X4°4144 MEDICALThuf BamwuJO SN&I1 THE VICIOUS CIRCLES OF NEURASTHENIA. [JUNE 27, '914 than a skeleton, and a fatal exitits ofteu closes the scene. THE VICIOUS CIRCLES OF NEUIRASTHENIA. Schofield thus describes tlle circle: BY A vicious circle is often kept up in these cases, wbich it is Absolutely essential to break. They begin, it may be, with loss Br Med J: first published as 10.1136/bmj.1.2791.1404 on 27 June 1914. Downloaded from JAMIESON B. HURRY, M.A., M.D., of appetite from some slight cause. -This'. .. leads to dis- READING. ordered thoughts, and the idea of disease is started. This, again, makes the appetite still more capricious; the thoughts NEURASTHENIA is mnore often than any otiler disorder therefore get still worse, and so the body starves the brain complicated by vicious circles. The result is a clhronic and the brain starves the body.6 self-perpetuating condition, distressing to the sufferer, In8omnnia.-Insomnia is anotlher psychogenous symptom harassinig to tile relatives, and baffling to the plhysician. of neurastlhenia wlhichl ofteln greatly impedes recovery; If a disorder is to be followed by speedy recovery, its the associated cerebral liyperaemia prevents the neurons reactions-for examiple, couglh, diarrhoea, pyrexia, etc.- obtaining the rest on wlliclh their recuperation so greatly must relieve thle primary condition. Such disorders may depends. -Sawyer tlhus describes the circle: be described as self-teriiiinating. Any cause whiclh directly prevents a repose duly deep of a - In nieurastilenia, on tlhe otiler lhalnd, tile reactions per- sufficient ntumber of those brain cells which are the organ-s of petuate tile primary conditioll. Suell reactions may be conscious thought will renider sleep impossible. Relative psycihical, and take tile formii of nosoplhobia, melancloly, cerebral hyperaemia is an inseparable consequence of such a anorexia, insomnia inter alios; or tlle reactions may be activity, and such relative cerebral hyperaemia becomes cardiac concurrenit btut subordiniate cause of insomnia. Here there is somatic, aild take tlle formn of disorder, dyspepsia, progression tlhrough a vicious circle of two terms, in whiclh the ovarian nieuralgia, asthenopia. All suchi reactions per- impulse of the morbi(d movement springs from the cerebral petuate tlhe primary neurastheniia. Camipbell Smith well cells.7 sums up tlle process whlen lie says: These four examnples will serve as illustrations of In nio comlnlaitli does it happen miiore often than in neur- psychical circles. It need hiardly be aclded tlhat several asthenia thiat the patient gets into a vicious circle, tle funda- circles frequently coexist; their effect will tllenl-1 imienital disorder prodducingc symiptoms ivliicli maintain anid aggravate the disease.' cumiiulative, and lessen the prospects of recovery. In tlhe laniguage of pathology we may say tllat tile cLronic exliaustion of tlle neurons wlliclil clharacterizes neurastlenia gives birtlh to secondlary disorders wilieli perpetuate tlle exhaustion of tile neurons. Tile sttudy of vicious circles is indispensable to tlle practitioner of miiedicine. At every cornier does lie meet vitlh tilis comiiplication, wlliclh is accountable for many of 8'~~~~~~~V tile tangled processes of disease. Mlatllieu alnd Roux thus emi-plhasize tlle imiiportance of circles in lneurotic dyspepsia: T'here is in these cases ani inlterlockiing system of vicious Nosophobia. Melancholy. circles wvitli which the phy-sician muitist be familiar if lhe wishes to uin(lerstand the miiec lainisrn of the diseased organ-ismiz, and if lie wishes his treatmenit to be logical anld useful.2 And tile samie is true of all departMents of practice. In fact, a large part of tthe ars )niedenzdi is concerned in dcaling witlh this comnplication. InI support of these propositions I may call as witniesses som-e independent autilorities wlho lhave referred to and sonilatic circles. allows psvycioal Space only refer- http://www.bmj.com/ elc3 t) a few typical examnples. Anorexia. Insomnnia. FIG. I.-CIRCLE-S ASSOCIATED WITH PsycHICA DisORI)31ms. PSYCIIICAL CIRCLES (FIG. 1). Phobias.-Disorder of tlle ideational life is a striking S.031ATIC CIRCLE3S (FIG. 2). feature of lleurastlienia. This often leads to the genesis which state Suchl a iiiultiplicity of thlese are met witli in neurastlieliia of anxieties and phobias, prolong thie of a few suffice. exlhaustion of the neurons. Thus Dubois writes: tl/at typical exaiples must Carditac Disorder.-Neulrastlienic persons are frequently In neurastheniia one must take into account the real fatigue obsessed wvitli tlle fe'ar of lie'art disease,and thle consequent of the nervous centres. on the onie resuilts which', hand, directly tlle Tlle of events. on 24 September 2021 by guest. Protected copyright. from morbid states of mind, ancd, oni the other, furnishes new worry intensifes neurastlienia. sequence food for auito-suggestionls. Here we have the eternial vicious is somlewvliat as followvs: The fear of organic lieart disease circle in wlich the neuroses travel. Their real ills give birth leads to auto-suggested sensatioias in tlle cardiac region, to timeir fears anid their plhobias, and, on the other lhand, their followed by disturbalice of tlle cardiac action, sucli as men tal representations of a pessitnistic inature create new tacliyeardia, occasionlal extr'a-s'ystoles with palpitation, ancl disorders.3 an intermnittenlt pulse. Tlle associated sensations tllen Binswalnger also well describes tllis circle: arouse distress anld terror, w^hicli in tlleir tUrn furtbler The execution of aniy plhysical or mental task whiclh on disturb the cardiac activity. Sucl attacksn are especia. y previous occasiolns had -brought on attacks of severe exhaus- comn-ion at niglit, and i-iiay be caused by niglitmare, and tion anid other symptomiis associated with it may reawvakeni ani the of tllis circle may reduce the neurasthenic imllaginary phobia of a similar attack of exliaustioni either at operation the commencement or during the executioni of the task. Such petson to acontition of uttelpmostration, or even lead to a phobia miiay then excite a series of abnormal seinsationis fatal syncope. Andre'-Thlomas thuts describes tlle condition: wllieli iii their turni provide fresh' food for the phobias anid NotoCilv Dasoneurastl-euia give rise to cardiac fisordersaenly intensify their influenice oil the emotional conidition. This aiixieties; Ibut car(liae, anxieties may also give rise to neur- vicious circle may evell culminate ini- a dread of death-that is, astlesdia.th Emotiohekeffs, t alise by aggaaeatefear, the in the imagiiiary cessatioil of all vital functions.4 swniptoens orcieate frestlones. Thu esequence of es M1enital Mlental depression is invsolved in a Xviciouis circle, w liicll will persist until he cail b)e Delpression7.- ano,ther colivinced that is anriss ofith his heart.8 comnlon symiiptoin of neurastlhenia and ag,gravates tlle No ny mynuateitheaeflothieigierset ada iodrn condition. Tlhus Miiller writes: Dys to a.-Psobablytledisestivee systecais more often The mental depression reacts ol illitrition. sleep, and the affected by vicious circles theanany otier systei, owiucg to other vital ftunctions, alId thus creates a grievous viciousl circle, tlae peculiarly intimate relation between tsecentral nervnus whiclh aggravates the primary disorder.5 systemo and tlle viscera. Dbunuond tlbusnefers to tllis Anorexia Nervosa.-A colmiplex circle miiay be establislhed liability whlen tlle perverted ideation leads to loss of appetite, The subject of neurastlheniia fails to digest his food, anid in a vicious circle refusal of food, and consequent emiiaciation. In severe suffers coilsequence, beinig established.9 cases the victim. usually a womuan, becomes a bedriddeim, Bain also writes: lhelpless invalid-a burden to herself and lher famnily. By Digestive disorders are very commoni , and, while primarily degrees the malnutrition reduces the body to little more due to the ilervous exhaustioni, tlle state of the stomach reacts Tnz B m JVNE 27i 1941 2THE VICIOUS CIRCLES OF NEURASTHENIA. I MZDI"L Joum" 140. - - I on the patient's condition,'and makes the ieurastheniaworse, so that a vicious circle is established.'0 THE BREAKING OF THE CIRCLE. The treatment of neurasthenia resolves itself- into Br Med J: first published as 10.1136/bmj.1.2791.1404 on 27 June 1914. Downloaded from Did space permit, it would be easy to show how breaking the vicious circles thatcomiplicate the disorder. pyorrhoea, atonic dyspepsia, gastrectasis, colitis, viscero- Hence the importance of the physician being familiar in ptosis, diarrhoea, vomiting may also form circles in neur- detail with the various factors whicli perpetuate the asthenia.- Wemust content ourselves witlh one qttotation morbid gyrations. Prepare your plan of campaign. Seek from Striimpell dealing witlh thecircle in constipation: the locus minoris resistentiae, and direct your brioadside Habitual constipation is frequentil associated with general so as to effect a breach at the weakest spot. In functional lieurasthenia. The nature of this association is probably not disorders the treatment of symptonms may in itself be of the same in every case. Ofteni neurasthenia and constipation great importanee. As Tuckey says, although with a tinge seem to be co-ordinate symptoms; sometimes existing consti- of pation has an unfavourable effect upon the psychical condition exaggeration: of patients, renderilng them feeble, fretful, out of sorts, and In neurasthenia and other functional diseases