Neurasthenia in Young Women BY HENRY B. DEALE, M.D. AND S. 8. ADAMS, M.D. Washington D. C. UPIIKTKD rftOM The American Journal or Obstetrics VoLXXIX. No. 3, ISM. NEW YORK WILLIAM WOOD * COMPANY, PUBLISHERS 1894 NEURASTHENIA IN YOUNG WOMEN.1 Tub topic we have selected for discussion this evening is one well worthy the consideration of the members of such a society. Not that it may be considered a disease belonging only to the gynecologist, but because cases of this nature are so frequently wrongly referred to the specialist for his care. Neurasthenia, in the vast majority of instances, is a disease that belongs to the general practitioner; though, due to a very prevalent belief that nervous troubles occurring in young wo- men depend generally upon some derangement of the organs of generation, the other causes being obscure, all symptoms are re- ferred to the uterus and ovaries and she is sent to a gynecologist. The disease as now recognized and named is a comparatively new one, Beard in 1868 first having formulated a train of symp- toms and grouped them under the name of neurasthenia. He considered it distinctly a disease of this country, hence it was also called the American disease, though this idea is scarcely upheld by subsequent experience. The most comprehensive definition of neurasthenia is that advanced by Bouveret, who defines it as a “disease of the nervous system, without organic lesion, which may attack any or all parts of the system, and characterized by enfeeblement of the nervous force, which may have all degrees of severity, from slight loosening of these forces down to profound and general prostration.” The line of demar- cation in this disease between hysteria on the one hand and melancholia on the other is indeed a fine one. Some consider both as phases of it, though this is hardly probable. Neuras- thenia may occur in both sexes and at all ages, but we have re- stricted ourselves to a consideration of the disease as it is mani- fested in young women. Many theories as to the causes of this condition have been 1 Read before the Washington Obstetrical and Gynecological Society. 2 DEALE AND ADAMS: NEURASTHENIA IN YOUNG WOMEN. advanced. A reflex cause, due to some derangement of some non- nervous organ, may probably produce a condition that simulates, at least to a great degree, neurasthenia, and which, under proper attention to this derangement of the organ or organs, may be entirely relieved. Whether this is neurasthenia, or merely a nervous state due to an exciting cause and depending on it, is certainly an open question, though I do not consider it a pure and simple neurasthenia. Another cause of this condition is one whose recognition we owe to the physiological chemist— namely, malnutrition and malexcretion, a comparatively new phase in medical etiology, but one full of interest and fascina- tion. Aitkin says “ that the healthy living organism may be- come poisoned, gradually and more or less slowly, by the accu- mulation within itself of deleterious substances normally elabo- rated.” This is now universally recognized as possible, and this accumulation may exert nearly its entire virulence upon the nerve cells and thereby cause a neurasthenic condition. That heredity is a ruling factor in the causation of this condi- tion cannot be doubted. Not that we inherit the condition itself, but we receive as a legacy a weakened nervous force, with less resistance and buoyancy than mark a normal state. It is, as in all physical inheritances, merely a tendency, sufficient probably for an ordinarily varied existence, but incapable of great excite- ment or an unvaried, humdrum life. This weakened nervous tendency inherited by a young girl or woman harassed by the ambitions of school life or social excitements, or annoyed with household and family cares (probably a dull monotony at best), all occurring early in a time of life when the entire organism, nervous as well as physical, is undergoing a great strain—all this seems sufficient to account for the nervous depression or exhaus- tion that so frequently results. May we not frequently attribute this neurasthenic condition to these simple every-day experiences rather than seek for some vague reflex or obscure chemical cause? Certainly these flrst should be investigated, trivial as they may seem. The symptomatology of neurasthenia is as varied as its occur- rence. No set of symptoms can be given as universal, the only positive feature being an utter collapse of the nervous as well as the physical energy, to that degree that one is incapacitated for all forms of mental and physical exertion. This may be ac- companied with sleeplessness, excitation of one or all the special DEALE AND ADAMS: NEURASTHENIA IN YOUNG WOMEN. 3 senses, constipation, and probably atonic dyspepsia. Each case is a law unto itself, and each presents its own characteristic symp- toms, some more, some less. This brief and very imperfect introduction to the discussion of this most important and at the same time obscure condition is presented with the hope that something new may be elicited from the observation of some of our members whose personal experience has afforded greater opportunities for its study. Diagnosis.—It is of the greatest importance to differentiate neurasthenia from the functional and organic diseases of the brain and spinal cord. This at first might seem to be an easy task; but when we consider that very many of the prominent symptoms of neurasthenia are also common to many of the principal organic changes in the brain and cord, it becomes more difficult. The diagnosis cannot be made from any one symptom, but from the history of the case, the etiological fac- tors, and the group of phenomena common to the neuroses which it simulates. The object of this paper is to confine the subject to unmar- ried women under 25 years of age, and to exclude all cases which require surgical interference. As the period from puberty to the twenty-fifth year, with its anatomical and physiological transformations and evolutions, is the time of greatest fertility and fecundity, so is it also the period of hyperexcitability in the function of the nervous organization of young women. The importance of a correct diagnosis is still further demanded to prevent unnecessary examinations and manipulations, to trans- form a mental sufferer into a hopeful invalid, or to guard against self-injury by reassurances of a certain, if not a speedy, cure. The symptoms of neurasthenia are changeable in char- acter, location, and intensity, and are continually recurring with- out any apparent provocation. They are seldom found in those diseases characterized by definite pathological alterations, but are the result of imagination, as formication, blushing, hot and cold flushes, nausea, vomiting after eating certain foods, hyper- esthesia of the scalp, headache, irregularity and intermittence of the pulse without cardiac lesion, insomnia, restlessness, aver- sion to certain persons and things, fear of bodily harm, an un- controllable desire for stimulants and narcotics, and the con- stant dread of becoming a hopeless invalid, perhaps to be con- signed to a hospital or an insane asylum. 4 DEALE AND ADAMS : NEURASTHENIA IN YOUNG WOMEN. In organic disease of the brain and cord the reflexes are decreased, while in neurasthenia they are augmented. Neu- rasthenia never affects the sanguineous, but the nervous tem- perament, which is characterized by “ vivacity of sensation, prompted by fickleness of determination, small, soft, and wasted muscles, and generally a slender form. Created by sedentary, studious, or fashionable life and the appliances which attend it, it is intensified as the case continues, and results sometimes in well-marked diseases” (Yandell). The neurasthenic must not be confounded with the true hypo- chondriac. In the former there is disease, in the latter only the fear of it. In the neurasthenic there is usually evidence of a nerve impoverishment, while the hypochondriac appears healthy and robust. The hypochondriac becomes hopeless over that which does not exist, while the neurasthenic loses hope as the nerve forces diminish. Hysteria has been frequently mistaken for neurasthenia, and a few writers make no distinction between them. Hysteria is more paroxysmal, and is found in those of emotional and excit- able nature whose physical condition is perfect but whose intel- lect is warped; neurasthenia engenders physical impairment combined with a bright but weakened intelligence. Hysteria may terminate suddenly, while neurasthenia and its accompa- nying disorders of functions are the result of reflex irritation from impoverished nerve elements. As many and varied symp- toms may result from neurasthenia, the general practitioner should be careful not to mistake effect for cause, thereby trans- ferring the responsibility to the alienist. Prognosis.—The prognosis, though usually good, depends upon each individual cause. It is true that symptoms may be successfully met and conquered as they arise, without alleviat- ing or eradicating the principal cause. If the prime etiological factor can be isolated and removed the cure will be speedy, otherwise the course of the disease will be protracted. Neglected or improperly managed neurasthenia may result in some permanent functional or organic disease of the nervous system. Such cases have been known to terminate in insanity, hysteria, special or general neuralgia, inebriety in one of its many forms, and in diseases of the reproductive organs. Treatment.—The treatment, to be successful, must be directed to the improvement of the general health, with sufficient atten- DEALE ANI> ADAMS : NEURASTHENIA IN YOUNO WOMEN. 5 tion to any prominent local manifestation which may arise. Each case must be studied as an entity and all treatment di- rected to it. There are various methods of general and local treatment, and perhaps all may be tried in a single case without avail. A change is sometimes beneficial, so we must not cling too tenaciously to any one method. The personal hygiene and habits of the neurasthenic should receive due consideration. She should be required to bathe sufficiently often to stimulate the skin to renewed activity, and a sufficient amount of exercise in the open air should be pre- scribed as a daily routine. She should be required to take a certain amount of rest, both of mind and body, during the day, but should not be encouraged into lazy or indolent habits. While she should be permitted to have a certain amount of en- tertaining company, she should be required at times to isolate herself. As the neurasthenic usually possesses an active, work- ing brain, she should be required to abstain from all undue men- tal excitement. The digestion should be carefully watched, and articles of food easy of digestion and assimilation should be prescribed. It may be necessary to place her upon a milk diet, in which case suitable quantities at short intervals should be given. Should the stomach refuse to retain food, rectal alimentation will be- come necessary. In 6iich cases it is better to nourish the pa- tient through the rectum until the irritability of the 6tomach is allayed and the desire for food returns. As the neurasthenic frequently sutlers from insomnia, means should be taken to en- courage sleep without the administration of soporifics. This may be done by prescribing a regular hour for retiring, and com- pelling the patient to avoid exciting conversations or reading just prior to bedtime. Travelling in distant countries may prove beneficial, and it is often desirable to have such patients spend a portion of their vacations in camp life or roughing it, where they may be free from sympathizing friends and indul- gent parents. Riding, sometimes on horseback, is always bene- ficial, but it must be done in the country where they will ob- tain fresh air and plenty of it. Often a change of climate may prove beneficial, but it is questionable whether the change of scene and removal from exciting causes may not be quite as beneficial as the change of meteorological conditions. The dress of the neurasthenic should be comfortable, suited to 6 DEALE AND ADAMS : NEURASTHENIA IN YOUNG WOMEN. the season, well fitting, and, if possible, lning from the shoulders so as to avoid pressure upon the thoracic and abdominal viscera. Medicinal agents employed in the treatment of neurasthenia are numerous, but almost all the methods of treatment are directed to the improvement of the general health and the nervous system. It may be necessary occasionally to administer an anodyne to relieve pain, or a stimulant to whip up the flagging heart; but even here great judgment should be exercised to avoid trans- forming the unhappy neurasthenic into a hopeless inebriate. Arsenic, cannabis indica, caffeine, cocoa, zinc, the bromides, chloral, strychnia, opium, alcohol, the mineral acids, and the phosphates have all been tried and have as often been found wanting. The external methods of treatment may often prove valuable. Electricity and massage have of late years been awarded much praise in the treatment of such cases. When applied it should be under the direction of the physician, who should prescribe the current and part to be treated and thelength of the stance. So should he also govern the application of massage. Some cases are benefited by one of the many spray baths. Hydrotherapeutics must also be directed by the physician him- self. A beneficial effect is sometimes derived by the applica- tion of small blisters or the mild cautery along the spinal region. Finally, if we wish to benefit this unsatisfactory class of cases we must assume complete control over the patient, write out clearly and succinctly the rules governing her daily life, and in- sist npon their enforcement. Even with the exercise of such precautionary measures a certain number will ultimately fall into the hands of the unscrupulous charlatan. MEDICAL JOURNALS PUBLISHED BY WILLIAM WOOD & COMPANY. MEDICAL RECORD. 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