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A Symposium by  Frederic H. Gerrish... James J. Putnam... E.W. Taylor... Boris Sidis... George A. Waterman... John E. Donley... Ernest Jones... Tom A. Williams...
Morton Prince

Boston: Badger, 1908






TAKING the various forms of the psycho-neuroses as a group there is no one symptom so frequently encountered as that of fatigue. Whether it be present early in the course of the disease, and seems to be the soil from which other symptoms develop, or whether it makes a later appearance as if in consequence of the struggle against existing symptoms, it too often presents a barrier to recovery which at times seems unsurmountable. Any effort on the part of the patient to struggle against this symptom so increases the fatigue as to accentuate other symptoms, and cause great discomfort, while on the other hand continued rest is courted in vain. In order to determine how this condition is to be met, let us turn our attention to the elements which go to make up this fatigue.



That the production of energy of every sort is the result of a katabolic process in the tissue called into activity is a fact too well established to require discussion, but unfortunately fatigue cannot be explained on the simple ground that the consumption of muscular substances alone produces exhaustion.

In addition to the diminished supply of the substances in the muscle necessary for the production of energy which results from muscular activity, we have also to recognize the rôle played by the action of the toxic products of oxidation accumulating in the tissue. The laboratory experiment of stimulating the isolated frog’s muscle until it can perform no more work, and then flushing out its blood vessels with normal salt solution to enable it to again respond to stimulation, represents the normal physiological process constantly going on in the human organism during its daily life.

While these two processes—the combustion of substances, and the local action of the products of katabolism—diminish the power of the muscle to carry on its function, the liberation of the poisonous substances into the general circulation gives rise to the general sense of fatigue in the individual. This has been well shown by Mosso, who demonstrated that the introduction of the blood of dogs that had been tetanized a few minutes, into the cerebral circulation of healthy dogs, gave rise to the signs of fatigue (difficulty in breathing, and more rapid beating of the heart), and Mosso believes that these noxious products, acting on the nervous system through the circulation, not only contribute largely to the feeling of fatigue, but also lessen the power of the nerve cells to carry on their function.

Parallel to these manifestations of muscular activity is a group of physiological and histological changes taking place in the central nervous system as a result of cerebral and reflex activity. Hodge demonstrated in 1892 that definite changes are to be found in cerebral and spinal ganglion cells of various animals resulting from normal activities of daily life as well as from excessive stimulation. He found that a comparison of nerve cells of animals killed in the morning with those of similar animals killed at the close of a day of activity, showed a diminution in the size of the neuclei with loss of the open reticulate appearance, and shrinkage in cell protoplasm with vacuolation and lessened staining power.

That this change in structure is associated with liberation of harmful products has been shown by Halliburton in his lecture on “The Chemical Side of Nervous Activity,” in which he maintains that under normal physiological conditions the injurious choline products of nerve katabolism can be demonstrated in the body, while in states attended with abnormally rapid nerve degeneration marked changes may be produced.



Aside from these physiological processes which contribute to make up what may be called physiological fatigue, there is a varying psychological factor which is present in all of us, tending to accentuate or diminish the degree to which it shall be recognized and admitted, whether consciously or not. The power of music to quicken the lagging steps of tired soldiers; the influence of the emotions in redoubling one's strength; the driving force of exhortation or promised reward, are well-known examples of the way in which the feelings of fatigue may be dispelled. Is it that the marching soldier is actually rendered less tired by the music, or that the threat or promise of reward makes any change in the physical condition of the individual? Such an assumption would be obviously absurd. This sudden change in the feeling described involves what might be termed the psychological element in the symptom of fatigue. In the minds of all of us a feeling of fatigue indicates a call for rest on the part of nature. When one begins to feel tired his mind becomes impressed with the fact, and the continued consciousness that this state exists serves to intensify the sensation to a greater or less degree, depending on the suggestibility of the individual. A veritable fatigue hyperesthesia develops. In some this psychological element may play by far the greatest part in the production of the symptom, so that the slightest muscular activity produces a feeling of exhaustion lasting for days, while in others, determination of purpose or interest in work may engender a disregard or an anesthesia for the symptom and thus enables them to do tremendous amounts of work with little discomfort. It is to this latter class that James refers in his “Energies of Men” in which he describes the process as a breaking through the zone of fatigue, or getting one's second wind. That the adoption of this habit has its merits to a certain extent in the former class is undoubted, but I am convinced that it is a dangerous recommendation for the latter class, which is naturally the one to carry it out most zealously.



It is an interesting problem for solution as to what takes place in those cases of pronounced fatigue in neurotic individuals, who at times are so quickly relieved of the symptom by a suggestion, as well as in those who are suddenly overwhelmed by a sense of exhaustion as a result of a nervous shock or a fright. Surely such sudden and decided changes cannot permit an explanation on the grounds of any of the physiological causative factors of fatigue. Is it not that a synthesis takes place in the former, and a dissociation in the latter, much as other manifestations of these processes may occur under similar conditions? The verification of this hypothesis might be found in the appearance and disappearance of fatigue encountered in the alternations of personalities described by Prince, Janet, and others.

That fatigue states, whether physiological, psychological, or psychopathological, may form a fertile soil for the development of psycho-neurotic symptoms is too often demonstrated to us to admit of question. In the routine of daily life, if one is assiduously devoting his energies to accomplishing certain ends, the rested individual who starts the day presents a very different mental attitude to his surroundings, to the one who returns home at night weary from his labors. The one starts out fresh and vigorous and filled with the joy of living, the other too often returns with slower step and perhaps with tired or aching head, irritable to those about, and critical of things he overlooked so easily in the morning. It requires, however, but the reconstructive power of sufficient nourishment and a good night's rest for the pendulum to swing back and establish the diurnal state of freshness. Fortunate is he who can carry on his life from day to day unruffled by the stress of extra burdens or the worry of added cares. In those who voluntarily undertake excessive amounts of work, or who are the unfortunate victims of the “slings and arrows of outrageous fortune,” the periods of recuperation may not prove sufficient to maintain the state of equilibrium, and a more or less prolonged state of fatigue may result with its various concomitant symptoms.

Continued fatigue with insufficient periods of rest may develop in strong, healthy individuals various forms of physical and mental symptoms similar to those seen in well-defined neuroses and psychoses. Attention has been called to this by Tissié and Feré, and it was well illustrated in the condition developed in the bicycle riders of the six-day race in Madison Square Gardens a few years ago. Various sorts of delusions and hallucinations were manifested by these men towards the close of the race—the idea that spectators were doing things to prevent their winning led to their repeatedly turning to escape imaginary obstacles, etc.

The ill effects of over-fatigue from excessive muscular exercise are usually quickly recovered from, but the conditions resulting from prolonged mental strain and worry are more liable to persist from the very nature of their cause, in being more continuous and unremitting. The story is a common one. One’s duties necessitating mental application have been requiring too many hours; they are not dropped in the evening; sleep is more difficult, and the diminished hours of recuperation lessen the power of application; recognition of this fact brings worry to the attack to precipitate the uncomfortable feelings of fatigue. Aside from lassitude and loss of power to concentrate, the most frequent symptom experienced in this state is a sense of discomfort in the head varying in character and location. This engenders the idea that something must be wrong within, and too frequently suggests that insanity is imminent, and gives rise to overwhelming fear and constant introspection, with all its harmful influences.

Distinct from the fatigue states of such etiology which may exist as a simple condition of weariness and diminished power of application, or may present the complication of morbid ideas developing from it, is the state of so-called “nervous exhaustion” found in individuals with a neurotic family history. Patients suffering from this condition have often experienced a series of nervous breakdowns, and never seem able to struggle to the normal level. Such individuals, though they present the same symptoms as the class described have the psychological element of fatigue developed out of all proportion to the physical, and every attempt at a departure from their life of rest and quiet is made under protest, and with the firm conviction that disaster is sure to follow.

That the type of fatigue brought about by prolonged overwork or strain requires rest, relaxation, and change of surroundings, combined with advice best adapted to counteract the morbid mental state which may be present, is apparent. This class comprises the cases which do well by giving up absolutely the sort of life which has absorbed them, and combining rest with activities of a different nature which will afford sufficient interest to divert the mind and prevent reflection.

The point must be recognized and seized, however, when this regime has played its part, and the time has come for putting the hand to the plough again, for it is all too easy for the memory of a previous breakdown and fear of its recurrence to render one loath to resume his former life again. It is on account of this fear and hesitation that it is advisable to keep in touch with the patient and prevent backsliding until he is well launched in his old life.

The larger class of patients so often descended from neurotic parents and presenting a history of attacks of previous nervous breakdowns, attempting again and again to take up the duties of life, but never seeming able to get sufficient reserve to carry on the struggle for any prolonged period of time, require management of a different sort. Such cases, as has been said, represent the psychological element of fatigue in its fullest development. The conviction that exhaustion will follow any amount of effort, physical or mental, is already a guarantee that it will result. On being told to do certain things a patient recently remarked, “Very well, I'll do it, but I know what will happen, and you must take the consequences.” Of course if she had followed orders in such a spirit the result must have been as she determined.

Frequently these patients have indulged in rest for months, or even years, without beneficial results. Physically sound, but unable to assume duties and responsibilities of life, they form a group too often misunderstood, and classed as uninteresting by the physician, yet woefully in need of proper direction.

Various systems for the management of this type of cases have been advanced by different men. The earliest complete method was that recommended by Dr. S. Weir Mitchell, and has since been referred to as the rest cure. In 1875 he published his first paper treating of this subject under the title of “Rest and the Treatment of Nervous Diseases,” and a few years later brought forth the first edition of his monograph “Fat and Blood.” As is well known, the essence of his method consists in pursuing his course along certain definite lines, treating all cases alike. Seclusion, rest, massage, electricity, and feeding have been the points on which he has laid particular stress. That he has been eminently successful in carrying out this method can be attested by the large number of patients who have been benefited under his care. That the principles he employs exercise their results according to his theories is, however, a question. It has been pointed out by Prince and others that the point on which he lays special stress, namely the increasing of the body weight and the production of more blood, does not by any means lead to the amelioration of functional nervous symptoms; that although change of surroundings may prove beneficial in many cases, complete isolation undoubtedly does harm in certain types, and that the general result produced by the completeness of the regime owes its success rather to the suggestive influence than to any physical change that takes place. This system has been more or less widely adopted with modifications by most of the sanitaria devoted to the treatment of nervous invalids, and the criticisms which may be applied to this method as employed by its originator are even truer here. For, lacking the unusual personality of the father of this regime, and the confidence inspired by his continued successes, the patient is too ready to accept the “rest cure” as such, in every sense of the word, and thus derive from it the feature which should be minimized, while he misses in so doing the factor which should be working against his psychic attitude toward his condition.

This has been so much recognized by many of the sanitaria during recent years that the facilities for exercise and occupation have to a large extent replaced those of rest and seclusion with gratifying results.

A new impetus has been given to the interest in psychotherapeutics by the widespread reading of the methods of Dubois, as set forth in his book, “The Psychic Treatment of Nervous Disorders,” published in 1905. This method, which has been termed the system of rational therapeutics, has for its aim the education of the patient oftentimes through more or less Spartan discipline, and through the presentation of bare facts and truths regardless of the patient's attitude towards his own condition. Whereas the method followed by Mitchell with its modifications as advocated by Déjerine and Barker have been to rest and isolate the patient and gradually win him from his symptoms by education as to their nature, and encouragement, meanwhile treating the various discomforts and increasing the patient's powers for activity, Dubois, on the other hand, begins by explaining to the patient the actual condition of things, and forces his opinion as to the psychic nature of the discomfort, and refuses treatment of this by drugs or chemical means. “Never,” said Dubois, in discussing the use of drugs a short time ago, “will I give a sleeping powder to a nervous patient except in cases of actual melancholia.” Whether this method can be generally adopted by practitioners is a great question. The remarkable personality of Dubois, and his firm conviction as to the ethical and therapeutic value of his method, render it peculiarly efficient. It is difficult to conceive of a patient not being strongly moved by his remarks, which are presented by him so forcibly, and clinched by his frequent repetition of his favorite phrase, “C'est la verité.”

It is apparent that the mental attitude of patients suffering from this chronic state must be changed. New groups of complexes must be formed. The knowledge that experience has shown that certain sensations have resulted from certain activities must be replaced by a conviction that these efforts may be made without harm.

Whether the result may better be brought about by the establishment of new complexes in the hypnotic state, or by persuasion and conviction established in the waking state, may be a question in some cases. If we are to consider that the unhealthy complexes dominant in these cases, rendering them unable to respond in a normal way to their surroundings, are to be looked upon as a dissociation, much as moods of depression are to be regarded, hypnosis may be offered as a rational method for establishing the normal state. Both Tuckey and Bramwell have reported cases in which the fatigue state has been successfully treated in this way.

Personally I have used the conversation method practiced by Dubois. Needless to say, the physical condition must be thoroughly investigated and any deficiencies recognized, while it should be assured that the bodily secretions are functioning in a normal manner.

At the start, the attitude of the patient toward his condition must be changed. The discouraged doldrum state must be attacked by a careful and truthful statement of the existing condition, and the possibilities set forth which must be attained, and will result as surely as the physical law of cause and effect is true. He must regard his condition in a new light, and new groups of complexes must be called into play and associated with his individual symptoms as well as with his attitude toward the future.

When physical or mental effort is called into play the fatigue or discomfort resulting should call up the new complexes established, and in order that this may follow, the association of the new complex groups must be more strongly welded to the symptoms than are the old groups of discouragement, indifference, fears, etc. It is here that the mistake is too frequently made of using general unmethodical encouragement, in place of strengthening the association between the desired complexes and the tasks to be performed. This is not to be accomplished in a hasty consultation, but the physician must spend sufficient time to feel himself thoroughly “en rapport” with his patient, so that both have a tacit understanding that they are taking up a task together which is going to be accomplished. Enthusiasm for the undertaking, increasing amounts of activity, and occupation best suited to the individual, form steps by which the patient may mount to his normal plane.

The rational acceptance of the feeling of fatigue must be forced upon him until it becomes for him a natural reflex, and this carries him a long way towards disregarding it, and its final disappearance. Frequently the patient remarks, “Yes, doctor, I have done as you said, but I feel so tired.” “That may be true,” is the reply, “but you were just as tired last week, and then you were accomplishing nothing. The difference is, that to-day you are so much nearer the goal.”

I am not in accord with the belief of Dubois that absolute disregard of all symptoms depending on the psychic state should be enforced upon the patient. Certainly the road is a much easier one for him to travel if the distressing head feelings are alleviated by a static current, or if ä gastric disorder is controlled by some simple remedy. The danger is to be avoided, however, of too much treatment of this sort.

The following cases are illustrative of the conditions which may be benefited by these methods.

CASE I. This patient was a student twenty-one years of age. His father and mother were both of neurotic families, and were themselves subject to moods of depression, while his sister was of a high strung and sensitive temperament. The patient had always been strong and rugged physically, and, except for certain disturbing ideas in real life such as come to imaginative children, had never had any nervous disorders. Slow to learn, he had found it difficult to pass the entrance examinations to college, and had some difficulty in keeping up with his class work. This was the more difficult on account of his love of sports. His whole ambition seemed to be to make the ‘Varsity team in football. His continued efforts to do well in his studies, with his constant worry lest he should not be able to do well in his athletics, caused him toward the middle of his first year in college to become more and more fatigued. This sense of weariness once started developed more rapidly, and made it nearly impossible for him to accomplish any work. In fact, so pronounced was the symptom, that repeatedly, on simply crossing the college yard, he returned to his room so exhausted that he felt obliged to lie down and rest.

His inability to keep up with his duties caused him greater and greater worry, and he suffered constantly from his head feeling tired, which rendered it impossible for him to concentrate his mind any length of time. This tired feeling in the head soon gave way to a constant sense of pressure over the forehead and the vertex, which caused him much alarm. Frequently when this was very distressing, he would be seized with the idea that he was going to lose his mind.

A careful examination of the patient showed an almost perfect physical condition. Never have I seen more splendid muscular development. There was no evidence of any disturbance of the organs of the thoracic or the abdominal cavities. The pupils were normal in size and reacted well. The knee jerks were equal and slight. The contrast between his story of utter physical exhaustion, and the picture he presented of such strength was very striking. Nor was he able to understand why he could not enter into things with his customary vigor. After explaining in detail to him the nature of his condition and the factors which were helping to keep him from recovery, he was made to realize what his possibilities were, and how he must apply himself to gain his ends. The tasks put upon him were made rapidly more and more difficult, so that at the end of six weeks he was doing a normal amount of studying, and was rated as one of the first-class men in putting the shot and throwing the hammer.

His condition continued to improve so that the following fall he played on the ‘Varsity football team, and then as well as during the two succeeding years of play was considered a tower of strength.

Except for a temporary difficulty of an entirely different nature this patient has been quite well since his recovery, a period now of several years.

CASE II. The second patient was a strong, well-looking man of twenty-two, who for years had been incapacitated for carrying on the work of daily life on account of his nervous condition.

A few years ago he was working very hard in college, and studying in a law office in addition. This he was able to keep up for a year, although he grew progressively more tired, and found himself more and more limited in his capacity for performing his duties. At the end of this time, one evening when he arrived at his home, as he was going upstairs he was suddenly overpowered with a sensation as if he were let down through a stairway, and were melting away into nothingness, and was conscious of a feeling of overpowering fear. A cold sweat broke out all over him, so that he got hot water bottles and crawled into bed under heavy coverings, still feeling strange. From that night on, the feeling of exhaustion which had been increasing for a number of months became doubly strong, and rendered him unable to carry on his work and studies. In the mean time similar attacks of fear and unreality returned at various intervals, and he was advised to leave his home and to enter a sanatorium.

The following two years were spent in various sanatoria and retreats, the patient meanwhile getting no stronger, but more and more losing confidence in himself. At the time when he made his first visit to me he was unable to go about alone on account of his great sense of fear that something would happen. The outside world seemed strange in a way which he found it difficult to explain. There was no power to concentrate the attention in following a conversation or in attempting to read; to such a degree did this symptom exist that he found it impossible to read a single paragraph in the newspaper understandingly. Attempts to move about simply rendered him more tired, and on the whole he declared himself utterly discouraged in trying to make any progress against his illness.

The treatment of the condition was rendered difficult in the beginning by the inability of the patient to give his attention long enough to grasp a continued line of argument. This was overcome gradually by forcing him to devote all his energies to mastering the content of longer and longer passages of reading at stated intervals, till he found himself able to read or attend lectures without effort. Meanwhile his fears were dispelled by the substitution of new complexes, so that now for a year he has been carrying on more work than is done by the average law student, and performing his duties in an eminently satisfactory manner.

Whereas the first case cited represents the psychical fatigue (hyperesthesia) as related more to physical effort, the second case is the type in which a physiological fatigue state developed into a psychopathological fatigue and finally into a condition of psychasthenia. Such cases at times have the distressing attacks of unreality and the overpowering fears developed to such a degree that hypnosis is necessary to overcome them. That new complexes may be forced upon them in the waking state when the distressing symptoms are not too deeply grounded is evidenced by the frequency with which this end has been accomplished.


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