With regard to medicinal treatment is may be said that while, as a rule,
drugs should be avoided if possible, there are cases in which good results
may result from their use. Tonics, especially if anaemia is present, are
often indicated and of these those worthy of special mention are iron, strych-
nine and the arsenic preparations. Sodium cacodylate or iron cacodylate
824 DISEASES OF THE NERVOUS SYSTEM.
may be given hypodermatically if the stomach is intolerant, the former in
doses of f of a grain (0.05) twice a day, the latter in doses of ^u of a grain
(0.02). The glycerophosphates may often be employed with benefit as follows:
I^ calcii glycerophosphatis, gr. ivss (0.30); sodii glycerophosphatis, potassii
glycerophosphatis, magnesii glycerophosphatis, gr. iss (o.io); ferri glycero-
phosphatis, gr. f (0.05). Fiat chartula no. i. Sig. Take two such powders
daily; or I^ calcii glycerophosphatis, 3iss (6.0); sodii glycerophosphatis, potassii
glycerophosphatis, magnesii glycerophosphatis, ferri glycerophosphatis, aa
gr. XXX (2.0) tincturas kolae, 5iiss (10. o); syrupi am-antii corticis amari, q.s.
ad 5vi (200.0). Misce et signa one tablespoonful during breakfast and
The syrup of hypophosphites may also be prescribed or subcutaneous
injections of sodium phosphate two parts, alcohol five parts, and distilled water
100 parts may be given. Of the latter 15 to 45 minims (1.0-3.0) should be
Another drug which has recently been much advocated is lecithin. It is
given in pill form â€” 4J to 7^ grains (0.3-0.5) daily â€” or hypodermatically in
oily solution, each injection containing y^po to 2^ grains (0.05-0.15) of lecithin.
Injections of artificial sera have been recommended as a stimulant to the
nervous system and to lower blood pressure. Such sera may be composed
of phenol in crystal form i part, sodium chloride 2 parts, sodium phosphate
4 parts, sodium sulphate 8 parts, distilled water 100 parts, or sodium phosphate
10 parts, sodium sulphate 5 parts, sodium chloride 2 parts, crystalline phenol
J part, distilled water 100 parts. Of the former solution 2J drachms (lo.o)
may be injected daily; of the latter i J to 2J drachms (5.0-10.0) twice a week.
The solutions should be sterilized immediately before administration.
The treatment of cardiac symptoms: The application of cold wet compres-
ses to the precordium or of the aether spray will relieve the palpitation or if
this is a result of gastric disorder, treatment should be directed to the stomach.
The bromides and the valerates may be indicated when this symptom is
the result of nervous excitability. The systematic employment of hydro-
therapeutic measures vsdll tend to diminish the cardiac irritability.
Gastric symptoms should be treated according to the principles suggested
in the sections on the treatment of neuroses of the stomach.
The pains and excessive nervousness may be allayed by the bromides or
occasional doses of salipyrine, acetphenetidine or exalgine. For the sleepless-
ness a warm bath or a wet pack taken before retiring will often prove effectual.
If drugs are necessary such mild h3^notics as sulphonethylmethane (gr. x â€”
0.66), sulphonmethane (gr. xx â€” 1.33) or veronal (gr. x to xv â€” 0.66 to i.o) may
be prescribed at intervals. Morphine should never be allowed.
In sexual neurasthenia with nocturnal emissions and spermatorrhoea general
treatment with attention to exercise and mode of life, together with the admin-
THE NEURASTHENIA OF THE MENOPAUSE. 825
istration of hyoscyamus and the bromides, is to be advised. The loins should
be sponged off with cold water or a cool sitz bath taken before retiring; no
food should be eaten just before going to bed and the rectum should be kept
.empty to avoid pressure upon the prostate and seminal vesicles. The pa-
tient's mind should be kept occupied and off from thoughts upon sexual mat-
ters and he should be assured that he has greatly magnified his trouble and
the possible consequences thereof.
The recent work done upon eye-strain renders it of paramount importance
that any defect of vision should be properly corrected by the ophthalmologist.
THE NEURASTHENIA OF THE MENOPAUSE.
The incidence of the menopause (climacteric or change of life) is character-
ized in many instances by the appearance of numerous manifestations analo-
gous to those of ordinary neurasthenia. The anatomical basis of these is
undoubtedly a disturbance of the sympathetic nervous system. On no
other ground can the symptoms be satisfactorily accounted for and on no
other theory can the triad of pallor, flush and sweating, in whatever sequence
they may appear, the tachycardia, the dyspnoeas, the neuralgias, the vertigo,
faintness, tinnitus aurium, headache, pruritus, the serous diarrhoeas, the
veritable downpour of urine and the varying mental moods be explained.
At the menopause, the slowly increasing blood pressure of the intermenstrual
period which reaches its maximum at the onset of the flow, falls rapidly to
its minimum at the termination of the period, going on in rhythmical cycle
for about thirty years, is now disturbed; vaso-dilatation and vaso-constriction
succeed and precede one another in irregular waves. Pathologically there
is an actual insanity of vaso-motor function.
The majority of the patients who suffer from symptoms due to the meno-
pause consult the specialist in internal medicine or the family physician, It
is equally true that both these fully realize the importance of gynaecological
operations and treatment and insist that their patients shall receive them
should such be necessary; consequently it behooves the physician to be able
to make a proper diagnosis of the condition. In accomplishing this object
malaria, purinaemia and other general maladies, as well as diseases of the
circulatory, alimentary and nervous systems must be intelligently sought and
excluded. Next, all local pathological conditions as determined by the gyne-
cologist must be remedied. Having concluded that the symptoms are due
to the menopause we have immediate necessity for a working hypothesis
which shall at once explain the manifestations of the condition and serve as
a basis for a successful treatment. Such a one has been discussed above and
as has been previously stated the patient's state can best be accounted for by
holding the sympathetic nervous system responsible.
826 DISEASES OF THE NERVOUS SYSTEM.
Treatment. Disturbed balance of the sympathetic nervous system is most
rapidly benefited by the use of the bromides. If the pulse is of good volume,
tension and rate, sodium bromide in 15 grain (i.o) doses four times daily
should be prescribed. If left ventricular hypertrophy exists the potassium salt,
in the same dosage should be given. If cardiac dilatation has supervened or
arterial pension is lowered, the ammonium salt, the dose also being of the
same size, is preferred. In the presence of dyspeptic symptoms or if prolonged
administration seems likely to be necessary, strontium bromide is advisable.
What the bromides accomplish with rapidity arsenic will achieve more slowly
but with greater permanence, consequently as the condition responds to the
former the doses are diminished and arsenic is added, the solution of potas-
sium arsenite (Fowler's solution) in 3 minim doses (0.2) after meals, being the
most useful preparation. The dosage should be gradually increased until
slight untoward symptoms arise, when the initial dose is resumed.
Since most of the patients are ansemic, iron, as iron and ammonium citrate,
in dose of 4 grains (0.25) three times daily is advisable. The following
combination of these remedies is suggested: Strontium bromide i ounce
(30.0); solution of potassium arsenite 2 drachms (8.0); iron and ammo-
nium citrate 2^ drachms (lo.o); cinnamon water to 4 ounces (120.0). Of this
mixture i teaspoonful (4.0) in a wineglass (60.0) of water is taken after each
meal and at bed time. As the patient progresses toward recovery the
amount of bromide is to be diminished while that of the arsenic is increased.
In some instances when cessation of the menstruation is speedily established,
and particularly after surgical removal of the ovaries in young subjects, the
administration of ovarian extract, 5 grains (0.33) thrice daily for one or two
months is necessary; the dose should be gradually lessened. In other instances
the vaso-motor disturbance may be more readily controlled by smaller â€” 3
grain (0.2) â€” doses in connection with the bromides and arsenic. Such em-
ployment of ovarian extract is only exceptionally advisable.
For special indications further medication may be prescribed: (i) Menor-
rhagia: This may be controlled by absolute quiet in bed with ice bags over
the hypogastrium. The fluidextract of hydrastis 30 drops (2.0) twice
daily, or better, cotarnine hydrochloride, either by the mouth in 5 grain
(0.33) doses in capsule, or hypodermatically in the same dose in a 10 percent,
aqueous solution, is useful. A formula which is often effective consists of
fluidextract of hydrastis 2 ounces (60.0); ergotine 2^ drachms (lo.o); syrup
to 5 ounces (150.0). Of this the dose is a teaspoonful (4.0) in a wineglass
of water every hour or two. In rare cases tamponade of the uterus under
thorough aseptic precautions may be necessary; more seldom it may be ad-
visable to add 10 percent, of gelatin to the gauze, the latter being plain or
impregnated with iodoform.
2. Neuralgia. This is best relieved by pills of monobromated camphor.
AMOK OR AMUCK. 827
2 grains (0.13); quinine valerate i grain (0.065); extract of gelsemium
(B.P.) 2 grains (0.13); extract of belladonna leaves i of a grain (0.012)
given four or five times daily. As an alternative pills of extract of belladonna
leaves i of a grain (0.012); extract of gelsemium (B.P.) 2 grains (0.13)
and zinc valerate 3 grains (0.2) may be administered twice daily.
3. Psychic Disturbance. Sulphonethylmethane (trional) 15 grains (i.o)
combined with heroine, ^^ of a grain (0.005) given at bedtime wiU
tend to insure sleep during the night and quiet during the following day;
or a suppository of dionine, ^ grain (0.03), in cocoa butter may accomplish
the same result. These prescriptions shoiild be used only occasionally.
4. Palpitation. The tinctiire of veratrum in 15 minim (i.o) doses
thrice daily to which may be added tincture of gelsemium 8 minims (0.5),
is usually effectual.
5. Constipation is best remedied by the use of saline laxatives as Rochelle
salt or such waters as Hunyadi Janos, Apenta, Rubinat Condal and the like.
The other symptoms referable to the digestive tract are also benefited by the
judicious use of salines.
6. Diarrhoea is usually of the nervous type and wiU yield readily to the
In the daily life of the patient, fatigue, wakefidness, sexual excitation, cold
baths and especially sea bathing, spiced and highly seasoned food, tea, coffee
and alcohol in all forms are to be avoided. In other words a quiet life from
which all extraneous sources of irritation are removed is advisable. When
it is remembered that at the menopause the mind of the patient is in a state
of unstable equilibrium the importance of this last injunction is apparent.
Rest, therefore, both physical and mental, is doubly essential. For exercise
and to secure the necessary fresh air daily walks in the open, but not to the
point of fatigue, are suggested.
AMOK OR AMUCK.
This is a maniacal condition, seen amongst the Malay race, in which the
individual affected runs through the streets in frenzy and with sword or other
lethal weapon in hand slays or maims every one he meets until he meets death
at his own hand or that of another. The disease as a rule attacks males and
occurs in young adult life. According to the most recent studies the condition
of Amok includes several states in which the affected individual commits
violent, unthinking, unpremeditated and impulsive acts while mentality is
blurred. Certain cases are classed as the insanity of adolescence, others as
epilepsy, others under the rather indefinite term malarial psychosis, while still
others are inexplicable.
Before the onset of the attack proper the patient for a number of days is
828 DISEASES OF THE NERVOUS SYSTEM.
lethargic, stuporous or morose and sometimes amnesic. The exciting cause
of the seizure is usually resentment at a real or imagined injury, loss of money,
anticipation of disgrace or punishment on account of some misdeed, the
sight or odor of blood or a marital grievance or infelicity. During the attack
there is entire absence of memory which is an important point in the differ-
entiatioriof this condition from that of latah.
The disease has been attributed to alcoholism, opium smoking and relig-
ious mania but while there is indubitably a religious element in some of the
cases, the two former factors may be excluded.
It is the opinion of authorities that the individual who is " running amok "
is not responsible for the acts committed during the frenzy.
Definition. A morbid condition in which the patient is unable to stand or
to walk while the sensation, muscular power and coordination of the limbs
remain normal. The affection is an hysterical functional neurosis and has
an setiology similar to that of hysteria. It has been observed as a sequela of
the acute infectious diseases and may result from nervous shock due to trau-
Symptoms. The symptoms typical of this condition are total or incomplete
inability to stand or walk, while the limbs may be used in swimming and the
patient is able to move them as he lies in bed. There is, in most cases, no
disorder of sensation, no spasticity, no rigidity, the power or coordination is
normal, and the muscles retain their normal strength.
In some instances the patient may be able to walk but the gait is some-
what spastic or ataxic, while in others the limbs may undergo sudden flexions
or the patient may manifest a saltatory spasm.
The prognosis is that of hysteria of the ordinary type and the treatment
is that of this latter disease, the rest cure and electricity being particularly
Synonyms. Traumatic Hysteria; Erichsen's Disease; Railway Spine;
Definition. An hysterical or neurasthenic condition following nervous
shock, particularly that due to sudden severe traumatism.
.etiology. This affection may be the result of severe mental shock resulting
from participation in or even witnessing railroad accidents, explosions, ship-
wrecks or other accidents. Even slight traumatisms, such as may result from
a slip upon the pavement or stairs, may cause it.
OCCUPATION NEUROSES. 829
Pathology. The morbid changes occurring in this disease are indefinite.
Fatal cases are few but degeneration of the p}T:amidal tracts has been found
after spinal concussion, and punctiform haemorrhages in the brain and cord,
sclerotic patches in the white matter and sclerosis of the cerebral vessels have
Symptoms. In certain cases these are not markedly different from those
of hysteria or neurasthenia due to other factors. Those referable to sensation
are headache and backache, spinal tenderness, numbness and tingling in the
extremities; hemiansesthesia with achromatopsia on the anaesthetic side or
contraction of the visual field may occur. Motor symptoms of various degrees,
tremor and even paralysis may be present. The reflexes may be exaggerated
in degree differing from time to time.
In severe cases with actual spinal concussion symptoms suggestive of organic
disease of the nervous system may develop. These may appear early or may
be gradual in their evolution and the accountable lesion has been found post
mortem in certain cases in the shape of a pachymeningitis. The symptoms
of such cases consist of pain in the head, back and other parts of the body,
hemianesthesia and areas of diminished cutaneous sensation and of tenderness,
loss of temperatiure sense and of muscular sense, the latter being bilaterally
symmetrical or irregular in distribution, disorders of smeU and taste and
diminution of the visual field with inequality of the pupils. Motor symptoms
are of various t}'pes; monoplegia with or without consequent contracture,
without atrophy and with persistence of normal electric irritability may occur
vnth diminution of the cutaneous reflexes, the deep reflexes being increased.
The mental symptoms are identical with those of marked hysteria.
Rarely in cases which have been primarily regarded as hysterical or neuras-
thenic, true organic changes evidenced by such symptoms as optic atrophy,
bladder disturbances, increased reflexes, paresis and tremor, develop. Such
cases may end in death, the organic changes being demonstrable upon autopsy.
The prognosis as regards recovery is good, few cases, however, are relieved
while litigation is in progress; even after the decision has been rendered in
the patient's favor the symptoms may persist but usually after the suit is
terminated gradual recover}^ begins. Rarely cases grow progressively worse
and melancholic symptoms develop, followed by dementia or paresis. In the
cases in which organic changes develop, the prognosis is unfavorable.
Treatment consists in the employment of the methods and means suggested
in the sections upon the treatment of hysteria and neurasthenia (pp. 819
Synonyms. Professional Spasm; Copodyscinesia.
Definition. This term is employed to designate a variety of nervous condi-
830 DISEASES OF THE NERVOUS SYSTEM.
tions characterized by involuntary spasm or cramp of the muscles employed
in performing some frequently repeated movement. The affection is seen
most frequently in writers and here is denominated writer's cramp or scrivener's
palsy; similar conditions occur in telegraphers, piano-forte and violin players,
typewriters, milkers, seamstresses, cigarmakers and other tradespeople who
continually perform the same muscular act in carrying out their occupations.
Etiology. While occupation neuroses occur in those of phlegmatic tem-
perament they seem to be more frequent in those of neurotic tendency. Men
seem to be more frequently afifiicted than women though this may be the case
because the male sex is more likely to be employed in occupations in which
the condition develops. Writer's cramp is the most common tj'pe of occupa-
tion neiirosis and according to Gowers it is seen more often in those who employ
imperfect methods in writing, using the little finger or wrist as fixed points,
whereas the elbow or forearm should properly remain stationary. Injury
may precede the onset of the affection.
Pathology. No morbid changes t}^ical of this disease have ever been
described. Various theories, however, have been advanced to account for
its occurrence. Of these the most probable is that the affection is a central
one and due to a disordered action of the nerve centers which control the
muscular movements employed in writing. Atrophy involving the affected
muscles is sometimes observed.
Symptoms. The first of these to appear is usually a cramp or spasm, chiefly
involving the thumb and forefinger. The pen may be grasped too forcibly
while the forefinger tends to slip off the pen, or the thumb may be flexed
and adducted. A "lock spasm" may occur in which the pen can be removed
from the grasp of the fingers only with difficulty. The hand feels weary
and aching; pain sometimes affecting the arm as weU as the hand may be
present. The patient's grasp of the pen may be weak while the hand-grip
remains normal. Tremor, most frequently of the index finger, may occur,
sometimes as a precursor of atrophy. Numbness and tingling of the hand
and forearm may be observed and if a true neuritis is present there is tender-
ness along the course of the affected nerve.
Marked cases may manifest such vaso-motor symptoms as glossy skin, a
condition resembling that of chilblains or hypersesthesia, while on an attempt
to write the skin may become hot and cyanosed.
Electric reaction in the early stages remains unchanged but late in the
disease the response of the motor nerve endings to faradism is diminished
while that to galvanism may be increased.
The prognosis in marked types of the disease is hardly favorable as regards
complete recovery although rarely this may take place. Patients exhibiting
sensory symptoms are more likely to recover than others in whom these are
lacking. Relapses are not uncommon.
OCCUPATION NEUROSES. 83 1
Treatment. Prophylaxis consists in the acquirement of a proper technique
in writing, as it is probable that if writing from the shoulder were in general
use, cases of writer's cramp would be rare. The various appHances calculated
to lessen the fatigue of writing are of little use, and invention of the typewriter
has rendered all such unnecessary. Fortunately the affection does not inter-
fere with the patient's ability to use this instrument. Learning to write with
both hands is a way out of the difi&culty unless both become affected with the
disease; this unfortunate circumstance may occur.
Rest of the affected part is essential to a cure and as an adjunct, attention
should be given to the patient's general hygienic condition. Fresh ah and good
food are necessities and, when indicated, the tonics, iron, arsenic, strychnine
and codliver oil should be employed.
Electricity may be prescribed with benefit, most authorities preferring the
galvanic current; its use should be continued for months, a current of four
milliamperes being sufficiently strong. The current may be applied every
day or two for from five to ten minutes. Various methods of using the current
have been advocated; the positive pole may be applied to the neck while the
negative is placed in the supraclavicular fossa being at intervals moved to the
skin over the affected muscles and nerves. The current may also be applied
to the spinal column, or it may be passed through the head. If marked tre-
mor is present the negative pole may be appHed to the spinal region while
the positive is placed over the nerves and muscles involved. An ascending
current through the affected arm, the negative pole being on the forearm
or ball of the thumb and the positive upon the neck, may be used. So many
variations in the technique of the electric treatment are employed by different
authorities that it seems safe to suggest that it is the fact that galvanism is
used that achieves benefit rather than that a special method is effectual beyond
A weak faradic current is indicated when paralysis and anaesthesia are
Hydrotherapeutic measures, massage and g}'mnastic exercises are useful,
particularly the last. The most efficacious are those employed by Wolff.
These consist of active and passive movements, the former are performed
.as follows: The fingers, hands, forearms, and upper arms are moved in
every direction possible, effort being made to contract forcibly each muscle
from six to twelve times. The exercise should last about half an hour, the
patient pausing after the completion of each movement.
The passive movements are performed in the same manner and as each
is made the operator offers opposition. Both active and passive movements
should be repeated two or three times a day. Massage, consisting especially
of percussion of the affected muscles, is given in connection with this treat-
ment. Re-education similar to that advocated in the treatment of locomotor
832 DISEASES OF THE NERVOUS SYSTEM.
ataxia produces good results. The patient is given systematic instruction in
holding the pen and writing.
VASO-MOTOR AND TROPHIC DISORDERS.
"Â» RAYNAUD'S DISEASE.
Synonyms. Symmetrical Gangrene of the Extremities; Local Asphyxia.
Definition. A vascular disease due to a disorder of the vaso-motor system
and characterized by three stages: (i) local syncope; (2) local asphyxia; (3)
-Etiology. The causation of this condition is indefinite and obscure.
The disease occurs less frequently in men than in women and is more com-
mon in indi^dduals in early adult life. Children may be affected.
Pathology. This also is not yet definitely determined. Raynaud suggested
that vascular spasm is responsible. The asphyxia occurs as a result of dila-
tation of the capillaries and minute veins with spasm of the small arteries as
an additional influence.
Symptoms. Of these the first remarked is a paleness of the affected part
followed by loss of sensation and a marble-like whiteness. The condition
simulates closely that due to exposure to cold and affects chiefly the fingers