** 
NATIONAL LIBRARY
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i;foe ^luittueli  Xectuvc
            1891
NEURASTHENIA
y;
MENTAL   SYMPTOMS
           By EDWARD COWLES,  M.D., LL.D.
                        m
Medical Superintendent of the Mcj.ean Asylum; Professor of Mental Diseases
     Dartmouth Medical School; Clinical Instructor in Mental Diseases
            Harvard Medical School; Fellow by Courtesy
                   Johns Hopkins University
Read before the Massachusetts Medical Society, June 9, 1891
               B OSTON
DAVID CLAPP & SON, PRINTERS, 115 HIGH ST.
                   189 1 
 
  Synopsis.—Neurasthenia is one of the  most frequent and im-
portant of  nervous diseases,  and its  mental  symptoms  afford
significant  indications  for  diagnosis,  prophylaxis and treatment.
The history of the subject shows the early recognition of depression
of feeling and weakened mental control, along with irritability, as
signs  of the characteristic nervous  weakness.   Insanity, in  it's
functional and curable forms, is always weakness, and its study is
useful  in relation to neurasthenia, because they have a common
etiology.
  The  animal organism is  biologically  a mechanism, made up of
minor  parts  or mechanisms.   Physiological activity always tends
to  fatigue,  which may be local  or  general.  The study of neu-
rasthenia,  or pathological fatigue,  presents  two essential con-
siderations:
  1. In normal  fatigue,  with the discharge  of energy,  the toxic
products of exercise are always formed in nerve and muscle tissues.
From  this  and other sources toxic elements may accumulate in the
blood and tissues; in pathological fatigue these contribute to a local
or  general inanition and  auto-intoxication.   Visible  changes in
nerve cells, attending normal fatigue, go to support the inference of
a molecular and chemical variation, in pathological fatigue, mani-
fested  as a condition of  exhausted or changed nutritional power-
These  changes bear a direct relation to the etiology and pathology
of  neurasthenia;  and  habit,  diathesis  and idiosyncrasy  have an
important  influence in  causing  "dispositions to repeat organic
processes," both  normal and  abnormal.  Physiological chemistry
gives  us  some  knowledge of the nature of  autogenous toxic
substance.
  2. The study of the mental  elements in normal and pathological
fatigue shows that the mental symptoms furnish a ready index of
the " fatigue":—(1) The emotional tone is either one of well-being
or ill-being, and the latter, with mental depression, indicates changes
in  the  " sense of body " or  common  sensations,  due  to deficient
energy, inanition and auto-intoxication; (2)  Special disorders of
intellect and will are shown by a  neurasthenic weakening of volun-
tary attention or the mental  power of inhibitory control, and of
memory, etc.
  The analysis of normal and pathological  fatigue shows that the
mental symptoms of the latter may be readily recognized, that they
correspond with the physical  events in neurasthenia, and that all
these phenomena, as far as  they go, are  in  unity with the  like
conditions  of melancholia.
  The  symptoms are objective and subjective,—mainly the latter,
        1 
           which include the mental symptoms.   These fall by  analysis into
           four distinct groups relating to (1) mental depression and a sense
           of ill-being, (2) diminished power of voluntary attention and men-
           tal control, (3)  introspection and worry, with attention acting in
           its attracted form, and (4) changes  in  the " sense of  body,"—irri-
           tability and hypersesthesia,  languor and anaesthesia.   Two  con-
           sequent conditions become prominent, and are of the highest clinical
           importance:—morning tire, and anaesthesia of  the sense of fatigue.
           The summary of symptoms leads to a definition, including both
           the physical and mental elements, as expressions of  the  inanition
           and auto-intoxication of pathological fatigue,  viz.:—neurasthenia
           is a morbid condition  of the  nervous  system, and its  underlying
           characteristics are excessive weakness, and  irritability or languor,
           with mental depression and weakened attention.
             The diagnosis is made clearer by an analy&is of the mental symp-
           toms, which are true and sensitive indices  of the lower physical
           changes.  This aids in prophylaxis.  Neurasthenia may be regarded
           as the initial term  of many  nervous  disorders  having  a varied
           etiology.
             The treatment with special reference to the objective  symptoms,
           logically includes elimination, nutrition, rest, exercise, massage and
           promotion of sleep.   The subjective, and especially the  mental in-
           dications, being the earliest, and most significant from first to last,
           are the best  guide to treatment;  this must be suited to the two
           different  stages of  neurasthenia,—to  the  conditions  of its first-
           effects, and its after-effects, and to  different types of patients.
             The plain philosophy of treatment is to recognize the mental
           symptoms as first showing the need of it, and to address it to the
           restoration of  a  healthy emotional tone  as  the central motive
           element;  the lowering of this, and the weakening  of attention and
           inhibitory control, are always the  earliest signs of neurasthenia.
             The maintenance of a normal sense of well-being is the sign of
           bodily health.   Normal  fatigue is  simply wholesome tire; exercise
           should always be kept within the  limits of pathological fatigue, in
           which the  sensory  over-tire,  as   fatigue-anaesthesia,  marks  the
           subtle beginning of danger.   The natural safeguard is in the early
           recognition of the other mental effects of " fatigue."
             These considerations go to prove the prime significance of the
           mental symptoms as  a guide to the prophylaxis  and  treatment of
           neurasthenia.
             Note.—This lecture will substantially  form  the third  of a  series of
           articles on "The Mechanism of Insanity"  now being published in  The
           American Journal of Insanity, and containing a more extended study of
0          the mental elements also involved in this subject. 
NEUKASTHENIA  AND ITS MENTAL
                 SYMPTOMS.
Mr. President and Fellows
  of the  Massachusetts Medical Society :—
  The founder of the Shattuck Lectureship, whose memory
is revered for his good works, and his loyalty to medicine
and  the  welfare of this  Commonwealth,  has provided for
special attention to the study of " diseases of its inhabitants,"
or "such other  subjects" as this Society may select.   Your
Committee, in  appointing me to the responsible duty  of
fulfilling its trust,  has done  me a great honor ;  I wish  to
express my high appreciation of it, and of the privilege  of
now addressing you.   With the foregoing indications as to
my  subject I find that in New  England  there is probably
no disease  more prevalent  than neurasthenia.  It was  the
thesis of Beard,—to whom the world so largely owes the
formulation of the accepted ideas of nervous  exhaustion
under the name given to it by him,—that it was  mainly an
"American disease."  He believed that the  chief and pri-
mary cause of its development and increase was " modern
civilization," and that it  had  its  "rise  and growth" and
highest expression,  in  the Northern  and Eastern parts of
our  country.   For the present occasion we may be per-
mitted to  accept these views  so  far  as to  find in them a
reason for the fitness of  this subject, as having a special
local interest in this State of Massachusetts.
  The subject of this lecture has been chosen with reference
to its practical importance for the general physician,  whose
usefulness  so largely and  exceptionally  lies in  preventive
medicine.  My  observations in the treatment of insanity 
4
the shattuck  lecture.
 have given me the conviction that in the commonly occur-
 ring and typical forms of mental  disorder, which are ot a
 functional  and curable character, nervous exhaustion always
 plays tin important part, both in the attending  conditions
 and the causation.   The treatment of these functional dis-
 orders, as far as the measures ordinarily regarded as thera-
 peutic can  go,  is little else than the  treatment of nervous
 exhaustion ;  this is the largest and most constant  factor in
 producing  the different  groups of symptoms in disordered
 mental activity.  Hence the practical usefulness of studying
 the varied  manifestations of debility in nervous function, in
 its  aspects  prodromic to mental  disturbance, both for the
 sake of cure of the existing disorder and for the prevention
 of the graver  degree  of exhaustion when insanity super-
 venes.  Neurasthenia, according to Striimpell,  is  certainly
 one of the  most frequent and important of nervous diseases.
  History.—The subject to be discussed is  neurasthenia,
 with special reference to the significance of its early mental
 symptoms as affording important  indications  for  diagnosis
 and  preventive treatment.   When  Beard,  in  18G8,  de-
 scribed under the term neurasthenia a wide range of symp-
 toms of "nervousness," or conditions of nervous exhaustion,
 he used the term as designating  "a  chronic functional dis-
 ease of the nervous system, the basis of which  is impoverish-
 ment of nervous tissue in excess of repair."   When, in 1880
 and 1881,  he  published in his latest works an elaboration
 of his well-known  views, there had been a very general
 acceptance  of the principles they involved ; and subsequently
 many  writers have classified neurasthenia as  a  neurosis,
from its having no discoverable  anatomical basis, and  as
signifying "nervous weakness."   Beard's attempt  to make
of neurasthenia a distinct affection has however  been much.
questioned.  But by his  originality and keenness  of obser-
vation and analysis,  he did  his  part in reducing a o-reat
array  of data to definite principles, and initiating the wide 
       neurasthenia and its mental symptoms.      5

application that is now being made of them.  In respect  to
their extension and particularly their relation to insanity, a
statement here of the position held by the earlier writers
will give the key to the present understanding of  the  sub-
ject.
   The "deficiency of mental control," "inability to concen-
trate the intellect on any  task," the rapid fatigue from "the
exercise  of concentration,"  the "mental irritability" and
" hopelessness " were recognized by Beard as notable  symp-
toms.  He also observed  the fact  that "neurasthenia  may
concentrate itself almost exclusively on the brain—cerebras-
thenia—with the symptoms of morbid fears and  impulses,
depression,  insomnia,  fulness,  headache, impairment  of
memory,  decline in  mental force  and power  of control."
But while making many such precise specifications of most
characteristic symptoms of melancholia in its  milder  mani-
festations he would only admit that neurasthenia  sometimes
leads to  insanity ; and that, while many cases of nervous
exhaustion,  with irritability, great depression, etc., tending
downward to melancholia, come to  the border line, they do
not  cross it as a  rule, though they may do so in extreme
cases.   Some cases of melancholia  in our asylums, he says,
have been neurasthenics, and some are saved from becoming
insane ; but he claimed neurasthenia to be a " distinct  dis-
ease,"  not " exhibiting the enormous defect that is seen in
insanity."
   The universally accepted  principles  of the  "rest  treat-
ment" that have  become so well  understood since  Weir
Mitchell's first  recommendation of them,  in  1875, in  a
regular and  systematic scheme  of treatment, need no  dis-
cussion here.   All are familiar with the classical description1
of his  cases of nervous exhaustion and his specification of
the essential elements of the treatment:—seclusion, certain
forms of  diet, rest in bed, massage, and electricity.  These
            1 Fat and Blood,  4th. Ed. 1885, pp. 38-43.
      2 
6    „          THE SHATTUCK LECTURE.

measures have stood the satisfactory test of experience by
their  use  in proper cases, in promoting "a liberal gain in
fat and  blood," of which  "the  gradual increase  will be  a
visible result  of the multitudinous changes in  digestive,
assimilative, and secretive power in which the wh >le  econ-
omy inevitably shares."   The great importance of the mental
element in  neurasthenia, and the widening application of
the principles  and plan of treatment in mental disorders  are
in fulfilment  of Mitchell's  own  prophetic words  that its
sphere of usefulness was likely to extend beyond the limits
originally set  by him.   The  bodily  conditions in  insanity
were  not  fully  recognized  as so largely those of  nervous
exhaustion  as  they really are;  and Mitchell, Goodell,  Play-
fair and others have held like  views on this point.   Mitchell
wrote, " The true melancholias, which  are  not merely  de-
pression of spirits from loss of  all hope of relief,  are best
left alone as far  as this treatment is concerned.   The nutri-
tive failures which so often accompany  them  must  be met
by other means than rest, seclusion, etc.": and  this opinion
was believed to be " sustained by some failures " on his part,
and by the opinions of others.
  It is interesting to note, however, how largely the plan of
treatment was  addressed to  the mental  condition of  the
patients :—the manner  in which their confidence  and co-
operation  was gained, and  particularly the seclusion, were
for their mental effect.  The need to " rest the organs of mind "
was noted, and that "it is thought with the friction of worry
which injures, and unless we  can secure an absence of this
it is vain to hope for help by the method" described.   It
was Playfair's rule that the mode of treatment is " valueless
without the cordial submissive  assistance of the  patient."
But we have now been taught by experience the efficacy of
these measures even when  enforced, in the nervous  exhaus-
tion of melancholia and mania.   All writers have observed
as did Mitchell, that " many neurasthenic people suffer from 
       neurasthenia and its mental symptoms.      7

any  prolonged effort at attention,"—also the common loss
of mental control.   It is this characteristic lessening of the
power of voluntary attention that becomes so significant in
its  diagnostic value, after we  have observed  its greater
weakening in the  graver  exhaustion  of melancholia.   The
common occurrence in the cases described  of a brain hyper-
esthesia* is mental  irritability,  the depression of feeling,
and  despondency, are equally significant and characteristic
of mental disorder from nervous weakness.
   Hereditary and  Acquired Neurasthenia.—The fact of
hereditary predisposition  was  observed  by all writers.
Beard characterized it as a congenital weak resistance of the
nervous system, entailing neurasthenia as a  disease,  or as
constituting  a nervous diathesis  upon  which  the disease
would  be  developed under  deficient nutrition.   But the
idea of it as a clinical entity to be differentiated from other
nervous and mental disorders has been  broadened by some
who  regard  neurasthenia  as the  primary condition  of all
nervous degeneracy,—not as itself a neurosis or a  psychosis,
but as the soil from which these may grow.   There are two
great groups of these affections, the hereditary and acquired.
When inherited there may be organic modifications, perma-
nent embryonic conditions, of the central nervous system as
found in idiocy, etc.,  according  to  Arndt;   or  there  may
simply be a neuropathic predisposition with organic changes
as yet undiscoverable,—a constitutional weakness and insta-
bility of the  nervous system,—and this is hereditary neuras-
thenia.   The form of acquired neurasthenia may occur in
the constitutionally strong, and both forms may  be  due to
any nutritional or toxic causes that can initiate a  condition
of  weakness and irritability  of the nervous  tissue.   Upon
such a basis of organic  and neurasthenic weakness, there
may  be engendered not only nervous disorders in general,
but processes of degeneracy; and there may be like disor-
ders  and degeneracy in respect of those  nervous  functions 
8
THE SHATTUCK LECTURE.
which we call mental.   All diseases being considered not as
"entities,"  but as morbid conditions and processes of which
we  observe the " symptoms,"  we may regard neurasthenia
as a disease either hereditary or acquired, and as manifested
by many mental symptoms.
 * General Relation  to  Insanity .—The statement  has
already  been  made that in certain forms  of insanity the
bodily conditions are essentially those of nervous exhaustion.
Of  the  great number of people, who are in neurasthenic
conditions,  it is true to  say  that only a certain proportion
become  insane.   But conversely, the proposition  may be
equally  true, that all people of previously sound health and
constitutions, who become insane with ordinary  functional
mental  disorders,  have their  psychoses dependent upon
neurasthenic conditions of the organism,  whether the ner-
vous power is annulled quickly by shock, or enfeebled more
slowly by prolonged stress or  other weakening influences.
The fundamental condition  here is acquired neurasthenia.
When it is hereditary there is a plainer dependence thereon
of mental symptoms that come more readily in  such cases
from stress, nutritive failure, etc.   Insanity is always weak-
ness from some cause or other,  and the group of symptoms in
any given case is a matter of  the kind and degree of ner-
vous exhaustion.   We  find the  mental  symptoms of  neu-
rasthenia in  insanity,  but  being  emphasized in  unequal
degrees in the latter condition,  their import is more clearly
revealed.  Thus we may learn  from  the study of insanity
how to understand and treat  the  lesser manifestations of
nervous exhaustion  in  its earliest stages,  as they are  com-
monly  seen by the general physician.    In  the study of
the mental conditions having a common etiology, it will be
of  advantage if in  either case  the source and genesis of the
symptoms can be made  clearer.   The present endeavor is to
make such a contribution  to the subject  from observations
of  mental disorders dependent  upon neurasthenia.  It will 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      9

first be necessary  to  consider  some of  the  fundamental
principles that must be  regarded in  the analysis and inter-
pretation of the data of clinical observations.
   The  Animal  Organism  a  Mechanism.—The animal
organism is regarded biologically  as  a mechanism which is
stimulated  to action by  its environment,  and in turn, acts
upon it.   Underlying  all  these  phenomena is reflex action
of  the nervous system, and physiologists generally agree to
consider every action as aroused  by  some definite cause or
stimulus.1  The mechanism, as a whole, is regarded as made
up  of minor mechanisms, when studied by the physiological
method which reasons  from structure to functional activity,
and from activity back to structure.   But the  physiologist
must observe  many "activities"  for  which he  can, as yet,
only infer  corresponding elementary  parts in the organism,
the relations of  which he can only study as they are repre-
sented by  their activities.   This is  peculiarly true of the
mental mechanism  and its activities,  such as attention and
memory.   We have to  assume that  every manifestation of
mind is correlated  to  a  definite  mode and sphere of brain
activity ; and  we can  conceive  it as  constituting  a mental
mechanism.   We  can conceive  also all  the  systems  and
organs of the body  as so many co-ordinated mechanisms,—
as the muscular, circulatory, and  digestive  mechanism, etc.
The nervous system as a mechanism, made  up  of many
local adaptations  to structure and function, presents a like
variety of  minor mechanisms, with  peripheral aud central
elements of co-ordinated ganglia, nerve-fibres, and nerve-
endings.   Any one of these minor nervous mechanisms  may
become neurasthenic from excessive or irregular exercise of
its functional activity ; the end-organs of the special senses,
and any part of the peripheral or central sensory apparatus
may  become separately fatigued,—allowance   being made
for  the  resistance  to  fatigue of  conducting nerve fibres.2
  1 Sedgwick.  Art. Reflex Actions, Ref. Hand Book of Med  Sciences.
  2 Bowditch.  Jour, of Physiol., Vol. 6, p,  133. 
10
THE SHATTUCK LECTURE.
The same is  true  of  the  nervous elements  of the  motor
mechanisms.  All  the  inhibitory  mechanisms, and  parti-
cularly, in the sympathetic system, neurasthenic  conditions
of the inhibitory vaso-motor centres are especially important
in the causation of  both local and  general disorders.   The
metabolic processes  in general may  suffer from central weak-
ness of  innervation and control; and there may be neuras-
thenia  of such special  organs  as  the heart, stomach,  and
liver.   Thus  there are many forms  and degrees  of the
phenomena  of  nervous exhaustion  classified  under  the
divisions  of cerebral, spinal, or general neurasthenia ;  and
hence neurasthenia  has been defined  by  Ziemssen1  as " a
functional weakness of the nervous system,  varying from
the slightest degree in  single localities  to  entire  loss of
strength in  the whole nervous system."   But though the
symptoms vary greatly according to the functions  of the
part affected, we are always led back to  one  principle :—
the weakness of the nervous system from some cause, what-
ever it may  be.
   The physiological basis of these phenomena is the princi-
ple of the storage  and discharge of energy of muscle and
nerve.    This accords  with the biological theory  that all
function is due to chemical changes taking place within the
organism, and  that the functional activity of  a  specialized
tissue depends primarily upon  these  changes  in the indi-
vidual cells.   The  fundamental idea is, that in the resting
state the cell  elaborates highly  complex compounds, and
that these break down  to yield the energy by which the cell
does its work.
   Importance of Physiology and Chemistry.—Such being
the character of the organic mechanism the difficulties  have
been very great in gaining an understanding  of these affec-
tions.   Writers have dwelt chiefly upon the facts, clinically
observed, of the expenditure of nerve  force and "the waste
       1 Neurasthenia.  Wood's Monographs, Vol. 1, 1889, p. 534. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     11

of nerve-tissue in excess of repair " ;  and emphasis has been
laid mainly upon the nutritional elements of the problem.
But while they have recognized the necessity of treating the
mental conditions upon which they made clinical observa-
tions, the larger import  of these mental  symptoms  has
escaped full  appreciation.   Moreover,  in  the  search for
lesions  explanatory of the  most  marked disturbances of
function, anatomy  and pathology  are as yet disappointing.
Physiology  offers greater aid, and  by the new laboratory
methods not  only bodily  but mental  activities may be
studied,  in  advance of our knowledge of the  structural
mechanisms upon which they depend.  Now newest  of  all,
comes the science of bacteriology with its wonderful revela-
tions, and the new discoveries in organic  and  physiological
chemistry; they  promise  to  throw great light upon these
mysteries of our problem.
   Two essential Considerations.—The present  status of
this problem gives us two important indications :—first, we
cannot  correctly conceive  the existence of a condition that
may  be called  " pure neurasthenia "  as a matter of simple
weakness from over-use, and inadequate rest and  nutrition,
but we  must make large account of the presence of toxic
materials  in  the tissues as  the immediate products of  this
normal  exercise;—and second, we must take  into account
also the nature  and manner of production of the mental
symptoms common to neurasthenia and insanity,  and their
significance   and value must  be  better understood   and
appreciated.   There is time here for only the  briefest men-
tion  of some of the conclusions  reached by the newer in-
vestigations in  the different branches of this  complicated
problem ; these  may serve  to indicate the  grounds  of the
arguments in support of the two foregoing propositions.
   1.  Toxic  Elements  in  Normal  and  Pathological
Fatigue.—The  normal organic mechanism, represented by a
healthy adult, may be taken as a standard for observation. 
12
THE SHATTUCK LECTURE.
When it is stimulated to activity there may be observed the
phenomena of use,  and of stress from over exercise,   -be-
ginning with the peripheral muscular mechanism, physiology
teaches us  that fatigue  is not the only result of muscular
contraction.   Noxious products are always yielded as the
results  of the attendant  chemical  change in  the  muscle-
substance, by  the decomposition of certain parts of which,
the  latent energy  is  set free  and expended in mechanical
work.  The restoration  to  the normal state  is  not alone
through rest, and processes of repair by  nutrition  and the
rebuilding of  the  complex  molecular  substances  of  the
muscular  tissue, but the blood current carries off the imme-
diate waste products, obstructive to function, while it brings
new raw  material.1
   Normal Fatigue.—Amuscle made to contract repeatedly,
whether  by  electrical stimulation or voluntary effort, will
yield regularly lessening  contractions until it ceases to re-
spond and is said to be " exhausted."  In the case of volun-
tary  contractions there  is  central  fatigue also  from  the
expenditure of energy in mental effort.   The difficulty  has
been to distinguish between the central nervous fatigue, and
the peripheral fatigue  of muscles ;  but Mosso,2 Maggiora,3
Lombard,4  and  others   have shown  that the  "curve  of
fatigue"  is alike in  each case.  They have demonstrated
experimentally in man, that there is an intimate  connection
between the fatigue of the central nervous system and that
of the muscles,—that there is loss of power by exercise in
both peripheral and central mechanisms,—and that the effects
in each may  be studied separately.   When certain  muscles
were experimentally fatigued by long continued work under
both  electrical and  voluntary  stimuli, it  was found that
other muscles  not  exercised were  also affected  and their
  1 Foster.  Physiology, 5th Eng. Ed. 1890, pp. 148-152.
  2 Arch. Ital. de Biol., 1890, pp. 123-186.  3 Ibid. pp. 187-241.  See review of
both articles  Amer. Jour. Psychol., Vol. III. pp. 377-381.
  * Amer. Jour. Psychol., Ibid. p. 24. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     13

power lessened,  as by a transmitted  toxic  influence.   It
was found  also that human muscles have an excitability and
energy peculiar to themselves, and  that  they weary inde-
pendently  of the  excitability  and energy  of the  nerve-
centres.  This shows that the muscles are the seat of cer-
tain  phenomena of  fatigue  which, thus far, have been
thought to  arise in  the  central nervous system and to belong
essentially  to it.   Under prolonged exercise there is les-
sened sensitiveness  as well as diminished power.
   In  a man  subjected to severe mental work, it was found
that the muscles, which had  been inactive,  were weakened
by it.   The result of such experiments  is regarded as going
to show that  a  poisonous  material, produced by chemical
changes  in the brain,  enters  the  circulation,  and, acting
upon  the  muscles,  weakens them.  These  demonstrations
are also in  accordance with the generally accepted physiolo-
gical  principle that the central nervous mechanisms, as do
the muscular, undergo a regressive metabolism  of tissue
upon exercise, and  that this is also of an oxidative character
with toxic  waste products.1   There is  also in nervous cen-
tres  a like loss  of normal excitability  with fatigue  and
exhaustion.
   Physiological Shrinkage and Recovery of  Cell-con-
tents.—A  further demonstration of the physiological changes
in nerve-cells is being  made by Hodge,2 in his experiments
begun in 1887, which  are of  the most significant  interest.
The electrical stimulation, in frogs and cats, of a nerve go-
ing to  a spinal ganglion caused, after a number of hours,  a
marked shrinkage  of the nerve-cells,  particularly  of  the
nuclei,  which lost  forty  per cent, of  their bulk;  the  cells
themselves, though decreased but  little in  size,  showed
extreme vacuolation in  the cell protoplasm ;  and the nuclei
of the cell capsule shrunk  to  a noticeable  degree.   The

    1 Foster. Op. cit., p. 154.
    2 Am. Jour, of Psychol., May, 1888; May, 1889, and Feb., 1891. 
14
THE SHATTUCK LECTURE.
change in the cells was  found to be generally in proportion
to the severity and duration of their stimulation.   It  was
shown that in a subsequent resting state the cells recover
their normal appearance, but by a slow process.   After five
hours  of  severe work and a shrinkage of 48.8 per cent, in
the nucleus,  recovery required twenty-four hours.   In the
cells of a worked ganglion there  are different degrees of
shrinkage of the nuclei,—from 5 to 80 per cent, of original
volume;   in the latter  the protoplasm  was  riddled  with
vacuoles  and the nucleus  shrunken to a  densely  staining
speck.   The  spinal ganglia of pigeons and English spar-
rows, after normal exercise, showed exactly similar changes ;
—the  difference between the  condition of the sparrows'
cells,  when rested in  the morning, and fatigued at night,
being much more marked, on some occasions, than could be
obtained by the most severe electrical stimulation.  Sadowski
has obtained the organic changes, of neurotic coagulation
and vacuoles  in central  cells,  from peripheral  stimulation,
mechanical and  electrical.    There can be no  doubt that
such visible changes are accompanied by chemical reactions
also ;  the  worked cells took  the staining differently, and it
is probable that new granules were formed  taking a darker
staining.    The evidence is important, that all these  changes
are normal, and correspond  with  the  daily  rhythm of rest
and activity,—sleep and waking.
  These  physiological  and  chemical  explanations  of the
conditions  following exercise, are supported by  an  evident
diminution and removal of  the substance of the nerve-cells
as a normal process.   It is shown that the actual  expendi-
ture of energy, muscular or nervous, is a factor which  has
always joined to it a toxic element in the products of the
changes normally  caused in the tissues by functional acti-
vity.   There may be local areas of toxic influences  hinder-
ing or inhibiting the  functions of distinct peripheral  or
central mechanisms ;  and the blood becoming charo-ed  with
them more general effects may be produced. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     15

  These are the  common  phenomena of a  normal active
life,  in the  daily  round, from  morning rest,  vigor and
alertness, to evening fatigue, weakness and heaviness,—both
in mind and  body.  The restoration of normal  conditions,
with  the re-storage  of  energy, comes through nutrition,
furnishing new raw material,—rest, to stop the expenditure
of energy and give time  for the chemical building up of cell-
contents, as well as for the removal of accumulated  waste
products,—and sleep, to hold in  abeyance the general nor-
mal  irritability, and afford effective  repose  to all  tissues
whose activities  can be  spared from the vegetative life.
Unused muscle wastes ;  when used it grows.   The nutri-
tion  of  a  muscle is favorably  affected by  its functional
activity.1   A  wholesome  degree  of fatigue  is  normally
attendant upon physiological use, through increased blood-
supply and re-actions promotive  of  nutrition ; this  may be
characterized as normal  fatigue  in  contradistinction to  the
more pronounced  effects which constitute exhaustion.
  Pathological Fatigue.—In contrast with  these normal
processes may  be placed the picture of the unbalanced con-
ditions  of waste and repair,—of expenditure  and storage
of  energy,—the  conditions  of pathological  fatigue,  or
neurasthenia.  In a  recent paper,  valuable for its concise
analysis of the subject, Dana2 has  given a comprehensive
definition.   He says, "Neurasthenia is a  morbid condition
of the nervous system whose  underlying  characteristics  are
excessive irritability and weakness ";  it is  "a condition in
which the nutrition of the nerve-cells is primarily at fault."
Can these phenomena be accounted  for in default of anato-
mical and pathological findings?  •
  It has been shown how inseparably  normal fatigue from
the discharge of tissue energy is accompanied by toxic pro-
ducts that increase the  fatigue.  Now every action of  the
        1 Foster.  Op. cit. p. 146.
        2 Art. Neurasthenia.  The Post-Graduate, January, 1891. 
16
THE SHATTUCK  LECTURE.
 mechanism is considered as aroused by some definite cause
 or stimulus.  Stimulation too soon repeated, without giving
 time for rest and repair, finds nerve-cells in fatigued areas,
 having less power to act because of inanition from  deficient
 rest and nourishment;  they are also hindered in action by
 the incomplete  removal of the toxic products  of  previous
 action,—in other words, there is inanition  and  auto-intoxi-
 cation.  Then further assimilation is hindered,—first by the
 lessened nutritive quality of the blood  from non-eliminated
 toxic  materials,—and second, by  the probable toxic weak-
 ening  of the cells' power to assimilate the  nutrition that is
 furnished them.  The development of  a  manifestly morbid
 condition may be  very slow  and insidious, or  more rapid
 according  as  the  balance of the processes of constructive
 and regressive metabolism is  more or less on  the side  of
 weakness,  exhaustion and  impoverishment.  In explaining
 the effect of this gradually failing  elimination  of  the  pro-
 ducts  of metamorphosis, acting as an irritating and exciting
 intoxication, Kowalewsky1 says,  "there will then be a  con-
 dition  of partial inanition of the  exhausted portion of the
 central nervous system, while, in the same part, partial auto-
intoxication is going  on,  and while the remainder of the
 organism is in its normal condition.  The result of a partial
inanition will be an increased excitability on the one  side,
 and, on the other, a quick  exhaustion  of the nervous  sys-
 tem ;  these are the constant characteristics  of  neurasthenia.
 Thus  a locally limited over-strain of a certain  part of the
 nervous system may lead to exhaustion and neurasthenia."
  It has been easy to understand  how the  " nervous weak-
ness "  so essentially  characteristic of neurasthenia, should
be a  logical result of  " exhaustion " by over-use ; here is
not only further  explanation  of this, but the "excessive
irritability"  is accounted for;  tissues,  weak from partial
 inanition, and, under constant stimulation  from toxic  irri-
           1 Centralblatt f. Nervenheiikunde, October, 1890. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      17

tation, almost  excited into action, are over-sensitive  upon
the addition of  ordinary stimuli.   It is a  kind of "hair
trigger" sensitiveness that amounts to hyperassthesia.
  The localized  neurasthenic conditions  being acquired in
this way in an organism previously healthy, it is  easy to see
how " entire loss of strength in the whole nervous system "
may come about, through its prolonged exercise without due
intervals of rest.   In the excess of nervous activity and of
the metabolic processes, there appears to arise from  the de-
composition or  "combustion" of  tissues,  a condition of
general inanition from inability of nerve-cells to take up the
nutriment and oxygen presented to them  in the circulation.
Kowalewsky describes this as a demand  for  oxygen in the
whole organism, or oxygen-hunger.   This tends to increase,
by  deprivation,  the  partial  and local inanition ;  and ob-
viously the blood may be  charged  with  an excess of the
products of regressive metamorphosis, through  inefficiency
of the eliminative processes,—often because of weakened
innervation.  Then,  he says, there  is general auto-intoxi-
cation which adds  its influence  to the limited  and  local
neurasthenic condition that may have been previously estab-
lished.   From this reasoning we derive four principal factors
that, as pathological  conditions,  operate in  presenting the
phenomena  of  neurasthenia,  and  make  up  its  clinical
picture :—
               1. Partial (local) inanition.
               2. Partial (local) auto-intoxication.
               3. General inanition.
               4. General auto-intoxication.

   This leads  to  the  conclusion that,  in  very many  cases
certainly, neurasthenia has its foundation amply accounted
for.    The condition of inanition  and  auto-intoxication,
whether partial" or general, may  vary according  to the
presence of one or more of the factors  and their different
values in  the  particular case.   The auto-intoxication will 
18              THE SHATTUCK  LECTURE.

affect one  mechanism, or organ, differently from  another,
according to the dissimilarity of structure and function ;
from different organs, or tissues, will  come different kinds
of toxic products, and their effect will vary also according
to their amount.   In anaemia, the general  impoverishment
of the blood, from its own  diseases, will of course con-
tribute to, and may initiate, both local and  general  neuras-
thenic conditions.   Even when the  blood supply is ample
there  may be locally  limited over-strain and nervous  ex-
haustion, probably due in part to the inability to assimilate
nutrition.   The  conclusion of this matter is that, in morbid
conditions, nervous weakness from inanition, due to expended
energy  and lack of nutrition of the  nervous system,  has
always joined to it the varied effects  of auto-intoxication as
a dual cause of neurasthenia.
   The Etiology of Neurasthenia,—Primary, Secondary
and, Hereditary.—The genesis  of  acquired neurasthenia
in a healthy organism can thus probably be largely accounted
for as a primary  neurosis  due to  the immediate effects of
over-strain, or a primary  and toxic disorder  of nutritional
functions.  The principle  may be  equally well applied to
the secondary neurasthenias,—those consequent upon other
diseases, each with its peculiar exhausting and toxic influ-
ences,  as  the essential feature  of  a general pathological
diathesis.   It is  as yet impossible to say what the  chemical
action in cell-protoplasm may be that causes the increased
excitability and  quicker exhaustion of nerve tissue,  when
they are consequent upon  the chronic auto-intoxication of
rheumatic  and   gouty  diathesis;  but the  transmission of
these diatheses by heredity  we cannot doubt, nor that chil-
dren inherit  neuropathic  and neurasthenic  predispositions
from rheumatic  and gouty  parents.   The  same is true of
all  the "constitutional"  diseases.   The  transmission of
the  effects  of   nervous   diseases,, alcoholism,   syphilis,
etc., may  sometimes be shown  in  structural changes  and 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     19

defects of the central nervous system,—sometimes, according
to Arndt,1  in permanent embryonic conditions from arrested
development, but  slightly demonstrable,  and constituting
the structural basis of hereditary neurasthenia.   AVhile this
term may still be fittingly applied to those cases where there is
only a predisposition to functional disturbances and disease of
the nervous system, the  close relationship of all these con-
ditions to organic changes is apparent.
   James Putnam,2 in his study of  the  etiology of sclerosis
of the spinal cord, notes the  predisposition by neuropathic
inheritance to degenerative  change,—the suggestion, by
some pathological  findings, of a strain of constitutional or
developmental weakness,—the general  enfeeblement of the
whole body  through  debilitating  influences, as  probably
initial to  a  primary  degeneration  becoming  relatively
chronic,—the increasing importance assumed by toxic in-
fluences  like syphilis, lead, arsenic, etc., and their conjunc-
tion  with  conditions of simple impairment of nutrition  as
contributive,—the influence of over-exertion with stimulation
and sensory irritation  inducing ganglionic exhaustion to a
pathological degree,—and  the  possible relation of acute to
chronic local anaeinia.
   According to Klebs,3 also, the most essential characteristic
of  all degeneration is the deposit in the tissue of substance
derived from nutritive changes in the part.  There are dis-
turbances of assimilation caused  either by the deposition of
non-assimilable material or by a diminution of the power of
assimilation of the tissue ; and the material may originate in
the part or be brought  to it from without.   As an example
of  this,  fatty degeneration is one of the most frequent and
important pathological conditions which occurs in conjunc-
tion with the protoplasmic structures  and the deterioration

           1 Die Neurasthenie, 1885, p. 110.
           2 Jour- of Nerv. and Ment. Diseases, Feb. 1891.
           3 Die Allgem. Pathol. II., pp. 54, 67 and 281, 286. 
20
THE SHATTUCK  LECTURE.
of  their functions.    General  fatty degenerations  always
arise  from influences  which are either of an  infectious or
toxic  nature.
  As to the processes of pure, real atrophy, Klebs says, we
have to deal with two  fundamentally different sorts  of  dis-
turbances of nutrition, according  as the necessary  food is
withheld from the parts,  or the power to assimilate it is
lessened.   In  the central nervous system, the frequency  and
significance of circulatory  disturbance depend on the easy
disturbance of the nervous elements in consequence of  the
withdrawal of nutrition.   The  mental functions may be
greatly disturbed by  even  simple  anaemias  if  continued a
certain length  of time.  Probably material  changes in the
composition of the blood  may  aid in  affording the local
anaemia the time  necessary for  bringing about  the process
of atrophy.   In favor of this  is the connection of many
acute  mental disturbances with infectious diseases, and their
occurrence after typhus, puerperal fever,  and acute articular
rheumatism.
  Pathology  of Neurasthenia.—These pathological con-
siderations indicate the  effects that may follow from such
initial causes as cerebral fatigue,  toxic influences, lessened
power of assimilation,  local anasmias,  etc.,  in  the easily
disturbed nervous elements.  As the greater  includes  the
less,  we must regard  the  initial functional  weakness and
irritability  of  acquired  neurasthenia, proceeding from  the
same  causes, as their  milder manifestations.  Inasmuch as
the "constitutional" taint  or diathesis may be transmitted,
we know not how, certain conditions in the individual may
be regarded  as  consequent upon it and  consistent with
clinical observations.   It is conceivable that the  inheritance
includes no more than " a  molecular or chemical variation "
in the central  nervous  system as the essential basis of  the
predisposition  in hereditary neurasthenia.   This implies "an
exhausted or changed nutritional power " i and it may affect
                    1 Kowalewsky, loc. cit. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      21

any special system or organ, as the central nervous system,
liver or kidneys.
  The foregoing considerations lead to a more precise con-
ception of neurasthenia as  a pathological condition, which
may be  the  outcome  of normal  activities of the organic
mechanism simply carried to excess,  and conceivable as a
subtle,  and  perhaps but  slight,  departure  from a normal
state.   The restoration of cell contents to a normal state,
following the physical  changes observed by Hodge in nor-
mal  fatigue, might  continuously fail  of being  quite  com-
plete ;   and  the "molecular or chemical variation"  would
then become established as the condition of  " exhausted or
changed nutritional  power."
  Habit, Diathesis and Idiosyncrasy.—There  are  other
considerations, relating to the effects observed as accompany-
ing the physiological use of the bodily mechanism, that are
of great importance  here.   They include as an active factor,
constantly and profoundly influencing  all the  activities of
the mechanism, the law of use and practice, constituting the
law of habit; they also include diathesis and idiosyncrasy.
These  modifying factors, or conditions, are nearly allied and
are not always discriminated.
  In regard to the  law of habit,  the  moment  the organic
mechanism is put  in use  the effect of the  law may be ob-
served.  In the reflex action of the organism it is a familiar
fact  that nervous  action  tends  to  follow  certain lines of
conduction,  along  sensory  and  motor  nerves, and through
transforming centres traversed before under like conditions ;
this  constitutes the "nervous circle,"  and  suggests  the
analogy of "paths " in the nervous mechanism.   The well
known effect of practice in the muscular mechanism conforms
to the law of use;  and it  must  be taken  for granted that
analogous processes of practice take place everywhere in the
nervous system and  its accessory organs.
  After any nervous action a changed  condition remains by
       3 
22
THE SHATTUCK LECTURE.
which a repetition of the action is rendered easier, and in all
processes dependent upon  the nervous  system there  are
after-effects which find  their  expression  in  what is called
"practice."1   According to  Wundt, the  molecular changes
in which this practice consists  being unknown, it still claims
material  after-effects, which continue  at  first,  but with no
practice gradually fall  away,  and  do not consist in a con-
tinuation of the function itself, but in facilitating its repeti-
tion ; the remaining molecular effects are to be thought of
as  functional  dispositions.  This functional disposition to
repeat organic processes constitutes the law of habit.2
  The disposition must then be considered as consisting in
a tendency of  cell-contents  to  repeat  the  physical   and
chemical changes that occurred before, upon  a repetition of
the given stimulation.  Thus  use and practice  are funda-
mental to the law of habit, and the conception of the "path
of practice " in the nervous system  implies  ultimately the
disposition of cells and cell-contents to repeat their processes
in such  a  way as  to constitute a habit; and through  the
effect of  habit, there come to be paths of least resistance for
the discharge of energy of nerve-cells.
  The law of sensory and motor habit, in the lower centres
of the mechanism, has a strictly physiological basis, and  the
process is a physiological  one  by  which these neural habits
are acquired,  from the  beginnings  with the labored  first
efforts to the facility of the most automatic of reflex actions.
As already stated a nerve-cell, or group  of  cells, receiving
an  impression  is  modified  in some  way, and   retains an
aptitude  or disposition  for reacting  again in the same  way.
This being true, the same  law  applies to all the co-ordina-
tions of  centres, as  groups of  cells, which acquire disposi-
tions to  act together;  whatever be  their functions,  they
become associated in action, and the law of association  is an
  1 See Radestock, Habit, trans, pp. 15-16.
  2 For further discussion of this subject see my article, " The Mechanism of
Insanity."  Am. Jour, ot Insanity, April, 1891, p. 475. 
        NEURASTHENIA AND ITS MENTAL SYMPTOMS.     23

extension of the law of habit that governs all neural activi-
ties.   There is  abundant  evidence of  such physiological
association, not only between neural and muscular activities
but  between these  and mental  processes.   This is true
whether these processes are simply physiological and normal,
or pathological in their nature.   The effects of  the laws of
habit and association are most significant as to the evidence
that during the  acute  stages of nervous and mental disor-
ders, accidental changes in  the play of nutrition, exhaustion,
and toxic inhibition, disturb the wonted channels of nervous
activity, and the currents  may be  arrested or diverted into
new created paths.   Such  variations of molecular activity
acquired by habit,  also tend to remain as " after-effects"
when  the  causes have passed  away.   The  readiness with
which such morbid  neural  habits may be acquired, and how
intimate are the relations of mind  and  body  in  their influ-
ence upon each other,  have been  well shown by Tuke,1 and
by AVeir Mitchell's  descriptions of  the  mimicry of disease.8
Prince3 has also shown how these laws  of habit and associa-
tion should be extended, in his study of " associated neuroses
and psychoses," in  hysteria, neurasthenia, etc.
   For these reasons the consideration of the constant influ-
ence of these laws  of  use, practice, habit and association,
should never be overlooked in  the study of these disorders
of physiological processes.  The  operation of  these  laws,
when long continued,  aids in inducing and perpetuating the
changes, or "after-effects," which are  conceived as some-
thin or more than "dispositions"  and not yet pathological,
 but as contributory and initial to such conditions and acting
 as "predispositions."
   In  normal conditions,  native  tendencies may  become
 established in the individual, by "education" of the nervous
 system through the operation of these laws.   These  are
           1 Influence  of the Mind upon the Body, 1884, 2d ed.
           2 Nervous Diseases, p. 60, et seq.
           3 Jour. Nerv. and Ment. Dis., May, 1891. 
24
THE SHATTUCK  LECTURE.
 fundamental also to the theory of localization of cerebral
 functions, as the specialization of function of certain centres.
 The remarkable fact  of the  restitution of  function  after
 cortical injuries affords reason for believing that there is the
 formation of new paths  in the remaining centres,  by which
 they become  "educated" to  duties  which  they  did  not
 originally possess.1
   The central and  peripheral  mechanisms  are  therefore to
 be regarded as alike having  specific  functions, both native
 and acquired, both being manifestations of  the law of habit
 and the important principle that our nervous  system, in its
 elementary parts, becomes educated to such specific functions.
 The study of the law of  specific nerve energy, and its re-
 lations to the  law of practice  and habit, furnishes further
 important evidence, not  only of the plastic  and changing
 character of our organic  mechanism when put in use, but of
 the fixedness given by habit to modes of action long in use,
 alike in health and disease.   This reveals the  potent influ-
 ence of habit in all organic activities, whether physiological
 or pathological.
   Native tendencies  when acquired and established  may
 come to be transmitted, appearing as a part of the hereditary
 endowment; then there  is a significant  analogy  between
 them and the recognized morbid " predispositions" which
 must have been largely acquired through the same laws.   It
 is well, therefore, in seeking for the pathology of neuras-
thenia,  to take account  of habit as  an element  both  of
neural  conditions and predispositions.  The force  of habit
tends to establish disordered activities by the direct operation
 of the  law of practice in the  irregular action.   In the evil
 effects  of "disuse*," and  the consequent loss of power, there
 is probably never complete disuse, and the effects of vicious
and deficient practice are manifestations of the primary law
of use.  The recovery from chronic invalidism, through re-
' James.  Psychology, Vol. I., pp. 24-30. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      25

sumption of right practice, finds sometimes striking exam-
ples,  as  in  "mind-cure," hypnotism,  etc.  These laws of
use, practice, habit,  and association in physiological pro-
cesses, also  help to an explanation of the clinical phenomena
of apparent  resistance to nutrition in confirmed neurasthenia.
They cannot be ignored as contributive, and they are, per-
haps, sometimes the sole cause of the underlying molecular
variations in the nerve-cells, whose exhausted and changed
nutritional power  is thus maintained.
   The relations of the diatheses to neurasthenia have  been
noted ;  great interest  also attaches to the study of the more
defined  and limited  tendencies known  as idiosyncrasies,1
which are innumerable in variety ; everybody has them, and
they  are but rarely discriminated  unless  made prominent
by their  singularity and inconvenience.    The  well-known
forms of idiosyncrasies against certain drugs, articles of food,
poisons,  etc., commonly  regarded as  constitutional  and
hereditary,  are known to be sometimes  suddenly acquired,2
when there  had been previous toleration, for example, in the
use of chloral, quinine, tea, tobacco, etc.  The changes in
the organism induced by drug habits are  of equal interest.
   The relations of all  these  phenomena to  molecular and
chemical variations finds explanation in the newer views as
to the physics and chemistry of cell activity.   It is probably
not too broad a conception of the law of habit to regard it
as capable of inducing, in  this way, and certainly as con-
tributory to, both diatheses  and idiosyncrasies.   The views
generally held of  these conditions  or results of activity lead
us to regard them as representing tendencies  to structural
change.   Habit, diathesis, and idiosyncrasy, may be char-
acterized as principal elements of variation in  the organic
mechanism.  In the direction of pathological  change they
describe conditions initial and antecedent to it,  being them-
   1 See Hutchinson, Pedigree of Disease, 1884.
   2 Field.  Art. Six Generic Drug Modifications. Boston Med. and Surg. Jour.,
June 26 and July 3, 1884. 
26
THE SHATTUCK  LECTURE.
selves not structurally  demonstrable, except  as to some
congenital peculiarities  classed as idiosyncrasies.   Habit,
thouo-h primarily normal, must, as a functional disposition
to repeat organic processes, increase the persistency of the
other two conditions.   Diathesis  is regarded  as having al-
ways a pathological interpretation and as being a proclivity*
to some peculiar type of disease;  it is both hereditary  and
acquired,  and carries  the idea of  persistency,—but  it  is
curable,  and having a toxic  element conforms  to the  con-
ception of a molecular and chemical variation.   Idiosyncrasy
is assumed to depend upon some structural change, usually
hereditary and not always tending to disease.   But being
sometimes acquired, and often existing as a susceptibility to
toxic influences, this implies again the occurrence of varia-
tions, of the character already mentioned, that may be initial
to pathological change.   And these implied variations serve
to account for the  manifestations of an exhausted or changed
nutritional power.
   While our present knowledge of the pathological condi-
tions in neurasthenia is  unsatisfactory, even with the most
logical of inferences, we  have to study,  with  all the more
care, the recognized influences at work in the genesis of this
nervous disorder.    In the study of  neurasthenia  it is of
special importance to note that such  individual  tendencies
and  idiosyncrasies may become emphasized with the  lowered
tone  of the nervous system, and  increased susceptibility to
toxic influences.
   Classification.—In  its acquired form,  in  a  previously
healthy organism, it is a primary or a secondary neurosis,—
primary when it is due to the immediate effects  of  nervous
over-strain, or to a primary and toxic disorder of nutritional
processes,—and secondary,  when consequent  upon  other
diseases having a  general  pathological diathesis with  its
peculiar exhausting and toxic influences.   There is an acute
1 Hutchinson, op. cit. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     27

stage, in which the double elements of causation are always
present:  exhaustion with  inanition,  and  toxicity.   It is
important to remember that the  acute stage may continue
for years with a series  of exacerbations, under recurrences
of  the  dual  causes,  and the  tendency of nature to effect
recovery, which may be finally established.  In the chronic
stage there  has  supervened the  " molecular or  chemical
variation" manifested as " an  exhausted or changed  nutri-
tional  power"  in  nerve-cells,—a condition  which  may
sometimes represent a partial recovery.   There  may  be, in
this  stage,  good  blood,  good   muscles,  a  well-working
mechanism, fairly good health, and physical comfort within
lessened limits of nervous strength.   The word chronic im-
 plies more  than  duration,—the transition is complete to
 the stage of  permanent change,  and the "constitutional
 predisposition" is fully acquired and  established.   It is this
 predisposition  transmitted,  which  constitutes  hereditary
 neurasthenia.   In this condition all the forms may occur in
 all degrees of severity, and may be ameliorated by prophy-
 laxis ;  it may even exist so quiescent and  concealed that it
 appears to have acute and active manifestations followed by
 recovery.
    Autogenous  Toxic  Substances.—In  support of these
 conclusions, there would seem to be no unreasonable stretch
 of inference in such an  analysis of the well-known  facts of
 the autogenous production of toxic substances, and of their
 action in the causation of neurasthenia.   Moreover, these
 facts,  and much past conjecture, are now  being reduced to
 scientific order by  the discoveries that have established the
 principle of autogenous disease.   It is shown  that  as the
  poisons of infectious  disease are the  chemical  products of
  the  action of bacteria upon organic matter, so there are like
  poisonous substances  that regularly  result from the chemical
  changes in non-infectious tissue-metabolism within the body.
  Just as ptomaines  are noxious to the  micro-organisms pro- 
28
THE SHATTUCK  LECTURE.
 ducing them,  so are the normal cells  injured  when the
 products of their own activity accumulate about them.  The
 discovery,  in some of these animal alkaloids (ptomaines and
 leucomaines), of the chemical poisons that have long  been
 sought, is  of special interest in the study of neurasthenia.
 Some of the substances,  not  alkaloids, formed in the alimen-
 tary  canal in  the  processes of  digestion, are  powerful
 poisons,—the albumoses and peptones normally  produced
in the breaking up of the proteids in the food.  As Vaughan1
 states it, in discussing the chemical factors in the causation
 of disease,  "it matters not whether the proteid molecule  be
 broken  up  by  organized ferments (bacteria), or by the unor-
ganized ferments of the digestive juices,—by the cells of the
liver, or by  those  still  unknown agencies which  induce
metabolic changes in all  the  tissues,—in  all cases poisons
may be formed.  These  poisons  will differ  in quality and
quantity according to the force which acts." A number  of
observers have shown that the peptones  may  have  an in-
tensely toxic action, should they reach the general circulation
unchanged.
  Hare2 explains  the  symptoms of biliousness as not de-
pending upon  the changes in  the bile,  but upon  failure  of
proper digestion in the stomach and intestine, coupled  with
the development of  irritative decomposition-products in-
cluding a large number of poisonous alkaloids.   Normally
these do not  form in the presence of the antiseptic bile
which counteracts the action  of the bacteria introduced with
the food and is always to be  found in the intestinal  canal.
The disorder of the hepatic function of destroying all poisons
of an organic character permits the entrance into the general
circulation  of these  substances,  some  of which act as  do
curare,  digitalis, atropine, muscarine  and  picrotoxine ; and
the number of these  compounds is indefinite.   He suo-o-ests
            1 Jour. Am. Med. Assoc, May 16, 1891, p. 16.
            2 Practical Therapeutics, 1890, p. 357. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      29

that when symptoms  of  such poisoning appear, relief may
be afforded by the known antidotes for those drugs.
  Brunton1 describes some symptoms  of dyspepsia, gener-
ally occurring about  two hours  after meals, as resembling
curare-poisoning of the peripheral ends of the motor nerves.
There are "muscular relaxation," "a curious weight in the
legs and arms "  which "feel heavy like lumps of lead."  He
says that the "melancholy and depression of spirits,"  asso-
ciated with disorder of the liver, depend upon noxious sub-
stances  passing  into the  general circulation because the liver
fails to  arrest them.    He notes the " hypochondriasis and
depression of spirits" associated with  oxaluria, when "the
patients complain  of incapability  of  exerting themselves,
the slightest exertion  bringing  on  fatigue."  Severer  cases
      ©                  ode
in  the  asylums have been described as  the insanity of
oxaluria.  But  Brunton says  these symptoms may occur
without oxaluria, and he conjectures the  presence of some
poison  in the blood.
   Halliburton2  describes choline and neurine as ptomaines
which may also be formed during life as leucomaines in  the
metabolic processes.   Choline is of great  importance as a
type of  these alkaloids,  and neurine is closely related to it.
Both act like  curare on the  end-plates.    Muscarine,  the
alkaloid from poisonous mushrooms, is of the same class,
and can be obtained also from choline  by oxidation ; it acts
directly upon  the muscular tissue  itself.   All  these  are
powerful poisons, and are antagonistic to  atropine in their
special  action on the heart and glandular  system.  Choline
was first obtained  by Strecker from bile, but choline and
neurine are among the  chief products of  decomposition of
lecithin.   This  important constituent of  nervous tissue is
found also in muscle, blood, and wherever cellular elements
exist in the body ; it is  also in eggs, milk, cheese and other
forms of food.
           1 Disorders of Digestion, 1886, pp. 42, 47-
          * Chemical Physiol, and Pathol., 1891, pp. 178, 530. 
30
THE SHATTUCK  LECTURE.
  In the changes of nitrogenous  metabolism  from nervous
and muscular tissue  through the complex series  of transi-
tion-products to the end-products discharged as  urea, uric
acid, etc., these are notably augmented after excessive mus-
cular work.  There are a number of the  intermediate  sub-
stances  which  are  credited  with possessing an  intensely
poisonous action ; this includes the  familiar phenomena  of
the still  undetermined  ur&mic poisoning.    According  to
Gautier,1 in the cycle of changes  in  the  normal  tissues  of
the body, there is  constantly  going  on  the formation  of
leucomaines and their subsequent destruction by  oxidation
before they have accumulated in  sufficient quantity to  pro-
duce poisonous effects.   Hydrocyanic acid plays a very im-
portant part in the molecular structure of  these bases.   One
of them, for example, xantho-creatine, studied  by Gautier,
is poisonous, producing in animals depression, somnolence,
and extreme fatigue ;  and it appears in physiologically active
muscles along with creatinine.   Monari has found this base
in the aqueous extract of the muscles of an exhausted  dog,
and also  in the urine of soldiers tired by several hours walk.
   The formation and excess of uric acid  in the  body, and
its  elimination, have been among  the  most  thoroughly
studied of  all the tox:c conditions.   Whether  it  is due to
an excessive formation  in  the liver, a defective  excretion
by the kidneys, or  to some abnormal state  of  the nervous
system, the many observers agree to its  production  of the
marked symptoms noted by Murchison,  among  which are
lassitude, headache, vertigo, insomnia, depression  of spirits,
irritability of temper, etc.   Garrod ascribes its retention to
failure of  excretion;   and  Haig2 has shown  that,  being
formed by normal  processes, its storage in the  body,  or
excretion,  are greatly  influenced by  the  comparative  al-
kalinity  of the blood, which may be made to vary  at will,
  1 Vaughan and Novy.  Ptomaines and Leucomaines, 1888, p. 269.
  8 Uric Acid in Diseases of the Nervous System, Brain, 1891, p. 63. 
NEURASTHENIA AND ITS MENTAL SYMPTOMS.     31
within considerable limits, by the kind of food, the process
of digestion, and the use of  drugs.   Thus the  ingestion of
acids, etc.,  reducing the alkalinity of the blood, and  there-
fore its solvent power, causes the accumulation of uric acid
in the tissues.   The blood being freed of uric acid, there is
diminished  arterial tension,  better  cerebral  nutrition, and
sometimes a temporary sense of well-being and exaltation.
This condition of the circulation is opposed to the elimina-
tion of uric acid, and favors  storage and retention  in the
tissues, tending  to later trouble.   But in such cases, when
from any cause there is increased  alkalinity  of the  blood,
the uric acid is  more soluble, and its presence in the circu-
lation  produces the mental symptoms described.1  Macfar-
lane2 believes that the lessened alkalinity of the  blood is the
important cause of the disorders of sleep in the gouty,  as
being  dependent primarily upon mal-nutrition  of the cere-
bral cells,  which  renders them irritable snd responsive  to
faint impressions.   Cells  imperfectly deprived of  their
detritus do not appear  to  take  up oxygen  readily, and
consequently they cannot be adequately nourished ; they
eventually  assume a state allied to that  met with in  neuras-
thenia.
   According to Haig, uric acid  in the blood contracts the
arterioles and capillaries all  over  the body, producing cold-
ness of the  surface and extremities, and  the headache  of
migraine as  a  local,  vascular  effect of uric acid.    With
lesser effects there are mental depression, dulness, and ina-
bility  for mental effort.   Von Jaksch,3 using the term uric-
acidgemia, has recently found that uric acid  accumulates in
the blood not only in gout  but in anaemic  conditions, and
considers that the cause of its appearance  is defective oxida-
tion.    Many observers have attributed gout to the  nervous
  i Ibid.  " Mental Depression and the Excretion of Uric Acid." Practitioner,
Nov., 1888.
  * Insomnia, 1890, pp. 234-236.
  3 See Halliburton, op. cit., p. 733-734;  and Haig, loc. cit. 
32
THE SHATTUCK LECTURE.
system.   Sir James Paget has pointed out that gout mainly
affects the sensory  parts  of the nervous  system.   These
studies show,  in respect to this one toxic influence, that its
presence in the body, in  other conditions as well as  the
gouty, bears an important relation  to  the  disorders of  the
nervous, circulatory and nutritional processes,—and to that
striking  symptom  of  a  sub-normal  surface  temperature
which is persistent in some forms of neurasthenia ;  it also
produces  characteristic mental symptoms  and  disturbance
of the sensory functions.1
   The way in which repeated muscular contraction causes
what is known as fatigue, is however very uncertain.  In
regard to the effect of the accumulation of  products of com-
bustion,  the increased acidity of fatigued muscles has been
noted by numerous observers since Ranke2  pointed out  the
depressing effect on muscular irritability  produced by all
acids,—the carbonic and  lactic among others, the muscle
being alkaline in a state of rest.  This excess of acid mani-
fests itself subjectively by the sensation of  fatigue, followed
by sleep.   The revival of exhausted muscles, upon renewal
of the blood stream, is due probably both to the  removal of
the acids and other products of contraction, and to the fresh
supply of oxygen,—the chief end-products of carbon and
hydrogen metabolism being  eliminated by several channels,
expired air, sweat  and urine.   Mosso3  considers that  the
poison which causes the symptoms of exhaustion is probably
not carbonic acid, but a substance produced in  small quan-
tities of  an alkaloid nature.
   In regard to the results of exercise of nerve tissue, it is
believed by some that fresh  brain, cord, or nerve, has nor-
mally an alkaline reaction.   All  observers, however,  agree
on the  most important fact,  that acidity, whether  present
  * See a review of the subject of auto-intoxication, in an editorial article on
  Fatigue as a Cause of Disease." Bost. Med. and Surg. Journal, June 28,1888.
  2 See Halliburton, op. cit., p. 433.
  3 Report of Internat. Med. Congress, Berlin, 1890. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      33

initially or not, increases on activity, and on  death,  and is
probably  due to lactic  acid.   This  inevitably suggests  a
comparison between nerve  and the closely  related tissue,
muscle.   The only known chemical changes during activity
of nerve  tissue is  the increase of acidity ; the only known
physical change is an electrical one, other than those shown
by  the demonstrations of Hodge.   Some  light may come,
from such studies, upon the darkness of our knowledge with
regard to the essential molecular changes that attend nervous
activity.   In' the chemical  reactions the great importance
of a healthy blood-supply is noteworthy here ;  the depriva-
tion of the  oxygen it  affords means an  abolition of  all
the  higher cerebral  functions, such as  consciousness and
volition.1
   There  can be little doubt that certain febrile  conditions
are autogenous ; they may  be due to excessive formation of
poisons in the body, or an  accumulation  of these  through
deficient elimination.  Bouchard  has shown that the urine
excreted  during the  hours of activity is  much more  toxic
than that excreted during the hours of rest.  Both  physical
and mental labor are accompanied by the formation of the
poisonous substances which  will accumulate if  the hours of
labor are  prolonged and those of rest shortened.2  As a
result of deficient elimination, "fatigue fever" is not uncom-
mon in its milder  forms, with its symptoms of impaired
appetite,   mental  and physical "irritability,"  restlessness,
insomnia  or fitful and unrefreshing sleep, and an  excited
brain  that will  not rest.   In a  severer  degree this self-
produced condition  is the "fever  of exhaustion"; and this
leads up to the deadly typhus which is  the highest  expres-
sion of the poisoning of the organism  by  itself or  by con-
tact with others under like conditions.3
   The general truth of  this matter is well summed up  by
        1  Halliburton, op. cit., pp. 515, 516.
        2  See Vaughan and Novy, op. cit., p. 293.
        3  See Aitken, The Animal Alkaloids, 2d Ed. 1889, p. 28. 
34
THE SHATTUCK  LECTURE.
Aitken1 when he  says that " the healthy living organism
may become poisoned  (gradually and more or less slowly)
by the accumulation within  its  self of deleterious substances
normally elaborated.   Hence the slow and insidious  onset
of much ill-health ; and from which recovery  is correspond-
ingly slow."  The few  examples  cited serve to show the
nature of the evidence, and that we have constantly to deal
with  definite toxic influences  in the processes of nutrition
and the discharge of energy in the  organic mechanism.   It
is true that we have as yet little precise knowledge of  these
toxic substances, and of their effects upon the nervous sys-
tem.   Many of those obtained are  probably  formed by the
action of the reagents used in the analysis, when their  exist-
ence in a free  state,  in healthy tissue,  is very doubtful.
But  though the science is yet  in  its infancy, we   know
enough to recognize  the  immense clinical importance  of
studying  the  chemical elements whose  positive influence
in the production of nervous symptoms must  now stand  as
an unquestioned fact.  It must be remembered also that we
are still compelled to study  functional  " activities," and dis-
ordered conditions of which  we can  find no trace in  the
organism.
  The study of the  general  organic  mechanism, so far,
shows that it may  be conceived as made up of many  minor
mechanisms which may be  studied  as represented by  their
activities.  Some  general  truths have been reached in  re-
gard to all of them as to their structure, their co-ordina-
tions, and the  results of their functional exercise.  These
conclusions are in support  of my first proposition, to  the
effect that,  when the mechanism is put into  use, physiolo-
gical activity and toxicity always occur together, and that
the condition thus  jointly produced has its  first  expression
in normal fatigue.   Moreover  it appears  that  in patholo-
gical  fatigue  or  nervous   exhaustion,  which  constitutes
              1 The Animal Alkaloids, 2d Ed., p. 20. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      35

neurasthenia, there results from excessive use and inanition,
a condition of " excessive irritability and  weakness " of the
nervous  system.  There is also,  in acute  neurasthenia,
always an increased toxicity, by its accumulation in fatigued
areas,  and  often  by general fatigue and auto-intoxication
through disordered nutritional processes.
   2.  JSlental  Elements in  Normal and  Pathological
Fatigue.—It is next in order to make a practical application
of general truths more precisely to the nervous and mental
mechanisms,  and  their special disorders in  neurasthenia.
This leads to  my second proposition, that to properly  study
our  problem  we  must  take  into  account the nature and
manner  of production of the mental symptoms common to
nervous exhaustion  and  insanity.   This brings out  the
main purpose of this  study of the relations between mind
and body :—to show how it is that  the mental  symptoms
furnish a ready index of the fatigue and auto-intoxication
 of nerve  and  muscle tissues, as a  guide  for  diagnosis,
 prophylaxis,  and  treatment;  and  also  to  show how  the
 general symptoms  of  nervous exhaustion  can  be  better
 understood by a proper interpretation of the  mental symp-
 toms.  The acute, acquired form  of neurasthenia  will  there-
 fore  be first considered with reference to the mental symp-
 toms, to show  what  they are, and how they are produced.
   All observers agree  that the symptoms of neurasthenia
 are largely subjective.   There  are objective  signs, but the
 physician mainly depends upon the  patient  himself to tell
 how he feels.  Every physician also  learns to qualify such
 statements according to his estimate  of  the  individual  and
 his mental state, under the bias of the characteristic "hope-
 lessness" and " worry," or even of the less intense "depres-
 sion of feeling."   These  symptoms pertain to the state  of
 the feelings, and constitute the emotional tone,  in  its  inti-
 mate dependence upon  bodily states which afford a general
 sense of comfort or discomfort,—of well-being or ill-being, 
36
THE SHATTUCK LECTURE.
more or less persistent.  This is quite independent of the
intellect,  and the passing feelings  which are normally at-
tendant upon pleasing or painful ideas.   These  disorders
of the feelings  and the emotional state constitute one dis-
tinct group of mental symptoms.
  All  the writers  on this  subject  have also given  promi-
nence to the striking clinical manifestations of "inability to
concentrate the mind,"—the weakening of the power of at-
tention.   Here  is another important group of  symptoms
that represent disorders of  the intellectual activities and
the voluntary power.   The most prominent of these, as a
sensitive  index  of nervous fatigue  and exhaustion, is the
attention.
  The Primary Data of Mental Activity,—two groups.
—All these mental activities have to deal with sensations as
furnishing the primary data of their operations.  There are
two groups also  of these  sensations :—the  first are the gen-
eral  organic  sensations, not intense enough  ordinarily  to
pass over the threshold of consciousness, but they constitute
the vast subconscious  inflow of minor sensations through all
the  sensory channels that lead to the sensorium from every
tissue  and organ,  and  from  every peripheral mechanism,
nervous or muscular,  in the  body;  the  second  are those
we are conscious of as presented through the special  senses
and  that  stand  in the  mind as perceptions,  ideas  and
memories;—these  are the  data of consciousness.   The
great complexity of this  matter can be made intelligible by
taking a  little time and patience to  grasp  some general
principles, and to reduce the complex elements to an orderly
arrangement in our conception of the mental mechanism.
  (1).  Organic Sensations and the Emotional  Tone.—
The organic sensations in the subconscious mechanism, de-
mand first consideration as best revealing something  of the
mystery  in the  relations between mind and body, and the
genesis of the mental symptoms in neurasthenia.  These 
        NEURASTHENIA AND ITS MENTAL SYMPTOMS.     37

 sensations, proceeding  from all the states of the body,  are
 in  some  degree  and form represented in the sensorium.
 They constitute the  sense  of  body,—the  sense  of person-
 ality.1   The line cannot be strictly drawn between the con-
 scious and the subconscious activities,  as  to  these organic
 sensations.  Many of the  sensations received through  the
 special senses and giving  knowledge  of the outer world,
 enter a passive consciousness, as the ticking of a clock that
 is not consciously perceived unless it stops, or  attention is
 turned to it.   There are  still weaker  sensations, coming
 through  the special senses, of which we are not conscious.
 In  like  manner, but  in  reverse   order,  the  great mass
 of the organic sensations  are  normally  unperceived,  but
 some  of them may  be intensified  enough, as by some dis-
 order, to  enter the  field of consciousness.   Those arising
 from the trophic, and  minor  inhibitory  mechanisms,  are
 among the most subtle and unfelt, as are those  from  vaso-
 motor changes in the general  and local circulation which
 are  most  important in their influence  upon mental states.
 But even among these, the inner  tingling sensations, fol-
 lowed by general chilliness and external pallor upon a sud-
 den idea of great danger, are  probably due to  the  swift
 vaso-motor constriction.    There  are  also  the  normally
 unperceived, though incessantly repeated sensations, which
 provoke and accompany the respiratory movements.  They
 may arise also  from the state of the muscles after exercise,
 even when inactive,  giving the feeling of fatigue and ex-
 haustion ;  or in an opposite condition may afford a general
 sense of vigor.   The muscular sense is a stronger repre-
 sentation  of the  organic  sensations  that are  sometimes
 classed with the  special  senses.   Hunger  and  thirst  are
 not localized sensations, but result from a discomfort of the
whole organism, being connected with the state of nutrition.2
 1 Ribot. The Diseases of Personality, trans. Chicago, 1891.
 2 Bain.  " The Senses and the Intellect," 3d Ed., 1888, Part II.
      4 
38              THE SHATTUCK  LECTURE.
   Sense of Well-being .—These normally latent or obscure
sensations, low  in intensity but  great  in volume, are per-
sistently flowing inward  beneath the fewer  but relatively
intense  and transient sensations from the special senses.   In
the healthy organism, refreshed  and vigorous, there is  an
equilibrium of physical sensations, or a multitude of agree-
able feelings attendant upon the exercise  of normal power.
This physical state produces a  mental  sense of well-being;
the persistence of this will give its special character to the
physical and mental  habitude,  or  the personality  of the
individual.
   Sense of Ill-being.—But in the conditions, represented
by a sense of ill-being, there are feelings of fatigue, depres-
sion, anxiety, languor, absence of desires,  a sense of lack
of power, of self-depreciation, and of personal unworthiness,
etc., of which the patient gives  account.   Beard  has well
characterized  this  " as  an  instinctive  consciousness  of
inadequacy for the task set before us."  " We are hopeless,"
he says, " because our nerve force is so reduced " ;—"a cer-
tain amount of  nerve  strength is necessary  to  supply the
courage requisite for simple existence."   The persistency of
these feelings is marked by a visible change of personality.
In slighter degrees these changes  are like those commonly
seen in  the  evening  tire of  an active  man,  from  which
restoration follows.   When,  however, in the processes of
waste and  repair, the balance  turns slowly and insidiously
to the  side of weakness of nervous  tissues,  whose corres-
ponding mental  activities show these symptoms of disability,
they stand as evidences of a  neurasthenic condition.  As
these morbid physical states persist, the ideas suggested  by
the morbid feelings,  and to account  for them, are framed by
degrees into some wrong conception.   Although there are,
however, many  cases of melancholia without delusions, yet
beliefs may be engendered consistent with the morbid state
of hopelessness, self-reproach, and worry.   In many  cases 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     39

special  delusions  are formed  for which the patient  gives
reasons, with a degree of intellectual integrity that is  pecu-
liar to melancholia.   These  allied  organic  and consequent
mental changes profoundly modify the personality in its in-
most  nature.    By  the  process described  this  is not the
violent and superficial effect  of sudden emotions, but results
from a slow and subtle process that irresistibly changes the
basis of the personality.   It  is easy to see how such morbid
organic sensations may be engendered in a  general neuras-
thenia and  produce  such a  train of  nervous  symptoms,
characterized by a sense of ill-being,  depression and  hope-
lessness.  Like results may come from  nervous  exhaustion
initiated in the brain itself, by  mental  overwork,  care and
anxiety.  Here  is  the  bond  between  well-being and ill-
being of body and the emotional tone.   It  is plain how the
changing states of mental feeling reflect the bodily states in
the alterations of the sense of  personality.
   Mental  Symptoms  of Auto-intoxication.—The new
evidence in regard to the  toxic elements engendered in the
body sustains these views, and  seems to offer the long sought
explanation of  many obscure conditions.  Full force should
be given to the fact that in all forms of functional activity
the fatigue proper, from the discharge of  energy and the
breaking down of material cell contents, has  always joined
with it the toxic influence of self-produced  waste products.
A\re are able to account for much that appears confusing in
the symptoms  of fatigue, by  ascribing their variations  to
differences in the kind and quantity of the  specific poisons
that are  developed in the various tissues.    For example,
while melancholia is generally  characterized by a disposition
to quietude  and  shrinking into seclusion,  some cases are
marked by great  mental  agitation and physical restlessness,
the essential physical and mental condition  being the  same.
A fair inference is that there is an irritating intoxication  in
such cases.   But  again  there  is the peculiar condition  of 
40
THE SHATTUCK  LECTURE.
  apparent stupor added to the ordinary melancholia, so  that
  in extreme cases the patient cannot move his limbs or utter
  a word, and the facial expression is blank.   This presents a
  more profound degree of the condition described by Brunton
  as like the poisoning by curare of the muscular mechanism.
  The absence of true psychic stupor in many such cases  is
  well proven.   It has been seen that these symptoms may be
  produced by  choline, neurine,  and muscarine, which are
  antagonistic  to atropine.   In  Hare's suggestion  that it  is
  possible to give relief by antagonistic remedies  when there
  are signs of auto-poisoning; he  mentions  dilated  pupils, a
  hot and  dry  skin,  dim  eyesight, rapid pulse,  as like  the
  effects of atropine.  Symptoms  resembling  them  in lesser
  degree  are seen  in  both • neurasthenia  and melancholia.
  Again a slow  and  full pulse with  high arterial tension, and
  a throbbing frontal headache,  suggests the  ptomaine like
  digitalin.   Some of these poisonous substances lower  the
  temperature ; it is often sub-normal in the graver neurasthenic
  conditions.  Upon the basis of such causes, and such a method
  of production, the  "excessive  irritability and weakness" of
  neurasthenia seem  amply accounted for.  By  means of local
 perversions, the weaker organic sensations sometimes  come
 to be felt, and may be so intensified  as  to bring them into
 the group of those that are consciously perceived and local-
 ized.  Languor, dulness, stupor and lethargy are like mani-
 festations of toxic influences.  These altered  sensations will
 be hereafter described.   They  are  of great psychological
 importance.   Reference has  already  been made to the re-
 lation of uric acid to diseases of the nervous system, and the
 characteristic symptoms  of lassitude, depression of spirits,
 etc.   Its formation, elimination, and possible  excess in the
 blood, are so essentially connected with the processes of waste
and repair as to make  these  symptoms most  significant  in
their relation to neurasthenia.
  The conditions of mental feeling, marked by the emotional 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     41

tone,  as states of well- or ill-being, have now been shown to
be intimately bound up  with the  great  volume of subcon-
scious bodily feelings, and representative of their predomi-
nating quality.  They are normally so low in intensity as
to be  undiscriminated ; but when intensified by morbid con-
ditions they become symptoms of  the existing disorder.
   (2).   Sensations from the Special Senses;—Percep-
tions, Ideas, etc., and Disorders of Intellect and  Will.—
It now remains to consider the other group of symptoms repre-
senting disorders of the intellect and volition as distinguished
from mental or physical feeling.  Of these disorders the most
important indications pertain to the attention.  All writers
on neurasthenia have noted the fact that the mental  symp-
toms  of the higher order are always prominent.   But what
is wanted is a sufficient analysis of them to show their two-
fold  significance.   A brief explanation should  make this
clear, and easy to understand, as it is necessary to be known.
On the  one hand the  disorder  may begin below in  the
sources of organic sensations, and  extend upward  into  the
higher mental  sphere.   The great mass of sensations  be-
neath are summed up into  our sense of physical personality.
Compared  with them, all  that comes  into our  conscious
minds through  the  special senses,  and  the  succeeding
perceptions, ideas, memories, judgments, feelings and voli-
tions, in the "circuit of consciousness," represents a small
item.    In  acute  neurasthenia, and true melancholia and
mania, there is always nutritional, toxic and functional weak-
ness,  fundamentally, in the organism ;  it is from this  that
the influences arise which  affect  our conscious feeling and
thinking making  these higher mental states the sensitive in-
dices  of the lower  physical changes.  For like reasons these
subconscious changes of personality, pervading and volumi-
nous, have a predominating influence.   When all goes well
with the organism, and it is in a condition of unfelt equilib-
rium, the processes of thinking and  feeling are adjusted, 
42
THE SHATTUCK  LECTURE.
more or less logically, to the varying environment, upon a
basis of a sense of well-being and normal love of life.   On
the other hand, a morbid process may be started  in these
higher activities, in a previously healthy and strong  organ-
ism ; but until the organism  itself suffers  a change to  the
specified nutritional and  functional weakness, there can be
no such mental symptoms as are  being studied here.  Nor-
mal mental  activities cannot produce " mental  symptoms "
except by first causing the characteristic  " weakness " some-
where  in the physical basis of them all.
   Familiar Facts of Mental Manifestations.    Consci-
ousness.—There is no need, in this matter, of entering into
psychological  speculation.   It  is  only necessary to consider
the final facts  of the manifestations of mind with which we
are most familiar.  We commonly  note the fact of con-
sciousness for  example, and distinguish between such states
as its absence  in coma, its  partial presence in sleep, or its
full activity in an alert and intelligent mind when we cannot
doubt  that some activity of organic elements is added which
was not present in the less active states,—as of coma, for ex-
ample.  We  use many phrases to describe different degrees
of this activity, meaning  always a  state  of consciousness
the sum total  of all its activities.
   The Attention.—The attention is the term applied to de-
note the mental action when a particular object of thought
is held in mind to the exclusion of others.  Active con-
sciousness is always attending  to some one  presentation in
its field,—this action is attention, and this activity is always
going  on in connection  with every other mental  action, or
object  of  thought.   The mind may attend to the  presented
perception  of  a   new  sensation,—a  re-presentation  in
memory,—an  abstract conception,—or the idea of a mus-
cular   movement.   The  larger importance of the  attention
is due  to the fact that in  it  resides the inhibitory power over
all mental operations.   The attention is to these  what  the 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      43

physiological principle of inhibition is to the lower  nervous
mechanisms.  It is the abatement of this higher inhibitory
power,  and  of its  regulating and  guiding  control, that
appears early and most  constantly in mental fatigue and
weakness.   This is manifested by changes in  the power of
attention.
  Ribot1  has made very clear, by a  simple  analysis, the
office of the attention.   It acts in  two  forms :—voluntary
attention is its acquired form gained as a result of the higher
evolution of man ;—spontaneous attention is  its natural or
primary form, when its action is attracted or reflex, as is so
manifest in children and animals.
   Spontaneous Attention.—Spontaneous attention being
first considered, the essential fact is that it is always attracted
to the object or idea  in  the mind  that most interests it, or
keeps it on the alert.   This  idea may be  intensified  in
interest by pleasurable  or painful  feeling,—by  a  desire or
a fear.   Now it has  been shown that when  the emotional
tone represents physical  well-being or  ill-being, ideas har-
monious with the  emotional tone will be intensified.  It has
been shown  also  that in  states of  ill-being and depression
the attention is persistently attracted by painful ideas which
are  thereby  further  intensified.  Thus  a state  of  habitual
mental  pain  shows  attention  attracted by,  and dwelling
upon, painful ideas.   This is the  basis  of worry,  and it is
thus shown how worry  intensifies its  own  cause.   The
clinical significance of worry, therefore, is that the weakened
attention is being  occupied  by painful ideas  which  are
intensified by the exaggerated  influence of a painful emo-
tional tone representing  a  weakened  and irritated physical
basis.  The painful ideas are  further  intensified  by  the
concentration upon  them of the attracted attention.   When
only attracted  attention  is  in   action,  as  in  extreme
conditions,  the spontaneous  flow of ideas  goes  through
         1 The Psychology of the Attention, trans., Chicago,  1890. 
44
THE SHATTUCK LECTURE.
 the mind in a wandering train, as in dreaming or delirium,
 without check or guidance ; and those ideas in the train most
 attract the attention  which are then in harmony with the
 emotional tone.
    Voluntary Attention.—The exact antithesis of this  is
 voluntary attention.   As to this, the essential fact is, that
 it is the  activity of inhibition.  The attention  directed and
 concentrated upon a  chosen  object of  thought is an act of
 volition.   A man controls his own mind by  willing his
 attention, as it were,  to be fixed upon some  one item or
 object, in the train of presented ideas,  to  the  exclusion of
 others.   He thinks about  what he chooses to think about:
 he may make the most worthy object  the  most interesting;
 by  dwelling upon  its  worthiness  he  intensifies it,  thus
 resisting  the attraction of less worthy interests and emotions.
 This directing of the  attention by the will may control and
 guide the processes of thinking,—may inhibit the prompt-
 ings of the emotions in  conduct; and it does manifest itself
 in  all  voluntary  action.  Attention  has  always  a motor
 element and expresses  itself in muscular movement.  In
 a healthy man,  with a  refreshed and vigorous  organism,
 and a trained intelligence and  attention, is found the most
 efficient expression of this  higher  power of inhibitory and
 guiding control.   This is an acquired power,  improved by
 training.   Now it is plain to see the importance of the clini-
 cal signs in regard to the higher inhibition.  Let there be
 weakening of nervous energy  from  any  cause,  then  the
 weakening of the voluntary  attention is a direct and immedi-
 ate sign of mental and general tire or exhaustion.   It  may
 be that, in such  a state,  as much or more "control " is exer-
 cised,  but it requires more effort and expenditure of nervous
 energy.
  The more the  higher control  power is lessened, the more
the spontaneous  attention is  left free to act.   The Gradual
reduction  of  the control power of the voluntary attention is 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     45

matter of common clinical observation  in  normal fatigue,
neurasthenia, melancholia, etc.   Here then  is further shown
the bond that  extends between  the  changes in the physi-
cal basis of  the personality and  the  changes in the  higher
power of attention which thus becomes  a sensitive index of
bodily conditions.   The  mental   attitude  at  any  given
moment  is determined by  the state of the attention.   This
is  always tending to act in a reflex and spontaneous manner
according to the  emotional tone, as attracted  by the most
interesting ideas.   When  bodily feeling is in equilibrium
the voluntary  direction of the  attention  is  easiest;  but
direction is always inhibition,—by  will and choice the ideas
are held in view that  stir the worthiest feelings, or a con-
senting will yields to those made interesting by desire.   Then
feelings as motives add intensification to the mental attitude,
and again we find the potent influence of the emotional tone.
It controls or  is  controlled.   This brings  out the practical
point that is of  present interest,—the need of the higher
inhibitory control and what it works against.   According to
Foster, just as physiological inhibition plays its part in the
lower mechanisms, so is it important in the whole work of
the central nervous system.   He says,1   "In all probability
many of the phenomena of nervous life are the outcome of a
contest between  what we call inhibitory,  and  exciting or
augmenting forces."
   Another practical point is of the greatest importance here
in regard to the  higher  inhibitory control,  acting through
voluntary attention.  It is the application of the principles
in the laws of practice, habit, and association.   The mental
activities do not escape the full force of  these laws.  When
once  a mental  attitude has been determined by the inter-
play  of  ideas,  feelings, and controlling or consenting will,
there  is a  functional disposition to repeat  the organic and
attendant psychical processes.  "Habits of thought" are
                      1 Op. cit., p. 918. 
46
THE SHATTUCK LECTURE.
acquired,  and they are characterized  either by a habit of
yielding to impulsive emotion, or as  determined by  a  con-
trolling inhibition.   The principle  of practice is  in like
manner always  ready  to  reinforce the power of voluntary
attention.  Hence we see  that the attention, as the agent of
the will,  has  to work against also  the effects  of practice
and  habit  which tend to become fixed by states of feeling,
the associations of which with ideas are also strengthened
by  habit;  while at  the same  time,  voluntary  atten-
tion  trained by practice leads to  the  highest  acquire-
ments  of  mental power.   Conversely, we see the import of
the lessening of inhibitory,  selecting, and  directing power.
in states of nervous fatigue and exhaustion.  Whatever the
physician may discover in the bodily  condition of his  neuras-
thenic patient, or whatever he may infer of its pathology,
he should always remember the effects of habit in the  men-
tal activities.   The nervous invalid  may remain such, even
under  strongly recuperative tendencies, simply from mental
habit,  confirming it both by misuse and disuse of  normal
power.  The patient, powerless to contend alone against the
forces  of weakness and habit,  must have a physician for both
mind and body.
   Mental Symptoms in Normal  Fatigue.—The fatigue
of the attention will vary in  its manifestations in different
degrees of nervous fatigue and exhaustion.   Its predomina-
ting significance is  also  shown by its relation to mental
symptoms which may be sufficiently  illustrated  by  a not
uncommon experience.   Suppose that after a day's profes-
sional labor you have spent  a long evening at your desk.
Your  probable mental condition may then be as follows :—
There is lessened mental activity.  Voluntary attention is
fatigued, and  in spite of much effort you repeatedly find
your spontaneous attention  attracted along some  train  of
ideas to a subject remote from the  one  you are tryino- to
keep in mind.  Sense-perception is  less  acute,—the  atten- 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      47

tion shows fatigue by inattention to incoming sensations.
There is less power of memory,—it is less retentive, because
diminished attention to impressions renders them less vivid,—
its  recalling power  is  slower  and  weaker,—and  in the
underlying association of ideas  there is a spontaneous flow
which  is  controlled  only  by unusual  effort  of  will,—the
association process is itself slower, the vocabulary diminishes,
and even  familiar names  and words may  not be recalled.
The logical processes work more slowly in making compari-
sons and judgments,  and in reasoning  to conclusions,—-the
tired attention with  effort holds on to one  member of  a
proposition while  another  slips  away.   With growing
torpor your attention may cease  to  be stimulated and you
may fall asleep.   There is a lowering of the emotional tone
and a quietude of feeling with lessening of natural vivacity ;
there is a diminished sense of adequacy of power, and tasks
seem difficult that after  rest will appear easy enough.   An
abatement  of  power to control  the  motor  mechanism  is
apparent  as requiring more effort  of attention.   This  is
normal fatigue ;  it will be seen that  in every phase of these
 activities the attention shows the effects of fatigue in lessened
 control.   Restoration follows when in the repose of rest  and
 sleep, the circulation removes the acid  waste products, etc.,
 that caused the somnolence,  while it supplies the materials
 for rebuilding the cell-contents  so that  they may again yield
 energy upon being stimulated.
   Mental Symptoms  in  the  Genesis of Pathological
 Fatigue.—When the  process  of  restoration is continu-
 ously incomplete, and  after a time a  similar degree of ex-
 haustion  is persistently  established,  the symptoms may not
 be quite  the same in respect to the  toxic influences.  It  is
 plain  that there will have been going on an active process
 of removing them,  though  incompletely ;  and we have  to
 conceive of a partial inanition and an irritating intoxication
 as  contributing  to  the  "excessive irritability" when  it 
48
THE SHATTUCK LECTURE.
exists, as it commonly does, in neurasthenia.   Then the
normal  fatigue  has  passed over into pathological fatigue.
Recurring  now,  for  example, to  the  picture  of evening
fatio-ue, after a day of hard work both physical and mental,
a significant sequel might follow it.   Suppose then you are
suddenly called to a patient, whose life is in danger.  You
are aroused.  For many  hours  you may anxiously work
over the case with no apparent lack of energy or failure  of
the resources  of your experience and skill.   But when re-
lief comes,  and  you try to get  rest in sleep, you only lie
awake, restless,  your mind excitedly reviewing  the  scenes
you have passed through, your will powerless to inhibit  the
train of ideas, and you have a painful sense of nervous ten-
sion and irritability.
   There would   seem to be in this  condition a  ready ex-
planation  of acute exhaustion,  or excessive fatigue  and
toxicity.  This  is the  initial stage of pathological fatigue.
Such an incident is  instructive  in many ways.  It shows
how the store of nervous energy  is held in reserve,  within
the limits  of  normal  fatigue under ordinary stimulation.
But unwonted interest  being aroused and attention  stimu-
lated, the mechanism responds with an increase of cerebral
circulation,  and  large  cortical areas are  probably  excited to
action.   While  more  nutrition is  thus  taken  up,  more
energy is given  out;  and  although there is  a more rapid
removal of  waste products it  is not complete,  and  these
gradually accumulate  until some  degree  of exhaustion is
manifested.   Then in the search for the power of control
over mental processes,  the attention  failing in its  office
becomes conspicuous by its absence or lessened power.
   The mental mechanism is commonly stimulated to action
by  the external   circumstance, as in the incident just  re-
lated.   The interest excited by the event arouses  the atten-
tion which, acting   in  both its  reflex  and   voluntary
forms, intensifies all  the mental activities.   A like experi- 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     49

ence  is still more  common, in  which there is absence  of
immediate objective interest, and the mental  action proceeds
more subjectively and from volition.  Take another instance
of evening fatigue, and  suppose, for example,  you have
been delaying the writing of a medical paper which must be
read to-morrow.  With fatigue equal to that yielded to many
times before, you approach  the  task to  which a  mixed in-
terest is now  added by your reflection upon the need  of
preparation and the consequences of  failure  to acquit your-
self properly.  With much effort of will and attention, you
apply yourself to the beginning of the  mental work.  Pre-
sently the sense of  fatigue and  effort has passed away,—the
subject itself gathers  interest,—and  you  have a  sense  of
satisfaction in the  exercise  of  mental power.   You may
desist at last, not with  consciousness of mental fatigue, but
because the lateness of the hour claims your attention.   But
as before  you may  lie awake with an over-stimulated brain
and weakened inhibition ; and  this condition may represent
simply  a less degree  of  over-fatigue  than  in  the former
instance.
  In  the  first of  these two cases, external  circumstance
furnished the immediate stimulating interest;—in the latter
case it is memory and  expectation, but the attention is more
clearly  voluntary  and  the  whole  process subjective.   In
both cases the role  of the attention is apparent.  It becomes
evident also that the feeling of fatigue does not measure it,
but only represents the fact of  fatigue  within normal limits,
beyond which there is  a reserve of nervous energy that may
be drawn upon by  stimulating the   nervous mechanism
through an extra effort of voluntary attention.  The explan-
ation  of  the  attendant  physiological processes throws light
upon  the whole matter.  Ribot1  says  it is highly probable
and almost universally admitted, that  attention, even when
not directed toward any region of the body,  is accompanied
                       Op. cit., p. 19. 
50              THE  SHATTUCK LECTURE.
by  local hyperasmia  of certain parts of the  brain.   This
result  of  the greater functional  activity  is  caused  by  a
dilatation of the arteries, which itself is caused  by the action
of the vaso-motor nerves upon the muscular integuments of
the arteries.   But the  vaso-motor  branches  of  the. great
sympathetic are independent of the  action of  the will, and
are not influenced directly by voluntary attention ; they are
however subjected to  all the influences of the emotions.  It
is shown by the experiments of Mosso and others that the
slio-htest and most transient emotion causes an afflux of blood
to the brain.   Maudsley2 says, "We may  fairly conclude
that the effect of attention to a  current of thought is  to
quicken the  circulation in  the nervous sub-strata  which
minister to it;  not otherwise  than  as wdien  some earnest
thought has taken hold of the mind, it keeps up an active
circulation in the brain,  and will not let us  go  to sleep."
  These considerations  enable  us to distinguish  the main
elements of the  mechanism that  were involved in the last
two cases  of  evening fatigue.   In both,  interest  and emo-
tion were  the immediate excitants  of the  increased  blood-
supply  and brain  activity;—in one,  the emotion attended
the thought  of the external  circumstance  of a  patient in
danger, and  attention  was  largely  spontaneous,—in  the
other,  the emotion accompanied  the  thought voluntarily
chosen  to  be held in  attention,  although  its interest was
more remote.   So  the  attention once becoming  active,  in
whichever  form, the same  results then followed in either
case, and the order was  as  follows :—attention, intensified
ideas with mental feeling of interest or emotion, vaso-motor
dilatation, quickened circulation and nutrition,  increased ex-
penditure of energy and  waste products, and over-fatigue to
the degree of exhaustjpn and irritability.
  These phenomena of our commonest  experience therefore
bear this  plain interpretation.  It  is  fundamental in our
               2 Physiology of Mind, 3d Ed., p. 316. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      51

nature, in the earlier stages of development, as in children
and  animals, that our inner  physiological activities  and
their  expression  in conduct are largely subject to the feel-
ings,—our  mechanisms  are driven by untutored interests,
emotions or blind instincts.  But in the later development
of the acquired  forces of  intellect and  will,  we  control,
select, and direct, through attention, the chosen, impelling
interests, combined with  much yielding and consenting to
the primary forces of our emotional nature.
   It  is a common clinical observation that, with the begin-
ning  of  failure  of  higher psychical control, the  more
mechanical laws of cerebration are brought more freely into
play, and we come at last to the  phenomena of weakening
 attention as the index of the more spontaneous flow of ideas
 along the  paths of habit and association.   Fatigue of the
 power of voluntary attention,  which goes along with cere-
 bral  fatigue, is equivalent to the beginning of the failure of
 control.
   In the mental conditions  last described, the  symptoms of
 a general  and  cerebral  neurasthenia thus developed reveal
 the  importance  of the attention, and the high office of its
 voluntary power in respect  to  all mental activities.   In the
 abatement  of natural vigor in any of them, the physician
 should see signs suggestive of neurasthenia.
    The Sense of Effort,  and  Discharge of Energy in
 Attention.—A further development of symptoms may fol-
 low  if the  patient continues in a neurasthenic state.  While
 the  action  of spontaneous attention is  always without a
 sense of effort,  as in its passive exercise in revery which may
 be restful, it may on the other hand when concentrated,  as
 in continued worrying, be  accompanied by expenditure of
 energy and cerebral  exhaustion.   Hence  the maxim that
 worry  is  worse than work.   But  voluntary  attention is
 normally accompanied by a discharge of energy and a sense
 of  effort.   The feeling of  effort is at a minimum  when the 
52
THE SHATTUCK  LECTURE.
  body  is  strong,  but with increasing fatigue  the  sense  of
  voluntary effort grows  greater because  more  is needed  to
  accomplish the  same result  as  before.   This  of course  is
  attended by a conscious sense of mental inadequacy through
  a sense of resistance to  effort, which, added to the feeling
  of physical inadequacy already existing and  accompanied
  by painful emotion, increases the force of self-depreciation.
  There is deeper depression, more intense worry,  increasing
  cerebral exhaustion,  and lessening mental control by will
  and attention.
    Correspondence of the Train of Mental and Physical
  Events in Neurasthenia.—The preceding analysis of these
  conditions shows what may be the train of concomitant and
  increasing disturbances  of nutrition :—there  is  local and
  then general  inanition  and irritating auto-intoxication,—
  then vaso-motor constriction, perhaps from irritative elements
  in the blood, and local or general anamiias,—or a  vitiated
  blood-supply that does not nourish,—or  again a hyperemia
 from which we may infer a constriction-paralysis, in a condition
 manifested by  a  temporarily increased activity,  and mental
 facility which is still a manifestation  of inhibitory weakness.
 Thus a process beginning in the general organism, perhaps
 with disorders  of digestion,  may  lead  by a sequence of
 events to such results as  these.  The causes continuing,  or
 being renewed after partial  recovery,  which may happen
 many times in  a  single case, the descent  to graver degrees
 of  exhaustion  in melancholia may  be accelerated  by in-
 somnia.   This, we have  to infer, is  due to a hyperassthesia
 from weakness  and toxic irritation of the central mechanism.
   The process  may begin with an earlier  event:—through
necessity  or mistaken  zeal  the  individual over-exerts his
brain in mental work under the spur  of interest  and  forced
attention.   Here is indeed purely mental initiation of cere-
bral exhaustion which may start the  train  of events even in
a strong man.  Then with an over-worked brain,  and under- 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     13

worked respiration and muscular movements, as in sedentary
habits,  the  cerebral waste  of tissue is increased and  the
nutrition is diminished, by both local and general conditions.
Such a special condition,  for example, as  the  uric  acid
diathesis, may be engendered by deficient elimination. From
a  cerebral neurasthenia  all the other  events may follow.
In this form, however, there may be failure of special func-
tions,  as of memory, for example, in some of its elements.
A not infrequent symptom is forgetfulness  of names  and
words,—the fatigued word-memory centres are slow in re-
calling, or the word-uttering  centres are slow in acting,  and
there are the symptoms of brain exhaustion with a hesitation
of speech that is unduly  alarming.   The mental  work of a
physician or a lawyer is a good example of a peculiar strain
of these central mechanisms.   There is the daily continuous
 effort  of listening 4to  the  details of medical  cases, or to
 evidence and  pleadings in some important cause, often  fol-
 lowed by work at late hours.  It  is not strange that there
 should be a consequent condition of special  fatigue of the
 attention and memory.
   The  Unity of Conditions in Neurasthenia and Melan-
 cholia, etc.—The essential element in  all cases is, that the
 fact of a profound deterioration of nervous energy in the
 organic  basis  is  represented mentally as  a more or less
 va«ue sense  of failing power, together with a  conscious re-
 duction of mental control.  This is true alike for neurasthe-
 nia and melancholia, as  has been shown.
    Alienists have long  recognized  these morbid  states  as
 associated with variations of nutrition and as fundamental
 to melancholia, hypochondria,  and other like disorders.
    Meynert1  believes melancholia  to  be a symptom of dis-
 turbance of nutrition of the cortex of the hemispheres de-
 pendent upon diminished blood supply.  Benedickt8 believes

                 ' Wiener Med. Presse, June 6, 1889.
                 2 Medicine Moderne, Feb. 5, 1891.
0 
54
THE SHATTUCK  LECTURE.
 that neurasthenia is a psychic disease of cortical origin, due
 to  emotion  and  overstrain,  and that it is peculiar to the
 learned  professions and  business demanding trained,  alert
 intelligence.   Marcus1 describes neurasthenia  as a change
 in the functional tonus of the whole central nervous system,
 with  increased  excitability  and  tendency  to  exhaustion.
 The patient is always depressed on account of his incapacity,
 which leads to doubt,  anxiety and hopelessness, with a feel-
 ing  of inadequacy  to ordinary effort.   These  patients are
 neurasthenic, he says, before becoming insane.
   Thus  it is to be seen  that  the neurasthenic condition,
 being  dependent primarily upon nutritional  weakness  and
 presenting a train of definite mental symptoms, may,  when
 once established, grow worse  by degrees even  to  the  pro-
 foundest melancholia,  in which the same physical conditions
 and  the same  mental symptoms, from  like causes as  in
 neurasthenia, are present as a part of the characteristic group
 of symptoms.   It may be said, as  Beard  tried to show,
 that neurasthenia is not melancholia,  but it cannot  be  said
 that melancholia is not neurasthenia.   Many  cases called
 neurasthenia are as truly mild melancholia.  It is a matter of
 the degree of exhaustion ;  in the graver degrees new symp-
 toms are added.   Further  evidence of this is to be seen in
 the study of the  intellectual symptoms in still more profound
 degrees of exhaustion.  But it is already evident from these
 considerations that, in all  these conditions, the symptoms
 are dependent primarily upon changes in  the organic basis
of the personality.
  Definition of Neurasthenia.—A  summing up  of the
 conditions that furnish the clinical manifestations of melan-
cholia would include those of neurasthenia and more.   The
 study of melancholia,  as has been said, is therefore instruc-
tive as revealing the import of the milder manifestations in
neurasthenia.   The common  conditions  of nervous  weak-
            1 Allgem. Zeitsch. f. Psych., xlvi. 487, 1889. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      55

ness and irritability,  and  of the special  weakening of the
attention and mental depression, have  been sufficiently no-
ticed.  But one other prominent condition should  be taken
into account in the definition of neurasthenia.   The physi-
cal lassitude and languor, and motor weakness,  pointed out
by Brunton as  suggesting curare-poisoning, has its counter-
part also in the condition often observed in melancholia and
characterized  as  mental stupor which it  simulates.   The
definition of neurasthenia, properly extended to include the
more prominent manifestations,  both mental and physical,
may be  stated as a morbid condition of the nervous sys-
tem, the underlying characteristics being excessive weak-
ness and irritability or languor, with mental depression.
   Cerebral Neurasthenia, and "Insistent  and  Fixed
Ideas."—Cerebral neurasthenia being once established the
general form is then usually developed ;  but the  first may
exist by  itself,  as has been shown, and be of long standing
in a healthy organism.   The same is probably true of spinal
neurasthenia.   This  central affection  is  likely to involve,
directly or indirectly, other co-ordinated mechanisms.   An
acute neurasthenia may  be rapidly  developed by  mental
shock or the like ; it is as if, by a great discharge of energy,
the brain cells  are quickly brought to a state of exhaustion
with inability to perform fully their  function of  taking  up
nutrition,  or to  act  in their normal and habitual associa-
tions, because of being "thrown out of gear."
   A unique form  of cerebral neurasthenia may  be brought
about by the affections known as "insistent and fixed ideas."
These are often started accidentally as uncorrected associa-
tions of ideas  and feelings,  and being at first purely dis-
orders of ideation they become fixed by habit and intensified
by accompanying emotions usually painful, and  sometimes
engender f>reat worry  and anxiety, because the patient is
conscious  of his  inability to control his own mind against
the ideas he knows to be absurd.  The worry in these cases 
56
THE SHATTUCK  LECTURE.
may cause a true cerebral neurasthenia.   There is a special
form  of these  " fears " that is  the most likely to lead to a
true melancholia in cases in which  there is a strong body
with  a  tired brain,—it is the fear of heredity, when  based
upon  a fixed idea that may have  some appearance of truth
and cannot be corrected as being absurd.  Then the worry is
increased both  by habit and  fatigue.   In general it should
be said  that " insistent and fixed ideas "  are primarily acci-
dental disorders of ideation, often occurring  in  the strong
but more likely  to happen to the  weak.   They  are  the
cause of neurasthenia quite as often  as they are a symptom
of it.   The morbid  association  being once  formed, it  be-
comes fixed  by  habit, inducing  or  increasing the cerebral
fatigue,  and constituting an association-psychosis, or more
properly  an  association  psycho-neurosis.   When these af-
fections are better understood, an explanation will probably
be  found for  much  that is now called hysteria,  the neuro-
mimesis,  etc.,  including,  in the insistent associations, other
feelings than fears, that occupy the attention.
   Secondary, Chronic,  and Hereditary Neurasthenia.—
The  forms  of neurasthenia so  far discussed are  those  that
are acquired,  acute and primary.   Secondary neurasthenia,
or the form occurring after other definite diseases, often not
nervous,  must be regarded as belonging to the class having
special  toxic  causes.   The poisoning may  be direct,  and
sometimes recurrent, as in the  specific constitutional dis-
eases, due to,  or inducing, nutritional and degenerative dis-
orders, such as gout, rheumatism, syphilis,  etc.   Or it  may
be  indirectly due to such  diseases as puerperal fever, typhoid
fever, etc., in  which it may be  inferred  that, although  the
toxic materials have  passed away,  a process of inanition
once started  persists,  or continues  to  develop.   Chronic
neurasthenia has already been characterized, and includes
conditions of  partial recovery,  in which a  "constitutional
predisposition" is  fully acquired and established.  This is 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     57

consistent  with  periods  of partial efficiency and  comfort,
with lessened reserve energy.
  Hereditary neurasthenia, as a  transmitted predisposition,
is a usual cause of localized neurasthenia in special systems
or organs.   In these cases  and  in  those with a general
neuropathic condition, often  inherited,  there  is a tendency
to all  forms and degrees of neurasthenic disorder, for the
reason that,  it being a condition of nervous instability and
weak resistance, the organism  yields to slighter degrees of
stress  than  in  ordinary states.   The  nervous equilibrium
becoming unbalanced by slighter causes the departure  from
the general habitude of the  individual  is less, and restora-
tion to it  easier, than when the normal resistance is great
and the break-down is a greater  change.   When  a  strong
man  breaks down it may therefore be  more difficult for
him to get well than  for one less robust and stable.  When
there  is such  a predisposition,  however, the prophylaxis
should be more diligent against neurasthenia and  mental
                    ©     ©
disorders.   It  should be remembered  also  that  in these
neuropathic cases  one  may inherit  a  strong brain  and  a
weak  body,  and vice versa.
   Symptoms.—The  symptoms  of neurasthenia,   being
manifestations of weakness of the nervous system, proceed
from variations from the normal  condition of nerve-cells,—
molecular  and chemical, not yet demonstrably pathological,
and implying a weakened  or changed  nutritional  power.
The vascular changes—the cerebral  and spinal hyperemias
and anaemias—are  due  to  disturbances  of the  inhibitory
vaso-motor  centres.    As  Dana  says,  "Neurasthenia  is
primarily cellular and secondarily vascular."  Local anaemias
may be initiated by  an  irritative blood-supply,—the  vaso-
motor constriction starting the deficiency of nutrition in the
nervous centres ;  we may infer that  this leads sometimes  to
hyperemias, just as digitalis first stimulates the cardiac in-
hibition,  and  then  by  over-stimulation and  a toxic  effect
paralyzes it. 
58              THE SHATTUCK LECTURE.
  The fundamental and initial condition being thus a weak-
ness of nerve-cells from excessive waste and deficient repair,
to which there is  a toxic addition to the "fatigue,"  then
two types of symptoms must be recognized,—those char-
acterized by a  too  quick  response to stimulation, due  to
"irritability" or hyperesthesia, and those due to a slowing
or annulment of functional power, manifested by "languor,"
or even  a  complete suspension  of function.   These  con-
ditions of abated  power, with " irritability " or " languor,"
occur in different  degrees, and are  common to  the sensory,
central and motor parts of the mechanism ; they often affect
one part  more than the others, according to the localization
of the "fatigue," or the kind of toxicity.  The symptoms
of neurasthenia are mainly subjective.
   The objective  symptoms may  be first considered, by
noting the common physical conditions.   There is  a general
appearance of abated vigor, bodily weariness, languor and
mental depression, and loss of weight.  There is not neces-
sarily  anemia, but this is  common in young persons and
women;  it is  not  present  in  many adults  who may be
physically  well-nourished or plethoric.   There  may be
tremor of the  hands,  sometimes only  following  muscular
effort or  mental  excitement.  Uneasiness, restlessness and
excessive irritability are also common.
  Loss of  vaso-motor  tone  is indicated by cold hands and
feet, and the temperature is often sub-normal in  the more
exhausted cases.  Morbid blushing is common in nervous
exhaustion in both sexes, from slight  mental or physical
causes.   A characteristic form of the blushing is that which
                                         ©
occurs in patches  upon  the  neck  and cheeks, of  a  bright
color and  with  well-marked  borders   slowly spreading.
This may appear  with  only the effort and interest of an
ordinary  conversation.   The disturbances of the circulation
are marked by cardiac palpitations, and  the phenomena of
an "irritable heart."  The pulse shows frequent  and rapid 
        NEURASTHENIA AND ITS MENTAL SYMPTOMS.     59

 variations in arterial tension ; it may  be reduced in fre-
 quency with increase of tension,  or be  more  frequent and
 weaker, and often quickly  accelerated by  exertion or slight
 emotional excitement.
   Dilatation of the pupils is a common  symptom,  and may
 be due to paralysis of the third  nerve  or  irritation of the
 sympathetic.   These suggest  nervous weakness, irritability
 and perhaps different toxic  influences.  A striking peculiar-
 ity is a  quick  and frequent  alternation between  this  and
 contraction.   The atonic voice is  peculiarly significant,—it
 is faint and husky,  and frequently varies in force.  Some-
 times it will suddenly change to  a higher  pitch and sound
 thin and  weak.   Respiration is not  changed in frequency,
 but deficient respiratory expansion may  be observed, with
 the symptoms of compensatory sighing and yawning.
   The appetite  is poor; there are disorders of gastric and
 intestinal digestion, gastric irritability with  atonic dyspepsia,
 and  constipation,  sometimes  alternating  with  nervous
 diarrhoea  ; and flatulence with feelings of distention : there
 is gastric neurasthenia, and a "torpid"  or "neurasthenic"
 liver, and the important  toxic consequences.   Elimination
 generally is greatly at fault,  by  liver,  kidneys  and skin.
 The urine varies  in specific gravity, being usually low in
 younger persons, with phosphates in excess.  Older persons
 have  more digestive and  hepatic disorder,  and  a condensed
 urine with sometimes excess  of  phosphates,   urates, and
 oxalates.   Traces of albumen and casts  are common in the
 depressed cases, as in melancholia.  The peculiar symptoms
 of " uric-acidemia" are so common in neurasthenic condi-
 tions  that a careful study of this  toxic  element is likely to
be profitable.
   Neurasthenic  irritability of the bladder  and urethra occurs
 in both sexes ;  and  in women the lowered nervous tone is
 manifested  in  menstrual  disorders.   While  amenorrhea
occurs, particularly in  the  graver  cases,  as in melancholia, 
60
THE SHATTUCK  LECTURE.
etc., it is often  physiologically conservative; there may be
an increase of the  flow,  and even the ordinary amount, in
anemic conditions, becomes relatively a hemorrhage.   Many
such cases are kept indefinitely  in  a state of exhaustion by
losing monthly all the upbuilding they can gain.  Irregular
menstruation and dysmenorrhoea are also common.  Women
in general suffer more than men  from sensory and irritative
symptoms,—there  is more pain, headache, and neuralgia,
and the  complications of  hysteria  occur.   The diseases
peculiar to women may  be  either the causes  or  effects of
neurasthenia.   The  symptoms  of sexual  functional  dis-
orders, generally, should always  be first studied carefully,
as probably expressions of a general neurasthenia.   This is
true also of the disorders  peculiar to adolescence and the
climacteric,—at the latter period of life men  also are prone
to neurasthenic  troubles.
   Insomnia has already been especially noticed as a symp-
tom of  irritability,—a cerebral  over-excitation from  local
irritation, or that condition initiated by  intensified interest
and attention until the symptoms of " fatigue" supervene.
Macfarlane defines insomnia as an evidence  of  vigilance in
                                               ©
the cerebral cells,  initiated  and maintained by some per-
turbing element in the system, of which  it may be the sole
symptom.
   The subjective symptoms are thus broadly characterized
for convenience, as those of which the patient himself gives
account.  This division from the objective symptoms is open
to criticism ;  the  thesis  of this discussion  is,  in  part, to
show  that the inner conditions are largely revealed by men-
tal symptoms which are obvious to the  clinician  who  obeys
Kiafft-Ebing's injunction to pursue an untiring observation
of the psychical  processes.  While the  patient may describe
his feelings and  tell his thoughts, in their subjective aspects,
the clinical observer sees the plain  and often contradictory
significance of the patient's unwitting expressions of mental 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      61

phenomena that are objectively manifested in his appearance
and conduct.   The physician, taking  into  account  all the
data,  solves parodoxes and  makes interpretations, that the
patient cannot make of what he feels and seems to perceive.
It is a part of the present  purpose to  make clear some of
these apparently conflicting indications.
   The study of the symptoms of neurasthenia means, then,
the observation, and the  careful analysis and discrimination,
of the physical signs on the one hand,  to differentiate them
from  the  manifestations  of more definite nervous diseases
which are so often  simulated in  this disorder.  We have,
on the  other hand, with these observations as guides, to
discriminate in like manner the mental signs as expressed
in the patient's appearance, conduct, and speech.  The sub-
jective symptoms  are, therefore, of two kinds,—what the
patient tells of  his bodily  sensations and mental feelings,
and of his ideas of them, and  what he manifests otherwise
as expressions  of his mental condition.  The business of
the physician is to make  an  interpretation  of these  pheno-
mena, consistent with physical facts, and to give his patient
treatment that  is often  as  much  of  the  mind  as  of the
body.
   The  first  and most obvious  mental  signs, taking  the
evidence from  both  of the  sources just specified,  are the
characteristic depression  of  feeling,—lowering  of emotional
tone and a sense of ill-being.   Coincident  with  these, but
derived more from the patient's own statements, are a de-
crease of  the power of voluntary attention,—attention be-
coming reflex,—and  sometimes  decrease of the power of
memory in its  elements  of retention and recalling,  and in
the association of ideas.   The first order of  these symptoms
represents, in the changes of emotional tone, etc., the con-
comitant changes  in  the organic personality,—the  patient
speaks  despondingly  and  appears dejected,—he has  "the
blues."   The second order shows, in the lessening of men-
f 
62
THE SHATTUCK LECTURE.
tal activity and inhibitory power, the abatement of cerebral
energy,—the patient becomes conscious  of this because of
the increased sense of effort, and he may tell of it  before it
can be observed by others.1   The sources and " mechanism "
of these  two orders of symptoms have been shown.
   A third order of symptoms proceeds from the first two,
as has been shown ; it is somewhat later in appearance and
marks a  graver degree of nervous exhaustion.   It  includes
         ©        ©
introspection,  or  dwelling   by  attracted   attention   upon
anxieties or painful ideas,   intensified by the prevailing
emotional tone,—retrospection,  which is  a constant  and
striking symptom in those who,  from a sense of inadequacy,
lose hope and therefore interest  in the future, and find it in
the reviewing of past experiences, errors or  wrong doings,—
and apprehension, as sometimes  a feeling  of  hopelessness,
or vague fear of inability to  meet the requirements of the
future or  the  consequences  of the  morbidly intensified
memories of past misdeeds.   These constitute the condition
of worry and hypochondria.
   All these orders  of symptoms  are usually present in
slight degrees, and coincident  at  the very  beginning of
pathological fatigue.  Their severity increases with  decreas-
ing energy,—from transient " fits of the blues " to  the most
marked forms of the  disease.  When the condition  con-
tinues, reasoning is likely to  be soon  influenced by  the bias
of morbid feeling, and the law of practice, habit and associa-
tion comes in, tending  to fix the morbid " habits of thought"
            7       ©                                ©
as well as the disorder  in  the  concomitant physiological
processes.  Then secondary  effects  begin  to  demand  dis-
crimination, and the force of habit must never be forgotten.
For example, a business  man, having become neurasthenic
from over-work and worry,  may attend  to his  affairs, with
excess of application, and feel better doing so, through the
effect of  habit,  and  the  stimulating effect  of attention and
interest as  excitants of cerebral activity and  a quickened
                    1 See Notes, p. 105.
# 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      63

circulation.   Let him  attempt,  however, to turn his atten-
tion to other matters, as to rational recreation, and his loss
of power to control his own mind betrays itself.  At the
beginning of the attempted relaxation, as in taking a vaca-
tion, there is more of mental effort, and of the depression of
feeling, than in  keeping on  with his habitual occupations,
though harmful.  Or,  again, such an  experience as  that
described in a letter from  a medical friend, who has had
large success in  treating neurasthenia, and who contributes
unintentional testimony on this point, as follows :—"I  have
been feeling so  good-for-nothing  and so blue  that I  have
feared almost everything.  These 'rheumatics' are not very
comfortable companions, and the fear  that they might get so
bad as to prevent me from riding, has depressed me a  good
deal.   I know that in  other ways  I am much better than a
year ago, but in the past three  weeks,  when the letting  up
of work has come,  there  has  also come a letting down of
spirits.   The work now is not more than one third of  what
I do when decently busy, but I get very tired when evening
comes.   I am all played  out."  It is  altogether probable
that had not his  active season  been  terminated so soon  by
the summer vacations, he would have gone on with his  work
and postponed the onset of his  " fatigue " and the return of
his annual  attack  of  sciatica,—but  doubtless  with  more
serious consequences at a later day.
   These cases  show  the  three orders of symptoms, and
represent later  stages  of the conditions noted  in the two
examples of evening  fatigue  illustrating the  genesis  of
pathological fatigue.   They bear also a curious resemblance
to another very common experience :—An occasion of severe
mental labor,—perhaps of night-work and little sleep,—is
followed by a day of excitable alertness of mind and body;
there is a sense  of nervous  strain, but with an undue men-
tal facility and  physical  irritability.   But after  the  next
night's rest a sense of fatigue, languor, and malaise may 
64
THE SHATTUCK LECTURE.
come—the second-day tire  that leads to the inference  of
the elimination of  an irritating  stimulation revealing the
real fatigue.   In  cases of neurasthenia,  at  more  advanced
stages, from  long-standing  or  a  more rapid development,
the effects of habit  upon  the  disordered physiological and
mental activities become more pronounced.   New symptoms
also appear,  due  to greater changes in the nutritional pro-
cesses, and particularly in the sensory mechanism.
   The three  orders of symptoms described refer to strictly
mental phenomena and contain no mention of the irritability
and languor  common  in  this disease.   These latter symp-
toms  are both mental and physical,  and  they are direct
manifestations of changes in bodily conditions.   They now
remain  to be characterized as constituting a fourth order.
We have therefore  to examine further the subjective symp-
toms in respect to  altered sensations.   They  include both
those from the special senses and the largely predominating
organic sensations.   They may be distinguished as hyperes-
thesia, paresthesia and anesthesia.
   Hyperesthesia may be held to include all the phenomena
of excessive  irritability.   It may be sensory or  motor, or
central and mental.   General morbid sensitiveness is mani-
fested   by "nervousness"  and restlessness;  the  patients,
especially women, have a sense of "tension " and difficulty of
self-control.   There may be irritative and neurasthenic con-
ditions  of all the  organs and minor mechanisms.  The local
hyperesthesias are very many—as  of touch, in which how-
ever there is  no real increase of delicacy, but almost always
a  diminution.  In  many  cases the commonly  unperceived
organic  sensations  are intensified.  The sense of pain  be-
longs  to this group of " common sensations,"  and they
include  the  neuralgias along  with which  there  may be  a
duller perception of tactile  impressions.   Itching, burning,
and other conditions bordering on pain,  are included in this
group of sensations that differ from the tactile sense. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     65

  Sensitiveness to ordinary stimuli in the organs of special
sense, particularly of sight and  hearing, is common.   The
visual troubles are not very serious, but there is always some
weakness and increased irritability.   Reading causes fatigue
and pain and  leads to headache ; and there is sensitiveness
to light.  Muscular insufficiencies occur.  Visual memories
are lessened.   The  hearing is over-sensitive in many cases,
and  the patient is  very  intolerant of  slight noises.   This
may be due  to the  general  mental  irritability, and to
expectant attention.   These neurasthenic symptoms may be
continued after  recovery as the effects  of  mental habit.
Hyperesthesia may  be regarded as the first degree of sensory
disorder and weakening.
   Paresthesia, or perverted sensation, may be considered
 as representing a second  degree of sensory  disturbance and
 change from  normal feeling, and may be general or local.
 Internally these disorders include giddiness, vertiginous sen-
 sations, a sense of muscular relaxation, etc.   According to
 Gowers, the  afferent  impressions constantly passing to the
 cerebro-spinal  centres,  fail  to  affect  consciousness  under
 normal circumstances.   But repeated  attention may vastly
 increase the sensitiveness of the perceptive  centres to such
 impressions,  and from such increase  arise sensations of great
 discomfort, sometimes  amounting to  pain.   In the case of
 an intelligent lady  whose conscientious efforts to disregard
 her ills  stamped the description as genuine, there was, at
 times for many months, a feeling " like a stream of pounded
 glass running down the spine into the pelvic cavity."   There
 may be perversions of the peripheral sensations, as pressure
 on the top of  the  head  and of a  band about it, a sense of
 expansion  of the skull or as if it were empty.   Feelings of
 flushing, both local and general, may  occur, and numbness
  and coldness as alterations of  the  temperature  sense, etc.,
  in different parts of the body.   This and the sense of pres-
  sure are to be distinguished as special functions, differing 
66
THE SHATTUCK LECTURE.
 from  tactile  sense.    Creeping  sensations,  tinglings and
 formication, are common among the paresthesias.
   Anaesthesia is the final degree of changed sensations, and
 may be partial or complete.   For  example,  numbness  of
 the hands and feet is not uncommon ;  and there are limited
 anesthesias of the tactile sense in various parts of the  body,
 or this being retained,  there may be analgesia  as simply the
 loss of the sense of pain.   The lowering of sensory activity
 in general, or diminished  sensitiveness,  has been observed.
 This is common enough to demand recognition as one of the
                     ©                ©
 characteristics of neurasthenia along with "excessive irrita-
 bility ; "  in both alike  there  is  probably a toxic influence,
 or its secondary effects.   There may  be limited  areas  of
 anesthesia or  hemi-anesthesia,  particularly  in  hysterical
 conditions, although " hysteria is essentially  a mental disease
 involving the emotional faculties and the will."
   The importance of these altered sensations is very great for
 their diagnostic value and as a guide to  treatment in neuras-
 thenia.   Such disorders  of the  sensory apparatus of the
 special senses, as is well known, lead to the  illusions and
 hallucinations, or disorders of sense-perception, in the graver
 degrees of the exhaustion  of melancholia and mania.    But
 the organic or common  sensations are of fundamental import-
 ance,  for, according  to Ribot, "As the  organism, so the
 personality."   Taking the evidence of our bodily  feelings,
 the  sense  of  physical  personality  is  the  organized  and
 coordinated sum of  its  elementary  factors.   Persisting
 alterations of organic sensations are aberrations of  the phy-
 sical personality, or as  Bertrand calls them, " the hallucina-
 tions of the sense of the body."   A man believes himself to
 be what he feels himself to be.   He finds in the evidence
 furnished by the sum-total of his feelings the data for his
judgments  of  himself.   These  sensorial  alterations are
 doubtless expressions of more deeply seated  disorder due to
 localized and limited  derangements  of the circulation.  A 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     67

limited  central exhaustion  and  excitation may  be  accom-
panied peripherally by vascular  irritability and disturbance.
  The relation of these altered  sensations to their mental
effects has been considered, and something has been said of
the converse effects of mental states, as to the emotional tone
and attention, upon the physiological activities.  The mutual
influence  of  mind  and body  upon each  other  is of  great
importance here, as to the causation of the conditions mani-
fested by  these changes in  the  organic sensations.  Mosso
has demonstrated that hyperemia of the brain is coincident
with  mental  work.   It is physiological  that  centres  be-
coming inactive resume a normal and comparatively anemic
state.   The  removal of the excess of waste that  attends
activity being accomplished by due  periods of rest,  the
centres  recover  their normal  condition, and work may be
resumed  on  awaking from sleep.   With  over-work of the
brain, and prolonged and probably localized hyperemias,
the  exhausted  vaso-motor apparatus  becomes  unable  to
control the  blood-supply;  local  and relatively chronic
hypeiemia in the  over-exercised  centres  may follow and
become pathological.   In  this state work may be continued
by  voluntary  effort, but there is sleeplessness, and breaking
down of  the  general health.   The exhausted and poisoned
brain, and nervous system generally, afford only a defective
innervation to the  various organs of the body ;  and the
characteristic symptoms of dyspepsia, constipation, palpita-
tion, and the like,  appear,  with all their sequele of altered
sensations.
   Macfarlane1 describes the symptoms of this condition of
neurasthenia  as tolerably uniform,—sleeplessness being one
of the most urgent, usually associated with throbbing blood-
vessels  and restless cerebration, dreams connected with the
daily work,   and  the  sleep obtained  being  disturbed and
unrefreshinf.  The element of  worry has been shown to be
                      1 Op. cit., pp. 78-82. 
68
THE SHATTUCK  LECTURE.
a prime factor in all these  neurasthenic  conditions.  It is
especially noteworthy that  Macfarlane  mentions  certain
symptoms of present interest,—they are the most prominent
sio-ns of the earlier alterations of coenesthesis so well studied
  ©
by Ribot.  The former says, "Exhaustion and misery  are
felt in the morning;  depression, despondency, and irrita-
bility during the day.   All mental and physical  work is
accomplished with  an effort,  concentration of thought is
difficult,  and headache is seldom absent."
  Two  Special  Conditions resulting  from  Changed
Sensations.—The  more  greatly altered  sensations, when
localized and limited, may be estimated correctly, while the
more general and pervading ones  cannot be so  well  cor-
rected.   There are two promineut conditions due to changes
in these general sensations that are of the highest  clinical
        ©                                   ©
importance in neurasthenia.
  The first of these conditions is "morning depression" or
" morning tire." It is sometimes called "morning misery"
but the tire  is the essential  fact.   Both the mental  feelings
and the common sensations  are altered by increase of inten-
sity, and measurably represent the  truth as to the bodily
condition, although they still appear contradictory and  lead
to mental error.   For  example,  a patient having fairly
comfortable and cheerful  feelings during  the latter half of
the day and in the evening, sleeps more or less  well till the
early hours  of  the morning.  But on awaking  he is in the
depths of depression.  Instead of being refreshed by sleep,
all his feelings  of inadequacy, misery and hopelessness are
then at their keenest.  The physical signs of exhaustion are
more manifest.  The patient feels  added  alarm because the
sleep has not done him any good in the natural way.  After
breakfast he feels better, and by the middle of the forenoon
his   circulation  is  again active  and  steady and  perhaps
accelerated.  The press  of  business and  the daily interests
are stimulating, and  his nerve-cells, while probably giving 
       NEURASTHENIA ,\D ITS MENTAL SYMPTOMS.      69

out as much as they are taking in of energy, are evidently
better nourished than in  the nocturnal condition of func-
tional inactivity.  This  symptom  is significant by its daily
recurrence.  It is among the leading ones of neurasthenia;
and it may occur in all  degrees,  from the morning feelings
of being unrefreshed, to a recurring sense of misery and des-
pair that prompts to  suicide.   The physician should detect
this   symptom  of  morning  tire  and depression,  which
appears early in the  disease, and should not  be misled by
the patient's evening sense of comfort.  The morning more
nearly represents his true  condition.
   This symptom of "morning tire" has long been observed
in melancholia,  but  it  is now  being better  explained  as
evidence  of  neurasthenia.   The  "mechanism" of  these
phenomena of " distressing awakening," is most complex and
involves the problems of the physiology of sleep, the rhythm
of nocturnal rest and relaxation  and daily activity,  and the
" pathology of night," of which   interesting studies are of
late being made.1   A valuable bibliography of the  subject
is given by Ch. Fere.2  Broadbent3 says, "It is in the early
morning that depression of spirits is liable to be at its worst
in nervous debility,  so called;   or  there  is  the  morning
headache  which is relieved by the bath and  breakfast, or
 wears off as the day advances ; or the subject of this affection
 is more tired on waking up than on going to bed."  Haig4
 says he has " no difficulty in proving that it is just in these
 early morning hours that  the excess of  uric acid in the
 blood is  greatest,  and its  effects on arterial tension most
 marked."   Uric acidemia in its  relation to disorders of the
 circulation, and  to  irritability,  languor,  and  depression,
 certainly invites careful inquiry.
   The significance of these tired awakenings is very great,
              ' See Macfarlane, Lancet, Vol. I., 1891, p. 824.
              2 Art. Pathology of Night. Brain, Oct. 1889, p. 308.
              3 The Pulse, p. 76.
              4 Loc. cit.
          6 
70
THE SHATTUCK  LECTURE.
 as a symptom of morbid sleep which may be due to a variety
 of causes, involving particularly the weakness of functional
 power, through its exhaustion or annulment by  toxic influ-
 ences  as in neurasthenia.
   The other special condition is that of anesthesia of the
 sense  of fatigue.   It results from altered organic sensa-
 tions ;  and the  truth  as to  the bodily state is obscured by
 the change or absence of certain data of sensation that go to
        ©                                           ©
 make  up a man's judgment of himself.   The indications are
 paradoxical and misleading.
   In the example of morning tire just mentioned the exces-
 sive work  and worry might go on with increase  of cerebral
 or general exhaustion ; also the mental misery of the morn-
 ing might  be continued.  Then a strange phenomenon may
 happen.   The patient,  who  has before complained of his
 fatigue, now says he does  not feel tired.   He  may have no
 definite sensations of inner discomfort from the dyspepsia,
 constipation, etc., although the  general miserable feelings
 will continue with lessening or disappearance of the evening
 recuperation.   Still, he claims that  he is  not tired,—that
 there  is nothing the  matter.   His  attention  is more and
 more concentrated  upon  the objects  that  have habitually
 interested him, or upon his morbid ideas,  with lessening
 power  to turn from them.  Thus the process goes on in its
 vicious train.
   This is one of the commonest of all symptoms, and often
 appears early and  in  slight  degrees.   It  represents the
 descent of  the patient's condition towards the depths of ner-
 vous exhaustion,  and  to  a  point where the sensory power
 itself is materially lessened.   The patient, previously guided
 by the sense of fatigue in desisting from effort,  has now lost
 his guide,—his  natural feeling.   He cannot  believe his
 physician or his friends that he is over-tired.   He is con-
scious of inefficiency, mental and physical; and he feels added
self-reproach because he cannot  accomplish what he ouofit 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      71

when he does not feel sufficiently ill or fatigued to justify
relaxation from duties that are pressing, or seem so to him.
The stimulation of change, travel, etc., is often prescribed
when there  is this  fictitious  appearance  of the patient's
ability to bear it.  Tired women will carry on their domestic
duties by " working on  their nerves," or  walk for miles
without natural fatigue, seeking  health in  " exercise " when
it is most damaging.   This symptom comes out most clearly
in cases that have advanced  to melancholia, but it is  a true
index of the neurasthenic state in all its stages, and has its
lesser forms in many of the milder cases.   In the  extreme
cases the lifting  up  of  such  patients from the depths of
exhaustion  is a  most interesting process  to  watch, when
they " come to the sense of feeling."   If previously agitated,
restless and apparently unfatigued, they grow more quiet,—
sometimes they take to their beds with a profound  sense of
weakness.   They say they feel  worse, and are alarmed as
well as their friends ;  but they are really better.  This is a
distinct stage in the  upward progress toward recovery.
   The conditions of melancholia, in  its  most neurasthenic
stages, are among those in which this symptom of change
of the sensations that  go to make up the sense of fatigue is
most plainly declared.   In one class of cases there are the
conditions of diminished  sensitiveness, dulness or languor,
affecting in  different  degrees   both sensory  and  mental
activities even to the degree of apparent  or real  stupor, in
which the motor  paresis is so  striking a symptom.   There
is in these cases a manifest consistency in  the presence of a
bluntino- effect upon  the  sense of fatigue.   It seems con-
sistent enough also in  that class of cases in which there are
the associated symptoms of mental agitation, irritability and
restlessness  as manifestations of hyperesthesia,  that  are
continually prompting  the patient to motor activity,—just
as analgesia may  exist with a hyperesthesia which  itself is
attended by  a diminution in delicacy of touch.   It is  of 
72              THE SHATTUCK  LECTURE.
course true that the attention plays its part in the matter,—
the attention being occupied  by intensified ideas and emo-
tions either of  pleasure or of  pain,  there  may  be, for the
time, an unconsciousness of the sense of fatigue that might
be felt if attended to ; so it is in hypnotism, or when contu-
sions are not perceived in a foot-ball scrimmage, or even fatal
wounds in battle by men who live long enough to tell of them.
But this fact does not militate against the validity of clinical
observations  and confessed experiences in the cases of many
intelligent patients in whom the condition is of long continu-
ance.   In the extreme cases of agitation  and restlessness,
as is well known, the patients will  walk  and walk by the
hour, sleep fitfully, turn in their beds or leave them many
times,  often  restlessly changing  their positions by day and
by night.   Like symptoms of restlessness are observed also
in many cases of neurasthenia  without the mental symptoms
requisite for a diagnosis of  melancholia, but both  these
classes of patients often declare the absence or blunting of
the sense of  fatigue.   It should be  understood that these
references are made  to melancholia because it presents this
symptom in so pronounced a way as to reveal its importance,
and something of its nature;  its recognition in its lesser
manifestations  in neurasthenia  thus becomes easier.
   This phenomenon appears in cases presenting such early
stages as those described to illustrate the genesis of patholo-
gical fatigue.  There is evidence of this peculiar symptom
in the graphic  statement, quoted from  the physician  who
felt excessive tire and the " letting down of spirits " as  soon
as his  work was  reduced to  one  half of that he  had just
previously been doing.   All the conditions of the " fatigue "
were undoubtedly present before the " letting up of work "
in which the exciting stimulation to activity possibly created
peculiar toxic products  which obscured the real condition.
At all events,  in such  conditions  as these and the equally
common experience  of the " second-day tire," there is that 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     73

state of pathological fatigue  which is marked by a notable
absence of a due  sense of tire.   It is certainly obvious, as
a physiological fact, and  as a clinical observation,  as in the
illustrative cases,  that the  degree of  bodily  and mental
fatigue is  not measured  by the feeling  of it.  It is one of
the most familiar of all familiar facts that men and women
are continually  over-doing  themselves  without knowing it.
When a condition of pathological fatigue is established,  this
anesthesia of the sense of fatigue, in some degree, becomes
a part of  the general  condition.   It is  important to recog-
nize it,—to give it a name,—to teach the patient to under-
stand it,—and then its great value as a diagnostic guide to
treatment will appear.  Knowledge of it also has  often the
happiest effect upon the  patient  in gaining  that condition
which Mitchell  sought before the rest  treatment  could be
begun,—"the absence of thought with the friction of worry
which injures."   The  patient  being  at fault in attempting
to judge of himself by his altered and blunted sensations, is
always alarmed at the mystery of his anomalous and contra-
dictory feelings.   With  the  feeling  of  inadequacy from  a
sense of abated motor power there  is  exhaustion also of
sensory power.   An intelligent patient always understands
when told that there is tire,  not only  in the  power to do
things,  but  in  the  power  to  feel the  tire.  An  apparent
mystery is readily cleared up by this explanation, because
it so fits the  facts  of the patient's  experience.   Then he can
see the force of the rule  that he must limit  his exercise by
quantity and time, and not by feeling.
   In the  wide range of  conditions from  the milder to the
severer stages,  they are  constantly  presenting paradoxical
phenomena,  as  they may  well do, when the one neurasthenic
cause is the basis alike  for  anesthesia  and  hyperesthesia
and all their attendant trains of symptoms which are appa-
rentlv so contradictory.  Not in all cases does  this anesthesia
of the sense of fatigue appear, nor always in like associations 
74
THE SHATTUCK LECTURE.
with other symptoms.   There  are different classes of cases
also  according  to  temperament,  character,  and  habit.
Women with the "New-England conscience" need always
to be held back against over-effort, and too early effort in all
stages of the disease, particularly of convalescence.  Whether
or not in  the  course of the neurasthenia there has been a
middle period of  melancholia,  or the like, the principle is
always the same.   Then  in  such cases, in the condition of
relative comfort and  exhilaration which  makes the delight
of the period of  convalescence,  there is always  danger of
over-exertion.  The sense of fatigue not being fully recov-
ered, it is at one  time felt  and again lost, as a sequence of
some indiscretion  in  exercise—some  over-stimulation of
emotion, either pleasurable or painful.  This is the time for
the greatest caution.   But when at  last the patient feels
naturally tired, even though  upon moderate effort, and can
appreciate the restfulness of repose,  then  is  convalescence
assured if conducted with  care within  the limits of the recov-
ered energy.
  This analysis and estimate of  the clinical manifestations
of neurasthenia go to  show  how  gravely significant and
dangerous is  the condition  which  is represented  by the
symptom of diminished sensitiveness, or anesthesia of the
sense of fatigue.   Immediately concurrent with the induc-
tion  of  pathological  fatigue,  with  its  dual  elements of
diminished energy and  auto-intoxication,  almost  the very
first effect of these  is to begin the annulment of  the  sense
that  prompts   to  the  conservation  of  nervous  energy.
When this peculiar and  very common  effect is produced,
the greater the exhaustion the less  the direct sense of it
through the normal channels.   The  patient vaguely feels a
lessened adequacy to  effort of body or mind,—a lowering
of the  emotional  tone,—many  sensations  of miserv as
emphasized in the  morning  tire,—much  irritability and
restlessness,—and all the changes characterized as  hyperes- 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     75

thesia, paresthesia and anesthesia; in like manner there is
alteration of the sense of  fatigue, in some of  its complex
elements.
  Thefre is another class of cases in sharp contrast with the
type just described.  They have usually  been long ill and
have developed  secondary  conditions.   Rest being  at last
enforced, by the  completeness  of  the   break-down,  or
becoming a habit by indulgence, the rest treatment is some-
times carried too far,  probably, beyond the  point where
exercise should begin.   This  is  a  point difficult to deter-
mine, but the positive gaining of weight  is a  good guide.
But in the condition of the prolonged  "bed-cases," or in
the relapsing cases, there is likely to come, when they grow
fat  and  when  they do  not,  a state  in  which  fatigue is
keenly  felt.   As an extreme manifestation  of this is  the
inability to sit upright, to hear reading or talking, etc. ; even
the slightest muscular exertion, as the raising of an arm, is
distressing, and there is great sensitiveness to sound or light.
There is not only " horrible depression " upon slight exer-
tion,  but a  "terrible  exhaustion."  The  quickened pulse,
palpitation,  change in color,  etc.,  are physical  signs  in
proof of great  weakness in such cases.   This appears, in-
deed, like hyperesthesia of the sense of fatigue in  some of
its complex elements : but when  these cases are led to con-
valescence, it is long before the natural  sense of  fatigue,
and resistance to its quick disturbance, is recovered.  With
the dyspeptic aversion to food, the weakened power of assi-
milation of what is taken, the discouragement  of many re-
lapses,  and all the effects of habit, these cases are  difficult
enough.
  The mechanism of the sense of fatigue  is obscure,  as is
the complexity of its origin.   The difficulty of distinguishing
between  the  central nervous  fatigue  and the peripheral
fatigue  of muscles has been  noted.   The central  sense of
innervation, and of the  need of increasing effort with  the 
76
THE SHATTUCK  LECTURE.
increasing fatigue, would seem to be necessarily an element
in it.   But  this  very  mental activity  of brain cells  is
assumed to yield, along with waste products and work, the
organic sensations of fatigue.   Again, the same is true  of
the muscular sense,  or sense of weight, as affording  sensa-
tions  of work  being  done,  of  exhausted energy,  or  of
disability of contractile power.  But the  muscular sense is
said to belong rather to the  special  senses,  and we see it
still acting  normally  in the  cases of pronounced fatigue-
anesthesia, when there is no marked ataxic change of mus-
cular  coordination, even  in very restless and irritable cases.
Is it,  indeed, but a  question of the degree of alteration  of
the muscular sense?  With doses of alcohol, ether, and the
like,  we may first blunt the sense  of fatigue, then more and
more  the sense of weight, even  to  its  annulment  as the
necessary element in  coordination of  muscular movement,
and the result may  be the ataxy of intoxication.  In the
transitions between  these  first and last  stages of changed
sensations, as the effect of  one and the same poison, does
the common phenomenon of the  anesthesia of the sense of
fatigue in neurasthenia  represent  but a first  stage, as a
peculiar effect of some special poisoning?   AYe have not as
yet, in the study of these pathological conditions, the data of
experimental study  to demonstrate the mechanism of this
symptom.   But we have certainly the final fact of its clini-
cal manifestation, and it  stands  the  test of  the practical
application of this explanation of it.
   With this additional study of these alterations of organic
sensations, the way  is prepared  for  a characterization  of
them  in a summing up  of the symptoms of neurasthenia.
Three orders of these symptoms  have been set down ; the
fourth should therefore include those relating to the  altera-
tions  of sensitiveness, both in  the direction of anesthesia
and hyperesthesia, and should present the  conclusions  drawn
from  this last analysis and estimate of them.   The following
statement, then, is meant to include, in their four orders, 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     77

      The Subjective Symptoms of Neurasthenia.
1.   Depression of spirits,—lowering of the emotional tone
      and a sense of ill-being.
2.   Decrease of the power of attention (reflex attention),
      and sometimes of memory.'
3.   Morbid introspection, retrospection and apprehension
       (worry, hypochondria).
4.   Diminished sensitiveness, dulness and languor (anes-
      thesia) ; irritability and restlessness (hyperesthesia).
  These minor orders of symptoms go to make up a symp-
tom-group that forms  a  clinical  picture of neurasthenia,
covering the elements  of many possible variations of its
forms.   The sources and mechanism of each order of symp-
toms have been studied, and this should furnish the data for
a precise definition of the  disease.    That of  Dana  has
already been amended, in  these pages, to  include the ele-
ment of languor that represents the fundamental  element of
toxic blunting of sensitiveness ;  and while this, and the spe-
cification of excessive weakness and irritability, imply a men-
tal  element, the prime importance of this, as early  recognized
by  Beard and  Mitchell, is not adequately noted.  On the
basis of the foregoing summary of symptoms the amended
definition may  be written as  follows :—Neurasthenia  is  a
morbid condition  of the nervous system, and  its under-
lying characteristics are excessive weakness, and irrita-
bility or languor, with mental depression and weakened
attention.
   Diagnosis.—Neurasthenia being  regarded as a condition
of  the  nervous system, manifested  by functional  disorder
and without structural changes being  as yet demonstrable,
and presenting  symptoms of so many variable  phases, its
determination  as  a  disease  is  peculiarly  limited  to  the
method of exclusion.   It is not only a direct result of stress
and wear on the one hand, but it is  so  constantly secondary
to debilitating influences of all kinds,—the " general debility"
of  our  fathers in medicine,—that it has often to  be differen-
1 sm :wcb, p. ioj. 
78
THE SHATTUCK LECTURE.
tiated as being the remote and not the immediate effect or
symptom of some antecedent disease.  In other words such
a disease may pass away and leave the nervous symptoms to
continue as if somewhat by  habit.  On the other hand, it
is the initial condition  and often the sole basis of a great
variety of symptom-groups,  which are framed into pictures
of "clinical  entities"; it must therefore  be differentiated
from those disorders  of the nervous system in which some-
thing has been added to the simple neurasthenia, of graver
functional disturbance and  perhaps of  definite structural
change.
  Neurasthenia often  stands  as a  middle  term  between
general etiological conditions  and nervous  disorders.   It
simplifies and clarifies  the  view, to regard neurasthenia as
the common etiological and initial term to many varieties of
symptom-groups, and  even  of definite nervous  diseases,
about which there is  so much confusion as to their etiology.
This is peculiarly true of  mental diseases  with which we
cannot yet get beyond  a classification of symptom-groups.
  The nutrition of  nerve-cells being  primarily  at fault,
toxic influences being always primarily present,  central  dis-
order of  the  nervous system  being usually  manifested by
the earliest  symptoms,  and  cerebral exhaustion  through
mental strain being  one of  the most common forms,  the
diagnosis must often  be made solely upon the subjective  and
mental signs.   This  may be done  early enough  for pro-
phylaxis  in  many  cases.    Any   notable  and persistent
alteration from the natural  manner and appearance, indica-
ting a lowering of the  emotional tone, in persons otherwise
in  apparent good health, suggests inquiry as  to the cause of
the abatement of natural vivacity  and the lack of  the usual
mental control manifested by unwonted irritability of tem-
per which may be confessed.   These premonitory indica-
tions are of  the most practical value.  Active professional
and  business men who  do much  brain-work and incline 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      79

to sedentary habits,  women  under a  monotonous strain of
domestic life or  subjected  to special  mental  anxiety  and
grief, or the indolent who suffer especially from functional
disuse and  defective  elimination, all, at times, are likely to
experience  these mental signs of "fatigue" and toxicity.   The
primary order of symptoms  being  present, and the causes
continuing, some of those  of the  other  three  orders  that
have been  specified  will  soon  be  manifest in  some slight
degree, and be more  or  less slowly developed.   The study
of the  genesis  of these subjective  symptoms  and  their
nature as summed up in  the foregoing section, may serve to
show how  their  natural  order  of development affords  a
method of  analysis that is an aid to diagnosis.
   Neurasthenia should first be differentiated from the ante-
cedent conditions, with  a discrimination of its  immediate
and remote causes.  This demands a  determination, as far
as possible, of the nature of the  inanition and the auto-
intoxication, whether partial or  general,—and, otherwise,
the study  of the "mechanism" of the symptoms.   This
implies, at the  outset, a careful  study of all  the objective
symptoms  by the usual methods of diagnosis.   Their char-
acter as due to  neuroses must  be established  as  at  least
probable, to the exclusion of organic diseases of the nervous
system, although these may still have a neurasthenic basis
that is amenable  to treatment.  The inquiry is then led into
the central "weakness," the diagnosis of  which  points out
the need of general treatment rather than of medication for
the localized  disorders.   The objective  items of the most
practical diagnostic  importance in this regard are of two
classes, and pertain  to the elimination of toxic waste  pro-
ducts, and  to the processes of repair by nutrition and tonic
influences.
   The way is now clear for  a further  differentiation of the
subjective or mental symptoms  to  determine  the diagnosis
and  prognosis  with respect to melancholia.    It must be 
80
THE SHATTUCK LECTURE.
remembered that many cases of melancholia have no more
than the four orders of symptoms,—no delusions, and no
essential impairment of integrity of the reasoning power ;—
it is a question of degree.  On  the  other  hand, very pro-
nounced manifestations of these orders of symptoms, more
than in  some of the cases of melancholia, will not truly bear
that diagnosis, although the underlying  organic  conditions
are of  the  same  nature  in  both  these  types of cases.
Difficult as it is to draw the line between " nervous prostra-
tion " and melancholia, the crucial test may perhaps be best
stated  as  a question  of the degree of impairment  of the
higher power of inhibitory control,—the weakening of the
voluntary power exercised through  the attention.   There
may come  a time in  these conditions  when  painful ideas
become so  dominant,  because  of the  inability to  inhibit
them, as to endanger  the patient by promptings  to suicide.
Then we  say,  it is melancholia,  and that there must be
medical restraint.   But in  many cases the true conditions of
melancholia are established before this symptom comes.  It
is a matter of temperament, education, training,  "habits of
thought,"—there are those nobler souls who withstand to
the last degree the nervous exhaustion, the misery of mental
pain, and the terrible temptation to seek relief through "the
open door."  But many are weak in will and inhibition,
and yield early to specious reasoning and  the  bias of the
emotional tone, for whom recovery would be as sure as from
other forms of functional weakness.   But this bias of emo-
tional tone, which more or less influences all  alike, may
depend  exactly upon those alterations of the " sense of body"
which annul the instinctive love of life, thus technically
establishing the diagnosis of melancholia.   The differential
diagnosis of neurasthenia and  melancholia,  then, depends
upon an estimate of the degree of nervous exhaustion with
reference to the  mental symptoms, particularly as to depres-
sion of feeling and weakened  inhibition.   This estimate 
NEURASTHENIA AND ITS MENTAL SYMPTOMS.     81
must include a judgment of the individual as to character and
of the probable continuance or increase of the alterations in
the organic  sensations as affecting the natural instinct  of
self-preservation.   Such alterations  become the  basis of a
fifth order of symptoms which complete the symptom-group
that constitutes a typical melancholia.'
   The  physical or objective  signs  do not afford a good
differential guide as between  neurasthenia and melancholia.
The latter may exist without more pronounced symptoms of
general  debility,   disorders  of  digestion,  etc.,  than are
common  to  neurasthenia, although they are often seen in
 melancholia, as anemia, a sub-normal temperature, and a
 urine  which may  be scanty and  condensed, etc.,  which
 suggests  special  study  as  to its  indications of deficient
 elimination.
   The two special conditions of morning tire and anesthesia
 of the sense of fatigue have been described as of the highest
 diagnostic value in  respect  to the  neurasthenic condition.
 They do not afford' differential indications, however, except
 that these symptoms are usually  more pronounced in mel-
 ancholia.  It should be noted  that morning tire is common
 as a transient symptom after  excesses in  dissipation or in
 over-work, but it becomes significant in neurasthenia by its
 more or less persistent recurrence.1
    Hypochondria  may  be  differentiated as being subject to
 the principles just stated  in so far  as that it is a milder, or
  a sub-acute, melancholia,  in which  the patient has peculiar
  worries  over his  own bodily ills.
    Insistent or fixed  ideas  may or may not be diagnostic of
  neurasthenia.   They are common  in melancholia, mania,
  etc.  in  the genesis of delusions, and may continue as sequels
  of such mental storms  through the effects of mental habit
  and association of ideas,  etc.  While they are more likely
  to occur in neurasthenia,  and thus  become a  symptom of it,
   they  are  sometimes  initiated in  persons constitutionally
                       1 See Nu.ts, p. 105. 
82
THE SHATTUCK  LECTURE.
 sound and become the  cause of neurasthenia  by the worry
 that may  attend  them.  They  may directly  initiate it, in
 fact, as a neurasthenic weakening of inhibition, and in some
 limited disorder of physiological processes as an association
 psycho-neurosis.  The correct diagnosis of these ideational
 disorders is important and valuable as  affording indications
 for prognosis and treatment.   Hysteria as allied to these
 affections often  has  a neurasthenic basis and   appears as a
 complication;  and  it  is  peculiarly characterized by  the
 anesthesias of the special senses.
   Treatment.—The diagnosis of the neurasthenic condition
 having been made, upon a physical and mental examination
 that for special reasons should be thorough in all particulars,
 the plan of treatment  should  be carefully laid out.   The
 objective indications will be first considered.
   Elimination of waste products is logically a prime ele-
 ment of the treatment.  Not  only should the alimentary
 canal be regularly and thoroughly  evacuated, and the work
 of the kidneys be efficient, but the removal of the accumu-
 lations of toxic  materials stored up in the tissues should  be
 aided.   Constipation from  intestinal atony, as a frequent
 symptom of neurasthenia,  will itself directly cause  nervous
 irritability, depression, etc., and the functions of the various
 organs will be generally impaired.  This demands a proper
 regulation  of the bowels ;  and all means  should be tried
 before  regularly  resorting to laxatives,—but they  must
 be used if  needed.   The  milder  ones,  like  compound
 licorice powder,  may be used  at first,  or the compound
 rhubard or cathartic pills.   But a cholagogue purgative has
 often an excellent effect,—one-sixth grain doses of  calomel
 every hour or half  hour,—or  five  grains  of grey  powder
 every hour until action  occurs,—or  a few doses thus given
followed by a saline laxative.  A glass of cold or hot water,
 with perhaps some saline like Carlsbad salts, may be taken
 at bed-time or in the morning; the hot  water especially has 
        NEURASTHENIA AND ITS MENTAL SYMPTOMS.      83

 a washing-out effect upon  the  upper part of the intestinal
 tract, and acts as a solvent upon the  contents  of the  intes-
 tines.   Brunton1 says  that many cases  of nervous irritabi-
 lity, depression and weakness appear like neurasthenia and
 hypochondria.   Nervine tonics, sedatives, etc., are  not
 needed ;  but  for good  results  you must treat  the  bowels.
 Massage  of the  abdomen is  useful,  and smajl enemata of
 plain warm water, the  rule being observed to solicit action
 at a certain hour every day.   Fruit should be taken freely,
 and a good proportion of solid food when possible.   Minute
 doses of aloin and strychnia,  or one-tenth of a grain of aloin
 alone, or one or two grains of extract of cascara sagrada,2
 regularly after each meal, have a gentle and excellent effect;
 the morning doses and later those at noon,  may be omitted
 as the patient improves.   But the practical rule must be to
 give what suits the patient in each case.
   Elimination by the kidneys is of the first importance.  In
 cases of neurasthenia it is commonly found that  the patients
 drink too little water, which is the best diluent and diuretic.
 Prescribe  pure  spring  or distilled  waters,  which may be
 aerated,—not too much at meals, but between  them or half
 an hour before;  this should be  done  particularly when the
 urine is scanty and of  high specific gravity.    As Brunton
 says, it "tends to wash away  the waste products from the
 cells of which  our  organs are composed, to  clear out the
uric acid,  urea,  and phosphates through our kidneys  and
 thus prevent renal and vesical calculi, and also to wash out
 our liver and prevent gall-stones, while it helps to keep the
bowels  in action."   In prescribing the daily  consumption of
hot water, a slice of lemon in  it may overcome the dislike
of it.   A part of the beneficial effect of milk is doubtless
due to increased ingestion of the water it contains, and  milk
and lime water,  or  soda-water,  may  be given to the same
  » Lancet, June 20,1891, p. 1365.
  2 This dru"- will be disappointing if it is not the  product of the well-selected
and matured°plaiit, and reliably prepared. 
84              THE SHATTUCK LECTURE.
effect.   Skim milk and  whey  are  good diluents,  and best
suit some  conditions of digestion.
  Brunton regards the views of Haig, as to the elimination
of uric acid, as an important contribution to our knowledge
of the subject.   These views  have already been quoted, to
the effect  that the production of an excess of uric acid in the
body is due to its deficient  elimination in the urine ; Haig
says also  that " it may be looked upon as going on to some
extent in  every one during the best years of nutrition and
bodily activity," tending to its accumulation in the tissues.
Uric acidemia is therefore  regarded by him and others as a
condition  that may ordinarily  occur  apart  from the  gouty
diathesis,  and be a source of much  nervous disorder, includ-
ing the feelings  of depression,  heaviness, drowsiness  after
meals,  disinclination  for  bodily  and  mental   exertion,
sleeplessness, etc.,  which  are the symptoms common to
neurasthenia.   The periodical attacks of headache, mental
depression, etc., are  thus  accounted for  in young people
whose storage is less of uric  acid, and the  indication for
treatment is a change from nitrogenous to farinaceous food.
The persistence of these mental symptoms in older people
indicates  the probable need  of clearing out the accumulation
of uric acid in the tissues, spleen, liver, etc.  The  taking of
alkalies according to  the plan of  treatment  recommended,
and the disorders  of nutrition, etc., that increase  the alka-
linity of  the blood,  make  it a solvent of  the  stored  uric
acid ; this will cause acidemia, with a relatively slow, high-
tension pulse, and the usually accompanying  symptoms.  It
is greatest after meals and  in the morning hours before and
after  breakfast, during  the "alkaline tide" of the  blood.
Coincident  with  this is the "morning  tire," as   has  been
stated.    But if acids are given, wines or  condiments con-
taining them, or opium and other  drugs that act like them,
—as nux  vomica,  iron, nitro-glycerine,  nitrite of amyl,—
the uric  acid is driven  out of the blood  into the  tissues, 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     85

relaxing arterioles by reducing tension, and improving  the
circulation.   Mercury by a like action reduces the excretion
of uric acid in urine, producing diuresis.   All this is to the
temporary relief of  the disturbing symptoms, but it  is  not
elimination and they tend to return in a worse  degree.   If
there are  exacerbations  of headache, with nausea, etc.,—
for example, a "bilious  attack,"—give aromatic  spirits of
ammonia or  nux vomica in place of acids ; or, when acids
fail, opium or mercury in small doses will sometimes succeed
in affording the temporary relief  then essential.   Elimina-
tion is probably  best  effected by a  course of salicylate of
soda, with  an acid mixture in alternate doses for weeks or
months, till the daily excretion of uric acid remains for some
time at the level of normal formation (1-33) as to urea ; at
the same time there should be as  little of nitrogenous food as
is compatible with healthy nutrition.  The  effect  is  to re-
 move  the cause of the irritative vascular disturbance.  Then
dieting  is  the main reliance, to  limit the  formation and re-
      ©
tention of uric acid.   Haig recognized  the fact that when
 the nervous  system is  depressed by fatigue, deficient food,
 etc., disturbance of function  will be produced by a  smaller
 amount of uric acid in the blood than at other times.   It is
 significant that  these  symptoms, common  to  neurasthenia
 and melancholia,  are  often  observed in  the  latter to be
 ameliorated along  with the  return  of normal excretion by
 the kidneys.   Reference has been made  to Brunton's  con-
jecture that oxaluria indicates the presence  of  some special
 poison  in  the  blood.   Cases  with  this symptom are com-
 monly  treated  in  the  asylums   with nitro-muriatic  acid;
 Wood1 reports  some interesting cases of  impending melan-
 cholia successfully treated in this way.  Such considerations
 give new  interest  to  the physiological processes of elimi-
 nation, and enlarge a special  field for  investigation  into
 the causes  and treatment  of the  nutritional disorders  of
 neurasthenia.
     7             » Therapeutic Gazette, 1885, p. 793. 
86
THE SHATTUCK LECTURE.
    The excretory action of the skin should receive attention,
  and it is promoted by  bathing and  bodily exercise.   The
  neurasthenic do  not  bear cold bathing well,  and its effect
  upon those who have previously used it to advantage should
  be observed.   The effects of the warm bath should be  noted
  while it is being  taken, and afterwards, so that its tempera-
  ture and  duration may  be  regulated to suit the patient.
  Tepid  and warm baths at night have a sedative and hypnotic
  effect also, and may be employed two or three times a week,
  oftener when  well borne.   The Turkish  bath when  judi-
  ciously given is  useful in some such cases.   The morning
  sponging with cool water, not  more than 20° F. below the
  temperature of the skin,  should be regularly practised.  It
  should be given by the  nurse  until  the  patient  is strong
 enough not to need assistance,—then  the  muscular effort is
 good in addition to the effect of the rubbing with a coarse
 towel,  which should always follow the bath.   At first the
 temperature of the water may be  such as to give only a
 slight sense of coolness, and later it may gradually be made
 cooler.   The patient  should  never feel cold or weak  after
 the bath ;   the  test of its being beneficial  is the  sense of
 warmth and comfort,  or  invigoration  that it  gives.   The
 sitz bath and foot bath have their special indications.    Sea-
 bathing on the northern New-England coast is not beneficial
 to those who are much advanced  in neurasthenia ; in warmer
 waters it is often  invigorating and useful, and should  bear
 the test of the after-effects.
   Menstrual irregularities are often neurasthenic and should
 be carefully observed and  treated, though rarely by drugs.
 The douche may  be used, when indicated, under ordinary
 rules.   Suspension of the flow may be looked upon as con-
 servative.   An  ordinary  flow for  the individual  is often
relatively too much, and  should be limited.  The patient
usually  has  aggravation of nervous discomfort  or severer
symptoms at such  times, and  should be kept in bed from 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     87

the beginning of the  flow,  or the day  before,  until one
or more days after.   Fluid extract of ergot has sometimes
an excellent  effect,  in  five to  ten drop  doses, three times
daily, for two weeks before the event, or all the month.   It
regulates as well as diminishes the flow.  Large hot douches,
twice daily, when it is  desired to arrest it after one or two
days, have been employed with  great advantage.   Two to
four such douches are usually sufficient.
  Nutrition  as  the main  element  of the process of re-
pair demands careful  attention.  All  the food should  be
given that the digestive  powers  will  bear, it being remem-
bered that they  are weakened  with the   other functions.
Easily digested articles may  be required for a  time,  but
avoid slops if the  patient  can possibly  take solid food.
Ignore a little dyspepsia as not always requiring drugs ; it
will disappear as the patient gains in strength.   Milk, fish,
eggs, vegetables, fruit in abundance, and farinaceous articles,
are the main reliance, noting  any special difficulty there
be'in  the digestion of starchy foods.
  A variety of plain meats is not contra-indicated, except
that nitrogenous articles should be limited in the treatment
of uric acidemia.   Haig mentions that Lange successfully
treated certain conditions of periodical depression from this
cause by a diminution of meat  foods, etc. ; and Broadbent
used the  milk diet with success  in the frequent association
of mental depression with high tension of the pulse.   Sugar
and starch must sometimes be  avoided ;  give cream, malt,
etc., and good butter may be freely  used,  when increase of
weight is  indicated;  weigh  the patient  regularly,  every
month at least.   A table-spoonful of malt and the same of
whiskey or rum in milk, is a good addition to the light meal
that must be  taken when there is  much acid  dyspepsia.
One half  drachm  doses of aromatic spirits of ammonia, at
each meal, are useful in this condition.
  Give soups, and  prescribe water  for its value in nutri- 
88
THE SHATTUCK LECTURE.
tional processes, as well as a diluent and diuretic.  Milk,
eggs, good beef tea, porridges of Mellin's  Food,  with the
addition  of peptonized beef-powder,  etc., afford  a variety
for luncheons between meals and at bed-time.   In the long
interval between this  and  breakfast, especially  when the
patient is wakeful by night, a glass of milk or the  like, and
better if warmed, is most useful  in anticipation of the morn-
ing tire.   This  significant symptom of  neurasthenia  is  an
important index also for general  treatment.   For this condi-
tion  give on awaking a glass of warm beef tea, or of milk
with a spoonful of whiskey or  rum,  and it will lessen the
" misery."   As  a rule,  however,  stimulants should be but
little used.   In the weaker cases,  with  much dyspeptic
disorder, the regular milk-diet,  as  much as can be borne,
and  frequent  feeding,  may be employed along  with the
"rest-treatment."   At  the  beginning of the treatment  a
                             ©     ©
precise plan of dieting  should be written out,  with the pre-
scription for each of the  fixed  hours for meals.  Require
the nurse,  if there is one, to keep an  exact record of  what
is taken, along with the clinical chart  and other notes.
  Rest,  as a prime requisite, should be at first absolute and
continuous, or partial.   The first is appropriate  when there
is general exhaustion,  or  conditions of  body  that admit of
it as an aid in improving the general nutrition for  the relief
of local  neurasthenia.   It is contra-indicated  in the graver
degrees of depression, and especially of irritable restlessness
and  agitation.   Then it must be modified,  and some degree
of partial  rest  may  be employed.  The point  is to  get as
much rest  as possible for the patient, until he has acquired
some storage of energy, to permit of its use within physio-
logical limits, and to relieve the distressing sensations that
are  the basis of the lowered  emotional  tone.   Get all the
rest possible  without  increasing the irritation.   In  some
cases the regulation  time of six  weeks is enough for the
absolute rest;  sometimes  many months of partial rest are 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     89
                    %
required.   There seems  to  be no  rule except careful trial.
In the bed-cases the time seems to be indicated by a positive
gain in  weight and improved quietude of feeling ; then it
may be necessary that exercise  should be urged  upon the
patient.
   Exercise, properly regulated, is essential; it should be
begun gently and increased  gradually  in  all cases ;  in the
severer ones  the  patients  may  get up first  in  the  after-
noon, then after a time in the forenoon, but should be kept
in bed till after breakfast for a long time.   Get them out
of doors daily for fresh air and moderate exercise.  This is
the  plan  for partial  rest  to which cases of pronounced
depression and restlessness  should  be  subjected  as far as
practicable.   When the irritability is great, permit them to
get  up occasionally, to  lie  on a  couch,  etc., but promote
resting in any way it  can  be  gained.  Exercise should
always be kept within, the limits of fatigue,—this is the
golden rule of neurasthenia.  Macfarlane  well says that
fatigue invariably  intensifies the  symptoms, whatever the
limit may  be;  and this  must  be  determined  for every
individual case.
   The guides to the limit of fatigue are  most obscure.  It
 has been seen that the feeling of it does  not measure it in
 the well, and that  in the weak one of the most  important
 facts in the disorders of the "sense of body" is  what may
 be called anesthesia of the  sense of fatigue.   There is no
 escape from the logic of this condition,—the patient's appre-
 ciation of it must  always be interpreted, by the physician,
 who must also study all the signs of fatigue and  direct the
 patient as to the kind and  amount of exercise.   The effect
 of this, upon pulse and temperature, for example, should be
 watched.   When the temperature is sub-normal,  the condi-
 tions of elimination, nutrition and rest should be carefully
 maintained.   Then  even  a  little exercise  often seems  to
 increase the irritability  ; but when the temperature becomes 
90              THE SHATTUCK LECTURE.
                                     ■
normal  more exercise  can usually be borne  without this
effect, in the more  acute  stages of neurasthenia.   In cases
of long standing or  partial recovery, of the  irritable and
ambitious  or conscientious  type,  great  depression and  a
sense of " terrible  exhaustion " may  follow  as a reaction
from  indiscretion in exercise ; this may  be prompted by a
period of comfort when the sense of fatigue may have been
quite reliable as a guide within the narrow limits of mueh
repose and gentle  effort,  but it is quickly lost  under a little
stimulation or  excitement.  Such  a  patient may astonish
and  mystify all  concerned  by  extraordinary displays  of
apparent endurance, but  it has to  be  "paid for" with the
repentance  that comes  with the exhausting reaction that
may amount to a true relapse.   These effects not being ap-
preciated  by the  patient as simple signs of  fatigue, the
"repentance " is quite sure to take the form of renewed and
intensified self-reproach, with all its harmful effects.
  The careful  prescription of  exercise is one of the  most
important duties of the physician in these cases.   Within
due limits it increases vigor by  the law of physiological use.
It quickens digestive processes  and excites the  appetite, and
promotes sleep.  He must "follow up" his patient and protect
him in this particular, until he has acquired a sufficient reserve
of energy, and a sufficiently normal  "sense of body" to be his
own guide.   If the physician does not do this he will surely
let his patient suffer painful  relapses which too often occur
in spite of all advice.   For patients having cerebral  exhaus-
tion,  though bodily  well nourished,  and with  effects  of
sedentary habits, exercise  should be coupled  with  efficient
elimination, but it should  be remembered that there is also
increased central fatigue with all voluntary muscular effort.
This must  be carefully limited  at first, in these as in other
cases, while reasonable  entertainment is a  necessity.
  Massage counteracts the  tendency  to enfeeblement  from
prolonged rest,—it affords exercise without the expenditure 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.      91

of energy by the patient,—it promotes the removal of the
toxic and waste materials from the tissues, and their healthy
nutrition.  It  must be  managed with care and not be too
long continued, but may be followed by medical or general
gymnastics of the gentler kinds, or other voluntary  muscular
exertion, to the extent to which the patient bears it without
aggravation  of the neurasthenic  symptoms.    Electrical
treatment has been  much  commended both for its sedative
and stimulant effects,  in the forms of  central galvanization
                                            ©
or general faradization ; the  functions generally improve
under its tonic influence.  It may be  employed for a  few
weeks every other day.  It often has a mental  effect.
   Sleep should be promoted with as little use of hypnotics
as possible.  They  tend to spoil the  appetite and to pro-
duce secondary effects.  Toxic quietude of brain cells may
not promote their  rest and nutrition.   In the diverse causa-
tion  of neurasthenia the conditions inducing  insomnia are
varied.   Its cause  should  be determined,  in  each case, as
nearly as possible.  There may be some special toxic influ-
ence, errors of diet, too much  mental work  and.too little
bodily exercise, the  rheumatic  or gouty  diathesis,   etc.
While the blood tension is usually low in anemic conditions,
it is  ao-ain hio-h, and a few minute doses of calomel at night
with alkalies during the day,  are indicated.   Sleeplessness
from physical  over-fatigue, may  be  relieved  by the  wet
pack, a warm bath, or massage,  with  some liquid nourish-
ment in moderate quantity,—with  a  little wine  or  brandy
and  a biscuit.1   If  the  patient  must  have something for a
hypnotic, do the least harm possible.  In such cases Folsom2
uses preferably an unpleasant  drug,—a  few  minims of
paraldehyde in a drachm of chloroform water,  and this  can
be repeated a number of times.   This drug is a safe one in
drachm doses,  when  it  can be  taken ; and a  second dose
          i Macfarlane, op. cit., p. 118.
          2 Bost. Med. and Surg. Journal, July 10, 1890, p. 29. 
92
THE SHATTUCK  LECTURE.
may be given after two or three hours ;  peppermint water
is  a good  vehicle for it.   Sulfonal  is, at present, to be
regarded as one of the safest hypnotics.  Begin with  ten
or fifteen grains, and  when its  cumulative effect is  gained,
reduce it to ten  or seven  grains ; it should be  pulverized
and  given  in a moistened spoon,  one and a half hours
before its  effect  is  expected.    Phenacetine, five or  ten
grains, two or three times daily, is sometimes a good adju-
vant when  there is nervous distress and  restlessness ;  or it
may be repeated every hour, or  half hour, till twenty or
thirty grains are given, for the relief of pain.   Warm baths
and night feeding  are verv effective in the long run.  Most
      ©        ©        •>                  ©
patients who lie much in  bed can get on with comparatively
little sleep.  It is  better to go without as much as is  desired,
or wait for it to come, rather than  to create a drug habit.
Two or three hours each  night  will do very well for a con-
siderable time in such cases.  Beware of using the bromides
and chloral continuously.   Patients are sometimes  brought
to the asylums in  toxic conditions from these drugs, or from
paraldehyde.  The first may *e given moderately for a short
time  only,—not  more than  one week.   Iron and other
tonics that improve the appetite  may be  given  when well
borne.   Aromatic spirits of ammonia in half drachm doses
may be used frequently and safely in paroxysmal nervousness.
   The subjective  and mental symptoms, in relation  to treat-
ment, demand the special attention that their importance in
diagnosis indicates.   In  studying the objective  symptoms,
a  general  though brief review was made of the measures
ordinarily  regarded as therapeutic.   This  included  not only
the physical signs, but necessarily also that group  of  coin-
cident subjective indications of  which we  can only know by
what the patient says of  his bodily condition ;  his apprecia-
tion of it may be  mainly correct and  corroborative of the
physician's observatioas,  or be interpreted as consistent with
them.  This  includes  the  inward reactions, or  negative 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     93

symptoms of the physical  disorder,  according to  Putnam1,
distinguishing them  from the positive or objective signs.
  But we have seen how the normally correct appreciation
of the " sense of body " is qualified  in  the well;  and how
with the onset and increase of pathological "fatigue"  there,
is an  increasing impairment of appreciation, requiring in-
terpretation by the physician.   We have seen also how the
impaired and altered "sense of body," and special senses as
well,  in respect  to the  group of subjective symptoms just
mentioned, affect the strictly mental  indications.  All can
agree  as to  the  symptoms of  neurasthenia  being mainly
subjective ;  and as to the  fundamental facts of irritability
and languor in mind and body,—and  of mental  depression
and  weakened control.   Our study  of the  mechanism of
these alterations  of  mental activity leads us  to see clearly
the significance of such  effects, and that "the  higher mental
states are the sensitive indices of the lower physical chang-
es," affording us the truest guides to diagnosis and the need
of treatment.
  The subjective  symptoms, with a  correct  interpretation
of mental states, are the chief guides to diagnosis and treat-
ment.  They give the earlier and finer indications, for they
always exist  when  there  is neurasthenia; they  are  often
present, and complained of, when there are no clear objec-
tive signs.  The paramount importance of the mental condi-
tion becomes plain because it has to be  treated from first to
last;  there is often no guide but this.   Even when all ob-
jective signs have for some time  disappeared, there can be
no assurance of recovery until the patient can say that there
is permanent freedom from the depression,  irritability,  or
languor of feeling, and that he  has acquired  the power to
control his own mind, and his  natural force is  not abated.
The most critical periods of the  progress towards recovery,
when the danger of  relapse is greatest, are when  the  only
       ' J. J. Putnam.  Art. Neurasthenia, Ref. Handb. of Med. Sc. 
94
THE SHATTUCK  LECTURE.
guides to the limits of fatigue are the subjective and mental
symptoms,—what the patient feels and thinks as to his own
condition.  But that itself does not guide,—it is continually
leading astray the patient  and often the physician.  The
true guide is to know what  it is that makes  the patient feel
and think as he does.  It is upon the correct interpretation
of the mental  signs  that successful treatment   largely de-
pends.
   A correct knowledge of the working of the  mental ele-
                    ©                ©
ments is essential to put the physician into a proper and con-
trolling relation to the case.  The very first indication for
treatment is that the confidence of the patient should  be
gained as soon  as possible.  This  is aided  by  the  careful
examination, that should  always be made, in every particu-
lar, bodily and mental, that is needed to establish the diagno-
sis.   It is then important to give the patient a  clear under-
standing of the nature of the malady.   Intelligent patients
are always very ready to accept correct explanations of their
condition  and experiences, and it is often most satisfactory to
them to know,  for example, the reason for  the morning tire,
and  to understand the principle of anesthesia of the sense of
fatigue.  They  know  what it is to be too tired to feel  fatigued.
The first thing is, therefore, to know what is the  matter, and
then to get the patient  to know it; this gains  the willing
and  intelligent  cooperation of the invalid,—relieves greatly
the worry,—and thus directly promotes repose  and the ar-
rest  of exhausting processes both  in body  and  mind.  All
writers agree as to the importance of gaining such-coopera-
tion, and  advise careful attention to this part of the  treat-
ment of such cases.
  When the physician thus appeals to the understanding and
interest of his patient, he addresses himself  exactly to the
moulding of the mental elements  that are involved in the
malady,-—he sets himself, at the outset,  to treat the symp-
toms that all observers note as among the earliest to appear. 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     95

The first clinical procedure, then, with which the treatment
is begun, is to get the whole story of the patient's experi-
ences with reference to the symptoms, as soon as  practica-
ble.   When neurasthenic patients come to the physician,
they have usually made a number of attempts at "resting,"
and have suffered as many relapses because the golden  rule
of keeping within the limits of fatigue was not followed to
the completion of convalescence.  The patient comes  be-
cause he has begun  to  think  that  something serious is  the
matter, and that because recovery  does not come it  may
never come.
  The  treatment of  neurasthenia,  with  respect  to  the
indications given by the mental elements, resolves itself into
procedures  suited to  two  general  groups  of indications.
These may be broadly  distinguished  as the first-effects  and
the after-effects of the neurasthenic condition.  Among the
first-effects, or those attendant upon the active operation of
the neurasthenic  influences, are  the  direct and  immediate
results of excessive expenditure of energy, deficient repair,
toxic  effects, etc. ; these may represent the formative stages
of the supposed " molecular or chemical variation" that is
manifested as "an exhausted or changed nutritional power."
Among the  after-effects  these  changed conditions become
more  pronounced ; the expenditure of energy may be greatly
lessened, but it is limited by its relation to weakened assim-
ilation ; the toxic elements may have been largely  eliminat-
ed, though  some of their effects  remain ; the condition is
more  strictly  one  of "irritable weakness," and all the
secondary effects of  morbid habit  and association are in full
force.   The neurasthenic condition  as modified   by  after-
effects presents a materially different problem as to mental
treatment.
  In  the early and  active stage of neurasthenia, the problem
is a relatively simple one for the analysis and interpretation
of the mental symptoms  as a guide to treatment.   The his- 
96
THE SHATTUCK LECTURE.
tory of the case should make it easy to distinguish the four
orders  of the subjective  symptoms, and  to  trace  their
development.  Take for example the case of the  physician
whose  account of it was quoted, in a previous page, from
his letter.  At the closing of a busy year, while still doing
very active work, he felt that it required  greater effort; he
could not help worrying unduly ; there were threatenings of
the sciatica to which he had been most subject at  that time
in the year, and he  sometimes  felt considerably  fatigued.
After three weeks of greatly lessened work,  the four orders
of symptoms  were more plainly revealed ;  there was  (1)
" a letting down of spirits;" (2) lessened control over  his
worry ; (3) the worry was consequently increased, and there
was (4) an altered "sense of body," shown in nervous irri-
tability and languor, and excessive  sense of fatigue.   The
condition being further interpreted, there  was  more real
"fatigue," but it was concealed  by a  fatigue-anesthesia
when he was  still  active, than  later when he felt  it more
keenly  after partial  rest.   In other words, he was really
better when he felt worse, — he was recovering his  sense of
fatigue.   This was proved by the sequel:  in the fourth week,
with no change in affairs, etc., and no treatment other than
the  comparative rest, he  was  quite well, was changed in
appearance, had recovered  his cheerfulness, and  began his
summer  vacation  with better  zest than for a  long time
before.
   In another case, a lady engaged in clerical work  had for
three months an increasing  tendency to aching and  a sense
of pressure in the head, and to waking early  in  the morn-
ing ; she would not  confess to morning " tire," but  said she
felt "worse" then; she worried, felt the need  of greater
effort to begin her daily task, but "could work faster" than
before, and being conscious of not feeling well, she expected
a short vacation to restore her  strength.   On returning to
duty, the work seemed very difficult and  not half  done on 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.     97

the first day, and impossible the next, from weakened mental
control;  the insomnia, worry, etc., greatly increased, and
a  prolonged  rest with careful treatment had to be ordered.
She knew she wras "running down," by failing appetite and
loss of weight.  Otherwise,  there was little in  either of
these  persons besides the subjective symptoms to call  atten-
tion to the neurasthenic condition ;  neither was it appreciated
by them until there  was lessened stimulation  by work to  be
done.   The four orders of symptoms  were plainly shown in
the last case ; their  earlier recognition  would have clearly
guided  treatment obviously  necessary to  have  saved the
patient from so dangerous an  approach to  a  serious mental
breakdown.   This applies particularly  to  the fourth order
of symptoms, — to the  fatigue-anesthesia,  and  the de-
ceptive  facility  from irritable  weakness,  that enabled the
patient to  " work faster," thus  increasing  her danger.   In
the more  advanced cases, the mental indications, as first
effects, are clearer,  and their analysis easier.  Their value
as guides to treatment is more readily apparent, pointing to
their orioin in organic inanition and auto-intoxication as the
double cause of  the "fatigue."
   The  after-effects  of the  neurasthenic  condition present
modifying indications that have to be met in the plan of
 treatment.   These  are seen  in the  later stages,  either in
 convalescence or chronicity.   The significance of the symp-
 toms, in this regard, has been pointed out.   For example,
 one who has regained some reserve of nervous energy, and
 maintains a fair  degree of comfort when effort is kept within
 his limits  of fatigue, may be prompted by desire, or a sense
 of duty, to over-exertion.  The undue quickness of response
 to the stimulation of interest and attention is to be recognized
 as an evidence of the irritability of unstable weakness.  The
 apparent ease and zest of the effort is not  due to real power,
 but there is a speedy blunting of the  sense of fatigue.   The
 reaction of exhaustion and mental misery that come as after- 
98
THE SHATTUCK  LECTURE.
 effects are not to be  interpreted  as the patient  feels and
 thinks,  but  as  precise  manifestations  of—(1)  changed
 organic sensations  shown  in  a lower  emotional  tone and
   ©
 ''hopelessness,"—(2) the decrease of the  mental power of
 control in weakened attention,—(3) worry,  self-reproach,
 and  apprehension  as  simply  signs  of  a relapse  of the
 tr fatigue," the limits of which were exceeded in breaking the
 rule of treatment.  The fundamental weakness  is  shown,
 from the beginning of  the event,  in  (4)  the susceptibility
 to stimulation and quickly  changed sensations, followed by
 increased exhaustion and irritability.
   Such an analysis of a later stage of neurasthenia reveals
 the four orders of symptoms as we may  observe them in a
 case under proper treatment, in which there may be #  mea-
 surably effective elimination, but defective assimilation still
 remaining, and therefore prolonged inanition.  The irrita-
 ble weakness  is more characteristic, and the  indications for
 treatment are all the more  significant.  The  whole matter
 comes, in fine, to  this :—the condition  is one of  deficiency
 of nervous energy,—the problem  is to  effect a re-storage
 of that energy.   It is a part of the process that the power
 to do things  can only  be  maintained or regained  by the
 doing  of  them,—by the law of use  and  disuse.   But the
 patient must  always be "kept within the  limits of fatigue "
 during treatment, through convalescence, to established re-
 covery.
  In these later conditions the  advantage  of intelligent co-
                                     ©           O
 operation  on the part of  the patient becomes more evident.
 It is a part of the  treatment,  therefore,  that the patient
 should  be taught to make a correct  interpretation  of his
 symptoms ; he will  thus  become an  aid  to the physician,
and learn finally to be  his own guide as to  the limitation
of effort.   One cannot " go by feeling"  whose power  to
feel is itself disordered, and this lesson  once learned has
a therapeutic  value  by leading the patient to  "go by judo-- 
         NEURASTHENIA AND ITS MENTAL SYMPTOMS.     99

 ment."  But it is precisely because of weakened attention
 and  morbidly intensified feeling,  that the better and often
 accepted judgment cannot  be  held.   Here comes in one
 of the  chief duties of the physician with  respect  to the
 patient's  mental condition.    It  has been  seen that his
 "exercise"  must be  followed  and guided  with persistent
 care.   As the changes in bodily conditions are best revealed
 by the mental  indications, these  should be followed with
 sufficiently close observation, and  encouraging counsel, to
 enable the patient to hold  to  the  way of recovery and to
 faith in the necessary means.   It is a part of the physician's
 business to repeatedly uplift  his patient by explaining the
 newly arising worries, and directing as to diet and exercise.
 If he is left to himself too  early in regard to all these mat-
 ters,  relapses are very  sure  to come through inability to
 interpret correctly the altered sensations and the fallacious
 appearances of returning strength.
   The foregoing considerations apply particularly  to  the
 large class of patients that  have to be systematically "held
 back"  in  all stages of the  neurasthenic  conditions.  The
 opposite class of cases  has  been  mentioned  that  require
 urging to  effort, when the proper  time  comes.   Here is
 revealed more plainly another modification,  as  an  after-
 effect, that always introduces great difficulty into  the treat-
 ment.   It is the effect of  the  laws of  use  and  disuse,—
 of practice, habit, and association.   The  long  continuance
 of disordered activity  has created a " functional disposition
 to repeat organic processes " in a morbid way, and it  has
 been shown how this involves a like association of morbid
 ideas and feelings.
   The " functional disposition " may work to good or bad
 results.  In  either case the principle is the same,—the law
 of use and practice rules.  To overcome a harmful "disposi-
tion" to  repeat organic and  mental  processes is  exactly to
re-acquire  good habits by the practice of them.  Hence it is 
100
THE SHATTUCK  LECTURE.
 that the power to do things comes by  doing them, and by
 gradually gaining the effects of practice.   Small beginnings
 are  necessary  in these  cases  of neurasthenia.   It  is the
 persistence of repetition that is efficient.   In the  condition
 of first-effects there is  lack of power,  and it  is  plain  that
 there is  no place for heroic methods of breaking up  morbid
 "dispositions" and habits.  More harm than good is likely
 to be done by dominating methods unless based upon a clear
 insight.   But forceful  measures may  sometimes  be wisely
 used ;  it is only when  power  is sufficiently restored  that
 such measures are justifiable as against morbid  habit in the
 "after-effects."    Confidence  gained,  and the truth made
 plain,  are the best helps. In the peculiar cases requiring it the
 best way is for the physician to suggest in advance the  new
 effort  to be made, "not now,  but by and by," when the pa-
 tient is going to  be read}' for it.   He becomes familiar with
 the  idea, and when  the  time  comes the  expected effort  is
 successfully made.  This is leading along by holding back ;
 such patients are  afraid of being " pushed," they have usually,
 in the  earlier stages  of the malady, made mistakes in "push-
 ing" themselves or by having it done by  others.  The patient's
 mind  should always be  prepared  in advance for changes.
 Much  is gained  by  giving  the confident expectation of re-
 covery.   This is one of the best remedies of all,  and it can
 be truthfully applied because most cases of true neurasthenia
 should get well.
   The rule has been laid down that "exercises hould always
 be kept  within the limits of fatigue," and  we know that the
 guides to those limits are most obscure.   It is  equally the
 responsible task  of the physician not to overdo  his duty, in
 the  cases that have to be held back, and in  those  that have
•to be urged to effort.   It is  precisely  in the extreme cases
 of the  latter class,—what Mitchell would call the "vampi re "
 type,—that the greatest discretion must be used.   Such pa-
 tients  are often the victims of morbid association-rhabit  and 
       NEURASTHENIA AND ITS MENTAL SYMPTOMS.    101

a self-indulging egoism.; under the spur of a seemingly per-
verse interest, they will sometimes make unwonted and ex-
traordinary effort.   We must realize that this may be done
without a concurrent sense of fatigue, which may come later
in a real and  most painful way.   Then the patient has a
new argument to sustain her self-deception that all effort is
bad ; and even the physician is sometimes put at fault if his
heroic measures are not successful.  There is need of sym-
pathetic helpfulness even here.
   We often ask  ourselves,  in  all cases requiring enforced
effort, what are the "limits of  fatigue"?  It is  perhaps the
clearest guide in  such cases that " exercise " may be pressed
with safety while the fatigue of it is felt, even sometimes
to the degree of painful  tire.    To avoid " fatigue" is  to
keep within the limits of pathological fatigue,  which gives
due warning by the signs  of fatigue-anesthesia.   This rule
applies as well to the graver cases of neurasthenia present-
ing mental symptoms,  when the progress  upward toward
recovery reaches the degree where normal fatigue is felt.
In such cases, after the symptom has been left  behind that
technically differentiates melancholia, it is neurasthenia the
rest of the way to health.
   A change  from the usual surroundings often does great
good.   The breaking  up of painful associations, on the
principle of "out of sight, out of mind," always holds good
to some degree.   Even homesickness is often  salutary,—it is
a natural and wholesome " worry " that works to advantage
when  it displaces  a  morbid  worry.   Dependence upon
devoted and sometimes over-sympathetic relatives is likely
to endanger the formation of degenerative  habits in long
and  severe cases.l
   It has often been said that the very first requisite for suc-
cessful treatment is to gain the confidence  of the patient;
this  recoo-nizes  the  leading  importance of the  mental ele-
ment.  It is a  part of this requisite, however,  that the
       8              ' See Nuics, p. 105. 
102
THE SHATTUCK  LECTURE.
 physician should first earn the confidence he seeks to gam.
 It is the interest the patient has in the means for cure that
 is the most helpful motive ;  and  we have seen what control
 a feeling of interest has  over the  attention.  But the pa-
 tient's interest is very exactly measured by  what he feels is
 the physician's interest.   This means  sympathy,—for  that
 and such interest are one.  The  physician's sympathy  must
 be genuine,—no one more quickly than such a patient de-
 tects a false tone in it.   No one  more readily sees the fit-
 ness of good explanations.  But the way to true sympathy
 is plain,—it springs from knowledge.   The physician should
 first know  his case,—then all that  is  needful follows.   No
 good physician, who acquaints himself with the marvellous
 simplicity that underlies and rules  the elements of his pa-
 tient's suffering, and thus sees the way to cure, but must be
 keenly alive to  the worthiness of  the  most skilful efforts.
 The patient's interest will then take care  of itself,—his at-
 tention is held through motive interest.   In mental matters
 all this is strictly physiological, which Bucknill  says is true
 of all that  is meant by "moral treatment."

   Conclusion.—The purpose of this study of neurasthenia is
 to contribute something in  the search for the philosophy of
 its treatment.  To make this  philosophy practical, it must be
 drawn down to plain terms.   We have seen that the central
 fundamental fact is nervous weakness,  manifested primarily
 in two ways: — (1)  by  an  exactly  parallel  weakness of
 mental inhibitory control  through voluntary attention,  and
 (2) by the central  motive element of a lowered  emotional
 tone, from  a sense of ill-being.  The first of these indications
 may be concealed, even from the patient himself,  by intensi-
 fied interest and increase of effort; the second he feels  and
 Boon betrays.
  The complex accessory  conditions of changes in the  sen-
 sations,—  irritability and hyperesthesia, languor and anes-
thesia,  and their causes,—have been explained.   These are 
        NEURASTHENIA AND ITS MENTAL SYMPTOMS.    103

manifested a little later than the primary mental effects.  The
prime indices of the  neurasthenic  condition, therefore, are
weakened mental control and a painfully intensified motive
element.  It is this central emotional tone, determining inter-
est, that has the sway ; this is our point of attack.   There
are two ways of approach to it: (1) through the body, restor-
ing its strength and well-being,—mental comfort and control
follow ; (2) through attracted attention and suggested ideas
we reach the emotional tone,—healthful feeling and interest
attend upon wholesome ideas.
   While the patient is in the condition of first-effects, as long
as the causes of bodily ill-feeling persist, we can only palliate,
or prevent increase of trouble,—only transient effects are pro-
duced by influencing  the emotional tone in the second way.
Here  the chief aim is physical restoration ;  this being soon
accomplished, all is well.   We prescribe rest and urge nutri-
tion ;  this means also elimination.   But in the condition of
after-effects, the problem is changed.   The toxicity of true
neurasthenia being removed, and that of special diatheses, as
of uric acid, being controlled, we have to deal with inanition
from cell inaction, and the effects of habit.  The patient finds
it easiest and most interesting to attend to the habitual asso-
ciation of morbid ideas and feelings.   The body in repose
is then comparatively comfortable,  while there is only a weak
tolerance  of a  little  effort and toxicity; the  way  to the
motive element for the  stimulation of healthful interest is
throuo-h ideas.  But effort is  painful,  the will is weak, habit
     ©                       L
is strono-.  Hence we instruct our patient how to understand
his contradictory symptoms ; we  introduce corrective factors
into  his  mental  equations, raise or  reduce  others  to their
true powers,  and eliminate the  constants of error.   Then
we prescribe exercise, urge practice within the limits  of fa-
tioue, and maintain elimination and nutrition.   By physio-
logical use,  the will  recovers its power, exercise promotes
assimilation  and elimination,  and  increased vigor;  effort 
104             THE  SHATTUCK LECTURE.
becomes easy, wholesome interests revive, and the emotional
tone is one of ease and comfort.
   The maintenance of a sense of well-being, under reason-
able effort of body and mind, is the sign of obedience to the
rule that " exercise should always be kept within the limits
of fatigue."  Normal fatigue is simply wholesome  tire,—
then rest is welcome and is followed  by immediate comfort.
Pathological  fatigue is attended by fatigue-anesthesia, and
this marks the beginning of danger.   We find  our natural
safeguard against that danger in observing the mental effects
    ©      ©             ©            ©
that quickly manifest their close relation to normal  fatigue
and its toxic products.  But we  have seen that when whole-
some tire passes over into pathological fatigue,  there comes
over-tire not only to the  central and motor, but to the  sen-
sory, elements of the mechanism.   The recognition of the
mental effects of the changes in  the " sense of body " is our
constant guide to prophylaxis and treatment,—for both of
these uses the golden rule is that exercise should always be
kept within the limits of pathological fatigue.   Fatigue-
anesthesia betrays us into its toils,—it is a danger-signal if
we recognize its significance.  It  becomes conspicuous by
the absence of normal fatigue when there is the presence of
other signs,—the first of these are the mental effects of fa-
tigue.   This teaches us the precise  and saving significance
of all these mental signs.
   In these considerations lies the proof of the proposition
with which the discussion was begun :—neurasthenia, for a
guide to its prophylaxis and treatment, makes itself known
to us mainly through the  significance  of its mental symp-
toms. 
NOTES.
  Page 62, line  4,  at  the  end of the sentence.    Here is found the
beginning of the  sense of  inadequacy of effort,  especially the mental
element of it. so strikingly characterized by Beard and Mitchell.   The
patient has a certain consciousness of inability to control his own mind
in his wonted  way, and  the consequent sense of more mental effort
being required becomes tantamount to  a sense of  lessened  power or
an increase of the resistance or difficulty to be overcome.
  Page 77, near  the top of the page.  The second  order of symptoms
may be amended  to read as  follows:—
  2.  Decrease of the power of voluntary attention (reflex attention),
and sometimes of memory;  a sense  of inadequacy of effort.
  Page 81, at the end of the first paragraph.   It will be said that there
may be a condition of true melancholia without this fifth order of symp-
toms.  Such a condition is one in which there is always reluctance, and
often difficulty, in undertaking to make a differentiation between neuras-
thenia and melancholia; it is indeed the difficulty of drawing the line
between sanity and  insanity.   If,  then, without this fifth order, the
morbid condition  is admitted to be a true melancholia, we must regard
it at the same time as an intensified neurasthenia with its four orders
of symptoms.  With the development of the fifth order,—which in-
cludes the suicidal impulse,—in the sequence often clinically observed,
the  diagnosis is then clearly established.
  Page 81, at the end  of the third  paragraph.   The fact that these
two striking conditions  are  common to  neurasthenia and melancholia
goes to prove their etiological unity.
  Page 101, at the end of the third paragraph.   Seclusion is a  thera-
peutic measure that has been strongly recommended,  and it claims
more than a mere  mention here.   Its special  value,  for  its  mental
effects,  along with  absolute rest in bed, in proper  cases, is seen in
those of  profound cerebral  exhaustion in which mental stimulation of
all  kinds must be  minimized.   It has its value, in part, from its
including a change of associations,  as the effects of habit need to be
overcome in such cases.   The use of it is contraindicated, as absolute
rest is, in the extreme cases of irritable weakness,  and especially in
those of  more pronounced depression  and  weakened attention.   In
these cases it is  sometimes of  greater value to  relieve agitation and
restlessness, and  to  attract  the attention outwardly from the persistent
worryino-.   The  rule is to give such patients  as  much seclusion, as
well as rest, as can be  borne  without increasing-  the depression and
irritability.  After a time the good effects of both appear in increasing
quietude.   This  applies alike to  neurasthenia and melancholia. 
 
V
fit 'XJ
The Shattuck Lecture
1891
NEURASTHENIA
MENTAL SYMPTOMS^
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