been far lower and complications much less numerous and severe. Some of the patients had marked delirium and symptoms of meningismus. I would suggest in very severe cases of complicating meningism the use of lumbar puncture. This would promptly relieve the symptoms, as reported sometime ago by Dr. Musser in the use of spinal puncture in cases of pneumonia.

It seemed that very little treatment was necessary, comparatively speaking, in cases occurring among negroes. They recovered in a large proportion of the cases. The incidence of the disease seemed much less in the negro race and the disease was certainly not so severe and so fatal in the dark-complexioned people as in those of lighter color, the blond.

Convalescence

A liberal diet should be given. For the cough, which may hang on, I found syrup of hydriodic acid (fresh) in teaspoonful doses very useful. This may be given every three hours in milk or water. If the cough is painful and distressing, a capsule containing small doses of dionin, heroin, or codeine with grs. 2 1-2 to 3 each of gualcol carbonate and terpin hydrate, is very useful. For the anemia, wine of citrate of iron, vinum ferri amarum, or vinum ferri et ammonii citratis or "vinum ferri" may be used.

A pill or capsule containing cinchonidine sulphate, grs. 1 to 2; ext. gentian, gr. 1; ext. nucis vom. gr. 1-8 to 1-4, ferri sulphatis (exsicc.) grs. 3 may be given 3 or 4 times daily after meals, or, elixir of iron, quinine, and strychnine may be ordered.

Ordinarily, very little medication is necessary or indicated during the convalescent period. Food, air and sunlight and rest do the work.

Summary and Conclusions

To summarize, (1) The exact cause of this epidemic disease and its complications, is not known. It is probably due to a severe malignant infection, mixed in character, with virulent strains of several wellknown microorganisms. (2) Mixed bacterial vaccines have proven their worth as a prophylactic measure and deserve further trial. (3) Bacterial vaccines have been of great help in the treatment of the disease and its complications. Although not so scientific as a specific antiserum or antitoxin, and probably not so efficient, yet, since we are not fortunate

enough to have such antitoxin, we are justified in continuing the use of mixed or combined vaccine (or serobacterins) as a therapeutic measure in view of the numerous encouraging reports from everywhere. (4) A multiplicity of remedies was useless and of very little benefit. Good food, fresh air and rest in bed were highly important. I did not starve any of my patients. They all received plenty of good wholesome light nourishing food. (5) Antipenoumococcic serum (type I) certainly is indicated in undoubted complicated cases of lobar pneumonia occurring in this epidemic, especially if due to the Type-I Pneumococcus, but should be used before the type of the infection is reported by the laboratory, as any delay may prove fatal. (6) The chief drug treatment in my cases consisted of giving a combination of aspirin with or without caffeine citrate and cinchonidine sulphate and fairly large doses of strychnine. Codeine, with or without citrate of potassium or sodium, for the cough. (7) The entire treatment, as a whole, in my mind, should be based chiefly to accomplish two ends: (a) The alleviation of the pains, cough, insomnia, and other discomforting symptoms during the first two or three days of the disease; (b) The treatment of the severe toxemia by sweating at the very beginning of the disease, by the use of hot drinks, with or without whisky, hot external applications, vapor bath, together with an ice-cap to the head, and the abovementioned "urotropin comp. capsule"; opening of the bowels, and flushing them out by enemata, and plenty of water to drink with the addition of orange juice, lemonade, and milk, etc., thus mildly stimulating the kidneys to action. The acidosis element in this severe infection is counteracted by the use of the bicarbonate-ofsodium enemata, and enteroclysis, and the administration of the citrate of potash or citrate of soda, with or without liquor ammonii acetatis, which was given also to alleviate the cough as above mentioned. (8) Isolation and quarantine of houses in which sufferers of the disease are confined would probably be more efficient than the widespread "bans" issued by Boards of Health. These latter tend to scare and frighten the populace unnecessarily, cause great inconvenience, dissatisfaction, and are highly questionable as an efficient

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Migraine

HE vast majority of headaches of an intense character and which are

loosely classed as migraine are, really, of toxic or anemic origin and, therefore, do not properly belong in the realm of nervous disorders. There is, however, a small proportion among them that constitute genuine neurovascular phenomena, consisting, as they do, in a spasmodic contracture of the vessels that supply the brain and thus cause an artificial and temporary anemia that manifests itself as very intense headache. These headaches mostly are limited to one side of the head (hemicrania).

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Theroretically, of course, we ought to be able to relieve these headaches quite simply by the administration of some quick and powerful dilator of the arteries, of vasomotors, such as nitroglycerin, or one of the nitrite salts, or atropine in tiny doses. Unfortunately, however, it seems that when once one of these neurotic spasms has established itself, it defies all therapeutic efforts at unlocking, and ordinarily persists until released by a natural process of reaction similar to the process that brought it about. Not infrequently these patients are relieved of their headache quite suddenly and completely by the occurrence of some unexpected and powerful distraction of their attention.

If we can catch the headache in its threatening stages, and the patient can be persuaded to take vigorous action against it, then, instead of trying to "fight it off," it is usually a very easy matter to head it off by the means just indicated, namely, by reducing the blood tension and quieting the nervous system with moderate doses of sodium nitrite or acetanilid and monobromated camphor, in combination with a mild alkaline-the bicarbonate of sodium or of potassium. This, coupled with an hour or so of rest in a cool darkened room or else a brisk walk in the fresh air, according to the temperament

attack; or, a hot bath followed by an hour's seclusion and rest is an excellent prophylactic.

When once the attack has established itself, though, more heroic measures are necessary. The same remedies recommended above may be prescribed, but, they must be given in larger doses and-what is more important, still-they must be given in hot water or else immediately followed by a draft of hot water. During the attack, the digestive tract shares in the neurovascular spasm and thus is incapacitated for absorbing anything, unless the spasm first is relieved by flooding the membranes with hot water. Hence if the medicines are simply swallowed at such a time, they remain inert in the stomach and small intestine and, so, have no effect. In administering these remedies, it is my practice to have the patient swallow half a tumblerful of hot water or hot physiologic salt-solution five minutes before taking the medicine and another half-glassful immediately afterward.

Sometimes relief can be obtained by inducing rather violent emesis. Many patients themselves have discovered the efficacy of this procedure, although they do not know its precise reason, and they induce vomiting by tickling the fauces or by swallowing mustard in lukewarm water. The general idea is, that this helps by removing from the stomach irritating contents. This, however, is not the explanation. It is the act of vomiting that brings about a relaxation of the entire vasomotor mechanism and, therefore, relieves the neurovascular spasm. Consequently, mere gavage will not serve this purpose; active vomiting must occur.

There are, of course, exceptionally severe cases, in which still more heroic measures must be employed. In such instances, about the only recourse left us is, to compel sleep (which, after all, is the most effective unlocker of such spasms) by means of some powerful hypnotic. But, in

choosing our agent, it is necessary that we avoid those that contract, and must select those that tend to dilate the blood-vessels. Opiates are, for this reason, undesirable. Sulfonal and trional are ideal in such cases, given in doses of 10 to 15 grains in hot water; but, unfortunately, they are not, as a rule, powerful enough in severe attacks. For a more compelling hypnotic, a mixture of sodium bromide and chloral hydrate (of the former, 20 grains, and, of the latter, 10 grains) in hot water is very effective. If the circulatory function of the patient be habitually poor, it is well to give, in addition, a dose of digitalin. This will not interfere with the hypnotic or relaxant action of the other two drugs, but, will guard against collapse.

Neurasthenia

It should be remembered that neurasthenia is, essentially, a chronic malady, that its development often is as rapid as its advent is insidious, and the final recognition of its presence may occur only after weeks or months of its existence and after the entire nervous system has become involved. The individual may have been enjoying normal health for some time. Suddenly he manifests a strange, unwonted disposition, is peevish, a prey to unreasoning fears, loses sleep and appetite, is listless and distracted, perhaps even indifferent in his family-relations, and evidently a victim of secret care. Gradually he realizes the fact that he is not himself, that his nerves are seriously unstrung, and that he requires a changehe is neurasthenic and powerless to cope with the conditions to which he is subject.

Rest, Physical and Mental. It can not be too strongly impressed upon the sufferer that great benefit can be derived from rest. This regimen may be regulated according to the severity of the case, being relative or absolute in proportion to the requirements indicated. In milder cases,

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few hours of extra sleep daily may prove an efficient means of relief.

Only the most careful study of each individual case can rightly determine the precise procedure to be adopted. The difficulty in determining whether the neurasthenic condition or the gastrointestinal disease was the primary condition of any given patient, often is very great and frequently insurmountable; still, from a prac

tical point of view, this does not seem to be important.

If the gastrointestinal disease is purely neurasthenic in its inception, it soon becomes much more than this in a large number of cases, and it calls for much the same line of treatment, whether it is primary or secondary. Always, though, rest must be considered the essential and rational basis of the line of treatment chosen, everything else being subservient to its beneficent influence.

Bearing in mind always that the particular neurosis under consideration is, largely and often chiefly, psychological, it is impossible to overestimate the reflex importance of rest in its salutary action upon the mind. Perfect relief from bodily fatigue works wonders in effecting general amelioration, although in many instances gentle and well-regulated exercise is of unquestionable value, especially in certain states and in certain stages of recovery. Released from the wearing anxieties that finally have resulted in a neurasthenic condition, the mental faculties of the victim gradually but surely regain their normal strength and elasticity, particularly if the environment is such as to inspire reawakening hope and confidence.

A new life appears to accompany the results of carefully studied and judicious treatment, and in compulsory, yet, grateful repose the patient soon finds that his thoughts are brighter and more cheerful, his capacity for mental enjoyment is keener, and his physique markedly improved under the influence of the general recuperation. Sleep and healthy digestion which have, perhaps, long been strangers to him, assume a natural phase; troubles which but lately oppressed the mind with persistent anxiety appear purely imaginary or at least are deprived of their baneful effect, while the entire system sponds favorably to the new regimen and watchful care.

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The records of this treatment abound in illustrations of its beneficent agency in restoring normal conditions. It is emphasized strongly here as of unique, paramount, importance, in which experience leads me to place almost implicit faith. Change of scene and recreation often is more important than mere physical rest. Hydrotherapy, in the opinion of the most-competent authorities, is an invaluable ally in dealing with neurasthenia. It even has been asserted that there is probably no chronic disease in which its application contributes more largely to the betterment of the patient's condition and which renders the beneficial effects of a changed environment, the removal of etiologic factors, of proper diet, electricity, and medication more pronounced and enduring.

Nearly half a century ago, Preiss wrote: "Prolonged continuance of anomalies of the nervous system not rarely deranges important functions. Since all function depends upon nerve action and no other remedy is capable of altering the nervous system in a mild manner so rapidly, surely, easily, and thoroughly as water, this simple remedy must occupy the first rank as a nerve tonic." Other eminent writers have similarly endorsed the value of hydrotherapy and balneotherapy in neurasthenia; Jolly recommending the inbibition of large quantities of water as an aid to renal and peristaltic action, its external application being valuable in those cases in which increased excitability is combined with tendency to exhaustion.

One hardly can overestimate the efficacy of cold rubs, half and full baths, with friction, of douches, sprays, and so forth, in their favorable influence upon the cutaneous tissues and upon the circulation and tone of the vessels. Krafft-Ebing asserts that "in the management of neurasthenia the water-treatment is of the greatest value, because, as applied (preferably in institutions), it admits of all possible excitant, calming, and alterative effects upon the diseased organism and its tissue changes." He considers hydrotherapy important in reducing insomnia, while in pronounced neurasthenia he regards it as a valuable aid in regulating cardiac activity, dilating the peripheral vessels and increasing or diminishing (as desirable) the cerebral circulation.

Various hydriatric measures may be adopted, all of them more or less efficacious, according to the conditions in which they are applied. Klemperer is authority for the assertion, amply corroborated by experience, that "in hydrotherapeutic efforts we observe quite an extraordinary and incomparable stimulation of the nervous system, which is reflected upon the various organs." Dr. William N. Draper, speaking of this procedure, remarks: "It

seems to be more effective than any treatment by medicine in stimulating the nervecenters, in restoring the equilibrium of the circulation and reviving the activity of the organic functions," adding forcibly that "its best results require the appurtenances of a well-ordered establishment, where all the various methods of applying water can be wisely and skilfully

directed."

Many like testimonials might be adduced to show that in the water-treatment there resides a veritable means of restoration. "Who can calculate," says Dr. Frederick Peterson, "to what degree we may thus influence the biochemical processes of the body, the metabolism of tissues, the carrying off of degenerated and toxic substances, or determine how much we may affect the vascular neuroses, the local anemias, and the hyperemias of the brain and spinal cord?"

Electrotherapy. With regard to electricity, especially the static form, its use in the treatment of local neurasthenic symptoms such as morbid cephalic sensations, extreme intestinal atony, weakness of the sexual organs, etc., is generally conceded. In these conditions both faradism and galvanism, combined or alternated, have proved beneficial. Much depends upon the constant application of this subtle force. So far as experiment has shown, its curative property in certain cases seems undeniable, while, as a therapeutic agent in obstinate neuroses, it is inferior to rest and hydrotherapy.

Drug-treatment. - The treatment of neurasthenia is marred by the usual quackeries that fix upon a single symptom as the disease. The drugs generally prescribed for their tonic effect are, as Bremer observes, nux vomica or its alkaloids, arsenic, phosphorus, quinine, bromides, iron, hypophosphites, and few others. None of these remedies will cure; iron is particularly objectionable, since, as a rule, it is not well borne by the neurasthenic. Quinine often is administered in excessive doses for the erroneously assumed complication of malarial infection.

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There is no drug (and I say this after careful and long observation) that can restore or create nerve-strength and brainvigor, as is so often claimed by proprietary-medicine men. The majority of the much-advertised nerve-tonics are not worth a trial; still, these articles are in great vogue, owing to recommendations of sadly mistaken physicians in good standing. The thousands of barrels of so-called "nerve-tonics" taken annually mean misery to untold numbers of neurasthenics and their families, since such patients, when poor, consider it of greater importance to buy their "nerve-tonics" at the rate of $1.00 a bottle, than to provide necessities for the family.

Physical Exercise. Complicating the drug-prescription errors there are the errors involving exercise and diet. One of the commonest and most-disastrous prescriptions of this kind given to the neurasthenic, as Bremer properly says, is, to "take plenty of fresh air and exercise." The "fresh" part of the injunction is all right (in some sanitariums, such patients often are compelled to be in the open air all day, even though in bed and when too weak to move about or sit up), but, the prescribing of "exercise" is all wrong There is a widespread delusion that exercise is beneficial under all circumstances. The acme is reached when the gymnasium and athletics are recommended to every neurasthenic. Many athletics and prizefighters become neurasthenics by dint of too much muscular exercise. Even in laboring men that have heavy work to perform nervous prostration often results.

Whenever and as often as a muscle is contracted, certain brain-cells enter into activity. The brain in one or more of its parts is, in neurasthenics, the most easily irritated and exhausted. Going to the close functional dependence and interdependence of all parts of the brain, work

of the motor-region governing muscle contraction during exercise must affect other weakened and easily irritable parts. Some cerebrasthenics whose slightest mental effort is followed by brain-fag can walk long distances without feeling any fatigue, but, this often is an expression of overfatigue.

The Diet is an important factor, but, like other measures, this also is badly abused. Neurasthenics not seldom are advised to eat plenty of nourishing food; and they will gorge themselves, without considering that it is not the amount of nutriment-even when properly digested and absorbed that determines nutrition, but, the use to which the digested food can be put in the tissues.

The artificial foods have the effect of weakening the stomach by rendering it, so to speak, apathetic, thus interfering with the churning of the food and the secretion of gastric juice. One ounce of butter with bread digested naturally outweighs a pound of beef incorporated in the system under artificial conditions. Beef-extracts are especially objectionable for neurasthenics. Milk and fresh fruit often disagree with these patients. Dietetics, therefore, should be a matter of individual prescription rather than of any general directions. Excess of the proteids and excess of the starches and sugars are to be avoided, since these two excesses, acting in a vicious circle, aggravate each other. Starchy food fermenting in the intestine favors absorption of proteid products of decomposition.

[To be continued.]

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