Neurasthenia

NEURASTHENIA (from Greek neuron-nerve and asthenia-weakness), nervous weakness, one of the most popular diagnoses alongside hysteria in practical medicine at the end of the 19th century and the first two decades of the 20th century. As a distinct disease, N. was first described by the American physician Beard, who saw the cause of N. in the extremely intense struggle for existence, which reached its apex in capitalist-industrial America (the first description was given by Beard in a journal article in 1869; his book on N., which attracted general attention, appeared in 1880). However, the symptoms of N., in one combination or another, had been noted under various names long before Beard: nervousness, nervous erethism, neuropathy, cerebral anemia, nervous cachexia, etats nerveux, etc. The vagueness of these names, combined with the summary descriptions given to the various manifestations of everyday 'nervousness,' made them unsuitable for practical medical purposes. Beard's merit was that he invested the term he proposed with more precise content: mild excitability and rapid exhaustion of nervous functions as the main signs of the disease. Despite this, the concept of N. still differed so greatly in generality that it seemed possible to apply it to a whole range of neuropsychiatric pictures, the belonging of which to a single group seemed more than doubtful. The framework of N. included pictures that were so different in quantitative and qualitative relations, for example, simple headache with prolonged fatigue and reluctance to work on one hand, and severe states of fear, obsessive thoughts, and impulsive actions on the other. Charcot was the first to bring some order to this motley collection of syndromes, recognizing two types of N., differing from each other in origin, course, and outcome: 1) true N. on the basis of excessive activity of the nervous system with phenomena of weakening of neuropsychic functions and various symptoms in the somatic sphere, and 2) N. on a specially predisposed basis of hereditary predisposition-constitutional N., in which, along with more sharply expressed neuropsychiatric symptoms, purely psychic deviations come to the forefront (doubts, anxiety, fears, phenomena of obsessiveness). The first form leads to recovery under appropriate life and treatment conditions, the second-with difficulty yields to the most complex and qualified medical measures. This question received significant clarification after syndromes not belonging here were excluded from the framework of N.: Pierre Janet (P. Janet) isolated the syndromes of psychasthenia (a concept almost merging with the obsessive-compulsive neurosis), Freud described neurosis of fear separately, and various authors isolated rudimentary forms of manic-depressive psychosis (cyclothymia-Wilmanns, P. Kahn, Sukhanov, Kannabikh); after refining the diagnosis of some endocrinopathies (mainly hyper- and hypothyroidism), initial forms of organic diseases (progressive paralysis, arteriosclerosis), and finally rudimentary cases of schizophrenia (Bleuler, Wiesel, Gilyarovsky), the boundaries of the 'neurasthenic neurosis' narrowed even further. After being freed from all these foreign ingredients, so little core remained from N. that there was a tendency to generally deny its existence, since in any given case it was always possible to explain 'irritable weakness' by the presence in the patient of any of the listed diseases. However, in recent times N. has been restored as an independent type of disease, but the term itself is given a more precise and limited meaning. Only such disorders of neuropsychic activity are included under this concept, which in a previously healthy individual are caused by clearly identifiable in each case exhausting and tiring factors; N. passes and as a rule leaves no traces after the elimination of their etiological prerequisites. N. is thus an exogenous type of reaction, essentially the most benign. The hypothetical substrate of N. must be considered some biochemical-biological changes in nerve substance, differing only quantitatively from the biochemical correlates of normal nervous activity. In such a precisely limited sense, the indicated changes in the life activity of tissues can be designated as 'functional,' since they merge with normal pictures through gradual transitions and barely perceptible degrees and do not result in any patho-anatomical changes detectable by modern research methods. These functional deviations of the neuropsychic sphere were usually isolated in the group of 'neuroses' and 'psychoneuroses.' N. is characterized by the predominance of neuropsychiatric signs. General characteristics of neurasthenic syndromes. All symptoms of N. indicate the underlying state of irritable weakness of the nervous system. Under this term is meant the combination of phenomena of increased excitability on one hand (physical and psychological hyperesthesia, hyperalgesia, neuralgia, convulsions), and phenomena of rapid exhaustion and weakening of function on the other (physical and mental fatigue, muscle weakness, instability of attention, lethargy of initiative, etc.). Until recently, the scholastic division of N. into 1) cerebral N., 2) spinal N., and 3) visceral N. was very popular, according to which department of the nervous system is inadequate; visceral N. in turn was divided into several groups: cardiovascular (neurosis of the heart, vasomotor neurosis), gastrointestinal and finally sexual N., which occupies an important place in manuals on nervous diseases and in urological monographs. Such fragmentation of the body according to individual functions, ignoring the integrity of the patient's personality, must be recognized as completely incorrect. Not to mention the theoretical premises, experience shows that with a more in-depth study of any visceral neurasthenic, certain psychic components in the pathogenesis of the disorder are easily revealed, which of course has great importance in choosing therapy. Etiological factors of neurasthenic syndromes. Can be distributed among the following groups. 1. Exhaustion of the nervous system from lack of nutrients (large blood loss after operations, hemorrhages, rapidly occurring childbirth, prolonged breastfeeding, etc.). 2. Poisoning of the nervous system by various poisons: a) industrial (lead, mercury, phosphorus, aniline, etc.) and b) nervous (alcohol, nicotine, morphine, cocaine and other narcotics). This group of neurasthenic syndromes is more appropriately designated by direct etiological terms: saturnism, mercurialism, alcoholism, morphinism, nicotineism, etc. 3. Poisoning and exhaustion of nerve centers under the influence of infectious-biological poisons (influenza, typhoid, angina, malaria, etc.)-'infectious and post-infectious N.' in prodromal periods, at the height of the course and during convalescence from acute infections. To this group, it is also more appropriate to apply etiological terminology, for example 'post-infectious weakness.' This also includes neurasthenic syndromes in chronic diseases (tuberculosis, cancer, syphilis), as well as in lesions of internal organs and endocrinopathies (diabetes, gout, hyper- and hypothyroidism, etc.). 4. Exhaustion of the nervous system after excessive functioning: prolonged transitions, sports excesses, sexual excesses, strong mental tension with insufficient rest. The main pathogenetic moment in this group is the direct disturbance of nutrition of nerve centers and the accumulation in them of products of life metamorphosis (see Fatigue). An important role here is played by the disturbed dynamics of the brain in the form of those special efforts directed at overcoming the feeling of fatigue in order to continue work. The feeling of fatigue, as is known, serves as a braking-protective reaction, signaling danger in the form of biochemical disorganization; it prompts the cessation of function, i.e., rest. Active overcoming of fatigue causes at a certain stage artificial excitation and overexcitation, after which a new type of inhibition (parabiotic, characteristic of overwork) is established. This mechanism causes the most typical and pure in form neurasthenic phenomena, that functional syndrome which apparently alone deserves the name N., namely: acquired temporary nervous weakness on the basis of overwork and exhaustion in a previously healthy person. Studied until recently mainly on representatives of such professions as teachers, bank employees, cashiers, actors, students, N. was considered almost as an exclusive privilege of mental work. However, indications have long existed that workers of physical labor also suffer from it to a very significant degree (Petrovsky, report to the Pirogov Congress; Rot, Public care for the nervous, Proceedings of the II Congress of domestic psychiatrists, 1907). Experimental study of fatigue phenomena (Kraepelin, Mosso, Levit, Nechaev) showed that mental fatigue clearly comes to the fore with any muscular work requiring precise execution and concentrated attention.

As the mechanisms of such somato-psychic fatigue were gradually clarified, factors causing neurasthenia (N.) among the industrial proletariat under conditions of capitalist production were discovered. Along with the duration of work and unsanitary conditions (temperature, noise, etc.), the following points are primarily distinguished: 1) the monotony of labor processes, which has a braking effect on the nervous system and contributes to the rapid accumulation of fatigue and depression ('man as an appendage of the machine,' Marx); 2) lack of interest in work, dissatisfaction with one's working life; 3) awareness of the extreme unreliability of one's economic existence, threat of unemployment, competition, feelings of resentment and unexpressed tension (Hellpach, Engels). To this are added unsatisfactory housing conditions, overcrowding with insufficient rest in the home environment, scarcity of refreshing entertainments, and the associated ingrained tendency in daily life toward alcoholic excesses, which add their specifically intoxicating components to the neurasthenic picture. Under these conditions, N. in a physical worker thus represents complex reactions of the entire organism to the unfavorable and exhausting working conditions in capitalist production. An important component of this reactive picture is the aforementioned negative emotions. Laboratory research (Cannon) showed that such affective experiences as depression, melancholy, anxiety, and fear are accompanied by a series of phenomena from the autonomic nervous system, endocrine apparatus, and other internal organs (increase of adrenaline in the blood, spasm of peripheral vessels, decreased blood flow to the brain, decreased neuromuscular excitability, etc.). Despite the complete obviousness that all the above-mentioned factory and industrial hazards characteristic of capitalism serve as the most important factors in the origin of N., the too broad use of this term was an obstacle to making it the starting point for socio-pathological research in general, since it is completely obvious that older authors described under the name N. such heterogeneous pictures that have nothing in common (unexpressed forms of organic diseases, endocrinopathies, chronic intoxications, etc.). Neurasthenia in its social aspect only now emerges as a special task before the science of social and occupational diseases. However, the few data from surveys of workers in the main branches of production in the USSR already allow one to conclude that the morbidity of borderline states and psychoneuroses (including N.) is decreasing. This decrease is clearly shown in the following data provided by Subbotnik. Morbidity (in %) of hysteria and N. among Moscow workers with temporary loss of work capacity. Branches of industry; Men Women 1925 1928 1925 1928 1 1.5 0.8 3.6 1 2.3 0.9 0.5 1.7 1 !>³ 0.1 1.4 1.3 2.3 1.0 4.4 3.4 Processing of mineral products i 0.5 1.4 -. 1 - 4.2 1.8 11.1 3.0 Processing of animal products i 1.8 1.3 1.7 ! 1.7 2.7 3.6 1.3 i 0.7 3.5 2.3 2.1 ! 1.0 - - 1 - 3.6 ! 2.8 ; ____ 2.5 1 ¹'⁷ All industry..... 1.3 | 0.7 1.9 1.7 These results must be attributed entirely to the fundamental reconstruction of production on the basis of socialist labor, i.e., conditions where the 'organization of the environment proceeds with a plus sign, where emotions, feelings, and vigorous charge proceed under the sign of collectivism, for the individual other possibilities of mobilizing one's internal resources' are revealed (Vnukov). There is no doubt that in many branches of labor the heavy legacy of the past is far from being overcome. The consciousness of the need for proper distribution of the working day, rational use of days off, cultural entertainment, and other conditions directly affecting the tone of the central nervous system has not yet sufficiently penetrated the broad masses of workers. Among workers of more qualified mental labor (teachers, doctors, technicians, trade and office workers, etc.), these exogenous factors often continue to have their tiring and exhausting effect, resulting in numerous neurasthenic symptoms. It should be borne in mind that mental tension itself occupies a secondary place in the etiology of N. Prolonged but calm and measured work of a scientific researcher does not cause disturbances in brain dynamics. A different picture is obtained in persons who work without any rest and with insufficient hours of sleep. The risk of contracting N. is significantly increased with an abundance of depressing emotions, such as reluctance to engage in a particular type of labor, anxiety about the outcome of work when rushed and unable to manage one's time, etc. However, despite the extreme prevalence of these phenomena and the lack of proper work habits, N. is observed significantly less frequently than was previously assumed when this term was given an excessively broad content. For this reason, it is quite understandable that the indications of most modern psychoneurologists that N. as a disease is generally rare are quite understandable. The experience of imperialist and civil wars (especially the experience of the revolution) showed that the human nervous system is capable of withstanding enormous strain and deprivation without giving neurasthenic reactions, especially if these strains are accompanied by emotional elevation in which elements of a positive character predominate (combat and revolutionary enthusiasm, collective striving toward revolutionary goals, etc.). The symptomatology of N. can be conditionally divided into 1) neuro-somatic and 2) neuro-psychic phenomena. It has already been pointed out that it is not possible to attribute all neurasthenic disorders to psychogenic origin (emotions, internal conflicts). However, it is completely obvious that the psychological component participates even in such apparently purely somatogenic neurasthenic reactions that arise from blood loss, childbirth, abortions, nursing, prolonged malnutrition, sleep deprivation. Psychological influences are found to a very strong degree in some particularly distressing diseases (sufferings of the sexual organs, venerealism), but here one more often has to speak not of N. in the narrow sense, but of reactive depression and the manifestation of various kinds of psychopathies. Therefore, in so-called 'sexual neurasthenia,' it is always necessary to strive to clarify the psychopathic factors even where their influence is masked or consciously denied. Insufficient assessment of this factor in a number of cases leads to inadequate therapy with a predominance of local treatment (dilatation, cauterization, massage), which aggravates the fixation of the patient's attention on the sexual sphere, whereas often only psychotherapeutic intervention is sufficient to eliminate extremely distressing syndromes of many years' standing. Among the symptoms, predominantly of a neuro-somatic nature, functional disorders of the sense organs ('light dazzles, eyes tire, vision becomes clouded, letters merge when reading') are often observed. Many patients cannot tolerate noise, music is unbearable, causing headache (hyperacusia), etc. Increased sensitivity of the skin to tactile, temperature, and painful sensations is noted. Simple stroking of the head causes severe pain (trichalgia). Spontaneously appearing painful sensations are a particularly distressing symptom in N. Headache with a feeling of pressure as if from a heavy hat on the head ('Charcot's neurasthenic helmet'), a hoop constricting the skull, or with a feeling of expansion, with the character of migraine-like attacks, as well as with that peculiar sensation of a 'stale' head, 'emptiness' in the head, 'brain fogginess,' etc., which many 'neurasthenics' complain about, are in the first place; symptoms characteristic of Meniere's disease (pseudo-Meniere disease) are also observed. Pains in the back and sacrum are common, giving rise to hypochondriacal fears (tabes, consequence of masturbation). In the neuromuscular system, along with increased fatigue, painful sensations and phenomena typical of N. such as idiomatic muscular excitability in the form of fibrillary twitchings, general neuromuscular restlessness, convulsions, etc., also appear. In the vasomotor system, phenomena of increased reflex excitability (various forms of dermographism, erythema, acrocyanosis, etc.) are noted; blood pressure is often lowered by 20-30 mm. Moderate enlargement of the heart to the left (Brugsch) is often observed in the absence of noticeable myodegeneration and as a simple result of decreased muscle tone; in such cases, a systolic murmur can sometimes be detected. An increase in blood pressure is observed less frequently.

From the gastrointestinal tract, a characteristic weakness is noted: against a background of general decrease in appetite, flashes of minute hunger occur, quickly satisfied by small portions of food, after which a feeling of heaviness in the epigastric region and complete aversion to food set in. In the urine, large amounts of oxalates (oxaluria) are often found. Tendon and skin reflexes do not show significant anomalies. Their increase is most common. Disorders in the sexual sphere are common for N.: insufficiency of erections, ejaculatio praecox, frigidity in women, intensification of cardiovascular symptoms and a feeling of weakness post coitum. In the presence of a psychopathic constitution, fixation of symptoms of irritative weakness in the genital area often occurs, which gives rise to prolonged disorders of a special character (psychic impotence, sexual neurasthenia). The psychic sphere in N. represents a series of quantitative deviations from the norm. The threshold of irritation for affects of a negative nature is usually lowered. Reactively-labile mood is extremely characteristic for N. Minor failures and inevitable frictions in life are perceived with excessive sharpness, a feeling of dissatisfaction, impatience, annoyance, resentment, cowardice, sadness, anxiety, fear, etc. easily appears. However, in true N., which is the result of exhaustion and fatigue in a subject with a sound nervous system (not a neuropath or psychopath), such affective deviations do not differ in particular depth and are smoothed out in one way or another, although such equalization requires a longer time than in the norm. Affects of a negative nature in N. are expressed by intensified neuro-vegetative symptoms: vasomotor, respiratory, skin and others. In the vast majority of cases, the psychic state of a neurasthenic is characterized by more or less prolonged depression with a feeling of inadequacy, inner restlessness and pessimistic mood. Among other psychic features of the neurasthenic syndrome, the following are most common: attention is weakened, complaints of inability to concentrate, distractibility; when attempting to overcome absent-mindedness, fatigue quickly sets in, accompanied by various unpleasant sensations: headache, pain in the eyes, crawling of ants, palpitations, etc. Concentrating on these unpleasant sensations, the patient is even more deprived of the ability to continue the started work (reading, writing, etc.). Disturbance of attention causes various degrees of impairment of the function of memorizing and reproducing (memory disorder). The patient has difficulty recalling names, facts, chronological sequence of events, as he does not concentrate sufficiently on the associative links leading to finding the desired. On the other hand, there is observed an excessively prolonged fixation on some affectively colored event of recent or distant past, sometimes some indifferent combinations of words, some melody, etc. are pursued—the beginning of phenomena of psychic obsession, which acquires the significance of an isolated syndrome in the presence of a corresponding psychopathic constitution. On the basis of weakened attention and insufficiency of memory, a feeling of general uncertainty, psychic inadequacy naturally develops, and as a result—a depressive mood colored by depressing thoughts of hypochondriacal content ('loss of capacity for work', 'disability', with all the consequences arising from this for the patient himself and his family). However, in pure N., hypochondriacal disturbances of well-being usually do not reach a significant degree. Although patients tend to assume in themselves diseases of the heart, lungs, intestines, spinal cord, the beginning of psychoses, etc., they are relatively easily amenable to explanation and refutation. In those cases where the hypochondriacal element stubbornly and sharply comes to the forefront (i.e., there is a difficult-to-correct tendency to interpret one's neuro-somatic sensations in the spirit of undoubtedly organic disease), it is always a matter of the predominance of psychopathic constitutional ingredients or else of the initial stages of completely heterogeneous processes (schizophrenia, cerebral arteriosclerosis, progressive paralysis, presenile mental diseases). Differential diagnosis. The diagnosis of N. is made by exclusion. As a rule, it is always necessary to keep in mind the possibility of such organic diseases of the brain, the initial stages of which sometimes coincide in all details with neurasthenic states. This group includes above all preparetic N. Recognition is greatly facilitated in the presence of neurological and psychopathological signs (pupils, reflexes, serological data, hints of dementia). But in the absence of such identifying points, the diagnosis may remain undetermined for a long time. Too much importance should not be attached to the subjective attitude of the patient toward his illness, as many paralytics at the beginning of the disease not only do not show euphoria or frivolity, but, on the contrary, are extremely concerned about their condition and even directly express suspicion of the beginning of progressive paralysis in them. It is also recommended not to overestimate individual dysarthric signs in stuttering: many neurasthenics begin to stutter from embarrassment, expectation, etc. Initial forms of cerebral arteriosclerosis give typical symptoms of N.; there is no doubt that the first description of N. (Beard) as a special disease was built to a large extent on the study of early arteriosclerotics from the class of New York businessmen. Brain tumors in the initial stages also give indistinctly neurasthenic pictures. One should never neglect the examination of the fundus of the eye. The initial stages of schizophrenia, especially the mild forms of this disease, form neurasthenic syndromes. Here differential diagnostic difficulties sometimes arise when there are no particularly characteristic changes in personality (autism, emotional inadequacy), hallucinations, delusional ideas, etc. One should always remember that schizophrenia often debuts with persistent headaches, painful sensations in different parts of the body, paresthesias, i.e., a syndrome that completely fits within the framework of classical N. If, moreover, the appearance of the disease was preceded by a certain exogenous moment (muscular strains, sexual excesses, infection, examination), then an error in favor of N. can easily be made. Cyclothymia in the depressive phase also often gives a neurasthenic syndrome with an abundance of subjective neuro-somatic sensations and disorders of vegetative functions (cyclsomnia; Pletnev). Here the differential diagnostic points are the absence or insufficiency of an exogenous cause, similar attacks in the anamnesis, genetic data (p-cycloid family). The prognosis in N. first of all depends on the possibility of eliminating pathogenic factors (excessive muscular and mental strains connected with negative emotions, sexual excesses, etc.). As phenomena lacking gross structural changes of nervous substance, as functional phenomena—neurasthenic syndromes are characterized by their complete reversibility [of course, provided they are not complicated by biological moments (constitutional nervousness, neuropathy), chronic infections (malaria, syphilis, etc.), intoxications (alcoholism, nicotineism, etc.), diseases of internal organs, metabolism and organic processes in the central nervous system (mainly arteriosclerosis)! Even in severe forms of N., the personality of a person remains completely untouched, full working capacity is restored and 'he finds his former place in life' (Vnukov). From this point of view, the problem touched upon in European and Russian literature of 'early invalidation of personality' (Fruhverbrauch M. Meyer's and 'acquired disability' of Gannushkin) is resolved, representing an extremely complex pathological phenomenon in the genesis of which the most diverse of the above-mentioned factors complicating N. participate. But even if one admits that prolonged intense work without rest with 'careless' distribution of the day can as a result (and in combination with other factors) lead to persistent changes in the vascular system (pra-sclerotische irreparable organisch bedingte Stoning; M. Meyer), these phenomena still cannot be considered as something fatal, inaccessible to therapeutic and preventive measures. 'The destructive process can be stopped at any moment and is stopped, without giving its harmful consequences' (Gannushkin). Prevention of N. is closely connected with the radical transformation of labor and way of life; carried out in the USSR by socialist reorganization of life. Correct regulation of labor and rest in quantitative and qualitative aspects (hygiene of labor) is the basis of neuropsychiatric prevention. The scientific development and practical dissemination of psychotechnics should set as its task the improvement of professional selection.

In this direction, it is quite possible not only to completely eliminate negative emotions, which are in the closest connection with work in capitalist enterprises, but also to develop positive emotions (the joy of labor when working 'according to one's calling'). A large place in the prevention of N. is occupied by the organization of rest, possible only with the complete elimination of the survivals of the old way of life (first of all, unfavorable housing conditions: cramped conditions, overcrowding, noise), and along with this, the widespread dissemination of healthy entertainment instead of the traditionally customary alcoholic excesses. Great importance should be attached to the protection of motherhood and infancy as a factor increasing the biological value of the new generation. In the same direction should also be directed the efforts of hygiene for youth. Revolutionary-class education, polytechnicalism in school, development of collectivist emotions, timely and correct information in the field of sexual questions, prevention of masturbation and too early onset of sexual life, healthy sexual abstinence during physical culture, cultural entertainment, complete elimination of alcohol and drugs. Then follows the organized struggle with pathological fatigue, socialist forms of labor and labor protection, rationalization of labor processes, NOT and etc. In general, the prevention of N. should be based on widely organized dispensaryization of both individuals and entire collectives. Great importance is attached to counseling points on questions of labor, daily life, sexual life, as well as cultural and sanitary-educational work. The treatment of N. is connected first of all with the elimination of the causal factor. Temporary cessation and regulation of work, transition to another type of labor activity in accordance with individual indications is often in itself a sufficiently health-improving measure. If such causal indications cannot be carried out, it is advisable to carry out special psychological impact with the aim of strengthening compensatory mechanisms, raising the conscious attitude toward labor, developing greater endurance and conscious purposefulness in the direction of social goals. However, as has already been noted, in the vast majority of true cases, one-sided psychologism should be avoided. This is especially true of acute cases of N., where rest and reduction of irritations to a possible minimum are primarily indicated. Here removal from the usual conditions is recommended, preferably to special health resorts (rest homes of sanatorium type, psychoneurological sanatoriums), where the treatment of these cases should be oriented toward physiotherapy, provided however there are sufficient factors contributing to raising the emotional tone in a positive direction. Here the so-called active rest with individually selected physical exercises (rhythmic gymnastics), non-tiring and interesting occupational therapy, distraction of attention to mental work of completely different content than that which led to the development of the neurasthenic syndrome, games are useful. In some cases, a sharp change of impressions is advisable: a trip to the seashore, an educational excursion, etc. A large contingent of patients with true N. receives undoubted benefit from staying at resorts despite the often noisy nature of resort life, while patients with other psychoneuroses with predominance of constitutional factors receive significantly less benefit from staying at resorts (Yushchenko, Azbukin, Volevich, Khoroshko). From physiotherapeutic procedures, air baths are indicated, which reduce skin sensitivity (and general), favorably affect the acetate, sleep and general well-being. Sun baths are less indicated due to the increase in body temperature and excessively strong effect of the rays on the labile vasomotor apparatus (weakness, dizziness, palpitations, insomnia are common). The same applies to 'mountain sun'. Hydrotherapy plays a large role with its undoubted effect on the cardiovascular system, metabolism, and peripheral nerve apparatus. Long evening baths are indicated for insomnia; wet wraps, rubbing, pouring, dousing in the morning hours. Electrotherapeutic procedures, which are significantly overestimated by practical physicians and which in most cases represent hidden psychotherapy, do not play an essential role in true N. As for direct psychotherapy, the latter begins with the most careful examination of the patient, even if the physician is in advance sure that it is a matter of pure N., and ultimately comes down to a detailed explanation to the patient of the nature of his nervous symptoms, clarification of their causes, destruction of hypochondriacal fears, and raising the tone of the psyche. Attention must be paid to the somatic state: improve nutrition (Weir-Mitchell method), eliminate possible accompanying complications. Of medicinal substances, some importance is attached to iron, arsenic, phosphorus, as well as strychnine with its tonic effect on the cardiovascular and nervous systems. On the other hand, the traditional prescription of bromides, which most often only increase the feeling of pressure in the head, muscle weakness, and general depression, is extremely inappropriate. Narcotics are equally contraindicated.