Certain drugs in certain nervous diseases.
T. D. ADLERMAN, M.D., BROOKLYN, N. Y.
Consulting Neurologist and Psychiatrist, Cumberland Hospital, Department of Hospitals, City of New York; Consulting Neurologist, Brooklyn Cancel-Institute, City of New York; Lecturer on Psychology. School of Nursing; Consulting Neurologist, Shore Road Hospital; Neurologist, National Home for Incurables.
In presenting this short paper, it is not the intention of the writer to go into any history of any of the drugs mentioned here, nor to describe the physiological action of the drugs presented, as this is not the object of this paper.
Nor is it our intention to consider any disease with regard to the symptomotology, etiology or prognosis, all of which you may easily find in any of your reference works.
We will simply name a disease and then review such drugs as are used by the writer in his practice.
Meningitis.—I am not going to say anything about the use of serums in the different forms of this affliction, as we are to deal with drugs only.
Aconite is a very useful drug in the very beginning of the first stage of meningitis. A severe chill of short duration, followed by a marked and rapid rise in the temperature in your patient, are my indications for the use of aconite in meningitis. The patient at this stage will present a marked restlessness with a rough, dry skin. Administer your aconite here in small doses, repeating frequently until the patient's skin assumes a moist appearance, and then give no more. At no time have we ever known the resumption of aconite to produce any benefits. When improvement ceases, some other drugs must be used. With the use of aconite, give the patient liberal quantities of hot water.
Trifacial neuralgia is not a very easy disease to handle or cure. Yet we have seen many cases which were accorded great relief by aconite.
Speaking of the use of aconite, let us not overlook the stubborn, persistent cases of neuralgia which very often will give way to aconite after resisting all other remedies. This is especially so in all cases of neuralgia which are caused by exposure to cold and wet winds. Considering aconite outside of the domain of neuralgia, its most prominent place is in all inflammatory diseases which are associated with increased respiration.
The action of aconite in reducing fever is too well known for me to spend time on this particular phase, yet I would like to particularly impress upon you the use of aconite in all inflammatory conditions of the puerperal state, no matter if it is a pelvic peritonitis or a metritis.
Let me not forget to say a word about aconite in mental states. In cases where the patient is full of fears of approaching death, he is afraid of men, afraid of ghosts who are all around him, give aconite. There are great possibilities for the use of this drug in melancholia of different kinds, as well as in the depressive state of neurasthenia. Speaking of depression and manic depressive states, we must not overlook ignatia amara. This drug will receive more attention at our hands. We must study this drug in all cases of the depression of the mind. Many were the cases that I improved where the patient was "down and out" with nothing to live for, after some severe loss.
Belladonna.—The chill is not so very severe, but the temperature is high, while the skin may be either dry or moist. The pulse is rapid, full and bounding. The face is flushed and the pupils are very much dilated. Many cases of meningitis are delirious, convulsion may come and go, and come again, all which to us is a clear call for belladonna.
After belladonna has reduced the fever of meningitis, very often we encounter the pais of meningitis. These pais will make their appearance in the occiput. The muscles of the neck and back become more rigid, more stiff, when we must at once discontinue the use of belladonna, and administer frequent but small doses of bryonia. Bear in mind that bryonia and belladonna do not seem to work well together.
I am not saying at this time that meningitis is curable with the three above mentioned drugs. I am not saying anything about all other measures used by many neurologists in this dreaded disease. I am simply calling your attention to these three drugs, which in our estimation are clearly indicated in meningitis.
Do not forget that belladonna has a clear field in cases of incontinence of urine, especially if the mucous membrane of the bladder is very sensitive. Our experience with belladonna in cases of migraine was certainly very satisfactory and worth recording. In nearly all these cases where I was able to administer belladonna just before the expected attack, I never had a failure. The reflex convulsions of childhood open a very wide range of the use of belladonna. What can be more clear in these cases than the head, which is hot, and the staring eyes with the dilated pupils?
Multiple Neuritis.—You all know this disease. No matter what drugs you may use, bear in mind the cause of the trouble. The remedies called for are rhus tox., nux vom., bryonia, and ergot.
Rhus tox. covers all cases of multiple neuritis which are associated with traumatism, overexertion and exposure to wet or cold. There are pains and stiffness around the joints in all these cases and rhus tox. certainly exerts a very good influence. When I hear that these pains increase in damp weather, I give rhus tox.
In the alcoholic cases of multiple neuritis, the very best results are obtained from nux vom. and actea racemosa. The colicky pains in these cases associated with other stomach symptoms, the vomiting of bitter eructations, all to me are indicative of nux vom. In the cases in which you find delirium tremors, we give actea racemosa. In cases where the pains of multiple neuritis are more or less spasmodic, I find that actea racemosa acts very much better than nux.
There are any number of cases of multiple neuritis which exhibit sensations of internal coldness and external heat. The contraction of the blood vessels has to be taken into consideration, and ergot should be administered in these cases. These sensations of cold and heat are often associated with marked discoloration of the skin, all of which are markedly influenced by ergot.
Hysteria.—There are many forms of this affliction. It would be indeed a foolish statement to say that all forms of hysteria are amenable to drug treatment, or that drugs that I will mention will cure all the cases of hysteria, yet drugs like conium, gelsemium, ignatia, avena sativa, passiflora all play a very important part in the treatment of many cases of hysteria.
The treatment and the uses of these drugs are all associated with the cause producing the hysteria, and cases which call for pulsatilla will not answer if you use asafoetida.
In many cases you will find the so-called globus hystericus with or without a marked constriction of the chest; ignatia amara will produce results that will astonish you. The crying and laughing in these cases is often associated with twitching of a group of muscles, but no matter what other symptoms there may be, the case wants to enjoy his or her "sadness" all alone, and to me this plainly calls for ignatia, and it works.
The cases of hysteria, with loss of consciousness, with jerkings of the muscles, especially of the arms and fingers, with some shouting before the "play to the gallery" of unconsciousness, all call for conium maculatum.
The unconsciousness of hysteria assumes two forms: One with the violent convulsions during the unconscious period, which calls for conium, and the other unconsciousness with complete relaxation of the patient, which calls for gelsemium. In the hysterical cases which are associated with great depression, and a fear of going insane, actea racemosa acts like a specific in most cases. Were I asked what other remedies I rely upon in the treatment of hysteria, I would answer that in nearly all the cases I found indications for belladonna, ignatia, asafoetida, pulsatilla, sepsis, and cannabis indica are all called for at times. The study of symptoms and the indications for drugs to be used in hysteria is an important matter and must be done with care.
Sciatica, sciatic neuralgia, a dangerous subject for any writer. Opinions are many, the treatments advanced are legions, and failures of cure by the thousands. I am giving you here a few of the remedies which in my hands gave me good results. The cases of sciatica which are intermittent seem to me to be amenable only to one remedy, and that is arsenicum. The pais usually extend along the great sciatic nerve. These pains are very much worse at night. Arsenicum does not produce results, however, in all of these cases. We then administer colocynth. This drug is called for in cases where the pains are either on the right or left side, starting from hip and shooting down the posterior part of the thigh to the knee only. I do not deny that the heat that I employed in these cases must have helped me some in obtaining results.
Sciatica due to exposure calls, of course, for rhus tox. Here I find numbness so often associated with intense pains. Cimicifuga, which is considered by many to be such a good remedy, I could do without.
One of the most horrible diseases with which humanity is cursed is Parkinson's Disease. Until late we could do very little for the relief of this affliction. Some time ago, considering the symptoms such as the continual salivation, the ever-increasing shakings of the hands and body, the peculiar forward, uncertain, shovelling walk, came to our mind the powerful action as an antispasmodic of stramonium. We had then on hands at the hospital some cases of Parkinson's. We ordered a fresh tincture made and proceeded to administer stramonium in 10-drop doses every three hours with no results whatever. We ordered an increase of 5 drops every three hours up to 49 drops per dose four times per day with the same disappointing results. We persisted until 60 drops were taken per dose of the U. S. tincture freshly made, four times daily. Improvement was noticed and after two weeks the shaking was very much diminished, the salivation was gone, and the walk became practically normal. We persisted with the drug, with the complete satisfaction of obtaining a disappearance of the shaking of the hands. We now start all of these cases with 20-drop doses four times every day, increase the dose till we come to 60 drops per dose taken four times every day. In administering this drug, look out for the physiological sign of this drug. When these appear, stop the administration of stramonium for twenty-four hours.
A word or two about melancholia of involution. As you know, this type is one of the hardest to treat. Whether you class this type with other types of manic depressive insanity or whether you class it as an entity does not matter here. I only want to call your attention to the drug staphisagria used by me in these cases. It is certainly very effective. In a recent case which came under the care of the writer, after the usual treatment by other psychiatrists, the indications for staphisagria stood out plainly to me. The apprehension for death, the fear of misfortunes, the loss of all her holdings, and at the same time increased sexual excitability—what other drug could be administered?
There is no doubt in my mind that many of you have met those peculiar cases, whereby you are not able to make a positive diagnosis. The case seems to be neither a neurosis nor a psychosis, and yet the case is peculiar in many phases. He or she is oversensitive to a great degree. The least word uttered without any intention of offense is taken up as a serious and positive reflection—the patient resents it as a personal matter. At the same time, the case, while normal in many other respects, is somewhat sad, though he or she can not define the reason or the sadness itself. The case is often timid and very uncertain in his actions. These cases call for ignatia. This remedy is really a godsend and many were the cases that we pulled out of their little holes so to say and were able to find themselves to a normal state.
This paper is but a short review of what can be done with drugs if we only study the indications and keep our eyes open.
DR. F. E. THORNTON (Chicago, Ill.): I am reminded of what old Professor Whitford used to say over and over again to the men who sat before him, that belladonna was the greatest remedy in the whole materia medica. In the last few years I have had a number of cases of oedema of the lungs, and several cases of nephritis where I had the lungs fill up with mucus, and with marked cyanosis. One case I saw at midnight, and I immediately gave 1/50 atropine. In fifteen minutes the rales had stopped. In four hours I gave her another dose, and the oedema was gone. Do not forget atropine when you see a case like that, and do not hesitate to give even 1/30 of a grain if the oedema is great.
DR. E. G. SHARP (Guthrie, Okla.): I want to compliment Dr. Adlerman on this paper. I got some original thoughts out of it, and with papers like that I think our meetings would be more worth while.
DR. P. A. DEOGNY (Milford, Neb.): I am not able to discuss with Dr. Adlerman the indications of drugs in nervous diseases, but I would like to say this, that several years ago Dr. Adlerman started to write a materia medica, and I have been disappointed all these years to think it has never been published. I believe if Dr. Adlerman would give us some of his experience every year along the line he has given us today, it would be one of the finest things that could happen to this organization.
DR. E. B. SHEWMAN (Cincinnati, Ohio): What is the average life of a patient with Parkinson's Disease?
DR. CLOYCE WILSON (Cincinnati, Ohio): In my experience, the drug stramonium is not always valuable. I was much interested in Dr. Adlerman's treatment of Parkinson's Disease with large doses of this drug. I personally think that where a case is treated that way and shows some little improvement and then finally succumbs to a surgical operation, there is a question whether Parkinson's disease causes the death. I have found stramonium not always dependable. I have had some remarkable results in its use as a relaxing agent in various conditions, I mean in general practice, and then again I have seen absolutely no results, possibly through fear of giving too large a dose. I have seen too large doses given and the effects are much the same as too large doses of atropine, and it is well to remember that the atropine of commerce does not come from belladonna, but is obtained from stramonium and other related drugs pharmacologically. I would like to ask Dr. Adlerman if he has used subculoid stramonium.
DR. W. W. WHEAT (Rosedale, Ind.): What effect would aconite have in a case of meningitis if given during the chill ?
DR. T. D. ADLERMAN (closing): Why did I not use specific tincture? I did not use specific tincture in the Parkinson's case because I could not obtain it in that institution. I did not like their tincture, so I ordered a pharmacist to make me some fresh tincture.
Large doses. There are indications when you must discontinue using stramonium. When the patient says his mouth and tongue are dry, with practically no saliva, then stop stramonium for twelve to twenty-four hours.
Replying to Dr. Wilson, I am willing to take 60 drops of stramonium, freshly made, every four hours, and I will be here to eat dinner tonight.
The average life of a patient with Parkinson's Disease—that is a question I could take an hour to answer. I have seen cases of Parkinson's Disease finished in three months, while others last a long, long time. The disease is essentially chronic and progressive. The duration is from ten to forty years. I remember one case of Parkinson's Disease which was rather perplexing. It was a question in my mind whether I had not made a mistake in diagnosis. The case was in a city hospital. We administered our remedies and the man went home, apparently much improved. Three months after he came in with a well-developed case of muscular atrophy. I have always asked myself the question whether I made a mistake—was the Parkinson's the beginning of the muscular atrophy?
DR. E. B. SHEWMAN: I have heard it said that the average life was seven years.
DR. ADLERMAN: I have had cases which lasted from nine to twelve years, and one case, going on its eleventh year, will probably outlive me.
DR. BYRON H. NELLANS (Cincinnati, Ohio): I am interested in Parkinson's syndrome following sleeping sickness. I have one sister who was an invalid and in 1919 had sleeping sickness, which two years later was complicated with heart disease. Dr. Adlerman has seen this case in consultation with several other psychiatrists. The treatment today is 90 drops of stramonium three times a day, 2 grains of luminal (raised lately to 3), and 1/60 hydrobromide. She has been taking that for two years.
DR. T. D. ADLERMAN: When I was called to see Dr. Nellans' sister I was still foolish enough to use stramonium in small doses, with practically no results. I am glad to hear that he is using it in 90-drop doses. However, I did not say that stramonium will cure every case. I gave you my experience up to date, but there are certain complications where perhaps this drug may not produce results. As I remember. Dr. Nellans' case was well established and there was some other complications, but I do not recall them just now. But I believe you will get some results from the 90 drops of stramonium.
In conclusion, let me tell you that this applies to all drugs, whether specific medicines, fluid extracts, or U. S. tinctures. You will often have a failure because you do not take into consideration the morphology of the patient, the make-up of the patient. Where perhaps to a man with the stature of Dr. Hite. who is sitting here, I would give a certain dose, to give the same dose to a man with the phisique of Dr. Sharp would be foolish in my estimation. The dosage there must be different. You must take into consideration the make-up of the patient and give the dose accordingly. It is up to you to know the physiological action of any drug you prescribe, and to discontinue when necessary.