NEURASTHENIA Since we have become familiar with the neurasthenia of adults not only in its severe and well-developed forms but also in its initial and milder, rudimentary manifestations, there can be no doubt that children are subject to neurasthenia.
The exact nature of the functional anomaly which we now- call neurasthenia is best described by the words "irritable weakness," i. e., a pathologic increase of irritability and diminished resistance to fatigue. The two factors go hand in hand, but not in the same degree, the irrita bility being sometimes more marked, while at other times weakness is the most prominent factor.
Although neurasthenia represents a disease of the entire nervous system, Wm do not find in an individual ease that all the various nervous functions are equally affected. Quite often the disturbances appear to be isolated or localized, so to speak, ancl it is only after a thorough examination of the patient, or more frequently after we have observed his subsequent development, that we realize that the individual symp tom is the expression of a pathologic change which is responsible for a variety of other symptoms. This explains the variegated character of the disease.
Before describing the symptomatology, a few words must be devoted to a general question, namely, the distinction between neurasthenia and hysteria. While the two diseases are frequently- combined in the same individual, nevertheless, since we have adopted Alabius' law* in re gard to the psychogenic origin of hysterical symptoms we refuse to recognize as genuine transitional forms either "neuro-hysteria" or "neuro-epilepsy." In our opinion these conditions merely represent combinations—intricate and difficult to unravel, it is true of two related, but nevertheless intrinsically distinct neuroses, neurasthenia and hysteria. At the same time we can readily see that the same clinical symptoms may be produced by either of the two neuroses, as will be illustrated by examples both in this chapter and in that on Hysteria.
Neurasthenia is by no means always a permanent, invariable, con stitutional anomaly; it may bc temporary, developing under the influence of bodily or psychic fatigue, and disappear as soon as the cause is removed; but there is no essential difference in the manifestations of the two forms.
Symptomatology.—Unlike hysteria, the occurrence of neurasthenic symptoms does not depend on a certain degree of psychic development, and we accordingly see the abnormal irritability manifesting itself in the simple reflex processes of very young infants. Perhaps the earliest symptom is an abnormal tendency to fright; the sudden .starting of the sleeping or quietly resting infant under the influence of a sudden noise, or bright illumination. The sudden start is sometimes accompanied
by a cry, which is purely reflex; it has as yet no psychic counterpart, there is no fear of any impending evil. The violent crying and strug gling of many young infants in the bathtub is a similar phenomenon. The mothers usually think the child is afraid of falling. Whether the child is distressed by vertigo or some similar sensation, we do not know. Continuous crying, day and night, and abnormally light sleep may also be early symptonas of neurasthenia; but one should be cautious in mak ing such a diagnosis, because somatic diseases (disturbances of nutrition., interference with nasal respiration from eoryza) may be the true cause. Sometimes mild general twitching of the whole body can be elicited by tapping any part of the person. It is very difficult to estimate whether -.he reflexes are exaggerated in infants.
The symptoms of neurasthenia are both somatic and psychic. Among the former we distinguish between subjectice and paroxysmal, such as headache, vomiting, syncope; and the objective and permanent symptoms, which are comparable to the stigmata of hysteria and of great diagnostic value because they can always be discovered by examin ing the patient. It should be emphasized, however, that they are fre quently absent or present only in part in cases of pronounced neuras thenia. These objective and permanent symptoms are: Increase of the tendon and periosteal reflexes, the cutaneous and mucous membrane reflexes being normal or greatly diminished (absence of corneal reflex and pharyngeal reflexes); tremor of the eyelids, or incomplete closure of the palpebral fissure when the child attempts to close its eyes Rosen bach's phenomenon); increase in blood pressure* to 110 or over 150 mg. of mercury instead of SO to 90 mg. (Heim, Strauss); changes in the pulse rate; alternating inequality of the pupils (1likloszewski, Pick, Schoumann and others); evanescent variable differences in the innervation of the tw-o sides of the body, observed both in the facial muscles and in the muscles of the extremities; sudden changes of color and the appearance of fleeting erythema in the temples, neck, upper portions of the chest ,,erytherna pudendi) when the clothing is removed for purposes of examination; slight tremor and shaking of the hands; hurried, noisy manner of speech or stammering. Amesthesia such as occurs in hysteria does not belong to the picture of neurasthenia, and the above-mentioned absence of pharyngeal and corneal reflexes is by no means accompanied by amrsthesia or byperxsthesia of these parts (Kiewe). Similarly Bartenstein has shown that Head's zones in children cannot be regarded as stigmata of neurasthenia in the absence of disease of the internal organs.