A practical treatise on nervous exhaustion

Front matter

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Preface To The Second Edition

Wirutn less than a month after the publication of this work, it became manifest that the large edition would soon be exhausted.

The subject of neurasthenia, after long standing and waiting at the doors of science, has, at last, gained admission: although, like all new comers, it must for a time be the subject of curiosity, of suspicion, of ridicule, and of fear.

As this work was prepared very slowly and with especial painstaking and care, and was published only after innumerable revisions extending over many years, the changes in the present edition have been mostly restricted to the correction of a few typographical mistakes.

It seems proper and needful to state here that the philosophy of neurasthenia is contained in the third chapter—that devoted to the nature and diagnosis; the enumerations of symptoms, some known, others unknown or overlooked—being only secondary to the main issue, their interpretation.

The third chapter is, indeed, the book; and if those who fail to entirely comprehend it will re-read it but one-half as many times as it has been re-written, they will be able to see it from the author’s stand-point.

On the part of some friendly critics, the inquiry has been made whether the philosophy of neurasthenia, as herein taught, originated with its author. This universal inquiry, which is xx PREFACE TO THE SECOND EDITION.

addressed to every new claim in science, is the product, not so much of moral as of intellectual deficiency ; expressive of the want of an early discipline in logic and the consequent arrest of development of the scientific sense, rather than of any severe passion for injustice or any desire to carry the old maxim, “speak only good of the dead,” to the extreme of speaking only ill of the living.

But even those best trained in the principles of science, as taught in the writings of Whewell and Jevons, find therein no clearly formulated solution to the daily recurring problem, What constitutes a discovery in science ?

So far as is practicable in a few words, I will here attempt to give this inquiry a general answer that shall apply not only to this special topic, but to all scientific discoveries in every department.

The first honor in science belongs to him who organizes. To organize a science—to vitalize it, so that it may live and grow—is to make one’s self expert in it, and to point out the way for others also to become experts.

There are three stages of evolution through which all new ideas, before they are received into the full and unchallenged fellowship, have passed, are now passing, or are destined to pass.

First—the stage of indifference.

In this stage, the thinker not only has no opponents, but no audience; he must be his own listener and critic, as well as his own and only disciple. Not afew of the great discoverers, like Copernicus, have died before their discoveries could evolve out of this long and dreary period.

Secondly—the stage of denial.

PREFACE TO THE SECOND EDITION. Xxl

A few are awaking to the new truth, but declare that it is not truth. This is the non-expert’s hour and the delusionist’s opportunity to lead that opposition which is, everywhere, the inspiration and the sustenance of genius. Active opposition is, therefore, an encouragement to the friends of ideas; it is the first sign of growth—the plant has burst through the soil, and must meet with the winds and the storms.

Thirdly—the stage of contests of priority.

Now men say the discovery is important and true, but did not originate with the discoverer; some non-expert hath done this. The activity of this stage keeps history alive; since those who have risen to its level drink the past to its dregs for proofs that the world’s work has not been done by its workers ; they become themselves original in their search for originality. In this stage, indeed, antiquarian research attains oftentimes the wisdom of philosophy and the perfection of art; since it is demonstrated again and again that what we call modern science is really ancient; that the latest truths are but survivals of the oldest; and that Newton and Faraday, Hunter and Harvey, Fulton and Morse were but feeble and conscienceless imitators. During this very year, it has been shown with a clearness and force that suggest pure mathematics, that Edison, the controller of hundreds of patents, is one of the few Americans who never invented anything.

These three stages are not always distinctly defined, but they always exist, and must be traversed by every new thought that comes to an unwelcoming world.

The philosophy of this work, after long lingering in the first, is now passing, in the minds of students of this side of the ner vous system, from the second into the third of these stages.

XxX PREFACE TO THE SECOND EDITION.

It has been asked whether neurasthenia is a new disease. A disease is new, that is, new to science, however old it may be in experience, its discovery dates from the time when it is made a part of the organized knowledge of men. Over the whole empire of science this principle, based on the unconscious reasoning of the generations, has attained the force and the sovereignty of law. For eons upon eons, men have looked upon the stars, but Copernicus first saw them with expert eyes and brought astronomy into science; for thousands of years before Aristotle men had used deduction; for thousands of years before Bacon they had used induction: but Aristotle and Bacon, formulating the instincts of mankind—the highest reach of all philosophy—are yet the organizers of reason ; from the foundations of the earth lightning had flamed in the sky, but Franklin first harnessed it in the service of men; Jenner was not the first to practise vaccination, neither was he the first to practise it successfully ; but he was the first to practise it scientitically, and he is justly honored as its father. Others had produced anzesthesia by inhalation, but Morton organized it and gave it to surgery and the world. A thousand Icelanders, through thousands of years, may have wandered to these coasts, but Columbus was the discoverer of America. The theory of natural selection had been the dream of many generations, and in various countries, including our own, had been suggested and expressed; but only Darwin organized it, made himself expert in it, and prepared the way for others also to become expert in this realm of biology. Not the prospectors, nor the hunters and trappers, but those who develop the mines and level the wilderness are the pioneers of civilization and the real founders of States.

PREFACE TO THE SECOND EDITION. XXlll

Near the great track of navigation lies this unknown realm of pathology—neurasthenia. Many voyagers may have touched these shores, or in wonder have gazed upon them from the distant main, or, perchance have been borne unwillingly towards them by hostile gales, carrying back unheeded or forgotten tidings. But what is this mysterious land? Is it an island, is it a peninsula, isitacontinent? Toward what seas, through what climes does it extend? Where are the boundaries between it and the contiguous realms of hypochondria, of hysteria, of malaria, and of insanity? What are its fauna, its flora—its streams, its lakes, its mountain peaks, its precious ores, its populations? Thousands have guessed at these queries—he who answers them brings neurasthenia into science, and makes it the permanent possession of mankind.

Here, as everywhere, that automatic action of the faculties that we call instinct, comes nearer to the heart of truth than the conscious and controlled action that we call reason; it is when men essay to become logical that they are most likely to stumble and fall. If the above analysis be of value, it is in this—that it formulates the instinctive recognition of mankind, which always goes with the stream of justice, as reason so often goes against it, and in time fails not to confer the crown of science on those who organize it.

G. M. B. 13 West 29TH St., NEw YorK, May 1st, 1880.

Why the Study of Neurasthenia has been neglected.—The Symptoms of a Subjective Character.—Reasoning vs. Observation.— Less Frequent in Europe.—More Medicine used in America.....1-10

Chapter II. Symptoms Of Nervous Exhaustion

How to Study Cases.—Tenderness of the Scalp.—Cerebral Irritation. —Dilated Pupils.—Sick Headache and Various Forms of Head Pain.—Pain, Pressure, and Heaviness in the Head.—Changes in the Expression of the Eye.—Congestion of the Conjunctiva.— ‘Disturbances of the Nerves of Special Sense.—Neurasthenic Asthenopia.—Musce Volitantes.—Noises in the Ears.—Atonic Voice.—Deficient Mental Control.—Mental Irritability.—Hopelessness.—Morbid Fears.—Astraphobia or Fear of Lightning.— Topophobia or Fear of Places.—Agoraphobia or Fear of Open Places.—Claustrophobia or Fear of Closed Places.—Anthropophobia or Fear of Society.—Monophobia or Fear of being Alone. —Phobophobia or Fear of Fears.—Mysophobia or Fear of Contamination.—Pantaphobia or Fear of Everything.—Symptomatic Merely.—Morbid Fears Rarely Exist Alone.—Flushing and Fidgetiness.—Frequent Blushing.—Sleeplessness.—Bad Dreams.— Insomnia.—Drowsiness.—Tenderness of the Teeth and Gums.— Nervous Dyspepsia (Dyspepsie Asthénique).—Deficient Thirst and Capacity for Assimilating Fluids.—Desire for Stimulants and Narcotics.—Dryness of the Skin.—Abnormalities of the Secretions.—Abnormal Dryness of the Skin, Joints, and Mucous Membranes.—Sweating Hands and Feet with Redness (Palmar

XXV1 CONTENTS.

Hy peridrosis).—Salivation.—Tenderness of the Spine (Spinal Irritation) and of the whole Body (General Hyperesthesia).—Coccyodynia.—Peculiarities of Pain in the Back.—Heaviness of the Loin and Limbs.—Shooting Pains simulating those of Ataxy.— Podalgia (Pain in the Feet).—Tremulous and Variable Pulse and Palpitation of the Heart (Irritable Heart).—Local Spasms of Muscles (Tremors).—Dysphagia (Difficulty of Swallowing).— Convulsive Movements, especially on going to Sleep.—Cramps. —Special Idiosyncrasies in regard to Food, Medicines, and external Irritants.—Sensitiveness to Weather.—Sensitiveness to Cold or Hot Water.—Sensitiveness to Changesin the Weather.—Sunstroke brings on many Symptoms of Neurasthenia.—Localized Peripheral Numbness and Hyperesthesia.—A Feeling of Profound Exhaustion Unaccompanied by Positive Pain.—Ticklishness.—Vague Pains and Flying Neuralgias.—General or Local Itching (Pruritus).—General and Local Chills and Flashes of Heat.—Cold Feet and Hands.—Nervous Chills.—Sudden giving way of General or Special Functions.—Temporary Paralysis.— Diseases of Men (Involuntary Emissions, Partial or Complete Impotence, lritability of the Prostatic Urethra).—Diseases of Women.—Oxalates, Urates, Phosphates, and Spermatozoa in the Urine.—Gaping and Yawning.—Appearance of Youth.—Rapid Decay and Irregularities of the Teeth.—Hemi-neurasthenia.— Course and Caprice of the Symptoms.—Time of Life at which Neurasthenia is most Frequent.—Frequency of these Diseases.— How such Cases are usually diagnosticated.—Multitude of the Symptoms.—Correlation of Nervous Symptoms

Chapter III

NATURE AND DIAGNOSIS OF NERVOUS EXHAUSTION. Distinguished from Organic or Structural Nervous Disease.—1. Symptoms of Organic Diseases fixed and stable.—2. Neurasthenia has some Symptoms peculiar to itself,—8. In Neurasthenia reflex Activity increased.—Reflexes from Brain, Digestion, and Reproductive Apparatus.—Relation of Genital Troubles in both Sexes to Neurasthenia.—4, Neurasthenia most common where Nervous Diathesis predominates,—Characteristics of Nervous Diathesis,—

CONTENTS. XXVll

Distinguished from Hypochondriasis or Pathophobia.—General Hopelessness.—Groundless Fear of Disease.—Distinguished from Cerebral and Spinal Anzmias and Hypereemias.—Distinguished from Anzmia.—Distinguished from Hysteria.—Distinguished from Syphilis.—Distinguished from common Cold and Rheumatism.—Differential Diagnosis of Cerebrasthenia (Brain.Exhaustion) and Myelasthenia (Spinal Exhaustion).—Pathology and Rationale.—Vaso-Motor Reflexes.—Functional as distinguished from Organic Disease.—Recapitulation...............000000- 86-117

Chapter IV. Prognosis And Sequences Of Nervous Exhaustion

Recent Progress made in the Treatment of Neurasthenia and Allied Affections.—Relief and Recovery of Special Symptoms.—Prognosis depending on the hereditary Character of the Disease.— Working Order.—Sequence of Neurasthenia.—Insanity (Melancholia).—Hysteria and Hystero-Epilepsy.—General Neuralgia. — Inebriety.—Meconism (Opio-Mania),—Disease of the Reproductive Organs.—Hay Fever.—Writer’s Cramp.—Trance.—Paralysis and Organic Diseases of the Spinal Cord.—Exophthalmic Goitre.—Certain Stages of Bright’s Disease (Albuminuria). . . 118-132

Chapter V

TREATMENT AND HYGIENE OF NERVOUS EXHAUSTION. Each case of Neurasthenia is a study of itself.—Digestive Hygiene.— Milk Diet.—Rectal Alimentation.—Rest Cure vs. Work Cure.— Rest and Isolation.—A New Impression Needed.—Seclusion and Non-seclusion. — Brain-work in Nervous Diseases.—The Psychology of Patients to be studied.—Enumeration of Principal Remedies.—Arsenic.—Cannabis Indica —Caffeine.—Tea Tasting. — Caffeinism. — Coca.—Zinc Combinations. — Duboisia.— Cimicifugin.—Trailing Arbutus. — Eucalyptus.—Hydrastis.— Bromides.—Chloral.—Chloral Asthenopia.—Strychnia.—Opium. —Alcohol.—Mineral Acids. —Cod-Liver Oil.—Phosphates.—Koumiss.—External Modes of Treatment.—Electricity.—Massage. —Metalloscopy and Metal Therapeutics.—Recent Experiments

Xxviil CONTENTS.

in that Line.—Nitrous Oxide.—Philosophy of the Plan of Treatment.—Nerve Alteratives. Local Treatment of Uterus and Prostate and Prostatic Urethra.—Effects of Self-Abuse.—Persistence in Treatment.—Treatment of Sequences.—General and Special Effects of this Combined Treatment.—Improvement in Sleep.— Mental and Physical Sedation.—Increase in Fat and Weight of the Body.—Improvement in Appetite and Digestion.—Relief of Pain and Exhaustion.—Increased Capacity for Muscular and Cerebral Toil.—Travelling as Medicine often injurious.— Horseback Riding, when to be avoided.—Clothing should be warm.— Climatology of Nervous Diseases.—Neurasthenics benefited by a warm Climate.—Sea Air vs. Mountain Air.—Nervous Diseases of Americajand Hurope comparedsj-.0) ==) --2 se =e eee ee 133-193

NERVOUS EXHAUSTION. (NEURASTHENIA,)

Chapter I. Introduction

WHY THE STUDY OF NEURASTHENIA HAS BEEN NEGLECTED.

THERE is a large family of functional nervous disorders that are increasingly frequent among the in-door classes of civilized countries, and that are especially frequent in the Northern and Eastern parts of the United States, but of which our standard works of medicine and our lecture-rooms give little or no information.

The sufferers from these maladies are counted in this country by thousands and hundreds of thousands; in all the Northern and Eastern States they are found in nearly every brain-working household; and yet one might graduate at all of our colleges, read all of our most-used medical treatises, and converse with the majority of our ablest practitioners, without obtaining any just ideas in regard to the nature or treatment of these maladies. Even when these affections are treated of at all, it is, as a rule, one-sidedly, partially, and erroneously. Thus, neurasthenia is confounded with genéral anemia; cerebrasthenia (exhaustion of the brain) is assigned to cerebral aneniia or hyperemia. Myelasthenia (exhaustion of the spinal cord) or spinal irritation is confounded with spondylitis or spinal congestion, or is attri- 1

2 WHY NEGLECTED.

buted to mere circulatory irregularities, as anemia or hyperemia; sick headache is regarded as a disease of the stomach, and treated with antacids and purgatives; physical hysteria is stigmatized as a malady of the imagination; hay fever is supposed to be parasitic or infectious; inebriety is mistaken for drunkenness; while cerebral irritation and the different varieties of morbid fear are not mentioned at all.

Conversing on the subject, not long since, with a very intelligent interne of one of our largest hospitals, I found that neither in the medical school nor in the hospital had he received any suggestions relating to any of these functional diseases of the nervous system, although, if he should ever engage in private practice among the better classes of any of our larger cities, he will meet these diseases every day and every hour, and his success will depend to a considerable extent on his skill in managing them.

These disorders are transmissible oftentimes, taking the place of each other. They run in families more demonstrably than scrofula, or cancer, or consumption. Indeed, one great cause of the rapid increase of these disorders during the first quarter of the century has been inheritance. It is not difficult to find families in which all these diseases are represented; and there are individuals who at different times, or at the same time, suffer from all or nearly all of them.

I have said that in Europe these affections are but little known; but, in hability to them, all the European countries are not alike. They appear to be least common in Germany and Russia, Italy and Spain; considerably more frequent in France, and more frequent still in England.

Although these difficulties are not directly fatal, and so do not appear in the mortality tables; although, on the contrary, they may tend to prolong life and to protect the system against febrile and inflammatory diseases, yet the amount of suffering that they

INTRODUCTION. 3 cause is enormous. Volumes are written on typhoid and other fevers; but in this country these neuroses, although not fatal, cause more distress and annoyance than all forms of fever combined, excepting perhaps those of a malarious origin. Fevers kill, it is true, while these neuroses do not; but to many death is by no means the most disagreeable of the many symptoms of disease. <A cyclopedia of medicine, adapted to the wants of the practitioner in the northern and eastern parts of this country, should contain a full volume devoted to these diseases; and yet, so blind is our deference to Europe, so fearful are we of making our own independent, original observations of the maladies peculiar to this land, and so completely are we tethered to hospital and dispensary experience, that up to the present time there is no monograph even on these diseases, and all attempts to study them, or to diffuse a knowledge in regard to them, are met or. have until recently, been met at every step with inappreciation or positive opposition.

These diseases I bring into one family, because they have a common pathology, a common prognosis, a common history, and acommon treatment. They all occur under similar conditions, and in similar temperaments. ‘They are all diseases of civilization, and of modern civilization, and mainly of the nineteenth century, and of the United States. They are to be distinguished from certain other nervous diseases, as epilepsy, and psychical or mental hysteria, and especially are they to be distinguished from unquestioned structural or congestive diseases, such as locomotor ataxy, progressive muscular atrophy, tetanus, and apoplexy, all of which diseases are probably thousands of years old, are not restricted to civilization, though more frequent in civilized countries, and are as common in Europe as in America, if not more so. These organic or structural nervous diseases also occur chiefly in the strong or comparatively strong; they are not diseases

4 THE SYMPTOMS OF A SUBJECTIVE CHARACTER.

of nervous debility, and abound more among the muscle-working than among the brain-working classes.

The centre and type of this family of functional nervous diseases is neurasthenia, or mervous exhaustion. To understand this disease is, therefore, to be prepared to understand all the members of the family to which it belongs. For this reason it is that to the study of neurastheuia in its varied forms and phases this work is devoted.

Why is it that this important field of science has been so little studied? Why has a disease which is more frequent than any other nervous disease, indeed may be regarded as the king of the neuroses, succeeded so successfully in escaping the attention of men of science? The answer to this query is somewhat complex:

First of all, the symptoms of neurasthenia are largely of a swbjective character, and to one who does not suffer them, appear trifling and unreal; many of them do not appeal directly to the senses of the scientific observer: the physician can only know of their existence through the statements of the patient, or through his conduct. Unlike the existence of surgical, and acute, and inflammatory diseases, the phenomena of which the physician can see and feel, and for the study of which he is little, if at all, dependent on the patient’s intelligence or honesty, they do not appeal directly to the eye, or ear, or touch, and are in fact quite out of the range of all modern appliances to supplement the defects of the senses, as the ophthalmoscope and laryngoscope, or even the spectroscope. It is the tendency of the partially trained mind everywhere to reject or doubt what cannot be confirmed by the eyes or ears; forgetting that the capacities of the five senses of man are so meagre that they practically shut him out from nature; forgetting that the great natural forces, as light, heat, electricity, magnetism, gravity, are quite beyond the reach of any one of the senses, or all of them combined, scientific men

INTRODUCTION. 5 have allowed themselves to ignore and despise some of the most remarkable, interesting, and instructive phenomena of the nervous system both in health and disease, for the only reason that they cannot be seen, and heard, and felt.*

Then again, many of these indefinite symptoms of neurasthenia, considered alone and by themselves, are so small, and feeble, and unimportant to those who do not understand their importance, that science passes them by and gives attention to matters incomparably less important and valuable.

Physicians who pass by these obscure phenomena of the nervous system, as unworthy of their notice, may be reminded of this, that modern science, in all of its branches, and particularly in biology, is constructed out of slight, trifling, and unnoticeable facts and phenomena of nature. Thus, the philosophy of evolution, which marks the highest achievement of the human intellect, is built up entirely of minute and apparently insignificant facts, which scientific men of past generations would have been ashamed to notice. Neurasthenia is indeed passing through, in this generation, the same history as insanity in the past. The time was when the symptoms of insanity were believed to indi-

* Dr. Jewell, in a recent lecture, remarks as follows:

‘‘In the physical science of to-day, there is clearly too little dependence on, because there is so much ignorance of, the nature and conditions of inference. It is almost habitually placed at a disadvantage as compared with direct sense, observation, and physical demonstration. But this arises out of wrong conceptions as to its nature and value, as well as out of an over-estimate of the dependence which we may legitimately place on the ‘evidence of the senses.’ From these remarks you may gather, that I am aware of the real nature of the description I am about to give, and also of the objections which a too realistic scientific spirit might raise against it as to its substantial correctness.”

I may here also refer to my series of papers on the Scientific Study of Human Testimony, in the Popular Science Monthly (May, June, and July, 1878, and March and April, 1879), where the relations of inductive to deductive reasoning as discussed.

6 REASONING VS. OBSERVATION.

cate, not diseases, but the possessing of an evil spirit; so now, very many of the symptoms of neurasthenia have been regarded by men of science as imaginations of the patients, proofs of hypochondria—a vague term which, in this generation, covers all symptoms which the physician either doubts or misinterprets.

Although neurasthenia is comparatively a modern disease, although its symptoms, as herein described, are surpassingly more frequent now than in the last century, yet not a few of these symptoms have existed, particularly in this country, but more or less in all civilized countries, for at least a century or longer; and they have been brought to the attention of physicians in their practice, but they have not received their attention; the sufferers have simply been dismissed as hypochondriacs, just as with our ancestors, cases of hysteria and insanity were shunned or dismissed as possessed of the devil.

A second cause for the neglect of this disease is, that a successful study of it requires an exercise of the reasoning, as well as of the observing powers. Since the time of Lord Bacon, and notably during the last half century, the power of scientific observation—seeing, hearing, and feeling, and touching facts of nature —has developed with almost alarming rapidity, and the habit has even become popularized, so that individuals of but moderate powers are, in limited and narrow spheres, enabled to make original observations. It is in the powers of reasoning from observations, in co-ordinating the phenomena of nature, pointing out their relations, and deducing laws from the observed phenomena, that the limitation of the human brain is seen at the greatest disadvantage. To one accurate and original reasoner, there can be found a thousand original and accurate observers —men who can see, and hear, and feel, without being able to go behind the phenomena that strike their senses, and explore through dark and devious pathways the domain of general law.

INTRODUCTION. Y

In medicine, especially in the study of the nervous system, deductive as well as inductive reasoning is needed. In order to study neurasthenia and allied diseases, such as inebriety, or hysteria, or hay fever, it is needful, not only to carefully observe the phenomena, but to observe large numbers of them simultaneously, and to study them in their relations to each other, and to other facts of nature; and to do all this with faculties so well disciplined and trained that there shall be no over-estimate of the relative importance of special facts, and no overlooking of any phenomena, however trifling.

The third cause of the neglect of neurasthenia and allied affections is, that we have depended too exclusively, in the investigation of disease, on the material found in hospitals, dispensaries, and other institutions of chartity. For reasons that will be made clear in this work, neurasthenic disorders are not found to any very great extent in charitable institutions, and are quite rare among that class for whom such institutions are organized; those, therefore, who give the bulk of their time and thought to charitable work among the abjectly poor in institutions, or even out of them, will have but little opportunity to study any of the symptoms or disorders referred to in this treatise.

Young men in their profession, who have the leisure and the power for independent observation, throw themselves into charitable work, where very many of the symptoms and phases of the disease which they will be required to combat when they enter private practice, scarcely ever appear. Unmindful of the profound and just remark, attributed to a member of the English parliament, in a discussion of the problem how to relieve the poor: ‘‘Charity creates much of miseries it relieves, but does

? oblivious also of the not relieve all the misery that it creates;’ historical fact that very many of the noblest and most beautiful discoveries of modern medicine and surgery have been made

8 LESS FREQUENT IN EUROPE.

outside of hospitals, physicians are yet taught and inspired, by every form of influence, to “give their time and force to public institutions, and that, too, in a period of life when, if ever, original work is to be done.

The result of this unscientific philanthropy is that the miseries of the poor have been increased in manifold ways, and the miseries of the rich, the comfortable, and intelligent have been unstudied and unrelieved.*

When our young men in science learn, as they are now beginning to learn, that much of charity is really but another term for cruelty; and that it is possible to make original contributions to science from the material obtained in private practice; that Fifth Avenue is in some features a very much better field for pathological study than Five Points; then we may expect and hope that neurasthenia, the most common, one of the most distressing, and scientifically one of the most instructive and interesting of the nervous diseases of modern times, will receive a trifle of the reflection and observation that are now bestowed on such minor maladies as ataxia and muscular atrophy, with the discussions of which our text-books and literature are oppressively burdened.

A fourth cause of the neglect of neurasthenia and allied diseases is, that we, in this country, where the disease most abounds, have depended so exclusively on European precedence and experience. Until quite lately, the majority of our text-books were of European origin; not only for original studies, but for compilation and text-books we have looked to England and France and Germany. In Europe these functional nervous diseases, although they exist, yet are so rare that even specialists in diseases

*It is proper to add that this evil of unwise and injurious charity is now becoming recognized by the profession of New York and other great cities, and that attempts have been made, though not very successfully, during the past year, to remedy the difficulty. The strong and truthful paper of Dr. Sturgis on this subject is especially worthy of note.

INTRODUCTION. 9 of the nervous system do not see them constantly, and when they see them, do not, with very few exceptions, recognize or treat them. *

Neurasthenia is an American disease in this, that it is very much more common here than in any other part of the civilized world, and here it first received its name and description; it could not be expected that European authorities would be the pioneers, either in the study of its nature or treatment. Neurasthenia indeed, like the decay of the teeth, which in some cases is really one of the symptoms of the neurasthenic tendency, was first made of special consequence in this country.

Within recent years, various statistics have been published on the subject of the disproportion of doctors of medicine to population. It is said, and truthfully, that in this country there are more physicians in proportion to the people than in any other country. These statistics have been brought up mainly by those who seek in some way to limit the graduation of doctors; but the figures have been used in such a way as to give an impression not entirely correct. The fallacy in them is this, that Americans need more doctoring than any other people; they have more illnesses of various kinds—major and minor—than any of the European nations. A hundred well-to-do families in our large cities would send for a doctor to treat them very many more times than a hundred equally conditioned families in England, France, or Germany. This fact, taken in connection with the fact that our population extends over a wide territory, makes it possible to support a larger number of physicians than in any other country of equal population. What is true of doctors is equally true of drug stores; the meagreness of the apothecary shops strikes one immediately on visiting Europe. The Americans take very much

SS Eron, Exb, of Heidelberg, tells me that in Germany, as in this country, it has been the fashion to diagnose neurasthenia as hypochondria.

10 MORE MEDICINE USED IN AMERICA.

more medicine, both prescribed and unprescribed, than Europeans; they take a larger variety, they take finer qualities; hence it is that very many of our drug stores are palaces* containing an immense quantity of medicinal preparations, including not only all that are used in Europe, but many that are peculiar to this country, or at least but very little known abroad.