CEREBRAL EXHAUSTION WITH SPECIAL REFERENCE TO ITS GALVANO-BALNEOLOGICAL TREATMENT GEORGE M. SCHWEIG, M. D. MEMBER OF THE NEW YORK COUNTY MEDICAL SOCIETY AND OF THE MEDICAL JOURNAL A88( CIATION OF THE CITY OF NEW YORK; ONE OF THE PHYSICIANS TO THE NEW YORK LYING-IN ASYLUM, ETC., ETC. Ft •om ‘The Meduull. Recorb*’! of November 4th 1876 flew IJorft COSMOPOLITAN PRINTING OFFICE 11 SPRUCE STREET CEREBRAL EXHAUSTION WITH SPECIAL REFERENCE TO ITS GALVANO-BALNEOLOGICAL TREATMENT BY GEORGE M. SCHWEIG, M. I). MEMBER OF THE NEW YORK COUNTY MEDICAL SOCIETY AND OF THE MEDICAL JOURNAL ASSOCIATION OF THE CITY OF NEW YORK; ONE OF THE PHYSICIANS TO THE NEW YORK LYING-IN ASYLUM, ETC., ETC. From “The Medical Record” of November 4th 1876 COSMOPOLITAN PRINTING OFFICE 11 SPRUCE STREET CEREBRAL EXHAUSTION. WITH SPECIAL REFERENCE TO ITS GALVANO-RAI.NEOLOGICAL TREATMENT. BY GEORGE M. SCHWEIG, M. I). few (Read before the “Medical Journal Association,” Oct. 2d, tS7t>.) Neurasthenia, or “ nervous exhaustion, is a very- comprehensive term, which may apply to the cerebral, spinal or sympathetic nervous system, or to any or all of these combined. Indeed, although referable primarily to one or other of them, the affection rarely advances far without one or both of the sister-systems becoming involved—a very natural sequence, when we consider their close relations, anatomically as well as physiologic- ally. I propose in the present paper to limit myself to the form that involves primarily the brain, and which may aptly be termed cerebral neurasthenia or exhaustion. Let us glance briefly at the etiology, pathology and symptomatology of this affection, and we will then be prepared to proceed more intelligently to the discussion of a rational treatment. Of causes, we have the predisposing and the direct. The chief predisposing cause may be sought in a mind that lacks stamina, or staying power. As a feeble 4 muscle succumbs readily to continued trying activity, a thus feeble mind, be it otherwise never so clear, or even brilliant, will yield prematurely to long-continued deep thought or hard study. The inherited neuropathic diathesis is no doubt an important factor in the genesis of the disease. As may be readily inferred from the nature of their avocations, physicians, lawyers, inventors, etc., furnish proportionately the largest contingent to this class of patients. So far as my o a n observations go, the disease occurs almost exclusively in the middle- aged, the young and the old being comparatively ex empt. A word in regard to the influence of sex. Although occurring almost exclusively in the male, I do not believe that therefore the female is less predisposed to this affection. It seems to me, on the contrary, that this disproportion is owing alone to the circumstance that, in the present order of things throughout the civilized world, man does the hard brain-workythe proportion of females who devote themselves to the learned professions or other pursuits requiring mental exertion, being too inconsiderable to deserve more than passing mention. This, I admit, is of late becoming less so than it formerly was ; but I contend also, that when women shall come to furnish a numerically respectable quota to the pro- fessions that demand intellectual work, they will then also furnish their proportion, or more than this, of cases of cerebral exhaustion. The main direct cause of cerebral neurasthenia is simply “ abuse of the mental faculties.” As is the case with many other organs, the mind can be over-fatigued, again and again, until finally prostration, more or less complete and permanent, supervenes. In quite a num- 5 her of instances, however, we have a supplementary cause in collateral influences on the mind, in the shape of de- pressing emotions and thoughts resulting from family or business troubles, sickness, etc., that render this organ less competent to bear up under taxations that, under ordinary circumstances, it might have sustained with impunity. With respect to pathology, little is to be said. We know that primarily the disease is merely functional; observation, however, teaches that it is frequently the predecessor of so-called “ idiopathic cerebral softening.” Whether in such instances the cerebral neurasthenia is merely the initiatory symptom of the softening, or the cause of this, is for the present an open question. Theo- retically, we may assume that in cerebral exhaustion a foundation for organic changes has been laid by the repeated hyperaemke superinduced by the increased afflux of blood which, physiology teaches us, must have accom. panied each separate mental strain. In a considerable proportion of the cases, these passing active hypenemige lead to a permanent and more or less intense passive hypersemia, due directly to oft-repeated over-dilatation of the capillaries. The absence in cerebral exhaustion of any uniform anatomical change or lesion, compels us to cast our eyes in another direction. Of all theories as to the pathology, none appears to me more likely or reasonable than that of nutritive changes; indeed, I can think of no other. The nature of these changes is matter for the future histologist. Before leaving the subject ot pathology, it appears to me appropriate to cite a few words from Professor 6 Ebb,* treating of a kindred subject—“Spinal Neuras- thenia.” Speaking of the nature of that affection, he says: “ It appears most natural that we have to do here with subtile nutritive changes in the spinal cord, which we are compelled for the present to assume in so many diseases of the nervous system. . . . We possess as yet no knowledge whatever in regard to the nature of the nutri" tive changes that take place here. . . . The theory that appears to me more reasonable than any other, is that we have to do with an enhancement and fixation of the physiological “ fatigue ” of the nerve elements, that always follows severe and protracted irritation. In such pathological cases, then, we have only to suppose that this fatigue is not compensated rapidly and promptly, as is the rule under physiological conditions.” The symptoms that may follow in the train of cere- bral exhaustion are so manifold and varied, that to treat of them in detail would be entirely beyond the limits of the present paper. I shall therefore confine myself to the more prominent and constant of them. As a rule, the first symptom noticed by the patient is a disinclination for mental labor. If this feeling be for the time overcome, and an attempt made to perform brain work, a comparatively brief application will Miffice to exhaust the power of thought, and bring on confusion of ideas. The mind has lost its staying-power. In some cases the memory is enfeebled, in others it remains quite unaffected. To these purely mental symptoms, certain physical ones are soon superadded. * Ziemssen, Hand-Book of Special Pathology and Therapeutics ; Vo. XI., Part II., p. 378. 7 Agrypnia is a very common concomitant from the beginning. Of regional morbid phenomena, those within the sphere of the pneumogastric nerve take precedence, both as to and importance, over all others. Among them may be classed : Disturbances oi the heart’s action, the functions of the stomach, liver, intestinal canal, etc. Vasomotor disturbances are common. Cerebral nerves other than the pneumogastric may in turn become involved. Thus we often have here neuralgia of varied form and intensity. At first located in some of the cranial nervous ramifications, these appear frequently within the sphere of the sympathetic and spinal nervous systems, and may then be classed as secondary phenomena. I have never observed paralysis, although one patient told me that in the beginning of his trouble, which was some six years before 1 saw him, he had several attacks of hemiplegia without loss of consciousness, from which he made a spontaneous recovery in less than twenty-four hours. At a later period he had another attack, this time accompanied by loss of consciousness. Paretic conditions, on the othei hand, are the rule, although they rarely make their appearance until the disease has existed for some time. Judging from symptoms pointing in that direction — such as vasomotor disturbances, regional pareses, neuralgise or parsesthesise, there can be no doubt that both the sympathetic system and spinal cord—especially its upper portion, become functionally involved after a shorter or longer period. From a local cerebral disturb- ance, if not checked in time, we thus see developed, more or less speedily, a general neurasthenia, with a tendency to organic and perhaps fatal lesions. 8 This mere glance at the nature and manifestations of cerebral exhaustion and its sequela} is yet, I believe, suf- ficient to render apparent the necessity of instant and energetic treatment as early as possible, when we have still to contend with the primary condition alone. In addition to their aim to relieve the morbid condition it- self, our therapeutic efforts become at this time even more important as a prophylactic against organic and perhaps incurable sequelae. The diagnosis of cerebral exhaustion in its first stage should present little difficulty; yet it is precisely here, where its recognition is of most importance, that mistakes in diagnosis most frequently occur. Where the trouble is looked upon as cerebral, the absence of unilateral symptoms, such as hemiparesis or hemiplegia, and other characteristic signs of special organic cerebral lesions, will usually suffice to stamp the trouble as functional, and, in conjuction with a just appreciation of the anam- nesis and phenomena presented, lead to a recognition of its true nature. It is not, however, in this direction that diagnostic errors are most frequent. Of the instances of mistaken diagnosis that have come under my notice, nearly all were in the direction of the abdominal viscera. The symptoms due to functional disturbance of the pneumogastric were looked upon as primary conditions. The stomach was often accused, but that scapegoat par excellence, the liver was generally held responsible for everything. The golden opportunity for a rapid and decisive therapy was thus often irretrievably lost, entailing much and prolonged suffering, that might have been obviated by a prompt, correct diagnosis and rational treatment. 9 In the more advanced stages, even where the neuras- thenia has become general, or organic disease developed, the history of the case will, if minutely investigated, al- most always throw light on the origin and primordial nature of the trouble. The prognosis depends not only on the severity of the case, the duration of the cause and the hereditary disposition of the patient with respect to nervous disease, but also, and perhaps chiefly, on the patient’s ability to lay aside all other considerations, and follow out strictly the course laid out for him by his medical attendant. A\ here this can be done unqualifiedly, a favorable prog- nosis is the rule. We may now proceed to a consideration of the treatment of cerebral exhaustion. The one great object of a therapeutic course is patent; it is to seek, by appro, priate tonization and physiological stimulation, in con- junction with the much-needed rest, to restore to the brain its lost vigor; to correct its impaired nutrition; in short, to bring it back to a normal state. To effect this, it is of the utmost importance that no time should be wasted with tonic measures that exercise but little if any immediate influence on the brain. In view of the important share that prophylaxis bears in the indications for treatment, great circumspection is re- quisite in order to choose such remedies as are best calculated to insure speedy results. 1 will now proceed to describe the treatment which of all others has ren- dered me the best services. The very first condition for treatment, the sine qua non, is “ rest for the exhausted brain ;” not a brief rest of days, nor even weeks, but absolute abstinence from 10 all mental tasks throughout the entire treatment, and until health is perfectly restored. Unless this can he absolutely complied with, other measures are useless, or nearly so. It will be well if at the same time all dis- agreeable emotions, cares, or harassing thoughts of any kind can be avoided. This, I know, is not always possible, but should be carried out as fully as circum- stances wil1 allow. Of remedied agents, I have found galvanism to sur- pass iu efficiency all others. At a first glance, it would seem as though the objects to be attained by this could be best realized through direct galvanization of the brain. This, however, is impracticable. A direct current of sufficient intensity to influence the brain, would prove injurious on the principle that enfeebled organs will not bear strong stimulation. Moreover, we cannot with the utmost care prevent the occurrence at times, during galvanization of the brain, of giddiness, ocular flashes, faintness, etc.—-all undesirable phenomena, to be avoided in the electrical treatment of functional enfeeblement of the brain. If, on the other hand, we employ a current so feeble that occurrences such as those enumerated be- come impossible, or at least very remote, and that strong stimulation is out of the question, it becomes very questionable, to say the least, whether a current reaches the brain at all; and if yes, it will be too insignificant to accomplish any therapeutic results. My own experi- ence, then, with galvanization of the brain, has long since led me to abandon it in the initial treatment of cases of enfeeblemeut of that organ The manner in which I hereto affect the brain is by general galvanization, administered in its only 11 perfect form—the* galvanic bath. By its means the brain is made to sustain a reflex or indirect influence f rom all points of the periphery, and at the same time, thiough derived currents, a mild direct impression, w hichfan l>e regulated at will, not only by modifying the intensity of the current, but also by establishing more or less perfect communication between the occiput and the water of the bath, This direct influence differs from or- dinary cerebral galvanization, whether bipolar or uni- polar, in that here no electrode is applied directly to the cranium, which during the entire process is never for a moment in a direct line between the two poles of the battery. It is never attended with any of the undesir- able phenomena enumerated above as not always avoid- able in local galvanization. There are, indeed, no subjective sensations during the bath to indicate that the brain is being acted on at all. Nevertheless, an in- terruption or reversal of the current will promptly produce the galvanic taste, and, if the current has sufficient tension ocular flashes, etc., thus establishing beyond doubt the fact that the cranial nerves, resp. the brain, participate fully in the galvanic influence. The galvanic bath, then, of appropriate intensity for each individual case and stage, I look upon as the most valuable of all remedies we possess for the treatment of cerebral exhaustion. Bringing, at one and the same time, a suitably modified unipolar direct current and a reflex stimulus from every point of the periphery to bear on the brain, it stands unique among electro-therapeutic procedures. It not only furnishes to the brain tone and the much-needed physio- logical stimulation that tend to enhance its nutrition, but, through its invigorating influence on this organ, 12 allays the irritability that is so frequent a concomitant of debility, and thus becomes a sedative, and most efficient hypnotic. Its stimulating influence on the vasomotor system, together with its counter-irritant action on the skin, render the galvanic bath a very superior, if not the best equalizer of the circulation that we possess, causing it thus to exercise a further beneficial influence on the suffering brain by unloading its surcharged bloodvessels. In addition to these direct therapeutic effects of the galvano-electric bath, this becomes, where the faradic current is added, a means for symptomatic an I also pro- phylactic treatment, more universally applicable and useful than any other single remedy. Of its hypnotic properties, as well as its influence on the circulation, I have already spoken, and in both these respects it does all than can be expected or desired for any agrypnia or vasomotor disturbances that may be present. The well- known anti-neuralgic properties of the galvanic current render it also an efficient corrective for any intercurrent neuralgia;. The circumstance that in the bath no organ in the body is exempt from the elec'ric influence, is of great importance in the treatment of functional disturb- ances of the important organs that are innervated by the pneumogastric and sympathetic nerves. Thus, dys- peptic symptoms, hepatic torpor, irregular cardiac action, morbid modifications of the alvine process, etc., are as a rule rapidly ameliorated. Thus far I have considered the effects of the galvanic current alone. The faradic current, however, may like- wise be employed with great advantage, chiefly in the treatment and for the prophylaxis of paretic conditions. Passive muscular contractions of any group or groups of 13 muscles can be obtained in the faradic bath with great nicety, both as to locality and energy of contraction. The importance of this will be readily conceded. Nor is its influence on paresis the sole benefit to be derived from the faradic current. By the very muscular con- tractions thus evoked, capillary stases are relieved, and a mighty auxiliary is thus furnished the galvanic current in its effects on the circulation. On the whole, then, the electric bath meets all the indications of the disease but one, viz.: special nourish- ment for the brain. In addition to an appropriate diet, this may be best supplied by the exhibition of either phosphorus or cod-liver oil, or both, according to indica- tions in individual cases. The phosphorus may be given pure (in pill or solution) or as phosphide of zinc. Where electricity is employed, I consider medicinal stimulants superfluous; nor, with one exception, do I know of any other remedial agents, in addition to those enumerated, from which special benefit might be expected. The ex- ception I allude to is the bromides. These may be ad- vantageously given in cases that are characterized by irritability so intense or cerebral hyperaemia so decided as to indicate the employment of some additional remedy to combat these special conditions. As for further symptomatic treatment other than that furnished by the electric bath, such may become necessary, an I must be determined as occasion arises, according to the best judgment ol the practitioner. A few words as to the mode ot administration of the baths in the treatment of cerebral neurasthenia. It is impossible in this respect to lay down any routine formula, either in regard to the duration of the bath, the 14 temperature of the water, or the intensity or direction of the current. Each case has its own laws. A few general suggestions may nevertheless be not out of place. Very mild currents should be employed in the be- ginning. As recuperation advances, stronger currents may be gradually introduced. The intensity of the currents should be carefully regulated to keep pace with the gradually increasing capacity of the various organs to respond to the electric stimulus without detriment. Both currents may be used from the first, although the faradic current is strictly necessary only where paretic or sub-paralytic conditions exist. The galvanic should precede the faradic current, and be employed for not more than ten minutes. Where irritability is a feature of the case, the current should be descending—otherwise ascending. This may be followed by the faradic current, not of sufficient intensity for the first few baths, how- ever, to cause any but slight muscular contractions. In most of the cases iron may be advantageously added to the bath. The duration of the baths should at first not exceed fifteen minutes; in some cases this even is too long, the patient complaining of being fatigued perhaps after the lapse of ten minutes. Where this is the case, the bath should be at once terminated. It is, in these cases, not the electric current, but the warm-water bath, that gives rise to the sense of fatigue. Later on in the treatment, the duration of the baths may be from twenty to twenty-five minutes, according to indications. The practitioner who is familiar with the physiolo- gical and therapeutic effects of electricity, will readily grasp the requirements of individual cases; while he who has not given attention to the subject, will either 15 have to abandon the method, or relegate its application to some colleague who possesses the necessary informa- tion. The clinical tableau presented by cerebral exhaustion is so variable, that to introduce here a clinical record of one or two eases only would serve no purpose. As my limits therefore do not admit of the introduction of a sufficient number of cases, I must for the present refrain from a clinical consideration of the subject. New York, 1W Second Avenue.