of clearly defined neurocirculatory asthenia presented itself at the Base Hospital during my service there. The complex then seems to bear a very definite relationship to the emotional status of the various races of peoples. Probably for this same reason as well as from, in part environmental influences, the condition is apparently much more commonly seen in urban than in rural communities.

The statement has already been made that the syndrome is not frequent in old age. There are several explanations for this fact. No doubt the first and most important one is that the normal changes of age are such as to diminish or profoundly modify the typical manifestations of the type. There is a further definite factor playing a large rôle here. As a class these patients are shortlived. The British in particular have shown that these people are particularly susceptible to the infections, and that they succumb to them in a considerably higher percentage than entirely normal persons. They also endure the buffets and stresses of life much less well; they wear themselves out as it were by their over-emotional expenditure. They withstand such conditions as diabetes, nephritis, and particularly the cardiac disorders in a definitely subnormal way.

We may quite satisfactorily group our signs and symptoms shown in this syndrome under the heads of circulatory, nervous and mental, endocrine, respiratory, digestive and muscular.

CIRCULATORY

Though apparently entirely secondary in nature and definitely not

etiologic in character, the circulatory manifestations are clinically the most. important and striking in many cases, and they dominate the average case. As a rule marked tachycardia is present. Tests show, however, that the cardiac rate is chiefly influenced by emotional rather than by physical conditions. Very often slight exercise, well within the physical possibilities of the patient, such for example as the usual tests for cardiac muscle reserve will cause a slowing of the rate even down to the normal, while emotional stimulation will almost without exception augment it. Irregularities are often present but analysis shows them to be chiefly of sinus origin in uncomplicated youthful cases. True paroxysmal tachycardia eventually develops in a good many instances, particularly in those of long duration. Cardiac murmurs are almost always present. They do not usually follow established routes of transmission, nor do they occur constantly. constantly. They are most commonly found at the base of the heart and as a rule they disappear or decrease in intensity on moderate exercise. Notwithstanding all this, the cardiac reserve is lowered in almost all instances and very few of these patients have a normal cardiac muscle efficiency, especially for long continued, though perhaps moderate demands, and cardiac exhaustion occurs very much earlier than in normal persons. The blood pressure is ordinarily low, except when complications have taken place. In certain cases quite a marked pseudo "pistol shot" may be audible over the larger peripheral trunks and in some cases the diagnosis of a

true aortic endocarditis may be apparently justified. Needless to say prognosis in the two conditions is very different.

Many cases show also marked throbbing of the peripheral vessels, such as appears in true cardiac palpitation, or in Grave's disease. Slowing of the capillary return, particularly in the skin of the extremities is usually seen. The hands may be blue, as deeply cyanosed and as cold as in advanced cardiac degeneration. This phenomenon, which is often transitory, is usually accompanied by a cold sweat, especially profuse over the hands, feet and the skin of the axillae. Marked flushing and paling of the skin, especially of that of the face, is ordinarily present. It is developed mostly by emotional stimuli. Dermographia of all sorts is very striking. All these manifestations are exaggerated by emotional stress, most of them are diminished by mild physical exercise.

As a rule the heart is found on fluoroscopic or X-ray examination to be small rather than large, often it is of the "droplet" type, long and narrow. Rarely only, in spite of the overaction usually manifest, is a hypertrophy of the left ventricle present. Under too great physical demand, or even from merely over emotional stress, acute dilatation occasionally appears in apparently previously normal hearts. These cases can not respond to a cardiac demand of a degree normal to the average healthy person. This is especially shown during the acute infections where acute dilatation often appears without an apparent adequate cause. Hypoplasia of the aorta and other

major trunks is the rule. These patients are usually very sensitive to the vaso-dilators. They do not as a class react satisfactorily to the digitalis group of drugs.

NERVOUS AND MENTAL

Of little less characteristic nature are the nervous and mental evidences of this dycrasia. The patients are almost without exception neurotics and very emotional, though occasionally repressed. As a rule they are voluble and overly expressive of their discomfort and and complaints. They weep easily, profusely and frequently, like the type of women described so eloquently by the elder Mr. Weller. Their reponses to nervous and mental stimuli are almost invariably overreactions or exaggerations. It is important to mention here that some of these cases occasionally manifest attacks of syncope, closely simulating those occurring in petit mal. Most of them eventually get well from these attacks, as the general condition. improves or if the reverse follows, these attacks take on more certainly evidences of hysteria. Often these syncopal or "fainting" attacks promptly disappear under favorable emotional and sexual adjustments.

The knee jerks are greatly exaggerated, so are all the other normal nerve reactions. A pseudo ankle clonus may be present. Sleep is usually fitful and inadequate. Sleeplessness is in fact one of the most serious symptoms of the condition which the physician is called upon to treat. One must not, however, get the idea that all the nervous reactions are abnormal in their nature. Among many subjects of this disease the

creations of genius are evolved from these overly sensitive reactions. Musicians, actors, writers and painters are frequently of the type. In nearly all the arts and in some of the sciences these overly emotional responses bear rich fruit in the works of real genius, acts of heroism and in the highest evidences of intelligence. Let us not forget this fact, though we also admit a close relationship to hysteria, shell shock and other allied disorders.

This is also well illustrated in the selection of occupation by persons of this type. Almost without notable exception, successful men suffering from this complex are found in the ranks of mental, in contradistinction to physical, occupations. Those subjects of this syndrome who elect laborious vocations are for the greater part failures, while a large number become notable successes in those channels of work which require emotional and mental effort. This same tendency is shown in the selection of sports and games. Subjects of this syndrome rarely select outdoor recreation but prefer those diversions better calculated to their capabilities, such as cards, chess, dancing and the like.

ENDOCRINE

It is extremely difficult, even impossible to separate the signs of endocrine disturbance from the nervous and mental symptoms of the complex. Probably there is no true separation. In by far the larger number of cases definite thyroid hypertrophy is manifest and such indications of hyperthyroidism as sweating, tremor of the hands and tongue, and dermo

graphia are strikingly manifest. A very large number of cases show the so-called Goetsch reaction, and there is considerable evidence that the tachycardia present is at least in part an evidence of hyperthyroidism. I have myself described the condition as being a hyperthyroidism, though I now feel that, although hyperthyroid activity is a part of the condition, it is not invariably so, nor is this the the sole explanation of the syndrome.

There is no doubt whatever but that a great many cases of neurocirculatory asthenia are considered by many practitioners as simple instances of hyperthyroidism, particularly as of the "forme fruste" type. It is a misfortune, however, when these cases are treated on this sole assumption, as not a few of them are.

Hyperthyroidism is further simulated when an exophthalmus develops under emotional excitement. This is present in many cases in varying degrees. In all probability this sign of the complex admits of the same explanation as that concerned in Grave's disease. It varies greatly from day to day just as it does in true exophthalmic goitre, but it is not a hall mark of the disease.

Certain symptoms present in some cases suggest that adrenal defects may be present in the condition. This is notably suggested by the almost universal early exhaustion whch is shown. The usual low blood pressure also suggests adrenal defect, but when renal complications appear this may be altered into a hypertension. My personal belief is that the adrenal plays no important rôle in the complex. I believe also that

As is the case with the heart muscle, so also with that of the skeletal system, poor muscle tone is the rule. Though many of these patients may show considerable muscle adroitness few indeed have a normal muscle reserve or endurance. Early exhaustion of the skeletal muscle was one of the symptoms particularly commented upon by the Civil War observers, and by military and medical authorities alike. It is real, not merely psychic, but it is strongly influenced by the emotional and endocrine status.

There are of course many other symptoms and signs which occur

in this complex, but it is my purpose not to complicate this rather complicated clinical picture unnecessarily and I shall omit their delineation, hoping, however, that you will bring many of these points out in the discussion which I trust will follow this paper:

In the treatment of this condition it seems to me that we have a double rôle to play, one social, the other medical. Many of the cases which come to us are still young and while the type of the general condition is very evident, once your attention. has been attracted to it, it may not then be far advanced. Very much can be done with these early cases. One must not try to make a silk purse out of a sow's ear, to use a homely old phrase. I would rather paraphrase it here, however, and say that one should not attempt to make a sow's ear out of a silk purse, for it seems to me that recognized and properly directed most of these patients may be guided into channels of effort in which they may become most useful and productive citizens, but never if they are allowed to elect occupations and trainings for which they can never adequately fit themselves. The election of an occupation should then take full cognizance of the fact that these individuals can never rise to a truly normal physical standard. Their activities must be chiefly directed along those lines of endeavor in which mental adroitness replaces physical stamina, and in which their over-emotional output is capitalized and utilized instead of becoming a culture medium for neurasthenic and hysterical imaginings.