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While looking over my case books for the last 3 years I was struck by the frequent occurrence of cases of great similarity, consulting me for diseases mostly treated previously under the various diagnosis of hypochondriasis, hysteria, female weakness, nervous debility and other names. Excluding from my list all cases where organic diseases were detected or suspected, there still remained on record 98 cases that in spite of their differences yet had so many common features, and such a general resemblance that I grouped them together as belonging to one distinct class under the head of neurasthenia. Many of these patients had been treated for other diseases, the existence of which I could not admit, or at least not recognize as giving a full explanation of their condition. The numbers being so great I venture to present some of the more salient and important points, the rather as the disease exhibits difficulties both in diagnosis and treatment. To deal intelligently with these tedious and troublesome cases requires both skill and tact, and is frequently unsatisfactory both for patients and physicians so that they usually go the rounds of all available practitioners frequently coming finally into the hands of quacks who may do them a great deal of harm.

The only merit of the few remarks, for which I ask your kind indulgence, is that they are derived from personal observation and recorded facts. In the first place I wish to call attention to the symptoms. These patients were all chronic sufferers, the disease in many cases extending over a number of years, rarely over less than six months, but the symptoms were usually very variable, only a few being constant during the whole period of illness. In a majority of cases where the beginning was so recent that it could be distinctly remembered, the onset was quite sudden; there was frequently first a more or less severe attack of some kind of nervous depression, for instance of great nervous prostration, sudden pain in region of heart or in the head, and then often an interval of several days or weeks of tolerably fair health, often followed by a sudden loss of mental and physical energy or some other breakdown, from which the patient only partly and gradually recovered to lapse into a condition of impaired health with numerous symptoms of a diseased nervous system.

The most constant, not to say the only, constant symptom has in my cases been inability to perform any kind of severe work. This symptom has been constant but variable in degree, ranging from inability to turn in bed, or to speak above a whisper to the less pronounced impairment of energy known as loss of ambition or loss of taste for the work that formerly was a pride and joy. That this want of strength was not imaginary, far less assumed from special motives, was evident from many concomitant symptoms, for instance from the muscular tremblings, the palpitations, or the pains that followed attempts to work. And another evidence of the reality of this muscular and nervous insufficiency I thought I found in the consistency of this symptom. There were certainly some cases, in which the patient thought himself unable to perform acts which he actually could perform if he tried hard, but the surprise of the patient at this was so manifest, that it became evident, that there had been a time at which the act had been impossible; the feeling of prostration afterwards was proof of the impairment of strength.

In this symptom of prostration I see a distinctive feature of the disease enabling me to draw the diagnosticating line between this disease (or group of diseases) and those apparently somewhat similar conditions, in which a person imagines himself ill, for instance from reading pseudo medical literature, or from fear of having exposed himselt to a contagious disease. This condition is not a sickness, although the patient may describe many peculiar symptoms, and may worry himself into a melancholic condition. But that class of office bores who consult you for “seminal weakness" is usually engaged in work, or is at least able to do so; such people may neglect their work to study their supposed cases, examine their tongues, fæces, urine, etc., but they are able to work and do not get excessively fatigued. It is different with the true neurasthenic, who frequently tries to work, perhaps because he is compelled to do so in order to support himself or family; but has to give up because palpitation, pain and great exhaustion compel him to. Many of my recorded cases have tried time and again, but had to give up and were worse afterwards. I have no doubt that many persons are unjustly punished in armies, on board ships, and in prisons because they refuse to perform work, which they actually are unable to do, although the unprofessional observer can see no sign of sickness about them. It is not only the muscular power that is impaired, the inability to perform mental work is nearly as well pronounced. I have met with many cases of neurasthenia among theological students, where the disease is very prevalent under the combined influence of hard study, insufficient and improper food, and the depressing feeling of poverty. A great number of theological students, at least amongst the Scandinavians, are supported on charity; these young men, about whose desire to work there can be no question, have often declared themselves unable to do so, or at least very much less apt than they had been formerly. Many of them I have known to go through their courses and to break down after they came out as ministers or teachers.

Amongst the other symptoms of this disease, those from the digestive organs deserve a prominent place. But very few neurasthenics have a perfect digestion, but the symptoms of indigestion are very different in the different cases. Cardiac oppression, flatulence, acidity of the stomach, furred tongue, costiveness, diarrhoea, colic and indescribable but nevertheless real sensations in the abdominal organs are so common, and so prominent, that many patients come with the diagnosis dyspepsia, and I must admit that many have gone away from me with that diagnosis, which further observation and more careful study have compelled me to change to neurasthenia. The distinguishing feature assisting in correcting the diagnosis has been the weakness, and the variability of the symptoms. Uncomplicated dyspepsia rarely leads to great bodily weakness and to loss of flesh; catarrhal gastritis and atonic dyspepsia which might be expected to interfere seriously with the nutrition, do not produce emaciation in any noticeable degree; gastric ulcer, cancer of the stomach or beginning pulmonary consumption should always be suspected, where dyspeptic symptoms are connected with considerable loss of flesh. In neurasthenia the loss of strength is quite marked, and loss of flesh is sometimes seen, but the opposite condition, that of an unhealthy fatness, is quite frequently seen. Such persons, mostly females, suffer frequently from a peculiar sensation in the abdomen, which induces the belief that they are infested with tapeworms, or other worms. These patients will sometimes state, that they have passed worms or parts of worms, a statement which careful cross-questioning usually proves to be unreliable, but the patient's belief is undoubtedly genuine enough, and finds its probable explanation in an increased sensitiveness of the viscera, making the patient conscious of the peristaltic movements, which in health make no impression upon the perceptive faculties. Such feelings vary with other abnormal sensations in the abdomen, sometimes described as pains in the hypochondria, in the groins and in the flanks. Tenderness in the different abdominal regions is quite common, and I have on several occasions found exquisite tenderness in the groins, not only in females, where a supposed inflamed ovary has been accounted as the cause, but also in men, where no such organ can be accused of producing it

The pelvic organs are very frequently the seat of abnormal sensations, more so in females, than in males, and in my opinion very often leading to mischievous so called gynecological treatment. I have yet to see the first case of a female neurasthenic, who has been treated by several doctors (and most of them have been treated by many) who has not been supplied with a collection of pessaries, had the uterine lips sewed together, or slit open, been treated locally with curetting, iodine, glycerine, tampons, suppositories, etc. The symptoms complained of are usually bearing down, backache, frequent desire to urinate, descensus of the womb, etc. I have been struck with the fact that the symptoms vary with the different nationalities, thus affording evidence of the difficulty the patient has in properly explaining the sensations; their descriptions correspond to the popular pathological conceptions amongst their surroundings. As an illustration I will mention, that among the ignorant class of Scandinavians the womb is felt to move about in the body, sometimes being felt in cardia, sometimes in the throat, and sometimes even in the head. It is only after they have become acquainted with American popular medical notions that their uteri take a downward course, that they get bearing-down pains, a symptom which they characteristically enough,are unable to translate or even describe,


but which they have adopted from the books they have read or the reports they have heard of fellow-sufferers. Also men may exhibit symptoms from the uro-genital system as peculiar sensations in penis, pains in testicles, frequent desire to urinate, unusual coldness of penis, etc., but less commonly than women. If they have read quack pamphlets, and if they have committed masturbation, they may describe such symptoms as the pamphlets mention and usually with a fluency and readiness that suggests that it is second hand information offered as the best description of the vague sensations actually present. In some of the few cases, where I suspected frequent masturbation or other sexual excess as the possible cause of the nervous disease, the symptoms from the sexual system were absent.

Of symptoms from the circulatory apparatus palpitations have been met with very frequently, and not only the subjective feeling of the beating of the heart, but sometimes a remarkably frequent pulse, without any discoverable organic disease or enlargement of the heart. In a couple of cases the pulse habitually exceeded 120;

. in one case it was irregular and frequent, in many cases it was very easily excited, as in some cases there was also a tendency to blushing and to headache which seemed to depend on cerebral congestions.

C. Gerhardt (in Volkmanns Klin Vortr, No. 209) states in an article about disturbances of the vaso-motor nerves, that all authors look upon neurasthenia as chiefly an expression of so-called angioneurosis. The rapid pulse in such cases would then have to be explained as a paralysis of fibres of the pneumogastric, or overexcitement of the sympathetic nerve. This sounds very probable for a number of cases, where palpitation and rapid pulse are found, but as far as my experience goes, these symptoms by no means constant. It may be that other vaso-motor nerves are implicated in other cases, and especially that the intracranial circulation is irregular, mainly through vascular spasm, or paralysis of the vessels of the brain through morbid condition of the sympathetic nerve.

As concerned the muscular apparatus the most prominent symptom was the general muscular debility; fibrillar twitchings and painful tonic cramps, mostly in muscles of calf and leg are mentioned; but as these also are found in healthy people, especially adolescents after unusual exercise, they may not have been symptoms of disease. In that class of neurasthenics, which we call hysterical, cramps,

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