Exhaustion

EXHAUSTION, the excessive expenditure of the total sum of the physical-chemical reserves of the organism, entailing a more or less sharp drop in its energy and vital activity. In a normal state, the well-being of each organ, system of organs, and the entire organism is maintained by the correct ratio between assimilation and dissimilation. It is precisely the ratio of these two values that is important, not their absolute quantities: dissimilation may, for example, be increased without any concerns regarding exhaustion if the expenditure of energy is correspondingly compensated by its formation. Even an increase in metabolism, which inevitably goes hand-in-hand with increased dissimilation, is in itself desirable as a factor contributing not only to the intensification of the vital manifestations of the organism but also to its plastic, creative activity; on this basis, a whole series of therapeutic measures is directed toward precisely such an increase in metabolism (mountain climbing, hydrotherapy, etc.). The danger of exhaustion is created only in the case when the expenditure of substances sharply and protractedly dominates over their intake, which in turn can be caused by two kinds of deviations: either a sharp increase in expenditure without corresponding compensation or a reduced intake, even if the expenditure of the substance does not exceed the limits of the usual norm. Conditions for the first exist during any backbreaking, excessive labor (moderate, rational labor acts, on the contrary, beneficially, because work itself trains the organ, contributes to a more lively blood supply to it, and consequently to its nutrition), as well as during many diseases, especially infectious ones; in these, besides the toxic breakdown of substances, the reduction of assimilation on the basis of the depressive action of poisons on the functions of cellular elements has a certain significance, as does the weakening of appetite; reduced intake, however, takes place depending on such factors as a lack of food (starvation), mechanical obstacles to the passage of food (strictures, cancer of the esophagus, etc.), as well as from all those moments that disrupt the correct absorption and assimilation of nutrients (destruction of gastric glands in cancer of this organ; loss of food through persistent diarrhea; difficult absorption of fat in diseases of the pancreas; disruption of carbohydrate utilization in diabetes, etc.). Although at the basis of any exhaustion, in essence, as stated, lies a discrepancy between the expenditure of energy and its accumulation, between dissimilation and assimilation, i.e., a factor of a biophysical and biochemical order, nevertheless, by the disruption of certain functions, one can distinguish physical exhaustion and neuro-psychic exhaustion, and in addition, biochemical exhaustion in the sense of the depletion in the organism of reserves of certain substances, such as: proteins, fats, carbohydrates, water, mineral substances. They also speak of the exhaustion of individual organs, such as the brain (equivalent to neuro-psychic exhaustion), the heart, bone marrow, etc. General physical exhaustion cannot but go hand-in-hand with a lowering of the general biotonus, although the degree of lowering of the latter is not the same for different organs and systems of the organism, depending on the causative factor. Most often, against the general background of weakening, muscular adynamia dominates, which in general starvation, for example, is easily explained by the earlier and predominant breakdown of muscle substance. It has been truly established that the decrease in the weight of individual organs proceeds disproportionately to the drop in the total body weight in starving individuals, namely: while the latter drops by 35-50%, adipose tissue loses 93-97% of its weight, glands and muscles—40-50%, blood, bone marrow—30%, bones—10-14%, brain and heart—2-3%. Neuro-psychic exhaustion, caused mainly by insufficient replenishment of nutritional material to the cerebral cortex in comparison with its expenditure, can in some cases lead to mental diseases (see below). Such disorders arise under the influence of various kinds of factors acting in an exhausting manner on the organism in general and on the cerebral cortex in particular. Some of them act chronically, such as fatigue and starvation, while others, such as severe blood loss, cause rapid exhaustion of the cerebral cortex. Here, however, harmful metabolic products formed in connection with the action of exhausting factors also take part. Exhaustion of other organs is observed under analogous conditions: thus, exhaustion of the bone marrow can occur during repeated profuse hemorrhages, as well as during severe infections, when an increased workload, which can become excessive under certain conditions (production of antibodies), falls to the lot of this organ; exhaustion of the heart occurs as a result of either acute overstrain of the heart muscle or chronically acting conditions accompanied by the presentation of increased demands to this organ (exhaustion of the hypertrophied heart in decompensated valvular defects, as well as during difficulties in the lesser or greater circle of blood circulation, or finally, again, during severe infections, where intoxication usually plays the decisive role). Of the individual types of biochemical exhaustion, there is reason to speak of protein exhaustion only in comparatively rare cases due to certain peculiarities of this kind of metabolism. Whereas fat metabolism is entirely determined by the number of calories necessary under given conditions, and with excessive fat nutrition the amount of fat burned in the organism does not change under otherwise equal conditions, the intensity of protein metabolism depends on the supply of proteins, changing in one direction or another in accordance with the amount of proteins in the food. As a consequence of this, only a small amount of protein is deposited in the body of an adult, which subsequently goes to replace wearing-out tissues; the excess of protein beyond what is needed for this is burned. Significant protein reserves in the body of adults, therefore, cannot exist (during pregnancy, it is true, the assimilation of N prevails over its expenditure, but the reserves of plastic substances immediately go to the construction of the fetus), and only in the growing organism does this deposition occur in larger amounts. With the exception of childhood, one has to speak of protein exhaustion, therefore, not so much in the sense of exhaustion of protein reserves as in the sense of the breakdown of tissues, as can take place, for example, during starvation or during severe diseases leading to cachexia. Exhaustion of fat depots can occur in all cases of increased combustion, and it should be kept in mind that fat is a material primarily consumed by the organism during an increased demand for nutrients and thus protects proteins from combustion (cf. the above-cited figures regarding the expenditure of substances during starvation). Even simple hyperthermia, if it is not too ephemeral, may prove sufficient to cause noticeable emaciation of the organism, although fat disappears from different parts of the body with different speeds (the face, for example, thins faster than the abdomen). Fat disappears with even greater ease from fat depots during severe debilitating diseases of an infectious or non-infectious nature (such is, for example, one of the forms of diabetes—the so-called "lean diabetes"). Simmonds' disease, associated with the destruction of the pituitary gland, always, and Basedow's disease and immoderate sexual activity—very often, go hand-in-hand with a more or less significant emaciation of the body. In general, however, one has to deal more often with endocrine obesity than with endocrine thinness. Lipoid exhaustion of the adrenal cortex (mainly cholesterol esters) is observed especially during sepsis (Kawamura), less regularly, but still quite often, during a whole series of other diseases of both an infectious and non-infectious nature, such as: paratyphoid, cholera, pneumonia, scarlet fever, diphtheria, tuberculosis in the stage of cavity formation, and during disintegrating carcinoma. At the same time, morphological changes in the cells of the adrenal cortex go hand-in-hand with such disappearance, amounting to the so-called "honeycomb degeneration" (first the formation of vacuoles, later the cells appear swollen, the protoplasm acquires a structure like a honeycomb). Carbohydrate exhaustion takes place, among other things, in diabetes depending on the reduced ability of tissues to utilize sugar, which is consequently excreted in the urine. Ehrlich, by a direct experiment (puncture with a trocar into the liver), showed that the liver in such cases becomes sharply depleted of glycogen (increased glycogenolysis). Conversely, in the epithelium of the renal tubules and in leukocytes, some accumulation of glycogen is found in such cases, apparently doomed to be excreted from the organism. The "shaking out" of glycogen from the liver is also observed during tetanoid states (during convulsions). Furthermore, any more or less significant lowering of the general nutrition of the organism (undernutrition, etc.) is accompanied, in parallel with the reduction of fat depots, by a depletion of carbohydrate reserves and, first and foremost, by a depletion of the liver of glycogen. Along with the just-listed types of biochemical exhaustion, it is possible for the organism to be depleted of other substances, for example, Ca (parathyreoprivic tetany, osteomalacia), Fe, P, vitamins, but in these cases, just as in relation to proteins (in adults), it is not so much a matter of exhausting reserves as such in the proper sense of the word, as it is of the loss of the indicated substances by the tissues.

The depletion of "water depots" leads to the thickening of the blood and a dangerous decrease in the water content within the cells themselves. This results in the retention of metabolic products due to insufficient urine secretion and the development of uremic symptoms. Phenomena of this kind are observed in cholera. To a certain extent, dehydration also occurs in diabetes, which makes understandable such phenomena as dry skin in diabetics, cracking of the lips, and the development of cataracts. The consequences of exhaustion vary depending on its degree and type: in some cases, they may be a transient phenomenon and be reversible (such as, for example, many cases of exhaustion of fat depots), while in others, the phenomena of exhaustion signal the presence of a serious disease leading to death (cancer, diabetes). Something in between is also possible, when it does not lead to a lethal outcome, but exhaustion undermines the well-being of the organism for a long time, especially a growing one, lowering its value in an immuno-biological, endocrine, and other respects (cf. the observations of Shtefko, Lyubarsky, Hülse, and a number of other authors during the last imperialist war and the famine in the USSR in the years following the war). One should distinguish the concepts of cachexia and marasmus from exhaustion.

G. Sakharov.

Paralysis of exhaustion. Exhaustion is one of the etiological factors on the basis of which various disorders of the nervous system develop, most often paralysis; it is not only the exhaustion of the nervous system itself that plays a role, but also that of other systems of the organism. Paralyses that develop following epileptic seizures are explained, in addition to other causes, by phenomena of exhaustion of the nervous system. They usually develop after prolonged and severe seizures. Exhaustion that has developed on the basis of insufficient blood flow to the elements of the nervous tissue, especially to the cells, can also cause paralysis or paresis. Poor and insufficient nutrition, starvation, insomnia, fatigue from physical work, fatigue from mental labor, various kinds of emotions, sexual excesses—all these factors lead to exhaustion, on the basis of which various nervous phenomena can develop, up to and including paralysis. The changes occurring during exhaustion in the cells of the nervous system can be observed in all constituent parts of the cellular element. The first, earliest manifestation of the disease of the cell is a change in its tigroid, namely, chromatolysis occurs; then the formation of vacuoles in the cellular protoplasm follows. The external outlines of the cell and its volume also change sharply, the cell increases in size, becomes swollen; changes also occur in the cell nucleus, it loses the clarity of its contours, moves to the periphery, and decreases in volume. The changes occurring in the cell are reflected in its function. In prolonged processes, the fibers begin to change secondarily. In experiments on animals, exhaustion resulting from excessive function caused paralysis; upon autopsy, changes analogous to those described above were found. Clinically, paralyses appearing on the basis of epileptic seizures develop in the following way: the section that was first seized by the attack is paralyzed; pareses or paralyses can remain for a fairly long time, especially after repeated and intense seizures; if the seizures disappear for a long time, then the paralyses pass; in the case of repeated seizures, the paralyses gradually increase both in intensity and in spread. Paralyses can be of the monoplegic, paraplegic, and hemiplegic type—all of them belong to spastic paralyses; in the hemiplegic type, Wernicke-Mann type contractures, increased reflexes, clonus, and pathological reflexes are observed. The course and outcome depend on the etiological moment; if it is possible at the beginning of the disease to eliminate the causes that triggered the exhaustion, then under favorable circumstances, the paralyses may pass or, in any case, improve. The prevention of exhaustion also depends on the etiological moment (proper lifestyle, rationalization of labor), in epilepsy—appropriate treatment and regimen. Treatment—bed rest, elimination of unfavorable conditions that caused the paralysis.

E. Kononov. Psychoses of exhaustion—a very rare phenomenon, developing only on the basis of extreme starvation or after excessive overwork, especially that associated with a lack of sleep. In cases of the latter kind, two successive phases are noted: first—lethargy, immobility, indifference, difficulty and superficiality of thinking, and a depressed-irritable mood, and then (if rest does not occur)—slight agitation with a tendency to hallucinations, predominantly visual, bearing an anxious coloring and having as their content events actually experienced by the subject. Sometimes confusion is also added. These phenomena, which are connected with the excessive excitation of the nervous tissue, usually disappear quickly after sufficient sleep and rest. Stiefler, during the siege of Przemyśl, observed several dozen cases of mental disorder, apparently owing their origin to the combined action of starvation and excessive fatigue. Some of them proceeded in the form of delirious states, differing from other similar forms only by the small participation of motor activity: the patients experienced their delirium while almost not moving. Other cases of disorders had more of an amential coloring or presented a picture of stupor. Similar pictures were also observed here during the famine of 1921–22.