THE TREATMENT OF NEURASTHENIA, WITH SPECIAL REFERENCE TO THE REST-CURE. Read before the Section on Therapeutics at the Pan- American Medical Congress. BY F. X. DERCUM, M.D., Clinical Professor of Diseases of the Nervous System, Jefferson Medical Col- lege; Neurologist to Philadelphia Hospital; Assistant Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases. REPRINTED FROM THE THERAPEUTIC GAZETTE, DECEMBER 15, 1893. DETROIT, MICH. : GEORGE S. DAVIS, PUBLISHER. 1893. The Treatment of Neurasthenia, with Special Reference to the Rest-Cure. Notwithstanding the many advances made by modern therapeutics, nervous exhaustion in its various forms still remains one of the most trying and difficult conditions with which physicians have to contend. It presents such varied symptoms and is often so general- ized in character that some writers even deny it the position accorded to other affections. However, even if it be not as sharply outlined as other diseases, one must admit that there is a genuine morbid state of the nervous system present in the condition known as neurasthe- nia. Because many of the symptoms are sub- jective and because patients frequently find it difficult to give us an accurate conception of the various morbid sensations which they expe- rience, the outlines of a given case are often vague. However, the fact that certain symp- toms or groups of symptoms constantly recur, and the fact that we have such definite etio- logical factors as prolonged nervous strain, ex- hausting illnesses, and great physical or mental shock, proves that we have a well-established clinical entity before us. 2 Neurasthenia has always been regarded as an affection without a pathology. However, C. F. Hodge * has shown that in nerve-cells certain changes take place due to functional activity. These changes affect all of the cell contents, and there can be no doubt that they are char- acteristic of fatigue. These fhcts render it ex- tremely probable that there not only is a pathology to neurasthenia, but that this pathol- ogy is to be sought for largely in intracellular changes. Hodge, it will be remembered, proved that, as a result of electrical stimulation, the nuclei of nerve-cells decrease markedly in size, and that their outlines, instead of remaining smooth, become jagged and irregular, and that they also react differently to staining reagents; and, further, that the cell protoplasm undergoes slight shrinkage in size, becomes vacuolated, and also reacts differently to staining reagents; and, finally, that even the cell capsule itself, if present, shows changes in the size of its nuclei. He further proved, by his researches upon birds and bees, that these processes take place equally in normal fatigue. Among the most interesting results achieved by Hodge is also the demon- stration that exhausted nerve-cells recover their normal appearance if allowed to rest for a suffi- cient time; and, further, noted the fact that the process of recovery is slow, requiring many hours of rest. Certainly we have in these facts a hint as to what is present in the condition which is known as nervous exhaustion. It is probable that the nerve-cells in a typical case undergo changes * Journal of Morphology, vol. ii. p. 95. 3 similar to those which have been described by Hodge in his experiments. However, it is probably characteristic of neurasthenia that re- pair either does not take place at all or always imperfectly. It seems to me that this hypothe- sis enables us to understand many of the symp- toms presented. The underlying feature of nervous exhaus- tion is a diminution in the capacity for the sus- tained expenditure of energy. If it be true that the nerve-cells have undergone changes similar to those described by Hodge, and if it, further, be true that for some reason complete repair has not taken place, we have all the conditions necessary to explain this symptom. Not only do the results of Hodge furnish us with an ex- planation of the condition presented by the efferent or motor side of the nervous apparatus, but they also render comprehensible many of the sensory and subjective symptoms. For instance, the backache and the headache present in neurasthenia are, if we pause to ana- lyze them, peculiar in that they resemble the sensations often produced by normal fatigue. They seem to be grossly exaggerated fatigue sensations. Certainly the backache of neuras- thenia differs from the backache of lumbago, or the backache due to actual disease of the spine or spinal contents. Certainly, too, the neuras- thenic headache differs markedly from head- aches due to other causes. Not only are symp- toms present in the sensory and motor spheres which would suggest exhausting change in the nerve-cells, but also, as is well known, in the vaso-motor apparatus and in the behavior of the various glands and viscera. In the ten- dency to irregular flushing, in anomalies of 4 sweating, in the anomalies of the secretion of urine, in the general atony of the digestive tract, we have instances of this condition. Certainly our position relative to neurasthenia has been materially improved by the researches of Hodge, inasmuch as they enable us to for- mulate a rational and conceivable pathology of this curious affection. From what will be said farther on, it will be seen, however, that the researches of Hodge, even in their fullest ap- plication, do not yet enable us to explain all that is found. Certainly such curious symp- toms as the tinnitus aurium, the persistent throbbing in the limbs, and the various chill- like creepings, and other strange anomalies of sensation which we meet with, still lack an ex- planation. Further, another element makes its appear- ance when we reflect that when morbid pro- cesses continue for a length of time they are apt to be followed by more or less permanent changes,—changes that we are in the habit of referring to as “terminal changes” in discuss- ing other diseases. We see at once that the pathology of neurasthenia may be a very com- plicated one. Some of these changes can occa- sionally be traced. Such, for instance, are the changes which are sometimes noted in the blood- vessels of chronic neurasthenics. In persons who have been the victims of nervous exhaustion for years, and in whom repair has never had an opportunity of fully asserting itself, we find oc- casionally that the blood-vessels have become more or less thickened,—that is, they show changes of age at a relatively early period, and the heart also gives evidence of the same thing. In neurasthenics in whom the trouble has been 5 profound, and who have suffered for very many years, atheroma of the blood-vessels can frequently be detected with very great ease. Certainly, when the blbod-vessels and heart give us the signs of premature age, we have every reason to believe that all of the other tis- sues share more or less in this process,—that is, in a general tendency to premature senescence. These changes, I say, can occasionally be traced in the blood-vessels. I believe that they also take place in the muscles and even in the bones, but of this direct proof is as yet wanting. It is extremely probable that the nervous system itself will in the future studies, made under more exact and favorable conditions, show changes on a par in their significance with those which are occasionally found in the blood-vessels. Recognizing, then, the fact that in neuras- thenia the nerve-cells undergo a change which is in all probability similar to that which they undergo in normal fatigue, and that added to this we have, due to the persistence of fatigue in all probability, secondary or terminal changes taking place, we can readily understand how it is that some of our neurasthenic cases are so in- veterate, why it is that some of them yield so little to even the most radical treatment. A third element which largely influences the results of treatment lies in the fact that some of our patients are what might be called heredi- arily neu rasthenic,—i.e., persons who make their start in life with a nervous system in which cell wear and tear takes place readily, and in whom recuperative power is unusually feeble. They are peculiar in the fact that their neuras- thenia is manifested relatively early in life; they are apt to be feeble as children, often, but 6 not always, of small physical development, and are persons in whom fatigue is brought about by very slight exertions, either mental or physi- cal. I know of no more unsatisfactory class of cases to treat than these cases of hereditary neurasthenia. The factors, then, which influence the results of treatment in neurasthenia primarily are : first, whether we have an hereditary case to deal with ; secondly, if not hereditary, the time during which the neurasthenia has lasted ; thirdly, in non-hereditary cases, the result is influenced, according to my individual experience, as to whether a given case be the outcome of pro- longed nervous strain, or whether it has been suddenly produced by a physical or mental shock. The last group, or the traumatic neu- rasthenics, so called, are, in my experience, more difficult to treat than those in whom the neurasthenia is acquired in other ways. With these preliminary observations, let us turn our attention to the means that we have at hand for the treatment of a case of neuras- thenia. From what has been said, it is evi- dent that rest is an imperative factor. Cer- tainly, if the waste be rapid and repair be slow, the diminution of function—the securing of as complete a rest as possible—is the object to be aimed at. We all know that absolute rest, physiologically speaking, is an impossibility ; but, at the same time, that the degree of rela- tive rest which is practicable to obtain is very great. The question in any given case nat- urally turns at once, How much rest does this case require ? Every practical physician knows that it is most frequently impossible for persons actively engaged in pursuits of life to take ab- 7 solute rest; nor, in fact, is absolute rest always a necessity. Very frequently the most astound- ing changes can be brought about by relative rest. In the high pressure of modern civiliza- tion, especially as is represented on this conti- nent, the temptation to overwork is extreme; and in very many cases of neurasthenia, if the unphysiological excess of work be stopped, re- covery will result. You are, doubtless, all of you familiar with the scheme of “ partial” rest, so called, instituted by Dr. Mitchell, in which the patient, often an active business-man, is di- rected to prolong the hours of rest in bed, to rise not earlier than nine or ten in the morn- ng, and to retire with the onset of evening. A man following this direction must necessarily curtail the hours devoted to work, and very often this simple expedient is sufficient to bring about a most favorable result. However, cases are brought to us of greater and greater severity, —cases which vary from those in which a few hours of rest in bed during the day is requisite, to those in whom absolute rest for weeks and months is imperative. How much are we to expect from rest ? As I have already said, it is exceedingly probable that permanent or terminal changes are often present in neurasthenia. This factor of itself necessitates that the results to be attained by rest will, in given cases, be limited. In others, again, it will be followed by the most gratify- ing results. Finally, regarding the rest, let us remember that if our case of neurasthenia be a profound one and of long duration, this rest must be as nearly absolute as it is possible for us to make it. Dr. Weir Mitchell has already pointed out 8 how this is to be accomplished, how in very bad cases the patient is not even allowed to feed her- self, is not even allowed to turn in bed without the assistance of the nurse, is not even allowed to leave the bed to empty the bowels or void the urine. Now, while rest is undoubtedly a factor of prime importance, rest of itself, as Dr. Mitchell has shown, is not without its attendant evils. (See Seguin Lecture and “ Fat and Blood.”) It is well known that a joint, if not moved, will stiffen and finally become anchy- losed ; it is well known that a muscle which is not exercised will waste away, and it is prob- able that analogous changes take place in other tissues. How to combat these evils is a prob- lem which now presents itself. If we exercise our patient we expend his strength. Evidently the solution of the problem is to obtain the effects of exercise without this expenditure. That it is our ordinary custom to obtain these effects by massage and by electricity I need hardly point out, nor is it my intention to go over the ground already so well covered by Dr. Mitchell and by Dr. Playfair. I have only the following suggestion to make, based on my own experience. It is that these agents be used at first very sparingly, and only later in the treatment to their full extent. To this point I shall return in greater detail. The diet in cases of neurasthenia is, of course, of prime importance, and upon its proper man- agement will depend as much as upon anything else the result achieved in a given case. You are familiar with the methods ordinarily pur- sued ; with the fact that milk constitutes a large portion of the diet; that the patient is placed habitually upon milk at first, and that 9 later on other food is added. The neurasthenic is almost of necessity a dyspeptic; he lacks both the desire to eat and the ability to digest food properly. He presents that train of symp- toms with which we are all familiar under the name of ‘‘ nervous dyspepsia. ’ ’ Very frequently the patient objects strenuously to the milk, as- serting over and over again that he cannot di- gest it, that the milk will be vomited, that it gives rise to pain, and so on. The custom under these circumstances is to in some way modify the milk, either by the addition of some diluent, as weak tea or one of the car- bonated waters, or peptonized milk or kumyss is administered. Most often, however, you will find that the inability to take milk is very much exaggerated, and my own habit is never to ask a patient the question, “ Does milk agree with you?” I simply order it. I am careful, however, to order it in small quantities, begin- ning with about four ounces every two hours, and excluding absolutely all other food. This amount is, of course, insufficient for the needs of the body. I now find that, even if a disgust for milk is present, the patient being placed upon a very small amount of food, and becoming in a day or two very hungry, becomes extremely grateful for the milk and takes it eagerly. My habit is next to increase the milk very slowly, being careful at first to keep my patient a little hungry all of the time. Finally, in the course of a week or ten days, I increase the amount to eight, ten, or even twelve ounces every two hours, as the case may be. If I find that the patient is quite hungry by the fourth or fifth day, I add a small slice of stale bread with but- ter once or twice a day. This I finally permit 10 the patient to have three times daily. The diet is then further increased by a soft-boiled egg, or perhaps by a mere fraction thereof at break- fast. Finally, a small chop or steak is given at noon, and a small quantity of thoroughly-boiled rice may be given for supper. Upon these be- ginnings a substantial diet is finally built up, until the patient eats three large meals a day, such, for instance, as a breakfast of fruit, cracked wheat, one or two soft-boiled eggs, or a good-sized steak or several chops, bread and butter, and, milk; a dinner of a good slice, of roast beef, with vegetables and boiled rice (in place of potatoes). The supper I prefer leaving as a light meal of bread, butter, fruits, light pudding, and milk. It will be noticed that in this dietary coffee, chocolate, tea, and cocoa are absolutely omitted. Further, that malt extract, cod-liver oil, and beef-tea (all recommended by others) are not used. My own studies of these cases have convinced me that soups, beef-tea, and broths possess rela- tively little value; that they simply occupy space which can otherwise be given to milk, which certainly has a far higher nutritive power. The same, I think, holds true of tea, chocolate, and cocoa, while coffee is exceedingly objec- tionable, inasmuch as the neurasthenic is an individual who has in the vast majority of cases already exhausted stimulants, not only coffee, tea, and alcohol, but also the various narcotics, in the vain hope to find relief. I believe that coffee and alcohol, even in moderate use, should be avoided. Wine, beer, and milk-punch find, therefore, no place in my dietary. Another element of importance in the treat- ment is, as Dr. Mitchell and Dr. Playfair have 11 both pointed out, the isolation of the patient. Not only is our patient the victim of neurasthe- nia, but in very many instances she is also hys- terical, inasmuch as neurasthenia and hysteria are often inextricably intertwined. Under these circumstances, isolation, the withdrawal of the patient from the influences of relatives and friends, is of the utmost importance. How deleterious home surroundings are under these circumstances I need not dwell upon, as they have been sufficiently discussed by others. I need only to say that in cases of nervous pros- tration which are sufficiently pronounced to require rest in bed, isolation is imperative, and that it should be absolute. No exceptions should be made in favor of any relative,— mother, sister, or daughter; nor should any communication ever reach the sick-room, ex- cept through the mouth of the doctor, and then, even, should be most guarded and most general in character. My experience accords with that of Drs. Mitchell and Playfair, that even slight infringements upon this rule are sometimes fol- lowed by the most disastrous results. We find, then, that our resources for com- bating profound neurasthenia comprise rest, ar- tificial exercise (namely, massage and elec- tricity), a special diet, and isolation. The success which attends our efforts in any given case depends largely upon the way in which the various means at our disposal are utilized. No doubt every one who has es- sayed the rest-cure has developed certain methods of his own which he finds give him the best results. My own experience has led me to adopt the following: The patient is placed in bed. As a rule, she is extremely 12 nervous and perhaps hysterical. Frequently she is a stranger amid strange surroundings. She is left by her friends in the care of a physician whom she knows only by reputa- tion, and of a nurse of whom she knows less. It is my custom, therefore, to begin treatment in the most gradual manner, in order that the patient may become, in the first place, accustomed to her bed, for lying in bed is in the beginning quite a task to even neurasthenic people; and, in the second place, that she may become acquainted with and acquire confidence in her nurse. I, therefore, at the first visit am in the habit of examining my patient thor- oughly if I find that the examination is well borne and causes no excitement, but only in part if she be very nervous. Frequently I do not finish my examination until the next or even the third visit. I simply order a small quantity of milk, as already explained, and in- struct the nurse that she shall give the patient that evening a light and rapid sponge-bath, be- cause, in the first place, the patient will have a chance to become a little acquainted with her nurse, and because the bath in most instances favors sleep. Generally I do not direct that massage shall begin until the second or third day, and then I direct the nurse to continue it only for a short time and to make it very gen- tle and superficial in character. My reasons for beginning the massage in so gradual a man- ner are, first, that the patient may become ac- customed to the touch of the hands of the nurse ; secondly, I direct, when I once begin with the massage, that it shall be given in the evening, as the gentle, superficial stroking which I direct to be given at first soothes the patient. Just 13 as the diet is very gradually increased, so should the massage be very gradually increased both in depth and vigor; finally, the administration of the massage should be increased to at least an hour. Dr. Playfair recommends that the pa- tient be massaged for even three hours. This I do not consider necessary, and am indeed doubtful whether anything is gained, if indeed something be not lost, by this prolonged rubbing. Another point which I have come to regard as important is that the massage be performed by the nurse; this, of course, necessitates that our nurse be also an expert masseuse. My ex- perience has been that if the patient be treated by a regular masseuse at certain intervals in the day, the visit of this third person, with whom the patient has also to become acquainted, acts as a disturbing factor; to use an every-day ex- pression, the patients are apt to be “ upset” by it. In one instance I am satisfied it was the only factor which prevented my achieving a successful result. Regarding the details of the massage, I do not believe that they are of as much importance as is sometimes believed. The special method or school which the masseuse follows has no in- fluence on the general result. In this I am en- tirely in accord with Dr. Playfair. One prac- tical point, however, suggests itself. As a rule, you are aware that a slight elevation in temper- ature takes place. Occasionally the reverse is the case: a limb that has been rubbed grows cold. In the last instance the nurse should be specially cautioned not to expose the patient’s person any more than is absolutely necessary. Electricity I do not regard as of the same 14 value or importance as massage. In this I am in accord with the writers already quoted. However, it is a remedy which I almost invari- ably utilize, but generally as follows: In the first place, I believe that almost all that can be gained by artificial exercise can be gained by massage, and we must remember that most pa- tients are excessively afraid of the battery. The average neurasthenic is hysterical, and the mere mention of a battery, or the sound of the vibrations of the interrupter, will make them very nervous. Sometimes, indeed, marked de- pression follows its use. However, as in mas- sage, its application must be begun in a very gradual manner. A scarcely perceptible cur- rent is at first used, and the nurse, who has been previously instructed in the points of Ziemssen, is made to use the slowly-interrupted current in such a way that each group of mus- cles contract a given number of times. Until the patient becomes accustomed to this often unpleasant sensation, the application may be limited to the forearms and legs. Later it may be applied to the thighs, arms, and trunk. Electricity is doubtless a useful adjuvant to the rest-cure, but it is only an adjuvant. At the same time its utility cannot be questioned. I never use it early or in the beginning of a case. I am fearful—and, in fact, such has frequently been my experience—that the excitement and the irritation consequent upon its use act dele- teriously upon the patient. Further, the exer- cise that it gives the muscles I am confident frequently tires and exhausts, and I have ob- served it several times to retard the increase in weight which otherwise takes place. My habit is to begin with it only several weeks after the 15 treatment has been well under way, and some- times only in the latter part of a case, prepara- tory to getting the patient out of bed. Supposing that our treatment is now well under way, how shall we determine whether we are making satisfactory progress ? In the first place, if our patient is taking a large amount of food, and massage is having its proper effect, the color of the patient should improve. The pa- tient should, as the masseuse expresses it, “pink” readily under her touch. The limbs, too, should gradually become firmer to pressure. However, another and more important guide than this is the change in weight shown by the patient. Starting with the patient much below normal weight, as many of our neurasthenic subjects are, the changes which the weight un- dergoes should be our guide. Occasionally it is noticed that in the first few days there is a progressive loss of weight, but soon the patient begins to gain, and in the average case gains rap- idly. Patients gain in the course of from eight to twelve weeks as much as twenty-five, or even thirty-five, pounds. I can confirm from per- sonal observation and personal experience all that has been said upon this subject by Drs. Mitchell and Playfair. One of my patients ac- tually gained forty-two pounds in the course of three months. I have learned to regard the progressive increase in weight as the most valu- able index attainable regarding the progress of a case. I consider it of far more value than the persistence or non-persistence of such symptoms as backache or headache, or general nervous feeling. My experience with the various sub- jective symptoms is that some of them disap- pear relatively early, others persist; but even 16 the latter in the majority of cases grow fainter and fainter, until at last they no longer im- press themselves upon the consciousness of the patient.' In those instances in which obscure subjective sensations seem to be permanent, it is not improbable that more or less definite changes—“ the terminal changes”—have taken place, and that these persistent symptoms are due to the latter. It will be noticed that in the above plan of treat- ment drugs find no place. However, it is occa- sionally judicious to use a few remedies. Not in- frequently, for instance, the indigestion of our paitents is complicated by a veritable gastric ca- tarrh. Indeed, I may say that this is, , in my expe- rience, more frequently the case than not. I am, therefore, in the habit of prescribing nitrate of silver, say one-fourth of a grain, combined with one-fourth of a grain of hyoscyamus, to be taken half an hour before meals. Sometimes, also, at the beginning of the treatment, we find that the patient’s tongue is coated and that the bowels are loaded. In such case I frequently pre- scribe small doses of calomel and bicarbonate of sodium until the desired effect is obtained. In other words, general principles must guide us in the use of medicines in these cases, though, as far as possible, medicines are to be avoided. In a number of cases a laxative of some sort be- comes necessary. The choice of this is largely a matter of personal judgment; the simpler the remedy the better. I myself am in the habit of using the fluid extract of cascara, given at night, and, if possible, in gradually diminish- ing doses. Occasionally special symptoms require spe- cial interference. It may be that the headache 17 is so intense as to demand active interference. In this case I am in the habit of relying upon phenacetin, and sometimes administer moderate doses of bromide of ammonium at the same time. Frequently, too, the insomnia is so pro- found that it does not yield to the general treat- ment. We find, however, as a rule, that pa- tients who are taking a large amount of milk sleep a great deal. The excess of food seems to have a soporific or sedative influence, and therefore narcotics are rarely indicated. The massage, too, if given in the latter part of the day, favors sleep. Sometimes, though not al- ways, a wet sheet, followed by a gentle rub- bing, or a hot sponge-bath, rapidly given, act as sedatives. Occasionally, however, insomnia is so profound that we are driven to the use, for a time at least, of drugs. The milder drugs— say small doses of sulphonal, possibly of bro- mide—should be given. The stronger nar- cotics should practically never be used. For- tunately, in the average case we can get along without them. It will be noticed that strychnine and arse- nic, so much vaunted in neurasthenia, are drugs rarely used by myself. They are dis- tinctly stimulants, and should, therefore, on general principles, I believe, be avoided. In a large number, perhaps the majority, of cases the treatment can be conducted successfully from beginning to end without the use of any other drug than an occasional laxative. Let us suppose, now, that our patient is pro- gressing favorably; she is gaining steadily in weight; the tissues are becoming firmer; the annoying subjective symptoms are disappearing. When are we to get her out of bed ? How are 18 we to know when the maximum amount of good has been obtained by the method pur- sued ? In neurasthenic cases of long standing it is probable that our best guide is the change shown by the body-weight. If a decided in- crease has taken place and it then ceases, it is probable that the maximum increase has been reached,—/.