Chicago, Ill.

THE MEDICAL TREATMENT OF

NEURASTHENIA

Few diseases so well illustrate the ancient tale of the seven blind men and the elephant as does neurasthenia. Most of us, in forming a mental conception of any malady, are influenced especially by some single case that has made a particularly powerful impression upon us. Same with other things—many of us, if asked to describe an ideal woman, would immediately begin with the inventory of some single specimen. Some would be just tall enough, plump enough, fair enough, her eyes would be? her hair- -? nose -? and so along the list of charms. She would be beautiful, amiable, witty, fascinating; and, above all, she would believe the portrayer just about right.

Dr. Gould would unhesitatingly ascribe neurasthenia to eyestrain, and adduce many telling examples of relief afforded by fitting the eyes with glasses. Each specialist could "copper" this by cases of his own, of similar import. Acton and the early, or theologic, school of specialists in the study of sexual excess attributed neurasthenia to this cause. This commends itself to many as very likely to be true; but the lesson taught by impartial, open-eye and open-mind observation is rather the astonishing abuse of the sexual function nature can endure without permanent injury. I mean in the young. The train of symptoms described in "Mlle. X, My Wife," must be peculiar to France, for never in my forty years of practice have I witnessed any case of the sort, from

sex-excess.

Fecal Autotoxemia an Ever-present Element. Two etiologic factors are constantly present in neurasthenia-fecal autotoxemia and a drain of nerve-force. The latter may be in an eye needing aid, or any other fault that is a constant source of slight irritation. A corn may answer, as every step causes a little pain or discom

energy in a day is considerable. It is apt to be some slight irritation, too little to induce the individual to have the nuisance abolished. The result is a leakage of nerveforce, a loss that prevents the individual accumulating a reserve, inducing that irritable weakness we term erethism. Slight causes induce explosions of temper, that by a normal person would be unnoticed, and these further exhaust the already scanty supply of vitality.

It is immaterial whether we set down fecal toxemia as an etiologic or a semeiologic feature, it is always present as cause or effect; and if the latter, it contributes to the aggravation of the original malady. The influence of a strain of fecal toxins in the blood upon the delicate extrasensitive nervous cells can not but be harmful. Health to the nerve-centers and nervefibers means a plentiful supply of nutriment in the shape of pure, clean, normal blood.

That the emotions, sentiments, and beliefs may be tinged and influenced by such a toxin, is abundantly evident to the reader of Samuel Johnson, Carlyle, and other of the great morbid grouches. There is a story told of Voltaire, that one day, after comparing sentiments with an English lord, the two came to the conclusion that life was not worth while and agreed to commit suicide next morning. The Briton came to the appointment on time, but Voltaire excused himself with the remark that "his bowels had moved meantime." If the mental functions can be so powerfully influenced by fecal toxins, where is the difficulty in attributing to the same cause a similar interference with the physiologic functions, as presided over by the nerves?

The First Therapeutic Duty is, therefore, that thorough cleansing and disinfection of the alimentary canal we inculcate as a routine measure, and which is always applicable, except in the few cases where specifically contraindicated. No matter if there is a troublesome and debilitating diarrhea; if the urine tests show the presence of skatol or even of indican, there is retained fecal matter that must be dislodged, while reaccumulation must be prevented.

But here we come upon the leading principle in the treatment of neurasthenia: the quick exhaustion of the patient's excitability, and consequent depression, following very moderate doses. Cathartics suitable for ordinary persons can not be given to neurasthenics. The mildest laxatives and intestinal tonics are to be employed, and then very cautiously; these to be aided by similarly cautious abdominal massage and passive exercises. The enema is a cause of rectal debility.

Intestinal Regulators. After the bowels have once been emptied by colonic flushing and saline laxatives, they may be regulated by the smallest doses of cascarin, or the combinations of aloin, strychnine, atropine, capsicin and emetin, that will induce one daily evacuation. This is to be taken in three doses, to secure a tonic rather than a stimulant action.

Tests of the urine should be made, to ensure full action It is a nice bit of work to meet this need exactly.

The next indication is to find the leak and mend it, whatever it may be. Many an abnormality is so trifling that the patient refuses to believe it has aught to do with his ill health. Treat whatever you can find that needs treatment, no matter if there is no obvious connection with the symptoms.

The Restoration of Nerve-force would seem to demand that prince of nervines, strychnine. But here again we meet the difficulty of quick exhaustion of reactive power. Only the smallest doses are advisable, and generally we shall do better by substituting the milder brucine. Even of this, 1-2 milligram every one to four hours is better than large doses three times a day.

If the patient requires iron or quinine, as he usually does, the same principle of very small and frequent dosage is applicable. Many of these patients do better without arsenic, in truth, often have been drugged too freely with this potent remedy. One milligram of quinine hydroferrocyanide with each dose of brucine is a good average dose. Let these be taken on the tongue, in granule form, and allowed to dissolve and be absorbed thence.

Dietary Regimen.-Then always improve the chance of a little extra gastric strength, by giving a little food within twenty minutes, when the toning of digestion is at its height. Give but an ounce or two of some soft, easily digested food, such as that particular patient craves and can digest. Artificial digestants should always accompany the food, to initiate the digestive process, a thing more difficult in neurasthenia than the completing of it when once begun. The vegetable digestant papayotin is of great value, but sometimes hydrochloric acid and pepsin do better. Here also the small dose of acid must rule.

To Improve Vital Powers. Quite frequently it is well to give the vital powers a little boost by a week of zinc phosphide; a centigram one hour before meals, so as to prevent its decomposition by the gastric juice and the development of phosphoretedhydrogen eructations. Then follow with lecithin for the rest of the month.

The use of nuclein should be governed by the blood examination. If the leukocytes are scanty, put 10 drops of nuclein solution on the tongue four times a day, to be absorbed from the buccal mucosa. So, also, if the red corpuscles and hemoglobin are below par, the ordinary food may be reinforced by several small doses daily of bovinine, sanguiferrin, or some similar product. The materials are so nearly homologous with the blood that they are assimilated with less difficulty. This renders the raw white of egg a useful article of diet.

The same rule of speedy exhaustion applies to the no-drug therapeutics. I have seen many cases of neurasthenia

turned out from the masseurs and electricians worse than they went there. One of the worst cases that ever applied to me came from an institution where they "used no drugs." The lady went to bed, and remained there a week before she had recovered sufficiently to feel like getting up and dressing. Her exhaustion was pitiable. Nevertheless these things are very useful adjuncts to a well-devised drug and dietary treatment, when applied sensibly. Beware of the enthusiast.

The management of a neurasthenic is a matter of months, even of a year or more.

Treatment of Gout. We have quoted from Dr. W. C. Post, Maquoketa, Iowa, very many times, but we feel sure that our readers are interested in what the doctor has to say. We quote this month from his paper on the treatment of gout. He outlines his method of medicinal treatment for an acute attack as follows:

"Calomel, 1-6 grain; bilein, 1-8 grain; podophyllin, 1-6 grain, every half hour for six or eight doses, followed by a full dose of effervescent magnesium sulphate, this last to be kept up every morning until convalescence. Veratrine, 1-134 grain, every two hours, well diluted, with the addition of aconitine, 1-134 grain, if temperature is high. Calcium sulphocarbolate, 10 grains in solution every two hours till stools have a normal odor, then four times a day. Colchicine, 1-67 to 1-33 grain at night, in solution, for its specific effect, varying dose according to gastric or intestinal disturbance. If pain is very acute, add 10 grains of aspirin to the doses of calcium sulphocarbolate. Apply spirosal, betula oil (oil of wintergreen) to the joints and wrap with cotton or wool. Give Do plenty of pure but not cold water. not use sodium salts in acute gout, but salts of calcium and magnesium preferably, as these best neutralize the intestinal and hemic acidosis which precipitates the attack."

We again quote from Dr. Ernst, Brigdewater, Nova Scotia, to give his method of treatment of gout:

"I had a case last winter, in a widow, age 44, who consulted me for hives, as she thought. Examining her urine, I found the excretion of urinary solids very much below

normal. Uric-acid crystals were found in the sediment. The woman was very plethoric, had a great appetite, but was unable to take much exercise in the open air. I found it necessary to cut down her diet to milk, eggs, fruit and vegetables, for about two weeks; and of that only enough to satisfy hunger. The woman followed her work all through the treatment. Every night at bedtime enough pilocarpine was given to produce slight sweating; some nights veratrine, gr. 1-134, was also given. The bowels were kept quite free with calomel, podophyllin, and salines, given on the Abbott plan; and enough sulphocarbolates were given to keep the stools sweet and clean. A calcalith tablet was given, with a glass of water, every four hours during the day. All the medicine was given 'to effect.' It required about three weeks to remove the trouble, and patient continued to take the medicine for about two weeks longer. It is now about four months since the attack, without any signs of the trouble returning. Patient lost several pounds during the time she was taking medicine.”

EXAMINATION QUESTIONS

1. What is neurasthenia? What causes it? Outline briefly its most important symptoms.

2. Differentiate carefully between neurasthenia and hysteria.

3. Give the relationship between neurasthenia and the occurrence of indigestion, telling of the characteristics of the cases of "nervous dyspepsia", so called.

4. Outline the "rest-treatment," telling us what American physician first made this treatment prominent. Describe hydrotherapeutic measures

which are of value.

5. What relation does autotoxemia bear to neurasthenia, and what therapeutic measures do you suggest for its correction?

6. What tonic medication would you advise? What two drugs are, in your opinion, most generally useful? What drug, frequently given in these cases, is generally contraindicated?

7. Outline a dietary scheme for a neurasthenic woman who is below her normal weight.

8. Describe a case occurring in your own practice, and tell how you treated it.

Tuberculosis as a Disease of the Masses, and How to Combat It. International Prize Essay. By S. Adolphus Knopf, M. D. New York. Seventh American edition, thoroughly revised and greatly enlarged. 1911. Price, single copy, in paper, 25 cents; 20 or more copies, 20 cents each; postage extra; 50 or more copies, 15 cents each, postage extra. Elegantly bound in cloth, 50 cents each, postage prepaid; 20 or more copies, 40 cents each, postage extra.

It is not necessary to introduce to our readers Professor Knopf's well-known prize essay on tuberculosis, because in its earlier editions it has had a circulation probably wider than any other publication of the kind, not only in this country and in Europe, but all over the civilized world. The monograph has been published in 27 foreign editions and in 24 different languages.

The present edition is more than half as large again as the first one, and presents in brief and clear terms the practical results of tuberculosis study so far as they are of interest and value to the laity. We would certainly advise our readers to order for their patients a number of copies of this excellent little pamphlet and to be sure and study it themselves.

The Bookworm has consulted the little volume quite often and always found it of valuable assistance, both in his popular essays and in his talks to the laity on tuberculosis. He acknowledges gratefully his indebtedness to Dr. Knopf, than whom nobody in this country does more to teach the people how to live so as to prevent the acquirement of consumption and, if

the disease is actually established, how to live so as to check its advance and also how to prevent the spread of infection.

BUTLER'S "PHYSICIAN DETECTIVE"

The Exploits of a Physician Detective. By George F. Butler, M. D. Chicago: The Clinic Publishing Company. 1908. Price $1.00.

The Bookworm has repeatedly written in encouragement of outside reading for physicians, that is, reading of nonmedical books, and has emphasized the interest which we naturally feel for books written by physicians and for those concerning physicians.

Turning the pages of Dr. Butler's detective stories, during a few leisure moments, the writer was impressed with the psychologic problems involved in them. To mention only one, the first story deals with a phase of religious mania in a cultured and refined woman that makes even murder

appear a pleasing sacrifice to the Almighty. Every physician has seen enough instances of mental aberration to grant that such outré things can really happen. Dr. Butler has told these stories in a very fascinating manner, and the readers of CLINICAL MEDICINE will do well to secure a copy.

THE PRESCRIBER

The Bookworm was recently favored with the bound fourth volume of The Prescriber (1910). This is a most excellent little monthly journal, edited by Thomas Stephenson, F. R. S. E., F. C. S., 137 George St., Edinburg.

While the volume does not, of course, lend itself to review, we wish to say that we

have throughout the year read and consulted the monthly copies of the journal with considerable interest and advantage. The editorials are distinguished by their erudition and conservative progressiveness, if we may use this paradox; the abstracts from current scientific literature are complete enough to serve their purpose and in many cases even complete enough for research-workers. The Prescriber has set itself the task of following and recording the therapeutic progress, and this task is excellently accomplished. The subscription price of only 5 shillings a year is low, and the value received is immense. We congratulate Dr. Stephenson on his splendid little journal.

A Practical Treatise on Rectal Diseases: Their Diagnosis and Treatment by Ambulant Methods. By Jacob Dissinger Albright, M. D. With 32 plates, 4 of which are in colors, and 39 illustrations throughout the text. Published by the author, 3228 North Broad Street, Philadelphia. 1909. Price $4.00.

The author of this volume is well known to physicians through his numerous writings, which all have the purpose of aiding the general practitioner in enlarging his usefulness and in improving his condition. In his "The General Practitioner as a Specialist," a book which has passed through several editions, much information.

and encouragement is given, tending to make office practice both successful and remunerative.

In the present volume Dr. Albright deals with one particular field of medical activity which cannot be said to be overcrowded, and which yet promises, not only fair, but excellent returns for one who acquires the proper qualifications. The treatment of rectal diseases by ambulant methods is important because of the well-known fear of the hospital and of general anesthetics and because of the natural reluctance to being "shelved" even for a few weeks.

Any book that comes from Dr. Albright's pen carries its own recommendation. We do not feel the need of discussing the author's views beyond saying that they are well presented. Diagnosis, etiology, and treatment of the various rectal and anal diseases are clearly set forth, without guage" which to many practitioners would any undue recourse to "laboratory lanbe worse than Greek. The book is intended for the practitioner and is well calculated to be of great assistance to him.

COCROFT'S "GROWTH IN SILENCE”

Growth in Silence. By Susanna Cocroft. Published by the Physical Culture Extension Society, Chicago.

This little booklet, adorned with the well-known picture of Miss Cocroft, is a pretty collection of "good thoughts" such as are claimed by many to be conducive to obtaining and preserving health. And who shall gainsay this assertion? Physicians have, until in quite recent years, been altogether too oblivious of the importance of the mental attitude and peace in securing health, and the lesson has, in fact, been taught us, not by physicians, but by lay men and lay women.

Miss Cocroft's picture has for years been a familiar one in the better class of popular journals, pointing out the advertisements of her physical-culture courses, and if we are to judge the efficiency of her teachings from their effects upon herself, we must confess that she looks younger today than she did years ago.