COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64122166 RC343 .Se4 Lectures on some poi — I '' Lectures on Some Points in the ! Treatment and Manage- ment of Neuroses. E. C. SEGUIN, M. D., PROVIBENOE, E. I., CORBESPONDING UEMBSB OF THK SOCltT^ DE BIOLOGIE OF I'ARIS, ASD OF THE VEBKIN FUK INMKRB MEDICIN OF BERLIN, ETC. RECAP EKPEINTED FBOM Stje NetD Yorft KWeWcal Joutnal for April 5, 26, May 17, 31, 1890. v^<^3^^ <^^v Columbia (HnitiersJitp intljeCitpofllmgork College of l^tv^icmna anb ^mqtoni iLibrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/lecturesonsomepoOOsegu LECTURES ON SOME POINTS IX THE TREATMENT AND MANAGE31ENT OF NEUROSES DELIVERED BEFORE THE MEDICAL SOCIETY OF THE UNIVERSITY OF TORONTO, MARCH 11 axd 12, 1890 BY E. C. SEGCIX, M. D. PROVIDENCE, R. I. CORRESPONDING MEilBER OF THE SOCIETE DE BIOLOGIE OF PARIS, AND OF THE TEREIN FLm INNERE MEDICIN OF BERLIN, ETC. REPRINTED FROM THE NEW yore; MEDICAL'^JOURNAL' NEW YORK D. APPLETON AND COMPANY 1890 Copyright, 1890, bt d. appleton and company, LECTURES OX SOME POINTS IX THE TREATMENT AND MANAGEMEXT OF XEUROSES. LECTUEE r. Introductory Beinarks. — Therapeutics is generally con- sidered as the highciit department or function of medicine. In a certain sense it is true that we become physicians for the express purpose of battling with disease, of wholly over- coming it, or at least of retarding its progress and of alle- viating the sutferings of the sick and wounded. All the complicated education, preparatory and strictly medical, which we go through tends to prepare us for the successful practice of what is often known pnpularlv as the healing art. While an exact diagnosis is an indispensable preliminary to rational treatment, and while the making of a correct diag- nosis in obscure and rare cases of disease is a source of just pride to the practitioner, yet nothing can compare with the satisfaction, both for ourselves and for the patient and his relatives, which is afforded by tlie successful issue of a well- planned treatment, or the judicious alleviation of suffering in incurable cases. How do we learn therapeutics? T put it in this way, gentlemen, because I am still learning the art, and expect to go on learning more and more of it to the end of my 4- LKCTURKS ON SOME POINTS IN THE professional life. There are several correlated sources of instruction in therapeutics. We first are taught the natural history and physico-chemical characters of the drugs to be employed ; that is materia niedica or, better, pharmacology. In many medical schools students are now required to han- dle and personally examine the plants and substances used as drugs. Happy those of you who have the opportunity of spending a few months at work in a pharmacy acquiring a practical knowledge of these elements of therapeutics. A summer vacation or two thus employed would amply re- ward you for the loss of amusement and rest. This branch of elementary teaching should include, which it rarely does, I regret to say, the subjects of diet, hygiene, and more me- chanical therapeutic agencies — such as water, massage, electricity, [)hysical exercises, ventilation, etc. Next we are taught the physiological action of the more potent drugs upon the animal and human organisms. It is only in a few schools that a separate chair and laboratory exist for this important part of the curriculum. Usually we learn this somewhat piecemeal from the professors of pliysi- ology and of therapeutics. Still, there remains much more to learn — viz., the laws of compounding of remedies and of their application to manifestations of disease, or to what are called indications (usually disturbed physiological func- tions). This we learn partly from the professor of thera- peutics, and in part also from the teachers of practical or clinical medicine at the bedside. Hence the reason why a professor of therapeutics should be a practical and experi- enced physician ; his teaching should be a happy combina- tion of experimental knowledge and of sifted practical ex- perience. While I regard careful and well-controlled tests on man as the final criterion of the utility of a drug, I am not one of those who scorn the aid of the laboratory or of graphic records of the action of drugs on animals, high J TREATMENT AND MANAGEMENT OF NEUROSES. 5 or low in the scale. Bv all means, let us liave all the light we can in this ditBcult and still uncertain branch of knowl- edge, and let us Be prepared to base our trials of a drug on human beings upon knowledge of its nature and of its ac- tion upon the nervous and circulatory apparatuses, etc., of animals. Thus far, as students and as young graduates in medicine, canyon go, but after a few years of practice new views open to you, and you thirst for still further knowledge of a more special sort. You want the results of the personal experi- ence of phvsicians who have devoted years to a closer study of certain diseases, and their treatment by potent remedies, chemical or mechanical, to help you in your daily practice, or to assist you in original observations of your own. Xow, this higher, or more refined, or better sifted knowledge of therapeutics, for which there is not room in text-books, you obtain through medical journals, by read- ing new works on clinical medicine, whether in book or pamphlet form, and, lastly, by listening to special lectures embodying the results of many years of patient observa- tion. In this more specialized study of therapeutics you will have to read and perhaps listen to a good deal of raw and useless matter, you will meet with a multitude of pre- mature announcements as to the virtues of drugs or opera- tions, and you will also have to encounter and criticise the honest enthusiast, who reports only favorable cases and be- lieves that everything supports his plan of treatment. You will also have to m.eet the flood of fashionable ren]edies, floated and pushed by hasty medical experimenters and by interested producers. To extract the wheat from this chaff will require good judgment in your reading, and careful conservatism in your experiments upon patients. Always seek for the other view of a therapeutic claim, inquire for the unsuccessful cases, and make your own tests quietly 6 LECTURES ON SOME POINTS IN THE without promising yourself or your patients too niucli from a new remedy or operative procedure. Time and repeated tests will settle tlie question safely, and you will thus save yourselves self-reproach and just criticism by others. The mite which I now contribute to the admirable course of instruction at this University, by the courtesy of the council of your medical society, is in the nature of a, resutne of considerable personal experience with the treatment and management of functional nervous affections or neuroses. In three lectures I can not, of course, treat systematically so large a subject — one requiring much detailed explanation to make one's experience of value to others. All I can do is to consider some important sections of the topic, partly in a positive way, advising you what to do for neuroses ; and partly, also, in a negative way, warning you what not to do, or to do most cautiously in these affections. Every state- ment I shall make will be based upon clinical experience, uninfluenced, I hope, by theory and fashion, and my warn- ings relative to the abuse of certain agents will be given without fear or favor. As announced, the course will consist of three lectures, the first treating of some details of treatment of neuroses; the second, of the diet, hygiene, and moral management of neuroses; the third, on the abuse of certain drugs, more especially the bromides, morphine, and alcohol, in the treat- ment of neuroses. Let us enter at once upon the question of the treatment of some of the more important neuroses. I. Epilepsy. — This formidable affection has no uniform pathology ; it is as yet only a symptom, which may be pro- duced by numerous pathological conditions. Of organic or symptomatic epilepsies, some are due to encephalic disease or injury ; others depend upon a peripheral (i. e., non-en- cephalic) disease or injury; and, lastly, they may represent TREATMENT AND 5IAXAGEMENT OF NEUROSES. 7 toxsemic conditions, as 1 he urEemic (falsely so-called), gouty, etc. It is usually not difficult to recog-nize such cases, and to subject them to a more or less rational treatment, based upon the causal indication revealed by our analysis. But there remain many cases of epilepsy in which the most careful examination fails to reveal the presence of any gross lesion or toxa^mic state; and these go to make up tlie group of idiopathic epilepsy. The aggressions of scientific patho- logical research and perfections in diagnosis tend constantly to reduce this group. There are also cases in which, dur- ing many years, the epilepsy appears idiopathic, and finally, perhaps in the course of a few weeks or months, definite symptoms of cerebral disease appear and enable the physi- cian to properly classify the case. In this connection I. might cite the case of the wife of a physician who had for several years been under the care of Brown-Sequard, and who had been examined by several other" eminent physi- cians. Her attacks consisted of grand and 2oelit mal of the most vulgar kind, usually with an epigastric ascending aura ; the spasms were bilateral and typical in kind (tonic fol- lowed by clonic movements) ; in the pctil mal, staring, drool- ing, and swallowing movements were prominent. Her facies and manner were those of a common epileptic. Yet, about the time she was placed in my hands, right hemi- symptoms (numbness, ansesthesia, and paresis) appeared, and under observation choked disc began and developed fully. Autopsy revealed a gliomatous formation involving the left thalamus and internal capsule. My belief is that the new formation was present from the very onset of the epi- lepsy eleven years before, that it at first grew very slowly, and toward the last very rapidly. Thus, a case may, owing to imperfections in our methods of diagnosis, appear as idio- pathic at one time and symptomatic or organic later on. Idiopathic epilepsy presents itself to the careful student S LRCTl'RE.S OX SOME POINTS IX TIIK with numerous patlioloo'ical signs or stignnata, no one of which can safely be pointed out as the chief or truly causal factor. Thus we notice in many epileptics the existence of hereditary taints of various sorts, apart from occasional direct inheritance of the disease. The child's progenitors have been debauched, addicted to sexual and alcoholic ex- cesses ; the victims of syphilis or of chronic starvation The patient himself is frequently microcephalic, or has a marked cranial asymmetry ; his teeth are deficient or de- formed; his head and long bones may exhibit signs of rhachitis; or his head may be abnormally large from hydro- cephalus, or it is indented by pressure of forceps or pelvic bones during delivery. In some cases there is a history of asphyxial state at birth, with or without convulsions. Other conditions found which may play a part — how important we should be very cautious in stating — are defective eyes (re- fractive and muscular deficiencies), undeveloped uterus, feeble or diseased heart, etc. Acquired habits, such as early and excessive self-abuse in both sexes, the precocious use of alcohol or tobacco, undoubtedly lead to epilepsy in predisposed subjects. The same may be said of severe acute diseases, and the occurrence of an accidental (toxic, reflex, or febrile) convulsive seizure in infancy. Other at- tacks follow, in some cases within a few months or a year, in others several years after, and then the seizures become more and more frequent, constituting chronic epilepsy. In these cases we may, of course, suspect that a cerebral in- jury or lesion caused, accompanied, or followed the first eclamptic attack, but we can not always prove its existence; and, besides, it should be remembered that a great many children have one or several eclamptic attacks during early infancy, in what I have termed the period of convulsibility,* * N. Y. Medical Record, vol. xx, Aug. 6, 13 ; and Opera Minora New York, 1884, p. 549. TREATMEXT AND ilAXAGEMEXT OF NEUROSES. 9 without ever baviuo- a recurrence. The element of heredi- tary predisposition here plays a most important part in giv- ing efficacy to an exciting cause. I have made this somewhat extended analysis of the pathological conditions observed in the victims of idiopathic epilepsy, because upon them we may sometimes base ra- tional treatment of an accessory or co-operative sort. While the routine anti-epileptic treatment is being systematically carried out, these secondary conditions may be — yes, should by all means be — studied and corrected. An epileptic may present several such conditions simultaneously — viz., de- fective eyes, dysmenorrhcjea, and indigestion — each condi- tion no doubt playing some part in the genesis of attacks. I say attacks, because in these cases the true cause of the disease lies deeper and at the present time beyond our ken, while the exciting cause of attacks is sometimes recogniza- ble. Another reason for dwelling on these morbid states or secondary causal conditions is to warn you against at- taching too great an importance to any one of them and being thus led into a one-sided, unscientific treatment of epilepsy. We are just now witnessing the decline of such an attempt. A few years ago a very able oculist* per- suaded himself that eye- strain was the cause of epilepsy in a large proportion of cases, and his subsequent experience has been forced to come to the support of this preconceived and limited view of the pathology ^of epilepsy. He has treated a large number of patients by withdrawing their bromides, giving them glasses, and cutting their ocular mus- cles or tendons on a large scale. And the results ? — at first, as usual witii the therapeutic outcome of blind enthusiasm, fifty per cent, of cases were reported '' cured." f You may imagine the astonishment of the profession at such a claim. * George T. Stevens, in New York Medical Journal, April 16, 1887. I Loc. cit. 10 LECTURES OX SOME POINTS IN THE Yet since the publication of the paper referred to in 1887 the inventor of the treatment and his followers have not published another case of " cure." * This treatment was tested by a commission appointed by the Xew York Neurological Society, which, after two years and a half of work conjointly with Dr. Stevens, re- ported last November. Of the nine epileptic patients, not one was cured or much improved, three were slightly im- proved, and the majority unimproved. And it should be added that several cases (not counted because they did not submit to treatment for four months) withdrew because they were very much worse. One patient (under my own observation) would probably have died in status epileplicus had not the bromides been resumed. The question is thus apparently settled that treating the ocular defects of epilep- tics will not cure epilepsy, though it may reduce the sum total of exciting causes of attacks in some patients. f Yet * Dr. A. L. Ranney is a firm believer in Dr. Sieven.s's teaching with reference to the ocular theory of epilepsy, yet, after treating many cases after Stevens's method, he can only give us the following sununary of results in his excellent Lectures on Nervous Diseases, New York, 1888, p. 482 : '' That a persi.-tence of epileptic attacks for years does not necessarily render recovery impossible is proved by the fact that I have personally had three cases where c-onvulsive seizures have been thus far arrested by tenotomies which I performed upon the eye muscles. All of these cases had been kept constantly under bromides for several years without apparent l»enefit Ijefore they were placed under my care. Over a year has now elapsed since two of them have taken any drugs or have had an epileptic fit, and the third has passed several months without an attack." The author does not expressly say that these cases are " cured," and very wisely, for any one familiar with the natu- ral history of epilepsy knows that (1) in some rare cases inexplicable long intervals occur without treatment ; (2) that a case should not be reported as cured until at least five years have passed without any kind of epih[Aif seizure, not merely convulsive ones. f T'iVe Report of Commission (a non official and imperfec-t report) in .Journal of Nervous and Mental Diseases, November, 1889. TREATMEXT AND MANAGEMENT OF NEUROSES. H the practice — aa unscientific and injurious practice, as I do not hesitate to call it when iadiscriminately applied — is still in full blast; necessary bromide treatment is suspended, muscles are cut and recut, an impossible [1) balance of ocu- lar muscular forces being sought for, and glasses are ordered and re-ordered for the same patient. It will take some time yet for this local treatment to find its true le\rel. The de- fective eyes of epileptics should be corrected, but there is the same demand on the part of the pathologicciUy con- ditioned stomach, ovary, foreskin, etc., of our epileptics. In these diseased or disordered or defective and strained organs arise secondary causal intluences which should by all means be removed; but from that to "curing" epilepsy is a long, long way. And while these causes of irritation are treated the bromide should not be withdrawn, or not wholly. The same remarks apply to that other fashionable treat- ment of epilepsy and hystero-epilepsy, now also happily declining — viz., that by removal of one or both ovaries. Wh: t outrageous cases of useless mutilation have thus oc- curred under the pressure of medical sathority and of popu- lar craze for novelty and fair promises ! The operation of castration in women is undoubtedly sometimes justified, and some few cases of hystero-epilepsy are relieved by it, hut it is a measure to be resorted to only upon the most exact and clear indications, never hapliazard or as a fanciful last resort. Thus, gentlemen, I would make a strong plea for an attempt at a rational treatment of idiopathic epilepsy by a searching examination of the patient and by the careful re- moval of the various secondary causes or exciting condi- tions you may discover. In close connection with this lies the hygiene of epileptics, a subject with which I shall deal in a subsequent lecture. I now pass to the consideration of the routine or pallia- 12 LECTURES OX SOME POINTS IN THE live treatment of epilepsy, a treatment necessary in both the symptomatic and the idiopathic forms of the disease. I refer to the systematic use of the bromides and allied anti- epileptic (or anti-convulsive) drugs. It is here that I may be able to offer you the fruits of many years of prac- tice and of many experiments as to substances and modes of administration. I shall fully state the drawbacks and uncertainty of the treatment, and try to enable you to carry it out successfully. It is a matter requiring much care and tact on your part, as well as intelligent co-operation and un- usual perseverance on the patient's part. Right here let me state that I am a pessimist as to the curability of idiopathic epilepsy, and have not yet pub- lished any case as cured. I have records of patients, and have patients actually under observation, who have had no seizures of any sort for periods varying from eleven to three years. Yet, only a year ago, an old patient wrote me of a recurrence of attacks after eleven years (several of which were without treatment) of freedom. Other cases have shown recurrence after seven years, five years, and many after two years of absolute freedom from any manifestation of the disease. Of course in these cases the bromide treat- ment had been discontinued, sometimes by my direction, sometimes by the patient, who had grown to have a false security or disregarded ray warning. Whether a long- continued bromide treatment can cure epilepsy is a question which I believe can be answered in the affirmative, but this result is obtained, alas! only in an exceedingly small pro- portion of cases. Nearly all the so called cures which you will hear of and read are prematurely reported (and this applies particularly to cases treated by surgical means). In my opinion, as regards medical cases, an interval of at least five years without the slightest seizure, with a gradual re- duction of the medicines during the fourth year and one TREATMENT AND MANAGEMENT OF NEUROSES. 13 year without meclizine, should be the necessary preliminary condition to a report of cure. With respect to surgical cases, it would be wise to wait at least two years before placing them on record as cured. How many observers have placed such checks on their results i The Routine Bromide Treatment of Epilepsy. — Tn under- taking- the care of a case of this affection, you should stip- ulate for plenty of time to study the case in all its aspects, aad for rather frequent visits at first for the purpose of ad- justing* the doses, securing proper hygiene, etc. In the first place, remember that you are prescribing the drug not against the disease as a sort of entity or tangible enemy, but for the individual patient to reduce the excita- bility of parts of his nervous system to a certain point. The susceptibility of persons to the action of bromides varies very greatly. From these two considerations you readily perceive how delicate a matter it is to find the right dose for. a given patient; it sometimes requires one or two months of experimentation. I have made it a nile to re- quire epileptics who reside at a distance from me to stay in New York, or come in twice a week for one month at least. To see a case of epilepsy once and prescribe a bromide treatment is a most reprehensible, careless practice; the pa- tient either receives too little of the remedy and attacks continue, or else he is brominized with sad if not dangerous results. In any case the end is failure, which throws dis- credit upon the physician and fortifies the opponents of this treatment. Allow me to state several laws relative to the dosage of bromide which I have worked out from my ex- perience, successful and unfortunate. We learn much by our errors. (rt) Subjects vary greatly in their capacity for resisting bromides. I have known unpleasant bromism produced in an adult woman by thirty grains a day for a week or 14 LECTURES ON SOME POINTS IN THE two ; wliile, on the other hand, I have given as inucli as one hundred and tifty grains ^^er diem to a girl fifteen years of age, and to one strong youth of twenty, from one hundred and sixty to two hundred grains per diem, with no marked hromism. These extremes teach caution. (h) Children, little children particularly, bear much larger doses of bromides proportionately than adults (as is the case with the iodides). Many epileptic children of from two to six years will need between forty and sixty grains per diem to arrest attacks; and take these quantities with- out bromism. The salt is probably absorbed more quickly and excreted more thoroughly than in adults. (c) There is a certain proportion, in adults, between the size and weight of the patient and his capacity for resisting drugs. The lady I have referred to as having been bromin- ized by thirty grains a day was much below the usual size and delicate in every way. This rule is one which is fol- lowed in physiological experiments on animals; in modern researches the weight of the animal experimented on is al- ways noted. There are exceptions to the rule, but it is of some help in giving your first directions. (d) The existence of organic cardiac disease, or of sim- ply feeble heart with a sluggish, relaxed state of circulation, generally decreases the ability to withstand bromides; hence the necessity of examining your patient's heart and arteries before prescribing, and of occasionally combining digitalis with the bromides. (e) Organic cerebral disease of any sort increases sus- ceptibility to bromism ; hence in cases of symptomatic or organic epilepsy, in which you should aUvays give some bro- mide while the rational indication treatment is being carried out, you should be extremely cautious; bromism may super- vene with moderate doses, sometimes very rapidly, thus blur- ring the diagnosis and leading to a premature fatal prognosis. TREATMENT AND MANAGEMENT OF NEUROSES. 15 (/) Acne slioiild never serve as a guide to the dosage of bromides. Its appearance does not depend as much upon the quantity of the drug given as upon peculiarities in the patient, as, for example, an unhealthy state of the skin with over-development of the sebaceous glands, and deficient ex- cretion of the bromine by other channels. Just as with iodides, a patient may have much acne while taking small doses of bromides, and vice versa. In some persons, fortunately, the acne shows most on the back and chest. Acne can be much controlled, though rarely entirely pre- vented, by giving the drug according to my method of large dilution in alkaline water, and by administering full doses of arsenic from time to time. We occasionally meet with indivitUiais who develop extremely severe acne of the confluent form, giving rise to the condition I have termed ulcus elevatum* more especially on the legs and arms. In such cases we should substitute some other anti-epileptic medicine in a way to be detailed further on. {g) Impending bromism is indicated by loss of reflex action in the palate and throat (and we should aim to ob- tain this effect in all epileptics), somnolence during the day, weakness, staggering gait, a dull, expressionless facies, partial aphasia, partial dementia, increasing knee-jerk, feeble car- diac action and reduced arterial tension, a peculiar foul breath, coated tongue, and anorexia. Jn the more advanced stages, hallucinations with associated delirium (sometimes active), increased difticulty in speaking, heavily coated brown tongue, and a typhous state appear. Death may ensue. In a subsequent lecture T shall dwell at some length on bromism as a factor in diagnosis and prognosis. In the treatment of idiopathic epilepsy we aim to keep up a slight degree of bromism, and this requites extreme care in the first dosage and in directing the necessary variations in * Opera Minora, p. 629. m LECTURES ON SOME POINTS IN THE doses from time to time afterward. I may be mistaken, but I consider it one of the most delicate tasks in medicine to keep a patient steadily at the point of therapeutic bro- misin for several years, avoiding truly toxic effects, and not allowing the nervous apparatus to re-acquire enough excita- bility to permit of an attack. In some cases we can never attain this happy mean, something in the patient's condi- tion or in his mode of life causing inexplicable oscillations. A frequent objection to bromide treatment by parents is that it tends to produce dementia and insanity. The reply to this is that scores of years before the bromides were used in medicine it was known that dementia and in- sanity were frequent results of the disease — its termination in many cases. This danger is inherent in the disease, and 1 do not believe that more epileptics become demented now than did fifty years ago ; probably fewer, as we certainly control the disease better and almost cure it much more often than our predecessors. A judicious bromide treatment does not, 1 firmly believe, produce or hasten dementia in epileptics. [h) Now let us consider the choice of bromide and method of administration. My own conclusion, based on a good deal of experimenting, is that it is best to use a single bromide and to administer it simply dissolved in water. I have failed to become convinced that there is much difference in the anti-epUeptic action of the different bromides,* or that there is any advantage to be gained* by combining them. The bromide of sodium has seemed to me less irritating to the gastro-intestinal tract, and, when freely diluted, it presents the advantage of being almost tasteless. " In using bromide of potassium we have, besides the bromic effect, a depressing influence upon the heart from the potassium. Many years * If there is any theoretical chemical difierence it is in favor of sodium bromide, one atom of which contains seventy-eight per cent, of bromine, while potassium bromide contains only fifty-three per cent. TREATMENT AND MA\A(iEMENT OF NEUROSES. 17 H<2;o I o-avc up the complex formulas which were then in vogue [e.g., Brown-Sequard's celebrated mixture, etc.), and wrote for a simple watery .solution. Having many cases to treat in clinic and private practice, I resolved to adopt a standard solution so calculated that one teaspoonfnl should contain about fifteen grains of the bromide (single or com- bined). This formula has remained useful since I adopted, six years ago, the metric system; one teaspoonfnl contains about one gramme. By means of such a formula I have fuund it easy to follow up the systematic treatment of many patients. The doses can, of course, be varied in- finitely between extremes simply by directing so many tea- spoonfuls or half-teaspoonfuls to be taken in the day, and if the patient (often seen only at long intervals) tells or writes y<>u how many teaspoonfuls he is taking, you can at once calculate the quantity of bromide which is being used without referring to records or prescription-stubs. I see no reason to regret having adopted this plan, and can cordially recommend it to you. The formulas are : Apothecaries Weight. IJ Sodii broraidi 3 iss. ; Aqua? 3 vij. One teaspoonfnl contains about fifteen grains of the salt. Metric Weight. Sodium bromide 45*00 ; AVater >. 200-00. One teaspoonfnl contains nearly one gramme of bromide. The calculation is based upon the assumption that 3 vij, or 200 grammes, contain from forty-seven to forty-nine tea- spoonfuls. The small errors which occur in such formulas, and such as arise from awkward or careless measurement by the pa- tient, can only amount to one or two grains per dose, and are of no special importance, because you feel \our way 18 LECTURES ON SOME POINTS IN IIIE along with increasing or decreasing doses until the desired effect is obtained. As it is, however, extremely important that the same measure be constantly employed by a patient during the course of his treatment, I usually direct that a measuring or medicine glass, clearly marked in teaspoon- fuls, be used, because teaspoons vary a great deal. Accessory medicines, such as belladonna, arsenic, digi- talis, mix vomica, etc., 1 almost always give by separate pre- scriptions, so that their doses may be varied independently. With reference to the vehicle, I may say that I have been thanked numberless times by patients for omitting syrups, bitters, and even flavored water from the prescription. Of course, any of the common soluble bromides may be given by the same formula. The bromide of zinc and monobro- mate of camphor are better administered in capsules. (i) Perhaps the greatest peculiarity in my method of giving the bromides has been to insist on large dilution of the dose. I believe that much of the gastric irritation re- ported by physicians as obstacles to a thorough bromide treatment is due to the giving of from twenty to forty grains of bromide in an ounce or two of water. I have met with patients who by direction used only an ounce of water with each dose. I direct that the smaller doses, say up to thirty grains, be given in half of a large tumblerful of water, and the larger doses, from thirty to sixty grains, in a big tumblerful ; to be drank slowly in all cases. At this degree of dilution the salty taste of the drug is hardly perceived, and I believe that it is most quickly absorbed even by a delicate stomach. At least I can state it as a fact that 1 have seldom had gastric derangement in my epileptics. As regards a choice of liquids for dilution, ordinary drinking-water will do, but T believe that a slightly alkaline water favors the rapid and easy absorption of the remedy, and prevents its decomposition in the stomach. Conse- TREATMENT AND MANAGEMENT OF NEUROSES. 19 quently I usually order the dose to be taken in artificial Vichy water (siphons), or in Buffalo or Londonderry lithia waters.* Where a more decided alkaline effect is desirable, imported Vichy water ("Celestins" or " Hopital " best), or the " still '' lithia water made by the Hygeia Company, of New York, which contains a useful amount of carbonate of lithium — viz., twelve grains to the U. S. gallon of distilled water, or 1 to o,000.f For poor or clinic patients I direct that a pinch (a quarter of a teaspoonful) of bicarbonate of sodium be added to the glass of water. The bromides may be administered in milk, and I frequently order this in the case of little children. (j) Time of administration. This varies more or less according to the nature of the' case in hand, and you should choose the hours of giving the bromide only after a careful study of the symptoms, particularly as to the chronology of the attacks. It is partly for this purpose that during the first two or three interviews with the patient you should en- deavor, with the help of his relatives or companions, to con- struct a table of the attacks which have preceded the first interview, so as to have, as far as possible, a graphic repre- sentation of the order and frequency of attacks. This can seldom be done except for a few days or weeks prior to the first visit, because of want of any record and imperfect recol- lection by patient and friends. However, as the case pro- gresses under your care, such a diagram is gradually con- structed and proves of much help in practice. My first general rule is to give as few doses per diem as possible. * For more details on the utility of alkaline waters as a vehicle for certain remedies, see Archives of Medicine (New York), vol. vi, August, 1881, and Opera Minora, p. 529. f We still need from our enterprising manufacturers a supply of pure (distilled) waters, " still " and sparkling, containing efficient quan- tities of remedies, such as lithium and potassium carbonates, arsenic, iron, etc., singly or in combination. 2 ) LEOTURE.S ON SOME POLNT.S IN THE This is partly to make punctual taking more easy, partly uot to interfere with the patient's occupation or school-work, and also in some cases to keep the treatment concealed froni those out of the family circle. A second rule is to give most, or even all, of the bromide destined to influence the patient for twenty-four hours at a time within four to six honrs of the time when attacks are most likely (judging by the rec- ord) to occur; very much as we give quinine for intermit- tent fever. In a few eases all attacks occur in the night, between 10 p. m. and 7 a. m. In such cases it has been my practice to administer all the day's bromide at one dose of forty, sixty, eighty, or even over a hundred grains, properly diluted, at some time during the evening — between immedi- ately after the evening meal (7 or 8 p. m.) and midnight. In some cases, where the seizure is most probable just before rising, I have the patient roused at 2 or 4 a. m. to take part or the whole of his dose. Tn many cases both diurnal and noc- turnal attacks occur distributed with some regularity ; and in these I give the larger part of the total daily dose from four to six hours before the most dangerous time. Thus it is very common for me to order (to an adult male patient) two teaspoonfuls (=30 grains) of the bromide solution on rising, and two or three, or even four teaspoonfuls after sup- per, or vice versa. This often suffices to keep up a varying degree of therapeutic bromism, deepest during that half of the day when attacks arc most to be apprehended. In some cases no sort of regularity can be ascertained ; attacks are liable to occur at any time. Then the bromide must be given three or four times a day in about equal doses. The first dose of the day T almost always direct to be taken on waking, in order to secure a bromic influence as early as possible in the day. It should here be remarked that while this early dose largely diluted is very acceptable to and easily absorbed by most patients, it occasionally TREATMENT AND MANAGEMENT OF NEUROSES. 21 causes gastric irritatiou, and must be postponed until the pa- tient shall have had some food. Other doses during the day I always give after food, except, of course, the bedtime dose. A small point of practical importance which I might mention here is that a dose of Carlsbad salts, or drops of nux vomica, may with great advantage be given witli the early morning dose to many patients. In the case of patients who are obliged to travel about, and of those who need only one dose at bedtime, it is well to have the bromide put up in powders of the proper size. Sodium bromide is sometimes delitjuescent, but this diffi- culty is obviated by using waxed paper, and keeping all the powders in a tightly closed tin box. In the same cases ef- fervescent salts of lithia or potash may be used to make the alkaline solution at the time of taking. Having thus spoken of the exhibition and division of the daily dose, I will now consider the question of uniform- ity of dosage fron:i day to day, week to week, etc. In a few cases, particularly those of grand mal, in which attacks oc- cur only at night, after you have discovered the dose neces- sary to produce therapeutic bromism, it is not necessary to make any change for months or even years, I have had patients doing well (/. e., perfectly free from attacks and in good health) taking four teaspoonfuls (= 60 grains of XaBr) of the solution, or an equivalent powder, at bedtime for three years and more. Many cases Tiave attacks at in- tervals which may be quasi-regular — e. (/., pre-menstrual, fortnightly or weekly (approximately). In such cases much good may be done by increasing the daily dose just before the dangerous period and keeping this up for a few days then returning to a minimum quantity. In this way the bromism is made to follow a curve corresponding to but an- ticipating that of the attacks. In many female epileptics, whose epilepsy is not at all of reflex origin, many more at- 22 LECTURES ON SOME POINTS IN THE tacks are grouped about the beginning of tbe menses or oc- cur just before. In such cases very small doses (from ten to twenty grains twice a day) will suffice for the majority of the days in each month, if the dose be raised to forty or sixty grains twice a day for the four or six dangerous days. There are many other reasons which demand a tempo- rary increase or decrease in the daily dose of bromides in epilepsy, and you should always bear these in mind. Only by unceasing vigilance can you prevent relapses or avoid plunging your patient into a deplorable state of bromism. Reasons for increase of dose : 1. Increasing age and size of young patients ; particularly the approach of the menstrual function. A chronic case of epilepsy which, at the age of ten or twelve years, has been doing well with from twenty to sixty grains of bromide a day, will need an increased dose every two years at least (unless, of course, the attacks have been completely suspended). 2. The exposure of the patient to unusual excitement or fatigue. Thus, in a chronic case, I direct an extra dose of ten, fifteen, or twenty grains to be taken before the patient goes to a party, or to the theatre, or before starting on a journey. This little precau- tion is, I believe, of much service, and enables yon to keep the ordinary dose down to a minimum. Reasons for reduc- ing the dose of bromide : 1. When a patient has been three years without any manifestation of the disease, I begin a systematic reduction of the bromide, taking off from a half to one teaspoonful (7 to 15 grains) every three or four months. This brings tbe dose down to a very small quan- tity by the end of the fourth year, when, in very promising [i. e., perfectly healthy) subjects the medicine may be alto- gether omitted and strict hygiene alone enjoined. But, even then, after four years of perfect freedom from grand or petit mal, I believe that it is well to give some bro- mide occasionally, when the patient is to be exposed to *^ TREATMENT AND MANAGEMENT OF NEUROSES. 23 excitement, worry, or fatigue. 2. The seasons of the year, by their influence on health and bodily strength, make some difference in the dosage. Thus, maximum doses are well borne in autumn and winter, while in the hot, debilitating summer months a marked reduction should be made in many cases, under penalty of pathological bromism. 3. Temporary ill-health. One of my cardinal rules, and one whieb I enjoin most emphatically upon the patient and his friends at the beginning of treatment, is that the bromides may be reduced, but must never be wholly omitted — at least, not without the direct order of a skilled physician. During common colds, attacks of diarrhoea, simple acute febrile diseases, and surgical affections a certain reduction should be made, as under these cooditions bromism easily ensues. Besides, we know that injuries and acute diseases of themselves act as anti-epileptics, and that there is little danger of an attack until convalescence is advanced. Still, a small quantity should be given every day. In case of very severe illness, especially those in which a typhous condition or tendency is present, the drug may be discontinued for a few days, to be resumed in small doses as soon as recov- ery begins. (k) It is extremely difficult to insure the necessary regularity in the taking of broniides, and without abso- lute exactness in this respect success is impossible. One difficulty lies in the forgetfulness and feeble-mindedness of many epileptics; they mean to take their medicine regu- larly, but often forget it. This obstacle I have to a great extent overcome in my practice by insisting that the doses shall be given, even to adult patients, by another person — a relative or friend of the patient. I now make this a condi- tion of my assuming charge of a case. I make some one else than the patient responsible for the dosage. It causes trouble to the family, but the results are gratifying. Be- r^ 2-1: LECTURES ON' ROME POINTS I\ THE sides the element of forgetfuliiess, there is the danger, by no means imaginary, that the patient shall take an extra dose, or a double dose when he has the fancy. Occasion- ally we have to deal with a friendless patient, or one who is exceptionally well-bulanced and exact; in which cases we nnist or may allow him to take the medicine himself. The adjuvants to the treatment may usually be left in the pa- tient's hands, except often the arsenic. Other obstacles con- sist in the over-confidence, discouragement, or ignorance of the patient. Very often, when a person has been taking bromide for several months, or a year or more, and has been free from attacks, he will of liis own accord cease or intermit the bromide, with the certain result of relapse. Or, after seeking the proper dose for many weeks, the epi- leptic attacks continue or unpleasant bromisra is produced, and in such cases only full confidence on the patient's part and frank statements of the .difficulties by the phy- sician can insure continuance. Ignorance of the nature of the attacks is a considerable difficulty in the way of suc- cessful treatment. Frequently the patient knows next* to nothing of his disease, or thinks that he "faints," or has " dizzy " or " nervous spells," and naturally lie rebels against the rigid hygiene and exact dosage you direct. Occasionally, in the case of a very docile child, it may be well to keep the nature of the ailment secret, and trust to parental authority and watchfulness to secure thorough treatment. Usually, however, the better plan is to tell the patient, in guarded terms, that he has epilepsy, or that his attacks resemble or threaten epilepsy. By tact the physi- cian can, in this, as in cardiac disease, tell the patient enough to insure obedience without producing alarm or despair. More especially is this frankness necessary when patients are from sixteen to thirty years of age, a time when court- ing is in order and when a matrimonial engagement may be TREATMENT AND MANAGEMENT OE NEUROSES. 25 contracteJ with or witlioiit the parents' knowledo'e. Much misery may be jirevented by letting; the patient know more or less about his ailment, and making him understand that an engagement should not be thought of until a cure has been obtained. A difficulty, also due to ignorance, is that patients, relatives, and even the family physician, refuse to admit the epileptic nature of very slight attacks. I have known a physician allow his own daughter to go on for twelve years with petit mal without making any attempt at treatment or seeking advice.* Travel sometimes stands in the way of continuous treatment, but it need not if you are careful to give written directions to your patient, and see that he goes off with a sufficient supply of medicines and with prescriptions. In order to insure regularity in the treatment, my custom has been to explain the nature of the case, and the absolute necessity of faithful, exact treatment, to the patient and his responsible relatives or friends, and to tell them that I shall give up the case unless everything is done precisely as ordered. Besides, to avoid any excuse for neglect, I give written directions at each visit about the medicines, diet, hygiene, and amount of work to be allowed. This means trouble and the expenditure of a little more time, but, gentlemen, it also means success, relative or abso- lute. More especially is it desirable to give written instruc- tions to cases which, as they are doing well, you see only a few times a year. From these statements you perceive that I am in favor of what has been termed the continuous dosage of bromide as against the intermittent giving of larger doses. Most emphati- cally I am. The latter plan must, of necessity, be to a great extent a haphazard or " hit-or-miss" plan of treatmerit.f * Opera Minora, p. 547, Case IX. Also ia N. Y. Medical Record, Aug. 6 and 13, 1881. f Dr. L. C. Gray, in an excellent paper on this subject (N. Y. Med, 2 26 LECTURES ON SOME POINTS IN THE I would have you always bear in mind that the problem is to give just as little bromide as shall secure the patient against attacks; a distinct therapeutic broniism is to be produced and kept up, and pathological bromism avoided. It may seem to some of you that I have gone into the question of the administration of bromides at an unneces- sary length, but I think I am justified in this by the fact that the books accessible to practitioners do not, and indeed can not, give necessary details, and that I have found the failure of excellent physicians in cases of epilepsy to be due to want of knowledge of many of the points I have brought to your attention. I trust that this will be an acceptable excuse for being so prolix. Besides, I trust that 1 have suc- ceeded in impressing upon you that the successful manage- ment of a bromide treatment requires extreme attention to details and ceaseless vigilance, besides knowledge. The question is often asked, Can you not give some other drug besides bromides to subdue or control the at- tacks ? In some cases this is asked because the patient is tired of taking bromides, or has a prejudice against them, but in other cases the reason is much stronger, and consists in the fact that the patient is unfavorably affected by bro- mides, severe confluent acne (ulcus elevatum), persistent in- digestion, undue somnolence from small doses, or dementia being produced. Such cases are rare, but are just those that tax our resources. A few years ago the answer would have been negative ; no drug was then known which con- trolled epilepsy in a manner at all comparable with that of bromides. Belladonna, zinc, nitrate of silver, nux vomica, arsenic, etc. — an endless number of drugs — have been pro- posed for the treatment of this disease, but not one of them will secure long intervals of freedom. Some of them, Jour., June 28 and July 5, 1884), has likewise reported his failure with the intermittent plan. TREATMENT AND MANAGEMENT OF NEUROSES. 27 particularly belladonna and nux vomica (or tlieir alkaloids), are useful as adjuvants to the bromide treatment, and should not be neglected. In the year 1882, guided by the well-known efficacy of chloral hydrate in eclampsia of adults or children, and in status epilepticus, I began incorporating some of this drug with the bromides, substituting a certain amount of chloral for a like amount of bromide. I adopted two formulas on the same plan as my simple bromide solutions, viz. : (1) A weaker solution : Apothecaries^ Weight. ^ Chlorali 3 ij ; Sodii brouiidi . 3 x ; Aqufe 3 vij. Metric Weight. I^ Chloral 7-50; Sodium bromide 37*50 ; Water 200-00. One teaspoonful of this solution contains about three grains of chloral and twelve grains of bromide. (2) A stronger solution : Apothecaries' Weight. IJ Chlorali 3 ^s. ; Sodii bromidi. 3 j ; Aqupe >. . 3 vij. Metric Weight. IJ Chloral ". 15-00; Sodium bromide 30-00 ; Water 200-00. Each teaspoonful contains, approximately, 5 grains of cliloral and 10 grains of sodium bromide ^15 grains (1*00) of anti-convulsive drugs. I have been credited, through a friendly mistake, with 28 LECTURES ON SOME POINTS IN IHE proposing chloral as a "cure" for epilepsy. Such a claim would be absurd ; I have never referred to any drug as a " cure " for epilepsy. But I have found this new combina- tion of much utility in the long continued treatment of some cases of epilepsy ; that is all. In a few cases 1 have gradu- ally increased the chloral to an equal quantity with the bromide, or even more. What are the indications for tlie use of a chloral-bromide solution in preference to a simple bromide solution ? First and foremost, the occurrence of very severe acne, of confluent form, with resultant large, elevated, foetid ulcers on vario.s parts of the body, more especially the legs. In 1882 * I gave a description of this lesion, which is extremely painful, and which can hardly be cured while the patient is taking useful doses of bromide. Later I learned that the lesion had already been described by Voisin.f In several such cases I have substituted chloral for a large part of the bromide, with remarkable results, the ulcers healing rapidly under a simple antiseptic dressing, the patient's general health improving by cessation of pain and better sleep, and, equally iuiportant, the attacks being prevented fully as well, perhaps better, than by the free use of bromide alone. In the last ten years I have had under my care a case of in- curable chronic epilej)sy (from three to six attacks a year), in which simple but deeply-marking acne of the face had repeatedly led the patient to give up bromide treatment, with the usual result of aggravation of attacks each time, ller face was and is still extensively scarred, as if by small- pox. In the last two years, taking a solution (same stand- ard strength) of equal parts of bromide and chloral, she has * Opera Minora, p. 629 ; or Archives of Medicine (New York), October, 1882. f De I'emploi du bromure de potassium dans les maladies nerveuses. Paris, 1875. TREATMENT AND MANAGEMENT OF NEUROSES. 29 had fewer attacks ttan at any previous time, and hardly one pustule a month has appeared. Another indication for this general substitution of more or less chloral for equivalent parts of bromide is unusual de- bility and mental dullness from the amount of bromide found necessary to control the attacks. If, in such a case, we reduce the bromide even by half a teaspoonful (7^ grains, or 0*50), convulsions recur. Now, with such a pa- tient, you will be surprised at the improvement which fol- lows giving some chloral (never as much as for severe acne). The first few doses u)ay produce a (quasi-normal) sleepy feeling, but this soon wears off ; the circulation improves, the patient grows stronger, and the memory and other mental functions rapidly regain as much power as they had prior to saturation by bromide. This category of cases is quite large, and in feeble, demented epileptics I often begin treatment with the weaker chloral-bromide solution, using the stronger later, if bromism is too easily produced. Occasionally we meet with a case in which the cessation of epileptic seizures through bromide treatment is followed by the appearance of mental disturbance, usually mania. I have not seen such a case (they are excessively rare out of asylums) since beginning to use chloral, but I incline to the opinion that its substitution, in part or wholly, for the bro- mide might control both the physical and psychical mani- festations of the disease. I am confident that chloral is as good an anti-epileptic or anti-convulsive agent as the bromides, and that it is much better tolerated by some patients ; it certainly af- fects the cardiac nerves and cortex of the brain less un- favorably. Occasionally, 1 may say rarely, ocular irritation has been produced by the chloral, but no other bad effect 30 LECTURES ON SOME POINTS IN THE has been observed. The narcotic effects of the drug are not noticed, or very sliglitly, after a few days or weeks of use. This lecture is already so long that I can only refer very briefly to a few of the many other points of interest in the treatment of epilepsy. I have already expressed my opinion as to the value of castration, ocular treatment, and the administration of the numerous drugs which from time to time have been fash- ionable, and from which each originator expected so much. These are accessory or adjuvantial treatments or remedies, each one useful in well-selected cases, and we should en- deavor constantly to discover indications for their use ; but I beg you never to depend solely on any one of these meas- ures or drugs, however lauded it may be by its advocates. In idiopathic epilepsy (and to a less degree in the symptom- atic form) a continuous systematic treatment by bromides, alone or combined with chloral, is indispensable, and I be- lieve that it is criminal to omit it. Without it our patient is sure to have more and more attacks (even if a temporary long interval be at first obt^^ined, as in a few of the cases treated by section of ocular muscles and by glasses). With the bromide treatment, carefully watched, we are able to relieve almost all cases of (jrand mal, and in a certain pro- portion of cases to obtain intervals of from one to five years free from seizures — almost a cure. The evil effects of bromide saturation are avoidable in ninety-nine out of one hundred cases by watchfulness and by co-operative medication, and especially by attention to hygiene and diet {vide next lecture). The treatment of petit vial is much less satisfactory than that of grand mal, and frequently it is not at all checked by reasonable doses of bromides, or even when broraism is well marked. Although there is a slight tonic TREATMENT AND MANAGEMENT OF NEUROSES. 31 spasm in nearly all petit-mal seizures, the motor zone and apparatus are less involved than in grand mal, so that reme- dies like bromides and chloral which diminish the excita- bility of those parts of the brain are not theoretically suffi- cient, and seldom succeed in practice. I have derived good results from combining with a very moderate bromide course the free use of strychnine and atropine or belladonna, giving usually the sulphate of strychnine dissolved in dilute nitro-muriatic acid, gr. ij t>) 3 j (0-10 to 30'00), the dose to vary from six to six- teen drops after meals, well diluted. Atropine is conve- niently given in the shape of pills or granules oi -^^-^ grain (0-0002), which are manufactured by several reliable firms. I give from three to four or even six a day — enough to pro- duce a decided effect on the pupils and mouth. Digitalis, ergot, and ergotine have seemed to succeed in some cases of petit mal, and I am inclined to think that it is in such cases tl>at accessory treatment of existing ocular defects may be of greatest use. In this may lie the reason for the success of atropine or of strychnine in diverse cases. In some there is weakness of accommodation and feebleness of the interni (exophoria) ; these will be benefited by nux vomica or strychnine, which has, as I have been led to believe by sev- eral years' observation, a specific effect upon the third cere- bral nerve, strengthening it and its attached muscles (inter- nal recti and ciliary muscle). In other cases, where the externi are weak (esophoria), belladonna or atropine, by producing a paretic condition of the third nerve and de- pendent muscles (including the iris), relieves the strain and brings relief. I desire to enter a caveat also as regards the beneticial action of these two drugs in different cases of headache and of cephalic paraisthesia (many cases of so- called cerebral hypertemia) from eye-strain. The drugs atropine or strychnine may be used in such cases for diag- 32 LECTURES OX SOME POINTS IN THE nostic as well as for therapeutic purposes. Allow rae to repeat that I believe that strychnine strengthens the third cranial nerve and its raiiscles (especially the internal rectus and ciliary nuiscle), while atropine (also gelseminni and co- niura and mydriatics generally) produces a paresis of the same nerve and muscles. Thus one drug acts as a tonic of special local action and of considerable duration, while the other relieves strain by relaxing or weakening the same nervo-rauscular apparatus. These organic affinities are not more singular than others which are well known in the fields of experimental and practical therapeutics. Let me ask yon to make a trial of these two indications in your treatment of headaches, bad feelings about the head (oc- cipital usually), and epilepsy — overactive interni and ciliary muscle calling for atropine, weak interni and ciliary muscle calling for strychnine. Digitalis, strophanthus, and caffeine^ are especially use- ful prescribed occasionally for patients whose hearts are dis- eased or weak and whose peripheral circulation is sluggish. They also best counteract some of the worst effects of too much bromide. A word about arsenic. It is invaluable as a remedy for the acne which annoys epileptics so much. Some authori- ties advise giving small doses (from three to six drops) of Fowler's solution with each dose of bromide for long pe- riods, but I have obtained better results by directing that a arger dose be taken for a short time occa>ionally ; thus, at one-twentieth-of-a-grain arscnious-acid granule after each meal for one week in each month. Thorough washing of the face with a good soap and with a little ammonia added to the (warm) water should be practiced daily. * Pure caifeine only should be used, the citrate being a doubtful salt of very uncertain strength, TREATMENT AND MANAGEMENT OF NEUROSES. 33 Ointments are of little use, the best being those containing sulphur.* Iron and cod-liver oil are frequently called for in the course of a long-continued antiepileptic treatment. I shall refer more at length to the use of cod-liver oil while speak- ing of diet. One of the remedies to which I attach much importance, particularly in idiopathic epilepsy in children whose teeth are bad or notched or typically Hutchinsonian, is the bichloride of mercury. I give it for long periods of time in doses of from ji^- to -3L of a grain (0-0008 to 0*002) in an elixir of gentian or calisaya bark. My experience with iodide of potassium in such cases has not been satisfactory, though I mean to make further experiments in this direc- tion. A number of drugs which at one time had a transient run owing to hasty reports by enthusiasts — such as oxide and sulphate of zinc, borax, curare, nitrate of silver — are now believed to be nearly useless, and are seldom prescribed; they certainly should never be depended upon to the ex- clusion of bromide. I have taken up so much time with the details of the treatment of epilepsy that I can add but little of what I had intended saying about the treatment of some other neu- roses. Consequently I may be pardoned if I put the result of my experience in this matter in the form of brief didactic statements. IT. Chorea. — [a) Our mainstay in the treatment of this affection is still arsenic. I have long taught that one reason * The following modification of Diih ring's formula has seemed use- ful : 5 Sulph. precip 3 j (4-00) ; Camphorae 3 ss. (2-00) ; Cerati. simpl., ) -- z /ikaa\ *^ ' - iia 5 ss. (15-00). Ungt. aq. rosa?, ) o v / M. Sig. : To be applied at bed-time. , 34 LECTURES ON SOME POINTS IN THE why the medicinal treatment of chorea has seemed to be of little utility, and why a belief has grown up that the disease might terminate spontaneously, or only with the help of hygiene and tonics about as quickly as when strong drugs are used, is because physicians, almost without exception, give nearly useless doses of arsenic (Fowler's solution). Case after case has come to me, pursuing its semi-chronic or positively chronic course, while the patient was taking from six to ten drops of the solution. I have satisfied my- self that chorea can be greatly shortened by the proper ex- hibition of arsenic, but that to obtain a striking result it is necessary, in most cases, to go beyond fifteen drops three times a day. In many choreic patients when the dose of ten or twelve or fourteen drops of Fowler's solution three times a day has been attained, gastro-intestinal disturbance and redness of the eyes are apt to appear and necessitate a cessation of the treatment for two or three days. The important prac- tical point to recollect is that after this interval of rest you can and should begin again with the dose at which you left off, and then go on to the really efiicacious doses of from eighteen to twenty-five, or even twenty-seven, drops after each meal. Few cases of chorea, in my experience, show much improvement.until a dose of sixteen to eighteen drops ter die is reached. In the case of arsenic, even more than in that of iodides and bromides, very free dilution of the dose is necessary; a large tumblerful of alkaline water, "still" or effervescent, should be given with each dose. Another error in practice is to oblige the patient to drink the dose at once. There is no necessity for this, and it is much better borne if it is taken in divided drinks during the hour following a meal. As regards the evil effects of arsenic, I have only once ^n my large experience found albumin or albumin and casts TREATMENT AND MANAGEMENT OF NEUROSES. 35 in the urine of clioreic patients, even when their eyes were puffj. In this single case the patient was an adult, and it is very probable, from the nature of the casts found, that renal disease existed prior to the administration of the arsenic. Herpes is said to be an occasional result of the excessive use of arsenic, I have had only one case in which, while the twelve-year-old child was taking about twenty -five drops ter die, there appeared a large vesicle on one side of the right thumb just back of the nail, which left quite a deep scar. Symptoms of multiple neuritis or of optic neuritis I have never seen from the medicinal use of ar- senic. It is still my practice, however, to examine the urine of choreic patients from time to time during the arsenical treatment. (6) A most important factor in the successful treatment of chorea, especially in its chronic and relapsing forms, is rest — absolute rest. I can not overestimate its value. In many cases of simple recent chorea (first attacks of less than six months' duration) I have obtained a complete cure in three weeks by a combination of absolute rest, full dosage of arsenic, and nutritious food. The patient must not be allowed to play or read in bed, but should be amused by other persons by conversation and reading. Nor do I al- low several members of the family (especially other children) to be in the same room at one time. The rest should be mental as well as physical. Some of these patients are sleepless at first, but a few evening doses of chloral or of hyoscyamia will procure quiet sleep, and may soon be omit- ted or given only twice a week. When the choreic move- ments have entirely ceased, the arsenic should be stopped at once rather than gradually, but release from the rest should be done only in the most cautious manner, and even during later convalescence for two or three months it is well to have the patient lie perfectly quiet for an hour or two in 36 LECTURES ON SOME POINTS IN THE the latter part of the afternoon. Of course many choreic patients are anieinic and need iron, cold sponging followed by hard rubbing (but not massage). x\gain, others with weak hearts need digitalis or strophanthus as an adjuvant to the arsenical treatment. Except in cases where great irritability or sexual excitement exists, I consider the bro- mides as contra-indicated and injurious. Chorea is essen- tially a disease in which nerve power, particularly the inhibi- tory cerebral action, is deficient, and in such a condition the bromides only perpetuate or aggravate the evil. Circum- cision is necessary in some cases ; treatment of vulvar irri- tation in others. Of all the other modes of treatment of chorea, there is only one which I desire to speak of at some length. I refer to the correction of ocular defects. This is really an important matter, and Dr. Stevens deserves great credit for having so strongly called the attention of the profession to the desirability of examining by strict modern methods the refraction and oculo-motor functions of the eyes in all choreic subjects.* IJis idea of the im- portance of ocular defects or eye-strain in the genesis of chorea is, I think, extravagant, and I doubt if any case of general chorea has ever been or can be cured within a month by ocular treatment alone. Of the five cases of chorea treated by Dr. Stevens for the commission of the New York Neurological Society, f only one was cured (? a trace of cho- rea reappears in this patient [No. 1] J about the time of each menstrual period), and one (No. 4 of Report) was decidedly improved, but both these patients had been thirty months under treatment, had each had from thirteen to fourteen * George T. Stevens, Functional Nervous Diseases, New York, 1887, p. 81 et seq. \ Journal of Nervous and Mental Diseases, New York, November, 1889. J Idem, December, 1889 ; full histories of cases are there given. TREATMENT AND MANAGEMENT OF NEUROSES. 37 tenotomies performed, and had worn from eight to twelve pairs of glasses ! In one of these cases (Case 1) improvement really began at about the thirtieth week of treatment, and in the other (Case 4) after the fifty-second week. One of these cases (No. 1) had resisted a treatment by arsenic and rest (?) of three months' duration, but the other (No. 4) never had a thorough arsenic course and was not put to bed (they were both patients of mine), but was turned over to Dr. Stevens within twelve weeks after my taking charge of him. In one other case (No. 11) some improvement appeared, leaving two cases unimproved. These results show conclu- sively that we can not depend on ocular treatment alone for the cure of chorea. I believe, however, that eye-strain here, as in epilepsy, is an accessory or secondary cause of much importance, and that every choreic person should be tested for defects and those found thoroughly corrected. It is possible that the rest-treatment to which I am so partial acts partly by relieving the patient of eye-strain, and what has been stated would also serve to explain why school-work is so injurious to choreic children and so often causes re- lapses. But the true pathological caase or condition of chorea, gentlemen, lies deeper than in ocular defects, or phimosis, or self-abuse, or cardiac disease. There is in all cases a fundamental, preliminary defect in cerebral power, often associated with anaemia ; a weak brain (often small) supplied with thin blood by a weak Tieart are conditions (besides inherited neurotic tendencies) which I hold to be fundamental in chorea, and which you should study most carefully in each case. On a brain so conditioned exciting causes of various sorts act powerfully, and a truly rational treatment demands their discovery and removal. (c) Is exercise good for choreic children ? In the ordi- nary sense of the word, I would reply emphatically No. Many a time have I observed immediate improvement in a 38 LECTURES ON SOME POINTS IN THE choreic child from stopping such exercises as tricycle riding, running games, etc., without enforcing strict rest, and be- fore much arsenic had been taken. The question is differ- ent with respect to systematic gymnastics. This has been and is still recommended as a cure for chorea, but my ex- perience with it has been unfortunate, perhaps for want of judicious instructors. Only this winter I cured a case of chorea of two years' duration (a chronic case) by partial rest (one hour in the forenoon and two hours in the after- noon) and arsenic, cod-liver oil, and cold sponging, in seven weeks, this period including a week's illness from influenza. When convalescence was well marked and only very slight jerks were visible occasionally, I sent the child to a special gymnasium in New York where the drill was personally directed by a lady physician, but in a week the child was much worse. Still, I am inclined to think that, during convalescence from chorea, the practice of a few gymnastic movements under a teachei's or parent's guidance, and with no one else present, may prove of advantage. The move- ments I have them do are (1) deep inspiratory acts with simultaneous outstretching of the arms to the fullest extent so as to expand the thorax thoroughly — from four to ten such inspirations are enough for one seance ; (2) forward and backward movements of the arms; (3) stooping forward so as to touch the toes with the finger-tips ; (4) rising from a squatting posture. Every movement should be slowly done with force and completely finished. A seance of five minutes twice a day is long enough, and a few minutes of rest should follow. Very light wooden dumb-bells may be used, or weak rubber straps attached to the wall (a simple "par- lor gymnasium ") are not objectionable, but Indian clubs I do not allow, because they must be used with rapid and rather bewildering movements. {d) The prophylaxis of chorea after a first attack is a TREATMEXT A\D MANAGEMENT OF NEUROSES. 39 subject of much importance, as too many cases relapse year after year, usually after two or three months of school-work in winter, or after over-exertion during the summer vaca- tion. Hygiene, including sufficient nutritious (animal and fatty) food, is here of prime importance, as it has been my experience that a period of anaemia and debility (" running down," as the popular phrase is) often precedes the reap- pearance of choreic jerks. If the child have defective eyes, they should be re-examined before the beginning of every school-year and necessary changes made in glasses ; but, above all, the child should be made to wear the glasses (in spectacle-frames much better) constantly, or exactly as or- dered by the oculist. With these and other precautions it is not necessary to withdraw a child from school (unless the school-room is seriously defective in light, ventilation, etc.) after a first attack of chorea ; yet it is well to forbid such children naaking unusual exertions to compete for prizes, indulging in violent play, etc. Til. Migraine. — ^Yriting in 18V7,* I made a strong plea for the systematic and prolonged use of cannabis indica in this disease. I was then strongly impressed with the idea that, besides the (unknown) central functional lesion in this disease, conditions of raal-assimilation and lithaemia played an important part in the pathology of the attacks. It is a fact that a considerable number of the victims of migraine are gouty, and present*from time to time deposits of oxalate of lime, uric acid, and positively excessive urates; and I still believe that this indication should be met by diet, exercise, and medicinal treatment. But since the publication of that essay a new and most * A contribution to the therapeutics of migraine, Opera Minora, p. 242; New York Medical Record, December 8, 18*77. Cannabis indica was first recommended as a remedy (given in continued doses for months) for migraine by Dr. Greene in the Practitioner, vol. ix, p. 267, 1872. 40 LECTURES ON SOME POINTS IN THE powerful light has been thrown upon the pathology of mi- graine by the researches of oculists and neurologists. Thom- son and Weir Mitchell* had already called attention to the importance of ocular defects and consequent nervous strain in headacbes (they did not specify migraine), and suggested that they be treated by glasses. These observers and many oculists since were not aware of the powerful eye- strain resulting from the ill-balanced action of the extemal ocular muscles, which probably is just as important a factor as errors of refraction. It is here that the profession owe a debt to Dr. Stevens,f of New York, for his methods of testing the ocular muscles and for the persistence with which he has urged treatment of eye-faults in migraine and other headaches. The proportion of subjects of migraine who have ocular defects is amazing; very nearly all have either errors of refraction or muscular insufliciency, or both combined. This was noticed before Stevens's name was known in connection with the subject, for in 1882 I re- ceived from Dr. G. C. Savage, J of Jackson, Tenn., a very courteous letter challengino- me to furnish a case of mi- graine in a person with normal eyes. I have not yet met with one, though I have been told of two or three by ocu- lists in whom I have confidence. Of course the statement as to the invariable concomitance of eye-faults with mi- graine presupposes that the patients have been examined thoroughly — i. e., under the full effects of atropine for re- fractive errors, and by Stevens's method for muscular insuf- ficiency. I regret to say that there are still oculists of good * Headaches from Eye Strain. Am. Jour, of tlie Med. Sci., 1876, i, p. 363. f Functional Nervous Diseases, New York, 1881. X Shortly after this, Dr. Savage published an article entitled Head- ache caused by Eye-strain, in the Philadelphia Medical and Surgical Re- porter, July, 1882. TREATMENT AND MANAGEMENT OF NEUROSES. 41 standing wbo examine the eyes of headache eases in the most careless way, ordering glasses without having used atropine, and ignoring the muscles altogether. This has happened under my observation in New York within six months. Better no glasses than to procure them (often at considerable expense) without a searching examination ; headaches are aggravated, other distressing feelings are pro- duced in the head, and the disgusted patient flings away his glasses and can only rarely be induced to submit to another trial of treatment in this direction. The fact that subjects of migraine have defective eyes partly explains the remarkable transmission of the disease through several generations in one family, particularly in the female members, who are more apt to strain their eyes than males, because their needle and piano work requires very exact fixation and accommodation for long periods of time. Another argument in favor of the ocular origin of migraine is that other remarkable fact that in many persons of both sexes the attacks diminish and cease between the ages of forty and fifty years. It is at this period that the power of accommodation becomes exhausted and a large part of the unconscious strain which has been going on from early youth is removed. Still the gouty or lith?emic disposition is also hereditarj', but perhaps not as extensively so as ocular defects. With reference to the good effects of cannabis indica (also belladonna or atropine) when used systematically in the largest doses the patient can comfortably bear, I could in 1882 give no explanation ; but now it seems to me that the modus agendi is pretty clear. The principle involved I have already referred to — viz. : that mydriatics (belladonna, atropine, cannabis indica, hyoscyamine, etc.) exert a seda- tive and even a paralyzing influence on the third cere- bral nerve and its attached muscles (including the ciliary). 42 LECTURES ON SOME POINTS IN THE Now, in many cases of headache, whether of the migraine type or not, there is an (usually) unconscious effort or strain in accommodation, expended chiefly upon the ciliary mus- cles and the internal recti. It is by this effort, costing the expenditure of so much nervous force or energy, that the ocular defect (hypermetropia, hypermetropic astigmatism, myopic astigmatism, or astigmatism ; weakness of the in- terni or a combination of this with ocular defect?) is over- come and corrected more or less successfully for longer or shorter periods of time. This theory of the genesis of headache explains its first appearance (as a rule) when the patient first begins to pursue studies requiring much read- ing or begins to apply herself more to needle-work (from eight to fifteen years of age) ; its remarkable diminution in frequency and its frequent cessation when the accommoda- tive power is lost (between forty-two and fifty years of age) ; but also the more puzzling phenomenon of the late ap- pearance (between twenty and thirty years of age) of a first paroxysm followed by others more or less frequently. In these cases of late headaches, the patient, being in good health, is able to expend a large amount of nerve force through the third nerve apparatus, and successfully corrects the ocular defect so as to render reading, writing, etc., fairly easy. But let this person have an acute illness (pneumonia, typhoid fever, lying in, etc.), or be obliged to nurse a child, or lose vitality in other ways, or has to use the eyes exces- sively for a time — the nerve power falls to a minimum, the strain relatively becomes much greater, and headache or pariBsthesise about the head appear. From very exact study of a number of cases of headache and of paraisthesise about the head (often falsely denominated cerebral hyperaemia), I feel sure that a healthy person may bear with ocular defects and the strain nece!>sary to nearly overcome them until far along in adult life, or even until accommodation begins to TREATMENT AND MANAGEMENT OF NEUROSES. 43 fail, before the symptoms show themselves. It should also be borne in mind that these two groups of symptoms due to eye-strain may develop very rapidly — almost suddenly — in an adult. I have oliserved several cases in which the pa- tients traced the onset of symptoms to one particular day, when something seemed to give way in the head, and there- after they had never been quite free from pain, pressure, fullness, numbness, etc., in the head. I beg that you will excuse this digression, but I was anxious to have a chance to lay before you a theory of headaches, and especially of paraesthesiae about the bead, which I have long entertained. But do not forget in these cases the deeply rooted or hereditary fault in the central nervous system, and in some cases the influence of litbsemia, wrong diet, and inert habits. To go back. It is in these cases of migraine and of non- typical headaches that the mydriatics do good, and they do good by reducing the accomodative effort and relieving the strain. Of course, by themselves they afford only partial or temporary relief; but, when combined with correction of the ocular defect by appropriate glasses and in some cases tenotomy, and, if a reduction in the use of the eyes can be secured, a cure results. Allow me to add one word about a class of cases of parsesthesise about the head, in which the symptoms are most pronounced when the patient is oTl the street, or in a large room, or at the theatre and church ; in other words, when his eyes should receive impressions from a distance, especially from moving objects (people, carriages, etc.), distinctly and easily upon homologous parts of both retinae. In these cases, besides refractive faults, there is very often, if not invariably, weakness of the external recti, or the condition designated by Stevens as esophoria. Sometimes a pseudo-agoraphobia results also ; the patient 44 LECTURES ON SOME POINTS IN THE is afraid to go out, or into theatres and churches. If he perseveres, the head symptoms are intensified, and great general nervousness, even a hysteroid attack, is brought on. In these cases the mydriatics (given by the mouth) exert a most happy influence; and section of one or both of the internal recti may at once produce an apparent cure. I qualify the word, because the rapid healing of the divided muscle (or tendon) usually brings about a relapse and ne- cessitates other operations. We do not yet feel sure that the operative treament of these cases affords more lasting relief than the use of prisms and of the appropriate inter- nal remedies for long periods of time. This question of the relation between ocular defects and cephalic symptoms is one of the most interesting practical ones of the day, and the more skilled physicians engage in its study, the sooner shall we arrive at definite therapeutic rules which may be applied deductively to future cases, which form a by no means insignificant proportion of the chronic diseases we are called upon to treat. Two precautions are necessary previous to beginning the treatment of a case of migraine by cannabis indica : First, to make sure that a good extract is used to dispense the pills; and, second, that the patient continues to procure the same quality of extract during the entire treatment if possible. Extract of Indian hemp is one of the uncertain preparations, and I have been in the habit for several years of specially writing for Herring's English extract. Squibb's preparation is also good, and T doubt not that a number of others may be equally so. The reason for al- ways using the same quality of extract for a given patient is that, as you increase the doses, very unexpected and sometimes decidedly unpleasant effects may be produced through a change of extract by the druggist. I usually begin by ordering a sixth of a grain (0-01) TREATMENT AND MANAGEMENT OF NEUROSES. 45 alone or in combination with arsenions acid — a sixtieth of a a^rain (Q-OOl) — or with iron, or with digitalis, according to indications, in pilular form, to he given three times a day, before meals usnally. Each week I increase the dose by a sixth of a grain (Q-Gl) until the maximum of toleration Is reached — /. e., a dose a little less than that which pro- duces a light-headed, semi-drowsy, dreamy state. Most adult male patients are able, after some training, to take a grain (0*06) of the best extract three times a day; women seldom more than a third or half a grain (0-02 to 0'03). This maximum dose is to be kept up for many months, a year, or longer. Occasionally, as in the con- tinuous giving of bromides, the patient develops, from some change in his condition, a greater susceptibility to the drug, so that it is sometimes necessary to vary the maxi- mum dose. During this prolonged treatment the patient's eyes may be corrected, his diet regulated, physical exercise gradually carried to considerable proportions, and, in some cases, the use of the eyes in reading, sewing, etc., reduced to a minimum. AVhen I refer to regulation of diet, ^ mean with refer- ence to the lithsemia (oxaluria) which is manifest in so many cases of migraine, and I do not refer to ordinary in- digestion. I must take this opportunity of saying that few quasi-medical notions have been so mischievous in practice as that which explains attacks of migranie and epilepsy by indigestion or " biliousness," The chief support of this notion (it is not worthy of the name of theory) is the fact that in migraine, and in some cases of epilepsy, vomiting (of partly digested food or of bilious material) is a promi- nent accompaniment of the attack. Careful observation and theoretical considerations long ago led me to look upon this vomiting as a result or as one of the symptoms of attacks of migraine and epilepsy ; and neurological authori- 46 LECTURES ON SOME POINTS IN THE ties agree in supporting this view. Migraine and epilepsy continue in spite of most careful regulation of diet based on supposed dyspepsia, and in most cases the vomited matter contains only good food partly digested. The rejected mass is very sour, but this is normal ; bile is also ejected if the act of vomiting is severe, but this is only due to strong prolonged muscular effort, and in no wise indicates a " bil- ious state." The same critical remarks apply, to my mind, to the real relation of vomiting to sea-sickness; the gastric dis- order is usually secondary and of no pathological importance. Besides, we well know that the headache of indigestion is diffused, often frontal ; the pain dull, with a tendency to drowsiness or even stupor — characters in sharp contrast to the neuralgic, unilateral, and paroxysmal (quasi-periodical) pain of migraine. I beg that you will pardon this digres- sion, but I have been led to make it because I have met with so many cases of migraine, and some few cases of epi- lepsy, which had been either neglected or maltreated be- cause of the physician's belief in this popular notion. The treatment of migraine which I have outlined — viz., that by the continued use of cannabis indica (or belladonna), by the correction of ocular defects, and of lithaemia — consti- tutes the general or interparoxysmal treatment. During a paroxysm it is best to suspend the medicines for twenty- four or forty-eight hours. In the suffering of the attack of migraine, often excru- ciating, patients clamor for relief, and not in vain. AVe are able to do much for their comfort. First of all, let me entreat you never to give morphine or opium. Patients who have tasted of this forbidden but delicious fruit will ask you for it at once, urging all sorts of reasons. The objections to the use of morphine in this and other neuroses I shall con- sider at length in a subsequent lecture. The two most suc- cessful remedies for the attack are antipyrine and caffeine. TREATMENT AND MANAGEMENT OF NEUROSES. 47 These should be given as early as possible — even before the onset of pain, as can be done in those cases which present optic or sensory precursory symptoms, or even only a sense of malaise. I believe that antipyrine was first given in mig'raine by Dr. T. S. Robertson,* of New York, tbough his paper on the subject appeared somewhat later than that by Dr. White, f of England. With Dr. Robertson, I believe that it is best to give a massive single dose of the remedy (at least after a preliminary trial has not revealed any un- due susceptibility to the drug), say of fifteen (!•) or twenty grains (1*50) to a female patient, and twenty (1'50) to thirty grains (2*) to a male patient. In the last year 1 have always given some digitalis — from five to ten minims — with each dose, to counteract the depressing effect of antipyrine on the heart. In many cases such a dose cuts short the at- tack. Unfortunately, some patients find that the drug- loses its efficacy after a while. Still, it is at present our most successful remedy. Caffeine is very efficacious in cases which have an optic aura or premonitory symptom — such as hemianopsia, hemi- chromatopsia, or hazy vision for a few ninutes before the neuralgic pain appears. I formerly gave the citrate of caf- feine, but some three years ago became convinced that this was a very unreliable preparation, and began giving pure caffeine with much better results. To an adult male patient I give, at the first warning of attack, or-when the pain be- gins, a grain and a half (0-10) every quarter of an hour until the pain ceases or five doses have been taken. This often aborts the attack. In some patients the drug pro- duces an excited, tremulous condition, which, however, is preferred to the pain. The granular effervescent salt of bromide and caffeine (so-called bromo-caffeine) is of much * N. Y. Medical Record, 188*7, vol. 1, p. 517. f Cited in Medical News, July 10, 1886. 48 LECTURES ON SOME POINTS IN THE inferior efficacy, and I advise you not to use it, unless you can not procure caffeine. Paullinia or guarana, as powder, fluid extract, or elixir, occasionally succeeds also; but full doses must be given — a teaspoonful of the fluid preparation every half-hour till four or five doses have been taken. Its efficacy depends upon caffeine, which is its active alkaloid (four to five per cent.). Nitrite of amyl by inhalation has been proposed and used, but my experience with it has been unsatisfactorj'. It was advised on a theoretical ground which I believe to be unsound — viz., the vascular theory of migraine, first ad- vanced by Du Bois-Keymond. According to this theory, which has had the support of several distinguished names, there are two varieties of migraine — one angeiospastic, in which the arteries of the face, eye, and brain (on one side) are in a state of spasm, and the parts supplied by them ischsemic. In the other variety, termed angeioparalytic, the same arteries are relaxed and the parts are hyperaimic. In the angeiospastic form (which is said to be the more common) nitrite of amyl is theoretically indicated. Un- fortunately, gentlemen, clinical observation does not justify any such classification. For my part, as regards the state of the arterial circulation in migraine, I believe that there is always a spastic or contracted state of the arteries at first (as in epilepsy), and that this is followed by dilatation or relative paralysis of the vessels.* Practically it has been proved that amyl rarely relieves the pain, and nevei' (in my * There are many reasons for thinking that the arteries usually con- tracted in migraine are the po«terior cerebral and its branches which supply the sensory areas or divisions of the hemispheres, and the caudal fasciculi of the internal capsule. In cases where hemianopsia precedes the pain, spasm of the occipital artery (supplying the cuneus on one side) may quite surely be assumed to occur. TREATMENT AND^MANAGEMENT OF NEUROSES. 49 experience) cuts the attack short. In some cases it in- creases the suffering. AVlien the pain is fully developed there is very little to be done except to keep the patient in a darkened room, perfectly quiet. Sometimes Duquesnel's aconitine, a gran- ule of one two-hundredth of a grain every hour till some numbness appears, gives relief. I have also obtained relief from bromides, chloral, croton-chloral, and sulphonal, in full doses. A hypodermic injection of crystallized hyoscyamine (one fiftieth of a grain) sometimes gives relief for several hours, and is not objectionable, as morphine is, because habit is never entailed by its use. External applications (cold, heat, sinapisms, the menthol cone, galvanism, etc.) have given relief in isolated cases, but so rarely as not to be of much value. But by all means try everything in a given case, except to give morphine. This will relieve the pain, but assuredly increase the frequency of the paroxysms and the (apparent) severity of the pain, each attack being " worse than the last," and requiring more of the fatal remedy. The end for the patient is the morphine habit ; for you, the reproaches of the patient and his rela- tives. The question is often asked, Is it better to give up to an attack of migraine, or to struggle against it and go about one's duties as far as possible ? You wjll have to decide this question for each case by a study of the attack and of the patient. Most patients, particularly women, do best if they retire to a quiet, dark room and try to rest during the paroxysm. Others, usually men, with strong will- power and attacks of moderate severity, can go about their daily duties tolerably well and are no worse off. Everything here de- pends on the patient's susceptibility to pain and his power of reaction, or, to put it psychologically, upon the relation existing between his sensibility and his volitional energy. 3 50 LECTURES ON SOME POINTS IN THE In this way, by a rational continuous treatment between paroxysms and the use of a few harmless drugs to cut short or moderate the attacks, the life of most subjects of mi- graine can be made absolutely or relatively comfortable until the age of spontaneous cessation of the disease is reached. A very interesting point in the natural history of mi- graine is its occasional aggravation and transformation into constant headache, usually occipital, between the fortieth and fiftieth years, I have not the time to enter upon a consideration of this singular phase of the disease, which is as yet unexplained, and which taxes the physician's re- sources to the utmost. Allow me, however, just a moment to make a general remark about the symptom headache. We are almost daily asked to prescribe for headache at one seance^ off-hand as it were, and with the expectation of success. Not only is this done by patients, but physicians bring or send headache cases to a specialist with the idea that an hour of careful examination will reveal the pathology of the headache, and that the advice given must lead to relief if not to cure. I would here express it as my deliberate opinion, as the re- sult of much study of the subject, that there is no problem presented to the physician so difficult as that of the pa- thology and therapeutics of a chronic headache. Frequently several days of study of the patient, with the assistance of the best ophthalmologist, arc required to solve the problem ; and there are cases in which, after months of study and trial of remedies, we are obliged to give up in despair ; we have not discovered the pathology of the case, and all our remedies, including ocular treatment, fail to give relief. I would urge you to study every case of chronic headache presented to you patiently and thoroughly before giving an opinion or beginning a systematic treatment. The pallia- TREATMENT AND MANAGEMENT OF NEUROSES. 51 tive remedies may, of course, be prescribed at once, but truly curative measures should only be adopted after suf- ficient observation. What I have said of the use of caffeine at the onset of an attack of migraine should be supplemented by the state- ment that very strong black coffee (infusion) may also suc- ceed. The addition of lemon-juice recommended by some is useless. As in many cases of migraine nausea and vomiting are present at quite an early stage, preference should be given to caffeine, as being less bulky than anti- pyrine. Besides, caffeine powders may be carried about in the pocket and used early if an attack begins during the day vphile the patient is away from home. If you will allow me another digression, I should like to refer to a matter of great importance in general practice — viz., the use of coffee in dyspepsia, fermentative dyspepsia more particularly. If there is one direction more often and more emphatically given than any other to dyspeptic people it is to drink no coffee or tea. In some way the use of tea and coffee has come to be looked upon as highly in- jurious to digestion by the laity and physicians. Yet I believe that there never was a greater medical delusion. It may have originated from the fact, which I recognize, that the abuse of very hot drinks (tea, coffee, and I would say soups also) may give rise to chronic gastritis. The chief reason, however — very good so far as ft goes — is that dys- peptic persons feel worse after taking what is called coffee at breakfast. Some eight or ten years ago I began to sus- pect that the reason why breakfast coffee disagreed was because its composition made it a liquid favorable to fer- mentation. The cup of coffee which almost every one takes at breakfast (and tea at breakfast or lunch) is a mixture of coffee, ridiculously weak usually, milk or cream, and sugar. This " cup of coffee " is unquestionably bad for dyspeptics, 52 LECTURES ON SOME POINTS IN THE and perhaps not overdigestible for any one. After my re- turn from Europe in 1883 1 began giving dyspeptic pa- tients good strong coffee, without milk, cream, or sugar,* with their breakfast of meat or eggs, and very little bread (no other farinaceous food, of course). It was at first diffi- cult to induce patients to make the trial, as they were so prejudiced by former medical statements that coffee was bad for their digestion and for their " nerves." The results were extremely gratifying, and I have gradually made it a part of my diet regime for all patients suffering from evident fermentative dyspepsia, with or without catarrh, and from so-called nervous dyspepsia. I direct that they shall take one large breakfast-cup of strong (dark-brown) coffee, made without boiling, not too hot, without sugar, cream, or milk, with their breakfast. In cases where nervous prostration and early morning mental depression are marked I order, in addition, a small cup of the same coffee, with a two-grain pill of quinine before rising and attempting to dress. I have induced two or three of my professional friends to try this revolutionary practice, and they are so far satisfied with the results. Why should not plain infusion of coflTee be beneficial to dyspeptic, nervous, worn-out subjects ? It contains no ele- ment of fermentation, and, if made without boiling, hardly any tannin. We introduce into the patient's stomach so much hot water (which is well known to be favorable to digestion), p^ws a certain quantity of caffeine. Now, caffeine is a cardiac tonic, an exhilarant, and a diuretic — three properties which meet indications presented by these pa- tients — viz., feeble, irregular cardiac action, nervous and mental depression, insuflScient renal action. In this lies the advantage of coffee infusion ; it stimulates the heart * One third or one quarter of a grain of saccharin may be used to sweeten. TREATMENT AND MANAGEMENT OF NEUROSES. 53 and kidneys. Dr. S. Weir Mitchell recommended, many years ago, a cup of black coffee in tbe early morning for cases of neurasthenia; but bis main object was to obtain a stimulating action on the intestines ; it does favor the oc- currence of daily alvine evacuations. But I think that the indications which I say it fills are much more important. What are the objections to coffee? It may cause so much cerebral excitement as to postpone or banish sleep ; but this objection does not hold as against coftee at the beginning of the day. It causes tremor or, popularly speaking, " nervousness" in some persons ; but this, I think, is rare, and is usually caused by the use of excessively strong cof- fee. Caffeine and coffee have, in the last ten years, assumed a justly prominent place in our list of potent physiological remedies. I can and do urge you to make a trial of black coffee in your dyspeptic and nervous cases. In some cases the effect of the very early cup of coffee is wonderful ; the quasi -melancholia passes off; the patient rises, takes her cold sponge-bath and dresses with comparative ease, and comes down to breakfast with some energy and ambition. 54 LECTURES ON SOME POINTS IN THE LECTURE II. V. Trigeminal Neuralgia or Tic Douloureux. — In this affection, as iu epilepsy, we have cases in which there is recognizable gross disease of the nervous system, and oth- ers in which the most careful examination reveals only sub- jective symptoms — viz., pain and hypersesthesia. In other words, we have symptomatic and idiopathic cases. The lat- ter are by far more common, and it is about this form of the disease, in its aggravated chronic type, that I desire to lay my therapeutic experience before you. You are all doubtless familiar with the disease. Parox- ysmal pain, often of the most intense, piercing, darting char- acter, affects one of the large divisions of the fifth cerebral nerve, or more than one; rarely all its branches, lingual and deep auricular included. The paroxysms recur every few moments while the patient is awake, and last from a few sec- onds to two or three minutes. Lacrymation accompanies pain in the ophthalmic division, salivation appears when the inferior division is involved. At the onset of pain, speech is suspended, the patient contracts his features, closing the eyes and drawing up the mouth on the affected side (an automatic, protective, associated movement which has given rise to the utterly unfounded belief that the facial or sev- enth nerve is involved and that there is a morbid spasm) ; he often claps one hand tightly over the seat of pain, or rubs it violently ; he may groan or cry out aloud in his TREATMENT AND MANAGEMENT OF NEUROSES. 55 agony. These signs are so striking that almost always we can make a diagnosis without asking a question by observ- ing the fades of the patient. Such cases, of months' and of many years' duration, have long been deemed beyond the reach of drugs, and have been (during this century at least) placed under the surgeon's care for operative treatment. Some cures have been obtained by exsection of pieces of the aflEectqd nerves, or by removal of Meckel's ganglion, but the large majority of cases relapse after an interval of a few months. The disease has been one of the opprohria of medicine. I am, however, glad to be able to tell you that in the last thirteen years we physicians have been able to cope fully as well as surgeons with this dread disease. Some cures have been obtained, and numerous patients greatly relieved by the use of that potent alkaloid, aconitine. It was first used for this purpose in France by Professor Gubler, who published a short paper upon it early in 1877.* I immediately bad soraeof Duquesnel's crystallized aconitine imported by a New York pharmacist who always displayed zeal- in furthering the use of new and rare drugs,f and began using it. K first report upon its use in trigeminal neuralgia was made by me to the New York Therapeutical Society J in October, 1878. Out of six cases treated by myself and other members of the society, all severe and of long standing, two were cured (?), three slightly relieved, and one unaffected. One of the cured cases had existed for seven years.*' I have since learned that we did not * Gazette hebdomadaire, 9 fev., 1877. f The late Mr. Neergaard. X New York Medical Journal, December, 1878. * I should add that two or three years after that report a relapse occurred and the patient has never been free from pain since. She now occasionally reports at the Manhattan Eye and Ear Hospital, hav- ing thus been faithful to me for fifteen years. 56 LECTURES ON SOME POINTS IN THE then give enough aconitine or persevere long enough in its use. From quite a large experience since, I am able to say that very few cases are not relieved by aconitine, and that a fair proportion can be cured, or at least given intervals of from one to three years — results which, I think, compare very favorably with those obtained by surgical measures. For the treatment of these cases I have come to rely upon the combined uses of aconitine and " mixed treatment," so-called. The alkaloid is now readily obtained in any part of the country, or can be procured by the country practitioner from one of the great cities in a short time. It is one of the few drugs which I think it best to order as made up by the large manufacturers. McKesson & Robbins and Schieffe- lin, in New York, make pills of Duquesnel's crystallized aconitine (the kind you should always specify in your pre- scriptions) of the strength of one two-hundredth of a grain, which, by repeated tests at different times, I have found to be absolutely reliable. I might say that, being moderately sensitive to the drug, I make it a duty to test the pills or grannies of these firms on myself once or twice a year. Two of these pills will produce in me distinct tingling numbness in the face, tongue, and extremities for two or three hours, also a disagreeable sense of chilliness or cold- ness, most marked along the spine. These pills, thus known to be strong and uniform at different times, I give in pro- gressive doses to a patient with trigeminal neuralgia until the numbness is felt throughout the body, with chilliness, and in some cases nausea and faintness. Begin cautiously with this drug, gentlemen, but, after finding that your patient is not abnormally affected by it, proceed to the fullest doses fearlessly if you wish to succeed. Nowhere in medicine is there more demand for cautious temerity (if I may be par- doned the expression) and confidence in the use of your TREATMENT AND MANAGEMENT OF NEUROSES. 57 weapon than in the dosage of aconitine. I have had no fatal result from it, in spite of many bold experiments.* At first I give one pill twice a day to women (who occa- sionally exhibit undue susceptibility to its influence f), and three times a day to male patients. These doses usually produce no effect, remedial or toxic, so I increase gradu- ally but steadily until in some cases I give twelve pills a day (two every three hours) before obtaining the uni- versal numbness, etc., which denote the full physiological effects of the remedy. During the spring of 1889 I gave, on one day only, as many as fourteen of these pills (equal to fourteen tvvo-hundredths, or, roughly speaking, one thir- teenth of a grain (0"0045)) to a large young girl twenty years of age. She felt numb through the whole body, was a little faint, and was nauseated. In the majority of cases two pills three or four times a day will produce physiological effects and suspend the pain even of severe trigeminal neu- ralgia. Having thus found the dose which is both toler- ated and efficacious, I keep it up daily for several weeks after the pain has ceased, and in convalescence direct the patient to take a large dose — two or thre? pills — at once on the least return of sharp pain. The "mixed treatment" which I now always give simul- taneously with the aconitine to patients with trigeminal neu- ralgia, whether they give a syphilitic history or not, J needs * The Physiological Effect of Aconitia in Posterior Spinal Sclero- sis ; Can it become an Aid in Differential Diagnosis ? Opera Minora, p. 492, and Journal of Nervous and Mental Diseases, July, 1881. f Case of a woman unpleasantly affected by one dose of one four- hundredth of a grain (0'00015), by Dr. Andrew H. Smith; cited in Opera Minora, p. 601, and Archives of Medicine (New York), June, 1882. :j: Vide The Efficacy of Iodide of Potassium in Non-Syphilitic Dis- ease of the Nervous System, Archives of Medicine (New York), June, 1883. And I believe that mercury also has a similar efficacy in some cases. 58 LECTURES ON SOME POINTS IN THE only a few words of explanation. I combine the red iodide of mercury, in doses gradually increased from one twentieth of a grain (0"003) to one sixth or one fifth of a grain (O-Ql) with from twenty to forty-five grains (1'50 to o'OO) of iodide of potassium in water, 3 j (4'0), largely diluted after each meal. Though I have several times given the larger doses of potassium iodide — from 60 to 150 grains (4*0 to 10*0) three times a day — I think that is rarely ad- visable. This medication I continue for two or three months steadily, then give a month's course of it every few months afterward. Very often, if not always, as a case of trigeminal neu- ralgia approaches cure there are spots or areas on the face or head that are exquisitely sensitive to touch, and irritation of them gives rise to a momentary return of more or less of the original pain. This hyperaesthesia can readily be over- come by blistering or lightly cauterizing the part. In the last ten years I have several times successfully employed this accessory treatment; in the last case, during the past winter, a hyperaesthetic and algogenic spot on the lower lip was rendered normal by one application of the Paquelin cautery. It has also been my custom to give an abundance of nutritious food to these patients, and cod-liver oil as well. They often present themselves in an emaciated, anajmic condition from starvation. Chewing is impossible in many cases, and swallowing is so painful that they take as little food as possible to escape paroxysms of neuralgia. In this stage, before the pain is subdued, I order stated quantities of rich milk, or cream and milk, to be taken in twenty- four hours ; also so many eggs (from four to eight) taken raw, or beaten with the milk, or slightly cooked. Often it is well to allow some brandy or whisky with the milk. I also urge the patient to take the expressed juice of beef, TREATMENT AND MANAGEMENT OF NEUROSES. 59 strong coffee, and oatmeal porridge. Under sucli a diet, with relief of pain by the aconitine, the patient rapidly re- gains color, weight, and strength ; his nervous system is better nourished and less susceptible to the molecular vibra- tions which cause pain. Thus food (including cod-liver oil) becomes a part of the treatment. Some cases of trigeminal neuralgia, not always the old- est ones, resist this treatment. I have had two such under my care in the last sixteen months, one of them being that of the young lady who was able to take fourteen pills of aconitine in one day. The inferior maxillary nerve was finally resected in this case, but, after an interval of seven months of perfect freedom from pain, it reappeared last No- vember, and again resisted treatment. Still I maintain that the present standpoint of the me- dicinal therapeutics of this disease is vastly advanced from what it was ten years ago. VI. Basedow's Disease. — Although I know that I am trying to crowd too much into these lectures, I feel that I must add something which may be novel to you in the treatment of the obscure neurosis kno^^'n by this name, or as exophthalmic goitre. The usual treatment by iodide of potassium, iron, etc., and by galvanization of the neck, is familiar to all. The two new measures I wish to call your attention to are, first, the systematic employment of aconi- tine, and, second, bandaging of the protruding eyeballs. In 1884 I rather accidentally discovered that aconitine (the crystallized aconitine of Duquesnel) exerted a powerful re- ducing influence on nervous or irritative fast pulse — i. e., a fast pulse with high tension and normal heart, easily dis- tinguished from the fast pulse of cardiac disease or general debility or fever.* Aconitine, in granules of one two-hun- * Of course it has been long known that aconite reduces the pulse, I refer to a very decided effect upon a special sort of pulse. 60 LECTURES ON SOME POINTS IN THE dredth of a grain, greatly reduces the pulse-rate and also the arterial tension. In Basedow's disease I give from three to eight pills a day — enough to produce slight tingling in the lips and extremities — for days and weeks, occasionally stopping for a few days. On the average, it is necessary to give two pills three times a day; under this the pulse-rate steadily falls from the upper limits of 160 or 140 a minute to below 100. After that the fall is slower, but in many cases goes on until 90, 80, and even 70 beats are recorded to the minute. At the same time the eyes and neck usual- ly improve. This treatment occasionally fails, but it never does any harm. I have used it in quite a number of cases, some without goitre and exophthalmia, since 1884, and it has been tried with good results by several of ray profes- sional friends. At the same time iodide of potassium or iron may be given and galvanism applied in the usual way. Bandaging of the eyes has never to my knowledge been practiced. In the last two years I have tried it in two cases with excellent results; complete reduction of the exophthal- mia in one case. A carefully molded pad of soft cotton is placed over each eye, filling the orbit, and a light (of not more than three turns) flannel bandage applied with gentle but decided pressure. At first I do this for only an hour twice a day ; later for periods of two or four hours. In one of the cases the bandage was applied at 10 p. m. and allowed to remain all night. During the progress of the second case, which, though it has existed for at least three years, is much improved, I have made occasional ophthalmoscopic examinations without detecting any damage due to the pressure. The pressure should not be great, as it is in- tended simply to counteract the dilatation of vessels in the orbit which is the usual immediate cause of the exoph- thalmia. TREATMENT AND MANAGEMENT OF NEUROSES. 61 The Diet and Hygiene of Nervous Patients. Much has already been written, and most ably, by my friend Dr. S. Weir Mitchell on this subject, chiefly in his books on the treatment of nervous diseases in women,* which no practitioner should be without. Other physicians have given their views on the topic in detached journal articles. I am therefore excused from treating the matter systematic- ally, and shall only refer to a few measures which have in- terested me very much and have been reasonably successful in my hands : I. Diet. — In considering the diet advisable for a victim of one of the neuroses, a consideration of prime importance is to bear in mind the constitution of the nervous tissues — brain, spinal cord, nerves, and ganglia. The first point I desire to bring to your attention is the fundamental one, that the central nervous system and periph- eral nerves are very largely made up of fatty substances. These are complex in their composition, some including an atom of phosphorus. Cholesterin alone. (which is a non- saponifiable fat) makes up 52 per cent, of the dried white substance of the brain according to Petrowsky. This sub- stance makes up 18*6 per cent, of the gray substance, which contains nearly twice as much lecithin (17 per cent.) as the medullary matter. Albuminoids preponderate in the gray substance (55 per cent, in the gray ta^4-7 per cent, in the white). Cerebrin, which is a fat united to a molecule of nitrogen (it is perhaps an acid in its relations), is abundant in the medullary substance (9*5 per cent.) and almost ab- sent from the gray (0*53 per cent.). Thus, in general terms, it may be said that albuminoids preponderate in the gray * Fat and Blood, Philadelphia, 1877. Lectures on Diseases of the Nervous System, especially in Women, Philadelphia, second edition, 1885. 62 LECTURES ON SOME POINTS IN THE substance (cortex and ganglia), while fats and fatty acids are much more abundant in the medullary or myelinic sub- stance. An extraordinary quantity of phosphoric acid and phosphates exists in the ash of cerebral substance — viz., 93*57 per cent. (Breed). We know very little of the nor- mal or actual combinations, relations, and genesis of these substances. Funke and Wundt think that the force-producing or combustion capacity of these substances must be very great, and that the tissue metamorphosis must be very rapid. Singularly, though writing in 1887, Wundt* ignores the strongest evidence we have of the activity of nutritive (chemical) processes in health — viz., the demonstrations by Lombard and Schiff that cerebral activity is always accom- panied by a local rise of temperature — a rise which is rela- tively great and which takes place almost instantly. In neuroses there is no active tangible lesion, but the nervous system is ill-nourished and exhausted. The mal- nutrition may be congenital, produced by severe infantile disease, or due to bad diet, or to want of power to assimi- late the food elements which go to repair the nervous tis- sues. In other cases excessive nervous action, such as acute or chronic excess, leads to functional exhaustion which undoubtedly is inseparable from chemical waste. We are not yet, unfortunately, in possession of any chemico-patho- logical data in this direction, as autopsies are rare in neu- roses, and they do not now include a chemical analysis of the nervous organs. Furthermore, I doubt if the normal chemical composition of nervous matter is well enough known, and if our methods of analysis are yet good enough, to enable us to gather such data. Perhaps we shall learn something in this direction some day. One remarkable * Grundziige der physiologischen Psychologic, 3te Aufl., i, p. 39 et seq. TREATMENT AND MANAGEMENT OF NEUROSES. 63 fact has been ascertained in the way of pathological anato- my — viz., that the brain and spinal cord do not par- ticipate to any great extent in the atrophy and visible waste of organs and tissues in marasmic conditions. This may be owing to the peculiar physical conditions, as re- gards atmospheric pressure, in which these organs are placed. The contents of the skull can not vary in their entirety. If the solids are reduced, serum or lymphatic fluid must at once replace them; so that, very probably, chemistry will some day reveal a real marasmus of the gray and white substance, which is concealed by excess of water in the tissues. I can not conceive of a case of extreme cerebral neurasthenia without chemical changes (especially in the cortex of the brain). We must, therefore, now pro- ceed upon theoretical grounds in stating the indications, and upon a careful estimate of empirical results. The great fact that the nervous tissues are largely made up of fats and of phosphates should not escape our attention while planning the diet of a case of nervous disease. Now what are the results of empirical practice or " ex- perience " ? They are open to sources of error, chiefly from the bias and narrow enthusiasm of specialists who re- port their experience, yet it is chiefly upon them that we should base our dietetic treatment; and it must be so until physiological chemistry shall have made much more prog- ress. I shall offer you my own experience. Before proceeding to state what neurotic patients should eat, it will be instructive to inquire into their previous habitual diet. In the first place, in working up the history of your cases of migraine, ordinary neuralgia, neurasthenia, and hys- teria, more especially, you will be struck with the number of patients who have " always " disliked fatty foods, and eaten hardly any, except butter. Even this is almost total- 64 LECTURES ON SOME POINTS IN THE ly oraitted by some. On the other hand, many of these patients have eaten or drank an excess of substances made up of carbon and hjdrogen (starches, sugars, and alcohol). These statements are especially true of women who com- plain of various neuralgias with a neurasthenic basis. An- other peculiarity of these patients is that they drink very little water; and some of them have actually lost the sense of thirst — are " never thirsty." If you examine the urine of such patients you will find it of high specific gravity, with deposits of crystals of oxa- late of calcium ; often also uric acid, and, of course, amor- phous urates when the amount of water is deficient. To put it another way, lithsemia and oxaluria are fre- quent concomitants of the neurasthenic state, more espe- cially in those presenting neuralgic symptoms. lu the great neuroses the occurrence of these deposits is less frequent and not at all regular. It is, as you know, an unsettled question at the present day, as it has been for forty years, whether the deposits are the result of the neurotic state, or whether they are more directly produced by improper food and hygiene, and themselves cause the symptoms. At the present time the weight of expert opinion is in favor of the latter view, so that the question of diet assumes an immense importance in the treatment of neurasthenia, neuralgia, etc. The theoretical question of the relation between aliments and oxaluria (lithaeraia, gout, and diabetes also) is one which appertains largely to physiological chemistry and would re- quire an elaborate chemical statement for its proper under- standing. The best liteiature on the subject consists of Bence Jones's classical book,* a clinical lecture by Professor William H. Draper, of New Yorkf (who has taught this doctrine continuously for the last twenty-five years), and * Lectures on Pathology and Therapeutics, London, 1867. f American Clinical Lectures, No. 12. 1875. TREATMENT AND MANAGEMENT OF NEUROSES. 65 the clinical work of Cantani, of Naples;* the last an admi- rable work, though as regards the dietetic treatment of oxaluria and gout the author is apparently unaware that physicians in New York were many years in advance of him, and does not do justice to Bence Jones. For ray part, I have for a long time been thoroughly convinced that the excessive use of starchy and saccharine foods, so prevalent in this country, is a potent cause of oxaluria and lithaemia, and thus indirectly of neurasthenia ; my practice has been based on this belief, and I have no reason to modify it. Another instructive consideration in approaching the question of the proper diet of nervous patients lies in what we now know of alcoholism and the almost exclusive use of rice (starch) as food. These hydrocarbons, taken in excess con- tinuously, give rise to a very peculiar, easily recognized dis- ease — viz., multiple neuritis, or multiple degenerative neuri- tis. We constantly see sporadic cases of this sort in persons who have reduced their solid healthy food to a minimum and have lived on alcoholic beverages. Tn some persons no very great quantity of alcohol is needed to set up the diseases, provided that it has been usea steadily dav after day in relative excess. We ignore the modus agendi of alcohol in setting up inflammatory (?) changes in the cylin- der axes and segmentnl degeneration of the myelin in a large number of cerebro-spinal nerves in the same subject. Probably it is a toxic action exerted thr7)ugh the blood and lymphatic channels. Though endemic multiple neuritis, affecting large numbers of persons in one country, or town, or on a ship (so-called beri-beri in India, China, and South America ; kakki in Japan) may be caused, as some think, by a special poison (microbic?), there can be no doubt as to the influence of exclusive rice diet. This has been proved * Specielle Pathologie und Therapie der Stoffwechselkrankheiten, German edition, Bd. ii, Berlin, 1880. QQ LECTURES ON SOME POINTS IN THE in Japan, where, in the last six years, the reduction or omis- sion oF rice from the dietaries of the army and navv and of penal institutions (bread being substituted) has almost eradicated the disease, which had assumed enormous pro- portions up to 1884.* In 1886 I published three cases of beri-beri f developed in Cuba, Central America, and Para, in Brazil. My Para patient, a very intelligent merchant, told me that in his family, as in others of well-to-do and of poorer people, rice was eaten in various forms, from liquid to solid, five times a day ; it was the staple food. That something besides the rice is required to produce beri-beri is indicated by the fact that the disease first appeared in Brazil as late as 1864, and was traced by some people to the use of rice imported from China. Still, it is a most important and interesting fact that aii abuse of carbonated food or drink may give rise to an in- flammatory or degenerative affection of nerves widely spread throughout the body, and sometimes fatal by involvement of the pneuraogastric, phrenic, and intercostal nerves. Ad- mitting this, how can we escape the conclusion (which I firmly believe to be just and applicable to our daily prac- tice) that a lesser abuse of the same substances (starch, sugar, and alcohol) must cause malnutrition and irritation of the nervous system, with, in some cases, slight neuritis? (Some cases of neurasthenia and of neuralgia exhibit symp- toms which can be best explained by admitting a mild and restricted neuritis of one or several nerves.) These considerations — viz., the neglect of and distaste of nervous patients for fats and water, the frequent pres- ence of oxaluria in the same patients, the evil effects of the * B. Scheube, in Deutsch. Archiv f. klin. Med., xxi, p. 141 ; xxii, p. 83. f Notes on Three Cases of Tropical Beri-beri, Phila. Med. News Dec. 18, 1886. TREATMENT AND MANAGEMENT OF NEUROSES. 67 exclusive use of starchy and alcoholic substances, besides the theoretical chemical explanations included in the mod- ern doctrines of oxaluria and lithjieraia — have led me to the adoption of the following rules of diet for nervous patients in general, but more especially for sufferers from neuras- thenia (not, of course, in cases in which an evident periph- eral or accidental cause exists), neuralgia, and nervous dys- pepsia : 1. The use of much water, at least three pints a day, not including the black coffee at breakfast. Good common water will do, but you can secure obedience better by order- ing a mild medicinal water — as Apollinaris, the Buffalo or Londonderry lithia waters, Poland Spring water, the Giess- hiibler of Carlsbad (not laxative), etc. Some water should be used with the food, but the best time to take a tumbler- ful is between three and four hours after meals. The wa- ter then helps to clear the stomach of remnants of the meal, besides furnishing the liquid required by the blood and tis- sues. In some cases, where subacute or chronic gastric catarrh exists, it is best to order hot water, to be taken as above stated — part with food, part four hours after. Un- doubtedly, the Salisbury system had a partial scientific foundation, both as to the exclusion of starchy foods and the free use of water. It is, however, a ridiculous and often injurious practice as usually carried out. 2. I take every opportunity and use every artifice to make most of my nervous patients eat fatty food : pork, fat of roast beef, butter, cream, cod-liver oil. Many of them fight against this direction, but you must insist, and speak of it as a strictly medicinal matter; you order an extra quantity of butter, or cold pork, or cod-liver oil as medi- cines. Usually the patient yields, and in a few months be- comes quite reconciled to his diet. In many persons this dislike for (and supposed inability to digest) fatty sub- 68 LECTURES ON SOME POINTS IN THE stances is due to nothing except a bad example set in early life l)y some parent or other relative. The expression, " Oh, I can't bear" that, or "I can't eat" this article of food is quickly caught up by the child, and by association and habit (repeated hearing and witnessing) grows into a firm belief that the article of food is bad or that he can not di- gest it. Many persons imagine that they can not take cod- liver oil, yet ninety out of a hundred are laboring under a delusion. I insist on a trial, sometimes only at bed-time, beginning with a teaspoonful, which is to be gradually in- creased to a tablespoonful, or even two. Emulsions I almost never prescribe ; the phosphates, etc., with which the oil is mixed being inert. Some emulsions which contain other definite remedies — quinine, iodine, etc.* — I occasionally or- der, but I much prefer to have the patient take the pure oil (the purest, clearest oil), and to give the remedies sepa- rately in sufficient doses. A good way to take cod oil is to float the dose on a little iced water. Chocolate and lemon- peel are the best substances to remove the taste. Whisky should never be given simply to make the oil more desir- able, only when a clear indication exists for the use of alco- hol. The time relation between the dose of oil and meals is immaterial. I usually allow the patient to please himself, though often it is better borne after food. The use of fat pork is a fair substitute for cod-liver oil, and some patients who will not overcome their prejudice against the oil will learn to like the pork. The idea is not mine ; it originated with a country practitioner whose name T have never been able to learn. I stumbled on the sug- gestion a good many years ago, and have been well pleased * I also make an exception in the case of Savory and Moore's pan- creatic emulsion (Snglish), which has proved very acceptable to pa- tients and beneficial. I usually give a heaped teaspoonful of it mixed in a large cupful of hot, rich milk between meals and at bed-time. TREATMENT AND MANAGEMENT OF NEUROSES. 69 with it. The patient is directed to select a square piece of salted side of pork, extra thick, and solid, with almost no lean. This should be boiled not too long, and laid away in a cold box. To use it : Day after day very thin, even, neat slices are cut from the cold piece by means of a very sharp carving knife. This had better not be done before the pa- tient, but the pieces (six to eight) brought to hiia attract- ively dished. A slice is to be laid on one very thin slice of dense (home-made) bread, seasoned sharply with salt and pepper, or, according to taste, with mustard or Worcester- shire sauce. There should be very little bread. The dish may be used two or three times a day. Butter is willingly eaten by most patients in extra quantities, say two ounces with each meal. Cream is another substitute for cod-liver oil, but this, as well as milk (vide infra), I prefer to give between meals. It may be asked, if the purpose is to provide fatty sub- stance for the better nutrition of the nervous system, or of the system generally, why not make use of those other well- known fat-making substances, sugar and alcohol ? The rea- son is, I think, evident. Oil, butter, cream, and fat of meats are ready for the processes of emulsion and of intesti- nal digestion. Alcohol and sugar (starches still more in- directly) require to be transformed into fat by complicated chemical actions within the body. This process is defective in many nervous patients, or, if not defective, it constitutes a drain on the patient's resources. It is an intimate or- ganic strain. The excess of carbon goes to make up oxalic and lithic acids, and thus the patient is injured. 3. In many nervous cases I greatly reduce the amount of starchy and sweet foods, partly to save chemical labor and render full oxygenation more easy, partly because in many cases there is actual oxaluria or lithtemia. In these cases it is not at all necessary to restrict the patient as closely as in 70 LECTURES ON SOME POINTS IN THE well -developed gout or diabetes. The so-called Salisbury plan, while it affords immediate relief to many symp- toms, is unnecessary, absurd, and even injurious in most cases. If you consider the habitual dietary of Americans you will see what an excessive amount of starchy food is used daily. At breakfast there is of course bread (often of an indigestible kind), oatmeal or wheaten grits, in many fami- lies potatoes with the meat, and sometimes buckwheat or other cakes, or fried hominy to be eaten with syrup or sugar at the close of the meal. The nitrogenous food is usually eaten sparingly or not at all. In such a breakfast, watered with a sweet mixture of very weak coffee, milk, and sugar, what a capital " mess " for fermentation we have in the stomach ! Eructations, sometimes tremendous in vol- ume, are first results of such a breakfast, but the more seri- ous evils are developed later and deeper, as results of very imperfect oxidation of the carbon of this "mess." Then for dinner and supper starchy food is used, even if not excess- ively. We again find potatoes (in many families three times a day), cakes, puddings, pies, etc., make their appear- ance. Supper is in many American families a meal well calculated to develop flatulent dyspepsia and oxaluria. Often no meat is on the table, but bread and butter, preserves, cakes, oysters, and tea or " coffee." Even in better-in- formed families, where some form of nitrogenous or animal food is used at each and every meal, there is usually, I be- lieve, a relative excess of starchy and sweet elements. One of the worst things in the popular dietary is the eating of an orange or two before breakfast. Here is a quantity, from two to three ounces, of sweet-acid liquid introduced into the empty stomach. It hinders the free flow of gastric juice (this is an inference from the well-known opposite effects of alkalies and acids on the production of gastric juice). Then in cases of lithaemia, oxaluria, and nervous TREATMENT AND MANAGEMENT OF NEUROSES. 71 dyspepsia this drink is of such a nature as to increase the formation of oxalic acid. I wish that physicians would everywhere exert their influence to banish this custom — which is a misunderstood transplantation of a Cuban custom (Cubans take only coftee after their morning fruit, and do not eat breakfast until eleven or twelve o'clock), practiced nowhere else in the civilized world — from among our people. The only physiological preliminary to break- fast, in my opinion, should be a glass of water, of ordi- nary temperature for healthy persons, and hot for dys- peptics. I make the necessary reduction in starchy and saccha- rine elements in my patients' diet by directing as follows : The breakfast coffee to be taken without sugar or milk; potatoes (both kinds) to be wholly excluded for three or four weeks, then resumed moderately, three times a week or once a day. Oatmeal, " grits," and similar cereals should also be absolutely suspended fur a while, and then resumed in small quantities — for example, one tablespoonful of good oatmeal with much cream after breakfast. This last is an important point. Usually people eat (at breakfast) the starchy food first ; then, if any appetite is left (which is not always), the meat or eggs are proceeded with. The best food, the most necessary for the nutrition of the body, that needing a free outpouring of gastric juice, and that digested with least chemical waste — beef, mutfbn, poultry, game, eggs, and fish — should be eaten first and chiefly. Bread I almost always reduce, advising stale or well-toasted bread. I am not a partisan of fancy breads, except in some cases bread containing the bran ; the best bread for me is the whitest, lightest, and best cooked. Desserts of all kinds I reduce also, by cutting oif the worst, i. e., the most starchy, leaving raw or stewed fruit, plain ice cream, and nuts. Even these, as in the case of 72 LP^CTURES ON SOME POINTS IN THE bread, should be used in smaller quantities than is usual. In some cases acid fruits must be forbidden. When I have thus sketched out a moderate diet-list, the patient usually exclaims : " Well, doctor, what shall I eat with my meat? You have cut oflE my vegetables," The potato habit has become so developed in this country that numbers of people rarely eat other vegetables, and know only a limited number of the numerous non-starchy or slightly starchy vegetables furnished us by Nature. I often reply: "How did your ancestors get along, as we have known the potato only about a century ? " I attach a posi- tive value to green foods, and consequently urge my patients to eat freely of spinach and other " greens," string beans, celery, asparagus, beats, turnips, cauliflower, lettuce of vari- ous sorts, cucumbers, and tomatoes (not in oxaluric pa- tients). Cabbage and onions are non-starchy articles pre- senting the peculiarity of being more digestible raw than when cooked. Peas, rice, and corn T place in an intermedi- ate grade (with bread), to be used sparingly. By a little study of the market and by using canned articles (the best grades of which are, I believe, perfectly healthful) the pa- tient's anxious questjon can be answered, and he need not suffer from want of variety. Condiments and pickles I sel- dom prohibit; and it has been an old form of compact be- tween young lady patients and me that they can have pick- les occasionally if they will give up candy. Soups are usually indigestible, but I allow plain bouil- lon. It may have some nutritive value in itself, but it also increases the output of gastric juice.* Meats, fish, and eggs should be cooked in a simple way, by boiling, roast- ing, or very quick dry frying. Gravies and sauces are among prohibited articles, but I have not found a light dressing of oil, vinegar, salt, and pepper on a salad to be * Herzen, La digestion stomacale, p. 121. TREATMENT AND MANAGEMENT OF NEUROSES. 73 injurious (lemon juice may be used in place of vinegar). The mixed salads served with a mayonnaise sauce are bad, though the chicken and even the plain lobster meat are di- gest) ble. In many nervous cases, and in all where dyspepsia is evident, T furthermore advise that simple processes of cook- ing be used, chiefly roasting and broiling for meats. Some forms of frying are not objectionable, providing the fat is kept out of the flesh (fish) by a protective "batter" which is to be removed. Also, I try to induce patients to eat simple meals, partaking freely of two or three articles only. A ''course dinner" is not over-good for healthy stomachs, and is certainly bad when dyspepsia exists. Stimulants are usually injurious to neurasthenic, neural- gic, and lithtemic persons, who are very susceptible to their effect, a teaspoonful of whisky or brandy sometimes causing much distress. In a few selected cases I allow one glass of good claret or atablespoonful (measured out as medicine) of whisky with one or two meals. The practice of taking " a teaspoonful or so," as the patients say, of brandy or whisky when they feel weak or badly, or just before eating, to give them an appetite, I am strongly opposed to, and oblige my patients to cease the practice, which is often set agoing by careless medical advice. You understand that the foregoing is a scheme for a moderate or normal diet; it will agree~ with nearly every one. I live mainly so, except that I am able, when I wish, to digest some dessert and more stimulant. Cases with prominent dyspeptic symptoms call for various modifications of this diet, and, of course, the oxaluric or diabetic state requires a specially restricted dietary. In framing diet-lists for your patients (and I beg leave to assure you that it brings reward to give thought and 4 74 LECTURES ON SOME POINTS IN THE time to do this and to do it always in writing) pray bear in mind the facts, as I believe them to be, that most people eat too much carbonaceous food ; that dyspepsia, lithaemia, oxaluria, gout, and diabetes are cousins if not brothers ; and, lastly, that you are devising a diet for the patient before you, and must therefore also bear in mind his idiosyncra- sies and, to a certain, extent what he tells you of his experi- ence with respect to individual articles of food. Yet you should not follow his statements blindly, because they are open to many sources of error, or the patient may wish to mislead you because he dislikes some of the foods you want him to use. As regards milk diet, I must refer you to the books and to recent articles on the more digestible preparations of milk. One thing I should wish to strongly impress upon you, and that is the undesirability of taking milk with solid food. It may do for a strong person who has unusually good digestion. The milk, in reality, is an addition to the nitrogenous part of the food, and its casein calls for an extra allowance of gastric juice. I often give a glass of milk between meals and at bed-time. In some cases of oxaluria and lithsemia, one or even two meals may be made to consist wholly of good milk — one quart drank slowly in the course of an hour. The addition of a small pinch of bicarbonate of sodium and of salt to each glassful is good ; and one very thin, light cracker may also be al- lowed to each glassful in some cases. A most extravagant practice sprang up a few years ago with respect to the diet of epileptics. Some one proposed (and readily found followers) to feed epileptics on farina- ceous and vegetable food, animal food being thought to be an excitant and favorable to convulsions. This fad is pass- ing away, I am glad to say, for there is nothing in it. Many a case has come to me aggravated after a trial of this TREATMENT AND MANAGEMENT OF NEUROSES. 75 diet and careless bromide treatment, and great improve- ment followed the resumption of a moderate normal diet, with systematic medication. I have, however, one rule with respect to the diet of these patients — they should eat a light evening meal (a milk meal, or a little animal food), but never eat before retiring. It is generally admitted that going to bed with a full stomach is very provocative of nocturnal or matutinal seizures. I fail to see the philosophy of depriving epileptics of animal food, since it gives strength and increases (normal) nerve power. A priori I should ex- pect a starchy diet to cause nervousness by the setting up of oxaluria and lith&emia. I might as well here refer to the rest of the hygiene of epileptics. I aim to restrict them as little as possible in respect to food, amusements, and occupation. The reduc- tion in these should be mainly quantitative, in my opinion. Thus I allow many of my epileptics to go to sociables, theatres, and even quiet parties, but I make sure that they are in bed by 11 p. m., or at latest, once in a while, by mid- night. Before going to any such amusement they are to take a little extra bromide. School work is no doubt too much for most, epileptic children, but, on the other hand, idleness is also bad ; so I usually allow from two to four hours of study, or private teaching, in different cases. Play involving violent exertion (ball, tennis, running games, etc.) I forbid. In general it may be said that a monotonous, moderately busy life is the best for an epileptic. The good effects of monotony or regularity of living, combined with quiet, is well shown by the remarkable remissions which sometimes occur, without medication, after an epileptic has been received into a hospital or asylum. A question which has puzzled the minds of the ablest physicians is how to supply the nervous system with the phosphorus and phosphates which form so striking a pro- 76 LECTURES ON SOME POINTS IN THE portion of its composition (93*57 percent, of the brain-ash). The market is flooded with phosphates, hypophosphites, and cerebral derivatives with high-sounding names, yet we have no experimental or good clinical evidence that any of these preparations are assimilable. Phosphorus, I believe, should be given pure, in the shape of solution in alcohol and gly- cerin (Thompson's solution, or tinct. phosphori, 3 j = ^V grain (0-003)), or dissolved in oil (oleum phosphoratum), or as pil. phosphori. The pills in the market give alto- gether too small doses of phosphorus, which should be ad- ministered in doses varying from ^ of a grain (O'OOl) to ■gV (0'003), three times a day — the oil and pills after food, the tincture (diluted, if necessary, with glycerin) on an empty stomach and without water. Food, however, conveys an appreciable amount of phosphorus into the system in a naturally assimilable state. About the pleasant indulgences of life — the use of to- bacco and sexual intercourse. I am not rigid or dogmatic on this point. Many of my nervous patients are not at all injured (retarded in recovery) by the use of one mild cigar a day ; the cases are rare, I believe, where we must make the patient give up tobacco absolutely. The sacriiice is very great, you must admit, and we should not demand it except fur the strongest reasons. As regards sexual inter- course, I never, under any circumstance, advise it to young men as a remedial or sanitary measure. The considerations which led me at the beginning of my practice to adopt this rule are complex, but to me of fibsolute force. It is said that continence causes nervous symptoms, but I must say, gentlemen, that I do not believe that this is so, unless the patient's imagination has been already perverted, or where bad practices have been established. In married patients I follow the same rule as for tobacco — viz., enjoin great moder- ation ; indulgence two or three times a month. You can TREATMENT AND MANAGEMENT OF NEUROSES. 77 soon determine in such patients whether the act is injuri- ous. Very often, however, I advise the use of separate beds. This is partly to secure the patient against jostling or annoyance by the snoring of the companion, though also to prevent involuntary and ungratitied sexual excitement, which I consider as particularly exhausting. Many patients with insomnia are at once benefited by having the exclusive use of a large bed. The two beds may be in one room in cases where the nervous person is afraid to be alone. I should add to what I have said of tobacco that, besides reducing your patient's allowance, it is desirable to prevent him from go- ing to and staying in places where he must inhale much smoke (club-rooms, etc.). 78 LECTURES ON SOME POINTS IN THE LECTURE III. II. Rest. — The extreme importance of rest in chorea has been already stated. In some cases of neurasthenia and of hysteria absolute rest and separation from the family are called for. This " rest treatment " of neurasthenic condi- tions you will find fully detailed in Mitchell's books. With regard to the great majority of cases of neuras- thenia, nervous dyspepsia, migraine, neuralgia, etc., a judi- cious partial rest is sufficient, and, indeed, all that most patients can afford to have, as comparatively few patients have the means of entering a sanitarium or of going away from home with a nurse for three or four months. In all such cases I direct one or two periods of physical and men- tal rest in each day. The patient is to retire to a quiet room, away from noises and calls by relatives (children especially), and lie quietly for an hour or two. Undress- ing is not necessary, but, in the case of women, the corset should be removed. No one should be in the room, and diversion is to be sought by reading or by pleasant lines of thought, directed toward the time when the cure shall have been accomplished. This is a variety of treatment by " mental suggestion " in the wide-awake state which should never be omitted. Urge your patient to look forward and never backward, to do her best to ignore her numerous paraesthesiae or secondary symptoms, and to try to keep her mind occupied with ideas relative to the happy time TREATMENT AND MANAGEMENT OF NEUROSES. 79 when she shall be well. This requires judicious, forcible, and cheerful conversation on your part, and, where it is pos- sible, through your suggestion, on the part of persons near the patient. When the patient lives in a small house, in which it is impossible to have a room for the above purpose, T advise that she spend the hour or two hours at a friend's house, or that she (female patients constitute the majority of such cases) send the children clear away from the house for the time. In these ways, in spite of unfavorable social conditions, you may be able to secure rest for your patients. At first this lying quietly is very hard ; the patient is more nervous, feels " as if she would fly," etc. ; but by persever- ance the difficulty is overcome by the establishment of the new habit. III. Seclusion is especially successful in hysterical cases, more especially those in whiclj there is mimicry of a serious disease, voluntary starvation, or apparent sleep (lethargy). In -some cases forty- eight hours of rigid separation from the sympathy and attention of relatives will cure or greatly relieve a case of " fancy hysteria," as I call it. 1 have prac- ticed this treatment regularly (whenever the relatives of the patient would permit) for at least fifteen years, and had had many successful cases before Charcot published his ex- perience on the subject. The following case will serve as an illustration : In 1878 I was called, to see a very bright girl of thirteen years, the daughter of a healthy physician, but of a nervous (hysterical and choreic) mother. The child had witnessed many of her mother's severe seizures. The child had been suffering for a week or more from an excruciating " neuralgia " of the left hand and forearm, which no treatment, general or local, had relieved. She seemed in good health, and complained only of her hand, which she held rather rigid in a conical attitude, in con- stant fear of its being touched, handled, or moved. The 80 LECTURES ON SOME POINTS IN THE pain, she declared, was all through the forearm and hand ; it did not follow the distribution of any one or two of the three nerves which supply the hand. There was neither anaesthesia nor atrophy nor discoloration, but great hyperaes- thesia was present. She was constantly attended by her mother, her father had almost given up practice in order to be with her frequently, and her young friends were call- ing on her, sending her notes and bouquets — in other words, she was a badly coddled invalid. I might add that she had not presented any of the common hysterical symp- toms, a fact rather common in the history of similar cases of neuro-mimisis. After a few days of attendance, I became convinced that the case was one of delusional pain in a hys- terical subject, and, after trying several remedies, persuaded the father to let me try moral treatment for a week. The room was stripped of some of its pretty things, notes and bouquets were intercepted, the parents resolutely kept away from the patient's room and floor, and the servant was di- rected to leave the (plain) food on the table by the bed without holding any conversation with the child — in short, she was rigidly secluded one afternoon. The next day about noon, while the door was opened to allow of her food being brought in, she called out loudly so that her father heard her on the floor below, " I am better, papa." The next day she went down stairs well, and remained so. Now this case was one which, judging by experience, would have grown worse and worse under treatment and misplaced sympathy; the "neuralgia" would have extended to other parts, spasmodic attacks supervened, and perhaps semi-star- vation practiced, wrecking the child's life. I will ask you to remember that this was done in 1878. When you propose a thorough rest-cure or seclusion in a case of neurasthenia or hysteria the family are always anxious to have this carried out at home. Usually I believe TREATMENT AXD MANAGEMENT OF NEUROSES. 81 that this leads to failure, more especially in the case of neur- asthenic women worn out by child-caring and household duties and worries. They must get clear away, and, if pos- sible, to another city. In the house a thousand sights and sounds suggest lines of thought relative to matters which have exhausted the patient, and, besides, there is often added a feeling of self-reproach for the apparent (obliga- tory) neglect of customary duties. By all means, remove the patient from her own house to a hotel, boarding-house, or to a friend's residence. In some cases of hysteria, if you have the earnest co-operation of relatives, the treat- ment may successfully be carried out at home, but even in such cases you should have a good nurse with the pa- tient. IV. Bathing. — I have great faith in cold water judi- ciously applied. With the use of the"ppck"my expe- rience has been limited, though I think that I have ob- tai-ned good results from local cold packs to the epigastrium and abdomen in neurasthenia and nervous dyspepsia, and round about the genitals in impotence and irritable weak- ness of the male organs. The pack is to be left on from half an hour to an hour only. The use of cold water in such a way as to bring about reaction and a permanent improvement in circulation has been prominent in my treatment of j^euroses. 1. The cold douche, general or spinal. This should be short, from five to twenty seconds by the watch, the head protected by an oiled-silk cap. The short cold spinal douche certainly seems to have a beneficial effect in neuro- ses and in posterior spinal sclerosis. Force should be given to the jet, and this is best done in establishments furnished with suitable apparatus. Unfortunately, in this country the *' water-cures " are not what they should be, and a physi- cian's prescriptions are disregarded by the medical men in 82 LECTURES ON SOME POINTS IN THE charge; they follow their own plan, which, I understand from statements of patients, consists chiefly in immersion baths, long-continued packs, and the electric bath. At the patient's home a rubber tube and nozzle may be fast- ened to the delivery tube in the bath-room, and the part sprayed by a relative or servant. If there is no running water with power, it is necessary to throw the water with as much force as possible from a cup or pitcher upon the back or other parts. 2. Rubbing with a cold, wet towel or sheet (using salted water preferably). In the sheet application I usually have the patient stand naked in a warm room, the nurse or mas- seur throws the wet sheet over his shoulders, and then rubs every part of the body below the head very briskly and hard with the cloth. This step may last from two to three minutes. The patient is then dried and lies on a sofa or bed wrapped in a blanket while the operator applies ordi- nary friction or regular massage to the whole body. This second step of the operation is usually much too long, a manipulation of from thirty to forty minutes being long enough for strong patients, while many ought not to be rubbed for more than ten or fifteen. In this matter you should keep a strict control over the masseurs or nurses, as they almost all are convinced that they must give the pa- tient an hour of hard work. Dr. Douglas Graham, of Bos- ton, and Dr. Murrell, of London, have both insisted on this point — viz., that massage should be moderate and never exhausting, 3. The simple cold sponge-bath is practiced by many of my patients. I direct this to be very brief, not more than two minutes. In winter it is well for the patient to stand in hot water during the sponging. It is to be followed by hard rubbing, done by the patient when he is fairly strong, or by a relative or nurse when he is weak. In many cases, TREATMENT AND MANAGEMENT OF NEUROSES. 83 where reaction is feeble, it is better to have this done at bed-time, as the patient can at once get into bed, and react more fully. 4, The cold foot-bath has been recommended very highly in cases of neurasthenia and of parsesthesise in the head (miscalled cerebral hypersemia). The feet and legs are to be immersed in cold water for one, two, or three minutes, then rubbed hard. In some cases this brings about a strong reaction. 5. There are two opposite conditions of the hands and feet met with in practice which are very amenable to the proper use of water. I refer to cold or burning feet and hands. For the latter I direct a short douche with the hottest water which can be borne twice a day. For cold extremities (which are by far more common) I make use of the cold bath (one to tv.^o minutes) or of cold showering. I have warmed the feet of hundreds of people by having them give their feet a hard rub under a stream of cold water night and morning, the good results appearing in the course of ten days or a fortnight. In connection with the symptom of habitual cold feet, I would refer to the proper foot covering. I have become con- vinced that too warm or woolen stockings are conducive to cold feet, by having in great numbers of cases witnessed very rapid improvement follow a change to light cotton or thread hose. The explanation is simple. Woolen socks or stockings favor perspiration ; this occurs under a practically impervious covering (the shoe) and evaporation is pre- vented. The result is moist, cold feet. Thread or light cotton hose, on the contrary, keep the feet dry, and conse- quently warmer. On the rest of the body, in spite of outer clothing, evaporation goes on fairly well, and the use of wool is admissible. Menstruation need interrupt these various uses of cold 84 LECTURES ON SOME POINTS IN THE water only for two days, as after that, in my opinion, the flow is seldom checked by the application. 6. This leads me to mention a most important matter — viz., the checking of menstruation in ana?mic female pa- tients. I am thoroughly convinced that the profuse flow of women at the present day is not only unnecessary but is a great loss, and I have attempted to check it in my cases, with marked benefit. Internal remedies — such as ergot, tannic acid, etc. — exert little or no influence on the flow. The bromides are much more potent, but they must be given freely and almost continuously, which of course would be injurious to weak and neurasthenic patients. Following the advice and successful practice of Lowenthal, of Lausanne,* I have made use of large hot vaginal injections twice a day from the beginning of the menses in several cases with de- cided eflPect in reducing the flow or shortening the " pe- riod " by one or two days. In some cases I believe that even tamponing, as advocated by Gehrung, f of St, Louis, would be justifiable to prevent the recurrent monthly anae- mia which is the curse of so many women's lives. Exercise, — Many neurasthenic patients will tell you that they have exercise enough in their household duties and business conditions ; but in saying this they make an enormous mistake. These patients are tired and exhausted by their occupations, but they have not had physiological exercise, I can not here enter upon a consideration of the ■ vahie of the various forms of exercise, by simple muscular action and by the aid of apparatus. Suffice it to say that by exercise I mean the systematic use of certain muscles with a clear object, local or general, in view. Walking is * Revue de therapeutique, 1888, cited by Gehrung, Am. Jour, of Obstet., 1888, p. 1138. f Am. Jour, of Obstet., 1888, p. 1138, and 1889, p. 1072. TKEATMExNfT AND MANAGEMENT OF NEUROSES. 85 what I almost invariably require of my nervous patients (excepting those who have severe uterine or ovarian lesions). A walk after breakfast is my favorite order, but this is partly to oblige the patient to get a supply of fresh air after having been housed so long. It is surprising how many intelligent women do not realize the fact that they are frequently indoors from six or seven o'clock in the evening until one or two the next afternoon. Nor do many patients who " can not eat " breakfast appreciate that they are thus made to go nearly eighteen hours without useful food. Walking and other exercises should be carried to the point of slight fatigue, but exhaustion should be avoided, and in this we must trust the patient's judgment. Many patients should take broth or hot milk on coming in from the morning walk and lie down for half an hour. One ex- ercise I would especially recommend — viz., the practice of forcible inspiration. In this the patient is to be almost un- dressed, at least free from restraint about the body, stand erect, place the closed fists over the breast, and extend the arms slowly and fully, with all possible force, at the same time that the thorax is expanded and raised to the utmost by a slow inspiration taken with the mouth open. This is very fatiguing when properly done, and from six to eight breaths twice a day will be sufficient. You will be sur- prised, I am sure, at the increase in chest breathing and the general improvement which this simple exercise brings about. It should be kept up, night and morning, for many months. Systematic gymnasium work would be good if we every- where had judicious instructors; unfortunately, most gym- nastic teachers are ignorant of the principles of physiologi- cal gymnastics, and overwork the pupil, besides developing muscles which medically are of no importance. It would 86 LECTURES ON SOME POINTS IN THE be well, in sending a patient to a gymnasium, to specify in writing what exercises you deem necessary. I referred a while ago to the desirability of giving neur- asthenic patients fresh air, and this leads me to throw out the following additional hints. Patients who are unable to leave their room from the severity of their symptoms or because you are carrying out a rest-cure should have fresh air daily. In such cases I direct that the patient shall be well covered up (if bed-rid- den), with a cap on, and that all the windows be opened wide for a time (from ten minutes to an hour) once or twice a day. For patients who are able to sit up, I order that they shall put on a hat, outer garment, and even gloves (dressed as for going out), and that the windows be then opened as above described. I do this even in midwinter, when the patient must use furs and warm gloves to keep warm, with the happiest results. You will often find neurasthenic patients in a very warm room. This, I believe, is very bad for them. It reduces their nervous vitality and hinders the normal reactions which are essential to a good circulation. I always have a thermometer placed in the patient's sitting and bed rooms, and direct that the temperature shall never be allowed to reach 70° F. From 66° to 68° is the best temperature. If the patients complain of feeling cold, have them put on more clothing, or be covered up more (if in bed). Another, mischievous practice is the long-continued use of hot water in bags or bottles placed at the patient's feet. This practice prevents reactions and reduces the energy of the vaso-motor nerves. To use a hot application immediately after a cold one to favor reaction is reasonable and successful, but I be- lieve that the continued application of heat is pernicious. The waim or hot bath, with complete immersion of the body for from ten to thirty minutes, finds a place in my TREATMENT AND MAXAGEMENT OF NEUROSES. 87 practice. I use it in some cases of insomnia where excita- bility or a condition of " fidgets " is prominent. In some insane asylums of Europe these prolonged warm baths, sometimes kept up for several hours, under the supervision of a medical man, are used to allay the excitement of acute and chronic mania, in preference to the use of mechanical or chemical restraint. I have certainly been pleased with the effect of a long, hot bath at bed-time in excited cases of insomnia and in some states of " nervousness." Passive exercise has been fully treated of in the works on rest-cure. It consists in gentle faradization of most of the muscles of the body, or in massage combined with so- called Swedish movements. My observation has been that masseurs usually do too much ; they often exhaust them- selves and the patient, too, in their attempt to give the worth of their fee. In most cases, I instruct the operator myself as to the length of the treatments and the proportion of massage and passive movement which is to be observed. As before stated, I often direct that the manipulation be preceded by a rapid, brisk cold sponging or toweling. Mas- sage, like active exercise, should never be carried to the point of exhaustion. The Abuse of Certain Drugs in the Treatment of Neuroses. I. Alcohol. — While I believe that-alcoholic stimulants may play a wholesome or profitable role in dietetics and therapeutics, I think that these liquids are habitually used to excess, and fear that the medical profession is not quite free from the reproach of having been the means of starting many persons down the hill of alcoholism. You will often hear it said that the most injurious form of stimulation — i.e., that by "drams" or drinks of the stronger liquors — is more prevalent in English-speaking nations than on the continent of Europe. 1 am not so sure of this, for the ha- 88 LECTURES ON SOME POINTS IN THE bitual daily use of strong drink is a widely spread evil in the whole of northern Europe and in Switzerland. You will be told that the use of beer, ale, and native (pure, though rough) wines, which are drank mostly at meals in Germany, France, Italy, and Spain, is not harmful. This, from con- siderable observation, I think is a dangerous error. What these beverages lack in strongly intoxicating power is made up by the larger quantities which are ingested, and I think that much mild chronic alcoholism is thus set up, in a perfect- ly " temperate " way, besides the production of gastric dis- ease (dilatation and catarrh), and of the lithiemic and gouty dyscrasias. In other words, I am convinced that most civil- ized people who use stimulants take too much ; though, of course, dram-drinking of whisky, brandy, anisette, schnapps, etc., sets up gastric and nervous disease more quickly. In the interests of the race in general and of the families whose medical advisers we are, there can be no question but that it is our duty to set our faces against alcoholic excesses and to be careful that our prescriptions do not serve as a temp- tation or an excuse to patients. Allow me to be more specific. I have known several cases of alcoholism in women which had their starting point many years before in a carelessly given order to take some stimulant before dinner, on the plea that it would give an appetite. Again, I have known a woman to contract a strong alcohol habit by " taking a teaspoonful or so of brandy " when she felt badly, by a physician's advice. It is especially in the case of female patients with chronic gas- tric or nervous affections that it is dangerous to prescribe stimulants, except temporarily under careful watching. In severe acute diseases, as fevers, pneumonia, etc., the free use of alcohol for a few weeks docs not seem to create a habit or craving; as the patient progresses in convalescence more and more solid food is taken, and the stimulant may TREATMENT AND MANAGEMENT OF NEUROSES. 89 be reduced to a normal minimum at meals, or left off alto- gether. Another objection to the use of stimulants in neuroses is that they tend to weaken the patient's power of resistance to disease. In other cases, particularly where the vaso- motor and cardiac nerves are weak, they produce, in small doses, the cerebral symptoms we call tipsiness or intoxica- tion, and increase the palpitation and sense of pulsation which is often felt by these patients in a most troublesome way. Two years ago I saw in consultation a young married woman who had these symptoms, particularly palpitation with sensation of turning over of the heart, with a pulse sel- dom below 110, and made to rise to 120, 140, and higher by very slight exertion. She would spend half the night sitting or half lying, in mortal fear of stoppage of the heart. She was kept in the house by this fear, and also by the fact that any exertion increased her pulse-rate very much. I found that along with an otherwise well-appointed treatment she was taking " a teaspoonful or so " of brandy every three or four hours, or when she felt " weak and badly." Stopping the alcohol absolutely and giving one two-hundredth of a grain of aconitia every four hours relieved these cardiac symptoms so much that in a few weeks the patient slept well and was out walking and driving. The diagnosis of chronic alcoholism in private patients (women especially) is difficult, and often can not be deter- mined positively until you have had the patient under your care for some time, when, by repeated questions addressed to the patient and her relatives, you gradually learn the whole truth about the number and size of the drinks he or she has been taking and how far back the practice dates. A nurse with tact and shrewdness is here of immense assist- ance. You will be surprised at the light which such patient 90 LECTURES ON SOME POINTS IN THE observation will tlirow on some obscure and unmanageable cases. There is not as much lying about stimulants as there is about opium or morphine or cocaine, but the patient con- stantly tries to impress you with the moderation he has ob- served. Let me ask you, gentlemen, to prescribe alcoholic stimu- lants, especially to women, only on the clearest indications, to direct that the liquor be measured out exactly as by your order, and seek an early opportunity of stopping it. In cases of simple sub-nutrition and anaemia, ale and good claret or Burgundy wine, taken with food, doubtless assist in the flesh and blood-making processes. In cases where a gouty or lithajmic element is present, the least harmful stimulant is whisky or gin, largely diluted, with the solid meals. Be- fore meals stimulants certainly do much harm ; they seem to create an appetite, but this, 1 fear, is usually only a local sensation due to the intense irritation and hyperemia in- duced by the dram. Pray never order a drink hee