Cerebral Neurasthenia is that variety in which a condition of incapacity for work and for responsibility has been induced by excessive mental work, by constant and onerous responsibility, usually associated with much worry and anxiety, and emotional strain, perhaps, in reference to family or financial affairs. The patient usually complains of constant headache, yet when the headache is analysed, it is found to consist rather in abnormal cephalic sensations, not of a strictly painful character. Weight at the top of the head is frequently complained of, and pain and discomfort at the back of the head and in the neck is another frequent symptom. Unusual sounds on movement of the head are complained of, and some degree of tinnitus is often present. The patient is seen to be in a curiously sensitive condition. He is conscious of sensations which in the healthy are not perceived at all; ordinary duties assume an exaggerated aspect; he hesitates to come to any decision, being pulled first in one direction and then in another by the various considerations which come before him. He not only sees things through an enlarging medium, he sees them also distorted out of their true relations and their relative importance, and he is quite unable to use his judgment. Such a condition, from its very nature, is apt, unless forcibly interrupted by a complete cessation of work and by a change of environment, to perpetuate and intensify itself. The patient's bodily condition suffers, he becomes thin, loses his appetite and his sleep, and is in danger of becoming a chronic invalid.

In the so-called spinal form of neurasthenia the symptoms are mostly of the nature of what might be called spinal irritation. There is frequently pain of a severe character in the back, often throughout the length of the spine, but in many cases much intensified in the cervical region and in the region of the coccyx. With this pain is frequently associated weakness in the lower limbs, and a tendency to jerking and irritability of them. The knee-jerks are usually very active; there may be some pseudo-clonus present, but the plantar reflex is not of the extensor type, and indeed it may be difficult, or even impossible, to elicit any reflex at all from the sole. Such cases as this are frequently traumatic in origin, the so-called "railway spine." Yet it must be acknowledged that frequently all those signs and symptoms are present, yet without any previous accident, and without any pending action for damages. So that it is very important not to be misled into considering such cases in which an action is pending as necessarily or inevitably "constructive " in character. Head pains, especially in the occipital region, are frequently associated with these spinal symptoms, and this fact goes to show that the classification which is attempted here is, in a great degree, artificial in character.

Although those two classes of neurasthenia are fairly distinct, numerous cases occur in which both sets of symptoms are present, one set, perhaps, predominating. And in reference to cases of so-called sexual neurasthenia, in which the patient's thoughts are much occupied with the misinterpretation of sexual sensations, or with the fear and apprehension of sexual impotence, or with remorse for some form of sexual depravity and dread of its consequences - in these cases also the sensations and symptoms described in the cerebral and spinal types may be present. So that in neurasthenia it must be recognized that we are dealing with a malady of numerous phases, and that the symptoms depend upon a condition of weakness or exhaustion of the nervous system, in any or all its parts, and that this is associated with a strong introspective tendency which exaggerates and perverts and distorts any symptoms which may be present.

There is a large and important group of cases to which Weir Mitchell first called attention, consisting of the most part of women, who have become thin, dyspeptic and anaemic, who are unable to take exercise without excessive fatigue, in whom slight exertion causes palpitation or actual distress, or who are frequently "highly-strung" and emotional. In many such cases the determining cause of ill-health has been some prolonged strain of anxiety in reference to illness of a near and often a dear relation, frequently combined with the actual nursing of the relation. When one considers the frequently exacting character of the duties which such a one imposes upon herself - the irregular and often scanty meals, the long hours of devoted duty in a sickroom, the absence of fresh air and of exercise and the ever present anxiety - it is not to be wondered at that ill-health is often the result. And one also has to remember how frequently chronic illness breeds selfishness and how such a patient often becomes an actual " vampire," as Oliver Wendell Holmes puts it, to all about her, and most of all to those most devoted to her. It is not to be wondered at that so often the termination of such an illness leaves several of the household in a condition of almost complete prostration. No doubt, it is the case that occasionally under judicious management by means of change, and variety, and care, such cases of exhaustion get well without any recourse to special treatment. Yet in others the condition does not improve, pain and dyspepsia and even local uterine trouble may be superadded, too much attention may be paid to this as a cause of illness when it is merely a symptom, and salvation may be sought at the hands of the gynaecologist. But it must be added that nowadays many gynaecologists recognize the condition and take steps to remedy it by the general line of treatment which will be alluded to presently.

There is one variety of the condition to which particular attention should be called. It was first described by Sir William Gull under the name of anorexia nervosa, and the trying conditions alluded to above as so frequently productive of the condition are by no means an invariable precursor in this variety. The subject of it is usually a girl between the ages of seventeen and twenty-five, although I have known it occur in a woman over thirty. The patients are usually energetic, and not infrequently have some particular hobby to which they are devoted. Carelessness about food and the absence of any compelling appetite lead to irregularity in feeding, the meals become scrappy and meagre and the patient gradually wastes. The loss of appetite grows, food becomes positively distasteful, and even moderate indulgence in it leads to nausea or actual retching, and the vomiting of a little mucus. The patient becomes still thinner, weakness is superadded, walking becomes more and more difficult, but even when extreme emaciation has occurred the patient may still be able to walk about. But she is then nothing more than a living skeleton, and she seems to be in the last stage of phthisis, although there is no cough and no evidence of lung disease. Such a patient may actually die, apparently simply exhausted, or she may become infected with some malady which will bring about death. Yet if she is taken in hand and treated properly, she will become quite well, and any one who has watched such a case get well will confess that no more gratifying experience can be met with in medicine than the cure of such a condition.