[Reprint from the Alienist and Neurologist, July, 1882.] Note on the Essential Psychic Signs of General Functional Neuratrophia or Neurasthenia.* C. H. Hughes, M. D., St. Louis. 44 ' I AHE subject of latent and unrecognized morbid mind,” said Forbes Winslow in his classical and unequaled treatise on Obscure Diseases of the Brain and Mind, “is yet in its infancy.” Much that was unknown to the profession before this great observer penetrated the then unexplored wilderness of obscure cerebro-mental pathology, and led others to the later discovery of new truth, still remained undiscovered up to the time of his death. Much has since become familiar ground, but more yet remains to be brought to light, both within and external to the brain, in connec- tion with the nervous system and related mind. Among the subjects of which we have of late years learned much, and of which we are destined to yet learn * Read before the Missouri State Medical Association, at Hannibal, Mo., May 18, 1882. 2 C. H. Hughes. more, is that of general functional neurathrophia or neu- rasthenia, for which we are so much indebted to Van Deusen, a Michigan insane asylum superintendent, who, in 1867, first emphatically differentiated it in this country as a distinct form of disease. The Kalamazoo Hospital superintendent had, up to that time studied and described it as “ a form of nervous exhaustion culminating in insanity,” its usual ending when not arrested in its course by fortuitous circumstances in the life and surroundings of the patient, or successful treatment. Since Van Deusen’s concise pioneer description, the contributions of Beard, Ball and Benedikt, Cordes, Erb, Gowers, Jewell and the present writer have appeared, until the few sentences of the past having been extended to pages and pages have been enlarged to volumes. But it is still possible to more briefly describe its distinguishing features than has yet been done, so that it may be even more generally recognized. This brief description is possible through its characteristic psychic symptoms, some of which are never absent when the disease is present. We draw the picture solely from our personal observation of the disorder. Neurasthenia, differentiated from its complications, antecedents and gravest sequences, is a more or less general failure of the normal nutrition appropriating power in the higher nerve centers, especially the psychical, leading to consequences short of appreciable structural change—a pure neuratrophia which is only functional in its effects and confined, in expression, to an altered and lowered functionation in the nervous system itself. The neuratrophia here is solely functional, not at all structural, so far as can be sensibly appreciated, whatever struc- tural change may be conceded in neurasthenia being merely conjectural and undemonstrable, except through theoretical deduction. Thus we should restrict and circumscribe the term neurasthenia, were we to use the term at all, but we prefer in its stead the more definite term, functional neuratrophia. Psychic Signs of Neuratrophia. 3 General functional neuratrophia (if you do not cavil at the term we offer,) is a state of nerve starvation due to causes inherent in the nervous system itself, having its appropriate symptomatic expression in nervous exhaustion and its immediate sequences, the chief and most signifi- cant of which are psychical. The physical symptoms, how- ever, are not to be ignored, though we do not intend to here discuss them. The general tired feeling and sensa- sation of inadequacy to the demands of duty in the presence of some accustomed and easily performed mental work, and the quick break-down which follows the attempt, even though not forewarned by a sense of insufficiency and weariness, are significant. The transitory localizations of symptoms which appear in the progress of general neurasthenia have led to such distinctive differentiations as cerebrasthenia and myalas- thenia, according as the symptoms appear most promi- inently in the head or spine, and the term gangliasthenia has been proposed for ganglionic neuratrophia and, con- sequently, debility; but whether the heart, or the cord, or the brain functionate abnormally at different times, the brain always displays, early in the progress of this disease, evidence of the defective nutrition, and the failure is marked- ly in the vaso-motor centers, which, being inadequately nourished permit of secondary morbid vascular states, which are often mistaken for the primary disease. Neuratrophia is primary when a precedent anaemia is not the cause; secondary and symptomatic itself, where blood defects induce it, but then not strictly entitled to be called neuratrophia. General functional neuratrophia being, as we have said, so seldom entirely dissevered from cerebral debility from atrophic causes that the psychic symptoms con- tribute the most important, as they make the distin- guishing feature, in its symptomatology, the latter are the special evidences by which we may often differentiate from graver cerebro-spinal and sympathetic system disor- ders, and need only now claim our attention. 4 C. H. Hughes. The panophobia, of Esquirol; the pathophobia or hypochondriasis, of the old writers; the toxiphobia, of old alienists; and Hammond’s synonym mysophobia (the gravest of neurasthenic psychic symptoms, by the way); the claustra- phobia, of Ball; and its antipodal agoraphobia, of Maschede ; the monophobia, panophobia, phobophobia, astraphobia, anthropophobia, and topophobia of Beard ; the gynephobia, of Spitzka ; the sideromophobia, of Rigler ; the agoraphobia, of Westphal, with Rosenthal’s synonym of platzangst, and Benedikt’s similar platzschwindel; the syphilophobia; hydrophobia (dread of large bodies of water, a natual dread in horses); thanatophobia or necrophobia and necropalo- phobia (fear of death and grave yards); and the numberless other fears, needless here to name, not natural to certain persons, but which come upon them when neuratrophic ill-health overtakes them, are expressions of a certain psychical change, not at all limited by the special terms thus far coined to express them—not to be limited either by the many words likely to be constructed from Greek, Latin or Saxon languages by expert philologists amongst us. It would be an almost endless task to enumerate the many morbid fears of the neuratrophic. Their name is legion to a mind fertile in verbal coinage, and some are even unnameable. For example, such singu- lar morbid fear as that which takes possession of a naturally fearless man at the approach of a familiar face, and causes him to go away and hide himself, as happened lately with one of my patients ; such unfamiliar fear to a naturally brave men, of taking once delightful journeys, without rational cause for the newly awakened fear, save only in the state of the nervous system. The unusual fear and indecision which sometimes seizes once bold men without cause external to themselves, and partly paralyzes their psychic centers in the midst of “ enterprises of great pith and moment,” which, in their best estate they would, without hesitancy, have carried to successful issue, delighting in encountering and overcoming the real obstacles which their present feeble brains build in fancy Psychic Signs of Neuratrophia. 5 too high to overcome. This is debility of brain, and the fears, forebodings of evil and morbid unnatural dreads of adverse consequences of ordinary mental movements are its characteristics, and associated with these are the timidity and irresolution or transitory, fleeting, or spas- modic decision supplementing the former natural firmness of mind, apparent when the brain was strong. The mental substratum underlying these unaccustomed morbid fears and dreads, and morbidly colored percep- tions, conceptions and misconceptions, is timidity or irresolution and irritability of manner and speech not natural to the person, and this state of morbid feeling has not been reasonably acquired by any rational experience in the history of the person.* A change less marked, but none the less real than that which takes place in insanity, has come over the natural mental character of the victim of general functional neuratrophia. This character- istic change in his manner of thought, feeling or move- ment is noted by his friends, in marked cases, as well by his physician. A degree of mental and nervous instability and irritability accompanies this timidity, and is the essential basis of the morbid fears the victin of functional neuratrophia feels. He weeps more easily and sleeps more difficultly than he used to. Nerve instability, mental timidity, dread and fear and easily hurt feelings, and later on, illusion and hallucination. Later still, delusions obtrude, when insanity confronts us, of which general functional neuratrophia, with special cerebrasthenic expres- sion, is a most frequent precursor in many organisms. But timidity underlies the morbid fears, as, later on, the hallucinations underlie the culminating delusions. This fact has not been noted by others, and it is the most important fact to the general practitioner, for the initial stage of unnatural timidy and irresolution, which the family physician may discover if he looks for it, *Some men are naturally superstitious and fearful of evil happenings Some fear to travel on steamboats, some on cars or to ascend heights, and some by reason of past experiences have special cause for certain fears. But the fear of the neura- trophic is causeless and unnatural to him and preceded by an unaccustomed irresolution and timidity. 6 C. H. Hughes. is the time when the impending calamity may be averted, by counselling the patient to promptly suspend business, and seek relief and recuperation in restorative medicine, and rest from mental strain through temporary change and recreation. Insanity is closely allied to neuratrophia, and is its frequent sequence as Van Deusen wrote. The morbid fears of the neurasthenic are but the shadows of graver coming mental events cast before. Often the advanced lunatic has no more of delusion than the trepidation and fear in their various forms, somewhat aggravated, of the neurasthenic. As neurasthenia frequently advances to insanity, so positive and well defined insanity sometimes recedes to simple neu- rasthenia. Esquirol has thus painted some of the advanced neuras- thenic denizens of Salpetriere and Charenton —“ Certain persons who suffer from panophobia are afraid at the approach of night and darkness” {Mai. Merit, p. 216), “ Lypema- niacs dread obscurity, solitude, insomnia, the terrors of sleep; fear, terror, jealousy and hallucinations keep them awake.” “ I once had in charge,” said he, “ a lady whom the slightest noise filled with terror, especially during the obscurity of the night. The steps of a person walking lightly caused her to shudder, and the wind caused her to tremble. The noise which she herself made while in bed frightened her and obliged her to utter cries of terror. I enabled this panophobist to sleep at night by keeping a light in her chamber, and placing a woman with her who watched during the whole night” {lb. p. 116). How like a phase of neurasthenia is this, and what is mania, often, but intensified, aggravated, cerebral neuras- thenia—exhaustion of the brain either from sanguineous impoverishment or blood pressure? True neurasthenia is neurotrophasthenia, from failure, from whatever cause on the part of the involved nerve centers to appropriate the requisite nutrition for that normal repair of tissue which is essen- tial to the maintenance of healthy tone and function, and Psychic Signs of Neuvatrophia. 7 like the unstrung lyre, responding “ out of tune and harsh ” to the player. If our experience did not give us many illustrations we could readily conjecture what might be its psychic symptoms. They are the symptoms of inadequate nerve nutrition, and in the higher centers of the cerebrum there are instability, irresolution, timidity, dread and fear, morbid and groundless suspicions, hallucination and delusion, not natural to the individual in his best estate, positive hallucinations and delusions, appearing generally when greater than mere neuratrophic changes are affected in the cerebrum, and the debility has passed into insanity and more or less organic change. This note would be anything but brief were we to attempt to name all the psychic signs of general functional neuratrophia. We have not even mentioned all of the morbid fears of the neurasthenic. No terms have yet been given to that inexplicable fear of one’s own voice and other familiar sounds once heard with pleasure by these nerve-weakened miserables, nor for the dread of certain dreams, of receiving once welcome visits from friends who have never offended, nor for the fear of riding in certain vehicles when no previous experience foundates the fear, and the numberless other nameless fears which unnaturally oppress these patients. The featiLre of functional neuratrophia to he italicized is the timidity not natural to the person out of which these fears grow, and give to the mental character that notable change in which irresolution replaces former decision of character, and supplements even natural fearlessness with fearfulness and dreads innumerable. Beard’s view, that the characteristic of neurasthenic fear is in the degree rather than in the kind, is only partly true. Their fears may be common to others, not neurasthenic, but they are not usual with the person afflicted with neuratrophia in his healthiest nerve condi- tion. The mental change of character in general func- tional neuratrophia is none the less real though far less 8 C. H. Hughes. in degree than that which attends upon insanity. It is seen in the mental movements as it is shown in the voice and walk and in functional nerve irritability and inertia. This change is a psychical timidity and indecision of mind and manner, whether it displays itself in monophobia, deutophobia, tritophobia, panophobia, or whether it has not taken shape in a single definite fear, or in multiple fears defined. The aim of this note is to be practical rather than learned, and it is hoped that it may be received in the spirit in which it is prepared. We think too much has been made of the subject by some writers. Perhaps you may conclude that we have made too little of it.