6. The irritable hypokinetic. Irritability[1] of a pathological type as a phase of lowered energy is well known to every physiologist and in the practical everyday world is seen in the tired and sick. There are people who from the very start of life show lowered endurance, who respond to certain stimuli in an excessive manner and are easily exhausted. This type the neurologist calls the congenital neurasthenic, and it may be we are dealing here with some defect in the elimination of fatigue products. This, however, is only a guess, and the disease factor, if there is any, is entirely unknown. I do not pretend that the person I am to describe is entirely representative of this group.
Indeed, no dozen cases would show all the symptoms and peculiarities of the irritable hypokinetic group.
[1] One must take care not to mistake the irritability which is the characteristic of all living tissue for the irritability here considered.
E. is a man at present thirty years of age. In person he is of average height, rather slender, with delicate features, somewhat bald, quick in action and speech. He flushes easily and thus often has high color, especially when fatigued or excited. This "vasomotor irritability," as the physicians call it, is quite common in this group of people, and in fact in all neurasthenia, whether acquired or congenital. Though I have described E. as belonging to the slender type of person, it is necessary to say that stout, rugged-looking people are often irritable and hypokinetic.
As a child E. "never could stand excitement or strain," as his mother says. What is meant is this: that he became overexcited under almost any circumstances and became profoundly fatigued afterwards. As we have seen, the intense diffusion of excitement throughout the whole body is a sign of the childish and inferior organism; as maturity approaches and throughout childhood excitability decreases and is better localized. When a noise is heard an infant jumps, and so do people like E., but the better controlled merely turn their head and eyes to see what the source of the noise may be. This lack of control of excitement extended in E.'s case to play, entertainment, novelty of any kind, crowds and especially to the disagreeable excitement of quarrels, fights, terrifying experiences, etc. Under anger he trembled, grew pale, and his shouts and screams were beyond control; under fear he became actually sick, vomited and showed a liability to syncope of an alarming kind. E. was not the selfish type of the neurasthenic; he was gentle and kind and ready to share with everybody, a lovable boy of an intensely sociable nature.
Nevertheless, his high excitability and his quick fatigue made it necessary to shelter him, for any effort at toughening merely brought about a "breakdown."
Here we must reemphasize the fundamental importance of the fatigue reactions. The normal fatigue reaction is to feel weary, to desire rest and to be able to rest and sleep. The abnormal reaction, one directly opposed to the well-being of the individual, is to feel exhausted, to become restless and to find it difficult to sleep. There are children who thrive on excitement and exertion; they sleep sounder for it, they recuperate readily and gain in strength and endurance with every ordinary burden put upon them. There are others to whom anything but the least excitement and exertion acts as a poison, making them restless and exhausted. Not all children who show this perverse fatigue reaction grow up with it. It may be only a temporary phase of their lives, but while it lasts it is very troublesome.
In E.'s case the overexcitable hypokinetic stage lasted until about the ninth year, and then there was a great improvement, though he still was of the same general type. He became a fairly good runner for a short distance, learned to swim, though he stood the cold water poorly, was clever and graceful as a dancer and was quite popular. At sixteen he left school to enter business, because of the straitened means of his family. He entered into adolescent period later and suffered greatly from his sixteenth to nineteenth year from, fatigue, hypochondriacal fears, and had to have a good deal of medical attention at this time. Sex questions perplexed him, for he became quite passionate and at the same time had much moral repugnance to illicit relations. His sexual curiosity was intense, and he read all manner of books on the subject, went to the burlesque shows on the sly and almost became obsessed on sex matters.
At this stage he made only a mediocre showing in his business career, though his evident honesty secured him promotion to a clerk's position. After his nineteenth year he seemed to gain again in energy and endurance and was fairly well until his twenty-eighth year, though he had to nurse his endurance at all times, developed very regular habits of sleep, diet, etc., and in this manner got along. Once he had an opportunity to join an organization which would have paid him a better salary, but the hours were irregular, and it would have demanded much exertion and excitement, so he passed it by.
In 1917 he joined the army, partly because of patriotic motives, partly because he was convinced that army life might develop his endurance and energy. He was sent to an army post in the South and within two months of his entrance had "broken down." He was sleepless, restless, was irritable and "jumpy," had lost appetite and the feeling of endurance. Life seemed intolerable, though he had no desire to do away with himself, for he had no quarrel with life itself but was disgusted with his inferiority. He was hospitalized, but this did little good and he was afterwards discharged as medically unfit.
