TililllllllUiiliir 
 
 HE Blues 
 
 (Nerve ExHAU3Tiai!if) 
 
 Causes afTa Ctire 
 
CORNELL 
 
 UNIVERSITY 
 
 LIBRARY 
 
RC 415 A^|™«""'""™«y Library 
 
 ^''^'•'"es (splanchnic neurasthenia); caus 
 
 3 1924 012 460 642 
 
Cornell University 
 Library 
 
 The original of tiiis book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924012460642 
 
Works by Albert Abrams, A.M.,M.D. 
 
 SPONDYLOTHE,RAPY 
 
 SPINAL-CONCDSSION AND THE APPLICA- 
 TION OF OTHER Methods to the Spinal- 
 Region in THE Treatment of Disease. 
 The subject of spinal therapeutics has re- 
 ceived less attention from the medical 
 profession than it deserves. The author 
 has endeavored to put it in a place befit- 
 ting its scientific importance, and to em- 
 phasize its great practical helpfulness in 
 the treatment of disease. Octavo, 418 
 pages, Illustrated . . . - . $3.50 
 
 THE, BLUES 
 
 (Nerve Exhaustion) Causes and Cure. 
 This volume directs attention to a new and 
 heretofore undescribed variety of nerve 
 exhaustion, whieh the author designates 
 Splanchnic Neurasthenia. From his vast 
 experience there is no variety of neuras- 
 thenia more amenable to treatment. 4th 
 Edition, 8vo, 296 pages. Illustrated • $1.50 
 
 AUTOINTOXICATION 
 
 An Exposition of the Causes, Symp- 
 toms and Treatment of Self-Poison- 
 ing. The human body as a receptacle and 
 laboratory of poisons is constantly exposed • 
 to the danger of being overpowered by the 
 alluring germs of auto-infedion. Its fun- 
 damental principles and relation to psy- 
 cho-therapy are here presented. Octavo, 
 268 pages, Illustrated • - . - $1.50 
 
 TramactioBS of THE ANTIS£,PTIC CLUB 
 
 Specially Reported Pen and Ink Sketches, 
 illustrating tiie fads and foibles of modern 
 M.D.'s. The funniest book yet. 206 pages. 
 Illustrated, De I/Uxe edition, |2.00; cloth, $1.00 
 
 E. B. TREAT & CO., Medical Pablahers 
 241-243 West 23d Street • • New York Citjr 
 
CEREBRAL AfJAmiA. 
 
 VCftTIOO. 
 rAINTNCSS, 
 
 ME pair Of. 
 
 ARTS. 
 
 Fig. 31. — Demonstrates the circulation of the blood and the effects of splanchnic 
 conjrestion on the abdominal organs. (Modified from Butler. ) 
 
THE BLUES 
 
 (SPLANCHNIC NEURASTHENIA) 
 
 CAUSES AND CURE 
 
 BY 
 
 ALBERT ABRAMS, A.M., M.D. (Heidelberg), F.R.M.S. 
 
 CONSULTING PHYSICIAN, DENVER NATIONAL HOSPITAL FOR CONSUMP- 
 TIVES, THE MOUNT ZION AND THE FRENCH HOSPITALS, SAN FRAN- 
 CISCO ; PRESIDENT OF THE EMANIJEL SISTERHOOD POLYCLINIC ; 
 FORMERLY PROFESSOR OF PATHOLOGY AND DIRECTOR OF 
 THE MEDICAL CLINIC, COOPER MEDICAL COLLEGE, 
 SAN FRANCISCO 
 
 ILLUSTRATED 
 
 FOURTH EDITION 
 
 BEVISED AND ENLARGED 
 
 NEW YORK 
 
 E, B. TREAT AND COMPANY 
 
 241-243 West 23D Street 
 
 19H 
 
CoPYHiaHT, 
 
 BY 
 
 E. B. TREAT AND COMPANY 
 
 1904—19^5—1908—1911 
 
PREFACE TO THE FOURTH EDITION. 
 
 The addition to this edition is embraced by Note 20, 
 in the appendix. Concussion of definite spinous proc- 
 esses is one of the most potential methods for eliciting 
 certain vertebral reflexes which the author has more 
 fully elaborated in his recent work on Spondylo- 
 THEKAPY. It is neither presumption nor exaggeration 
 which prompts the author's asseveration that, the re- 
 flexes in question may be evoked with the same cer- 
 tainty and precision as are the reflexes by the vivisec- 
 tionist in his laboratory. A just appreciation of the 
 latter fact by the clinician, will prove of great value to 
 him in the treatment of disease, notably splanchnic 
 neurasthenia. 
 
 Albeet Abeams. 
 
 246 Powell Street, 
 
 San Francisco, Cal., December, 1910. 
 
PREFACE TO THE THIRD EDITION. 
 
 The additions to this edition are embraced by note 19, 
 in the appendix and the chapter on intestinal auto-intoxi- 
 cation. 
 
 The latter subject is more exhaustively discussed in my 
 recent books " Man and his Poisons " and " Diagnostic- 
 Therapeutics." Intestinal auto-intoxication as we now 
 comprehend it, may be succinctly summarized as follows : 
 During digestion, a number of poisons or enterotoxins are 
 manufactured as a result of putrefaction of albuminoid 
 food in the intestines. These enterotoxins attain the 
 liver by way of the enterohepatic circulation where they 
 are made innocuous. From the liver they pass into the 
 general circulation and are excreted in the urine. If 
 albuminoid putrefaction is excessive, or, if the liver and 
 kidneys prove inadequate in either neutralizing or ex- 
 creting the poisons, intoxication of the organism ensues. 
 Intoxication is expressed by a motley group of ill-deflned 
 nervous symptoms which parade under the equivocal 
 designation, neurasthenia. Now, this conception of in- 
 testinal auto-intoxication is only partially correct. While 
 the usual enterotoxins are bacterial products, there are 
 also poisonous albumoses, i. e., intermediate products 
 manufactured in the digestion of albuminous food-stuffs. 
 It is well known, that when peptones and albumoses 
 (normal products of digestion) are injected directly into 
 
PREFACE TO THE THIRD EDITION. 
 
 the blood they are very poisonous, and even fatal, in their 
 effects. Falloise * has recently had an excellent opportu- 
 nity of studying this subject in a patient with a fistula 
 communicating with the small intestine. He concludes 
 that albuminoid-putrefaction is not the only process con- 
 cerned in auto- intoxication and that an aqueous extract of 
 the contents of the small intestine is infinitely more toxic 
 than an extract made from the contents of the large in- 
 testine. Hence, if we accept the prevailing opinion, that 
 putrefaction of the albuminous molecule is limited in' the 
 norm to the large intestine, factors, other than putrefac- 
 tion of the albuminous molecule must be concerned in in- 
 testinal auto-intoxication. One must not forget that there 
 is such a condition as " indigestion-toxemia " due either 
 to an excessive production of poisons or from enfeeble- 
 ment of the defenses. Thus there is an hepatic as well 
 as a gastric and intestinal dyspepsia and the liver dare 
 not be ignored even in the treatment of so plebeian an 
 affection as dyspepsia. 
 
 In note 14, reference is made to massage of the liver. 
 Sensitiveness of the liver is regarded by the author as 
 the most trustworthy evidence of auto-intoxication and 
 correct massage of the organ is a valuable aid in aug- 
 menting the efficiency of the liver as an organ of defense. 
 The most frequent point of tenderness is in the median 
 line midway between the end of the sternum and the 
 navel, and is demonstrable, by deep pressure at the end 
 of forced inspiration during the time the body of the 
 patient is inclined forward. 
 
 Massage of the liver must be primarily executed by the 
 physician, for unless it is done thoroughly no effects can 
 be achieved. The results are almost immediate ; the 
 
 * Archil). Internat. de Phyaiol. Vol. V. fasc. 2, p. 159, 1907. 
 
PREFACE TO THE THIRD EDITION. 
 
 liver sensitiveness rapidly disappears and with its disap- 
 pearance there is a corresponding improvement in the 
 condition of well-being. 
 
 Contrary to current opinion, I have found that in those 
 suffering from self-poisoning, diarrhea, or at any rate, 
 looseness of the bowels, prevails rather than constipation. 
 
 Thus it is that after effectual massage of the liver, 
 amelioration of the symptoms of auto-intoxication and 
 splanchnic neurasthenia preceed pari passu with a stool 
 of firmer consistency without necessarily interfering with 
 the regularity of the fecal evacuation. 
 
 Very frequently massage of the liver alone without 
 abdominal massage sufflces in splanchnic neurasthenia 
 and auto-intoxication, but in other instances, both must 
 be judiciously combined. The author must again em- 
 phasize the importance of correctly and thoroughly ex- 
 ecuting massage of the liver, for otherwise no results can 
 be expected from treatment and discredit will be unjustly 
 cast on the author's conception of splanchnic neurasthenia. 
 The author has found that massage of the liver properly 
 executed Avill show the presence in the urine of indican 
 although previously absent and if present before, it is in- 
 creased after massage. 
 
 Porter advocates the following simple test for indican 
 which the author likewise finds trustworthy : 
 
 Add in a test-tube equal quantities of urine and chem- 
 ically pure hydrochloric acid. To this mixture add 3 
 drops of a \per cent, solution of potassium permanganate. 
 If indican is present in the urine there will be formed a 
 purplish cloud in the fluid in the test tube. Then add a 
 few drops of chloroform, then one drop more of the 
 potash solution and a few drops more of chloroform and 
 shake vigorously. The deep blue color resulting is due 
 
PREFACE TO THE THIRD EDITION. 
 
 to precipitation of indican by chloroform and the amount 
 and intensity of the precipitated indican determine the 
 extent of the putrefactive changes going oh in the 
 alimentary tracts. 
 
 The subject of intestinal auto-intoxication, is intimately 
 associated with splanchnic neurasthenia, more often, how^ 
 ever, as an eifect, rather than as a cause. Auto-intoxica- 
 tion does exist as an independent affection and I venture 
 to say, that the latter condition is frequently maintained 
 by an insuflficient splanchnic vasomotor mechanism. It 
 is the disregard of the latter factor which nullifies our 
 therapeutic efforts which are often conceded to be im- 
 puissant in intestinal auto-intoxication. Disease typifies 
 a reaction the resultant of two factors ; a cause (the 
 irritant) and the effect (the tissue changes). Some 
 one has observed, that the ultimate trend of the phy- 
 sician was to prove that even food was poisonous, and 
 what has been suggested as a facetious prognostica- 
 tion, appears to have been endowed with reality, 
 when one seriously contemplates the endeavors of die- 
 etic revolutionists. Our dietetic sins can never be 
 solved by faddists. Many dietetic vagaries are as con- 
 sistent as the perfervid plea of the poet Shelley, who 
 wanted us to become vegetarians and marry our sisters. 
 The great danger with food lies in its excessive consump- 
 tion and the evils frequently attributed to food may be 
 minimized by habituation to changes in quantity rather 
 than in quality. 
 
 Dr. Abernethy made the discerning observation, " There 
 is no beast of burden in the world so overloaded as the 
 human stomach." 
 
 With patients who are opposed to dietetic moderation 
 one is constrained to employ methods which aim to 
 
PREFACE TO THE THIRD EDITION. 
 
 combat alimentary insufficiency and to immunize the 
 tissues against interminable dietetic insults. 
 
 The latter object is best achieved by improving the 
 splanchnic circulation. 
 
 The author acknowledges with gratitude the cordial 
 reception accorded to previous additions of his little book 
 by the members of his profession and hopes, that the 
 same success may continue to be achieved in cases of neu- 
 rasthenia which have proved resistant to the conven- 
 tional methods of treatment. 
 
 Albekt Abrams. 
 
 San Francisco, Cal., Feb. 1, 1908. 
 
PREFACE TO THE SECOND EDITION. 
 
 The author, when he first introduced the affection, 
 Splanchnic Neurasthenia, felt that he was treading pn 
 unknown territory and was apprehensive lest the pro- 
 fession would regard his theory as another innovation 
 which would soon be relegated to oblivion. To launch a 
 new theory in medicine, with its surfeit of theories and 
 theorists, is fraught with much risk to the offender,- who 
 must be prepared to await the fate accorded to nearly all 
 innovations, viz. : condemnation, discussion and, possibly 
 acceptance. My inauspicious prognostications, happily, 
 were not fulfilled, and this finds expression in the early 
 demand for a second edition. The author finds source 
 for congratulation when so eminent an authority as Dr. 
 J. H. Kellogg, in an address before the « International 
 Electrical Congress" at St. Louis, stated that in his 
 opinion the majority of neurasthenics suffered from con- 
 gestion of the portal system and that the sinusoidal cur- 
 rent to the abdomen is alone sufBcient to produce great 
 relief in a large class of neurasthenics. The author in 
 his most recent work, "Man and His Poisons," published 
 contemporaneously with this edition, seeks to elaborate 
 the subject of self-poisoning, which is so closely identified 
 with Splanchnic Neurasthenia. Notes 14 to 18 inclusive 
 with illustrations have been added to the appendix in this 
 edition. 
 
 Albert Abkams. 
 
PREFACE. 
 
 The object of this volume is to direct reference to a 
 new and heretofore undescribed variety of nerve exhaus- 
 tion, which I have designated as, Splanchnic Neuras- 
 thenia. This special form of nerve weakness is charac- 
 terized by paroxysms of depression of varying duration, 
 and which are specified popularly as " the blues." The 
 recognition of this special form of neurasthenia is of 
 more than theoretic interest. One cannot say of it as 
 did the mathematician, who, having demonstrated a new 
 mathematical theory, thanked God that it could not be 
 of the slightest utility to any living soul. A mere theory 
 may be of interest to members of our profession, but the 
 layman asks science for results. The recognition of 
 splanchnic neurasthenia and the factors involved in its 
 causation, imply our ability to cope with the evil and 
 offer to the sufferers not only amelioration, but cure in 
 many instances. My experience with neurasthenics has 
 extended over a period of many years, and I know of 
 no variety of neurasthenia which is more amenable to 
 treatment than the splanchnic form. Various writers 
 have hinted at an abdominal form of neurasthenia, but to 
 myknowledgetheyhave ignored the truesourceof origin. 
 A perusal of the subject matter of this Volume will 
 ^ow that I have referred the origin of splanchnic neu- 
 
PREFACE. 
 
 rasthenia, in brief, to a congestion of the intra-abdom- 
 inal veins. Man is distinguished from all other mam- 
 mals by his erect posture. " If an intelligent extra- 
 mundane " says Campbell, " were to see man for the 
 first time in the horizontal posture, it would never occvir 
 to him that it is natural for him to be erect. There is 
 something incongruous in an animal built on the longi- 
 tudinal plan standing and progressing upon one end of 
 its long axis." The erect posture of man places him at 
 a disadvantage in several directions, notably, however, 
 by increasing the height of the blood column with a cor- 
 responding increase of gravity on the circulation, thus 
 causing the blood to gravitate into the intra-abdominal 
 veins. Among the many resources of l^ature to combat 
 this tendency, the vigor of the abdominal muscles is par- 
 amount. The tonicity of the muscles in question is im- 
 paired by mal-hygienic clothing, occupation, disease, lack 
 of exercise and a host of other conditions. Even a phy- 
 siologic condition like pregnancy conduces to relaxation 
 of the abdominal wall and pendulous bejly, the so-called 
 hAnge-Tjauch of the Germans, and yet no one dreams of 
 restoring the defective musculature after pregnancy by 
 well directed exercises. The sports of the ancient 
 Greeks were specially directed toward development of 
 the abdominal muscles. In the sculptural works of the 
 old masters, the abdominal muscles are reproduced with 
 as much accuracy as the other muscles of the body, and 
 it is reasonable to assume, contrasting the art of the 
 ancients with that of the modern sculptors, that the de- 
 cadence of the abdominal muscles is a modern heritage ; 
 and so are hemorrhoids, constipation, hernia, and a mul- 
 titude of other evils that may be traced to enfeebled 
 abdominal muscles. It is surprising how little can be 
 
fRfiFACE. 
 
 achieved by feeble abdominal muscles, and how much 
 when the latter are developed by exercises. Individuals 
 who would flinch when the slightest abdominal pressure 
 was made, could after a few months' use of the abdom- 
 inal exerciser, throw heavy individuals seated on their 
 abdomens, up and down, as serenely as though they were 
 rubber balls. This exerciser permits essentially of trac- 
 tions being made by the abdomen, although the exercises 
 may be made in different directions. The abdominal 
 exerciser is likewise available in developing other mus- 
 cles of the body. In this connection, the experiments of 
 Prof. W. G. Anderson, of Yale University, may be re- 
 called with profit. The latter succeeded in practically 
 weighing the result of a thought's action. A student was 
 placed on a " muscle-bed," poised on a balance so that 
 the center of gravity of his body was exactly over its 
 center. When the student was directed to solve mathe- 
 matical problems, the increased weight of blood at his 
 head changed his center of gravitation and caused an 
 immediate dip of the balance to that side. The student 
 was further directed to imagine himself going through 
 leg gymnastics. As the feats were mentally performed, 
 one by one, the blood flamed to the limbs in sufficient 
 quantities to tip the balance, according to the movement 
 thought of. His experiments warrant the conclusion, 
 that the important thing in all exercises is the mental 
 effort put forth : thus, walking is inadequate exercise for 
 brain workers, as it is so purely automatic that it does 
 not call the blood from congested brain centers, which 
 continue solving intellectual problems. A run, a brisk 
 walk, with a definite object necessitating the thought of 
 speed, will send the blood to the legs and build them up. 
 There are a large number of gastric and intestinal affec- 
 
PREFACE. 
 
 tions with bizarre and protean symptoms, designated re- 
 spectively as gastric and intestinal neuroses, but which 
 in reality owe their genesis to a congestion of the intra- 
 abdominal veins. Such affections are essentially forms 
 of splanchnic neurasthenia and are specially amenable 
 to the treatment suggested in this book. The affections 
 in question often produce only local symptoms confined 
 to the abdominal sympathetic, and may never extend be- 
 yond the abdominal region to implicate the central nerv- 
 ous system. The treatment I have advocated for the 
 cure of splanchnic neurasthenia is based on purely phy- 
 siological reasoning. My exposition of the subject of 
 general neurasthenia I have purposely treated cursorily, 
 as it was my intention to employ it as a medium only in 
 introducing my special subject — splanchnic neuras- 
 thenia. 
 
 Albebt Abkams. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 THE BLUES. 
 
 PAoa 
 
 The blues and its allied condition neurasthenia. — ^Heredity 
 as a factor in the nervous constitution, — Personal effort as an 
 element in resisting and overcoming an unstable nervous 
 system 13 
 
 CHAPTER H. 
 
 GENERAL IRRITANTS OP NEURASTHENIA. 
 
 Hovsr irritants operate. — Overwork, worry, the abuse of al- 
 cohol, bodily diseases, etc., as causes of neurasthenia. — ^The 
 pathology of neurasthenia. — Brain changes in neurasthenia. 
 —Fatigue neurasthenia 23 
 
 CHAPTER m. 
 
 SPECIAL IRRITANTS OF NEURASTHENIA. 
 
 The primary factor in neurasthenia. — Sexual neurasthenia. 
 Uric acid neurasthenia. — Auto-toxemio neurasthenia. — Ab- 
 dominal neurasthenia. — Dyspepsia and neurasthenia. — 
 Splanchnic neurasthenia 89 
 
 CHAPTER rV. 
 
 THE GENERAL AND SPECIAL SYMPTOMS OP NEURASTHENIA. 
 
 Motor disorders. — Sensory disturbances. — Eye signs. — Ear 
 signs. — Brain signs. — Heart signs and the pulse. — Pulmo- 
 nary anemia. — Stomach and intestinal signs. — Sexual signs. 
 Forms of neurasthenia. — Diagnosis and prognosis of neu- 
 rasthenia 35 
 
CONTENTS. 
 CHAPTER V. 
 
 THE GENERAL TREATMENT OF NEURASTHENIA. 
 
 PASS 
 
 Objects of treatment. — Elimination of factors conducive to 
 tlie disease. — Treatment of the disease. — Climate. — Treat- 
 ment of the symptoms : insomnia, heart, stomach, intes- 
 tinal and sexual symptoms. — Hypnotism as a mode of cure. 81 
 
 CHAPTER VI. 
 
 SPLANCHNIC NEURASTHENIA.— THE BLUES. 
 
 Why the term, " the blues," has been employed to specify 
 this particular form of neurasthenia. — Data bearing on 
 splanchnic neurasthenia. — Intra-abdominal pressure, pul- 
 monary suction, vasomotor factor. — The abdominal sym- 
 pathetic. — Factors contributing to splanchnic neuras- 
 thenia Ill 
 
 CHAPTER VII. 
 
 THE SYMPTOMS OF SPLANCHNIC NEURASTHENIA. 
 
 History of a splanchnic neui-asthenic. — Analysis of the most 
 prominent symptoms. — Relaxed abdominal walls, protru- 
 sion of the abdomen. — Gas accumulation in the bowels. — 
 Increased abdominal tenderness. — Enlargement of the 
 liver. — InsufBcient lung development , 123 
 
 CHAPTER VIII. 
 
 THE TREATMENT OF SPLANCHNIC NEURASTHENIA. 
 
 The fundamental pi-inoiples governing treatment. — The 
 physical methods of treatment : abdominal massage, ab- 
 dominal exercises, respiratory exercises, electricity, ab- 
 dominal supporters and hydrotherapy. — Citation of cases 
 of splanchnic neurasthenia. — Action of purgatives in 
 splanchnic neurasthenia 137 
 
 CHAPTER IX. 
 
 INTESTINAL AUTO-INTOXICATION. 
 
 Factors determining auto-intoxication. — Symptoms. — Diagno- 
 sis. — Treatment. — Hepatic insufficiency 161 
 
APPENDIX. 
 
 PAOB 
 
 1. PuLMONART Anemia AND Insuppicient Development.... 189 
 3. The Cakdio-SplanChnic Phenomenon 300 
 
 3. Blood Prkssuke 315 
 
 4. The Stomach and Colon in Relation to the Heart. 318 
 
 5. Physical Examination op the Liver 230 
 
 6. The Liver Replex 381 
 
 7. Condition op the Lungs Antedating Pulmonary Tu- 
 
 berculosis and Breathing Exercises for Develop- 
 ing such Lungs 333 
 
 8. The Heart Replex 337 
 
 9. The Lung Replex op Dilatation 344 
 
 10. The Lung Reflex op Contraction 347 
 
 11. Sympathetic Pains 351 
 
 13. Heredity 353 
 
 13. The Sinusoidal Current 356 
 
 14. Massage of the Liver 259 
 
 15. Human Metabolism 364 
 
 16. Chemical Demonstration op the Action op the Sin- 
 
 usoidal Current 366 
 
 17. Testing Intra-Abdominal Tension 367 
 
 18. Percussion of the Stomach 369 
 
 19. The Vasomotor Test in Splanchnic Neurasthenia.. 273 
 
 20. Augmenting the Tone of the Splanchnic Circulation 276 
 
LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Fig. 1. Points of election on the abdominal surface for ex- 
 ecuting Auto-Massage, 136 
 
 Fig. 2. Method for executing auto-massage 140 
 
 Fig. 3. Apparatus for abdominal exercises 146 
 
 Fig. 4. Method of using the apparatus for abdominal exer- 
 cises 146 
 
 Fig. 5. Showing pleural spaces 190 
 
 Fig. 6. Pleural spaces on the lateral surface of the left lung. 190 
 
 Fig. 7. Patches on the front surface of chest 191 
 
 Fig. 8. Patches on the posterior surface of chest 191 
 
 Fig. 9. A, Clavicle. 1. Area of apex in normal breathing. 
 3. Apical area in deep breathing. 3. Apical area 
 after elicitation of lung reflex. B. Clavicle. Apical 
 
 area after strapping lower chest 194 
 
 Fig. 10. Extreme area of apical resonance on anterior surface 
 
 of the chest 196 
 
 Fig. 11. Extreme area of apical resonance on the posterior sur- 
 face of the chest ; 196 
 
 Pig. 12. Illustrating the cardio-splanchnic phenomenon 303 
 
 Fig. 13. 1. Radioscopic appearance of the heart before in- 
 sufflating the stomach. 3. Outline of the fundus 
 of the stomach 318 
 
LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Pig. 14. 1. Radioscopic appearance of the heart after insuf- 
 flating the stomach. 3. Outline of the fundus of 
 
 the stomach 219 
 
 Fig. 15. Patch of dulness in dislocation of the heart upward ; 
 
 patient in the erect position 330 
 
 Fig. 16. The Author's method of palpating the liver 220 
 
 Fig. 17. Same case, patient leaning backward 331 
 
 Fig. 18. Fluoroscopic picture in dislocation of the heart 333 
 
 Fig. 19. Method of percussing the lower liver border 225 
 
 Fig. 20. Arrangement of bottles for expiratory exercises 236 
 
 Pig. 31. Heart reflex in a boy aged eight years 238 
 
 Pig. 32. Heart reflex in a boy aged fourteen years 339 
 
 Fig. 23. Illustration of heart reflex in cardiac dilatation 343 
 
 Fig. 24. Sphygmogram showing condition of pulse before in- 
 haling ammonia 244 
 
 Pig. 35. Showing effects of ammonia during inhalation 245 
 
 Pig. 36. Mallet and pleximeter for eliciting the lung reflex of 
 
 contraction 248 
 
 Pig. 27. The lung I'eflexes of dilatation and contraction 249 
 
 Pig. 28. Respiratory Massage 261 
 
 Pig. 29. Concussional Massage 362 
 
 Pig. 30. Gauging the motor power of the stomach 371 
 
 Fig. 31. Demonstrates the circulation of the blood and the 
 efl'eets of splanchnic congestion on the abdominal 
 
 organs Frontispiece 
 
 Fig. 32. Patches of dullness in the norm when the erect 
 
 is substituted for the recumbent posture 276 
 
 Fig. 33. Diffused area of dullness in insufficiency of the 
 
 splanchnic vasomotor mechanism 277 
 
 Fig. 34. Vertebral dorsal spines 280 
 
 Fig. 35. The Polysine Generator 281 
 
THE BLUES. 
 
 CHAPTEE I. 
 
 THE BLUES. 
 
 THE BLUES, AND ITS ALLIED CONDITION NEURASTHENIA.— 
 HEREDITY AS A FACTOR IN THE NERVOUS CONSTITUTION.— 
 PERSONAL EFFORT AS AN ELEMENT IN RESISTING AND OVER- 
 COMING AN UNSTABLE NERVOUS SYSTEM. 
 
 RusKiN, in his "Thoughts of Beauty," is sponsor 
 for the epigram, " God has employed polor in His 
 creation as the unvarying accompaniment of all that is 
 purest, most innocent and most precious." Euskin, 
 evidently never had a " fit " of the blues. "Why blue 
 has been the color parodied to illustrate despondency 
 is beyond my ken, for blue has been apostrophized by 
 the painter, poet and litterateur as something expres- 
 sive of heaven, the firmament, truth, constancy, and 
 fidelity. The medical lexicographer pays no tribute 
 to the blues, notwithstanding the fact, that it is se- 
 curely incorporated in the vocabulary of every-day 
 life. I am with aforethought constrained to employ 
 the term ' ' blues " as it appeals with cogent signifi- 
 cance to the sufferer, and for the additional reason that 
 medical art has not truly interpreted its real pathology 
 nor substituted for it, in its nosology, a better or more 
 technical name. The individual with the blues is 
 
 13 
 
14 THE BLUES :— NEURASTHENIA. 
 
 never an object of compassion. This luxury is denied 
 him. Those nearest and dearest to him make him the 
 butt of ' their ridicule and ascribe his varied and obscure 
 symptoms to an undue indulgence of the imagination . 
 Driven to despair, he seeks a physician, and the latter 
 may or may not examine him; he may graciously 
 deign to feel his pulse and examine his tongue, and then 
 dismiss him with a prescription for a nerve tonic, and 
 the erudite admonition, "not to become a crank." 
 Physicians are often astute philosophers in sickness, 
 but such philosophy usually concerns the sickness of 
 the other fellow. Sydenham, who loved his profession 
 so well, was wont to observe that, ' ' the medical 
 art could not be learned so well and so surely as by 
 use and experience ; and that he who would pay the 
 nicest and most accurate attention to the symptoms of 
 distempers would succeed best in finding out the true 
 means of cure. ' ' And Plato contended that medicine 
 was an art which considered the constitution of the 
 patient and had principles of action and reason in each 
 case. There is no symptom which has not a cause for 
 its existence, and though the imagmation prove opera - 
 tTv eln exaggerating its significance, this merely proves 
 that it is i n itself not in a state of health. " Ko one." 
 avers TavSnge, " canbeahypochondriac at pleasure^ " 
 TKF~unf ortunate sufferer of the blues is acutely sus- 
 ceptible to any imputation which discredits the honesty 
 of his statements, and, apprehending no relief froin his 
 symptoms, soon falls into the ' ' slough of despond. ' ' 
 Such persons never feel ' ' just right ' ' ; their sleep is 
 disturbed and the morning heralds the periodical de- 
 pression and the unconsoling thought of unfitness for 
 the routine work of the day. Memory becomes de- 
 fective and loss of reason is apprehended. Then follow 
 
THE CAUSE AND CURE. I5 
 
 sexuaJ^_distttrba,Tifics, indigest ion, constipation,_ _vagii£ 
 head sensations, pa1pit.at,ioTi_»fjlTfll-iogvf.^ phobi as and 
 a, train of obscurp and indefinite symptoms which baffle 
 Interpretation and add immeasurably tn tbft sntfering 
 ^of th e. indiyJdBal. The picture of the neurasthenic 
 presents an insane revelry of the organs with the mind 
 in the background, perceiving physiologic as pathologic 
 functions. In the foreground stands the physician, a 
 solemn witness of the scene, and whose face, the 
 theatre of his soul, betrays the thought; how little 
 power his art has given him to interpret objectively 
 what is so acutely cognizant to the unfortunate 
 sufferer. The stomach of the patient may cause him 
 untold agony, yet analyze his stomach contents and 
 you will find that there is no anomaly of digestion ; 
 examine his palpitating heart which, with every thump, 
 increases his anxiety, and you listen to tones modified 
 neither in intensity nor in cadence; and thus you 
 proceed to examine organ after organ and there is 
 nothing revealed; your examination is negative and 
 your negative examination sustains your diagnosis; 
 you may call it what you wiU, neurasthenia or the 
 blues. An attack of the blues is nought else but an 
 acute neurasthenia or an aperiodic exacerbation of 
 chronic neurasthenia. Neurasthenia having been 
 firmly established in medical technology, it will be 
 under this name that the subject will be further dis- 
 cussed. 
 
 Dr. Beard, of New York, is the godfather of 
 neurasthenia, having Hellenized its correlative nerve 
 weakness. A medley of terms have been suggested to 
 spgf^if y thft varied s ymptoms and accompaniments of 
 jfiduced n erve forcST^z : hypochondriasis, nervous- 
 ness, brain strain, nervous waste, nervous prostration. 
 
16 THE BLUES :— NEURASTHENIA. 
 
 nervous exhaustion, nervous breakdown, spinal irrita- 
 tion, etc. , etc. The foregoing terms impose on us the 
 assumption that we are here dealing Avith an essentially 
 nervous disease, but further consideration of the subject 
 may convince us, as we proceed, that in many examples 
 of the affection, and I may add the great majority, the 
 nervous symptoms are merely secondary. The cause 
 may be resident elsewhere in the organism, the nervous 
 system as the point of least resistance, merely reacting 
 to repeated stimuli, like the rock which is pierced by 
 the drop of water ; not by its force, but by its frequency. 
 The preceding view assumes, then, that two essential 
 
 ^ 'factors are necessary in the genesis of neurasthenia.. 
 
 'viz: Anemfp.phlMnAr'nnuftiiyRU.'maTiA. a,n incentivftj the., 
 irritant. 
 
 ^~TEeTale of every neurasthenic may be written in 
 four chapters : 1. The sins of the fathers. 2. The 
 birth of a neurotic. 3. Struggle for existence on de- 
 ficient nerve capital. 4. A bankrupt nervous system. 
 Throughout the narrative, the continuity of human 
 foUy remains unsevered. "Our lives," says Darwin, 
 ' ' are but a bundle of consequences ; our present is but 
 the Outcome of the past. ' ' 
 
 The patient who solicits the counsel of the physician 
 submits himself as a problemn for analysis ; his con- 
 temporaneous symptoms proving only a link in the 
 genetic chain. The physician, like the ontogenist and 
 phylogenist respectively concerns himself not only with 
 the evolution of the individual, bat with his ancestral 
 development. The question of heredity* as a factor in 
 neurasthenia is an important one. Many modern 
 neurologists contend that heredity is responsible for 
 the majority of neurasthenics, and one prominent writer 
 * Appendix, note 13. 
 
THE CAUSE AND CURE. 17 
 
 recently demonstrated that in one hundred consecutive 
 cases of neurasthenia, a neurotic history could be elic- 
 ited in 70 per cent, of the cases. I feel confident in 
 asserting that if one hundred consecutive patients came 
 to me for the relief of so plebeian an ailment as corns, I 
 would likewise find no difficulty in obtaining a history 
 of morbid inheritance in a still larger percentage of 
 cases. We comprehend, by neurotic heredity, a num ber 
 of nervous diseases of direct hereditary character, trans- 
 mitted from generation to generation. The hereditary 
 taint may vary in degree from epilepsy and insanity to 
 the less serious heritage, neurasthenia. The indica- 
 tions of a neurotic heredity, known as stigmata, may 
 be manifested by defects of moral s ense, of memory, 
 attention, will, or iudgment. Tbe stigmata ot t.he 
 de generate mav be physical, psychic or both. All 
 writers who have made a psycho-anthropologio study 
 of degenerates do not attach the same significance to 
 physical stigmata as does Lombroso. The chief physi- 
 cal stigmata are : cranial and facial deviation, recession 
 of the lower jaw, large or small mouth and thick lips, 
 abnormally shaped and misplaced ears, defective and 
 misplaced teeth, and high palate. 
 
 Criminal anthropologists find such deformities very 
 common, although there are criminals who show no 
 peculiarities, a type referred to by Lombroso, as, ' ' the 
 criminal man." Unless the physical stigma has at- 
 tained such a degree of structural anomaly as to impair 
 the normal function of a part, no great importance is 
 attached to it. Some of the psychic stigmata are the^ 
 following: 1. Precocity or retarded evolution of in 
 teUect. 2. Extreme changeableness and irritability 
 3. Exaggerated consciousness and a fanatical religious 
 zeal or great moral depravity. 4, Intense egotism 
 2 
 
18 THE BLUES :— NEURASTHENIA. 
 
 Avith no regard for the feeling of others. 5. Extrava- 
 gant and cranky motives and desires. 6. One-sided 
 talents and disproportionate development of mental 
 faculties. It was Hawthorne, I believe, who said, 
 " Once in every half century, at longest, a family 
 should . . . forget all about its ancestors. ' ' 
 
 The hereditarian contends that ' ' the gods visit the 
 sins of the fathers upon the children' ' : " That we 
 are omnibuses in which all our ancestors ride ; ' ' and, 
 " that the life of each individual is, in some real sense, 
 a continuation of the lives of his ancestors." The 
 pessimistic fatalism expressed in the preceding epi- 
 grams seeks to eliminate the personal equation as a 
 factor in disease, thus limiting the responsibility to 
 heredity. "We must not forget, however, that the 
 autocratic reasoning of the hereditarian is by no means 
 final, nor must we blindly submit to a ruling which 
 would deprive the unfortunate neurotic of all hope. 
 
 A recent writer. Prof. Putnam, ^ attempts to ex- 
 plode the baneful argument of the hereditarian, and 
 assures us that a just regard for the laws of hygiene 
 will help to avert disease. He says that " fortunately 
 for the educational outlook, the evidence has begun to 
 accumulate that a morbid inheritance is not the inev- 
 itably crushing and baneful thing that it has been 
 thought. "We come into the world, each one a being of 
 limited capacity, but, in other respects, free to become 
 what circumstances make us, and responsible, to the ex- 
 tent of our capacity, for our lot. "We bring no ticket- 
 of -leave which stamps us as drunkards or maniacs on 
 probation, but we do bear, in the histories of our an- 
 cestors, a certificate that hints by what efforts and by 
 what avoidances we can make ourselves reasonable 
 successes in our respective lines. There is no original 
 
THE CAUSE AND CURE. 19 
 
 sin, and not even, as it seems to me, original propensity, 
 but only original capacity and original limitation, and 
 even limitation is only another name for latent 
 capacity. ' ' 
 
 Let us select consumption as a paradigm of an her- 
 editary disease, and learn to what degree personal effort 
 is responsible in averting it. The modern physician 
 assumes correctly that there is an inherited predis- 
 position to pulmonary tuberculosis, and that the sus- 
 ceptible individual, unlike the neurasthenic, betrays 
 unmistakable objective stigmata of such predisposi- 
 tion. If the physician, however, were dominated by 
 the pessimistic fatalism of the hereditarian, he could 
 extend no hope to the individual predisposed to con- 
 sumption; but fortunately he has weaned himself 
 from the irrational dogmas associated with this dire 
 disease, and he can confidently say to the individual in 
 question, ' ' Lead a regular and hygienic life and you 
 have nothing to fear from the taint of heredity. ' ' 
 
 To prevent an unstable and mental nervous organi- 
 zation, we must begin with the parents, and exercise 
 always, from birth on, eternal vigilance, which is the 
 only true passport to longevity and freedom from 
 disease. It was Voltaire who said, " If as much care 
 were taken to perpetuate a race of fine men as is done 
 to prevent the mixture of ignoble blood in horses and 
 dogs, the genealogy of every one would be written on 
 his face and displayed in his manners. ' ' Homiculture 
 or the physical culture of man corresponds to the 
 means adopted in improving the breed of the lower 
 animals. 
 
 In these days, when sentiment and not reason 
 dictates mating, it would prove fatuous to enlist the 
 cooperation of the individual, and there is urgent need 
 
20 THE BLUES :— NEURASTHENIA. 
 
 for legislative measures in this direction. Sanitary 
 marriages need not detract from the sentiment which 
 is associated with matrimony ; on the contrary, they 
 would confer on the matrimonial candidates a boon un- 
 attainable by any other means, and the progeny of 
 such marriages would receive health as a heritage, the 
 most sublime gift which parents can bequeath to their 
 children. 
 
 Christian civilization need not emulate nor revive 
 the laws of the Spartans, but from the latter many 
 valuable lessons could be learned. The Spartans 
 idolized what was beautiful and useful and sought by 
 vigorous means to attain them. The sick were not 
 allowed to marry, but the healthy were compelled to 
 enter wedlock. Bachelors were publicly denounced 
 after a certain age and banished from society. Mar- 
 riage was not permitted in either sex until the age of 
 maturity. The result of this Spartan system of mar- 
 riage was to produce for five hundred years the strongest 
 and bravest men and the most beautiful and healthy 
 women that this world has ever known. 
 
 The nervous and mental hygiene of the individual 
 begins at birth and ends only with the extinction of 
 life. It consists in the main of making the mind and 
 body insusceptible to environment by imposing con- 
 ditions which mean bodily discomfort and mental 
 hardship. We must put ourselves in Nature's place 
 and work as Nature works, or, as Huf eland, puts it, 
 "The nearer and truer we are to Mother Earth, and 
 the closer our intercourse with Nature, the closer we 
 approach the source of Eternal youth and health; 
 hence, it it only necessary to understand how nature 
 intended that we should live in order to live long and 
 comfortably ; art can do nothing to assist. ' ' 
 
THE CAUSE AND CURE. 21 
 
 SUMMARY. 
 
 1. The "blues" is a popular term emp oyed to 
 express a multitude of ill-defined symptoms, mainly 
 nervous, which have not, as yet, been included in the 
 category of diseases. 
 
 2. An attack of the blues is an attack of acute 
 neurasthenia or an aperiodic aggravation of chronic 
 nervousness. 
 
 3. Nervousness, while expressive of an enfeebled 
 nervous system, is an expression evoked by some irritant 
 resident somewhere in the organism, other than in the 
 nervous apparatus. 
 
 4. Heredity may be responsible for the susceptible 
 nervous system, and it devolves on the individual to 
 obey the laws of hygiene and to avail himself "of 
 momentary advantages, however minute, to withstand 
 the effects of conditions which either weaken or im- 
 prove the status of his vitality. ' ' 
 
 6. Heredity and environment may be effectually 
 fought by personal effort. 
 
CHAPTEE II. 
 
 GENERAL IRRITANTS OF NEURASTHENIA. 
 
 HOW lEKITANTS OPERATE. OTEEWOEK, WORRY, THE ABUSE 
 
 OF ALCOHOL, BODILY DISEASES &C, AS CAUSES OF NEUR- 
 ASTHENIA. THE PATHOLOGY OF NEURASTHENIA.- — -BRAIN 
 
 CHANGES IN NEURASTHENIA. FATIGUE NEURASTHENIA. 
 
 In the previous chapter, incidental mention was made 
 of the causes of neurasthenia which, having their in- 
 ception at birth, continue through life and are only ex- 
 tinguished by death. " As the twig is bent, the tree's 
 inclined." The mental and moral education of the 
 child should be our primary concern. It is customary 
 to regard neurasthenia as a disease of adult life, a con- 
 tention Avhich is as absurd as saying that adults only 
 have a nervous system. The neurasthenic never seems 
 to be rested j_ _that " tirpd feeling " i° giwnyp wi'i-,}^ lr\]jr,^ 
 j.nd this susceptibility to fatigue constitutes the primary 
 and fundamental symptom of the disease, and without 
 it the disease c a nnot be said to exist. It is true that 
 fatigue symptoms soon graduate into sensations of pains 
 and aches, to recur again and again, until they are 
 established as a permanent condition, dominated by a 
 morbid mentality. In childhood, neurasthenia may 
 be expressed wholly by the feeling of tire, and it is only 
 rarely that the morbid physical sensations obtrude them- 
 selves sufficiently in consciousness to make the mind a 
 
 23 
 
24 TilE BLUES :-NEaRASTHENlA. 
 
 factor in the vicious circle. It has been customary 
 recently to identify nerve force with electricity and if 
 the analogy is not scientifically correct, it will at least 
 subserve our purpose in enabling us to so manipulate 
 our subject matter as to deal with something more 
 tangible than nerve force. A recent writer, O'Brien,^ 
 says, ' ' I picture the nervous system and its mechanisms 
 in living action before my mind ; I see beside it the 
 central telegraph system of New York or London, with 
 its radii of lines and cables, telephonic and telegraphic ; 
 its multiple switches, batteries, relays, transformers, 
 condensers, resistances, shunts, duplex and automatic 
 circuits : all this mechanism, like the nervous system, 
 transmitting force and translating intelligence from 
 point to point by terminal instruments which move, 
 talk, write, print, light, inhibit, accelerate and regu- 
 late and in one hundred ways doing what is done in 
 the nervous system, and always by means of the same 
 force, the only form of force capable of such vast and 
 varied service. ' ' 
 
 The voluntary, automatic and reflex movements of 
 a child or adult, the employment of the senses and 
 every thought means the expenditure of so much nerve 
 force. When a muscle is fatigued by voluntary con- 
 traction, it involves not only the muscle but the nervous 
 system, and the latter to a larger degree than the 
 former. It is erroneous to suppose that a healthy 
 nervous system can be acquired by vigorous muscular 
 exercise. The latter always means an expenditure of 
 nerve force which may or may not be beyond the 
 capacity of the individual. Many nervous wrecks are 
 recruited from this fallacious argument. Muscular ex- 
 ercise is healthful to the extent of provoking pleasant 
 recreation and relief from mental work. Muscular ex- 
 
THE CAUSE AND CURE. 25 
 
 ercise makes a predatory raid on nerve force which, 
 being thus consumed, limits the mental powers of the 
 individual. The nervous hygiene of childhood embraces 
 the elimination of so many irritants that to enumerate 
 them would be beyond the scope of this work. Suffice 
 it to say, at this time, that tire in the child as well as 
 the adult is the signal of warning. Tire is Nature's 
 call for rest. Heed Nature and there is no danger 
 from any amount of work that we are desirous of do- 
 ing. The other chief irritants of neurasthenia are : 
 mental overwork associated with anxiety, worry or 
 excitement, the abuse of alcohol, tobacco, coffee, tea, 
 bodily disorders, physiologic factors and moral causes. 
 Mental Oveewokk. — Euskin, has correctly observed, 
 that, " no great intellectual thing was ever done by 
 great effort ; a great thing can only be done by a great 
 man, and he does it without effort. The body's work 
 and the head's work are to be done quietly and com- 
 paratively without effort. Neither limbs nor brain are 
 ever to be strained to their utmost. That is not the 
 way in which the greatest quantity .of work is to be 
 gotten out of them. They are never to be worked 
 furiously, but with tranquillity and constancy. We 
 are to follow the plough from sunrise f o sunset, but not 
 to pull in race boats at the twilight ; Ave shall get no 
 fruit out of that kind of work. ' ' The Solomonic rule 
 is not a bad one to follow, viz : eight hours for labor 
 and occupation, eight hours for rest, refreshment and 
 recreation and surcease of all labor, and eight hours for 
 sleep. The nervous system must be made equal to its 
 task. Nerve health depends on a moderate amount of 
 work well diluted with healthful and cheerful recrea- 
 tion. Gibson,^ expressed a Utopian idea, when he said, 
 ' ' Man is advancing to a stage when he shall no longer 
 
26 THE BLUES :-NEtfRASTaEMA. 
 
 remain a stranger to his own life processes. ' ' It would 
 be better for man were he conscious of his life processes 
 in the sense of knowiijg his capacity for work and the 
 need of rest when that is necessary. Such mental train- 
 ing could be designated as physiologic introspection, and 
 is the key-note of health. Holmes, in ' ' Over the Tea- 
 cups ' ' speaks as follows of the curve of health : " It is 
 a mistake to suppose that the normal state of health is 
 represented by a straight horizontal line. Independ- 
 ently of the well-known causes which raise or depress 
 the standard of vitality, there seems to be — I think I 
 may venture to say there is — a rhythmic undulation in 
 the flow of the vital force. The dynamo which fur- 
 nishes the working powers of consciousness and action 
 has its annual, its monthly, its diurnal, even its mo- 
 mentary ripples, in the current it furnishes. There 
 are greater and lesser curves in the movement of every- 
 day life— a series of ascending and descending move- 
 ments, a periodicity depending upon the very nature 
 of the force at work in the living organism. Thus we 
 have our good seasons and our bad seasons, our good 
 days and our bad days, life climbing and descending in 
 long or short undulations, which I have called the curve 
 of health. ' ' 
 
 The brain worker who works with discretion knoAvs 
 that the brain is capable of the greatest amount of 
 work without fatigue during the early morning hours, 
 for sleep has served to recuperate a fagged brain. 
 The discretionate brain worker also knows that there 
 is a daily ebb and flow of his nerve vigor. From the 
 early morning hours the ebb of nerve force begins, at- 
 taining its maximum discharge in the middle of the 
 afternoon, a time when the nervously exhausted are 
 the most weak. The evening meal temporarily stimu- 
 
THE CAUSE AND CURE. ^*J 
 
 lates the brain functions, masking as it were the de- 
 pressed state of the nervous system. Then follows 
 sleep. The brain worker requires more sleep than the 
 laborer. There are certain individuals whose occupa- 
 tions predispose them to neurasthenia. Thus it is, that 
 merchants, professional men, teachers and others fur- 
 nish large numbers of neurasthenics ; their mental ap- 
 plication is so profound and intense, that they exceed 
 the limits of human endurance without a conscious 
 knowledge of the fact. Then again, the brain worker 
 is usually a neurasthenic, for, in this strenuous life of 
 ours, mental achievement is only possible with a high- 
 ly irritable nervous system. " The power of original- 
 ity in new lines of thought ' ' as Maudsley puts it, 
 ' ' and stepping aside from the beaten track of reflec- 
 tion, is, of itself, a common indication of the insane 
 neurosis. ' ' 
 
 There are individuals who are incapable of appre- 
 ciating the great amount of work they really do ; they 
 blunt their sense of tire by artificial stimulants and ex- 
 citement. The latter class of individuals soon become 
 drug habitues or end their lives in asylums as paretics. 
 The predisposing cause of paresis so sententiously ex- 
 pressed by Mickle applies with equal cogency to neur- 
 asthenia : "A life absorbed in ambitious projects with 
 aU its strongest mental efforts, its long sustained anx- 
 ieties, deferred hopes, and straining expectation." 
 The individual who seeks to avoid neurasthenia by 
 mental inactivity should hearken to the couplet of 
 Cowper : 
 
 " Absence of occupation is not rest, 
 A miud quite vacant is a mind distressed." 
 
 The perpetuation of any living thing is dependent 
 on the continuance of its healthy activity. 
 
28 THE BLUES :-NEURASTHENIA, 
 
 WoEEY. An English writer of prominence asserts 
 that the majority of people kill themselves by lives of 
 indulgence of mind and body. Mental inactivity is 
 injurious to physical health, and it is rare to find the 
 idler among the list of centenarians. Healthy brain 
 activity is essential to life and justifies the aphorism 
 that " It is not work but worry that kills. ' ' That en- 
 viable man whom nothing worries is the kind, conside- 
 rate and patient man whom we occasionally meet in 
 this busy world. The ill-tempered, irritable and pes- 
 simistic individual, with deranged digestion and bloated 
 liver, is the man with an unbalanced nervous system, 
 who has simply disregarded the natural law of waste 
 and repair. Many acts of philanthrophy are forever 
 lost in the capriciousness of a disordered liver or a de- 
 fective digestive apparatus. "W orry, grief, passion and 
 fret ting are powerful nervous^shocks. ' ' There is iTo 
 sensation, ' ' says Tuke, '■ '■ whether general or special, 
 jexcited by agents~ac tiirg on the boHy" from~\ntirout, 
 jvhich c anno t also be ex c ited from within by emotion- 
 _al states affec ting t he sensory ganglia, such se nsation 
 being referred by tlielmind to th.e point at whTcIPt he" 
 nerve terminates in the body. ' ' The emotional states 
 arrest the function "oTHigestion and impair the bodily 
 functions. Self-control is a powerful palladium against 
 nervous prostration. It is exceptional to find a neu- 
 rasthenic in individuals who have acquired a knowledge 
 of self government. " Every one can master a grief 
 but he that has it," but we are all competent to con- 
 struct for ourselves a philosophy of complacency. Such 
 philosophy need not resolve itself into indolence and 
 apathy, nor need it assume the aspects of stoicism. 
 When misfortune or disaster overtakes the Turk he at- 
 tributes it to the will of God, or more often to fate 
 
THE CAUSE AND CURE. 29 
 
 (Kismet), and he piously ejaculates : " It is fate " {Kis- 
 met Mr) or ' ' God will provide ' ' (AUahherim). The cul- 
 tivation of some belief which inculates the doctrines of 
 contentment should be encouraged. It may be a diffi- 
 cult matter to control the emotions, but mastery can 
 be attained by training. I know many neurasthenics 
 who suffer relapses whenever exposed to some intense 
 emotion. When self control is difficult, individuals 
 must avoid conditions which introduce them to such 
 influences. They must avoid going to funerals, read- 
 ing death notices and newspapers with their daily 
 menu of sensationalism. They should cultivate the 
 companionship of people who may dream of unhappi- 
 ness but wake up laughing. The worries of some 
 people are often so ridiculous that they must be re- 
 garded as the emanations of a diseased mind. I knew 
 one woman, who, after a rest cure for neurasthenia, 
 suffered only one inconvenience, and that was, that 
 she had heard that recovery from a ' ' rest cure ' ' only 
 lasted five years, and at the end of that time she feared 
 she would suffer a relapse. My patient was very much 
 like the woman whose physician asked after her health 
 replied dolefully : "I feel very well ; but I always 
 feel bad when I feel well, because I know I am going 
 to feel worse afterwards. ' ' 
 
 THE ABUSE OF ALCOHOL, COFFEE, TEA, AND TOBACCO. 
 
 Alcohol, is one of the greatest scourges of the nerv- 
 ous system. Consumed even in the smallest amounts 
 by persons of a nervous temperament it will induce or- 
 ganic changes in the nerve tissues like those of old age. 
 The habitual use of alcohol stands foremost, after hered- 
 ity, as a single independent cause of insanity. The 
 
30 THE BLUES :— NEURASTHENIA. 
 
 psychic degeneration of alcoholism is characteristic, 
 and consists of gradually weakening memory and will, 
 slowness of perception and judgment, loss of the moral 
 and esthetic sense, with paroxysms of depression, anger 
 and irritability. There is no organ of the body which 
 is not implicated in chronic alcoholism, but it is as a 
 nerve intoxicant that its most pernicious effects are 
 manifest. The nervously iqclined first become addicted 
 to alcohol in some form believing that it is a stimulant. 
 This is not a fact, for its chief action is depressant and 
 under its influence the actual amount of work that is 
 capable of achievement is less than when it is not taken. 
 The stimulating effects of alcohol are more apparent 
 than real. By anesthetizing sensation, a temporary re- 
 lease only is secured from the morbid sensations ex- 
 perienced by thfe neurasthenic. 
 
 Morphin and a host of other remedies have a like 
 effect, and it is this fictitious sensation of well-being 
 that is responsible for the prevalence of drug addiction 
 among neurasthenics. There are many neurasthenics 
 whose symptoms may be directly traced to the alcohol 
 habit. Such individuals suffer from gastric and 
 nutritional disturbances, mental symptoms and para- 
 lysis. 
 
 The neurasthenic must be especially warned against 
 the so-called ' ' nerve foods ' ' and other preparations 
 advertised under fascinating names by unscrupulous 
 manufacturers, for many of them contain powerful 
 sedatives, which are merely palliative in their action and 
 ultimately conduce to some pernicious drug habit. 
 
 Coffee, Tea and Cocoa. Caffeine, the active princi- 
 ple of coffee, theine, of tea and the alkaloid of cocoa are 
 chemically identical and have the same vicious effects 
 when used inordinately. Many nervous affections are 
 
THE CAUSE AND CURE. 31 
 
 wholly attributable to their use, in fact, they may dup- 
 licate all the symptoms of neurasthenia. Nervous indi- 
 viduals display a definite idiosyncracy toward these sub- 
 stances, hence they should never be employed in such 
 persons. 
 
 Bodily Disoedeks. Syphilis is a paradigm of this 
 type of irritants. Here many factors conspire to 
 make the subject a likely victim of neurasthenia. 
 First, there is the mental factor, for there are 
 many persons who once having contracted the disease 
 interpret every bodily derangement as a manifestation 
 of syphilis. Then there is the reduced state of the 
 body induced by injudicious medication, or by the 
 poison of the disease itself, which makes the subject 
 susceptible. Nutritional disturbances provoked by 
 syphilis often make the nervous system the object of 
 least resistance. Syphilophohia, or the morbid dread 
 of having contracted syphilis produces intense mental 
 suffering in some individuals and it is also the case 
 when other venereal diseases have, or are supposed to 
 have been acquired. The anxiety of mind conquers 
 the entire being. Sleep, digestion and nutrition are 
 in consequence impaired, and the unending terror may 
 last a lifetime unless controlled by the physician, who 
 is often able by the modern aids of science, to make 
 innocuous the indiscretions arising from venereal disease. 
 Often the sexual madness has no real foundation; a 
 harmless skin eruption, lax, or too lightly drawn 
 testicles, innocent pimples and the like are apt to be 
 construed as manifestations of venereal disease. 
 
 Influenza . This affection is likely to be followed by 
 neurasthenia which is sometimes severe, prolonged and 
 obstinate. Other infectious diseases. Like malaria and 
 typhoid fever as weU as other debilitating diseases are 
 
32 THE BLUES :— NEURASTHENIA. 
 
 not infrequently followed by neurasthenia, and, indeed, 
 the convalescence of such diseases is made up almost 
 wholly of neurasthenic symptoms. 
 
 Railway Injuries. A nervous condition may follow 
 railway and other injuries, especially when associated 
 with fright. The neurasthenia following such acci- 
 dents is known 3iS traumatic neurasthenia, or "railway 
 spine," and differs in no wise from neurasthenia de- 
 pendent on other causes. 
 
 Physiological Factors. Puberty in both sexes, and 
 the puerperal state and change of life in women, as 
 well as the tissue changes peculiar to old age (senility), 
 are periods in life when the nervous system is subject 
 to excessive strain which increases its vulnerability. 
 Puberty occurs between the thirteenth and twentieth 
 years, a period of life in which remarkable physical 
 and mental changes occur. The evolution of the 
 sexual characters and development of reproduction, 
 give rise to new sensations and strong emotions. The 
 mind, especially of the boy, becomes charged with 
 emotional, sentimental, amatory and fantastic imagin- 
 ings and vicious habits are formed. In the p^ierperal ■ 
 state pregnancy diminishes the vitality of woman, de- 
 bilitating and weakening her entire system, thus mak- 
 ing her a prey to the many disorders consequent on 
 nervous breakdown. 
 
 The cham^e of life (menopause), in women between 
 the ages of forty and fifty years, is another epoch 
 fraught with mischief to the nervous system, and it is 
 rare to find in this period of involution, a woman free 
 from nervous manifestations. 
 
 The disequilibration associated with the cessation of 
 ovulation and menstruation is a menace to mental 
 integrity. 
 
THE CAUSE AND CURE. 33 
 
 During the senile period of life, tissue involution is 
 likely to be attended by numerous mental disorders. 
 A conspicuous sign is loss of memory for recent events 
 and the individual's interest becomes centered in his 
 physical comforts and needs. 
 
 MoEAL Causes. It is an axiom, that every time a 
 muscular movement is made, less resistance is made by 
 the nerve center in control of that special motion, and so 
 it is with the moral education of the child, the oftener 
 the latter is permitted to perpetuate a wrong, the 
 easier will its repetition become. Discipline of the 
 child begins at home and attention to their morals is 
 more important than books. — " A man," said Johnson, 
 " is in general better pleased when he has a good din- 
 ner upon his table, than when his wife speaks Greek, ' ' 
 and a parent would be better pleased if his boy could 
 be taught to escape the dominion of habit by self con- 
 trol than if he knew all the Euclidean axioms. Unfor- 
 tunately the boy does not know until later in life that 
 self-denial is of more value than indulgence. ' ' Those 
 who would be young when they are old should be 
 old when they are young. Old age in youth should 
 mean parental control. 
 
 BRAIN CHANGES IN NEURASTHENIA. 
 
 Physiologic experiments demonstrate that in fatigue 
 of the nervous system, the nerve cells, which in health 
 are plump, become shrunken and become restored to 
 their original shape and size only after prolonged rest. 
 Brain cells have been compared by a recent writer to 
 small baloons ready for an ascent. "When seen under 
 the microscope they are round and full and give evi- 
 dence of being distended. The cells of the tired brain, 
 3 
 
34: THE BLUES:— NEURASTHENIA. 
 
 on the other hand, are seen to be shrunken, as an air 
 ball or toy baloon, from which most of the air or gas 
 has escaped. 
 
 When our brains begin to work after a refreshing 
 rest or sleep they are, continues the same writer, full of 
 nerve fluid, which the absorbents of the body and brain 
 have stored up there like bees fill their comb. So soon 
 as work begins, this vital force is sapped to meet the 
 demands upon the brain, and the process that goes on 
 during the whole time it is working may be described 
 in the following way : 
 
 Imagine that these cells are small goblets filled with 
 liquid, and that they have a tiny stem, through which 
 runs a tube or opening ; the liquid in the goblet is 
 drained by the demands of mind and body, and slowly 
 trickles through the opening, drop by drop, until either 
 the work ceases or the goblet is exhausted. 
 
 This latter condition is not often reached, for the 
 simple reason that the owner of the brain is very much 
 more likely to collapse. When the coll has yielded 
 half its vital fluid you begin to experience a feeling of 
 fatigue, and if you go on drawing the contents of the 
 cells you are doing yourself injury in proportionate de- 
 gree, and nature will make you pay for it in some way 
 or other. 
 
 But all the cells are not involved in any kind of 
 mental work, which means that one part of the brain 
 may be very actively at work while the other is rest- 
 ing and storing up nerve fluid. Thus it is that a man 
 suffering from brain fag may leave his books and go 
 golfing or cycling and feel that he is really resting, 
 other cells are being called upon for work now, while 
 the tired ones, those required for mental activity are 
 enjoying repose. 
 
THE CAUSE AND CURE. 35 
 
 But it follows that the part of the brain which is 
 called into activity for bodily exercise is now getting 
 tired, while the other part.of the brain is still at work 
 to some extent, and so the whole of our brain cells be- 
 come fatigued, and total rest, in the shape of sleep, is 
 absolutely essential. 
 
 The ' ' neuron theory ' ' of Hodge,* is of special interest 
 in determining the pathology of neurasthenia. Hodge 
 studied the nerve ceUs of swallows, pigeons and bees 
 before and after fatigue and in all cases he observed 
 noteworthy changes. After rest, the cells were large 
 and plump,, well defined and the nuclei easily demons- 
 trated. After a day's flight, the cells became small, 
 the nuclei indistinct, the protoplasm granular and 
 shrunken and the cell processes striated. Dercum 
 claims, that in chronic cases of neurasthenia, the blood 
 contains toxic substances derived from the excessive 
 waste of nerve tissue ; and Mosso, who injected the 
 blood of a fatigued animal into one at rest, obtained in 
 the latter the characteristic signs of fatigue. The con- 
 clusion that may be formulated as the result of the 
 preceding observations is practically as follows : 
 
 Fatigue Neueasthenia. There is a neurastJienia de- 
 pendent on overwork or over-functioning, a form cor- 
 rectly specified by Savill,^ as "fatigue-neurasthenia" 
 which is dependent on exhaustion of the nerve cells. 
 The latter which may be aptly compared to electric 
 cells furnish a definite amount of electricity, but after 
 continuous use without intermission, they exhaust 
 themselves, and their output of electricity, an expres- 
 sion of their function, becomes diminished and the 
 mechanism of the organs can no longer be put in mo- 
 tion, or, if so, with great difficulty. Kest will restore 
 the storage capacity of the nerve cells as it will the 
 
36 THE BLUES :— NEURASTHENIA. 
 
 electric cells. There is the law of Edinger which is 
 quite apposite in relation to neurasthenia, viz : in- 
 creased function, if regularly and gradually increased 
 leads first of all to increas growth ; if carried to excess 
 however, or is irregular and spasmodic, it leads to 
 waste and degeneration of the tissues concerned. 
 
 Every function of the body is controlled and operated 
 by the nervous system. The latter which dominates 
 the functions of the mind likewise controls the action 
 of the muscles. We haven't two nervous systems nor 
 two brains and it is this mistaken conception of the 
 functions of the nervous system which has made con- 
 firmed neurasthenics out of individuals who have ex- 
 pended too much nerve force in excessive muscular 
 development under the supposition that they were de- 
 veloping their minds. If the theory of muscularity 
 were correct, intellectual giants would be recruited 
 from dray horses and pugilists. 
 
THE CAUSE AND ctritE. 37 
 
 SUMMARY. 
 
 1. The chief symptom of neurasthenia is tire. 
 "Without the latter sign, the disease cannot be said to 
 exist. 
 
 2. "While neurasthenia occurs most frequently be- 
 tween the ages of twenty and fifty, it may occur during 
 other periods of life. Children are by no means exempt 
 and, if the affection in the child is unrecognized, it is 
 because the nervous system of the child reacts differ- 
 ently to the exciting causes than does the same system 
 in the adult, and for the additional reason, that the 
 mind in the child is eliminated from participation in 
 
 -the physical symptoms. 
 
 3. Nerve force, has been compared to electricity, 
 but this comparison does not improve our conception of 
 the nature of nerve force, which like electricity is very 
 obscure. The comparison will aid the neurologist in 
 framing a positive knowledge concerning the action 
 and laws that govern nerve force, which in relation to 
 electricity are precise and extensive. 
 
 4. Muscularity is not essential to intellectual deve- 
 lopment, on the contrary physical overwork drains our 
 capital of nerve force and disturbs the equilibrium of 
 mental and physical health. The ' ' mens sana in cor- 
 pore sano' ' can only be attained by a judicious exercise 
 of both mind and body. 
 
 5. Nerve health is a condition subject to the discre- 
 tion of the individual : it is the resultant of the income 
 and expenditure of nerve force. 
 
 .6. Stimulants, like drugs used for the relief of nerv- 
 ousness, have been invented for both the patient and 
 physician. They relieve the former of obeying the 
 laws of hygiene and the latter of inculcating them. 
 
^8 THE BLUES :-MEURASTllEMiA. 
 
 They assist in the early death of foolish neurasthenics 
 so that their fellow sufferers may learn the correct 
 path to health. 
 
 7. " They who would be young when they are old, 
 must be old when they are young." Everything 
 which promotes the general health will promote re- 
 covery from neurasthenia, for anything which will in- 
 fluence health will have a corresponding effect on 
 Kealih. 
 
 8. That "An idle brain is the devil's workshop," 
 is never better illustrated than in an insane hospital." 
 
 9. In studying the relation which exists between 
 venereal and nervous diseases, we note the will of 
 omniscient Providence dedicating to virtue, vigorous 
 manhood and a noble life. When a staid and respected 
 member of society, developes in later years a post- 
 venereal disease, the picture he presents, is that of re- 
 spectability painted on a back -ground of vice. 
 
 10. Neurasthenia has no definite pathology and all 
 hypotheses which hint in that direction have not ex- 
 ceeded the realms of theory. We recognize the 
 disease as we do the physical forces by their effects, 
 viz : an acute or chronic functional nervous trouble 
 manifested by nervous weakness and irritability, in 
 which the patient is easily exhausted and is acutely 
 responsive to trivial irritations. 
 
 11. Self -culture embraces a training of the physical, 
 moral and intellectual parts of man. All must be 
 equally and judiciously trained. An exclusive train- 
 ing of the physical part will develop an athlete ; of 
 the moral, an enthusiast ; of the intellectual, a crank. 
 
CHAPTER III. 
 
 SPECIAL IRRITANTS OF NEURASTHENIA. 
 
 THE PEl'MAEY FACTOR IN NEURASTHENIA. SEXUAL NEUR- 
 ASTHENIA. CONGESTIVE NEURASTHENIA. URIO ACID 
 
 NEURASTHENIA. AUTO-TOXEMIC NEURASTHENIA. AB- 
 DOMINAL NEURASTHENIA. DYSPEPSIA AND NEURAS- 
 THENIA. SPLANCHNIC NEURASTHENIA. 
 
 In the preceding chapter, the cause of neurasthenia 
 was attributed in brief to overstrain of the nervous 
 system provoked by the various mental, moral and 
 physical causes, the result, as Beard puts it of mer- 
 civilizaUon. .Very soon investigators sought to ex- 
 plain how this irritability and weakness of the nerve 
 cells was brought about. Medical writers are being 
 rapidly weaned from the doctrine that an hereditarily 
 degenerate nervous system is the primary factor in 
 neurasthenia. The assumption of such an hypothesis 
 would mean the relegation of personal responsibility to 
 heredity and would grant immunity to the transgressor. 
 The fact is, that a number of neurasthenics owe their 
 infirmity to indiscretions, and a still larger class to 
 morbid organic functions, which, if corrected, would 
 cure their disease. 
 
 Charcot claimed that the working-classes were not 
 exempt from neurasthenia ; on the contrary, physical 
 
 39 
 
iO THE BLUES :-NEURASTHENIA. 
 
 fatigue, poverty and the constant anxiety to make 
 both, ends meet were as potent in inducing neuras- 
 thenia as the brain work of professional or business 
 men. 
 
 Physicians now recognize that certain predisposing 
 influences exist to induce neurasthenia, even though 
 an inherent weakness of the nervous sj'stem can be ex- 
 cluded. 
 
 As a result of this recognition, reference is now 
 made to special forms of neurasthenia which will en- 
 gage our attention. 
 
 Many aifections which have hitherto been recognized 
 as diseases by themselves are either symptomatic of 
 neurasthenia or induce the latter affection by their 
 persistency. 
 
 Sexual Neueasthenia. In their monograph on 
 Sexual Neurasthenia, 8 Beard and Kockwell, refer 
 to the various maladies of the male sexual appara- 
 tus, viz; impotence, spermatorrhoea, prostatorrhea, 
 irritable prostate, etc., as mere manifestations of 
 neurasthenia. The trend of modern opinion is not 
 only to regard sexual ailments as manifestations of 
 neurasthenia, but as the cause of the affection. Again, 
 the state which sexual disorders induce is not neces- 
 sarily a neurasthenic one. Witness as an instance the 
 masturbator. His condition is one of mental de- 
 pression with disinclination to work and study. He 
 is nervous and irritable : numb feelings are felt in the 
 hands and feet, etc. His physiognomy is character- 
 istic and by no means tallies with that of neurasthenia, 
 viz : pale complexion, furtive eye, dilated pupil, restless 
 and depressed appearance, moist and flabby palms, 
 etc. In women, masturbation is a frequent cause of 
 hysteroepilepsy. Freud ^ avers that neurasthenia can 
 
THE CAUSE AND CURE. 41 
 
 always be traced to excessive masturbation, unnatural 
 sexual intercourse, unsatisfied impulses, abstinency with 
 inflamed desires, interrupted coitus, etc., and he urges 
 the physician to assume an abnormal sexual life as his 
 guiding star in the causation of neurasthenia. 
 
 Hottinger ^ contends that many functional de- 
 rangements of the genito-urinary system, which have 
 been referred to as symptoms of neurasthenia, have 
 as their basis some form of prostatitis, and that the so- 
 called neurasthenia disappears when the prostatitis 
 is cured. Fuller ^ refers neurasthenia to a seminal vesi- 
 culitis ; Eavogli to a chronic urethritis and syphilis ; 
 and Eastman i" to impaired sexual gratification, lacera- 
 tion of the perineum, etc. in women. The foregoing 
 writers are unquestionably extreme in their views, but 
 their observations convey a modicum of truth if for 
 no other reason than to emphasize that a local source 
 of irritation may be responsible if not for neurasthenia, 
 at least for neurasthenic symptoms. 
 
 Congestive Neurasthenia. Whittle, of London, la 
 1889, wrote an interesting brochure on this special 
 form of neurasthenia, but it seems to have escaped the 
 serious consideration of the medical profession. I have 
 repeatedly been able to confirm the observations of 
 "Whittle. He describes a form of nerve depression re- 
 sulting from brain congestion and illustrates the re- 
 markable efficacy of bloodletting, either by leeches or 
 venesection, in its treatment. The particular patients, 
 who are thus benefited, look to the uninitiated eye, the 
 picture of health, but are really miserable victims to 
 whom actual pain or some evident disease would prove 
 an agreeable distraction. Their faces are flushed, eyes 
 watery and there is a lightness in the head with occa- 
 sional aching of a duU, heavy character about the fore- 
 
4^ THE BLUES :— Neurasthenia-. 
 
 head. The majority of cases occur between the ages of 
 thirty and forty, very few under twenty-five or over 
 fifty. This includes the most active and wearing period 
 of life. If a man can stand the strain of this period, he 
 will be proof against anything he may encounter 
 afterward. Congestive neurasthenia occurs more fre- 
 quently in males than females and the most constant 
 factor in its production is continuous brain strain. 
 
 During sleep, such as it is, the body rests but not 
 the brain. As a result the brain becomes unduly 
 charged with blood, leading to congestion, which noth- 
 ing seems to relieve so quickly and marvelously as 
 blood-letting. Leeching is one of the good remedies 
 out of fashion, and while formerly it was the custom 
 to bleed too much, it is unfortunate that now we do not 
 bleed enough. I remember one congestive neurasthenic 
 who, by actual calculation, had consulted twenty-three 
 different physicians, among whom were some of the 
 leading nerve specialists of Europe. In addition he 
 had made a number of sea voyages and visited many 
 celebrated spas but with absolutely no relief. Inci- 
 dentally an eye trouble necessitated the application of 
 leeches by his oculist to the temples, resulting in im- 
 mediate relief to his nerve symptoms which had hitherto 
 baffled all treatment. Six months later his old symp- 
 toms returned but the reapplication of leeches and the 
 withdrawal of blood from the brain vessels was as 
 successful as in the primary instance. 
 
 Uric Acid Neubasthenia. Brain workers often suffer 
 from a series of perplexing symptoms which baffle the 
 skill of their medical advisers. Such sufferers are 
 usually good livers and lead sedentary lives. "With 
 such, insomnia, headache, mental depression, backache, 
 1:1(1 dyspepsia are prominent signs. 
 
THE cause! and ctriiE. 4g 
 
 When Alexander Haig, of London, issued his work, 
 ' ' Uric acid as a factor in the causation of disease, ' ' he 
 attempted to make many problems clear which had 
 heretofore remained unrecognized. His uric acid 
 theory is briefly as follows : Uric acid occurs in the 
 blood in traces during health. It is derived chiefly 
 from foods, and persons who eat an excess of food and 
 take little exercise, produce an excessive quantity of 
 uric acid, which, accumulating in the blood, gives rise 
 to a train of symptoms. The blood being naturally 
 alkaline, holds the uric acid in solution, but, if from 
 any cause, the blood becomes acid, it can no longer 
 hold the uric acid in solution and consequently the 
 latter is precipitated. JSTow, the joints, muscles and 
 ligaments are favorable sites for the precipitation of 
 uric acid, hence those who suffer from uric acid poison- 
 ing complain of muscular pains in the back and joint 
 stiffness. This theory, while primarily fascinating, 
 soon became the subject of critical analysis with results 
 inimical to its tenability. It was shown that uric acid 
 was absolutely non-irritating to the tissues and could 
 be injected in large amounts into animals, as well as 
 administered in their food with no toxic results 
 whatever, in other words, uric acid itself does not 
 produce disease. 
 
 It is not the retention of uric acid in the system 
 which produces the so-called uric acid diathesis but 
 the presence of certain products, the result of deficient 
 oxidation. These products are known as the purin or 
 alloxuric bases, like xanthin, guanin, adenin, etc. They 
 are highly toxic, and are normally burned in the body 
 through the process of oxidation and are finally con- 
 verted and eliminated as uric acid, a very harmless 
 product. The toxic substances in question are derived 
 
44 f HE Blues :-neurasthenia. , 
 
 in part from food and in part from the worn out body 
 cells. 
 
 Woods-Hutchinson^^ clearly defines our present status 
 regarding the uric acid theory in referring to the nature 
 and causation of gout, viz : "A toxemia of varying 
 causation, usually of gastro-intestinal origin, accom- 
 panied by the formation of an excess of urates, this 
 excess of urates being due to the breaking down of the 
 leucocytes and fixed cells in the attempt to neutralise 
 the poison — in other words, being the measure of the re- 
 sisting power of the body tissues. The formation and 
 introduction of the toxins, be it well understood, are 
 by no means confined to the gouty; it is only the 
 nature of the resistance of the body to them that gives 
 the character of gout. ' ' 
 
 This carries us to a consideration of gastro-intestinal 
 diseases as a cause of neurasthenia, which I will include 
 under the caption of Auto-toxemic neurasthenia. 
 
 AuTo-ToxEMic Neueasthenia. In general, auto-tox- 
 emia refers to poisoning of the organism superinduced 
 by poisons generated within that organism, a condition, 
 in other words, of self infection. Self-infection may 
 occur from the following causes : 1. Retention in the 
 body of certain substances destined for excretion {Auto- 
 intoxication of retention). 
 
 2. Absorption of substances from normal or ab- 
 normal cavities of the body developed from putrefac- 
 tion or fermentation (Auto-intoxication of resorption). 
 
 3. Substances developed from disturbances in the 
 cells and secretions of organs (histogenic auto-intoxica- 
 tion). 
 
 4. Poisoning, the result of toxine absorption deve- 
 loped by micro-parasites (auto-intoxication of infection). 
 
 The second variety of auto-intoxication of which re- 
 
THE CAUSE AND CURE. 45 
 
 sorption from the gastro-intestinal canal is the most 
 conspicuous example and which is best understood will 
 occupy our attention. 
 
 Gasteo-intestinal auto-intoxication. — Bouchard ^ 
 was one of the first to show that man is constantly 
 standing, as it were, on the brink of a precipice. Every 
 moment of his life, he runs the risk of being overpowered 
 by poisons generated within his system. The healthy 
 and unhealthy body is a receptacle and laboratory of 
 poisons. Self poisoning is only inhibited by the activity 
 of the skin, kidneys and bowels. These poisons are 
 normally manufactured in our gastro-intestinal canal, 
 and were it not for the action of the bowels, kidneys 
 and skin, many of us would succumb to auto-intoxica- 
 tion. Aside from the excretory organs which promote 
 the excretion of the poisons, the alimentary canal and 
 the liver are endowed with functions capable of render- 
 ing innocuous many of the toxic substances. 
 
 The proponents of this theory maintain that in 
 health, auto-intoxication does not occur, either because 
 sufficient of the toxic material is not absorbed and is 
 rapidly excreted, or if absorbed, the poisons are made 
 inert by the action of the liver, blood and tissue cells. 
 On the other hand, self infection occurs in disease of 
 the gastro-intestinal mucous membrane which facili- 
 tates the entrance into the blood of the toxic sub- 
 stances, or because the liver and the tissue cells are 
 incapable of making them innocuous. 
 
 The symptoms of auto-intoxication are difficult of 
 enumeration, simply because the recognition of the 
 affection itself is difficult. 
 
 Observation however has taught us, that the toxic 
 products are capable of producing local symptoms, viz : 
 various digestive disturbances and general disturbances 
 
46 THE BLUES :— NEURASTHENIA. 
 
 of the nervous system. Such signs may duplicate the 
 symptomatic picture of neurasthenia with profound de- 
 pression, mental disturbances, epilepsy, locomotor 
 ataxia and mental exaltation. This varying symptom- 
 atic picture depends on the nature of the toxic sub- 
 stances absorbed, some exciting, others depressing the 
 nervous system. Schroeder von der Kolk, some years 
 ago, demonstrated that acute, confusional insanity was 
 associated with fecal accumulation in the colon. 
 
 As already stated, it is difficult to associate many of 
 the symptoms with gastro-intestinal poisoning and 
 here the results of treatment could offer us some assist- 
 ance. In a few instances, we know that manifold 
 nervous symptoms have subsided after free evacuation 
 of the bowels, but in my own observations, where 
 there was every reason to suspect intestinal auto- 
 toxemia, the results of treatment were quite unsatis- 
 factory. 
 
 The treatment in question was that which is con- 
 ceded to be the best for intestinal auto- toxemia: 1. An 
 exclusively milk diet which reduces to a minimum the 
 introduction of poisonous food products. 2. Daily ir- 
 rigation of the stomach and bowels. 3. Purgatives. 
 4. Intestinal antiseptics. I am constrained to con- 
 clude, that the auto-intoxication theory, while of great 
 scientific value and hints at many possibilities in the 
 future is not sufficiently developed at the present time 
 to prove of much practical value to the neurasthenic. 
 
 Abdominal Netjeasthenia. There are a number of 
 abdominal affections which have been cited as causes 
 of neurasthenia, and I have grouped them all under 
 the caption of abdominal neurasthenia. The belief 
 that the abdominal cavity was responsible for many 
 diseases, notably, hypochondriasis is of ancient origin. 
 
THE CAUSE AND CURE. 47 
 
 The term hypochondriasis, originated from the supposi- 
 tion that its cause was resident in the hypochondriac 
 region, owing to the feelings of distress and uneasiness 
 which prevailed there. Broussais (1772-1838) advo- 
 cated, as his most powerful treatment, the application 
 of leeches to the abdomen and as many as thirty to 
 fifty were applied at a single seance. This was hirud- 
 inomania with a vengeance. In 1785, Johann Kamp, 
 published a work, entitled, ' ' For physicians and 
 patients, a new method for the radical cure of perni- 
 cious diseases, specially hypochondriasis, which have 
 their origin in the abdomen. ' ' He refers to many nerv- 
 ous diseases which were unquestionably of abdominal 
 origin, and his treatment consisted in the main of 
 enemas made from decoctions of herbs. 
 
 Yoetsch, in 1874, published his work on " copros- 
 tasis ' ' (hardened fecal matter in the intestines), and 
 recites in detail the histories of fifty-eight patients 
 with manifold disturbances in different organs that 
 were directly attributed to habitual constipation. 
 
 In 1885, Grl6nard issued an important work, in 
 which he attributed neurasthenia to enter (rptosis, a con- 
 dition in which there was a prolapse of one or other of 
 the abdominal organs. The symptoms described by 
 him and known as Glenard's disease occurred in the 
 following order of succession : 1. Debility and lassi- 
 tude. 2. Sensations of uneasiness, weight, dragging, 
 craving, emptiness, etc., in the abdomen. 3. Symp- 
 toms of dyspepsia. 4. Nervous symptoms. The re- 
 searches of Grltoard were of great importance, but 
 subsequent observers did not confirm his conclusions in 
 their entirety. The conservative opinion now is, that 
 prolapse of the abdominal organs may occur without 
 
48 THE BLUES :— NEURASTHENIA. 
 
 neurasthenic symptoms and that neurasthenia may 
 occur without gastric symptoms. 
 
 Dunin,!^ in 1891, demonstrated that habitual con- 
 stipation is associated with a train of neurasthenic 
 symptoms, but he cautions, and in my experience 
 wisely, against the regular employment of purgatives 
 which only aggravate the symptoms. 
 
 Federn,^* in 1894, published a monograph, in 
 which he attempted to show, that nervous symptoms 
 (neurasthenia), contrary to accepted doctrines, are by 
 no means dependent on a nervous system faulty by 
 heredity, but that they are caused prima,rily by in- 
 testinal disturbances. The latter cause an increase in 
 , the blood pressure and to this must be attributed the 
 nervous symptoms. In this increased blood pressure, 
 he argues, there is a mechanic irritation of the tissues 
 and organs, for when the blood pressure is reduced to 
 normal all nervous manifestations cease. In the ma- 
 jority of neurasthenics, there is apartial intestinal atony 
 with or without constipation or intestinal catarrh. 
 
 Dyspepsia and Netjeasthenia. Most writers admit 
 that dyspepsia is frequently an associated condition of 
 neurasthenia, but its definite relation to the disease in 
 question is a matter of doubt. Some maintain that 
 neurasthenia may produce a particular kind of stom- 
 ach disturbance, others, that if stomach disturbances 
 develop they are merely manifestations of a neurasth- 
 enic condition. The latter view is based on the prin- 
 ciple, that in health all the organs work harmoniously : 
 One is dependent on the other for the normal perform- 
 ance of its work. If one suffers they all suffer, a 
 vicious circle being thereby established. 
 
 Some one organ, however, it may be the stomach, 
 heart or liver, usually bears the brunt of nervous ex- 
 
THE CAUSE AND CURE. 49 
 
 haustion. Why this is so, is difficult to say, other 
 than by supposing that every person like Achilles has 
 some vulnerable spot. Some persons when they have 
 a "nerve storm," center all their abnormal sensations 
 in the heart, others in the stomach, others in the head. 
 
 Still others contend that neurasthenia in a certain 
 proportion of cases is the result of the gastric disorder. 
 The latter contention is, however, difficult of definite 
 solution. Those who support the latter theory, notably 
 Savill,^* claim that dyspeptic disturbances often pre- 
 cede the symptoms of neurasthenia and ergo neuras- 
 thenia may be provoked by dyspepsia. "Who can tell, 
 however, if the dyspeptic disturbances were not the 
 initial symptoms of neurasthenia ? This much is true, 
 however, that gastric derangements, in fact all ab- 
 dominal affections complicating neurasthenia "are at- 
 tended by depression of spirits, circulatory, and many 
 vague nervous disturbances ; nutrition is seriously em- 
 barassed and there is a decided falling off in weight. 
 
 How a digestive disturbance operates is a matter of 
 conjecture only. There is necessarily a defective nutri- 
 tion of the nerve apparatus and there is also an in- 
 creased elaboration of toxic products. I believe that 
 many cases__ofj£ui:asiliattiaf'ai»dr4--wi«hrpa**ie^^ 
 
 b ejinder RtftOfT^" rny..c£Lrd^^lxtl£aXyJaM*~fdl^,•^mx^x'|^^^m^v^lM^ ~jm 
 
 abdominal origin: that-ja many cases, whatever the 
 na ture of the ailment, theneurasthiania.Tnfiy be referred 
 to a defect in the nerve apparatus which controls the 
 supply of blood in the abdominal cavity, and further- 
 more, that the condition is eradicable by the adoption 
 of certain simple methods based on scientific principles. 
 The form of neurasthenia in question, I will call 
 splamGhfbic neurasthenia^ which will be the subject of 
 discussion in succeeding chapters, 
 4 
 
50 THE BLUES :— NEURASTHENIA. 
 
 SUMMARY. 
 
 1. A congenital degenerate nervous system is not 
 the primary factor in neurasthenia, although such a 
 system will react more easily to irritants which pro- 
 duce the disease. 
 
 2. Deranged bodily functions are often responsible 
 for the neurasthenic state, and their recognition de- 
 mands unusual diagnostic acumen on the part of the 
 physician. The latter will heed the trite remarks of 
 Sir "William Savory : " Consciousness of one's ignorance 
 may do much to avert the errors of carelessness, and 
 he who has confidence in his own judgment should 
 of all rcien be most careful in inquiry. ' ' 
 
 3. The uric acid theory of neurasthenia is most fas- 
 cinating but faulty, and even the latter could be condoned 
 were definite results achieved by treatment executed 
 in accordance with the theory. The patient is not a 
 theoretician but an utilitarian. He visits his physi- 
 cian with a definite object in view, to get well, and 
 mere theories will not influence him. The uric acid 
 theory, it must be conceded, at least inculcates the 
 doctrine of moderation in eating and selection of food, 
 a doctrine which is most salutary in all diseases. 
 
 4. The theory of gastro-intestinal auto-intoxication, 
 while endowed with a modicum of truth, is in a practical 
 sense undeveloped and furnishes no definite clue to the 
 symptoms of self -poisoning nor to its treatment. 
 
 5. Gastro-intestinal disturbances, of whatever nature, 
 seriously compromise the integrity of the nervous 
 system, either by inducing neurasthenia or aggravating 
 it if it exists. 
 
THE CAUSE AND CURE. 51 
 
 6. There is a form of nervousness which I have 
 designated as splanchnic neurasthenia, which is capable 
 of cure, and the treatment is based on definite scientific 
 principles. 
 
 This special form of neurasthenia has heretofore es- 
 caped recognition. 
 
CHAPTEE lY. 
 
 THE GENERAL AND SPECIAL SYMPTOMS OF NEURAS- 
 THENIA. 
 
 MOTOB DISOKDEES. -SENSORY DISTUEBANCES.- EYE SIGNS 
 
 EAE SIGNS.— BEAIN SIGNS.— HEAET SIGNS AND THE PULSE. — 
 PDLMONAEY AlfEMIA.— STOMACH AND INTESTINAL SIGNS.— 
 SEXUAL SIGNS.— FOEMS OF NEUEASTHENIA. — DIAGNOSIS 
 AND PEOGNOSIS OF NEUEASTHENIA. 
 
 The Geneeal Symptoms. These may be divided 
 into: 1. Motor disorders. 2. Sensory disturbances. 
 3. Disturbances of the special senses. 
 
 Motoe Disoedees. Muscula/r fatigue is a constant 
 sign. Muscular contraction is excited through the 
 nervous system by nerve impulses which reach the 
 fibres of the muscle. Such contractions may be volun- 
 tary, automatic or reflex, but, in all instances, they 
 predicate a discharge of nerve force from a nerve 
 center. When a muscle contracts it transforms an 
 equivalent amount of energy. The latter consists in 
 oxidizing food substances contained in its fibers or 
 burning them at a relatively low temperature. The 
 chief food-substances consumed by a contracting muscle 
 are glucose or grape sugar, glycogen and fat. Fatigue 
 of muscle is essentially caused by the consumption of 
 material necessary for contraction and the storing up 
 in the muscle of waste products produced by its own 
 
 53 
 
54 THE BLUES :— NEURASTHENIA. 
 
 activity. Some people naturally tire more easily than 
 others owing to the fact that the waste products re- 
 sponsible for the fatigue in the one are less easily re- 
 moved or accumulate more readily. Massage of the 
 muscles rapidly remo'ves the evidence of fatigue, simply 
 because the waste products from the muscles are washed 
 away into the circulation by this maneuver. The 
 fatigue in neurasthenia probably has its origin in the 
 nervous system and only indirectly in the muscles ; for, 
 if we pursue the same argument which physiologists 
 accept as the cause of muscular fatigue, viz : the 
 accumulation of waste substances, it is reasonable to 
 assume, that a like condition prevails in the nervous 
 system. If one tests the strength of the muscles in 
 neurasthenia by means of the dynamometer, while the 
 muscles may show a diminished response, it is by no 
 means proportionate to the diminished vigor experienced 
 by the patient. 
 
 Marcet,^^ has shown that the time during which an 
 in,dividual can sustain a voluntary muscle contraction is 
 determined by the endurance of the brain centers en- 
 gaged in the act of volition, rather than by that of the 
 muscles themselves. The very moment these centers 
 are exhausted the muscle contraction gives way. An- 
 other fact developed by the same Avriter, and as it 
 seems to me, an important one which can be applied 
 to neurasthenia is, that volition can be fatigued when 
 exerted in imagination as well as in actual muscle 
 effort. 
 
 Muscular tire in the neurasthenic is expressed by 
 general muscular weakness, lack of endurance, a tired 
 feeling, a feeling of never being rested and a sensation 
 of extreme weariness on rising in the morning. In 
 severe cases, patients remain in bed for indefinite 
 
THE CAUSE AND CURE. 65 
 
 periods, having assured themselves by aid of their 
 morbid imagination that they are incapable of any 
 kind of muscular effort. When fatigue symptoms be- 
 come exaggerated, they become painful and are de- 
 scribed by the patient as aches. 
 
 Teemoe. This is often brought out by the slightest 
 muscular effort and Lemarcq, found it present in eighty- 
 five per cent, of neurasthenics. The tremor is a fine 
 one and present most often in the hands, but may be 
 general, including the knees, legs and the closed eye- 
 lids. In pronounced cases, the fine tremor may be 
 substituted by twitching of the muscles, and they may 
 become so pronounced in the face and tongue, that on 
 seeing such individuals for the first time, one is con- 
 strained to think of general paresis. All the reflexes 
 are exaggerated. 
 
 Sbnsoey DisTUEBANCEs.-^ea^acAe is a common sign. 
 It may be constantly present or evoked by any men- 
 tal or muscular effort or some emotion. In most 
 instances, the headache is not really described as an 
 ache, but a feeling of heavy weight or constriction 
 about the head. Some describe the sensation of a 
 closely fitting lead cap on the head. Charcot described 
 the head-sensation as the " casque neurasthenique," a 
 feeling as though the patient were wearing a tight- 
 fitting helmet. The head sensation may be also de- 
 scribed by the patient as a feeling of pressure or ache 
 in definite regions, notably the base of the brain, the 
 top or front of the head or at the temples. Still others 
 experience a heaviness or throbbing and a sensation as 
 if wind or water were running under the scalp. The 
 neurasthenic head sensations usually occur when the 
 patient wakes up and last during the day to disappear 
 on retiring. 
 
56 THE BLUES i-NELTRASTHENlA. 
 
 Backache, or a sensation of Aveariness, is a fre- 
 quent symptom and the older writers referred to this 
 symptom as ' ' spinal irritation. ' ' 
 
 If the signs of so called ' ' spinal irritation ' ' are pro- 
 nounced, the feeling of intense weariness prevents the 
 patient from sitting or standing for any length of time. 
 Women suffer more frequently than men from the back 
 sensations, and a favorite location for the tenderness 
 in women is at the- extreme end of the spine (Coccyg- 
 odynia) 
 
 All cases of backache are not necessarily of neuras- 
 thenic origin but are often due to &, faulty spinal 
 attitude. Thus the attitude of children with " round 
 shoulders" will substitute ligamentous for muscular 
 support. Deformities of the foot, like flat foot, will 
 conduce to pain in the back owing to the faulty atti- 
 tude assumed by such persons. 
 
 Pains in the Limbs. These are sensations various- 
 ly described as hot flushes, tingling, cold, numbness, 
 stiffness, soreness, etc., in any and all parts of the 
 body. In some instances, the pains become fixed in 
 some definite region, as over the heart or stomach, a 
 condition described by Blocq as ' ' topoalgia' ' or local 
 neurasthenia. I'l 
 
 SPECIAL SYMPTOMS. 
 
 Eye Signs. Vision is never seriously affected. An 
 early sign is a blurring of the vision on using the eyes 
 for any length of time and which may become so pro- 
 nounced that the patient is unable to perform any 
 work requiring the use of the eyes for any length of 
 time. Often the vision becomes veiled and things 
 look strange and unreal. Patients often complain 
 
THE CAUSE AND CURE. 5>l 
 
 of a defect in visual memory, i.e., they see some 
 familiar object, it may be a person or a thing, but 
 they do not remember it with their normal facUity. 
 It must be conceded, in the light of modern observa- 
 tion, that there are cases of neurasthenia, may I call 
 them ' ' ocular neurasthenias, ' ' which owe their origin 
 solely to some easily remedied eye defect. Such defect 
 may be due to an error in refraction or to defects in the 
 ocular muscles. 
 
 The remote effects of eye strain may include not 
 only neurasthenia but vertigo, migraine, chorea, and 
 epilepsy. The refractive condition of the eye is rarely 
 normal, and no muscles of the body are subjected to 
 such excessive strain as the ocular muscles. If one 
 wishes to appreciate the effects of eye strain, all that 
 is necessary is to wear for a few minutes the glasses of 
 another person suffering from astigmatism. In the 
 recognition of an ocular defect, the task of the physician 
 is by no means ended. He must determine whether 
 the eye-defect is alone responsible for the symptoms or 
 whether they are aggravated by other conditions, as 
 defective hygiene, bad habits, etc. ; he must treat the 
 nervous system after correction of the ocular defect, 
 and he must direct the patient to an oculist and not an 
 optician. Even all oculists are not specially skilled in 
 correcting errors of refraction and many relegate this 
 important matter to assistants or execute it in a per- 
 functory manner. 
 
 Drooping of the lids, inequality of the pupils or ex- 
 cessive mobility of the iris are symptoms which have 
 been observed in neurasthenia. It has been noted in 
 testing the visual field in neurasthenia, that when an 
 object is brought from without into and across the 
 field of vision that it is seen in wider range than when 
 
58 THE BLUES :-NEURASTHEN1A. 
 
 it is placed in the center of vision and carried gradually 
 outward toward the periphery. This is known as 
 " Foerster''s shifting type,'''' and is the reverse of the 
 normal condition. 
 
 Ear Signs. Abnormal ringing, singing, vsrhistling 
 and roaring sounds may be heard although hearing 
 may be intact. 
 
 As a rule, these signs are associated with some 
 actual disease of the middle ear, in elderly people, 
 with degenerative changes in the blood vessels, and in 
 young persons, vrith some abnormal state of the blood. 
 Hearing in neurasthenics is often hyperesthetic and 
 they show excessive sensibility to noises, the slightest 
 noise startles them. Even melodious music is borne 
 with intolerance. 
 
 Beain Signs. The capacity for mental work becomes 
 diminished. Any mental effort is attended by a sense 
 of fatigue and distress. Fixing the attention on any- 
 thing is deficient and often impossible, -and the ability 
 to originate ideas or to think intelligently or connectedly 
 becomes lessened, or is abolished entirely. There is 
 lack of will power, and this deficiency is frequently ex- 
 pressed by vacillation or indecision. Mental irritc^ility 
 is another sign added to the cerebral manifestations. 
 The patient becomes annoyed at little things which be- 
 fore failed to disturb his equilibrium. There is loss of 
 memory. Ideas do not occur with the usual vigor and 
 patients affirm that ' ' they cannot think straight. ' ' 
 The fear of insanity is common. Attracted by their 
 symptoms, they become introspective, misconstrue 
 their sensations and develop phobias or morbid fears. 
 Morbid fears rarely become insane delusions. Fear 
 in neurasthenics develops as a result of weakness or 
 loss of courage. 
 
THE CAUSE AND CURE. 59 
 
 Some fear to be alone, some fear darkness, others 
 narrow or high places, others crowds and still others an 
 open space, etc. Some fear dirt or infection by dis- 
 ease. A neurasthenic recognizes the absurdity of his 
 fears and is able to dispel them, whereas the hypoch- 
 ondriac regards such fears as actual conditions and 
 cannot be convinced to the contrary. 
 
 Morbid fears are technically described as follows : 
 
 1. Pathophobia, fear of disease. 
 
 2. Claustrophobia, fear of narrow spaces. 
 
 3. Photophobia, fear of light. 
 
 5. Mysophobia, fear of defilement. 
 
 Imperative conceptions and morbid impulses are not 
 unknown conditions in neurasthenia. The former re- 
 fer to ideas which the patient knows are absurd, but 
 which nevertheless occur to him and dominate his 
 thoughts, and often direct his actions. When he is 
 unable to recognize the absurdity of his conception, it 
 becomes a delusion. 
 
 A MoEBiD Impulse is an irresistible desire to commit 
 an act which the patient knows to be wrong. 
 
 Diminished Affection for those dear to him is 
 another sign which often distresses the patient. Es- 
 quirol observes that, " moral alienation is the first- 
 step to madness." The patient becomes irritable, 
 fault-finding and resentful. He dreads meeting ac- 
 '];uaintances or people. He approaches his daily task 
 vvith a sense of weariness. He becomes emotional and 
 lachrymose on the slightest pretext. Pie recounts the 
 history of his illness to every one who will listen and 
 often seems to delight in so doing. As a rule, he re- 
 gards the future with distrust. His feeling of mental 
 depression pictures all sorts of horrible things. He 
 fears that he will never get well or that he will become 
 
60 THE BLUES :— NEURASTHENIA. 
 
 ins:ine or paralyzed. lie cannot bear to read the 
 morning papers lest some accident, or murder or sudden 
 death may distress him. 
 
 Sleeplessness is one of the earliest signs. Some- 
 times there is difficulty in falling asleep, or the sleep 
 is constantly disturbed. Occasionally the sleep is 
 sound and deep, yet the patient awakens in the morn- 
 ing unrefreshed and often feels more depressed than 
 upon retiring. On closing the eyes in bed, there is, 
 at times, sudden jerking of the legs, or a feeling as of 
 falling. When dreams dist^irb the sleep, they indicate 
 that the latter is not sound, but partial. In dreams, 
 the brain is in part awake ; the will is dormant and 
 the imagination runs riot with incongruous and fantas- 
 tic images. When many brain centers are active, 
 dreams are consistent and coherent, while, when few 
 centers are working, they are unreal and extravagant. 
 Dreams are evidence of unsound sleep. The dreaming 
 period, in health, rarely occurs until the time for 
 awakening approaches. If the dreaming period comes 
 on early, there is some disorder present in the body 
 which retards the complete rest of the brain. Attempts 
 have been made to classify dreams, but such classifica- 
 tions, from a psychologic standpoint, are purely 
 arbitrary. 
 
 Restlessness is a frequent symptom. The patients 
 keep continually moving and are always ' ' on the fid- 
 get. ' ' If they are in one place, they want to be some- 
 where else, in fact, they really do not know what 
 they do want. 
 
 Vertigo or a feeling of dizziness or faintness is not 
 an unusual symptom. It is a disturbance of conscious- 
 ness, manifested by apparent movement of external 
 objects, or of the subject himself. If the person 
 
THE CAUSE AND CURE. 61 
 
 himself appears to move, it is known as subjective, and 
 if objects move as objective vertigo. 
 
 Vertigo experienced when reclining, and disappearing 
 on rising, is known as horizontal vertigo. 
 
 The attacks are usually subjective, short in duration 
 and unaccompanied by nausea. "While the sensation is 
 usually experienced while the patient is up and about, 
 some persons feel the sensation while in bed as though 
 they were sinking through it. Yertigo is a cause for 
 alarm in many patients. There is another form of ver- 
 tigo occurring in neurasthenics, which is essentially 
 psychogenetic. It is a sudden sensation of insecurity, 
 a fear of falling or loss of consciousness. In such in- 
 stances there is never any real vertigo, nor do the pa- 
 tients fall or lose consciousness, and the condition is 
 essentially a mental disease. Vertigo is occasioned by 
 such a multitude of conditions that a diagnosis of ' ' neu- 
 rasthenic vertigo ' ' is never warranted until other 
 conditions which are apt to cause it are carefully 
 excluded. 
 
 Heakt Signs. Heart Palpitation is a frequent 
 symptom. 
 
 Palpitation means that the patient is conscious of his 
 heart's action. A conscious knowledge of any organ 
 constitutes disease of that organ, not necessarily or- 
 ganic, but more often functional disease. A person 
 with a healthy heart is not conscious that he has such 
 an organ. In the mild forms of palpitation only a 
 fluttering or sinking feeling is experienced. In the 
 more severe forms, the heart beats violently against 
 the chest, the arteries throb and the action of the 
 heart is increased as many times as 150 pulsations per 
 minute. In nervous palpitation, the face becomes 
 flushed, and after the attacks large quantities of urine 
 
62 THE BLUES :— NEURASTHENIA. 
 
 are passed. An attack may last only a few minutes 
 or may continue for hours. Palpitation is most often 
 caused by some digestive disturbance or may result 
 from emotions or prolonged muscular or mental efforts. 
 
 "Eumpf's symptom," is sometimes present. It 
 consists of making pressure over some painful point in 
 the body which will bring up the pulse from 80 to 90 
 to over 100, and it will remain there for one or two 
 minutes. The heart may be unusually rapid in action 
 (heart hurry), slow, irregular or intermittent. There 
 may be pains localized in the heart region which radi- 
 ate down the arms [false angina pectoris). Cardiac 
 disturbances are most frequent in women, in young 
 persons and in those addicted to the inordinate use of 
 tobacco, tea, coffee and alcohol. In many neurasthe- 
 nics, the heart gives unquestionable evidence of weak- 
 ness, and this is a factor which must be taken into 
 serious consideration in the treatment of the patient. 
 
 The Pulse. Yarious attempts have recently been 
 made by clinicians to endow the pulse in neurasthenia 
 with, certain characteristics, but thus far all efforts in 
 this direction have been practically futile. My studies 
 in arterial tension in this disease show that the pulse 
 is move often of low than high tension, and when the 
 latter exists it is found in full blooded individuals, in 
 whom some form of intoxication may be surmised. 
 Erben, 18 after studying a large number of neurasthen- 
 ics observed that the customary increase in the pulse 
 rapidity that follows the movements of the body did 
 not take place if the patient bent far forward, or, as 
 Ortner pointed out, if they bend their heads backward. 
 After either posture, it was observed that the pulse, 
 after continuing its rhythm for from four to fifteen 
 beats, there was a sudden retardation of the pulse, 
 
THE CAUSE AND CURE. 63 
 
 which continued for about sixteen beats, after which 
 the pulse gradually attained its former rapidity. 
 
 Vasomotor Disturbances. When the vasomotor 
 center is weakened or irritable, flushing and pallor of 
 the skin occur at irregular intervals, specially in women, 
 with cold hands and feet, throbbing noises or fullness 
 in the head, spots before the eyes, dizziness, etc. 
 
 The Urine. This is usually normal, but, after a 
 ' ' nerve storm, " it is passed in large quantities, of a 
 pale color and of low specific gravity. Phosphates 
 may be present in excess as well as indican or oxalate 
 of lime, when the case is one of sexual neurasthenia. 
 
 The Temperature is usually normal, even though the 
 patients experience flushing or burning cutaneous 
 sensations. 
 
 The Blood is usually normal, although there are 
 neurasthenics, specially women and young girls, who 
 show an anemic condition of the blood. I have 
 show elsewhere i^ that anemia is often associated with 
 insufficient lung development, a form of anemia which 
 I have designated as pulmonary a/riem,ia.* In this 
 anemia of pulmonary origin there is not necessarily a 
 diminished number of red blood corpuscles nor of hemo- 
 globin, the element lacking being oxygen (Anoxemia). 
 Individuals, the subject of anoxemia, resist all the con- 
 ventional forms of treatment, but when treated by aid 
 of respiratory exercises to achieve lung development, 
 the anemia disappears. Much benefit is derived from 
 respiratory exercises in the treatment of neurasthenia, 
 and the improvement noted proceeds commensurately 
 with the oxygen-carrying capacity of the blood color- 
 ing matter. Other factors may have been at work in 
 improving the nervous symptoms, for we know that 
 * Appendix, note 1. 
 
64 THE BLUES :— NEURASTHENIA. 
 
 healthy lung ventilation means an increased flow of 
 blood and lymph in the nervous system, and this means 
 an augmented supply of oxygen, improved nutrition and 
 removal of waste products. 
 
 Stomach Signs. The more I observe dyspeptics, 
 the more certain is my conviction that nervousness is 
 responsible for the majority of cases. We are a na- 
 tion of dyspeptics, owing to our ceaseless and intense 
 living methods. Repair is not cornmensurate with 
 waste, and there comes a time to many of us when 
 our functions must suffer. All the organs of the body 
 in health work harmoniously; one is dependent on the 
 other for the normal performance of its work. If one 
 suffers, they all suffer, yet some one organ, it may be the 
 heart, the stomach or the liver, usually bears the brunt 
 of nerve exhaustion. 
 
 Nervous indigestion is a frequent complication of 
 nerve strain. The appetite may be unimpaired and even 
 voracious. At other times, the mere thought of food is 
 repugnant. Often the food eaten lies like a heavy 
 weight. The patient belches and is apt to bring up a 
 sour fluid, giving rise to heartburn. The tongue may 
 be perfectly clean throughout the disturbances of diges- 
 tion. The day has waned when the physician, after 
 casting a furtive glance at the tongue, feeling the pulse 
 and asking a few desultory questions about the stomach, 
 proceeds to prescribe what has been facetiously called a 
 " shotgun " prescription ; embodying pepsin and acid 
 to increase digestion, an alkali to correct acidity, a tonic 
 to promote digestion and a purgative to move the bowels. 
 Such a prescription is as much a contradiction as the 
 " whiskey cocktail " described by the perturbed French- 
 man, " a little whiskey to make it strong, a little water 
 
THE CAUSE AND CURE. (55 
 
 to make it weak, a little lemon to make it sour, a little 
 sugar to make it sweet, and then you say, here's to you, 
 and you drink it yourself." The seientifie physician 
 of to-day takes nothing for granted; he places the pa- 
 tient on a " test meal," after which, he withdraws the 
 contents of the stomach and subjects it to chemic analy- 
 sis. Having ascertained the ingredients of the gastric 
 juice, he is ready to fulfill his duties as an up-to-date 
 practitioner, and prescribe accordingly. In the major- 
 ity of cases of nervous dyspepsia, chemic analysis shows 
 no anomaly, and digestion, is found to have been com- 
 pleted within the normal time limit. The latter facts 
 are alone characteristic of nervous dyspepsia. Were the 
 digestive trouble of a nature other than nervous, there 
 would be decided changes in the gastric juice, and in 
 the character of the digestion. Nervous dyspeptics in- 
 stinctively discover that it is not wise to eat too much 
 when nervous or excited, for it is at such a time that 
 gastric signs predominate. 
 
 Intestinal Signs. The chief sign is constipation. 
 Torpidity of the bowels may run in families. Seden- 
 tary habits, coupled with excessive eating and a disre- 
 gard to the call of nature, as well as the character of 
 the food eaten, are common causes of constipation. In 
 neurasthenia, the muscular tone of the bowels suffers 
 and it becomes incapable of moving the fecal matter 
 onward into the rectum. There are some persons who 
 .are persistently constipated without suffering any in- 
 convenience. A patient once told me, in detailing his 
 symptoms, that as far as his bowels were concerned, 
 they were in perfect condition, as they moved regularly 
 once a week. The majority of persons, however, com- 
 plain that unless they have a daily evacuation they 
 5 
 
66 THE BLUES :-NEURASTHENIA. 
 
 suffer from languor, headache, loss of appetite and de- 
 pression. So potent an influence does a free evacuation 
 have on the condition of well-being that even Voltaire 
 was induced to write : " Those persons who are in good 
 position . . . whose bowels are freed by an easy, regu- 
 lar, peristaltic movement every morning as soon as they 
 have breakfasted . . . those who are thus favored by 
 nature are mild, affable, gracious, kind. A no from 
 their mouth comes with more grace than a yes from the 
 mouth of one that is constipated." 
 
 A recent German writer has collected a large num- 
 ber of cases of neurasthenia dependent wholly on con- 
 stipation and the evil results thereof. He contends, and 
 his contention cannot be questioned, that the bowels 
 normally manufacture poisons which, when ahsorbed, 
 influence the delicate nervous system. Hypochondriacs 
 are usually constipated, and so are the insane. One 
 of my patients, who is an habitual sufferer from consti- 
 pation, and has periodic " nerve storms," finds imme- 
 diate relief after taking a saline purgative. The physi- 
 ology of defecation is practically as follows: The fecal 
 matter formed in the large intestine sets up peristalsis, 
 which moves the fecal mass through the large bowel, 
 dropping it into the rectum. At the latter point " a call 
 of nature " takes place, and evacuation is the result. H 
 no response is made to this " call " by the individual, 
 whether through laziness or attention to other duties, 
 the watery portion of the fecal mass is absorbed, passes ■ 
 into the circulation and intoxicates the nervous system. 
 Persons who suffer from this auto-intoxication have a 
 muddy skin, dark rings under the eyes, cold extremities, 
 an unpleasant taste in the mouth, dark, offensive and 
 
THE CAUSE AND CURE. 67 
 
 insufficient bowel movements and a heavy urine, which 
 leaves a deposit on standing. 
 
 Mucous Enteritis is an intestinal neurosis oc- 
 curring specially in hysteric females and those of a 
 highly neurotic constitution. 
 
 The most important symptom associated with severe 
 colicky pain is the passage at varying intervals of long 
 threads of mucus, which are imperfect casts of the 
 gut. The disease is chronic and obstinate to treatment. 
 
 Sexual Signs. When the symptoms of neurasthenia 
 predominate in the sexual apparatus, we speak of sexual 
 neurasthenia. In neurasthenia the sexual power is 
 usually very much diminished, either by incomplete 
 erections, premature ejaculations or night emissions. 
 Married men find this weakness a source of much mental 
 suffering, and the constant fear of impotency prompts 
 them to seek medical advice. It is, without doubt, true 
 that the majority of functional troubles of the sexual 
 organs are of a neurasthenic nature. Whatever the 
 changes may be in his sexual apparatus, the unfortunate 
 sufferer is inclined to exaggerate them by a vivid imagi- 
 nation or the perusal of quack advertisements. ]S}"ormal 
 ingredients of the urine, such as phosphates and urates, 
 passed by such persons, are declared by charlatans, to be 
 seminal fluid. Although seminal fluid may be passed 
 during urination or defecation, it is nevertheless a rare 
 occurrence. 
 
 Involuntary seminal emissions in a healthy unmar- 
 ried man, occurring at different periods, must always 
 be regarded as an evidence of good health. It is only 
 when the emissions are followed by depression, vague 
 pains in the head, and a feeling of exhaustion, that they 
 are to be regarded as harmful. Some individuals suffer 
 
68 THE BLUES :— NEURASTHENIA. 
 
 no inconvenience from night emissions, occurring even 
 as often as several times a week, vyhereas, in others, 
 a simple emission once a week, or even less often, is 
 attended by the signs previously noted. Seminal emis- 
 sions may be the cause of nerve depression, not the con- 
 sequence of the loss of semen, but from the nerve 
 exhaustion following. More often, the emissions are 
 the result of nerve depression. It frequently happens 
 that sufferers from seminal emissions attribute their 
 troiible to the habit of self-abuse. While the habit is 
 unfortunately well nigh universal among both sexes 
 and animals, and frequently attended by dire results, 
 the latter have, no doubt, been greatly exaggerated. 
 
 Spermatorrhea, or the passing of semen with the 
 urine or during defecation, is indicative of grave de- 
 bility of the sexual apparatus. It is usually the result 
 of neglected or improperly treated seminal emissions. 
 Many cases of so-called spermatorrhea, it must be em- 
 phasized, are really urethral discharges, other than 
 semen. The microscope alone can determine the nature 
 of the discharge. 
 
 Impotence signifies one of the following conditions. 
 1. Deficiency of desire and power. 2. Deficiency of 
 power with increased desire. 3. Abnormal erectile 
 power, known as priapism, in which there is no dis- 
 charge of semen. Very often the impotence is imag- 
 inary, a form known as psychical impotency. It is 
 strange that people are not better educated in regard 
 to their sexual functions. All they learn is of a sug- 
 gestive nature by the reading of erotic literature and 
 quack advertisements. Among the prominent symp- 
 toms of sexual neurasthenia, are: dimness of vision, 
 back pains, mental depression and defective memory, 
 
TaE Cause and cure. 6d 
 
 dyspepsia, palpitation of the heart and dizziness. In 
 women, sexual neurasthenia presents symptoms similar 
 to those of man, although they occur with less frequency. 
 Some suffer from nocturnal orgasms, accompanied by 
 dreams, and they awake feeling nervous, depressed and 
 exhausted. In married women, the sexual appetite may 
 be increased at first, but it rapidly disappears, to be fol- 
 lowed very often by distaste or even disgust. 
 
 The Sexual Hypochokdkiac. This unfortunate 
 creature, boy, girl, man or woman, usually lives a life 
 of profound despondency, the result of a real or fancied 
 disturbance of the sexual organs. Such cases demand 
 a true explanation of the disorder, but when the morbid 
 state of mind is encouraged by the charlatan, only dire 
 results follow. There is no sufferer to whom truth is 
 more repellant than the sexual hypochondriac, in fact, his 
 morbid fear is a delusion which he wishes to have veri- 
 fied. The sexual hypochondriac may be the victim of 
 one of the following disorders : Involuntary seminal dis- 
 charges, impotency, masturbation, or syphilophobia. 
 
 Involuntary seminal discharges are quite natural and 
 occur in all persons who lead a correct and continent 
 life, and are not unlike menstruation occurring in 
 women at periodical intervals. The " night emissions " 
 are not necessarily the involuntary discharge of semen, 
 but are often made up of a fluid derived from the pros- 
 tate gland. Some persons secrete a larger quantity of 
 prostatic fluid than others, hence it is quite within the 
 limits of health for such individuals to have involuntary 
 discharges at more frequent intervals. Then, again, 
 the character of food eaten has a notable influence on 
 the amount of seminal or prostatic fluid secreted. The 
 milky character of the urine in the sexual hypochon- 
 
70 taE Blues :— NiiufeASTHENlA. 
 
 driac is not semen but phosphates, a fact which is made 
 evident when a little acid is added to the urine, result- 
 ing in the complete disappearance of the milky character 
 of the urine. The mucilage-like fluid observed at the 
 head of the penis, after stool, is often of no consequence, 
 consisting, as it often does, of the secretion of the pros- 
 tate gland. 
 
 Impotency, or fondly called, " lost manhood " by the 
 advertising quack, is in most instances an imaginary 
 condition. True manhood finds no index in the vigor 
 of the sexual apparatus. The more man approaches the 
 condition of brute creation, the more powerful is his 
 sexual instinct. 
 
 As man and woman ascend the scale of moral and 
 social life, there is less inclination for the performance 
 of the sexual act. Such individuals are both potent 
 and impotent at times. The best type of a married man 
 is only potent in the presence of his consort. If he 
 demonstrates this potency toward another, his moral 
 standard is as low as the negro who commits rape as 
 often as occasion permits. An indefinite number of un- 
 foreseen conditions, like mental and physical fatigue, 
 disgust, worry and anger, conduce to make every man 
 impotent at times. The fear and timidity which possess 
 the newly married are evidences of morality and not 
 sexual weakness. It has been estimated by a trust- 
 worthy statistician that at least 60 per cent, of young 
 husbands fail in the first attempt after marriage. .There 
 are many individuals who are impotent, owing to their 
 overwhelming fear of contracting some disease. There 
 are persons who manifest impotency toward certain 
 women, but who are fully capable of performing the 
 act with others. 
 
THE CAUSE AND CURE. 71 
 
 Unnatural practices are bound to be followed by Im- 
 potency. The sexual act, when aroused by artificial 
 means, finds no response when invoked by natural 
 methods. Sexual psychopathy, or the attainment of 
 sexual desire by unnatural means, is a stigma of degen- 
 eration manifested in persons who have inherited or ac- 
 quired a defective nerve organization, and is common 
 among the insane. 
 
 MASTTJEBATioiir may conduce to severe disturbances in 
 the mental and physical health, but as the habit is 
 stopped at an early period of life, as soon as the inde- 
 cency of the habit is explained, no possible consequences 
 ever arise. We must all encounter a period in life when 
 there is a conflict between the passions and one's better 
 self, but the latter is usually the victor in the combat. 
 It is not an exaggeration to maintain, that, in the ma- 
 jority of instances, the evils arising from masturbation 
 practiced moderately, and for a short period in youth, 
 are largely mental, developed from the loss of self-re- 
 spect and the sense of unmanliness. 
 
 FoEMs OF ISTeueasthenia. Beard makes the follow- 
 ing classification of neurasthenia : 
 
 1. Cerebral neurasthenia (cerebrasthenia, cerebral 
 exhaustion). 
 
 2. Spinal neurasthenia (myelasthenia, spinal ex- 
 haustion). 
 
 3. Digestive neurasthenia (nervous dyspepsia). 
 
 4. Sexual neurasthenia (sexual exhaustion). 
 
 5. Traumatic neurasthenia (traumatic exhaustion). 
 
 6. Hemi-neurasthenia (hemi-exhaustion). 
 
 Y. Hysterical neurasthenia (hysterical exhaustion). 
 
 A more modern classification is that of Dana.^" Here 
 
 the types of neurasthenia are made dependent upon 
 
72 THE BLUES :— NEURASTHENIA. , 
 
 the age, the sex, and the hereditary endowments of the 
 individual. 
 
 Peimaet Neurasthenia. Neurasthenia appearing 
 at the adolescent period is likely to be associated with a 
 primarily weak and nervous constitution. Mental 
 symptoms predominate, assuming the character of hypo- 
 chondriasis with fixed ideas or morbid fear. Sexual 
 ideas and symptoms likewise predominate. 
 
 HYSTEKO-NBtTBASTHENiA. Occurs in women asso- 
 ciated with hysteria. Much pain along the back, gives 
 rise to the condition known as " spinal irritation." 
 
 AcQuiEED Neurasthenia and Lithemia. Here, the 
 element of heredity is less marked, while the extrinsic 
 causes of neurasthenia dominate the situation, viz. : 
 Excessive eating, -drinking, shocks, injuries, poisons, 
 syphilis, and gouty tendencies. This form occurs dur- 
 ing the active period of life. 
 
 Climacteeic. This develops in the middle life and 
 is associated with arterial degeneration and a dimin- 
 ished resistance of the body generally. Physical weak- 
 ness is greater, associated with vasomotor disturbances, 
 and a tendency to melancholia. 
 
 Traumatic Neueasthenia. After injuries, how- 
 ever slight, but associated with fright and emotional 
 disturbance, the patient develops all the symptoms of 
 neurasthenia. The latter may consume several weeks 
 in developing, and do not always immediately follow the 
 injury. Such cases usually end in litigation and the 
 worry, incident to the trial, will aggravate the symp- 
 toms. After the trial the patient may get well, but this 
 is, by no means, the invariable rule. 
 
 Spinal Ieritation. In this form, to the picture of 
 neurasthenia is added painful symptoms related chiefly 
 
THE CAUSE AND CURE. 73 
 
 to tbe sensory nerves of the spine. The pain predomi- 
 nates in the lower part of the back and also in the back 
 of the neck. Exertion intensifies the pain. Relief and 
 comfort seem only to be secured by rest in bed, so they 
 go there and remain. 
 
 The spinal processes are sensitive to pressure and the 
 painful points vary at each examination. The arms 
 and legs are exceedingly weak, incapacitating the sub- 
 ject from any kind of exertion. 
 
 The duration of the affection may extend into years 
 or their invalidism may become permanent. While the 
 symptoms are essentially referred to the spine, the real 
 trouble has its seat in the brain, which mental sensitive- 
 ness aggravates. 
 
 ISTeueasthenia with Fixed Idea. This form is as- 
 sociated with a fixed idea of a depressing character relat- 
 ing either to fright or remorse, and worries and harasses 
 the patient through every moment of the waking hours. 
 The fixed idea may center itself on an intense fear of 
 death or that there is an incurable heart or kidney 
 trouble. Such patients may for a time be persuaded 
 to release themselves from their obsession, but it soon 
 recurs, despite all their efforts. 
 
 AwGioPATHic Neurasthenia. Here the vasomotor 
 symptoms predominate. Pulsation or beating of the 
 blood-vessels involves the whole body. 
 
 Grave N^eueasthenia. This is characterized by a 
 severe and serious type of exhaustion, both mental and 
 physical. Emaciation is a prominent sign. Only tem- 
 porary benefit results from treatment, and many of the 
 patients pass into permanent and hopeless invalidism. 
 Men who have reached or passed the middle period of 
 life are the usual subjects, and the condition suggests a 
 premature senescence of the nervous tissues. 
 
^^4: I'HE fiLUES :-NEUEASTHEN1A. 
 
 Diagnosis. There are several affections closely re- 
 lated to neurasthenia, and the boundary line is very 
 often so severely drawn that a differentiation from them 
 can only be determined by the results of treatment, time, 
 the judgment of the physician, and the vs^illingness of 
 the subject to patiently submit himself as an object of 
 study, of which time is the essence. A better under- 
 standing will thus be mutually established between the 
 physician and the patient, for the latter, like all neu- 
 rasthenics, will agree with Avieenna, " I prefer confi- 
 dence before art, precepts and all remedies whatever." 
 " Medical art," says Hippocrates, " consists of three 
 things: the patient, his malady, and the physician." 
 Moxon's witty paradox is also apposite. " It is quite as 
 important to know what kind of a patient the disease 
 has got, as to know what sort of a disease the patient 
 has got." 
 
 The diagnosis of neurasthenia, or its allied affec- 
 tions, is only warranted after a most painstaking exami- 
 nation of the patient. It is always wise in the exami- 
 nation of the subjects to regard neurasthenia merely as 
 a symptom rather than a disease, and to seek for some 
 local disturbance which reflexly instigates the nervous 
 symptoms. This statement may not receive the sanc- 
 tion of conventionalism, but evidence is rapidly accu- 
 mulating in support of this contention. The following 
 affections suggest differentiation : 1. Hysteria, 2. Hy- 
 pochondriasis. 3. Melancholia. 4. General paresis. 
 5. Insanity. 
 
 No physician can afford to depend on any single 
 method in diagnosis. Pathognomonic signs are as un- 
 common as specific drugs in disease, and the truly 
 skilled diagnostician is he who is catholic and eclectic 
 
THE CAUSE AND CUKE. 75 
 
 in the selection of his methods, and the most painstak- 
 ing in their application. 
 
 THE PATHOGNOMONIC SYMPTOxMS OF THE 
 VAEIOUS AFFECTIONS. 
 
 Neurasthenia. T^gtio-no ia tViP primgry gnrl -fm^rlg- 
 
 exertion. There is always a cause, notably over use and 
 abuse of functional activity abetted by a nervous sys- 
 tem, vyhich responds readily to irritants, but does not 
 recover in like ratio. The perverse reaction of the irri- 
 table, weakened nerve apparatus is characterized by sen- 
 sory, motor, vasomotor and psychic disturbances. The 
 prognosis is favorable. 
 
 Hysteria. Neurasthenia in men is in many re- 
 spects the equivalent of hysteria in women, modified 
 by sex, and with symptoms less developed. In hysteria 
 there is diminished control over the emotions, and the 
 symptoms occur in paroxysms (nerve storms) although 
 in the inter-paroxysmal period, the stigmata of the af- 
 fection are nearly always evident, viz: hysterogenic 
 zones, areas of anesthesia, hyperesthesia, etc. There is 
 a tendency to practice deception, a morbid craving for 
 sympathy, and a perversion of the moral nature. The 
 affection is of indefinite duration, although the hyster- 
 ical temperament lasts a lifetime. 
 
 ITypochondeiasis. Confined almost exclusively to 
 the male. An isolated mental disturbance with a 
 groundless fear of disease, which has no real existence, 
 but exists only in the imagination of the patient. Hy- 
 pochondriacs are bodily well with few or no stigmata 
 of neurasthenia. The cause is usually a solitary or 
 sedentary life. There is an hereditary taint. It begins 
 
te ME BLUES i-NEURASTHENIA, 
 
 gradiially and runs an even course of indefinite dura- 
 tion. The patient does not relax in his endeavors to 
 seek a remedy for his imaginary affection. 
 
 Melancholia. In the early stages of this affec- 
 tion there is a close resemblance to neurasthenia, and 
 the latter has been frequently defined as an abortive 
 form of melancholia. The rapid emaciation, frequent 
 pulse, persistent insomnia, extreme mental depression 
 vifith delusions and suicidal tendencies are signs which 
 distinguish this affection from neurasthenia. 
 
 General Paeesis. The symptoms of neurasthenia 
 in the primary stage are often responsible for errors in 
 diagnosis. In paresis, however, the mental disturb- 
 ances are more pronounced. Failure of memory, with 
 expansiveness of ideas, inability to write and spell cor- 
 rectly, tremor of the face, hands and tongue, and un- 
 equal pupils are signs which suggest paresis. 
 
 Folsom's diagnostic description of the early stages of 
 paresis is worthy of citation : " It should arouse sus- 
 picion if, for instance, a strong, healthy man, in or near 
 the prime of life, distinctly not of the nervous, neurotic 
 or neurasthenic type, shows some loss of interest in his 
 affairs or impaired faculty of attending to them ; if he 
 becomes varyingly absent-minded, heedless, indifferent, 
 negligent, apathetic, inconsiderate, and although able to 
 follow his routine duties, his ability to take up new work 
 is, no matter how little, diminished ; if he can less well 
 command mental attention and concentration, concep- 
 tion, perception, reflection, judgment; if there is an 
 unwonted lack of initiative, and if exertion causes un- 
 wonted mental and physical fatigue ; if the emotions are 
 intensified and easily change, or are excited readily 
 from trifling causes; if the sexual instinct is not rea- 
 
THE CAUSE AND CURE. 77 
 
 sonably controlled ; if the finer feelings are even slightly 
 blunted; if the person in question regards with placid 
 apathy his own acts of indifference and irritability and 
 their consequences, and especially if at times he sees 
 himself in his true light, and suddenly fails again to 
 do so; if any symptoms of cerebral vasomotor disturb- 
 ances are noticed, however vague or variable." 
 
 Insanity. Savill,^* in his excellent treatise, refers 
 to a mental disorder which is special to neurasthenia. 
 The recognition of such a mental state is of the utmost 
 importance, as such patients require no restraint nor 
 asylum treatment. It differs from true insanity in six 
 respects : 
 
 1. Marked bodily weakness precedes and accom- 
 panies the disorder. 
 
 2. The condition is curable by appropriate measures 
 after a duration of a few weeks or months. 
 
 3. The most prominent feature of the mental condi- 
 tion is mental weakness. Delusions and hallucinations, 
 as a rule, are absent. 
 
 4. It is diificult to make it correspond with any of 
 the types of insanity found in asylums. 
 
 5. The mental symptoms vary from day to day, and 
 lucid intervals occur from time to time, during which a 
 casual observer might find nothing wrong with them. 
 
 6. There is no family history of insanity. 
 
 Prognosis. As a rule, neurasthenia is a curable dis- 
 ease. The duration and permanency of cure is a mat- 
 ter based on the individual treated and the judgment 
 of the physician in the application of his resources. 
 The individual must be regarded from the following 
 standpoints : 
 
 1. History of heredity. 
 
78 THE BLUES :— NEURASTHENIA. 
 
 2. His nerve capital. 
 
 3. His environment. 
 
 4. His habits. 
 
 First of all, heredity plays only a subordinate role 
 in neurasthenia, provided the patient can be made con- 
 scious of the fact, that nerve health is a matter of indi- 
 vidual effort in the direction of rigid regard of hygienic 
 laws. If there is an abundance of reserve nerve capital, 
 a few weeks or months, will suffice to restore the indi- 
 vidual to a condition of well-being. Environment and 
 habits determine the permanency of a cure and relapses. 
 If the patient subjects himself after recovery to the 
 causes which induced his disease, he soon suffers from 
 another attack of nervous breakdown, drifts into a state 
 of chronic invalidism or becomes an habitue of some 
 drug habit. An attack of neurasthenia cripples a nerv- 
 ous system, and predisposes to other attacks, so that 
 eternal vigilance becomes the keynote of health. As a 
 rule, however, the neurasthenic enjoys a long life, for 
 he is ever conscious of his past experience, which guides 
 him safely along the pathway of hygienic living. Of 
 consumption, one has truly said, " If I knew what pro- 
 duced it, I could cure it. ' ' Just so with neurasthenia, 
 we know what will produce it, but do we give due regard 
 to the details in the patient's life history, any one of 
 which, if not eliminated, Avill suffice to perpetuate the 
 disease ? Our standard of progress is not evidenced by 
 the introduction of new drugs, the delirium of Avhich 
 threatens to annihilate rational therapeutics. Reliance 
 on the healing power of nature is an evidence of erudi- 
 tion. It affords the discerning physician an oppor- 
 tunity of knowing what not to do, and enables him to 
 apply the highest principles of the therapeutic art. 
 
THE CAUSE AND CURE. 79 
 
 SUMMARY. 
 
 1. Fatigue and the proneness to it is the primary 
 and essential sign of neurasthenia. It is relieved by 
 rest and instigated by exertion. 
 
 2. Neurasthenia is a functional disease, and the ex- 
 clusion of organic disease is absolutely essential before 
 the diagnosis of neurasthenia is warranted. Disease is 
 the sphinx of medicine. The interpretation of the signs 
 constitutes diagnosis, which is the (Edipus of medicine. 
 The translation may be correct, partially correct or 
 wrong. In all three instances, the result, as far as the 
 patient is concerned, will, as a rule, be the same, pro- 
 vided no treatment is instituted. To treat a disease, 
 other than by expectant methods, where the diagnosis is 
 in question, is adding insult to injury. 
 
 3. The objective are subsidiary to the subjective 
 symptoms in neurasthenia, for it is more often necessary 
 to know " what kind of a patient the disease has got, 
 as to know what sort of a disease the patient has got." 
 
 4. The patient who expects the physician to make 
 an immediate diagnosis, is a believer in miracles and, 
 carrying his absurdity to extremes, predicts like results 
 from treatment. Such a patient should be admonished 
 to consult Providence and not a physician, for he is as 
 mad as his nerves. 
 
 5. Neurasthenia lies on the borderland of insanity, 
 and if the patient is not even mildly insane, his symp- 
 toms are often severe enough to make him so. 
 
 6. The prognosis is dependent on a multitude of 
 factors : the patient, his habits, the cause of his disease, 
 the severity of reaction on the part of his nervous sys- 
 tem, etc. As a rule, the prognosis is good, for the logical 
 
80 THE BLUES :— NEURASlliENIA. 
 
 tendency of a pathologic condition is always toward a 
 physiologic ending. 
 
 " But, after all, I am a man, and not a theorem. A 
 system cannot suffer, but I suffer. Logic makes only 
 one demand — that of consequence; but life makes a 
 thousand ; the body wants health, the imagination cries 
 out for beauty, and the heart for love; pride asks for 
 consideration, the soul yearns for peace, the conscience 
 for holiness; our whole being is athirst for happiness 
 and for perfection ; and we, tottering, mutilated, and in- 
 complete, cannot always feign philosophic insensibility; 
 we stretch out our arms toward life, and we say to it 
 under our breath, ' Why — why — ^hast thou deceived 
 me ? ' " — Henei Fkedeeic Amiel. 
 
 And, I may append to the foregoing, because thou 
 hast deceived nature. 
 
CHAPTEK V. 
 
 THE GENERAL TREATMENT OF NEURASTHENIA. 
 
 OBJECTS OF TEEATMENT. ELIMINATION OF FACTOES 
 
 CONDUCIVE TO THE DISEASE. TEEATMENT OF THE 
 
 DISEASE. CLIMATE. TEEATMENT OF THE SYMP- 
 TOMS : INSOMNIA, HEART, STOMACH, INTESTINAL, AND 
 SEXUAL SYMPTOMS. HYPNOTISM AS A MODE OF CUEE. 
 
 The physiologic treatment of neurasthenia in general 
 aims to fulfil the following objects : 1. The removal of 
 the cause; 2. The treatment of the disease; 3. The 
 treatment of symptoms. 
 
 Under physiologic treatment is comprised the use of 
 remedial measures, other than the use of drugs, by 
 which the natural powers of the human body are so- 
 licited to combat disease. These natural measures can- 
 not be supplanted by the most skilful drugging, and 
 should be employed by the progressive physician to the 
 exclusion of drugs in such a disease as neurasthenia. 
 The monumental work of Solomon Solis Cohen, entitled 
 " A System of Physiologic Therapeutics," recently is- 
 sued in eleven octavo volumes, is an enduring tribute 
 to the value of physiologic therapeutics. 
 
 Elimination of Eactoes Conducive to Weueas- 
 TiiENiA. The ideal aim of the physician is unquestion- 
 ably the removal of the cause of neurasthenia, but even 
 6 8X 
 
82- THE BLUES :— NEURASTHENIA. 
 
 though this is possible, there yet remains the disease, 
 the effect of the cause, which must claim attention. 
 
 Sleep is, without doubt, the natural restorative of a 
 fagged brain. The writer, when suffering from. brain 
 tire, finds mo^e relief by three day's absolute rest in bed 
 than by a sojourn of two weeks in the country after the 
 conventional manner. Sleep is, however, a restorative 
 that cannot always be summoned at will. The inventor, 
 speculator, student and business ma^ must seek mental 
 recreation. The brain worker who seeks diversion and 
 does so constrainedly defeats the object of such diver- 
 sion. The diversion adopted must be agreeable. Travel 
 is often suggested as a method of mental recreation, but 
 it is often done in such a perfunctory way that the vic- 
 tim returns to his habitual routine work more exhausted 
 than recuperated. " They may change their skies, but 
 not themselves." Indulgence in extraneous literature, 
 the cultivation of a fad, some regulated exercise, like 
 golf, bicycling, hunting, etc., are excellent means of 
 diversion. Employment prevents melancholy- — it is 
 restful to the body. Inaction, idleness and the Constant 
 pursuit of pleasure, simply encourage premature old 
 age. Above all things in seeking physical exercises as a 
 means of diversion, one must be sure to avoid physical 
 overwork. Physical exhaustion is naught else but nerv- 
 ous fatigue, for every physical act is the result of 
 nervous energy. The limit of physical exercise is fa- 
 tigue. Rational exercise is not nerve exertion, but a 
 gradual and progressive use of muscles, diverting the 
 blood from the overtaxed brain throughout the entire 
 body. JTeurasthenics, who over-exercise, develop poi- 
 sons equally as injurious as those generated by brain 
 strain. 
 
THE CAUSE AND CURE. 83 
 
 Belief foe Wokeiment. " Worry, not work, 
 kills." Worry in persons previously unaccustomed to 
 great responsibilities is one of the greatest factors in 
 the premature loss of health and life. Worry, grief, 
 passion and fretting are powerful nervous shocks. They 
 arrest the functions of digestion and impair the bodily 
 functions. 
 
 Self-Control is a resourceful palladium against 
 nervous prostration. The latter affection is rarely en- 
 countered in those who have acquired a knowledge of 
 self-government. I refer to neurasthenia, incited by 
 ■worry, fretting, and emotional disturbances of any kind. 
 From what has preceded, we already know that there 
 are forms of neurasthenia which develop and are be- 
 yond the control of the individual. Man has been de- 
 fined as " a creature looking before and after." He 
 must know what his powers and limitations are before 
 he can intelligently exercise them to the benefit of his 
 mind and body. Man, by his unbridled indulgence of 
 his passions, is continually paying the penalty for his 
 sacrifice of self-control. We must, therefore, guard 
 ourselves from drifting upon the shoals of nervous 
 degradation. When nervous breakdown once occurs, re- 
 covery is only possible to a certain extent, and relapses 
 are frequent. As Courtney put it : " Hardly any of 
 them come out of the conflict unscathed, and though 
 many recover sufficiently to cope with the ordinary 
 duties and trials of life, they are never quite capable 
 of weathering its real storms." 
 
 THE TREATMENT OF THE DISEASE. 
 
 The Rest Cuke. In a little book, " Fat and Blood 
 and How to Make Them," Dr. Weir Mitchell has ere- 
 
84 THE BLUBS :— NEURASTHENIA. 
 
 ated a new era in curative medicine, and the victims 
 of nervous prostration and hysteria are his debtors. He 
 has simplified a task heretofore almost impossible of 
 attainment, viz. : The cure of a pronounced case of 
 nervous prostration. It would be ridiculous to affirm 
 that all cases can be cured by the rest cure, any more 
 than to say that any method of treatment, yet devised, 
 will cure all cases of the disease to which it is adapted. 
 This much one can conscientiously and conservatively 
 say — it cures and benefits a large percentage of cases 
 where the dominant causative factor is overwork, result- 
 ing from a perennial unrest of body and mind, while 
 in a sm'all percentage of cases, it aggravates rather 
 than benefits the disease. For instance, in splanchnic 
 neurasthenia, as well as in other forms, the rest cure 
 alone, gives only temporary relief, insomuch as the 
 therapeutic manoeuvres incident to the rest cure increase 
 the resistance of the nervous system, and make it less 
 responsive to a multitude of irritants. 
 
 The cardinal points of the rest cure are isolation of 
 the patient, rest with exercise and over-feeding. A rest 
 cure attempted at the patient's home is rarely attended 
 with success, hence the necessity of absolute isolation, 
 that is, the execution of the cure away from home to ob- 
 tain the necessary control of the patient. The most im- 
 portant element of treatment is moral control. Loving 
 and sympathetic relatives can never appreciate the na- 
 ture of the patient's symptoms. There are some pa- 
 tients who thrive poorly on absolute isolation, in which 
 instances they are occasionally permitted to see at in- 
 tervals their friends and members of their family. An 
 intelligent nurse is indispensable — a poor nurse is worse 
 than useless. The details of the method are essentially 
 
THE CAUSE AND CURE. 85 
 
 as follows: The patient is confined to bed, and under 
 no circumstances is allowed to get up, to read, or write. 
 The patient is even fed by the nurse, the object being 
 to secure perfect passivity of mind and body. Absolute 
 rest is not always enforced, the method being modified 
 to suit the individual ease. It is the rule for patients 
 to affirm that it is impossible for them to remain in bed 
 continuously, and it is but natural that they should 
 make this statement, for their extreme restlessness only 
 announces the instability of their nervous system. Con- 
 trary evidence is soon forthcoming after absolute rest 
 in bed and the manifestations of nerve irritability are 
 subdued. It is then that they share the enthusiasm of 
 the poet, when they proclaim : " O, bed ! O, bed ! de- 
 licious bed ! That heaven upon earth to the weary 
 head ! " 
 
 After rest in bed for several weeks the patient is al- 
 lowed to sit up. To facilitate digestion and build up 
 nutrition during the rest cure, massage and electricity 
 are employed daily. Massage and electricity give exer- 
 cise to the unused muscles, improve the circulation and 
 promote the absorption of nourishment. Insomuch, as 
 nearly all neurasthenics suffer from indigestion, and 
 consequently imperfect body nourishment, diet is a most 
 important factor in the rest treatment. Great discretion 
 must be exercised by the physician in the selection of the 
 proper diet, and when this is accomplished, it is sur- 
 prising what prodigious quantities of food can be taken 
 by the patient undergoing the rest cure. The improve- 
 ment in nutrition is manifested by increase in weight, 
 which may be all the way from 10 to 40 pounds. In 
 many individuals hydropathic treatment is employed, 
 with water at varying degrees of temperature, and it is 
 
86 The blues :=NEURASTHENIA. 
 
 surprising to note the sedative and tonic influences of 
 cold water when the patient is accustomed to its use. 
 
 The Partial Rest Treatment. In cases of mild 
 neurasthenia, and for patients who cannot give up their 
 entire time to the full rest treatment, which is often 
 the case in men, the following partial rest treatment 
 may be employed: On waking in the morning, a cup 
 of cocoa is taken, and the patient should remain in bed 
 twenty minutes longer; after this, the patient rises and 
 takes a cool or cold sponge or shower bath, after which 
 the skin is vigorously rubbed with a rough towel ; fol- 
 lowing the bath, breakfast is taken, after which the 
 patient should lie down for an hour and remain at 
 absolute rest, without reading. At 10 : 30, a glass of 
 milk is taken, when the patient may go out for a walk 
 or drive or attend to business. At 1 o'clock luncheon 
 or dinner is taken, after which meal the patient should 
 lie down for an hour. In the afternoon any recreation 
 may be taken, or attention paid to business until 6 : 30, 
 when dinner or supper is taken, followed by rest for an 
 hour. At 9 : 30 the patient should retire for the night. 
 Massage should be taken once a day; before rising in 
 the morning, after the morning cup of cocoa, or in the 
 evening before retiring. A wineglassful of malt should 
 be taken with each meal, and if the patient has impov- 
 erished blood, some simple iron preparation should be 
 taken. In conclusion, " It is reiterated," says Courtney, 
 " that affections of the brain and nervous system are in 
 greater measure preventable than those of other parts ; 
 consequently the mental and nervous salvation of the 
 individual is, practically speaking, to a very marked 
 extent, within his own hands, and may be worked out 
 
THE CAUSE AND CURE. 87 
 
 by him through rigid attention to the guidance of hy- 
 gienic laws." 
 
 THE TREATMENT OF SYMPTOMS.— INSOMNIA. 
 
 The Theoeies of Sleep. The cmeTnic theory sup- 
 poses that during sleep there is a decreased amount of 
 blood in the brain. The toxic theory supposes that in 
 consequence of the wear and tear of the body tissues, 
 waste products are generated which have a benumbing 
 influence on the brain cells, which preside over the 
 senses. A strong proof of the latter hypothesis is ad- 
 duced by the following observation of Striimpell : A 
 young man had lost all power of sensation except in the 
 right eye and the left ear. When the former was cov- 
 ered by a bandage and the latter stopped by a plug 
 the brain of the subject was practically isolated from 
 the outer world, and the invariable result was genuine 
 sleep. ' ' The substance of the brain, ' ' says Ham- 
 mond, in ' ' Sleep and Its Derangements, " "is con- 
 sumed by every thought, by every action of the will, 
 by every sound that is heard, by every object that 
 is seen, by every odor that is smeUed, by every pain- 
 ful or pleasurable sensation, and soon each instance 
 of our lives witnesses the decay of some portion of 
 its mass and the formation of new material to take its 
 place. ' ' 
 
 During sleep the physical and mental functions are at 
 rest. Sleep is more essential to life than food. In sleep, 
 muscular relaxation is absolute, and the amount of air 
 inspired by a normal man is one-seventh of that used 
 during similar periods of quiet wakefulness. The pulse 
 is less rapid, and the brain contains less blood. The 
 
88 THE BLUES :— NEURASTHENIA. 
 
 first few hours of sleep are the most valuable, because 
 they are most profound. 
 
 Amount of Sleep Necessaey. In the time of 
 Solomon, the twenty-four hours were divided into three 
 parts — eight hours for labor and occupation, eight hours 
 for rest, refreshment and recreation and surcease of all 
 labor, and eight hours for sleep. The object of sleep is 
 the reconstruction of overworked organs, and it would 
 be too arbitrary to determine the number of hours neces- 
 sary for sleep, for its real value lies more in the inten- 
 sity of sleep than on its duration. Again, the amount 
 of sleep necessary is commensurate with the mental and 
 physical exercise of the waking hours. Eight hours 
 of a disturbed, dreamy sleep is barely the equivalent 
 of two hours of a deep, dreamless sleep. For this rea- 
 son, we can easily understand why men of the greatest 
 mental activity are usually the briefest sleepers. Fred- 
 erick the Great required only five hours' sleep, and Pitt 
 only three hours. Brown says, that at four years, twelve 
 hours' sleep are needed; at fourteen years, ten hours; 
 at seventeen, nine and one-half hours; then seven or 
 eight hours during adult life. In old age, continuous 
 sleep is rare and the necessity less; but frequent naps 
 during the day and night make up the average. In cold 
 countries more sleep is required than in warm climates. 
 The length of time a person can live without sleep is 
 about three weeks. 
 
 Conditions Favoeing Sleep. A well ventilated 
 room, cool, dark and quiet. A comfortable bed with 
 a moderate amount of covering. Mental worries and 
 intense thoughts interfere with sleep. Sleep is a power- 
 ful habit. A person who awakens at a certain hour for 
 several successive nights, eventually establishes the habit 
 
THE CAUSE AND CURE. g9 
 
 of awakening at that hour. The habit should be culti- 
 vated of retiring and awakening at a definite hour. 
 
 The Cause of Insomnia oe Sleeplessness. Prof. 
 See divides all causes of insomnia into: 1. Psychical, 
 and 2. Physical. The causes of psychical insomnia in- 
 clude cases of sleeplessness dependent on mental emo- 
 tion, to thought, worry, that is, to causes not directly 
 dependent on organic disease. Young, the well-known 
 author of " ISTight Thoughts," was presumably thus af- 
 flicted— 
 
 " From short as usual and disturbed repose, 
 I awake. How happy those that wake no more ; 
 I awake emerging from a sea of dreams 
 Tumultuous, where my wrecked despondent thought 
 From wave to wave of fancied misery 
 At random drove, her helm of reason lost ! " 
 
 The worries of the student, the merchant, the specu- 
 lator, homesickness and disappointments are of this 
 order. In the treatment of such cases, the physician is 
 often powerless to act. 
 
 " Who shall minister to a mind diseased ; 
 Pluck from the memory a rooted sorrow, 
 'Ease out the written troubles of the brain, 
 And with some sweet oblivious antidote 
 Cleanse the stuffed bosom of that perilous stuff 
 Which Weighs upon the heart ? " 
 
 Physical Cattses. Every deviation of health is 
 characterized by disturbance of sleep, but in most cases 
 where a vicious sleep habit is established, it tends to 
 persist. Among the chief causes are : 1. Brain strain ; 
 2. Organic diseases of the brain and arteries ; 3. Stom- 
 ach and intestinal diseases; 4. Irritation of the sexual 
 Poisonous substances (toxic insomnia). 
 
90 THE BLUES :— NEURASTHENIA. 
 
 The Insomnia of Beain Strain. This means in- 
 crease in the supply of blood to the brain, eventuating 
 in cerebral congestion. It is an undoubted fact, that the 
 brain strain of severe mental labor is measu-rably les- 
 sened by an adequate amount of physical exercises. 
 Physiologists and hygienists have shown this to be true, 
 yet we must be cautious in going to the other extreme, 
 taking too much physical exercise; for otherwise, the 
 poisonous substances generated by muscular fatigue only 
 tend to excite the brain and tend to insomnia. 
 
 The Insomnia of Oeganic Diseases of the Bkain 
 AND Aeteries. Whenever the nutrition of the brain is 
 comprornised by actual disease, then insomnia of an ag- 
 gravating and persistent character results. When the 
 insomnia is caused by brain congestion, there is flushing 
 of the face, redness of the eyes, giddiness, confusion of 
 ideas, and sometimes stupor. Insanity may commence 
 with obstinate insomnia. 
 
 The Insomnia of Stomach and Intestinal Dis- 
 ease. In indigestion, toxic substances are developed 
 which irritate the brain and prevent sleep. In many in- 
 stances, the accumulation of gases in the stomach and 
 intestines by pressing on important organs, notably the 
 heart and lungs, induce sleeplessness indirectly. Some 
 persons sleep best, if, before retiring, they take a light 
 repast; others, on the contrary, would find such a pro- 
 cedure an indiscretion, certain to be followed by in- 
 somnia. Sleep after eating is a salutary procedure. It 
 draws the blood from the brain to the stomach, and thus 
 facilitates digestion. 
 
 Toxic Insomni4. Insomnia induced by the indis- 
 criminate use of poisonous substances like alcohol, cof- 
 fee, tea, tobacco, etc. E'ot infrequently the inhibition 
 
THE CAUSE AND OURE. 91 
 
 of any one of these substances will often cure an in- 
 tractable insomnia. 
 
 Symptoms of Insomnia. In the insomnia of neu- 
 rasthenia, the sleep is often interrupted by dreams of 
 the most abhorrent nature, which seem to dominate the 
 person in the wakeful state. As a result of insomnia, 
 many neurasthenics are restless, excited, querulous and 
 irritable. 
 
 Treatment of Insomnia. It has been truly said 
 that if sleep and hope should be taken from man, he 
 would be the most miserable being in existence. Much 
 can be obtained by obeying the laws of hygiene. Atten- 
 tion must be directed to a minute investigation of all 
 the bodily functions to ascertain the fundamental con- 
 dition, of which insomnia is a mere manifestation. We 
 possess many drugs which, when prescribed with discre- 
 tion, may be regarded as harmless, yet drugs should only 
 be used as a last resort, for any drug which induces sleep 
 by overpowering the body is not entirely without danger. 
 
 The bromides are the safest hypnotics, and so are, 
 lupulin, valerian and spirits of lavender. The use of 
 other hypnotics is fraught with danger, and should never 
 be prescribed until one has exhausted every other sim- 
 pler means to produce sleep, for of all beings the neu- 
 rasthenic is specially liable to succumb to a drug habit. 
 
 Generally speaking, an adequate amount of physical 
 exercise is necessary in -all sufferers from insomnia, 
 itfothing is more conducive to sleep than exercise taken 
 in the open air. Some diversion for the brain worker 
 may be found in change of scene and society. " Seeing 
 that too much sadness has congealed your blood, and 
 melancholy is the nurse of frenzy, therefore, have 
 thought it good for you to hear a play, and frame your 
 
9^ THE BLUES :-NEURASTHENIA. 
 
 mind to mirth and merriment, which bars a thousand 
 harms and lengthens life." 
 
 No detail should be neglected in ascertaining the 
 cause of insomnia. Tea or coffee should not be taken 
 at the evening meal, and tobacco should not be used, at 
 least some hours before retiring . A glass of warm milk, 
 or a cup of hot bouillon before retiring may prove bene- 
 ficial in inducing sleep. Some derive sleep by taking a 
 glass of beer or malt extract before retiring. If the 
 sufferer from insomnia be a literary man or student, all 
 intellectual effort should be stopped at least an hour 
 before retiring, and the interval filled in with some 
 extraneous dull reading. When this fails, no intellec- 
 tual work should be done after supper, reserving that 
 work for the early morning hours. Some cases of in- 
 somnia only yield after a complete change of scene free 
 from excitement and sightseeing. Active exercise be- 
 fore retiring, with dumb-bells, pulley-weights or Indian 
 clubs, followed by a tepid or warm sponge bath, often 
 induces healthful and refreshing sleep. Climate is an 
 essential consideration in those who suffer from insom- 
 nia. Warm climates are soothing, and cool climates 
 stimulating to the nervous system. On account of the 
 cool nights in the mountainous districts, refreshing sleep 
 can often be obtained. Some find benefit by residing at 
 the seashore. California has a marvelous diversity of 
 surface and corresponding varieties of climate. While 
 the climate of southern California is especially favor- 
 able for consumptives or persons with heart or kidney 
 diseases, northern California is better adapted to build 
 up the neurasthenic. The winds that sweep through the 
 Golden Gate often make the summer climate of San 
 Francisco somewhaj: harsh, yet there are districts in 
 
THE CAUSE AND CURE. 93 
 
 the immediate vicinity of San Francisco free from 
 winds and fogs, and there is no city in the world which 
 has such environs. About 125 miles from San Fran- 
 cisco, at Monterey, is the famous Del Monte hotel. 
 Here the climate is sedative and equable, and per- 
 mits of an out-door life throughout the year. The tem- 
 perature rarely rises above 80° F. The temperature 
 of the water averages 52° F. in January and 60° F. in 
 July. Neurasthenics, who suffer from insomnia, obtain 
 much relief at Monterey, where art has conspired with 
 Nature to make this one of the garden-spots of the world. 
 Hydeothbeapy is a valuable adjunct in the treat- 
 ment of insomnia. Schneller's experiments proved con- 
 clusively that ice applied to the head of an animal 
 caused contraction of the blood vessels of the brain, 
 which persisted for a short time after the ice was re- 
 moved. The brief application of cold or warm water 
 to the surface of the body is stimulating, but if pro- 
 longed, depressant. A cool sponge bath, or even a cold 
 plunge before retiring, will provoke sleep. The' sec- 
 ondary effect of cold to the skin, is to dilate the blood- 
 vessels, which draws the blood away from the brain. 
 Many sufferers find relief in a prolonged warm bath 
 before retiring, the effect being sedative on the nervous 
 system. Others find equal benefit in a hot foot bath. 
 Some find relief in a Turkish bath, followed by a gen- 
 eral massage. The wet pack has done heroic service for 
 many nervous persons. It is used as follows : A sheet 
 having been wrung out of cold water, is thrown over the 
 patient from neck to ankles, and over this several dry 
 blankets, with a hot-water bag to the feet and a cold 
 wet cloth to the forehead. The patient remains in the 
 pack from half an hour to an hour, and is then vigor- 
 
94 THE BLUES :— NEURASTHENIA. 
 
 ously rubbed with a coarse, dry cloth until the skin 
 glows. The wet pack may be given every night or sev- 
 eral times a week. 
 
 Hot compresses, consisting of flannels wrung out of 
 hot water, applied to the abdomen and covered with dry 
 flannels, are often efficacious. A hot bag may be sub- 
 stituted. The cold douche to the head, or a shower 
 bath to the head and spine, are frequently serviceable. 
 
 Massage is often of service in insomnia, when every 
 other hygienic measure fails. 
 
 Some persons can induce sleep by having recourse to 
 the hop pillow, which should be moistened with spirits 
 before being placed under the head of the patient. 
 Among drugs, bromide of potash is the least harmful. 
 For an adult, 30 grains may be taken in sweetened water 
 before retiring, and repeated in an hour, if necessary. 
 It is especially useful in nervous cases. 
 
 Electeicitt, when properly employed, especially in 
 the form of static electricity, is almost an indispensable 
 remedy in insomnia. Contrary results often follow its 
 injudicious application. The Galvanic current has a 
 tendency to make some persons sleepy, and is to be ap- 
 plied in the evening. The Faradic current makes most 
 people wakeful. Electricity is especially useful in in- 
 somnia of brain strain and alcoholism. 
 
 Hypitotism is likewise an indispensable agent when 
 judiciously employed. 
 
 A common procedure for inducing sleep is energetic 
 and frequently repeated opening and closing of the eye- 
 lids. Auto-suggestion is often of service. The patient 
 should go to bed with the firm conviction that sleep is 
 bound to follow. One may imagine observing all the 
 phenomena incident to sleep in another person. The 
 
THE CAUSE AND CUBE. • 95 
 
 reading of dull books or concentrating the mind on some 
 blank and wearying picture makes the mind receptive 
 to only one suggestion, viz, sleep. 
 
 " A flock of sheep that leisurely pass by 
 One after one ; tlie sound of rain and bees 
 Murmuring ; the fall of rivers, winds and seas, 
 Smooth fields, white sheets of water and pure skies." 
 
 Deeams. These are frequent concomitants of the 
 neurasthenic state. Dreams are not recalled when sleep 
 is profound, but occurring at the natural time of wak- 
 ing they are remembered. Dreams are made up of ideas 
 and emotions, which have no laws of association nor 
 coherence. In ancient times, dreams were regarded 
 with much significance, but the attempts of the scientist 
 to classify them has been attended with indifferent re- 
 sults. Diseases of the liver are supposed to be asso- 
 ciated with dreams of disturbed forms. 
 
 Nightmare. This may prove indicative of an irri- 
 tation somewhere in the organism, especially so in nerv- 
 ous individuals. Sleeping on the back induces it. The 
 causes of nightmare embrace almost all bodily ailments, 
 notably digestive disturbances, heart disease, worry and 
 excitement. 
 
 TREATMENT OF THE HEART SYMPTOMS. 
 
 Palpitation of the Heart. Absolute rest in bed 
 in a large ventilated and darkened chamber with the 
 clothing removed. The application of an ice-bag to the 
 region of the heart or cloths saturated in cold water 
 are very effective agents. Swallowing small pieces of 
 ice or drinking large draughts of cold water or a glass 
 of hot water, are procedures frequently adopted. To 
 prevent attacks of palpitation, excitement of all kinds 
 
96 THE BLUES :— NEURASTHENIA. 
 
 must be avoided, and tea, coffee, and alcohol must be 
 discontinued or at least reduced. When the palpitation 
 is dependent on impoverished blood, iron in some form 
 is serviceable. When a stomach disturbance is at the 
 bottom of the trouble, it must be cured. Electricity is 
 an effective agent. It should be given, if possible, twice 
 a day in the form of Galvanism ; the positive pole on the 
 back of the neck and the negative drawn along the course 
 of the pneumogastric nerves in the neck. Some cases 
 are benefited by residence at high altitudes,, others, by a 
 sea voyage. Not infrequently the application of cold 
 to the spine will arrest a paroxysm. When everything 
 else fails, the rest cure often yields good results. 
 
 TREATMENT OF THE STOMACH AND INTESTINAL 
 SYMPTOMS. 
 
 Neevous Dyspepsia. In the majority of in- 
 stances, indigestion is caused by too rapid eating 
 and the consumption of too much food. Digestion 
 begins in the mouth. This is especially true of the 
 digestion of starchy foods. Many dyspeptics are cured 
 of their evil by thoroughly masticating their food. A 
 meal should be regarded as -a pastime, not a necessity, 
 It is difficult and even impossible to lay down any 
 definite rule for the kind of food to be consumed, for 
 " one man's food is another man's poison." The nerv- 
 ous dyspeptic is, as a rule, poorly nourished. It is ab- 
 surd to suppose that nervous prostration can be cured 
 without increasing and making the nourishment effec- 
 tive. This statement refers to the qualitative and not 
 the quantitative consumption of food. An exhausted 
 nervous system demands a plentiful supply of good 
 nutritious food. Beard maintains, in his classic work 
 
THE CAUSE AND CURE. 97 
 
 on " Sexual neurasthenia," that flesh is the natural food 
 of man. His theory of diet is founded on the theory 
 of evolution, and finds expression in the following three 
 propositions: 1. Living beings feed on that which is 
 below them in the scale of development; 2. The best 
 food for man is that which is just below him or nearest 
 to him in the scale of development; 3. Food is difficult 
 of assimilation for man in proportion to its distance be- 
 low him in the scale of development. It is undoubtedly 
 true, that those who subsist exclusively upon meat are 
 capable of greater mental and physical exertion than 
 those who consume vegetable food. Animal food con- 
 tains the greatest variety of nutriment and is generally 
 most easily digested.. Beef is more nutritious and stim- 
 ulating than mutton. The flesh of very young animals 
 is less nutritious, and more difficult of digestion than 
 the flesh of the matured animal. Oysters are very 
 nutritious and digestible when consumed raw. Oatmeal 
 is a frequent cause of indigestion in the nervous dys- 
 peptic. Eggs, milk and fish are very nutritious. When 
 the dyspepsia is severe, an exclusive milk diet for sev- 
 eral weeks proves curative. The daily amount necessary 
 must never be less than three pints, and as much as a 
 gallon. A large glassful should be drunk slowly every 
 hour, and, when toleration is established, this amount 
 may be increased at shorter intervals. The digestibility 
 of the milk may be increased by adding a pinch of salt 
 or a teaspoonful of lime water to each glass. Some pre- 
 fer taking the milk diluted with water or seltzer. When 
 whole milk is loathsome, it may be skimmed or sub- 
 stituted by buttermilk or koumys. Farinaceous foods 
 should, as a rule, be excluded, as they create flatulency 
 and heartburn. Too much liquid should not be taken at 
 7 
 
98 THE BLUES :— NEURASTHENIA. 
 
 a meal, as it dilutes the gastric juice and inhibits diges- 
 tion. Hygienic measures, such as exercise and bathing, 
 are indispensable, for, by increasing the tone of the 
 nervous system, they indirectly improve digestion. Suf- 
 ferers from nervous dyspepsia will find material aid by 
 carrying out the partial rest treatment, and confining 
 themselves to the following diet, which excludes starchy 
 foods, which are notoriously indigestible in neurasthenic 
 persons. 
 
 On waking, eight ounces of equal parts of hot milk 
 and seltzer water, taken slowly. Breakfast, steak or 
 loin chops with fat, soft-boiled or poached egg, cream 
 toast (very little), half a pint of milk and a small cup of 
 coffee. Lunch, 10 a. m., small teacup of squeezed beef 
 juice with stale bread. 12m., rest or sleep. Midday 
 meal, 12 : 30 p. m., fish, chicken, scraped meat ball, stale 
 bread with plenty of butter, baked apples and cream, 
 two glasses of milk. Lunch, 4 p. m., bottle of koumys, 
 raw scraped beef sandwich or goblet of milk. 5 : 30 
 p. M., meat or fresh soup, roast or mutton, game, stale 
 bread (sparingly), fresh vegetables (excepting pota- 
 toes) . Eat slowly, chew the food thoroughly, and never 
 eat when excited or exhausted. Poorly prepared meals 
 are often a source of dyspepsia. Washing the stomach 
 by means of a tube is often indicated for the relief of 
 dyspepsia. Constipation is frequently a cause of dys- 
 pepsia and loss of appetite. 
 
 Personally, I have observed only temporary good to 
 result from the use of such agents as pepsin, pancreatin 
 and hydrochloric acid. To stimulate digestion, strych- 
 nin is often invaluable. The addition of common salt 
 to our food stimulates digestion. Alcohol should be 
 
THE CAUSE AND CUBE. 9h 
 
 stopped, although there can be no objection to a moder- 
 ate use of some light wine taken with meals. 
 RULES FOR DYSPEPTICS. 
 
 Rule i. Eat slowly and chew the food thoroughly. 
 If the foregoing are not observed, then the rule of Sir 
 Andrew Clark should be followed, viz. : Count the bites. 
 For every mouthful of meat thirty-two bites must be 
 allowed, or one bite to every tooth. If the meat is tough, 
 sixty-four bites must be allowed, and ninety-six bites, 
 if very tough. This rule is an almost positive protec- 
 tion against dyspepsia, dependent on hurried eating, 
 and will, in most instances, cure the disease. 
 
 Rule ii. Solids and liquids must be taken at sepa- 
 rate times. Liquid taken with food in those with weak 
 stomachs dilutes the gastric juice and retards digestion. 
 Then again, when liquids are not taken with the food 
 it induces the patient to chew the food thoroughly, or 
 otherwise it cannot be swallowed. If at breakfast, tea 
 or coffee must be drunk, it is better taken at the com- 
 pletion of the meal. 
 
 Rule hi. Farinaceous and proteid foods should not 
 be taken at the same meal, in other words, the same 
 character of food only should be introduced into the 
 stomach at the same meal. For example: Bread and 
 butter may be taken at breakfast, but no meat, fish 
 or eggs. Luncheon should consist of fish, eggs or meat, 
 but no bread, potatoes or other farinaceous food. Sup- 
 per should consist of the same kind of food as at lunch- 
 eon, or farinaceous food only. Introducing the same 
 kind of food into the stomach at each meal insures the 
 completion of digestion at the same time, and not at 
 different times, as would be the case, if the character 
 of the food takeo at a meal is different. 
 
100 THE BLUES ;— NEURASTHENIA. 
 
 KuLE IV. If liquid must be taken at a meal, the best 
 drink is hot water, taken on rising in the morning, at 12 
 o'clock, and again at 4 p. m. Taken at these intervals, 
 there v/il\ be no dilution of the gastric juice, and the 
 contents of the previous meal will be washed out of the 
 stomach. 
 
 Treatment of Constipation. .Each case of con- 
 stipation must be investigated as an individual one. 
 Habit is an important factor. The desire to go to stool 
 must never be neglected, in fact, it is to be encouraged 
 by a systematic habit of going to the toilet every morn- 
 ing, whether or not the desire is present. Such a prac- 
 tice will often cure the costive habit. Many persons 
 find that a cigar or a pipe after breakfast acts as a laxa- 
 tive. Massage of the abdomen is constantly practiced, 
 but I confess never to have seen any good results from 
 its use, save in children and very young persons. Many 
 persons succeed in obtaining a daily evacuation by tak- 
 ing certain articles of food. Fruit, raw or cooked, 
 taken at breakfast, is often effectual. Some find oat- 
 meal or brown bread to have a similar effect. 
 
 It is necessary for the patient to secure bowel action 
 to have in the intestines a certain bulk of fecal matter. 
 The sparing use of vegetables, fruits and water will 
 produce a small residue of undigested matter, hence it is 
 necessary to partake of food which contains a large 
 amount of cellulose, which remaining undigested, fills 
 the bowels and provokes vigorous peristalsis. Such 
 food consists of vegetables, fruits, coarse breads and 
 Avater. The vegetables that possess laxative properties, 
 are: spinach, lettuce, tomatoes, Spanish onions and cab- 
 bage. Honey and molasses, taken alone or with other 
 food, are frequently laxative. Some people find that 
 
THE CALfSE AND CUBE. lOl 
 
 coffee is likewise laxative. Eruit, as a laxative, is most 
 efficient when eaten alone, either before retiring or an 
 hour before breakfast. Sweet cider is loosening to the 
 bowels, whereas tea often constipates. Water should be 
 drunk in abundance, especially before retiring or on 
 rising in the morning. Others find that a glass of raw 
 milk taken before breakfast will act as a laxative. Exer- 
 cise is of great value, especially exercise like horse- 
 back riding, which brings the abdominal muscles into 
 play. The continued use of purgatives is a dangerous 
 practice. They are only temporary in action, and make 
 the bowels more constipated than ever. The least ob- 
 jectionable agents of this class are the natural purgative 
 waters, like Carlsbad and Hunyadi Janos. In Cali- 
 fornia we possess an effective natural water called 
 Bythinia. Suppositories of glycerin or a daily enema 
 of cold water is of great value. The same may be said 
 of olive oil. Glycerin (a tablespoonful to four table- 
 spoonfuls), thrown into the rectum is very effective. 
 Cold sponging and baths are valuable additions to the 
 measures suggested. 
 
 TREATMENT OF SEXUAL NEURASTHENIA. 
 
 Conjugal HYGiBsrE. N^ormal sexual intercourse is 
 the most powerful passion of human nature, conducive 
 to strong and vigorous health. When followed by a 
 feeling of well-being, it is healthful, but, if, on the con- 
 trary, it is followed by depression, the act is harmful. 
 Unnatural methods of intercourse, such as withdrawal, 
 use of condoms and prolongation of the act, are espe- 
 cially harmful, and are often the essential cause of a pro- 
 tracted siege of sexual neurasthenia. It must not be 
 forgotten that the health of the offspring is largely de- 
 
102 THE BLUES :-NEURASTHENIA. 
 
 pendent on the condition of the parents at the time of 
 the conception, and for this reason, the laws of sexual 
 hygiene should be observed most rigorously. Spitzka 
 affirms that " children begotten by a drunken father 
 have repeatedly been found to be epileptic, imbecile, 
 deaf, mute or insane." Undue repetition of the sexual 
 act is repugnant to the moral sense, and is certain to 
 be followed by evil consequences. Sexual intercourse 
 is intended for the purpose of reproduction, and the 
 prevention of conception is an injustice to society and 
 results in injury to both sexes. 
 
 The treatment of seminal emissions is generally a 
 simple matter, when conducted by the physician. Aside 
 from local measures, the building up of the nervous sys- 
 tem is an absolute essential. To arrest the emissions 
 entirely in a continent unmarried man is an impossi- 
 bility. What can be really achieved is this, to allow 
 the emissions to continue without any detriment, to 
 health. Marriage, while offering immunity in the ma- 
 jority of instances, is not invariably productive of such 
 results, for there are many married men who continue 
 to have emissions. This is, of course, usually unnatural, 
 and often indicates that the strength of the organs is 
 imperfect, or because no real pleasure is derived from 
 the act, or because there still remain traces of former 
 sexual troubles. Before emissions can be controlled, 
 sexual excitement and masturbation must be avoided. 
 The diet should be non-stimulating. Spices, alcoholic 
 drinks, strong coffee and tea must not be used. Before 
 retiring, very little fluid or food should be taken. Sleep 
 should not be prolonged, and early rising is important. 
 The patient should never lie on the back, and the cover- 
 ing should be light and the bed hard. When patients 
 
THE CAUSE AND CURE. 103 
 
 awake in the morning they should at once empty the 
 bladder. 
 
 The treatment of sexual neurasthenia in general, 
 means the correction of general nerve depression. Aside 
 from local treatment, which may be necessary when 
 strictures or old discharges complicate the trouble, or 
 when a tight prepuce exists or rectal irritation from 
 piles or retained fecal matter, the essential object al- 
 ways, is the relief of nerve-depression on which the 
 sexual disorders are dependent. Charlatans often ag- 
 gravate the sexual weakness and irritability by employ- 
 ing drugs and different kinds of apparatus, which tem- 
 porarily stimulate the debilitated organs, leaving them 
 in a worse condition than ever before. In no other 
 disease is meddlesome treatment so disastrous as in sex- 
 ual debility, and many individuals have been perma- 
 nently injured by such measures. There are no specific 
 drugs in the treatment of sexual neurasthenia. Even 
 moral treatment, so often vaunted by medical writers, 
 is of little avail, and while the mind frequently operates 
 to the disadvantage of the sexual apparatus, there is no 
 affection which is less amenable to moral treatment 
 than sexual neurasthenia. Patients see no results in 
 expectancy. They want results, and the results which 
 they are so eager to obtain can only be achieved by a 
 correct toning of the nervous system. 
 
 HYPNOTISM. 
 
 Treatment by suggestion, when intelligently em- 
 ployed in neurasthenia, is capable of marvelous effects 
 in ridding the patient of morbid ideas and in inducing 
 sleep, which, even with drugs, is often impossible. 
 
 Healthy suggestions made by the physician, I regard 
 
104 THE BLUES :-NEUIlASTHENlA. 
 
 as indispensable in the treatment of many cases. The 
 dangers of hypnotism are exaggerated, for no one can 
 be hypnotized against his wish. Prof. Bernheim, the 
 apostle of hypnotism, has this to say : " It is the duty 
 of the physician to select what is useful in suggestion, 
 and to apply it for the benefit of his patients. When, in 
 the presence of sickness, I think that therapeutic sug- 
 gestion has a chance of success, I should consider my- 
 self to blame, as a physician, if I did not propose it to 
 my patient, and if I did not even make a point of get- 
 ting his consent to its employment." The influence of 
 the mind on the body is every day illustrated by the in- 
 troduction of some new fad or delusion in the treatment 
 of disease. It is difiicult to conceive that such results 
 are effected by the mind as a simple thinking organ ; 
 on the contrary, the mind is psychodynamic, and must 
 be regarded as a force like light, heat and electricity 
 which operates for good or evil on the bodily functions. 
 Strong mental impressions may actuate disease, and 
 even death, or they may act by curing disease. Joy 
 and hope stimulate, whereas grief and despair depress 
 the bodily functions. Sutton presents the following 
 facts, which are apposite in this connection : 
 
 FiEST. That mental emotion may induce sickness 
 or death within a brief space of time, or even immedi- 
 ately, and in persons of robust health. 
 
 Second. The physical phenomena induced by such 
 cause indicate a deep perturbation — vibration — of the 
 nervous system, and are generally of a dynamic char- 
 acter. 
 
 Thied. Thought strongly directed to any part tends 
 to increase its vascularity and consequently its sensi- 
 bility. 
 
THE CAUSE AND CURE. 105 
 
 Fourth. Thought strongly directed away from any 
 part diminishes vascularity and lessens sensibility. The 
 more so when associated with powerful emotions. (A 
 key which unlocks Christian science and other " fads.") 
 
 Fifth. The emotions may cause sensations, either 
 by directly exciting the sensory ganglia and the cen- 
 tral extremities of the nerves of sensation, or by in- 
 ducing vascular changes in a certain part of the body, 
 which excite the sensitive nerves at their peripheral 
 termination. 
 
 Sixth. There is no sensation, whether general or 
 special, excited by agents acting on the body from with- 
 out, which cannot be excited also from within by emo- 
 tional states affecting the sensory ganglia, such sensation 
 being referred by the mind to the point at which the 
 nerve terminates in the body. (Tuke.) 
 
 Christian Science is suggestion plus absurdity; di- 
 vine healing, suggestion plus faith in God; Dowieism, 
 suggestion plus prayer and holy terror; Weltmerism, 
 suggestion plus imagination, pure; magnetic healing, 
 suggestion plus imagination, also; osteopathy, sugges- 
 tion plus massage; homeopathy, suggestion plus noth- 
 ing; allopathy, suggestion plus tubfuls of drugs that 
 either kill or cure ; regular or rational medicine, sugges- 
 tion plus the best common horse sense available, or sug- 
 gestion and medicine mixed with the best quality of 
 brains obtainable. No suggestion in this that the quality 
 of brains is indisputably good in all cases — or perhaps 
 in any. Yet that is the scientific principle at the base, 
 and it may be used with telling effect in all cases of 
 sickness, and is infinitely better than the delusions of 
 the day by so much as it substitutes intelligence for ig- 
 norance and does not produce that disaggregation of 
 
106 THE BLUES :— NEURASTHENIA. 
 
 personal consciousness and temporary insanity that is 
 the sine qua non in Christian Science, etc. 
 
 There are many competent writers who doubt the 
 utility of hypnotism in therapeutics and aver that its 
 results are achieved at the expense of demoralization. 
 My own observations with hypnotism as a therapeutic 
 agent extending over a period of fifteen years justify 
 me in the conclusion, that when judiciously employed 
 in carefully selected cases, it is a most effective agent, 
 and results may be attained which are incapable of 
 achievement by any other known means. The latter 
 statement refers not only to disease, but also of educa- 
 tion for the improvement of character and morals. It 
 was supposed at one time that only weak, sick, nervous 
 and hysterical women were susceptible to hypnotism, 
 but the extensive statistics of Liebault have shown that 
 almost anybody can be hypnotized, the susceptibility to 
 suggestion being influenced by willingness of the sub- 
 ject, his passivity and the power to concentrate the 
 thought or attention on the intended sleep. Intelligent 
 persons are more difficult subjects than mechanics or 
 laborers, because they permit their thoughts, whether 
 voluntary or involuntary, to wander to various objects 
 which distract the attention. Patience and renewed 
 seances are often rewarded by success in those who are 
 not susceptible to the influence. Young are more sus- 
 ceptible than old persons, and women more easily in- 
 fluenced than men. 
 
THE CAUSE AND CURE. loT 
 
 SUMMARY. 
 
 1. Reliance on the healing power of Nature is an 
 evidence of erudition. It affords the discerning physi- 
 cian an opportunity of knowing what not to do, a feat 
 often more difficult than doingj and enables him to 
 apply the highest principles of the therapeutic art. 
 
 2. " The confession and absolution of sanitary sins 
 is a constant physical force in medical practice. The 
 physician is the priest of health ; his gospel is the one 
 of right living." (Dr. H. C. Sawyer.) 
 
 3. " The attitude of a patient should be that of 
 a voyager who resigns himself to the captain, and does 
 not look for the further shore until the time comes." 
 (Beard.) 
 
 4. " There is wisdom in this beyond the rules of 
 physic. A man's own observation, what he finds good 
 and of what he finds hurt of, is the best physic to pre- 
 serve health." (Bacon.) 
 
 5. " We are all prone to forget — that we are deal- 
 ing with human beings whose hopes and fears are played 
 upon by our every word and act as subtly as the most 
 wonderful musical instrument is touched by the fingers 
 of the master performer. We may thus be the creators 
 of the sweetest strains of human feeling, or the insensi- 
 ble performers upon sweet bells jangled out of tune." 
 (Dr. Geo. M. Gould.) 
 
 6. " A physician whose horizon is bounded by an 
 historical knowledge of the human machine, and who 
 can only distinguish terminologically and locally, the 
 coarser wheels of this piece of intellectual clock-work, 
 may perhaps be idolized by the mob, but he will never 
 
108 THE BLUES :-NEtrRASTSENlA. 
 
 raise the Hippocratic art above the narrow sphere of a 
 mere bread-earning craft." (Schiller.) 
 
 7. " Any physician who neglects to approach phys- 
 ical symptoms through the mind will find the practice 
 of medicine a sorry task. The physician is often com- 
 pelled to conciliate the mind of the patient while Na- 
 ture is effecting the cure. 
 
 8. " To eat little, and that little of simple food, is 
 to prolong life." (Cornaro.) 
 
 9. " For my part, when I see a fashionable table set 
 out in all its magnificence, I fancy I see gouts and drop- 
 sies, fears and innumerable distempers lying in ambus- 
 cade among the dishes." (Addison.) 
 
 10. " Good ventilation and a certain amount of out- 
 of-door bodily exercise are of the greatest importance 
 and greatest necessity in insuring good, refreshing sleep, 
 as well as a good old age." (Hufeland.) 
 
 11. " Those are greatly mistaken who believe that a 
 modern physician is he who examines a patient most 
 carefully, auscultates and percusses, and is satisfied when 
 the autopsy corresponds with his diagnosis. Such a 
 medical man does not comprehend that the aim of all 
 medical service is the healing of the sick." (Oppolzer. ) 
 
 12. " Pathology is the physiology of the sick." 
 (Wunderlich.) 
 
 13. " Let me diet a person and I can give him al- 
 most any kind of disease known, — long life or short 
 life." (Dr. T. E. Allison.) 
 
 14. " Medicine has taken possession of hypnotism, 
 and it is only through her that such an agent can be 
 made of use to mankind and prevented from working 
 injury to the human race." (Charcot.) 
 
THE CAUSE AND CURE. 109 
 
 15, Decalogue of Health (Dr. Frank H. Hamil- 
 ton) : 
 
 " 1. The best thing for the inside of a man is the 
 outside of a horse." 
 
 "2. Blessed is he who invented sleep — ^but thrice 
 blessed the man who will invent a cure for thinking. 
 
 " 3. Light gives a bronzed or tan color to the skin ; 
 but where it uproots the lily it plants the rose. 
 
 " 4. The lives of most men are in their own hands, 
 and, as a rule, the just verdict after death would be — 
 felo de se. 
 
 " 5. Health must be earned — it can seldom be 
 bought. 
 
 " 6. A change of air is less valuable than a change 
 of scene. The air is changed every time the wind is 
 changed. 
 
 " 7. Mold and decaying vegetables in a cellar weave 
 shrouds for the upper chambers. 
 
 " 8. Dirt, debauchery, disease, and death are suc- 
 cessive links in the same chain. 
 
 " 9. Calisthenics may be very genteel, and romping 
 very ungenteel, but one is the shadow, the other the sub- 
 stance, of healthful exercise. 
 
 " 10. Girls need health as much — nay, more than 
 boys. They can only obtain it as boys do, by running, 
 tumbling — by all sorts of innocent vagrancy. At least 
 once a day girls should have their halters taken off, the 
 bars let down, and be turned loose like young colts. 
 
 " 11. The alimentary regimen in neurasthenia is im- 
 portant, for neurasthenics eat too much. The amount of 
 food consumed should be reduced to what is absolutely 
 necessary and this is gauged by weight and strength. 
 If the latter, grow less, the amount of food taken must 
 
110 THE BLUES :— NEURASTHENIA, 
 
 be increased, l^eurasthenics eat too mucli, but do not 
 drink enough. At least 3 pints of water should be ad- 
 vised for daily consumption. Digestion always means 
 an expenditure of nerve force, therefore it is wise to 
 remember that a minimum of food means a minimum of 
 digestive work. The foregoing facts are specially ap- 
 plicable in splanchnic neurasthenia. 
 
 " 12. I believe it was Carlyle, who said ' that the 
 average American meal was an unpunished crime.' 
 Nervous dyspeptics should not indulge in regulation 
 meals, but should eat often. This rule, if followed, will 
 reduce the task of a stomach suddenly overburdened with 
 food and will diminish the tendency to overeat. 
 
 " 13. The recent experiments of Prof. Anderson, of 
 Yale University, prove that the most important thing 
 in all exercises is the mental effort put forth. Exercises 
 if conducted automatically, will not divert the blood as 
 they should from the brain to the muscles. Prof. Gates, 
 was able, by thinking intently of one of his hands, when 
 it was immersed in a basin full of water, and willing 
 that the blood should flow there, to make the water over- 
 flow. The foregoing facts are sold by teachers of physi- 
 cal culture for good prices and they emphasize that very 
 little exercise, with the mind directing it, will effectually 
 rebuild the body." 
 
CHAPTEK VI. 
 
 SPLANCHNIC NEURASTHENIA. 
 
 THE BLUES. 
 
 WHY THE TEEM, " THE BLUES," HAS BEEN EMPLOYED TO. 
 SPECIFY THIS PAETICULAK POEM OP NEUEASTHENIA. 
 
 ■ DATA BEAEING ON SPLANCHNIC NEUEASTHENIA. 
 
 INTEA-ABDOMINAL PEESSUEE, PULMONAEY SUCTION, 
 
 VASOMOTOE FACTOE. THE ABDOMINAL SYMPATHETIC. 
 
 FACTOES CONTRIBUTING TO SPLANCHNIC NEUEAS- 
 THENIA. 
 
 RpLANCHNTc "N"EnRAS THENT A js. above all things, 
 cbaractp ^-i^firl hy attaoTfRnf dp,pre.i/iinn . a^bich .come xm 
 spontaneou sly without appa rent cause and depart , as 
 mysterio usly as they came. The subjects_o Fgufi]i^;:„ 
 tacks specify their condi tkiiL.ai-.the time as." a fiLoUMu 
 blues." " Theblues." occ ur usually in Jieuxasthenic ijfc 
 divi duals, and^ being of _short_dur.ation, iiumost jn- 
 stances ,. may be spoken of technically as .ajiaaks jol^fiUig 
 neurasthenia. Not infrequently, they may be of pro- 
 longed duration, in which instances, they may be re- 
 ferred to as exacerbations of chronic neurasthenia. To 
 clearly comprehend splanchnic neurasthenia, it will be 
 necessary to direct our attention to the abdomen and re- 
 strict consideration to intra-abdominal tension and the 
 effects of such tension on the blood circulation in the 
 abdomen. 
 
 Ill 
 
112 THE BLUES :— NEURASTHENIA. 
 
 Intea-Abdominal Tension. This refers to the 
 pressure in the abdominal cavity. In the normal sub- 
 ject, the pressure is positive, that is, it is greater than 
 the atmospheric pressure, hence the abdominal walls are 
 pressed outward. Tension within the abdomen is chiefly 
 dependent on the contraction of the abdominal walls, and 
 this in turn is dependent on the strength of the muscles 
 which make up the abdominal walls. In other words, 
 when the abdominal muscles are strong, all other things 
 being equal, intra-abdominal tension is increased, and 
 when they are feeble, the same tension is decreased. 
 
 FACTORS WHICH INCREASE AND DECREASE 
 INTRA-ABDOMINAL PRESSURE. 
 
 The tone of the anterior abdominal muscles is in- 
 creased in certain occupations which tend to develop 
 them. Thus, the strong, hard, flat abdomens of fisher- 
 men who fish with nets and spend many hours dragging 
 at the ropes may be contrasted with the protruding 
 bellies of shoemakers and tailors, in whom an insufficient 
 development of the muscles occurs, owing to their relaxa- 
 tion, the result of posture in their special occupations. 
 Tension is diminished, when fat accumulates in the walls 
 of the abdomen, in corset-wearing women and chiefly as 
 a result of pregnancy. Schwerdt,^^ refers to reduced 
 intra-abdominal pressure as a result of relaxation of the 
 whole nervous system, which reacts on the muscular 
 system. Other factors concerned in the reduction of ten- 
 sion are: 1. Hereditary factors; 2. Mental overwork; 
 3. Insufficient nourishment; 4. Chronic diseases. Ac- 
 cording to Glenard,^' diminution of the intra-abdominal 
 tension is due more to the lessening of the volume of 
 gas in the intestines than to any other cause. That this 
 
THE CAUSE AND CURE. 113 
 
 latter cause is important, I will endeavor to show later, 
 but I do not accept the view of Glenard, viz. : that intra- 
 abdominal tension is the expression of the forces which 
 regulate the relationship between the capacity of the 
 abdominal cavity and the volume of its contents. When 
 the abdominal walls atrophy, the intestines fill with 
 gas. 
 
 Effects of Diminished Intea-Abdominal Ten- 
 sion. The positive pressure exerted by the tonic con- 
 traction of the anterior abdominal muscles is probably 
 the most important factor in keeping the abdominal 
 organs in place, for when they are relaxed as a perma- 
 nent condition, their pressure on the underlying struc- 
 tures is insufficient and the result is, a dislocation of 
 the organs. This particular function of abdominal ten- 
 sion, while an important one, merits little consideration 
 in developing our particular subject, viz. : splanchnic 
 neurasthenia. While it is true, that dislocation of the 
 abdominal organs is associated with a very intractable 
 form of neurasthenia, with preponderance of abdominal 
 symptoms; in splanchnic neurasthenia, dislocation of the 
 abdominal organs has been an infrequent phenomenon 
 in my experience, and when present, was only indirectly 
 concerned in the nervous symptoms. In fact, in disloca- 
 tion of the abdominal organs, the development of subse- 
 quent nervous symptoms is due largely to the effects on 
 the abdominal circulation^ and this, together with ptosis 
 of the viscera, is only an effect of diminished intra- 
 abdominal tension. 
 
 Effects of Reduced Intea-Abdominal Tension 
 ON THE CiECULATioN. This is the most important fac- 
 tor concerned in splanchnic neurasthenia, and has re- 
 ceived scant consideration from physicians^ a most la- 
 
 a 
 
114 THE BLUES :— NEURASTHENIA. 
 
 mentable fact, considering the gravity of the issues in- 
 volved. Tension within the abdominal cavity directly 
 influences the blood circulation in the abdominal organs, 
 digestive functions and indirectly almost every organ of 
 the body. The abdominal veins are very capacious, and 
 experiments have taught, that they are capable of hold- 
 ing all the blood in the body. The amount of blood in 
 the abdominal or splanchnic veins is merely a question 
 of abdominal tension. When the latter is diminished, 
 the veins contain more blood than when the t«nsion is 
 increased. Hill and Barnard,^* have contributed largely 
 to this important subject in a physiologic direction, and 
 Campbell,^^ has sought to elaborate it practically. They 
 have demonstrated that there is a tendency of the blood 
 to accumulate in the splanchnic area, with consequent 
 syncope. Like the generality of veins, the great splanch- 
 nic veins are very susceptible to pressure, and the 
 amount of blood within them is greatly influenced by 
 pressure of the abdominal walls. Mere pressure of the 
 abdomen sufiices to squeeze out of the veins a large quan- 
 tity of blood. Thus gravity, posture, the accoutrements 
 of dress and other factors greatly influence the amount 
 of blood contained in the abdominal veins. More blood 
 accumulates in the veins in the erect than in the recum- 
 bent posture, and it is not an uncommon observation 
 for syncope to occur in bedridden patients, who are 
 suddenly constrained to get out of bed. The removal 
 of stays in women often induces a feeling of faintness, 
 and the same symptom may occur in susceptible- persons 
 when the bladder is voided or the feces discharged. 
 Three factors enter into consideration in the mechanism 
 of blood supply to the splanchnic vessels, viz. : 1. The 
 contraction of the abdominal muscles; 2. The act of 
 
THE CAUSE AND CURE. US 
 
 respiration; 3. The regulating vasomotor action of the 
 splanchnic vessels. 
 
 The Abdominal Factoe. The transversales mus- 
 cles maintain the anterior posterior abdominal walls in 
 fairly close contact, and prevent, in the erect posture, 
 gravitation of the blood into the splanchnic veins. 
 
 The Eespieatoey Factoe. That important muscle 
 of respiration, the diaphragm, acts in opposition to the 
 abdominal muscles. Weakness of the abdominal muscles 
 signifies a weak diaphragm. When the latter contracts, 
 it has to work against the intra-abdominal pressure, 
 which it increases, hence, if abdominal pressure is re- 
 duced by weakened abdominal muscles, the diaphragm 
 has little work to perform and consequently its strength 
 diminishes. Every time the diaphragm descends, the 
 intra-abdominal vessels are compressed, and the action 
 thus exerted is less evident in the tense arteries than in 
 the flaccid veins; the blood being squeezed out of the 
 latter into the right chambers of the heart. De Jager ^® 
 has shown, that even strong pressure upon the abdomen? 
 has little or no effect on the arteries, but serves to squeeze 
 a large quantity of blood from the splanchnic veins. 
 Hill has also shown that, in consequence of some failure, 
 in certain compensatory mechanisms, the blood gravi- 
 tates into the splanchnic veins from the right heart and 
 that pressure upon the abdomen will send back the blood 
 from these veins to the right heart, and thus re-establish 
 the circulation. 
 
 PuLMONAEY SucTioisr refers to the large quantity of 
 blood drawn into the lungs with each inspiration, and 
 this physiologic process has not been inaptly compared 
 to a species of dry cupping. Chapman ^"^ avers, " That 
 if at the termination of expiration the quantity of blood 
 
116 THE BLUES :— NEURASTHENIA. 
 
 in the lungs is from 1-15 to 1-18 of the total quantity of 
 blood in the body, at the termination of inspiration, it 
 will be from 1-12 to 1-13." The pulmonary vessels ex- 
 pand with each inspiration and contract during expira- 
 tion, the result being an increased flow of blood from 
 the right heart and the lungs; the dilated vessels, as 
 Campbell ^* puts it, " actually suck the blood out of 
 the right heart." 
 
 Vasomotor Factor. The splanchnic nerves possess 
 the power of regulating the amount of blood in the 
 splanchnic veins, and prevent the gravitation of blood 
 into them. 
 
 The quantity of blood, which may be forced by ab- 
 dominal pressure into the heart, and from thence into 
 the general circulation, has never been determined ob- 
 jectively until I directed attention to what I have called 
 the " Cardio-Splanchnic Phenomenon." * It was this 
 phenomenon which enabled me to appreciate the ten- 
 dency of blood to gravitate into the abdominal veins in 
 many neurasthenics, and to inhibit the symptoms of the 
 latter by treatment directed against this tendency. Be- 
 fore elaborating the phenomena which contribute to this 
 special form of neurasthenia, I wish briefly to direct 
 attention to the nerve apparatus, which presides over 
 the function of innervation of the organs contained in 
 the abdominal cavity, viz. : the abdominal sympathetic. 
 
 The Abdominal Sympathetic. The relations of 
 the great sympathetic with the cerebro-spinal axis, and 
 the nature of its functions is a matter involved in much 
 obscurity. This much we do know, however, that it 
 exerts an important influence over the circulation, secre- 
 tions and nutrition of the organs innervated by it. In 
 
 * ISee Appendix, Note 3, 
 
THE CAUSE AND CURE. H7 
 
 health, the alDdominal sympathetic confers an uncon- 
 scious sensibility to the abdominal organs, but when irri- 
 tated from any cause, violent pains and abnormal sensa- 
 tions are experienced, not only at the point of irrita- 
 tion, but reflexly, owing to its communication with 
 branches of the cerebro-spinal system of nerves, at re- 
 mote situations. Irritation of the splanchnic nerves is 
 attended primarily by contraction of the abdominal 
 vessels, but the latter soon dilate, leading to a stagna- 
 tion of blood. Byron Eobinson ^' refers to the celiac 
 ganglia, the largest in the body, as the Abdominal 
 Beain, which acts as a reflex center outside of the 
 spinal cord. 
 
 Meinert ^^ claims that the celiac plexus controls the 
 formation of hemoglobin in the spleen. The coats of all 
 the principal blood-vessels in the abdomen are supplied 
 by the sympathetic nerve, which regulates the vascular 
 supply to the organs. 
 
 FACTORS WHICH CONTRIBUTE TO THE DEVELOP- 
 MENT OF SPLANCHNIC NEURASTHENIA. 
 
 This form of neurasthenia is dependent essentially on 
 a stagnation of the blood in the splanchnic or abdominal 
 veins. This is the primary and fundamental condition 
 prevailing in splanchnic neurasthenia. The factors 
 which conduce to this condition are many, but in most 
 instances, it is lack of nerve force exerted through the 
 muscles of the abdomen and respiration and the nervous 
 mechanism which regulates the supply of bipod in the 
 veins. From this, one would be constrained to conclude, 
 that the phenomenon of blood stagnation in the abdom- 
 inal veins is not a primary but a condition secondary 
 to nervous exhaustion. In this contention, oi^e would be 
 
118 THE BLUES :-NEURASTHENIA. 
 
 partially correct, for, while it is usually a secondary 
 condition, it is not infrequently a primary one. It is 
 capable of aggravating a neurasthenic disposition, and 
 induces it when absent. By treatment directed toward 
 the stagnation of blood in the abdominal veins, I have 
 succeeded in curing many neurasthenics of their vicious 
 symptoms, notably, mental depression and of limiting 
 their fatigue signs to the sphere to which they properly 
 belong, the brain and spinal cord. This is practically 
 all that can be accomplished for the neurasthenic by the 
 physician. The fatigue symptoms of the former are 
 the result of his own indiscretion, and his mastery of 
 them presumes sufficient intelligence, which enables 
 him to recognize his own power of endurance. 
 
 Nebve Foece Lacking in the Muscles of the 
 Abdomen. I have already shown that the greater in- 
 tra-abdominal tension, the less blood will be contained 
 in the abdominal veins. Furthermore, that this tension 
 is largely dependent on the tone or tension of the 
 abdominal muscles. Now, tone in any muscle or group 
 of muscles is the product of a storm of nervous impulses 
 pouring into them from a nerve center, and when the 
 latter is fatigued, the tone of the muscle diminishes, 
 which is expressed by relaxation of the muscular fibers. 
 Therefore, nervous exhaustion is a frequent cause of 
 diminished tone of the abdominal muscles, which in 
 turn diminishes intra-abdominal tension, and conduces 
 to blood stagnation in the veins of the abdomen. ■ 
 
 Neeve Foece Lacking in the Function of E,espi- 
 EATioN. Here, as in the preceding condition, the same 
 cause prevails. Not only in neurasthenia, but in other 
 functional nervous diseases, respiratory exercises have 
 been shown to be of great value. This effect, to my 
 
THE CAUSE AND CURE. , 119 
 
 mind, has been achieved through their influence on the 
 abdominal circulation. The lungs are important ave- 
 nues for the elimination of poisonous substances, many 
 of which are scarcely known. By healthy lung action, 
 we may regulate the local and general blood and lymph 
 circulations. Such effects are not only local, but gen- 
 eral, for every protoplasmic unit of the body to live 
 must have its essential quantity of oxygen, and receiving 
 this, yields in return its products of activity. We have 
 already referred to " pulmonary suction," showing how, 
 with each inspiration, the blood is sucked, as it were, 
 from the veins throughout the body, and this, in refer- 
 ence to the abdominal veins constitutes an important 
 factor in" diminishing venous turgescence in the abdom- 
 inal cavity. The flow of blood is urged primarily into 
 the cavse and right heart, from the latter into the lungs, 
 and from the latter into the left heart. In other words, 
 depletion of the veins is accomplished by forcible res- 
 piration, so that the supply to the arteries is thereby 
 increased, and nutrition of the tissues and organs facili- 
 tated. The question of hlood pressure, as a result of 
 compression of the abdomen, is referred to in the ap- 
 pendix.* There is another factor concerned in respira- 
 tion, which bears on the venous circulation in the ab- 
 dominal cavity, and that is, the descent of the dia- 
 phragm. Every time the latter muscle descends in in- 
 spiration, it increases intra-abdominal tension, and ex- 
 presses a considerable amount of blood out of the intra- 
 abdominal veins into the right heart. The action of 
 the diaphragm in effecting this object is dependent on 
 the condition of the abdominal walls: if they are vig- 
 orous, intra-abdominal tension is increased, and the 
 * See Appendix, Note 3. 
 
l20 THE BLUES :-NEURASTHENtA. 
 
 quantity of blood squeezed out of the veins is correspond- 
 ingly augmented; if the abdominal walls are relaxed, 
 there is little or no effect on the intra-abdominal tension, 
 nor on the intra-abdominal veins. 
 
 Nekvb Foece Lacking in the I^eevous Mechan- 
 ism WHICH Regulates the Sttpplt of Blood in the 
 Abdominal Veins. The vasomotor nervous system 
 supplies the muscular tissue in the walls of the blood- 
 vessels and regulates their caliber. Ordinarily, the 
 small arteries are maintained in a state of moderate or 
 tonic contraction, which is necessary to force the blood 
 in a continuous stream through the capillaries and veins 
 back to the heart. Another function exercised by this 
 system is to regulate the amount of blood which flows 
 through the capillaries of any organ in proportion to its 
 needs. Thus, during digestion, it is imperative that 
 there should be a large quantity of blood supplied to the 
 digestive organs, hence at this time, the small arteries 
 of the splanchnic area are relaxed, and there is a large 
 amount of blood in this area, and a corresponding small 
 amount in other areas, such as the skin, and it is for 
 this reason that sensations of chilliness are experienced 
 after a capacious meal. Splanchnic neurasthenics for 
 a similar reason experience an intensification of their 
 symptoms after a full meal, for it is at this time that 
 the abdominal organs are surcharged with blood. The 
 most important vasomotor nerves of the body are the 
 splanchnics, with their cell stations situated in the 
 various ganglia of the abdominal plexuses. Now, in 
 many cases of neurasthenia (Angiopathic neurasthenia) 
 the vasomotor symptoms are extremely prominent, and 
 it would seem as if the nerve exhaustion in such cases 
 wdre mainly resident in the vasomotor system. 
 
THE CAUSE AND CURE. 121 
 
 Recapitulation. Reviewing the factors concerned 
 in splanchnic neurasthenia, we may deduce the follow- 
 ing : Defective innervation from any cause leads to con- 
 gestion of the abdominal veins; Venous congestion in- 
 terferes with a proper supply of arterial blood; The 
 tissues and organs bathed in pools of stagnant blood are 
 practically in a state of asphyxia ; The toxic products of 
 digestion, which are normally removed by an unim- 
 peded circulation, have a specifically poisonous effect 
 on the sympathetic system, a fact which is evident, owing 
 to the frequent occurrence of depression, prostration and 
 nervous symptoms in nearly all disorders of the ali- 
 mentary canal. Venous congestion diminishes the vital 
 tone of the organs and lessens their vital resistance. 
 This subject will be further elaborated in the next chap- 
 ter on the symptoms of splanchnic neurasthenia. 
 
122 THE BLUES :— NEURASTHENIA. 
 
 SUMMARY. 
 
 1. Depression is one of the most important symp- 
 toms of splanchnic neurasthenia, hence the layman 
 is prone to specify his sensations as a " fit of the blues." 
 
 2. " A fit of the blues " is, technically speaking, 
 acute neurasthenia, but it may also be an aggravated 
 paroxysm of chronic neurasthenia. 
 
 3. The entire question of splanchnic neurasthenia is 
 one of abdominal plethora, dependent on a variety of 
 causes, notably, diminished intra-abdominal tension, in- 
 sufficient lung development, and a defective vasomotor 
 apparatus. 
 
 4. The foregoing causes are dependent in a great 
 measure on diminished nerve tone, which seeks the fore- 
 going avenues for expression. 
 
 5. Splanchnic neurasthenia is one of the few forms 
 of neurasthenia amenable to permanent cure by meas- 
 ures having for their object the relief of abdominal 
 venous congestion. 
 
 6. Intra-abdominal venous congestion is tantamount 
 to asphyxiation of the abdominal viscera with all its evil 
 consequences. 
 
CHAPTEE VII. 
 
 THE SfMPTOMS OF SPLANCHNIC NEURASTHENIA, 
 
 HISTORY OF A SPLANCHNIC NEURASTHENIC. ANALYSIS 
 
 OE THE MOST PROMINENT SYMPTOMS. RELAXED AB- 
 DOMINAL WALLS, PROTRUSION OF THE ABDOMEN. 
 
 GAS ACCUMULATION IN THE BOWELS, INCREASED AB- 
 DOMINAL TENDERNESS, ENLARGEMENT OF THE LIVER, 
 AND INSUFFICIENT LUNG DEVELOPMENT. 
 
 I WILL introduce this subject by presenting, in detail, 
 the history of a patient, the subject of splanchnic neu- 
 rasthenia, after which, I will submit to analysis the 
 most prominent symptoms. 
 
 History of a Case of Splanchnic Neurasthenia. 
 The patient is an attorney, age 35. He presents no defi- 
 nite history of excesses of any kind. For the past three 
 years he has become exceedingly irritable, and has what 
 he calls " hlue streaks/' which come on at irregular in- 
 tervals without any apparent cause, although he is in- 
 clined to the belief that he can nearly always trace their 
 origin to some error in diet. What this error is, he does 
 not know; it is not any particular kind of food, but it 
 may be a late supper or a meal eaten hastily. At any 
 rate, during his " blue streaks," he has uncomfortable 
 abdominal sensations, which he is unable to describe 
 fully. Although his bowels move regularly during his 
 " blue periods," they are inclined to looseness. His 
 
 123 
 
124 THE BLUES :— NEURASTHENIA. 
 
 " blue streaks " have become more frequent of late, and 
 last longer. Intense mental depression and prostration 
 attend the attacks. At such times he is incapable of 
 doing work. He wants to be left severely alone during 
 the attacks. Of late, his memory has become affected, 
 and he is unable to concentrate his attention. He lacks 
 decision in his mental operations and control. He has 
 morbid fancies. He thinks that death would be a happy 
 release from his suffering, and constantly dwells on the 
 subject of self-destruction. In the intervals of his at- 
 tacks, which have become less and less frequent, he never 
 has the sensation of well-being. He can no longer pur- 
 sue his vocation with the same buoyancy as before, in 
 fact, he works automatically. His symptoms are inten- 
 sified after eating, and for an hour or so, after a meal, 
 he becomes horribly depressed and irritable. He has 
 no symptoms of indigestion in the ordinary sense, but 
 large quantities of gas accumulate in the bowels. For a 
 time, he practically starved himself, so that he could 
 be released from the depression and irritability follow- 
 ing meals. He has submitted himself to all kinds of 
 treatment without relief. One physician had treated 
 him for uric acid neurasthenia, and at that time he ex- 
 perienced temporary relief. My examination revealed 
 in brief the following: Imperfect lung development, 
 feeble heart action, protrusion of the abdomen with gas 
 accumulation in the bowels, exquisite sensitiveness of the 
 abdomen, enlargement of the liver, which was extremely 
 painful on pressure, and the abdominal walls were re- 
 laxed and showed no tone. Removal of the stomach 
 contents after a test meal demonstrated no anomaly. 
 
 This is in brief, the typical history of a case of 
 splanchnic neurasthenia. 
 
THE CAUSE AND CURE. 125 
 
 The objective signs will primarily merit our consider- 
 ation. 
 
 The Abdominal Walls. Eelaxation of the abdom- 
 inal walls is a common objective sign in this form of 
 neurasthenia. The abdomen is normally flat, and re- 
 mains so in health until the end of life. In some, 
 especially women, a hanging belly is best observed when 
 the patient assumes the erect posture. In the horizontal 
 position, the abdomen flattens and bulges at the sides. 
 The skin of the abdomen is loose, and this, together with 
 the flaccid walls, allows not only easy palpitation of the 
 underlying organs, but they may sometimes be seen. 
 Feeble abdominal muscles may be concealed by a large 
 deposit of fat, but the condition of the muscles may be 
 fairly gauged by directing the patient to raise the body 
 while lying supine or to bear down forcibly, when the 
 vigor of muscular contraction can be estimated by the 
 fingers. In pronounced cases, there is a wide space be- 
 tween the abdominal recti. Another method of testing 
 relaxed abdominal walls is to stand behind the patient, 
 place the hands at each side of the abdomen and then, 
 drawing the abdomen wall toward you, suddenly release 
 it; the degree of relaxation is determined by the dis- 
 tance which the abdominal wall falls after its release. 
 Stiller ^^ referred to a sign which was present in a large 
 number of neurasthenics, specially those who were lean 
 and dyspeptic, and that was, a mohile tenth rib, which 
 was not fixed with the cartilage to the other ribs, but was 
 either wholly free (or floating) or attached only with 
 ligament. This " Oosta fluctuans decima " is, accord- 
 ing to him, very common in delicate children and that 
 they are apt to become neurasthenics or enteroptotics 
 
126 THE BLUES :— NEURASTHENIA. 
 
 later in life, according as nervous or dyspeptic symp- 
 toms predominate. 
 
 Our main object in testing relaxation of the abdom- 
 inal wall in splanchnic neurasthenia is really to deter- 
 mine how far such relaxation comprises the intra-ab- 
 dominal venous circulation, and for this purpose 
 reference is made to the cardio-splanphnic phenomenon/''' 
 The more the latter is in evidence, as determined by the 
 degree of dulness and the extent of its area, the more 
 pronounced will be the circulatory embarrassment. 
 
 Pkoteusioit of the Abdomeiy. This occurs, as a 
 rule, owing to diminished intra-abdominal pressure on 
 the intestines, which allows their readier distension with 
 gas with consequent pressure effects on the abdominal 
 wall. 
 
 Gas AccuMULATioiY in the Bowels. This is a fre- 
 quent symptom, and, which I hope to show, is one 
 of compensation. The accumulation of gas in the intes- 
 tines increases intra-abdominal tension, and any increase 
 in the latter means diminished intra-abdominal venous 
 congestion. The gases of the intestinal canal are de- 
 rived in part from the air (oxygen and nitrogen), in 
 part from the ingesta (carbonic acid) and in part from 
 intestinal fermentation (ammonia, carbonic acid, hydro- 
 gen, hydrogen sulphide, etc.). Some of the gas is re- 
 moved by eructations and by flatus, as well as through 
 resorption by the blood-vessels, as is evidenced by the in- 
 creased excretion of carbonic acid through the lungs, oc- 
 curring usually about an hour after a meal. In the chem- 
 istry of respiration, the air in the lungs and the blood in 
 the capillaries are separated only by the thin capillaries 
 and alveolar walls. The blood parts with its excess of 
 * Appendix, Note 2. 
 
THE CAUSE AND CURE. 127 
 
 carbonic acid to the air in the lungs, and the blood simul- 
 taneously engages the oxygen from the air in the lungs. 
 This intake of oxygen and output of carbonic acid takes 
 place all over the body, and constitutes what is called 
 tissue-respiration. If we apply this theory to the con- 
 gested abdominal veins, we have the following: The 
 intestines and abdominal veins represent two chambers 
 containing a mixture of gases in unequal amount; dif- 
 fusion takes place until the percentage amount of each 
 gas in each chamber is the same. Owing to the stagna- 
 tion of blood in the abdominal veins, the latter contain 
 a large quantity of carbonic acid, hence carbonic acid dif- 
 fuses from the veins to the intestines. The intestines now 
 being inflated, increase intra-abdominal tension, which 
 in turn squeezes the blood out of the abdominal veins 
 to the right heart. After this manner, gas accumula- 
 tion in the intestines, is, as I view it, distinctly a com- 
 pensatory process, and the results attained by treatment 
 justify this conclusion. Gas accumulation in the intes- 
 tines in splanchnic neurasthenia gives rise to many 
 symptoms, especially referable to the heart.* 
 
 INCREASED SENSITIVENESS OF THE ABDOMEN.* 
 
 Splanchnic neurasthenics, as a rule, are very suscep- 
 tible to pressure made on the anterior abdominal wall. 
 The abdomen may be <iiffusely sensitive on deep pressure 
 or the sensitive points may be localized, and remind 
 one of the hysterogenic zones. The site of predilection 
 of the sensitive points is the lower abdomen. Not infre- 
 quently pains radiate to the back, to the neck and to the 
 legs, and may be of the most agonizing character. The 
 
 * Appendix, Note 4. 
 
 * Appendix, Note 11, 
 
128 THE BLUES :-NEURASTHENIA. 
 
 pains in question do not admit of localization with ref- 
 erence to any nerve trunk, or its terminal distribution, 
 and they are not modified by pressure, rest nor move- 
 ment. These facts suggest the abdominal origin of the 
 pains which are probably caused by congestion of the 
 intra-abdominal veins irritating the terminal ramifica- 
 tions of the splanchnic nerves. There is one fact worthy 
 of mention in diagnosis with reference to abdominal 
 sensitiveness and liver tenderness, and that is, if firm 
 compression of the abdomen is made with the hands and 
 the process repeated for several minutes, abdominal sen- 
 sitiveness, liver tenderness and the radiating pains be- 
 come markedly abated and even disappear after several 
 mimites. The phenomenon in question is clearly the 
 result of the maneuver, and receives the following expla- 
 nation : Abdominal compression will squeeze the blood 
 out of the intra-abdominal veins, and will thus remove 
 the source of irritation acting on the splanchnic nerves. 
 Enlaegement of the Livek.* This is an almost 
 invariable accompaniment of splanchnic neurasthenia. 
 Aside from enlargement, the liver is always palpable, 
 and found to be exquisitely painful. It is more painful 
 after eating, and the sensation of fullness experienced 
 after a meal by splanchnic neurasthenics is frequently 
 caused by hepatic engorgement. This hepatic tender- 
 ness is always associated with neurasthenic symptoms, 
 and is always more pronounced when the latter are in- 
 tensified. After a night's rest, the hepatic tenderness 
 is no longer evident in the morning, but soon after break- 
 fast it reappears and becomes more marked as the day 
 proceeds, increasing in severity after each meal. He- 
 patic enlargement and tenderness m&j be made to di§- 
 
 * Appendix : Note 5, 
 
THE CAUSE AND CURE. 129 
 
 appear in most instances by vigorous massage of the ab- 
 domen and the application of the sinusoidal current, 
 facts -which will be elaborated in the chapter on the 
 special treatment of splanchnic neurasthenia. The sin- 
 usoidal current induces what I have called the liver 
 reflex."^' The liver has from time immemorial been sur- 
 reptitiously accused of participation in an attack of " the 
 blues," and, for want of a better term, " biliousness " 
 has heretofore been employed to designate the condition. 
 I have frequently examined individuals during an at- 
 tack of " the blues," and have established the fact to my 
 own satisfaction that hepatic enlargement and tender- 
 ness accompany the paroxysm. Furthermore, that treat- 
 ment having for its object the depletion of the intra- 
 abdominal veins will abort an attack or diminish its 
 severity. In what way does the liver participate in the 
 attacks in question ? The amount of blood which the 
 liver contains has been estimated by Foster ^^ to be 
 equivalent to one-fourth the amount of blood contained 
 in the body. The blood is chiefly derived from the portal 
 vein, which collects blood from the stomach, intestine, 
 spleen and pancreas. Digestion incre_ases the amount 
 of blood contained in the intra-abdominal veins (physio- 
 logic congestion), a fact which accounts for the drowsi- 
 ness felt by some dyspeptics soon after eating, the result 
 of brain anemia from portal congestion. The cold ex- 
 tremities of some dyspeptics during the digestive stage 
 admit of the same explanation. 
 
 My investigations show that coincident with this con- 
 gestion of the intra-abdominal veins after meals there is 
 a corresponding rise in the blood pressure which is most 
 pronounced one hour after meals, then it gradually falls 
 * Appendix : Note 6- 
 
 9 
 
130 THE BLUES :— NEURASTHENIA. 
 
 until the next meal time. It is this increased blood 
 pressure after meals which aggravates the condition of 
 the splanchnic neurasthenic at such particular periods, 
 the augmented blood pressure injuring the delicate tis- 
 sues of the brain by a series of powerful uniform blows, 
 and one is justified in referring to such action as, the 
 traumatism of high blood pressure. 
 
 Now, the secretion of the bile is effected by stimula- 
 tion of the liver cell by digestive products carried to the 
 liver. Aside from the many established functions of the 
 liver, experiment and pathology demonstrate that the 
 liver is endowed with the function of not only arresting 
 but of destroying toxic substances which are developed 
 in the ordinary process of digestion and from intestinal 
 putrefaction. It is not diiScult to understand, then, why 
 it is, that in splanchnic neurasthenia, hepatic tenderness 
 and enlargement are worse after eating, and why it is, 
 that in this affection, mental depression and prostration 
 are such prominent symptoms: They are clearly the 
 result of auto-intoxication; the functions of the liver 
 being inhibited by congestion and the toxic products 
 from the intestinal canal being no longer arrested nor 
 destroyed pass into the circulation inducing pronounced 
 nervous symptoms, of which mental depression and pros- 
 tration are the most prominent. If there are periods 
 during the day in which nervous symptoms remit in 
 splanchnic neurasthenia, such periods occur several 
 hours after eating. Thus, in splanehnie neurasthenia, 
 the " fatigue curve " is not always identical with that 
 which occurs in neurasthenia, the result of overwork. 
 In the latter form of the affection, the ebb of nerve force 
 begins with the early morning hours, attains its maxi- 
 mum discharge in the middle of the afternoon, when the 
 
THE CAUSE AND CURE. 131 
 
 nervously exhausted are most weak. Many splanchnic 
 neurasthenics have and are being treated for a supposi- 
 titious uric acid intoxication. Whatever organ may be 
 accredited v?ith the manufacture of uric acid or the na- 
 ture of the symptoms produced by the latter, this much 
 is evident, that uric acid does no more in explaining 
 gout than it does the nervous symptoms supposed to be 
 attributed to it, but it hints at defective hepatic meta- 
 bolism, or as Yeo ^* would call it, " hepatic inadequacy." 
 In other words, there is some disturbance in function 
 antecedent to the accumulation of uric acid in the blood 
 which is responsible for gout, rheumatism, neurasthenia 
 and a multitude of allied affections. Experiments sug- 
 gest the theory that urea and uric acid are formed in 
 the liver,** and admitting, for the sake of argument, 
 that uric acid is responsible for the preceding affections, 
 and that the source of its production is in the liver, rea- 
 soning by analogy, this conclusion is warranted: that 
 an organ in a healthy state which produces any sub- 
 stance can also repress that substance when its over- 
 production is inimical to the integrity of the economy. 
 Approaching the final signs, which I have frequently 
 encountered in splanchnic neurasthenia, we have insuffi- 
 cient lung development and heart weakness. 
 
 Insufficient Lung Development. Diminished 
 intra-abdominal tension implies reduced strength of the 
 diaphragm, and the elimination of this powerful muscle 
 in respiration seriously compromises lung development, 
 hence, in splanchnic neurasthenia, the lungs fail to per- 
 form the work required of them, and another factor is 
 added to further embarrass the already imperfect ab- 
 dominal circulation. 
 
 Heart Weakness. Here many factors conspire to 
 
132 THE BLUES :-NEURASTHENIA. 
 
 bring about heart weakness. First, stagnatioK of blood 
 in the abdomen means an insufficient blood supply to the 
 heart; second, there is a deficient supply of oxygen in 
 the blood (Anoxemia), and the heart, like every tissue, 
 suffers; third, the toxic substances present in the blood 
 reduce the vital tone of the heart, and the resistance of 
 the latter, like every other organ in the body, is neces- 
 sarily reduced. In concluding this chapter, I wish to 
 emphasize the very important fact, that splanchnic neu- 
 rasthenia may exist without the appreciation of any 
 abdominal symptoms by the patient ; and on the other 
 hand, while the local abdominal symptoms may be slight, 
 the reflex symptoms may be so pronounced that they 
 compromise the integrity of all the organs including the 
 nervous system, the heart, the alimentary canal and the 
 sexual organs. 
 
THE Cause and cure. 133 
 
 SUMMARY. 
 
 1. The dominant symptoms of splanchnic neuras- 
 thenia are resident in the nervous system. 
 
 2. Many splanchnic neurasthenics are never cogni- 
 zant of abdominal symptoms; the latter being usually 
 elicited by the physician in the course of his examina- 
 tion. 
 
 3. The chief abdominal symptoms are: Abdominal 
 sensitiveness, tenderness of the liver and enlargement of 
 that organ and gaseous accumulation in the bowels. 
 
 4. It is often difficult to say hov? much of the nerv- 
 ousness in the average neurasthenic is due to intra- 
 abdominal venous congestion, for the latter condition 
 may aggravate the symptoms of neurasthenia. The only 
 test is the therapeutic one: by eliminating the venous 
 element, which is certainly possible of achievement, we 
 may observe the effect on the nervous -symptoms. 
 
 5. In splanchnic neurasthenia existing as an inde- 
 pendent affection, the relief of symptoms almost posi- 
 tively follows relief of the venous abdominal conges- 
 tion. 
 
 6. The Cardio-splanchnic phenomenon is a trust- 
 worthy index of the severity of the affection, and in 
 gauging the results of treatment. 
 
 Y. Splanchnic neurasthenia is specially encountered 
 in individuals with vigorous constitutions, in whom the 
 question of an unhygienic life does not enter into con- 
 sideration. Nor can the conventional factors always be 
 elicited in the history which conduce to neurasthenia. 
 
Fig. 1. — Points of election on the abdominal surface, marked by 
 crosses, for executing auto-massage. 
 
CHAPTEK VIII. 
 
 THE TREATMENT OF SPLANCHNIC NEURASTHENIA. 
 
 THE FUNDAMENTAL PEINCIPLES GOVERNING TREATMENT. 
 THE PHYSICAL METHODS OF TREATMENT ; ABDOMINAL 
 MASSAGE, ABDOMINAL EXERCISES, RESPIRATORY EXER- 
 CISES, ELECTRICITY, ABDOMINAL SUPPORTERS, AND 
 HYDROTHERAPY. CITATION OF CASES OF SPLANCH- 
 NIC NEURASTHENIA. ACTION OF PURG.ATIVES IN 
 
 SPLANCHNIC NEURASTHENIA. 
 
 The primary and fundamental condition prevailing 
 in splanchnic neurasthenia is a stagnation of blood in 
 the splanchnic or abdominal veins. This condition is 
 either primary or secondary to nervous exhaustion. The 
 treatment then, must not only embrace the neurasthenic 
 state, but the local condition of abdominal plethora. 
 The general treatment of neurasthenia has already been 
 discussed in Chapter V. This much is true, however: 
 1. That if neurasthenia is dependent on congestion of 
 the intra-abdominal veins, any treatment directed to- 
 ward the former, however effective, will only result in 
 temporary benefit. 2. Treatment directed toward the 
 relief of abdominal congestion alone will often perma- 
 nently arrest the neurasthenic symptoms. 3. Practically 
 all cases of neurasthenia are associated with abdominal 
 congestion, which serves to aggravate the neurasthenic 
 
 1.3T 
 
138 THE BLUES :— NEURASTHENIA. 
 
 symptoms, insomuch as one of the earliest evidences of 
 nerve waste is a diminished tone of the abdominal sym- 
 pathetic. 4. There are many instances of abdominal 
 congestion which never present the picture of neuras- 
 thenia, but are manifested by an ill-defined group of 
 symptoms, which baffle classification under any recog- 
 nized form of disease. In any case, the relief and cure 
 of abdominal congestion is imperative. I give expres- 
 sion to a conservative statement when I say, that in no 
 other form of neurasthenia are results achieved so posi- 
 tively, quickly, and permanently, as in the splanchnic 
 form of the affection. Here, our therapeutic maneuvers 
 cannot bear the imprint of suggestion, for we. can con- 
 trol the results of treatment by certain objective signs 
 which are indisputable, viz. : The reduction of hepatic 
 enlargement, the disappearance of hepatic and abdom- 
 inal tenderness, and the diminished grade of the Cardio- 
 splanchnie phenomenon ; and the gradual abatement of 
 the objective signs run parallel with the evanescence of 
 the subjective symptoms. We will now proceed to a dis- 
 cussion of the physical methods which are designed to 
 correct congestion of the abdominal veins. 
 
 Physical Methods which Cube Splanchnic Neu- 
 
 EASTHENIA BY EeLIEVING CONGESTION OF THE ABDOM- 
 INAL Veins : 1. Massage of the abdominal wall; 2. 
 Exercises which strengthen the abdominal muscles; 3. 
 Respiratory exercises; 4. Electricity to the abdomen; 
 5. Abdominal supporters; 6. Cold water. 
 
 Massage op the Abdominal Wall. When refer- 
 ence is made to this maneuver, it does not signify the 
 conventional massage, but a form of massage, executed 
 by the patient, which achieves three distinct objects : 1. 
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THE CAUSE AND CURE. 141 
 
 augmented tone, increase intra-abdominal tension, thus 
 clamping the intra-abdominal veins, as it were, and pre- 
 venting their engorgement; 2. It facilitates the return 
 of blood from the abdominal veins to the heart; 3. It 
 favorably influences reflexly the sympathetic nerve fibers 
 which dominate the supply of blood to the abdominal 
 organs. 
 
 Method op Abdomiwal Massage. 1. Method of 
 expulsion ; 2. Respiratory method. 
 
 Method of Expulsion. This method is designed 
 for the comparatively strong subject, for it must be re- 
 membered that abdominal manipulations of any kind act 
 reflexly on the heart.* To aid in the elucidation of 
 this maneuver, reference is made to the accompanying 
 illustrations: In figure 1, the abdomen is marked by 
 crosses, which indicate the points of election for exe- 
 cuting abdominal massage. In figure 2, the fingers are 
 in contact with one of these points. The fingers of the 
 left hand are first placed on the abdominal wall with a 
 varying degree of pressure, which is re-enforced by su- 
 perimposed pressure with the fingers of the other hand. 
 The subject next endeavors, by contraction of the ab- 
 dominal muscles, to overcome the pressure exerted by 
 the fingers. This constitutes the complete act of auto- 
 massage. It is repeated ten or more times over each 
 spot, depending on the endurance of the subject. When 
 the spots contiguous to the curvature of the ribs are 
 reached, the fingers must be passed as far as possible 
 under the ribs. The subject executes massage in the 
 recumbent posture, as this position best favors the return 
 of blood to the heart. The legs as seen in the illustra- 
 tion are well drawn up to relax the abdominal muscles, 
 * Appendix, Note 3. 
 
142 THE BLUES :-NEURASTHENIA. 
 
 so that they may be more easily and powerfully con- 
 tracted. The vigor of the massage may be gradually in- 
 creased by increasing the pressure of the fingers and the 
 number of manipulations over each spot. Massage exe- 
 cuted after the foregoing manner may be followed by a 
 sense of oppression in the heart region and fulness in 
 the head, sensations which may be referred to over-dis- 
 tension of the heart, due to the large quantities of blood 
 expressed into this organ from the abdominal veins. 
 After each contraction of the abdominal muscles, the 
 subject should take a forced deep breath, so as to suck 
 the blood into the lungs from the engorged right heart : 
 an act which will easily remove and prevent the sensa- 
 tions already referred to. The sensation of tingling, 
 which the patient experiences in the extremities during 
 massage, are rather pleasant than otherwise, and may 
 be referred to an improved circulation. Soreness of the 
 abdomen after initiation of the exercises may be dis- 
 regarded, being provoked by contraction of muscles un- 
 accustomed to exercise. 
 
 Eespieatoet Method. This Is a maneuver less 
 harsh than the former, having for its goal the same ob- 
 jects, and designed for subjects in whom the heart-action 
 is not strong. As in the expulsion method, the fingers 
 are placed in succession over each spot with a varying 
 degree of pressure and by a forced act of inspiration 
 only, the patient endeavors to remove the pressure ex- 
 erted by the fingers, maneuver may be repeated 
 over each spot a varying number of times, and the finger 
 pressure increased or diminished, according to the en- 
 durance of the subject. There are certain facts worthy 
 of mention in reference to this form of auto-massage. 
 As a rule, splanchnic neurasthenics suffer from hemor- 
 
THE OAtrSE AND CUtlE. I43 
 
 rhoids, and this is not extraordinary, considering the 
 engorgement of the abdominal veins. Auto-massage will 
 cure such hemorrhoids, not only in neurasthenics, but 
 in others, and I know of no simpler nor more effective 
 measure for the relief and cure of this obstinate affec- 
 tion. In reference to auto-massage on the action of the 
 bowels, all I can say is this, that some splanchnic neu- 
 rasthenics obtain relief from their constipation, others 
 find no relief, whereas, others, who are not constipated, 
 increase the number of their bowel movements. In 
 any event auto-massage will do much toward augment- 
 ing the tone of the intestines. 
 
 EXEECISES WHICH STRENGTHEN THE AbDOMINAL 
 
 Muscles. These exercises may be employed in con- 
 junction with auto-massage, or either may be executed 
 to the exclusion of the other, although if either method 
 is employed alone, preference is given to auto-massage. 
 Exercises for developing the abdominal muscles must 
 be regulated in duration and number by the age and 
 strength of the patient. 
 
 These exercises should be avoided if hernia exists, 
 unless primarily supervised by the physician. 
 
 Exercise 1. Rope-hauling exercise. Two strong 
 elastic cords, two feet in length and fixed into the floor 
 at one end, while to the free end rings are attached 
 which can be grasped by the hands. These cords are 
 stretched alternately by first pulling with one and then 
 with the other hand, as in rope-hauling. 
 
 Exercise 2. The patient lies on the floor and places 
 his feet against some resisting object, and then attempts 
 to assume the sitting posture. This exercise may be 
 repeated a number of times. Wlien the patient begins 
 
Ui THE BLUES i-NBtJRASTHENlA. 
 
 the exercises, he may assist himself in rising by aid 
 of the hands. 
 
 ExEEciSE 3. This requires the aid of an assistant. 
 The patient, seated on a stool, bends his body back- 
 wards and forwards. The forward movement is resisted 
 by the assistant, who grasps the shoulders from behind. 
 
 Exercise 4. The patient sits on a stool with his 
 back to the wall. On either side of him is a ring fixed 
 into the wall. Through each ring a cord passes, to the 
 ends of which weights are attached. The portion of 
 cord between the two rings is passed round the waist. 
 The body is then repeatedly bent toward the thighs and 
 the weights thereby raised. (Campbell.) 
 
 Steeistothening the Abdominal Muscles ey 
 Means of an Exeecisee. I have devised a simple ap- 
 paratus (see illustrations, figs. 3 and 4), which I regard 
 as most serviceable in this connection. The work put 
 upon the abdominal muscles by means of this apparatus 
 can be regulated to any degree, depending on the amount 
 of traction put upon the elastic cords. It consists of 4- 
 pieces of elastic cord, each one-half inch in width and 
 about 5 feet in length; a firm though yielding belt of 
 leather, very smooth on the surface, brought in contact 
 with the abdomen 4 inches in width and tapered at 
 the ends and provided with strap and buckle for fixation 
 around the abdomen ; two blocks of wood, provided with 
 4 holes for the elastic cords, each piece five inches in 
 width and about an inch in thickness. To each block 
 of wood a piece of firm leather is screwed, leaving a 
 projecting loop, which, in appearance, is not unlike a 
 stirrup. The leather stirrups are intended for the at- 
 tachment of snaps. The elastic cords are fixed by means 
 of a knot in each hole in one block of wood, the cord in 
 
Fig. 3. — Apparatus for 
 abdominal exercises. 
 
 Fig. 4. — Method of using the apparatus 
 for abdominal exercises. 
 
THE CAUSE AND CURE. I4Y 
 
 contact with the holes being wound with fine wire to pre- 
 vent wear ; then they pass across the front of the leather 
 belt, and to prevent slipping, across the belt three nar- 
 row strips of leather, vertically attached by means of 
 rivets, are placed, with apertures for the cords; then 
 the cords are passed through the holes of the other 
 block of wood, and fixed by means of knots, and here 
 likewise re-enforced by wire. The apparatus is then 
 attached to two screw eyes in the wall, when it is ready 
 for use. 
 
 The elastic cords, shown in the illustration, are cov- 
 ered with •webbing, and after a limited use of the ap- 
 paratus, become worn, leaving the rubber free. This 
 is a serious objection, and for this reason, solid rubber 
 cords, two in number and about one inch in width may 
 be employed; otherwise, the apparatus is made accord- 
 ing to the description already given. It is a matter of 
 little moment what kind of apparatus is employed, pro- 
 vided it permits of regulated abdominal traction. 
 
 The belt of the apparatus is first placed below the 
 navel and tightened by means of the strap and buckle ; 
 then the patient steps forward on a board placed on the 
 floor, which is provided with cleats arranged at conven- 
 ient distances. The real work is executed while stepping 
 forward, the backward movement being effected by the 
 elasticity of the cords. The number of tractions made 
 by the abdomen is regulated by the strength and en- 
 durance of the patient. After the lower abdomen is 
 exercised, the belt is fixed successively on the pavel, and 
 then above the navel, so that all parts of the abdominal 
 muscles may be included in the exercises. I advise 
 my patients that, after each traction by means of the 
 abdomen, a deep inspiration should be taken to prevent 
 
148 THE BLUES :-NEURASTHENIA. 
 
 accumulation of blood in the heart and to further its 
 circulation through the body. I further advise my 
 patients to exercise after rising and before retiring; to 
 begin with 10 tractions, in each position of the belt, viz. : 
 below, at and above the navel, 30 in all; and to grad- 
 ually increase the number to 75. 
 
 Eespikatoey Exeecises. We have already referred 
 in a previous chapter to the great value of pulmonary 
 ventilation^ in preventing disease and maintaining the 
 standard of health. The lungs are important avenues 
 for the elimination of poisonous substances generated 
 within the body; they regulate the local and general 
 blood and lymph circulations, not only in a quantita- 
 tive, but in a qualitative manner. Without properly de- 
 veloped lungs, no individual can be regarded as healthy. 
 While general exercises may and do contribute to res- 
 piratory gymnastics, the character of the exercises is 
 such that it is more than the average patient can do, 
 hence local pulmonary gymnastics are necessary for the 
 preservation of health. We have already shown that the 
 mere act of inspiration performs a double function in 
 relieving abdominal congestion, viz. : The descent of the 
 diaphragm, by increasing intra-abdominal tension, 
 squeezes the blood out of the intra-abdominal veins into 
 the heart; inspiration favors pulmonary suction, for 
 during this phase of respiration, the blood-vessels of the 
 lungs are expanded, and the blood is sucked, not only 
 out of the abdominal veins, but from the veins through- 
 out the body. It is only rarely in health that the lungs 
 in their entirety are physiologically active, and this 
 question is further discussed in the appendix.* Both 
 phases of respiration may be influenced by respiratory 
 
 * Appendix, Note 1. 
 
THE CAUSE AND CURE. 149 
 
 gymnastics, viz.: inspiration and expiration or both. 
 In the average case, it may be presumed that when in- 
 spiration is vigorous, expiration is equally vigorous, but 
 in those predisposed to pulmonary tuberculosis, we may 
 have, as my investigations show, a voluminous lung capa- 
 ble of performing the act of inspiration with normal 
 vigor, and yet the expiratory act may be seriously com- 
 promised.* Here attention will be directed to a simple 
 exercise for facilitating inspiration, and it may be exe- 
 cuted in conjunction with the use of the abdominal ap- 
 paratus previously described. I believe I am justified 
 in protesting against prolix methods for securing lung 
 development. Such methods accomplish little and de- 
 feat their object, which cause them soon to be relin- 
 quished. The Roentgen rays have furnished me with 
 indisputable proof in selecting simple methods for in- 
 flating the lungs. 
 
 It is well known that the lungs in health appear in 
 the fluoroscopic picture as light areas. The lungs ap- 
 pear brighter during inspiration than expiration; in 
 fact, the greater the lung inflation, the brighter the 
 reflex. I have examined patients with the fluoroscope 
 during the time " breathing tubes " were used, and while 
 the different postures and exercises were practiced, as 
 advocated by various writers, and I was imable to dem- 
 onstrate that any method was superior to that of forced 
 breathing. In fact, in some of the advocated methods, 
 the fluoroscope demonstrated the lung phase to be really 
 that of expiration, whereas, the object supposed to be 
 attained was lung inflation. To enhance the value of 
 forced inspiration with the object of attaining hyper- 
 ventilation of the lungs, the simple expedient of holding 
 * Appendix, Note 7. 
 
150 THE BLUES :— NEURASTHENIA. 
 
 the breath after full inspiration will be found of great 
 value. After a little practice, patients are able to hold 
 the breath fully two minutes. If, during this maneuver, 
 regional percussion is made, it will be found that the 
 position of the lung borders extend beyond the limits 
 attained by forced inspiration alone. The principle in- 
 volved in explanation of the foregoing phenomenon is 
 one relating to pneumatics, by raising the temperature 
 of a gas we increase the volume. Another simple 
 maneuver is to direct the patient, after taking a forced 
 inspiration, to count slowly. With a little practice, 80 
 can be counted without difficulty. This is an exercise 
 both for the inspiratory and expiratory forces. For rapid 
 lung development, inhalations of compressed air by the 
 aid of the pneumatic cabinet, is unquestionably the best 
 method. After a limited course of treatment the tho- 
 racic capacity may be increased 2 per cent., with a cor- 
 responding development both of chest measurements and 
 chest expansion. 
 
 The method which I earnestly advocate, when used 
 in connection with the abdominal exerciser, is that em- 
 ployed by the Swedish trainers, and after each or several 
 tractions are made by the abdomen, this exercise is 
 executed. It is as follows : The patient raises his arms 
 to the vertical position, at the same time taking a deep 
 inspiration. He then brings the arms dowuM^ard and 
 backward, thus describing a large movement of circum- 
 duction. When the patient practices forced inspiration, 
 he supports himself on his toes, inclining his body back- 
 ward during the entire period of inspiration. 
 
 Electricity 'to the Abdomen.* Of all methods, 
 this is unquestionably the most expeditious and thor- 
 * Appendix, Note 13, 
 
THE CAUSE AND CURE. 151 
 
 ough in the treatment of splanchnic neurasthenia, and 
 were I less conservative, I would regard it as a specific 
 measure. I have tested all forms of electricity, physi- 
 ologically and therapeutically, in relation to this special 
 affection, viz. : Galvanic, f aradic, static and high fre- 
 quency, but they are all subservient in their action to the 
 Sinusoidal Current. 
 
 The Sinusoidal Current * acts differently upon the 
 body from other forms of current, and this is due to the 
 number of alternations in a second, the quantity of cur- 
 rent, and the degree of electro-motive force. Owing to 
 the uniformity of the alternations, strong currents may 
 be employed without producing pain or muscular con- 
 tractions. The sinusoidal current possesses the prop- 
 erty of contracting the organs, specially the heart, in- 
 ducing what I have called the heart reflex, the lungs 
 (lung reflex of contraction) and the liver (liver re flex) .'^ 
 It is also endowed with the property of contracting the 
 veins, notable the intra-abdominal veins and of stimu- 
 lating the sympathetic abdominal nerve fibers. 
 
 The effect of this current in driving the blood from 
 the intra-abdominal veins back into the heart is evi- 
 denced by the cardio-splanchnic phenomenon, which is 
 elicited to a remarkable degree after its application. 
 The sinusoidal current, by the uniformity of its alterna- 
 tions, anesthetizes the terminal sympathetic nerve fibers 
 and this anesthesia is so marked in the skin between the 
 electrodes that no sensation is experienced by the pa- 
 tient, even after a pin prick during the application of 
 the current. 
 
 My usual method of application is to place one large 
 
 * Appendix, Note 6. 
 I Appendix, Note I3. 
 
152 THE BLUES :— NEURASTHENIA. 
 
 electrode above and another below the navel and fix 
 them in position by means of straps. The duration of 
 each application made daily must not be less than 15 
 minutes. 'Not infrequently while one electrode is ap-^ 
 plied to the abdomen the other may be applied to the 
 back of the neck, specially if the patient complains of 
 pains radiating to the back of the neck. Each applica- 
 tion is, as a rule, followed by a sensation of well-being, 
 which is never attained so expeditiously by any other 
 method of treatment. The strength of the current should 
 be as strong as the patient can tolerate, but never too 
 strong to induce unpleasant sensations. 
 
 I have also employed vibratory massage of the ad- 
 domen by means of a vibratory machine, as a substi- 
 tute for the sinusoidal current, but the effects can in no 
 wise be compared to the current. 
 
 Abdominal Suppobtees. The use of a properly- 
 fitting abdominal support or belt is only to be thought 
 of when the abdominal muscles are relaxed beyond the 
 hope of restoration by electricity, exercise, massage, etc. 
 There can be no objection, however, to use a support 
 in connection with the methods already referred to for 
 strengthening the abdominal muscles. The physician 
 should examine the support to determine whether it 
 merits its name, insomuch as the majority of abdominal 
 supporters on the market are worse than useless. In 
 dislocation of the abdominal viscera (Enteroptosis) the 
 wearing of an abdominal supporter affords much relief 
 to the wearer. The relief thus attained is not due 
 wholly to reposition of the organs, as is instanced in the 
 observations of Bial.^^ The latter applied transparent 
 bandages to cases of gastroptosis and transilluminated 
 the stomachs before and after the application of the 
 
THE CAUSE AND CURE. 153 
 
 bandages. No change in the position of the stomach 
 could be noted, and it is therefore most likely that ab- 
 dominal supporters act chiefly by compression of the 
 viscera, which in turn squeeze the blood out of the 
 turgid abdominal veins. 
 
 Cold Watee. After the morning exercises with the 
 abdominal apparatus, I insist on my patients taking a 
 lukewarm bath, or even a cold bath, if they are accus- 
 tomed to it, and by means of a spray douche direct cold 
 water from a certain height to fall on different parts 
 of the abdomen. This is a most effective means of aug- 
 menting the tone of the abdominal walls, and organs 
 and tissues of the abdomen. The circulation of the 
 blood, the motion of the alimentary canal and the process 
 of nutrition are thus stimulated reflexly by innumerable 
 nerves Avhich terniinate in the skin. 
 
 In concluding the subject of treatment for splanchnic 
 neurasthenia, it may be mentioned for the sake of com- 
 pleteness, that, when the anterior abdominal wall is be- 
 yond hope of repair, owing to its flabby and relaxed 
 condition, an operation may be suggested for its resec- 
 tion. This operation has been performed with success 
 by different surgeons. I have selected ten cases among 
 my splanchnic neurasthenics to illustrate the effects of 
 treatment according to the lines already laid down. 
 
 Case r. Vertiginous Symptoms. Merchant. Age 
 42. Pronounced symptoms of neurasthenia. The chief 
 symptom is vertigo, which has increased of late to such 
 a degree that he fears to go out without a companion. 
 One evening he had eaten too heartily of fresh fruit, 
 with the result that he developed an attack of intestinal 
 colic, and his vertigo became very much intensified. He 
 
154 THE BLUES :— NEURASTHENIA. 
 
 noted with much surprise that the pressure of his wife's 
 hands on his abdomen, while relieving his symptoms of 
 colic, likewise gave temporary relief to his vertigo. His 
 wife suggested the application of a bandage to his ab- 
 domen, with the result that as long as the bandage was 
 worn, the vertigo disappeared. After recovery from his 
 colic, he was able to go about unattended, provided he 
 wore a closely-fitting leather belt around his abdomen, 
 and if this belt were removed, the signs of vertigo would 
 recur. This case suggested to me the pertinent fact, 
 that the patient in question owed his vertiginous attacks 
 to gravitation of blood to the splanchnic area, and that 
 the application of his leather belt merely forced the 
 blood from the latter area into the general circulation. 
 After one month's treatment by means of the sinusoidal 
 current, daily applications, supplemented by abdominal 
 and respiratory exercises, the patient dispensed with his 
 leather belt, and was, in fact, cured. In this and other 
 cases, it is difficult to say how permanent. the cure really 
 is, and for this- reason, I enjoin my patients to continue 
 their exercises for an indefinite period. 
 
 Case ii. Chief symptom, pain radiating to the arms 
 and legs. Tailor; age 38. Has been unable to follow 
 his occupation for the last eight months, owing to par- 
 oxysms of pain, which radiate to the neck, arms and 
 legs. His arms feel " like paralyzed," and legs seem 
 unable to support his body. Has headaches. Suffers 
 from gas in the stomach and bowels. Has been losing 
 in weight, and cannot sleep. Has been subjected to 
 almSst all kinds of treatment by different physicians, 
 without any relief. Examination shows an enlarged and 
 sensitive liver, in fact, palpation of this organ almost 
 " causes him to faint." His abdominal wall lacks tone. 
 
THE CAUSE AND CURE. 155 
 
 Treatment by means of the sinusoidal current, one elec- 
 trode to the back of the neck and the other to the abdo- 
 men, supplemented by exercises, has enabled him, after 
 five weeks treatment, to return to work. 
 
 Case in. Mental symptoms. Clerk ; aged 29. Has 
 had syphilis. Has a feeling of pressure on the top of his 
 head. He is in constant dread that " something is going 
 to happen." Peels as though something were lodged 
 in his " belly," and that by taking a deep breath he is 
 able temporarily to dislodge it. While in my presence 
 during his early visits to my office, he was constantly 
 engaged' in taking forced inspirations. His memory is 
 poor, and he is unable to concentrate his attention on 
 anything. Examination demonstrated the conventional 
 stigmata of splanchnic neurasthenia. This patient had 
 taken three rest cures and for more than a year had 
 traveled about the country in search of health. After 
 two months' treatment, he was able to resume his work, 
 when he said " I never felt better in my life." 
 
 Case iv. Chief symptoms, depression and weakness. 
 Woman; married; age 46. Could not be persuaded to 
 leave her bed on account of extreme weakness. Was 
 very much depressed, and feared that her relatives were 
 going to take her to an insane asylum. She eats only 
 sparingly, contending that food distresses her. Her his- 
 tory prior to her illness, which has been gradual in its 
 approach, was uneventful. Examination showed no 
 liver enlargement nor tenderness. There was only one 
 point of abdominal tenderness. Pressure on the ab- 
 domen, kept up for several minutes, demonstrated the 
 cardio-splanchnic phenomenon to an unusual degree. 
 Treatment was begun with the sinusoidal current to the 
 abdomen, and after two weeks, she could be persuaded 
 
156 THE BLUES :— NEURASTHENIA. 
 
 to take the other exercises, with the result that in three 
 months she was discharged as cured. 
 
 Case v. Prominent symptom, pain in the liver 
 region. Woman; married; age 43. Is very much de- 
 pressed on account of pains in the region of the liver. 
 " Bloats " after eating. Has symptoms of indigestion. 
 Is constipated. Liver enlarged and tender. Abdominal 
 points of tenderness. After two weeks treatment pa- 
 tient returned home and, as she said, " completely 
 cured." 
 
 Case vi. Prominent symptom, " the blues." Elec- 
 trician ; age 40. Has no symptoms beyond attacks of 
 " the blues." Knows no cause for their occurrence. 
 The attacks may last a week, during which period he is 
 unfit for his occupation. Examination reveals the stig- 
 mata of splanchnic neurasthenia. Self-treatment by 
 massage and exercises. The result of treatment has 
 been that his blues, as he says, " are now a matter of 
 history only." 
 
 Case vii. Chief symptom, impotency. Teacher; 
 age 31 ; married. Very nervous and irritable. Always 
 depressed. Worries about his sexual condition. Has 
 attempted suicide. Associates his impotency with intes- 
 tinal indigestion, insomuch as he finds that whenever 
 he belches much gas, his sexual condition is worse. 
 Stigmata of splanchnic neurasthenia. Self-treatment by 
 massage practiced twice daily. After the third treat- 
 ment, improvement became manifest, and after four 
 weeks, he asserted that his sexual power was restored. 
 
 Case viii. Prominent symptom, palpitation of the 
 heart. Banker; married; age 53. Suffered for years 
 from palpitation of the heart. Attacks have become 
 more frequent and of longer duration. Worse after 
 
THE CAUSE AND CURE. I57 
 
 eating. Cardiac palpitation is associated with symp- 
 toms of indigestion. Fears that he has heart disease. 
 Has consulted many prominent physicians in this coun- 
 try and Europe. Has submitted to all kinds of treat- 
 ment, including a rest cure, lasting three months. Liver 
 not enlarged. No signs of organic heart disease. No 
 abdominal points of tenderness. Pulse rate, 90 per 
 minute, and can be reduced to normal after repeated 
 pressure on the abdomen. Treatment by means of the 
 sinusoidal current, and cure after three weeks treatment. 
 It may be remarked incidentally, that in this patient, 
 there were no stigmata of splanchnic neurasthenia, be- 
 yond the exaggerated presence of the cardio-splanchnic 
 phenomenon, and this' is the only clue to the affection in 
 a number of cases. 
 
 Case ix. Prominent symptom, indigestion. Capi- 
 talist; aged 62. Very much depressed and generally 
 nervous. Has a constant burning in the stomach. Does 
 not eat much on account of the food, which distresses 
 him. Has lost 25 pounds in weight. Nothing relieves 
 him. Has a pendulous abdomen. The stomach is di- 
 lated and dislocated. The liver is very much enlarged, 
 and is very sensitive to pressure. Abdominal points of 
 tenderness. Treatment, sinusoidal current to the ab- 
 domen and auto-massage. Relief after one week and 
 cure in seven weeks. 
 
 Case x. Prominent symptom, morhid fears. 
 Woman ; aged 28. Fears crowds and open spaces. Will 
 not handle door knobs, fearing infection. Very irritable 
 and " blue." Symptoms of indigestion. Faints easily. 
 Has headaches, and is constipated. Purgatives inten- 
 sify her symptoms, therefore, she allows herself to re- 
 main constipated rather than take a purgative. Exami- 
 
15s THE BLUES :— NEURASTHENiA. 
 
 nation reveals all the characteristic symptoms of splanch- 
 nic neurasthenia. Treatment by auto-massage resulted 
 in cure. 
 
 Action of Purgatives in Splanchnic Neuras- 
 thenia. The recital of the last case directs our atten- 
 tion to the use of purgatives in this particular affection. 
 As a rule, physicians, presuming that these cases respond 
 in their symptomatic make-up to intestinal auto-toxemia, 
 have habitual recourse to intestinal antiseptics and ca- 
 thartics. !tiow, cathartics in such subjects, in my ex- 
 perience, act unfavorably, for they induce a feeling of 
 faintness or vertigo and intensify the nervous symptoms. 
 The reason for all this is evident. Cathartics induce, by 
 their action, the determination of an increased supply 
 of blood to the abdominal organs, thereby augmenting 
 the symptoms dependent on congestion of the intra-ab- 
 dominal veins. I knovy several individuals who are con- 
 strained to defecate in the recumbent posture, other- 
 wise they will suffer from faintness. The faintness ex- 
 perienced by persons when they first assume the vertical 
 posture after a prolonged illness owes its genesis to the 
 same cause which operates in the instances already 
 mentioned. Hill and Barnard ^® have shown the in- 
 fluence of gravity on the circulation and the part per- 
 formed by the abdominal muscles in preventing the 
 gravitation of blood into the splanchnic veins. They 
 demonstrated that when the splanchnic vasomotor mech- 
 anism was intact, it was able to prevent such gravitation, 
 but when this mechanism was destroyed by section of the 
 splanchnic nerves, a second mechanism was brought into 
 operation, consisting of expiratory compressions of the 
 abdomen, occurring simultaneously with inspiratory 
 thoracic suctions, the former squeezing, the latter suck- 
 
THE CAUSE AND CURE. 150 
 
 ing the blood out of the splanchnic pool. Now faint- 
 ness occurring when the vertical posture is assumed, 
 means any one of three things, viz. : Diminished intra- 
 abdominal tension from relaxed abdominal walls, di- 
 minished thoracic suction or an enfeebled state of the 
 splanchnic vasomotor system. The loss of one mechan- 
 ism may and often is compensated by another. 
 
 The mechanism consisting of abdominal compressions 
 in expiration and thoracic suctions in inspirations, as 
 well as the splanchnic vasomotor mechanism, may be 
 destroyed by division of the cord at the first dorsal verte- 
 bra. If the animal operated on be then held vertically 
 with the head up, all the blood will collect in the splanch- 
 nic veins, and the empty heart continues vainly to beat ; 
 but after compressing the abdomen, the blood is squeezed 
 into the heart, thus restoring the circulation. 
 
CHAPTEE IX. 
 
 INTESTINAL AUTO-INTOXICATION. 
 
 "WHAT IS INTESTINAL AUTO-INTOXICATION? FOOD. THE 
 
 ORGANS OF DEFENSE. FACTORS DETERMINING AUTO- 
 INTOXICATION. SYMPTOMS OF AUTO-INTOXICATION. 
 
 THE DIAGNOSIS OF AUTO-INTOXICATION.— HEPATIC IN- 
 SUFB'ICIENOY. TREATMENT OF INTESTINAL AUTO-INTOX- 
 ICATION. 
 
 Elsewhere,* I have been rather conservative in 
 formulating conclusions respecting the significance of 
 auto-intoxication as a causative factor in neurasthenia. 
 Since then, however, many notable investigations 
 have endowed this subject with so much importance 
 that it dare not be ignored by the physician in the 
 treatment of his neurasthenic patients. Although 
 there are many neurasthenics who react favourably to 
 the methods of treatment suggested in this book, yet, 
 there are many others, who demand in addition, a 
 method of procedure which aims to minimise intestinal 
 putrefaction. 
 
 What is Intestinal Auto-Intoxication? Poisons 
 are common to animal and plant life and the human 
 body contains the most deadly poisons which are made 
 innocuous by physiologic metabolism. We have phos- 
 phorus in the bones and blood, hydrochloric acid in 
 the stomach, potassium sulphocyanide in the saliva 
 and even arsenic is found as a normal ingredient. 
 
 * Vide, page 45. 
 
 11 161 
 
1G3 THE Slues :-MEURasthenia. 
 
 Brunton, in " Lectures on the Action of Medicines," 
 tells us, that the saliva of some men is nearly as pois- 
 onous as the venom of a serpent and he assures us 
 further, that the juice of various glands when injected 
 directly into the blood will kill an animal as quickly 
 as a rifle-bullet. The poisons of man are manu- 
 factured normally in the intestines. The most im- 
 portant ingredients of the digestive secretions are the 
 ferments. Thus we have pepsin in the gastric juice; 
 trypsin and other ferments in the pancreatic juice and 
 enterokinase in the intestinal juices. These ferments 
 convert various kinds of food into more soluble and 
 diffusible products. In addition to the digestive fer- 
 ments, digestion is facilitated by the bacteria normally 
 inhabiting the intestinal canal. The bacteria of the 
 human intestine increase at the rate of 128,000,000,- 
 000,000 each day and the bacterial flora constitutes 
 one-third of the human excreta. It has been shown 
 that the presence of germs is not absolutely essential 
 for our well-being ; indeed, digestion of varied kinds 
 of foods is possible even when made sufficiently sterile 
 to exclude germs from the alimentary canal. Now, it 
 is a well-known fact, that even when normal products 
 of digestion like peptones and albumoses are injected 
 directly into the blood, they are very poisonous, and 
 even fatal, in their effects. The production of toxic 
 substances in the alimentary canal is augmented by bac- 
 terial action which gives rise to fermentation and jjutre- 
 faction. "Whereas the normal ferments of the digestive 
 fluids produce intestinal poisons or enterotoxins, we are 
 chiefly concerned with the poisonous substances ema- 
 nating from microbic putrefaction. One must by no 
 means conclude that putrefactive processes are rieces- 
 
THE CAUSE AND CURE. 163 
 
 sarily harmful, on the contrary, the clanger is only 
 manifested when they are excessive. Thus in the 
 norm, such processes assist digestion and inhibit the 
 entrance of poisonous products into the body. Leci- 
 thin, for instance, is found in large quantities in egg- 
 yolk and by the action of the pancreatic juice it is 
 broken up into many ingredients, notably, a poisonous 
 ptomain, known as cholin. We are, however, pro- 
 tected from the toxic action of the latter, by the bac- 
 teria which convert it into inoffensive products. 
 Food. — All food can be classified as follows : 
 
 1 . Proteid or albuminous food. The flesh of animals 
 consists chiefly of proteid and ordinary lean beef 
 contains about 20 per cent. Eggs contain about 10 per 
 cent, of proteids. 
 
 2. The carbohydrates or sugary foods (sugar and 
 starches). 
 
 3. Fats of animal and vegetable origin. 
 
 "We will limit ourselves to a brief discussion of the 
 toxic products derived from albuminous foods for the 
 reason, that they are chiefly concerned in the morbid 
 phenomena of auto-intoxication and for the additional 
 reason, that the biologic chemistry of the carbohy- 
 drates and fats is imperfectly understood. 
 
 It is often difficult to say when the action of the 
 intestinal juices ends and when bacterial action begins 
 but, it has been practically established that microbic 
 disintegration of the albuminous molecule results in 
 the formation of fatty acids and amino-acids, especially 
 leucin and tyrosin, substances producing a vile odor 
 like indol, phenol and skatol (belonging to the aromatic 
 series of compounds), as well as certain gaseous products. 
 
 Experiments have demonstrated that the putrefac- 
 
164 THE BLUES -.—NEURASTHENIA. 
 
 tion of the albuminous molecule is limited in the norm 
 to the large intestine but, in instances of intense 
 putrefaction, it may commence in the lower part of 
 the small intestine. The upper small intestine in 
 fasting animals is practically free of microbes. 
 
 It has been shown that only six-sevenths of the 
 albuminous food ingested is assimilated in the small 
 intestine whereas the balance becomes the prey of the 
 microbes. Among the toxic aromatic products of in- 
 testinal putrefaction is indol. The latter when given 
 to normal individuals even in small doses may produce 
 frontal headaches, nervous irritability and restlessness 
 and induces when administered in larger doses, diar- 
 rhea, insomnia and mental restlessness. 
 
 The continuous administration of indol in doses 
 large enough to betray its presence in the urine can 
 produce symptoms of neurasthenia and, there is no 
 longer any question among competent clinicians, that 
 the absorption of this substance from the products of 
 intestinal decomposition is responsible for many cases 
 of this disease. 
 
 The Organs of Defense. — In the norm, the poison- 
 ous substances in the intestinal canal are either not 
 absorbed or they are made innocuous and rapidly ex- 
 creted. Auto-protection of the organism against 
 self -poisoning is achieved either by organs which 
 arrest or transform the poisons or eliminate them. 
 The organs of defense practically represent the bodily 
 resistance. This equationally expressed for germ in- 
 fection is applicable to auto-intoxication, viz., 
 
 D, the disease, equals P, the poison, multiplied by T, 
 
THE CAUSE AND CURE. 165 
 
 its toxicity, multiplied by A, its amount, the product 
 being E, the resistance of the individual attacked. 
 The organs which arrest the poisons are the liver, 
 spleen, gastro-intestinal mucous membrane, lymph- 
 glands, adrenal bodies, thyroid gland, etc. The liver, 
 is the chief organ of defense. It converts the poisons 
 into non-toxic and assimilable substances, filters them, 
 and excretes them in the bile. If the liver is excluded 
 from the general circulation by connecting the portal 
 vein with the inferior vena cava, nervous manifesta- 
 tions, and even death may follow the ingestion of 
 meats. The organs of elimination are the skin, lungs, 
 kidneys, and intestines. Body-elimination by the 
 various excretory channels has been divided as follows : 
 By the lungs, 32 per cent; by the kidneys, 46-47 ^er 
 cent ; by the skin, 17 per cent; and by the feces, 5-9 
 per cent. 
 
 Bacteria are regularly convej''ed to the stomach with 
 the food, but their growth is generally inhibited by 
 the hydrochloric acid of the stomach. The food 
 passing quickly from the small to the large intestines, 
 an insuflicient time is allowed for the bacteria to 
 multiply. The normal epithelial cells of the intes- 
 tinal mucous membrane also protect the organism and 
 there is reason to believe, that they contain a sub- 
 stance (probably nucleinic acid) which possesses an 
 antibacterial action. Even though the toxic products 
 of bacterial action pass through the intestinal mucous 
 membrane, it is assumed that such toxins protect the 
 individual against the virulent action of the bacteria 
 from which they are derived. 
 
 We know that after a meal the white blood- 
 corpuscles increase in number {digestive leucocytosis), 
 
166 THE BLUES :-NEURASTHENIA. 
 
 and we also know, that nearly all intoxications and 
 infections produce the same result. Proteid food in- 
 fluences the result more than farinaceous food or a 
 mixed diet. In some diseases of the stomach and in- 
 testines, this post-digestive leucocytosis does not occur. 
 It may be assumed that in health, the organism pro- 
 tects itself against the absorbed products of bacterial 
 action by an increase in the number of white corpuscles 
 w^hich remove and destroy the toxic substances. It 
 is evident from what has preceded, that the intestinal 
 canal is a permanent source of intoxication and that 
 were it not for the organs of defense, one would con- 
 stantly suffer from the symptoms of self- poisoning. 
 
 Factors Which Determine Auto-Intoxication. — 
 The essential condition alwaj's present in auto-in- 
 toxication is a reduction in the antitoxic function of 
 the organs of defense. There are, however, predispos- 
 ing conditions favoring this reduction of normal 
 functional activity, one of the most important of which 
 is the condition prevailing in splanchnic neurasthenia, 
 vis., congestion of the veins of the abdomen. When 
 the latter is present, it interferes with a proper supply 
 of arterial blood, and in consequence the tissues and 
 organs are bathed in pools of stagnant blood — They 
 are practically asphyxiated. Again, the impeded cir- 
 culation cannot remove the toxic products of digestion 
 and bacterial action and, instead of the latter being at 
 once conveyed to the organs of elimination like the 
 kidneys, the}'' are arrested or transformed by the 
 organs of defense which soon prove inadequate to dis- 
 charge their anti-toxic function ; and then we have 
 the creation of symptoms which belong to the category 
 of self -poisoning. • 
 
THE CAUSE AND CURE. 167 
 
 Excessive albuminous food, that is to say, a diet 
 containing a large quantity of meat and eggs aug- 
 ments intestinal putrefaction and even though the 
 organs of defense are relatively normal they are inca- 
 pable of performing their functions when an increased 
 burden is thrust upon them. 
 
 Factors which retard the absorption of the products 
 of digestion favor auto-intoxication for the reason that 
 if they are not absorbed they become a prey to the 
 action of the intestinal microbes. It has been shown that 
 the ingestion of fluid during a repast hinders digestion 
 and this like any other factor which will retard diges- 
 tion, paves the way for intestinal putrefaction. The . 
 gastric juice inhibits the virulence of the intestinal 
 microbes and, if for any reason, the juice in question 
 "is abnormal, intestinal putrefaction is encouraged. 
 
 The biliary acids are endowed with antiputrefactive 
 properties and any anomaly in the biliary secretion 
 will likewise favor intestinal putrefaction. 
 
 It suffices to say that all affections of the digestive 
 apparatus by interfering with digestion will favor in- 
 testinal putrefaction and any condition favoring the 
 latter conduces to auto-intoxication. Again, constitu- 
 tional conditions may favor self -poisoning by reducing 
 the functional activity of the organs of defense. 
 Organs of elimination like the kidneys which are de- 
 fective cause the retention of toxic products which 
 should be excreted and are in consequence also respon- 
 sible for the symptoms of auto-intoxication. 
 
 The majority of people dig their graves with their 
 knives and forks, and Dr. Abernethy observed, 
 "There is no beast of burden in the world so over- 
 loaded as the human stomach." 
 
168 THE BLUES :— NEURASTHENIA. 
 
 Talmage remarked, that, "Many a man is trying to 
 do by prayer what can only be done by correct diet. ' ' 
 
 Many individuals start out in life with adequate 
 organs of defense but over-eating soon makes them in- 
 sufficient. 
 
 There are still others with congenitally defective 
 organs of defense or who possess through some anomaly 
 of heredity an insufficient digestive apparatus. 
 
 Symptoms of Intestinal Auto-Intoxication. — If 
 one were guided in the diagnosis of auto-intoxication 
 by the statements of the patient, the condition would 
 rarely be recognized. The fact is, the patients infre- 
 quently complain of symptoms of indigestion. They 
 usually inform us that their digestion is perfect. To 
 the lay individual, dyspepsia signifies, lack of appetite 
 or discomfort and flatulence or acidity after eating'. 
 It is only in aggravated cases that one encounters the 
 conventional symptoms of indigestion. In most in- 
 stances nervous symptoms precede the local symptoms 
 of indigestion. The symptoms are initiated by par- 
 oxysmal attacks of headache localized either in the 
 frontal or occipital region, by attacks of migraine, by 
 attacks of fatigue, depression and other neurasthenic 
 symptoms until eventually the symptoms become con- 
 tinuous and the classical picture of neurasthenia {toxic 
 neurastlienia) is developed. In association with the 
 neurasthenia, the nutrition suffers and wasting is a 
 prominent symptom. Not infrequently alternating 
 attacks of. diarrhea or constipation may direct the pa- 
 tient's attention to the digestive apparatus. The 
 majority of patients cannot account for their nervous 
 symptoms. By closely questioning maHy of these pa- 
 tients one may elicit much valuable information. The 
 
THE CAUSE AND CURE. 169 
 
 mere fact that an attack of diarrhea has succeeded an 
 unaccountable period of depression will suggest auto- 
 intoxication. In other instances, a paroxysm of irrita- 
 bility, insomnia, fatigue or headache has followed the 
 ingestion of some particular kind of food to which the 
 patient was unaccustomed. 
 
 In still other instances, although neurasthenic symp- 
 toms are always pr«»sent, they become accentuated 
 after hasty or excessive eating, a late supper, the in- 
 gestion of particular kinds of food or after the use of a 
 purgative (page 158). As a rule, the symptoms de- 
 velop on the following day or even several days after 
 the dietetic indiscretion. It is for the latter reason, 
 that the patient is unable to trace any connection be- 
 tween his nervous symptoms and his faulty digestive 
 apparatus. In these cases even in the absence of the 
 symptoms of indigestion, the physician will be able to 
 elicit the signs peculiar to splanchnic neurasthenia 
 (page 123). 
 
 The Diagnosis of Intestinal Auto-Intoxication. — 
 From what has preceded, it is evident to the physician 
 that the diagnosis of this affection is essentially object- 
 ive. One can never place any dependence on an 
 intuitive diagnosis ; on the contrary, there is no affec- 
 tion which demands a more thorough and exhaustive 
 analysis. 
 
 Despite the tedium of the examination, every neur- 
 asthenic should be investigated with the object of 
 determining whether auto-intoxication is responsible 
 for his symptoms and even though enterotoxins are 
 not the essential cause, they may accentuate them. 
 
 Unfortunately the precise methods of physiochem- 
 ical examinations are not available for the practitioner, 
 
170 THE BLUES :— NEURASTHENIA. 
 
 hence they will not be made the subject of discussion. 
 Such methods are accurately described in the recent 
 classical treatise of Combe.* 
 
 The TJeine. — The kidneys are the chief excretory 
 organs for the enterotoxins arising from intestinal 
 putrefaction and which have passed into the blood, 
 hence an examination of the urine is an important 
 procedure in the investigation of a suspected case of 
 auto-intoxication. 
 
 As a rule the quantity of urine in 24 hours is dim- 
 inished (oliguria) but despite this reduction of volume, 
 its concentration is not augmented and its coloration 
 is rather reduced. The specific gravity is usually be- 
 low the normal and the excretion of urinary solids is gen- 
 erally diminished. We know that as a result of microbic 
 action aromatic substances (indol, phenol and skatol) 
 are disengaged in the intestines and that they are ex- 
 ceedingly toxic, but owing to their conversion into 
 ethereal sulphates they are made innocuous. 
 
 Ptomains are likewise disengaged in intestinal pu- 
 trefaction and were we able to estimate these substances 
 with any degree of accuracy in the urine, the entire 
 question of auto-intoxication would be reduced to a 
 very simple problem. 
 
 However, no reliable practical method exists for de- 
 termining the ptomains, hence we must content our- 
 selves with the estimation of the aromatic substances. 
 
 The latter are probably not the real enterotoxins 
 but they develop as the ptomains parallel to the inten- 
 sity of the putrefactive process, hence their presence 
 serves as an index for determining the degree of intes- 
 tinal putrefaction. 
 
 * L' Auto' Intoxication Intestinale. Paris, 1907. 
 
The cause and cure. 171 
 
 The aromatic substances (phenol, indol, etc.) unite 
 with sulphuric acid and form the ethereal sulphates or 
 with giycuronic acid. 
 
 The Sulphates. — The sulphates in the urine are 
 derived from the metabolism of proteids in the body 
 and about one-tenth of the total sulphates are com- 
 bined with organic radicles known as ethereal sulphates 
 which originate from intestinal putrefactive processes. 
 Sulphuric acid is found in the urine in two forms : 
 
 1. As the inorganic or preformed sulphates in com- 
 bination with sodium and potassium ; 
 
 2. As the organic (ethereal or conjugate) sulphates 
 in combination with indol, phenol, and skatol. 
 
 The amount of the inorganic to the organic is as 10 
 to 1 and in the norm the total excretion of both is 
 from 30 to 45 grains. An increase in the excretion 
 of the total sulphates occurs in augmented intestinal 
 putrefaction. 
 
 It is important not only to know the absolute 
 amount of the ethereal sulphates in the urine but also 
 to know the ratio which this amount bears to the in- 
 organic sulphates. Indeed many investigators claim 
 that this ratio is a better index of Intestinal putrefac- 
 tion than is the absolute quantity of ethereal sulphates 
 excreted. As before remarked, this ratio in adults on 
 a mixed diet is about 1 : 10 but in disease this ratio 
 may vary from 1 : 7 to 1 : 1 . 
 
 The Ethereal Sulphates. — The only means of 
 making accurate estimations of the sulphates is by 
 weighing the Ba S04, but this is an elaborate process 
 inapplicable to clinical work. 
 
 The following is a simple test : Add an excess of 
 barium chlorid to a urine previously rendered strongly 
 
172 The BLtJES -.-NEtrEAStHEWA. 
 
 acid with hydrochloric acid and a whitish precipitate 
 of barium sulphate is formed, which is insoluble in 
 acid. 
 
 After allowing the urine to stand for several hours 
 in the test-tube, the height of the precipitate will in- 
 dicate approximately the quantity of ethereal sul- 
 phates. The quantity of the precipitate compared 
 with that from a normal urine will also afford a rough 
 estimate of the sulphates present. The organic sul- 
 phates are increased proportionally by the putrefactive 
 decomposition of proteid in the alimentary canal. 
 The ingestion of considerable quantities of meat will 
 increase, and an exclusive milk diet will decrease the 
 excretion of ethereal sulphates. 
 
 Indican. — When albuminous substances undergo 
 bacterial putrefaction in the intestine, aromatic sub- 
 stances (indol, skatol and phenol) are formed. The 
 demonstration of indol however may be accepted as 
 representing the other substances. When the indol is 
 absorbed it is oxidized forming indoxyl, and the latter 
 unites with the preformed potassium sulphate to be- 
 come potassium indoxyl-sulphate or, as it is generally 
 called, indican. The equation representing this trans- 
 formation is as follows : 
 
 C,H,N0-1-S0, <oS = SO, <^^|«^ +H,0 
 
 (ludoxyl) (Potassium (Potassium (Water). 
 
 Hydrogen Indoxyl-sul- 
 
 Sulphate) phate) 
 
 Some contend that if indican can be detected in the 
 urine, even by a feeble reaction, it is an indication 
 that it is excreted in excessive quantity. Indican in 
 the urine [indicanuria) suggests bacterial putrefaction 
 of the proteid substances in the intestines, for in 
 
THE CAUSE AND CURE. 173 
 
 perfect digestion of the proteids, ifc cannot be detected 
 in the urine. Indicanuria also occurs when albuminous 
 substances are decomposing in any part of the body as 
 in the putrid pus of peritonitis or empyema. 
 
 Tests foe Indican. — (Jaffe). Free the urine of sub- 
 stances interfering with the test by adding one-quarter 
 its volume of 10 per cent, solution of lead acetate and 
 then filtrating. To the filtrate add an equal amount 
 of concentrated hydrochloric acid and one to two 
 drops of a saturated solution of calcium chlorid diluted 
 one-half with water. If indican is present, first a 
 bluish-green tint, later, a distinct blue color appears. 
 If chloroform is now added and the whole thoroughly 
 shaken, the layer of chloroform will turn blue and 
 the depth of coloration indicates the quantity of in- 
 dican. In a normal urine this test gives only a rose' 
 or faint violet color. As a rule, unless the urine con- 
 tains albumin or is very dark it is unnecessary to first 
 precipitate with the lead solution. 
 
 Test of Obermayee. — Obermayer's reagent consists 
 of a solution of strong hydrochloric acid {sp. gr. 1.19) 
 to which has been added two parts to the thousand of 
 ferric chlorid. This fuming yellow liquid keeps indef- 
 initely. First precipitate the urine with a small 
 amount of a solution of lead acetate (avoiding an ex- 
 cess) and filter. Now take 15 cc. of the filtered urine 
 and mix with an equal bulk of Obermayer's reagent 
 and add 2 cc. of chloroform. Slowly iuA'^ert, but do 
 not shake the mixture in the tube, which is sealed 
 with the finger or a cork. This chloroform will be- 
 come colored in proportion to the amount of indican 
 present. It may be necessary to allow the whole to 
 stand for a short time for the complete oxidation of 
 
174 THE BLUES :-NEURASTHENlA. 
 
 the indoxyl by the ferric chlorid. Normal urine gives 
 a very faint blue by this method and any increase is 
 indicated by a deep blue tint in the chloroform. 
 
 The quantitative estimation of indican in the Ober- 
 mayer test may be made by comparing the chloroform 
 solution with solutions of pure indigo-blue in chloro- 
 form of known percentage; other methods are the 
 chromometer of Amann or the indicanurometer of 
 Bouma. For all practical purposes, the simple test 
 of Jaffe will suffice.* 
 
 Hepatic Insufficiency. — It has already been re- 
 marked, that the liver is the chief organ of defense 
 and insufficiency of this organ is among the chief 
 causes of auto-intoxication, hence the diagnosis of the 
 functional capacity of the liver is indicated. The 
 diagnosis of hepatic insufficiency is based on the 
 diminished excretion of urea and the presence of ab- 
 normal constituents in the urine. 
 
 Hypoazotueia. — Brouardel and other French clini- 
 cians have long regarded a deficient excretion of urea 
 as an important symptom of hepatic insufficiency, for it 
 is generally admitted that urea is formed in the liver. 
 Before concluding, however, that the urea is dimin- 
 ished, one must first establish the fact, that the patient 
 is ingesting a sufficient quantity of food. A man in a 
 state of nitrogenous equilibrium taking 100 grams of 
 proteid in his food daily will excrete daily about 33 to 
 35 grams (500 grains) of urea. If a patient according 
 to Hirschfeld ingests during one day a test diet of 500 
 grams of meat, 8 eggs, and 200 grams of bread, which 
 represents a total of 172.25 grams of proteid, he will 
 normally excrete 59 grams of urea. The normal per- 
 * Vide, Porter's test, preface to third edition. 
 
THE CAUSE AND CURE. 1^5 
 
 centage of urea in human urine is about 2 per cent. 
 One must also remember before concluding that the 
 liver is insufficient, that, in addition to a diminished 
 excretion of urea (hypoazoturia), there must be an 
 augmentation in the urine, of ammonia, uric acid and 
 purin bodies and the presence of leucin and tyrosin, 
 insomuch as these substances are converted into urea 
 by the liver. 
 
 Estimation of the Solids. — A simple and rapid 
 method for determining approximately the total urinary 
 solids excreted in 24 hours in 1000 parts of urine is to 
 multiply the last two figures of the specific gravity by 
 2. Thus, 1500 cc. of urine excreted in 24 hours with 
 a s;p. gr. of 1017=2X17 = 34 grams in 1000 cc. : in 
 1500cc. =34+17— 51 grams. About 50 grams of 
 solid matter is excreted in 24 hours : one-half of this 
 consists of urea and one-fourth of sodium chlorid. 
 
 Another simple method is to measure the total 
 quantity of urine excreted in 24 hours in ounces : mul- 
 tiply the number of ounces by the last two figures of 
 the specific gravity and add to the product one-tenth 
 of itself. Thus, if 60 ounces of urine were passed and 
 the sp. gr. is 1020, the calculation is as follows: 
 50X20 = 1000. Adding one-tenth of 1000 = 100 and 
 1000 + 100 = 1100, the number of grains of solid matter 
 excreted. The latter number of grains is normal for 
 a person weighing about 135 pounds. Persons weigh- 
 ins more or less should excrete relatively more or less 
 solids. Urea may be determined quantitatively by 
 Hind's modification of the Doremus ureometer. 
 
 Cholemia. This condition is provoked by the ab- 
 sorption of bilirubin, which should have been elimi- 
 nated into the Intestine with the bile. Two-thirds of 
 
176 THE BLUES :— NEURASTHENIA. 
 
 the toxicity of the bile is supposed to be due to bili- 
 rubin. In the average patient, hepatic insufficiency is 
 the underlying cause of cholemia. 
 
 The skin may be yellowish in hue and is usually 
 known as the "bilious complexion." The nervous 
 symptoms are not unlike those of neurasthenia, to 
 which mental symptoms are added varying from de- 
 spondency to delusional melancholia. The liver is 
 practically painful on pressure and even minor grades 
 of sensitiverfess may be determined by concussional 
 massage (vide appendix, note 14). Examination of 
 the urine for bilirubin in cholemia is usually without 
 result, although the following method of examination 
 of the blood is usually positive : about 3 cc. of blood 
 from the punctured finger is allowed to drop into a 
 dry, clean vessel, which is put aside without shaking 
 in a cool place for 24 hours. The serum is drawn off 
 from the clot and Gmelin's test * is used. Just above 
 the point of contact of the acid a bluish ring appears. 
 Even in normal serum, according to Hayem, the reac- 
 tion to bilirubin is positive in dilutions of 1 to 40,000 ; 
 if the serum, however, is diluted with two-thirds 
 normal salt solution and a positive reaction is obtained, 
 the diagnosis of cholemia is assured. 
 
 Physiologic Tests. — A well-known function of the 
 liver is to form glycogen from the saccharine and 
 amyloid matters in the food. It has been demonstrated, 
 that if the glycogenic function of the liver is impaired 
 its antitoxic functions are equally implicated. 
 
 According to Achard, the patient is given 150 
 
 * In Gmelin's test, crude yellow nitric acid is used or pure nitric 
 acid may be employed, if it is first heated with some organic sub- 
 stance like bits of wood. 
 
THE CAUSE AND CtJUE. lYY 
 
 grams of glucose; if sugar is found in the urine it 
 indicates hepatic insufficiency. 
 
 According to Naunyn, 100 grams of glucose given in 
 solution two hours after a breakfast of a roll and 
 butter with coffee will not cause glycosuria; if it 
 does, the glycogenic function of the liver is implicated. 
 According to the same author, if glycosuria foUoAvs 
 the dose cited, the individual may eventually suffer 
 from true diabetes. 
 
 Chiadini gives 60 grams of levulose, fasting, and if 
 the liver is intact no glycosuria will follow, but levu- 
 losuria will be observed in case of pathologic conditions 
 in the liver. 
 
 Chauffard attaches much importance to the inter- 
 mittent excretion in the urine of methylen blue when 
 this substance is used as a test. One may execute the 
 test by an intramuscular injection of a 5% solution of 
 methylen blue and the dose is 15 minims. It is ab- 
 sorbed into the blood from the point of injection as a 
 colorless derivative known as chromogen and it is 
 transformed by the liver and kidneys into methylen 
 blue. It is excreted in the bile and urine. In the 
 urine it is eliminated as methylen blue and partly as a 
 colorless derivative (chromogen). The latter is trans- 
 formed into methylen blue by boiling with acetic acid. 
 Chromogen commences to appear in the urine 15 
 minutes after the injection and the blue in about 
 30 minutes. The duration of elimination is from 35 
 to 60 hours. The elimination of blue reaches its 
 maximum about 4 hours after the injection and remains 
 at this level for about 4|^ hours and after about 35 
 hours, it assumes a pale green tint. 
 
 In hepatic insufficiency, the elimination is inter- 
 12 
 
1V8 THE BLUES i-NEtrRASTSENlA. 
 
 mittent ; it falls to the vanishing point to rise again 
 or it may disappear completely from the urine and 
 reappear later. 
 
 The greater the number of intermissions, the more 
 pronounced is the functional disturbance of the hepatic 
 cells. 
 
 To execute this test, the urine must be collected in 
 different receptacles every two hours. 
 
 Fecal Examination. — N"o physician dare aim at ac- 
 curacy in the diagnosis of intestinal auto-intoxication 
 without an examination of the function of the intestine 
 and this procedure has been so simplified by Schmidt* 
 that I will not go into the details of his method. One 
 may briefly refer to a simple method for determining 
 the presence of urobilin in the feces. About 10 grams 
 of the stools are rubbed in a mortar with a concen- 
 trated mercuric chlorid solution and allowed to stand 
 from 6 to 24 hours. 
 
 Urobilin will be colored red while bilirubin con- 
 verted into biliverdin imparts to the mass a green 
 color. Both substances indicate that the liver is func- 
 tionally active and that the biliary passages are open. 
 The microscope will show the green tint of bilirubin, 
 which may not be evident macroscopically because the 
 color is obscured by the large amount of urobilin. 
 
 Teeatment of Intestinal Auto-Intoxication.^A 
 variety of methods have been suggested in the treat- 
 ment of this affection and the writer has discussed some 
 of them in detail in his work on auto-intoxication, f 
 
 * Test Diet in Intestinal Diseases. F. A. Davis Co., 1906. 
 Translated by Aaron. 
 
 f Man and His Poisons, Abraras. E. B. Treat and Co., New 
 York, 1906. 
 
THE CAUSE AND CURE. l>jg 
 
 Intestinal putrefaction results from the action of 
 proteolytic bacilli on albuminous food and the primary 
 indication in treatment is to modify the culture medium 
 of the intestine so as to render it inimical to the organ- 
 isms in question. The best and the most certain method 
 of treatment is by means of an antiputrid regime. 
 
 It has been suggested that a sterile regime will 
 destroy the virulence of the bacterial flora of the 
 intestine, but observations show that sterile food will 
 diminish but does not completely inhibit intestinal 
 putrefaction. 
 
 An aseptic regime is best attained by the avoidance 
 of crude vegetables and fruits, for no matter how 
 thoroughly they are washed they still remain contam- 
 inated. 
 
 The cooking of foods will diminish the danger of in- 
 fection by destroying bacterial growths and larger 
 parasites (tapeworms and trichina). The cooking of 
 vegetable foods breaks up the starch-grains, bursting 
 the cellulose and thus permitting the digestive fluids to 
 come into immediate contact Avith the granulose. 
 
 Antiputrid Kegime. — As before remarked, this is 
 the most satisfactory means of antagonizing intestinal 
 putrefaction. The putrescent aliments are the proteids 
 and if the latter could be completely eliminated, there 
 would be no putrefaction and consequently no intes- 
 tinal auto-intoxication. All investigations show that 
 intestinal putrefaction augments parallel with the 
 quantity of albuminous food-stuffs. We know, how- 
 ever, that the proteids or albuminous food-stuffs are 
 true tissue builders and repairers and consequently 
 cannot be eliminated without compromising nutrition. 
 We do know, however, that the proteid requirements 
 
180 THE BLUES :— NEURASTHENIA. 
 
 of the individual have been exaggerated and that the 
 experiments of Professor Chittenden show, that men 
 can maintain health and muscular efficiency for long 
 periods on about half the amount of proteid which is 
 usually consumed. It would be difficult now to main- 
 tain, as did Herbert Spencer, that the consumers of 
 meat showed superior physical strength to the con- 
 sumers of rice, which would be equivalent to saying 
 that the Russians demonstrated more physical endur- 
 ance than the Japanese. One may conclude conserva- 
 tively, that we ordinarily consume more proteid food 
 than is necessary and that ingested in excess, it is 
 either conserved for future uses of the economy or re- 
 maining undigested, it must be reduced by bacterial 
 digestion. Instead of the individual requiring 120 
 grams daily of proteid according to the diet table of 
 Moleschott or 100 grams according to the diet of 
 Ranke, the amount of proteid may be reduced con- 
 siderably without prejudice to the individual. 
 
 If an individual were desirous of taking his daily 
 supply (1 00 grams) of proteid in the form of meat it 
 would be necessary for him to consume a little more 
 than one pound (500 grams) of meat. It was at one 
 time supposed that fats exercised no influence on intes- 
 tinal putrefaction, but more recent experiments have 
 demonstrated that this observation- is faulty and that 
 fats do increase intestinal putrefaction. 
 
 The lacto-farinaceous diet of Combe is the anti- 
 putrid regime par excellerice in the treatment of auto- 
 intestinal intoxication : it acts not by any destructive 
 influence on the intestinal flora but seeks only to modify 
 the soil in which the microbes live. 
 
 Milk. — Of all aliments, milk is probably the most 
 
THE CAUSE AND CURE. jgl 
 
 resistant to putrefaction and it has been found by 
 Winternitz that if a certain quantity of milk is given 
 with a meat diet, it will diminish the production of 
 enterotoxins. Milk owes its antiputrid properties to 
 the lactose which it contains and which under the in- 
 fluence of the aerobic baccili of the small intestine 
 {coli and lactis aerogenes) is decomposed into succinic 
 and lactic acids. These acids inhibit the action of the 
 proteolytic baccili in the large intestine from acting on 
 the albuminous food-stuffs. Cow's milk contains about 
 Z.5 per cent, of proteids (chiefly caseinogen) against 
 12.2^67' cen^. in the white of eggs and about '2,0 per 
 cent, in meats. 
 
 I find that some individuals ca,nnot tolerate even 
 small quantities of milk (raw or boiled) without causing 
 diarrhea. In such instances, I employ lactose (milk- 
 sugar). Cow's milk contains 5 per cent, of lactose, 
 hence if the individual will take about 400 grains of 
 lactose at each meal, he will have consumed an amount 
 equal to about 3 pints of milk daily. Very often raw 
 milk is tolerated when boiled milk is not. 
 
 It has also been proposed to substitute milk by a 
 number of aliments which already contain lactic and 
 succinic acids and many of them are more digestible 
 than the ordinary cow's milk. They are as follows : 
 
 1. Curdled milk. 
 
 2. Whey. 
 
 3. Buttermilk. 
 
 4. Koumiss. 
 
 5. Kefir. 
 
 6. Fresh cheese (^fromage a la creme). 
 Buttermilk owing to its small content of fat and 
 
 casein (chief proteid of milk) is a very desirable pro- 
 
182 THE BLUES :— NEURASTHENIA. 
 
 duct in auto-intoxication, insomuch as one knows that 
 these substances favor putrefaction. Again, the pres- 
 ence of lactic acid and lactose enables the latter to 
 produce lactic acid in statu nasoenti. Condensed butter- 
 milk may be obtained in flasks containing 330 grams, 
 and to prepare the buttermilk, one mixes the contents 
 of one flask with 660 grams of a decoction of cereals 
 thus obtaining 1 liter of porridge (^potage au hdbeurre). 
 
 The composition of Koumiss varies with its age, 
 containing on the first day about .96 per cent, of 
 lactic acid and about 1 per cent, on the 21st day after 
 its preparation. It contains nearly the same percent- 
 age of alcohol as beer. Koumiss is an agreeable and 
 easily digestible preparation. 
 
 Fresh soft cheese contains considerable assimilable 
 casein and therefore subserves a useful purpose in pro- 
 teid nutrition and it has all the advantages and none 
 of the disadvantages of milk. Thus the soft cheese 
 known &^ petit Suisse contains the following: albumin, 
 A per cent. ; casein, 24 per cent. ; lactose, 2 per cent. ; 
 and lactic acid, .%0 per cent. 
 
 Faeinaceous Aliments. — Combe formulates the fol- 
 lowing conclusions : 
 
 1. The carbohydrates or sugary foods prevent pro- 
 teid putrefaction in the intestine. 
 
 2. That in natural digestion, the farinaceous foods 
 (rice, farina of cereals and their derivatives) surpass 
 all other carbohydrates because they are less easily 
 absorbed and they penetrate more profoundly into the 
 intestine and only gradually furnish lactic and succinic 
 acids. 
 
 3. That the maximum quantity of farinaceous food 
 must be given with each repast and, if possible, to 
 
THE CAUSE AND CURE. 183 
 
 carry out this cramming process, this farinaceous 
 aliment must be given five or six times a day. 
 
 4. Interdict as far as possible all albuminous food- 
 stuffs but choose among them the least putrescent (like 
 eggs) and when they are used, combat their action by 
 an excess of farinaceous food. 
 
 5. In the ordinary forms of auto-intoxication, milk 
 mixed with farinaceous food is better supported than 
 milk alone. 
 
 6. Avoid fats which augment putrefaction and 
 choose butter in preference. 
 
 If one is desirous of carrying out, if only for test 
 purposes, an antiputrid regime, one may select the 
 following : 
 
 1. Milk or lactose as a substitute. 
 
 2. Cooked vegetables preferably as purees. 
 
 3. Preserved or cooked fruits. 
 
 4. "Weak coffee, tea or cocoa. 
 6. Toast with little butter. 
 
 6. Farinaceous foods prepared as puddings, or other- 
 wise. These must be consumed in abundance. 
 
 7. Buttermilk or Koumiss. 
 
 8. Fresh cream cheese. 
 
 Later, if the condition of the patient is ameliorated, 
 easily digestible albuminous food-stuffs like eggs, ham 
 and cold meat together with fresh fruits (preferably 
 bananas) may be permitted. 
 
 Antagonistic Miceobes. — Ever since Metchnikoff 
 directed attention to the fact that sour milk microbes 
 are antagonistic to the microbes of putrefaction, it is 
 quite the custom in France to employ the former in 
 the treatment of auto-intoxication. The chief charac- 
 teristic of the intestinal floral of the auto-intoxicated is 
 
184: THE BLUES :— NEURASTHENIA. 
 
 the marked diminution of the saccharolytic aerobic 
 baccilli and the preponderance of the proteolytic 
 anaerobic varieties. To modify the foregoing condi- 
 tion a vegetarian or lacto-vegetarian or lacto-farina- 
 ceous diet is indicated on account of the small quantity 
 of proteid matter which it contains and the lactic acid 
 which it produces. Another method is to feed the 
 subject with lactic acid ferments or microbes which 
 are innocuous but exert an inhibitory influence on the 
 microbes of putrefaction. There are now several lactic 
 acid culture mediums on the market but many of them 
 seem to lose their therapeutic action when prepared 
 in the form of tablets or globules. 
 
 Unquestionably, the liquid lactobacilUne, as it is 
 called, is the most eflicient. It may be taken in milk 
 or water directly from the small bottles in which it is 
 sold and one bottle (containing about half a teaspoonf ul) 
 a day is the average dose. During the first few days, 
 digestive disorders may follow its use but soon consti- 
 pation ceases, the stools lose their putrid odor, the 
 breath sweetens and the tongue becomes cleaner. The 
 signs of auto-intoxication disappear slowly but surely. 
 To make these good results permanent, the treatment 
 is continued on an average for 2| months. The fer- 
 ment is ordinarily employed in association with the 
 diet although some writers claim that nearly all the 
 effects can be secured from the ferment alone. Accord- 
 ing to Cohendy, it takes about six days before the 
 lactic acid microbes change the intestinal flora. If 
 diarrhea is caused by intestinal putrefaction, it is said 
 to be arrested by this bacterio-therapeutic method. 
 
 If lactic acid culture mediums cannot be obtained 
 then buttermilk or koumiss may be used. Holt sug- 
 
THE CAUSE AND CURE. 185 
 
 gests the following formula for the domestic manufac- 
 ture of koumiss: one quart of fresh milk, ^ oz. of 
 sugar, 2 oz: of water and a fresh piece of yeast cake 
 (^ inch square) are put in wired bottles and kept at a 
 temperature between 60 and 70° F. for one week : the 
 bottles are shaken 5 or 6 times a day. They are then 
 put upon the ice and kept ready for use. 
 
 This bacterio-therapeutic method may have to be 
 employed to the exclusion of the lacto-farinaceous diet 
 for there are some individuals who suffer from dys- 
 peptic symptoms if the latter is pursued too vigorously. 
 My personal observations show, that the diet is more 
 reliable than all other methods of treatment. 
 
 Intestinal Antiseptics. — Intestinal ascepticization 
 is in my experience a purely theoretic conception which 
 is rarely realized in practice. Intestinal antisepsis is 
 difHcult if not impossible for the following reasons : 
 
 1. An antiseptic strong enough to destroy germs is 
 equally destructive to the intestinal mucous membrane. 
 
 2. Germicides will destroy the innocent germs 
 which are concerned in digestion. 
 
 3. Germicides are rapidly absorbed or are made 
 chemically inert. 
 
 Calomel is without doubt the most efficient of all 
 intestinal antiseptics and it may act by inhibiting the 
 growth of the microbes and preventing the formation 
 of toxins. 
 
 I have already expressed myself (page 158) concern- 
 ing the action of purgatives. I may be permitted to 
 say, in addition thereto, that purgatives often intensify 
 the symptoms of auto-intoxication. They remove the 
 intestinal epithelium and mucus which practically act 
 as barriers against the absorption of enterotoxins. We 
 
186 THE BLUES :— NEURASTHENIA. 
 
 have discarded the swab in infectious diseases of the 
 throat for the reason, that it mechanically injures the 
 membrane of the throat and thus opens up new portals 
 of infection. In this sense the purgative is essentially 
 an intestinal swab. It not infrequently occurs that 
 purgation will intensify the symptoms of auto-intoxica- 
 tion on account of concentration of the poisons which 
 have already been absorbed into the blood. Now, it 
 is customary for some physicians to conclude, that, 
 because the patient has a daily movement, there can 
 be no intestinal auto-intoxication. Contrary to cur- 
 rent opinion, I have found that in those suffering from 
 self-poisoning, diarrhea, or at any rate, looseness of 
 the bowels, prevails rather than constipation ; it would 
 appear that this is nature's method of ridding the 
 organism of noxious products. Strassburger has shown 
 that retarded bowel-action, rather indicates diminished 
 decomposition-products which normally stimulate in- 
 testinal action. The odor of the feces often serves as 
 an index to the grade of intestinal putrefaction. 
 Healthy excreta are free from odor. 
 
 The Sinusoidal Cukkent. (Note 16, Appendix). — 
 The application of this current to the abdomen (each 
 sitting lasting from 15 minutes to one hour) is a valu- 
 able method of treatment which I have employed for 
 several years. It is especially applicable in cases of 
 auto-intoxication caused by splanchnic congestion. It 
 strengthens the abdominal muscles, relieves intra- 
 abdominal congestion and hyperaesthesia and promotes 
 the absorption and excretion of enterotoxins. Washing 
 the colon is an excellent method of treatment for acute 
 cases of auto-intoxication but I would not recommend 
 it as a routine method of treatment for the same 
 
THE CAUSE AND CURE. Jg? 
 
 reasons that I discountenanced the employment of 
 purgatives. Naturally in this, like in other diseases, 
 one must endeavor to improve the general health, for 
 everything that benefits the latter, will promote re- 
 covery from the particular disease on the broad prin- 
 ciple, that all that influences health equally influences 
 disease. 
 
 Bread and Feuit Diet. — The Haig theory may 
 be faulty but one is compelled to recognize this partic- 
 ular diet which he recommends in certain high-blood 
 pressure groups of intoxications, expressed as headache, 
 epilepsy, depression, etc. In such instances, the fol- 
 lowing diet is at least worthy of a trial. Roughly 
 speaking, an individual weighing 140 pounds is required 
 to consume 21 ounces of breadstuff a day, supplemented 
 by 7 ounces of dry fruits. To this may be added a 
 small quantity of potato or other vegetable, and any 
 fresh fruit in season. The bread may be made as a 
 pudding, using a little milk, but as far as possible 
 fluids should be excluded. The foregoing day's food 
 may be divided into three meals each containing 7 
 ounces of breadstuffs and 2 or 3 ounces of dry fruits. 
 A blood-pressure of about 135 mm. can be reduced in a 
 week or more to 120 mm. 
 
APPENDIX. 
 
 NOPE 1— PULMONARY ANEMIA AND INSUFFICIENT 
 LUNG DEVELOPMENT.* 
 
 The physiologic principles involved in respiration are 
 not always strictly in accord with clinical observation. 
 By this I mean that civilized man has so subverted 
 primeval respiration, by attire and modes of living, that 
 what is now regarded as physiologic, is really patho- 
 logic. Physiology teaches that the lungs, even at the 
 termination of expiration, are in a stretched condition, 
 and the experiment is frequently cited of making an 
 opening into the pleural cavity, which drives a certain 
 amount of air into the trachea. Without entering fur- 
 ther into a discussion of this matter, let us learn to what 
 degree such physiologic teaching is in conflict with clin- 
 ical evidence. The lungs do not by any means fully 
 occupy the thoracic space. The costal and visceral lay- 
 ers of the pleura make up a sac in which, so to speak, 
 the lungs are let in. In certain thoracic situations the 
 pleural sac is larger than the lung volume, and forms 
 spaces, known as pleural or reserve spaces. Such spaces 
 permit of changes in the lung volume, which otherwise 
 would be impossible. The pleural spaces exist through- 
 out the entire extent of the lung borders, the largest, 
 known as the sinus phrenicocostalis, being located at the 
 lower outer lung-border, at a point where the costal 
 passes over into the diaphragmatic pleura. Figs. 5 
 
 189 
 
190 THE BLUES :-NEURASTHENlA. 
 
 and 6 show the sites of the pleural spaces (shaded) on 
 the anterior and lateral aspects of the thorax. 
 
 Even the deepest inspirations are not sufficient to 
 cause the lungs to fully occupy the pleural spaces. The 
 pleural space on the lateral aspect of the thorax may be 
 filled, if the patient lies on the opposite side and con- 
 ducts deep and forced inspirations. In quiet respira- 
 tion, the difference in the position of the lower lung- 
 borders during the respiratory phase is about 1 cm., 
 
 Fig. 5. Shovring pleural spaces shaded. (Eichhorst), Fig. 6. Pleural spaces 
 (shaded) on the lateral surface of the left lung. (Eichhorst.) 
 
 whereas, if the respiratory excursions are more pro- 
 nounced, especially in the lateral chest region, the dif- 
 ference may be as great as 13 cm. This active mobility 
 of the lung borders is always greater than the passive 
 mobility, which is influenced by the body posture. Hav- 
 ing succinctly reviewed these anatomic facts, we will 
 now present the clinical findings, which contravene the 
 • American Medicine, Feb. 15, 1903. 
 
THE CAUSE AND CURE, 
 
 191 
 
 assumption of the physiologist, that the lungs are always 
 in a stretched condition. I have frequently directed at- 
 tention in the literature to constant areas of diminished 
 lung resonance, varying from dulness to flatness, as ob- 
 tained by percussion. In number and situation these 
 areas vary, but they admit in the aggregate of definite 
 localization. These areas of dulness, or atelectatic 
 zones, as I have called them, possess one characteristic 
 feature, they may be dispelled by repeated forced in- 
 spirations. By this simple maneuver, resonance will 
 supplant dulness. The atelectatic zones are dependent 
 
 Fig. 7.— Patches on the front sur- 
 face of chest. 
 
 Fig 8.— Patches on the posterior 
 surface of chest. 
 
 on circumscribed pulmonary atelectasis or collapse of 
 limited portions of the lung, and dissociated with any 
 demonstrable lesion. While it is true from the stand- 
 point of the physiologist, that the lungs are in a 
 stretched condition, it is equally true from the position 
 of the clinician that certain portions of the lungs are 
 collapsed and deprived of sufficient air to yield a dulness, 
 and in some instances, a flatness on percussion. The 
 atelectatic zones vary in size from a 25-cent piece to a 
 
192 THE BLUES -NEURASTHENIA. 
 
 dollar, or even larger, and are permanently absent when 
 the lungs are emphysematous, and temporarily so, after 
 repeated deep inspirations, but they reappear in a few 
 minutes, when tranquil breathing is resumed. In Tigs. 
 7 and 8 I have projected a composite picture defining 
 the situation of the atelectatic zones, based on an exami- 
 nation of over 100 apparently healthy persons, children 
 as well as adults. On the posterior surface of the chest, 
 the zones are more frequently encountered, and admit of 
 more definite localization than those on the anterior sur- 
 face of the thoracic wall. Since the advent of the 
 Rontgen rays, I have observed the following: (1) Ate- 
 lectatic zones throw circumscribed shadows on the fluoro- 
 scope, which will vary according to the degree and area 
 of the pulmonary atelectasis. (2) The shadows cast 
 by the atelectatic zones can be made to disappear by con- 
 tinuous forced breathing, and they will reappear after 
 a variable period when quiet breathing is resumed. (3) 
 Before deciding whether the shadow cast on the fluoro- 
 scope is really due to pulmonary consolidation, the sub- 
 ject should be instructed to make forced inspirations ; if 
 the shadow disappears, and is supplanted by a bright re- 
 flex, it is due to atelectasis ; if the shadow persists, pul- 
 monary consolidation may safely be concluded to exist, 
 excluding, of course, other anatomic conditions that 
 would interfere with the transmission of the Rontgen 
 rays to the fluoroscope. (4) Skiascopy of the lungs dem- 
 onstrates that the opacities on the fluoroscope, corres- 
 ponding to the atelectatic zones, greatly exceed the per- 
 cussional areas of the latter, and, furthermore, that in 
 individuals in whom no zones can be demonstrated by 
 percussion, opacities are sometimes present, which dis- 
 appear after forced inspiration. (5) Before and dur- 
 
THE CAUSE AND CURE. 193 
 
 ing a radioseopic examination of the lungs it is always 
 imperative to instruct the patient to practice forced 
 breathing. 
 
 What are the practical conclusions that may be formu- 
 lated as a result of the foregoing observations ? Danger 
 may accrue from confounding the physical signs of ate- 
 lectatic dulness with dulness caused by lung consolida- 
 tion, an error which can always be avoided, if the patient 
 is directed to practice forced inspirations before percus- 
 sion of the chest is attempted. Whenever a localized 
 dulness of the lung is detected, it is a wise provision 
 to instruct the patient to take a series of deep breaths; 
 if the dulness disappears, we are dealing with an ate- 
 lectatic zone, if, however, the dulness persists, we are 
 justified in concluding that there is some lung anomaly. 
 I hold that topographic percussion, as obtained ordinar- 
 ily, is of inconstant value. The limitation of organs by 
 percussion, especially the heart, will vary from day to 
 day, and the pereussional area of dulness in the same 
 case and at the same time will be variously obtained 
 ■ by different diagnosticians. The borders of the liver, 
 heart, and spleen are dependent on the degree of the 
 lung inflation, and must vary according to the activity 
 of respiration. Topographic percussion must always be 
 based on the state of pulmonary inflation, and the results 
 governed accordingly. The aid afforded by ausculta- 
 tion in the elimination of atelectasis is obvious. Aus- 
 cultation of the lungs should be conducted with the 
 patient in different postures, the object being to utilize 
 the actual respiratory capacity of the lungs, thus elim- 
 inating the auscultatory phenomena of atelectasis and 
 accentuating abnormal sounds, which may be present. 
 The recognition of the atelectatic zones is of the greatest 
 13 
 
194 
 
 THE BLUES :-NEUUASTHENlA. 
 
 importance to the skiascopist, as failure to recognize 
 them may lead to the grave error of misinterpreting the 
 shadows cast on the fluoroscope as evidence of lung 
 tuberculosis. Stubbert, in a contribution, maintains 
 that he is unable to confirm, my observations relative to 
 the atelectatic zones. It is gratifying, however, for me 
 to add, that Cabot, in his recent book, makes mention 
 of my observations, and confirms them. Any physician 
 who places sole reliance on percussion, or the shadows 
 cast on the fluoroscope, as evidence of lung consolida- 
 tion, will commit the 
 egregious blunder of 
 interpreting tuber- 
 culosis in more than 
 50 per cent, of the 
 patients comiijg to 
 him for examination. 
 In Fig. 9 A. we 
 observe the fluoros- 
 cope reproduction of 
 the lung apex in a 
 normal individual. 
 Note the area 
 
 Fig. 9.—^, c, Clavicle. 1. Area of apex in normal breatliing. 2. Apical 
 area in deep breathing. 3 Apical area after elicitation of lung reflex. B, 
 Apical area after strapping the lower chest. 
 
 of luminosity represented by the apex in tranquil breath- 
 ing. (1) Observe how this area is augmented after 
 forced deep breathing (2) and again after elicitation 
 of the lung reflex (3). Observe the extraordinary in- 
 crease in luminosity after strapping the lower chest 
 which permits of breathing in the upper chest only (B). 
 A word of caution is necessary to those who are desirous 
 
THE CAUSE AND CURE, 195 
 
 of confirming the latter observations. Owing to the 
 extraordinary respiration in the upper chest area, the 
 clavicles may obscure by their elevation, the luminous 
 apical area, hence, the latter area should only be gauged 
 when the patient practices forced expiration, which will 
 cause a descent of the clavicles. 
 
 I have already mentioned the fact that the atelectatic 
 zones may be dissipated by forced inspirations, but this 
 is not always true, for there are instances when only 
 repeated forced inhalations of compressed air will cause 
 their evanescence. There are two methods, which will 
 cause their disappearance: by evoking the lung reflex,* 
 which will be referred to later, and by change in the 
 posture of the patient. The latter method I have only 
 observed recently. I found that, when the patient bends 
 forward for a few seconds, the zones can no longer be 
 elicited. This phenomenon I attribute to interference 
 with the movements of the diaphragm, which evokes 
 compensatory costal breathing: Not infrequently the 
 lung apex in its entirety is atelectatic and this may even 
 occur in a condition of apparent health. Kernig con- 
 firms this observation, to which I have frequently re- 
 ferred. Experience has taught me to regard most highly 
 the observation originally referred to by Seitz, the value 
 of percussing the upper borders of the lung apices, for 
 the earliest evidence of tuberculosis. Both apices rise 
 usually to the same height as determined by percus- 
 sion, and the latter sign shows that the apices rise dur- 
 ing inspiration and fall during expiration. Any differ- 
 ence in the height of the apices or any retarded disloca- 
 tion during the phases of respiration must always be 
 regarded with grave suspicion, Figs. 10 and 11 show the 
 * Appendix, Note,' 9. 
 
196 THE BLUES :— NEURASTHENIA. 
 
 normal height of the apices. Owing to the difficulty ex- 
 perienced in the exact demarcation of the apices an- 
 teriorly, I rely almost wholly on the evidence furnished 
 on the posterior surface of the chest. 
 
 Atelectasis bears an important relation to pulmonary 
 tuberculosis and pulmonary anemia. In the former 
 affection, the zones bear an almost definite relation to 
 the points of election and paths of distribution of the 
 lesions in chronic pulmonary tuberculosis. 
 
 Pulmonary Anemia. In children, less often in 
 
 Fig. 10.— Extreme area of apical Fig. 11.— Extreme area of apical 
 resonance on anterior surface of the resonance on the posterior Surface of 
 chest. the chest. 
 
 adults, an anemia is often associated with atelectatic 
 zones. This anemia I have designated as pulmonary. 
 Pulmonary anemia attends multiplication or augmenta- 
 tion in area of the zones. The syndrome of anemia dis- 
 appears upon a course of methodic respiratory gymnas- 
 tics, while its recrudescence is always associated with 
 a reappearance of the atelectatic zones. Pulmonary 
 anemia is not an invariable concomitant of lung atelect- 
 asis, although as a rule, when anemia of pulmonary 
 origin is present, atelectatic zones may be demonstrated. 
 
THE CAUSE AND CURE. 197 
 
 In association with the anemia, fatigue on exertion, 
 dyspnea, and heart palpitation, anomalies of digestion 
 and constipation are usually present. Loss in weight 
 is quite characteristic of pulmonary anemia, whereas, 
 in the essential anemias, the well-nourished condition 
 of the patient is manifest. There is another sign which 
 distinguishes pulmonary from other forms of anemia, 
 the one exception being, perhaps, progressive pernicious 
 anemia, and that is, that while the ferruginous prepara- 
 tion benefit pure anemics, in pulmonary anemia they 
 are practically valueless, at any rate, the benefit accru- 
 ing from their use is evanescent. The real pathogno- 
 monic sign of pulmonary anemia is the therapeutic test 
 Subject such an individual to a single pneumatic cabinet 
 treatment, employing inhalations of compressed air, and 
 one invariably finds an increase in hemoglobin per- 
 centage if the anemia is of pulmonary genesis. The 
 quantity of iron in pulmonary anemia is probably 
 normal, the element lacking is oxygen, and this hypothe- 
 sis is evidently correct, inasmuch as all pulmonary ane- 
 mics were cured by breathing exercises only. The recog- 
 nition of pulmonary anemia as one of the earliest trust- 
 worthy signs of tuberculosis is of the greatest import- 
 ance. I cannot adduce statistics in support of my con- 
 tention, for that is a difficult matter. When, in the 18 
 3'ears of my practice, I encoimtered an instance of pul- 
 monary anemia, the patient was treated and not sub- 
 jected to scientific observation, so it is impossible for me 
 to say how many of my untreated cases of pulmonary 
 anemia would have terminated in bacillary tuberculosis. 
 There are certain observations in medicine which must 
 be purely empiric. T will instance a few observations 
 which have some bearing on this subject: 
 
198 THE BLUES :— NEURASTHENIA. 
 
 Obseevation I. In a tuberculous family, of whom 
 three members died of the disease, two daughters came 
 to my office for examination. In one daughter atelectatic 
 zones were variously distributed over the chest.. Hemo- 
 globin reduced to 60 per cent. Usual subjective symp- 
 toms of anemia. Treatment with the pneumatic cabi- 
 net. A period of five years has elapsed and the patient 
 is still healthy. The other daughter also had the sub- 
 jective symptoms of anemia, and the hemoglobin was re- 
 duced to 70 per cent. Only one atelectatic zone was 
 present, situated on the anterior surface of the chest 
 close to the manubrium sterni on the left side, and 
 about three inches in circumference. This patient un- 
 derwent no treatment. Two years later she returned 
 to my office with pronounced tuberculosis. Cavitation 
 of the lung corresponding to the atelectatic zone pre- 
 viously mentioned was evident. Six months later the 
 patient died. 
 
 Obseevation ii. A young man, aged 16. Pro- 
 nounced evidence of anemia. Atelectatic zones present. 
 Treatment with the pneumatic cabinet of short duration. 
 Three years later the patient died of tuberculosis. 
 
 Obseevatioit III. Girl, aged 14. Hemoglobin re- 
 duced to 50 per cent. Red corpuscles reduced to 70 
 per cent. Atelectatic zones present. No other symp- 
 toms. One year later patient presented herself with 
 symptoms of pulmonary tuberculosis. Patient cured. 
 
 The foregoing observations have been selected from 
 a small number of analogous cases, and only justify the 
 importance I have attached to pulmonary anemia as an 
 early sign of tuberculosis. If pulmonary anemia is de- 
 pendent on lung atelectasis, as I have attempted to 
 show, the treatment indicated is lung development. AH 
 
THE CAUSE AND CUEE. 199 
 
 my patients showed immediate and permanent improve- 
 ment after daily inhalations of compressed air. The 
 color of the patients improved, the oxyhemoglobin and 
 number of red corpuscles increased and the subjective 
 signs of anemia disappeared. Whenever the organism 
 is compelled to dispose of more oxygen it produces more 
 oxygen carriers. If relapses occur, which were not in- 
 frequent, they were attributed in the main to neglect 
 of lung gymnastics or a return to former modes of life. 
 
NOTE 2.— THE CARDIO-SPLANCHNIC PHENOMENON.* 
 
 Many of the facts here recorded with reference to 
 this phenomenon have appeared elsewhere in this work, 
 but their importance will bear repetition. 
 
 To my knowledge this is an .heretofore undescribed 
 phenomenon, as far as its clinical manifestation is con- 
 cerned. The facts, however, up to the point of its clin- 
 ical identification have been fully established by the 
 physiologic investigations of others. These facts are 
 identified with intra-abdominal tension, and the effects 
 of such tension on the blood circulation. Before de- 
 scribing the phenomenon in question, it will be apposite 
 to succinctly review a few essential points on the sub- 
 ject of intra-abdominal tension. The latter in the norm 
 is greater than the pressure of the atmosphere, and its 
 positive pressure is exerted on the viscera which in turn 
 press on the abdominal parietes, causing them to bulge. 
 Should a reverse condition of things prevail, the walls 
 of the abdomen would become retracted. Positive 
 intra-abdominal pressure is subject to two conditions, 
 viz. : the atmosphere pressure upon the yielding abdom- 
 inal walls and the vigor of contraction of the abdominal 
 muscles. For this reason, intra-abdominal pressure is 
 
 * American Journal of the Medical Sciences. 
 
 200 
 
THE CAUSE AND CURE. 201 
 
 most pronounced in individuals with powerful muscles, 
 and least evident in multiparous women with flaccid ab- 
 dominal walls. Clinicians recognize the secondary ef- 
 fects of low intra-abdominal tension in conducing to 
 splanchnoptosis, for, when the abdominal walls are re- 
 laxed as a permanent condition, their pressure on the 
 underlying structures is insufficient, and the result is a 
 ptosis of the viscera. The effects of reduced intra-ab- 
 dominal tension on the circulation has received but scant 
 consideration from clinicians, a most lamentable fact, 
 considering the gravity of the issue involved. Hill and 
 Barnard have largely contributed to this important sub- 
 ject, which has been practically elaborated in the ex- 
 cellent work of Campbell. They have demonstrated that 
 there is a tendency of the blood to accumulate in the 
 splanchnic area, with consequent syncope. Like the gen- 
 erality of veins, the great splanchnic veins are very sus- 
 ceptible to pressure, and the amount of blood within 
 them is greatly influenced by the pressure of the ab- 
 dominal walls. Mere pressure of the abdominal walls 
 suffices to squeeze out of them a large quantity of blood. 
 Thus gravity, posture, the accoutrements of dress, and 
 other factors greatly influence the amount of blood con- 
 tained in the splanchnic area. More blood accumulates 
 in the splanchnic veins in the erect than in the recumbent 
 posture, and it is not an uncommon observatipn for syn- 
 cope to occur in bedridden patients who are suddenly 
 constrained to get out of bed. The removal of stays in 
 women often induces a feeling of faintness, and the 
 same symptom may occur when a large quantity of 
 ascitic fluid is removed and in susceptible subjects when 
 the bladder is emptied or feces discharged. This feeling 
 of faintness or syncope, while present in the normal 
 
202 THE BLUES :— NEURASTHENIA. 
 
 subject in the foregoing conditions, is greatly accentu- 
 ated when the abdominal walls are flaccid. Three factors 
 enter into consideration in the mechanism of blood sup- 
 ply to the splanchnic vessels, viz. : 1. The contraction 
 of the abdominal muscles ; 2. The act of respiration, and, 
 3. The regulating vasomotor action of the splanchnic 
 vessels. The first factor is an important one, the trans- 
 versales maintaining the anterior and posterior abdom- 
 inal walls in fairly close contact and prevent in the erect 
 posture the gravitation of blood in the splanchnic area. 
 The second factor concerns the descent of the diaphragm 
 and pulmonary suction. Every time the diaphragm de- 
 scends, the intra-abdominal vessels are compressed, and 
 the action thus exerted is less evident in the tense arteries 
 than in the flaccid veins: the blood being squeezed out 
 of the latter into the right heart. De Jager has shown 
 that even strong pressure upon the abdomen has little 
 or no effect on the arteries, but serves to squeeze a large 
 quantity of blood from the splanchnic veins. Hill has 
 also shown that, in consequence of some failure in cer- 
 tain compensatory mechanisms, the blood gravitates into 
 the splanchnic veins from the right heart, and that pres- 
 sure upon the abdomen will send back the blood from 
 these veins to the right heart, and thus re-establish the 
 circulation. Such compression of the abdomen not only 
 augments the input into the right heart, but it likewise 
 increases, according to most writers, the systemic arter- 
 ial pressure by increasing the peripheral resistance in 
 the splanchnic area. 
 
 Pulmonary suction refers to the large quantity of 
 blood drawn into the lungs with each inspiration, and 
 this physiologic process has not been inaptly compared 
 to a species of dry cupping. Chapman avers " that if, at 
 
Fig. 12. — Illustrating the cardio-splanchnic phenomenon. The 
 shaded area indicates the dull area obtained after vigorous 
 compression of the abdomen. The contiguous area is the 
 superficial area of cardiac dullness. 
 
ftlfi CAUSE AND CURE.. S05 
 
 the termination of expiration, the quantity of blood in 
 the lungs is from 1-15 to 1-18 of the total quantity of 
 blood in the body, at the termination of inspiration, it 
 will be from 1-12 to 1-13." The pulmonary vessels ex- 
 pand with each inspiration, and contract during expira- 
 tion, the result being an increased flow of blood from 
 the right heart and the lungs: The dilated vessels, as 
 Campbell puts it, " actually sucks the blood out of the 
 right heart. The final factor, the splanchnic vasomotor 
 mechanism, in preventing the gravitation of blood into 
 the splanchnic veins, is an important one. Hill and 
 Barnard have demonstrated that the splanchnic vaso- 
 motor mechanism suffices to combat this contingency, 
 but when this mechanism is inhibited, as occurs when 
 the splanchnic nerves are cut, a second mechanism is 
 brought into prominence, viz. : Expiratory compressions 
 of the abdomen occurring simultaneously with inspira- 
 tory thoracic suctions, the former squeezing, and the 
 latter sucking the blood out of the splanchnic pool. The 
 latter mechanism compensates, however ineffectually, in 
 carrying out the circulation, and is referred to by Camp- 
 bell as the " respiratory mechanism." That the latter 
 mechanism is not as efficient as the vasomotor mechan- 
 ism is evidenced by the fact that the effects of gravity 
 may be entirely compensated for after the injection of 
 curare, which paralyzes the muscles. Both mechanisms 
 may be inhibited by division of the spinal cord at the 
 first dorsal vertebra, and if the animal operated on be 
 held with the head up all the blood accumulates in the 
 splanchnic veins, and the empty heart ceases to beat; 
 if, however, the abdomen of the animal is compressed, 
 the blood is expressed into the heart, and the circulation 
 is restored. AVith the foregoing facts at our command, 
 
S06 THE BLUES :-NEtJRASTHENlA. 
 
 we are in a position to appreciate what I have called the 
 cardio-splanchnic phenomenon. 
 
 If the lower sternal region, i. e., the part of the 
 sternum contiguous to the heart, is first percussed in the 
 standing and then again in the recumbent posture, one 
 may note a decided alteration in the percussion tone; 
 in the former attitude it is resonant or even hyperreso- 
 nant, in the latter, it is dull or even flat. This is the 
 cardio-splanchnic phenomenon. It may be elicited, but 
 less pronouncedly when the patient is in bed and sits up. 
 Vigorous compression of the abdomen will exaggerate 
 the phenomenon in all instances. Not infrequently the 
 deep or relative cardiac dulness will extend beyond the 
 right border of the sternum. In no instance was this 
 phenomenon absent, although hundreds of individuals 
 were examined. It must be conceded that, in a few 
 instances, the cardio-splanchnic phenomenon was only 
 feebly expressed by mere attitudinal changes, yet re- 
 enforcement of the maneuver by abdominal compression 
 rendered its elieitation easy. A few forced inspira- 
 tions will at once dispel the phenomenon, and it is like- 
 wise dispelled by the application of a vacuum cup to the 
 abdomen. If the liver and spleen are percussed first 
 in the erect and then in the recumbent posture, a decided 
 variation in regional percussion is obtained. In the 
 former attitude, the area of dulness is increased, in the 
 latter, it is decreased, and the splanchnic area of dulness 
 may completely disappear. These conditions are super- 
 added to the cardio-splanchnic phenomenon. Primarily, 
 it is necessary to adjust the discrepancy of my observa- 
 tions with those already accepted, and then to analyze 
 the manifestations, which give genesis to the cardio- 
 splanchnic phenomenon. Theoretically, one could at the 
 
THE CAUSE AND CURE. 207 
 
 outset assume that the situs of the heart, moi'e nearly 
 approaches the anterior chest wall in the erect than in 
 the recumbent posture, indeed it is not only assumed 
 but accepted by clinicians, that in the latter posture the 
 heart falls away from the thoracic wall. Even Kings- 
 cote perpetrates a similar error by assuming that the 
 preponderance of asthmatic seizures at night is caused 
 by the recumbent posture, the dilated heart in this posi- 
 tion causing it to impinge on the vagi. I have shown 
 elsewh.ere the fallacy of this contention. By aid of the 
 Rontgen rays, the triangular spaces in front and behind 
 the heart are clearly defined, and the rays give undeni- 
 able demonstration of the fact that change of posture 
 only slightly modifies, if at all, the area of these spaces ; 
 in fact, it may be observed in a number of instances, 
 that when the patient assumes the recumbent posture, the 
 anterior triangle is diminished and the posterior trian- 
 gular space is increased in area, facts which contravene 
 the contention that posture infliiences the relation of the 
 heart to the chest wall. Again, percussional results are 
 often influenced by the prejudicial preconceived ideas 
 of the clinician. The skilled physician, in his interpret- 
 ation of percussional phenomena, is guided not so much 
 by the ear as by the tactus eruditus; thus palpatory per- 
 cussion will yield results which would wholly escape 
 the observer, who is influenced only by what he hears, 
 and not by what he feels. In the elicitation of the 
 flardio-splanchnic phenomenon, palpatory percussion 
 must be our chief mentor. Others may contend that 
 my lung reflexes (the lung reflex of contraction and the 
 lung reflex of dilatation) and the heart reflex may ac- 
 count for the phenomenon in question, but all these 
 reflexes have been carefully eliminated, and play no role 
 
208 THE BLUES :— NEURASTHENIA. 
 
 in the cardio-splanehnic phenomenon. It is true that 
 in the recumbent posture the areas of splenic and hepatic 
 dulness become decreased, and this in accordance with 
 the well known fact that change of posture influences 
 the position of the lung borders, the so-called passive 
 mobility of the lung borders. In the recumbent, the 
 lower lung border descends about ^ inch lower than in 
 the erect posture. The decrease in the areas of hepatic 
 and splenic dulness as associated signs of the cardio- 
 splanehnic phenomenon takes into consideration only 
 the deep or relative hepatic dulness, together with 
 the additional fact, that the areas in question are 
 diminished to an extent not to be accounted for 
 by mere passive mobility of the lung borders. The 
 cardio-splanehnic phenomenon is easy of explana- 
 tion. In the erect posture, the blood leaves the 
 right heart, which topographically is underneath the 
 lower sternum, and tends to accumulate in the splanch- 
 nic area, whereas the recumbent posture opposes this 
 influence of gravity. Pressure of the abdomen, which, 
 in some instances must be vigorous, assists still further 
 in expressing the blood from the splanchnic veins and 
 sending it back to the heart. The same factors prevail 
 with relation to the liver and the spleen, the amount of 
 blood in the latter viscera being in direct proportion to 
 the amount of blood contained in the splanchnic veins 
 and in inverse proportion to the amount of blood con- 
 tained in the heart. Forced inspirations hasten the out- 
 put of blood from the heart, hence the almost immediate 
 evanescence of the cardio-splanehnic phenomenon after 
 vigorous breathing is executed. A word of caution is 
 here necessary to those who seek the elicitation of the car- 
 dio-splanehnic phenomenon. If the latter is provoked, in- 
 
THE CAUSE AND CURE. 200 
 
 struct the patient to conduct only superficial breathing 
 and not to wholly suspend it, otherwise, the blood will 
 accumulate in the right heart from this very maneuver. 
 The exhaustion of air by means of a vacuum cup applied 
 to the abdominal surface will decrease intra-abdominal 
 tension, and will consequently increase the quantity 
 of blood in the splanchnic veins, and in this manner the 
 right chambers of the hear.t will become depleted. I 
 have endeavored, by means of the Rontgen rays, to de- 
 termine whether any of the maneuvers already suggested 
 for provoking the cardio-splanchnic phenomenon in any 
 way influence the diameters of the heart, and my inves- 
 tigations show that they do not. If the latter observation 
 is correct, and there is every reason to believe that it 
 is, how then can we account for the increased dulness 
 of the lower sternum, the necessary concomitant of the 
 cardio-splanchnic phenomenon. In the norm, the ster- 
 num contiguous to the site of the right ventricle of the 
 heart, yields percussional resonance, which is caused in 
 the main by the transmission of the percussion blow to 
 the neighboring lung tissue. The percussion blow is 
 propagated from 1^ to 2f inches on the surface, and 
 to a depth of about 2^ inches. It is evident, then, that 
 in the normal subject, the dulness of the right ventricle is 
 not sufficiently pronounced to dampen the sound ob- 
 tained from the vibration of air within the lung alveoli. 
 It is, however, possible to conceive that if the right 
 ventricle were sufiiciently filled with blood, and this is 
 capable of fulfilment without any increase in the dimen- 
 sions of the chamber in question, that the normally reso- 
 nant sound of the lower sternal region could become dull 
 or even flat. Our final endeavor is to show the value 
 of the cardio-splanchnic phenomenon in diagnosis and 
 14 
 
210 THE BLUES :— NEURASTHENIA. 
 
 treatment. In estimating the size of the liver or spleen 
 by percussion, we must pay due regard to the position 
 of the patient, the amount of blood contained in the 
 right heart and the vigor of respiration. The size of ■ 
 the liver is dependent in a measure on the amount of 
 blood which it contains, and this has been estimated by 
 Foster to be equivalent to one-fourth the amount of blood 
 contained in the body. The skilled diagnostician will 
 not find it a difficult task to demonstrate the reduction 
 in the areas of hepatic and splenic dulness after repeated 
 forced inspirations. Such reduction cannot wholly be 
 accounted for by the opening up of atelectatic lung areas, 
 for, in the case of the liver, percussional results should 
 refer only to the deep or relative hepatic dulness. Sup- 
 posing the object of our examination is an enlarged liver 
 or spleen, and we wish to determine how much of this 
 enlargement is due to passive or active hyperemia, and 
 how much to hyperplasia of the connective tissues ? 
 
 Percussion in different attitudes, repeated forced in- 
 spirations and abdominal compression will solve this 
 question according to the methods previously advocated. 
 If we wish to apply a crucial test, all that is necessary 
 is to apply a vacuum cup to the abdomen, then in ac- 
 cordance with the fact already established, the liver and 
 spleen would become enlarged. Supposing a patient pre- 
 sents himself complaining of pressure in the sternal re- 
 gion, the nature of such pressure if due to an enlarged 
 right heart may be easily determined by application 
 of the vacuum cup to the abdomen ; the blood will be 
 expressed from the heart to the abdomen, and the sensa- 
 tion of pressure will at once disappear. Let us further 
 assume that we are confronted with an abdominal tumor 
 and it is difficult to say whether such a growth is con- 
 
THE CAXJSE! AND CtTftE. 211 
 
 Decied with the liver or the spleen, the application of the 
 vacuum cup may solve the problem, for if the growth 
 ill question is connected with the liver or spleen, the 
 latter viscera will show augmented dimensions, and con- 
 versely their areas will be diminished by vigorous com- 
 pressions of the abdomen. If the differential diagnosis 
 rests between a pericardial exudate and a dilated hearty 
 the elicitation of the cardio-splanchnic phenomenon 
 would point to the existence of the latter condition. 
 Idiopathic syncope and the vertiginous attacks of Glen- 
 ard's disease may be attributed to a defective splanchnic 
 vasomotor mechanism. Now, in the average normal sub- 
 ject the cardio-splanchnic phenomenon is fairly evident, 
 but in the conditions just cited, it is exaggerated. In 
 other words, the more perfect the mechanism, the less 
 pronounced is the phenomenon. There are a large num- 
 ber of respiratory affections which owe their dyspnea to 
 an overburdened right heart, and this is notably the 
 case in asthma. While I do not agree with Kingscote 
 " that a dilated heart is the essential cause of asthma," 
 yet I do contend that an enlargement of that viscus is 
 operative in predisposing to an asthmatic paroxysm and 
 augmenting its severity. I have succeeded in arresting 
 asthmatic paroxysms, which failed to yield to the con- 
 ventional methods by the application of a vacuum cup 
 to the abdomen. In these instances, suggestion probably 
 played no role, insomuch as the relief of the paroxysm 
 was coincident with the disappearance of the substernal 
 dulness. It is unnecessary to adopt the theory of Kings- 
 cote, that of a dilated heart striking the vagi, being re- 
 sponsible for the asthmatic attack, the overburdened 
 right ventricle being quite sufficient. Indeed, the pre- 
 dominance of attacks occurring at night, as well as the 
 
21^ I'HE BLUES :— NEURASTHENIA. 
 
 dyspnea in cardio-respiratory affections, can be ex- 
 plained by the augmented blood supply to the right ven- 
 tricle, as the result of the recumbent posture. In my 
 opinion, the upright position intuitively assumed in 
 orthopnea is not only due to the fact that the extraordi- 
 nary muscles of respiration may "work to better advan- 
 tage, but also for the additional reason that the blood 
 from the right heart is enabled to gravitate to the 
 splanchnic veins. 
 
 'Now in dyspnea from any cause, the implication of 
 the heart in the production of this symptom jnay be 
 gauged by expressing blood from the right heart by 
 means of the vacuum cup to the abdomen. If the dysp- 
 nea is relieved, we have reasonable assurance that it is 
 caused by an overburdened heart. Instances could be 
 multiplied, showing how the cardio-splanchiiic phenom- 
 enon may be employed in diagnosis, but the examples 
 already cited will suffice. In treatment, the phenomenon 
 suggests many possibilities in the direction of reestab- 
 lishing the circulation and in relieving the heart when 
 it is overtaxed. An accurate instrument for estimat- 
 ing the blood pressure is a trustworthy guide in de- 
 termining the value of any physical maneuver, which 
 has for its object cardiac stimulation. An equally effi- 
 cacious guide is the cardio-splanchnic phenomenon, not 
 only the phenomenon per se, but the degree of its demon- 
 stration. The precardial area of dulness is, as has al- 
 ready been intimated, not dependent so much on the 
 approximation of the heart to the anterior chest wall, 
 but rather to the amount of blood contained in the car- 
 diac chambers. Inversion of the subject accentuates the 
 cardio-splanchnic phenomenon and increase's the dulness 
 to the left of the lower sternal region, and diminishes it 
 
THE CAUSE AND CURE. 213 
 
 over the latter area. In instances of syncope, it appears 
 to me, that the object achieved is not so much the de- 
 termination of blood to the anemic brain as it is to the 
 determination of blood to the heart. I have sought to 
 devise some apparatus whereby continuous compression 
 of the abdomen may be effected in acute conditions de- 
 manding cardiac stimulation. The simplest means for 
 effecting this object is by means of a firm cushion ap- 
 plied to the abdomen and secured by a rubber bandage 
 or a broad strap, which permits of any degree of trac- 
 tion. Not infrequently continuous pressure, such as is 
 here described, gives rise to intereference with respira- 
 tion, in which instance, one must content themselves 
 with paroxysmal abdominal compression. 
 
 The relief of an overtaxed right heart is suggested in 
 so many cardio-respiratory troubles that it may be appo- 
 site to select croupous pneumonia as a paradigm. There 
 are so many indications and contradictions cited by 
 writers for venesection in this affection that it is really 
 problematic whether bleeding is beneficial or harmful ; 
 at any rate, its practice is purely empirical. It appears 
 to me that in the general management of the average 
 patient with pneumonia, the main object based on the- 
 oretic grounds, would be to preserve the quantity of 
 blood, for, after all, it is the chief stimulus for main- 
 taining the cardio-pulmonary circulation and furnishes 
 the leucocytes, which are such important factors in con- 
 ducing to a favorable issue. Instances do occur with- 
 out doubt, where bleeding is a justifiable procedure, 
 but it would prove more effective if the patient could 
 be bled into his own vesselst The application of a 
 vacuum cup to the abdomen meets this emergency, and 
 should be employed, if only as a tentative measure, 
 
214 THE BLUES :— NEURASTHENIA. 
 
 should an overburdened right ventricle with its con- 
 secutive phenomena warrant its employment. If this 
 maneuver is effective, it may be repeated, as it is a 
 harmless and painless procedure. 
 
NOTE 3.— BLOOD PRESSURE. 
 
 Aftek vigorous compression of the abdomen and coin- 
 cident with the developmentof the cardio-splanchnic phe- 
 nomenon, my investigations show, contrary to the obser- 
 vations of other clinicians, that the blood pressure falls. 
 This" is, in my mind, in accordance with two reasons : 1. 
 By abdominal compression so much blood is suddenly ex- 
 pressed into the right heart that the latter finds great dif- 
 ficulty in discharging its contents ; 2. Abdominal com- 
 pression reflexly inhibits the hea/rt action. Of the latter 
 fact, I have convinced myself while executing the ma- 
 neuver during the time the subjects were exposed to the 
 X-rays. For this reason, in restoring cardiac action in 
 syncope and other conditions, inversion of the patient or 
 the application of a rubber bandage or leather belt 
 around the abdomen, are safer procedures than abdomi- 
 nal compression. The question of blood-pressure in neu- 
 rasthenia has received ample consideration from investi- 
 gators, but nothing, however, of a practical value has 
 been definitely elicited. The instruments for gauging 
 blood pressure are erroneous, and so are the deductions 
 even with an instrument of recognized accuracy. I re- 
 gard the Riva Eocci instrument as more serviceable than 
 the tonometer of Gartner. The latter instrument is of 
 little value on account of vasomotor changes in the finger 
 of the patient, in hypertension and arterio-sclerosis. It 
 is inapplicable in the negro. In hypertension and arte- 
 rio-scerosis, clinical investigations have taught me aided 
 by my stethophonometer, which enables me to accur- 
 
 215 
 
216 THE BLUES :— NEURASTHENIA. 
 
 ately gauge the intensity of the heart sounds that un- 
 reserved reliance placed on the tonometer as an instru- 
 ment of precision in gauging blood pressure in arterio- 
 sclerosis is unwarranted by clinical evidence. 
 
 Arterio-sclerosis is by no means the general process 
 which is taught. On the contrary, it may be central, 
 peripheral or visceral. We may have a pronounced 
 type of intestinal sclerosis without evidence of its ex- 
 istence when gauged by the condition of the peripheral 
 arteries. I recall a ease of arterio-sclerosis of the coro- 
 nary arteries of the heart which came to autopsy, the 
 arteries in question being as rigid as the stem of a clay 
 pipe, yet the individual during life showed no high 
 pulse tension, no cord-like, resistant, tortuous nor ribbed 
 radials ; nor was there any evidence of heart hypertrophy 
 or accentuation of the second aortic sound. 
 
 It is usually taught that, when the tonometric figure 
 is low with clinical evidence of arterio-sclerosis, it is a 
 sign of failing heart power. The tonometer and other 
 like apparatus are constructed on the general principle 
 that, after the blood supply to a part is inhibited by 
 compression, the gradual removal of the latter will re- 
 lieve the obstruction and, when the point is attained at 
 which the intra-arterial is greater than the extra-arterial, 
 or capillary, pressure, it is indicated by a gauge which 
 registers the blood pressure. 'Now, in arterio-sclerosis, 
 even the smallest blood-vessels (arteriocapillary fibro- 
 sis), are firm and unyielding, hence the compression 
 of such vessels for gauging blood pressure conduces to 
 erroneous results. I have frequently noted by the aid 
 of the tonometer an apparent increase of blood pressure, 
 notwithstanding the fact that cardiac auscultation nega- 
 tived the existence of the same. Three factors make up 
 
THE CAUSE AND CURE. 217 
 
 the normal blood pressure, viz. : force of the ventricle, 
 frictional resistance of the capillaries, and arterial elas- 
 ticity. If the heart is weak, as is manifested hy an en- 
 feebled second aortic tone, increased cardiac blood pres- 
 sure cannot exist. I am, therefore, constrained to 
 conclude that in gauging blood pressure reliance should 
 only be placed on cardiac auscultation. 
 
 It is generally conceded that of all the factors that 
 make up blood pressure the resistance offered by the 
 blood-vessels is one of the most important. 
 
 If the vessels are dilated, the pressure falls; if con- 
 tracted, it will rise. The nervous mechanism which 
 controls the blood-vessels is tire vasoipotor apparatus, and 
 while the latter I concede may be reflexly influenced by 
 irritation from the blood-vessels themselves or from the 
 end organs of sensory nerves in general, we are inclined 
 to forget that the vasomotor apparatus may operate inde- 
 pendent of such influences. Emotions and the state of 
 the mind in general, greatly influence the caliber of the 
 blood-vessels through the vasomotor system of nerves. 
 Take neurasthenics as a paradigm, and I have examined 
 a large number of them at different periods under emo- 
 tional influences, intense mental application, and when 
 their brains were at rest and in each instance my re- 
 sults varied. Emotional influences and intellectual ac- 
 tivity increased blood pressure, while mental inactivity 
 reduced it. Again, increased cardiac pressure does not 
 react equally on all the blood-vessels, and this, evidenced 
 by the fact that the blood pressure in both radials is not 
 always the same. Another factor influencing blood 
 pressure is the heart volume, which is continually sub- 
 ject to reflex conditions (see Heart Reflex, appendix, 
 note 8). 
 
NOTE 4.— THE STOMACH AND COLON ON THE POSITION 
 OF THE HEART.* 
 
 I iiAVB referred elsewhere to the influence of a dilated 
 stomach on the position of the heart. The accompanying 
 illustrations show how easily the heart may be dislocated 
 by artificial distension of the stomach. It is unnecessary 
 
 FiQ. 13.— 1, radloscopic appearance o£ the heart before administration of a 
 Seidlitz powder ; 2, outline of the fundus of the stomach. The shadow of 
 the heart area as shown in this and in flg. 14, is only correct in reference to 
 the parts contiguous to the sternum as this bone obscures the heart sil- 
 houette. 
 
 to descant on the practical value of this observation. 
 Heart dislocation from stomach dilation is associated 
 with a circumscribed area of dulness in the left inter- 
 » Medical Record, Sept. 8, 1900. 
 218 
 
THE CAUSE AND CURE. 
 
 219 
 
 scapular region. Over this area, bronchial respiration is 
 heard. When the patient leans forward, dulness and 
 bronchial breathing disappear, to reappear when the 
 erect attitude is resumed. (Figs. 15, 17, 18.) 
 
 Leaning backward increases the area of dulness. The 
 phenomena in question are produced by a dislocated 
 heart compressing the lung, which fact is easily verified 
 by the rays. 
 
 Fig, 14.— 1, radioscopic appearance of the heart after administration of the 
 Seidlitz powder ; 2, outline of the fundus of the stomach. 
 
 The foregoing syndrome may be reproduced synthet- 
 ically by artificial distension of the stomach. An enor- 
 mously distended heart may produce identical signs. 
 Artificial insufflation of the colon is incapable of pro- 
 ducing the same degree of cardiac luxation. 
 
 These observations explain the heart distress and 
 pains after eating and from gas accumulations in neu- 
 rasthenia. 
 
NOTE 5.— PHYSICAL EXAMINATION OF THE LIVER. 
 
 The conventional methods of examining the liver are 
 by no means trustworthy. At the present time, palpa- 
 tion and percussion of the liver are the methods which 
 will alone claim our attention. 
 
 Fig. 15 —Patch of dulness in dislocation of the heart upward ; patient in 
 the erect position. 
 
 In 'palpating the liver, the physician proceeds exactly 
 as if he were going to palpate his own liver. The pa- 
 tient should stand with body inclined very far forward, 
 as shown in the illustration, then, with the fingers 
 lightly bent, in a hook-like manner, they are insinuated 
 
 220 
 
Fig. 16. — The author's method of palpating the liver. 
 
Fig. in. — Author's method of percu.ssiiig the lower liver border. The 
 illu.stratiou does not show sufficient inclinatiou of the body backward. 
 
THE CAUSE AND CURE. 221 
 
 well under the curvature of the ribs ; it Tvill be found 
 that, when the fingers are introduced under the ribs 
 in the right mammary line, they can be made to pene- 
 trate a considerable distance. The fingers being fixed, 
 in this situation and immobile, the patient is instructed 
 to take a deep breath and in accordance with the fact 
 that the liver alternately rises and falls during breath- 
 ing, the border approaches the fingers during inspiration 
 
 Fig, 17,— Patch of dulness in dislocation of the heart. Same patient lean- 
 ing backward. 
 
 and recedes during expiration. This is my method of 
 palpation, and I have rarely known it to prove unsatis- 
 factory. ( SJ a i iii E i 'nn i tisjaieBw ) 
 
 Ik Peecussiok of the Livee, we have first to deal 
 with the topographic percussion of the upper and then 
 the lower border of the organ. 
 
 In Peecussion of the Uppee Boedee, I have al- 
 
222 *HE BLtJES :-NEt7RASTHENlA. 
 
 ready introduced to the profession a modified method of 
 auscultatory percussion. 
 
 The modified method of auscultatory percussion, 
 which I here advocate, is suggested after several years' 
 experience in its employment. Its accuracy I have fre- 
 quently controlled by skiascopy. It embodies the prin- 
 ciple of transsonance. " It is available in topographical 
 
 Fig. 18.— Fluoroscopic picture in dislocation of the heart. Black areas, 
 shadows cast by normal heart. Shaded area, shadow of dislocated heart. 
 
 percussion, and for determining the density of the lungs 
 after a method which will be presently described. Per- 
 cussion transsonance is obtained when the thorax is per- 
 cussed, either directly or indirectly, at a time contempo- 
 raneous with auscultation at some remote point. In my 
 modified method of auscultatory percussion, the clav- 
 icles, sternum, ribs or vertebrae are percussed directly, 
 i. e., without the interposition of the finger as a plexi- 
 meter. The percussion-blow is either light or strong, ac- 
 
THE CAUSE AND CURE. 223 
 
 cording to whether the superficial or deep dulness is to 
 be elicited. If, for example, the area of cardiac dulness 
 is to be obtained, the clavicle or manubrium sterni is 
 percussed directly, and the stethoscope is gradually car- 
 ried towards the organ in all directions from the lung. 
 The area of the heart is at once indicated by a dull tone 
 supplanting a resonant one. A similar procedure is 
 carried out in eliciting the upper liver-horder, and the 
 splenic area of dulness. Lung-consolidation is also easy 
 of elicitation by this method. If, for example, the trans- 
 sonance of the apices is to be determined anteriorly, the 
 stethoscope remains fixed first over one and then over 
 the other apex, while immediate percussion is executed 
 on a prominent vertebra. If the apices are to be auscul- 
 tated posteriorly, the percnssion-blow is limited to the 
 manubrium sterni. It is possible by this method to out- 
 line the right auricle and the left ventricle on the pos- 
 terior chest-surface, provided the patient is in the erect 
 posture with body inclined slightly backward. The pec- 
 toral chest-piece of the stethoscope should possess a small 
 caliber for the better object of demarcating the outline 
 of organs. The fact must be emphasized that during the 
 time this method of auscultatory percussion is executed 
 the percussion-blow on some prominent bony structure 
 must be continuous and uniform, while the stethoscope 
 is carried toward the organ to be outlined. The percus- 
 sion-hammer, recently designed by Dr. Heinrich Stern, 
 of New York, will prove of great value in obtaining uni- 
 form results. 
 
 The drawbacks pertaining to my method are present 
 only in corpulent individuals, in whom the well-padded, 
 bony structures will not permit the percussion-blow to 
 be conveyed to any distance. Another drawback, which 
 
224 THE BLUES :-NEURASTfiENlA. 
 
 is also present in the conventional auscultatory percus- 
 sion is the inability to interpret the character of the per- 
 cussion-sounds. This is, of course, a matter of practice. 
 I cannot too highly extol this method, not only in topo- 
 graphical percussion, but also in determining the reso- 
 nating qualities of the pulmonary tissue. I have elicited 
 incipient lung-consolidation when the conventional 
 methods have failed. I have also used this method for 
 outlining the lower border of the stomach. The method 
 of procedure in determining the latter, is briefly as fol- 
 lows : With the finger the lower ribs over the semilunar- 
 shaped space of Traube are percussed, the stethoscope 
 being fixed primarily in the hypochondrium in order to 
 learn the character of the tympanitic tone. Then, while 
 percussion is continued, the end of the stethoscope is 
 gradually carried downward until the disappearance of 
 the tone indicates that we have reached the lower border 
 of the stomach. 
 
 Peecussion of the Lower Livee Boedee. The 
 value of regional hepatic percussion needs no expatia- 
 tion. No one, however skilled in percussion, can gain- 
 say the insurmountable difficulties which beset the clin- 
 ician in his attempts to demarcate an organ which is im- 
 mersed in an atmosphere of tympanitic sound, and the 
 edge of which does not exceed one centimeter in thick- 
 ness. Take into consideration the facts that the con- 
 tiguous viscera, stomach and intestines, vary in their de- 
 gree of inflation and in the character of their contents, 
 and we have additional factors which modify the ac- 
 curacy of our percussional results. Posture and the 
 phases of respiration are likewise disturbing elements. 
 A liver may be very much enlarged, yet percussion as 
 ordinarily practiced may give absolutely no evidence of 
 
THE Cause and cure. 227 
 
 enlargement, if examination is made in the recumbent 
 posture. A good rule to follow is never to declare the 
 liver to be enlarged unless it is palpable ; but palpation 
 may detect a liver which is dislocated, though not neces- 
 sarly enlarged; and, again, rigidity of the abdominal 
 parietes may negative the value of palpation. 
 
 In my " Manual of Diagnosis," I have referred to 
 two methods of determining the lower border of the 
 liver. One method is that described by C. Verstraelen, 
 which is based on the fact that the intensity of the heart 
 tones is well preserved over the entire hepatic region ; at 
 the lower border of the liver, however, the tones are 
 suddenly lost ; and in this way the lower liver border is 
 determined. The abdominal walls must be relaxed, 
 otherwise they will conduct the heart tones. This method 
 I consider imperfect, as it is never of value if the car- 
 diac tones are weak. Another method which I advo- 
 cated in the same book is as follows: The patient is 
 placed in a position favoring the approximation of the 
 liver to the abdominal walls. This position is the knee- 
 elbow one, or, if this is impossible, the erect posture, the 
 body being inclined forward. The edge of a large coin 
 is then deeply embedded in the abdominal walls, and the 
 free edge of the coin is percussed lightly and shifted 
 gradually upward from the tympanitic area until dul- 
 ness is elicited. If this dulness represents the liver bor- 
 der, then, in accordance with the fact that the liver un- 
 dergoes respiratory dislocation, the line of dulness will 
 be lower during inspiration and higher during the act 
 of expiration. The essential object embodied in this 
 method is to verify the correctness of the percussion bj' 
 dislocation of the organ during respiration. The latter 
 method is relatively inaccurate, as I have had occasion 
 
228 tHE Blues :— neurasthenia. 
 
 to observe by controlling the percussional results 1 
 palpation in numerous instances where the latter meth( 
 was easy of attainment. 
 
 A simple maneuver for mapping out the lower liv 
 border on the surface of the abdomen is as follows : T^ 
 patient is instructed to incline his body backward as f 
 as possible, and, to relieve the tedium of the posture, t' 
 body is supported by means of the hands resting ( 
 the hips. If percussion, which must be light, is now £ 
 tempted, the difficulty of determining the lower hepat 
 border is reduced to a minimum. (See Fig. 19). 
 
 If we analyze the rationale of this maneuver we w: 
 find that it involves a simple law in physics, viz. : th 
 sound waves are best conducted by the medium in whi( 
 they are produced. If the waves of sound are eompell( 
 to pass through media of different density, some of tl 
 waves will be lost by reflection, and the sound becom 
 correspondingly enfeebled. Solid bodies conduct soui 
 better than air. If percvission of the lower liver bord 
 is executed in the conventional manner, the percussi( 
 sound first passes through the relatively-dense abdomin 
 musculature and then through the air containing visce 
 before it reaches the liver. Theoretically at least, tl 
 percussion sound becomes enfeebled by the time 
 reaches the liver, inasmuch in the high pitch which r 
 veals anything solid is dependent on the loudness of t] 
 percussion note, which in turn depends on the force e 
 erted in percussion. We dare not employ a strong p€ 
 cussion sound in mapping out the lower hepatic bord« 
 for, by so doing, we set in vibration the air contain( 
 in the neighboring viscera and defeat the original obje 
 of our percussion, viz. : the elicitation of a dull soun 
 In the posture suggested, we approximate the surfa 
 
THE OaUSE and cure. 229 
 
 of the liver to the abdominal parietes, thus affording a 
 like medium for the transmission of the percussion 
 sound. When patients are compelled to assume a recum- 
 bent posture the same object may be achieved by direct- 
 ing them forcibly to contract the abdominal muscles 
 during the time percussion is executed. The results by 
 the latter maneuver, however, are less accurate, though 
 relatively better than by the conventional method of 
 percussion. 
 
 Percussion of the liver while the abdominal muscles 
 are. contracted is a valuable means of ascertaining sensi- 
 tiveness of the liver. It is a better method than palpa- 
 tion, which only admits of testing the sensitiveness of 
 the lower border of the liver. I am cognizant of the 
 dictum of Frerichs, who directed attention to the fact 
 that contraction of the abdominal muscles will fre- 
 quently yield a dulness on percussion, which is likely to 
 be confounded with the dulness of the liver. This objec- 
 tion is, to my mind, purely theoretic. There is one 
 condition, however, which demands consideration in per- 
 cussion of the lower liver border and that is the presence 
 of fecal concretions in the intestines contiguous to the 
 liver border. The observation is undoubtedly correct 
 that no one should rely on the results of liver percussion 
 unless the bowels have been previously cleaned by free 
 purgation. This teaching applies with all cogency to the 
 entire abdomen. Experience has taught me the follow- 
 ing simple method of determining the presence of fecal 
 matter. If by palpation or percussion we suspect the 
 existence of fecal stasis, massage of the suspected area 
 for a few seconds will dissipate the dull percussion 
 sound, which will then be supplanted by a tympanitic 
 percussion tone. It is therefore imperative, before de- 
 
230 THE BLUES :-NEURASTHENlA. 
 
 termining the lower border of the liver by the maneuver 
 already suggested, to massage that region for several 
 seconds. 
 
 There are two additional facts which deserve mention : 
 First, the patient must be cautioned to take no inspira- 
 tion before contracting the abdominal muscles, for by 
 so doing the liver will be dislocated downward ; second, 
 in practicing percussion, the finger receiving the per- 
 cussion blow must be firmly embedded in the abdominal 
 Ayall ; otherwise, the blow will not be directly transmitted 
 to the liver. 
 
 After we have ascertained the lower liver border after 
 the foregoing method, for corroborative purpose we may 
 elicit the liver reflex. (See Appendix, Note 6.) 
 
NOTE 6.— THE LIVER REFLEX. 
 
 MEifTioisr has already been made in this work of va- 
 rious visceral reflexes to which I have first directed atten- 
 tion. All these reflexes are of great clinical importance, 
 and in a therapeutic sense serve to explain the beneficial 
 action of electro and hydrotherapy as well as other pro- 
 cedures applied to the skin for remedial purposes. The 
 refiexes in question give objective demonstration how 
 agents acting on the skin reflexly stimulate nutrition of 
 the organs. 
 
 The liver reflex, which is here referred to for the first 
 time, is elicited by irritating the skin contiguous to the 
 lower liver border. The irritant may be a spray of 
 ether, scratching the skin with the finger nail, or the 
 blunt end of a pencil. Subsequent to any of these 
 maneuvers, the lower liver border may be observed by 
 percussion to recede a half-inch or more, depending on 
 the degree of irritation. The sinusoidal current acts 
 more efficiently in this regard than any irritant in caus- 
 ing the liver border to recede. This retraction of the 
 lower liver border is dependent entirely on contractility 
 of the liver itself, and not, as I have assured myself by 
 repeated observations, by any influence on the amount 
 of blood contained in the liver. I have already referred 
 to the fact (see Appendix, N^ote 2), that the size of the 
 liver can be graduated by the depth of respirations and 
 compression of the abdominal wall. 
 
 231 
 
232 THE BLUES :— NEURASTHENIA. 
 
 The liver reflex is dependent on contraction of the 
 muscular fibers contained in the fibrous coat of the liver 
 which, as is known, invests the entire gland and at the 
 transverse fissure, this coat turns into the substance of 
 the liver with the branches of the portal vein. 
 
NOTE 7.— THE CONDITIONS OF THE LUNGS ANTEDAT- 
 ING PULMONARY TUBERCULOSIS ; BREATHING EX- 
 ERCISES FOR DEVELOPING SUCH LUNGS.* 
 
 The early recognition of pulmonary tuberculosis gives 
 promise of its successful treatment, for, if there is one 
 fact which the phthisiologist has demonstrated for cura- 
 tive medicine, it is the curability of phthisis. To-day the 
 words of Brehmer are verified : '' Tuberculosis primis in 
 stadiis semper curabilis." The presence of shadows on 
 the screen, as determined by the rays, is a sign equally as 
 tardy as the recognition of tubercle bacilli in the sputa. 
 We are here concerned only with skiascopic evidence, 
 which betrays the disease at its very incipiency, even 
 before physical signs are manifest. In this respect, the 
 rays are of undoubted importance, and we possess a 
 means which permits of the very earliest possible diag- 
 nosis. Many of us, in our practice, meet with the 
 phthisiophobiac, and we are now in the possession of 
 means that will often rid that unfortunate individual 
 of his fear. Of course, to depend on the rays alone for 
 purposes of diagnosis Avould be to invite exclusivism, 
 which would be fraught with danger to the catholic 
 foundation on which diagnosis rests. There are two 
 early signs to which I wish to direct attention, viz. : 
 restriction of the excursions of the diaphragm, and the 
 emphysematous X-ray appearance of the lungs. The 
 physiologic diaphragmatic excursions vary according to 
 whether the breathing is quiet or forced. In quiet 
 
 * American Medicine, March 1, 1903, and Journal of the Amer. 
 Mild. Assoc, 
 
 233 
 
234 THE BLUES .-—NEURASTHENIA. 
 
 breathing, the extent of movement is about 1.8 cm. on 
 the right, and 1.5 cm. on the left side ; whereas, in forced 
 breathing, the difference in the position of the dia- 
 phragm between forced inspiration and expiration, aver- 
 ages 6.Y cm. on the right and 7 cm. on the left side. In- 
 dividuals with long thoraces show greater excursions of 
 the midriff than deep-chested persons. The restricted 
 diaphragmatic movements must be regarded as a very 
 suspicious sign of phthisis, other things being equal. 
 This sign, first referred to by Williams, of Boston, has 
 received universal confirmation, but, to my knowledge, 
 no theory has been advanced to explain its existence. I 
 have sought elsewhere an explanation for this curious 
 phenomenon, and I will briefly summarize my investiga- 
 tions, which gave birth to the theory that an emphysema- 
 tous condition of the lungs exists in phthisis. Eokitan- 
 sky noted that too voluminous lungs coupled with a small 
 heart characterized the phthisical habitus. 'No one 
 seemed to have contradicted this observation, and as a re- 
 sult it was soon relegated to oblivion. Brehmer revived 
 and vigorously defended this hypothesis. The too volu- 
 minous lungs of Rokitansky and Brehmer are lungs 
 which are practically the lungs of emphysema. In 
 health, the percussion note of the lungs is resonant dur- 
 ing inspiration and dull or even flat during expiration. 
 In emphysema, the percussion note is unchanged during 
 the two phases of respiration. This unchanged percus- 
 sion note heretofore recognized in pulmonary vesicular 
 emphysema is pathognomonic of lungs predisposed to 
 tuberculosis, and in lungs already affected. Associated 
 with the unchanged percussion sound there is an exten- 
 sion of the lung borders manifested by downward lung 
 dislocation and diminution to the extent of obliteration 
 
THE CAUSE AND CURE. 235 
 
 of the cardiac and splenic areas of absolute dulness and 
 diaphragmatic immobilization. As a rule, this lung em- 
 physema in phthisis is limited to the lower lobes and is 
 dependent on the fact that the air entering the respira- 
 tory tree travels in the direction of least resistance. Not 
 infrequently, emphysema is associated with atelectatic 
 zones. If physicians were to depend on percussional dul- 
 ness as an evidence of early phthisis, the affection would 
 never he recognised; lung resonance, not dulness, is the 
 early physical sign of phthisis. The rays are invaluable 
 in the recognition of the emphysematous condition. The 
 lungs seem too large for the chest, the diaphragm is low 
 and its excursions restricted. The lungs appear perma- 
 nently bright, not alternately so as in their normal con- 
 dition, and " statuesque " is about the best word to de- 
 scribe their appearance. It is interesting to observe 
 parenthetically, how such lungs contribute to the devel- 
 opment of phthisis. Defective pulmonary elasticity 
 means some defect in the pulmonary elastic tissues. It 
 may mean a congenital defect, as Cohnheim has ob- 
 served, in a large number of cases of emphysema. A 
 loss of pulmonary elasticity eliminates an important fac- 
 tor, not only in lung nutrition, but in the nutrition of 
 the entire organism. 
 
 The exercises, then, in individuals with the phthisical 
 lung, must be attempted not only in the direction of 
 promoting inspiration, but wliat is even more important, 
 in promoting the expiratory phase of respiration to expel 
 the residual stagnant air in the lungs. The following 
 simple method is serviceable : Two bottles, each capable 
 of holding a gallon of water, are connected, as shown in 
 the illustration. 
 
 The patient is directed, by expiration only, to trans- 
 fer the water from one bottle to another. After a little 
 
236 
 
 THE BLUES :— NEURASTHENIA. 
 
 practice, with a single forced expiration, this is possi- 
 ble of achievement. I direct my patient to carry out 
 
 this exercise, twice daily, each exercise 
 
 lasting 
 
 five 
 
 mmutes. 
 
 Tig. 20.— Arrangement of bottles for expiratory exercises. 
 
 The patient may also use with convenience and ad- 
 vantage a spirometer for exercising expiration. 
 
 This instrument will register the amount of air forced 
 out of the lungs. The simplest and cheapest instru- 
 ment for this purpose is the simplex spirometer. 
 
NOTE 8.— THE HEAET REFLEX.* 
 
 Some years ago, I first directed attention to a phe- 
 nomenon before undescribed, which I called the heart re- 
 flex. At that time I ascribed to it little clinical value, re- 
 garding it solely in the light of an interesting observa- 
 tion. Since then I have devoted considerable attention 
 to this reflex, vs^ith the object of ascertaining its practi- 
 cal application. The result exceded my expectations. 
 The heart reflex can be observed only with the Kontgen 
 rays, the fluorescent screen approximating the anterior 
 chest wall. The reflex is especially pronounced in chil- 
 dren, and is best seen in adults with thoraces scantily 
 furnished with musculature and panniculus. If we ir- 
 ritate the skin in the precordial region by vigorous 
 rubbing with a blunt instrument, a contraction of the 
 myocardium is observed. The myocardial contraction 
 is, as a rule, more manifest in the left than in the right 
 ventricle. The contraction thus induced is not sudden 
 and of momentary duration, as I described in my origi- 
 nal paper; on the contrary, its duration in children, on 
 whom most of my observations were made, is not less, as 
 a rule, than two minutes, and furthermore the myocar- 
 dial recession continues even after the source of cuta- 
 neous irritation is removed. The degree of myocardial 
 recession (heart reflex) varies greatly. In some persons 
 it is scarcely perceptible, while in other individuals the 
 heart may recede fully an inch on either side upon the 
 first application of the cutaneous irritant. The accom- 
 panying illustration (Fig. 21) shows the degree of 
 * Medical Record, Jan. 5, 1901. 
 
 237 
 
238 
 
 THE BLUES :— NEURASTHENIA. 
 
 myocardial recession (line B) after cutaneous irrita- 
 tion; A representing the normal outline of the heart 
 drawn on the fluoroscope. 
 
 This illustration is an exaggerated one, for, in the 
 many examinations made by me, I have never been able 
 to induce so marked a reflex. It is strange that in not 
 a few instances the myocardial recession, although rarely 
 
 Fig. 81.— Heart reflex in a boy aged eight years. Duration of reflex, two 
 and a lialf minutes. 
 
 absent when observed with a good X-ray apparatus, is 
 but slightly marked. For this vagary, I am unable to 
 account, occurring, as it does, in individuals with ap- 
 parently healthy heart-muscle. 
 
 In Fig. 22 we note a rough reproduction from the 
 fluoroscopic picture, demonstrating slight myocardial 
 
THE CAtJSE ANl) CUREi. 239 
 
 recession confined solely to the left ventricle; A, repre- 
 senting the cardiac outline before and B after cutaneous 
 irritation ; C is the upper hepatic line. 
 
 In my original papei*, I advocated the rhigolene or 
 ether spray as the best cutaneous irritant; since then, 
 however, I have tested different modes of cutaneous irri- 
 tation for clinical purposes, and I am now constrained 
 to conclude that friction of the skin by means of a rub- 
 
 Fig. 22.— Heart reflex in a boy aged fourteen years. Duration of reflex, 
 flf ty-five seconds. 
 
 ber (the ordinary pencil eraser is suitable) is the best 
 cutaneous irritant, for provoking this reflex. 
 
 The nearer we approximate the precordial region and 
 the more vigorous the cutaneous friction, other things 
 being equal, the more pronounced is the heart reflex. 
 The latter reflex may be slightly discharged, even 
 though the cutaneous irritant be applied to remote parts 
 of the body. In individuals with dilated hearts the 
 reflex is very evident, and of much longer duration than 
 in healthy hearts. 
 
240 tHE BLUES :-NEURASTSEN1A. 
 
 In a previous communication * I espoused the theory 
 that the real factor involved in balneo and mechano- 
 therapeutics (Schott) was dependent, not on the baths 
 and exercises as such, but owing to the cutaneous irri- 
 tation evoked by these maneuvers. In accordance with 
 this theory I have, since this contribution, employed 
 vigorous cutaneous friction by means of hand-rubbers 
 obtainable at any drug store, after immersion of the 
 patient in a warm bath for fifteen minutes; the warm 
 bath augmenting the sensitiveness of the skin. By this 
 simple and expeditious method, in chronic heart dis- 
 ease, 1 can adduce results emulating the conventional 
 Schott method. Eelief of dyspnea follows, there is re- 
 duction in cardiac volume, besides a marked reduction 
 in pulse rate, with increase in volume and force. 
 
 The following conclusions may be formulated in ref- 
 erence to my method of treatment and that of Schott. 
 
 1. Lung dilation follows the exercise and bath treat- 
 ment, the lung acting as an excretory channel for the 
 overburdened heart. 
 
 2. The cause of lung dilatation is dependent on 
 cutaneous irritation, induced by the exercises and baths. 
 
 3. A decrease in the volume of the heart also ensues, 
 and is likewise provoked by cutaneous irritation. 
 
 .In explanation of the heart and. lung reflexes, f we all 
 recognize the influence of the skin in physiological and 
 pathological conditions. According to v. Preusehen, 
 stimulation of the respiratory center is greater through 
 the cutaneous nerves than through the vagus branches of 
 the respiratory organs. In animals, which have been 
 made apnoeic, the application of cutaneous stimulation 
 (cold water) induced stronger respiratory movements, 
 
 * Medical News, Jan. 7, 1899. f Appendix, Notes 9 and 10. 
 
THE CAUSE AND CURE. 241 
 
 and he concludes that mechanical cutaneous stimulation 
 by flagellation, cold water, or the electric brush, is of 
 the greatest value in stimulating the center of respira- 
 tion. 
 
 The center for the inhibitory nerves of the heart ia 
 stimulated reflexly by centripetal nerves. In support 
 of this physiological axiom we need only recall the 
 " Klopf-Versuch " of Goltz, which demonstrates that 
 striking the abdomen in animals will inhibit the heart's 
 action. 
 
 I regard the heart reflex test as pathognomonic and 
 far exceeding all other methods yet recommended in 
 differentiating a dilatation of the heart from pericardial 
 effusion. This is conceded to be one of the most difficult 
 problems for the clinician. If, in a given case of in- 
 creased cardiac dulness, which has been carefully out- 
 lined, we vigorously rub the skin of the precordial re- 
 gion by means of a rubber, and note after two minutes 
 (the time necessary for the abolition of the lung reflex) 
 a reduction in cardiac dulness, we are justified in con- 
 cluding that we are dealing with cardiac dilatation and 
 not with a pericardial effusion. Let me illustrate my 
 meaning by reference to Figure (23). This is a 
 rough reproduction of a reaction obtained in a young, 
 man with massive dilatation of both ventricles. A, rep- 
 resents the percussional area of the heart before cu- 
 taneous friction. The dark area represents the area of 
 cardiac dulness after cutaneotis irritation, and is caused 
 not wholly by a reduction in cardiac volume, but also by 
 the kmg reflex of dilatation, which induces the lung to 
 encroach on the area of cardiac dulness. After waiting 
 two minutes, a time exceeding that necessary for the 
 lung to recede, the percussional area B is obtained, 
 16 
 
242 
 
 THE BLUES :— NEURASTHENIA. 
 
 which actually represents the decrease in the cardiac 
 area (heart reflex). If pericardial effusion were present 
 there would be some evidence of the lung reflex, but not 
 of the heart reflex. 
 
 We have yet to learn the value of the heart reflex as 
 an index to the condition of the myocardium.* 
 
 Since the publication of the foregoing I have studiedf 
 
 Fig. 33.— Illustration of heart reflex in Cardiac Dilatation. A, Percussional 
 area of dilated heart. Dark area, percussional area after cutaneous friction. 
 B, Percussional area, showing heart reflex persisting after abolition of the 
 lung reflex. 
 
 the heart reflex as an index to the condition of the myo- 
 cardium, and iind in brief that when the cardiac muscle 
 is beyond restitution in myocarditis and valvular dis- 
 eases the reflex cannot be elicited. Heretofore this re- 
 flex was only observed in the transverse cardiac diame- 
 ter, but it may also be noted in the sagittal diameter. 
 
 * The practical value of this reflex has been firmly established 
 by the recent investigations of Merklen and Heitz in a paper be- 
 fore the " Sociite Medicals des Hospitaux " on " La Reflexe Car- 
 diague D'Abrams" (La Presse Medicale, Aug. 1, 1903.) 
 
 f American Medicine, Jan. 3, 1903. 
 
THE Cause and cuee, 24S 
 
 The recognition of the heart reflex will often aid us in 
 excluding the murmurs of a relative insufficiency. Here 
 vigorous rubbing of the precordium will temporarily 
 dispel the latter murmurs. One may elicit the heart 
 reflex by irritation of more remote regions. I refer in 
 particular to the nose. Some years ago, I directed at- 
 tention to the pulmonary neurosis of dilation, which 
 could be evoked in almost every healthy person by irri- 
 tation of the nasal mucosa, and that such irritation was 
 inoperative if the mucosa were previously cocainized. 
 Later, I demonstrated that in persons suffering from 
 asthma of presumable nasal origin, impacation of cotton 
 in one or both nasal cavities would induce a typic asth- 
 matic paroxysm. One may easily observe by aid of the 
 X-rays that when ammonia is inhaled there is a decided 
 recession of the cardiac ventricles (heart reflex), es- 
 pecially the left, and that this heart reflex may be more 
 pronounced than when discharged through the skin of 
 the precordium. Ether and chloroform produce a simi- 
 lar though less pronounced effect. With the nose closed, 
 a similar though less pronounced effect of the vapors 
 may be obtained, presumably by their action on the 
 pharyngeal and laryngeal mucosa. In a few instances 
 the vapors produced a veritable heart inhibition. I 
 could observe no diminution in the intensity of the heart 
 tones during the inhalation of the vapors, yet the ac- 
 companying sphygmogram (Figs. 24, 25) shows a de- 
 cided difference in the output of blood into the general 
 circulation before and after the inhalation of ammonia. 
 These observations suggest the wise expedient of cocain- 
 izing the nasal mucosa before using an anesthetic, and 
 further suggest the cogent necessity of anesthetizing the 
 pharyngeal and laryngeal mucosa. 
 
NOTE 9;— THE LUNG REFLEX OF DILATATION* 
 
 AiTOTiiEK interesting phenomenon is what I have do- 
 nominated the " lung reflex." It illustrates the impor- 
 tant fact that the respiratory area may be influenced in- 
 directly by stimuli acting on the vagi. Elsewhere I 
 have shown the value of the lung reflex in diagnosis. 
 Here I will only consider its relation to lung develop- 
 ment. In a contribution by Mocucci, the suggestion 
 was made that when ether was sprayed over the left half 
 of the abdomen, marked reduction in volume of the 
 spleen was observed in 12 cases. In repeating the experi- 
 
 l^'-|j*Vt_CViwv«v\^a^ ioi/^oi^fttum/ 
 
 
 ■^ 
 
 ^\%^Jli.no 1 ' .' ^ ' '' 
 
 
 /Vj\ 
 
 Fig. ^.— Sphygmogram, showing condition of pulse before inhaling am- 
 monia. 
 
 ments, I likewise noticed a decided reduction in the area 
 of splenic dulness in all individuals on whom this 
 method was tried, irrespective of the fact whether en- 
 largement of the spleen existed or not. Investigations 
 convinced me that this diminution in the area of splenic 
 dulness was not real, but only apparent. When the 
 ether spray was directed over the region of the heart the 
 percussional area of that organ was reduced at once ; in 
 fact, the superficial area of cardiac dulness could be 
 obliterated by the maneuver. Similarly, when the spray 
 was directed over the hepatic region the superficial area 
 * American Medicine, Feb. 15, 1902. 
 
 244 
 
THE Cause and ctrRE. ^45 
 
 of dulness of that organ conld be reduced at once. 
 When the spray was directed over the border of the 
 lungs posteriorly, the lung borders could be made to de- 
 scend from two to four inches, dependent on certain 
 conditions. It was further ascertained that dislocation 
 of the lung borders by forced inspiration never ap- 
 proached the dilatation of the lungs produced by the 
 
 lQ A/vv^ok£(xll<nv ^ (Xyv>vrw<.'-nA-'(V 
 
 Fig. 35,— Showing effects of ammonia during inhalation, 
 
 cutaneous application of the ether spray. Further ex- 
 periments demonstrated in brief the fact, that the ap- 
 plication of any cutaneous irritant, whether the latter 
 be mechanic, cliemic, or electric, would always induce 
 acute dilatation of the lungs. Even in emphysematous 
 individuals the application of a cutaneous irritant still 
 further augmented the existing lung dilatation. The 
 question naturally arose, by what means could we es- 
 tablish the fact that the application of any cutaneoiis 
 irritant would cause acute dilatation of the lungs, a con- 
 dition which, it may be mentioned parenthetically, is 
 only of a few minutes duration. Such a hypothesis was 
 made tenable by the aid of conventional physical signs, 
 and the use of the fluoroscope. These aids show that 
 when the skin is irritated by means of cold, by friction, 
 or by a strong f aradic current, lung dilatation will ensue. 
 The degree of lung dilatation is dependent upon the 
 character of the irritant, and the severity of its appli- 
 
246 THE BLUES :— NEURASTHENIA. 
 
 cation. The response of the lung to dilatation is al- 
 ways greatest in that part of the lung contiguous to the 
 source of cutaneous irritation. Lung dilatation may 
 be recognized by the following physical signs: 1. Di- 
 minished respiratory excursions of the lung borders; 
 2. Extension of the pulmonary percussion note and ob- 
 literation of the cardiac and splenic areas of dulness ; 3. 
 Hyperresonance of the lungs; 4. Obliteration of the 
 apex beat. Auscultation is of no value as a physical 
 sign, inasmuch as the artificial dilatation does not last 
 longer than three Tuinutes after the source of cutaneous 
 irritation has been removed. Lung dilatation spreads 
 'from the source of cutaneous irritation involving pri- 
 marily circumscribed parts. In lungs, showing dimin- 
 ished resonance, the latter could always be increased by 
 cutaneous irritation over the part percussed. The X- 
 rays show how the brightness of the lungs is increased 
 by cutaneous irritation. By gradually applying the 
 irritant to different parts of the skin of the thorax, one 
 may note that eventually the entire lung may be made 
 to yield a more intense luminosity. This increased 
 luminosity, however, does not last longer than three 
 minutes in the average person, after which time the 
 lungs resume their normal appearance. 
 
 In a number of measurements made during the study 
 of the lung reflex after cutaneous irritation, I found 
 the average dislocation of the lower border of the lung 
 as follows : 
 
 Right sternal line 3J cm. 
 
 Right parasternal line 3| cm. 
 
 Right mammilary line 4 cm. 
 
 Bight axillary line 6 cm. 
 
NOTE 10.— THE LUNG KEFLEX OF CONTRACTION.* 
 
 I WISH to direct attention to the Cherchevsky sign of 
 early arteriosclerosis. This author contends that in 
 normal conditions the diameter of the aorta varies at 
 different times. It becomes dilated if the region over 
 the arch is struck with the percussion hammer, while it 
 shrinks in size if the blows are struck in the epigastrium. 
 In arteriosclerosis it is impossible to produce these 
 variations in diameter. The author has misinterpreted 
 the phenomenon obtained by his maneuver. What he 
 really elicits is a circumscribed lung contraction adja- 
 cent to the part struck on the chest by the hammer and 
 the blow on the epigastrium merely causes the collapsed 
 lung area to dilate, thus supplanting dulness by reson- 
 ance. Dull areas may be obtained in other chest re- 
 gions, especially in proximity to the sternum and spine, 
 if vigorous percussion is conducted. For this purpose, 
 I use a large wooden mallet and a pleximeter of felt. 
 The circumscribed dulness thus induced lasts but a few 
 seconds, but may be made to disappear at once by strik- 
 ing the epigastrium. Observed with the rays in a sus- 
 ceptible person, the jjlienomenon in question is a most 
 interesting study. After the blow is struck, the adja- 
 cent lung area becomes gradually dark, showing that the 
 air has been expelled from the lungs, whereas in a few 
 seconds the lung area becomes bright again. This re- 
 flex cannot be obtained if the nasal mucosa has been 
 previously cocainized, nor if the skin is irritated over 
 
 * American Medicine, Jan. 3, 1903. 
 
 247 
 
248 THE BLUES :— NEURASTHENIA. 
 
 the lung area, for then the counter reflex of lung dilata- 
 tion is elicited. The phenomenon just described I have 
 called the lung reflex of contraction to distinguish it 
 from the lung reflex of dilatation. 
 
 The lung reflex of contraction has the same value in 
 diagnosis and therapeutics as the counter reflex, but I 
 will reserve its consideration for a future contribution. 
 Suffice it to say at this time that we must hypothesize 
 two distinct functions of the vagus, one which will 
 enable it to dilate and fibers which can contract the 
 
 Fig. 26.— Mallet and plezimeter for eliciting the lung reflex of contraction. 
 
 bronchioles. This is the only hypothesis which per- 
 mits us to explain the lung reflexes. Aufrecht has re- 
 cently shown that the belief of only a circular layer con- 
 stituting the musculature of the bronchi is wrong, and 
 that by using the Biondi-IIeidenhain stain a longi- 
 tudinal muscular layer also exists. I contend, in view 
 of this histologic fact, coupled with a knowledge of the 
 lung reflexes and observations of asthmatics, that the 
 
THE CAUSE AND CURE. 
 
 249 
 
 theory of asthma must not alone be based on a spasm of 
 the circular fibers of the bronchi, but on an inability of 
 the -weaker longitudinal fibers to expel residual air im- 
 prisoned by the circular fibers. In support of this 
 theory I recall my observations with amyl nitrite. The 
 primary effect of inhalation of this drug is to augment 
 lung volume and then to diminish it so that its efficiency 
 in arresting paroxysms of asthma is actually dependent 
 
 Fig. 27.— The lung reflexes ot dilatation and contraction ; A, normal areas of 
 heart and upper liver border respectively ; LRD, region for eliciting lung re- 
 flex ot dilatation which, when struck, causes lung border to descend to B, and 
 cover heart area almost to obliteration ; LRC, regions for eliciting lung re- 
 flex of contraction which causes lung borders to recede to C. 
 
 on contraction of the longitudinal no longer antagon- 
 ized by the circular fibers. This action has its analog 
 in the bladder musculature when, in consequence of a 
 spasm of the sphincter vesicae, the weak detrusor 
 vesicae cannot expel the urine, and ischuria spastica 
 results. 
 
250 THE BLUES :— NEURASTHENIA. 
 
 Since the publication of the foregoing (American 
 Medicine, Jan. 3, 1903, pages 11-15), I have been able 
 to elicit the lung reflex of contraction after a manner 
 which will bring both lungs simultaneously into a condi- 
 tion of contraction. My observations with reference to 
 the latter maneuver I believe to be of great therapeutic 
 value, and they are to be embodied in a work which is 
 now in course of preparation. 
 
NOTE 11.— SYMPATHETIC PAINS. 
 
 Clinicians have for a long time recognized the fact 
 that in disease and irritation of the internal organs, 
 superficial pain and tenderness are often referred to 
 remote parts of the body. Thus in cardiac and aortic 
 disease, pain is experienced between the shoulders; a 
 carious tooth causes pain in the ear, etc. Head, who 
 has thoroughly investigated this subject, shows that 
 there is an intimate nervous connection between the 
 viscera and definite skin areas, manifested by pain and 
 tenderness appearing in sharply-localized regions on the 
 surface when definite organs become disordered. He 
 has also shown that in disease of the abdominal organs, 
 pain and tenderness not only occur on the surface of 
 the body, but the same .pain and tenderness appear over 
 certain are^s of the scalp. He explains the topographic 
 association of skin tenderness with visceral disease by 
 assuming that the nerve-supplies of the parts so related 
 find their origin within the same segment of the spinal 
 cord: Thus, when a painful stimulus is applied to a 
 part of low sensibility like an abdominal organ, which 
 is in close central connection with a part of much greater 
 sensibility, the pain produced is experienced in the part 
 of higher sensibility rather than in the part of lower 
 sensibility to which the stimulus was actually applied. 
 
 251 
 
NOTE 13.— HEREDITY. 
 
 Two factors are recognized by biologists as responsi- 
 ble for the actions and character of the living organism, 
 viz. : heredity and environment. It is often difficult to 
 determine whether a specific vital phenomenon is a re- 
 sult of inheritance or a reaction to environmental in- 
 fluences. Eesemblance to ancestors is an acknowledged 
 product of inheritance. 
 
 Galton has estimated that, of the total heritage of the 
 child, each of two parents contributes one-fourth, each 
 of the four grandparents one-sixteenth and the remain- 
 ing one-fourth is handed down by more remote ancestors. 
 The congenital resemblances may be anatomic, as ex- 
 pressed by physical resemblances, (facial features, 
 stature, color of hair and eyes) or by anatomic defects 
 of the eyes, cleft palate, monstrosities, etc. They may 
 be physiologic, as expressed by characteristic gestures, 
 peculiarities in gait, tendency to obesity, to .longevity, 
 and to certain diseases, such as gout, asthma and epi- 
 lepsy. They may be psychologic, as expressed by artis- 
 tic and moral qualities, traits of character, temperament, 
 mental diseases and proclivity to crime and suicide. 
 Characters transmitted from grandparent to child and 
 never appearing in the parent are referred to as latent 
 characters. Latent characters are very often associated 
 with sex. Character latent in the intermediate ancestor 
 is evidenced by the appearance of the female characteris- 
 tics in castrated males, and of male characteristics in fe- 
 males with diseased ovaries. Latency is further expressed 
 by atavis77i or reversion, terms which refer to the appear- 
 
 252 
 
THE CAUSE AND CURE. 253 
 
 ance in an individual of peculiarities known only in re- 
 mote ancestors, but not in the parent of the individual. 
 Darvyin instances many examples of reversion, such as 
 the frequent appearance of stripes upon the legs of 
 the mule, the latter being a hybrid from the horse 
 and the ass, both of which are comparatively unstriped, 
 but are unquestionably descended from a striped zebra- 
 like ancestor. The same writer attributes the degraded 
 state of half-castes to reversion to a primitive savage 
 condition, which, usually latent in both civilized and 
 savage races, is made manifest in the offspring that re- 
 sults from the union of both. Regeneration is likewise 
 a phenomenon of heredity, and refers to the capacity of 
 the organism to replace parts lost by accident or de- 
 stroyed by disease. The regenerative power becomes 
 progressively stronger as we descend in the scale of ani- 
 mal life. Thus a newt may replace a lost leg, a crab 
 a lost claw, the snail, an eye stalk or eye. A hydra may 
 be cut into pieces and each piece may re-grow into a 
 complete hydra. If an earth-worm is divided, one-half 
 may regenerate a new half which is in every respect 
 complete. The Inheritance of disease is not always the 
 transmission of an actual parental disease; on the con- 
 trary, a diseased parent may produce offspring that are 
 constitutionally weak, and the disease of the parent may 
 later on attack the constitutionally weak body. With- 
 out entering into a discussion of thetheories of inheri- 
 tance, modern biologists attribute much truth to the 
 theories of preformation and epigenesis. The first is 
 practically the Darwinian theory of pangenesis. It as- 
 sumes that the cells or units of the body increase by 
 cell-division or proliferation, retaining the same nature, 
 and that they ultimately become converted into the 
 
254 THE BLUES .— NEUEASHTENIA. 
 
 various tissues and substances of the body. Aside from 
 this means of increase, the cells throw off minute gran- 
 ules wJiich are dispersed throughout the whole system; 
 that these, when supplied with proper nutriment multi- 
 ply by self-division and are ultimately developed into 
 units like those from which they were originally de- 
 rived. These granules are collected from all parts of 
 the system to contribute the sexual elements, and their 
 development in the next generation forms a new being; 
 but they are likewise capable of transmission in a dor- 
 mant state to future generations, and may then be de- 
 veloped. Their development depends on their u.nion 
 with other partially developed or nascent cells which 
 precede them in the regular course of growth. The 
 granules are thrown off by every unit, not only during 
 the adult state, but during each stage of development of 
 every organism. The granules in their dormant state 
 have a mutual affinity for each other, leading to their 
 aggregation into buds or into the sexual elements. 
 Therefore, it is not the reproductive organs or buds 
 which generate new organisms, but the units of which 
 each individual is composed. Thus the theory of Dar- 
 win explains the regeneration of lost parts by supposing 
 that the granules of the part in question are dissemi- 
 nated throughout the body and have only to unite with 
 the nascent cells at the point of new growth. The theory 
 also explains reversion by supposing that the granules 
 lie dormant in one generation and develop in the next. 
 It further explains how acquired variations may be co- 
 genital, since an altered part throws off altered granules 
 and by collection of these in the germ sells the alteration 
 may be transmitted, thus explaining the transmission of 
 acquired characters. The theory of Epigenesis assumes 
 
I'iiE CAUSE ANt) CURE. ^55 
 
 that there is no preformation in the germ cells, but 
 rather a lack of organization which during growth, un- 
 der guidance of a mysterious power, gives place to dif- 
 ferentiation and the appearance of definite parts. 
 Much experimental work is now being done, chiefly on 
 marine invertebrates, to determine how many of the 
 characteristics of the offspring are duo to the original 
 qualities of the germ plasm and how much to the physi- 
 cal, chemical and physiologic phenomena of the imme- 
 diate environment of the developing embryo. Applying 
 the foregoing facts to the heredity of nervous diseases, 
 we have, first of all, the fact, that a nervous disease is 
 rarely directly inherited. What is really transmitted 
 is a general predisposition to nerve disease, the subjects 
 having inherited unstable and irritable nervous systems, 
 they possess, in other words, what is known as a neuro- 
 pathic constitvtion. Individuals of genius are neuro- 
 tics, as a rule, and may beget a progeny with neuropathic 
 constitutions, but such a tendency would be less likely, 
 if one of the parents were of a phlegmatic temperament. 
 Shock or injuries to the mother during the early months 
 of pregnancy may lead to nervousness in the offspring. 
 There are so-called family diseases which may be trans- 
 mitted by direct inheritance from parent to child, or 
 may skip a generation. In the latter instance, we have 
 a manifestation of atavism which rarely goes back more 
 than two generations. 
 
 Morbid traits, peculiar to a family, may reappear at 
 the same age in the offspring, but if such traits show a 
 tendency to disappear with each successive generation, 
 they appear later in life in the descendants. If such 
 traits become exaggerated, they appear at an earlier age 
 in the descendants. 
 
NOTE 13.— THE SINUSOIDAL CURRENT. 
 
 TnE use of the Sinusoidal current in Electro Thera- 
 peutics is of comparatively recent introduction, and 
 even now its effects are not fully appreciated by physi- 
 cians. 
 
 The character of this current, when produced with 
 proper apparatus, approximates a true alternating cur- 
 rent curve. 
 
 The use of this apparatus is to produce anaesthetic 
 effects on the Sensory and Motor nerves ; and by it, stim- 
 ulation to muscular action can be obtained without the 
 accompanying pain to the patient, which is attendant 
 on the uses of other currents, if used in the same propor- 
 tion. In consequence, a greater quantity of electricity 
 can be used than with the induction coil, so that more 
 physiological action of the muscles is obtained than by 
 other methods. Further, the more nearly the curve of 
 the current approaches to the true sinusoidal, the less 
 will be the effects resulting from polar action, thereby 
 avoiding electrolysis and eataphoresis. 
 
 The current is also found to be useful as a means of 
 improving the nutrition of muscular tissue, and also 
 for general muscular weakness. It also has the peculiar 
 property of allaying pain, if the alternations are suffi- 
 ciently rapid. 
 
 There are four forms of this apparatus in use by phy- 
 sicians. The first form is obtained by taking the cur- 
 rent direct from alternating lighting mains, moderating 
 
 256 
 
THE CAUSE AND CURE. 257 
 
 the strength by controlling apparatus. The number of 
 alternations per minyte are limited to that of the cen- 
 tral station. 
 
 The second form is obtained by cutting the wires of 
 any direct current motors, and obtaining one complete 
 alternation for each revolution. The disadvantage of 
 this apparatus is that the. number of alternations is 
 limited to the speed at vyhich the motor can be operated, 
 usually not exceeding 4000 to 6000 alternations per 
 minute, and has the further disadvantage that the lines 
 of magnetic force are cut by the revolving coils un- 
 equally so as to form an irregular curve, and in many 
 cases the apparatus is so designed that a change in the 
 speed varies the strength of the field. 
 
 The third form is obtained by using a direct current 
 motor to run a magneto-electric machine, the alterna- 
 tions of which are limited to the speed of the motor 
 operating the magneto, unless belting is itsed, then the 
 inequalities of the belt produce serious inequalities in 
 the current. 
 
 The fourth form has been invented by Dr. Kennelly, 
 associated with Mr. Thomas A. Edison, and is designed 
 to secure a true sine curve, a constant field, and increase 
 the alternations sufficiently to obtain anaesthetic effects ; 
 and constructed so that when belted to the motor it Avill 
 obtain a frequency up to 150.000 alternations per 
 minute. But this introduced belting causes irregulari- 
 ties which to overcome the owner of the Kennelly patents 
 has improved by designing and having built a motor 
 that will develop an equally high frequency, using a 
 direct connected couple; thus eliminating all belting 
 troubles. 
 
 The magnetic field of the Kennelly apparatus remains 
 
258 THE BLUES :— NEURASTHENIA. 
 
 constant at all speeds, but may be varied in strength as 
 desired. 
 
 The strength of current in patients' circuit is con- 
 trolled by a high resistance rheostat. 
 
NOTE 14— MASSAGE OF THE LIVER. 
 
 Tradition has endowed the liver as a participating fac- 
 tor in many morbid phenomena. Modern observation 
 justifies tradition, insomuch as a disordered liver deter- 
 mines temperament and manufactures ideas for weal or 
 woe. Many philanthropic acts have been forever lost in 
 the vagaries of an anomalous liver. The epigrammatist 
 who said, " to be happy, one must have a bad heart and a 
 good stomach," aimed indirectly at the truth in ascribing 
 our feeling of well-being to a perfect condition of the 
 digestive apparatus. The observation of the older clini- 
 cians still bears the imprint of truth, viz. : that the 
 mental condition of patients is more cheerful in diseases 
 above, than below the diaphragm. 
 
 It is important for us to know that an hepatic anom- 
 aly may exist without any clinical evidence of its exist- 
 ence. Reference has already been made (page 151) to the 
 beneficial action of the sinusoidal current in relieving 
 hepatic congestion. I believe that much of this action is 
 dependent on stimulation of the vaso- constrictor fibres in 
 the portal vein. Mall, in 1892, demonstrated such fibres in 
 the splanchnic nerve and that by their stimulation, twenty- 
 seven per cent of the blood could be displaced from the 
 splanchnic area and driven forward to the right heart. The 
 conventional methods of liver massage are delusive, for 
 the reason that they do not massage that organ. The 
 17 259 
 
260 THE BLUES : NEURASTHENIA. 
 
 nearest approach to liver massage is attained by vibratory- 
 massage of the liver region. I wish to direct attention to 
 two methods of liver massage, executed by the patient, 
 which are specially valuable : 1, respiratory massage, and, 
 2, concussional massage. 
 
 Rbspieatory Massage. — We know that in correct ab- 
 dominal breathing, the liver is rhythmically compressed 
 between the diaphragm and anterior abdominal wall. 
 We also know that if, for any reason, the abdominal walls 
 are weakened, as occurs after pregnancy and tight- 
 lacing, the liver is no longer adequately compressed in 
 breathing, and thus there is a mechanical impediment to 
 the active flow of bile, which favors the formation of 
 gall-stones. We are able to duplicate and accentuate 
 physiologic compression of the liver by substituting the 
 fingers of the patient for the anterior abdominal wall. 
 Reference is made to figure 28. The crosses are placed 
 respectively in the median line, in the region between 
 the nipple and the sternum, and in the nipple line. The 
 crosses indicate the different regions of the liver to be 
 subjected to respiratory massage. The patient bends 
 slightly forward and inserts the tips of his fingers deeply 
 into the upper abdominal region, and while maintaining 
 firm pressure takes a forced inspiration. I direct my 
 patients to commence with ten deep inspirations at each 
 cross and with successive morning and evening exercises 
 to increase the number to twenty. The exercises may 
 likewise be taken in the recumbent posture with the 
 thighs flexed on the abdomen. 
 
 Concussional Massage. — It is difficult to palpate the 
 liver, and for this reason, its anomalous sensitiveness 
 often escapes detection. If, however, the one hand (Fig. 
 29) is placed in contact with the liver region (shaded 
 
Fig. 28.— Respiratory Massage. 
 
Fig. "29. — Concussional Massage. 
 
THE CAUSE AND CURE. 263 
 
 area), and with the fist of the other hand, the fingers of 
 the hand in proximity with the chest is struck a series of 
 blows, the latter are transmitted to the liver, and its 
 sensitiveness is revealed. Prom numerous observations 
 made, I am justified in concluding that the irritability 
 of an individual is in direct proportion to the degree of 
 sensitiveness of his liver elicited after this manner. As 
 the sensitiveness of the liver is reduced after concussional 
 exercise, there is a corresponding reduction of the indi- 
 vidual's irritability. Of course I refer in these observa- 
 tions to the splanchnic neurasthenic. Concussional mas- 
 sage is executed twice daily over various points in the liver 
 region (shaded area) after respiratory massage, striking 
 the fingers of the -one hand in the total exercise from 20 
 to 100 blows of varying degrees of force. The equestrian 
 achieves his hygienic results in consequence of vibration 
 of the abdominal organs, which corrects digestive troubles, 
 constipation, and hepatic affections. Liver massage after 
 the manner recited, taken but once a day, is.equivalent to 
 a horseback ride of many miles. 
 
264 THE BLtES : NliUftASTfiENIA. 
 
 NOTE 15.— HUMAN METABOLISM. 
 
 There is much concerning nutrition that we know, and 
 a great deal more that we do not know. What is known 
 as a catalyzer, is a substance that by its presence alone 
 initiates chemic reactions, which otherwise would not 
 occur, or accelerates or inhibits such reactions. A conspic- 
 uous paradigm of catalysis is noted, when the mere pres- 
 ence of platinum hastens the burning of hydrogen gas in 
 oxygen at relatively low temperatures. Animal tissues 
 can disintegrate the albumen molecule, jind the effect cor- 
 responds to the action of the pancreatic and gastric 
 juices. This tissue digestion was referred to as auto- 
 digestion, but the term autolysis has been substituted. 
 The term metabolism is used to indicate the phenomena 
 attendant on . cell nutrition, etc ; i. e., the selection and 
 absorption of food, its digestion and the elimination of 
 waste-products by the intracellular ferments called 
 enzymes. "Wells * says : " All metabolism may be con- 
 sidered as a continuous attempt at establishment of 
 equilibrium " and the " living body, whether unicellular 
 or multicellular, is a vast, unceasing series of chemic re- 
 actions." What concerns the pancreatic secretion may 
 eventually hold good for the other digestive secretions. 
 It has been shown that the pancreatic secretion has not 
 only a direct influence as a digestive agent, but that when 
 absorbed, as occurs in pancreatic disease, it interferes with 
 the intracellular digestion of fat and sugar. Thus in 
 
 * Journal of the A. M. A. , Jan. 25, 1903. Lewis-American 
 Medicine, Aug. 13, 1905. 
 
THE CAUSE AND CUEE. 265 
 
 diabetes, which is probably the result of structural 
 changes in the pancreas, there is an increased amount of 
 fat in the blood.* Lewis t has recently studied this 
 subject in a practical direction, and I believe that his 
 observations will prove of material benefit in the treat- 
 ment of disease, the underlying factor in many instances 
 being merely nutritive disturbances which have invited 
 the accidental presence of germs. Lewis has investigated 
 tuberculosis, the susceptibility to which, he suggests, is 
 caused by some break or perversion somewhere in the 
 sequence of enzyme action. In diabetes, incipient tuber- 
 culosis, and chronic digestive disturbances, he continues, 
 there is a marked increase in the presence of sugars 
 and fats in the blood and urine. He believes that the 
 ferment action of the cells is profoundly influenced by 
 oxygen, hence the prestige of the open air treatment in 
 tuberculosis. He has derived much benefit in his tuber- 
 culosis cases from hypodermic injections of active 
 sterile preparations of fresh pancreatic gland. He rea- 
 sons, that the immediate introduction of pancreative 
 extract into the blood energizes or vitalizes the dormant 
 action of the intracellular ferments. 
 
 * Zeitsohrif t f. Klin. Med. xliii., Heft, 1 and 2. American 
 Journal of Physiology, vol. ix, p. 380. 
 ■f American Medicine, Aug. 13, 1905. 
 
266 THE BLUES : NEURASTHENIA. 
 
 NOTE 16.— CHEMICAL DEMONSTRATION OF THE ACTION 
 OF THE SINUSOIDAL CURRENT. 
 
 That the abdominal application (one large electrode 
 placed to the right and another to the left of the navel) 
 of this current increases the absorption of the products 
 of intestinal putrefaction, is evidenced by numerous 
 investigations in my laboratory. It was found that not 
 only indican, but likewise the ethereal sulphates were 
 increased in the urine after the abdominal application 
 of the current.* This fact further accentuates the 
 therapeutic value of the sinusoidal current. My results 
 were obtained with a current of not more than 8,000 
 alternations per minute. An increased frequency of 
 alternations is unnecessary and less effective. 
 
 * This subject is further elaborated in my most recent pub- 
 lication, " Man and His Poisons," E. B. Treat & Co., New York. 
 
THE CAUSE AND CUBE. 267 
 
 NOTE 17.— TESTING INTRA-ABDOMINAL TENSION. 
 
 Minor grades of reduced intra-abdominal tension may 
 exist without being detected. One method which I have 
 elaborated and which I regard as trustworthy, is the follow- 
 ing : having auscultated the heart tones, palpated the pulse, 
 defined by percussion the borders of the heart and esti- 
 mated the blood pressure in the erect posture; I have an 
 assistant stand behind the patient. The assistant with 
 his hands lifts the abdomen of the patient quite firmly 
 and forcibly upwards and steadily maintains this pres- 
 sure while the physician again executes the foregoing, 
 methods of examination. One finds even in minor grades 
 of reduced abdominal tension the following : the heart 
 tones become stronger than before the abdomen was sup- 
 ported, the pulse becomes endowed with more character 
 as is evidenced by palpation, but particularly by the 
 sphygmogram, the percussional areas of the heart and 
 liver become higher and more pronounced, and the blood 
 pressure is augmented from 5 to 30 mm. The altered 
 clinical symptoms are caused by heart prolapse (cardio- 
 ptosis), which observation has taught me, is an almost con- 
 stant symptom, in diminished intra-abdominal tension. 
 I find that a leather belt sufficiently broad and which 
 can be adjusted by the patient with varying degrees of 
 pressure is one of the best, simplest and cheapest abdom- 
 inal supporters. It matters little where the location of 
 the abdominal pressure resides as long as the latter is 
 augmented. With such a support as described, the 
 
268 THE BLUES : NEURASTHENIA. 
 
 abdomen below the belt bulges, but this seems in no wise 
 to influence the relief obtained by the patient. The 
 peroussional method of determining abdominal tension is 
 as follows : I first percuss the abdomen, then I ask the 
 patient to bear down as if he were attempting to void his 
 intestinal contents, then I percuss again. In proportion 
 to the degree of tension, the percussion note, during the 
 time the patient is bearing down becomes translated from 
 a tympanitic before, to a tympanitically dull, dull or even 
 flat sound. The flatter the sound, the greater the degree 
 of tension. In diminished tension, no change in the per- 
 cussion note is evident. In constipated individuals, the 
 latter fact is likewise evident, and I believe that consti- 
 pation may often be determined after this manner with- 
 out questioning the patient. The percussional changes 
 are most evident during the time the patient is standing, 
 and percussion of the lower half of the abdomen can be 
 accepted as the only criterion. 
 
THE CAUSE AND CURE. 269 
 
 NOTE 18.— PERCUSSION QF THE STOMACH. 
 
 iTumerous methods have been suggested for determin- 
 ing the lower border of the stomach. The employment 
 of what I have called the stomach reflex,* suffices to out- 
 line the lower stomach border. Ordinary percussion 
 will not differentiate gastric from intestinal tympany. 
 If, however, we concuss the Traube area after the man- 
 ner suggested in concussion massage of the liver (Fig. 
 29), a series of vigorous blows and then proceed to per- 
 cuss the stomach region, one finds that the latter area 
 which formerly yielded a tympanitic sound now evokes 
 a tympanitically dull or even flat sound (stomach reflex 
 of contraction.) The Traube area is that percussional 
 half-moon shaped space which normally yields on per- 
 cussion, a tympanitic sound, owing to the presence of 
 the cardiac end of the stomach. The Traube area is 
 bounded above and laterally by the contiguous borders of 
 the liver, lung and spleen. By striking the blows in the 
 Traube area, we render the gastric walls tense and when 
 air or gas in the stomach is under considerable tension, 
 pitch becomes higher, and the volume and intensity so 
 decrease, that percussion will elicit a dull sound or dull 
 tympanicity. 
 
 The stomach reflex of contraction is most conspicuous 
 when the patient is examined before the Roentgen rays. 
 According to this method the stomach is moderately dis- 
 tended by air after the conventional manner, and then 
 concussion is executed in the Traube area. One at once 
 observes after administration of the vigorous percussion 
 blows that the fundus of the stomach will recede fully 
 an inch or more. 
 
 * Medical Record, Sept. 3, 1904. Medicine, Jan. 1904. 
 
270 THE BLUES : NEUEASTHENIA. 
 
 The duration of the stomach reflex of contraction varies 
 from one-half to one and one- half minutes, and it is 
 therefore imperative to proceed at once with percussion 
 for the purpose of defining the gastric area. If, for any 
 reason, the reflex is abolished before topographic percus- 
 sion is completed, the reflex can again be elicited and the 
 complete area of the stomach outlined. Striking the 
 epigastrium will at once abolish the reflex in question. 
 If the patient leans backward as far as possible, the per- 
 cussion noted in the gastric area is intensified. In accu- 
 racy, this method for defining the lower stomach border 
 has one drawback, it causes a moderate recession of the 
 stomach border, hence on percussion one finds the lower 
 border of the stomach slightly higher than it should be. 
 This latter difficulty may be obviated by employing what 
 I have called the vagostomach reflex. The writer has 
 shown that when the head is thrown forcibly backward 
 so as to stretch the muscles of the neck to their utmost, 
 there is a stimulation of the pneumogastric nerves in the 
 neck. As the result of such stimulation one may induce 
 a limited area of dulness in the region of the manu- 
 brium sterni, which is of diagnostic value in the recogni- 
 tion of an asthmatic lung.* By the same maneuver, one 
 may inhibit the action of the heart, t Like the maneuver 
 of concussion in the Traube area, throwing the head 
 forcibly backward, we increase the tension of the gastric 
 walls and are thus able to convert a tympanitic into a 
 tympanitically dull sound and to differentiate the now con- 
 verted stomach dulness from the contiguous atmosphere 
 of tympany belonging to the intestines. To determine 
 
 » The Medical News, June 25, 1904. 
 
 t " Abrams on Diseases of the Heart," 1900, p. 59, and Phila- 
 delphia Medical Journal, September 39, 1900. 
 
THE CAUSE AND CURE. 
 
 271 
 
 the vagostomach reflex the percussion of the stomach is 
 executed with the patient in the erect posture. It must 
 be emphasized, that the stomach dulness only lasts during 
 the time the head is thrown forcibly backward. The 
 stomach reflex of contraction employed in conjunction 
 with the vagostomach reflex enables one to determine the 
 actual lower border of the stomach and to gauge the 
 motor power of the stomach. Reference is made to Fig. 
 30 for elucidating these facts. A. represents the lower 
 
 Fig. 30. — Gauging the motor power of the stomach. A. The lower border of 
 the stomach when the head is forcibly thrown backward. B. The lower border 
 of the stomach (by percussion), often concussing the Traube area. 
 
 border of the stomach as elicited when the head is 
 thrown forcibly backward ; B. represents the lower bor- 
 
2T2 THE BLUES : NEURASTHENIA. 
 
 der of the stomach (by percussion), after concussing the 
 Traube area. The greater the distance between A. and 
 B. the greater the motor power of the stomach. In the 
 norm, the degree of retraction in the median line is from 
 2 to 5 cm. I have found that •when one large electrode is 
 fixed in the Traube area and the other electrode at an in- 
 different point in the back, that with the sinusoidal 
 current, the stomach can be brought into a state of con- 
 traction. The latter fact suggests the importance of the 
 stomach reflex of contraction in the treatment of gastric 
 affections. 
 
THE CAUSili AND CUfti:. 273 
 
 NOTE 19.— THE VASOMOTOR TEST IN SPLANCHNIC NEU- 
 RASTHENIA. 
 
 Reference has already been made to the vasomotor 
 factor (page 116) and the demonstration of splanchnic 
 congestion by aid of the cardio-splanchnic phenomenon 
 (Note 2, appendix). Here we will accord brief attention 
 to what Crampton * calls, the " test of condition " which 
 is equally available in recognizing splanchnic neurasthe- 
 nia. The splanchnic circulation (Fig. 31) properly signi- 
 fies the arterial branches of the celiac axis, their branches 
 a,nd the radicles of the portal vein. This system is partly 
 arterial and partly venous. The erect posture of man 
 places him at a disadvantage in several directions, notably, 
 however, by increasing the height of the blood-column 
 with a corresponding increase of gravity on the circula- 
 tion, thus causing the blood to gravitate into the splanch- 
 nic vessels. Among the" resources of Nature to combat 
 this tendency the vigor of the abdominal muscles is para- 
 mount. The vasomotor factor is likewise predominant. 
 In standing, the splanchnic vessels are constricted by the 
 vasomotor action of the splanchnic nerves. If this con- 
 traction is effective against the augmented pressure 
 brought to bear through the gravity, the blood-pressure 
 in the upper body rises, and, if ineffective, it fails to rise 
 or falls. The splanchnic vasomotor mechanism, is the 
 latest in the body to develop and it appears only after 
 man has taken to the erect position. The mechanism in 
 
 * The Medical News, Sept. 16, 1905. 
 
0^4 TllE BLUES :-l^EURAStllEMA. 
 
 question is easily fatigued and according to my observa- 
 tions, its exhaustion is one of the earliest expressions of 
 splanchnic neurasthenia. When the blood-pressure falls, 
 the heart-rate is accelerated. If the rate of the heart is 
 increased with an augmentation of blood-pressure, it in- 
 dicates a relative insufficiency of the splanchnic mechan- 
 ism, for the ideal condition, is a rise of pressure with no 
 acceleration of the heart on standing. In employing this 
 test, the patient is directed to lie down flat upon a couch 
 with no head-rest. The armlet of the blood-pressure in- 
 strument is placed around the upper arm so that it bears 
 the same relation to the heart lying as it will when the 
 patient is standing, thus eliminating any hydrostatic 
 error. After the average pulse-rate is taken, the systolic 
 blood-pressure is determined. The pulse-rate and-pres- 
 sure are again estimated in the erect posture. The patient 
 must be allowed sufficient rest in both instances before 
 estimates are made, insomuch as the muscular effort alone 
 will modify the pulse-rate and-pressure. In the follow- 
 ing case the test shows an adequate automatism of the 
 splanchnic vasomotor mechanism and demonstrates a 
 good condition : 
 
 Pulse-Rate. Systolic Pressure. 
 
 Lying.— 58 120mm. 
 
 Standing.- 58 132mm. 
 
 Difference.— -1-13 
 
 The following case shows a poor record and demon- 
 strates an insufficient splanchnic vasomotor mechanism : 
 
 Rate. Pressure. 
 
 Lying. - 68 100 
 
 Standing.— 104 94 
 
 Difference. h36 — 6 mm. 
 
THE CAUSE AND CURE. 275 
 
 More accurate conclusions may be formulated when the 
 condition is already known and the test in question may 
 be accepted as a means of indicating the progress made 
 in chronic cases and the value of the remedies employed. 
 
276 THE BLUES:— NEURASTHENIA. 
 
 NOTE 20.— AUGMENTING THE TONE OF THE SPLANCHNIC 
 CIRCULATION. 
 
 Recapitulating certain facts concerning splanchnic 
 neurasthenia, we note that, it is a condition dependent 
 on intra-abdominal venous congestion superinduced by 
 insufficiency of the splanchnic vasomotor mechanism, 
 and that the neurasthenic symptoms resulting there- 
 from may be corrected by relief of the congestion and 
 by manoeuvers which will increase the efficiency of the 
 liver as an organ of defense {vide page 164). 
 
 As we have already demonstrated, the intra-abdominal 
 venous congestion in splanchnic neurasthenia may be 
 influenced in a variety of ways : 
 
 1. By abdominal massage (page 138) ; 
 
 2. By abdominal exercises (page 143) ; 
 
 3. By abdominal supporters (page 152) ; 
 
 4. By electricity to the abdomen (page 150) ; 
 
 5. By toning the splanchnic vasomotor mechanism. 
 The latter method is the most potential of all and 
 
 will be the subject of special consideration in this note. 
 It has already been observed on page 151 that when 
 the sinusoidal current is applied to the abdomen, the 
 blood is driven from the intra-abdominal veins back into 
 the heart. The latter action is chiefly due to the elicita- 
 tion of the liver reflex (page 129), which results in a de- 
 cided reduction in the volume of the liver. Insomuch 
 as it has been estimated that the latter organ contains 
 blood equivalent to one-fourth the amount of blood con- 
 tained in the body, it is not difficult to conceive that, 
 
THE CAUSE AND CURE. 2II 
 
 by contraction of the liver alone, considerable blood may 
 be expressed from the splanchnic circulation. 
 
 However, the author finds that it is now possible to 
 influence the latter circulation by direct stimulation of 
 the splanchnic nerves which. control the blood-vessels of 
 the abdominal organs. 
 
 True, digitalin or strophanthin, alone or in combi- 
 nation, quickly relieve abdominal congestion. They are 
 endowed with the property of constricting the splanch- 
 nic vessels alone, whereas digitoxin constricts all the 
 blood-vessels. 
 
 However, with pharmacotherapy, only temporary re- 
 sults are achieved and the latter should be superseded 
 whenever possible by physiotherapy. 
 
 Before describing the physio-therapeutic method of 
 the author, it is necessary to advert succinctly to the 
 splanchnic circulation. 
 
 The latter (Fig. 31, see frontispiece) properly com- 
 prises the arterial and venous supply to the abdominal 
 organs and is known as the Splanchnic Area. The 
 largest vascular areas in the body are: 
 
 1. The splanchnic area ; 
 ■2. The brain; 
 
 3. The muscles; 
 
 4. The skin. 
 
 The splanchnic area is large enough to contain almost 
 the entire volume of blood of the body. 
 
 If the portal vein (Fig. 31, see frontispiece) is tied, 
 practically the entire blood-volume of the body will ac- 
 cumulate in the intestinal and hepatic blood-vessels and, 
 in this way, an animal may be bled into its own veins. 
 
 Reference has already been made in the preface to 
 
2Y8 *HE BLUES:— NEURASTHENIA. 
 
 the first edition, and on page 201 to the incongruity of 
 an animal like man built on the longitudinal plan. The 
 erect posture of man causes the blood to gravitate into 
 the intra-abdominal veins. 
 
 The effect of gravity on the circulation is important. 
 The chief effect of gravity is that the veins become 
 filled with blood in the dependent parts. If an animal 
 is held with its legs hanging down, the amount of blood 
 going to the heart is reduced and the blood-pressure in 
 the arteries is consequently diminished. This hydro- 
 static effect of gravity, however, is overcome in the 
 norm, by constriction of the vessels of the splanchnic 
 area and, by augmented vigor of the respiratory appa- 
 ratus. 
 
 If a "hutch" rabbit is suspended by the ears with its 
 legs hanging down, it soon passes into unconsciousness 
 and will, if left in that position, die in about half an 
 hour. What occurs ? The blood leaving the brain ac- 
 cumulates in the abdomen of the animal but the de- 
 ficient tone of its splanchnic vasomotor mechanism is 
 unable to overcome the evil effects of gravity. 
 
 If the animal, however, is placed in a horizontal pos- 
 ture or, if while still suspended, the abdomen is squeezed 
 or bandaged, consciousness is soon restored. 
 
 A wild rabbit, owing to its efficient splanchnic vaso- 
 motor mechanism, suffers no inconvenience when held 
 in a vertical position. 
 
 The Splanchnic Nerves are the vasomotor nerves 
 of the abdominal blood-vessels and control the largest 
 vascular area in the body. 
 
 If the splanchnic nerves are stimulated the blood- 
 vessels contract, but when the nerves are cut the ves- 
 sels dilate. 
 
fHE OAUSfi AK^b CURE. £79 
 
 In the latter case a large amount of blood accumu- 
 lates in the abdominal vessels, resulting in an anemia 
 of the other parts of the body, which may be so great 
 (brain-anemia) as to cause death. 
 
 We shall presently learn that the physician can by 
 simple methods either increase or diminish the tone of 
 the splanchnic nerves, and in this respect he can achieve 
 results tantamount to the vivisectional experimentalist. 
 
 The splanchnic nerves are composed of fibers issuing 
 from the spinal cord in the fifth to the twelfth dorsal 
 nerves inclusive. The dorsal nerves in question corre- 
 spond to the spines of the second to the eighth dorsal 
 vertebra inclusive (Fig. 34). 
 
 If the spines in question are sinusoidalized, or better 
 still, struck in succession by means of a plexor and 
 pleximeter, the cardio-splanchnic phenomenon (pages 
 116 and 200) is at once brought into evidence. In 
 other words, the blood is expressed from the abdominal 
 vessels to the right heart. 
 
 Reference has been made on page 200 to the utilizar 
 tion of the cardio-splanchnic phenomenon in the diag- 
 nosis of splanchnic neurasthenia superinduced by intra- 
 abdominal venous..congestion, and to the test pf condition 
 on page 273. 
 
 Here reference will be made to a new and simpler 
 diagnostic aid. 
 
 If, in the norm, an individual assumes the recumbent 
 posture for several minutes and is then requested to 
 stand erect, and the physician at once proceeds to per- 
 cuss the lower part of the abdomen, he will elicit two 
 areas of dulness, as shown in Fig. 32. 
 
 The latter areas are usually of short duration and 
 may be dissipated at once by a series of deep breaths 
 
280 '^HE BLUES:— NEUfi,ASTHENlA. 
 
 or by striking the second to the eighth dorsal vertebral 
 spines. 
 
 What reasons have we for assuming that the dull 
 areas in question are caused by the accumulation of 
 blood in the abdominal blood-vessels? 
 
 1. The areas of dulness correspond to the largest ab- 
 dominal vessels ; 
 
 2. They are at once dissipated by deep breathing, 
 ■which facilitates the return of blood from the abdominal 
 vessels to the heart, and by striking or sinusoidalizing 
 the spines of the second to the eighth dorsal vertebrae. 
 The latter methods stimulate the splanchnic nerves, and 
 by thus constricting the vessels of the abdomen send the 
 blood to the heart. Thus it is that by the execution of 
 the methods in question, the cardio-splanchnic phenome- 
 non (page 200) is brought into evidence. 
 
 3. If a large vacuum cup {vide page 213) is ap- 
 plied to the abdomen at a point just above the navel, 
 and the cup is exhausted, tv?o areas of dulness corre- 
 sponding to Fig. 32 appear. 
 
 4. If, in a given individual, the dull areas correspond- 
 ing to rig. 32 are elicited by a change from the recum- 
 bent to the vertical position, such areas can no longer 
 be demonstrated by change of position if the vertebral 
 spines corresponding to the origin of the splanchnic 
 nerves are previously sinusoidalized or concussed. By 
 the latter method we have, at least temporarily, aug- 
 mented the tone of the splanchnic vasomotor mechanism, 
 thus inhibiting the gravitation of blood to the abdominal 
 vessels in sufficient amount to elicit dulness. 
 
 5. The dull areas may be evoked (although absent) 
 in the erect posture by sinusoidalization or concussion 
 
Fig. 32. — Patches of dullness in the norm, when the erect is 
 substituted for the recumbent posture; percussional evidence of 
 the gravitation of blood into the splanchnic vessels by the attitu- 
 dinal change in question. 
 
I'ig. ;>; —Diffused area of dullness in insufficiency of the splanchnic 
 vasomotor mechanism. Compare with the normal areas of dullness 
 in Fig. :!-. 
 
THE CAUSE AND CURE. 281 
 
 of the four lower dorsal spines (9th, 10th, 11th and 12th 
 dorsal vertebrae). 
 
 The author has determined empirically that the 
 spines in question correspond to segments in the spinal 
 cord which, when stimulated, will diminish the tone of 
 the splanchnic nerves, thus permitting a large quan- 
 tity of blood to gravitate into the patulous abdominal 
 vessels. 
 
 6. In splanchnic neurasthenics, the patches of dul- 
 ness are not isolated as in the norm, but the dulness is 
 diffused and occupies the entire lower abdomen (Fig. 
 33). With the betterment of the splanchnic neuras- 
 thenic, there is a corresponding diminution of the dul- 
 ness on percussion. The dulness in such patients is al- 
 ways more diffused and pronounced when the symp- 
 toms of the patient are accentuated, and it is even pos- 
 sible to elicit many of their sensations (vertigo, sinking 
 sensations, lack of energy, etc.) or aggravate them by 
 concussion or sinusoidalization of the four lower dorsal 
 spines, which, as we have shovTn, practically paralyze the 
 splanchnic nerves, thus causing an increased quantity 
 of blood to accumulate in the abdominal vessels.* 
 
 The author, based on an examination of hundreds of 
 cases with reference to the vigor of the splanchnic vaso- 
 motor mechanism, submits the following classij&cation : 
 
 1. Patients in whom no dulness in the lower ab- 
 domen can be elicited when a change is made from the 
 recumbent to the erect posture; a condition which 
 demonstrates an ideal vaso-motor mechanism; 
 
 2. Patients in whom a dulness of short duration 
 
 *The author suggests to the investigator that the dulness of intra- 
 abdominal congestion be utilized as a gauge in determining the 
 action of drugs on the splanchnic circulation. 
 
282 THE BLUBS:— NEURASTHENIA. 
 
 (lasting about one minute) is elicited (Fig. 32) on 
 change of position ; a condition representing an average 
 vaso-motor mechanism; 
 
 3. Patients in whom the dulness is diffused (Fig. 
 33) and persistent (longer than three minutes) after 
 change from the recumbent to the erect position ; a con- 
 dition representing an enervated mechanism ; 
 
 4. Patients in whom the dulness is diffused and 
 persistent in the erect posture without having previously 
 adopted the recumbent attitude. Here we are con- 
 fronted with the most accentuated types of splanchnic 
 neurasthenia. 
 
 From what has preceded it will be evident to the 
 physician that he must not base inferences on false 
 premises. He must assure himself that dulness of the 
 lower abdomen is really dependent on intra-abdominal 
 congestion by execution of the tests already cited. Thus 
 there will be an augmentation of the dulness if the four 
 lower dorsal spines are concussed, or conversely, the dul- 
 ness will be dissipated by deep breathing (in non- 
 aggravated types of congestion), or by concussion of the 
 upper dorsal spines (2nd to the 8th). 
 
 Teeatment.* — As already observed, stimulation of 
 the splanchnic nerves is the most valuable of all methods 
 of treatment in splanchnic neurasthenia. To stimulate 
 the nerves in question, two methods are available, viz. : 
 
 1. Concussion ; 
 
 2. Sinusoidalization. 
 
 *For more detailed information concerning physio-therapy of the 
 spinal region, the reader is referred to the recently published book 
 by the author, viz., SPONDYLOTHERAPY: The PHILOPOLIS 
 PRESS, 406 Lincoln Building, San Francisco or E, B, TREAT & CO,. 
 
 241 West 23d St., New York, 
 
THE CAUSE AND CURE. £83 
 
 CoKTCUSSioiir is more efficient than sinusoidalization. 
 Concussion is a mechanic stimulus and, when it is of 
 short duration, it augments the excitability of the 
 nerves, but when prolonged, the excitability is dimin- 
 ished or abolished. It is evident then that during a 
 seance of concussion the treatment must be interrupted 
 from time to time. 
 
 Mechanic stimuli are only effective when they are 
 applied with sufficient rapidity to produce a change in 
 the form of the nerve-particles. 
 
 In the therapeutic elicitation of the splanchnic reflex 
 of vaso-constriction the only kind of vibratory appa- 
 ratus which is effective is one giving the Peecussion 
 Stroke. All other motions, such as oscillations, shak- 
 ing and friction, interfere with the results. 
 
 In other words, it is CoisrcussiON and not vibration 
 which is effective in evoking vertebral reflexes. It is 
 imperative, therefore, that in the selection of an appa- 
 ratus, only one giving a powerful concussion-stroke 
 (a blow of at least 12 pounds) should be employed. 
 
 The concussor is applied directly to the spinous 
 processes in succession (Fig. 34), and the application 
 can be prolonged for several minutes at a time. The du- 
 ration of each daily seance should not be less than fif- 
 teen minutes. 
 
 In the event friction (an undesirable feature) at- 
 tends the use of the apparatus, one must interpose some 
 medium between the concussor and the spinous proc- 
 esses. Here a strip of linoleum is efficient and the 
 treatment must be interrupted at once if the patient 
 complains of a burning sensation. 
 
 If a layer of rubber (1 cm. in thickness) covers the 
 surface of the concussor, no heat is generated and there 
 
284 THE BLUBS:— NEURASTHENIA. 
 
 is no necessity for interposing a medium between the 
 skin and the concussor. 
 
 SiNusoiDALizATioN * may likewise be used for excit- 
 ing the splanchnic reflex of vaso-constriction. The rapid 
 sinusoidal current is employed for this object. 
 
 A large electrode is placed over the sacrum, whereas 
 a small interrupting electrode (which permits one to 
 close and open the circuit) is placed in succession over 
 the spinous processes, as shown in Fig. 34. 
 
 The daily seances must be at least of fifteen minutes' 
 duration. 
 
 The PoLYSiNE Geisteeatoe (Fig. 35), made by the 
 Mcintosh Battery and Optical Co., of Chicago, yields a 
 very efficient sinusoidal current. The dial selector at- 
 tached to this apparatus obviates the necessity of learn- 
 ing by rote the operation of the many switches in order 
 to obtain the required combinations. 
 
 In conclusion, the author wishes to direct attention 
 to the vertebral reflexes in diminishing the volume of the 
 liver, which in splanchnic neurasthenia (page 128) is 
 invariably enlarged. 
 
 Our conventional conception of the liver is that of an 
 organ which is hard and unyielding. 
 
 In reality, however, the organ in question is like a 
 sponge; it swells with augmenting, and diminishes in 
 volume with decreasing pressure. 
 
 Concussion of specific vertebral spinous processes 
 contracts the liver for the following reasons : 
 
 1. Concussion of the seventh cervical spine acts on 
 the general vaso-motor apparatus ; 
 
 * Reference to the sinusoidal current is made on pages 151, 256 
 and 266. 
 
Fig. 34. — Vertebral dorsal spines, which, when either concusbeil 
 or sinusoidalized, will evoke, A, the splanchnic reflex of vasocon- 
 striction, and B, the splanchnic reflex of vasodilation. The former 
 reflex is the one to be elicited in the treatment of splanchnic 
 neurasthenia. 
 
THE CAUSE AND CURE. 285 
 
 2. Concussion of the first three lumbar spines acts by 
 eliciting the liver reflex (page 231) ; 
 
 3. Concussion of the second to the eighth dorsal 
 spines, inclusive, acts by constriction of the splanchnic 
 blood-vessels. 
 
 In a number of measurements of the liver made in 
 the parasternal line, th^ author obtained the following 
 results : 
 
 1. Size of liver by percussion before concussion 12.5 cm. 
 
 2. " " " after concussion of 7th cervical spine 11 cm. 
 
 3. " ' " " 1st 3 lumbar spines 8 cm. 
 
 4. " " " " " " 2nd to 8th dorsal spines. 6 cm. 
 
 It is evident according to the foregoing measure- 
 ments that, after elicitation of the splanchnic reflex of 
 vaso-constriction (4), the greatest reduction in the vol- 
 ume of the liver is obtained. 
 
BIBLIOGRAPHY. 
 
 1. Shattuck Lecture — " Not the disease only, but also the man." 
 3. Journal American Med. Assoc. , March 7, 1903. 
 
 3. Medical Record, Nov. 23, 1903. 
 
 4. Journal of Morphology, Boston, 1893. 
 
 5. Clinical Lectures on Neurasthenia, 1903. 
 
 6. Sexual Neurasthenia, Beard and Rockwell, 1895. New Ed. 
 
 1903. 
 
 7. Weiner Klin. Woehenschrift, Nos. 3, 4, 5, and 7, 1898. 
 
 8. Corresp. f. Schweizer Aerzte, No. 6, 1897. 
 
 9. Medical Record, Feb. 5, 1898. 
 
 10. Medical News, June 25, 1898. 
 
 11. The Lancet, Jan. 31, 1903. 
 
 13. Auto intoxication in disease, 1894. 
 
 13. Ueber habituelle Stulilverstopfung deren Ursaehe u. Behand- 
 
 lung. Berlin, 1891. 
 
 14. Blutdruck und Darmatonie, 1894. 
 
 15. Clinical Lectures on Neurasthenia, 1903. 
 
 16. Croonian Lectures : British Medical Journal, vol. 1895, p. 6. 
 
 17. Archives Oen. de MM., Deo. 1893. 
 
 18. Wiener Klin. Woehenschrift, June 16, 1898. 
 
 19. American Medicine, Feb. 15, 1903. 
 
 30. Text-hook of Nervous Diseases, 1901. 
 
 31. Clinical Lectures on Neurasthenia, 1903. 
 
 ■ 33. Deutsch. Med. Wochenshrift, 1896, pp. 53, 73, 87. 
 23. Revue des Maladies de la Nutrition, 1896, pp. 733, 734. 
 34. Journal of Physiology, vol. xxi, p. 333. 
 
 25. Respiratory Exercises, 1898, p. 12. 
 
 26. Journal of Physiology, vol. vii, p. 202. 
 
 27. Lancet, 1894, vol. i, p. 587, 
 
 28. Respiratory Exercises, p. 86. 
 
 29. Phil. Med. Journal, Dec. 7, 1901. 
 
 30. Volkmann's Sammluiigen, Nos. 115, 116, 1895. 
 
 31. Archiv. f. Verdauungsk, Bd. ii, 1896, pp. 385-295. 
 33. Text-book of Physiology, 1893, p. 71. 
 
 33. Therapeutic Gazette, July 15, 1901. 
 
 34. Halliburton's Kirke's Physiology, p. 537. 
 
 35. Verliandl. d. Congr. f. iitnere Med. 1897, pp. 531-523. 
 
 36. Journal of Physiology, vol. xxi, p. 323. 
 
INDEX. 
 
 PAGE 
 
 Abdomen, sensitiveness of . . . ; 137 
 
 electricity to 150 
 
 Abdominal brain 117 
 
 massage 138, 141 
 
 muscles, exercise of 143 
 
 neurasthenia 46 
 
 supporters 153 
 
 sympathetic 116 
 
 walls 135 
 
 Affection, diminished 59 
 
 Alcohol 29 
 
 Anemia, pulmonary 63, 189, 196 
 
 Anglopathio neurasthenia 73 
 
 Anoxemia 63, 133 
 
 Antagonistic microbes 183 
 
 Antiputrid regime 179 
 
 Apparatus, Kennelly 257 
 
 Arteriosclerosis 316 
 
 Atavism 253 
 
 Atelectatic zones 191 
 
 Auscultatory percussion 333 
 
 Auto-intoxication 45 
 
 Auto-intoxication, factors which determine , 166 
 
 Autotoxemic neurasthenia 44 
 
 Backache , 56 
 
 Blood pressure 119, 315 
 
 Blues Ill 
 
 Brain, abdominal 117 
 
 signs 58 
 
 Bowels, gas in 136 
 
 289 
 
290 INDEX. 
 
 PAOB 
 
 Bread and fruit diet 187 
 
 Breathing exercises 333 
 
 Cardio-splanohnic phenomenon 116, 300 
 
 Casque neurasthenique 55 
 
 Change of life '. 32 
 
 Cholmeia 175 
 
 Christian science '. 105 
 
 Colon, action on heart : 318 
 
 Cocoa 30 
 
 Coffee 30 
 
 Conceptions, imperative 59 
 
 Congestive neurasthenia 41 
 
 Conjugal hygiene 101 
 
 Constipation, treatment of 100 
 
 Constitution, neuropatliic 355 
 
 Costa fluotuans decima 135 
 
 Cure, rest 83 
 
 Current, sinusoidal 151, 356 
 
 Curve of health 26 
 
 Dreams . . . -. 95 
 
 Dyspepsia, nervous 96 
 
 Dyspeptics, rules for 09 
 
 EsiT signs 58 
 
 Edinger, law of 36 
 
 Electricity to abdomen 150 
 
 Emissions, seminal 67 
 
 Enteritis, mucous 67 
 
 Enteroptosis 47 
 
 Estimation of the solids 175 
 
 Ethereal sulphates 171 
 
 Examination of liver 380 
 
 Exercises, abdominal 143 
 
 breathing 333 
 
 respiratory 148 
 
 Eye signs 56 
 
 strain 57 
 
INDEX. 291 
 
 PAGE 
 
 ■ Family diseases 355 
 
 Farinaceous aliments 183 
 
 Fecal examination 178 
 
 Foerster's shifting type 58 
 
 Food 163 
 
 Headache 55 
 
 Health, curve of 26 
 
 Heart, palpitation of 95 
 
 reflex 237 
 
 signs 61 
 
 weakness 131 
 
 Hepatic insufficiency 174 
 
 Heredity 18,31, 352 
 
 Human Metabolism, 364 ; Hydrotherapy 93 
 
 Hygiene, conjugal 101 
 
 mental 20, 25 
 
 Hypnotism 94,103 
 
 Hypoazoturia 174 
 
 Hypochondriac, sexual 69 
 
 Hypochondriasis 47, 75 
 
 Hysteria 75 
 
 Imperative conceptions 59 
 
 Impotence 68, 70 
 
 Impulses, morbid 59 
 
 Indican 172 
 
 Indican, tests for 178 
 
 Indigestion, nervous 64 
 
 Influenza 31 
 
 Insanity, neurasthenic 77 
 
 Insomnia 87, 89 
 
 climate in 92 
 
 symptoms of 91 
 
 treatment of 91 
 
 Intestinal antiseptics 185 
 
 Intestinal auto-intoxication 161 
 
 Intestinal auto-intoxication, the diagnosis of 169 
 
 " " " symptoms of 168 
 
292 INDEX. 
 
 PAGE 
 
 intestinal auto-intoxication, treatment of 178 
 
 Intra-abdominal pressure 112 
 
 Irritation, spinal 72 
 
 Kennelly apparatus 257 
 
 Klopf-Versuch 241 
 
 Lithemia 72 
 
 Liver border, 224, Liver Massage 259 
 
 enlargement of . 128 
 
 examination of 220 
 
 palpation of 220 
 
 percussion of 231 
 
 reflex 129, 230 
 
 Lung, antedating tuberculosis 233 
 
 development insufficient 131 
 
 reflex of contraction 247 
 
 reflex of dilatation 244 
 
 Massage 188 ; Massage of Liver 259 
 
 Masturbation 71 
 
 Melancholia 76 
 
 Menopause 33 ; Metabolism , 264 
 
 Milk 180 
 
 Morbid fears 58 
 
 impulses 59 
 
 Mucous enteritis 67 
 
 Muscular fatigue. 53 
 
 Nerve foods , 30 
 
 Nervous dyspepsia 96 
 
 Neurasthenia, abdominal 46 
 
 autotoxemic 44 
 
 blood in 63 
 
 brain signs in 58 
 
 brain changes in 33 
 
 congestive 41 
 
 and dyspepsia 48 
 
 ear signs in 58 
 
 eye signs in 56 
 
 forms of 71 
 
INDEX. 293 
 
 PAGE 
 
 Neurasthenia, heart signs of. 61 
 
 Intestinal signs of 65 
 
 irritants of , 23, 39 
 
 pliysiologic factors in 33 
 
 prognosis of 77 
 
 pulse in 63 
 
 sexual 40, 67, 101 
 
 special symptoms of , 53 
 
 splanchnic Ill 
 
 stomach signs of 64 
 
 traumatic 33 
 
 treatment of 81 
 
 uric acid 43 
 
 vasomotor disturbances of 63 
 
 Neurasthenic fatigne 35 
 
 insanity , 7? 
 
 Neuron theory . . . ; 35 
 
 Neuropathic constitution 355 
 
 Neurotic heredity 17 
 
 Nightmare. 95 
 
 Occupation. . . , 27 
 
 Organs of defense 164 
 
 Originality 27 
 
 Overwork 25, 53 
 
 Pains, sympathetic 251 
 
 Palpation of liver 330 
 
 Paresis 76 
 
 Pericardial effusion, diagnosis of 341 
 
 Phenomenon, cardio-splanchnic 116, 300 
 
 Phobias .58 
 
 Physiologic tests 175 
 
 Pleural spaces 187 
 
 Pressure, blood 119, 215 
 
 intra-abdominal 112, 113 
 
 Pulmonary anemia 63, 187, 196 
 
 suction 115 
 
 Pulse '. 62 
 
 Purgatives, action of 158 
 
294 INDEX. 
 
 PAOE 
 
 Railway spine 33 
 
 Reflex, heart 237 
 
 liter 139, 381 
 
 lung of contraction 247 
 
 lung of dilatation 344 
 
 Respiratory exercises 148 
 
 Rest cure 83 
 
 Rest cure, partial 86 
 
 Restlessness 60 
 
 Reversion 253 
 
 Riva-rocci 215 
 
 Rumpf's symptom 63 
 
 Self-control 28, 83 
 
 Seminal emissions, treatment of 102 
 
 Sensory disturbances 55 
 
 Sexual hypochondriac 69 
 
 neurasthenia 101 
 
 signs 67 
 
 Sinusoidal cun-ent 151,256, 266 
 
 Sleep 88 
 
 Sleeplessness 69, 89 
 
 Spermatorrhea 68 
 
 Spinal irritation 73 
 
 Splanchnic circulation, augmenting the tone of the 276 
 
 Splanchnic neurasthenia, cases of ., 123, 153 
 
 causes of 117 
 
 recapitulation of 121 
 
 symptoms of 123 
 
 the vasomotor test in 275 
 
 treatment of 137 
 
 Stethophonometer 215 
 
 Stigmata 17 
 
 Stomach, action on heart, 318 ; stomach percussion 269 
 
 Suction, pulmonary 115 
 
 Sulphates , 171 
 
 Supporters, abdominal 152 
 
 Sympathetic, abdominal 116 
 
 pains 251 
 
INDEX. 295 
 
 PAGE 
 
 Syphilis , 31 
 
 Tea 30 
 
 Tension, intra-abdominal 113, 113, 267 
 
 The sinusoidal current 213 
 
 Tonometer ; 215 
 
 Test of Obermayer 173 
 
 Tremor 55 
 
 Uric acid - 43 
 
 dia#iesis 43 
 
 intoxication 131 
 
 Urine 170 
 
 Vertigo 60 
 
 forms of 61 
 
 Vessels, splanchnic 114 
 
 Walls, abdominal 135 
 
 Water, cold 153 
 
 Weakness, heart 131 
 
 Worriment, relief for. 83 
 
 Worry 28, 39 
 
 Zones, atelectatic 191 
 
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