Some Causes and Characteristics 
of Neurasthenia. 
BY 
A. D. ROCKWELL, M. D, 
REPRINTED FROM 
Xeto Yorft Metical Journal 
for November 18, 1893. Reprinted from the New York Medical Journal 
for November 18, 1893. 
SOME CAUSES AND CHARACTERISTICS OF 
NEURASTHENIA* 
A. D. ROCKWELL, M. D. 
While very little has been added during the past few 
years to onr knowledge of the aetiology, pathology, or 
treatment of neurasthenia, yet it will, I think, be admitted 
by all whose experience entitles their opinion to weight that 
the disease is in most instances entirely curable, and in 
some cases self-curable. The enunciation and widespread 
diffusion of this idea I consider most important, for in 
neurasthenia we are dealing with a condition of mind and 
body that occasions more misery and paralysis of utility 
than many an organic and incurable disease, and because 
added to those wearisome and subjective symptoms of dis- 
tress which only the neurasthenic himself appreciates and 
the physician who listens to his tale of woe, is a condition 
of utter hopelessness, and a resistive tendency that some- 
times very materially interferes with the success of thera 
peutic measures. The true neurasthenic has a double burden 
to bear, in that, being sick and in despair, friends, relatives, 
and associates, in their ignorance, take little care to conceal 
* Read before the Section in Neurology of the New York Academy 
of Medicine, October 13, 1893. 
Copyright, 1893, by D. Appleton and Company. 2 
NEURASTHENIA. 
their opinion that all these symptoms are mere figments of 
the imagination. 
Fully aware of this incredulity and of the inability of 
friends to appreciate his condition, many a neurasthenic 
aggravates his condition by concealment and brooding, and 
the end is sometimes suicide. It is admittedly true that, in 
general, pathology and the aetiology of disease are far in 
advance of therapeutics, but in neurasthenia we have a 
notable example of the reverse of this. 
Our knowledge of its pathology is still conjectural and 
unsatisfactory, and in the study of its genesis and gradual 
development the most painstaking observation and analy- 
sis are still required. It is a source of satisfaction, at all 
events, that whatever tentative knowledge we possess in 
this direction does but confirm the correctness of the 
generally accepted methods of treatment. 
In a note on Nervous Diseases in Low Races and 
Stages of Culture (Science, Dec. 16, 1892) Dr. D. Gr. Brin- 
ton holds that those are in error who claim that “ diseases 
of the nervous system have greatly increased with the de- 
velopment of civilization.” My own very positive convic- 
tion, based upon a somewhat extended experience in the 
treatment of neurasthenic cases, is quite the reverse of 
this. In hospitals, in dispensaries, and among the very 
poor everywhere a typical case of neurasthenia is difficult 
to find, but among the well-to-do and the intellectual, and 
especially among those in the professions and in the higher 
walks of business life, who are in deadly earnest in the race 
for place and power, this peculiar impoverishment of nerve 
force that we call neurasthenia appears with alarming fre- 
quency. Dr. Brinton says also that civilization, so far 
from increasing this class of maladies, is one of the most 
efficient agents in reducing them in number and severity, 
especially when freed from religious excitement and “ com- NEURASTHENIA. 
3 
petitive anxieties.” It is, however, these very “ competi- 
tive anxieties,” so intensified in this country, this worry of 
business and professional life, that civilization fosters and 
deepens. American nervousness is indeed a distinctive 
phrase, and the frequency with which allusion is made to 
it gives it, in the minds of many, a meaning apart from 
that ordinarily ascribed to the term. We hear very little 
of English, French, or German nervousness, and yet, in a 
large record of cases, the writer has thus far failed to de- 
tect any widely divergent lines of differentiation between 
the functional nervous manifestations of the different 
nationalities. But while the general characteristics of the 
nervous temperament are very much the same, whether ob- 
served in the English or German, French or American, and 
while the same general causes underlie each class of cases, 
it can not be denied that in America there are climatic con- 
ditions and business and social environments to the influ- 
ence of which the nervous system is peculiarly susceptible, 
especially if complicated with evil habits, excesses, tobacco, 
alcohol, worry, or special excitements. 
An American in England is frequently surprised to find 
that he is able to indulge in malt and spirituous liquors to 
an extent that he would never attempt in his own country, 
while the Englishman, if for any time a resident here, finds 
to his cost that excesses in eating and drinking impose a 
heavier tax upon the conservative processes of the body 
than in the humid atmosphere of his insular home. 
A gentleman of a convivial turn who makes frequent 
trips to England tells me that on his pedestrian excursions 
through the country he is accustomed to drink malt liquors 
with impunity, while in this country, under the same 
conditions of exercise, he can take but a comparatively 
small amount without impleasant results. The Englishman 
is less nervous than his American cousin, not because he is 4 
NEURASTHENIA. 
less abstemious in his eating and drinking, but because ex- 
cesses in certain directions are less hurtful in his climate 
than in ours. 
No more exact delineator of certain English types and 
habits has ever written than Anthony Trollope. His 
Man about Town, with his enormous capacity for brandy 
and soda, is a unique creature in his way, and quite puts 
to shame the comparatively mild potations of his American 
counterpart. With the will, perhaps, to indulge as freely 
as the Englishman, the American succumbs to alcoholic ex- 
cesses that are relatively far less, and with symptoms that 
are oftener nervous than bilious or gouty. Another potent 
factor in the production of the so-called American nervous- 
ness, which is really nervelessness, is the hurry and worry 
of business and professional life on this side of the water. 
My observing friend Marshall P. Wilder says that “the 
English have acquired the virtue of deliberation and are 
never in a hurry or fret; all business is conducted in a quiet, 
leisurely way that seems to an American like child’s play, 
but is in dead earnest all the same. Your English banker 
will be found in some little building not at all like an Ameri- 
can bank, and with very few clerks in sight. Nobody rushes 
breathlessly in or out, yet the amount of business transacted 
daily in that dingy little building is enormous.” 
In the older countries men plod along in the footsteps 
of their fathers, generation after generation, with little 
possibility and therefore little thought of entering a higher 
social grade. Here, on the contrary, no one is content to 
rest with the possibility ever before him of stepping higher, 
and the race of life is all haste and unrest. It is thus 
readily seen that the primary cause of the increase of neu- 
rasthenia in this country is civilization itself, with all that 
the term implies, with its railwajq telegraph, telephone, and 
periodical press intensifying in ten thousand ways cerebral NEURASTHENIA. 
5 
activity and worry. As before intimated, another impor- 
tant causative factor is found in the relative dryness of 
our atmosphere as well as in our extremes of heat and cold. 
Evidences of the dryness of this climate are observed in 
the drier and stiffer hair grown by Americans and in their 
leanness compared to the English and German. In the 
Northwest this peculiarity of climate is more positive even 
than in the East, as evidenced by the readiness with which 
meats when hung in the air are dried and preserved. It 
may be only a coincidence, but the writer has remarked 
the greater proportional number of neurasthenics coining 
from that portion of the country. 
Then, again, no one can estimate the importance of the 
natural electricity of the body nor altogether analyze the 
part it plays in the human economy. What is an excess 
and what a deficiency has never been demonstrated, but we 
do know that dry air prevents the natural electricity of the 
body from being conducted away, and it is rational to be- 
lieve that a constant excess of electricity in the body may 
in some cases so overstimulate as to excite a degree of 
nervousness that amounts to disease. 
Fortunately, however, man has it in his power to rise 
superior to climate; can adapt his methods of living to the 
vicissitudes of climate. 
The cause and cure of disease in general are very much 
in what we eat and drink and the way we live. If the 
American would cease squandering his vital forces by ex- 
cesses, exercise a little common sense in what he eats and 
drinks, and practice the gospel of rest advocated by Her- 
bert Spencer, he might bid defiance in great measure to 
climate and regain the old-fashioned constitution of his 
fathers. 
Benedict understood this when he said that “if the 
Americans would learn from the Germans how to amuse 6 
NEURASTHENIA. 
themselves instead of yawning on holidays, the danger of 
neurasthenia would be diminished. Whoever has not 
learned how to play and jest easily succumbs to mental 
work.” 
All physiology and all pathology begin and end in the 
cell, and it is quite as important to recognize the facts of 
cellular nutrition in dealing with the functional diseases of 
the nervous system as where its nutrition is perverted and 
poisoned by microbic agencies. The vitality of the cell is 
the important and underlying factor in health and disease, 
and experimental physiology, in relation to changes in 
nerve cell 3 under stimulation, is already throwing some 
light upon the aetiology and pathology of neurasthenia. 
Electrical excitation of a nerve in association with a 
spinal ganglion is followed in a few hours not only by some 
diminution in the size of the nerve cells, but by a very con- 
siderable shrinkage of the nuclei of the cell capsule, and 
this change in the cell is found to be generally in propor- 
tion to the severity and duration of their stimulation. 
It is a specially significant fact also that the cell recov- 
ers its normal activity and appearance only after long 
hours of rest, five hours of stimulation producing an ex- 
haustion and change that requires twenty-four hours of 
rest to restore. 
Associated with these actual changes in the nerve cells 
are chemical reactions that add a toxic element to the ac- 
tual muscular and nervous expenditure of energy. What 
takes place in nerve cells under artificial stimulation takes 
place also, in all probability, in greater or less degree in the 
ordinary activities of daily life, and the fatigue of mind 
and body which follows concentrated or prolonged effort is 
in the same way dissipated by rest and sleep. This is 
what is to be normally fatigued. 
Muscular activity through attendant chemical changes NEURASTHENIA. 
7 
always yields certain noxious products that are both ob- 
structive and destructive, and it is not alone rest and sleep 
that restore the normal organic tone of mind and body, but 
also the flow of blood which, while it deposits new mate- 
rial, carries away the waste products which clog and poison 
the system. A person may be said to be normally fatigued 
just so long as complete recuperation follows rest and 
sleep. Even where, through electrical stimulation or by 
effort of will, the repeated muscular contractions result in 
such absolute exhaustion that the muscle refuses to respond, 
or responds only imperfectly, to artificial stimuli or volun- 
tary effort, it is still only normal fatigue if through dis- 
use the muscular fibers regain in a few hours or days their 
usual tone. In involuntary muscular contractions there is 
no mental effort, and therefore no fatigue of the central 
nervous system, but in voluntary muscular effort there is a 
certain expenditure of energy that fatigues brain as well as 
muscle. On the other hand, severe mental labor results in 
a weakening of the inactive muscles—a condition supposed 
to be due to toxic influences following chemical changes in 
the brain. It is believed, and this belief is in accordance 
with accepted physiological principles, that both brain and 
muscle when exercised undergo a regressive metabolism of 
tissue of an oxidative character. The poisonous material 
thus set free acts upon the muscles through the circulation 
and weakens them. 
If this voluntary or involuntary stimulation of muscular 
activity is frequently repeated to the verge of exhaustion, 
and until the recuperative power fails to bring back the 
muscular tone to its normal level, we have passed the bounds 
of normal fatigue. The muscles, or the brain, if the strain 
has been along the line of mental effort, are now suffering 
from pathological fatigue, a condition in which the nutrition 
of the nerve cells is primarily at fault—an unbalanced condi- 8 
NEURASTHENIA. 
tion of waste and repair; in other words, neurasthenia. 
The inanition and auto-intoxication of neurasthenia or 
pathological fatigue are direct results of those visible 
changes in nerve cells and the toxic products of exercise 
which accompany normal fatigue. Overstrain, from what- 
ever cause, and the derangement of nutrition, initiated and 
determined by repeated toxic influences, must be accepted 
as the essential causes and pathological state of the neuras- 
thenic condition. 
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