THE NEURASTHENIC AND PSYCHASTHENIC

PSYCHOSES.*

BY HENRY P. FROST, M. D.,

First Assistant Physician, Buffalo State Hospital, Buffalo, N. Y.

The mental disorders which are discussed in this paper are of special interest to the asylum alienist, not because of their frequency, for in our experience at the Buffalo State Hospital they constitute only one per cent of the admissions (twenty cases in five years), but because of the relative lucidity and intelligence of the patients, the readiness with which they furnish a full account of their troubles, and their general amenability to treatment. Concerning the last mentioned point I venture the opinion that for severe cases of neurasthenia and psychasthenia the definite authority and the more or less rigid routine of a State hospital are extremely valuable aids in the re-establishment of will power and self-control. The conditions certainly remove some of the difficulties inherent in the management of these cases in private practice and to a less extent in sanitariums. I do not purpose, however, to discuss the well-worn topic of treatment, either general or psychic, of these disorders, nor yet to repeat familiar theories concerning their nature, causes and symptoms, but merely to present and comment upon the records of a few cases illustrating various phases and types.

It is necessary, though, in the interest of clearness and for the more orderly presentation of my material, to take some account of the question whether we are considering under these heads a single disorder or two fairly distinct clinical forms. While admitting, as we all must, a close relationship between neurasthenia and psychasthenia and recognizing the occurrence of many cases with well-marked features of both, I believe that the subject is much befogged by regarding them as identical, except in the degree of the mental involvement. From a consideration of typical cases, which alone are of value in establishing clinical forms, espe

*Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.

cially in mental medicine, I hold with those who see in neurasthenia a state of bodily and mental fatigue, mostly acquired, de pendent on a great variety of causes, manifesting itself psy chically by such symptoms as failure of attention and application, indecision, emotional instability, lack of self-control and a feeling of general uneasiness and depression of spirits-together with a host of nervous symptoms comprised under the term "irritable weakness"; and regard psychasthenia as an expression of constitutional neuropathy, relatively independent of fatigue or ex haustion, having mental factors far more prominent in the etiology, and characterized by morbid anxieties, fears and impulses.

I avoid as far as possible going over ground already well covered by Blumer, Collins, Courtney, Schwab and many others in the easily accessible literature of this subject in our own country by restricting myself to a discussion of severer and more compli cated cases, most of the contributions referred to having dealt with what I may term the sanitarium rather than the asylum types.

I shall cite first a few cases of the neurasthenic type and then several which I conceive to be instances of psychasthenia; and as these histories lose much of their interest if too briefly sketched, I desire to recite them in some detail.

The first case is that of a young woman in whom the principal cause of the trouble was a severe anemia of long duration. The onset was with hysteriform features, but a relapse during convalescence was characterized by typical symptoms of neurasthenia. An accidental inoculation with Christian Science thought at just the right time had a happy effect, and furnishes an interesting exhibit in the form of a letter written by the patient explaining its operation.

L. M., a single woman, age 33, admitted June 13, 1907.

Family History.-No insanity or neuroses. Mother an invalid from rheumatism for ten years. Patient was normal in infancy and childhood. At school she was bright; she graduated from high school. At the age of puberty she became anemic and has never been entirely well since. Her menses are irregular, often absent. She has been regarded as notional and peculiar and nervous, and has had a morbid fear of disease; was recently under treatment by an osteopath. She and her invalid mother lived alone and not very congenially, each jealous of the other's demands, apparently. Psychosis. Her present illness began in February. She complained of being nervous, did not want to be left alone, demanded a trained nurse.

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se wh This not being supplied, she stiffened out in bed, holding her limbs rigid, , most and lay motionless for nine weeks, usually with eyes closed, rarely whispermanifesting a word or two. She had to be spoon-fed and she paid no attention to the calls of nature. In April she came out of this condition and began to walk about the neighborhood, sometimes at night, in a very nervous and depressed state of mind.

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its-On admission, patient was very depressed, but she was composed in the manner, talked readily and coherently; was quite clear as to time and place and her memory was unimpaired.

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She said: "Everything is lost for me-even God cannot help me now. I just have to exist; it is terrible. If I could only forget what terrible things happened to ruin all my hopes! I suffered so much; my mind will go crazy or turn to stone or something."

This hopeless condition was brought on by lonesomeness, by being left alone when she was nervous. God had whispered to her to go downstairs, but she had not obeyed Him, and for that disobedience she would have to suffer in this world and the next. No other hallucinations were admitted. She explained that when she lay in apparent stupor for so long she felt too ving weak to move, and she did not think her conduct in this or any other sle respect had been irrational.

Physical Examination.-She is of good-sized frame and well rounded, but her muscles are soft and she is extremely anemic. The red cells number 3,600,000, and there is considerable poikilo-cytosis; leucocytes 6000; hemoglobin 35 per cent. Heart action is irritable and a soft, systolic murmur is present. Pulse rate about go. She is dyspneic on slight exertion. Urine is pale; specific gravity 1010; no albumen or casts. She has slight exophthalmos, but no enlargement of the thyroid. Subjective complaints are: weakness, dizziness, palpitation, sensation of a lump in the throat. Pupils are normal; vision normal, but at times she sees black spots before her eyes. There is some tremor of tongue and hands. Further examination is negative.

The patient improved slowly under treatment with iron and arsenic, hydrotherapy and massage. She continued depressed for three months, but beyond some contrariness and an unreasonable disposition she did not display any marked psycho-neurotic traits. Then she gradually brightened up, and with returning health got into a state that was regarded as nearly normal, but she did not wish to go home and resume her dull life there. In January, six months after her admission, she returned from a visit of several days with friends, not feeling well-tired, suffering with a cold. She stated that she had been out on a very blustery day and got chilled and exhausted.

After this experience she grew rapidly worse mentally. She was nervous, did not sleep, complained of palpitation, flashes, sweats, excessive weakness. She spoke in a whisper; was unwilling to make the slightest exertion; objected to taking a bath. No improvement occurred until after six weeks, and then it was very slow. At the end of three months she was still in

bed and very fussy, counting her pulse and respiration, harping on her weakness and measuring her expenditure of strength with the utmost care.

A letter, which she wrote to me at this time, describes her condition better than anything I can say. It was written with such faint strokes of the pencil as to be scarcely legible.

"Doctor, if you wish my nerves to get well and strong, as of course you do, please don't ask me to do too large stunts at first, that only frighten me and use up my nerves instead of strengthening them. It matters not in what way, if I overdo, it causes my nerves and heart to get over-tired and sets me back. Up and down the dormitory and sun-parlor was most overwhelming.

"I know, doctor, you mean all right, but you can hardly know how very little I can endure. I know how it is for I have been through this several times before and know perfectly well from years of sad experience. That day when I went over to Mr. P's, the wind was blowing fifty miles an hour, and when I reached Forest Avenue I was so cold and numb and tired I felt as though I would drop dead. My nerve force gave out then, I suppose, and I am a bankrupt until my reserve nerve force is restored.”

Gradual improvement continued and six months after her relapse she was in a fair way to get well, though not yet rid of whims and attributes of nervous invalidism. At this stage she made the acquaintance of another patient, a woman of culture, who was a Christian Scientist. From her she imbibed an interest in "Science," and the effect was indeed most striking. She announced that she was cured through this agency and given strength and wisdom to keep well hereafter. She became bright, energetic and self-reliant, and was eager to go out and spread the new gospel. So she went home and took care of her mother, assumed other duties, took a new and more cheerful view of life, and at last report was healthy and happy, preparing to get married.

Let me quote from a letter she wrote, announcing her salvation:

"Dear Mother: I have something to tell you as to the condition of my mind and thoughts. It has been now so long, nearly twenty months of that evil, erroneous, dark, wrong condition of my mind. It was hopeless to me. I could see no way out. I studied on my condition as to how I ever got into it, what it really was and whether there was any way of getting out. I thought of it religiously, metaphysically, physiologically and every way I knew how until I began getting the right thoughts, began seeing the truth, the light, the good, and I happened to hear a sentence spoken by a lady which made it all clearer to me-it was just the thoughts I had been arriving at. I began talking with her a bit, and lo, I had worked myself out by the great truth of Christian Science and did not know the principles of it. She is a Christian Scientist and a member of the First Church of Christ, Scientist, here in Buffalo. I began then studying it (I have her text-book, 'Science and Health,' her Bible and quarterly Bible lessons) and it is giving me the right thoughts, showing me the right, the good, truth, life, love, God. These are all synonyms, you know. The science or advanced

thought illumines the Bible-makes it so much plainer to understand what the great Mind, God, love, life, good, truth, right, are.

"My mind was in the wrong condition. I had thought wrong-I allowed the wrong to predominate till I got where I could see no good or Godmyself, anybody or anything-when I at last reached what was, of course, just a hell-hell, death, evil, error is a condition of the mind where one can see or think no good-it is not a place way off somewhere-it is within us, just as we can have heaven, eternal life, good, right, God, within us. It is just as we choose the right thoughts (or right mind, which is God) make us do right and be right, which is happiness forever, but the wrong thoughts of everything make us do wrong and be wrong and there is no hope or happiness.

"I began it years ago, and reached the climax that February, you know; = though my body was healthy, my mind got all wrong, and as mind is

everything and controls everything, I collapsed entirely-just from wrong:thinking, and hence wrong-doing and wrong-being. If your mind is wrong

you will do everything wrong; and all will be wrong. But there is hope and life and good and love and God to him that overcometh the error, the death, wrong, evil."

My second case, though very unlike the one just cited, is interesting for the same reason, in that it gives us an inside view of an unusual psychological experience, largely in the patient's own words and, therefore, more definite than any general descriptive statements. It is the history of an episode in the life of a neurotic man of middle age, taxed beyond his endurance with work and worry, suddenly collapsing, losing his mental grasp and experiencing the sensation of his personality being split into two divisions a higher and a lower consciousness, a material and a spiritual.

W. H. S., admitted November 25, 1905, is a man 55 years of age, a skilled mechanic and inventor. His parents and brothers and sisters were nervous, but there is no insanity in his family. His father was a somnambulist and was interested in hypnotism. When S. was a boy he was frequently hypnotized, and several surgical operations were performed on him painlessly while he was in this state. When his father died, he was so upset that he lay in a cataleptic trance with rigid limbs for several hours. He is afraid to witness exhibitions of hypnotism, fearing to succumb and do something absurd. He also dreads to approach the edge of a precipice because of the impulse to jump over. He is a poor sleeper; he has horrid dreams, as of falling; his health was never robust; in several attacks of typhoid and malarial fever he was delirious and “went double.” He has had syphilis, which is cured; and some years ago he nearly lost his sight from nicotine poisoning, having smoked excessively. He has taken a moderate amount of alcohol to brace up on; he is very susceptible to its effects.