the ner- 
vous system—and others still are here described for the first 
*Dr. Austin Flint, Sr., in his Practice of Medicine, has a very short chapter on 
“ Nervous Asthenia;” and my own paper was substantially republished in London, 
in Dr. Hugh Campbell’s work on “ Nervous Exhaustion,” with but little addi- 
tional matter. Dr. Weir Mitchell, of Philadelphia, has recently published a clin- 
ical lecture on the subject. Dr. J. S. Jewell, of Chicago, has also discussed the 
subject suggestively, though not systematically, in able review articles, and in a 
contribution to the American series of Clinical Lectures. NERVOUS EXHAUSTION. 
3 
time. Some of these symptoms are of such a positive char- 
acter, and so frequent, as well as peculiar, that they give 
names to diseases, and for convenience sake, are spoken of as 
diseases, although they are but manifestations of the neu- 
rasthenia. I present the symptoms without regard to logical 
order. 
Tenderness of the Scalp.—This is a phenomenon of cerebral 
irritation (Cerebra-asthenia) which is to the head what spinal ir- 
ritation is to the spine. As in spinal irritation, the whole spine 
may he 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 vertebrae; so in cerebral irritation, there 
may be tenderness over the entire scalp; or it may be con- 
fined to the vertex, or to certain points in the forehead. 
Sometimes the scalp is so tender that brushing the hair causes 
pain; even touching the tips of the hair is disagreeable. At 
the vertex, the tenderness is sometimes accompanied by a 
feeling of heat and burning, that may be somewhat relieved 
by firm pressure. This cerebral tenderness, like spinal ten- 
derness, is superficial and peripheral, not deep-seated nor 
central, as some have supposed. It is the tenderness of the 
ramifications of the occipital and other nerves that supply the 
scalp, just as spinal irritation is tenderness of the superficial 
nerves of the bones of the spinal column. 
A frequent spot of tenderness is found over the eyebrow 
and in the left temple. This is found in sick headache, and 
in connection with it, there may be tenderness of the nape of 
the neck. A sudden jar, as when one slips in going down 
stairs, may, in these cases of cerebral irritation, cause tempo- 
rary pain, as though the head itself had been struck. Emo- 
tional 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 analagous 
states, spinal tenderness and general hyperesthesia. 
Tenderness of the Spine {Spinal Irritation, Myelasthenia) 
and of the Whole Body.—When the spine is so tender as 4 
CERTAIN SYMPTOMS OF 
to become an important and permanent affliction, and to 
overshadow other symptoms of the neurasthenic state, it 
is called spinal irritation; but strictly, it is a symptom 
like cerebral irritation not properly a disease as such, al- 
though, as a matter of convenience, there can be no harm 
practically in describing it as a disease. In regard to this 
symptom of nervous exhaustion these points are noticeable: 
First, its great frequency in the higher classes, especially 
among women. I suppose if one should go through Fifth 
Avenue, of Few York city, and examine the spines of all the 
ladies between fifteen and forty-five years of age, he would 
find in quite a percentage of cases, that at times, there would 
be tenderness 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 lumbar vertebrae. 
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 hyperesthesia, like the local hy- 
peresthesia of the spine, appears and disappears under any 
subjective or objective exciting causes, and is attended usually 
by a feeling 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 on 
application of electricity. Many women always have spinal 
irritation during the period of menstruation. 
Greneval or Local Itching.—ltching occurring without any 
visible change in the appearance of the skin, is a common 
experience; but is not regarded as pathological, unless it be 
quite severe and persistent. In certain nervous states, it be- 
comes an element of positive distress. Itching of the scalp 
sometimes immediately follows any prolonged and exhaust- 
ing intellectual exertion. I know a man who was once trou- 
bled with a general prickly feeling all over the body, and was 
sufficiently annoyed thereby to take treatment for it. Cer- 
tain regions of the face, arms and legs may be the local seats 
of itching, which varies with the general condition of the NERVOUS EXHAUSTION. 
5 
nervous system. A lady patient of mine, of neurotic inherit- 
ance and temperament, was liable to terrible attacks of itch- 
ing on a limited region of the arm; which attacks followed 
quickly, almost instantly, after nervous disturbance, and were 
not accompanied by the appearance of prurigo. 
Abnormalities of the /Secretions.—ln nervous exhaustion, the 
eyes may become moistened more readily than in health, and 
under a very slight emotion of pleasure or of pain. The 
flood-gates seem, as it were, to stand ajar, and on trifling agi- 
tation, the tears flow forth. In grave cerebral disease, this 
symptom is common enough, hut in functional disease—sim- 
ple nervous exhaustion—it is even more common. 
In nervous debility, also, the sebaceous glands may refuse 
to do their duty; the hair and heard become dry and stiff, and 
much pomade is needed. The hair then falls off or becomes 
grey in patches. Dryness of the skin in this state is a symp- 
tom familiar to all, likewise is excessive and morbid per- 
spiration in the axilla, or in the hands or feet, or other parts 
of the body. Clamminess of the hands is, in young men, almost 
diagnostic of sexual exhaustion. In this state, also, there 
may be a suppression of the spermatic secretion—so that de- 
sire and power are wanting; with the improvement in nervous 
vigor, the secretion reappears. Likewise frequent and obsti- 
nate constipation of the nervously exhausted is oftentimes a 
result of suppressed intestinal secretion. 
Tenderness of the Teeth and Gums.—Attacks of tenderness 
ot all the teeth, accompanied by a whitish appearance of the 
gums, I have noticed in nervous exhaustion. In these at- 
tacks, which may result from over-work or excess, all the 
teeth may lie very tender on 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 tenderness 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, coccodynia; of the 
breast, irritable mammae; of the ovaries, irritable ovaries; ot 
the teeth, here described, dental irritation; of the womb, 
uterine irritation; of the stomach, nervous dyspepsia; of the 
heart, irritable heart; of the eyes, neurasthenic asthenopia; 6 
CERTAIN SYMPTOMS OF 
of the whole surface of the body, general hyperesthesia; and 
all these various symptoms and expressions, without doubt, 
have a common pathology in nervous exhaustion. 
Vague Pains and Flying Neuralgias.—The so-called “grow- 
ing pains ” in the young are probably of this class; the force 
in the system is insufficient to maintain growth without suf- 
fering a degree of impoverishment which expresses itself by 
a subdued growl of pain. 
Waving, heating, rolling sensations are often felt by the 
neurasthenic, even when not exactly hysterical. Shooting 
neuralgic pains in the limbs, or nearly all parts of the body, 
cause much suffering with this class of patients. Sometimes 
flying neuralgias are confounded with the neuralgia of incipi- 
ent locomotor ataxia, which they, in some respects, resemble, 
but are not as violent, and do not have so much of the boring 
character. 
Flushing and Fidgetiness.—Patients of this class oftentimes 
easily flush and easily faint; the inhibitory action of the sym- 
pathetic is readily interfered with by any slight emotion; 
Fidgetiness and nervousness, inability to keep still—a sensa- 
tion that amounts to pain—is sometimes unspeakably dis- 
tressing. Although it cannot be defined, it may be an accom- 
paniment of growing pains, and is one of the myriad results 
of spinal irritation. Sometimes in writing, the hand and aim 
become so nervous and fidgety, that to continue writing 
would be the severest torture. When the legs feel this way, 
the sufferer must up and walk or run even, though he be de- 
bilitated 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. 
Tremulous and Variahle Pulse and Occasional Palpitations.— 
In the nervous, the rapidity and quality of the pulse-beats 
may vary in many ways during the process of counting. 
Frequently the pulse of the nervously exhausted is compres- 
sible, and almost always it is more rapid than normal* rang- 
ing between 75 and 90, frequently going up to 95 and 100 and 
more. In exceptional instances, nervous exhaustion has a 
very slow pulse, in the neighborhood of 40 or less. 
Sudden Giving Way of General or Special Functions.—The 
treacherousness of nervous exhaustion is one of its most con- NERVOUS EXHAUSTION. 
7 
stant characteristics; its symptoms lurk in ambush and burst 
upon us when least looked for, when we fancy ourselves ut- 
terly and forever delivered from their presence. The neu- 
rasthenic patient cannot, therefore, trust himself a half hour 
or even a moment in advance. In the morning, he may be, 
or feel, able to walk five miles; in the afternoon, from no 
traceable cause, it may be a task to cross the street. Even 
in the midst of any labor—mental or muscular—his strength 
gives out as suddenly as if he were struck by lightning. I 
knew a man prostrated for two years with profound neuras- 
thenia, who, if he rose and crossed the room, might become 
absolutely aphonic. Two ladies have been under my care 
who could walk readily for perhaps a block or more, when 
instantly, and without warning, their legs would give way 
beneath them. 
Special Idiosyncrasies in Regard to Food, Medicine and Exter- 
nal Irritants.—When the nervous system becomes exhausted, 
it is apt to develop various idiosyncrasies not before ob- 
served; some of them are of high interest. Opium, for 
example, is likely to aggravate insomnia in many neurasthenic 
patients, instead of putting them asleep, unless, indeed, very 
large doses are used. Formerly opium was our chief—almost 
our only dependence when we wished to put one asleep. How 
we scarcely think of using it for that purpose in the treat- 
ment of the nervous, except when there is severe pain to be 
relieved. Opium for the nervously exhausted prevents sleep 
almost as much as coffee. So frequent is this idiosyncrasy, 
that were it not for the bromides and cannabis indica and 
electricity, we would be utterly disarmed in the presence of 
these cases. 
In regard to alcohol, some are so susceptible that a drop 
of any form of liquor is instantly and injuriously felt in some 
part of the system. Others, on the other hand, lose all un- 
pleasant susceptibility to alcohol, and can bear it in incredi- 
ble quantities, and may sometimes be profited by it. A lady 
whom I know, had for years been passing through a series of 
symptoms of nervous depression that our most honored ex- 
perts had failed to relieve. One day an ignorant and, I be- 
lieve, irregular practitioner came into her house, and without 
inquiring into her case at all, told her in a rough and author- 8 
CERTAIN SYMPTOMS OF 
itative manner to get the best of claret and drink it freely. 
The chance shot, sent in the dark and without aim, struck 
the very centre of the hull’s eye; the lady bought the best of 
claret, drank it with astonishing freedom, and found that it did 
for her what the best expert skill of our city had failed to do. 
. Coffee often acts badly with these cases. The other day 
a young man, who consulted me for sexual exhaustion with 
nervous dyspepsia, told me if he drank a single cup of coffee 
in the morning he was unable to attend to his business with 
comfort, and could not calculate or write correctly. 
Incidentally, I will remark that the development of idiosyn- 
crasies, through nervous sensitiveness, acquired or inherited, is 
the real philosophy of hay fever—a malady which, as I have 
shown in my work on that subject, has increased as culture 
and civilization have increased, and which is found usually 
in those who have had some other nervous symptoms. As 
an effect of this inherited or acquired nervo-sensitiveness, 
there appears in one person an idiosyncrasy against bright 
sun-light, so that exposure to it brings on the symptoms of 
hay fever; in another, a similar idiosyncrasy as to dust—the 
most common of all the excitants of this disease; in an- 
other, against fresh hay; in another, against ipecac or other 
drugs; in another, against old hay; in another, against the 
odor of roses, or other flowers; in another, against the pol- 
len of corn, or of some of the grasses, or of certain weeds or 
Roman wormwood, or golden rod; in another, against some 
one of the common fruits—as grapes, apples, pears or 
peaches, or strawberries, or raspberries, or watermelons; and 
so on infinitely—new developments appearing every year. 
On this theory, I based the nerve treatment of hay fever, and 
predicted that by means of electricity, strychnine, arsenic and 
other sedative and tonic remedies, we should be able to 
greatly relieve and break up this distressing disorder. Last 
year this prediction was fulfilled not only in my own practice, 
but also in that of other physicians.* 
Another idiosyncrasy developed by nervous exhaustion is 
sensitiveness to cold or hot water. A patient of mine could 
never bear to even dip his hands in hot water, so disagreea- 
*Hay fever regularly decreases as we go South. In the Gulf States it is com- 
paratively rare, although it is found here and there in every State. In this re- 
spect also, it follows the analogy of other nervous diseases to which it is allied. NERVOUS EXHAUSTION. 
9 
ble were the sensations it produced; the same patient was 
abnormally ticklish and timid. 
Dr. Harris, in a recent article on functional nervous trou- 
bles,* relates a case of a man of middle life, who, on getting 
up in the morning, would feel entirely well; but as soon as 
he had washed and wiped his hands they would begin to 
burn, tingle and ache very much, as when brought near the 
fire after exposure to snow. After a few seconds, they 
would begin to swell, and would continue to swell for five or 
ten minutes to such a degree that he could not close or use 
them. In the course of an hour or more the swelling would 
go down, but would recur whenever he rubbed his hands. 
The phenomena disappeared in a week without treatment. 
Sensitiveness to Changes in the Weather is a very often ob- 
served symptom of nervous debility; depression of the nerves 
makes the body a good barometer. For twenty-four hours 
and more before a storm comes on, the aching and worn 
nerves foretell in every part of the physical organism what is 
coming. The sky may be clear, but the spirits are cloudy. 
The tenderness of bunions and corns, the aching and stiff- 
ness of rheumatic and neuralgic sufferers, the general gloomi- 
ness and misery of the exhausted before and during bad 
weather are not imaginations, but realities as truly as small- 
pox or the measles, and quite as much worthy of professional 
study and consideration. 
Patients of this class are oftentimes made profoundly worse 
by the depressing atmosphere of dog days, and generally by 
the extreme heat of our summers. The latter half of Au- 
gust is especially severe on these cases. 
A Feeling of Profound Exhaustion Unaccompanied by Posi- 
tive Pain.—Attacks of a sensation of absolute exhaustion, as 
though the body had not strength to hold together, comes 
on very often in the nervously exhausted. This feeling of 
exhaustion, though not exactly pain in the usual sense of 
the word, is yet, in many cases, far worse than pain. These 
attacks may come on suddenly without warning, and may 
suddenly disappear. In the morning, one may be able, or 
*St. Louis Medical and Surgical Journal, April, 1878. Dr. Harris assumes 
hat many of the cases that he relates are of exclusively malarial origin, and that 
tsuch symptoms are only seen in malarial regions. In this supposition he is 
quite in error. 10 
CERTAIN SYMPTOMS OP 
feel able, to run on a wager; in the afternoon of the same 
day sitting quietly in a chair seems to be an exhausting ef- 
fort to which every nerve and bone and muscle is unequal. 
The going-to-die feeling is quite common in these cases, and 
at first causes alarm. It may be experienced either in the 
day or at night, on going to sleep, or on awaking from sleep. 
This symptom, like many of these symptoms, appears at pu- 
berty and at the change of life; it indicates that the system 
is straining under the burden placed upon it. 
Ticldishness.—hi early all persons are susceptible to the form 
of irritation that we call tickling; but in nervous exhaustion 
this susceptibility may become a severe annoyance. A gen- 
tleman once under my treatment for many of the symptoms 
described in this paper—spinal irritation being prominent— 
was so ticklish on the breast, stomach and abdomen, that it 
was very difficult—indeed, quite impossible—to apply elec- 
tricity to those parts with any satisfaction. 
Desire for Stimulants and Narcotics.—When the nervous sys- 
tem loses, through any cause, much of its nervous 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 temporarily propping 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 phi- 
losophy of many cases of opium or alcohol inebriety. 
Hot only for the relief of pain, but for the relief of ex- 
haustion, deeper and more distressing than pain, do both 
men and women resort to the drug shop. I count this as one 
of the great causes of the recent increase of opium and al- 
cohol inebriety among women. Frequently an inherited ten- 
dency to inebriety is utterly latent, and does not break out un- 
til affliction, or some form of worry or distress, robs the brain 
of its nerve force. Very many cases illustrative of this have 
been published by my friend, Dr. T. D. Crothers, now super- 
intendent of the Walnut Hill Asylum for Inebriates, Hart- 
ford, Conn. 
Insomnia.—The wakefulness of the nervous is a symptom 
at once common and distressing, and is sometimes rebellious 
to all our bromides, and even to chloral. Sometimes it is the NERVOUS EXHAUSTION. 
11 
very first symptom of nervous disturbance, expressive of a 
mild phase of difficulty, and disappearing as the disease gets 
worse. In other cases, it is constant and obstinate from first 
to last. This symptom may yield to electricity when other 
medication has no power. 
Nervous Dyspepsia (.Dyspepsie Asthenique).—lt is one of the 
peculiarities of nervous dyspepsia that it abhors a vacuum; is 
always much worse when the stomach is nearly or quite 
empty. Patients so afflicted need to take light meals, and to 
take them frequently—perhaps very many times daily. 
In cases—not a few—nervous dyspepsia is the first noticea- 
ble symptom of nervous exhaustion—the earliest sign that the 
body is giving way; and for years, the stomach may be func- 
tionally disordered before the brain, or spinal cord, or other 
parts or organs show signs of yielding; hence the quite com- 
mon belief that dyspepsia leads to softening of the brain. The 
true philosophy is that nervous dyspepsia is a symptom of the 
same general pathological condition as all the orders of symp- 
toms here noted, and it may follow as well as lead this multitu- 
dinous army. A literary gentleman whom I once met gave a 
history of nervous exhaustion from over-confinement, that after 
some years broke out through the pneumogastric nerve, caus- 
ing profound and obstinate dyspepsia that for a long time 
made him a complete invalid; the symptoms were almost as 
bad as those of cancer of the stomach, and yet the disturb- 
ance was entirely functional, and the patient improved. 
Flatulence with annoying rumbling in the bowels, these pa- 
tients complain of very frequently; also nausea and diar- 
rhoea. 
Partial Failure of Memory.—Memory is a measure of mind. 
When rightly studied, it is perhaps the most delicate of all 
neurometers or indicators of the nervous force in health and in 
disease. With the growth of the brain in childhood, mem- 
ory grows, and it declines with the slow decay of normal old 
age. Partial failure or treacherousness of memory is not 
not only a sign, but in some cases, one of the very first signs 
of exhaustion of the nervous system. Business men find 
that they cannot depend on their memories as formerly ; they 
forget details of engagements—sometimes those of impor- 
tance—and thus are variously inconvenienced. 12 
CERTAIN SYMPTOMS OF 
Sexual Exhaustion, or that form of nervous exhaustion 
that is noticed in young men who oyen-excite or over-use the 
genital function, in the natural or unnatural way, is usually, 
if not always, accompanied by failure of memory; but other 
forms of nervous exhaustion in both sexes, offer the same 
symptom. 
Deficient Mental Control.—lnability to concentrate the in- 
tellect on any task, as in writing or thinking, is a notable 
symptom. The mind wanders away in every direction, and 
when brought back by an effort of the will, is liable to be soon 
again lost in reverie. 
In some eases, the exercise of concentration, or even slight 
attention, is exceedingly irksome and painful, causing dis- 
tress sometimes in the head, sometimes in the back or ex- 
tremities, or other parts of the body. 
Seminal Emissions—Partial or Complete Impotence.—Occa- 
sional seminal emissions in the healthy and unmarried are phy- 
siological—that is, they are not symptoms of disease, but nor- 
mal and necessary results of abstaining from sexual intercourse. 
Such involuntary discharges, when excessively frequent, are 
both results and causes of disease, indicating an abnormal, 
usually an exhausted state of the nervous system, and in turn 
re-acting on the nervous increasing the very exhaus- 
tion that causes it. Such, in general, is the philosophy of all, 
or nearly all, cases of frequent involuntary seminal emissions. 
An attack of acute disease of any kind may leave the sys- 
tem, during convalescence, in a state where seminal dis- 
charges may take place with far greater than the normal fre- 
quency; on return to health, this symptom, with all other 
symptoms of debility, disappears. 
Chronic neurasthenia is often accompanied, as one of its 
symptoms, by seminal emissions, even in those who are mar- 
ried; indeed, some of the most persistent cases I have seen 
have been in married men. 
Impotence—partial or absolute—when it appears as an ef- 
fect of neurasthenia, as it frequently does, usually recovers 
with the improvement in the nerves, sometimes without spe- 
cial treatment. 
Changes in the Expression of the Eyes and Countenance.—• 
In sexual exhaustion, downcastness of the features, aversion NERVOUS EXHAUSTION. 
of the eyes, and general sheepiness of manner, with dark cir- 
cles beneath the eyes, are symptoms that have long been ob- 
scured, but these signs, taken individually, are not pathog- 
nomonic of any special form of nervous exhaustion, since 
they appear in nervous and digestive debility, however 
caused. It is, however, undeniable that these symptoms, in 
their entirety, do occur very frequently in the debility asso- 
ciated with sexual disorder, and may, perhaps, be set down 
as distinctive of that form of nerve disorder. 
The mere expression of the eye is modified by disease in a 
way that it is hard to analyze or describe. How a night’s de- 
bauch affects the expression is well known," In chronic ner- 
vous exhaustion from any cause or combination of causes, 
this expression of debility may become chronic—a perma- 
nent state that is revealed at once on meeting and addressing 
the sufferer. 
A lady whom I once treated for numerous nerve difficul- 
ties, and who entirely recovered, told me that as she got bet- 
ter the whites of her eyes were of a clearer blue, and conse- 
quently, to her delight, more attractive. This fact was ob- 
served by several of her friends as well as myself. 
Mental Depression with General Timidity.—ln disease, as 
in health, fear is one of the symptoms of weakness—an emo- 
tion with wdiich the instinct of self-preservation environs 
every form of incapacity. 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 
efforts that require much vital expenditure. In that form of 
nervous exhaustion known as sexual exhaustion, senseless 
timidity is one of the diagnostic features; fear of society, fear 
of the indefinite future, unwillingness to enter upon any en- 
terprise, inability to look one squarely in the face, downheart- 
edness and indefinite distrust. Patients of this kind will walk 
up and down before a physician’s office many times before ven- 
turing to enter. This timidity becomes a serious matter in busi- 
ness, making success very difficult. One of my patients trou- 
bled with cerebral exhaustion, of very large wealth, and great 
business experience, tells me that, desiring once to borrow, on 14 
CERTAIN SYMPTOMS OF 
perfect security, some money for a certain business purpose, 
he walked several times up and down the front of the office 
of the capitalist whose aid he sought, before he could sum- 
mon the strength to go in. 
The mental depression of the nervously exhausted is 
largely independent of external conditions, although it may 
be aggravated by them—especially by bad weather; a cer- 
tain amount of blood and nerve force is needed for happiness. 
A very eminent theologian and preacher, who consulted 
me three or four years ago, told me that when he had charge 
of a parish, the responsibility of sitting in his pulpit and lis- 
tening to a travelling agent, exhausted him more than preach- 
ing himself, for the reason that he continually feared that the 
stranger would say or do some indiscreet thing. 
Responsibility of any kind, without any labor, even when 
unconscious, may powerfully affect the system, and in various 
ways. Thus a young man whom I knew, who was badly 
troubled with seminal losses, causing great nervous exhaus 
tion, resolved to try the woman cure, and made regular ap- 
pointments with a lady friend. It was a new experience for 
him, and he professed to have no pleasure in the sexual act, 
and felt somewhat timid and distrustful about the matter. 
The consequence was that the responsibility of meeting his 
appointment would always cause him to have free pas- 
sages from the bowels, although generally he was very con- 
stipated. 
Morbid Fear of Special Kinds {Agoraphobia and Astraphohia). 
Fear of leaving home, of going out of the house, of going 
anywhere alone, of crossing a ferry, of crossing an open 
square, of going through a narrow alley, of going away from 
the neighborhood of shops or open places of refuge, are some 
of the phases that this symptom develops. This symptom is 
not very common, but when it, does occur, it is very annoy- 
ing and. sometimes quite obstinate. It is a ludicrous and ab- 
surd symptom, but it may occur in persons of intelligence and 
ability and good sense. It is analogous in some respects to 
the utter helplessness that some experience when standing on 
an elevation; the will is put to rout completely, and cannot 
rally at the call of reason. NERVOUS EXHAUSTION. 
15 
I was consulted not long ago by a physician, who was so 
harassed by this symptom of nervous exhaustion that he was 
unable to attend to his practice. His physical strength was 
sufficient, but on account of the agoraphobia, he could not 
go any distance from his office with any comfort. He would 
be working in his garden, but when requested to go a mile, 
or even less, to see a patient, he could not respond. On 
walking out with him one morning, I observed that he turned 
the corners often so as to keep about such a distance from 
the hotel, where he was stopping. Under electrical and 
other treatment, the physician is improving, and is attending 
to his profession. 
Hr. C. L. Mitchell tells me of a gentleman who was so 
badly agoraphobic that he was unable to leave his house, 
without'company, and accordingly he paid a man $20,000 to 
be his constant companion. There have been men who, by 
this symptom, have been kept as close prisoners as though 
within tire walls of a penitentiary. In some instances, though 
not in all, this strange symptom seems to be traceable di- 
rectly to sexual excess of some kind. 
Sometimes very bad cases of this malady entirely recover. 
I have known three persons who were unable to cross the 
Brooklyn Ferry, and all got well in a few weeks or months. 
My friend, Hr. H. E. Smith, of Bronxville, H. Y., tells 
me of a lady who is unable to cross Harlem river on the 
cars, and consequently cannot visit Hew York city. 
I have now under my care a lady in whom the agorapho- 
bia takes the form of inability to go to church. It was in 
church that she was first taken with a peculiar and hard-to- 
be-described lightness of the head; and she 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 electrical treatment, he 
recovered. 
The term astraphobia, or fear of lightning, I have applied 
to that form of nervousness that is painfully affected before 
and during thunder storms. Headaches, neuralgias of va- 
rious kinds, depression, spasms, are some of the symptoms 16 
CERTAIN SYMPTOMS OF 
of this state, which, in gome instances, is hereditary, and runs 
in families.* 
Fear of Society is a phase of morbid fear that is common 
enough in all forms of nervous exhaustion, hut is, perhaps, 
most often noticed in sexual complications. With fear, 
blushing of a senseless but overpowering. character is often 
combined; the victims are ashamed to enter the presence of 
ladies—-to enter the presence of any one; .they cannot look 
any one in the face, but in conversation keep their eyes 
turned down or aside. 
Sick Headache and Various Forms of Head Pain.—-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 headaches 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 shak- 
ing 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. Rarely, or never, do young children 
have it, and it usually stops before old age. It is a symptom 
that belongs to the perturbable and active years, and may 
quickly show itself when, from any cause, the nervous sys- 
tem is depleted of its force. 
Pain 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 con- 
gested ; 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 complaint; also a symptom usually defined 
as “ I cannot tell how I feel.” 
Here I may remark that very much has been said, is now 
said, and for a long time probably will continue to be said of 
*Beard & Rockwell’s Medical and Surgical Electricity, 2d ed., p. 456. NERVOUS EXHAUSTION. 
17 
circulatory disturbances as the pathology of all these and kin- 
dred symptoms; and when such a symptom is declared to de- 
pend on cerebral or spinal anaemia or hypersemia, it is sup- 
posed that we have solved all the problems that relate to it. 
For a number of years, I have been contending that circula- 
tion is a result of innervation. The brain and spinal cord, im- 
poverished of nerve force, are unable to maintain the balance 
of the ebb and How of the blood of the arteries and veins; con- 
sequently anaemias and congestions arise that may be tran- 
sient or more or less permanent. But the disease is not the 
anaemia nor the hyperaemia (although both anaemia and hy- 
peraemia, when they occur, may and do induce certain symp- 
toms peculiar to themselves); but it is the neurasthenia— 
the nervous exhaustion, the decline in the quantity or quality 
of nerve force—that presides over the circulation, although 
it cannot, like the blood, be weighed, measured, analyzed or 
studied under the microscope. This view, though scarcely 
listened to, and not at all understood, when first pressed, is 
now slowly gaining its way among the neurologists, both of 
Europe and America. 
There may be anaemia of the nerve-centres without ex- 
haustion, as after haemorrhages; and there may be sudden 
congestion of the spinal cord, from taking cold, or of the 
brain from various causes—but these are not the conditions 
of which lam here speaking. They occur in those who are 
not nervously exhausted; indeed, congestions are more likely 
to occur in the plethoric and strong; they come rather under 
the head of acute and traumatic disorders. 
Disturbances of the Nerves and Organs of Special Sense.— 
Nervous exhaustion often causes dilatation of the pupils— 
sometimes dilatation of one pupil and contraction of the 
other. These conditions are temporary and changing—not 
permanent—as in certain organic diseases. 
Another malady of the eye is what I may call neurasthenic 
asthenopia, or the irritable eye, from nervous exhaustion, 
not depending on any muscular or accommodative trouble, 
but symptomatic purely, revealing nothing to the ophthalmo- 
scope or other tests of modern ophthalmology, but none the 
less painful, distressing and sometimes exceedingly obstinate. 18 
CERTAIN SYMPTOMS OF 
This disease of the eye, symptomatic of nervous exhaustion, 
I observed and called attention to a number of years ago, but 
could find no formal recognition of it in the standard text- 
books of ophthalmology. But, very recently, Dr. Mathewson, 
in conversation on the subject, tells me that this third form 
of asthenopia is now, under various names, coming into re- 
cognition in the journals and societies devoted to diseases of 
the eye. 
An attack of this neurasthenic asthenopia—which is oft- 
times so severe that reading or writing, or sewing, are ac- 
complished only with great pain, and the eyes are painful and 
tender on pressure even when not used—an attack of this 
kind may last half an hour, or three hours, or three months; 
and, like analogous states in other parts of the body, with 
which it is often accompanied, may come and go very sud- 
denly. In looking at the eye when in one of these attacks, 
we observe often a passively-congested state of the conjunc- 
tiva. 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 pathology of cerebral 
irritation, of spinal irritation, of irritation of the mammae, 
the ovaries and testes, and of sick headache and many other 
forms of neuralgia. The notion which has been advocated— 
that this neurasthenic asthenopia, or irritable eye, is peculiar 
to women, and always reflected from the uterus, and there- 
fore to be called uterine asthenopia, is but an adumbra- 
tion 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 ophthalmology. This form of eye weakness is 
quite susceptible to the influence of psychical contagion. A 
number of years ago it spread through many of the colleges 
and seminaries of the country—in some instances compel- 
ling young men to abandon their plans of liberal education. 
Muscce Volitantes, or floating specks before the eyes, often an- 
noy even the slightly nervously exhausted; in these cases, the 
ophthalmoscope is only of negative assistance. Under excit- 
ing causes, the specks suddenly appear and disappear. The 
liability to them may be a habit of one’s life. NERVOUS EXHAUSTION. 
19 
Noises in the Ears in the shape of sudden explosions or pulsa- 
tions, to say nothing of other varieties of tinnitus auriurn, are 
quite common in cerebral exhaustion, especially when attended 
with congestion. These explosions 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 it appears. A feeling of 
fulness and oppression in the head sometimes attend these 
symptoms. Subjective odors of various kinds—as of ozone or 
phosphorous; also abnormal subjective tastes—hitter or sour; 
likewise fleeting symptoms of cerebral exhaustion are ob- 
served. 
Localized Peripheral Numbness and Ilypercesthesia.—ln any 
portion of the periphery—the face, the arms, the ends of the 
fingers, the thighs, the legs and the toes—there may be, in 
nervously exhausted patients, persistent numbness of a defi- 
nitely localized character, or excessive sensibility, similarly 
localized. In some cases, this local peripheral hyperesthesia 
amounts to a very distressing disease. I was once consulted 
by a physician who had hyperesthesia of the left hand, caused 
apparently by local injury acting on a nervous diathesis. The 
condition was very obstinate, and caused much distress. I 
once had under my care a lawyer who had a burning feeling 
in the thumb and fingers of the right hand, with pain some- 
times running up the arm. At first I suspected that the 
symptoms were premonitory of writer’s cramp. The patient 
went to Europe and took various treatments under the direct 
tion of Charcot and other neurologists without important 
benefit; but is now able to pursue the routine of his profes- 
sion. I have now under my care a gentleman who has had, for 
a long time, a sensation of numbness and burning at the ends 
of his thumbs, at the bottom of the heels, and around the 
legs and ankles. These symptoms are accompanied by the 
usual symptoms of cerebral exhaustion and congestion—pain 
in the head, a feeling of fulness and pressure, and mental de- 
pression. Sometimes there are flying, stinging, pricking 
sensations in the feet and legs, that caused one European 
physician to make the diagnosis of “flying gout.” With hy- 
giene and electrical treatment, this patient has improved in CERTAIN SYMPTOMS OP 
a manner most encouraging; and what is of chief interest just 
here, the improvement in the peripheral symptoms has ex- 
actly kept pace with the improvement in the brain symptoms, 
showing their common nature. 
Symptoms of this kind excite fear and dread—oftentimes 
as indicating grave and structural brain disease, or as pre- 
monitory of apoplexy; but in the majority of cases, they are 
the results and signs of functional—not structural trouble, 
and occur in people who live to old age. 
I have seen a number of cases where there was numbness 
on a limited area of the thigh, and all have recovered or per- 
manently improved without a very bad history. 
Among other special symptoms coming under this head, I 
may mention a crawling or creeping as of insects just beneath 
the skin—a sensation as though a pin or many pins were just 
touched to the skin; a tendency for the legs and arms to “go 
to sleep/’ under far slighter pressure than in the normal state 
of health, is observed in cases of this class. Sitting a very 
short time in a hard chair, riding in an omnibus, or car or 
carriage may cause the foot to get asleep, when, in entire 
health, no such effect would have been produced by the same 
cause. 
I have now under my treatment a man who often wakes 
up at night with a strong but transient sensation of numb- 
ness in the little finger and inner side of the third finger, 
confined to the track of the ulnar nerve. In other cases, 
other nerves of the arm may be involved, and all the fingers 
may be numb. Kumbness of this kind usually goes away 
after a little shaking and rubbing. It is more likely to come 
on at night from lying on the arm; but in the daytime, also, 
it may occur when the arm rests for a few moments over the 
back of a chair. When one is specially exhausted or wor- 
ried from any cause, this transient and local numbness is 
more likely to show itself. The pathology of this state is 
probably, if not certainly, an obstruction in the passage of 
the nerve force through mechanical pressure. In the highest 
health, sufficient pressure will produce this condition, and if 
the pressure be kept up, permanent paralysis may occur; but 
in nervous exhaustion, when the nerve force moves slowly 
and with very little vis a ter go, much slighter pressure suffices NERVOUS EXHAUSTION. 
21 
to obstruct its passage-—just as water, flowing slowly through 
a rubber tube, can be checked by a gentle touch of the An- 
ger, but if flowing rapidly and with great force, needs a stop- 
cock. 
Greneral and Local Chills and Flashes af Heat.—-Disturbance 
of circulation both follows and accompanies disturbance of 
innervation. Creeping chills up and down the spine are 
commonplace; but there are symptoms allied to this not so 
familiar. Thus Dr. J. H. Sterling had under his treatment, 
at one time, a lady whose knees were literally as cold as ice— 
that is, they felt to her as cold as though they were packed 
in ice. I knew of a case where there were limited and small 
areas of heat and cold sensations on the arms. I have also 
known cases where the ankles were cold, even when other 
parts of the body were comfortable. After fatigue or worry, 
the penis and scrotum, as well as the ears, or one ear, and 
one foot or both feet, and one hand or both hands, may be 
cold to the touch—even in warm weather, and in a hot room, 
or when thickly wrapped up. Patients in this state are, in- 
deed, like Harry Gill, very, very cold, no matter what they 
put on; the skin may be almost blistered, as they stand near 
the fire, and yet chills are running all over them. 
Long writing, which may produce symptoms of writer’s 
cramp in others, may, in the nervously exhausted person, 
cause coldness of the fingers, hand or arm, especially when 
the arm is elevated. Yet more minutely may this symptom 
of coldness be localized; spots as small as the point of a pin 
apparently—especially on the face—may be pinchingly or 
stingingly cold—this sensation quickly appearing and quickly 
disappearing. 
Local Spasms of Muscles,—'What are called “ fibrillary con- 
tractions,” and which sometimes occur in progressive mus- 
cular atrophy, are also noticed in the various shades of ner- 
vous exhaustion. An individual muscle or part of a muscle 
may twitch occasionally or frequently, so as to cause consid- 
erable annoyance, and in some cases, unnecessary anxiety. 
As these vibrations occur in the orbicularis, and other mus- 
cles of the face, these spasms are very familiar; they come 
and leave without warning, and suddenly. I was once con- 
versing on nervous diseases with a well known physician, CERTAIN SYMPTOMS OP 
when, all at once, the orbicularis of one of his eyes began to 
twitch vigorously; he said it was the first time in his life that 
he had experienced anything of the kind; he regarded the 
use of tobacco as the probable cause. 
The stomach, in nervous dyspepsia, may be the seat of sim- 
ilar spasms, which may follow any excitement or emotion, as 
of fear or responsibility. A sensation like that of a reverse 
aura seems to go downward to the pit of the stomach from 
the nerve centres, and excites spasm, apparently, of the mus- 
cles of the stomach itself. 
I close with these suggestions: 
First.—The above detailed symptoms are not imaginary, 
but real; not trifling, but serious; although not usually dan- 
gerous. In strictness, nothing in disease can be imaginary. 
If I bring on pain by worrying, by dwelling upon myself, 
that pain is as real as though it were brought on by an ob- 
jective influence. Modern science is built up in a degree by 
observations of phenomena that all the ancient and medieval 
world regarded as beneath observation. Is not the observing 
and right interpreting of subtle, obscure, elusive and out-of- 
the-way phenomena of disease the best test of scientific skill ? 
Secondly.—These symptoms of nervous exhaustion are, in 
a measure, interchangeable—antagonistic to each other—and 
nervous exhaustion is itself antagonistic to many other dis- 
eases—especially of the acute and inflammatory sort. Dis- 
eases prevent disease ; diseases cure disease; diseases are an- 
tidotes to disease. Sufferers from chronic neurasthenia are 
safer in the midst of epidemics than others are; they are not 
subject, as are the robust and full-blooded, to violent and fa- 
tal fevers; and when attacked, they are more likely to sur- 
vive. To this numerous class of sufferers, it is, then, a conso- 
lation that their disease is itself medicine and hygiene. 
Opium-eaters, I am told, are comparatively exempt from ma- 
laria, and in the East pass unharmed through the epidemics 
of cholera. 
Likewise alcohol inebriates do not usually suffer from ordi- 
nary nervous exhaustion. Excesses of any kind that injure 
us in one way may save us from being injured in other ways. 
Alcohol seems to act as as internal counter-irritation. 
The interchangeableness of these symptoms is also note- NERVOUS EXHAUSTION. 
23 
worthy. In nervous exhaustion, nothing is constant except 
inconstancy. The symptoms chase each other like the 
shadows of summer clouds across the landscape. The mo- 
ment one leaves, another and several stand ready to take 
their place. In a single day, one may go through the whole 
gamut of all these notes of disease. 
Thirdly.—The periodical and rhythmical character of some 
of these symptoms is of much interest. 
While this paper is being revised, I have been consulted 
by a clergyman of middle life, who, with many other symp- 
toms of neurasthenia, is troubled with attacks of special and pe- 
culiar depression, lasting for about a day, more or less. These 
attacks are ushered in usually by a feeling of mental exalta- 
tion ; then come diplopia, with other abnormal phenomena 
of vision, and so on through quite a regular series of nervous 
symptoms. Prostration from heat was the original cause of 
the attacks, which are now brought on by any mental or phy- 
sical exhausting or disturbing influence. The patient finds 
that a drop or two of belladonna taken during the stage of 
exaltation will always break up the attack, and now he 
always carries a bottle of that remedy in his pocket. I once 
had under treatment a young man who had attacks of ner- 
vous depression every day about noon ; they lasted but for a 
short time, but were as periodic as chills and fever—and like 
chills, and like the preceding case, passed through definite 
stages. 
Fourthly.—Ferrous exhaustion is compatible with the ap- 
pearance of perfect health. 
For this reason, as well as on account of the slippery, fleet- 
ing and vague return of their symptoms, patients of this 
class get hut trifling sympathy. Sometimes they are fat and 
hearty, and have a ruddy, vigorous, strength-suggestive bear- 
ing ; sometimes also they grow fatter as they grow worse. 
Foticeably the disappearance of symptoms in the stomach, 
and the appearance in their stead of symptoms in the brain 
and spinal cord, is followed by increase in weight that de- 
ceives the friend, the physician, and even the patient himself. 
Thus it happens that patients get the least sympathy when 
they most need it. 
F our years since, a prominent politician consulted me for 24 
CERTAIN SYMPTOMS OF NERVOUS EXHAUSTION 
a medley of nervous symptoms induced by sunstroke—a not 
uncommon cause of neurasthenia. He was an enormous, 
herculean man, but gave a history that would well have be- 
fitted the most delicate and hysterical woman. 
Fifthly.—Nervous exhaustion is a modern disease, and pre- 
eminently an American disease, and in this country is chiefly 
found in the North and East. This disease must, therefore, 
be studied here; we cannot, as in so many other diseases, 
look to Germany for light and information—for in Germany 
this condition is comparatively unknown, and in France and 
England is far more rare than with us. It is a disease al- 
most exclusively of the well-to-do classes, and can, therefore, 
be satisfactorily studied only in private practice. Medical 
treatises founded entirely on hospital and dispensary expe- 
rience are of little service to those who desire guidance in the 
analysis of this or of kindred disorders. 
Sixthly.—The treatment of nervous exhaustion should be 
in general of a sedative and tonic character; should not be 
exclusively applied to any one of these special symptoms, 
but to the whole condition—to the main trunk and not to 
the separate branches. Electricity in central and general 
applications with both currents, varied and abundant food, 
passive exercise, as massage, in some cases, absolute rest 
iu bed, in others, mild, active exercise, and the judicious use 
of such remedies as relate to the nerve-centres, counter- 
irritation by very small blisters, or the actual cautery, dry 
cold to the urethra through the cooling catheter, for the special 
form known as sexual exhaustion; fats, fish and phosphates 
of various kinds—and internally, cannabis indica in small 
doses, combined with the bromides, strychnine, of course, 
with calabar bean, the preparations of zinc and arsenic, gel- 
seminum and bromohydrie acid, caffein, malt and oil—under 
this system of treatment, adapted with care and study for in- 
dividualid iosyncrasjes, and combined with right hygiene, the 
majority of cases of neurasthenia can be permanently relieved, 
if not substantially cured.