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Vol. XXIV 29

ST. LOUIS, JANUARY 10, 1906.

Papers for the original department must be contributed exclusively to th's magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted.

A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof.

Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose.

COLLABORATORS.

ALBERT ABRAMS, M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
S. SOLIS COHEN, M. D., Philadelphia, Pa.
W. T. CORLETT, M. D., Cleveland.
ARCHIBALD CHURCH, M. D., Chicago.
N. S. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.

Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.

THOMAS LINN, M. D., Nice, France.
FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia.
NICHOLAS SENN, M. D, Chicago.

FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D., Evansville, Ind.
REYNOLD W. WILCOX, M. D., New York.
H. M. WHELPLEY, M. D., St. Louis.
WM. H. WILDER, M. D., Chicago, Ill.

LEADING ARTICLES

No. 1

symptomatic neurasthenia. While neurasthenia is not as common an affection as many suppose, it is a distinct clinical entity whose cause is overfunctioning or undue expenditure of nervous energy, and whose manifestations are symptoms and signs which indicate nervous weakness and nervous irritability. It is true fatigue neurosis and the expression "irritable weakness," often used, is one fairly descriptive of its chief characteristics.

This reference to neurasthenia as a psychosis and a symptom of disease outside of the nervous system suggests a word or two at the outset about the treatment. While it is true that the insane may be neurasthenic or the neurasthenic become insane, the terms neurasthenia and psychosis are not interchangeable; nevertheless a psychic element which has its underlying cause in heredity is present in most cases of true neurasthenia. From first to last the body as well as the mind of the neurasthenic should be treated, suggestion and encouragement, which is continuing suggestion, being potent factors in the successful management of the disorder. Another fact which has some bearing upon the question of the existence of genuine, uncomplicated neurasthenia is that in symptomatic

THE TREATMENT OF NEURASTHENIA.* neurasthenia, unless the neurasthenic ele

CHAS. K. MILLS, M. D.

PHILADELPHIA, PA.

Professor of Neurology in the University of Pennsylvania.

IT is necessary in order that my views with regard to the therapeutics of neurasthenia should be clearly presented, to say a few words about its definition and nature. Recently some tendency has been shown to return to the views which prevailed before Beard, in 1880, impressed the profession and the community with the idea that neurasthenia or nervous exhaustion de served separate recognition in our nosology. Dana, for instance, in a paper significantly entitled "The Passing of Neurasthenia," would relegate the majority of cases so diagnosticated to the psychoses, and of the cases left he believes that many should be regarded as illustrations of nervous disorder dependent upon the disease of non-nervous organs. I do not, however, accord with the view that all cases, or nearly cases, come either under the psychiatric pale or are to be regarded as instances of

all

Read before the Philadelphia Neurological Society, November 8, 19.5.

The

ment is recognized in the therapeutic measures adopted, the treatment instituted with only the primary causal conditions in mind, will probably meet with little success. proper method of treatment in symptomatic neurasthenia is one which takes into consideration both the neurasthenic and the underlying non-nervous disease. Whatever is done for heart, stomach, liver, kidneys or blood, the patient needs also mental and physical rest and the inspiration of well-directed suggestion.

A single illustrative case may be of value in this connection. A young married man came to me from a distance to be treated for neurasthenia. He had gradually become more and more nervous, irritable and depressed. He occupied an important commercial position, but not one sufficiently calling upon his energies to entirely account for his breakdown. He suffered from an annoying vitreous opacity and an old orchitic trouble; also from a congenital, partial arrest of development of one lower extremity. His mind had become concentrated on the symptoms and conditions which were not in themselves sufficient to cause any serious apprehensions. He

had worried himself into a state of extreme neurasthenia because of affections easily cured, or at least relieved. The first thing necessary to do in this case as in so many others, was to remove the patient from his environment and to put him on as complete rest as possible, and to forcibly impress him with the idea that all his annoying symptoms were transient, or at least could be remedied, and that no reason existed why he should not in a short time be in as good health as he had been one or two years before. Proper attention was given to his eyes, to his somewbat crippled limb, to his genitalia, but at the same time he was placed upon a thorough rest treatment, at first nearly complete and later made partial. Isolation, massage, electricity, hydrotherapy and other measures, hereafter to be referred to, were used, and as they were gradually withdrawn, systematized exercises and increasing occupation were substituted. The man made a good recovery in less than three months.

Before taking up special measures for the treatment of neurasthenia, a few words should be said about its prophylaxis, and it would be time saving to include in these remarks suggestions regarding not only the methods of preventing its occurrence, but also of its recurrence after recovery through time or treatment. The age is strenuous. Notwithstanding the pace which is set in almost all walks of life, however, many succeed in passing to middle life and later, and then succumb not to neurasthenia, but to arteriosclerosis or some other degenerative disease. The predisposd neurasthenic who tends to early exhaustion of his nervous system may, in spite of his neuropathic heredity, have within him great possibilities in some directions, and it is well worth while to conserve and develop his powers. The physical and mental endowments and limitations of the child should receive the close attention of the parent and the educator. The seeds of neurasthenia may be sown in the preparatory school or in the college, and especially in the latter, where so often a false standard, or at least one that is not suited to the average members of a class, is set. After the general education or training of the youth is completed, another great step towards the prevention of neurasthenia is that which is taken when care is exercised, both by the individual and his advisers, in the choice of an occupation which is suited to his inherited endow ments.

Passing now to the question of the preven tion of neurasthenia in those engaged in active pursuits, it should be remarked that not a few of those who suffer from nervous or other breakdown do so because their lives and

work are full of unrest. Of two business men who have equal amounts of work to do, and are practically equal in physical strength and mental capacity, one goes about his tasks with a steadiness and system that do not wear either upon himself or those with whom he comes in contact; the other with such restlessness and unnecessary output as to keep himself in a half exhausted state and those around him disturbed and disquieted. Perhaps his unrest is shown in the unnecessary steps that he takes, or the unnecessary rapidity with which he takes them; in talking too long or too excitedly; in driving when leading would do better;-in brief, in expending more energy than is necessary even for the full accomplishment of the work in hand. The feelings of those compelled by fate to keep company with these useful but irritating mortals is best expressed by the slang expression, "Give us a rest;". but as a rule they neither rest themselves or let anyone about them rest. One man does his work with smoothness and with only that loss of vitality which is easily repaired by his daily food and sleep, the other is always giving out more than can thus be supplied. One saves his forces at the same time that he uses them, the other is wasting much that he might easily save. One physician is worn out before his hours of work are half expired; the other goes evenly and quietly through the hard day's work. The work that nags and harrasses one man scarcely ruffles the other.

Probably no one thing is more important in the prophylaxis and treatment of neurasthenia than the avoidance or prevention of worry. Genuine neurasthenia seldom occurs in one with a healthy inheritance, simply through persistent and severe mental work. The biographies of scholars, technologists, and professional men who have obtained celebrity afford ample evidence of the truth of this statement. On the other hand, it is a matter not only of history, but of common experience, that anxiety and worry, whether caused by domestic disturbances or embarrassments and perplexities in business and professional life, are fruitful sources of the exhaustion and irritability which are the sign manual of neurasthenia. Probably no one factor is more important in the production of the neurasthenic state than the worries of domestic life. Res angustoe domi. The student of mathematics, of law, of medicine, or of any vocation requiring intellectual capacity and presistent labor may continue his work through long hours for many weeks or months with no more visible result than normal mental and physical fatigue. But add to this an embarrassing or nagging domestic life, and neurasthenia is one of the most fre

quent consequences. One's life should be so regulated, not only by himself, but with the assistance of those by whom he is constantly surrounded, that unnecessary anxiety and worry are as far as possible eliminated.

Passing now to a consideration of the treatment of neurasthenia, before taking up the different therapeutic methods and measures, attention must be directed to the fact that at least two sets of neurasthenic patients need to be recognized in considering plans of treatment. One set must be treated at home or not at all, because of financial or other reasons, and another, the patients included in which can be removed from home and their usual environment and undergo a comparatively expensive form of treatment. The methods to be employed in the two classes of cases are fundamentally the same, but differ in their manner of application and in the degree in which particular measures can be carried out. The general practitioner, is often confronted with the problem of what to do with a neurasthenic patient who cannot undergo an expensive rest treatment, and who indeed may be unable to secure the advantages even of a short journey or change of climate and surroundings.

Whether the patient is treated at his home or in a house or hospital where the so-called rest cure is undertaken, the most important measures of treatment will be the same. These are rest, regulated diet, recreation, change, massage, electricity, exercise, work and medicinal and special therapeutic measures. The keynote of the treatment in all cases is rest. As fatigue due to over-functioning is the most important element in the development of true neurasthenia, it is a necessary corrolary that prevention of the overexpenditure of nervous energy demands first consideration as a therapeutic measure. The first thing that the physician should do is to look into the exact manner of life led by the patient, man or woman. This can often be so readjusted as to bring about a less wearing existence.

A word might be said here about underrest, which is not quite the same as overwork. Even with time and opportunity at their disposal, many business and professional men, and in fact many in all walks of life, do not know how to rest even when they have time and opportunity. They worry and drive themselves even in their efforts at diversion and recreation; in all things they unnecessarily waste energy. They should be taught to do their tasks and duties with less mental and physical output; to sit when they would ordinarily stand, to talk quietly instead of with undue excitement, to substitute complacency for anxiety, and to work steadily without con

sidering too much the time of completion of the task before them.

The mode of rest treatment pursued without taking patients from their homes is usually spoken of as the partial rest treatment. The method of carrying it out necessarily varies somewhat with the conditions in which the patient is placed. Some matters are of first importance. The hours of sleep should be largely increased. Many men and women who are in the habit of being in their beds only eight hours, or even less, can readily increase the time to twelve or fifteen hours without really interfering with their work. Fourteen to sixteen hours of recumbency out of the twenty-four should be taken whenever it is possible to accomplish this result. eight or nine in the evening, and by taking is best brought about by going to bed at one or two hours during the day, preferably late in the morning or early in the afternoon.

It

All disturbing influences should be eliminated during the periods of day and of night rest. The woman should know nothing of household cares or of her children; nor should the man be troubled with anything either within or outside of his immediate household.

Some

With regard to the use of food, electricity, bathing, diversions and medicine, the remarks which will be made later when discussing the full rest treatment are almost equally applicable in discussing the partial rest treatment either at home or elswehere. modifications of the suggestions given when considering the full rest treatment as regards the administration of food and the use of exercise, diversions, etc., of course, will be necessary, but these are chiefly such as would be so apparent as to need no detailed consideration. It might be well, however, to say something with regard to massage used at the homes of patients. For business men and for women who are much engaged with domestic and other duties during the day, a good plan is tc have the supper between six and seven, to spend the time between this meal and 8:30 or 9 o'clock in quiet conversation, reading or amusement, then to have general massage for forty-five minutes to an hour. This treatment may prove not only restful to the patient, but may add in the bringing on of sleep when insomnia is pres

ent.

Careful arrangement should be made so that the patient will not be disturbed at the conclusion of the treatment. General faradization may sometimes be alternated with massage to the advantage of the patient, although on the whole it will prove less useful in the home treatment than massage and Swedish movements.

Milk and eggs should form the stand by in bringing food to the maximum in the home. as well as in the full rest treatment of neurasthenia.

Walking, horseback riding, golf and tennis playing are among the most useful outdoor exercises and diversions for neurasthenics, but when used the greatest care should be taken not to bring on undue fatigue. All modes of exercise should be used sparingly at first.

Automobiling is, in my experience, a nerve exhausting method of taking exercise and diversion. The reason for this is that those who resort to this method of transportation and exercise usually show little judgment in regard to speed and keep themselves over exhilarated and in a state of nervous tension.

Let us next take up the subject of the complete rest treatment, a method of great value for a large percentage of cases of neurasthenia. I might be permitted to say here a few words about its indiscriminate use. The mistake is not infrequently made of putting patients upon this treatment without due consideration, and as a consequence it falls into unmerited disrepute. Many cases of melancholia, for instance, are not well adapted to this therapeutic measure; in other instances of this disease one or two weeks of the treatment is sufficient, other measures being introduced rapidly, including moderate exercise out of doors. A purely hysterical case is not always helped by the rest treatment. Symptomatic neurasthenia often does well under this treatment, which, as a rule however, must be modified somewhat according to the nature and peculiarities of the case.

The main features of the complete rest treatment are: (1) isolation, (2) rest in bed, (3) regulated diet, (4) massage and Swedish movements, (5) faradic electricity, (6) systematized respiratory exercises, (7) bathing, (8) diversion and recreation, (9) medicines. Without isolation this treatment will frequently be complete failure. Again and again, because of the difficulties surrounding the removal of a patient from home, I have tried the experiment of isolating a patient in some portion of his or her own house; usually it is a flat failure. A woman who remains anywhere in a house in which she is accustomed to direct or attend to the wants or needs of others can never thoroughly relax mentally and physically for periods of days or weeks. She may promise to give up servants, visitors, friends, children and husband during the allotted period of treatment, but in spite of herself, in nine cases out of ten, will not be able to carry out her promise. It is far better to

attempt the partial rest treatment with an hour or two in bed during the day and ten or twelve from evening until morning, allowing the patient to be up and doing during the rest of the day, than to attempt the complete rest cure by what is supposed to be isolation in some part of the patient's own house. It is better, on the other hand, to have the treatment elsewhere than at home, even in those cases in which good judgment seems to dictate that the patient should be allowed occasionally to see some member of her family.

It may seem unnecessary to say that the rest should be in bed, but it happens sometimes that patients, as well as others, believe that rest in bed is necessary for only portion of the day, the recumbent position on a couch or sitting taking its place in part. For the first weeks of the treatment, at least, the rest should be in bed and as absolute as possible. Whether the patient is allowed to feed herself can only be decided by the peculiarities of the cases; in most instances she can, and the taking of food should be done in the half sitting position in bed, using a table. table. After several weeks, or a week or two, if the treatment is of short duration, the patient can be placed upon a couch for a portion of the day, and still later upon a couch and in a chair. This change should not be made until after a certain definite time is allotted for walking in the room. Even the position in bed is at times somewhat important; usually the head should not be too high and the patient should be encouraged to lie in different positions, that is, on the back or on either side and always with as complete muscular relaxation as possible.

One of the chief objects of the treatment is to rapidly or slowly improve the general nutrition of the patient by the skillful use of diet; I follow no fixed rule. Sometimes I begin with a complete milk diet, increasing in frequency and in amount, slowly or rapidly acccording to what seems to be the requirements of the individual case; cases, however, which do well on milk alone for more than a few days are not in my experience numerous. In some cases the diet may still be kept one largely of milk, adding only a few articles as raw or slightly boiled eggs, albumin water, Horlick's malted milk or some one of the forms of beef extract. In the majority of cases of neurasthenia the diet can soon be made mixed. In all cases, however, certain articles should be eschewed and others should be given particular favor. Much depends upon the manner in which food is prepared; broiled and roast meats are to be preferred. Oysters should be given raw, broiled or dry panned. Green veget

ables such as lettuce, spinach and celery can be used with considerable freedom. It is not necessary to exclude potatoes altogether as is sometimes advised, but they should be used sparingly either roasted or mashed. Peas and rice thoroughly well cooked, may be used and fruits not too freely. The lighter forms of dessert like tapioca, corn starch, spanish cream, cream puffs and ice cream may be introduced after a time. The main object in the use of food is its increase to the point of full, or what would ordinarily be, over-feeding without disturbance of the digestion of the patient. I find raw eggs a valuable addition to the ordinary diet list. They may be taken in numbers varying from four to twelve a day according to the circumstances and to the amount of other food taken. Beef extract gives a variety to the diet, but does not add much to its real value.

Massage and Swedish movements cannot be dispensed with in the rest treatment. I can only give a few suggestions. As a rule, the massage can be given by the nurse who has charge of the patient; it is not always best that this should be done. The introduction of a masseuse from the outside may be either a useful measure or a disturbing element. Which it will be depends upon the patient sometimes, but more frequently on the masseuse. Massage at first should be given for a comparatively short time, thirty or thirty-five minutes, but later can be increased to forty, fifty or sixty minutes.

Electricity used only in the form of general faradization with a slowly interrupted current is less useful than massage, but often should be employed. Here again the method of its use is important. In not a few cases, the nurse who attempts to give faradic electricity to a patient is unskillful or irritating in her method of doing this. On the whole, I prefer the method of direct muscular faradization supplemented with gliding or labile currents applied to the entire limb or part. The nurse holding two moistened electrodes in one hand, passes from cne muscle to another; then placing one electrode to the spine or in the neighborhood of the nerve plexus, the electrode is passed from point to point down the limb.

Generally I begin the use of systematized respiratory exercises early; sometimes after the second or third week and while the patient is still in bed. These are, in the first place, movements of the upper and lower limbs and of the trunk accompanied by deep breathing. Later when the time comes for the patient to be taken out of bed for a period of half an hour, five minutes of this time can be given up to systematized exercises. One mode of exercise which has proved useful in

my hands as a supplementary treatment to rest, massage and other measures, is slow respiratory exercises, either indoors or out of doors. For the indoor exercises I have for years made use of those given in a little book by Blaikie, entitled "Sound Bodies for Boys and Girls." It was intended originally for a school book, but the prescribed lessons correspond so well to what is required that they afford an easy method of ordering exercises. The physician or nurse can vary the exercises as seems best suited to the needs of the patient.

While bathing is useful in the home treatment of neurasthenia, it can be employed to greater advantage in the complete rest cure where time and attendants are at full command. A daily sponge bath, with or without the addition of alcohol, is perhaps the best all around hydriatic measure. Most neurasthenics will not stand cold sponge bathing, at least not at first, and those who, ill-advised or of their own initiation, resort suddenly to cold sponge bathing, or spraying or immersion in the hope of hardening and strengthening their nervous systems, may find that they have made a serious mistake. The cool or cold sponge, the spray, the douche and the immersion bath may prove beneficial to the neurasthenic, but usually a patient must be educated to them. With regard to the time of day when baths are taken, it is with sufferers of neurasthenia as it is with those in health, that the best time for one patient may not be that for another. Warm baths are usually best taken in the evening, tepid or cold baths in the morning, but there are many exceptions to these rules as to time.

In the daily schedule of a patient under the rest treatment diversion in the form of reading, conversation, games and light work like knitting are usually of use early or late in the course of treatment. Considerable judgment may be necessary in the selection of suitable books and suitable games, but no rules can be laid down to govern this matter. The judgment and good taste of both physician and nurse, combined with the experience soon gained with the patient, will serve "to guide in this part of the treatment.

A few words might be said in conclusion, about seasonal vacations, resorts, climate and travel. These remarks are of course, applicable to patients convalescing under the influence of rest treatment or to others in whose cases it seems advisable to resort to change of climate and location rather than to indoor measures. Business and professional men and women whose manner of living calls for undue expenditure of nervous force, should have at least two periods of vacation during the year. One of these should be taken pre

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