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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/16230-8.txt b/16230-8.txt new file mode 100644 index 0000000..5eda0a3 --- /dev/null +++ b/16230-8.txt @@ -0,0 +1,5377 @@ +The Project Gutenberg EBook of Fat and Blood, by S. Weir Mitchell + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Fat and Blood + An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria + +Author: S. Weir Mitchell + +Editor: John K. Mitchell + +Release Date: July 7, 2005 [EBook #16230] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK FAT AND BLOOD *** + + + + +Produced by Kathryn Lybarger, Janet Blenkinship and the +Online Distributed Proofreading Team at https://www.pgdp.net + + + + + + +FAT AND BLOOD: + +AN ESSAY ON THE TREATMENT OF CERTAIN FORMS OF + +NEURASTHENIA AND HYSTERIA. + + + +BY + +S. WEIR MITCHELL, M.D., LL.D. HARV., + +MEMBER OF THE NATIONAL ACADEMY OF SCIENCES. + + + +_EIGHTH EDITION._ + + +EDITED, WITH ADDITIONS, BY + +JOHN K. MITCHELL, M.D. + + + +PHILADELPHIA: + +J.B. LIPPINCOTT COMPANY. + +LONDON: 5 HENRIETTA STREET, COVENT GARDEN + +1911. + + + +Copyright, 1877, by J.B. LIPPINCOTT & CO. + +Copyright, 1883, by J.B. LIPPINCOTT & CO. + +Copyright, 1891, by J.B. LIPPINCOTT COMPANY. + +Copyright, 1897, by J.B. LIPPINCOTT COMPANY. + +Copyright, 1900, by J.B. LIPPINCOTT COMPANY. + +Copyright, 1905, by S. WEIR MITCHELL. + + +ELECTROTYPED AND PRINTED BY J.B. LIPPINCOTT COMPANY, PHILADELPHIA, +U.S.A. + + + + +PREFACE TO THE EIGHTH EDITION. + + +The continued favor which this book has enjoyed in Europe as well as in +this country has rendered me doubly desirous to make it a thorough and +clear statement of the treatment of the kind of cases which it discusses +as carried out in my practice to-day. + +In the endeavor to do this, the present edition, like the last two, has +been carefully revised by my son, Dr. John K. Mitchell, and there is no +chapter, and scarcely a page, where some alteration or addition has not +been made, besides those of the sixth and seventh editions, as the +result of added years of experience. Especially in the chapters on the +means of treatment some details have been thought worth adding to help +the statement so often repeated in the book that success will depend on +the care with which details are carried out. The chapter on massage, +rewritten for the last edition, has been once more revised and somewhat +extended, in order to make it an accurate as well as a scientific, if +brief, statement of the best method which use and observation have +taught us. A chapter on the handling of several diseases not described +in former editions has been added by the editor. + +S. WEIR MITCHELL. + +SEPTEMBER, 1899. + + + + +CONTENTS. + + PAGE +CHAPTER I. +INTRODUCTORY 9 + +CHAPTER II. +GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED 14 + +CHAPTER III. +ON THE SELECTION OF CASES FOR TREATMENT 33 + +CHAPTER IV. +SECLUSION 50 + +CHAPTER V. +REST 67 + +CHAPTER VI. +MASSAGE 80 + +CHAPTER VII. +ELECTRICITY 108 + +CHAPTER VIII. +DIETETICS AND THERAPEUTICS 119 + +CHAPTER IX. +DIETETICS AND THERAPEUTICS--(_Continued_) 171 + +CHAPTER X. +THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC +PARAPLEGIA, SPASTIC PARALYSIS, AND PARALYSIS +AGITANS 197 + +INDEX 233 + + + + +CHAPTER I. + +INTRODUCTORY. + + +For some years I have been using with success, in private and in +hospital practice, certain methods of renewing the vitality of feeble +people by a combination of entire rest and excessive feeding, made +possible by passive exercise obtained through the steady use of massage +and electricity. + +The cases thus treated have been chiefly women of a class well known to +every physician,--nervous women, who, as a rule, are thin and lack +blood. Most of them have been such as had passed through many hands and +been treated in turn for gastric, spinal, or uterine troubles, but who +remained at the end as at the beginning, invalids, unable to attend to +the duties of life, and sources alike of discomfort to themselves and +anxiety to others. + +In 1875 I published in "Séguin's Series of American Clinical Lectures," +Vol. I., No. iv., a brief sketch of this treatment, under the heading +of "Rest in the Treatment of Nervous Disease," but the scope afforded +me was too brief for the details on a knowledge of which depends success +in the use of rest, I have been often since reminded of this by the many +letters I have received asking for explanations of the minutiĉ of +treatment; and this must be my apology for bringing into these pages a +great many particulars which are no doubt well enough known to the more +accomplished physician. + +In the preface to the second edition I said that as yet there had been +hardly time for a competent verdict on the methods I had described. +Since making this statement, many of our profession in America have +published cases of the use of my treatment. It has also been thoroughly +discussed by the medical section of the British Medical Association, and +warmly endorsed by William Playfair, of London, Ross of Manchester, +Coghill, and others; while a translation of my book into French by Dr. +Oscar Jennings, with an introduction by Professor Ball, and a +reproduction in German, with a preface by Professor von Leyden, have +placed it satisfactorily before the profession in France and Germany. + +As regards the question of originality I did not and do not now much +concern myself. This alone I care to know, that by the method in +question cases are cured which once were not; and as to the novelty of +the matter it would be needless to say more, were it not that the charge +of lack of that quality is sometimes taken as an imputation on a man's +good faith. + +But to sustain so grave an implication the author must have somewhere +laid claim to originality and said in what respect he considered himself +to have done a totally new thing. The following passage from the first +edition of this book explains what was my own position: + +"I do not wish," I wrote, "to be thought of as putting forth anything +very remarkable or original in my treatment by rest, systematic feeding, +and passive exercise. All of these have been used by physicians; but, as +a rule, one or more are used without the others, and the plan which I +have found so valuable, of combining these means, does not seem to be +generally understood. As it involves some novelty, and as I do not find +it described elsewhere, I shall, I think, be doing a service to my +profession by relating my experience." + +The following quotation from Dr. William Playfair's essay[1] says all +that I would care to add: + + "The claims of Dr. Weir Mitchell to originality in the introduction + of this system of treatment, which I have recently heard contested + in more than one quarter, it is not my province to defend. I feel + bound, however, to say that, having carefully studied what has been + written on the subject, I can nowhere find anything in the least + approaching to the regular, systematic, and thorough attack on the + disease here discussed. + + "Certain parts of the treatment have been separately advised, and + more or less successfully practised, as, for example, massage and + electricity, without isolation; or isolation and judicious moral + management alone. It is, in fact, the old story with regard to all + new things: there is no discovery, from the steam-engine down to + chloroform, which cannot be shown to have been partially foreseen, + and yet the claims of Watt and Simpson to originality remain + practically uncontested. And so, if I may be permitted to compare + small things with great, will it be with this. The whole matter was + admirably summed up by Dr. Ross, of Manchester, in his remarks in + the discussion I introduced at the meeting of the British Medical + Association at Worcester, which I conceive to express the precise + state of the case: 'Although Dr. Mitchell's treatment was not new + in the sense that its separate recommendations were made for the + first time, it was new in the sense that these recommendations were + for the first time combined so as to form a complete scheme of + treatment.'" + +As regards the acceptance of this method of treatment I have to-day no +complaint to make. It runs, indeed, the risk of being employed in cases +which do not need it and by persons who are not competent, and of being +thus in a measure brought into disrepute. As concerns one of its +essentials--massage--this is especially to be feared. It is a remedy +with capacity to hurt as well as to help, and should never be used +without the advice of a physician, nor persistently kept up without +medical observation of its temporary and more permanent effects. + + + + +CHAPTER II. + +GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED. + + +The gentlemen who have done me the honor to follow my clinical service +at the State Infirmary for Diseases of the Nervous System[2] are well +aware how much care is there given to learn whether or not the patient +is losing or has lost flesh, is by habit thin or fat. This question is +one of the utmost moment in every point of view, and deserves a larger +share of attention than it receives. In this hospital it is the custom +to weigh our cases when they enter and at intervals. The mere loss of +fat is probably of small moment in itself when the amount of restorative +food is sufficient for every-day expenditure, and when the organs are in +condition to keep up the supply of fat which we not only require for +constant use but probably need to change continually. The steady or +rapid lessening of the deposits of hydro-carbons stored away in the +areolĉ of the tissues is of importance, as indicating their excessive +use or a failure of supply; and when either condition is to be suspected +it becomes our duty to learn the reasons for this striking symptom. Loss +of flesh has also a collateral value of great import, because it is +almost an invariable rule that rapid thinning is accompanied soon or +late with more or less anĉmia, and it is uncommon to see a person +steadily gaining fat after any pathological reduction of weight without +a corresponding gain in amount and quality of blood. We too rarely +reflect that the blood thins with the decrease of the tissues and +enriches as they increase. + +Before entering into this question further, I shall ask attention to +some points connected with the normal fat of the human body; and, taking +for granted, here and elsewhere, that my readers are well enough aware +of the physiological value and uses of the adipose tissues, I shall +continue to look at the matter chiefly from a clinical point of view. + +When in any individual the weight varies rapidly or slowly, it is nearly +always due, for the most part, to a change in the amount of adipose +tissue stored away in the meshes of the areolar tissue. Almost any grave +change for the worse in health is at once betrayed in most people by a +diminution of fat, and this is readily seen in the altered forms of the +face, which, because it is the always visible and in outline the most +irregular part of the body, shows first and most plainly the loss or +gain of tissue. Fatty matter is therefore that constituent of the body +which goes and comes most easily. Why there is in nearly every one a +normal limit to its accumulation we cannot say, nor yet why this limit +should vary as life goes on. Even in health the weight of men, and still +more of women, is by no means constant, but, as a rule, when we are +holding our own with that share of stored-up fat which belongs to the +individual we are usually in a condition of nutritive prosperity, and +when after any strain or trial which has lessened weight we are slowly +repairing mischief and laying by fat we are equally in a state of +health. The loss of fat which is not due to change of diet or to +exercise, especially its rapid or steady loss, nearly always goes along +with conditions which impoverish the blood, and, on the other hand, the +gain of fat up to a certain point seems to go hand in hand with a rise +in all other essentials of health, and notably with an improvement in +the color and amount of the red corpuscles. + +The quantity of fat which is healthy for the individual varies with the +sex, the climate, the habits, the season, the time of life, the race, +and the breed. Quetelet[3] has shown that before puberty the weight of +the male is for equal ages above that of the female, but that towards +puberty the proportional weight of the female, due chiefly to gain in +fat, increases, so that at twelve the two sexes are alike in this +respect. During the child-bearing time there is an absolute lessening on +the part of the female, but after this time the weight of the woman +increases, and the maximum is attained at about the age of fifty. + +Dr. Henry I. Bowditch[4] reaches somewhat similar conclusions, and shows +from much more numerous measurements of Boston children that growing +boys are heavier in proportion to their height than girls until they +reach fifty-eight inches, which is attained about the fourteenth year. +Then the girl passes the boy in weight, which Dr. Bowditch thinks is due +to the accumulation of adipose tissue at puberty. After two or three +years more the male again acquires and retains superiority in weight and +height. + +Yet as life advances there are peculiarities which belong to individuals +and to families. One group thins as life goes on past forty; another +group as surely takes on flesh; and the same traits are often inherited, +and are to be regarded when the question of fattening becomes of +clinical or diagnostic moment. Men, as a rule, preserve their nutritive +status more equably than women. Every physician must have been struck +with this. In fact, many women lose or acquire large amounts of adipose +matter without any corresponding loss or gain in vigor, and this fact +perhaps is related in some way to the enormous outside demands made by +their peculiar physiological processes. Such gain in weight is a common +accompaniment of child-bearing, while nursing in some women involves +considerable gain in flesh, and in a larger number enormous falling +away, and its cessation as speedy a renewal of fat. I have also found +that in many women who are not perfectly well there is a notable loss +of weight at every menstrual period, and a marked gain between these +times. + +I was disappointed not to find this matter dealt with fully in Mrs. +Jacobi's able essay on menstruation, nor can I discover elsewhere any +observations in regard to loss or gain of weight at menstrual periods in +the healthy woman. + +How much influence the seasons have, is not as yet well understood, but +in our own climate, with its great extremes, there are some interesting +facts in this connection. The upper classes are with us in summer placed +in the best conditions for increase in flesh, not only because it is +their season of least work, mental and physical, but also because they +are then for the most part living in the country under circumstances +favorable to appetite, to exercise, and to freedom from care. Owing to +these fortunate facts, members of the class in question are apt to gain +weight in summer, although many such persons, as I know, follow the more +general rule and lose weight. But if we deal with the mass of men who +are hard worked, physically, and unable to leave the towns, we shall +probably find that they nearly always lose weight in hot weather. Some +support is given to this idea by the following very curious facts. Very +many years ago I was engaged for certain purposes in determining the +weight, height, and girth of all the members of our city police force. +The examination was made in April and repeated in the beginning of +October. Every care was taken to avoid errors, but to my surprise I +found that a large majority of the men had lost weight during the +summer. The sum total of loss was enormous. As I have mislaid some of +the sheets, I am unable to give it accurately, but I found that three +out of every five had lessened in weight. It would be interesting to +know if such a change occurs in convicts confined in penitentiaries. + +I am acquainted with some persons who lose weight in winter, and with +more who fail in flesh in the spring, which is our season of greatest +depression in health,--the season when with us choreas are apt to +originate[5] or to recur, and when habitual epileptic fits become more +frequent in such as are the victims of that disease. + +Climate has a good deal to do with a tendency to take on fat, and I +think the first thing which strikes an American in England is the number +of inordinately fat middle-aged people, and especially of fat women. + +This excess of flesh we usually associate in idea with slothfulness, but +English women exercise more than ours, and live in a land where few days +forbid it, so that probably such a tendency to obesity is due chiefly to +climatic causes. To these latter also we may no doubt ascribe the habits +of the English as to food. They are larger feeders than we, and both +sexes consume strong beer in a manner which would in this country be +destructive of health. These habits aid, I suspect, in producing the +more general fatness in middle and later life, and those enormous +occasional growths which so amaze an American when first he sets foot in +London. But, whatever be the cause, it is probable that members of the +prosperous classes of English, over forty, would outweigh the average +American of equal height of that period, and this must make, I should +think, some difference in their relative liability to certain forms of +disease, because the overweight of our trans-Atlantic cousins is plainly +due to excess of fat. + +I have sought in vain for English tables giving the weight of men and +women of various heights at like ages. The material for such a study of +men in America is given in Gould's researches published by the United +States Sanitary Commission, and in Baxter's admirable report,[6] but is +lacking for women. A comparison of these points as between English and +Americans of both sexes would be of great interest. + +I doubt whether in this country as notable a growth in bulk as +multitudes of English attain would be either healthy or desirable in +point of comfort, owing to the distress which stout people feel in our +hot summer weather. Certainly "Banting" is with us a rarely-needed +process, and, as a rule, we have much more frequent occasion to fatten +than to thin our patients. The climatic peculiarities which have changed +our voices, sharpened our features, and made small the American hand and +foot, have also made us, in middle and advanced life, a thinner and +more sallow race, and, possibly, adapted us better to the region in +which we live. The same changes in form are in like manner showing +themselves in the English race in Australia.[7] + +Some gain in flesh as life goes on is a frequent thing here as +elsewhere, and usually has no unwholesome meaning. Occasionally we see +people past the age of sixty suddenly taking on fat and becoming at once +unwieldy and feeble, the fat collecting in masses about the belly and +around the joints. Such an increase is sometimes accompanied with fatty +degeneration of the heart and muscles, and with a certain watery +flabbiness in the limbs, which, however, do not pit on pressure. + +Alcoholism also gives rise in some people to a vast increase of adipose +tissue, and the sodden, unwholesome fatness of the hard drinker is a +sufficiently well known and unpleasant spectacle. The overgrowth of +inert people who do not exercise enough to use up a healthy amount of +overfed tissues is common enough as an individual peculiarity, but there +are also two other conditions in which fat is apt to be accumulated to +an uncomfortable extent. Thus, in some cases of hysteria where the +patient lies abed owing to her belief that she is unable to move about, +she is apt in time to become enormously stout. This seems to me also to +be favored by the large use of morphia to which such women are prone, so +that I should say that long rest, the hysterical constitution, and the +accompanying resort to morphia make up a group of conditions highly +favorable to increase of fat. + +Lastly, there is the class of fat anĉmic people, usually women. This +double peculiarity is rather uncommon, but, as the mass of thin-blooded +persons are as a rule thin or losing flesh, there must be something +unusual in that anĉmia which goes with gain in flesh. + +Bauer[8] thinks that lessened number of blood-corpuscles gives rise to +storing of fat, owing to lessened tissue-combustion. At all events, the +absorption of oxygen diminishes after bleeding, and it used to be well +known that some people grew fat when bled at intervals. Also, it is said +that cattle-breeders in some localities--certainly not in this +country--bleed their cattle to cause increase of fat in the tissues, or +of fat secreted as butter in the milk. These explanations aid us but +little to comprehend what, after all, is only met with in certain +persons, and must therefore involve conditions not common to every one +who is anĉmic. Meanwhile, the group of fat anĉmics is of the utmost +clinical interest, as I shall by and by point out more distinctly. + +There is a popular idea, which has probably passed from the +agriculturist into the common mind of the community, to the effect that +human fat varies,--that some fat is wholesome and some unwholesome, that +there are good fats and bad fats. I remember well an old nurse who +assured me when I was a student that "some fats is fast and some is +fickle, but cod-oil fat is easy squandered." + +There are more facts in favor of some such idea than I have place for, +but as yet we have no distinct chemical knowledge as to whether the +fats put on under alcohol or morphia, or rapidly by the use of oils, or +pathologically in fatty degenerations, or in anĉmia, vary in their +constituents. It is not at all unlikely that such is the case, and that, +for example, the fat of an obese anĉmic person may differ from that of a +fat and florid person. The flabby, relaxed state of many fat people is +possibly due not alone to peculiarities of the fat, but also to want of +tone and tension in the areolar tissues, which, from all that we now +know of them, may be capable of undergoing changes as marked as those of +muscles. + +That, however, animals may take on fat which varies in character is well +known to breeders of cattle. "The art of breeding and feeding stock," +says Dr. Letheby,[9] "is to overcome excessive tendency to accumulation +of either surface fat or visceral fat, and at the same time to produce a +fat which will not melt or boil away in cooking. Oily foods have a +tendency to make soft fats which will not bear cooking." Such +differences are also seen between English and American bacon, the former +being much more solid; and we know, also, that the fat of different +animals varies remarkably, and that some, as the fat of hay-fed horses, +is readily worked off. Such facts as these may reasonably be held to +sustain the popular creed as to there being bad fats and good fats, and +they teach us the lesson that in man, as in animals, there may be a +difference in the value of the fats we acquire, according as they are +gained by one means or by another. + +The recent researches of L. Langer have certainly shown that the fatty +tissues of man vary at different ages, in the proportion of the fatty +acids they contain. + +I have had occasion, of late years, to watch with interest the process +of somewhat rapid but quite wholesome gain in flesh in persons subjected +to the treatment which I shall by and by describe. Most of these persons +were treated by massage, and I have been accustomed to question the +masseur or masseuse as to the manner in which the change takes place. +Usually it is first seen in the face and neck, then it is noticed in the +back and flanks, next in the belly, and finally in the limbs, the legs +coming last in the order of gain, and sometimes remaining comparatively +thin long after other parts have made remarkable and visible gain. +These observations have been checked by careful measurements, so that I +am sure of their correctness for people who fatten while at rest in bed. +The order of increase might be different in people who fatten while +afoot. + +Facts of this nature suggest that the putting on of fat must be due to +very generalized conditions, and be less under the control of local +causes than is the nutrition of muscles, for, while it is true that in +wasting from nerve-lesions the muscular and fatty tissues alike lessen, +it is possible to cause by exercise rapid increase in the bulk of muscle +in a limb or a part of a limb, but not in any way to cause direct and +limited local increment of fat. + +Looking back over the whole subject, it will be well for the physician +to remember that increase of fat, to be a wholesome condition, should be +accompanied by gain in quantity and quality of blood, and that while +increase of flesh after illness is desirable, and a good test of +successful recovery, it should always go along with improvement in +color. Obesity with thin blood is one of the most unmanageable +conditions I know of. + +The exact relations of fatty tissue to the states of health are not as +yet well understood; but, since on great exertion or prolonged mental or +moral strain or in low fevers we lose fat rapidly, it may be taken for +granted that each individual should possess a certain surplus of this +readily-lost material. It is the one portion of our body which comes and +goes in large amount. Even thin people have it in some quantity always +ready, and, despite the fluctuations, every one has a standard share, +which varies at different times of life. The mechanism which limits the +storing away of an excess is almost unknown, and we are only aware that +some foods and lack of exertion favor growth in fat, while action and +lessened diet diminish it; but also we know that while any one can be +made to lose weight, there are some persons who cannot be made to gain a +pound by any possible device, so that in this, as in other things, to +spend is easier than to get; although it is clear that the very thin +must certainly live, so to speak, from hand to mouth, and have little +for emergencies. Whether fat people possess greater power of resistance +as against the fatal wasting of certain maladies or not, does not seem +to be known, and I fancy that the popular medical belief is rather +opposed to a belief in the vital endurance of those who are unusually +fat. + +That I am not pushing too far this idea of the indicative value of gain +of weight may be further seen in persons who suffer from some incurable +chronic malady, but who are in other respects well. The relief from +their disease, even if temporary, is apt to be signalled by abrupt gain +in weight. A remarkable illustration is to be found in those who suffer +periodically from severe pain. Cessation of these attacks for a time is +sure to result in the putting on of flesh. The case of Captain +Catlin[10] is a good example. Owing to an accident of war, he lost a +leg, and ever since has had severe neuralgic pain referred to the lost +leg. These attacks depend almost altogether on storms. In years of +fewest storms they are least numerous, and the bodily weight, which is +never insufficient, rises. With their increase it lowers to a certain +amount, beneath which it does not fall. His weight is, therefore, +indirectly dependent upon the number of storms to the influence of which +he is exposed. + +At present, however, we have to do most largely with the means of +attaining that moderate share of stored-away fat which seems to indicate +a state of nutritive prosperity and to be essential to those physical +needs, such as protection and padding, which fat subserves, no less than +to its ĉsthetic value, as rounding the curves of the human form. + +The study of the amount of the different forms of diet which is needed +by people at rest, and by those who are active, is valuable only to +enable us to construct dietaries with care for masses of men and where +economy is an object. In dealing with cases such as I shall describe, it +is needful usually to give and to have digested a surplus of food, so +that we are more concerned now to know the forms of food which thin or +fatten, and the means which aid us to digest temporarily an excess. + +As to quantity, it suffices to say that while by lessening food we may +easily and surely make people lose weight, we cannot be sure to fatten +by merely increasing the amount of food given; something more is wanted +in the way of digestives or tonics to enable the patient to prepare and +appropriate what is given, and but too often we fail miserably in all +our means of giving capacity to assimilate food. As I have said before, +and wish to repeat, to gain in fat is, in the feeble, nearly always to +gain in blood; and I hope to point out in these pages some of the means +by which these ends can be attained. + + _Note_.--The statements made on page 21 and the following + paragraphs about obesity in England and with us are no longer + exact, but have been allowed to stand in the text as recording + facts true at the time of writing them, in 1877. At the present a + medical observer familiar with both countries must note several + decided changes: more fat people, more people even enormously + stout, are seen with us than formerly, and fewer of the + "inordinately fat middle-aged people" in England than used to be + encountered. With us the over-fat are chiefly to be found among the + women of the well-to-do classes of the cities, and from thirty + years old onward. They persecute the medical men to reduce their + weight, and the vast number of advertisements of quack and + proprietary remedies against obesity indicate how wide-spread the + tendency must be. + + Among women somewhat younger, as indeed among men, the American + observer whose recollection takes him back twenty-five years must + note a more hopeful change, a very decided average increase of + stature, not merely in height but in general development. This + change is to be seen throughout the whole country, and must be + taken first as a sign of improved conditions of food and manner of + life, and next, if not more largely, of the new interest and + partnership of girls in the wholesome activities of field and wood. + + + + +CHAPTER III. + +ON THE SELECTION OF CASES FOR TREATMENT. + + +The remarks of the last chapter have, of course, wide and general +application in disease, and naturally lead up to what I have to say as +to the employment of the systematic treatment to describe which is my +chief desire. Its use, as a whole, is limited to certain groups of +cases. In some of the worst of them nothing else has succeeded hitherto, +or at least as frequently. In others the need for its application must +depend on convenience and the fact that all other and readier means have +failed. It is, of course, difficult to state now all the groups of +diseases in which it may be of value, for already physicians have begun +to find it serviceable in some to which I had not thought of applying +it,[11] and its sphere of usefulness is therefore likely to extend +beyond the limits originally set by me. It will be well here, however, +to state the various disorders in which it has seemed to me applicable. +As regards some of them, I shall try briefly to indicate why their +peculiarities point it out as needful. + +There are, of course, numerous cases in which it becomes desirable to +fatten and to make blood. In many of them these are easy tasks, and in +some altogether hopeless. Persons who are recovering healthfully from +fevers, pneumonias, and other temporary maladies gather flesh and make +blood readily, and we need only to help them by the ordinary tonics, +careful feeding, and change of air in due season. + +It may not, however, be out of place to say here that when the +convalescence from these maladies seems to be slower than is common, and +ordinary tonics inefficient, massage and the use of electricity are not +unimportant aids towards health, but in such cases require to be handled +with an amount of caution which is less requisite in more chronic +conditions of disordered health. + +In other and fatal or graver maladies, such as, for example, advanced +pulmonary phthisis, however proper it may be to fatten, it is almost an +impossible task, and, as Pollock remarks, the lung-trouble may be +advancing even while the patient is gaining in weight. Nevertheless, the +earlier stages of pulmonary tuberculosis are suitable cases, and with +sufficient attention to purity and frequent change of air in their rooms +tubercular sufferers may be brought by this means to a point of +improvement where open-air and altitude cures will have their best +effects. + +There remains a class of cases desirable to fatten and redden,--cases +which are often, or usually, chronic in character, and present among +them some of the most difficult problems which perplex the physician. If +I pause to dwell upon these, it is because they exemplify forms of +disease in which my method of treatment has had the largest success; it +is because some of them are simply living records of the failure of +every other rational plan and of many irrational ones; it is because +many of them find no place in the text-book, however sadly familiar they +are to the physician. + +The group I would speak of contains that large number of people who are +kept meagre and often also anĉmic by constant dyspepsia, in its varied +forms, or by those defects in assimilative processes which, while more +obscure, are as fertile parents of similar mischiefs. Let us add the +long-continued malarial poisonings, and we have a group of varied origin +which is a moderate percentage of cases in which loss of weight and loss +of color are noticeable, and in which the usual therapeutic methods do +sometimes utterly fail. + +For many of these, fresh air, exercise, change of scene, tonics, and +stimulants are alike valueless; and for them the combined employment of +the tonic influences I shall describe, when used with absolute rest, +massage, and electricity, is often of inestimable service. + +A portion of the class last referred to is one I have hinted at as the +despair of the physician. It includes that large group of women, +especially, said to have nervous exhaustion, or who are defined as +having spinal irritation, if that be the prominent symptom. To it I must +add cases in which, besides the wasting and anĉmia, emotional +manifestations predominate, and which are then called hysterical, +whether or not they exhibit ovarian or uterine disorders. + +Nothing is more common in practice than to see a young woman who falls +below the health-standard, loses color and plumpness, is tired all the +time, by and by has a tender spine, and soon or late enacts the whole +varied drama of hysteria. As one or other set of symptoms is prominent +she gets the appropriate label, and sometimes she continues to exhibit +only the single phase of nervous exhaustion or of spinal irritation. Far +more often she runs the gauntlet of nerve-doctors, gynĉcologists, +plaster jackets, braces, water-treatment, and all the fantastic variety +of other cures. + +It will be worth while to linger here a little and more sharply +delineate the classes of cases I have just named. + +I see every week--almost every day--women who when asked what is the +matter reply, "Oh, I have nervous exhaustion." When further questioned, +they answer that everything tires them. Now, it is vain to speak of all +of these cases as hysterical, or as merely mimetic. It is quite sure +that in the graver examples exercise quickens the pulse curiously, the +tire shows in the face, or sometimes diarrhoea or nausea follows +exertion, and though while under excitement or in the presence of some +dominant motive they can do a good deal, the exhaustion which ensues is +out of proportion to the exercise used. + +I have rarely seen such a case which was not more or less lacking in +color and which had not lost flesh; the exceptions being those +troublesome instances of fat anĉmic people which I shall by and by speak +of more fully. + +Perhaps a sketch of one of these cases will be better than any list of +symptoms. A woman, most often between twenty and thirty years of age, +undergoes a season of trial or encounters some prolonged strain. She may +have undertaken the hard task of nursing a relative, and have gone +through this severe duty with the addition of emotional excitement, +swayed by hopes and fears, and forgetful of self and of what every one +needs in the way of air and food and change when attempting this most +trying task. In another set of cases an illness is the cause, and she +never rallies entirely, or else some local uterine trouble starts the +mischief, and, although this is cured, the doctor wonders that his +patient does not get fat and ruddy again. + +But, no matter how it comes about, whether from illness, anxiety, or +prolonged physical effort, the woman grows pale and thin, eats little, +or if she eats does not profit by it. Everything wearies her,--to sew, +to write, to read, to walk,--and by and by the sofa or the bed is her +only comfort. Every effort is paid for dearly, and she describes herself +as aching and sore, as sleeping ill and awaking unrefreshed, and as +needing constant stimulus and endless tonics. Then comes the mischievous +role of bromides, opium, chloral, and brandy. If the case did not begin +with uterine troubles, they soon appear, and are usually treated in vain +if the general means employed to build up the bodily health fail, as in +many of these cases they do fail. The same remark applies to the +dyspepsias and constipation which further annoy the patient and +embarrass the treatment. If such a person is by nature emotional she is +sure to become more so, for even the firmest women lose self-control at +last under incessant feebleness. Nor is this less true of men; and I +have many a time seen soldiers who had ridden boldly with Sheridan or +fought gallantly with Grant become, under the influence of painful +nerve-wounds, as irritable and hysterically emotional as the veriest +girl. If no rescue comes, the fate of women thus disordered is at last +the bed. They acquire tender spines, and furnish the most lamentable +examples of all the strange phenomena of hysteria. + +The moral degradation which such cases undergo is pitiable. I have heard +a good deal of the disciplinary usefulness of sickness, and this may +well apply to brief and grave, and what I might call wholesome, +maladies. Undoubtedly I have seen a few people who were ennobled by long +sickness, but far more often the result is to cultivate self-love and +selfishness and to take away by slow degrees the healthful mastery which +all human beings should retain over their own emotions and wants. + +There is one fatal addition to the weight which tends to destroy women +who suffer in the way I have described. It is the self-sacrificing love +and over-careful sympathy of a mother, a sister, or some other devoted +relative. Nothing is more curious, nothing more sad and pitiful, than +these partnerships between the sick and selfish and the sound and +over-loving. By slow but sure degrees the healthy life is absorbed by +the sick life, in a manner more or less injurious to both, until, +sometimes too late for remedy, the growth of the evil is seen by +others. Usually the individual withdrawn from wholesome duties to +minister to the caprices of hysterical sensitiveness is the person of a +household who feels most for the invalid, and who for this very reason +suffers the most. The patient has pain,--a tender spine, for example; +she is urged to give it rest. She cannot read; the self-constituted +nurse reads to her. At last light hurts her eyes; the mother or sister +remains shut up with her all day in a darkened room. A draught of air is +supposed to do harm, and the doors and windows are closed, and the +ingenuity of kindness is taxed to imagine new sources of like trouble, +until at last, as I have seen more than once, the window-cracks are +stuffed with cotton, the chimney is stopped, and even the keyhole +guarded. It is easy to see where this all leads to: the nurse falls ill, +and a new victim is found. I have seen an hysterical, anĉmic girl kill +in this way three generations of nurses. If you tell the patient she is +basely selfish, she is probably amazed, and wonders at your cruelty. To +cure such a case you must morally alter as well as physically amend, and +nothing less will answer. The first step needful is to break up the +companionship, and to substitute the firm kindness of a well-trained +hired nurse.[12] + +Another form of evil to be encountered in these cases is less easy to +deal with. Such an invalid has by unhappy chance to live with some near +relative whose temperament is also nervous and who is impatient or +irritable. Two such people produce endless mischief for each other. +Occasionally there is a strange incompatibility which it is difficult to +define. The two people who, owing to their relationship, depend the one +on the other, are, for no good reason, made unhappy by their several +peculiarities. Lifelong annoyance results, and for them there is no +divorce possible. + +In a smaller number of cases, which have less tendency to emotional +disturbances, the phenomena are more simple. You have to deal with a +woman who has lost flesh and grown colorless, but has no hysterical +tendencies. She is merely a person hopelessly below the standard of +health and subject to a host of aches and pains, without notable organic +disease. Why such people should sometimes be so hard to cure I cannot +say. But the sad fact remains. Iron, acids, travel, water-cures, have +for a certain proportion of them no value, or little value, and they +remain for years feeble and forever tired. For them, as for the whole +class, the pleasures of life are limited by this perpetual weariness and +by the asthenopia which they rarely escape, and which, by preventing +them from reading, leaves them free to study day after day their +accumulating aches and distresses. + +Medical opinion must, of course, vary as to the causes which give rise +to the familiar disorders I have so briefly sketched, but I imagine that +few physicians placed face to face with such cases would not feel sure +that if they could insure to these patients a liberal gain in fat and in +blood they would be certain to need very little else, and that the +troubles of stomach, bowels, and uterus would speedily vanish. + +I need hardly say that I do not mean by this that the mere addition of +blood and normal flesh is what we want, but that their gradual increase +will be a visible result of the multitudinous changes in digestive, +assimilative, and secretive power in which the whole economy inevitably +shares, and of which my relation of cases will be a better statement +than any more general one I could make here. + +Such has certainly been the result of my own very ample experience. If I +succeed in first altering the moral atmosphere which has been to the +patient like the very breathing of evil, and if I can add largely to the +weight and fill the vessels with red blood, I am usually sure of giving +general relief to a host of aches, pains, and varied disabilities. If I +fail, it is because I fail in these very points, or else because I have +overlooked or undervalued some serious organic tissue-change. It must be +said that now and then one is beaten by a patient who has an +unconquerable taste for invalidism, or one to whom the change of moral +atmosphere is not bracing, or by sheer laziness, as in the case of a +lady who said to me, as a final argument, "Why should I walk when I can +have a negro boy to push me in a chair?" + +It will have been seen that I am careful in the selection of cases for +this treatment. Conducted under the best circumstances for success, it +involves a good deal that is costly. Neither does it answer as well, and +for obvious reasons, in hospital wards; and this is most true in regard +to persons who are demonstratively hysterical. As a rule, the worse the +case, the more emaciated, the more easy is it to manage, to control, and +to cure. It is, as Playfair remarks, the half-ill who constitute the +difficult cases. + +I am also very careful as to being sure of the absence of certain forms +of organic disease before flattering myself with the probability of +success. But not all organic troubles forbid the use of this treatment. +Advanced Bright's disease does, though the early stages of contracted +kidney are decidedly benefited by it, if proper diet be prescribed; but +intestinal troubles which are not tubercular or malignant do not; nor do +moderate signs of chronic pulmonary deposits, or bronchitis.[13] + +Some special consideration needs to be given to the subject of +heart-disease. Especially in cases of broken compensation, by lessening +the work required of the heart so that it needs to beat both less often +and with less force, the simple maintenance of the recumbent position is +a great aid to recovery, and massage properly used will still further +relieve the heart. Disturbed compensation is usually accompanied by +failure of nutrition, often by distinct anĉmia, and these and the +anxiety which naturally enough affects the mind of a person with cardiac +disorder are all best handled, at first at least, by quiet and rest. +Later, the methods of Schott, baths and resistance movements, may carry +the improvement further. Even in old and established cases of valvular +disease much may be done if the patient have confidence and the +physician courage enough to insist upon a sufficient length of rest. The +palpitation and dyspnoea of exophthalmic goitre are promptly helped by +rest and massage, and with other suitable measures added, cures may be +effected even in this intractable ailment. + +In former editions I have advised against any attempt to treat the true +melancholias, which are not mere depression of spirits from loss of all +hope of relief, by this method, but wider experience has convinced me +that rest and seclusion may often be successfully prescribed to a +certain extent and in certain cases. + +Those in which the most good has been done have been the cases of +agitated melancholia with attacks, more or less clearly periodic, of +excitement, during which their delusions take acuter hold of them and +drive them to wild extravagance of noisy talk and bodily restlessness. +Whether such patients must be put to bed or not one must judge in each +instance, taking into account the general nutrition. In my own practice +I certainly do put them to bed now much oftener than formerly. It is not +desirable to keep them there for the six or eight weeks which full +treatment would demand. Usually it will be of advantage to order, say, +two weeks of "absolute rest," observing the usual precautions about +getting the patient up, prescribing bed again when the early signs of an +attack of agitation appear, and keeping him there for a couple of days +on each occasion, during which the full schedule of treatment is to be +minutely carried out. + +Goodell and, more recently, Playfair have pointed out the fact that some +cases of disease of the uterine appendages such as would ordinarily be +considered hopeless, except for surgical treatment, have in their hands +recovered to all appearances entirely; and my own list of patients +condemned to the removal of the ovaries but recovering and remaining +well has now grown to a formidable length. Playfair observes also that +he believes it possible that in even very severe and extensive disease +the health of the patient may be sufficiently improved to render +operation unnecessary.[14] + +In cases of floating kidney some very satisfactory results have been +reached by long rest; and although it may be necessary to keep the +patient supine for three months or more, the reasonable probability of +permanent replacement of the organ is much greater than from operative +attempts at fixation, apart from the danger and pain of surgical +procedures. Persons with floating kidney are nearly always thin, often +giving a history of rapid loss of weight, have usually various symptoms +of gastric and intestinal disturbance, and present therefore subjects in +all ways suitable for a fattening and blood-making _régime_ which shall +furnish padding to hold the kidney firmly in its normal place. + +The treatment of locomotor ataxia and some allied states by this method, +with certain modifications, has yielded such good results that I now +undertake with reasonable confidence the charge of such patients; and +the subject is so important and has as yet influenced so little the +futile drugging treatment of these wretched cases that it seems worth +while to devote a special chapter to it, although the affections named +can scarcely be said to be included under the head of neurasthenic +disease. + +In the following chapters I shall treat of the means which I have +employed, and shall not hesitate to give such minute details as shall +enable others to profit by my failures and successes. In describing the +remedies used, and the mode of using them in combination, I shall relate +a sufficient number of cases to illustrate both the happier results and +the causes of occasional failure. + +The treatment I am about to describe consists in seclusion, certain +forms of diet, rest in bed, massage (or manipulation), and electricity; +and I desire to insist anew on the fact that in most cases it is the +combined use of these means that is wanted. How far they may be modified +or used separately in some instances, I shall have occasion to point out +as I discuss the various agencies alluded to. + + + + +CHAPTER IV. + +SECLUSION. + + +It is rare to find any of the class of patients I have described so free +from the influence of their habitual surroundings as to make it easy to +treat them in their own homes. It is needful to disentangle them from +the meshes of old habits and to remove them from contact with those who +have been the willing slaves of their caprices. I have often made the +effort to treat them where they have lived and to isolate them there, +but I have rarely done so without promising myself that I would not +again complicate my treatment by any such embarrassments. Once separate +the patient from the moral and physical surroundings which have become +part of her life of sickness, and you will have made a change which will +be in itself beneficial and will enormously aid in the treatment which +is to follow. Of course this step is not essential in such cases as are +merely anĉmic, feeble, and thin, owing to distinct causes, like the +exhaustion of overwork, blood-losses, dyspepsia, low fevers, or nursing. +There are but too many women who have broken down under such causes and +failed to climb again to the level of health, despite all that could be +done for them; and when such persons are free from emotional excitement +or hysterical complications there is no reason why the seclusion needful +to secure them repose of mind should not be pleasantly modified in +accordance with the dictates of common sense. Very often a little +experimentation as to what they will profitably bear in the way of +visits and the like will inform us, as their treatment progresses, how +far such indulgence is of use or free from hurtful influences. Cases of +extreme neurasthenia in men accompanied with nutritive failures require +as to this matter cautious handling, because, for some reason, the ennui +of rest and seclusion is far better borne by women than by the other +sex. + +Even in cases whose moral aspects do not at once suggest an imperative +need for seclusion it is well to remember, as regards neurasthenic +people, that the treatment involves for a time daily visits of some +length from the masseur, the doctor, and possibly an electrician, and +that to add to these even a single friendly visitor is often too much +to be readily borne; but I am now speaking chiefly of the large and +troublesome class of thin-blooded emotional women, for whom a state of +weak health has become a long and, almost I might say, a cherished +habit. For them there is often no success possible until we have broken +up the whole daily drama of the sick-room, with its little selfishness +and its craving for sympathy and indulgence. Nor should we hesitate to +insist upon this change, for not only shall we then act in the true +interests of the patient, but we shall also confer on those near to her +an inestimable benefit. An hysterical girl is, as Wendell Holmes has +said in his decisive phrase, a vampire who sucks the blood of the +healthy people about her; and I may add that pretty surely where there +is one hysterical girl there will be soon or late two sick women. If +circumstances oblige us to treat such a person in her own home, let us +at least change her room, and also have it well understood how far we +are to control her surroundings and to govern as to visitors and the +company of her own family. Do as we may, we shall always lessen thus our +chances of success, but we shall certainly not altogether destroy them. + +I should add here a few words of caution as to the time of year best +fitted for treatment. In the summer seclusion is often undesirable when +the patient is well enough to gain help by change of air; moreover, at +this season massage is less agreeable than in winter, and, as a rule, I +find it harder to feed and to fatten persons at rest during our summer +heats. That this rule is not without exception has been shown by Drs. +Goodell and Sinkler, both of whom have attained some remarkable +successes in midsummer. + +One of the questions of most importance in the carrying out of this +treatment is the choice of a nurse. Just as it is desirable to change +the home of the patient, her diet, her atmosphere, so also is it well, +for the mere alterative value of such change, to surround her with +strangers and to put aside any nurse with whom she may have grown +familiar. As I have sometimes succeeded in treating invalids in their +own homes, so have I occasionally been able to carry through cases +nursed by a mother, or sister, or friend of exceptional firmness; but to +attempt this is to be heavily handicapped, and the position should never +be accepted if it be possible to make other arrangements. Any firm, +intelligent woman of tact, a stranger to the patient, is better than +the old style of nurse, now, happily, disappearing. The nurse for these +cases ought to be a young, active, quick-witted woman, capable of firmly +but gently controlling her patient. She ought to be intelligent, able to +interest her patient, to read aloud, and to write letters. The more of +these cases she has seen and nursed, the easier becomes the task of the +doctor. Young, I have said she ought to be, but youthful would be a +better word. If, as she grows older, the nurse loses the strenuous +enthusiasm with which she made her first entrance into her work, +scarcely any amount of conscientious devotion or experience will ever +replace it; but there are fortunate people who seem never to grow old in +this sense. It is always to be borne in mind that most of these patients +are over-sensitive, refined, and educated women, for whom the +clumsiness, or want of neatness, or bad manners, or immodesty of a nurse +may be a sore and steadily-increasing trial. To be more or less isolated +for two months in a room, with one constant attendant, however good, is +hard enough for any one to endure; and certain quite small faults or +defects in a nurse may make her a serious impediment to the treatment, +because no mere technical training will dispense in the nurse any more +than in the physician with those finer natural qualifications which make +their training available. Over-harshness is in some ways worse than +over-easiness, because it makes less pleasant the relation between nurse +and patient, and the latter should regard the former as her "next +friend." Let the nurse, therefore, place upon the doctor the burden of +decision in disputed matters; his position will not be injured with the +patient by strict enforcement of the letter of the law, while the +nurse's may be. But one nurse will suit one patient and not another: so +that I never hesitate to change my nurse if she does not fit the case, +and to change if necessary more than once. + +The degree of seclusion should be prescribed from the first, and it is +far better to find that the original rules may be profitably relaxed +than to be obliged to draw the lines more strictly when the patient has +at first been indulged. For instance, it is well to forbid the receipt +of any letters from home, unless anxious relatives insist that the +patient must have home news. In that case the letters should be mere +bulletins, should contain nothing, no matter how trifling, that might +annoy a too sensitive person, and, most important of all, should come to +the nurse and by her be read to the patient. + + + + +CHAPTER V. + +REST. + + +I have said more than once in the early chapters of this little volume +that the treatment I wished to advise as of use in a certain range of +cases was made up of rest, massage, electricity, and over-feeding. I +said that the use of large amounts of food while at rest, more or less +entire, was made possible by the practice of kneading the muscles and by +moving them with currents able to effect this end. I desire now to +discuss in turn the modes in which I employ rest, massage, and +electricity, and, as I have promised, I shall take pains to give, in +regard to these three subjects, the fullest details, because success in +the treatment depends, I am sure, on the care with which we look after a +number of things each in itself apparently of slight moment. + +I have no doubt that many doctors have seen fit at times to put their +patients at rest for great or small lengths of time, but the person who +of all others within my knowledge used this means most, and used it so +as to obtain the best results, was the late Professor Samuel Jackson. He +was in the habit of making his patients remain in bed for many weeks at +a time, and, if I recall his cases well, he used this treatment in just +the class of disorders among women which have given me the best results. +What these are I have been at some pains to define, and I have now only +to show why in such people rest is of service, and what I mean by rest, +and how I apply it. + +In No. IV. of Dr. Séguin's series of American Clinical Lectures, I was +at some pains to point out the value of repose in neuralgias, and +especially sciatica, in myelitis, and in the early stages of locomotor +ataxia, and I have since then had the pleasure of seeing these views +very fully accepted. I shall now confine myself chiefly to its use in +the various forms of weakness which exist with thin blood and wasting, +with or without distinct lesions of the stomach, womb, or other organs. + +Whether we shall ask a patient to walk or to take rest is a question +which turns up for answer almost every day in practice. Most often we +incline to insist on exercise, and are led to do so from a belief that +many people walk too little, and that to move about a good deal every +day is well for everybody. I think we are as often wrong as right. A +good brisk daily walk is for well folks a tonic, breaks down old +tissues, and creates a wholesome demand for food. The same is true for +some sick people. The habit of horse-exercise or a long walk every day +is needed to cure or to aid in the cure of disordered stomach and +costive bowels, but if all exertion gives rise only to increase of +trouble, to extreme sense of fatigue, to nausea, to headache, what shall +we do? And suppose that tonics do not help to make exertion easy, and +that the great tonic of change of air fails us, shall we still persist? +And here lies the trouble: there are women who mimic fatigue, who +indulge themselves in rest on the least pretence, who have no symptoms +so truly honest that we need care to regard them. These are they who +spoil their own nervous systems as they spoil their children, when they +have them, by yielding to the least desire and teaching them to dwell on +little pains. For such people there is no help but to insist on +self-control and on daily use of the limbs. They must be told to exert +themselves, and made to do so if that can be. If they are young, this +is easy enough. If they have grown to middle life, and created habits of +self-indulgence, the struggle is often useless. But few, however, among +these women are free from some defect of blood or tissue, either +original or acquired as a result of years of indolence and attention to +aches and ailments which should never have had given to them more than a +passing thought, and which certainly should not have been made an excuse +for the sofa or the bed. + +Sometimes the question is easy to settle. If you find a woman who is in +good condition as to color and flesh, and who is always able to do what +it pleases her to do, and who is tired by what does not please her, that +is a woman to order out of bed and to control with a firm and steady +will. That is a woman who is to be made to walk, with no regard to her +complaints, and to be made to persist until exertion ceases to give rise +to the mimicry of fatigue. In such cases the man who can insure belief +in his opinions and obedience to his decrees secures very often most +brilliant and sometimes easy success; and it is in such cases that women +who are in all other ways capable doctors fail, because they do not +obtain the needed control over those of their own sex. I have been +struck with this a number of times, but I have also seen that to be too +long and too habitually in the hands of one physician, even the wisest, +is for some cases of hysteria the main difficulty in the way of a +cure,--it is so easy to disobey the familiar friendly attendant, so hard +to do this where the physician is a stranger. But we all know well +enough the personal value of certain doctors for certain cases. Mere +hygienic advice will win a victory in the hands of one man and obtain no +good results in those of another, for we are, after all, artists who all +use the same means to an end but fail or succeed according to our method +of using them. There are still other cases in which mischievous +tendencies to repose, to endless tire, to hysterical symptoms, and to +emotional displays have grown out of defects of nutrition so distinct +that no man ought to think for these persons of mere exertion as a sole +means of cure. The time comes for that, but it should not come until +entire rest has been used, with other means, to fit them for making use +of their muscles. Nothing upsets these cases like over-exertion, and the +attempt to make them walk usually ends in some mischievous emotional +display, and in creating a new reason for thinking that they cannot +walk. As to the two sets of cases just sketched, no one need hesitate; +the one must walk, the other should not until we have bettered her +nutritive state. She may be able to drag herself about, but no good will +be done by making her do so. But between these two classes, and allied +by certain symptoms to both, lie the larger number of such cases, giving +us every kind of real and imagined symptom, and dreadfully well fitted +to puzzle the most competent physician. As a rule, no harm is done by +rest, even in such people as give us doubts about whether it is or is +not well for them to exert themselves. There are plenty of these women +who are just well enough to make it likely that if they had motive +enough for exertion to cause them to forget themselves they would find +it useful. In the doubt I am rather given to insisting on rest, but the +rest I like for them is not at all their notion of rest. To lie abed +half the day, and sew a little and read a little, and be interesting as +invalids and excite sympathy, is all very well, but when they are bidden +to stay in bed a month, and neither to read, write, nor sew, and to have +one nurse, who is not a relative,--then repose becomes for some women a +rather bitter medicine, and they are glad enough to accept the order to +rise and go about when the doctor issues a mandate which has become +pleasantly welcome and eagerly looked for. I do not think it easy to +make a mistake in this matter unless the woman takes with morbid delight +to the system of enforced rest, and unless the doctor is a person of +feeble will. I have never met myself with any serious trouble about +getting out of bed any woman for whom I thought rest needful, but it has +happened to others, and the man who resolves to send any nervous woman +to bed must be quite sure that she will obey him when the time comes for +her to get up. + +I have, of course, made use of every grade of rest for my patients, from +repose on a lounge for some hours a day up to entire rest in bed. In +milder forms of neurasthenic disease, in cases of slight general +depression not properly to be called melancholias, in the lesser grades +of pure brain-tire, or where this is combined with some physical +debility, I often order a "modified" or "partial rest." A detailed +schedule of the day is ordered for such patients, with as much +minuteness of care as for those undergoing "full rest" in bed. Here the +patient's or the household's usual hours may be consulted, a definite +amount of time allotted to duties, business, and exercise, and certain +hours left blank, to be filled, within limits, at the patient's +discretion or that of the nurse. + +So many nervous people are worried with indecision, with inability to +make up their minds to the simplest actions, that to have the +responsibility of choice taken away greatly lessens their burdens. It +lessens, too, the burdens which may be placed upon them by outside +action if they can refuse this or that because they are under orders as +to hours. + +The following is a skeleton form of such a schedule. The hours, the +food, the occupations suggested in each one will vary according to the +sex, age, position, desires, intelligence, and opportunities of the +patient. + +7.30 A.M. Cocoa, coffee, hot milk, beef-extract, or hot water. Bath +(temperature stated). Rough rub with towel or flesh-brush: bathing and +rubbing may be done by attendant. Lie down a few minutes after +finishing. + +8.30 A.M. Breakfast in bed. (Detail as to diet. Tonic, aperient, malt +extract as ordered.) May read letters, paper, etc., if eyes are good. + +10-11 A.M. Massage, if required, is usually ordered one hour after +breakfast; or Swedish movements are given at that time. An hour's rest +follows massage. Less rest is needed after the movements. (Milk or broth +after massage.) + +12 M. Rise and dress slowly. If gymnastics or massage are not ordered, +may rise earlier. May see visitors, attend to household affairs, or walk +out. + +1.30 P.M. Luncheon. (Malt, tonic, etc., ordered.) In invalids this +should be the chief meal of the day. Rest, lying down, not in bed, for +an hour after. + +3 P.M. Drive (use street-cars or walk) one to two and a half hours. +(Milk or soup on return.) + +7 P.M. Supper. (Malt, tonic, etc., ordered; detail of diet.) + +Bed at 10 P.M. Hot milk or other food at bedtime. + +This schedule is modified for convalescent patients after rest-treatment +by orders as to use of the eyes: letter-writing is usually forbidden, +walking distinctly directed or forbidden, as the case may require. It +may be changed by putting the exercise, massage, or gymnastics in the +afternoon, for example, and leaving the morning, as soon as the rest +after breakfast is finished, for business. Men needing partial rest may +thus find time to attend to their affairs. + +If massage is not ordered, there is nothing in this routine which costs +money, and I have found it apply usefully in the case of hospital and +dispensary patients. + +In carrying out my general plan of treatment in extreme cases it is my +habit to ask the patient to remain in bed from six weeks to two months. +At first, and in some cases for four or five weeks, I do not permit the +patient to sit up, or to sew or write or read, or to use the hands in +any active way except to clean the teeth. Where at first the most +absolute rest is desirable, as in cases of heart-disease, or where there +is a floating kidney, I arrange to have the bowels and water passed +while lying down, and the patient is lifted on to a lounge for an hour +in the morning and again at bedtime, and then lifted back again into the +newly-made bed. In most cases of weakness, treated by rest, I insist on +the patient being fed by the nurse, and, when well enough to sit up in +bed, I order that the meats shall be cut up, so as to make it easier +for the patient to feed herself. + +In many cases I allow the patient to sit up in order to obey the calls +of nature, but I am always careful to have the bowels kept reasonably +free from costiveness, knowing well how such a state and the efforts it +gives rise to enfeeble a sick person. + +The daily sponging bath is to be given by the nurse, and should be +rapidly and skilfully done. It may follow the first food of the day, the +early milk, or cocoa, or coffee, or, if preferred, may be used before +noon, or at bedtime, which is found in some cases to be best and to +promote sleep. + +For some reason, the act of bathing, or even the being bathed, is +mysteriously fatiguing to certain invalids, and if so I have the general +sponging done for a time but thrice a week. + +Most of these patients suffer from use of the eyes, and this makes it +needful to prohibit reading and writing, and to have all correspondence +carried on through the nurse. But many neurasthenic people also suffer +from being read to, or, in other words, from any prolonged effort at +attention. In these cases it will be found that if the nurse will read +the morning paper, and as she does so relate such news as may be of +interest, the patient will bear it very well, and will by degrees come +to endure the hearing of such reading as is already more or less +familiar. + +Usually, after a fortnight I permit the patient to be read to,--one to +three hours a day,--but I am daily amazed to see how kindly nervous and +anĉmic women take to this absolute rest, and how little they complain of +its monotony. In fact, the use of massage and the battery, with the +frequent comings of the nurse with food, and the doctor's visits, seem +so to fill up the day as to make the treatment less tiresome than might +be supposed. And, besides this, the sense of comfort which is apt to +come about the fifth or sixth day,--the feeling of ease, and the ready +capacity to digest food, and the growing hope of final cure, fed as it +is by present relief,--all conspire to make most patients contented and +tractable. + +The intelligent and watchful physician must, of course, know how far to +enforce and when to relax these rules. When it is needful, as it +sometimes is, to prolong the state of rest to two or three months, the +patient may need at the close occupation of some kind, and especially +such as, while it does not tax the eyes, gives the hands something to +do, the patient being, we suppose, by this time able to sit up in bed +during a part of the day. + +The moral uses of enforced rest are readily estimated. From a restless +life of irregular hours, and probably endless drugging, from hurtful +sympathy and over-zealous care, the patient passes to an atmosphere of +quiet, to order and control, to the system and care of a thorough nurse, +to an absence of drugs, and to simple diet. The result is always at +first, whatever it may be afterwards, a sense of relief, and a +remarkable and often a quite abrupt disappearance of many of the nervous +symptoms with which we are all of us only too sadly familiar. + +All the moral uses of rest and isolation and change of habits are not +obtained by merely insisting on the physical conditions needed to effect +these ends. If the physician has the force of character required to +secure the confidence and respect of his patients, he has also much more +in his power, and should have the tact to seize the proper occasions to +direct the thoughts of his patients to the lapse from duties to others, +and to the selfishness which a life of invalidism is apt to bring +about. Such moral medication belongs to the higher sphere of the +doctor's duties, and, if he means to cure his patient permanently, he +cannot afford to neglect them. Above all, let him be careful that the +masseuse and the nurse do not talk of the patient's ills, and let him by +degrees teach the sick person how very essential it is to speak of her +aches and pains to no one but himself. + +I have often asked myself why rest is of value in the cases of which I +am now speaking, and I have already alluded briefly to some of the modes +in which it is of use. + +Let us take first the simpler cases. We meet now and then with feeble +people who are dyspeptic, and who find that exercise after a meal, or +indeed much exercise on any day, is sure to cause loss of power or +lessened power to digest food. The same thing is seen in an extreme +degree in the well-known experiment of causing a dog to run violently +after eating, in which case digestion is entirely suspended. Whether +these results be due to the calling off of blood from the gastric organs +to the muscles, or whether the nervous system is, for some reason, +unable to evolve at the same time the force needed for a double +purpose, is not quite clear, but the fact is undoubted, and finds added +illustrations in many of the class of exhausted women. It is plain that +this trouble exists in some of them. It is likely that it is present in +a larger number. The use of rest in these people admits of no question. +If we are to give them the means in blood and flesh of carrying on the +work of life, it must be done with the aid of the stomach, and we must +humor that organ until it is able to act in a more healthy manner under +ordinary conditions. It may be wise to add that occasional cases of +nervousness or of nervous disturbance of digestion are seen in which the +patient assimilates food better if permitted to move about directly +after a meal; and I recall one instance of very persistent gastric +catarrh where the uncomfortable symptoms following meals only began to +disappear when as an experiment the patient was ordered to take a quiet +half-hour's stroll after each meal, instead of the rest usually ordered. + +I am often asked how I can expect by such a system to rest the organs of +mind. No act of will can force them to be at rest. To this I should +answer that it is not the mere half-automatic intellectuation which is +harmful in men or women subject to states of feebleness or neurasthenia, +and that the systematic vigorous use of mind on distinct problems is +within some form of control. It is thought with the friction of worry +which injures, and unless we can secure an absence of this, it is vain +to hope for help by the method I am describing. The man harassed by +business anxieties, the woman with morbidly-developed or ungoverned +maternal instincts, will only illustrate the causes of failure. Perhaps +in all dubious cases Dr. Playfair's rule is not a bad one, to consider, +and to let the patient consider, this mode of treatment as a hopeful +experiment, which may have to be abandoned, and which is valueless +without the cordial and submissive assistance of the patient. + +The muscular system in many of such patients--I mean in ever-weary, thin +and thin-blooded persons--is doing its work with constant difficulty. As +a result, fatigue comes early, is extreme, and lasts long. The demand +for nutritive aid is ahead of the supply, or else the supply is +incompetent as to quality, and before the tissues are rebuilded a new +demand is made, so that the materials of disintegration accumulate, and +do this the more easily because the eliminative organs share in the +general defects. And these are some of the reasons why anĉmic people are +always tired; but, besides this, all real sensations are magnified by +women whose nervous systems have become sensitive owing to a life of +attention to their ailments, and so at last it becomes hard to separate +the true from the false, and we are thus led to be too sceptical as to +the presence of real causes of annoyance. Certain it is that rest, under +proper conditions, is found by such sufferers to be a great relief; but +rest alone will not answer, and it is needful, as I shall show, to bring +to our help certain other means, in order to secure all the good which +repose may be made to insure. + +In dealing with this, as with every other medical means, it is well to +recall that in our attempts to help we may sometimes do harm, and we +must make sure that in causing the largest share of good we do the least +possible evil. + +"The one goes with the other, as shadow with light, and to no +therapeutic measure does this apply more surely than to the use of rest. + +"Let us take the simplest case,--that which arises daily in the +treatment of joint-troubles or broken bones. We put the limb in splints, +and thus, for a time, check its power to move. The bone knits, or the +joint gets well; but the muscles waste, the skin dries, the nails may +for a time cease to grow, nutrition is brought down, as an arithmetician +would say, to its lowest terms, and when the bone or joint is well we +have a limb which is in a state of disease. As concerns broken bones, +the evil may be slight and easy of relief, if the surgeon will but +remember that when joints are put at rest too long they soon fall a prey +to a form of arthritis, which is the more apt to be severe the older the +patient is, and may be easily avoided by frequent motion of the joints, +which, to be healthful, exact a certain share of daily movement. If, +indeed, with perfect stillness of the fragments we could have the full +life of a limb in action, I suspect that the cure of the break might be +far more rapid. + +"What is true of the part is true of the whole. When we put the entire +body at rest we create certain evils while doing some share of good, and +it is therefore our part to use such means as shall, in every case, +lessen and limit the ills we cannot wholly avoid. How to reach these +ends I shall by and by state, but for a brief space I should like to +dwell on some of the bad results which come of our efforts to reach +through rest in bed all the good which it can give us, and to these +points I ask the most thoughtful attention, because upon the care with +which we meet and provide for them depends the value which we will get +out of this most potent means of treatment. + +"When we put patients in bed and forbid them to rise or to make use of +their muscles, we at once lessen appetite, weaken digestion in many +cases, constipate the bowels, and enfeeble circulation."[15] + +When we put the muscles at absolute rest we create certain difficulties, +because the normal acts of repeated movement insure a certain rate of +nutrition which brings blood to the active parts, and without which the +currents flow more largely around than through the muscles. The lessened +blood-supply is a result of diminished functional movement, and we need +to create a constant demand in the inactive parts. But, besides this, +every active muscle is practically a throbbing heart, squeezing its +vessels empty while in motion, and relaxing, so as to allow them to fill +up anew. Thus, both for itself and in its relations to the areolar +spaces and to the rest of the body, its activity is functionally of +service. Then, also, the vessels, unaided by changes of posture and by +motion, lose tone, and the distant local circuits, for all of these +reasons, cease to receive their normal supply, so that defects of +nutrition occur, and, with these, defects of temperature. + +"I was struck with the extent to which these evils may go, in the case +of Mrs. P., ĉt. 52, who was brought to me from New Jersey, having been +in bed fifteen years. I soon knew that she was free of grave disease, +and had stayed in bed at first because there was some lack of power and +much pain on rising, and at last because she had the firm belief that +she could not walk. After a week's massage I made her get up. I had won +her full trust, and she obeyed, or tried to obey me, like a child. But +she would faint and grow deadly pale, even if seated a short time. The +heart-beats rose from sixty to one hundred and thirty, and grew feeble; +the breath came fast, and she had to lie down at once. Her skin was +dry, sallow, and bloodless, her muscles flabby; and when, at last, after +a fortnight more, I set her on her feet again, she had to endure for a +time the most dreadful vertigo and alarming palpitations of the heart, +while her feet, in a few minutes of feeble walking, would swell so as to +present the most strange appearance. By and by all this went away, and +in a month she could walk, sit up, sew, read, and, in a word, live like +others. She went home a well-cured woman. + +"Let us think, then, when we put a person in bed, that we are lessening +the heart-beats some twenty a minute, nearly a third; that we are +causing the tardy blood to linger in the by-ways of the blood-round, for +it has its by-ways; that rest in bed binds the bowels, and tends to +destroy the desire to eat; and that muscles at rest too long get to be +unhealthy and shrunken in substance. Bear these ills in mind, and be +ready to meet them, and we shall have answered the hard question of how +to help by rest without hurt to the patient." + +When I first made use of this treatment I allowed my patients to get up +too suddenly, and in some cases I thus brought on relapses and a return +of the feeling of painful fatigue. I also saw in some of these cases +what I still see at times under like circumstances,--a rapid loss of +flesh. + +I now begin by permitting the patient to sit up in bed, then to feed +herself, and next to sit up out of bed a few minutes at bedtime. In a +week, she is desired to sit up fifteen minutes twice a day, and this is +gradually increased until, at the end of six to twelve weeks, she rests +on the bed only three to five hours daily. Even after she moves about +and goes out, I insist for two months on absolute repose at least two or +three hours daily, and this must be understood to mean seclusion as well +as bodily quiet, free from the intrusion of household cares, visitors, +or any form of emotion or excitement, pleasureable or otherwise. In +cases of long-standing it may be desirable to continue this period of +isolation and to order as well an hour's lying down after each meal for +many months, in some such methodical way as is suggested in the schedule +on page 64. + +The use of a hammock is found by some people to be a very agreeable +change from the bed during a part of the day. + +The physician who discharges his patient when she rises from her bed +after her two or three months' treatment, or who neglects to consider +the moral and mental needs and aspects of each case, will find that many +will relapse. Even when the patient has left the direct care of the +doctor and returned to home and its avocations she will find help and +comfort in the knowledge that she can apply to him if necessary, and it +is well to hold some sort of relation by occasional visits or +correspondence, however brief, for six months or a year after treatment +has been completed. + + + + +CHAPTER VI. + +MASSAGE. + + +How to deprive rest of its evils is the title with which I might very +well have labelled this chapter. I have pointed out what I mean by rest, +how it hurts, and how it seems to help; and, as I believe that it is +useful in most cases only if employed in conjunction with other means, +the study of these becomes of the first importance. + +The two aids which by degrees I learned to call upon with confidence to +enable me to use rest without doing harm are massage and electricity. We +have first to deal with massage, and I give some care to the description +of details, because even now it is imperfectly understood in this +country, and because I wish to emphasize some facts about it which are +not well known, I think, on either side of the Atlantic. + +Massage in some form has long been in use in the East, and is well known +as the _lommi-lommi_ of the slothful inhabitants of the Sandwich +Islands. In Japan it is reserved as an occupation for the blind, whose +delicate sense of feeling might, I should think, very well fit them for +this task. It is, however, in these countries less used in disease than +as the luxury of the rich; nor can I find in the few books on the +subject that it has been resorted to habitually as a tonic in Europe, or +otherwise than as a means of treating local disorders. + +It is many years since I first saw in this city general massage used by +a charlatan in a case of progressive paralysis. The temporary results he +obtained were so remarkable that I began soon after to employ it in +locomotor ataxia, in which it sometimes proved of signal value, and in +other forms of spinal and local disease. At first I had to train nurses +to use it, but I soon found that, although it was of some service to +their patients, no one could use massage well who was not continually +engaged in doing it. Some men do it better than any woman; but I prefer, +nevertheless, for obvious reasons, to reserve men for male patients, +except that in cases where _strength_ is of moment, as in the forced +movements and the very hard rubbing needed for old articular adhesions, +in which force must be exercised without violence, it is usually +impossible to secure the necessary power in a feminine manipulator. + +A few years later I resorted to it in the first cases which I treated by +rest, and I very soon found that I had in it an agent little understood +and of singular utility. + +It will be necessary, in pursuance of my plan, to describe as minutely +as the limits of a chapter will allow how and why this means is +employed. The process and order of what is known to the manipulator as +"general massage" follows. + +After three or four days in bed have somewhat accustomed the patient to +the general routine of treatment, a masseur or masseuse is set to work. +If any special care is needed,--the avoidance of manipulating one part +or added attention to another, tender handling of a sensitive or timid +patient,--these matters have been ordered in advance by the physician. +An hour midway between meals is chosen, and, the patient lying in bed +between blankets, the manipulator begins, usually with the feet. A few +rapid rubs of the whole foot and leg are given to start with; then the +leg, except the foot and ankle, is covered up, and the operation +commences upon the foot, of which the skin is picked up and rolled +between the fingers, the whole foot receiving careful attention,--the +toes are pulled, bent, and moved in every direction, the inter-osseous +groups worked over with the thumbs and fingers or finger-tips, the +larger muscles and subcutaneous tissues squeezed and kneaded, and last +the whole mass of the foot rolled and pressed against the bones with +both hands. A few rapid upward strokings with some force complete the +treatment of the part, and the ankle is next dealt with. The joint is +moved in every possible direction, slowly but firmly, the crevices +between the articulating bones sought out and kneaded with the +finger-tips, and the foot and ankle are then carefully covered. After +the same rapid stroking upward of the leg with which it began has been +repeated for the sake of the slight stimulation of the skin-vessels and +nerves, the muscles of the leg are treated, first by friction of the +more superficially placed masses, then by careful deep kneading +(_pétrissage_) of the large muscles of the calf, twisting, pressing, and +rolling them about the bone with one hand while the other supports the +limb. In fat or heavily-muscled subjects it may be necessary to use both +hands to get sufficient grasp of the muscles. The tibialis anticus and +muscles of the outer side of the leg are operated upon by rolling them +under the finger-tips and by pressing with the thumb while firmly +pushing upward from the ankle to the knee. At brief intervals the +manipulator seizes the limb in both hands and lightly runs the grasp +upward, so as to favor the flow of the venous blood-currents, and then +returns to the kneading of the muscles,--and each part is finished by +light yet firm upward stroking, the hand returning downward more +lightly, yet without breaking its contact with the skin. + +Care must be taken as the different groups of muscles are treated that +the leg is placed in the position which will most completely relax the +ones to be operated upon. Any tension of muscles wholly defeats the +effort of the masseur. + +After completing the process upon both legs, the arm is next treated in +the same manner, the hand receiving somewhat more detailed attention +than the foot. Pains must be taken to reach the several groups of the +forearm by operating from both sides of the arm. The ordinary +manipulation of the shoulder can be accomplished with the patient lying +down; but if special conditions, such as articular stiffening, call for +unusual care or unusual force, it will be found best to treat the +shoulder with the patient seated. The treatment of the arms is concluded +with upward stroking (_effleurage_), as with the leg. + +In the order usually pursued, the back is the next region treated. The +patient lies prone, folding the arms under the head; a firm pillow is +put under the epigastric region, so as to the better relax the back +muscles, which are too tense when a person lies flat. Beginning from the +occiput, both hands stroke firmly and rapidly downward and outward to +the spines of the scapulĉ, at first lightly, then with increasing force. +Then the whole back is vigorously rubbed--scrubbed one might call +it--with up-and-down strokes, as a preliminary application. The erector +spinĉ masses are treated by careful finger-tip kneading. Working from +the spine outward to the axillary line, the muscles of the ribs are +acted upon with flat-hand rubbing. The groups of the upper back and +shoulder-blades are kneaded and squeezed, the arms being partly +abducted so as to separate the shoulder-blades and allow the operator to +reach the muscles underlying them. The lumbar regions receive their +manipulation last. If it is desirable to give special attention or an +extra share of manipulation to any part of the spinal region, this is +done as the physician may have ordered, and the whole process is +completed by downward friction over the spine, given vigorously and as +rapidly as possible. + +The chest is the next region to be handled, the patient turning from the +prone to the supine position. In women the breasts are usually best left +untouched unless special conditions demand their treatment. + +The last and perhaps most important part of the process of general +massage is the rubbing of the abdomen. Particular care is needed to +secure complete relaxation, as nervous patients and, still more, +hysterical patients are apt to present extreme rigidity of the abdominal +muscles. The head is raised by pillows, the knees are slightly flexed +and sometimes supported by a folded pillow also. With this position the +rigidity generally yields to gentle persistence, at any rate after a +few treatments. If it does not do so, a lateral decubitus may be tried, +a position in which the intestinal regions may be very thoroughly +treated, and in which, if there be gastric dilatation, the stomach-walls +can be best reached. Sweeping circular frictions about the navel as a +centre begin the process; the abdominal walls are then kneaded and +pinched[16] with one or both hands; deep, firm kneading of the whole +belly with the heel of the hand follows, the movements following the +course of the colon. Next, the fingers of one hand are all held together +in a pyramidal fashion and thrust firmly and slowly into the abdomen, in +ordinary cases both hands being used thus alternately, in fat or +resisting abdomens one hand pressing upon and aiding the other, and +travelling thus over the ascending, transverse, and descending colon. +To conclude, the whole belly is shaken by a rapid vibratory motion of +the hands (to which is sometimes added succussion by slapping with the +flat or cupped hand), and the whole process ends with quick, circular +rubbing of the surface. + +In cases of troublesome constipation or where other special indications +exist, treatment of the abdomen may be much extended beyond the limits +here suggested, and indeed it must be remembered that the process of +"general massage" as described is capable of a great variety of useful +modification to meet individual needs, and is so modified daily by the +careful physician and the watchful masseur. It would not be possible or +desirable here to describe all the movements which a skilful rubber +makes in his treatment, and I have only attempted a skeleton-statement. +It will perhaps be noticed by those familiar with the technique of +massage that nothing is here said about the use of the movements classed +under the general head of "tapotement," the tapping and slapping +motions. They have no proper place in the treatment of cases of +nervousness, and usually will serve only to irritate and annoy the +patient, and often greatly to increase the nervous excitement. Their +routine use or over-use constitutes one of the defects of the system of +massage as usually practised by the Swedish operators; and when patients +tell me, as many do, that "they cannot stand massage," it is often found +that the performance of a great deal of this useless and fretting +manipulation has constituted a great part of the treatment, and that +deep, thorough, quiet kneading can be perfectly borne. + +A few precautions are necessary to observe. The grasping hand should +carry the skin with it, not slip over the skin, as the drag thus put +upon the hairs will, if daily repeated, cause troublesome boils. The use +of a lubricant avoids this, and is a favorite device of unskilful +manipulators. It also does away with much of the good effected by +skin-friction, is uncleanly, very annoying to many patients, promotes an +unsightly growth of hair, and should be avoided except where it is +desired to rub into the system some oleaginous material. There are +exceptional cases where a very dry, harsh skin or a tendency to +excessive sweating during massage makes the use of some unguent +desirable. Cocoa-oil may be used, or what is perhaps more agreeable, +lanolin softened to the consistency of very thick cream by the addition +of oil of sweet almonds. As little as possible should be made to serve. + +Too much care cannot be used to cover with stockings and warm wraps the +parts after in turn they have been subjected to massage. As to time, at +first the massage should last half an hour, but should be increased in a +week to a full hour. I observe that Dr. Playfair has it used twice a day +or more, and I have since had it so employed in some cases, letting the +masseuse come before noon, and allowing the nurse to use it at night if +it does not interfere with sleep, which is a matter to be tested solely +by experiment. Commonly, one hour once daily suffices. I was at one time +in the habit of suspending the use of both massage and electricity +during menstruation, because I found occasionally that these agents +disturbed or checked the normal flow. Of late, however, I continue to +employ both agents, but confine them to the limbs. I have met with rare +cases in which almost any massage gave rise to a uterine hemorrhage, and +in which the utmost caution became necessary. + +Women who have a sensitive abdominal surface or ovarian tenderness have +of course to be handled with care, but in a few days a practised rubber +will by degrees intrude upon the tender regions, and will end by +kneading them with all desirable force. The same remarks apply to the +spine when it is hurt by a touch; and it is very rare indeed to find +persons whose irritable spots cannot at last be rubbed and kneaded to +their permanent profit. + +Sometimes when the patient is found to be much exhausted by massage, it +is well to give some stimulating concentrated food afterwards; +occasionally it may be necessary both before and after. In this case it +would be well to see that the rubbing was not being made too severe. + +Very rarely I find a patient to whom all massage is so disagreeable or +produces such annoying nervousness as to make manipulation impossible; +sometimes, though very rarely, massage, especially frictional movements, +causes sexual excitement when applied in the neighborhood of the genital +organs, or even on the buttocks and lower spine, and this may occur in +either sane or insane patients: if the rubber observe any signs of this, +it will of course be best to avoid handling the areas which are thus +sensitive. + +Another complaint sometimes made is of chilliness after treatment, and +especially of cold feet. If this is not lessened after a few days, the +lower extremities may be rubbed last instead of first, or as is now and +then useful, the whole order of massage may be changed so as to begin +with the abdomen, chest, and upper extremities and conclude with the +back and legs.[17] + +Beginning with half an hour and gradually increasing to about an hour (a +little more for very large or very fat people,--a little less for the +small or thin) the daily massage is kept up through at least six weeks, +and then if everything seems to be going along well, I direct the rubber +or nurse to spend half of the hour in exercising the limbs as a +preparation for walking. This is done after the Swedish plan, by making +very slowly passive and extreme extensions and flexions of the limbs for +a few days, then assisted movements, next active unassisted movements, +and last active movements gently resisted by nurse or masseuse. When the +patient is able to sit and stand, it is well to keep up and extend the +number of these gentle gymnastic acts and to encourage the patient to +make them habitual, or at least to keep them up for many months after +the conclusion of treatment.[18] + +At the seventh week massage is used on alternate days, and is commonly +laid aside when the patient gets up and begins to move about. + +In 1877, several of the members of the staff of the Infirmary for +Nervous Disease, and especially my colleague, Dr. Wharton Sinkler, +obliged me by studying with care the influence of massage on +temperature, and some very interesting results were obtained. In +general, when a highly hysterical person is rubbed, the legs are apt to +grow cold under the stimulation, and if this continues to be complained +of it is no very good omen of the ultimate success of the treatment. But +usually in a few days a change takes place, and the limbs all grow warm +when kneaded, as happens in most people from the beginning of the +treatment.[19] The extremely low temperature of the limbs of children +suffering with so-called essential paralysis is well known. I have +frequently seen these strangely cold parts rise, under an hour's +massage, six to ten degrees F. In such small limbs, the long contact of +a warm hand may account for at least a part of this notable rise in +temperature. In adults this can hardly be looked upon as a cause of the +rise of temperature produced by massage, first, because the long +exposure of large surfaces incident to the process is calculated to +lessen whatever increase of heat the contact of the hand may cause, and +secondly, because this rise is a very variable quantity, and because +occasionally some other and less comprehensible factors actually induce +a fall rather than a rise in the thermometer as a result of massage. + +In very nervous or hysterical women, ignorant of what the act of +kneading may be expected to bring about, and especially in such as are +thin and anĉmic and have either a somewhat high or an unusually low +normal temperature, we may find at first a slight fall of the +thermometer, then a fairly constant rise, with some irregularities, and +at last, as the health improves, a lessening effect or none at all. + +The most notable rise is to be found in persons who, owing to some +organic disease, have acquired liability to great changes of +temperature. + +It is impossible to observe the increase of heat which follows both +massage and electricity without inferring that these agents must for a +time, like exercise and other tonics, increase the tissue-waste by the +stimulus they cause of the general and interstitial circulations, and by +the direct influence they seem to have on the tissues themselves. I have +sought to study this matter carefully by placing patients on a fixed and +competent diet of milk alone, and by estimating the waste of tissues as +shown in the secretions before and after the use of massage. This study, +although it was never completed in a satisfactory manner, would seem to +show that massage does not much alter the total elimination of the +entire day, but causes a large and abrupt increase within three hours, +followed by a compensatory decline.[20] + +I add a number of tables, which very well illustrate the facts above +stated as to rise of temperature. + +Mrs. J., at rest, on the usual diet. Manipulation at 11, daily: + +Before Massage. After Massage. + +100 100 + +100 100-1/5 + +99-2/5 99-4/5 + +99-4/5 100 + +99-2/5 100 + +100 100 + +99-4/5 100 + +99-4/5 100 + +Miss P., ĉt. 24, hysteria: + +Before Massage. After Massage. + +99-1/4 99-1/4 + +98-1/4 99 + +98-1/2 99 + +98-1/4 99 + +98-1/4 98-1/4 + +99 99-3/4 + +100-1/5 100-2/5 + +100-2/5 101-2/5 + +100-2/5 100-3/5 + +100-3/5 100 + +Mrs. L., a very thin, feeble, and bloodless woman, ĉt. 29 years: + +Before Massage. After Massage. + +99 100 + +98-1/2 99-1/5 + +98 98-2/5 + +99 100 + +98-2/5 98-4/5 + +99 99-4/5 + +100 100-1/5 + +99 99-4/5 + +Mrs. P., ĉt. 31, feeble and anĉmic, nervous, slight albuminuria and +chronic bronchitis. Liable to fever. 3 P.M.: + +Before Massage. After Massage. + +101-3/5 102 + +100 100-4/5 + +99 99-4/5 + +100 101 + +99-2/5 100-1/5 + +99-4/5 100-3/5 + +100-3/5 101-3/5 + +100-2/5 99-4/5 + +100-3/5 100-2/5 + +100-3/10 100-9/10 + +99-1/5 99-4/5 + +These temperatures were taken always before 4 P.M., and at intervals of +three days. Her morning temperature was usually 99° to 99-4/5°, and in +the evening, 9 to 10 o'clock, it always rose to 100°, 101°, and at times +to 102°. + +As I have said already, there are persons who, under circumstances +seemingly alike, have from massage a large rise of temperature, and +others who experience none. I give a single case of what is rare but not +exceptional,--an almost constant fall of temperature. + +Miss N., ĉt. 21, hysteria, good condition: + +Before Massage. After Massage. + + 98 97-3/5 + + 98-1/2 98-1/2 + + 98 98 + + 98-2/5 98 + + 98-4/5 98 + +These facts are, of course, extremely interesting; but it is well to add +that the success of the treatment is not indicated in any constant way +by the thermal changes, which are neither so steady nor so remarkable as +those caused by electricity. + +If now we ask ourselves why massage does good in cases of absolute rest, +the answer--at least a partial answer--is not difficult. The secretions +of the skin are stimulated by the treatment of that tissue, and it is +visibly flushed, as it ought to be, from time to time, by ordinary +active exercise. Under massage the flabby muscles acquire a certain +firmness, which at first lasts only for a few minutes, but which after a +time is more enduring and ends by becoming permanent. The firm grasp of +the manipulator's hand stimulates the muscle, and, if sudden, may cause +it to contract sensibly, which, however, is not usually desirable or +agreeable. The muscles are by these means exercised without the use of +volitional exertion or the aid of the nervous centres, and at the same +time the alternate grasp and relaxation of the manipulator's hands +squeezes out the blood and allows it to flow back anew, thus healthfully +exciting the vessels and increasing mechanically the flow of blood to +the tissues which they feed. It is possible also that a real increase in +the production of red corpuscles is brought about by repeated +applications of massage, as will be seen later on. + +The visible results as regards the surface-circulation are sufficiently +obvious, and most remarkably so in persons who, besides being anĉmic and +thin, have been long unused to exercise. After a few treatments the +nails become pink, the veins show where before none were to be seen, +the larger vessels grow fuller, and the whole tint of the body changes +for the better. + +In like manner the sore places which previously existed, or which were +brought into sensitive prominence by the manipulation, by degrees cease +to be felt, and a general sensation of comfort and ease follows the +later treatments. + +Although this plan of acting on the muscles seems to dispense with any +demands upon the centres, it is not to be supposed that it is altogether +without influence on these parts. In fact, extreme use of massage +occasionally flushes the face and causes sense of fulness in the head or +ache in the back. The actual large increase in the number of corpuscles +in the circulation brought about by massage may be one of the reasons +for this. We have added, perhaps, millions of cells to the number in the +vessels in a very short time, and need not be astonished if some signs +of plethora follow. Moreover, in some spinal maladies it has effects not +to be altogether explained by its mechanical stimulation of the muscles, +nerves, and skin. + +That the deep circulation shares in the changes which are so obvious in +the superficial vessels has been shown by various observers of +experimental and clinical facts. Firm deep muscle-kneading of the +general surface will almost always slow and strengthen the pulse. If the +abdomen alone is thoroughly rubbed the same effect appears in the pulse, +but less in degree, and massage of the abdomen has also a distinct +effect in increasing the flow of urine, a fact worth remembering in +cases of heart-disease. In a case of albuminuria from exercise, W.W. +Keen has shown that massage did not cause the return of the albumin +after rest, though exercise did, a difference due to the opposite +effects upon blood-pressure of the two forms of activity. Lauder-Brunton +has shown that more blood passes through a masséed part after treatment. +Dr. Eccles and Dr. Douglas Graham both found a decided decrease in the +circumference of a limb after massage, showing how completely the veins +must have been emptied, for the time at least,--an emptying which would +surely be followed by an increased flow of arterial blood into the +treated region. Dr. J.K. Mitchell, in 1894,[21] made a large number of +examinations of the blood before and after massage, some in patients +under treatment for a variety of disorders affecting the integrity of +the blood, and a few in perfectly healthy men. With scarcely an +exception there was a large increase in the number of corpuscles in a +cubic millimetre, and an increase, though of less extent, in the +hĉmoglobin-content. Studies made at various intervals after treatment +showed that the increase was greatest at the end of about an hour, after +which it slowly decreased again; but this decrease was postponed longer +and longer when the manipulation was continued regularly as a daily +measure.[22] The author's conclusions from these examinations were +interesting, and I quote them somewhat fully. The fact that the +hĉmoglobin is less decidedly increased than the corpuscular elements +makes it seem at least probable that what happens is, that in all the +conditions in which anĉmia is a feature there are globules which are not +doing their duty, but which are called out by the necessities of +increased circulatory activity brought about by massage. If this is the +first effect, yet as it is observed that the increase of corpuscles, at +first passing, soon becomes permanent, we must conclude that massage has +the ultimate effect of stimulating the production of red corpuscles. + +One sometimes hears doubts expressed whether a patient with a high-grade +anĉmia is not "too feeble for such strong treatment" as massage. This +study of one of the ways in which massage affects such cases may fairly +be taken as proof of the certainty and safety of its effect on them, +provided always it be done properly and with intelligence. Some check +upon this may be had, as is said elsewhere, by the general effect upon +the patient. It may be repeated that the pulse should be slower and +stronger after an hour of deep massage, and that this effect will not be +produced by superficial rubbing (indeed, with light or too rapid +manipulation the pulse may become both less strong and more rapid), and +finally the flow of urine should be increased. With these easily +observed facts to aid, it may readily be judged whether massage is being +rightly applied or not without the need of a visit from the physician +during the hour of treatment. A final test might readily be made by +examination of the blood and counting the red corpuscles before and +after treatment. No doubt in very bad cases a small increase or none +would be found at first, but a week of daily manipulation should show a +distinct addition to the blood count. A striking instance in which this +examination was repeatedly made is related on p. 184. + +"It is evident that our present definitions of anĉmia are insufficient. +An essential part of the description in all of them is that there are +defects of number, of color, or of both in the blood. This is not +necessarily or always true. The fault may lie in a lack of activity or +of availability in the corpuscles. The state of things in the system may +be like the want of circulating money during times of panic, when gold +is hoarded and not made use of, and interference with commerce and +manufactures results. + +"Neither an anĉmic appearance nor a blood-count is alone enough for a +certain diagnosis. Other signs must be used as a check on the blood +examination for the establishment of the existence of anĉmia. For +instance, many cases here recorded had full normal or even supra-normal +corpuscle-count, with a good percentage of hĉmoglobin. Yet they +presented every external sign of poverty of blood: pallor of skin and, +more important still, of mucous membranes, cold extremities, anorexia, +indigestion, dyspnoea on trifling exertion. In such cases we must suppose +either that the total volume of the blood is reduced, or that the +usefulness of the corpuscles is in some way impaired, or that both these +troubles exist together."[23] + +I have said above that the face was not touched in the course of the +rubbing. There are cases, however, in which massage of the head and face +may be usefully practised. Some obstinate neuralgias are helped by it +temporarily, and very often it is of use with other means to aid in a +permanent cure. Many headaches of a passing character may be dissipated +promptly by careful massage of the head or by downward stroking over the +jugular veins at the sides of the neck to lessen the flow of blood into +the cerebral vessels, where the pain is due to congestion or distention, +and careful manipulation of the facial muscles in paralysis is of +service in restoring loss of tone and improving their nutrition. It is +worth adding here, as women patients frequently say that during their +illness the hair has become thin or shown a great tendency to fall, that +daily firm finger-tip massage of the head for ten or twelve minutes, +followed by rubbing into the scalp of a small amount of a tonic, either +a bland oil or if need be of some more stimulating material, will in a +great majority of the instances where loss of hair is due to general +ill-health perfectly restore its vigor and even its color. + +I am accustomed to pay a good deal of attention to the observations made +on these and other points by practised manipulators, and I find that +their daily familiarity with every detail of the color, warmth, and +firmness of the tissues is of great use to me. + +A great deal of nonsense is talked and written as to the use and the +usefulness of massage. The "professional rubber" not unnaturally makes a +mystery of it, and patients talk foolishly about "magnetism" and +"electricity;" but what is needed is a strong, warm, soft hand, directed +by ordinary intelligence and instructed by practice; and this is the +whole of the matter, except in the massage of such obscure conditions +as need full knowledge of the anatomical relations and physiological +functions of the parts to be rubbed. It is a fact that I have known +country physicians who, desiring to use massage and not having a +practitioner of it within reach, have themselves trained persons to do +it, with considerable resultant success. + +It is not, perhaps, putting it too strongly to say that bad massage is +better than none in those cases in which manipulation is needed. Very +little harm can result from its use even by unskilled hands, provided +that reasonable intelligence direct them. + + + + +CHAPTER VII. + +ELECTRICITY. + + +Electricity is the second means which I have made use of for the purpose +of exercising muscles in persons at rest. It has also an additional +value, of which I shall presently speak. + +In order to exercise the muscles best and with the least amount of pain +and annoyance, we make use of an induction current, with interruptions +as slow as one in every two to five seconds, a rate readily obtained in +properly-constructed batteries.[24] This plan is sure to give painless +exercise, but it is less rapid and less complete as to the quality of +the exercise caused than the movements evolved by very rapid +interruptions. These, in the hands of a clever operator who knows his +anatomy well, are therefore, on the whole, more satisfactory, but they +require some experience to manage them so as not to shock and disgust +the patient by inflicting needless pain. The poles, covered with +absorbent cotton well wetted with salt water, which may be readily +changed, so as not to use the same material more than once, are placed +on each muscle in turn, and kept about four inches apart. They are moved +fast enough to allow of the muscles being well contracted, which is +easily managed, and with sufficient speed, if the assistant be +thoroughly acquainted with the points of Ziemssen. The smaller electrode +should cover the motor-point and the larger be used upon an indifferent +area. After the legs are treated, the muscles of the belly and back and +loins are gone over systematically, and finally those of the chest and +arms. The face and neck are neglected. About forty minutes to an hour +are needed; but at first a less time is employed. The general result is +to exercise in turn all the external muscles.[25] + +No such obvious and visible results are seen as we observe after +massage, but the thermal changes are much more constant and remarkable, +and show at least that we are not dealing with an agent which merely +amuses the patient or acts alone through some mysterious influence on +the mental status. + +A half-hour's treatment of the muscles commonly gives rise to a marked +elevation of temperature, which fades away within an hour or two. This +effect is, like that from massage, most notable in persons liable to +fever from some organic trouble, and it varies as to its degree in +individuals who have no such disease. + +The first case, Miss B., ĉt. 20, is an example of tubercular disease of +the apex of the right lung. She had a morning temperature of 98-1/2° to +99-1/2°, and an evening temperature of 100° to 102°. + +Electricity was used about 11 o'clock daily, with these results: + + Before Electricity. After Electricity. + +November 25 99 99-3/5 + " 27 97-3/5 100 + " 28 98 99 + " 29 98-4/5 99-4/5 + +December 2 100-1/5 101-3/5 + " 4 99-1/5 100-1/5 + " 5 99-2/5 99-1/5 + +Mrs. R., ĉt. 40, the next case, was merely a rather anĉmic, feeble, and +thin woman, who for years had not been able to endure any prolonged +effort. She got well under the general treatment, gaining thirteen +pounds on a weight of ninety-eight pounds, her height being five feet +and one inch. The facts as to rise of temperature are most remarkable, +and, I need not say, were carefully observed. + +Temperature taken in the mouth while at rest in bed. + + Before Electricity. After Electricity. + +April 2 98-2/5 98-4/5 + " 3 98-1/5 98-2/5 + " 4 98-1/5 98-2/5 + " 5 98 98-3/5 + " 6 97-9/10 98-7/10 + " 7 98 98-5/10 + " 8 98 98-3/5 + " 9 98 98-1/10 + " 10 98-2/5 98-3/5 + " 11 98-5/10 98-7/10 + " 12 98-3/5 99-1/10 + " 13 98-1/5 99-5/10 + " 14 98-2/5 99-1/5 + " 16 98-4/10 99-1/10 + " 17 98-5/10 99-2/10 + " 18 98-7/10 99-1/10 One hour later, 99-1/10 + " 19 98-9/10 99-3/10 " " " , 98-4/5 + + Before Electricity. After Electricity. + +April 20 99 99-1/10 + + " 21 98-9/10 99-2/10 + Menstrual period. + + " 30 98-3/5 98-3/5 + +May 1 98 98-5/10 + + " 2 98 98-3/10 + +The third case, Miss M., ĉt. 33, was that of a pallid woman, the +daughter of a well-known physician in the South. She suffered for six +years with "nervous exhaustion," headaches, pain in the back, intense +depression of spirits, nausea, and repeated attacks of hysteria. She +slept only under anodynes, and used stimulants freely. Under the use of +rest and the adjuvant treatment described, Miss M. made a thorough +recovery, and was restored to useful active life. + +Miss M. Thermometer held in mouth. + + Before Electricity. After Electricity. + +May 14 99-1/10 99-1/10 } Menstruating; general + } faradization only. + " 15 99 99-1/5 } + + " 16 99-1/5 99-1/5 Gen'l faradization and limbs. + + " 17 98-4/5 99-1/5 + + " 18 98-4/5 99-1/5 + + " 19 98-1/5 98-4/5 + + " 21 98-3/5 99 + + " 22 98-4/5 99-1/10 + + Before Electricity. After Electricity. + +May 25 98-1/10 98-4/10 + + " 26 98-1/10 99-1/10 + + " 29 98-3/5 99 + + " 30 98-5/10 99-1/10 + + " 31 98-9/10 99-1/10 + +Mrs. P., ĉt. 38, was a rather nervous woman, easily tired, but not +anĉmic and not very thin. She improved greatly under the treatment. + + Before Electricity. After Electricity. + +January 27 98-3/5 99-1/5 Thermometer in axilla ten + + " 29 98-2/5 99-1/5 minutes before and after. + + " 30 99-1/5 99-3/5 + + " 31 98-4/5 99-2/5 + +February 1 99 99-2/5 + Menstrual period. + +February 8 98-2/5 99-1/5 + + " 9 98-3/5 99 + + " 10 98-2/5 99 + + " 12 98-1/5 99-3/5 + + " 13 98-2/5 99 + + " 14 98-2/5 98-3/5 + + " 15 98-2/5 98-4/5 + + " 19 99 98-2/5 + + " 20 98 99 + + " 23 98-3/5 99-4/5 Thermometer in mouth five + + " 24 99 99-2/5 minutes before and after. + + " 27 99-1/5 99-3/5 + + " 28 98-4/5 99-4/5 + Menstrual period. + +Menstrual period. + + Before Electricity. After Electricity. + +March 13 99 99-2/5 + + " 14 98-4/5 98-4/5 + + " 15 99 99-1/5 + +Miss R., ĉt. 27, was a fair case of hysterical conditions; over-use of +chloral and bromides; anorexia and loss of flesh and color. + +Thermometer in mouth. + + Before Electricity. After Electricity. + +May 15 100 100 } + } General faradization + " 16 100 100 } for fifteen minutes. + } + " 17 100-1/5 100-2/5 } + + " 18 98-2/5 98-3/5 } General faradization, + } fifteen minutes, also of + " 19 99-4/5 100-1/10 } arm muscles, twenty minutes. + +May 20 100-1/10 100 + General faradization, ten + " 22 99-2/5 99-3/5 minutes; arms and legs + twenty minutes. + " 26 99-1/10 99-2/10 + + " 27 99-3/10 99-4/10 + + " 28 99-2/5 99-2/5 + + " 29 99-3/10 99-3/10 + + " 30 99-1/10 99-4/10 + + " 31 99-1/10 99-2/10 + +June 2 99-3/5 99-4/5 + + " 4 99-5/10 99-6/10 + + " 6 99-3/10 99-5/10 + + " 7 99-3/10 99-5/10 + +I have given these full details because I have not seen elsewhere any +statement of the rather remarkable phenomena which they exemplify. It +may be that a part at least of the thermal change is due to the muscular +action, although this seems hardly competent to account for any large +share in the alteration of temperature, and we must look further to +explain it fully. No mental excitement can be called upon as a cause, +since it continues after the patient is perfectly accustomed to the +process. I should add, also, that in most cases the subject of the +experiment was kept in ignorance of the fact that a rise of the +thermometer was to be expected. Is it not possible that the current even +of an induction battery has the power so to stimulate the tissues as to +cause an increase in the ordinary rate of disintegrative change? Perhaps +a careful study of the secretions might lend force to this suggestion. +That the muscular action produced by the battery is not essential to the +increase of bodily heat is shown by the next set of facts to which I +desire to call attention. + +Some years ago, Messrs. Beard and Rockwell stated that when an induced +current is used for fifteen to thirty minutes daily, one pole on the +neck and one on either foot, or alternately on both, the persistent use +of this form of treatment is decidedly tonic in its influence. I believe +that in this opinion they were perfectly correct, and I am now able to +show that, when thus employed, the induced current causes also a decided +rise of temperature in many people, which proves at least that it is in +some way an active agent, capable of positively influencing the +nutritive changes of the body. + +The rise of temperature thus caused is less constant, as well as less +marked, than that occasioned by the muscle treatment. I do not think it +necessary to give the tables in full. They show in the best cases, rises +of one-fifth to four-fifths of a degree F., and were taken with the +utmost care to exclude all possible causes of error. + +The mode of treatment is as follows: At the close of the +muscle-electrization one pole is placed on the nape of the neck and one +on a foot for fifteen minutes. Then the foot pole is shifted to the +other foot and left for the same length of time. + +The primary current is used, as being less painful, and the +interruptions are made as rapid as possible, while the cylinder or +control wires are adjusted so as to give a current which is not +uncomfortable. + +It is desirable to have electricity used by a practised hand, but of +late I have found that intelligent nurses may suffice, and this, of +course, materially lessens the cost. In very timid or nervous people, or +those who at some time have been severely "shocked" by the application +of electricity in the hands of charlatans, it is common to find the +patient greatly dreading a return to its use. In this case, if the +battery be started and the poles moved about on the surface as usual, +but without any connection being made, one of two things will +happen,--either the patient will naturally find it very mild, and will +submit fearlessly to a gentle and increasing treatment, or else her +apprehensions will so dominate her as to cause her to complain of the +effects as exciting or tiring her, or as spoiling her sleep. A few words +of kindly explanation will suffice to show her how much expectation has +to do with the apparent results, and she will be found, if the matter be +managed with tact, to have learned a lesson of wide usefulness +throughout her treatment. + +However, there are occasional, though very rare, cases in which it is +impossible to use faradism at all by reason of the insomnia and +nervousness which result even after very careful and gentle application +of the current. On the other hand, some patients find the effect of the +electric application so soothing as to promote sleep, and will ask to +have it repeated or regularly given in the evening. + +I have been asked very often if all the means here described be +necessary, and I have been criticised by some of the reviewers of my +first edition because I had not pointed out the relative needfulness of +the various agencies employed. In fact, I have made very numerous +clinical studies of cases, in some of which I used rest, seclusion, and +massage, and in others rest, seclusion, and electricity. It is, of +course, difficult, I may say impossible, to state in any numerical +manner the reason for my conclusion in favor of the conjoined use of all +these means. If one is to be left out, I have no hesitation in saying +that it should be electricity. + + + + +CHAPTER VIII. + +DIETETICS AND THERAPEUTICS. + + +The somewhat wearisome and minute details I have given as to seclusion, +rest, massage, and electricity have prepared the way for a discussion of +the dietetic and medicinal treatment which without them would be neither +possible nor useful. + +As to diet, we have to be guided somewhat by the previous condition and +history of the patient. + +It is difficult to treat any of these cases without a resort at some +time more or less to the use of milk. In most dyspeptic cases--and few +neurasthenic women fail to be obstinately dyspeptic--milk given at the +outset, and given alone by Karell's method for a fortnight or less, +enormously simplifies our treatment. Even after that, milk is the best +and most easily managed addition to a general diet. As to its use with +rest and massage as an exclusive diet in obesity alone or in extreme +fatness with anĉmia, I spoke in a former edition with a confidence +which has been increased by the added experience of physicians on both +sides of the Atlantic. Finally, there are exceptional cases of +intestinal pain of obscure parentage or seemingly neuralgic, of +dyspepsia incorrigible by other treatments, which, having resulted in +grave general defects of nutrition, are best treated by several weeks of +milk diet, combined with rest, massage, and electricity. Milk, +therefore, must be so much used in these cases in connection with the +general treatment I am describing that it is perhaps as well to say more +clearly how it is to be employed when given alone or with other food. I +am the more willing to do this because I have learned certain facts as +to the effects of milk diet which have, I believe, hitherto escaped +observation. In fact, the study of the therapeutic influence and full +results of exclusive diets is yet to be made; nor can I but believe that +accurate dietetics will come to be a far more useful part of our means +of managing certain cases than as yet seems possible. + +We are indebted chiefly to Dr. Karell, of St. Petersburg, for our +knowledge of the value of milk as an exclusive diet, and to Dr. Donkin +for the extension of Karell's treatment to diabetes. I shall formulate +as curtly as possible the rules to be followed in using milk as an +exclusive diet in dyspeptic states, and in anĉmia with obesity, and in +the latter state uncomplicated by defective hĉmic conditions. + +For fuller statements as to the reasons for the various rules to be +observed in using milk, I must refer the reader to Karell's paper and to +Donkin's book. + +Have the utmost care used as to preservation of the milk employed, and +as to the perfect cleansing of all vessels in which it is kept. Use +well-skimmed milk, as fresh as can be had, and, if possible, let it be +obtained from the cow twice a day. Or if this is not possible, or where +any doubt exists as to the condition of the milk, or any difficulty is +experienced in keeping it fresh, it may be pasteurized as soon as +received by heating it to 160°, keeping it some minutes at this point, +and at once chilling on ice. For this purpose it is best to have the +milk in bottles, and to heat by immersing the bottles in a water-bath. +For longer preservation, as, for example, when travelling, sterilizing +may be more thoroughly done by greater heat and lengthened immersion. +Still, these should be expedients for use only when milk cannot be +secured fresh and in good order, as it is more than doubtful if the milk +is so well borne when it has been altered by these processes. + +For ordinary daily use it might be better to let all the milk for the +day be peptonized in the morning with pancreatic extract, to the extent +which is found to be agreeable to the patient's taste, and then preserve +it by placing it upon ice. In this way milk may be kept for several +days. Then, too, it has been found that where even skimmed milk upsets +the stomach of patients, milk prepared in this manner can be taken +without trouble. In peptonizing, the directions which accompany the +powders to be used for that purpose should be followed carefully. It is +to be remembered that if the patient desires to take the milk warm, the +process of conversion into peptones, which has been stopped by the cold, +will be promptly started again when the fluid is warmed, and then a very +few minutes will suffice to make it disagreeably bitter. At first the +skimming should be thorough, and for the treatment of dyspepsia or +albuminuria the milk must be as creamless as possible. The milk of the +common cow is, for our purposes, preferable to that of the Alderney. It +may be used warm or cold, but, except in rare cases of diarrhoea, should +not be boiled. + +It ought to be given at least every two hours at first, in quantities +not to exceed four ounces, and as the amount taken is enlarged, the +periods between may be lengthened, but not beyond three hours during the +waking day, the last dose to be used at bedtime or near it. If the +patient be wakeful, a glass should be left within reach at night, and +always its use should be resumed as early as possible in the morning. A +little lime-water may be added to the night milk, to preserve it sweet, +and it should be kept covered. + +The milk given during the day should be taken at set times, and very +slowly sipped in mouthfuls; and this is an important rule in many cases. +Where it is so disagreeable as to cause great disgust or nausea, the +addition of enough of tea or coffee or caramel or salt to merely flavor +it may enable us to make its use bearable, and we may by degrees abandon +these aids. Another plan, rarely needed, is to use milk with the general +diet and lessen the latter until only milk is employed. If these rules +be followed, it is rare to find milk causing trouble; but if its use +give rise to acidity, the addition of alkalies or lime-water may help +us, or these may be used and the milk scalded by adding a fourth of +boiling water to the milk, which has been previously put in a warm +glass. Some patients digest it best when it has the addition of a +teaspoonful of barley-or rice-water to each ounce, the main object being +to prevent the formation of large, firm clots in the stomach,--an end +which may also be attained by the addition at the moment of drinking of +a little carbonated water from a siphon. For the sake of variety, +buttermilk may be substituted for a portion of the fresh milk, and +though less nourishing it has the advantage of being mildly laxative. + +When used as an exclusive diet, skimmed milk gives rise to certain very +interesting and what I might call normal symptoms. Since at first we can +rarely give enough to sustain the functions, for several days the +patient is apt to lose weight, which is another reason why exercise is +in such cases undesirable. This loss soon ceases, and in the end there +is usually a gain, while in most rest cases an exclusive milk diet may +be dispensed with after a week. Where milk is taken alone for weeks or +months, it is common enough to observe a large increase in bodily +weight. I have seen several times active men, even laboring men, live +for long periods on milk, with no loss of weight; but large quantities +have to be used,--two and a half to three gallons daily. A gentleman, a +diabetic, was under my observation for fifteen years, during the whole +of which time he took no other food but milk and carried on a large and +prosperous business. Milk may, therefore, be safely asserted to be a +sufficient food in itself, even for an adult, if only enough of it be +taken. + +During the first week or two, exclusive milk diet gives rise to a marked +sense of sleepiness. It causes nearly always, and even for weeks of its +use, a white and thick fur on the tongue, and often for a time an +unpleasant sweetish taste in the early morning, neither of which need be +regarded. Intense constipation and yellowish stools of a peculiar odor +are usual. Of the former I shall speak in connection with the use of +milk in special cases. The influence of milk on the urinary secretion is +more remarkable, and has not been as yet fully studied. + +There is, of course, a large flow of urine; and in dropsical cases due +to renal maladies this may exceed the ingested fluid and carry away very +rapidly the dropsical accumulations. It is sometimes annoying to nervous +persons because of the frequent micturition it makes necessary. I have +discovered that while skimmed milk alone is being taken, uric acid +usually disappears almost entirely from the urine, so that it is +difficult to discover even a trace of this substance; nor does it seem +to return so long as nothing but creamless milk is used. Almost any +large addition of other food, but especially of meat, enables us to find +it again. Creatine and creatinine also seem to lessen in amount, but of +the extent of this change I am not as yet fully informed. + +A yet more singular alteration occurs as to the pigments. If after a +fortnight or less of exclusive milk diet we fill with the urine a long +test-tube, and, placing it beside a similar tube of the ordinary urine +of an adult, look down into the two tubes, we shall observe that the +milk urine has a singular greenish tint, which once seen cannot again be +mistaken. If we put some of this urine in a test-tube carefully upon hot +nitric acid, there is noticed none of the usual brown hue of oxidized +pigment at the plane of contact. In fact, it is often difficult to see +where the two fluids meet. + +The precise nature of this greenish-yellow pigment has not, I believe, +been made out; but it seems clear that during a diet of milk the +ordinary pigments of the urine disappear or are singularly modified. A +single meal of meat will at once cause their return for a time. + +These results have been carefully re-examined at my request by Dr. +Marshall in the Laboratory of the University of Pennsylvania, and his +results and my own have been found to accord; while he has also +discovered that during the use of milk the substances which give rise to +the ordinary fĉcal odors disappear, and are replaced by others the +nature of which is not as yet fully comprehended. The changes I have +here pointed out are remarkable indications of the vast alterations in +assimilation and in the destruction of tissues which seem to take place +under the influence of this peculiar diet. Some of them may account for +its undoubted value in lithĉmic or gouty states; but, at all events, +they point to the need for a more exhaustive study both of this and of +other methods of exclusive diet. + +As regards milk, enough has here been said to act as a guide in its +practical use in the class of cases with which we are now concerned; but +I may add that it is sometimes useful, as the case progresses, to employ +in place of milk, or with it, some one of the various "children's +foods," such as Nestle's food, or malted milk. + +Before dealing with the treatment of the anĉmic and feeble and more or +less wasted invalids who require treatment by rest and its concomitant +aids, I desire to say a few words as to the use of rest, milk dietetics, +and massage in people who are merely cumbrously loaded with adipose +tissues, and also in the very small class of anĉmic women who are +excessively fat and may or may not be hysterical, but are apt to be +feeble and otherwise wretched. + +Karell has pointed out that on creamless milk diet fat people lose +flesh; and this is true; so that sometimes this mode of lessening weight +succeeds very well. But it does not always answer, because, as in +Banting, loss of weight is apt to be accompanied with loss of strength, +so that in some cases the results are disastrous, or at least alarming. +I do not know that this is ever the case if the directions of Mr. +Harvey[26] are followed with care and the weight very deliberately +lessened. But for this few people have the patience; and, even if they +can be induced to follow out a strict diet, it is often useful to be +able to cut off very rapidly a large amount of weight, and so shorten +the period of strict regimen, or at least put over-fat persons in a +condition to exercise with a freedom which had become difficult, and +thus to provide them with a healthful means of preventing an +accumulation of adipose matter. This can be done rapidly and with safety +by the following means. The person whose weight we decide to lessen is +placed on skimmed milk alone, with the usual precautions; or at once we +give skimmed milk with the usual food, and in a week put aside all other +diet save milk and all other fluids. When we find what quantity of milk +will sustain the weight, we diminish the amount by degrees until the +patient is losing a half-pound of weight each day, or less or more, as +seems to be well borne. Meanwhile, during the first week or two rest in +bed is enjoined, and later for a varying period rest in bed or on a +lounge is insisted upon, while at the same time massage is used once or +twice a day, and later in the case Swedish movements. At the same time, +the pulse and weight are observed with care, so that if there be too +rapid loss, or any sign of feebleness, the diet may be increased. In +many such cases I allow daily a moderate amount of beef- or chicken- or +oyster-soup,--more as a relief to the unpleasantness of a milk diet than +for any other reason. + +When the weight has been sufficiently lowered, we add to the diet beef, +mutton, oysters, etc., and finally arrange a full diet list to include +but a moderate amount of hydro-carbons. Meanwhile, the milk remains as a +large part of the food, and the active Swedish movements are still kept +up as a habit, the patient being directed by degrees to add the usual +forms of exercise. + +If we attempt to make so speedy a change in weight while the patient is +afoot, the loss is apt to be gravely felt; but with the precautions here +advised it is interesting and pleasant to see how great a reduction may +be made in a reasonable time without annoyance and with no obvious +result except a gain in health and comfort. + +Cases of anĉmia in women with excess of flesh have to be managed in a +somewhat similar fashion, but with the utmost care. In such persons we +have a loss of red blood-globules, perhaps lessened hĉmoglobin, weak +heart, rapid pulse, and general feebleness, with too much fat, but not, +or at least rarely, extreme obesity. The milder cases may profit by +iron, with rest and very vigorous massage, but in old cases of this +kind--they are, happily, rare--the best plan is to put the patient at +rest, to use massage, restrict the diet to skimmed milk, or to milk and +broths free from fat, and with them, when the weight has been +sufficiently lowered, to give iron freely, and by degrees a good general +diet, under which the globules rise in number, so that even with a new +gain in flesh there comes an equal gain in strength and comfort. The +massage must be very thoroughly done to be of service, and it is often +difficult to get operators to perform it properly, as the manipulation +of very fat people is excessively hard work. As to other details, the +management should be much the same as that which I shall presently +describe in connection with cases of another kind. + +I add two cases in illustration of the use of rest, milk, and massage +in the treatment of persons who are both anĉmic and overloaded with +fat. + +Mrs. P., ĉt. 45, weight one hundred and ninety pounds, height five feet +four and a half inches, had for some years been feeble, unable to walk +without panting, or to move rapidly even a few steps. Although always +stout, her great increase of flesh had followed an attack of typhoid +fever four years before. Her appearance was strikingly suggestive of +anĉmia. + +She was subject to constant attacks of acid dyspepsia, was said to be +unable to bear iron in any form, and had not menstruated for seven +months. She had no uterine disease, and was not pregnant. Two years +before I saw her she had been made very ill owing to an attempt to +reduce her flesh by too rapid Banting, and since then, although not a +gross or large eater, she had steadily gained in weight, and as steadily +in discomfort. + +She was kept in bed for five weeks. Massage was used at first once +daily, and after a fortnight twice a day, while milk was given, and in a +week made the exclusive diet. Her average of loss for thirty days was a +pound a day, and the diet was varied by the addition of broths after +the third week, so as to keep the reduction within safe limits. Her +pulse at first was 90 to 100 in the morning, and at night 80 to 95, her +temperature being always a half degree to a degree below the normal. At +the third week the latter was as is usual in health, and the pulse had +fallen to 80 in the morning, and 80 to 90 at night. + +After two weeks I gave her the lactate of iron every three hours in full +doses. In the fourth week additions were made to her diet-list, and +Swedish movements were added to the massage, which was applied but once +a day; and during the fifth week she began to sit up and move about. At +the seventh week her pulse was 70 to 80, her temperature natural, and +her blood-globules much increased in number. Her weight had now fallen +to one hundred and forty-five pounds, and her appearance had decidedly +improved. She left me after three and a half months, able to walk with +comfort three miles. She has lived, of course, with care ever since, but +writes me now, after two years, that she is a well and vigorous woman. +Her periodical flow came back five months after her treatment began, and +she has since had a child. + +Early in the spring of 1876, Mrs. C., ĉt. 40, came under my care with +partial hysterical paralysis of the right and hemi-anĉsthesia of the +left side. She had no power to feel pain or to distinguish heat from +cold in the left leg and arm, though the sense of touch was perfect. The +long strain of great mental suffering had left her in this state and +rendered her somewhat emotional. Her appetite was fair, but she was +strangely white, and weighed one hundred and sixty-three pounds, with a +height of five feet five inches. As she had had endless treatment by +iron, change of air, and the like, I did not care to repeat what had +already failed. She was therefore put at rest, and treated with milk, +slowly lessened in amount. Her stomach-troubles, which had been very +annoying, disappeared, and when the milk fell to three pints she began +to lose flesh. With a quart of milk a day she lost half a pound daily, +and in two weeks her weight fell to one hundred and forty pounds. She +was then placed on the full treatment which I shall hereafter describe. +The weight returned slowly, and with it she became quite ruddy, while +her flesh lost altogether its flabby character. I never saw a more +striking result. + +I have been careful to speak at length of these fat anĉmic cases, +because, while rare, they have been, to me at least, among the most +difficult to manage of all the curable anĉmias, and because with the +plan described I have been almost as successful as I could desire. + +Let us now suppose that we have to deal with a person of another and +different type,--one of the larger class of feeble, thin-blooded, +neurasthenic or hysterical women. Let us presume that every ordinary and +easily attainable means of relief has been utterly exhausted, for not +otherwise do I consider it reasonable to use so extreme a treatment as +the one we are now to consider. Inevitably, if it be a woman long ill +and long treated, we shall have to settle the question of uterine +therapeutics. A careful examination is made, and we learn that there is +decided displacement. In this case it is well to correct it at once and +to let the uterine treatment go on with the general treatment. If there +be bad lacerations of the womb or perineum, their surgical relief may +await a change in the general status of health,--say at the fourth or +fifth week. If there be only congestive or other morbid states of the +womb or ovaries, they are best left to be aided by the general gain in +health; but in this as in every other stage of this treatment it is +unwise, and undesirable therefore, to lay down too absolute laws. Having +satisfied ourselves as to these points, and that rest, etc., is needful, +we begin treatment, if possible, at the close of a menstrual period, +because usually the monthly flow is a time at which there is little or +no gain, and by starting our treatment when it is just over we save a +week of time in bed. + +The next step is, usually, to get her by degrees on a milk diet, which +has two advantages. It enables us to know precisely the amount of food +taken, and to regulate it easily; and it nearly always dismisses, as by +magic, all the dyspeptic conditions. If the case be an old one, I rarely +omit the milk; but, although I begin with three or four ounces every two +hours, I increase it in a few days up to two quarts, given in divided +doses every three hours. If a cup of coffee given without sugar on +awaking does not regulate the bowels, I add a small amount of watery +extract of aloes at bedtime; or if the constipation be obstinate, I give +thrice a day one-quarter of a grain of watery extract of aloes with two +grains of dried ox-gall. I find the simple milk diet a great aid +towards getting rid of chloral, bromides, and morphia, all of which I +usually am able to lay aside during the first week of treatment.[27] Nor +is it less easy with the same means to enable the patient to give up +stimulus; and I may add that in the treatment of the congested stomach +of the habitual hard drinker the milk treatment is of admirable +efficacy. As I have spoken over and over of the use of stimulus by +nervous women, I should be careful to explain that anything like great +excess on the part of women of the upper classes, in this country at +least, is, in my opinion, extremely rare, and that when I speak of the +habit of stimulation I mean only that nervous women are apt to be taught +to take wine or whiskey daily, to an extent that does not affect visibly +their appearance or demeanor. + +Meanwhile, the mechanical treatment is steadily pursued, and within +four days to a week, when the stomach has become comfortable, I order +the patient to take also a light breakfast. A day or two later she is +given a mutton-chop as a mid-day dinner, and again in a day or two she +has added bread-and-butter thrice a day; within ten days I am commonly +able to allow three full meals daily, as well as three or four pints of +milk, which are given at or after meals, in place of water. + +After ten days I order also two to four ounces of fluid malt extract +before each meal. The fluid malt extracts which now reach us from +Germany have become less trustworthy than they formerly were. Some of +them keep badly, and are uncertain in composition, one bottle being +good, another bad. The more constant, and at the same time most +agreeable, extracts are those now made in this country. Although their +diastasic powers are usually less than is claimed for them, and vary +greatly even in the best makes, they so far have seemed to me on the +whole more satisfactory than the imported malts. It is very desirable +that a thorough chemical study should be made of the various malt +extracts, solid and liquid. I am sure that some of them are defective +in composition, or vary notably as to the amount of alcohol they +contain. + +No troublesome symptoms usually result from this full feeding, and the +patient may be made to eat more largely by being fed by her attendant. +People who will eat very little if they feed themselves, often take a +large amount when fed by another; and, as I have said before, nothing is +more tiresome than for a patient flat on her back to cut up her food and +to use the fork or spoon. By the plan of feeding we thus gain doubly. + +As to the meals, I leave them to the patient's caprice, unless this is +too unreasonable; but I like to give butter largely, and have little +trouble in getting this most wholesome of fats taken in large amounts. A +cup of cocoa or of coffee with milk on waking in the morning is a good +preparation for the fatigue of the toilet. + +At the close of the first week I like to add one pound of beef, in the +form of raw soup. This is made by chopping up one pound of raw beef and +placing it in a bottle with one pint of water and five drops of strong +hydrochloric acid. This mixture stands on ice all night, and in the +morning the bottle is set in a pan of water at 110° F. and kept two +hours at about this temperature. It is then thrown on to a stout cloth +and strained until the mass which remains is nearly dry. The filtrate is +given in three portions daily. If the raw taste prove very +objectionable, the beef to be used is quickly roasted on one side, and +then the process is completed in the manner above described. The soup +thus made is for the most part raw, but has also the flavor of cooked +meat.[28] + +In difficult cases, especially those treated in cool weather, I +sometimes add, at the third week, one half-ounce of cod-liver oil, given +half an hour after each meal. If it lessen the appetite, or cause +nausea, I employ it thrice a day as a rectal injection; and in cases +where the large doses of iron used cause intense constipation, I find +the use of cod-oil enemata doubly valuable, by acting as a nutriment and +by disposing the bowels to act daily. This may be given as an emulsion +with pancreatic extract. This will suit some people well, and result in +a single passage daily, but in others may be annoying, and be either +badly retained or not retained at all, and may give rise to tenesmus. + +The question of stimulus is a grave one. In too many cases which come to +me, I have to give so much care to break off the use of all forms of +alcoholic drinks that I am loath to resort to them in any case, although +I am satisfied that a small amount is a help towards speedy increase of +fat. Its use is, therefore, a matter for careful judgment, and in +persons who have never taken it in excess, or as a habit, I prefer to +give, with the other treatment, a small daily ration of stimulus: an +ounce a day of whiskey in milk, or a glass of dry champagne or red wine, +seems to me useful as an adjuvant, and as increasing the capacity to +take food at meals. Nevertheless, alcohol is not essential, and for the +most part I give none, except the small amount--some four per +cent.--present in fluid malt extracts. Even this is found to excite +certain persons, and it is in such cases easy to substitute the thicker +extracts of malt, or the Japanese extract, made from barley and rice. + +So soon as my patient begins to take other food than milk, and +sometimes even before this, I like to give iron in large doses. In +hospital practice the old subcarbonate answers very well, being cheap, +and not unpalatable when shaken up in water or given in an effervescent +draught of carbonated waters. In private practice large doses of salts +of iron, as four to six grains of lactate at meal-time, are +satisfactory; but the form of iron is of less moment than the amount. + +Very often I meet with women who cannot take iron, either because it +disturbs the stomach, causes headache, or constipates, or else because +they have been told never to take iron. In the latter case I simply add +five grains of the pyrophosphate to each ounce of malt, and give it thus +for a month unknown to the patients. It is then easy to make clear to +them that iron is not so difficult to take as they had been led to +believe, and when it has ceased to disagree mentally I find that I am +able to fall back on the coarser method. If iron constipate, as it may +and does often do when used in these large doses, the trouble is to be +corrected by fruit, and especially pears, by the pill of the watery +extract of aloes and ox-gall already mentioned, by extracts of cascara +or of juglans cinerea, which may be added to the malt extract ordered +with the meals, or by enemata of oil, or oil and glycerin, or a glycerin +suppository. The instances in which iron gives headache and sense of +fulness are very rare when the patient is undergoing the full treatment +described, and, as a rule, I disregard all such complaints, and find +that after a time I cease to hear anything more of these symptoms. + +Unless some especial need arises, iron, in some form, is the only drug I +care to use until the patient begins to sit up, when I order nearly +always sulphate of strychnia, in rather full doses, thrice a day, with +iron and arsenic. + +Probably no physician will read the account I have here detailed of the +vast amount of food which I am enabled to give, not only with impunity +from dyspepsia, but with lasting advantage, without some sense of +wonder; and, for my own part, I can only say that I have watched again +and again with growing surprise some listless, feeble, white-blooded +creature learning by degrees to consume these large rations, and +gathering under their use flesh, color, and wholesomeness of mind and +body. It is needless to say that it is not in all cases easy to carry +out this treatment. + +When the full treatment has been reached, and kept up for a few days, I +begin to watch the urine with care, because if the patient be overfed +the renal secretion speedily betrays this result in the precipitation of +urates. When this occurs at all steadily, I usually give directions to +lessen the amount of food until the urine is again free from sediment. + +Nearly always at some time in the progress of the case there are attacks +of dyspepsia, when it suffices to cut down the diet one-half, or to give +milk alone for a day or two. Diarrhoea is more rare, and has to be met +in like manner; or, if obstinate, it may be requisite to give the milk +boiled. Occasionally the rapid increase of blood is shown by nasal +hemorrhage, which needs no especial treatment. + +Perhaps I shall make myself more clear if I now relate in full the +diet-list of some of my cases, and the mode of arranging it. + +I take the following case as an illustration from my note-book: + +Mrs. C., a New England woman, ĉt. 33, undertook, at the age of sixteen, +a severe course of mental labor, and within two years completed the +whole range of studies which, at the school she went to, were usually +spread over four years. An early marriage, three pregnancies, the last +two of which broke in upon the years of nursing, began at last to show +in loss of flesh and color. Meanwhile, she met with energy the +multiplied claims of a life full of sympathy for every form of trouble, +and, neglecting none of the duties of society or kinship, yet found time +for study and accomplishments. By and by she began to feel tired, and at +last gave way quite abruptly, ceased to menstruate five years before I +saw her, grew pale and feeble, and dropped in weight in six months from +one hundred and twenty-five pounds to ninety-five. Nature had at last +its revenge. Everything wearied her,--to eat, to drive, to read, to sew. +Walking became impossible, and, tied to her couch, she grew dyspeptic +and constipated. The asthenopia which is almost constantly seen in such +cases added to her trials, because reading had to be abandoned, and so +at last, despite unusual vigor of character, she gave way to utter +despair, and became at times emotional and morbid in her views of life. +After numberless forms of treatment had been used in vain, she came to +this city and passed into my care. + +At this time she could not walk more than a few steps without flushing +and without a sense of painful tire. Her morning temperature was 97.5° +F., and her white corpuscles were perhaps a third too numerous. After +most careful examination, I could find no disease of any one organ, and +I therefore advised a resort to the treatment by rest, with full +confidence in the result. + +In this single case I give the schedule of diet in full as a fair +example: + +Mrs. C. remained in bed in entire repose. She was fed, and rose only for +the purpose of relieving the bladder or the rectum. + +October 10.--Took one quart of milk in divided doses every two hours. + +11th.--A cup of coffee on rising, and two quarts of milk given in +divided portions every two hours. A pill of aloes every night, which +answered for a few days. + +12th to 15th.--Same diet. The dyspepsia by this time was relieved, and +she slept without her habitual dose of chloral. The pint of raw soup was +added in three portions on the 16th. + +17th and 18th.--Same diet. + +19th.--She took, on awaking at 7, coffee; at 7.30, a half-pint of milk; +and the same at 10 A.M., 12 M., 2, 4, 6, 8, and 10 P.M. The soup at 11, +5, and 9. + +23d.--She took for breakfast an egg and bread-and-butter; and two days +later (25th) dinner was added, and also iron. + +On the 28th this was the schedule: + +On waking, coffee at 7. At 8, iron and malt. Breakfast, a chop, +bread-and-butter; of milk, a tumbler and a half. At 11, soup. At 2, iron +and malt. Dinner, closing with milk, one or two tumblers. The dinner +consisted of anything she liked, and with it she took about six ounces +of burgundy or dry champagne. At 4, soup. At 7, malt, iron, +bread-and-butter, and usually some fruit, and commonly two glasses of +milk. At 9, soup; and at 10 her aloe pill. At 12 M., massage occupied an +hour. At 4.30 P.M., electricity was used for an hour in the manner which +I have described. + +This heavy diet-list, reached in a few days by a woman who had been +unable to digest with comfort the lightest meal, seemed certainly +surprising. I have not given in full the amount of food eaten at +meal-time. Small at first, it was increased rapidly owing to the +patient's growing appetite, and became in a few days three large meals. + +It is necessary to see the result in one of these successful cases in +order to credit it. Mrs. C. began to show gain in flesh about the face +in the second week of treatment, and during her two months in bed rose +in weight from ninety-six pounds to one hundred and thirty-six; nor was +the gain in color less marked. + +At the sixth week of treatment the soup was dropped, wine abandoned, the +iron lessened one-half, the massage and electricity used on alternate +days, and the limbs exercised as I have described. The usual precautions +as to rising and exercise were carefully attended to, and at the ninth +week of treatment my patient took a drive. At this time all mechanical +treatment ceased, the milk was reduced to a quart, the iron to five +grains thrice a day, and the malt continued. At the sixth week I began +to employ strychnia in doses of one-thirtieth of a grain thrice a day at +meals, and this was kept up for several months, together with the iron +and malt. The cure was complete and permanent; and its character may be +tested by the fact that at the thirtieth day of rest in bed, and after +five years of failure to menstruate, to her surprise she had a normal +monthly flow. This continued with regularity until eighteen months +later, when she became pregnant. The only drawback to her perfect use of +all her functions lay in asthenopia, which lasted nearly a year after +she left my care. Fatigue of vision for near work is a common condition +of the cases I am now describing, and is apt to persist long after all +other troubles have vanished. When there is no asthenopia I usually +think well of the general chance of recovery; but in no case of feeble +vision do I omit at some period of the treatment to have the optical +apparatus of the eye looked at with care, because pure asthenopia, apart +from all optical defects, is a somewhat rare symptom. + +Neither am I always satisfied with the ophthalmologist's dictum that +there is a defect so slight as to need no correction, being well aware, +as I have elsewhere pointed out, that even minute ocular defects are +competent mischief-makers when the brain becomes what I may permit +myself, using the photographer's language, to call sensitized by +disease. + +The following illustrations of success in this mode of treatment are +taken from Dr. Playfair's book:[29] + +"Early in October of last year I was asked to see a lady thirty-two +years of age, with the following history. She had been married at the +age of twenty-two, and since the birth of her last child had suffered +much from various uterine troubles, described to me by her medical +attendant as 'ulceration, perimetritis, and endometritis.' Shortly after +the death of her husband, in 1876, these culminated in a pelvic abscess, +which opened first through the bladder and afterwards through the +vagina. Paralysis of the bladder immediately followed the appearance of +pus in the urine, and from that time the urine was never spontaneously +voided, and the catheter was always used. Soon after this she began to +lose power in the right leg, and then in the left, until they both +became completely paralyzed, so that she could not even move her toes, +and lay on her back with her legs slightly drawn up, the muscles being +much wasted. Towards the end of 1877, after some pain in the back of +her neck and twitching of the muscles, she began to lose power in her +left arm and in her neck, so that she lay absolutely immobile in bed, +the only part of her body she was able to move at all being her right +arm. Up to this time the pelvic abscess had continued to discharge +through the vagina, and occasionally through the bladder, but it now +ceased to do so, and there were no further symptoms referable to the +uterine organs. Her general condition, however, remained unaltered, in +spite of the most judicious medical treatment. She was seen, from time +to time, by several of our most eminent consultants, all of whom +recognized the probable hysterical character of her illness, but none of +the remedies employed had any beneficial effect. There was almost total +anorexia, the amount of food consumed was absurdly small, and the +necessary consequence of this inability to take food, combined with four +years in bed with paralysis of the greater part of the body, and the +habitual use of chloral to induce sleep, had reduced a naturally fine +woman to a mere shadow. In October, 1880, her medical attendant was good +enough to bring her to London for the purpose of giving a fair trial to +the Weir Mitchell method of treatment, with the ready co-operation of +herself and her friends, and she was conveyed on a couch slung from the +roof of a saloon carriage, so as to avoid any jolt or jar, since the +slightest movement caused much suffering. Two days after her arrival my +friend Dr. Buzzard saw her with me, and, after a careful and prolonged +electrical examination, came to the conclusion that contractility +existed in all the affected muscles, and that the paralysis was purely +functional. I could find no evidence in the pelvis of the abscess, the +uterus being perfectly mobile, and apparently healthy. After a few days' +rest the treatment was commenced on October 16, the patient being +isolated in lodgings with a nurse of my own choosing; and this was the +only difficulty I had with her, since she naturally felt acutely the +separation from the faithful attendant who had nursed her during her +long illness. Her friends agreed not to have communication with her of +any sort. It is needless to give the details of the treatment in this +and the following cases. A mere abstract will suffice to indicate the +rapid and satisfactory progress made. + +"_October_ 16.--Twenty-two ounces of milk were taken, in divided doses, +in twenty-four hours; on the 17th, fifty ounces of milk; on the 18th, +the same quantity of milk repeated; massage for half an hour; on the +19th, milk as before; bread-and-butter and egg; massage for an hour and +a half; twenty minims of dialyzed iron twice daily; on the 21st, a +mutton-chop in addition to the above; massage an hour and fifty minutes. +To-day she passed water for the first time for four years, and the +catheter was never again used. Chloral discontinued, and she slept +naturally all night long. On the 23d, porridge and a gill of cream were +added to her former diet; massage three hours daily, and electricity for +half an hour, and this was continued until the end of the treatment. +Maltine was now given twice daily. + +"_October_ 30.--She is now consuming three full meals daily of fish, +meat, vegetables, cream, and fruit, besides two quarts of milk and two +glasses of burgundy. Considerable muscular power is returning in her +limbs, which she can now move freely in bed. + +"_November_ 6.--Sat in a chair for an hour. The massage and electricity +are being gradually discontinued, and the amount of food lessened. + +"_November_ 17.--Walked down-stairs, and went out for a drive, and +henceforth she went out daily in a Bath-chair. She has increased +enormously in size, and looks an entirely different person from the +wasted invalid of a few weeks ago. + +"On November 26 she went to Brighton quite convalescent, and on December +11 came up of her own accord to see me, drove in a hansom to my house, +and returned the same afternoon. She has since remained perfectly strong +and well, and has resumed the duties of life and society. + +"A somewhat curious phenomenon in this case, which I am unable to +account for, was the formation on the anterior surface of the legs, +extending from below the patellĉ half-way down the tibiĉ, of two large +sacs of thin fluid, containing, I should say, each a pint or more, +freely fluctuating, and quite painless. I left them alone, and they have +spontaneously disappeared." + +"In May, 1880, I saw with Dr. Julius, of Hastings, an unmarried lady, +aged thirty-one. Her history was that she had been in fairly good health +until five years ago, when, during her mother's illness, she overtaxed +her strength in nursing, since which time she has been a constant +invalid, suffering from backache, bearing down, inability to walk, +disordered menstruation, and the usual train of uterine symptoms. She +used to get a little better on going to the sea-side, but soon became +ill again, and in October, 1879, she was completely laid up. The least +standing or walking brought on severe pain in her back and side, and she +gave up the attempt, and had since remained entirely confined to her bed +or sofa, suffering from constant nausea, complete loss of appetite, and +depending on chloral and morphia for relief. Many efforts had been made +to break her of this habit, but in vain. Her medical attendant had +recognized the existence of a retroflexion, but no pessary remained _in +situ_ for more than a day or so, and he suspected that she herself +pulled them out. I was unable to do more than confirm the diagnosis that +had been made as to her local condition, but the pessary I introduced +shared the fate of its predecessors, and she remained in the same +condition,--in no way benefited by my visit. Things going on from bad to +worse, Dr. Julius sent her to London for treatment in the early part of +December. I now determined to try the effect of the method I am +discussing, of which I knew nothing when I first saw her. It was +commenced on December 11, and everything went on most favorably. A week +after it was begun, when her attention was fully occupied with the diet, +massage, etc., I introduced a stem pessary, being tempted to try this +instrument, which I rarely use, by the knowledge that she was at perfect +rest, and that no form of Hodge had previously been retained. I do not +think she ever knew she had it, and it remained _in situ_ for a month, +when I removed it and inserted a Hodge, which was thenceforth kept in +without any trouble. I may say that I do not think the retroflexion had +much to do with her symptoms, except, doubtless, at the commencement of +her illness, and she probably would have done quite as well without any +local treatment. She rapidly gained flesh and strength, and very soon I +entirely stopped both chloral and morphia, and she never seemed to miss +them. On December 11, when the treatment was commenced, she weighed 5 +st. 9 lbs. On January 20 she weighed 7 st. On January 25 she walked +down-stairs, and went out for a drive, and from that time she went out +twice daily. She complained of no pain of any kind, and, although she +wore a Hodge, she did not seem to have any uterine symptoms. On February +1 she went to the sea-side, looking rosy, fat, and healthy, and has +since returned to her home in the country, where she remains perfectly +strong and well. A few days ago she came to town, a long railway +journey, on purpose to announce to me her approaching marriage." + +"On September 10 a gentleman came to consult me on the case of his wife, +in consequence of his attention having been directed to my former papers +by a relative who is a well-known physician in London. He informed me +that his wife was now fifty-five years of age, and that she had passed +ten years of her married life in India. At the age of thirty she was +much weakened by several successive miscarriages, and then drifted into +confirmed ill health. He wrote, on making an appointment, as follows: 'I +will give you at once a short outline of her case. We have been married +thirty-four years, of which the last twenty have been spent by her in +bed or on the sofa. She is unable even to stand, and finds the pain in +her back too great to admit of her sitting up. She is utterly without +strength, of an intensely nervous temperament, and suffers incessantly +from neuralgia. She has, moreover, an outward curvature of the spine. +There is not the slightest symptom of paralysis. Fortunately, she does +not touch morphia, or any narcotic or stimulant, beyond a glass or two +of wine in the day. That she has long been in a state of hysteria is the +opinion of nearly all the many medical men who have seen her.' + +"Although the attempt to cure so aggravated a case as this was certainly +a sufficiently severe test of the treatment, I determined to make the +trial, and had the patient removed from her own home and isolated in +lodgings. I found her in bed, supported everywhere by many small +pillows, and wasted more than, I think, I had ever seen any human being. +She really hardly had any covering to her bones, and looked somewhat +like the picture of the living skeleton we are familiar with. It may +give some idea of her emaciation if I state that, though naturally not a +small woman, her height being five feet five and a half inches, she +weighed only 4 st. 7 lbs., and I could easily make my thumb and +forefinger meet round the thickest part of the calf of her leg. The +curvature of the spine said to exist was a deceptive appearance, +produced by her excessive leanness, and the consequent unnatural +prominence of the spinous processes of the vertebrĉ. I could detect no +organic disease of any kind. The appetite was entirely wanting, and she +consumed hardly any food beyond a little milk, a few mouthfuls of bread, +and the like. From the first the patient's improvement was steady and +uniform. The way she put on flesh was marvellous, and one could almost +see her fatten from day to day. Within ten days all her pains, +neuralgia, and backache had gone, and have never been heard of since, +and by that time we had also got rid of all her little pillows and other +invalid appliances. + +"It may be of interest, as showing what this system is capable of, if I +copy her food diary on the tenth day after the treatment was begun; and +all this, this bedridden patient, who had lived on starvation diet for +twenty years, not only consumed with relish, but perfectly assimilated. + +"Six A.M.: ten ounces of raw meat soup. 7 A.M.: cup of black coffee. 8 +A.M.: a plate of oatmeal porridge, with a gill of cream, a boiled egg, +three slices of bread-and-butter, and cocoa. 11 A.M.: ten ounces of +milk. 2 P.M.: half a pound of rump-steak, potatoes, cauliflower, a +savory omelette, and ten ounces of milk. 4 P.M.: ten ounces of milk and +three slices of bread-and-butter. 6 P.M.: a cup of gravy soup. 8 P.M.: +a fried sole, roast mutton (three large slices), French beans, potatoes, +stewed fruit and cream, and ten ounces of milk. 11 P.M.: ten ounces of +raw meat soup. + +"The same scale of diet was continued during the whole treatment, and, +from first to last, never produced the slightest dyspeptic symptoms, and +was consumed with relish and appetite. At the end of six weeks from the +day I first saw her she weighed 7 st. 8 lb.,--that is, a gain of 3 st. 1 +lb. It will suffice to indicate her improvement if I say that in eight +weeks from the commencement of treatment she was dressed, sitting up to +meals, able to walk up and down stairs with an arm and a stick, and had +also walked in the same way in the park. Considering how completely +atrophied her muscles were from twenty years' entire disuse, this was +much more than I had ventured to hope. She has now left with her nurse +for Natal, and I have no doubt that she will return from her travels +with her cure perfected." + +"Early in August I was asked to see a lady, aged thirty-seven, with the +following history:--'As a girl of sixteen she had a severe neuralgic +illness, extending over months: excepting that, she seems to have +enjoyed good health until her marriage. Soon after this she had a +miscarriage, and then two subsequent pregnancies, accompanied by +albuminuria and the birth of dead children.' 'During gestation I was not +surprised at all sorts of nervous affections, attributing them to +urĉmia.' The next pregnancy terminated in the birth of a living +daughter, now nearly three years old; during it she had 'curious nervous +symptoms,--_e.g._, her bed flying away with her, temporary blindness, +and vaso-motor disturbances.' Subsequently she had several severe shocks +from the death of near relatives, and gradually fell into the condition +in which she was when I was consulted. This is difficult to describe, +but it was one of confirmed illness of a marked neurotic type. Among +other phenomena she had frequently-recurring attacks of fainting. 'These +were not attacks of syncope, but of such general derangement of the +balance of the circulation that cerebration was interfered with. She was +deaf and blind; her face often flushed, sometimes deadly cold; her hands +clay-cold, often blue, and difficult to warm with the most vigorous +friction. These attacks passed off in from twenty minutes to a couple +of hours.' Soon 'the attacks became more frequent, with the reappearance +of another old symptom,--acute tenderness of the spine, especially over +the sacrum. Then came frequent and persistent attacks of sciatica, and +gradual loss of strength.' About this time there appears to have been +some uterine lesion, for a well-known gynĉcologist went down to the +country to see her. Eventually 'she became unable to do anything almost +for herself, for the nervous irritability had distressingly increased. +To touch her bed, the ringing of a bell, sometimes the sound of a voice, +sunlight, &c., affected her so as to make her almost cry out.' 'If she +stood up, or even raised her hands to dress her hair, they immediately +became blue and deadly cold, and she was done for.' Then followed +palpitations of a distressing character, with loud blowing murmur, and +pulse of 120 to 140, for which she was seen by an eminent physician, who +diagnosed them to be caused by 'slight ventricular asynchronism, with +atonic condition of the cardiac as well as of all other muscles of the +body.' 'She has no appetite whatever.' 'Any attempt at walking brings on +sciatica. She cannot sit, because the tip of the spine is so sensitive; +any pressure on it makes her feel faint. She cannot go in a carriage, +because it jars every nerve in her body. She cannot lie on her back, +because her whole spine is so tender.' + +"When consulted about this lady, I gave it as my opinion that any +attempt at cure was hopeless as long as she remained in the country +house in which she lived. I was informed that it was absolutely +impossible to get her away, as she could not bear the motion of any +carriage, still less of a railway, without the most acute suffering. +Eventually the difficulty was got over by anĉsthetizing her, when she +was carried on a stretcher to the nearest railway station, and then +brought over two hundred miles to London, being all the time more or +less completely under the influence of the anĉsthetic, administered by +her medical attendant, who accompanied her. I found this lady's state +fully justified the account given of her. She was intensely sensitive to +all sounds and to touch. Merely laying the hand on the bed caused her to +shrink, and she could not bear the lightest touch of the fingers on her +spine or any part near it. She lay in a darkened room at the back of the +house, to be away from the noise of the streets, which distressed her +much. She was a naturally fine and highly-cultivated woman, greatly +emaciated, with a dusky, sallow complexion, and dark rims round her +eyes. I could find no evidence of organic disease of any kind. Whatever +lesion of the uterine organs had previously existed had disappeared, and +I therefore paid no attention to them. Within a week I had the patient +lying in a bright sunlit room in the front of the house, with the +windows open, and she complained no longer of the noise. Within ten days +the whole spine could be rubbed freely from top to bottom, and from the +first I directed the masseuse to be relentless in her manipulation of +this part of the body. In a few weeks she had gained flesh largely, the +dusky hue of her complexion had vanished, and she looked a different +being. The only trouble complained of was sleeplessness, but it did not +interfere with the satisfactory progress of the case, and no hypnotic +was given. After the first few days we had no return of the nerve-crises +which in the country had formed so characteristic a part of her illness. +Her hands and feet also, at first of a remarkable deadly coldness, soon +became warm, and remained so. In five weeks she was able to sit up, and +before the fifth week of treatment was completed I took her out for a +drive through the streets in an open carriage for two hours, which she +bore without the slightest inconvenience, and the result of which she +thus described in a letter the same evening: 'I never enjoyed anything +more in my life. I cannot describe my delight and my astonishment at +being once more able to drive with comfort. My back has given me no +trouble, and I was not really tired.' This lady has since remained +perfectly well, and I need give no better proof of this than stating +that she has started with her husband on a tour round the world, _viâ_ +India, Japan, and San Francisco, and that I have heard from her that she +is thoroughly enjoying her travels." + +"The last example with which I shall trespass on your patience I am +tempted to relate because it is one of the most remarkable instances of +the strange and multiform phenomena which neurotic disease may present, +which it has ever been my lot to witness. The case must be well known to +many members of the profession, since there is scarcely a consultant of +eminence in the metropolis who has not seen her during the sixteen +years her illness has lasted, besides many of the leading practitioners +in the numerous health-resorts she has visited in the vain hope of +benefit. My first acquaintance with this case is somewhat curious. About +two months before I was introduced to the patient, chancing to be +walking along the esplanade at Brighton with a medical friend, my +attention was directed to a remarkable party at which every one was +looking. The chief personage in it was a lady reclining at full length +on a long couch, and being dragged along, looking the picture of misery, +emaciated to the last degree, her head drawn back almost in a state of +opisthotonos, her hands and arms clenched and contracted, her eyes fixed +and staring at the sky. There was something in the whole procession that +struck me as being typical of hysteria, and I laughingly remarked, 'I am +sure I could cure that case if I could get her into my hands.' All I +could learn at the time was that the patient came down to Brighton every +autumn, and that my friend had seen her dragged along in the same way +for ten or twelve years. On January 14 of this year, I was asked to meet +my friend Dr. Behrend in consultation, and at once recognized the +patient as the lady whom I had seen at Brighton. It would be tedious to +relate all the neurotic symptoms this patient had exhibited since 1864, +when she was first attacked with paralysis of the left arm. Among +them--and I quote these from the full notes furnished by Dr. +Behrend--were complete paraplegia, left hemiplegia, complete hysterical +amaurosis, but from this she had recovered in 1868. For all these years +she had been practically confined to her bed or couch, and had not +passed urine spontaneously for sixteen years. Among other symptoms, I +find noted 'awful suffering in spine, head, and eyes,' requiring the use +of chloral and morphia in large doses. 'For many years she has had +convulsive attacks of two distinct types, which are obviously of the +character of hystero-epilepsy.' The following are the brief notes of the +condition in which I found her, which I made in my case-book on the day +of my first visit. 'I found the patient lying on an invalid couch, her +left arm paralyzed and rigidly contracted, strapped to her body to keep +it in position. She was groaning loudly at intervals of a few seconds, +from severe pain in her back. When I attempted to shake her right hand, +she begged me not to touch her, as it would throw her into a +convulsion. She is said to have had epilepsy as a child. She has now +many times daily, frequently as often as twice in an hour, both during +the day and night, attacks of sudden and absolute unconsciousness, from +which she recovers with general convulsive movements of the face and +body. She had one of these during my visit, and it had all the +appearance of an epileptic paroxysm. The left arm and both legs are +paralyzed, and devoid of sensation. She takes hardly any food, and is +terribly emaciated. She is naturally a clever woman, highly educated, +but, of late, her memory and intellectual powers are said to be +failing.' + +"It was determined that an attempt should be made to cure this case, and +she was removed to the Home Hospital in Fitzroy Square. She was so ill, +and shrieked and groaned so much, on the first night of her admission, +that next day I was told that no one in the house had been able to +sleep, and I was informed that it would be impossible for her to remain. +Between 3 P.M. and 11.30 P.M. she had had nine violent convulsive +paroxysms of an epileptiform character, lasting, on an average, five +minutes. At 11.30 she became absolutely unconscious, and remained so +until 2.30 A.M., her attendant thinking she was dying. Next day she was +quieter, and from that time her progress was steady and uniform. On the +fourth day she passed urine spontaneously, and the catheter was never +again used. In six weeks she was out driving and walking; and within two +months she went on a sea-voyage to the Cape, looking and feeling +perfectly well. When there, her nurse, who accompanied her, had a severe +illness, through which her ex-patient nursed her most assiduously. She +has since remained, and is at this moment, in robust health, joining +with pleasure in society, walking many miles daily, and without a trace +of the illnesses which rendered her existence a burden to herself and +her friends. + +"In conclusion, I may remark that it seems to me that the chief value of +this systematic treatment, which is capable of producing such remarkable +results, is that it appeals, not to one, but many influences of a +curative character. Every one knew, in a vague sort of way, that if an +hysterical patient be removed from her morbid surroundings a great step +towards cure is made. Few, however, took the trouble to carry this +knowledge into practical action; and when they did so they relied on +this alone, combined with moral suasion. Now, I am thoroughly convinced +that very few cases of hysteria can be preached into health. Judicious +moral management can do much; but I believe that very few hysterical +women are conscious impostors; and the great efficacy of the Weir +Mitchell method seems to me to depend on the combination of agencies +which, by restoring to a healthy state a weakened and diseased nervous +system, cures the patient in spite of herself." + + + + +CHAPTER IX. + +DIETETICS AND THERAPEUTICS--(CONTINUED). + + +As additional illustrations I shall now state a few cases of my own, +without entering into minute details of treatment. + +The following case is reported by Dr. John Keating, who watched it with +care throughout: + +P.D., male, ĉt. 53, after more than thirty years of close attention to +business, which severely tried both mental and physical endurance, found +himself, in January, 1877, at the close of some months of gradually +increasing feebleness, absolutely unable to fulfil his usual duties, and +the most alarming symptoms manifested themselves. There was a remarkable +loss of nervous and muscular force; his limbs refused their support; his +appetite failed; the recollection of ordinary phrases involved distinct +and painful effort; sleep became unattainable, except under the +influence of powerful narcotics, and even that brief slumber was +rendered valueless by the incessant convulsive twitching of the muscles. + +His physician prescribed iron and strychnia; ordered an immediate +abandonment of all business, and instant departure to a point where +telegraph-wires were unknown and mails infrequent. He went at once to +the Bahamas, passing a month in that delicious climate in absolute +inaction; more than another month was consumed in slowly returning; but, +though some flesh had been gained, there was only a trifling improvement +in the nervous condition. + +May 1, 1877, Dr. Mitchell examined Mr. P.D. The patient was sallow and +emaciated, and coughed every few moments. He had night-sweats, nervous +twitching, and slight dulness on percussion at the apex of the right +lung, with prolonged expiration and roughened inspiration, and some +increase of vocal resonance. + +Mr. P.D. was allowed to be out of bed once a day four hours, and to +spend one hour at his place of business. The treatment was as follows: + +At 6 A.M., a tumbler of strong, hot beef-tea, made from the Australian +extract. + +At 8 A.M., half a tumbler of iron-water, and breakfast, consisting of +fruit, steak, potatoes, coffee, and a goblet of milk. At 8.30 A.M., a +goblet of milk mixed with a dessertspoonful of Loefland's extract of +malt, with six grains of citrate of iron and quinine. + +At 10 o'clock Dr. Keating administered the electricity. + +At 12 o'clock Mr. P.D. might be dressed, making as little personal +effort as possible. The second goblet of milk and malt was administered, +and a carriage took him to his office, where he might remain till two +o'clock, when the carriage brought him for dinner, preceded by half a +tumbler of iron-water. All walking was forbidden. + +After dinner (which included a goblet of milk) the third goblet of milk +and malt was swallowed; then a short drive might be taken, but by four +o'clock the patient must be undressed and in bed. + +At 6 P.M. the third dose of iron-water presented itself, and a light +supper of fruit, bread-and-butter, and cream, followed by the fourth +goblet of milk and malt. Two quarts of milk were thus swallowed every +day in addition to all other food. + +At 9 P.M., massage one hour, with cocoa-oil, followed by beef-soup, four +ounces. + +At the fourth week the soup was given up; dialyzed iron was substituted +for all other forms. June 4, electricity was given up. The malt was +continued until June 20. + +May 6, Mr. D. weighed in heavy winter dress one hundred and twenty-five +pounds; June 20, in the lightest summer garb, he weighed one hundred and +thirty-three pounds; in August his weight rose to one hundred and forty +pounds, and he has continued to gain. When last I saw him, a year later, +he was strong and well, had no cough, and had ceased to be what he had +been for years--a delicate man. + +I am indebted to the late Professor Goodell for the following case, +which I never saw, but which was carried on with every detail of my +treatment. As the testimony of an admirable observer, it is valuable +evidence. Professor Goodell writes as follows: + +"Some four years ago, Mrs. Y., a very highly intelligent lady, from a +neighboring city, came to consult me. She suffered dreadfully at each +monthly period, and had constant ovarian pains and a wearying backache, +which kept her on a lounge most of the day. She was also barren, and +altogether in a pitiable condition. After a two months' treatment she +returned home very much better, and soon after conceived. As pregnancy +advanced, many of her old symptoms came back, but it was hoped that +maternity would rid her of them. The shock of the labor, however, proved +too great for her already shattered nervous system. She became far more +wretched than before, and again sought my advice. + +"At this time I found all her old pains and aches running riot. She got +no relief from them night or day without large doses of chloral. The +slightest exertion, such as sewing, writing, and reading for a few +minutes, greatly wearied her. Even the simple mental effort of casting +up the weekly housekeeping expenses of a very small household upset her, +and she had to give it up. The act of walking one of our blocks, or of +going down a short flight of stairs, or of riding for an hour in a +well-padded carriage, gave her such 'unspeakable agony'--to use her own +words--that she would have an hysterical attack of screams and tears. So +emotional had this constant nerve-strain made her that she could not +sustain an ordinary conversation without giving way to tears. Much of +her time was spent in bed; in fact, she was practically bedridden. + +"I tried in vain to wean her from her anodynes, and failed altogether in +doing her any good, although many remedies were resorted to, and various +modes of treatment adopted. Finally, in sheer despair, I put her to bed, +and began your treatment of rest, with electricity, massage, and +frequent feeding. The first trace of improvement showed itself in a +greater self-control, and in a lessening of her aches and pains. Next, +smaller doses of the anodyne were needed, until it was wholly withheld. +Then she began to pick up an appetite, which, towards the close of the +treatment, became so keen that, between three good meals every day, she +drank several goblets of milk and of beef-tea. At the outset I had +stipulated for six weeks of this treatment, and it was with reluctance +that my patient yielded to my wish. But when the time was up she had +become so impressed with the wonderful benefits she had received and was +receiving, that she begged to have the treatment continued for two weeks +more. At the end of that time she had gained at least thirty pounds in +weight, and had lost every pain and ache. Her night-terrors, which I +forgot to mention as one of her distressing symptoms, had wholly +disappeared, and she could sleep from nine to ten hours at a stretch. I +now sent her into the country, where she is continuing to mend, and is +astonishing her friends by her scrambles up and down the steep hills. + +"Such were the salient features of this case; and I can assure you that +I was as much impressed by the happy results of the treatment as were a +host of anxious and doubting friends. + +"Very faithfully yours, +"WM. GOODELL." + + * * * * * + +Miss C., an interesting woman, ĉt. 26, at the age of 20 passed through a +grave trial in the shape of nursing her mother through a typhoid fever. +Soon after, a series of calamities deprived her of fortune, and she +became, for support, a clerk, and did for two years eight hours' work +daily. Under these successive strains her naturally sturdy health gave +way. First came pain in the back, then growing paleness, loss of flesh, +and unending sense of tire. Her work, which was a necessity, was of +course kept up, steadily at first, but was soon interfered with by +increase of the menstrual flow, with unusual pain and persistent +ovarian tenderness. Very soon she began to drop her work for a day at a +time. Then came an increasing asthenopia, with evening headaches, until +her temper changed and became capricious and irritable. When I saw her, +she had been forced to abandon all labor, and had been treated by an +accomplished gynĉcologist, and was said to be cured of a prolapsus uteri +and of extensive ulceration, despite which relief she gained nothing in +vigor and endurance and got back neither color nor flesh. + +She went to bed December 10, and rose for the first time February 4, +having gained twenty-nine pounds. She went to bed pale, and got up +actually ruddy. In a month she returned to her work again, and has +remained ever since in health which enables her, as she writes me, "to +enjoy work, and to do with myself what I like." + +Miss L., ĉt. 26, came to me with the following history. At the age of 20 +she had a fall, and began in a week or two to have an irritable spine. +Then, after a few months, a physician advised rest, to which she took +only too kindly, and in a year from the time of her accident she was +rarely out of bed. Surrounded by highly sympathetic relatives, to whom +chronic illness was somewhat novel, she speedily developed, with their +tender aid, hyperĉsthetic states of the eye and ear, so that her nurses +crept about in a darkened room, the piano was silenced, and the children +kept quiet. By slow degrees a whole household passed under the selfish +despotism of an hysterical girl. Intense constipation, anorexia, and +alternate states of dysuria, anuria, and polyuria followed, and before +long her sister began to fail in health, owing to the incessant +exactions to which she too willingly yielded. This alarmed a brother, +who insisted upon a change of treatment, and after some months she was +brought on a couch to this city. + +At the time I first saw her, she took thirty grains of chloral every +night and three hypodermic injections of one-half grain of morphia +daily. As to food, she took next to none, and I could only guess her +weight at about ninety pounds. She was in height five feet two and a +half inches, and very sallow, with pale lips, and the large, indented +tongue of anĉmia. I made the most careful search for signs of organic +mischief, and, finding none, I began my treatment as usual with milk, +and added massage and electricity without waiting. Her digestion seemed +so good that I gave lactate of iron in twenty-grain doses from the third +day, and also the aloes pill thrice a day. It is perhaps needless to +state that I isolated her with a nurse she had never seen before, and +that for seven weeks she saw no one else save myself and the attendants. +The full schedule of diet was reached at the end of a fortnight, but the +chloral and morphia were given up at the second day. She slept well the +fourth night, and, save that she had twice a slight return of polyuria, +went on without a single drawback. In two months she was afoot and +weighed one hundred and twenty-one pounds. Her change in tint, flesh, +and expression was so remarkable that the process of repair might well +have been called a renewal of life. + +She went home changed no less morally than physically, and resumed her +place in the family circle and in social life, a healthy and well-cured +woman. + +I might multiply these histories almost endlessly. In some cases I have +cured without fattening; in others, though rarely, the mental habits +formed through years of illness have been too deeply ingrained for +change, and I have seen the patient get up fat and well only to relapse +on some slight occasion. + +The intense persistency with which some women study and dwell upon their +symptoms is often the great difficulty. Even a slight physical annoyance +becomes for one of these unhappily-constituted natures a grave and +almost ineradicable trouble, owing to the habit of self-study. + +Miss P., ĉt. 29, weight one hundred and eleven pounds, height five feet +four inches, dark-skinned, sallow, and covered with the acne of +bromidism, had had one attack which was considered to have been +epileptic, and which was probably hysterical, but on this matter she +dwelt with incessant terror, which was fostered by the tender care of a +near relative, who left her neither by night nor by day. Vague neuralgic +aches in the limbs, with constant weariness, asthenopia, anĉmia, loss of +appetite, and loss of flesh, followed. Then came spinal pain and +irregular menstruation, a long course of local cauterizations of the +womb, spinal braces, and endless tonics and narcotics. + +I broke up the association which had nearly been fatal to both women, +and, confidently promising a cure, carried out my treatment in full In +three months she went home well and happy, greatly improved in looks, +her skin clear, her functions regular, and weighing one hundred and +thirty-six pounds. + +It is vain to repeat the relation of such cases, and impossible to put +on paper the means for deciding--what is so large a part of success in +treatment--the moral methods of obtaining confidence and insuring a +childlike acquiescence in every needed measure. + +Another class of cases will, however, bear some further illustration. We +meet with women who are healthy in mind, but who have some chronic pain +or some definite malady which does not get well, either because the +usual tonics fail, or because their occupations in life keep them always +in a state of exhaustion. If by rest we slow the machinery, and by +massage and electricity deprive rest of its evils, we can often obtain +cures which are to be had in no other way. This is true of many uterine +and of some other disorders. + +Miss B., ĉt. 37, height five feet five inches, weight one hundred and +fifteen pounds, a schoolteacher, without any notable organic disease, +had a severe fall, owing to an accident while driving. A slight swelling +in the hurt lumbar region was followed by pain, which became intense +when she walked any distance. Loss of color, flesh, and appetite ensued, +and, after much treatment, she consulted me. I could find nothing beyond +soreness on deep pressure, and she was anything but hysterical or +emotional. + +Two months' rest with the usual treatment brought her weight up to one +hundred and thirty-eight pounds, and she has been able ever since to do +her usual work, and to walk when and where and as far as she wished. + +Several years ago I treated with some reluctance a lady who had +extensive bronchitis and a slight albuminuria. This woman was a mere +skeleton, with every function out of order. I undertook her case with +the utmost distrust, but I had the pleasure to find her fattening and +reddening like others. Her cough left her, the albumen disappeared, and +she became well enough to walk and drive; when a sudden congestion of +the kidneys destroyed her in forty-eight hours. + +The following case of extreme anĉmia, with striking resemblance to the +pernicious type in some of its features, is especially interesting for +the ease and rapidity of improvement under rest and massage without +electricity or excessive amounts of food. + +Mrs. T., ĉt. 40, the mother of several children, had been unwell for +years, and almost totally incapacitated for exertion for two years +before admission, in January, 1894. She complained of extreme +feebleness, distaste for and inability to digest food, a great and +constant difficulty in swallowing, shortness of breath, dropsy of the +ankles if she walked or stood, hemorrhoids from which some bleeding +often occurred, extreme constipation, constant chilliness, and frequent +violent headaches. Her appearance was that of a person with pernicious +anĉmia, a very yellow muddy skin, dry and harsh to the touch, and the +hands and feet cold, almost to the point of pain. + +On examination the spleen was decidedly large; the lower border of the +stomach reached to the level of the umbilicus. Two cardiac murmurs were +present, the one a sharp and well-defined mitral regurgitant sound, +confirmed by the dyspnoea and dropsy as organic, the other a loud +musical murmur of hĉmic origin. The trouble in deglutition proved to be +due to an oesophageal narrowing. The blood examination bore out the +suggestion of probable pernicious anĉmia, the red cells being only +1,500,000, hĉmoglobin 18 per cent.: the microscope showed microcytes, +megaloblasts, nucleated red cells, and a large increase in white +corpuscles. In order to study the effect of massage alone upon the blood +no other treatment was used, though of course the patient was kept at +"absolute rest." No drugs were given, electricity was not used, and +extra food was omitted, as the irritability of the oesophagus made her +unwilling to attempt the exertion and annoyance of frequent feeding. The +general chilliness was at once helped by massage, and in a few days only +felt in the small hours of the night, and the patient gained weight from +the first. After one week of treatment a blood count was made: red cells +were 3,800,000, more than double the former figure; hĉmoglobin, 35 per +cent., almost double its original value. On the same day, one hour after +the completion of an hour's massage, the corpuscular count had attained +5,400,000, the hĉmoglobin remaining 35 per cent. + +At the end of two weeks the hĉmic murmur had faded into a faint soft +bruit, though the mitral murmur was unchanged, the skin had improved in +color, the aches and weariness were gone, and the blood count had +reached nearly five million cells, with 50 per cent. of hĉmoglobin. The +extraordinary results of the blood examination were confirmed by +observations made by Professor Frederick P. Henry, Dr. Judson Daland, +and Dr. J.K. Mitchell, who all practically agreed. Professor Henry made +several studies and stained a number of slides, verifying in his report +the statements of the presence of megaloblasts and nucleated red cells +made above. + +Owing to the necessity for an operation on the hemorrhoids, which caused +loss of blood, the patient was somewhat retarded in her progress to +recovery, but by the tenth week was so far better that the blood showed +no microscopic abnormalities, the count was full normal, and the +hĉmoglobin over 70 per cent. Her color and strength were good, the heart +was perfectly strong, the anĉmic murmur was gone, and the oesophagus +was so much less irritable that it was possible to begin dilatation of +the stricture. + +I have heard within a year that though occasionally annoyed by this last +trouble if she becomes much fatigued, she has remained in other ways +well. + +Mrs. G., the daughter of nervous parents, was always a nervous, +over-sensitive, serious child, worked hard at Vassar, broke down, +recovered, returned to college, was attacked with measles, which proved +severe, and by the time she graduated had been made by her own +tendencies and the anxious attention of her family into a devoted member +of the class which I may permit myself to describe as health-maniacs. + +Health-foods, health-corsets, health-boots, the deeply serious +consideration of how to eat, on which side to sleep, profound +examination of whether mutton or lamb were the more digestible +flesh,--these were her occupations,--and two or three years before her +panic about her health had been made worse by the discovery of an aortic +stenosis, of which an over-frank doctor had thought it best to inform +her. When I saw her she had been three years married, was childless, +and, between the real cardiac disease and her own anxieties about it, +had driven herself into a state of great physical debility and a mental +condition approaching delusional insanity. + +A too restricted diet, lacking both in variety and appetizingness, had +had its usual result of upsetting digestion and destroying desire for +food. Even with the small amounts which she ate she considered it +necessary to chew so carefully and to feed herself so slowly that from +one hour to an hour and a half was used for each meal. The heart, +under-nourished, beat feebly, there was constant slight albuminuria with +evidences of congested kidneys, and she could only rest in a semi-erect +position. + +The heart condition, with its renal results, proved the most rebellious +part of the trouble. A firm and intelligent nurse soon overcame the +difficulties and delays about food, and my final refusal to discuss them +disposed for the time of some of the fanciful theories about digestion +and so on. Her meals were ordered in every detail, and she was told that +they were prescribed and to be taken like medicine, and, fed by the +nurse, she began to take more nourishment. Massage relieved some of the +labor of the heart, and gradually the semi-erect posture was exchanged +inch by inch for a semi-recumbent one. Not to prolong the relation of +details, it was found needful to keep this lady in bed for five months +before the heart seemed to recover sufficiently to allow her to get up. +Even then, although improved in color, flesh, and blood condition, she +had to attain an erect station almost as slowly as she had had to reach +recumbency. Slow, active Swedish movements, to which gentle resistance +movements were very gradually added, helped the heart. Her cure was +completed by five or six months' camp-life in the woods, and she is now +the mother of a healthy child and herself perfectly well, the valvular +disease only to be detected by the most careful examination, and never, +even during pregnancy and parturition, causing any annoyance. + +The surgeons, who once thought a floating kidney could be permanently +fixed in its place by stitching, have now concluded that this is very +doubtful, and the treatment of this displacement is never very +satisfactory by any method. Still, some success has followed long rest +in the supine position, which encourages the kidney to return to its +normal place, until careful full feeding has renewed or increased the +fatty cushions which hold it up. It is best during the first weeks of +treatment not to allow the patient to sit or stand, or if she should be +unable to avoid the occasional need for these positions, an abdominal +binder must be applied by the nurse and drawn tightly before she moves. +The masseuse is directed to avoid any movements which might further +displace the organ, and may cautiously push it upward and hold it there +with one hand while with the other the manipulation of the abdomen is +performed. However long it may require, the patient should not get up +until examinations, supine, lateral, prone, and erect, combine to assure +us that the kidney is replaced. Repeated investigation of this point +will be required,--for the kidney will sometimes be in place for a +little while and next day or even a few hours later have slipped down +again. Before any exertion is permitted, even ordinary walking, an +accurate close-fitting abdominal belt with a kidney-pad should be +applied. Those kept in stock are seldom properly adjusted, and usually +have the pad in the wrong place. If rightly made, they can be worn with +comfort and tight enough to be useful. If not rightly made, they are +useless instruments of torture. + +Mrs. Y., ĉt. fifty-six, was sent to Dr. J.K. Mitchell by Professor Osler +for treatment. She had all the usual intestinal derangements and +discomforts attendant upon a floating kidney: constipation alternated +with diarrhoea, or rather with a sort of intestinal incontinence; vague +pains in the back, flanks, and stomach were frequent; attacks of acute +pain began in the right hypogastrium and ran down to the symphysis or +into the groin; she had constant flatulence, weight, and oppression +after food; was pale, flabby, and emaciated, but had no emotional or +nervous symptoms except an annoying amount of insomnia. The lower border +of the stomach was fully two inches below the navel in the middle-line, +even when only a glass of water had been taken. It was a little lower +after a small meal. The colon was distended and very variable in +position, probably changing its relations with the landmarks as it +happened to be more or less filled with food or gases. The abdominal +walls were flabby, relaxed, and pendulous, and the whole surface tender. +The patient gave a history of sudden loss of flesh with almost no +reason some three years before, and increasing indigestion in all forms +ever since. The tenderness made careful abdominal study difficult, but +lessened enough after a few days in bed to permit the perception of a +displacement of the right kidney, whose lower edge could be felt on a +level with the umbilicus and two inches to the right of it. No change of +position would bring it any lower. Examined with the patient prone, +two-thirds of the kidney could be outlined, extremely tender, and +causing nausea and sinking if pressed upon. + +The chief trouble in treatment proved to be the irritability of the +intestines, which was brought on in most unexpected fashion by foods of +the simplest kind. For some time it was so persistent that the suspicion +of intestinal tuberculosis was entertained; but it finally disappeared, +and after that the case progressed more favorably and she was out of bed +with a tight belt and kidney-pad in a little more than twelve weeks. The +kidney was then, and has remained since, in its normal position. The +patient gained twelve pounds in weight, and should have gained more, but +she found the hot weather during the latter weeks of her treatment very +trying. The intestinal indigestion was only partially relieved, but the +gastric symptoms, the general pains, and weakness all disappeared, and +with precaution she will continue to improve. It is best to advise the +constant use of the belt in such a case. In a patient who has made a +large gain in flesh, as this one did not, and who has been found after +some months to maintain the increased weight, the belt might gradually +and experimentally be left off; but repeated examinations should be made +for a year or two to be sure that no displacement results. + +I could relate cases of gain in flesh without manifest relief. As I have +said, these are rare; but it is less uncommon to see great relief +without improvement in weight at all, or until the patient is up and +afoot for some weeks; and I could also state several cases in which a +repetition of the treatment won a final and complete success after the +first effort at cure had failed or but partially succeeded; and of this, +I believe, Professor Goodell has seen several examples. + +I have mentioned more than once the singular return of menstruation +under this treatment, and as examples I add a brief list of some +notable instances. + +Mrs. N., ĉt. 29, no menstruation for five years; return of menstruation +at thirtieth day of treatment; continued regularly ever since during +three years. + +Mrs. C., ĉt. 42, eight years without menstruation; return at fourteenth +day of treatment; now regular during five months. + +Miss C., ĉt. 22, no menstruation for eight months; return at close of +sixtieth day of treatment; regular now for four months. + +Miss A., ĉt. 26, irregular; missing for two or three months, and then +menstruating irregularly for two or three months. No flow for two +months. Menstruated at nineteenth day of treatment, and regular during +thirteen months ever since. + +I had at one time intended to give, in the first edition of this work, a +summary of all my cases, with the results; but what is easy to do in +definite maladies like typhoid fever becomes hard in cases such as I +here relate. In fevers the statistics are simple,--patients die or get +well; but in cases of nervous exhaustion, so called, it is impossible to +state accurately the number of partial recoveries, or, at least, to +define usefully the degrees of gain. For these reasons I have not +attempted to furnish full statistics of the large number of cases I have +treated. + +In the debate before the British Medical Association the question of the +permanence of cures by this method was the subject of discussion. I have +lately been at some pains to learn the fate of many of my earlier cases, +and can say with certainty that every case then treated was selected +because all else had failed, and that I find relapses into the state +they were in when brought to me to have been very uncommon. A vast +proportion have remained in useful health, and a small number have lost +a part of their gains. I now make it a rule to keep up some relation +with patients after discharge, by occasional visits or by letter, and +believe that in this way many small troubles are hindered from becoming +large enough to cause relapses. + +I said in my first edition that I did not doubt that the statements I +made would give rise in some minds to that distrust which the relation +of remarkable cures so naturally excites; and this I cannot blame. Every +physician can recall in his own practice such cases as I have +described, and every medical man of large experience knows that many of +these women are to him sources of anxiety or of therapeutic despair so +deep that after a time he gets to think of them as destined irredeemably +to a life of imperfect health, and finds it hard to believe that any +method of treatment can possibly achieve a rescue. + +I am fortunate now in having been able to show that in other hands than +my own, both here and abroad, this treatment has so thoroughly justified +itself as to need no further defence or apology from its author. It has +gratified me also to learn that in many instances country physicians, +remote from the resources of great cities, have been able to make it +available. As I have already said, I am now more fearful that it will be +misused, or used where it is not needed, than that it will not be used; +and, with this word of caution, I leave it again to the judgment of time +and my profession. + + + + +CHAPTER X. + +THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC PARAPLEGIA, SPASTIC PARALYSIS, +AND PARALYSIS AGITANS. + + +In my earliest publication on the treatment of diseases by rest, etc., +locomotor ataxia was alluded to as one of the troubles in which +remarkable results had been obtained. Rest alone will do much to +diminish pain and promote sleep in tabes, rest with massage and +electricity will do more. It is not necessary to order complete +seclusion for such cases, but some special measures will be needed in +addition to those already described as of use in various disorders, and +these will be discussed in this chapter. + +While this is not a treatise on diagnosis, some brief +symptom-description is needed to enable one to define clearly the +methods of treatment at different stages. + +In the middle or late stages there need be little uncertainty in +uncomplicated cases; in the earlier periods diagnosis is by no means +easy. A history may usually be elicited of important heralding +symptoms, such as former or present troubles with the muscles of the +eyes, the occurrence of vague but sharp and recurring pains, vertigo, an +impairment of balance, unnoticed perhaps, except when walking in the +dark or when stooping to wash the face, or especially when going down +stairs. Attacks of 'dyspepsia,' as unrecognized visceral crises are +often called, should render one suspicious. If, on examination, loss or +impairment of knee-jerk be shown, contraction of the pupil with +Argyll-Robertson phenomenon and defective station, but little doubt can +exist. The discovery by the ophthalmoscope of some degree of beginning +optic neuritis would make assurance more sure, and this can often be +detected in a very early stage of the disease. + +Much controversy has been spent on the question of the share of syphilis +in producing tabes, and out of the battle but two facts emerge fairly +certain, the one that syphilis often precedes the disease, the other +that anti-syphilitic medication is commonly of no service. But syphilis +is so frequently antecedent that a history of that infection may make +certain the diagnosis when doubt exists. This may be an important +point, for some of the cardinal symptoms are occasionally absent; cases +are seen with no incoördination, sometimes with the station unaffected, +even, though rarely, with the knee-jerk preserved. + +The diagnosis established, treatment will somewhat depend upon the stage +which the disease has reached. + +In the pre-ataxic stage, where slight unsteadiness, often not +troublesome except in the dark or with closed eyes, sharp stabbing pains +here and there, numbness of the feet, girdle-sense in the region of +chest, waist, or belly, some recurrent difficulty in emptying the +bladder, a fugitive partial palsy of the external muscles of the eye, +are the chief or, perhaps, the only complaints, it would not be +justifiable to put the patient to bed at complete rest. This early stage +calls for a different plan of treatment, to be presently described. + +In the middle or more distinctly ataxic period long rest in bed should +be prescribed, and will be gratefully accepted by a patient whose +sufferings from incoördination, pains, and numbness of the extremities +are often so great as to incapacitate him. + +The bladder muscles share in the ataxia, and the consequent retention +of urine frequently causes cystitis, and may endanger life by the +involvement of the kidneys. + +The bowels cannot be emptied or are moved without the patient's +knowledge, and these annoyances combine with the pain and nervous +apprehension to drive the victim into a melancholic or neurasthenic +state. He suffers, too, from want of occupation, from the absence of +exercise, from the anticipation of worse changes in the near future, and +usually by the time he reaches the specialist has been more or less +poisoned with iodide of potash and mercury, and perhaps with morphia. + +In the third, the paralytic stage, which seldom comes on until the +symptoms have lasted for years, there is gradual loss of power and +ataxia, increasing until he is totally unable to walk. If a patient is +not seen until this condition of things has been reached, but little can +be hoped from any treatment, though in a few cases energetic measures +may bring about a marked improvement, which is rarely lasting. + +A combination of tabes with lateral sclerosis, or with general paralysis +of the insane, is sometimes seen, but needs no special consideration. + +The first or pre-ataxic stage is, to the great detriment of patients, +too seldom recognized. The pains are called rheumatic, the eye symptoms +are lightly passed over or glasses are ordered, the difficulty of +micturition is treated by drugs, and the slightly impaired balance +unnoticed or unconsidered. + +When such a patient comes into our hands the history, and especially the +history of predisposing causes, needs the most careful examination. It +is well established that syphilis is a common precedent of ataxia, +occurring in at least two-thirds of the cases; it is even more firmly +settled that iodide and mercury in large doses do no good in advanced +ataxia. I say in advanced ataxia, because a few cases are seen in which +the syphilis has been of recent occurrence, or where the spinal symptoms +are of decidedly acute character, and in these anti-syphilitic +medication is needed and useful; but such cases should be described as +acute or subacute spinal syphilis, not as ataxia. When nerve +degeneration has once begun, iodide will do little good and mercury may +do positive harm, if used in large doses. The other common predisposing +causes, exposure to cold, over-exertion, sexual excess, need concern us +only as they suggest warnings to be given, especially when the patient +is improving. Until he does improve not much need be said about them; he +cannot indulge in venery, as sexual power is usually (though not always) +lost early in the disease; and the incoördination lessens his +opportunities of exposure or over-exertion. + +During this stage some patients complain most of the numbness, +girdle-sense, and incoördination; others of the stabbing pains or the +bladder weakness. The general treatment must be much the same, however, +in all, with special attention besides to the special needs of each +individual. + +Fatigue makes all the symptoms worse, increases pain, and impairs still +more the muscular incoördination; it is, therefore, of the first +importance in every instance to forbid all over-exertion. Walking, more +than any other form of exercise, hurts these cases. The patient should +not walk beyond his absolute necessities. To get the needed fresh air, +let him, according to his situation in life, drive out or use the +street-cars. In some cases the use of a tricycle on a level floor or on +good roads is not so harmful as walking, for obvious reasons; this +tricycle exercise may at first be made a passive or mild exercise by +having the machine pushed by an attendant. To replace the effects upon +the circulation and bowels of physical activity massage may be used, and +the masseur must have directions as to gentle handling of the tender +places at first. These are usually in fixed positions, and can be +avoided or only lightly touched. The shooting pains may be lessened by +deep, slow massage in the tracks of the nerves affected. If, as +generally happens, there are also regions of defective sensation, these +should receive after the general manipulation active, rapid circular +friction, and, perhaps, experimentally, open-hand slapping. As +constipation is one of the troublesome features, the abdomen should have +particular attention, and an unusual amount of time be given to +manipulations of the colon, as described in the chapter on massage. A +full hour's rest in bed, preferably in a darkened room, must follow the +rubbing. + +A schedule for the day on about the lines of the "partial rest" +schedule, as described on a previous page, should be followed. A +prolonged warm bath, with cool sponging after, if the latter be well +borne, is useful in lessening pains and nervous irritability,--and this +may begin the day or be used at any convenient hour. + +At an hour as far from the massage as possible lessons in co-ordinate +movements are given, after a week or ten days of massage has prepared +the muscles, and baths and a quiet life have steadied the nerves. For +many years past, certainly fifteen or sixteen, the students and +physicians who have followed my service at the Infirmary for Nervous +Diseases have seen this systematic training given, and no doubt they +received with some amusement the excitement about it as a new method of +treatment when it was proclaimed in Europe two or three years ago. + +The indication for this teaching appeared too obvious to publish or talk +much about. The patient has incoördination; one, therefore, does one's +best to teach him to co-ordinate his movements by small beginnings and +by small increases. + +The lessons may be given by the physician at first and be executed +under his eye. After a few days any tolerably intelligent patient should +be able to carry them out alone, but still each new movement should be +personally inspected to make sure that it is done correctly. + +In patients in the first stage of ataxia the most striking result of +incoördination is the impairment of station. We therefore begin with +balancing lessons. The patient is directed to stand at "Attention," head +up and chest out, not looking at his feet, as the ataxic always wishes +to do. At first this is enough to require; it will not do to be too +particular about how his feet are placed, so long as he does not +straddle. He can repeat this effort for himself a dozen times a day, for +a minute or two each time. Next we try the same position with a little +more care about getting the feet pretty near together and parallel, or +with the toes turned out only a very little. In another couple of days a +little more severity may be exercised about maintaining the correct +attitude,--heels touching, hands hanging down, and eyes looking straight +forward,--and until he is able to do this _easily_ it is best to ask +nothing more. Then he is requested to stand on one foot, being permitted +just to touch a chair-back or the attendant's hand to give confidence. +This is practised until he can keep his erect station for a few seconds +without difficulty. This point of improvement may be reached in three +days or a week or may take a fortnight. Women, as I have before +observed, although rarely in America the victims of tabes, when they do +have it have far less disturbance of balance than men, and this is to be +attributed to their life-long habit of walking without seeing their +feet. I have found in the few cases of ataxia in women that I have seen +that they benefited much more quickly by these balance instructions than +did men, though their other symptoms were in no way different. + +Continuing every day the practice of all the previous lessons, movements +are rapidly added as soon as station is better. A brief list of them +follows. When the exercises grow so numerous as to take overmuch time, +the simpler early ones may be omitted. + +When the learner is able to stand on one foot, let him slowly raise the +other and put it on a marked spot on the edge of a chair. This, like all +the other exercises, must be practised with both feet. + +Stand erect without bending forward and put one foot straight back as +far as possible. + +Do the same sideways. + +Stand and bend body slowly forward, backward, and sideways, with a +moment's rest after each motion. + +Having reached this point, I usually order the patient to practise all +these with closed eyes. When he can do this, he begins to take one or +two steps with shut eyes, first forward, then sideways, then backward. +If he falter or move without freedom, he is kept at this until he does +it confidently. Then exercises in following patterns traced on the floor +are begun. In hospitals, or where bare floors are to be found, the +patterns may be drawn with chalk. In carpeted rooms, which by the way +are less suited for the work than plain boards or parquet floors, a +piece of half-inch wide white tape may be laid in the required pattern, +first in a straight line, later, as proficiency is gained, in curved, +figure-of-eight, or angular patterns. The patient must be made to walk +_on_ the line, putting one foot directly in front of the other, with the +heel of the forward foot touching the toe of the one behind. + +Walking over obstacles is tried next. Wooden blocks measuring about six +by twelve inches and two inches thick are stood on edge at intervals of +eighteen inches and the patient walks over them, thus training several +groups of muscles; the blocks are at first set in straight lines, then +in curving patterns. An ordinary octavo book makes a good substitute for +a block. + +If the trunk muscles are affected by the ataxia, further exercises are +ordered for them, bending and twisting movements, picking up objects +from the floor, etc. For the hands and arms, which, except in those very +rare cases where the ataxia first shows itself in the upper extremities, +seldom exhibit much incoördination in the primary and middle stages, the +movements are the picking up of a series of different-shaped small +articles, arranging objects like dominoes, marbles, or the kindergarten +sticks in patterns, bringing the fingers of the two hands one after +another together, or touching a finger to the ear or the nose, at first +with open and then with shut eyes. + +With these methods, needing not more than twenty minutes three times a +day, the ataxic symptoms sometimes rapidly diminish. In certain cases no +other improvement will be observed, showing that what has taken place +is of course not an alteration of the diseased nerve-tissues for the +better, as no treatment can restore sclerotic spinal tissue to a normal +state, but is merely a substitution of function, in which other and +associated nerve-tracts have replaced in control the ones affected. + +As to the pains and bowel and bladder disturbances, their handling will +be discussed in considering the treatment of the next or middle stage of +tabes. In this period the ataxic symptoms are most prominent; the gait +has become so unsteady that the patient needs canes to walk at all and +must constantly watch his feet. He walks a little better when well under +way, but at starting or when standing still he sways and totters. The +girdle-sense is severe and constant, various pains assail the body and +limbs; the numbness of the feet, often described as a feeling "like +walking with a pillow under the foot," still further incommodes his +walking.[30] The bladder control may be so enfeebled as to require +daily catheterization, and the bowels move only with enemas or +purgatives, and often without the patient's knowledge, owing to the +anĉsthesia which affects the rectum and its vicinity. + +One of the first things to attend to when patients are in this stage is +the bladder, as the retention is the only condition likely to produce +serious disorder. Cystitis is or may be present, and with the retention +is a constant threat to the kidneys. Catheterization and washing out +with an antiseptic must be regularly practised while treatment is used +to improve the condition. + +For these patients rest in bed is a prime necessity in order to remove +all excuse for exertion. The method of application of massage has +already been suggested. Care must be taken that the patient eats well +and of the best food. Except for occasional gastric or intestinal crises +of pain, sometimes with vomiting, sometimes with diarrhoea, the +digestive functions are usually well performed, unless the stomach has +been greatly upset by over-use of iodide. The most liberal feeding +consistent with good digestion is indicated, for it must be remembered +that we are dealing with a disease in which degenerative changes play +an important part. The usefulness of electricity in ataxia has been +denied by some authors, while others praise it indiscriminately. Perhaps +a reason for this difference of opinion may be found in its different +effects upon individual patients; but I see few in whom I do not find +electricity in one or another form helpful. For pains I order the +galvanic current through the affected nerves as strong as the man is +able to bear. If after a few days of this the pains are unchanged, a +rapidly interrupted faradic current is tried, and failing to do good +with this, I use light cauterization or a series of small blisters to +the spine at the point of exit of the painful nerves. Galvanization of +the bladder with an intravesical electrode is sometimes of service to +strengthen its capacity for contraction. Faradism is applied in the form +just described, using a wire brush as an electrode to the areas of +numbness and anĉsthesia. Lately I have found that this current in a +strength which would be very painful to the normal skin will in some +instances relieve the feeling of pressure and dull discomfort about the +rectum and perineum, and it has been successful when galvanism did no +good. In patients within reach of a static machine, this form may be +used for the numbness if the others do not help it. + +For the attacks of pain, if general, a prolonged hot bath lasting from +ten to twelve minutes, at a temperature of 100° F. or even more, should +be first tried; if this fail, antipyrin, phenacetin, acetanilid, or +cannabis indica may be used, or, as a last resort, morphia. For the +local pains hot water is also useful, and in the intervals I order +applications of hot water to the tender points, as hot as can be borne, +alternating with ice-water, each rapidly applied three or four times. In +severe attacks, and with all due caution to avoid habituation, cocaine +injections may be given. In cases with high arterial tension the daily +administration of nitroglycerin in full doses will not only lower the +tension but decrease the pains in force and frequency. + +For several years past in all patients with the general lowering of +nervous force and vitality so common in this disease I have habitually +used the testicular elixir of Brown-Séquard. The ridiculous length to +which organic therapeutics have been carried, the extravagant +advertising claims, and an absurd expectation of impossible results have +combined to make the profession shy of those organic preparations which +have not very good evidence in their favor, and for some time I shared +in this prejudice against the Brown-Séquard fluid. A talk with that most +distinguished physician and an examination of some of his cases led me +to a trial for myself, and I am at present very well convinced that, +whether a physiologic basis can reasonably be assumed or not, we have in +the fluid a tonic remedy of great power. While I have used it with good +effect in other conditions, it is in ataxia that I have found it of most +value. + +The glycerin extract is freshly prepared from bulls' testicles in exact +accordance with the directions of the discoverer. It is used +hypodermatically every other day, beginning with a diluted ten-minim +dose and increasing by two or three drops up to about forty minims. The +effect is at its height twelve to twenty-four hours after the +administration in most patients, hence the reason for using it only once +in two days. The skin is prepared, the needles and syringe disinfected, +and the tiny puncture sealed afterwards with as minute care as would be +given to a surgical operation. By these precautions the danger of +abscess, always considerable if hypodermics are carelessly given, is +minimized. As the dose is large, a site must be selected for the +injection where the tissue is loose, otherwise the pain will interfere +with the desired frequency of use. The buttocks serve best, or the outer +masses of the pectoral muscles, or the abdominal muscles. If the +administration causes pain (due in part to the large quantity used and +in part to the local effect of glycerin), a fraction of a grain of +cocaine may be added to the solution when measured out for use. + +It may at once be said, emphatically, that in some cases remarkable +results have followed the use of this material, while in others no good +has been done; but the same may be said of most plans of treatment in +this disorder. As to possible danger from it, no harm has been done to +any patient known to me, except that abcesses have occurred sometimes, +though very rarely, for in many hundreds of injections it has been my +good fortune to see abscesses form only three or four times, two of +these instances, by curious ill luck, being in physicians. Patients +describe a stimulating effect not unlike that of strong coffee, +following a few hours after use and lasting for a day. The sexual +appetite, if present, is increased; if absent, it is often renewed, +sometimes in elderly men to an inconvenient extent. In one tabetic +subject who had lost desire and ability for more than three years both +returned in sufficient force to allow him to beget a child. This +patient, like most of the others, was ignorant of what drug was being +used and of what effects might be expected, so suggestion played no +part. Apart from this special effect, the solution acts only as a highly +stimulating tonic. + +The full dose of forty minims or thereabouts is maintained for a +fortnight or less, and then gradually diminished in the same way that it +was increased. Sometimes, when the effect has been good, a second +"course" may be given after two or three weeks' interval. + +During the treatment by hypodermic the masseur should be told to avoid +rubbing where the injections have been given. A few trials with the +fluid internally have produced so little result of any kind that I am +inclined to think the gastric juices must alter it so as to lessen or +wholly destroy its power. + +As to other drugs, experience has not given me much confidence in any +of those usually recommended. Strychnia, belladonna, and those +antiseptic drugs which are eliminated chiefly by the kidneys are of use +when cystitis has to be treated and the bladder muscles urged to +activity. Arsenic, the chloride of gold and sodium, and chloride of +aluminium are suggested by various authorities, but they have not been +of any value in my hands. In hopeless cases, where all treatment fails, +as will sometimes happen, or in patients in whom the paralytic stage is +already far advanced, if other measures are unsuccessful, morphia is +left as a forlorn hope, which will at least relieve their pains. + +An outline report of several cases of different types and degrees is +appended: + +M.P. of North Carolina, ĉt. thirty-seven, general health excellent until +syphilis in 1894, was admitted to the Infirmary in 1898. He had had for +two years recurrent attacks of paralysis of the external rectus muscle +of the right eye, slight gastric crises, and stabbing pains in the legs; +station very poor, but strength unimpaired, and he was able to walk +after being a few minutes on his feet; when first rising he was very +unsteady. Knee-jerk lost, no reinforcement. No sexual power. Some +difficulty in emptying the bladder. Examination showed slight atrophy of +both optic nerves, Argyll-Robertson pupil, and myosis. He was ordered +two weeks' rest in bed, with massage, cool sponging daily, and +galvanization of the areas of neuralgia. After two weeks he was allowed +to get up gradually, to occupy himself as he pleased, but not to walk. +Lessons in balance and co-ordination were begun in the fourth week of +treatment, and supervised carefully for two weeks more. When his station +and gait were both improved, he was permitted to walk, always with care +not to fatigue himself. At this time, six weeks from commencement of +treatment, his eyes were glassed by Dr. de Schweinitz. He had gained +some pounds in weight, and walked on straight lines without noticeable +incoördination, but in turning short or walking sharp curves he was +still unsteady. He found walking much easier than formerly and was less +easily tired. After nine weeks he could stand or walk, even backward, +with closed eyes. He was sent home for the summer, with directions to +continue his co-ordination movements, to walk very little, and take +such exercise as he needed on horseback, riding quietly. He had still +some stabbing pains two or three times daily. + +He reported in one month, and again in six months, "No improvement in +the pains, but I walk well and briskly, can jump on a moving street-car, +and have ridden a horse twenty miles in a day without fatigue." + +This case was in one way favorable for treatment: the patient, an +educated and intelligent man, helped in every way, carrying out minutely +all orders, and had the good sense to begin treatment early. But the +acuteness and rapidity of onset of the tabetic symptoms were so great +that in a little more than two years they had reached a condition which +most cases only attain in from five to ten years, and this makes the +prognosis somewhat less favorable. + +In the instance to be next related there was also antecedent syphilis, +and the patient had already been heavily dosed with iodides and +repeatedly salivated with mercury. His recovery was and has remained +remarkably complete. + +H.B., travelling salesman, from New York, ĉt. forty, single, a large, +strongly-made man, a hard worker, given to excesses in sexual +indulgence and alcohol for years. Syphilis was contracted fifteen years +before the first traceable symptoms of ataxia, which had shown +themselves after an attack of grippe, in 1890, in sudden remittent +paralysis of the external muscles of the right eye, followed within a +few months by gastric crises, general lightning pains appearing a few +months later. During the two years succeeding he was drenched with drugs +and grew steadily worse. When admitted to the hospital in 1892 he was +very ataxic in the legs, suffered greatly from gastric and other pains, +difficulties with bladder and rectum, loss of sexual power, various +anĉsthetic areas, could not stand with eyes open unless he had help, +total loss of knee-jerk, paralysis of right rectus, indigestion from the +irritation of the stomach from medicines as well as from the disease, +and, though muscular and over-fat, was flabby and pallid. He had no +ataxia or loss of sensibility in the upper half of the body. He was in +bed for two weeks, on milk diet, with warm baths and massage. Systematic +movements were begun and massage continued. After the stomach improved +he grew better with unusual rapidity. He is now able to work hard again, +travels extensively, can walk strongly, but wisely takes his exercise +more in the form of massage and systematic gymnastics. He appears to +report himself once or twice a year. There has been a partial return of +sexual ability. + +The next case has points of interest in the later history, but the first +examinations and early treatment may be passed over briefly. X.Y., ĉt. +forty-two, a steady, sober merchant, closely confined by his business, +always of excellent habits, with no possible suspicion of syphilis, was +seen first in 1894 in a somewhat advanced stage of tabes, but with no +optic or gastric disturbances. His station was very bad, but when once +erect and started he could walk without a stick. Girdle-pains very +marked; bowels very constipated; some trouble in emptying bladder; +several points of fixed sharp pain; lightning pain occasional and +severe, but not frequent. He was ordered to bed for six weeks. +Galvanism, alternate hot- and cold-water applications to the tender +spots, careful massage, and a two-months' course of Brown-Séquard fluid +after getting up made a new man of him. Massage and systematic exercise +were kept up together for six months. The massage was stopped and the +exercises continued, and improvement went on steadily, though the fixed +pains kept up in only slightly less severity. + +In a year the patient was better in general health, looks, and spirits +than he had been for many years before, and remained in good order, +except for the daily recurrences of paroxysms of pain of varying but not +unbearable severity for two years. He then presumed for a month on his +strength, and took much more exercise afoot than was wise, worked late +at night over his books, had some additional nervous strain from +business worries, and came to Dr. J.K. Mitchell in October, 1898, barely +able to crawl with two canes, having lost weight, become sleepless, +suffered great increase of pain, and grown so ataxic that he could +scarcely walk. This change had all occurred in three or four weeks. He +became steadily worse for two or three weeks till he could not stand or +walk at all, had cystitis from retention, violent attacks of rectal +tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with +almost total anĉsthesia of the sacral region, buttocks, scrotum, and +perineum, inability to retain fĉces, while passages from the bowels took +place without his knowledge. He found that an increase in the rectal +and abdominal pain followed lying down. He therefore spent day and night +sitting up. At the end of three weeks there was total paralysis of the +legs, and the outlook seemed most unfavorable. + +Massage was begun again, strychnia and salol were administered, and a +short course of full doses of the testicular fluid was given. A rapidly +interrupted faradic current, with an uncovered electrode, to the +neighborhood of the rectum, bladder, and buttocks, greatly relieved the +anĉsthesia, upon which galvanism had no effect; and, in brief, from a +state which looked almost as if the last paralytic stage of tabes had +suddenly come upon him, he recovered in two months, and is now (July, +1899) better than he was a year ago, before the relapse, and will +probably remain so, as he has had his warning. + +Without multiplying case histories, it may be said that ataxic +paraplegia (a combination of lateral and posterior sclerosis) may be +treated in much the same manner. In this disease there is usually much +less pain than in ataxia, but greater weakness, and late in its course +some rigidity in the extensor groups of the legs; the knee-jerk is +preserved or exaggerated. The disease is a rare one. But two recent +distinct cases are in my list, and one of these, the one here reported, +seems rather more like an ataxia with some anomalous symptoms. The +second one had the symptom, uncommon in this malady, of very frequent +and excessively severe stabbing pains, and though his co-ordination grew +somewhat better, he improved very little in any other way, which, as his +trouble was of fourteen years standing, was not astonishing. + +The other patient, seen in 1897, was a rancher from New Mexico, +thirty-three years old, who had led an active, hard-working, +much-exposed life, but had been perfectly well until 1891, when he was +said to have had an attack of spinal meningitis, from which he recovered +very slowly. Four years later he noticed numbness of feet and weakness +of legs, great enough to make it hard for him to get a leg over his +horse. Some pains were felt in the limbs, and a constriction about the +chest and abdomen, which had steadily increased in severity. Sharp +attacks left distinct bruise-marks at the seat of pain each time. Could +not empty bladder. Gait feeble, spastic, and paralytic, could not mount +steps at all or stand without aid, sway very great. Knee-jerks and +muscle-jerks increased, especially on left; ankle-clonus; very slight +loss of touch-acuity in lower half of body. Eyes: muscles and +eye-grounds negative; pupils equal and active. Bladder could not be +emptied; cystitis. Ordered rest, massage, electricity, and full doses of +iodide in skimmed milk. In this way he was able to take without distress +or indigestion amounts as large as four hundred and forty grains a day. +When education in balance, etc., was begun he could not walk without +aid, or more than a few steps in any way. In three months from the time +he went to bed he walked out-of-doors alone with no stick, and in five +months went back to work. The bladder did not improve much until after +regular washing out and intravesical galvanism were used, with full +doses of strychnia. He was soon able to empty the organ twice a day, and +since leaving the hospital writes that it gives him very little +annoyance, though as a measure of precaution he uses a catheter once +daily. His pains have entirely disappeared, and he is daily on horseback +for many hours. + +In spastic paralysis, whether in the slowly-developing forms in which it +is seen in adults, due sometimes to multiple sclerosis, sometimes to +brain tumor, sometimes following upon a transverse myelitis, or in the +central paraplegia or diplegia of "birth-palsies," some very fortunate +results have followed the careful application of the principles of +treatment already described. Absolute confinement to bed is seldom +required or in adults desirable, though exercise should be carefully +limited to an amount which can be taken without fatigue, and some hours' +rest lying down is usually advantageous. + +Assuming that the necessary treatment for the disease originating the +paralysis is to be carried on in the ordinary way, I will only describe +the special forms and methods of exercise I have found serviceable. +Whatever the cause, this will be much the same, though in birth-palsies +the teaching may have to include groups of muscles and instruction in +the co-ordination of actions which are not affected in adult subjects. + +First, as to massage: the operator must direct his efforts primarily to +the relaxation of the tense muscles, secondarily to the strengthening of +the opponent groups, this last being of special importance where actual +contraction has taken place. He should make frequent attempts by +stretching the rigid groups to overcome the spasm, which in large +muscle-masses may be done by grasping with both hands, taking care not +to pinch, and pulling the hands apart in the line of the muscle's long +axis, thus stretching the muscles. Pressure will sometimes accomplish +the same end, and it will be found in certain cases that by kneading +_during action_,--that is, while the patient endeavors to produce +voluntary contraction,--the result will be better. Except in the most +spastic states, a certain degree of relaxation is possible by effort, +though not without practice, and this has to be constantly inculcated +and encouraged. After a period varying in length according to the case, +lessons in co-ordinating movements are begun. It is best for the +patient's encouragement to start with the least affected muscles, so +that, seeing the good results, he may be stimulated to persistent +effort. The lessons differ only in detail from those given in the list +under tabes. Improvement is slower than in ataxia. + +In birth-palsy cases not much can be accomplished in the way of +education, beyond the attempt by such means as ordinary gymnastics and +lessons in drill and walking offer, until the child shall have reached +an age when he is able to comprehend what is being attempted. For the +imbecile, idiotic, or backward a training-school is the proper place, +where mental and bodily functions may both receive attention and where +constant intelligent supervision is available. + +Many children the subjects of cerebral diplegia are credited with less +intelligence than they really possess, partly because they are +necessarily backward, and partly because of their difficulty in +expressing themselves, the speech-muscles sharing in the disease. These +muscles need to be carefully educated, and this might almost be made the +subject of a treatise by itself. Each case will require study as to the +special difficulties in the way of speech. Some experience most trouble +with the vowel sounds, more find the consonants the worst obstacles. +Patient practice in forming the sounds soon produce some results; the +pupil must be taught, like the deaf mute, to watch and imitate the +movements of the lips and tongue. + +Séguin's books and the numerous special works should be consulted by the +physician or parent desiring to pursue these methods to their fullest +development. + +When once the control of muscular movement begins to improve, more +elaborate exercises may be set. In speech, if the patients be +intelligent, they will sometimes be amused and profitably trained at the +same time by the effort to learn and repeat long words or nonsensical +combinations of difficult sounds, like the "Peter Piper" nursery rhymes. + +B.M., ĉt. fourteen, an intelligent lad, of Jewish parentage, suffered a +forceps-injury at birth, and had convulsive seizures later. He began to +make futile attempts at walking when five or six years of age, when the +spastic rigidity was first noticed. His speech was better at this time +than later, and a sort of relapse seemed to be precipitated by a fall in +which he struck his head when seven years of age. His mother, finding it +almost impossible to teach him to walk, devoted herself faithfully to +improving his mind, so that at fourteen years of age he read well and +enjoyed books, and was mentally clear, observant, and docile. His speech +was almost incomprehensible,--stuttering, thick, and nasal. He stood, +swaying in every direction, though not apt to fall, with bent knees, +rounded shoulders, every muscle in the extremities rigid, the mouth +half-open, the head projected forward, and, upon attempting to move, +the toes turned in, the legs almost twined around one another, and, +unless supported, he would stumble and twist about, scarcely able to get +forward at all. With a guiding hand he did a little better. His first +lessons were in "setting-up drill," while the feeble, disused muscles +were strengthened by massage, which served at the same time to help his +very irritable and imperfect digestive apparatus, so that it was soon +possible to give him a greater variety and more nourishing kinds of food +than he had before been able to take. He was kept in bed up to three +o'clock in the afternoon, the morning hours occupied with massage and a +half-hour's lesson in erect standing, with slow trunk movements +afterwards. An hour after dinner he was dressed and taken for two hours +in a carriage or street-car. He did his reading and some study on his +return, and had another half-hour's drill, superintended by his mother. +In two or three weeks some improvement began to be observable in his +attitude, and a great change in his color and general expression, but it +was three months before it was thought wise to attempt education in +small co-ordinate movements. At about the same time speech-drill was +commenced. + +In all these lessons the greatest care was taken that adequate rest +should intervene between each series of efforts, and it was always found +that fatigue distinctly impaired his co-ordination, as did emotion or +indigestion. When his speech grew clearer he was set tasks of learning +many-syllabled words and also began to practise drawing patterns. Every +new lesson was first given under medical supervision and then continued +by his mother or by the masseur. To shorten the history it will suffice +to say that in six months he was able to go to school, where with +certain allowances made for his thick speech by a kindly master he did +well, and returned to his home in the South able to walk without +attracting attention, to speak comprehensibly, to write a good letter, +and with every prospect fair for a still greater improvement, which I +learn he has since made. + +The important things to be recognized in the treatment of these cases +are, first, that rest in proper proportion allows of the patients doing +an amount of exertion which, ungoverned, or performed in wrong ways +would harm them; secondly, that full feeding is of value, because these +disorders are mostly of the character of degenerations and involve +failure of nutrition in various directions; and, lastly, that the +exactness of routine is of the highest moral and mental as well as +physical importance. + +Paralysis agitans needs scarcely more than to be mentioned as amenable +to the same methods, with small differences in the application of +details. Body movements to counteract the tendency to rigidity in the +flexor groups of spinal muscles will be especially useful, as the +stiffness of these is one of the causes of displacement forward of the +centre of gravity, a displacement which results in the festination +symptom usually seen in such cases. Prescriptions of special exercises +for the muscle-masses particularly involved in each instance must be +given, remembering that contraction of the affected muscles will to a +certain degree overcome their rigidity even at first, and to a still +greater extent as the patient reacquires voluntary control. + + + + +INDEX. + + +Acne, caused by massage, 89. + +After-treatment, importance of, 79, 195. + +Albuminuria, from exercise, 101. + +Alcoholism producing fat, 23. + +American race peculiarities, 17, 21, 32. + +Anĉmia. _Vide_ Cases. + blood-count in, 102. + diagnosis of, 104. + effects of massage in, 101. + fatigue in, 72. + +Anĉmic obesity, 24, 128. + +Asthenia. _Vide_ Cases. + +Asthenopia, 67, 145, 149. + +Ataxia. _Vide_ Cases. + bathing in, 204, 212. + co-ordinate movements in, 204. + symptoms of, 197. + treatment of, 197. + + +Bathing, effects of, 67. + in ataxia, 204, 212. + +Birth-palsy. _Vide_ Cases. + +Bleeding, causing increase of fat, 24. + +Blood changes from massage, 99, 101, 185. + +Bowditch on weight at different ages, 17, 23. + +Bright's disease, a contraindication, 45. + +Brown-Séquard's elixir, 212. + +Brunton on effects of massage, 101. + + +Cases: + albuminuria, 183. + amenorrhoea, 149, 193. + anĉmia, extreme, 184. + aortic stenosis, 187. + asthenia, 111, 172, 182. + ataxia, 216, 218, 220. + birth-palsy, 226. + chloral habit, 150, 154, 174, 178. + hysteria, 76, 114, 154, 157, 160, 165, 181. + hysteria and neurasthenia, 112. + hystero-epilepsy, 165. + kidney, floating, 191. + morphia habit, 154, 165. + neurasthenia, 144, 171, 174. + neurasthenia and pulmonary disease, 149, 160. + obesity, anĉmic, 132, 134. + paralysis, hysterical, 134, 150. + paraplegia, ataxic, 223. + paraplegia, spastic, 228. + tabes. _Vide_ Ataxia. + uterine disease and chloral habit, 150, 154. + +Cases, selection of, 33, 60. + +Chloral habit. _Vide_ Cases. + treatment of, 137. + +Chorea, 33. + +Cod-liver oil enema, 140. + +Constipation caused by milk diet, 125. + +Contraindications to rest, etc., 45. + +Corpulence, Harvey on, 129. + + +Diet-list, 144, 146, 159. + +Dietetics, 119, 171. + +Drug-habits, treatment of, 137. + + +Eccles on massage, 101. + +Electricity, 108. + Beard on, 115. + causing insomnia, 118. + during menstruation, 90. + in ataxia, 211. + in constipation, 109. + mode of using, 108, 116. + rise of temperature from, 110, 116. + when needed, 118. + + +Face, massage of, 105. + +Fat in alcoholism, 23. + in its relation to health, 16. + increased by bleeding, 24. + milk-diet in, 128. + mode of accumulation of, 27. + reduction of, 128. + varieties of, 25. + +Food, amount of, 146, 159. + in obesity, 130. + + +Goitre, exophthalmic, 46. + +Gymnastics, Swedish, 92. + + +Harvey on corpulence, 129. + +Head, massage of, 105. + +Headache from massage, 100. + massage for, 105. + +Heart-disease, treatment of, 45. + +Hysteria. _Vide_ Cases. + + +Introduction, 9. + +Iodide in ataxia, 201. + +Iron, use of, 142. + + +Jackson on rest, 58. + + +Karell on milk-treatment, 120, 128. + +Keen on albuminuria, 101. + +Kidney, floating. _Vide_ Cases. + belt for, 190. + treatment of, 48, 66, 189. + + +Letheby on fattening stock, 26. + + +Malt extract, 138. + Japanese extract of, 141. + +Marshall on urinary changes, 127. + +Massage, 80. + abdominal, 86. + amount of, 92. + blood-changes from, 101. + causing acne, 89. + causing headache, 100. + chilliness from, 91. + during convalesence, 34. + during menstruation, 90. + Eccles on, 101. + effect on temperature, 93. + effects of general, 98, 101. + frequency of use, 90. + in anĉmia, 101. + in heart-disease, 46. + in spastic paralysis, 225. + Lauder-Brunton on, 101. + lubricant undesirable in, 89. + of face, 105. + of head, 105. + order of application, 82, 91. + sexual excitement from, 91. + why useful, 98. + +Melancholia, treatment of, 46. + +Menstruation, effects of rest on, 149, 193. + electricity during, 90. + massage during, 90. + +Milk, in alcoholism, 137. + in chloral habit, 137. + pasteurized, 121. + peptonized, 122. + quantity to be used, 123. + sterilization of, 121. + +Milk diet, 119. + constipation caused by, 125. + disappearance of uric acid during use of, 126. + effects of, on urinary pigments, 126. + general effects of, 124. + in obesity, 128. + in obesity with anĉmia, 128. + Karell on, 120, 128. + precautions in using, 123. + sleepiness from, 125. + stools during use of, 125. + urinary changes from, 126. + +Morphia habit, treated by rest, etc., 137, 154, 165. + +Movements, co-ordinate, in ataxia, 204. + in paralysis agitans, 231. + in paraplegia, 223. + in spastic paralysis, 226. + Swedish, 92. + + +Neurasthenia. _Vide_ Cases. + +Nurse, choice of, 53. + + +Obesity, milk diet in, 128. + with anĉmia, 128. + with anĉmia. _Vide_ Cases. + +Ovarian disorders treated by rest, etc., 47. + + +Paralysis agitans, 231. + +Paraplegia, ataxic, 223. + spastic, 228. + +Partial rest, 63. + schedule for, 64. + +Peculiarities of American race, 17, 21, 32. + +Phthisis, gain of weight in, 35. + Pollock on, 35. + +Playfair on nerve-prostration, 12, 150. + + +Quetelet on gain of weight at different ages, 17. + + +Rest, 57. + definition of, 62. + effects of, on menstruation, 149, 193. + in ataxia, 203, 210, 230. + in neuralgia, 58. + in spinal disease, 58, 197, 230. + Jackson on, 58. + length of, 66, 68. + mental, 71. + mode of terminating, 63, 78. + moral uses of, 69. + partial, 62. + reasons for, 61, 70, 182. + + +Schedule for partial rest, 64. + +Seclusion, 50. + +Selection of cases, 33, 60. + +Soup, raw, mode of making, 139. + +Spine, irritable, 163, 178. + +Syphilis preceding tabes, 198, 201. + + +Tabes. _Vide_ Ataxia. + +Temperature after electric treatment, 110, 116. + after massage, 93. + +Treatment, season for, 53. + selection of cases for, 33. + + +Urinary pigments, changes in, during milk diet, 126. + + +Weight at different ages, Bowditch on, 17, 23. + gain or loss of, 14. + loss of, relation to an anĉmia, 15. + Quetelet on, 17. + + + + +THE END. + +FOOTNOTES: + +[Footnote 1: The Systematic Treatment of Nerve Prostration and Hysteria. +London, 1883.] + +[Footnote 2: The Pennsylvania Orthopĉdic Hospital and Infirmary for +Diseases of the Nervous System.] + +[Footnote 3: Sur l'Homme, p. 47, et seq.] + +[Footnote 4: Growth of Children, p. 31.] + +[Footnote 5: See a valuable paper by Dr. Gerhard, Am. Jour. Med. Sci., +1876. Also Lectures on Diseases of the Nervous System, especially in +Women. S. Weir Mitchell. Phila., 1881, p. 127. See also the papers by +Dr. Morris J. Lewis on the seasonal relations of chorea, analyzing seven +hundred and seventeen cases of chorea as to the months of onset (Trans. +Assoc. Amer. Phys., 1892), and Osler On Chorea (1894).] + +[Footnote 6: Statistics (Anthropological) Surgeon-General's +Bureau--1875.] + +[Footnote 7: This excess of corpulence in the English is attained +chiefly after forty, as I have said. The average American is taller than +the average Englishman, and is fully as well built in proportion to his +height, as Gould has shown. The child of either sex in New England is +both taller and heavier than the English child of corresponding class +and age, as Dr. H.I. Bowditch has lately made clear; while the English +of the manufacturing and agricultural classes are miserably inferior to +the members of a similar class in America.] + +[Footnote 8: Zeitschrift für Biol., 1872. Phila. Med. Times, vol. iii., +page 115.] + +[Footnote 9: Letheby on Food, pp. 39, 40, 41.] + +[Footnote 10: Am. Jour. Med. Sci.; Proc. Phil. Coll. of Phys., 1883; +Phil. Med. News, April, 1883.] + +[Footnote 11: Chorea. See Lancet, Aug. 1882.] + +[Footnote 12: "Nurse and Patient." S. Weir Mitchell. Lippincott's +Magazine, Dec. 1872.] + +[Footnote 13: See Philip Karell's remarks on the use of treatment by +milk in cardiac hypertrophy. Edin. Med. Jour., Aug. 1866.] + +[Footnote 14: Trans. Obst. Soc. of London, vol. xxxiii.] + +[Footnote 15: Séguin Lecture, _op. cit._] + +[Footnote 16: "Pinch" is used to avoid the use of a technical term, but +should be understood to mean the grasping and squeezing of a part with +the whole hand, using the palmar portion of the fingers to press the +grasped mass against the "heel" of the hand. Fuller technical details of +the massage process and consideration of its effects will be found in +the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham, +Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's +"System of Medicine" (1896), by Dr. John K. Mitchell.] + +[Footnote 17: Dr. Symon Eccles in "The Practice of Massage" recommends +this order.] + +[Footnote 18: Some care is needed not to overwork patients. For details +I must refer to manuals of Swedish Gymnastics.] + +[Footnote 19: See also page 91.] + +[Footnote 20: A number of observations in late years have been made upon +the effect of massage upon elimination. Among the articles to which the +practitioner desiring further to study this subject may be referred +are,-- + +_Edin. Clin. and Path. Jour_., Aug., 1884. + +_Jour, of Physiol._, vol. xxii., p. 68. + +_Centralbl. f. Inner. Med._, 1894, No. 40, p. 944. + +_Munch. Med. Woch._, April 11 and April 18, 1899 (Influence of bodily +exercise upon temperature in health and disease). + +Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque +and Marette, and Maggiora.] + +[Footnote 21: American Journal of the Medical Sciences, May, 1894.] + +[Footnote 22: Numerous examinations made since have quite uniformly +agreed with the former remarkably constant results.] + +[Footnote 23: J.K. Mitchell, _loc. cit._] + +[Footnote 24: Most induction batteries are without any arrangement for +making infrequent breaks in the current.] + +[Footnote 25: In the extreme constipation of certain hysterical women, +good may be done by placing one conductor in the rectum and moving the +other over the abdomen so as to cause full movement of the muscles. This +means must at first be employed cautiously, and the amount of +electricity carefully increased. It is doubtful if any movement of the +intestinal muscle-fibres is thus caused, but that it is a useful method +of stimulation in obstinate cases may be taken as proved.] + +[Footnote 26: Harvey on Corpulence.] + +[Footnote 27: The management of the morphia or chloral habit becomes +much more easy under a milk diet, massage, and absolute rest, and I can +with confidence commend their use in these difficult cases. Massage in +the morning is liked, and general surface-rubbing without +muscle-kneading at night very often proves remarkably soothing, while +the rest in bed cuts off many opportunities to indulge in the temptation +to secure the desired drugs.] + +[Footnote 28: I have found that this may be usefully replaced by one of +the numerous peptonized foods described in the pamphlets issued by the +manufacturers of the peptonizing powders. The ready-made peptonized +preparations vary very much, like some of the beef extracts, but a trial +will discover which of them is best fitted for an individual case.] + +[Footnote 29: Nerve Prostration and Hysteria.] + +[Footnote 30: It is worth mentioning that where ataxic patients have to +use canes, a crutch-cane with a base some six or eight inches long and +well shod with roughened rubber is far more useful and safer than the +ordinary stick.] + + + + + +End of the Project Gutenberg EBook of Fat and Blood, by S. 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Weir Mitchell + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Fat and Blood + An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria + +Author: S. Weir Mitchell + +Editor: John K. Mitchell + +Release Date: July 7, 2005 [EBook #16230] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK FAT AND BLOOD *** + + + + +Produced by Kathryn Lybarger, Janet Blenkinship and the +Online Distributed Proofreading Team at https://www.pgdp.net + + + + + + +</pre> + +<p><a name="Page_1" id="Page_1"></a></p><p><a name="Page_2" id="Page_2"></a></p><p><a name="Page_3" id="Page_3"></a></p> + + + + + +<h1>FAT AND BLOOD:</h1> + +<h3>AN ESSAY ON THE TREATMENT OF CERTAIN FORMS OF</h3> + +<h3>NEURASTHENIA AND HYSTERIA.</h3> + + +<p class='center'>BY</p> + +<h2>S. WEIR MITCHELL, M.D., LL.D. HARV.,</h2> + +<h3>MEMBER OF THE NATIONAL ACADEMY OF SCIENCES.</h3> + + + +<p><i>EIGHTH EDITION.</i></p> + + +<p>EDITED, WITH ADDITIONS, BY</p> + +<p>JOHN K. MITCHELL, M.D.</p> + + + +<p>PHILADELPHIA:</p> + +<p>J.B. LIPPINCOTT COMPANY.</p> + +<p>LONDON: 5 HENRIETTA STREET, COVENT GARDEN</p> + +<p>1911.</p> + +<p><a name="Page_4" id="Page_4"></a>Copyright, 1877, by J.B. LIPPINCOTT & CO.</p> + +<p>Copyright, 1883, by J.B. LIPPINCOTT & CO.</p> + +<p>Copyright, 1891, by J.B. LIPPINCOTT COMPANY.</p> + +<p>Copyright, 1897, by J.B. LIPPINCOTT COMPANY.</p> + +<p>Copyright, 1900, by J.B. LIPPINCOTT COMPANY.</p> + +<p>Copyright, 1905, by S. WEIR MITCHELL.</p> + + +<p>ELECTROTYPED AND PRINTED BY J.B. LIPPINCOTT COMPANY, PHILADELPHIA, +U.S.A.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_5" id="Page_5"></a></p> +<h2><a name="PREFACE_TO_THE_EIGHTH_EDITION" id="PREFACE_TO_THE_EIGHTH_EDITION"></a>PREFACE TO THE EIGHTH EDITION.</h2> + + +<p>The continued favor which this book has enjoyed in Europe as well as in +this country has rendered me doubly desirous to make it a thorough and +clear statement of the treatment of the kind of cases which it discusses +as carried out in my practice to-day.</p> + +<p>In the endeavor to do this, the present edition, like the last two, has +been carefully revised by my son, Dr. John K. Mitchell, and there is no +chapter, and scarcely a page, where some alteration or addition has not +been made, besides those of the sixth and seventh editions, as the +result of added years of experience. Especially in the chapters on the +means of treatment some details have been thought worth adding to help +the statement so often repeated in the book that success will depend on +the care with which details are carried out. The chapter on massage, +rewritten for the last edi<a name="Page_6" id="Page_6"></a>tion, has been once more revised and somewhat +extended, in order to make it an accurate as well as a scientific, if +brief, statement of the best method which use and observation have +taught us. A chapter on the handling of several diseases not described +in former editions has been added by the editor.</p> + +<p>S. WEIR MITCHELL.</p> + +<p>SEPTEMBER, 1899.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_7" id="Page_7"></a></p> +<h2><a name="CONTENTS" id="CONTENTS"></a>CONTENTS.</h2> + +<!-- Autogenerated TOC. Modify or delete as required. --> +<p> +<a href="#PREFACE_TO_THE_EIGHTH_EDITION"><b>PREFACE TO THE EIGHTH EDITION.</b></a><br /> +<a href="#CHAPTER_I"><b>CHAPTER I. INTRODUCTORY</b></a><br /> +<a href="#CHAPTER_II"><b>CHAPTER II. GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED</b></a><br /> +<a href="#CHAPTER_III"><b>CHAPTER III. ON THE SELECTION OF CASES FOR TREATMENT</b></a><br /> +<a href="#CHAPTER_IV"><b>CHAPTER IV. SECLUSION</b></a><br /> +<a href="#CHAPTER_V"><b>CHAPTER V. REST</b></a><br /> +<a href="#CHAPTER_VI"><b>CHAPTER VI. MASSAGE</b></a><br /> +<a href="#CHAPTER_VII"><b>CHAPTER VII. ELECTRICITY</b></a><br /> +<a href="#CHAPTER_VIII"><b>CHAPTER VIII. DIETETICS AND THERAPEUTICS</b></a><br /> +<a href="#CHAPTER_IX"><b>CHAPTER IX. DIETETICS AND THERAPEUTICS—(<i>Continued</i>)</b></a><br /> +<a href="#CHAPTER_X"><b>CHAPTER X. THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC +PARAPLEGIA, SPASTIC PARALYSIS, AND PARALYSIS +AGITANS</b></a><br /> +<a href="#INDEX"><b>INDEX.</b></a><br /> +</p> +<!-- End Autogenerated TOC. --> + + + + + +<hr style="width: 65%;" /><p><a name="Page_9" id="Page_9"></a></p> +<h3><a name="CHAPTER_I" id="CHAPTER_I"></a>CHAPTER I.</h3> + +<h4>INTRODUCTORY.</h4> + + +<p>For some years I have been using with success, in private and in +hospital practice, certain methods of renewing the vitality of feeble +people by a combination of entire rest and excessive feeding, made +possible by passive exercise obtained through the steady use of massage +and electricity.</p> + +<p>The cases thus treated have been chiefly women of a class well known to +every physician,—nervous women, who, as a rule, are thin and lack +blood. Most of them have been such as had passed through many hands and +been treated in turn for gastric, spinal, or uterine troubles, but who +remained at the end as at the beginning, invalids, unable to attend to +the duties of life, and sources alike of discomfort to themselves and +anxiety to others.</p> + +<p>In 1875 I published in "Séguin's Series of American Clinical Lectures," +Vol. I., No. iv., a brief sketch of this treatment, under the heading +<a name="Page_10" id="Page_10"></a>of "Rest in the Treatment of Nervous Disease," but the scope afforded +me was too brief for the details on a knowledge of which depends success +in the use of rest, I have been often since reminded of this by the many +letters I have received asking for explanations of the minutiæ of +treatment; and this must be my apology for bringing into these pages a +great many particulars which are no doubt well enough known to the more +accomplished physician.</p> + +<p>In the preface to the second edition I said that as yet there had been +hardly time for a competent verdict on the methods I had described. +Since making this statement, many of our profession in America have +published cases of the use of my treatment. It has also been thoroughly +discussed by the medical section of the British Medical Association, and +warmly endorsed by William Playfair, of London, Ross of Manchester, +Coghill, and others; while a translation of my book into French by Dr. +Oscar Jennings, with an introduction by Professor Ball, and a +reproduction in German, with a preface by Professor von Leyden, have +placed it satisfactorily before the profession in France and Germany.</p> + +<p><a name="Page_11" id="Page_11"></a>As regards the question of originality I did not and do not now much +concern myself. This alone I care to know, that by the method in +question cases are cured which once were not; and as to the novelty of +the matter it would be needless to say more, were it not that the charge +of lack of that quality is sometimes taken as an imputation on a man's +good faith.</p> + +<p>But to sustain so grave an implication the author must have somewhere +laid claim to originality and said in what respect he considered himself +to have done a totally new thing. The following passage from the first +edition of this book explains what was my own position:</p> + +<p>"I do not wish," I wrote, "to be thought of as putting forth anything +very remarkable or original in my treatment by rest, systematic feeding, +and passive exercise. All of these have been used by physicians; but, as +a rule, one or more are used without the others, and the plan which I +have found so valuable, of combining these means, does not seem to be +generally understood. As it involves some novelty, and as I do not find +it described elsewhere, I shall, I think, be doing a service to my +profession by relating my experience."</p> + +<p><a name="Page_12" id="Page_12"></a>The following quotation from Dr. William Playfair's essay<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> says all +that I would care to add:</p> + +<div class="blockquot"><p>"The claims of Dr. Weir Mitchell to originality in the introduction +of this system of treatment, which I have recently heard contested +in more than one quarter, it is not my province to defend. I feel +bound, however, to say that, having carefully studied what has been +written on the subject, I can nowhere find anything in the least +approaching to the regular, systematic, and thorough attack on the +disease here discussed.</p> + +<p>"Certain parts of the treatment have been separately advised, and +more or less successfully practised, as, for example, massage and +electricity, without isolation; or isolation and judicious moral +management alone. It is, in fact, the old story with regard to all +new things: there is no discovery, from the steam-engine down to +chloroform, which cannot be shown to have been partially foreseen, +and yet the claims of Watt and Simpson to originality remain +practically un<a name="Page_13" id="Page_13"></a>contested. And so, if I may be permitted to compare +small things with great, will it be with this. The whole matter was +admirably summed up by Dr. Ross, of Manchester, in his remarks in +the discussion I introduced at the meeting of the British Medical +Association at Worcester, which I conceive to express the precise +state of the case: 'Although Dr. Mitchell's treatment was not new +in the sense that its separate recommendations were made for the +first time, it was new in the sense that these recommendations were +for the first time combined so as to form a complete scheme of +treatment.'"</p></div> + +<p>As regards the acceptance of this method of treatment I have to-day no +complaint to make. It runs, indeed, the risk of being employed in cases +which do not need it and by persons who are not competent, and of being +thus in a measure brought into disrepute. As concerns one of its +essentials—massage—this is especially to be feared. It is a remedy +with capacity to hurt as well as to help, and should never be used +without the advice of a physician, nor persistently kept up without +medical observation of its temporary and more permanent effects.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_14" id="Page_14"></a></p> +<h3><a name="CHAPTER_II" id="CHAPTER_II"></a>CHAPTER II.</h3> + +<h4>GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED.</h4> + + +<p>The gentlemen who have done me the honor to follow my clinical service +at the State Infirmary for Diseases of the Nervous System<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> are well +aware how much care is there given to learn whether or not the patient +is losing or has lost flesh, is by habit thin or fat. This question is +one of the utmost moment in every point of view, and deserves a larger +share of attention than it receives. In this hospital it is the custom +to weigh our cases when they enter and at intervals. The mere loss of +fat is probably of small moment in itself when the amount of restorative +food is sufficient for every-day expenditure, and when the organs are in +condition to keep up the supply of fat which we not only require for +constant use but probably need to <a name="Page_15" id="Page_15"></a>change continually. The steady or +rapid lessening of the deposits of hydro-carbons stored away in the +areolæ of the tissues is of importance, as indicating their excessive +use or a failure of supply; and when either condition is to be suspected +it becomes our duty to learn the reasons for this striking symptom. Loss +of flesh has also a collateral value of great import, because it is +almost an invariable rule that rapid thinning is accompanied soon or +late with more or less anæmia, and it is uncommon to see a person +steadily gaining fat after any pathological reduction of weight without +a corresponding gain in amount and quality of blood. We too rarely +reflect that the blood thins with the decrease of the tissues and +enriches as they increase.</p> + +<p>Before entering into this question further, I shall ask attention to +some points connected with the normal fat of the human body; and, taking +for granted, here and elsewhere, that my readers are well enough aware +of the physiological value and uses of the adipose tissues, I shall +continue to look at the matter chiefly from a clinical point of view.</p> + +<p>When in any individual the weight varies rapidly or slowly, it is nearly +always due, for the <a name="Page_16" id="Page_16"></a>most part, to a change in the amount of adipose +tissue stored away in the meshes of the areolar tissue. Almost any grave +change for the worse in health is at once betrayed in most people by a +diminution of fat, and this is readily seen in the altered forms of the +face, which, because it is the always visible and in outline the most +irregular part of the body, shows first and most plainly the loss or +gain of tissue. Fatty matter is therefore that constituent of the body +which goes and comes most easily. Why there is in nearly every one a +normal limit to its accumulation we cannot say, nor yet why this limit +should vary as life goes on. Even in health the weight of men, and still +more of women, is by no means constant, but, as a rule, when we are +holding our own with that share of stored-up fat which belongs to the +individual we are usually in a condition of nutritive prosperity, and +when after any strain or trial which has lessened weight we are slowly +repairing mischief and laying by fat we are equally in a state of +health. The loss of fat which is not due to change of diet or to +exercise, especially its rapid or steady loss, nearly always goes along +with conditions which impoverish the blood, and, on the other hand, the +gain of fat <a name="Page_17" id="Page_17"></a>up to a certain point seems to go hand in hand with a rise +in all other essentials of health, and notably with an improvement in +the color and amount of the red corpuscles.</p> + +<p>The quantity of fat which is healthy for the individual varies with the +sex, the climate, the habits, the season, the time of life, the race, +and the breed. Quetelet<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> has shown that before puberty the weight of +the male is for equal ages above that of the female, but that towards +puberty the proportional weight of the female, due chiefly to gain in +fat, increases, so that at twelve the two sexes are alike in this +respect. During the child-bearing time there is an absolute lessening on +the part of the female, but after this time the weight of the woman +increases, and the maximum is attained at about the age of fifty.</p> + +<p>Dr. Henry I. Bowditch<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> reaches somewhat similar conclusions, and shows +from much more numerous measurements of Boston children that growing +boys are heavier in proportion to their height than girls until they +reach fifty-eight inches, which is attained about the fourteenth <a name="Page_18" id="Page_18"></a>year. +Then the girl passes the boy in weight, which Dr. Bowditch thinks is due +to the accumulation of adipose tissue at puberty. After two or three +years more the male again acquires and retains superiority in weight and +height.</p> + +<p>Yet as life advances there are peculiarities which belong to individuals +and to families. One group thins as life goes on past forty; another +group as surely takes on flesh; and the same traits are often inherited, +and are to be regarded when the question of fattening becomes of +clinical or diagnostic moment. Men, as a rule, preserve their nutritive +status more equably than women. Every physician must have been struck +with this. In fact, many women lose or acquire large amounts of adipose +matter without any corresponding loss or gain in vigor, and this fact +perhaps is related in some way to the enormous outside demands made by +their peculiar physiological processes. Such gain in weight is a common +accompaniment of child-bearing, while nursing in some women involves +considerable gain in flesh, and in a larger number enormous falling +away, and its cessation as speedy a renewal of fat. I have also found +that in many women who are not perfectly well there is a <a name="Page_19" id="Page_19"></a>notable loss +of weight at every menstrual period, and a marked gain between these +times.</p> + +<p>I was disappointed not to find this matter dealt with fully in Mrs. +Jacobi's able essay on menstruation, nor can I discover elsewhere any +observations in regard to loss or gain of weight at menstrual periods in +the healthy woman.</p> + +<p>How much influence the seasons have, is not as yet well understood, but +in our own climate, with its great extremes, there are some interesting +facts in this connection. The upper classes are with us in summer placed +in the best conditions for increase in flesh, not only because it is +their season of least work, mental and physical, but also because they +are then for the most part living in the country under circumstances +favorable to appetite, to exercise, and to freedom from care. Owing to +these fortunate facts, members of the class in question are apt to gain +weight in summer, although many such persons, as I know, follow the more +general rule and lose weight. But if we deal with the mass of men who +are hard worked, physically, and unable to leave the towns, we shall +probably find that they nearly always lose weight in hot weather. Some +support is given to this idea by the following very curi<a name="Page_20" id="Page_20"></a>ous facts. Very +many years ago I was engaged for certain purposes in determining the +weight, height, and girth of all the members of our city police force. +The examination was made in April and repeated in the beginning of +October. Every care was taken to avoid errors, but to my surprise I +found that a large majority of the men had lost weight during the +summer. The sum total of loss was enormous. As I have mislaid some of +the sheets, I am unable to give it accurately, but I found that three +out of every five had lessened in weight. It would be interesting to +know if such a change occurs in convicts confined in penitentiaries.</p> + +<p>I am acquainted with some persons who lose weight in winter, and with +more who fail in flesh in the spring, which is our season of greatest +depression in health,—the season when with us choreas are apt to +originate<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> or to recur, and <a name="Page_21" id="Page_21"></a>when habitual epileptic fits become more +frequent in such as are the victims of that disease.</p> + +<p>Climate has a good deal to do with a tendency to take on fat, and I +think the first thing which strikes an American in England is the number +of inordinately fat middle-aged people, and especially of fat women.</p> + +<p>This excess of flesh we usually associate in idea with slothfulness, but +English women exercise more than ours, and live in a land where few days +forbid it, so that probably such a tendency to obesity is due chiefly to +climatic causes. To these latter also we may no doubt ascribe the habits +of the English as to food. They are larger feeders than we, and both +sexes consume strong beer in a manner which would in this country be +destructive of health. These habits aid, I suspect, in producing the +more general fatness in middle and later life, and those enormous +occasional growths which so amaze an American when first he sets foot in +London. But, whatever be the cause, it is probable that members of the +prosperous classes of English, over forty, would outweigh the average +American of equal height of that period, and this must make, I should +think, some difference in their relative <a name="Page_22" id="Page_22"></a>liability to certain forms of +disease, because the overweight of our trans-Atlantic cousins is plainly +due to excess of fat.</p> + +<p>I have sought in vain for English tables giving the weight of men and +women of various heights at like ages. The material for such a study of +men in America is given in Gould's researches published by the United +States Sanitary Commission, and in Baxter's admirable report,<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> but is +lacking for women. A comparison of these points as between English and +Americans of both sexes would be of great interest.</p> + +<p>I doubt whether in this country as notable a growth in bulk as +multitudes of English attain would be either healthy or desirable in +point of comfort, owing to the distress which stout people feel in our +hot summer weather. Certainly "Banting" is with us a rarely-needed +process, and, as a rule, we have much more frequent occasion to fatten +than to thin our patients. The climatic peculiarities which have changed +our voices, sharpened our features, and made small the American hand and +foot, have also made us, in middle and advanced life, a thinner <a name="Page_23" id="Page_23"></a>and +more sallow race, and, possibly, adapted us better to the region in +which we live. The same changes in form are in like manner showing +themselves in the English race in Australia.<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a></p> + +<p>Some gain in flesh as life goes on is a frequent thing here as +elsewhere, and usually has no unwholesome meaning. Occasionally we see +people past the age of sixty suddenly taking on fat and becoming at once +unwieldy and feeble, the fat collecting in masses about the belly and +around the joints. Such an increase is sometimes accompanied with fatty +degeneration of the heart and muscles, and with a certain watery +flabbiness in the limbs, which, however, do not pit on pressure.</p> + +<p>Alcoholism also gives rise in some people to a vast increase of adipose +tissue, and the sodden, unwholesome fatness of the hard drinker is a +<a name="Page_24" id="Page_24"></a>sufficiently well known and unpleasant spectacle. The overgrowth of +inert people who do not exercise enough to use up a healthy amount of +overfed tissues is common enough as an individual peculiarity, but there +are also two other conditions in which fat is apt to be accumulated to +an uncomfortable extent. Thus, in some cases of hysteria where the +patient lies abed owing to her belief that she is unable to move about, +she is apt in time to become enormously stout. This seems to me also to +be favored by the large use of morphia to which such women are prone, so +that I should say that long rest, the hysterical constitution, and the +accompanying resort to morphia make up a group of conditions highly +favorable to increase of fat.</p> + +<p>Lastly, there is the class of fat anæmic people, usually women. This +double peculiarity is rather uncommon, but, as the mass of thin-blooded +persons are as a rule thin or losing flesh, there must be something +unusual in that anæmia which goes with gain in flesh.</p> + +<p>Bauer<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a> thinks that lessened number of blood-corpuscles gives rise to +storing of fat, owing to <a name="Page_25" id="Page_25"></a>lessened tissue-combustion. At all events, the +absorption of oxygen diminishes after bleeding, and it used to be well +known that some people grew fat when bled at intervals. Also, it is said +that cattle-breeders in some localities—certainly not in this +country—bleed their cattle to cause increase of fat in the tissues, or +of fat secreted as butter in the milk. These explanations aid us but +little to comprehend what, after all, is only met with in certain +persons, and must therefore involve conditions not common to every one +who is anæmic. Meanwhile, the group of fat anæmics is of the utmost +clinical interest, as I shall by and by point out more distinctly.</p> + +<p>There is a popular idea, which has probably passed from the +agriculturist into the common mind of the community, to the effect that +human fat varies,—that some fat is wholesome and some unwholesome, that +there are good fats and bad fats. I remember well an old nurse who +assured me when I was a student that "some fats is fast and some is +fickle, but cod-oil fat is easy squandered."</p> + +<p>There are more facts in favor of some such idea than I have place for, +but as yet we have no distinct chemical knowledge as to whether the +<a name="Page_26" id="Page_26"></a>fats put on under alcohol or morphia, or rapidly by the use of oils, or +pathologically in fatty degenerations, or in anæmia, vary in their +constituents. It is not at all unlikely that such is the case, and that, +for example, the fat of an obese anæmic person may differ from that of a +fat and florid person. The flabby, relaxed state of many fat people is +possibly due not alone to peculiarities of the fat, but also to want of +tone and tension in the areolar tissues, which, from all that we now +know of them, may be capable of undergoing changes as marked as those of +muscles.</p> + +<p>That, however, animals may take on fat which varies in character is well +known to breeders of cattle. "The art of breeding and feeding stock," +says Dr. Letheby,<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> "is to overcome excessive tendency to accumulation +of either surface fat or visceral fat, and at the same time to produce a +fat which will not melt or boil away in cooking. Oily foods have a +tendency to make soft fats which will not bear cooking." Such +differences are also seen between English and American bacon, the former +being much more <a name="Page_27" id="Page_27"></a>solid; and we know, also, that the fat of different +animals varies remarkably, and that some, as the fat of hay-fed horses, +is readily worked off. Such facts as these may reasonably be held to +sustain the popular creed as to there being bad fats and good fats, and +they teach us the lesson that in man, as in animals, there may be a +difference in the value of the fats we acquire, according as they are +gained by one means or by another.</p> + +<p>The recent researches of L. Langer have certainly shown that the fatty +tissues of man vary at different ages, in the proportion of the fatty +acids they contain.</p> + +<p>I have had occasion, of late years, to watch with interest the process +of somewhat rapid but quite wholesome gain in flesh in persons subjected +to the treatment which I shall by and by describe. Most of these persons +were treated by massage, and I have been accustomed to question the +masseur or masseuse as to the manner in which the change takes place. +Usually it is first seen in the face and neck, then it is noticed in the +back and flanks, next in the belly, and finally in the limbs, the legs +coming last in the order of gain, and sometimes remaining comparatively +thin long after other parts have <a name="Page_28" id="Page_28"></a>made remarkable and visible gain. +These observations have been checked by careful measurements, so that I +am sure of their correctness for people who fatten while at rest in bed. +The order of increase might be different in people who fatten while +afoot.</p> + +<p>Facts of this nature suggest that the putting on of fat must be due to +very generalized conditions, and be less under the control of local +causes than is the nutrition of muscles, for, while it is true that in +wasting from nerve-lesions the muscular and fatty tissues alike lessen, +it is possible to cause by exercise rapid increase in the bulk of muscle +in a limb or a part of a limb, but not in any way to cause direct and +limited local increment of fat.</p> + +<p>Looking back over the whole subject, it will be well for the physician +to remember that increase of fat, to be a wholesome condition, should be +accompanied by gain in quantity and quality of blood, and that while +increase of flesh after illness is desirable, and a good test of +successful recovery, it should always go along with improvement in +color. Obesity with thin blood is one of the most unmanageable +conditions I know of.</p> + +<p>The exact relations of fatty tissue to the states <a name="Page_29" id="Page_29"></a>of health are not as +yet well understood; but, since on great exertion or prolonged mental or +moral strain or in low fevers we lose fat rapidly, it may be taken for +granted that each individual should possess a certain surplus of this +readily-lost material. It is the one portion of our body which comes and +goes in large amount. Even thin people have it in some quantity always +ready, and, despite the fluctuations, every one has a standard share, +which varies at different times of life. The mechanism which limits the +storing away of an excess is almost unknown, and we are only aware that +some foods and lack of exertion favor growth in fat, while action and +lessened diet diminish it; but also we know that while any one can be +made to lose weight, there are some persons who cannot be made to gain a +pound by any possible device, so that in this, as in other things, to +spend is easier than to get; although it is clear that the very thin +must certainly live, so to speak, from hand to mouth, and have little +for emergencies. Whether fat people possess greater power of resistance +as against the fatal wasting of certain maladies or not, does not seem +to be known, and I fancy that the popular medical belief is rather +opposed to <a name="Page_30" id="Page_30"></a>a belief in the vital endurance of those who are unusually +fat.</p> + +<p>That I am not pushing too far this idea of the indicative value of gain +of weight may be further seen in persons who suffer from some incurable +chronic malady, but who are in other respects well. The relief from +their disease, even if temporary, is apt to be signalled by abrupt gain +in weight. A remarkable illustration is to be found in those who suffer +periodically from severe pain. Cessation of these attacks for a time is +sure to result in the putting on of flesh. The case of Captain +Catlin<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a> is a good example. Owing to an accident of war, he lost a +leg, and ever since has had severe neuralgic pain referred to the lost +leg. These attacks depend almost altogether on storms. In years of +fewest storms they are least numerous, and the bodily weight, which is +never insufficient, rises. With their increase it lowers to a certain +amount, beneath which it does not fall. His weight is, therefore, +indirectly dependent upon the number of storms to the influence of which +he is exposed.</p> + +<p><a name="Page_31" id="Page_31"></a>At present, however, we have to do most largely with the means of +attaining that moderate share of stored-away fat which seems to indicate +a state of nutritive prosperity and to be essential to those physical +needs, such as protection and padding, which fat subserves, no less than +to its æsthetic value, as rounding the curves of the human form.</p> + +<p>The study of the amount of the different forms of diet which is needed +by people at rest, and by those who are active, is valuable only to +enable us to construct dietaries with care for masses of men and where +economy is an object. In dealing with cases such as I shall describe, it +is needful usually to give and to have digested a surplus of food, so +that we are more concerned now to know the forms of food which thin or +fatten, and the means which aid us to digest temporarily an excess.</p> + +<p>As to quantity, it suffices to say that while by lessening food we may +easily and surely make people lose weight, we cannot be sure to fatten +by merely increasing the amount of food given; something more is wanted +in the way of digestives or tonics to enable the patient to prepare and +appropriate what is given, and but too often <a name="Page_32" id="Page_32"></a>we fail miserably in all +our means of giving capacity to assimilate food. As I have said before, +and wish to repeat, to gain in fat is, in the feeble, nearly always to +gain in blood; and I hope to point out in these pages some of the means +by which these ends can be attained.</p> + +<div class="blockquot"><p><i>Note</i>.—The statements made on page 21 and the following +paragraphs about obesity in England and with us are no longer +exact, but have been allowed to stand in the text as recording +facts true at the time of writing them, in 1877. At the present a +medical observer familiar with both countries must note several +decided changes: more fat people, more people even enormously +stout, are seen with us than formerly, and fewer of the +"inordinately fat middle-aged people" in England than used to be +encountered. With us the over-fat are chiefly to be found among the +women of the well-to-do classes of the cities, and from thirty +years old onward. They persecute the medical men to reduce their +weight, and the vast number of advertisements of quack and +proprietary remedies against obesity indicate how wide-spread the +tendency must be.</p> + +<p>Among women somewhat younger, as indeed among men, the American +observer whose recollection takes him back twenty-five years must +note a more hopeful change, a very decided average increase of +stature, not merely in height but in general development. This +change is to be seen throughout the whole country, and must be +taken first as a sign of improved conditions of food and manner of +life, and next, if not more largely, of the new interest and +partnership of girls in the wholesome activities of field and wood.</p></div> + + + +<hr style="width: 65%;" /><p><a name="Page_33" id="Page_33"></a></p> +<h3><a name="CHAPTER_III" id="CHAPTER_III"></a>CHAPTER III.</h3> + +<h4>ON THE SELECTION OF CASES FOR TREATMENT.</h4> + + +<p>The remarks of the last chapter have, of course, wide and general +application in disease, and naturally lead up to what I have to say as +to the employment of the systematic treatment to describe which is my +chief desire. Its use, as a whole, is limited to certain groups of +cases. In some of the worst of them nothing else has succeeded hitherto, +or at least as frequently. In others the need for its application must +depend on convenience and the fact that all other and readier means have +failed. It is, of course, difficult to state now all the groups of +diseases in which it may be of value, for already physicians have begun +to find it serviceable in some to which I had not thought of applying +it,<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a> and its sphere of usefulness is therefore likely to extend +<a name="Page_34" id="Page_34"></a>beyond the limits originally set by me. It will be well here, however, +to state the various disorders in which it has seemed to me applicable. +As regards some of them, I shall try briefly to indicate why their +peculiarities point it out as needful.</p> + +<p>There are, of course, numerous cases in which it becomes desirable to +fatten and to make blood. In many of them these are easy tasks, and in +some altogether hopeless. Persons who are recovering healthfully from +fevers, pneumonias, and other temporary maladies gather flesh and make +blood readily, and we need only to help them by the ordinary tonics, +careful feeding, and change of air in due season.</p> + +<p>It may not, however, be out of place to say here that when the +convalescence from these maladies seems to be slower than is common, and +ordinary tonics inefficient, massage and the use of electricity are not +unimportant aids towards health, but in such cases require to be handled +with an amount of caution which is less requisite in more chronic +conditions of disordered health.</p> + +<p>In other and fatal or graver maladies, such as, for example, advanced +pulmonary phthisis, how<a name="Page_35" id="Page_35"></a>ever proper it may be to fatten, it is almost an +impossible task, and, as Pollock remarks, the lung-trouble may be +advancing even while the patient is gaining in weight. Nevertheless, the +earlier stages of pulmonary tuberculosis are suitable cases, and with +sufficient attention to purity and frequent change of air in their rooms +tubercular sufferers may be brought by this means to a point of +improvement where open-air and altitude cures will have their best +effects.</p> + +<p>There remains a class of cases desirable to fatten and redden,—cases +which are often, or usually, chronic in character, and present among +them some of the most difficult problems which perplex the physician. If +I pause to dwell upon these, it is because they exemplify forms of +disease in which my method of treatment has had the largest success; it +is because some of them are simply living records of the failure of +every other rational plan and of many irrational ones; it is because +many of them find no place in the text-book, however sadly familiar they +are to the physician.</p> + +<p>The group I would speak of contains that large number of people who are +kept meagre and often <a name="Page_36" id="Page_36"></a>also anæmic by constant dyspepsia, in its varied +forms, or by those defects in assimilative processes which, while more +obscure, are as fertile parents of similar mischiefs. Let us add the +long-continued malarial poisonings, and we have a group of varied origin +which is a moderate percentage of cases in which loss of weight and loss +of color are noticeable, and in which the usual therapeutic methods do +sometimes utterly fail.</p> + +<p>For many of these, fresh air, exercise, change of scene, tonics, and +stimulants are alike valueless; and for them the combined employment of +the tonic influences I shall describe, when used with absolute rest, +massage, and electricity, is often of inestimable service.</p> + +<p>A portion of the class last referred to is one I have hinted at as the +despair of the physician. It includes that large group of women, +especially, said to have nervous exhaustion, or who are defined as +having spinal irritation, if that be the prominent symptom. To it I must +add cases in which, besides the wasting and anæmia, emotional +manifestations predominate, and which are then called hysterical, +whether or not they exhibit ovarian or uterine disorders.</p> + +<p><a name="Page_37" id="Page_37"></a>Nothing is more common in practice than to see a young woman who falls +below the health-standard, loses color and plumpness, is tired all the +time, by and by has a tender spine, and soon or late enacts the whole +varied drama of hysteria. As one or other set of symptoms is prominent +she gets the appropriate label, and sometimes she continues to exhibit +only the single phase of nervous exhaustion or of spinal irritation. Far +more often she runs the gauntlet of nerve-doctors, gynæcologists, +plaster jackets, braces, water-treatment, and all the fantastic variety +of other cures.</p> + +<p>It will be worth while to linger here a little and more sharply +delineate the classes of cases I have just named.</p> + +<p>I see every week—almost every day—women who when asked what is the +matter reply, "Oh, I have nervous exhaustion." When further questioned, +they answer that everything tires them. Now, it is vain to speak of all +of these cases as hysterical, or as merely mimetic. It is quite sure +that in the graver examples exercise quickens the pulse curiously, the +tire shows in the face, or sometimes diarrhoea or nausea follows +exertion, and though while under excite<a name="Page_38" id="Page_38"></a>ment or in the presence of some +dominant motive they can do a good deal, the exhaustion which ensues is +out of proportion to the exercise used.</p> + +<p>I have rarely seen such a case which was not more or less lacking in +color and which had not lost flesh; the exceptions being those +troublesome instances of fat anæmic people which I shall by and by speak +of more fully.</p> + +<p>Perhaps a sketch of one of these cases will be better than any list of +symptoms. A woman, most often between twenty and thirty years of age, +undergoes a season of trial or encounters some prolonged strain. She may +have undertaken the hard task of nursing a relative, and have gone +through this severe duty with the addition of emotional excitement, +swayed by hopes and fears, and forgetful of self and of what every one +needs in the way of air and food and change when attempting this most +trying task. In another set of cases an illness is the cause, and she +never rallies entirely, or else some local uterine trouble starts the +mischief, and, although this is cured, the doctor wonders that his +patient does not get fat and ruddy again.</p> + +<p>But, no matter how it comes about, whether <a name="Page_39" id="Page_39"></a>from illness, anxiety, or +prolonged physical effort, the woman grows pale and thin, eats little, +or if she eats does not profit by it. Everything wearies her,—to sew, +to write, to read, to walk,—and by and by the sofa or the bed is her +only comfort. Every effort is paid for dearly, and she describes herself +as aching and sore, as sleeping ill and awaking unrefreshed, and as +needing constant stimulus and endless tonics. Then comes the mischievous +role of bromides, opium, chloral, and brandy. If the case did not begin +with uterine troubles, they soon appear, and are usually treated in vain +if the general means employed to build up the bodily health fail, as in +many of these cases they do fail. The same remark applies to the +dyspepsias and constipation which further annoy the patient and +embarrass the treatment. If such a person is by nature emotional she is +sure to become more so, for even the firmest women lose self-control at +last under incessant feebleness. Nor is this less true of men; and I +have many a time seen soldiers who had ridden boldly with Sheridan or +fought gallantly with Grant become, under the influence of painful +nerve-wounds, as irritable and hysterically emotional as the veriest +girl. If no <a name="Page_40" id="Page_40"></a>rescue comes, the fate of women thus disordered is at last +the bed. They acquire tender spines, and furnish the most lamentable +examples of all the strange phenomena of hysteria.</p> + +<p>The moral degradation which such cases undergo is pitiable. I have heard +a good deal of the disciplinary usefulness of sickness, and this may +well apply to brief and grave, and what I might call wholesome, +maladies. Undoubtedly I have seen a few people who were ennobled by long +sickness, but far more often the result is to cultivate self-love and +selfishness and to take away by slow degrees the healthful mastery which +all human beings should retain over their own emotions and wants.</p> + +<p>There is one fatal addition to the weight which tends to destroy women +who suffer in the way I have described. It is the self-sacrificing love +and over-careful sympathy of a mother, a sister, or some other devoted +relative. Nothing is more curious, nothing more sad and pitiful, than +these partnerships between the sick and selfish and the sound and +over-loving. By slow but sure degrees the healthy life is absorbed by +the sick life, in a manner more or less injurious to both, until, +sometimes too late for remedy, the <a name="Page_41" id="Page_41"></a>growth of the evil is seen by +others. Usually the individual withdrawn from wholesome duties to +minister to the caprices of hysterical sensitiveness is the person of a +household who feels most for the invalid, and who for this very reason +suffers the most. The patient has pain,—a tender spine, for example; +she is urged to give it rest. She cannot read; the self-constituted +nurse reads to her. At last light hurts her eyes; the mother or sister +remains shut up with her all day in a darkened room. A draught of air is +supposed to do harm, and the doors and windows are closed, and the +ingenuity of kindness is taxed to imagine new sources of like trouble, +until at last, as I have seen more than once, the window-cracks are +stuffed with cotton, the chimney is stopped, and even the keyhole +guarded. It is easy to see where this all leads to: the nurse falls ill, +and a new victim is found. I have seen an hysterical, anæmic girl kill +in this way three generations of nurses. If you tell the patient she is +basely selfish, she is probably amazed, and wonders at your cruelty. To +cure such a case you must morally alter as well as physically amend, and +nothing less will answer. The first step needful is to break up the +<a name="Page_42" id="Page_42"></a>companionship, and to substitute the firm kindness of a well-trained +hired nurse.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></p> + +<p>Another form of evil to be encountered in these cases is less easy to +deal with. Such an invalid has by unhappy chance to live with some near +relative whose temperament is also nervous and who is impatient or +irritable. Two such people produce endless mischief for each other. +Occasionally there is a strange incompatibility which it is difficult to +define. The two people who, owing to their relationship, depend the one +on the other, are, for no good reason, made unhappy by their several +peculiarities. Lifelong annoyance results, and for them there is no +divorce possible.</p> + +<p>In a smaller number of cases, which have less tendency to emotional +disturbances, the phenomena are more simple. You have to deal with a +woman who has lost flesh and grown colorless, but has no hysterical +tendencies. She is merely a person hopelessly below the standard of +health and subject to a host of aches and pains, without notable organic +disease. Why <a name="Page_43" id="Page_43"></a>such people should sometimes be so hard to cure I cannot +say. But the sad fact remains. Iron, acids, travel, water-cures, have +for a certain proportion of them no value, or little value, and they +remain for years feeble and forever tired. For them, as for the whole +class, the pleasures of life are limited by this perpetual weariness and +by the asthenopia which they rarely escape, and which, by preventing +them from reading, leaves them free to study day after day their +accumulating aches and distresses.</p> + +<p>Medical opinion must, of course, vary as to the causes which give rise +to the familiar disorders I have so briefly sketched, but I imagine that +few physicians placed face to face with such cases would not feel sure +that if they could insure to these patients a liberal gain in fat and in +blood they would be certain to need very little else, and that the +troubles of stomach, bowels, and uterus would speedily vanish.</p> + +<p>I need hardly say that I do not mean by this that the mere addition of +blood and normal flesh is what we want, but that their gradual increase +will be a visible result of the multitudinous changes in digestive, +assimilative, and secretive power in which the whole economy inevitably +<a name="Page_44" id="Page_44"></a>shares, and of which my relation of cases will be a better statement +than any more general one I could make here.</p> + +<p>Such has certainly been the result of my own very ample experience. If I +succeed in first altering the moral atmosphere which has been to the +patient like the very breathing of evil, and if I can add largely to the +weight and fill the vessels with red blood, I am usually sure of giving +general relief to a host of aches, pains, and varied disabilities. If I +fail, it is because I fail in these very points, or else because I have +overlooked or undervalued some serious organic tissue-change. It must be +said that now and then one is beaten by a patient who has an +unconquerable taste for invalidism, or one to whom the change of moral +atmosphere is not bracing, or by sheer laziness, as in the case of a +lady who said to me, as a final argument, "Why should I walk when I can +have a negro boy to push me in a chair?"</p> + +<p>It will have been seen that I am careful in the selection of cases for +this treatment. Conducted under the best circumstances for success, it +involves a good deal that is costly. Neither does it answer as well, and +for obvious reasons, in <a name="Page_45" id="Page_45"></a>hospital wards; and this is most true in regard +to persons who are demonstratively hysterical. As a rule, the worse the +case, the more emaciated, the more easy is it to manage, to control, and +to cure. It is, as Playfair remarks, the half-ill who constitute the +difficult cases.</p> + +<p>I am also very careful as to being sure of the absence of certain forms +of organic disease before flattering myself with the probability of +success. But not all organic troubles forbid the use of this treatment. +Advanced Bright's disease does, though the early stages of contracted +kidney are decidedly benefited by it, if proper diet be prescribed; but +intestinal troubles which are not tubercular or malignant do not; nor do +moderate signs of chronic pulmonary deposits, or bronchitis.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a></p> + +<p>Some special consideration needs to be given to the subject of +heart-disease. Especially in cases of broken compensation, by lessening +the work required of the heart so that it needs to beat both less often +and with less force, the simple maintenance of the recumbent position is +a great aid to recovery, and massage properly <a name="Page_46" id="Page_46"></a>used will still further +relieve the heart. Disturbed compensation is usually accompanied by +failure of nutrition, often by distinct anæmia, and these and the +anxiety which naturally enough affects the mind of a person with cardiac +disorder are all best handled, at first at least, by quiet and rest. +Later, the methods of Schott, baths and resistance movements, may carry +the improvement further. Even in old and established cases of valvular +disease much may be done if the patient have confidence and the +physician courage enough to insist upon a sufficient length of rest. The +palpitation and dyspnoea of exophthalmic goitre are promptly helped by +rest and massage, and with other suitable measures added, cures may be +effected even in this intractable ailment.</p> + +<p>In former editions I have advised against any attempt to treat the true +melancholias, which are not mere depression of spirits from loss of all +hope of relief, by this method, but wider experience has convinced me +that rest and seclusion may often be successfully prescribed to a +certain extent and in certain cases.</p> + +<p>Those in which the most good has been done have been the cases of +agitated melancholia <a name="Page_47" id="Page_47"></a>with attacks, more or less clearly periodic, of +excitement, during which their delusions take acuter hold of them and +drive them to wild extravagance of noisy talk and bodily restlessness. +Whether such patients must be put to bed or not one must judge in each +instance, taking into account the general nutrition. In my own practice +I certainly do put them to bed now much oftener than formerly. It is not +desirable to keep them there for the six or eight weeks which full +treatment would demand. Usually it will be of advantage to order, say, +two weeks of "absolute rest," observing the usual precautions about +getting the patient up, prescribing bed again when the early signs of an +attack of agitation appear, and keeping him there for a couple of days +on each occasion, during which the full schedule of treatment is to be +minutely carried out.</p> + +<p>Goodell and, more recently, Playfair have pointed out the fact that some +cases of disease of the uterine appendages such as would ordinarily be +considered hopeless, except for surgical treatment, have in their hands +recovered to all appearances entirely; and my own list of patients +condemned to the removal of the ovaries but recovering and remaining +well has now grown <a name="Page_48" id="Page_48"></a>to a formidable length. Playfair observes also that +he believes it possible that in even very severe and extensive disease +the health of the patient may be sufficiently improved to render +operation unnecessary.<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a></p> + +<p>In cases of floating kidney some very satisfactory results have been +reached by long rest; and although it may be necessary to keep the +patient supine for three months or more, the reasonable probability of +permanent replacement of the organ is much greater than from operative +attempts at fixation, apart from the danger and pain of surgical +procedures. Persons with floating kidney are nearly always thin, often +giving a history of rapid loss of weight, have usually various symptoms +of gastric and intestinal disturbance, and present therefore subjects in +all ways suitable for a fattening and blood-making <i>régime</i> which shall +furnish padding to hold the kidney firmly in its normal place.</p> + +<p>The treatment of locomotor ataxia and some allied states by this method, +with certain modifications, has yielded such good results that I <a name="Page_49" id="Page_49"></a>now +undertake with reasonable confidence the charge of such patients; and +the subject is so important and has as yet influenced so little the +futile drugging treatment of these wretched cases that it seems worth +while to devote a special chapter to it, although the affections named +can scarcely be said to be included under the head of neurasthenic +disease.</p> + +<p>In the following chapters I shall treat of the means which I have +employed, and shall not hesitate to give such minute details as shall +enable others to profit by my failures and successes. In describing the +remedies used, and the mode of using them in combination, I shall relate +a sufficient number of cases to illustrate both the happier results and +the causes of occasional failure.</p> + +<p>The treatment I am about to describe consists in seclusion, certain +forms of diet, rest in bed, massage (or manipulation), and electricity; +and I desire to insist anew on the fact that in most cases it is the +combined use of these means that is wanted. How far they may be modified +or used separately in some instances, I shall have occasion to point out +as I discuss the various agencies alluded to.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_50" id="Page_50"></a></p> +<h3><a name="CHAPTER_IV" id="CHAPTER_IV"></a>CHAPTER IV.</h3> + +<h4>SECLUSION.</h4> + + +<p>It is rare to find any of the class of patients I have described so free +from the influence of their habitual surroundings as to make it easy to +treat them in their own homes. It is needful to disentangle them from +the meshes of old habits and to remove them from contact with those who +have been the willing slaves of their caprices. I have often made the +effort to treat them where they have lived and to isolate them there, +but I have rarely done so without promising myself that I would not +again complicate my treatment by any such embarrassments. Once separate +the patient from the moral and physical surroundings which have become +part of her life of sickness, and you will have made a change which will +be in itself beneficial and will enormously aid in the treatment which +is to follow. Of course this step is not essential in such cases as are +merely anæmic, feeble, and thin, owing to <a name="Page_51" id="Page_51"></a>distinct causes, like the +exhaustion of overwork, blood-losses, dyspepsia, low fevers, or nursing. +There are but too many women who have broken down under such causes and +failed to climb again to the level of health, despite all that could be +done for them; and when such persons are free from emotional excitement +or hysterical complications there is no reason why the seclusion needful +to secure them repose of mind should not be pleasantly modified in +accordance with the dictates of common sense. Very often a little +experimentation as to what they will profitably bear in the way of +visits and the like will inform us, as their treatment progresses, how +far such indulgence is of use or free from hurtful influences. Cases of +extreme neurasthenia in men accompanied with nutritive failures require +as to this matter cautious handling, because, for some reason, the ennui +of rest and seclusion is far better borne by women than by the other +sex.</p> + +<p>Even in cases whose moral aspects do not at once suggest an imperative +need for seclusion it is well to remember, as regards neurasthenic +people, that the treatment involves for a time daily visits of some +length from the masseur, the doctor, and possibly an electrician, and +that to add <a name="Page_52" id="Page_52"></a>to these even a single friendly visitor is often too much +to be readily borne; but I am now speaking chiefly of the large and +troublesome class of thin-blooded emotional women, for whom a state of +weak health has become a long and, almost I might say, a cherished +habit. For them there is often no success possible until we have broken +up the whole daily drama of the sick-room, with its little selfishness +and its craving for sympathy and indulgence. Nor should we hesitate to +insist upon this change, for not only shall we then act in the true +interests of the patient, but we shall also confer on those near to her +an inestimable benefit. An hysterical girl is, as Wendell Holmes has +said in his decisive phrase, a vampire who sucks the blood of the +healthy people about her; and I may add that pretty surely where there +is one hysterical girl there will be soon or late two sick women. If +circumstances oblige us to treat such a person in her own home, let us +at least change her room, and also have it well understood how far we +are to control her surroundings and to govern as to visitors and the +company of her own family. Do as we may, we shall always lessen thus our +chances of success, but we shall certainly not altogether destroy them.</p> + +<p><a name="Page_53" id="Page_53"></a>I should add here a few words of caution as to the time of year best +fitted for treatment. In the summer seclusion is often undesirable when +the patient is well enough to gain help by change of air; moreover, at +this season massage is less agreeable than in winter, and, as a rule, I +find it harder to feed and to fatten persons at rest during our summer +heats. That this rule is not without exception has been shown by Drs. +Goodell and Sinkler, both of whom have attained some remarkable +successes in midsummer.</p> + +<p>One of the questions of most importance in the carrying out of this +treatment is the choice of a nurse. Just as it is desirable to change +the home of the patient, her diet, her atmosphere, so also is it well, +for the mere alterative value of such change, to surround her with +strangers and to put aside any nurse with whom she may have grown +familiar. As I have sometimes succeeded in treating invalids in their +own homes, so have I occasionally been able to carry through cases +nursed by a mother, or sister, or friend of exceptional firmness; but to +attempt this is to be heavily handicapped, and the position should never +be accepted if it be possible to make other arrangements. Any firm, +intelligent woman of <a name="Page_54" id="Page_54"></a>tact, a stranger to the patient, is better than +the old style of nurse, now, happily, disappearing. The nurse for these +cases ought to be a young, active, quick-witted woman, capable of firmly +but gently controlling her patient. She ought to be intelligent, able to +interest her patient, to read aloud, and to write letters. The more of +these cases she has seen and nursed, the easier becomes the task of the +doctor. Young, I have said she ought to be, but youthful would be a +better word. If, as she grows older, the nurse loses the strenuous +enthusiasm with which she made her first entrance into her work, +scarcely any amount of conscientious devotion or experience will ever +replace it; but there are fortunate people who seem never to grow old in +this sense. It is always to be borne in mind that most of these patients +are over-sensitive, refined, and educated women, for whom the +clumsiness, or want of neatness, or bad manners, or immodesty of a nurse +may be a sore and steadily-increasing trial. To be more or less isolated +for two months in a room, with one constant attendant, however good, is +hard enough for any one to endure; and certain quite small faults or +defects in a nurse may make her a serious impediment <a name="Page_55" id="Page_55"></a>to the treatment, +because no mere technical training will dispense in the nurse any more +than in the physician with those finer natural qualifications which make +their training available. Over-harshness is in some ways worse than +over-easiness, because it makes less pleasant the relation between nurse +and patient, and the latter should regard the former as her "next +friend." Let the nurse, therefore, place upon the doctor the burden of +decision in disputed matters; his position will not be injured with the +patient by strict enforcement of the letter of the law, while the +nurse's may be. But one nurse will suit one patient and not another: so +that I never hesitate to change my nurse if she does not fit the case, +and to change if necessary more than once.</p> + +<p>The degree of seclusion should be prescribed from the first, and it is +far better to find that the original rules may be profitably relaxed +than to be obliged to draw the lines more strictly when the patient has +at first been indulged. For instance, it is well to forbid the receipt +of any letters from home, unless anxious relatives insist that the +patient must have home news. In that case the letters should be mere +bulletins, <a name="Page_56" id="Page_56"></a>should contain nothing, no matter how trifling, that might +annoy a too sensitive person, and, most important of all, should come to +the nurse and by her be read to the patient.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_57" id="Page_57"></a></p> +<h3><a name="CHAPTER_V" id="CHAPTER_V"></a>CHAPTER V.</h3> + +<h4>REST.</h4> + + +<p>I have said more than once in the early chapters of this little volume +that the treatment I wished to advise as of use in a certain range of +cases was made up of rest, massage, electricity, and over-feeding. I +said that the use of large amounts of food while at rest, more or less +entire, was made possible by the practice of kneading the muscles and by +moving them with currents able to effect this end. I desire now to +discuss in turn the modes in which I employ rest, massage, and +electricity, and, as I have promised, I shall take pains to give, in +regard to these three subjects, the fullest details, because success in +the treatment depends, I am sure, on the care with which we look after a +number of things each in itself apparently of slight moment.</p> + +<p>I have no doubt that many doctors have seen fit at times to put their +patients at rest for great or small lengths of time, but the person who +of <a name="Page_58" id="Page_58"></a>all others within my knowledge used this means most, and used it so +as to obtain the best results, was the late Professor Samuel Jackson. He +was in the habit of making his patients remain in bed for many weeks at +a time, and, if I recall his cases well, he used this treatment in just +the class of disorders among women which have given me the best results. +What these are I have been at some pains to define, and I have now only +to show why in such people rest is of service, and what I mean by rest, +and how I apply it.</p> + +<p>In No. IV. of Dr. Séguin's series of American Clinical Lectures, I was +at some pains to point out the value of repose in neuralgias, and +especially sciatica, in myelitis, and in the early stages of locomotor +ataxia, and I have since then had the pleasure of seeing these views +very fully accepted. I shall now confine myself chiefly to its use in +the various forms of weakness which exist with thin blood and wasting, +with or without distinct lesions of the stomach, womb, or other organs.</p> + +<p>Whether we shall ask a patient to walk or to take rest is a question +which turns up for answer almost every day in practice. Most often we +incline to insist on exercise, and are led to do <a name="Page_59" id="Page_59"></a>so from a belief that +many people walk too little, and that to move about a good deal every +day is well for everybody. I think we are as often wrong as right. A +good brisk daily walk is for well folks a tonic, breaks down old +tissues, and creates a wholesome demand for food. The same is true for +some sick people. The habit of horse-exercise or a long walk every day +is needed to cure or to aid in the cure of disordered stomach and +costive bowels, but if all exertion gives rise only to increase of +trouble, to extreme sense of fatigue, to nausea, to headache, what shall +we do? And suppose that tonics do not help to make exertion easy, and +that the great tonic of change of air fails us, shall we still persist? +And here lies the trouble: there are women who mimic fatigue, who +indulge themselves in rest on the least pretence, who have no symptoms +so truly honest that we need care to regard them. These are they who +spoil their own nervous systems as they spoil their children, when they +have them, by yielding to the least desire and teaching them to dwell on +little pains. For such people there is no help but to insist on +self-control and on daily use of the limbs. They must be told to exert +themselves, and made to do so if that can <a name="Page_60" id="Page_60"></a>be. If they are young, this +is easy enough. If they have grown to middle life, and created habits of +self-indulgence, the struggle is often useless. But few, however, among +these women are free from some defect of blood or tissue, either +original or acquired as a result of years of indolence and attention to +aches and ailments which should never have had given to them more than a +passing thought, and which certainly should not have been made an excuse +for the sofa or the bed.</p> + +<p>Sometimes the question is easy to settle. If you find a woman who is in +good condition as to color and flesh, and who is always able to do what +it pleases her to do, and who is tired by what does not please her, that +is a woman to order out of bed and to control with a firm and steady +will. That is a woman who is to be made to walk, with no regard to her +complaints, and to be made to persist until exertion ceases to give rise +to the mimicry of fatigue. In such cases the man who can insure belief +in his opinions and obedience to his decrees secures very often most +brilliant and sometimes easy success; and it is in such cases that women +who are in all other ways capable doctors fail, because they do <a name="Page_61" id="Page_61"></a>not +obtain the needed control over those of their own sex. I have been +struck with this a number of times, but I have also seen that to be too +long and too habitually in the hands of one physician, even the wisest, +is for some cases of hysteria the main difficulty in the way of a +cure,—it is so easy to disobey the familiar friendly attendant, so hard +to do this where the physician is a stranger. But we all know well +enough the personal value of certain doctors for certain cases. Mere +hygienic advice will win a victory in the hands of one man and obtain no +good results in those of another, for we are, after all, artists who all +use the same means to an end but fail or succeed according to our method +of using them. There are still other cases in which mischievous +tendencies to repose, to endless tire, to hysterical symptoms, and to +emotional displays have grown out of defects of nutrition so distinct +that no man ought to think for these persons of mere exertion as a sole +means of cure. The time comes for that, but it should not come until +entire rest has been used, with other means, to fit them for making use +of their muscles. Nothing upsets these cases like over-exertion, and the +attempt to make them walk usually ends in some <a name="Page_62" id="Page_62"></a>mischievous emotional +display, and in creating a new reason for thinking that they cannot +walk. As to the two sets of cases just sketched, no one need hesitate; +the one must walk, the other should not until we have bettered her +nutritive state. She may be able to drag herself about, but no good will +be done by making her do so. But between these two classes, and allied +by certain symptoms to both, lie the larger number of such cases, giving +us every kind of real and imagined symptom, and dreadfully well fitted +to puzzle the most competent physician. As a rule, no harm is done by +rest, even in such people as give us doubts about whether it is or is +not well for them to exert themselves. There are plenty of these women +who are just well enough to make it likely that if they had motive +enough for exertion to cause them to forget themselves they would find +it useful. In the doubt I am rather given to insisting on rest, but the +rest I like for them is not at all their notion of rest. To lie abed +half the day, and sew a little and read a little, and be interesting as +invalids and excite sympathy, is all very well, but when they are bidden +to stay in bed a month, and neither to read, write, nor sew, and to have +one nurse, <a name="Page_63" id="Page_63"></a>who is not a relative,—then repose becomes for some women a +rather bitter medicine, and they are glad enough to accept the order to +rise and go about when the doctor issues a mandate which has become +pleasantly welcome and eagerly looked for. I do not think it easy to +make a mistake in this matter unless the woman takes with morbid delight +to the system of enforced rest, and unless the doctor is a person of +feeble will. I have never met myself with any serious trouble about +getting out of bed any woman for whom I thought rest needful, but it has +happened to others, and the man who resolves to send any nervous woman +to bed must be quite sure that she will obey him when the time comes for +her to get up.</p> + +<p>I have, of course, made use of every grade of rest for my patients, from +repose on a lounge for some hours a day up to entire rest in bed. In +milder forms of neurasthenic disease, in cases of slight general +depression not properly to be called melancholias, in the lesser grades +of pure brain-tire, or where this is combined with some physical +debility, I often order a "modified" or "partial rest." A detailed +schedule of the day is ordered for such patients, with as much +<a name="Page_64" id="Page_64"></a>minuteness of care as for those undergoing "full rest" in bed. Here the +patient's or the household's usual hours may be consulted, a definite +amount of time allotted to duties, business, and exercise, and certain +hours left blank, to be filled, within limits, at the patient's +discretion or that of the nurse.</p> + +<p>So many nervous people are worried with indecision, with inability to +make up their minds to the simplest actions, that to have the +responsibility of choice taken away greatly lessens their burdens. It +lessens, too, the burdens which may be placed upon them by outside +action if they can refuse this or that because they are under orders as +to hours.</p> + +<p>The following is a skeleton form of such a schedule. The hours, the +food, the occupations suggested in each one will vary according to the +sex, age, position, desires, intelligence, and opportunities of the +patient.</p> + +<p>7.30 A.M. Cocoa, coffee, hot milk, beef-extract, or hot water. Bath +(temperature stated). Rough rub with towel or flesh-brush: bathing and +rubbing may be done by attendant. Lie down a few minutes after +finishing.</p> + +<p>8.30 A.M. Breakfast in bed. (Detail as to <a name="Page_65" id="Page_65"></a>diet. Tonic, aperient, malt +extract as ordered.) May read letters, paper, etc., if eyes are good.</p> + +<p>10-11 A.M. Massage, if required, is usually ordered one hour after +breakfast; or Swedish movements are given at that time. An hour's rest +follows massage. Less rest is needed after the movements. (Milk or broth +after massage.)</p> + +<p>12 M. Rise and dress slowly. If gymnastics or massage are not ordered, +may rise earlier. May see visitors, attend to household affairs, or walk +out.</p> + +<p>1.30 P.M. Luncheon. (Malt, tonic, etc., ordered.) In invalids this +should be the chief meal of the day. Rest, lying down, not in bed, for +an hour after.</p> + +<p>3 P.M. Drive (use street-cars or walk) one to two and a half hours. +(Milk or soup on return.)</p> + +<p>7 P.M. Supper. (Malt, tonic, etc., ordered; detail of diet.)</p> + +<p>Bed at 10 P.M. Hot milk or other food at bedtime.</p> + +<p>This schedule is modified for convalescent patients after rest-treatment +by orders as to use of the eyes: letter-writing is usually forbidden, +walking distinctly directed or forbidden, as the <a name="Page_66" id="Page_66"></a>case may require. It +may be changed by putting the exercise, massage, or gymnastics in the +afternoon, for example, and leaving the morning, as soon as the rest +after breakfast is finished, for business. Men needing partial rest may +thus find time to attend to their affairs.</p> + +<p>If massage is not ordered, there is nothing in this routine which costs +money, and I have found it apply usefully in the case of hospital and +dispensary patients.</p> + +<p>In carrying out my general plan of treatment in extreme cases it is my +habit to ask the patient to remain in bed from six weeks to two months. +At first, and in some cases for four or five weeks, I do not permit the +patient to sit up, or to sew or write or read, or to use the hands in +any active way except to clean the teeth. Where at first the most +absolute rest is desirable, as in cases of heart-disease, or where there +is a floating kidney, I arrange to have the bowels and water passed +while lying down, and the patient is lifted on to a lounge for an hour +in the morning and again at bedtime, and then lifted back again into the +newly-made bed. In most cases of weakness, treated by rest, I insist on +the patient being fed by the nurse, and, when well enough to sit up in +<a name="Page_67" id="Page_67"></a>bed, I order that the meats shall be cut up, so as to make it easier +for the patient to feed herself.</p> + +<p>In many cases I allow the patient to sit up in order to obey the calls +of nature, but I am always careful to have the bowels kept reasonably +free from costiveness, knowing well how such a state and the efforts it +gives rise to enfeeble a sick person.</p> + +<p>The daily sponging bath is to be given by the nurse, and should be +rapidly and skilfully done. It may follow the first food of the day, the +early milk, or cocoa, or coffee, or, if preferred, may be used before +noon, or at bedtime, which is found in some cases to be best and to +promote sleep.</p> + +<p>For some reason, the act of bathing, or even the being bathed, is +mysteriously fatiguing to certain invalids, and if so I have the general +sponging done for a time but thrice a week.</p> + +<p>Most of these patients suffer from use of the eyes, and this makes it +needful to prohibit reading and writing, and to have all correspondence +carried on through the nurse. But many neurasthenic people also suffer +from being read to, or, in other words, from any prolonged effort at +attention. In these cases it will be found that if the nurse will read +the morning paper, and as <a name="Page_68" id="Page_68"></a>she does so relate such news as may be of +interest, the patient will bear it very well, and will by degrees come +to endure the hearing of such reading as is already more or less +familiar.</p> + +<p>Usually, after a fortnight I permit the patient to be read to,—one to +three hours a day,—but I am daily amazed to see how kindly nervous and +anæmic women take to this absolute rest, and how little they complain of +its monotony. In fact, the use of massage and the battery, with the +frequent comings of the nurse with food, and the doctor's visits, seem +so to fill up the day as to make the treatment less tiresome than might +be supposed. And, besides this, the sense of comfort which is apt to +come about the fifth or sixth day,—the feeling of ease, and the ready +capacity to digest food, and the growing hope of final cure, fed as it +is by present relief,—all conspire to make most patients contented and +tractable.</p> + +<p>The intelligent and watchful physician must, of course, know how far to +enforce and when to relax these rules. When it is needful, as it +sometimes is, to prolong the state of rest to two or three months, the +patient may need at the close occupation of some kind, and especially +<a name="Page_69" id="Page_69"></a>such as, while it does not tax the eyes, gives the hands something to +do, the patient being, we suppose, by this time able to sit up in bed +during a part of the day.</p> + +<p>The moral uses of enforced rest are readily estimated. From a restless +life of irregular hours, and probably endless drugging, from hurtful +sympathy and over-zealous care, the patient passes to an atmosphere of +quiet, to order and control, to the system and care of a thorough nurse, +to an absence of drugs, and to simple diet. The result is always at +first, whatever it may be afterwards, a sense of relief, and a +remarkable and often a quite abrupt disappearance of many of the nervous +symptoms with which we are all of us only too sadly familiar.</p> + +<p>All the moral uses of rest and isolation and change of habits are not +obtained by merely insisting on the physical conditions needed to effect +these ends. If the physician has the force of character required to +secure the confidence and respect of his patients, he has also much more +in his power, and should have the tact to seize the proper occasions to +direct the thoughts of his patients to the lapse from duties to others, +and to the selfishness which a life of invalidism <a name="Page_70" id="Page_70"></a>is apt to bring +about. Such moral medication belongs to the higher sphere of the +doctor's duties, and, if he means to cure his patient permanently, he +cannot afford to neglect them. Above all, let him be careful that the +masseuse and the nurse do not talk of the patient's ills, and let him by +degrees teach the sick person how very essential it is to speak of her +aches and pains to no one but himself.</p> + +<p>I have often asked myself why rest is of value in the cases of which I +am now speaking, and I have already alluded briefly to some of the modes +in which it is of use.</p> + +<p>Let us take first the simpler cases. We meet now and then with feeble +people who are dyspeptic, and who find that exercise after a meal, or +indeed much exercise on any day, is sure to cause loss of power or +lessened power to digest food. The same thing is seen in an extreme +degree in the well-known experiment of causing a dog to run violently +after eating, in which case digestion is entirely suspended. Whether +these results be due to the calling off of blood from the gastric organs +to the muscles, or whether the nervous system is, for some reason, +unable to evolve at the same time the force needed for a <a name="Page_71" id="Page_71"></a>double +purpose, is not quite clear, but the fact is undoubted, and finds added +illustrations in many of the class of exhausted women. It is plain that +this trouble exists in some of them. It is likely that it is present in +a larger number. The use of rest in these people admits of no question. +If we are to give them the means in blood and flesh of carrying on the +work of life, it must be done with the aid of the stomach, and we must +humor that organ until it is able to act in a more healthy manner under +ordinary conditions. It may be wise to add that occasional cases of +nervousness or of nervous disturbance of digestion are seen in which the +patient assimilates food better if permitted to move about directly +after a meal; and I recall one instance of very persistent gastric +catarrh where the uncomfortable symptoms following meals only began to +disappear when as an experiment the patient was ordered to take a quiet +half-hour's stroll after each meal, instead of the rest usually ordered.</p> + +<p>I am often asked how I can expect by such a system to rest the organs of +mind. No act of will can force them to be at rest. To this I should +answer that it is not the mere half-auto<a name="Page_72" id="Page_72"></a>matic intellectuation which is +harmful in men or women subject to states of feebleness or neurasthenia, +and that the systematic vigorous use of mind on distinct problems is +within some form of control. It is thought with the friction of worry +which injures, and unless we can secure an absence of this, it is vain +to hope for help by the method I am describing. The man harassed by +business anxieties, the woman with morbidly-developed or ungoverned +maternal instincts, will only illustrate the causes of failure. Perhaps +in all dubious cases Dr. Playfair's rule is not a bad one, to consider, +and to let the patient consider, this mode of treatment as a hopeful +experiment, which may have to be abandoned, and which is valueless +without the cordial and submissive assistance of the patient.</p> + +<p>The muscular system in many of such patients—I mean in ever-weary, thin +and thin-blooded persons—is doing its work with constant difficulty. As +a result, fatigue comes early, is extreme, and lasts long. The demand +for nutritive aid is ahead of the supply, or else the supply is +incompetent as to quality, and before the tissues are rebuilded a new +demand is made, so that the materials of disintegration accumulate, and +<a name="Page_73" id="Page_73"></a>do this the more easily because the eliminative organs share in the +general defects. And these are some of the reasons why anæmic people are +always tired; but, besides this, all real sensations are magnified by +women whose nervous systems have become sensitive owing to a life of +attention to their ailments, and so at last it becomes hard to separate +the true from the false, and we are thus led to be too sceptical as to +the presence of real causes of annoyance. Certain it is that rest, under +proper conditions, is found by such sufferers to be a great relief; but +rest alone will not answer, and it is needful, as I shall show, to bring +to our help certain other means, in order to secure all the good which +repose may be made to insure.</p> + +<p>In dealing with this, as with every other medical means, it is well to +recall that in our attempts to help we may sometimes do harm, and we +must make sure that in causing the largest share of good we do the least +possible evil.</p> + +<p>"The one goes with the other, as shadow with light, and to no +therapeutic measure does this apply more surely than to the use of rest.</p> + +<p>"Let us take the simplest case,—that which <a name="Page_74" id="Page_74"></a>arises daily in the +treatment of joint-troubles or broken bones. We put the limb in splints, +and thus, for a time, check its power to move. The bone knits, or the +joint gets well; but the muscles waste, the skin dries, the nails may +for a time cease to grow, nutrition is brought down, as an arithmetician +would say, to its lowest terms, and when the bone or joint is well we +have a limb which is in a state of disease. As concerns broken bones, +the evil may be slight and easy of relief, if the surgeon will but +remember that when joints are put at rest too long they soon fall a prey +to a form of arthritis, which is the more apt to be severe the older the +patient is, and may be easily avoided by frequent motion of the joints, +which, to be healthful, exact a certain share of daily movement. If, +indeed, with perfect stillness of the fragments we could have the full +life of a limb in action, I suspect that the cure of the break might be +far more rapid.</p> + +<p>"What is true of the part is true of the whole. When we put the entire +body at rest we create certain evils while doing some share of good, and +it is therefore our part to use such means as shall, in every case, +lessen and limit the ills we cannot wholly avoid. How to reach these +ends<a name="Page_75" id="Page_75"></a> I shall by and by state, but for a brief space I should like to +dwell on some of the bad results which come of our efforts to reach +through rest in bed all the good which it can give us, and to these +points I ask the most thoughtful attention, because upon the care with +which we meet and provide for them depends the value which we will get +out of this most potent means of treatment.</p> + +<p>"When we put patients in bed and forbid them to rise or to make use of +their muscles, we at once lessen appetite, weaken digestion in many +cases, constipate the bowels, and enfeeble circulation."<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a></p> + +<p>When we put the muscles at absolute rest we create certain difficulties, +because the normal acts of repeated movement insure a certain rate of +nutrition which brings blood to the active parts, and without which the +currents flow more largely around than through the muscles. The lessened +blood-supply is a result of diminished functional movement, and we need +to create a constant demand in the inactive parts. But, besides this, +every active muscle is practically a <a name="Page_76" id="Page_76"></a>throbbing heart, squeezing its +vessels empty while in motion, and relaxing, so as to allow them to fill +up anew. Thus, both for itself and in its relations to the areolar +spaces and to the rest of the body, its activity is functionally of +service. Then, also, the vessels, unaided by changes of posture and by +motion, lose tone, and the distant local circuits, for all of these +reasons, cease to receive their normal supply, so that defects of +nutrition occur, and, with these, defects of temperature.</p> + +<p>"I was struck with the extent to which these evils may go, in the case +of Mrs. P., æt. 52, who was brought to me from New Jersey, having been +in bed fifteen years. I soon knew that she was free of grave disease, +and had stayed in bed at first because there was some lack of power and +much pain on rising, and at last because she had the firm belief that +she could not walk. After a week's massage I made her get up. I had won +her full trust, and she obeyed, or tried to obey me, like a child. But +she would faint and grow deadly pale, even if seated a short time. The +heart-beats rose from sixty to one hundred and thirty, and grew feeble; +the breath came fast, and she had to lie <a name="Page_77" id="Page_77"></a>down at once. Her skin was +dry, sallow, and bloodless, her muscles flabby; and when, at last, after +a fortnight more, I set her on her feet again, she had to endure for a +time the most dreadful vertigo and alarming palpitations of the heart, +while her feet, in a few minutes of feeble walking, would swell so as to +present the most strange appearance. By and by all this went away, and +in a month she could walk, sit up, sew, read, and, in a word, live like +others. She went home a well-cured woman.</p> + +<p>"Let us think, then, when we put a person in bed, that we are lessening +the heart-beats some twenty a minute, nearly a third; that we are +causing the tardy blood to linger in the by-ways of the blood-round, for +it has its by-ways; that rest in bed binds the bowels, and tends to +destroy the desire to eat; and that muscles at rest too long get to be +unhealthy and shrunken in substance. Bear these ills in mind, and be +ready to meet them, and we shall have answered the hard question of how +to help by rest without hurt to the patient."</p> + +<p>When I first made use of this treatment I allowed my patients to get up +too suddenly, and in some cases I thus brought on relapses and a <a name="Page_78" id="Page_78"></a>return +of the feeling of painful fatigue. I also saw in some of these cases +what I still see at times under like circumstances,—a rapid loss of +flesh.</p> + +<p>I now begin by permitting the patient to sit up in bed, then to feed +herself, and next to sit up out of bed a few minutes at bedtime. In a +week, she is desired to sit up fifteen minutes twice a day, and this is +gradually increased until, at the end of six to twelve weeks, she rests +on the bed only three to five hours daily. Even after she moves about +and goes out, I insist for two months on absolute repose at least two or +three hours daily, and this must be understood to mean seclusion as well +as bodily quiet, free from the intrusion of household cares, visitors, +or any form of emotion or excitement, pleasureable or otherwise. In +cases of long-standing it may be desirable to continue this period of +isolation and to order as well an hour's lying down after each meal for +many months, in some such methodical way as is suggested in the schedule +on page 64.</p> + +<p>The use of a hammock is found by some people to be a very agreeable +change from the bed during a part of the day.</p> + +<p><a name="Page_79" id="Page_79"></a>The physician who discharges his patient when she rises from her bed +after her two or three months' treatment, or who neglects to consider +the moral and mental needs and aspects of each case, will find that many +will relapse. Even when the patient has left the direct care of the +doctor and returned to home and its avocations she will find help and +comfort in the knowledge that she can apply to him if necessary, and it +is well to hold some sort of relation by occasional visits or +correspondence, however brief, for six months or a year after treatment +has been completed.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_80" id="Page_80"></a></p> +<h3><a name="CHAPTER_VI" id="CHAPTER_VI"></a>CHAPTER VI.</h3> + +<h4>MASSAGE.</h4> + + +<p>How to deprive rest of its evils is the title with which I might very +well have labelled this chapter. I have pointed out what I mean by rest, +how it hurts, and how it seems to help; and, as I believe that it is +useful in most cases only if employed in conjunction with other means, +the study of these becomes of the first importance.</p> + +<p>The two aids which by degrees I learned to call upon with confidence to +enable me to use rest without doing harm are massage and electricity. We +have first to deal with massage, and I give some care to the description +of details, because even now it is imperfectly understood in this +country, and because I wish to emphasize some facts about it which are +not well known, I think, on either side of the Atlantic.</p> + +<p>Massage in some form has long been in use in the East, and is well known +as the <i>lommi-lommi</i><a name="Page_81" id="Page_81"></a> of the slothful inhabitants of the Sandwich +Islands. In Japan it is reserved as an occupation for the blind, whose +delicate sense of feeling might, I should think, very well fit them for +this task. It is, however, in these countries less used in disease than +as the luxury of the rich; nor can I find in the few books on the +subject that it has been resorted to habitually as a tonic in Europe, or +otherwise than as a means of treating local disorders.</p> + +<p>It is many years since I first saw in this city general massage used by +a charlatan in a case of progressive paralysis. The temporary results he +obtained were so remarkable that I began soon after to employ it in +locomotor ataxia, in which it sometimes proved of signal value, and in +other forms of spinal and local disease. At first I had to train nurses +to use it, but I soon found that, although it was of some service to +their patients, no one could use massage well who was not continually +engaged in doing it. Some men do it better than any woman; but I prefer, +nevertheless, for obvious reasons, to reserve men for male patients, +except that in cases where <i>strength</i> is of moment, as in the forced +movements and the very hard rubbing <a name="Page_82" id="Page_82"></a>needed for old articular adhesions, +in which force must be exercised without violence, it is usually +impossible to secure the necessary power in a feminine manipulator.</p> + +<p>A few years later I resorted to it in the first cases which I treated by +rest, and I very soon found that I had in it an agent little understood +and of singular utility.</p> + +<p>It will be necessary, in pursuance of my plan, to describe as minutely +as the limits of a chapter will allow how and why this means is +employed. The process and order of what is known to the manipulator as +"general massage" follows.</p> + +<p>After three or four days in bed have somewhat accustomed the patient to +the general routine of treatment, a masseur or masseuse is set to work. +If any special care is needed,—the avoidance of manipulating one part +or added attention to another, tender handling of a sensitive or timid +patient,—these matters have been ordered in advance by the physician. +An hour midway between meals is chosen, and, the patient lying in bed +between blankets, the manipulator begins, usually with the feet. A few +rapid rubs of the whole foot and leg are given to start <a name="Page_83" id="Page_83"></a>with; then the +leg, except the foot and ankle, is covered up, and the operation +commences upon the foot, of which the skin is picked up and rolled +between the fingers, the whole foot receiving careful attention,—the +toes are pulled, bent, and moved in every direction, the inter-osseous +groups worked over with the thumbs and fingers or finger-tips, the +larger muscles and subcutaneous tissues squeezed and kneaded, and last +the whole mass of the foot rolled and pressed against the bones with +both hands. A few rapid upward strokings with some force complete the +treatment of the part, and the ankle is next dealt with. The joint is +moved in every possible direction, slowly but firmly, the crevices +between the articulating bones sought out and kneaded with the +finger-tips, and the foot and ankle are then carefully covered. After +the same rapid stroking upward of the leg with which it began has been +repeated for the sake of the slight stimulation of the skin-vessels and +nerves, the muscles of the leg are treated, first by friction of the +more superficially placed masses, then by careful deep kneading +(<i>pétrissage</i>) of the large muscles of the calf, twisting, pressing, and +rolling them about the bone with one hand <a name="Page_84" id="Page_84"></a>while the other supports the +limb. In fat or heavily-muscled subjects it may be necessary to use both +hands to get sufficient grasp of the muscles. The tibialis anticus and +muscles of the outer side of the leg are operated upon by rolling them +under the finger-tips and by pressing with the thumb while firmly +pushing upward from the ankle to the knee. At brief intervals the +manipulator seizes the limb in both hands and lightly runs the grasp +upward, so as to favor the flow of the venous blood-currents, and then +returns to the kneading of the muscles,—and each part is finished by +light yet firm upward stroking, the hand returning downward more +lightly, yet without breaking its contact with the skin.</p> + +<p>Care must be taken as the different groups of muscles are treated that +the leg is placed in the position which will most completely relax the +ones to be operated upon. Any tension of muscles wholly defeats the +effort of the masseur.</p> + +<p>After completing the process upon both legs, the arm is next treated in +the same manner, the hand receiving somewhat more detailed attention +than the foot. Pains must be taken to <a name="Page_85" id="Page_85"></a>reach the several groups of the +forearm by operating from both sides of the arm. The ordinary +manipulation of the shoulder can be accomplished with the patient lying +down; but if special conditions, such as articular stiffening, call for +unusual care or unusual force, it will be found best to treat the +shoulder with the patient seated. The treatment of the arms is concluded +with upward stroking (<i>effleurage</i>), as with the leg.</p> + +<p>In the order usually pursued, the back is the next region treated. The +patient lies prone, folding the arms under the head; a firm pillow is +put under the epigastric region, so as to the better relax the back +muscles, which are too tense when a person lies flat. Beginning from the +occiput, both hands stroke firmly and rapidly downward and outward to +the spines of the scapulæ, at first lightly, then with increasing force. +Then the whole back is vigorously rubbed—scrubbed one might call +it—with up-and-down strokes, as a preliminary application. The erector +spinæ masses are treated by careful finger-tip kneading. Working from +the spine outward to the axillary line, the muscles of the ribs are +acted upon with flat-hand rubbing. The groups of the upper back and +shoulder-<a name="Page_86" id="Page_86"></a>blades are kneaded and squeezed, the arms being partly +abducted so as to separate the shoulder-blades and allow the operator to +reach the muscles underlying them. The lumbar regions receive their +manipulation last. If it is desirable to give special attention or an +extra share of manipulation to any part of the spinal region, this is +done as the physician may have ordered, and the whole process is +completed by downward friction over the spine, given vigorously and as +rapidly as possible.</p> + +<p>The chest is the next region to be handled, the patient turning from the +prone to the supine position. In women the breasts are usually best left +untouched unless special conditions demand their treatment.</p> + +<p>The last and perhaps most important part of the process of general +massage is the rubbing of the abdomen. Particular care is needed to +secure complete relaxation, as nervous patients and, still more, +hysterical patients are apt to present extreme rigidity of the abdominal +muscles. The head is raised by pillows, the knees are slightly flexed +and sometimes supported by a folded pillow also. With this position the +rigidity generally yields to gentle persistence, at <a name="Page_87" id="Page_87"></a>any rate after a +few treatments. If it does not do so, a lateral decubitus may be tried, +a position in which the intestinal regions may be very thoroughly +treated, and in which, if there be gastric dilatation, the stomach-walls +can be best reached. Sweeping circular frictions about the navel as a +centre begin the process; the abdominal walls are then kneaded and +pinched<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">[16]</a> with one or both hands; deep, firm kneading of the whole +belly with the heel of the hand follows, the movements following the +course of the colon. Next, the fingers of one hand are all held together +in a pyramidal fashion and thrust firmly and slowly into the abdomen, in +ordinary cases both hands being used thus alternately, in fat or +resisting abdomens one hand pressing upon and aiding the other, and +travelling thus over the ascending, transverse, and <a name="Page_88" id="Page_88"></a>descending colon. +To conclude, the whole belly is shaken by a rapid vibratory motion of +the hands (to which is sometimes added succussion by slapping with the +flat or cupped hand), and the whole process ends with quick, circular +rubbing of the surface.</p> + +<p>In cases of troublesome constipation or where other special indications +exist, treatment of the abdomen may be much extended beyond the limits +here suggested, and indeed it must be remembered that the process of +"general massage" as described is capable of a great variety of useful +modification to meet individual needs, and is so modified daily by the +careful physician and the watchful masseur. It would not be possible or +desirable here to describe all the movements which a skilful rubber +makes in his treatment, and I have only attempted a skeleton-statement. +It will perhaps be noticed by those familiar with the technique of +massage that nothing is here said about the use of the movements classed +under the general head of "tapotement," the tapping and slapping +motions. They have no proper place in the treatment of cases of +nervousness, and usually will serve only to irritate and annoy the +patient, and often greatly to increase the nervous excitement.<a name="Page_89" id="Page_89"></a> Their +routine use or over-use constitutes one of the defects of the system of +massage as usually practised by the Swedish operators; and when patients +tell me, as many do, that "they cannot stand massage," it is often found +that the performance of a great deal of this useless and fretting +manipulation has constituted a great part of the treatment, and that +deep, thorough, quiet kneading can be perfectly borne.</p> + +<p>A few precautions are necessary to observe. The grasping hand should +carry the skin with it, not slip over the skin, as the drag thus put +upon the hairs will, if daily repeated, cause troublesome boils. The use +of a lubricant avoids this, and is a favorite device of unskilful +manipulators. It also does away with much of the good effected by +skin-friction, is uncleanly, very annoying to many patients, promotes an +unsightly growth of hair, and should be avoided except where it is +desired to rub into the system some oleaginous material. There are +exceptional cases where a very dry, harsh skin or a tendency to +excessive sweating during massage makes the use of some unguent +desirable. Cocoa-oil may be used, or what is perhaps more agreeable, +lanolin softened to the consistency of very thick cream by the addition +of oil of sweet <a name="Page_90" id="Page_90"></a>almonds. As little as possible should be made to serve.</p> + +<p>Too much care cannot be used to cover with stockings and warm wraps the +parts after in turn they have been subjected to massage. As to time, at +first the massage should last half an hour, but should be increased in a +week to a full hour. I observe that Dr. Playfair has it used twice a day +or more, and I have since had it so employed in some cases, letting the +masseuse come before noon, and allowing the nurse to use it at night if +it does not interfere with sleep, which is a matter to be tested solely +by experiment. Commonly, one hour once daily suffices. I was at one time +in the habit of suspending the use of both massage and electricity +during menstruation, because I found occasionally that these agents +disturbed or checked the normal flow. Of late, however, I continue to +employ both agents, but confine them to the limbs. I have met with rare +cases in which almost any massage gave rise to a uterine hemorrhage, and +in which the utmost caution became necessary.</p> + +<p>Women who have a sensitive abdominal surface or ovarian tenderness have +of course to be handled with care, but in a few days a practised rubber +will by degrees intrude upon the tender <a name="Page_91" id="Page_91"></a>regions, and will end by +kneading them with all desirable force. The same remarks apply to the +spine when it is hurt by a touch; and it is very rare indeed to find +persons whose irritable spots cannot at last be rubbed and kneaded to +their permanent profit.</p> + +<p>Sometimes when the patient is found to be much exhausted by massage, it +is well to give some stimulating concentrated food afterwards; +occasionally it may be necessary both before and after. In this case it +would be well to see that the rubbing was not being made too severe.</p> + +<p>Very rarely I find a patient to whom all massage is so disagreeable or +produces such annoying nervousness as to make manipulation impossible; +sometimes, though very rarely, massage, especially frictional movements, +causes sexual excitement when applied in the neighborhood of the genital +organs, or even on the buttocks and lower spine, and this may occur in +either sane or insane patients: if the rubber observe any signs of this, +it will of course be best to avoid handling the areas which are thus +sensitive.</p> + +<p>Another complaint sometimes made is of chilliness after treatment, and +especially of cold feet. If this is not lessened after a few days, the +lower extremities may be rubbed last instead of <a name="Page_92" id="Page_92"></a>first, or as is now and +then useful, the whole order of massage may be changed so as to begin +with the abdomen, chest, and upper extremities and conclude with the +back and legs.<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">[17]</a></p> + +<p>Beginning with half an hour and gradually increasing to about an hour (a +little more for very large or very fat people,—a little less for the +small or thin) the daily massage is kept up through at least six weeks, +and then if everything seems to be going along well, I direct the rubber +or nurse to spend half of the hour in exercising the limbs as a +preparation for walking. This is done after the Swedish plan, by making +very slowly passive and extreme extensions and flexions of the limbs for +a few days, then assisted movements, next active unassisted movements, +and last active movements gently resisted by nurse or masseuse. When the +patient is able to sit and stand, it is well to keep up and extend the +number of these gentle gymnastic acts and to encourage the patient to +make them habitual, or at least to keep them up for many months after +the conclusion of treatment.<a name="FNanchor_18_18" id="FNanchor_18_18"></a><a href="#Footnote_18_18" class="fnanchor">[18]</a></p> + +<p><a name="Page_93" id="Page_93"></a>At the seventh week massage is used on alternate days, and is commonly +laid aside when the patient gets up and begins to move about.</p> + +<p>In 1877, several of the members of the staff of the Infirmary for +Nervous Disease, and especially my colleague, Dr. Wharton Sinkler, +obliged me by studying with care the influence of massage on +temperature, and some very interesting results were obtained. In +general, when a highly hysterical person is rubbed, the legs are apt to +grow cold under the stimulation, and if this continues to be complained +of it is no very good omen of the ultimate success of the treatment. But +usually in a few days a change takes place, and the limbs all grow warm +when kneaded, as happens in most people from the beginning of the +treatment.<a name="FNanchor_19_19" id="FNanchor_19_19"></a><a href="#Footnote_19_19" class="fnanchor">[19]</a> The extremely low temperature of the limbs of children +suffering with so-called essential paralysis is well known. I have +frequently seen these strangely cold parts rise, under an hour's +massage, six to ten degrees F. In such small limbs, the long contact of +a warm hand may account for at least a part of this notable <a name="Page_94" id="Page_94"></a>rise in +temperature. In adults this can hardly be looked upon as a cause of the +rise of temperature produced by massage, first, because the long +exposure of large surfaces incident to the process is calculated to +lessen whatever increase of heat the contact of the hand may cause, and +secondly, because this rise is a very variable quantity, and because +occasionally some other and less comprehensible factors actually induce +a fall rather than a rise in the thermometer as a result of massage.</p> + +<p>In very nervous or hysterical women, ignorant of what the act of +kneading may be expected to bring about, and especially in such as are +thin and anæmic and have either a somewhat high or an unusually low +normal temperature, we may find at first a slight fall of the +thermometer, then a fairly constant rise, with some irregularities, and +at last, as the health improves, a lessening effect or none at all.</p> + +<p>The most notable rise is to be found in persons who, owing to some +organic disease, have acquired liability to great changes of +temperature.</p> + +<p>It is impossible to observe the increase of heat which follows both +massage and electricity with<a name="Page_95" id="Page_95"></a>out inferring that these agents must for a +time, like exercise and other tonics, increase the tissue-waste by the +stimulus they cause of the general and interstitial circulations, and by +the direct influence they seem to have on the tissues themselves. I have +sought to study this matter carefully by placing patients on a fixed and +competent diet of milk alone, and by estimating the waste of tissues as +shown in the secretions before and after the use of massage. This study, +although it was never completed in a satisfactory manner, would seem to +show that massage does not much alter the total elimination of the +entire day, but causes a large and abrupt increase within three hours, +followed by a compensatory decline.<a name="FNanchor_20_20" id="FNanchor_20_20"></a><a href="#Footnote_20_20" class="fnanchor">[20]</a></p> + +<p><a name="Page_96" id="Page_96"></a>I add a number of tables, which very well illustrate the facts above +stated as to rise of temperature.</p> + +<p>Mrs. J., at rest, on the usual diet. Manipulation at 11, daily:</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Massage"> + +<tr><td align='left'>Before Massage.</td><td align='left'> After Massage.</td></tr> + +<tr><td align='right'>100</td><td align='right'>100</td></tr> + +<tr><td align='right'>100</td><td align='right'>100-1/5</td></tr> + +<tr><td align='right'>99-2/5</td><td align='right'>99-4/5</td></tr> + +<tr><td align='right'>99-4/5</td><td align='right'>100</td></tr> + +<tr><td align='right'>99-2/5</td><td align='right'>100</td></tr> + +<tr><td align='right'>100</td><td align='right'>100</td></tr> + +<tr><td align='right'>99-4/5</td><td align='right'>100</td></tr> + +<tr><td align='right'>99-4/5</td><td align='right'>100</td></tr> +</table></div> + +<p>Miss P., æt. 24, hysteria:</p> + + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Massage"> + +<tr><td align='left'>Before Massage.</td><td align='left'> After Massage.</td></tr> + +<tr><td align='right'>99-1/4</td><td align='right'>99-1/4</td></tr> + +<tr><td align='right'>98-1/4</td><td align='right'>99</td></tr> + +<tr><td align='right'>98-1/2</td><td align='right'>99</td></tr> + +<tr><td align='right'>98-1/4</td><td align='right'>99</td></tr> + +<tr><td align='right'>98-1/4</td><td align='right'>98-1/4</td></tr> + +<tr><td align='right'>99</td><td align='right'>99-3/4</td></tr> + +<tr><td align='right'>100-1/5</td><td align='right'>100-2/5</td></tr> + +<tr><td align='right'>100-2/5</td><td align='right'>101-2/5</td></tr> + +<tr><td align='right'>100-2/5</td><td align='right'>100-3/5</td></tr> + +<tr><td align='right'>100-3/5</td><td align='right'>100</td></tr> +</table></div> + +<p><a name="Page_97" id="Page_97"></a></p> +<p>Mrs. L., a very thin, feeble, and bloodless +woman, æt. 29 years:</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Massage"> + +<tr><td align='left'>Before Massage.</td><td align='left'> After Massage.</td></tr> + +<tr><td align='right'>99</td><td align='right'>100</td></tr> + +<tr><td align='right'>98-1/2</td><td align='right'>99-1/5</td></tr> + +<tr><td align='right'>98</td><td align='right'>98-2/5</td></tr> + +<tr><td align='right'>99</td><td align='right'>100</td></tr> + +<tr><td align='right'>98-2/5</td><td align='right'>98-4/5</td></tr> + +<tr><td align='right'>99</td><td align='right'>99-4/5</td></tr> + +<tr><td align='right'>100</td><td align='right'>100-1/5</td></tr> + +<tr><td align='right'>99</td><td align='right'>99-4/5</td></tr> +</table></div> + +<p>Mrs. P., æt. 31, feeble and anæmic, nervous, slight albuminuria and +chronic bronchitis. Liable to fever. 3 P.M.:</p> + + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Massage"> + +<tr><td align='left'>Before Massage.</td><td align='left'> After Massage.</td></tr> + +<tr><td align='right'>101-3/5</td><td align='right'>102</td></tr> + +<tr><td align='right'>100</td><td align='right'>100-4/5</td></tr> + +<tr><td align='right'>99</td><td align='right'>99-4/5</td></tr> + +<tr><td align='right'>100</td><td align='right'>101</td></tr> + +<tr><td align='right'>99-2/5</td><td align='right'>100-1/5</td></tr> + +<tr><td align='right'>99-4/5</td><td align='right'>100-3/5</td></tr> + +<tr><td align='right'>100-3/5</td><td align='right'>101-3/5</td></tr> + +<tr><td align='right'>100-2/5</td><td align='right'>99-4/5</td></tr> + +<tr><td align='right'>100-3/5</td><td align='right'>100-2/5</td></tr> + +<tr><td align='right'>100-3/10</td><td align='right'>100-9/10</td></tr> + +<tr><td align='right'>99-1/5</td><td align='right'>99-4/5</td></tr> +</table></div> + + +<p>These facts are, of course, extremely interesting; but it is well to add +that the success of the treatment is not indicated in any constant way +by the thermal changes, which are neither so steady nor so remarkable as +those caused by electricity.</p> + +<p>If now we ask ourselves why massage does good in cases of absolute rest, +the answer—at least a partial answer—is not difficult. The secretions +of the skin are stimulated by the <a name="Page_99" id="Page_99"></a>treatment of that tissue, and it is +visibly flushed, as it ought to be, from time to time, by ordinary +active exercise. Under massage the flabby muscles acquire a certain +firmness, which at first lasts only for a few minutes, but which after a +time is more enduring and ends by becoming permanent. The firm grasp of +the manipulator's hand stimulates the muscle, and, if sudden, may cause +it to contract sensibly, which, however, is not usually desirable or +agreeable. The muscles are by these means exercised without the use of +volitional exertion or the aid of the nervous centres, and at the same +time the alternate grasp and relaxation of the manipulator's hands +squeezes out the blood and allows it to flow back anew, thus healthfully +exciting the vessels and increasing mechanically the flow of blood to +the tissues which they feed. It is possible also that a real increase in +the production of red corpuscles is brought about by repeated +applications of massage, as will be seen later on.</p> + +<p>The visible results as regards the surface-circulation are sufficiently +obvious, and most remarkably so in persons who, besides being anæmic and +thin, have been long unused to exercise. After a few treatments the +nails become <a name="Page_100" id="Page_100"></a>pink, the veins show where before none were to be seen, +the larger vessels grow fuller, and the whole tint of the body changes +for the better.</p> + +<p>In like manner the sore places which previously existed, or which were +brought into sensitive prominence by the manipulation, by degrees cease +to be felt, and a general sensation of comfort and ease follows the +later treatments.</p> + +<p>Although this plan of acting on the muscles seems to dispense with any +demands upon the centres, it is not to be supposed that it is altogether +without influence on these parts. In fact, extreme use of massage +occasionally flushes the face and causes sense of fulness in the head or +ache in the back. The actual large increase in the number of corpuscles +in the circulation brought about by massage may be one of the reasons +for this. We have added, perhaps, millions of cells to the number in the +vessels in a very short time, and need not be astonished if some signs +of plethora follow. Moreover, in some spinal maladies it has effects not +to be altogether explained by its mechanical stimulation of the muscles, +nerves, and skin.</p> + +<p>That the deep circulation shares in the changes <a name="Page_101" id="Page_101"></a>which are so obvious in +the superficial vessels has been shown by various observers of +experimental and clinical facts. Firm deep muscle-kneading of the +general surface will almost always slow and strengthen the pulse. If the +abdomen alone is thoroughly rubbed the same effect appears in the pulse, +but less in degree, and massage of the abdomen has also a distinct +effect in increasing the flow of urine, a fact worth remembering in +cases of heart-disease. In a case of albuminuria from exercise, W.W. +Keen has shown that massage did not cause the return of the albumin +after rest, though exercise did, a difference due to the opposite +effects upon blood-pressure of the two forms of activity. Lauder-Brunton +has shown that more blood passes through a masséed part after treatment. +Dr. Eccles and Dr. Douglas Graham both found a decided decrease in the +circumference of a limb after massage, showing how completely the veins +must have been emptied, for the time at least,—an emptying which would +surely be followed by an increased flow of arterial blood into the +treated region. Dr. J.K. Mitchell, in 1894,<a name="FNanchor_21_21" id="FNanchor_21_21"></a><a href="#Footnote_21_21" class="fnanchor">[21]</a> made a <a name="Page_102" id="Page_102"></a>large number of +examinations of the blood before and after massage, some in patients +under treatment for a variety of disorders affecting the integrity of +the blood, and a few in perfectly healthy men. With scarcely an +exception there was a large increase in the number of corpuscles in a +cubic millimetre, and an increase, though of less extent, in the +hæmoglobin-content. Studies made at various intervals after treatment +showed that the increase was greatest at the end of about an hour, after +which it slowly decreased again; but this decrease was postponed longer +and longer when the manipulation was continued regularly as a daily +measure.<a name="FNanchor_22_22" id="FNanchor_22_22"></a><a href="#Footnote_22_22" class="fnanchor">[22]</a> The author's conclusions from these examinations were +interesting, and I quote them somewhat fully. The fact that the +hæmoglobin is less decidedly increased than the corpuscular elements +makes it seem at least probable that what happens is, that in all the +conditions in which anæmia is a feature there are globules which are not +doing their duty, but which are called out by the necessities of +increased circulatory activity brought about by <a name="Page_103" id="Page_103"></a>massage. If this is the +first effect, yet as it is observed that the increase of corpuscles, at +first passing, soon becomes permanent, we must conclude that massage has +the ultimate effect of stimulating the production of red corpuscles.</p> + +<p>One sometimes hears doubts expressed whether a patient with a high-grade +anæmia is not "too feeble for such strong treatment" as massage. This +study of one of the ways in which massage affects such cases may fairly +be taken as proof of the certainty and safety of its effect on them, +provided always it be done properly and with intelligence. Some check +upon this may be had, as is said elsewhere, by the general effect upon +the patient. It may be repeated that the pulse should be slower and +stronger after an hour of deep massage, and that this effect will not be +produced by superficial rubbing (indeed, with light or too rapid +manipulation the pulse may become both less strong and more rapid), and +finally the flow of urine should be increased. With these easily +observed facts to aid, it may readily be judged whether massage is being +rightly applied or not without the need of a visit from the physician +during the hour of treatment. A final test <a name="Page_104" id="Page_104"></a>might readily be made by +examination of the blood and counting the red corpuscles before and +after treatment. No doubt in very bad cases a small increase or none +would be found at first, but a week of daily manipulation should show a +distinct addition to the blood count. A striking instance in which this +examination was repeatedly made is related on p. 184.</p> + +<p>"It is evident that our present definitions of anæmia are insufficient. +An essential part of the description in all of them is that there are +defects of number, of color, or of both in the blood. This is not +necessarily or always true. The fault may lie in a lack of activity or +of availability in the corpuscles. The state of things in the system may +be like the want of circulating money during times of panic, when gold +is hoarded and not made use of, and interference with commerce and +manufactures results.</p> + +<p>"Neither an anæmic appearance nor a blood-count is alone enough for a +certain diagnosis. Other signs must be used as a check on the blood +examination for the establishment of the existence of anæmia. For +instance, many cases here recorded had full normal or even supra-normal +corpuscle-count, with a good percentage of hæmo<a name="Page_105" id="Page_105"></a>globin. Yet they +presented every external sign of poverty of blood: pallor of skin and, +more important still, of mucous membranes, cold extremities, anorexia, +indigestion, dyspnœa on trifling exertion. In such cases we must suppose +either that the total volume of the blood is reduced, or that the +usefulness of the corpuscles is in some way impaired, or that both these +troubles exist together."<a name="FNanchor_23_23" id="FNanchor_23_23"></a><a href="#Footnote_23_23" class="fnanchor">[23]</a></p> + +<p>I have said above that the face was not touched in the course of the +rubbing. There are cases, however, in which massage of the head and face +may be usefully practised. Some obstinate neuralgias are helped by it +temporarily, and very often it is of use with other means to aid in a +permanent cure. Many headaches of a passing character may be dissipated +promptly by careful massage of the head or by downward stroking over the +jugular veins at the sides of the neck to lessen the flow of blood into +the cerebral vessels, where the pain is due to congestion or distention, +and careful manipulation of the facial muscles in paralysis is of +service in restoring loss of tone and improving their nu<a name="Page_106" id="Page_106"></a>trition. It is +worth adding here, as women patients frequently say that during their +illness the hair has become thin or shown a great tendency to fall, that +daily firm finger-tip massage of the head for ten or twelve minutes, +followed by rubbing into the scalp of a small amount of a tonic, either +a bland oil or if need be of some more stimulating material, will in a +great majority of the instances where loss of hair is due to general +ill-health perfectly restore its vigor and even its color.</p> + +<p>I am accustomed to pay a good deal of attention to the observations made +on these and other points by practised manipulators, and I find that +their daily familiarity with every detail of the color, warmth, and +firmness of the tissues is of great use to me.</p> + +<p>A great deal of nonsense is talked and written as to the use and the +usefulness of massage. The "professional rubber" not unnaturally makes a +mystery of it, and patients talk foolishly about "magnetism" and +"electricity;" but what is needed is a strong, warm, soft hand, directed +by ordinary intelligence and instructed by practice; and this is the +whole of the matter, except in the massage of such obscure <a name="Page_107" id="Page_107"></a>conditions +as need full knowledge of the anatomical relations and physiological +functions of the parts to be rubbed. It is a fact that I have known +country physicians who, desiring to use massage and not having a +practitioner of it within reach, have themselves trained persons to do +it, with considerable resultant success.</p> + +<p>It is not, perhaps, putting it too strongly to say that bad massage is +better than none in those cases in which manipulation is needed. Very +little harm can result from its use even by unskilled hands, provided +that reasonable intelligence direct them.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_108" id="Page_108"></a></p> +<h3><a name="CHAPTER_VII" id="CHAPTER_VII"></a>CHAPTER VII.</h3> + +<h4>ELECTRICITY.</h4> + + +<p>Electricity is the second means which I have made use of for the purpose +of exercising muscles in persons at rest. It has also an additional +value, of which I shall presently speak.</p> + +<p>In order to exercise the muscles best and with the least amount of pain +and annoyance, we make use of an induction current, with interruptions +as slow as one in every two to five seconds, a rate readily obtained in +properly-constructed batteries.<a name="FNanchor_24_24" id="FNanchor_24_24"></a><a href="#Footnote_24_24" class="fnanchor">[24]</a> This plan is sure to give painless +exercise, but it is less rapid and less complete as to the quality of +the exercise caused than the movements evolved by very rapid +interruptions. These, in the hands of a clever operator who knows his +anatomy well, are therefore, on the whole, more satisfactory, but they +require some experience to manage them so as not to shock and disgust +the patient by inflicting needless <a name="Page_109" id="Page_109"></a>pain. The poles, covered with +absorbent cotton well wetted with salt water, which may be readily +changed, so as not to use the same material more than once, are placed +on each muscle in turn, and kept about four inches apart. They are moved +fast enough to allow of the muscles being well contracted, which is +easily managed, and with sufficient speed, if the assistant be +thoroughly acquainted with the points of Ziemssen. The smaller electrode +should cover the motor-point and the larger be used upon an indifferent +area. After the legs are treated, the muscles of the belly and back and +loins are gone over systematically, and finally those of the chest and +arms. The face and neck are neglected. About forty minutes to an hour +are needed; but at first a less time is employed. The general result is +to exercise in turn all the external muscles.<a name="FNanchor_25_25" id="FNanchor_25_25"></a><a href="#Footnote_25_25" class="fnanchor">[25]</a></p> + +<p><a name="Page_110" id="Page_110"></a>No such obvious and visible results are seen as we observe after +massage, but the thermal changes are much more constant and remarkable, +and show at least that we are not dealing with an agent which merely +amuses the patient or acts alone through some mysterious influence on +the mental status.</p> + +<p>A half-hour's treatment of the muscles commonly gives rise to a marked +elevation of temperature, which fades away within an hour or two. This +effect is, like that from massage, most notable in persons liable to +fever from some organic trouble, and it varies as to its degree in +individuals who have no such disease.</p> + +<p>The first case, Miss B., æt. 20, is an example of tubercular disease of +the apex of the right lung. She had a morning temperature of 98-1/2° to +99-1/2°, and an evening temperature of 100° to 102°.</p> + +<p>Electricity was used about 11 o'clock daily, with these results:</p> + + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='left'>Before Electricity.</td><td align='left'> After Electricity.</td></tr> + +<tr><td align='left'>November</td><td align='left'>25</td><td align='right'>99</td><td align='right'>99-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>27</td><td align='right'>97-3/5</td><td align='right'>100</td></tr> + +<tr><td align='center'>"</td><td align='left'>28</td><td align='right'>98</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>29</td><td align='right'>98-4/5</td><td align='right'>99-4/5</td></tr> + +<tr><td align='left'>December</td><td align='left'>2</td><td align='right'>100-1/5</td><td align='right'>101-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>4</td><td align='right'>99-1/5</td><td align='right'>100-1/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>5</td><td align='right'>99-2/5</td><td align='right'>99-1/5</td></tr> +</table></div> + +<p><a name="Page_111" id="Page_111"></a>Mrs. R., æt. 40, the next case, was merely a rather anæmic, feeble, and +thin woman, who for years had not been able to endure any prolonged +effort. She got well under the general treatment, gaining thirteen +pounds on a weight of ninety-eight pounds, her height being five feet +and one inch. The facts as to rise of temperature are most remarkable, +and, I need not say, were carefully observed.</p> + +<p>Temperature taken in the mouth while at rest in bed.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='center'>Before Electricity.</td><td align='center'> After Electricity.</td></tr> + +<tr><td align='left'>April</td><td align='left'>2</td><td align='right'>98-2/5</td><td align='right'>98-4/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>3</td><td align='right'>98-1/5</td><td align='right'>98-2/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>4</td><td align='right'>98-1/5</td><td align='right'>98-2/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>5</td><td align='right'>98</td><td align='right'>98-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>6</td><td align='right'>97-9/10</td><td align='right'>98-7/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>7</td><td align='right'>98</td><td align='right'>98-5/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>8</td><td align='right'>98</td><td align='right'>98-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>9</td><td align='right'>98</td><td align='right'>98-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>10</td><td align='right'>98-2/5</td><td align='right'>98-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>11</td><td align='right'>98-5/10</td><td align='right'>98-7/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>12</td><td align='right'>98-3/5</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>13</td><td align='right'>98-1/5</td><td align='right'>99-5/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>14</td><td align='right'>98-2/5</td><td align='right'>99-1/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>16</td><td align='right'>98-4/10</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>17</td><td align='right'>98-5/10</td><td align='right'>99-2/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>18</td><td align='right'>98-7/10</td><td align='right'>99-1/10</td><td align='left'> One</td><td align='left'>hour</td><td align='left'>later</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>19</td><td align='right'>98-9/10</td><td align='right'>99-3/10</td><td align='center'> "</td><td align='center'>"</td><td align='center'> " ,</td><td align='right'>98-4/5</td></tr> +</table></div> + + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='center'>Before Electricity.</td><td align='center'> After Electricity.</td></tr> + +<tr><td align='left'>April</td><td align='left'>20</td><td align='right'>99</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>21</td><td align='right'>98-9/10</td><td align='right'>99-2/10</td></tr> +</table></div> + +<p class='center'>Menstrual period.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='center'>Before Electricity.</td><td align='center'> After Electricity.</td></tr> + +<tr><td align='left'>April</td><td align='left'>30</td><td align='right'>98-3/5</td><td align='right'>98-3/5</td></tr> + +<tr><td align='left'>May</td><td align='left'>1</td><td align='right'>98</td><td align='right'>98-5/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>2</td><td align='right'>98</td><td align='right'>98-3/10</td></tr> +</table></div> + + +<p>The third case, Miss M., æt. 33, was that of a pallid woman, the +daughter of a well-known physician in the South. She suffered for six +years with "nervous exhaustion," headaches, pain in the back, intense +depression of spirits, nausea, and repeated attacks of hysteria. She +slept only under anodynes, and used stimulants freely. Under the use of +rest and the adjuvant treatment described, Miss M. made a thorough +recovery, and was restored to useful active life.</p> + +<p>Miss M. Thermometer held in mouth.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='left'>Before Electricity.</td><td align='left'> After Electricity.</td></tr> + +<tr><td align='left'>May</td><td align='left'>14</td><td align='right'>99-1/10</td><td align='right'>99-1/10</td><td align='left'>} Menstruating; general</td></tr> + +<tr><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'> } faradization only.</td></tr> + +<tr><td align='center'>"</td><td align='left'>15</td><td align='right'>99</td><td align='right'>99-1/5</td><td align='left'>}</td></tr> + +<tr><td align='center'>"</td><td align='left'>16</td><td align='right'>99-1/5</td><td align='right'>99-1/5</td><td align='left'> Gen'l faradization and limbs.</td></tr> + +<tr><td align='center'>"</td><td align='left'>17</td><td align='right'>98-4/5</td><td align='right'>99-1/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>18</td><td align='right'>98-4/5</td><td align='right'>99-1/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>19</td><td align='right'>98-1/5</td><td align='right'>98-4/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>21</td><td align='right'>98-3/5</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>22</td><td align='right'>98-4/5</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>25</td><td align='right'>98-1/10</td><td align='right'>98-4/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>26</td><td align='right'>98-1/10</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>29</td><td align='right'>98-3/5</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>30</td><td align='right'>98-5/10</td><td align='right'>99-1/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>31</td><td align='right'>98-9/10</td><td align='right'>99-1/10</td></tr> +</table></div> + +<p>Mrs. P., æt. 38, was a rather nervous woman, easily tired, but not +anæmic and not very thin. She improved greatly under the treatment.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='left'>Before Electricity.</td><td align='left'> After Electricity.</td></tr> + +<tr><td align='left'>January</td><td align='left'>27</td><td align='right'>98-3/5</td><td align='right'>99-1/5</td><td align='left'> Thermometer in axilla ten</td></tr> + +<tr><td align='center'>"</td><td align='left'>29</td><td align='right'>98-2/5</td><td align='right'>99-1/5</td><td align='left'> minutes before and after.</td></tr> + +<tr><td align='center'>"</td><td align='left'>30</td><td align='right'>99-1/5</td><td align='right'>99-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>31</td><td align='right'>98-4/5</td><td align='right'>99-2/5</td></tr> + +<tr><td align='left'>February</td><td align='left'>1</td><td align='right'>99</td><td align='right'>99-2/5</td></tr> +</table></div> + +<p class='center'>Menstrual period.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='left'>Before Electricity.</td><td align='left'> After Electricity.</td></tr> + +<tr><td align='left'>February</td><td align='left'>8</td><td align='right'>98-2/5</td><td align='right'>99-1/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>9</td><td align='right'>98-3/5</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>10</td><td align='right'>98-2/5</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>12</td><td align='right'>98-1/5</td><td align='right'>99-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>13</td><td align='right'>98-2/5</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>14</td><td align='right'>98-2/5</td><td align='right'>98-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>15</td><td align='right'>98-2/5</td><td align='right'>98-4/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>19</td><td align='right'>99</td><td align='right'>98-2/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>20</td><td align='right'>98</td><td align='right'>99</td></tr> + +<tr><td align='center'>"</td><td align='left'>23</td><td align='right'>98-3/5</td><td align='right'>99-4/5</td><td align='left'> Thermometer in mouth five</td></tr> + +<tr><td align='center'>"</td><td align='left'>24</td><td align='right'>99</td><td align='right'>99-2/5</td><td align='left'> minutes before and after</td></tr> + +<tr><td align='center'>"</td><td align='left'>27</td><td align='right'>99-1/5</td><td align='right'>99-3/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>28</td><td align='right'>98-4/5</td><td align='right'>99-4/5</td></tr> +</table></div> + +<p class='center'>Menstrual period.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='left'>Before Electricity.</td><td align='left'> After Electricity.</td></tr> + +<tr><td align='left'>March</td><td align='left'>13</td><td align='right'>99</td><td align='right'>99-2/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>14</td><td align='right'>98-4/5</td><td align='right'>98-4/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>15</td><td align='right'>99</td><td align='right'>99-1/5</td></tr> +</table></div> + +<p>Miss R., æt. 27, was a fair case of hysterical conditions; over-use of +chloral and bromides; anorexia and loss of flesh and color.</p> + +<p>Thermometer in mouth.</p> + +<div class='center'> +<table border="0" cellpadding="1" cellspacing="0" summary="Effects of Electricity"> + +<tr><td align='left'></td><td align='left'></td><td align='left'>Before Electricity.</td><td align='left'> After Electricity.</td></tr> + +<tr><td align='left'>May</td><td align='left'>15</td><td align='right'>100</td><td align='right'>100</td><td align='left'>} General faradization</td></tr> + +<tr><td align='center'>"</td><td align='left'>16</td><td align='right'>100</td><td align='right'>100</td><td align='left'>} for fifteen minutes.</td></tr> + +<tr><td align='right'></td><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'>}</td></tr> + +<tr><td align='center'>"</td><td align='left'>17</td><td align='right'>100-1/5</td><td align='right'>100-2/5</td><td align='left'>}</td></tr> + +<tr><td align='center'>"</td><td align='left'>18</td><td align='right'>98-2/5</td><td align='right'>98-3/5</td><td align='left'>} General faradization,</td></tr> + +<tr><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'>} fifteen minutes, also of</td></tr> + +<tr><td align='center'>"</td><td align='left'>19</td><td align='right'>99-4/5</td><td align='right'>100-1/10</td><td align='left'>} arm muscles, twenty minutes.</td></tr> + +<tr><td align='center'>"</td><td align='left'>20</td><td align='right'>100-1/10</td><td align='right'>100</td></tr> + +<tr><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'> General faradization, ten</td></tr> + +<tr><td align='center'>"</td><td align='left'>22</td><td align='right'>99-2/5</td><td align='right'>99-3/5</td><td align='left'> minutes; arms and legs</td></tr> + +<tr><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'></td><td align='left'> twenty minutes.</td></tr> + +<tr><td align='center'>"</td><td align='left'>26</td><td align='right'>99-1/10</td><td align='right'>99-2/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>27</td><td align='right'>99-3/10</td><td align='right'>99-4/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>28</td><td align='right'>99-2/5</td><td align='right'>99-2/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>29</td><td align='right'>99-3/10</td><td align='right'>99-3/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>30</td><td align='right'>99-1/10</td><td align='right'>99-4/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>31</td><td align='right'>99-1/10</td><td align='right'>99-2/10</td></tr> + +<tr><td align='left'>June</td><td align='left'>2</td><td align='right'>99-3/5</td><td align='right'>99-4/5</td></tr> + +<tr><td align='center'>"</td><td align='left'>4</td><td align='right'>99-5/10</td><td align='right'>99-6/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>6</td><td align='right'>99-3/10</td><td align='right'>99-5/10</td></tr> + +<tr><td align='center'>"</td><td align='left'>7</td><td align='right'>99-3/10</td><td align='right'>99-5/10</td></tr> +</table></div> + +<p>I have given these full details because I have <a name="Page_115" id="Page_115"></a>not seen elsewhere any +statement of the rather remarkable phenomena which they exemplify. It +may be that a part at least of the thermal change is due to the muscular +action, although this seems hardly competent to account for any large +share in the alteration of temperature, and we must look further to +explain it fully. No mental excitement can be called upon as a cause, +since it continues after the patient is perfectly accustomed to the +process. I should add, also, that in most cases the subject of the +experiment was kept in ignorance of the fact that a rise of the +thermometer was to be expected. Is it not possible that the current even +of an induction battery has the power so to stimulate the tissues as to +cause an increase in the ordinary rate of disintegrative change? Perhaps +a careful study of the secretions might lend force to this suggestion. +That the muscular action produced by the battery is not essential to the +increase of bodily heat is shown by the next set of facts to which I +desire to call attention.</p> + +<p>Some years ago, Messrs. Beard and Rockwell stated that when an induced +current is used for fifteen to thirty minutes daily, one pole on the +neck and one on either foot, or alternately on <a name="Page_116" id="Page_116"></a>both, the persistent use +of this form of treatment is decidedly tonic in its influence. I believe +that in this opinion they were perfectly correct, and I am now able to +show that, when thus employed, the induced current causes also a decided +rise of temperature in many people, which proves at least that it is in +some way an active agent, capable of positively influencing the +nutritive changes of the body.</p> + +<p>The rise of temperature thus caused is less constant, as well as less +marked, than that occasioned by the muscle treatment. I do not think it +necessary to give the tables in full. They show in the best cases, rises +of one-fifth to four-fifths of a degree F., and were taken with the +utmost care to exclude all possible causes of error.</p> + +<p>The mode of treatment is as follows: At the close of the +muscle-electrization one pole is placed on the nape of the neck and one +on a foot for fifteen minutes. Then the foot pole is shifted to the +other foot and left for the same length of time.</p> + +<p>The primary current is used, as being less painful, and the +interruptions are made as rapid as possible, while the cylinder or +control wires <a name="Page_117" id="Page_117"></a>are adjusted so as to give a current which is not +uncomfortable.</p> + +<p>It is desirable to have electricity used by a practised hand, but of +late I have found that intelligent nurses may suffice, and this, of +course, materially lessens the cost. In very timid or nervous people, or +those who at some time have been severely "shocked" by the application +of electricity in the hands of charlatans, it is common to find the +patient greatly dreading a return to its use. In this case, if the +battery be started and the poles moved about on the surface as usual, +but without any connection being made, one of two things will +happen,—either the patient will naturally find it very mild, and will +submit fearlessly to a gentle and increasing treatment, or else her +apprehensions will so dominate her as to cause her to complain of the +effects as exciting or tiring her, or as spoiling her sleep. A few words +of kindly explanation will suffice to show her how much expectation has +to do with the apparent results, and she will be found, if the matter be +managed with tact, to have learned a lesson of wide usefulness +throughout her treatment.</p> + +<p>However, there are occasional, though very <a name="Page_118" id="Page_118"></a>rare, cases in which it is +impossible to use faradism at all by reason of the insomnia and +nervousness which result even after very careful and gentle application +of the current. On the other hand, some patients find the effect of the +electric application so soothing as to promote sleep, and will ask to +have it repeated or regularly given in the evening.</p> + +<p>I have been asked very often if all the means here described be +necessary, and I have been criticised by some of the reviewers of my +first edition because I had not pointed out the relative needfulness of +the various agencies employed. In fact, I have made very numerous +clinical studies of cases, in some of which I used rest, seclusion, and +massage, and in others rest, seclusion, and electricity. It is, of +course, difficult, I may say impossible, to state in any numerical +manner the reason for my conclusion in favor of the conjoined use of all +these means. If one is to be left out, I have no hesitation in saying +that it should be electricity.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_119" id="Page_119"></a></p> +<h3><a name="CHAPTER_VIII" id="CHAPTER_VIII"></a>CHAPTER VIII.</h3> + +<h4>DIETETICS AND THERAPEUTICS.</h4> + + +<p>The somewhat wearisome and minute details I have given as to seclusion, +rest, massage, and electricity have prepared the way for a discussion of +the dietetic and medicinal treatment which without them would be neither +possible nor useful.</p> + +<p>As to diet, we have to be guided somewhat by the previous condition and +history of the patient.</p> + +<p>It is difficult to treat any of these cases without a resort at some +time more or less to the use of milk. In most dyspeptic cases—and few +neurasthenic women fail to be obstinately dyspeptic—milk given at the +outset, and given alone by Karell's method for a fortnight or less, +enormously simplifies our treatment. Even after that, milk is the best +and most easily managed addition to a general diet. As to its use with +rest and massage as an exclusive diet in obesity alone or in extreme +fatness with anæmia, I spoke <a name="Page_120" id="Page_120"></a>in a former edition with a confidence +which has been increased by the added experience of physicians on both +sides of the Atlantic. Finally, there are exceptional cases of +intestinal pain of obscure parentage or seemingly neuralgic, of +dyspepsia incorrigible by other treatments, which, having resulted in +grave general defects of nutrition, are best treated by several weeks of +milk diet, combined with rest, massage, and electricity. Milk, +therefore, must be so much used in these cases in connection with the +general treatment I am describing that it is perhaps as well to say more +clearly how it is to be employed when given alone or with other food. I +am the more willing to do this because I have learned certain facts as +to the effects of milk diet which have, I believe, hitherto escaped +observation. In fact, the study of the therapeutic influence and full +results of exclusive diets is yet to be made; nor can I but believe that +accurate dietetics will come to be a far more useful part of our means +of managing certain cases than as yet seems possible.</p> + +<p>We are indebted chiefly to Dr. Karell, of St. Petersburg, for our +knowledge of the value of milk as an exclusive diet, and to Dr. Donkin +for <a name="Page_121" id="Page_121"></a>the extension of Karell's treatment to diabetes. I shall formulate +as curtly as possible the rules to be followed in using milk as an +exclusive diet in dyspeptic states, and in anæmia with obesity, and in +the latter state uncomplicated by defective hæmic conditions.</p> + +<p>For fuller statements as to the reasons for the various rules to be +observed in using milk, I must refer the reader to Karell's paper and to +Donkin's book.</p> + +<p>Have the utmost care used as to preservation of the milk employed, and +as to the perfect cleansing of all vessels in which it is kept. Use +well-skimmed milk, as fresh as can be had, and, if possible, let it be +obtained from the cow twice a day. Or if this is not possible, or where +any doubt exists as to the condition of the milk, or any difficulty is +experienced in keeping it fresh, it may be pasteurized as soon as +received by heating it to 160°, keeping it some minutes at this point, +and at once chilling on ice. For this purpose it is best to have the +milk in bottles, and to heat by immersing the bottles in a water-bath. +For longer preservation, as, for example, when travelling, sterilizing +may be more thoroughly done by greater heat and <a name="Page_122" id="Page_122"></a>lengthened immersion. +Still, these should be expedients for use only when milk cannot be +secured fresh and in good order, as it is more than doubtful if the milk +is so well borne when it has been altered by these processes.</p> + +<p>For ordinary daily use it might be better to let all the milk for the +day be peptonized in the morning with pancreatic extract, to the extent +which is found to be agreeable to the patient's taste, and then preserve +it by placing it upon ice. In this way milk may be kept for several +days. Then, too, it has been found that where even skimmed milk upsets +the stomach of patients, milk prepared in this manner can be taken +without trouble. In peptonizing, the directions which accompany the +powders to be used for that purpose should be followed carefully. It is +to be remembered that if the patient desires to take the milk warm, the +process of conversion into peptones, which has been stopped by the cold, +will be promptly started again when the fluid is warmed, and then a very +few minutes will suffice to make it disagreeably bitter. At first the +skimming should be thorough, and for the treatment of dyspepsia or +albuminuria the milk must be as creamless as possible. The milk of <a name="Page_123" id="Page_123"></a>the +common cow is, for our purposes, preferable to that of the Alderney. It +may be used warm or cold, but, except in rare cases of diarrhoea, should +not be boiled.</p> + +<p>It ought to be given at least every two hours at first, in quantities +not to exceed four ounces, and as the amount taken is enlarged, the +periods between may be lengthened, but not beyond three hours during the +waking day, the last dose to be used at bedtime or near it. If the +patient be wakeful, a glass should be left within reach at night, and +always its use should be resumed as early as possible in the morning. A +little lime-water may be added to the night milk, to preserve it sweet, +and it should be kept covered.</p> + +<p>The milk given during the day should be taken at set times, and very +slowly sipped in mouthfuls; and this is an important rule in many cases. +Where it is so disagreeable as to cause great disgust or nausea, the +addition of enough of tea or coffee or caramel or salt to merely flavor +it may enable us to make its use bearable, and we may by degrees abandon +these aids. Another plan, rarely needed, is to use milk with the general +diet and lessen the latter until only milk is <a name="Page_124" id="Page_124"></a>employed. If these rules +be followed, it is rare to find milk causing trouble; but if its use +give rise to acidity, the addition of alkalies or lime-water may help +us, or these may be used and the milk scalded by adding a fourth of +boiling water to the milk, which has been previously put in a warm +glass. Some patients digest it best when it has the addition of a +teaspoonful of barley-or rice-water to each ounce, the main object being +to prevent the formation of large, firm clots in the stomach,—an end +which may also be attained by the addition at the moment of drinking of +a little carbonated water from a siphon. For the sake of variety, +buttermilk may be substituted for a portion of the fresh milk, and +though less nourishing it has the advantage of being mildly laxative.</p> + +<p>When used as an exclusive diet, skimmed milk gives rise to certain very +interesting and what I might call normal symptoms. Since at first we can +rarely give enough to sustain the functions, for several days the +patient is apt to lose weight, which is another reason why exercise is +in such cases undesirable. This loss soon ceases, and in the end there +is usually a gain, while in most rest cases an exclusive milk <a name="Page_125" id="Page_125"></a>diet may +be dispensed with after a week. Where milk is taken alone for weeks or +months, it is common enough to observe a large increase in bodily +weight. I have seen several times active men, even laboring men, live +for long periods on milk, with no loss of weight; but large quantities +have to be used,—two and a half to three gallons daily. A gentleman, a +diabetic, was under my observation for fifteen years, during the whole +of which time he took no other food but milk and carried on a large and +prosperous business. Milk may, therefore, be safely asserted to be a +sufficient food in itself, even for an adult, if only enough of it be +taken.</p> + +<p>During the first week or two, exclusive milk diet gives rise to a marked +sense of sleepiness. It causes nearly always, and even for weeks of its +use, a white and thick fur on the tongue, and often for a time an +unpleasant sweetish taste in the early morning, neither of which need be +regarded. Intense constipation and yellowish stools of a peculiar odor +are usual. Of the former I shall speak in connection with the use of +milk in special cases. The influence of milk on the urinary secretion is +more remarkable, and has not been as yet fully studied.</p> + +<p><a name="Page_126" id="Page_126"></a>There is, of course, a large flow of urine; and in dropsical cases due +to renal maladies this may exceed the ingested fluid and carry away very +rapidly the dropsical accumulations. It is sometimes annoying to nervous +persons because of the frequent micturition it makes necessary. I have +discovered that while skimmed milk alone is being taken, uric acid +usually disappears almost entirely from the urine, so that it is +difficult to discover even a trace of this substance; nor does it seem +to return so long as nothing but creamless milk is used. Almost any +large addition of other food, but especially of meat, enables us to find +it again. Creatine and creatinine also seem to lessen in amount, but of +the extent of this change I am not as yet fully informed.</p> + +<p>A yet more singular alteration occurs as to the pigments. If after a +fortnight or less of exclusive milk diet we fill with the urine a long +test-tube, and, placing it beside a similar tube of the ordinary urine +of an adult, look down into the two tubes, we shall observe that the +milk urine has a singular greenish tint, which once seen cannot again be +mistaken. If we put some of this urine in a test-tube carefully upon hot +nitric acid, there <a name="Page_127" id="Page_127"></a>is noticed none of the usual brown hue of oxidized +pigment at the plane of contact. In fact, it is often difficult to see +where the two fluids meet.</p> + +<p>The precise nature of this greenish-yellow pigment has not, I believe, +been made out; but it seems clear that during a diet of milk the +ordinary pigments of the urine disappear or are singularly modified. A +single meal of meat will at once cause their return for a time.</p> + +<p>These results have been carefully re-examined at my request by Dr. +Marshall in the Laboratory of the University of Pennsylvania, and his +results and my own have been found to accord; while he has also +discovered that during the use of milk the substances which give rise to +the ordinary fæcal odors disappear, and are replaced by others the +nature of which is not as yet fully comprehended. The changes I have +here pointed out are remarkable indications of the vast alterations in +assimilation and in the destruction of tissues which seem to take place +under the influence of this peculiar diet. Some of them may account for +its undoubted value in lithæmic or gouty states; but, at all events, +they point to the need for a more exhaustive <a name="Page_128" id="Page_128"></a>study both of this and of +other methods of exclusive diet.</p> + +<p>As regards milk, enough has here been said to act as a guide in its +practical use in the class of cases with which we are now concerned; but +I may add that it is sometimes useful, as the case progresses, to employ +in place of milk, or with it, some one of the various "children's +foods," such as Nestle's food, or malted milk.</p> + +<p>Before dealing with the treatment of the anæmic and feeble and more or +less wasted invalids who require treatment by rest and its concomitant +aids, I desire to say a few words as to the use of rest, milk dietetics, +and massage in people who are merely cumbrously loaded with adipose +tissues, and also in the very small class of anæmic women who are +excessively fat and may or may not be hysterical, but are apt to be +feeble and otherwise wretched.</p> + +<p>Karell has pointed out that on creamless milk diet fat people lose +flesh; and this is true; so that sometimes this mode of lessening weight +succeeds very well. But it does not always answer, because, as in +Banting, loss of weight is apt to be accompanied with loss of strength, +so that in some cases the results are disastrous, or at <a name="Page_129" id="Page_129"></a>least alarming. +I do not know that this is ever the case if the directions of Mr. +Harvey<a name="FNanchor_26_26" id="FNanchor_26_26"></a><a href="#Footnote_26_26" class="fnanchor">[26]</a> are followed with care and the weight very deliberately +lessened. But for this few people have the patience; and, even if they +can be induced to follow out a strict diet, it is often useful to be +able to cut off very rapidly a large amount of weight, and so shorten +the period of strict regimen, or at least put over-fat persons in a +condition to exercise with a freedom which had become difficult, and +thus to provide them with a healthful means of preventing an +accumulation of adipose matter. This can be done rapidly and with safety +by the following means. The person whose weight we decide to lessen is +placed on skimmed milk alone, with the usual precautions; or at once we +give skimmed milk with the usual food, and in a week put aside all other +diet save milk and all other fluids. When we find what quantity of milk +will sustain the weight, we diminish the amount by degrees until the +patient is losing a half-pound of weight each day, or less or more, as +seems to be well borne. Meanwhile, during the first week or two rest in +bed is enjoined, and later for a varying period rest in bed or <a name="Page_130" id="Page_130"></a>on a +lounge is insisted upon, while at the same time massage is used once or +twice a day, and later in the case Swedish movements. At the same time, +the pulse and weight are observed with care, so that if there be too +rapid loss, or any sign of feebleness, the diet may be increased. In +many such cases I allow daily a moderate amount of beef- or chicken- or +oyster-soup,—more as a relief to the unpleasantness of a milk diet than +for any other reason.</p> + +<p>When the weight has been sufficiently lowered, we add to the diet beef, +mutton, oysters, etc., and finally arrange a full diet list to include +but a moderate amount of hydro-carbons. Meanwhile, the milk remains as a +large part of the food, and the active Swedish movements are still kept +up as a habit, the patient being directed by degrees to add the usual +forms of exercise.</p> + +<p>If we attempt to make so speedy a change in weight while the patient is +afoot, the loss is apt to be gravely felt; but with the precautions here +advised it is interesting and pleasant to see how great a reduction may +be made in a reasonable time without annoyance and with no obvious +result except a gain in health and comfort.</p> + +<p>Cases of anĉmia in women with excess of <a name="Page_131" id="Page_131"></a>flesh have to be managed in a +somewhat similar fashion, but with the utmost care. In such persons we +have a loss of red blood-globules, perhaps lessened hæmoglobin, weak +heart, rapid pulse, and general feebleness, with too much fat, but not, +or at least rarely, extreme obesity. The milder cases may profit by +iron, with rest and very vigorous massage, but in old cases of this +kind—they are, happily, rare—the best plan is to put the patient at +rest, to use massage, restrict the diet to skimmed milk, or to milk and +broths free from fat, and with them, when the weight has been +sufficiently lowered, to give iron freely, and by degrees a good general +diet, under which the globules rise in number, so that even with a new +gain in flesh there comes an equal gain in strength and comfort. The +massage must be very thoroughly done to be of service, and it is often +difficult to get operators to perform it properly, as the manipulation +of very fat people is excessively hard work. As to other details, the +management should be much the same as that which I shall presently +describe in connection with cases of another kind.</p> + +<p>I add two cases in illustration of the use of <a name="Page_132" id="Page_132"></a>rest, milk, and massage +in the treatment of persons who are both anĉmic and overloaded with +fat.</p> + +<p>Mrs. P., æt. 45, weight one hundred and ninety pounds, height five feet +four and a half inches, had for some years been feeble, unable to walk +without panting, or to move rapidly even a few steps. Although always +stout, her great increase of flesh had followed an attack of typhoid +fever four years before. Her appearance was strikingly suggestive of +anæmia.</p> + +<p>She was subject to constant attacks of acid dyspepsia, was said to be +unable to bear iron in any form, and had not menstruated for seven +months. She had no uterine disease, and was not pregnant. Two years +before I saw her she had been made very ill owing to an attempt to +reduce her flesh by too rapid Banting, and since then, although not a +gross or large eater, she had steadily gained in weight, and as steadily +in discomfort.</p> + +<p>She was kept in bed for five weeks. Massage was used at first once +daily, and after a fortnight twice a day, while milk was given, and in a +week made the exclusive diet. Her average of loss for thirty days was a +pound a day, and the <a name="Page_133" id="Page_133"></a>diet was varied by the addition of broths after +the third week, so as to keep the reduction within safe limits. Her +pulse at first was 90 to 100 in the morning, and at night 80 to 95, her +temperature being always a half degree to a degree below the normal. At +the third week the latter was as is usual in health, and the pulse had +fallen to 80 in the morning, and 80 to 90 at night.</p> + +<p>After two weeks I gave her the lactate of iron every three hours in full +doses. In the fourth week additions were made to her diet-list, and +Swedish movements were added to the massage, which was applied but once +a day; and during the fifth week she began to sit up and move about. At +the seventh week her pulse was 70 to 80, her temperature natural, and +her blood-globules much increased in number. Her weight had now fallen +to one hundred and forty-five pounds, and her appearance had decidedly +improved. She left me after three and a half months, able to walk with +comfort three miles. She has lived, of course, with care ever since, but +writes me now, after two years, that she is a well and vigorous woman. +Her periodical flow came back five months after her treatment began, and +she has since had a child.</p> + +<p><a name="Page_134" id="Page_134"></a>Early in the spring of 1876, Mrs. C., æt. 40, came under my care with +partial hysterical paralysis of the right and hemi-anæsthesia of the +left side. She had no power to feel pain or to distinguish heat from +cold in the left leg and arm, though the sense of touch was perfect. The +long strain of great mental suffering had left her in this state and +rendered her somewhat emotional. Her appetite was fair, but she was +strangely white, and weighed one hundred and sixty-three pounds, with a +height of five feet five inches. As she had had endless treatment by +iron, change of air, and the like, I did not care to repeat what had +already failed. She was therefore put at rest, and treated with milk, +slowly lessened in amount. Her stomach-troubles, which had been very +annoying, disappeared, and when the milk fell to three pints she began +to lose flesh. With a quart of milk a day she lost half a pound daily, +and in two weeks her weight fell to one hundred and forty pounds. She +was then placed on the full treatment which I shall hereafter describe. +The weight returned slowly, and with it she became quite ruddy, while +her flesh lost altogether its flabby character. I never saw a more +striking result.</p> + +<p><a name="Page_135" id="Page_135"></a>I have been careful to speak at length of these fat anæmic cases, +because, while rare, they have been, to me at least, among the most +difficult to manage of all the curable anæmias, and because with the +plan described I have been almost as successful as I could desire.</p> + +<p>Let us now suppose that we have to deal with a person of another and +different type,—one of the larger class of feeble, thin-blooded, +neurasthenic or hysterical women. Let us presume that every ordinary and +easily attainable means of relief has been utterly exhausted, for not +otherwise do I consider it reasonable to use so extreme a treatment as +the one we are now to consider. Inevitably, if it be a woman long ill +and long treated, we shall have to settle the question of uterine +therapeutics. A careful examination is made, and we learn that there is +decided displacement. In this case it is well to correct it at once and +to let the uterine treatment go on with the general treatment. If there +be bad lacerations of the womb or perineum, their surgical relief may +await a change in the general status of health,—say at the fourth or +fifth week. If there be only congestive or other morbid states of the +womb or ovaries, they are best left <a name="Page_136" id="Page_136"></a>to be aided by the general gain in +health; but in this as in every other stage of this treatment it is +unwise, and undesirable therefore, to lay down too absolute laws. Having +satisfied ourselves as to these points, and that rest, etc., is needful, +we begin treatment, if possible, at the close of a menstrual period, +because usually the monthly flow is a time at which there is little or +no gain, and by starting our treatment when it is just over we save a +week of time in bed.</p> + +<p>The next step is, usually, to get her by degrees on a milk diet, which +has two advantages. It enables us to know precisely the amount of food +taken, and to regulate it easily; and it nearly always dismisses, as by +magic, all the dyspeptic conditions. If the case be an old one, I rarely +omit the milk; but, although I begin with three or four ounces every two +hours, I increase it in a few days up to two quarts, given in divided +doses every three hours. If a cup of coffee given without sugar on +awaking does not regulate the bowels, I add a small amount of watery +extract of aloes at bedtime; or if the constipation be obstinate, I give +thrice a day one-quarter of a grain of watery extract of aloes with two +grains of dried ox-gall. I find the <a name="Page_137" id="Page_137"></a>simple milk diet a great aid +towards getting rid of chloral, bromides, and morphia, all of which I +usually am able to lay aside during the first week of treatment.<a name="FNanchor_27_27" id="FNanchor_27_27"></a><a href="#Footnote_27_27" class="fnanchor">[27]</a> Nor +is it less easy with the same means to enable the patient to give up +stimulus; and I may add that in the treatment of the congested stomach +of the habitual hard drinker the milk treatment is of admirable +efficacy. As I have spoken over and over of the use of stimulus by +nervous women, I should be careful to explain that anything like great +excess on the part of women of the upper classes, in this country at +least, is, in my opinion, extremely rare, and that when I speak of the +habit of stimulation I mean only that nervous women are apt to be taught +to take wine or whiskey daily, to an extent that does not affect visibly +their appearance or demeanor.</p> + +<p><a name="Page_138" id="Page_138"></a>Meanwhile, the mechanical treatment is steadily pursued, and within +four days to a week, when the stomach has become comfortable, I order +the patient to take also a light breakfast. A day or two later she is +given a mutton-chop as a mid-day dinner, and again in a day or two she +has added bread-and-butter thrice a day; within ten days I am commonly +able to allow three full meals daily, as well as three or four pints of +milk, which are given at or after meals, in place of water.</p> + +<p>After ten days I order also two to four ounces of fluid malt extract +before each meal. The fluid malt extracts which now reach us from +Germany have become less trustworthy than they formerly were. Some of +them keep badly, and are uncertain in composition, one bottle being +good, another bad. The more constant, and at the same time most +agreeable, extracts are those now made in this country. Although their +diastasic powers are usually less than is claimed for them, and vary +greatly even in the best makes, they so far have seemed to me on the +whole more satisfactory than the imported malts. It is very desirable +that a thorough chemical study should be made of the various malt +ex<a name="Page_139" id="Page_139"></a>tracts, solid and liquid. I am sure that some of them are defective +in composition, or vary notably as to the amount of alcohol they +contain.</p> + +<p>No troublesome symptoms usually result from this full feeding, and the +patient may be made to eat more largely by being fed by her attendant. +People who will eat very little if they feed themselves, often take a +large amount when fed by another; and, as I have said before, nothing is +more tiresome than for a patient flat on her back to cut up her food and +to use the fork or spoon. By the plan of feeding we thus gain doubly.</p> + +<p>As to the meals, I leave them to the patient's caprice, unless this is +too unreasonable; but I like to give butter largely, and have little +trouble in getting this most wholesome of fats taken in large amounts. A +cup of cocoa or of coffee with milk on waking in the morning is a good +preparation for the fatigue of the toilet.</p> + +<p>At the close of the first week I like to add one pound of beef, in the +form of raw soup. This is made by chopping up one pound of raw beef and +placing it in a bottle with one pint of water and five drops of strong +hydrochloric acid. This mixture stands on ice all night, and in the +morning the bottle is set in a pan of water at 110° F.<a name="Page_140" id="Page_140"></a> and kept two +hours at about this temperature. It is then thrown on to a stout cloth +and strained until the mass which remains is nearly dry. The filtrate is +given in three portions daily. If the raw taste prove very +objectionable, the beef to be used is quickly roasted on one side, and +then the process is completed in the manner above described. The soup +thus made is for the most part raw, but has also the flavor of cooked +meat.<a name="FNanchor_28_28" id="FNanchor_28_28"></a><a href="#Footnote_28_28" class="fnanchor">[28]</a></p> + +<p>In difficult cases, especially those treated in cool weather, I +sometimes add, at the third week, one half-ounce of cod-liver oil, given +half an hour after each meal. If it lessen the appetite, or cause +nausea, I employ it thrice a day as a rectal injection; and in cases +where the large doses of iron used cause intense constipation, I find +the use of cod-oil enemata doubly valuable, by acting as a nutriment and +by disposing the bowels to act daily. This may be given as an <a name="Page_141" id="Page_141"></a>emulsion +with pancreatic extract. This will suit some people well, and result in +a single passage daily, but in others may be annoying, and be either +badly retained or not retained at all, and may give rise to tenesmus.</p> + +<p>The question of stimulus is a grave one. In too many cases which come to +me, I have to give so much care to break off the use of all forms of +alcoholic drinks that I am loath to resort to them in any case, although +I am satisfied that a small amount is a help towards speedy increase of +fat. Its use is, therefore, a matter for careful judgment, and in +persons who have never taken it in excess, or as a habit, I prefer to +give, with the other treatment, a small daily ration of stimulus: an +ounce a day of whiskey in milk, or a glass of dry champagne or red wine, +seems to me useful as an adjuvant, and as increasing the capacity to +take food at meals. Nevertheless, alcohol is not essential, and for the +most part I give none, except the small amount—some four per +cent.—present in fluid malt extracts. Even this is found to excite +certain persons, and it is in such cases easy to substitute the thicker +extracts of malt, or the Japanese extract, made from barley and rice.</p> + +<p><a name="Page_142" id="Page_142"></a>So soon as my patient begins to take other food than milk, and +sometimes even before this, I like to give iron in large doses. In +hospital practice the old subcarbonate answers very well, being cheap, +and not unpalatable when shaken up in water or given in an effervescent +draught of carbonated waters. In private practice large doses of salts +of iron, as four to six grains of lactate at meal-time, are +satisfactory; but the form of iron is of less moment than the amount.</p> + +<p>Very often I meet with women who cannot take iron, either because it +disturbs the stomach, causes headache, or constipates, or else because +they have been told never to take iron. In the latter case I simply add +five grains of the pyrophosphate to each ounce of malt, and give it thus +for a month unknown to the patients. It is then easy to make clear to +them that iron is not so difficult to take as they had been led to +believe, and when it has ceased to disagree mentally I find that I am +able to fall back on the coarser method. If iron constipate, as it may +and does often do when used in these large doses, the trouble is to be +corrected by fruit, and especially pears, by the pill of the watery +extract of aloes <a name="Page_143" id="Page_143"></a>and ox-gall already mentioned, by extracts of cascara +or of juglans cinerea, which may be added to the malt extract ordered +with the meals, or by enemata of oil, or oil and glycerin, or a glycerin +suppository. The instances in which iron gives headache and sense of +fulness are very rare when the patient is undergoing the full treatment +described, and, as a rule, I disregard all such complaints, and find +that after a time I cease to hear anything more of these symptoms.</p> + +<p>Unless some especial need arises, iron, in some form, is the only drug I +care to use until the patient begins to sit up, when I order nearly +always sulphate of strychnia, in rather full doses, thrice a day, with +iron and arsenic.</p> + +<p>Probably no physician will read the account I have here detailed of the +vast amount of food which I am enabled to give, not only with impunity +from dyspepsia, but with lasting advantage, without some sense of +wonder; and, for my own part, I can only say that I have watched again +and again with growing surprise some listless, feeble, white-blooded +creature learning by degrees to consume these large rations, and +gathering under their use flesh, color, and whole<a name="Page_144" id="Page_144"></a>someness of mind and +body. It is needless to say that it is not in all cases easy to carry +out this treatment.</p> + +<p>When the full treatment has been reached, and kept up for a few days, I +begin to watch the urine with care, because if the patient be overfed +the renal secretion speedily betrays this result in the precipitation of +urates. When this occurs at all steadily, I usually give directions to +lessen the amount of food until the urine is again free from sediment.</p> + +<p>Nearly always at some time in the progress of the case there are attacks +of dyspepsia, when it suffices to cut down the diet one-half, or to give +milk alone for a day or two. Diarrhoea is more rare, and has to be met +in like manner; or, if obstinate, it may be requisite to give the milk +boiled. Occasionally the rapid increase of blood is shown by nasal +hemorrhage, which needs no especial treatment.</p> + +<p>Perhaps I shall make myself more clear if I now relate in full the +diet-list of some of my cases, and the mode of arranging it.</p> + +<p>I take the following case as an illustration from my note-book:</p> + +<p>Mrs. C., a New England woman, æt. 33, under<a name="Page_145" id="Page_145"></a>took, at the age of sixteen, +a severe course of mental labor, and within two years completed the +whole range of studies which, at the school she went to, were usually +spread over four years. An early marriage, three pregnancies, the last +two of which broke in upon the years of nursing, began at last to show +in loss of flesh and color. Meanwhile, she met with energy the +multiplied claims of a life full of sympathy for every form of trouble, +and, neglecting none of the duties of society or kinship, yet found time +for study and accomplishments. By and by she began to feel tired, and at +last gave way quite abruptly, ceased to menstruate five years before I +saw her, grew pale and feeble, and dropped in weight in six months from +one hundred and twenty-five pounds to ninety-five. Nature had at last +its revenge. Everything wearied her,—to eat, to drive, to read, to sew. +Walking became impossible, and, tied to her couch, she grew dyspeptic +and constipated. The asthenopia which is almost constantly seen in such +cases added to her trials, because reading had to be abandoned, and so +at last, despite unusual vigor of character, she gave way to utter +despair, and became at times emotional and morbid in her views of life. +After <a name="Page_146" id="Page_146"></a>numberless forms of treatment had been used in vain, she came to +this city and passed into my care.</p> + +<p>At this time she could not walk more than a few steps without flushing +and without a sense of painful tire. Her morning temperature was 97.5° +F., and her white corpuscles were perhaps a third too numerous. After +most careful examination, I could find no disease of any one organ, and +I therefore advised a resort to the treatment by rest, with full +confidence in the result.</p> + +<p>In this single case I give the schedule of diet in full as a fair +example:</p> + +<p>Mrs. C. remained in bed in entire repose. She was fed, and rose only for +the purpose of relieving the bladder or the rectum.</p> + +<p>October 10.—Took one quart of milk in divided doses every two hours.</p> + +<p>11th.—A cup of coffee on rising, and two quarts of milk given in +divided portions every two hours. A pill of aloes every night, which +answered for a few days.</p> + +<p>12th to 15th.—Same diet. The dyspepsia by this time was relieved, and +she slept without her habitual dose of chloral. The pint of raw soup was +added in three portions on the 16th.</p> + +<p><a name="Page_147" id="Page_147"></a>17th and 18th.—Same diet.</p> + +<p>19th.—She took, on awaking at 7, coffee; at 7.30, a half-pint of milk; +and the same at 10 A.M., 12 M., 2, 4, 6, 8, and 10 P.M. The soup at 11, +5, and 9.</p> + +<p>23d.—She took for breakfast an egg and bread-and-butter; and two days +later (25th) dinner was added, and also iron.</p> + +<p>On the 28th this was the schedule:</p> + +<p>On waking, coffee at 7. At 8, iron and malt. Breakfast, a chop, +bread-and-butter; of milk, a tumbler and a half. At 11, soup. At 2, iron +and malt. Dinner, closing with milk, one or two tumblers. The dinner +consisted of anything she liked, and with it she took about six ounces +of burgundy or dry champagne. At 4, soup. At 7, malt, iron, +bread-and-butter, and usually some fruit, and commonly two glasses of +milk. At 9, soup; and at 10 her aloe pill. At 12 M., massage occupied an +hour. At 4.30 P.M., electricity was used for an hour in the manner which +I have described.</p> + +<p>This heavy diet-list, reached in a few days by a woman who had been +unable to digest with comfort the lightest meal, seemed certainly +surprising. I have not given in full the amount of <a name="Page_148" id="Page_148"></a>food eaten at +meal-time. Small at first, it was increased rapidly owing to the +patient's growing appetite, and became in a few days three large meals.</p> + +<p>It is necessary to see the result in one of these successful cases in +order to credit it. Mrs. C. began to show gain in flesh about the face +in the second week of treatment, and during her two months in bed rose +in weight from ninety-six pounds to one hundred and thirty-six; nor was +the gain in color less marked.</p> + +<p>At the sixth week of treatment the soup was dropped, wine abandoned, the +iron lessened one-half, the massage and electricity used on alternate +days, and the limbs exercised as I have described. The usual precautions +as to rising and exercise were carefully attended to, and at the ninth +week of treatment my patient took a drive. At this time all mechanical +treatment ceased, the milk was reduced to a quart, the iron to five +grains thrice a day, and the malt continued. At the sixth week I began +to employ strychnia in doses of one-thirtieth of a grain thrice a day at +meals, and this was kept up for several months, together with the iron +and malt. The cure was complete and permanent; and its character may <a name="Page_149" id="Page_149"></a>be +tested by the fact that at the thirtieth day of rest in bed, and after +five years of failure to menstruate, to her surprise she had a normal +monthly flow. This continued with regularity until eighteen months +later, when she became pregnant. The only drawback to her perfect use of +all her functions lay in asthenopia, which lasted nearly a year after +she left my care. Fatigue of vision for near work is a common condition +of the cases I am now describing, and is apt to persist long after all +other troubles have vanished. When there is no asthenopia I usually +think well of the general chance of recovery; but in no case of feeble +vision do I omit at some period of the treatment to have the optical +apparatus of the eye looked at with care, because pure asthenopia, apart +from all optical defects, is a somewhat rare symptom.</p> + +<p>Neither am I always satisfied with the ophthalmologist's dictum that +there is a defect so slight as to need no correction, being well aware, +as I have elsewhere pointed out, that even minute ocular defects are +competent mischief-makers when the brain becomes what I may permit +myself, using the photographer's language, to call sensitized by +disease.</p> + +<p><a name="Page_150" id="Page_150"></a>The following illustrations of success in this mode of treatment are +taken from Dr. Playfair's book:<a name="FNanchor_29_29" id="FNanchor_29_29"></a><a href="#Footnote_29_29" class="fnanchor">[29]</a></p> + +<p>"Early in October of last year I was asked to see a lady thirty-two +years of age, with the following history. She had been married at the +age of twenty-two, and since the birth of her last child had suffered +much from various uterine troubles, described to me by her medical +attendant as 'ulceration, perimetritis, and endometritis.' Shortly after +the death of her husband, in 1876, these culminated in a pelvic abscess, +which opened first through the bladder and afterwards through the +vagina. Paralysis of the bladder immediately followed the appearance of +pus in the urine, and from that time the urine was never spontaneously +voided, and the catheter was always used. Soon after this she began to +lose power in the right leg, and then in the left, until they both +became completely paralyzed, so that she could not even move her toes, +and lay on her back with her legs slightly drawn up, the muscles being +much wasted. Towards the end of 1877, after some pain in the back <a name="Page_151" id="Page_151"></a>of +her neck and twitching of the muscles, she began to lose power in her +left arm and in her neck, so that she lay absolutely immobile in bed, +the only part of her body she was able to move at all being her right +arm. Up to this time the pelvic abscess had continued to discharge +through the vagina, and occasionally through the bladder, but it now +ceased to do so, and there were no further symptoms referable to the +uterine organs. Her general condition, however, remained unaltered, in +spite of the most judicious medical treatment. She was seen, from time +to time, by several of our most eminent consultants, all of whom +recognized the probable hysterical character of her illness, but none of +the remedies employed had any beneficial effect. There was almost total +anorexia, the amount of food consumed was absurdly small, and the +necessary consequence of this inability to take food, combined with four +years in bed with paralysis of the greater part of the body, and the +habitual use of chloral to induce sleep, had reduced a naturally fine +woman to a mere shadow. In October, 1880, her medical attendant was good +enough to bring her to London for the purpose of giving a fair trial <a name="Page_152" id="Page_152"></a>to +the Weir Mitchell method of treatment, with the ready co-operation of +herself and her friends, and she was conveyed on a couch slung from the +roof of a saloon carriage, so as to avoid any jolt or jar, since the +slightest movement caused much suffering. Two days after her arrival my +friend Dr. Buzzard saw her with me, and, after a careful and prolonged +electrical examination, came to the conclusion that contractility +existed in all the affected muscles, and that the paralysis was purely +functional. I could find no evidence in the pelvis of the abscess, the +uterus being perfectly mobile, and apparently healthy. After a few days' +rest the treatment was commenced on October 16, the patient being +isolated in lodgings with a nurse of my own choosing; and this was the +only difficulty I had with her, since she naturally felt acutely the +separation from the faithful attendant who had nursed her during her +long illness. Her friends agreed not to have communication with her of +any sort. It is needless to give the details of the treatment in this +and the following cases. A mere abstract will suffice to indicate the +rapid and satisfactory progress made.</p> + +<p>"<i>October</i> 16.—Twenty-two ounces of milk were <a name="Page_153" id="Page_153"></a>taken, in divided doses, +in twenty-four hours; on the 17th, fifty ounces of milk; on the 18th, +the same quantity of milk repeated; massage for half an hour; on the +19th, milk as before; bread-and-butter and egg; massage for an hour and +a half; twenty minims of dialyzed iron twice daily; on the 21st, a +mutton-chop in addition to the above; massage an hour and fifty minutes. +To-day she passed water for the first time for four years, and the +catheter was never again used. Chloral discontinued, and she slept +naturally all night long. On the 23d, porridge and a gill of cream were +added to her former diet; massage three hours daily, and electricity for +half an hour, and this was continued until the end of the treatment. +Maltine was now given twice daily.</p> + +<p>"<i>October</i> 30.—She is now consuming three full meals daily of fish, +meat, vegetables, cream, and fruit, besides two quarts of milk and two +glasses of burgundy. Considerable muscular power is returning in her +limbs, which she can now move freely in bed.</p> + +<p>"<i>November</i> 6.—Sat in a chair for an hour. The massage and electricity +are being gradually discontinued, and the amount of food lessened.</p> + +<p>"<i>November</i> 17.—Walked down-stairs, and went <a name="Page_154" id="Page_154"></a>out for a drive, and +henceforth she went out daily in a Bath-chair. She has increased +enormously in size, and looks an entirely different person from the +wasted invalid of a few weeks ago.</p> + +<p>"On November 26 she went to Brighton quite convalescent, and on December +11 came up of her own accord to see me, drove in a hansom to my house, +and returned the same afternoon. She has since remained perfectly strong +and well, and has resumed the duties of life and society.</p> + +<p>"A somewhat curious phenomenon in this case, which I am unable to +account for, was the formation on the anterior surface of the legs, +extending from below the patellæ half-way down the tibiæ, of two large +sacs of thin fluid, containing, I should say, each a pint or more, +freely fluctuating, and quite painless. I left them alone, and they have +spontaneously disappeared."</p> + +<p>"In May, 1880, I saw with Dr. Julius, of Hastings, an unmarried lady, +aged thirty-one. Her history was that she had been in fairly good health +until five years ago, when, during her mother's illness, she overtaxed +her strength in nursing, since which time she has been a constant +invalid, suffering from backache, bearing down, inability to walk, +disordered menstruation, <a name="Page_155" id="Page_155"></a>and the usual train of uterine symptoms. She +used to get a little better on going to the sea-side, but soon became +ill again, and in October, 1879, she was completely laid up. The least +standing or walking brought on severe pain in her back and side, and she +gave up the attempt, and had since remained entirely confined to her bed +or sofa, suffering from constant nausea, complete loss of appetite, and +depending on chloral and morphia for relief. Many efforts had been made +to break her of this habit, but in vain. Her medical attendant had +recognized the existence of a retroflexion, but no pessary remained <i>in +situ</i> for more than a day or so, and he suspected that she herself +pulled them out. I was unable to do more than confirm the diagnosis that +had been made as to her local condition, but the pessary I introduced +shared the fate of its predecessors, and she remained in the same +condition,—in no way benefited by my visit. Things going on from bad to +worse, Dr. Julius sent her to London for treatment in the early part of +December. I now determined to try the effect of the method I am +discussing, of which I knew nothing when I first saw her. It was +commenced on December 11, and everything went on most favorably. A <a name="Page_156" id="Page_156"></a>week +after it was begun, when her attention was fully occupied with the diet, +massage, etc., I introduced a stem pessary, being tempted to try this +instrument, which I rarely use, by the knowledge that she was at perfect +rest, and that no form of Hodge had previously been retained. I do not +think she ever knew she had it, and it remained <i>in situ</i> for a month, +when I removed it and inserted a Hodge, which was thenceforth kept in +without any trouble. I may say that I do not think the retroflexion had +much to do with her symptoms, except, doubtless, at the commencement of +her illness, and she probably would have done quite as well without any +local treatment. She rapidly gained flesh and strength, and very soon I +entirely stopped both chloral and morphia, and she never seemed to miss +them. On December 11, when the treatment was commenced, she weighed 5 +st. 9 lbs. On January 20 she weighed 7 st. On January 25 she walked +down-stairs, and went out for a drive, and from that time she went out +twice daily. She complained of no pain of any kind, and, although she +wore a Hodge, she did not seem to have any uterine symptoms. On February +1 she went to the sea-side, looking rosy, fat, and healthy, and <a name="Page_157" id="Page_157"></a>has +since returned to her home in the country, where she remains perfectly +strong and well. A few days ago she came to town, a long railway +journey, on purpose to announce to me her approaching marriage."</p> + +<p>"On September 10 a gentleman came to consult me on the case of his wife, +in consequence of his attention having been directed to my former papers +by a relative who is a well-known physician in London. He informed me +that his wife was now fifty-five years of age, and that she had passed +ten years of her married life in India. At the age of thirty she was +much weakened by several successive miscarriages, and then drifted into +confirmed ill health. He wrote, on making an appointment, as follows: 'I +will give you at once a short outline of her case. We have been married +thirty-four years, of which the last twenty have been spent by her in +bed or on the sofa. She is unable even to stand, and finds the pain in +her back too great to admit of her sitting up. She is utterly without +strength, of an intensely nervous temperament, and suffers incessantly +from neuralgia. She has, moreover, an outward curvature of the spine. +There is not the slightest symptom of paralysis. Fortunately, <a name="Page_158" id="Page_158"></a>she does +not touch morphia, or any narcotic or stimulant, beyond a glass or two +of wine in the day. That she has long been in a state of hysteria is the +opinion of nearly all the many medical men who have seen her.'</p> + +<p>"Although the attempt to cure so aggravated a case as this was certainly +a sufficiently severe test of the treatment, I determined to make the +trial, and had the patient removed from her own home and isolated in +lodgings. I found her in bed, supported everywhere by many small +pillows, and wasted more than, I think, I had ever seen any human being. +She really hardly had any covering to her bones, and looked somewhat +like the picture of the living skeleton we are familiar with. It may +give some idea of her emaciation if I state that, though naturally not a +small woman, her height being five feet five and a half inches, she +weighed only 4 st. 7 lbs., and I could easily make my thumb and +forefinger meet round the thickest part of the calf of her leg. The +curvature of the spine said to exist was a deceptive appearance, +produced by her excessive leanness, and the consequent unnatural +prominence of the spinous processes of the vertebræ. I could detect no +organic disease <a name="Page_159" id="Page_159"></a>of any kind. The appetite was entirely wanting, and she +consumed hardly any food beyond a little milk, a few mouthfuls of bread, +and the like. From the first the patient's improvement was steady and +uniform. The way she put on flesh was marvellous, and one could almost +see her fatten from day to day. Within ten days all her pains, +neuralgia, and backache had gone, and have never been heard of since, +and by that time we had also got rid of all her little pillows and other +invalid appliances.</p> + +<p>"It may be of interest, as showing what this system is capable of, if I +copy her food diary on the tenth day after the treatment was begun; and +all this, this bedridden patient, who had lived on starvation diet for +twenty years, not only consumed with relish, but perfectly assimilated.</p> + +<p>"Six A.M.: ten ounces of raw meat soup. 7 A.M.: cup of black coffee. 8 +A.M.: a plate of oatmeal porridge, with a gill of cream, a boiled egg, +three slices of bread-and-butter, and cocoa. 11 A.M.: ten ounces of +milk. 2 P.M.: half a pound of rump-steak, potatoes, cauliflower, a +savory omelette, and ten ounces of milk. 4 P.M.: ten ounces of milk and +three slices of <a name="Page_160" id="Page_160"></a>bread-and-butter. 6 P.M.: a cup of gravy soup. 8 P.M.: +a fried sole, roast mutton (three large slices), French beans, potatoes, +stewed fruit and cream, and ten ounces of milk. 11 P.M.: ten ounces of +raw meat soup.</p> + +<p>"The same scale of diet was continued during the whole treatment, and, +from first to last, never produced the slightest dyspeptic symptoms, and +was consumed with relish and appetite. At the end of six weeks from the +day I first saw her she weighed 7 st. 8 lb.,—that is, a gain of 3 st. 1 +lb. It will suffice to indicate her improvement if I say that in eight +weeks from the commencement of treatment she was dressed, sitting up to +meals, able to walk up and down stairs with an arm and a stick, and had +also walked in the same way in the park. Considering how completely +atrophied her muscles were from twenty years' entire disuse, this was +much more than I had ventured to hope. She has now left with her nurse +for Natal, and I have no doubt that she will return from her travels +with her cure perfected."</p> + +<p>"Early in August I was asked to see a lady, aged thirty-seven, with the +following history:—'As a girl of sixteen she had a severe neuralgic +<a name="Page_161" id="Page_161"></a>illness, extending over months: excepting that, she seems to have +enjoyed good health until her marriage. Soon after this she had a +miscarriage, and then two subsequent pregnancies, accompanied by +albuminuria and the birth of dead children.' 'During gestation I was not +surprised at all sorts of nervous affections, attributing them to +uræmia.' The next pregnancy terminated in the birth of a living +daughter, now nearly three years old; during it she had 'curious nervous +symptoms,—<i>e.g.</i>, her bed flying away with her, temporary blindness, +and vaso-motor disturbances.' Subsequently she had several severe shocks +from the death of near relatives, and gradually fell into the condition +in which she was when I was consulted. This is difficult to describe, +but it was one of confirmed illness of a marked neurotic type. Among +other phenomena she had frequently-recurring attacks of fainting. 'These +were not attacks of syncope, but of such general derangement of the +balance of the circulation that cerebration was interfered with. She was +deaf and blind; her face often flushed, sometimes deadly cold; her hands +clay-cold, often blue, and difficult to warm with the most vigorous +friction. These <a name="Page_162" id="Page_162"></a>attacks passed off in from twenty minutes to a couple +of hours.' Soon 'the attacks became more frequent, with the reappearance +of another old symptom,—acute tenderness of the spine, especially over +the sacrum. Then came frequent and persistent attacks of sciatica, and +gradual loss of strength.' About this time there appears to have been +some uterine lesion, for a well-known gynæcologist went down to the +country to see her. Eventually 'she became unable to do anything almost +for herself, for the nervous irritability had distressingly increased. +To touch her bed, the ringing of a bell, sometimes the sound of a voice, +sunlight, &c., affected her so as to make her almost cry out.' 'If she +stood up, or even raised her hands to dress her hair, they immediately +became blue and deadly cold, and she was done for.' Then followed +palpitations of a distressing character, with loud blowing murmur, and +pulse of 120 to 140, for which she was seen by an eminent physician, who +diagnosed them to be caused by 'slight ventricular asynchronism, with +atonic condition of the cardiac as well as of all other muscles of the +body.' 'She has no appetite whatever.' 'Any attempt at walking brings on +sciatica. She cannot sit, <a name="Page_163" id="Page_163"></a>because the tip of the spine is so sensitive; +any pressure on it makes her feel faint. She cannot go in a carriage, +because it jars every nerve in her body. She cannot lie on her back, +because her whole spine is so tender.'</p> + +<p>"When consulted about this lady, I gave it as my opinion that any +attempt at cure was hopeless as long as she remained in the country +house in which she lived. I was informed that it was absolutely +impossible to get her away, as she could not bear the motion of any +carriage, still less of a railway, without the most acute suffering. +Eventually the difficulty was got over by anæsthetizing her, when she +was carried on a stretcher to the nearest railway station, and then +brought over two hundred miles to London, being all the time more or +less completely under the influence of the anæsthetic, administered by +her medical attendant, who accompanied her. I found this lady's state +fully justified the account given of her. She was intensely sensitive to +all sounds and to touch. Merely laying the hand on the bed caused her to +shrink, and she could not bear the lightest touch of the fingers on her +spine or any part near it. She lay in a darkened room at the back of the +house, to be away from <a name="Page_164" id="Page_164"></a>the noise of the streets, which distressed her +much. She was a naturally fine and highly-cultivated woman, greatly +emaciated, with a dusky, sallow complexion, and dark rims round her +eyes. I could find no evidence of organic disease of any kind. Whatever +lesion of the uterine organs had previously existed had disappeared, and +I therefore paid no attention to them. Within a week I had the patient +lying in a bright sunlit room in the front of the house, with the +windows open, and she complained no longer of the noise. Within ten days +the whole spine could be rubbed freely from top to bottom, and from the +first I directed the masseuse to be relentless in her manipulation of +this part of the body. In a few weeks she had gained flesh largely, the +dusky hue of her complexion had vanished, and she looked a different +being. The only trouble complained of was sleeplessness, but it did not +interfere with the satisfactory progress of the case, and no hypnotic +was given. After the first few days we had no return of the nerve-crises +which in the country had formed so characteristic a part of her illness. +Her hands and feet also, at first of a remarkable deadly coldness, soon +became warm, and remained so.<a name="Page_165" id="Page_165"></a> In five weeks she was able to sit up, and +before the fifth week of treatment was completed I took her out for a +drive through the streets in an open carriage for two hours, which she +bore without the slightest inconvenience, and the result of which she +thus described in a letter the same evening: 'I never enjoyed anything +more in my life. I cannot describe my delight and my astonishment at +being once more able to drive with comfort. My back has given me no +trouble, and I was not really tired.' This lady has since remained +perfectly well, and I need give no better proof of this than stating +that she has started with her husband on a tour round the world, <i>viâ</i> +India, Japan, and San Francisco, and that I have heard from her that she +is thoroughly enjoying her travels."</p> + +<p>"The last example with which I shall trespass on your patience I am +tempted to relate because it is one of the most remarkable instances of +the strange and multiform phenomena which neurotic disease may present, +which it has ever been my lot to witness. The case must be well known to +many members of the profession, since there is scarcely a consultant of +eminence in the metropolis who has not seen her during the six<a name="Page_166" id="Page_166"></a>teen +years her illness has lasted, besides many of the leading practitioners +in the numerous health-resorts she has visited in the vain hope of +benefit. My first acquaintance with this case is somewhat curious. About +two months before I was introduced to the patient, chancing to be +walking along the esplanade at Brighton with a medical friend, my +attention was directed to a remarkable party at which every one was +looking. The chief personage in it was a lady reclining at full length +on a long couch, and being dragged along, looking the picture of misery, +emaciated to the last degree, her head drawn back almost in a state of +opisthotonos, her hands and arms clenched and contracted, her eyes fixed +and staring at the sky. There was something in the whole procession that +struck me as being typical of hysteria, and I laughingly remarked, 'I am +sure I could cure that case if I could get her into my hands.' All I +could learn at the time was that the patient came down to Brighton every +autumn, and that my friend had seen her dragged along in the same way +for ten or twelve years. On January 14 of this year, I was asked to meet +my friend Dr. Behrend in consultation, and at once recognized the +patient as the <a name="Page_167" id="Page_167"></a>lady whom I had seen at Brighton. It would be tedious to +relate all the neurotic symptoms this patient had exhibited since 1864, +when she was first attacked with paralysis of the left arm. Among +them—and I quote these from the full notes furnished by Dr. +Behrend—were complete paraplegia, left hemiplegia, complete hysterical +amaurosis, but from this she had recovered in 1868. For all these years +she had been practically confined to her bed or couch, and had not +passed urine spontaneously for sixteen years. Among other symptoms, I +find noted 'awful suffering in spine, head, and eyes,' requiring the use +of chloral and morphia in large doses. 'For many years she has had +convulsive attacks of two distinct types, which are obviously of the +character of hystero-epilepsy.' The following are the brief notes of the +condition in which I found her, which I made in my case-book on the day +of my first visit. 'I found the patient lying on an invalid couch, her +left arm paralyzed and rigidly contracted, strapped to her body to keep +it in position. She was groaning loudly at intervals of a few seconds, +from severe pain in her back. When I attempted to shake her right hand, +she begged me not to touch her, as it <a name="Page_168" id="Page_168"></a>would throw her into a +convulsion. She is said to have had epilepsy as a child. She has now +many times daily, frequently as often as twice in an hour, both during +the day and night, attacks of sudden and absolute unconsciousness, from +which she recovers with general convulsive movements of the face and +body. She had one of these during my visit, and it had all the +appearance of an epileptic paroxysm. The left arm and both legs are +paralyzed, and devoid of sensation. She takes hardly any food, and is +terribly emaciated. She is naturally a clever woman, highly educated, +but, of late, her memory and intellectual powers are said to be +failing.'</p> + +<p>"It was determined that an attempt should be made to cure this case, and +she was removed to the Home Hospital in Fitzroy Square. She was so ill, +and shrieked and groaned so much, on the first night of her admission, +that next day I was told that no one in the house had been able to +sleep, and I was informed that it would be impossible for her to remain. +Between 3 P.M. and 11.30 P.M. she had had nine violent convulsive +paroxysms of an epileptiform character, lasting, on an average, five +minutes. At 11.30 she became absolutely unconscious, and remained so +<a name="Page_169" id="Page_169"></a>until 2.30 A.M., her attendant thinking she was dying. Next day she was +quieter, and from that time her progress was steady and uniform. On the +fourth day she passed urine spontaneously, and the catheter was never +again used. In six weeks she was out driving and walking; and within two +months she went on a sea-voyage to the Cape, looking and feeling +perfectly well. When there, her nurse, who accompanied her, had a severe +illness, through which her ex-patient nursed her most assiduously. She +has since remained, and is at this moment, in robust health, joining +with pleasure in society, walking many miles daily, and without a trace +of the illnesses which rendered her existence a burden to herself and +her friends.</p> + +<p>"In conclusion, I may remark that it seems to me that the chief value of +this systematic treatment, which is capable of producing such remarkable +results, is that it appeals, not to one, but many influences of a +curative character. Every one knew, in a vague sort of way, that if an +hysterical patient be removed from her morbid surroundings a great step +towards cure is made. Few, however, took the trouble to carry this +knowledge into practical action; and when <a name="Page_170" id="Page_170"></a>they did so they relied on +this alone, combined with moral suasion. Now, I am thoroughly convinced +that very few cases of hysteria can be preached into health. Judicious +moral management can do much; but I believe that very few hysterical +women are conscious impostors; and the great efficacy of the Weir +Mitchell method seems to me to depend on the combination of agencies +which, by restoring to a healthy state a weakened and diseased nervous +system, cures the patient in spite of herself."</p> + + + +<hr style="width: 65%;" /><p><a name="Page_171" id="Page_171"></a></p> +<h3><a name="CHAPTER_IX" id="CHAPTER_IX"></a>CHAPTER IX.</h3> + +<h4>DIETETICS AND THERAPEUTICS—(CONTINUED).</h4> + + +<p>As additional illustrations I shall now state a few cases of my own, +without entering into minute details of treatment.</p> + +<p>The following case is reported by Dr. John Keating, who watched it with +care throughout:</p> + +<p>P.D., male, æt. 53, after more than thirty years of close attention to +business, which severely tried both mental and physical endurance, found +himself, in January, 1877, at the close of some months of gradually +increasing feebleness, absolutely unable to fulfil his usual duties, and +the most alarming symptoms manifested themselves. There was a remarkable +loss of nervous and muscular force; his limbs refused their support; his +appetite failed; the recollection of ordinary phrases involved distinct +and painful effort; sleep became unattainable, except under the +influence of powerful narcotics, and even that brief slumber was +rendered valueless by the incessant convulsive twitching of the muscles.</p> + +<p><a name="Page_172" id="Page_172"></a>His physician prescribed iron and strychnia; ordered an immediate +abandonment of all business, and instant departure to a point where +telegraph-wires were unknown and mails infrequent. He went at once to +the Bahamas, passing a month in that delicious climate in absolute +inaction; more than another month was consumed in slowly returning; but, +though some flesh had been gained, there was only a trifling improvement +in the nervous condition.</p> + +<p>May 1, 1877, Dr. Mitchell examined Mr. P.D. The patient was sallow and +emaciated, and coughed every few moments. He had night-sweats, nervous +twitching, and slight dulness on percussion at the apex of the right +lung, with prolonged expiration and roughened inspiration, and some +increase of vocal resonance.</p> + +<p>Mr. P.D. was allowed to be out of bed once a day four hours, and to +spend one hour at his place of business. The treatment was as follows:</p> + +<p>At 6 A.M., a tumbler of strong, hot beef-tea, made from the Australian +extract.</p> + +<p>At 8 A.M., half a tumbler of iron-water, and breakfast, consisting of +fruit, steak, potatoes, coffee, and a goblet of milk.<a name="Page_173" id="Page_173"></a> At 8.30 A.M., a +goblet of milk mixed with a dessertspoonful of Loefland's extract of +malt, with six grains of citrate of iron and quinine.</p> + +<p>At 10 o'clock Dr. Keating administered the electricity.</p> + +<p>At 12 o'clock Mr. P.D. might be dressed, making as little personal +effort as possible. The second goblet of milk and malt was administered, +and a carriage took him to his office, where he might remain till two +o'clock, when the carriage brought him for dinner, preceded by half a +tumbler of iron-water. All walking was forbidden.</p> + +<p>After dinner (which included a goblet of milk) the third goblet of milk +and malt was swallowed; then a short drive might be taken, but by four +o'clock the patient must be undressed and in bed.</p> + +<p>At 6 P.M. the third dose of iron-water presented itself, and a light +supper of fruit, bread-and-butter, and cream, followed by the fourth +goblet of milk and malt. Two quarts of milk were thus swallowed every +day in addition to all other food.</p> + +<p>At 9 P.M., massage one hour, with cocoa-oil, followed by beef-soup, four +ounces.</p> + +<p><a name="Page_174" id="Page_174"></a>At the fourth week the soup was given up; dialyzed iron was substituted +for all other forms. June 4, electricity was given up. The malt was +continued until June 20.</p> + +<p>May 6, Mr. D. weighed in heavy winter dress one hundred and twenty-five +pounds; June 20, in the lightest summer garb, he weighed one hundred and +thirty-three pounds; in August his weight rose to one hundred and forty +pounds, and he has continued to gain. When last I saw him, a year later, +he was strong and well, had no cough, and had ceased to be what he had +been for years—a delicate man.</p> + +<p>I am indebted to the late Professor Goodell for the following case, +which I never saw, but which was carried on with every detail of my +treatment. As the testimony of an admirable observer, it is valuable +evidence. Professor Goodell writes as follows:</p> + +<p>"Some four years ago, Mrs. Y., a very highly intelligent lady, from a +neighboring city, came to consult me. She suffered dreadfully at each +monthly period, and had constant ovarian pains and a wearying backache, +which kept her on a lounge most of the day. She was also barren, and +altogether in a pitiable condition. After a <a name="Page_175" id="Page_175"></a>two months' treatment she +returned home very much better, and soon after conceived. As pregnancy +advanced, many of her old symptoms came back, but it was hoped that +maternity would rid her of them. The shock of the labor, however, proved +too great for her already shattered nervous system. She became far more +wretched than before, and again sought my advice.</p> + +<p>"At this time I found all her old pains and aches running riot. She got +no relief from them night or day without large doses of chloral. The +slightest exertion, such as sewing, writing, and reading for a few +minutes, greatly wearied her. Even the simple mental effort of casting +up the weekly housekeeping expenses of a very small household upset her, +and she had to give it up. The act of walking one of our blocks, or of +going down a short flight of stairs, or of riding for an hour in a +well-padded carriage, gave her such 'unspeakable agony'—to use her own +words—that she would have an hysterical attack of screams and tears. So +emotional had this constant nerve-strain made her that she could not +sustain an ordinary conversation without giving way to tears. Much of +her time was <a name="Page_176" id="Page_176"></a>spent in bed; in fact, she was practically bedridden.</p> + +<p>"I tried in vain to wean her from her anodynes, and failed altogether in +doing her any good, although many remedies were resorted to, and various +modes of treatment adopted. Finally, in sheer despair, I put her to bed, +and began your treatment of rest, with electricity, massage, and +frequent feeding. The first trace of improvement showed itself in a +greater self-control, and in a lessening of her aches and pains. Next, +smaller doses of the anodyne were needed, until it was wholly withheld. +Then she began to pick up an appetite, which, towards the close of the +treatment, became so keen that, between three good meals every day, she +drank several goblets of milk and of beef-tea. At the outset I had +stipulated for six weeks of this treatment, and it was with reluctance +that my patient yielded to my wish. But when the time was up she had +become so impressed with the wonderful benefits she had received and was +receiving, that she begged to have the treatment continued for two weeks +more. At the end of that time she had gained at least thirty pounds in +weight, and had lost every pain and ache.<a name="Page_177" id="Page_177"></a> Her night-terrors, which I +forgot to mention as one of her distressing symptoms, had wholly +disappeared, and she could sleep from nine to ten hours at a stretch. I +now sent her into the country, where she is continuing to mend, and is +astonishing her friends by her scrambles up and down the steep hills.</p> + +<p>"Such were the salient features of this case; and I can assure you that +I was as much impressed by the happy results of the treatment as were a +host of anxious and doubting friends.</p> + +<p> +"Very faithfully yours,<br /> +"WM. GOODELL."<br /> +</p> + +<hr style='width: 45%;' /> + +<p>Miss C., an interesting woman, æt. 26, at the age of 20 passed through a +grave trial in the shape of nursing her mother through a typhoid fever. +Soon after, a series of calamities deprived her of fortune, and she +became, for support, a clerk, and did for two years eight hours' work +daily. Under these successive strains her naturally sturdy health gave +way. First came pain in the back, then growing paleness, loss of flesh, +and unending sense of tire. Her work, which was a necessity, was of +course kept up, steadily at first, but was soon interfered with by +increase <a name="Page_178" id="Page_178"></a>of the menstrual flow, with unusual pain and persistent +ovarian tenderness. Very soon she began to drop her work for a day at a +time. Then came an increasing asthenopia, with evening headaches, until +her temper changed and became capricious and irritable. When I saw her, +she had been forced to abandon all labor, and had been treated by an +accomplished gynæcologist, and was said to be cured of a prolapsus uteri +and of extensive ulceration, despite which relief she gained nothing in +vigor and endurance and got back neither color nor flesh.</p> + +<p>She went to bed December 10, and rose for the first time February 4, +having gained twenty-nine pounds. She went to bed pale, and got up +actually ruddy. In a month she returned to her work again, and has +remained ever since in health which enables her, as she writes me, "to +enjoy work, and to do with myself what I like."</p> + +<p>Miss L., æt. 26, came to me with the following history. At the age of 20 +she had a fall, and began in a week or two to have an irritable spine. +Then, after a few months, a physician advised rest, to which she took +only too kindly, and in a year from the time of her acci<a name="Page_179" id="Page_179"></a>dent she was +rarely out of bed. Surrounded by highly sympathetic relatives, to whom +chronic illness was somewhat novel, she speedily developed, with their +tender aid, hyperĉsthetic states of the eye and ear, so that her nurses +crept about in a darkened room, the piano was silenced, and the children +kept quiet. By slow degrees a whole household passed under the selfish +despotism of an hysterical girl. Intense constipation, anorexia, and +alternate states of dysuria, anuria, and polyuria followed, and before +long her sister began to fail in health, owing to the incessant +exactions to which she too willingly yielded. This alarmed a brother, +who insisted upon a change of treatment, and after some months she was +brought on a couch to this city.</p> + +<p>At the time I first saw her, she took thirty grains of chloral every +night and three hypodermic injections of one-half grain of morphia +daily. As to food, she took next to none, and I could only guess her +weight at about ninety pounds. She was in height five feet two and a +half inches, and very sallow, with pale lips, and the large, indented +tongue of anæmia. I made the most careful search for signs of organic +mis<a name="Page_180" id="Page_180"></a>chief, and, finding none, I began my treatment as usual with milk, +and added massage and electricity without waiting. Her digestion seemed +so good that I gave lactate of iron in twenty-grain doses from the third +day, and also the aloes pill thrice a day. It is perhaps needless to +state that I isolated her with a nurse she had never seen before, and +that for seven weeks she saw no one else save myself and the attendants. +The full schedule of diet was reached at the end of a fortnight, but the +chloral and morphia were given up at the second day. She slept well the +fourth night, and, save that she had twice a slight return of polyuria, +went on without a single drawback. In two months she was afoot and +weighed one hundred and twenty-one pounds. Her change in tint, flesh, +and expression was so remarkable that the process of repair might well +have been called a renewal of life.</p> + +<p>She went home changed no less morally than physically, and resumed her +place in the family circle and in social life, a healthy and well-cured +woman.</p> + +<p>I might multiply these histories almost endlessly. In some cases I have +cured without fattening; in others, though rarely, the mental <a name="Page_181" id="Page_181"></a>habits +formed through years of illness have been too deeply ingrained for +change, and I have seen the patient get up fat and well only to relapse +on some slight occasion.</p> + +<p>The intense persistency with which some women study and dwell upon their +symptoms is often the great difficulty. Even a slight physical annoyance +becomes for one of these unhappily-constituted natures a grave and +almost ineradicable trouble, owing to the habit of self-study.</p> + +<p>Miss P., æt. 29, weight one hundred and eleven pounds, height five feet +four inches, dark-skinned, sallow, and covered with the acne of +bromidism, had had one attack which was considered to have been +epileptic, and which was probably hysterical, but on this matter she +dwelt with incessant terror, which was fostered by the tender care of a +near relative, who left her neither by night nor by day. Vague neuralgic +aches in the limbs, with constant weariness, asthenopia, anæmia, loss of +appetite, and loss of flesh, followed. Then came spinal pain and +irregular menstruation, a long course of local cauterizations of the +womb, spinal braces, and endless tonics and narcotics.</p> + +<p><a name="Page_182" id="Page_182"></a>I broke up the association which had nearly been fatal to both women, +and, confidently promising a cure, carried out my treatment in full In +three months she went home well and happy, greatly improved in looks, +her skin clear, her functions regular, and weighing one hundred and +thirty-six pounds.</p> + +<p>It is vain to repeat the relation of such cases, and impossible to put +on paper the means for deciding—what is so large a part of success in +treatment—the moral methods of obtaining confidence and insuring a +childlike acquiescence in every needed measure.</p> + +<p>Another class of cases will, however, bear some further illustration. We +meet with women who are healthy in mind, but who have some chronic pain +or some definite malady which does not get well, either because the +usual tonics fail, or because their occupations in life keep them always +in a state of exhaustion. If by rest we slow the machinery, and by +massage and electricity deprive rest of its evils, we can often obtain +cures which are to be had in no other way. This is true of many uterine +and of some other disorders.</p> + +<p>Miss B., æt. 37, height five feet five inches, <a name="Page_183" id="Page_183"></a>weight one hundred and +fifteen pounds, a schoolteacher, without any notable organic disease, +had a severe fall, owing to an accident while driving. A slight swelling +in the hurt lumbar region was followed by pain, which became intense +when she walked any distance. Loss of color, flesh, and appetite ensued, +and, after much treatment, she consulted me. I could find nothing beyond +soreness on deep pressure, and she was anything but hysterical or +emotional.</p> + +<p>Two months' rest with the usual treatment brought her weight up to one +hundred and thirty-eight pounds, and she has been able ever since to do +her usual work, and to walk when and where and as far as she wished.</p> + +<p>Several years ago I treated with some reluctance a lady who had +extensive bronchitis and a slight albuminuria. This woman was a mere +skeleton, with every function out of order. I undertook her case with +the utmost distrust, but I had the pleasure to find her fattening and +reddening like others. Her cough left her, the albumen disappeared, and +she became well enough to walk and drive; when a sudden congestion of +the kidneys destroyed her in forty-eight hours.</p> + +<p><a name="Page_184" id="Page_184"></a>The following case of extreme anæmia, with striking resemblance to the +pernicious type in some of its features, is especially interesting for +the ease and rapidity of improvement under rest and massage without +electricity or excessive amounts of food.</p> + +<p>Mrs. T., æt. 40, the mother of several children, had been unwell for +years, and almost totally incapacitated for exertion for two years +before admission, in January, 1894. She complained of extreme +feebleness, distaste for and inability to digest food, a great and +constant difficulty in swallowing, shortness of breath, dropsy of the +ankles if she walked or stood, hemorrhoids from which some bleeding +often occurred, extreme constipation, constant chilliness, and frequent +violent headaches. Her appearance was that of a person with pernicious +anæmia, a very yellow muddy skin, dry and harsh to the touch, and the +hands and feet cold, almost to the point of pain.</p> + +<p>On examination the spleen was decidedly large; the lower border of the +stomach reached to the level of the umbilicus. Two cardiac murmurs were +present, the one a sharp and well-defined mitral regurgitant sound, +confirmed by <a name="Page_185" id="Page_185"></a>the dyspnoea and dropsy as organic, the other a loud +musical murmur of hæmic origin. The trouble in deglutition proved to be +due to an oesophageal narrowing. The blood examination bore out the +suggestion of probable pernicious anæmia, the red cells being only +1,500,000, hæmoglobin 18 per cent.: the microscope showed microcytes, +megaloblasts, nucleated red cells, and a large increase in white +corpuscles. In order to study the effect of massage alone upon the blood +no other treatment was used, though of course the patient was kept at +"absolute rest." No drugs were given, electricity was not used, and +extra food was omitted, as the irritability of the oesophagus made her +unwilling to attempt the exertion and annoyance of frequent feeding. The +general chilliness was at once helped by massage, and in a few days only +felt in the small hours of the night, and the patient gained weight from +the first. After one week of treatment a blood count was made: red cells +were 3,800,000, more than double the former figure; hæmoglobin, 35 per +cent., almost double its original value. On the same day, one hour after +the completion of an hour's massage, the corpuscular count had attained<a name="Page_186" id="Page_186"></a> +5,400,000, the hæmoglobin remaining 35 per cent.</p> + +<p>At the end of two weeks the hæmic murmur had faded into a faint soft +bruit, though the mitral murmur was unchanged, the skin had improved in +color, the aches and weariness were gone, and the blood count had +reached nearly five million cells, with 50 per cent. of hæmoglobin. The +extraordinary results of the blood examination were confirmed by +observations made by Professor Frederick P. Henry, Dr. Judson Daland, +and Dr. J.K. Mitchell, who all practically agreed. Professor Henry made +several studies and stained a number of slides, verifying in his report +the statements of the presence of megaloblasts and nucleated red cells +made above.</p> + +<p>Owing to the necessity for an operation on the hemorrhoids, which caused +loss of blood, the patient was somewhat retarded in her progress to +recovery, but by the tenth week was so far better that the blood showed +no microscopic abnormalities, the count was full normal, and the +hæmoglobin over 70 per cent. Her color and strength were good, the heart +was perfectly strong, the anæmic murmur was gone, and the <a name="Page_187" id="Page_187"></a>oesophagus +was so much less irritable that it was possible to begin dilatation of +the stricture.</p> + +<p>I have heard within a year that though occasionally annoyed by this last +trouble if she becomes much fatigued, she has remained in other ways +well.</p> + +<p>Mrs. G., the daughter of nervous parents, was always a nervous, +over-sensitive, serious child, worked hard at Vassar, broke down, +recovered, returned to college, was attacked with measles, which proved +severe, and by the time she graduated had been made by her own +tendencies and the anxious attention of her family into a devoted member +of the class which I may permit myself to describe as health-maniacs.</p> + +<p>Health-foods, health-corsets, health-boots, the deeply serious +consideration of how to eat, on which side to sleep, profound +examination of whether mutton or lamb were the more digestible +flesh,—these were her occupations,—and two or three years before her +panic about her health had been made worse by the discovery of an aortic +stenosis, of which an over-frank doctor had thought it best to inform +her. When I saw her she had been three years married, was childless, +and, between the real cardiac dis<a name="Page_188" id="Page_188"></a>ease and her own anxieties about it, +had driven herself into a state of great physical debility and a mental +condition approaching delusional insanity.</p> + +<p>A too restricted diet, lacking both in variety and appetizingness, had +had its usual result of upsetting digestion and destroying desire for +food. Even with the small amounts which she ate she considered it +necessary to chew so carefully and to feed herself so slowly that from +one hour to an hour and a half was used for each meal. The heart, +under-nourished, beat feebly, there was constant slight albuminuria with +evidences of congested kidneys, and she could only rest in a semi-erect +position.</p> + +<p>The heart condition, with its renal results, proved the most rebellious +part of the trouble. A firm and intelligent nurse soon overcame the +difficulties and delays about food, and my final refusal to discuss them +disposed for the time of some of the fanciful theories about digestion +and so on. Her meals were ordered in every detail, and she was told that +they were prescribed and to be taken like medicine, and, fed by the +nurse, she began to take more nourishment. Massage relieved some of the +labor of <a name="Page_189" id="Page_189"></a>the heart, and gradually the semi-erect posture was exchanged +inch by inch for a semi-recumbent one. Not to prolong the relation of +details, it was found needful to keep this lady in bed for five months +before the heart seemed to recover sufficiently to allow her to get up. +Even then, although improved in color, flesh, and blood condition, she +had to attain an erect station almost as slowly as she had had to reach +recumbency. Slow, active Swedish movements, to which gentle resistance +movements were very gradually added, helped the heart. Her cure was +completed by five or six months' camp-life in the woods, and she is now +the mother of a healthy child and herself perfectly well, the valvular +disease only to be detected by the most careful examination, and never, +even during pregnancy and parturition, causing any annoyance.</p> + +<p>The surgeons, who once thought a floating kidney could be permanently +fixed in its place by stitching, have now concluded that this is very +doubtful, and the treatment of this displacement is never very +satisfactory by any method. Still, some success has followed long rest +in the supine position, which encourages the <a name="Page_190" id="Page_190"></a>kidney to return to its +normal place, until careful full feeding has renewed or increased the +fatty cushions which hold it up. It is best during the first weeks of +treatment not to allow the patient to sit or stand, or if she should be +unable to avoid the occasional need for these positions, an abdominal +binder must be applied by the nurse and drawn tightly before she moves. +The masseuse is directed to avoid any movements which might further +displace the organ, and may cautiously push it upward and hold it there +with one hand while with the other the manipulation of the abdomen is +performed. However long it may require, the patient should not get up +until examinations, supine, lateral, prone, and erect, combine to assure +us that the kidney is replaced. Repeated investigation of this point +will be required,—for the kidney will sometimes be in place for a +little while and next day or even a few hours later have slipped down +again. Before any exertion is permitted, even ordinary walking, an +accurate close-fitting abdominal belt with a kidney-pad should be +applied. Those kept in stock are seldom properly adjusted, and usually +have the pad in the wrong place. If rightly made, <a name="Page_191" id="Page_191"></a>they can be worn with +comfort and tight enough to be useful. If not rightly made, they are +useless instruments of torture.</p> + +<p>Mrs. Y., æt. fifty-six, was sent to Dr. J.K. Mitchell by Professor Osler +for treatment. She had all the usual intestinal derangements and +discomforts attendant upon a floating kidney: constipation alternated +with diarrhoea, or rather with a sort of intestinal incontinence; vague +pains in the back, flanks, and stomach were frequent; attacks of acute +pain began in the right hypogastrium and ran down to the symphysis or +into the groin; she had constant flatulence, weight, and oppression +after food; was pale, flabby, and emaciated, but had no emotional or +nervous symptoms except an annoying amount of insomnia. The lower border +of the stomach was fully two inches below the navel in the middle-line, +even when only a glass of water had been taken. It was a little lower +after a small meal. The colon was distended and very variable in +position, probably changing its relations with the landmarks as it +happened to be more or less filled with food or gases. The abdominal +walls were flabby, relaxed, and pendulous, and the whole surface tender. +The <a name="Page_192" id="Page_192"></a>patient gave a history of sudden loss of flesh with almost no +reason some three years before, and increasing indigestion in all forms +ever since. The tenderness made careful abdominal study difficult, but +lessened enough after a few days in bed to permit the perception of a +displacement of the right kidney, whose lower edge could be felt on a +level with the umbilicus and two inches to the right of it. No change of +position would bring it any lower. Examined with the patient prone, +two-thirds of the kidney could be outlined, extremely tender, and +causing nausea and sinking if pressed upon.</p> + +<p>The chief trouble in treatment proved to be the irritability of the +intestines, which was brought on in most unexpected fashion by foods of +the simplest kind. For some time it was so persistent that the suspicion +of intestinal tuberculosis was entertained; but it finally disappeared, +and after that the case progressed more favorably and she was out of bed +with a tight belt and kidney-pad in a little more than twelve weeks. The +kidney was then, and has remained since, in its normal position. The +patient gained twelve pounds in weight, and should have gained more, but +she found the hot weather during the <a name="Page_193" id="Page_193"></a>latter weeks of her treatment very +trying. The intestinal indigestion was only partially relieved, but the +gastric symptoms, the general pains, and weakness all disappeared, and +with precaution she will continue to improve. It is best to advise the +constant use of the belt in such a case. In a patient who has made a +large gain in flesh, as this one did not, and who has been found after +some months to maintain the increased weight, the belt might gradually +and experimentally be left off; but repeated examinations should be made +for a year or two to be sure that no displacement results.</p> + +<p>I could relate cases of gain in flesh without manifest relief. As I have +said, these are rare; but it is less uncommon to see great relief +without improvement in weight at all, or until the patient is up and +afoot for some weeks; and I could also state several cases in which a +repetition of the treatment won a final and complete success after the +first effort at cure had failed or but partially succeeded; and of this, +I believe, Professor Goodell has seen several examples.</p> + +<p>I have mentioned more than once the singular return of menstruation +under this treat<a name="Page_194" id="Page_194"></a>ment, and as examples I add a brief list of some +notable instances.</p> + +<p>Mrs. N., æt. 29, no menstruation for five years; return of menstruation +at thirtieth day of treatment; continued regularly ever since during +three years.</p> + +<p>Mrs. C., æt. 42, eight years without menstruation; return at fourteenth +day of treatment; now regular during five months.</p> + +<p>Miss C., æt. 22, no menstruation for eight months; return at close of +sixtieth day of treatment; regular now for four months.</p> + +<p>Miss A., æt. 26, irregular; missing for two or three months, and then +menstruating irregularly for two or three months. No flow for two +months. Menstruated at nineteenth day of treatment, and regular during +thirteen months ever since.</p> + +<p>I had at one time intended to give, in the first edition of this work, a +summary of all my cases, with the results; but what is easy to do in +definite maladies like typhoid fever becomes hard in cases such as I +here relate. In fevers the statistics are simple,—patients die or get +well; but in cases of nervous exhaustion, so called, it is impossible to +state accurately the number of <a name="Page_195" id="Page_195"></a>partial recoveries, or, at least, to +define usefully the degrees of gain. For these reasons I have not +attempted to furnish full statistics of the large number of cases I have +treated.</p> + +<p>In the debate before the British Medical Association the question of the +permanence of cures by this method was the subject of discussion. I have +lately been at some pains to learn the fate of many of my earlier cases, +and can say with certainty that every case then treated was selected +because all else had failed, and that I find relapses into the state +they were in when brought to me to have been very uncommon. A vast +proportion have remained in useful health, and a small number have lost +a part of their gains. I now make it a rule to keep up some relation +with patients after discharge, by occasional visits or by letter, and +believe that in this way many small troubles are hindered from becoming +large enough to cause relapses.</p> + +<p>I said in my first edition that I did not doubt that the statements I +made would give rise in some minds to that distrust which the relation +of remarkable cures so naturally excites; and this I cannot blame. Every +physician can recall in his own practice such cases as I have +<a name="Page_196" id="Page_196"></a>described, and every medical man of large experience knows that many of +these women are to him sources of anxiety or of therapeutic despair so +deep that after a time he gets to think of them as destined irredeemably +to a life of imperfect health, and finds it hard to believe that any +method of treatment can possibly achieve a rescue.</p> + +<p>I am fortunate now in having been able to show that in other hands than +my own, both here and abroad, this treatment has so thoroughly justified +itself as to need no further defence or apology from its author. It has +gratified me also to learn that in many instances country physicians, +remote from the resources of great cities, have been able to make it +available. As I have already said, I am now more fearful that it will be +misused, or used where it is not needed, than that it will not be used; +and, with this word of caution, I leave it again to the judgment of time +and my profession.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_197" id="Page_197"></a></p> +<h3><a name="CHAPTER_X" id="CHAPTER_X"></a><b>CHAPTER X.</b></h3> + +<h4>THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC PARAPLEGIA, SPASTIC PARALYSIS, +AND PARALYSIS AGITANS.</h4> + + +<p>In my earliest publication on the treatment of diseases by rest, etc., +locomotor ataxia was alluded to as one of the troubles in which +remarkable results had been obtained. Rest alone will do much to +diminish pain and promote sleep in tabes, rest with massage and +electricity will do more. It is not necessary to order complete +seclusion for such cases, but some special measures will be needed in +addition to those already described as of use in various disorders, and +these will be discussed in this chapter.</p> + +<p>While this is not a treatise on diagnosis, some brief +symptom-description is needed to enable one to define clearly the +methods of treatment at different stages.</p> + +<p>In the middle or late stages there need be little uncertainty in +uncomplicated cases; in the earlier periods diagnosis is by no means +easy.<a name="Page_198" id="Page_198"></a> A history may usually be elicited of important heralding +symptoms, such as former or present troubles with the muscles of the +eyes, the occurrence of vague but sharp and recurring pains, vertigo, an +impairment of balance, unnoticed perhaps, except when walking in the +dark or when stooping to wash the face, or especially when going down +stairs. Attacks of 'dyspepsia,' as unrecognized visceral crises are +often called, should render one suspicious. If, on examination, loss or +impairment of knee-jerk be shown, contraction of the pupil with +Argyll-Robertson phenomenon and defective station, but little doubt can +exist. The discovery by the ophthalmoscope of some degree of beginning +optic neuritis would make assurance more sure, and this can often be +detected in a very early stage of the disease.</p> + +<p>Much controversy has been spent on the question of the share of syphilis +in producing tabes, and out of the battle but two facts emerge fairly +certain, the one that syphilis often precedes the disease, the other +that anti-syphilitic medication is commonly of no service. But syphilis +is so frequently antecedent that a history of that infection may make +certain the diagnosis when <a name="Page_199" id="Page_199"></a>doubt exists. This may be an important +point, for some of the cardinal symptoms are occasionally absent; cases +are seen with no incoördination, sometimes with the station unaffected, +even, though rarely, with the knee-jerk preserved.</p> + +<p>The diagnosis established, treatment will somewhat depend upon the stage +which the disease has reached.</p> + +<p>In the pre-ataxic stage, where slight unsteadiness, often not +troublesome except in the dark or with closed eyes, sharp stabbing pains +here and there, numbness of the feet, girdle-sense in the region of +chest, waist, or belly, some recurrent difficulty in emptying the +bladder, a fugitive partial palsy of the external muscles of the eye, +are the chief or, perhaps, the only complaints, it would not be +justifiable to put the patient to bed at complete rest. This early stage +calls for a different plan of treatment, to be presently described.</p> + +<p>In the middle or more distinctly ataxic period long rest in bed should +be prescribed, and will be gratefully accepted by a patient whose +sufferings from incoördination, pains, and numbness of the extremities +are often so great as to incapacitate him.</p> + +<p><a name="Page_200" id="Page_200"></a>The bladder muscles share in the ataxia, and the consequent retention +of urine frequently causes cystitis, and may endanger life by the +involvement of the kidneys.</p> + +<p>The bowels cannot be emptied or are moved without the patient's +knowledge, and these annoyances combine with the pain and nervous +apprehension to drive the victim into a melancholic or neurasthenic +state. He suffers, too, from want of occupation, from the absence of +exercise, from the anticipation of worse changes in the near future, and +usually by the time he reaches the specialist has been more or less +poisoned with iodide of potash and mercury, and perhaps with morphia.</p> + +<p>In the third, the paralytic stage, which seldom comes on until the +symptoms have lasted for years, there is gradual loss of power and +ataxia, increasing until he is totally unable to walk. If a patient is +not seen until this condition of things has been reached, but little can +be hoped from any treatment, though in a few cases energetic measures +may bring about a marked improvement, which is rarely lasting.</p> + +<p>A combination of tabes with lateral sclerosis, or with general paralysis +of the insane, <a name="Page_201" id="Page_201"></a>is sometimes seen, but needs no special consideration.</p> + +<p>The first or pre-ataxic stage is, to the great detriment of patients, +too seldom recognized. The pains are called rheumatic, the eye symptoms +are lightly passed over or glasses are ordered, the difficulty of +micturition is treated by drugs, and the slightly impaired balance +unnoticed or unconsidered.</p> + +<p>When such a patient comes into our hands the history, and especially the +history of predisposing causes, needs the most careful examination. It +is well established that syphilis is a common precedent of ataxia, +occurring in at least two-thirds of the cases; it is even more firmly +settled that iodide and mercury in large doses do no good in advanced +ataxia. I say in advanced ataxia, because a few cases are seen in which +the syphilis has been of recent occurrence, or where the spinal symptoms +are of decidedly acute character, and in these anti-syphilitic +medication is needed and useful; but such cases should be described as +acute or subacute spinal syphilis, not as ataxia. When nerve +degeneration has once begun, iodide will do little good and mercury may +do positive harm, if <a name="Page_202" id="Page_202"></a>used in large doses. The other common predisposing +causes, exposure to cold, over-exertion, sexual excess, need concern us +only as they suggest warnings to be given, especially when the patient +is improving. Until he does improve not much need be said about them; he +cannot indulge in venery, as sexual power is usually (though not always) +lost early in the disease; and the incoördination lessens his +opportunities of exposure or over-exertion.</p> + +<p>During this stage some patients complain most of the numbness, +girdle-sense, and incoördination; others of the stabbing pains or the +bladder weakness. The general treatment must be much the same, however, +in all, with special attention besides to the special needs of each +individual.</p> + +<p>Fatigue makes all the symptoms worse, increases pain, and impairs still +more the muscular incoördination; it is, therefore, of the first +importance in every instance to forbid all over-exertion. Walking, more +than any other form of exercise, hurts these cases. The patient should +not walk beyond his absolute necessities. To get the needed fresh air, +let him, according to his situation in life, drive out or use the +street-<a name="Page_203" id="Page_203"></a>cars. In some cases the use of a tricycle on a level floor or on +good roads is not so harmful as walking, for obvious reasons; this +tricycle exercise may at first be made a passive or mild exercise by +having the machine pushed by an attendant. To replace the effects upon +the circulation and bowels of physical activity massage may be used, and +the masseur must have directions as to gentle handling of the tender +places at first. These are usually in fixed positions, and can be +avoided or only lightly touched. The shooting pains may be lessened by +deep, slow massage in the tracks of the nerves affected. If, as +generally happens, there are also regions of defective sensation, these +should receive after the general manipulation active, rapid circular +friction, and, perhaps, experimentally, open-hand slapping. As +constipation is one of the troublesome features, the abdomen should have +particular attention, and an unusual amount of time be given to +manipulations of the colon, as described in the chapter on massage. A +full hour's rest in bed, preferably in a darkened room, must follow the +rubbing.</p> + +<p>A schedule for the day on about the lines of the "partial rest" +schedule, as described on a <a name="Page_204" id="Page_204"></a>previous page, should be followed. A +prolonged warm bath, with cool sponging after, if the latter be well +borne, is useful in lessening pains and nervous irritability,—and this +may begin the day or be used at any convenient hour.</p> + +<p>At an hour as far from the massage as possible lessons in co-ordinate +movements are given, after a week or ten days of massage has prepared +the muscles, and baths and a quiet life have steadied the nerves. For +many years past, certainly fifteen or sixteen, the students and +physicians who have followed my service at the Infirmary for Nervous +Diseases have seen this systematic training given, and no doubt they +received with some amusement the excitement about it as a new method of +treatment when it was proclaimed in Europe two or three years ago.</p> + +<p>The indication for this teaching appeared too obvious to publish or talk +much about. The patient has incoördination; one, therefore, does one's +best to teach him to co-ordinate his movements by small beginnings and +by small increases.</p> + +<p>The lessons may be given by the physician at <a name="Page_205" id="Page_205"></a>first and be executed +under his eye. After a few days any tolerably intelligent patient should +be able to carry them out alone, but still each new movement should be +personally inspected to make sure that it is done correctly.</p> + +<p>In patients in the first stage of ataxia the most striking result of +incoördination is the impairment of station. We therefore begin with +balancing lessons. The patient is directed to stand at "Attention," head +up and chest out, not looking at his feet, as the ataxic always wishes +to do. At first this is enough to require; it will not do to be too +particular about how his feet are placed, so long as he does not +straddle. He can repeat this effort for himself a dozen times a day, for +a minute or two each time. Next we try the same position with a little +more care about getting the feet pretty near together and parallel, or +with the toes turned out only a very little. In another couple of days a +little more severity may be exercised about maintaining the correct +attitude,—heels touching, hands hanging down, and eyes looking straight +forward,—and until he is able to do this <i>easily</i> it is best to ask +nothing more. Then he is requested to stand on one foot, being permitted +<a name="Page_206" id="Page_206"></a>just to touch a chair-back or the attendant's hand to give confidence. +This is practised until he can keep his erect station for a few seconds +without difficulty. This point of improvement may be reached in three +days or a week or may take a fortnight. Women, as I have before +observed, although rarely in America the victims of tabes, when they do +have it have far less disturbance of balance than men, and this is to be +attributed to their life-long habit of walking without seeing their +feet. I have found in the few cases of ataxia in women that I have seen +that they benefited much more quickly by these balance instructions than +did men, though their other symptoms were in no way different.</p> + +<p>Continuing every day the practice of all the previous lessons, movements +are rapidly added as soon as station is better. A brief list of them +follows. When the exercises grow so numerous as to take overmuch time, +the simpler early ones may be omitted.</p> + +<p>When the learner is able to stand on one foot, let him slowly raise the +other and put it on a marked spot on the edge of a chair. This, like all +the other exercises, must be practised with both feet.</p> + +<p><a name="Page_207" id="Page_207"></a>Stand erect without bending forward and put one foot straight back as +far as possible.</p> + +<p>Do the same sideways.</p> + +<p>Stand and bend body slowly forward, backward, and sideways, with a +moment's rest after each motion.</p> + +<p>Having reached this point, I usually order the patient to practise all +these with closed eyes. When he can do this, he begins to take one or +two steps with shut eyes, first forward, then sideways, then backward. +If he falter or move without freedom, he is kept at this until he does +it confidently. Then exercises in following patterns traced on the floor +are begun. In hospitals, or where bare floors are to be found, the +patterns may be drawn with chalk. In carpeted rooms, which by the way +are less suited for the work than plain boards or parquet floors, a +piece of half-inch wide white tape may be laid in the required pattern, +first in a straight line, later, as proficiency is gained, in curved, +figure-of-eight, or angular patterns. The patient must be made to walk +<i>on</i> the line, putting one foot directly in front of the other, with the +heel of the forward foot touching the toe of the one behind.</p> + +<p>Walking over obstacles is tried next. Wooden <a name="Page_208" id="Page_208"></a>blocks measuring about six +by twelve inches and two inches thick are stood on edge at intervals of +eighteen inches and the patient walks over them, thus training several +groups of muscles; the blocks are at first set in straight lines, then +in curving patterns. An ordinary octavo book makes a good substitute for +a block.</p> + +<p>If the trunk muscles are affected by the ataxia, further exercises are +ordered for them, bending and twisting movements, picking up objects +from the floor, etc. For the hands and arms, which, except in those very +rare cases where the ataxia first shows itself in the upper extremities, +seldom exhibit much incoördination in the primary and middle stages, the +movements are the picking up of a series of different-shaped small +articles, arranging objects like dominoes, marbles, or the kindergarten +sticks in patterns, bringing the fingers of the two hands one after +another together, or touching a finger to the ear or the nose, at first +with open and then with shut eyes.</p> + +<p>With these methods, needing not more than twenty minutes three times a +day, the ataxic symptoms sometimes rapidly diminish. In certain cases no +other improvement will be ob<a name="Page_209" id="Page_209"></a>served, showing that what has taken place +is of course not an alteration of the diseased nerve-tissues for the +better, as no treatment can restore sclerotic spinal tissue to a normal +state, but is merely a substitution of function, in which other and +associated nerve-tracts have replaced in control the ones affected.</p> + +<p>As to the pains and bowel and bladder disturbances, their handling will +be discussed in considering the treatment of the next or middle stage of +tabes. In this period the ataxic symptoms are most prominent; the gait +has become so unsteady that the patient needs canes to walk at all and +must constantly watch his feet. He walks a little better when well under +way, but at starting or when standing still he sways and totters. The +girdle-sense is severe and constant, various pains assail the body and +limbs; the numbness of the feet, often described as a feeling "like +walking with a pillow under the foot," still further incommodes his +walking.<a name="FNanchor_30_30" id="FNanchor_30_30"></a><a href="#Footnote_30_30" class="fnanchor">[30]</a> The bladder control may be so enfeebled as to re<a name="Page_210" id="Page_210"></a>quire +daily catheterization, and the bowels move only with enemas or +purgatives, and often without the patient's knowledge, owing to the +anæsthesia which affects the rectum and its vicinity.</p> + +<p>One of the first things to attend to when patients are in this stage is +the bladder, as the retention is the only condition likely to produce +serious disorder. Cystitis is or may be present, and with the retention +is a constant threat to the kidneys. Catheterization and washing out +with an antiseptic must be regularly practised while treatment is used +to improve the condition.</p> + +<p>For these patients rest in bed is a prime necessity in order to remove +all excuse for exertion. The method of application of massage has +already been suggested. Care must be taken that the patient eats well +and of the best food. Except for occasional gastric or intestinal crises +of pain, sometimes with vomiting, sometimes with diarrhoea, the +digestive functions are usually well performed, unless the stomach has +been greatly upset by over-use of iodide. The most liberal feeding +consistent with good digestion is indicated, for it must be remembered +that we are dealing with a disease in which degen<a name="Page_211" id="Page_211"></a>erative changes play +an important part. The usefulness of electricity in ataxia has been +denied by some authors, while others praise it indiscriminately. Perhaps +a reason for this difference of opinion may be found in its different +effects upon individual patients; but I see few in whom I do not find +electricity in one or another form helpful. For pains I order the +galvanic current through the affected nerves as strong as the man is +able to bear. If after a few days of this the pains are unchanged, a +rapidly interrupted faradic current is tried, and failing to do good +with this, I use light cauterization or a series of small blisters to +the spine at the point of exit of the painful nerves. Galvanization of +the bladder with an intravesical electrode is sometimes of service to +strengthen its capacity for contraction. Faradism is applied in the form +just described, using a wire brush as an electrode to the areas of +numbness and anæsthesia. Lately I have found that this current in a +strength which would be very painful to the normal skin will in some +instances relieve the feeling of pressure and dull discomfort about the +rectum and perineum, and it has been successful when galvanism did no +good. In patients within reach of a static <a name="Page_212" id="Page_212"></a>machine, this form may be +used for the numbness if the others do not help it.</p> + +<p>For the attacks of pain, if general, a prolonged hot bath lasting from +ten to twelve minutes, at a temperature of 100° F. or even more, should +be first tried; if this fail, antipyrin, phenacetin, acetanilid, or +cannabis indica may be used, or, as a last resort, morphia. For the +local pains hot water is also useful, and in the intervals I order +applications of hot water to the tender points, as hot as can be borne, +alternating with ice-water, each rapidly applied three or four times. In +severe attacks, and with all due caution to avoid habituation, cocaine +injections may be given. In cases with high arterial tension the daily +administration of nitroglycerin in full doses will not only lower the +tension but decrease the pains in force and frequency.</p> + +<p>For several years past in all patients with the general lowering of +nervous force and vitality so common in this disease I have habitually +used the testicular elixir of Brown-Séquard. The ridiculous length to +which organic therapeutics have been carried, the extravagant +advertising claims, and an absurd expectation of impossible results have +combined to make the profession <a name="Page_213" id="Page_213"></a>shy of those organic preparations which +have not very good evidence in their favor, and for some time I shared +in this prejudice against the Brown-Séquard fluid. A talk with that most +distinguished physician and an examination of some of his cases led me +to a trial for myself, and I am at present very well convinced that, +whether a physiologic basis can reasonably be assumed or not, we have in +the fluid a tonic remedy of great power. While I have used it with good +effect in other conditions, it is in ataxia that I have found it of most +value.</p> + +<p>The glycerin extract is freshly prepared from bulls' testicles in exact +accordance with the directions of the discoverer. It is used +hypodermatically every other day, beginning with a diluted ten-minim +dose and increasing by two or three drops up to about forty minims. The +effect is at its height twelve to twenty-four hours after the +administration in most patients, hence the reason for using it only once +in two days. The skin is prepared, the needles and syringe disinfected, +and the tiny puncture sealed afterwards with as minute care as would be +given to a surgical operation. By these precautions the danger of +<a name="Page_214" id="Page_214"></a>abscess, always considerable if hypodermics are carelessly given, is +minimized. As the dose is large, a site must be selected for the +injection where the tissue is loose, otherwise the pain will interfere +with the desired frequency of use. The buttocks serve best, or the outer +masses of the pectoral muscles, or the abdominal muscles. If the +administration causes pain (due in part to the large quantity used and +in part to the local effect of glycerin), a fraction of a grain of +cocaine may be added to the solution when measured out for use.</p> + +<p>It may at once be said, emphatically, that in some cases remarkable +results have followed the use of this material, while in others no good +has been done; but the same may be said of most plans of treatment in +this disorder. As to possible danger from it, no harm has been done to +any patient known to me, except that abcesses have occurred sometimes, +though very rarely, for in many hundreds of injections it has been my +good fortune to see abscesses form only three or four times, two of +these instances, by curious ill luck, being in physicians. Patients +describe a stimulating effect not unlike that of strong coffee, +following a few hours after use and <a name="Page_215" id="Page_215"></a>lasting for a day. The sexual +appetite, if present, is increased; if absent, it is often renewed, +sometimes in elderly men to an inconvenient extent. In one tabetic +subject who had lost desire and ability for more than three years both +returned in sufficient force to allow him to beget a child. This +patient, like most of the others, was ignorant of what drug was being +used and of what effects might be expected, so suggestion played no +part. Apart from this special effect, the solution acts only as a highly +stimulating tonic.</p> + +<p>The full dose of forty minims or thereabouts is maintained for a +fortnight or less, and then gradually diminished in the same way that it +was increased. Sometimes, when the effect has been good, a second +"course" may be given after two or three weeks' interval.</p> + +<p>During the treatment by hypodermic the masseur should be told to avoid +rubbing where the injections have been given. A few trials with the +fluid internally have produced so little result of any kind that I am +inclined to think the gastric juices must alter it so as to lessen or +wholly destroy its power.</p> + +<p>As to other drugs, experience has not given <a name="Page_216" id="Page_216"></a>me much confidence in any +of those usually recommended. Strychnia, belladonna, and those +antiseptic drugs which are eliminated chiefly by the kidneys are of use +when cystitis has to be treated and the bladder muscles urged to +activity. Arsenic, the chloride of gold and sodium, and chloride of +aluminium are suggested by various authorities, but they have not been +of any value in my hands. In hopeless cases, where all treatment fails, +as will sometimes happen, or in patients in whom the paralytic stage is +already far advanced, if other measures are unsuccessful, morphia is +left as a forlorn hope, which will at least relieve their pains.</p> + +<p>An outline report of several cases of different types and degrees is +appended:</p> + +<p>M.P. of North Carolina, æt. thirty-seven, general health excellent until +syphilis in 1894, was admitted to the Infirmary in 1898. He had had for +two years recurrent attacks of paralysis of the external rectus muscle +of the right eye, slight gastric crises, and stabbing pains in the legs; +station very poor, but strength unimpaired, and he was able to walk +after being a few minutes on his feet; when first rising he was very +<a name="Page_217" id="Page_217"></a>unsteady. Knee-jerk lost, no reinforcement. No sexual power. Some +difficulty in emptying the bladder. Examination showed slight atrophy of +both optic nerves, Argyll-Robertson pupil, and myosis. He was ordered +two weeks' rest in bed, with massage, cool sponging daily, and +galvanization of the areas of neuralgia. After two weeks he was allowed +to get up gradually, to occupy himself as he pleased, but not to walk. +Lessons in balance and co-ordination were begun in the fourth week of +treatment, and supervised carefully for two weeks more. When his station +and gait were both improved, he was permitted to walk, always with care +not to fatigue himself. At this time, six weeks from commencement of +treatment, his eyes were glassed by Dr. de Schweinitz. He had gained +some pounds in weight, and walked on straight lines without noticeable +incoördination, but in turning short or walking sharp curves he was +still unsteady. He found walking much easier than formerly and was less +easily tired. After nine weeks he could stand or walk, even backward, +with closed eyes. He was sent home for the summer, with directions to +continue his co-ordination movements, to walk very little, and <a name="Page_218" id="Page_218"></a>take +such exercise as he needed on horseback, riding quietly. He had still +some stabbing pains two or three times daily.</p> + +<p>He reported in one month, and again in six months, "No improvement in +the pains, but I walk well and briskly, can jump on a moving street-car, +and have ridden a horse twenty miles in a day without fatigue."</p> + +<p>This case was in one way favorable for treatment: the patient, an +educated and intelligent man, helped in every way, carrying out minutely +all orders, and had the good sense to begin treatment early. But the +acuteness and rapidity of onset of the tabetic symptoms were so great +that in a little more than two years they had reached a condition which +most cases only attain in from five to ten years, and this makes the +prognosis somewhat less favorable.</p> + +<p>In the instance to be next related there was also antecedent syphilis, +and the patient had already been heavily dosed with iodides and +repeatedly salivated with mercury. His recovery was and has remained +remarkably complete.</p> + +<p>H.B., travelling salesman, from New York, æt. forty, single, a large, +strongly-made man, a hard worker, given to excesses in sexual +indul<a name="Page_219" id="Page_219"></a>gence and alcohol for years. Syphilis was contracted fifteen years +before the first traceable symptoms of ataxia, which had shown +themselves after an attack of grippe, in 1890, in sudden remittent +paralysis of the external muscles of the right eye, followed within a +few months by gastric crises, general lightning pains appearing a few +months later. During the two years succeeding he was drenched with drugs +and grew steadily worse. When admitted to the hospital in 1892 he was +very ataxic in the legs, suffered greatly from gastric and other pains, +difficulties with bladder and rectum, loss of sexual power, various +anæsthetic areas, could not stand with eyes open unless he had help, +total loss of knee-jerk, paralysis of right rectus, indigestion from the +irritation of the stomach from medicines as well as from the disease, +and, though muscular and over-fat, was flabby and pallid. He had no +ataxia or loss of sensibility in the upper half of the body. He was in +bed for two weeks, on milk diet, with warm baths and massage. Systematic +movements were begun and massage continued. After the stomach improved +he grew better with unusual rapidity. He is now able to work hard again, +travels exten<a name="Page_220" id="Page_220"></a>sively, can walk strongly, but wisely takes his exercise +more in the form of massage and systematic gymnastics. He appears to +report himself once or twice a year. There has been a partial return of +sexual ability.</p> + +<p>The next case has points of interest in the later history, but the first +examinations and early treatment may be passed over briefly. X.Y., æt. +forty-two, a steady, sober merchant, closely confined by his business, +always of excellent habits, with no possible suspicion of syphilis, was +seen first in 1894 in a somewhat advanced stage of tabes, but with no +optic or gastric disturbances. His station was very bad, but when once +erect and started he could walk without a stick. Girdle-pains very +marked; bowels very constipated; some trouble in emptying bladder; +several points of fixed sharp pain; lightning pain occasional and +severe, but not frequent. He was ordered to bed for six weeks. +Galvanism, alternate hot- and cold-water applications to the tender +spots, careful massage, and a two-months' course of Brown-Séquard fluid +after getting up made a new man of him. Massage and systematic exercise +were kept up together for six months. The massage was <a name="Page_221" id="Page_221"></a>stopped and the +exercises continued, and improvement went on steadily, though the fixed +pains kept up in only slightly less severity.</p> + +<p>In a year the patient was better in general health, looks, and spirits +than he had been for many years before, and remained in good order, +except for the daily recurrences of paroxysms of pain of varying but not +unbearable severity for two years. He then presumed for a month on his +strength, and took much more exercise afoot than was wise, worked late +at night over his books, had some additional nervous strain from +business worries, and came to Dr. J.K. Mitchell in October, 1898, barely +able to crawl with two canes, having lost weight, become sleepless, +suffered great increase of pain, and grown so ataxic that he could +scarcely walk. This change had all occurred in three or four weeks. He +became steadily worse for two or three weeks till he could not stand or +walk at all, had cystitis from retention, violent attacks of rectal +tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with +almost total anæsthesia of the sacral region, buttocks, scrotum, and +perineum, inability to retain fæces, while passages from the bowels took +place without his <a name="Page_222" id="Page_222"></a>knowledge. He found that an increase in the rectal +and abdominal pain followed lying down. He therefore spent day and night +sitting up. At the end of three weeks there was total paralysis of the +legs, and the outlook seemed most unfavorable.</p> + +<p>Massage was begun again, strychnia and salol were administered, and a +short course of full doses of the testicular fluid was given. A rapidly +interrupted faradic current, with an uncovered electrode, to the +neighborhood of the rectum, bladder, and buttocks, greatly relieved the +anæsthesia, upon which galvanism had no effect; and, in brief, from a +state which looked almost as if the last paralytic stage of tabes had +suddenly come upon him, he recovered in two months, and is now (July, +1899) better than he was a year ago, before the relapse, and will +probably remain so, as he has had his warning.</p> + +<p>Without multiplying case histories, it may be said that ataxic +paraplegia (a combination of lateral and posterior sclerosis) may be +treated in much the same manner. In this disease there is usually much +less pain than in ataxia, but greater weakness, and late in its course +some rigidity in the extensor groups of the legs; the <a name="Page_223" id="Page_223"></a>knee-jerk is +preserved or exaggerated. The disease is a rare one. But two recent +distinct cases are in my list, and one of these, the one here reported, +seems rather more like an ataxia with some anomalous symptoms. The +second one had the symptom, uncommon in this malady, of very frequent +and excessively severe stabbing pains, and though his co-ordination grew +somewhat better, he improved very little in any other way, which, as his +trouble was of fourteen years standing, was not astonishing.</p> + +<p>The other patient, seen in 1897, was a rancher from New Mexico, +thirty-three years old, who had led an active, hard-working, +much-exposed life, but had been perfectly well until 1891, when he was +said to have had an attack of spinal meningitis, from which he recovered +very slowly. Four years later he noticed numbness of feet and weakness +of legs, great enough to make it hard for him to get a leg over his +horse. Some pains were felt in the limbs, and a constriction about the +chest and abdomen, which had steadily increased in severity. Sharp +attacks left distinct bruise-marks at the seat of pain each time. Could +not empty bladder. Gait feeble, spastic, and paralytic, could not mount +steps at all or <a name="Page_224" id="Page_224"></a>stand without aid, sway very great. Knee-jerks and +muscle-jerks increased, especially on left; ankle-clonus; very slight +loss of touch-acuity in lower half of body. Eyes: muscles and +eye-grounds negative; pupils equal and active. Bladder could not be +emptied; cystitis. Ordered rest, massage, electricity, and full doses of +iodide in skimmed milk. In this way he was able to take without distress +or indigestion amounts as large as four hundred and forty grains a day. +When education in balance, etc., was begun he could not walk without +aid, or more than a few steps in any way. In three months from the time +he went to bed he walked out-of-doors alone with no stick, and in five +months went back to work. The bladder did not improve much until after +regular washing out and intravesical galvanism were used, with full +doses of strychnia. He was soon able to empty the organ twice a day, and +since leaving the hospital writes that it gives him very little +annoyance, though as a measure of precaution he uses a catheter once +daily. His pains have entirely disappeared, and he is daily on horseback +for many hours.</p> + +<p>In spastic paralysis, whether in the slowly-developing forms in which it +is seen in adults, due <a name="Page_225" id="Page_225"></a>sometimes to multiple sclerosis, sometimes to +brain tumor, sometimes following upon a transverse myelitis, or in the +central paraplegia or diplegia of "birth-palsies," some very fortunate +results have followed the careful application of the principles of +treatment already described. Absolute confinement to bed is seldom +required or in adults desirable, though exercise should be carefully +limited to an amount which can be taken without fatigue, and some hours' +rest lying down is usually advantageous.</p> + +<p>Assuming that the necessary treatment for the disease originating the +paralysis is to be carried on in the ordinary way, I will only describe +the special forms and methods of exercise I have found serviceable. +Whatever the cause, this will be much the same, though in birth-palsies +the teaching may have to include groups of muscles and instruction in +the co-ordination of actions which are not affected in adult subjects.</p> + +<p>First, as to massage: the operator must direct his efforts primarily to +the relaxation of the tense muscles, secondarily to the strengthening of +the opponent groups, this last being of special importance where actual +contraction has taken place. He should make frequent attempts by +<a name="Page_226" id="Page_226"></a>stretching the rigid groups to overcome the spasm, which in large +muscle-masses may be done by grasping with both hands, taking care not +to pinch, and pulling the hands apart in the line of the muscle's long +axis, thus stretching the muscles. Pressure will sometimes accomplish +the same end, and it will be found in certain cases that by kneading +<i>during action</i>,—that is, while the patient endeavors to produce +voluntary contraction,—the result will be better. Except in the most +spastic states, a certain degree of relaxation is possible by effort, +though not without practice, and this has to be constantly inculcated +and encouraged. After a period varying in length according to the case, +lessons in co-ordinating movements are begun. It is best for the +patient's encouragement to start with the least affected muscles, so +that, seeing the good results, he may be stimulated to persistent +effort. The lessons differ only in detail from those given in the list +under tabes. Improvement is slower than in ataxia.</p> + +<p>In birth-palsy cases not much can be accomplished in the way of +education, beyond the attempt by such means as ordinary gymnastics and +lessons in drill and walking offer, until the <a name="Page_227" id="Page_227"></a>child shall have reached +an age when he is able to comprehend what is being attempted. For the +imbecile, idiotic, or backward a training-school is the proper place, +where mental and bodily functions may both receive attention and where +constant intelligent supervision is available.</p> + +<p>Many children the subjects of cerebral diplegia are credited with less +intelligence than they really possess, partly because they are +necessarily backward, and partly because of their difficulty in +expressing themselves, the speech-muscles sharing in the disease. These +muscles need to be carefully educated, and this might almost be made the +subject of a treatise by itself. Each case will require study as to the +special difficulties in the way of speech. Some experience most trouble +with the vowel sounds, more find the consonants the worst obstacles. +Patient practice in forming the sounds soon produce some results; the +pupil must be taught, like the deaf mute, to watch and imitate the +movements of the lips and tongue.</p> + +<p>Séguin's books and the numerous special works should be consulted by the +physician or parent desiring to pursue these methods to their fullest +development.</p> + +<p><a name="Page_228" id="Page_228"></a>When once the control of muscular movement begins to improve, more +elaborate exercises may be set. In speech, if the patients be +intelligent, they will sometimes be amused and profitably trained at the +same time by the effort to learn and repeat long words or nonsensical +combinations of difficult sounds, like the "Peter Piper" nursery rhymes.</p> + +<p>B.M., æt. fourteen, an intelligent lad, of Jewish parentage, suffered a +forceps-injury at birth, and had convulsive seizures later. He began to +make futile attempts at walking when five or six years of age, when the +spastic rigidity was first noticed. His speech was better at this time +than later, and a sort of relapse seemed to be precipitated by a fall in +which he struck his head when seven years of age. His mother, finding it +almost impossible to teach him to walk, devoted herself faithfully to +improving his mind, so that at fourteen years of age he read well and +enjoyed books, and was mentally clear, observant, and docile. His speech +was almost incomprehensible,—stuttering, thick, and nasal. He stood, +swaying in every direction, though not apt to fall, with bent knees, +rounded shoulders, every muscle in the extremities rigid, the mouth +half-open, the <a name="Page_229" id="Page_229"></a>head projected forward, and, upon attempting to move, +the toes turned in, the legs almost twined around one another, and, +unless supported, he would stumble and twist about, scarcely able to get +forward at all. With a guiding hand he did a little better. His first +lessons were in "setting-up drill," while the feeble, disused muscles +were strengthened by massage, which served at the same time to help his +very irritable and imperfect digestive apparatus, so that it was soon +possible to give him a greater variety and more nourishing kinds of food +than he had before been able to take. He was kept in bed up to three +o'clock in the afternoon, the morning hours occupied with massage and a +half-hour's lesson in erect standing, with slow trunk movements +afterwards. An hour after dinner he was dressed and taken for two hours +in a carriage or street-car. He did his reading and some study on his +return, and had another half-hour's drill, superintended by his mother. +In two or three weeks some improvement began to be observable in his +attitude, and a great change in his color and general expression, but it +was three months before it was thought wise to attempt education in +small co-ordinate move<a name="Page_230" id="Page_230"></a>ments. At about the same time speech-drill was +commenced.</p> + +<p>In all these lessons the greatest care was taken that adequate rest +should intervene between each series of efforts, and it was always found +that fatigue distinctly impaired his co-ordination, as did emotion or +indigestion. When his speech grew clearer he was set tasks of learning +many-syllabled words and also began to practise drawing patterns. Every +new lesson was first given under medical supervision and then continued +by his mother or by the masseur. To shorten the history it will suffice +to say that in six months he was able to go to school, where with +certain allowances made for his thick speech by a kindly master he did +well, and returned to his home in the South able to walk without +attracting attention, to speak comprehensibly, to write a good letter, +and with every prospect fair for a still greater improvement, which I +learn he has since made.</p> + +<p>The important things to be recognized in the treatment of these cases +are, first, that rest in proper proportion allows of the patients doing +an amount of exertion which, ungoverned, or performed in wrong ways +would harm them; sec<a name="Page_231" id="Page_231"></a>ondly, that full feeding is of value, because these +disorders are mostly of the character of degenerations and involve +failure of nutrition in various directions; and, lastly, that the +exactness of routine is of the highest moral and mental as well as +physical importance.</p> + +<p>Paralysis agitans needs scarcely more than to be mentioned as amenable +to the same methods, with small differences in the application of +details. Body movements to counteract the tendency to rigidity in the +flexor groups of spinal muscles will be especially useful, as the +stiffness of these is one of the causes of displacement forward of the +centre of gravity, a displacement which results in the festination +symptom usually seen in such cases. Prescriptions of special exercises +for the muscle-masses particularly involved in each instance must be +given, remembering that contraction of the affected muscles will to a +certain degree overcome their rigidity even at first, and to a still +greater extent as the patient reacquires voluntary control.</p> + + + +<hr style="width: 65%;" /><p><a name="Page_232" id="Page_232"></a></p><p><a name="Page_233" id="Page_233"></a></p> +<h3><a name="INDEX" id="INDEX"></a>INDEX.</h3> + + +<p> +Acne, caused by massage, 89.<br /> +<br /> +After-treatment, importance of, 79, 195.<br /> +<br /> +Albuminuria, from exercise, 101.<br /> +<br /> +Alcoholism producing fat, 23.<br /> +<br /> +American race peculiarities, 17, 21, 32.<br /> +<br /> +Anæmia. <i>Vide</i> Cases.<br /> +<span style="margin-left: 1em;">blood-count in, 102.</span><br /> +<span style="margin-left: 1em;">diagnosis of, 104.</span><br /> +<span style="margin-left: 1em;">effects of massage in, 101.</span><br /> +<span style="margin-left: 1em;">fatigue in, 72.</span><br /> +<br /> +Anæmic obesity, 24, 128.<br /> +<br /> +Asthenia. <i>Vide</i> Cases.<br /> +<br /> +Asthenopia, 67, 145, 149.<br /> +<br /> +Ataxia. <i>Vide</i> Cases.<br /> +<span style="margin-left: 1em;">bathing in, 204, 212.</span><br /> +<span style="margin-left: 1em;">co-ordinate movements in, 204.</span><br /> +<span style="margin-left: 1em;">symptoms of, 197.</span><br /> +<span style="margin-left: 1em;">treatment of, 197.</span><br /> +<br /> +<br /> +Bathing, effects of, 67.<br /> +<span style="margin-left: 1em;">in ataxia, 204, 212.</span><br /> +<br /> +Birth-palsy. <i>Vide</i> Cases.<br /> +<br /> +Bleeding, causing increase of fat, 24.<br /> +<br /> +Blood changes from massage, 99, 101, 185.<br /> +<br /> +Bowditch on weight at different ages, 17, 23.<br /> +<br /> +Bright's disease, a contraindication, 45.<br /> +<br /> +Brown-Séquard's elixir, 212.<br /> +<br /> +Brunton on effects of massage, 101.<br /> +<br /> +<br /> +Cases:<br /> +<span style="margin-left: 1em;">albuminuria, 183.</span><br /> +<span style="margin-left: 1em;">amenorrhoea, 149, 193.</span><br /> +<span style="margin-left: 1em;">anæmia, extreme, 184.</span><br /> +<span style="margin-left: 1em;">aortic stenosis, 187.</span><br /> +<span style="margin-left: 1em;">asthenia, 111, 172, 182.</span><br /> +<span style="margin-left: 1em;">ataxia, 216, 218, 220.</span><br /> +<span style="margin-left: 1em;">birth-palsy, 226.</span><br /> +<span style="margin-left: 1em;">chloral habit, 150, 154, 174, 178.</span><br /> +<span style="margin-left: 1em;">hysteria, 76, 114, 154, 157, 160, 165, 181.</span><br /> +<span style="margin-left: 1em;">hysteria and neurasthenia, 112.</span><br /> +<span style="margin-left: 1em;">hystero-epilepsy, 165.</span><br /> +<span style="margin-left: 1em;">kidney, floating, 191.</span><br /> +<span style="margin-left: 1em;">morphia habit, 154, 165.</span><br /> +<span style="margin-left: 1em;">neurasthenia, 144, 171, 174.</span><br /> +<span style="margin-left: 1em;">neurasthenia and pulmonary disease, 149, 160.</span><br /> +<span style="margin-left: 1em;">obesity, anæmic, 132, 134.</span><br /> +<span style="margin-left: 1em;">paralysis, hysterical, 134, 150.</span><br /> +<span style="margin-left: 1em;">paraplegia, ataxic, 223.</span><br /> +<span style="margin-left: 1em;">paraplegia, spastic, 228.</span><br /> +<span style="margin-left: 1em;">tabes. <i>Vide</i> Ataxia.</span><br /><a name="Page_234" id="Page_234"></a> +<span style="margin-left: 1em;">uterine disease and chloral habit, 150, 154.</span><br /> +<br /> +Cases, selection of, 33, 60.<br /> +<br /> +Chloral habit. <i>Vide</i> Cases.<br /> +<span style="margin-left: 1em;">treatment of, 137.</span><br /> +<br /> +Chorea, 33.<br /> +<br /> +Cod-liver oil enema, 140.<br /> +<br /> +Constipation caused by milk diet, 125.<br /> +<br /> +Contraindications to rest, etc., 45.<br /> +<br /> +Corpulence, Harvey on, 129.<br /> +<br /> +<br /> +Diet-list, 144, 146, 159.<br /> +<br /> +Dietetics, 119, 171.<br /> +<br /> +Drug-habits, treatment of, 137.<br /> +<br /> +<br /> +Eccles on massage, 101.<br /> +<br /> +Electricity, 108.<br /> +<span style="margin-left: 1em;">Beard on, 115.</span><br /> +<span style="margin-left: 1em;">causing insomnia, 118.</span><br /> +<span style="margin-left: 1em;">during menstruation, 90.</span><br /> +<span style="margin-left: 1em;">in ataxia, 211.</span><br /> +<span style="margin-left: 1em;">in constipation, 109.</span><br /> +<span style="margin-left: 1em;">mode of using, 108, 116.</span><br /> +<span style="margin-left: 1em;">rise of temperature from, 110, 116.</span><br /> +<span style="margin-left: 1em;">when needed, 118.</span><br /> +<br /> +<br /> +Face, massage of, 105.<br /> +<br /> +Fat in alcoholism, 23.<br /> +<span style="margin-left: 1em;">in its relation to health, 16.</span><br /> +<span style="margin-left: 1em;">increased by bleeding, 24.</span><br /> +<span style="margin-left: 1em;">milk-diet in, 128.</span><br /> +<span style="margin-left: 1em;">mode of accumulation of, 27.</span><br /> +<span style="margin-left: 1em;">reduction of, 128.</span><br /> +<span style="margin-left: 1em;">varieties of, 25.</span><br /> +<br /> +Food, amount of, 146, 159.<br /> +<span style="margin-left: 1em;">in obesity, 130.</span><br /> +<br /> +<br /> +Goitre, exophthalmic, 46.<br /> +<br /> +Gymnastics, Swedish, 92.<br /> +<br /> +<br /> +Harvey on corpulence, 129.<br /> +<br /> +Head, massage of, 105.<br /> +<br /> +Headache from massage, 100.<br /> +<span style="margin-left: 1em;">massage for, 105.</span><br /> +<br /> +Heart-disease, treatment of, 45.<br /> +<br /> +Hysteria. <i>Vide</i> Cases.<br /> +<br /> +<br /> +Introduction, 9.<br /> +<br /> +Iodide in ataxia, 201.<br /> +<br /> +Iron, use of, 142.<br /> +<br /> +<br /> +Jackson on rest, 58.<br /> +<br /> +<br /> +Karell on milk-treatment, 120, 128.<br /> +<br /> +Keen on albuminuria, 101.<br /> +<br /> +Kidney, floating. <i>Vide</i> Cases.<br /> +<span style="margin-left: 1em;">belt for, 190.</span><br /> +<span style="margin-left: 1em;">treatment of, 48, 66, 189.</span><br /> +<br /> +<br /> +Letheby on fattening stock, 26.<br /> +<br /> +<br /> +Malt extract, 138.<br /> +<span style="margin-left: 1em;">Japanese extract of, 141.</span><br /> +<br /> +Marshall on urinary changes, 127.<br /> +<br /> +Massage, 80.<br /> +<span style="margin-left: 1em;">abdominal, 86.</span><br /> +<span style="margin-left: 1em;">amount of, 92.</span><br /> +<span style="margin-left: 1em;">blood-changes from, 101.</span><br /> +<span style="margin-left: 1em;">causing acne, 89.</span><br /> +<span style="margin-left: 1em;">causing headache, 100.</span><br /> +<span style="margin-left: 1em;">chilliness from, 91.</span><br /> +<span style="margin-left: 1em;">during convalesence, 34.</span><br /> +<span style="margin-left: 1em;">during menstruation, 90.</span><br /> +<span style="margin-left: 1em;">Eccles on, 101.</span><br /> +<span style="margin-left: 1em;">effect on temperature, 93.</span><br /> +<span style="margin-left: 1em;">effects of general, 98, 101.</span><br /> +<span style="margin-left: 1em;">frequency of use, 90.</span><br /><a name="Page_235" id="Page_235"></a> +<span style="margin-left: 1em;">in anæmia, 101.</span><br /> +<span style="margin-left: 1em;">in heart-disease, 46.</span><br /> +<span style="margin-left: 1em;">in spastic paralysis, 225.</span><br /> +<span style="margin-left: 1em;">Lauder-Brunton on, 101.</span><br /> +<span style="margin-left: 1em;">lubricant undesirable in, 89.</span><br /> +<span style="margin-left: 1em;">of face, 105.</span><br /> +<span style="margin-left: 1em;">of head, 105.</span><br /> +<span style="margin-left: 1em;">order of application, 82, 91.</span><br /> +<span style="margin-left: 1em;">sexual excitement from, 91.</span><br /> +<span style="margin-left: 1em;">why useful, 98.</span><br /> +<br /> +Melancholia, treatment of, 46.<br /> +<br /> +Menstruation, effects of rest on, 149, 193.<br /> +<span style="margin-left: 1em;">electricity during, 90.</span><br /> +<span style="margin-left: 1em;">massage during, 90.</span><br /> +<br /> +Milk, in alcoholism, 137.<br /> +<span style="margin-left: 1em;">in chloral habit, 137.</span><br /> +<span style="margin-left: 1em;">pasteurized, 121.</span><br /> +<span style="margin-left: 1em;">peptonized, 122.</span><br /> +<span style="margin-left: 1em;">quantity to be used, 123.</span><br /> +<span style="margin-left: 1em;">sterilization of, 121.</span><br /> +<br /> +Milk diet, 119.<br /> +<span style="margin-left: 1em;">constipation caused by, 125.</span><br /> +<span style="margin-left: 1em;">disappearance of uric acid during use of, 126.</span><br /> +<span style="margin-left: 1em;">effects of, on urinary pigments, 126.</span><br /> +<span style="margin-left: 1em;">general effects of, 124.</span><br /> +<span style="margin-left: 1em;">in obesity, 128.</span><br /> +<span style="margin-left: 1em;">in obesity with anæmia, 128.</span><br /> +<span style="margin-left: 1em;">Karell on, 120, 128.</span><br /> +<span style="margin-left: 1em;">precautions in using, 123.</span><br /> +<span style="margin-left: 1em;">sleepiness from, 125.</span><br /> +<span style="margin-left: 1em;">stools during use of, 125.</span><br /> +<span style="margin-left: 1em;">urinary changes from, 126.</span><br /> +<br /> +Morphia habit, treated by rest, etc., 137, 154, 165.<br /> +<br /> +Movements, co-ordinate, in ataxia, 204.<br /> +<span style="margin-left: 1em;">in paralysis agitans, 231.</span><br /> +<span style="margin-left: 1em;">in paraplegia, 223.</span><br /> +<span style="margin-left: 1em;">in spastic paralysis, 226.</span><br /> +<span style="margin-left: 1em;">Swedish, 92.</span><br /> +<br /> +<br /> +Neurasthenia. <i>Vide</i> Cases.<br /> +<br /> +Nurse, choice of, 53.<br /> +<br /> +<br /> +Obesity, milk diet in, 128.<br /> +<span style="margin-left: 1em;">with anæmia, 128.</span><br /> +<span style="margin-left: 1em;">with anæmia. <i>Vide</i> Cases.</span><br /> +<br /> +Ovarian disorders treated by rest, etc., 47.<br /> +<br /> +<br /> +Paralysis agitans, 231.<br /> +<br /> +Paraplegia, ataxic, 223.<br /> +<span style="margin-left: 1em;">spastic, 228.</span><br /> +<br /> +Partial rest, 63.<br /> +<span style="margin-left: 1em;">schedule for, 64.</span><br /> +<br /> +Peculiarities of American race, 17, 21, 32.<br /> +<br /> +Phthisis, gain of weight in, 35.<br /> +<span style="margin-left: 1em;">Pollock on, 35.</span><br /> +<br /> +Playfair on nerve-prostration, 12, 150.<br /> +<br /> +<br /> +Quetelet on gain of weight at different ages, 17.<br /> +<br /> +<br /> +Rest, 57.<br /> +<span style="margin-left: 1em;">definition of, 62.</span><br /> +<span style="margin-left: 1em;">effects of, on menstruation, 149, 193.</span><br /> +<span style="margin-left: 1em;">in ataxia, 203, 210, 230.</span><br /> +<span style="margin-left: 1em;">in neuralgia, 58.</span><br /> +<span style="margin-left: 1em;">in spinal disease, 58, 197, 230.</span><br /> +<span style="margin-left: 1em;">Jackson on, 58.</span><br /> +<span style="margin-left: 1em;">length of, 66, 68.</span><br /> +<span style="margin-left: 1em;">mental, 71.</span><br /><a name="Page_236" id="Page_236"></a> +<span style="margin-left: 1em;">mode of terminating, 63, 78.</span><br /> +<span style="margin-left: 1em;">moral uses of, 69.</span><br /> +<span style="margin-left: 1em;">partial, 62.</span><br /> +<span style="margin-left: 1em;">reasons for, 61, 70, 182.</span><br /> +<br /> +<br /> +Schedule for partial rest, 64.<br /> +<br /> +Seclusion, 50.<br /> +<br /> +Selection of cases, 33, 60.<br /> +<br /> +Soup, raw, mode of making, 139.<br /> +<br /> +Spine, irritable, 163, 178.<br /> +<br /> +Syphilis preceding tabes, 198, 201.<br /> +<br /> +<br /> +Tabes. <i>Vide</i> Ataxia.<br /> +<br /> +Temperature after electric treatment, 110, 116.<br /> +<span style="margin-left: 1em;">after massage, 93.</span><br /> +<br /> +Treatment, season for, 53.<br /> +<span style="margin-left: 1em;">selection of cases for, 33.</span><br /> +<br /> +<br /> +Urinary pigments, changes in, during milk diet, 126.<br /> +<br /> +<br /> +Weight at different ages, Bowditch on, 17, 23.<br /> +<span style="margin-left: 1em;">gain or loss of, 14.</span><br /> +<span style="margin-left: 1em;">loss of, relation to an anæmia, 15.</span><br /> +<span style="margin-left: 1em;">Quetelet on, 17.</span><br /> +</p> + + +<h3><a name="THE_END" id="THE_END"></a>THE END.</h3> + +<div class="footnotes"><h3>FOOTNOTES:</h3> + +<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> The Systematic Treatment of Nerve Prostration and Hysteria. +London, 1883.</p></div> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> The Pennsylvania Orthopædic Hospital and Infirmary for +Diseases of the Nervous System.</p></div> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> Sur l'Homme, p. 47, et seq.</p></div> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Growth of Children, p. 31.</p></div> + +<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> See a valuable paper by Dr. Gerhard, Am. Jour. Med. Sci., +1876. Also Lectures on Diseases of the Nervous System, especially in +Women. S. Weir Mitchell. Phila., 1881, p. 127. See also the papers by +Dr. Morris J. Lewis on the seasonal relations of chorea, analyzing seven +hundred and seventeen cases of chorea as to the months of onset (Trans. +Assoc. Amer. Phys., 1892), and Osler On Chorea (1894).</p></div> + +<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> Statistics (Anthropological) Surgeon-General's +Bureau—1875.</p></div> + +<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> This excess of corpulence in the English is attained +chiefly after forty, as I have said. The average American is taller than +the average Englishman, and is fully as well built in proportion to his +height, as Gould has shown. The child of either sex in New England is +both taller and heavier than the English child of corresponding class +and age, as Dr. H.I. Bowditch has lately made clear; while the English +of the manufacturing and agricultural classes are miserably inferior to +the members of a similar class in America.</p></div> + +<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> Zeitschrift für Biol., 1872. Phila. Med. Times, vol. iii., +page 115.</p></div> + +<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> Letheby on Food, pp. 39, 40, 41.</p></div> + +<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> Am. Jour. Med. Sci.; Proc. Phil. Coll. of Phys., 1883; +Phil. Med. News, April, 1883.</p></div> + +<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> Chorea. See Lancet, Aug. 1882.</p></div> + +<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> "Nurse and Patient." S. Weir Mitchell. Lippincott's +Magazine, Dec. 1872.</p></div> + +<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> See Philip Karell's remarks on the use of treatment by +milk in cardiac hypertrophy. Edin. Med. Jour., Aug. 1866.</p></div> + +<div class="footnote"><p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> Trans. Obst. Soc. of London, vol. xxxiii.</p></div> + +<div class="footnote"><p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a> Séguin Lecture, <i>op. cit.</i></p></div> + +<div class="footnote"><p><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">[16]</span></a> "Pinch" is used to avoid the use of a technical term, but +should be understood to mean the grasping and squeezing of a part with +the whole hand, using the palmar portion of the fingers to press the +grasped mass against the "heel" of the hand. Fuller technical details of +the massage process and consideration of its effects will be found in +the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham, +Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's +"System of Medicine" (1896), by Dr. John K. Mitchell.</p></div> + +<div class="footnote"><p><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">[17]</span></a> Dr. Symon Eccles in "The Practice of Massage" recommends +this order.</p></div> + +<div class="footnote"><p><a name="Footnote_18_18" id="Footnote_18_18"></a><a href="#FNanchor_18_18"><span class="label">[18]</span></a> Some care is needed not to overwork patients. For details +I must refer to manuals of Swedish Gymnastics.</p></div> + +<div class="footnote"><p><a name="Footnote_19_19" id="Footnote_19_19"></a><a href="#FNanchor_19_19"><span class="label">[19]</span></a> See also page 91.</p></div> + +<div class="footnote"><p><a name="Footnote_20_20" id="Footnote_20_20"></a><a href="#FNanchor_20_20"><span class="label">[20]</span></a> A number of observations in late years have been made upon +the effect of massage upon elimination. Among the articles to which the +practitioner desiring further to study this subject may be referred +are,—<br /><br /> + +<i>Edin. Clin. and Path. Jour</i>., Aug., 1884.<br /><br /> + +<i>Jour, of Physiol.</i>, vol. xxii., p. 68.<br /><br /> + +<i>Centralbl. f. Inner. Med.</i>, 1894, No. 40, p. 944.<br /><br /> + +<i>Munch. Med. Woch.</i>, April 11 and April 18, 1899 (Influence of bodily +exercise upon temperature in health and disease).<br /><br /> + +Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque +and Marette, and Maggiora.</p></div> + +<div class="footnote"><p><a name="Footnote_21_21" id="Footnote_21_21"></a><a href="#FNanchor_21_21"><span class="label">[21]</span></a> American Journal of the Medical Sciences, May, 1894.</p></div> + +<div class="footnote"><p><a name="Footnote_22_22" id="Footnote_22_22"></a><a href="#FNanchor_22_22"><span class="label">[22]</span></a> Numerous examinations made since have quite uniformly +agreed with the former remarkably constant results.</p></div> + +<div class="footnote"><p><a name="Footnote_23_23" id="Footnote_23_23"></a><a href="#FNanchor_23_23"><span class="label">[23]</span></a> J.K. Mitchell, <i>loc. cit.</i></p></div> + +<div class="footnote"><p><a name="Footnote_24_24" id="Footnote_24_24"></a><a href="#FNanchor_24_24"><span class="label">[24]</span></a> Most induction batteries are without any arrangement for +making infrequent breaks in the current.</p></div> + +<div class="footnote"><p><a name="Footnote_25_25" id="Footnote_25_25"></a><a href="#FNanchor_25_25"><span class="label">[25]</span></a> In the extreme constipation of certain hysterical women, +good may be done by placing one conductor in the rectum and moving the +other over the abdomen so as to cause full movement of the muscles. This +means must at first be employed cautiously, and the amount of +electricity carefully increased. It is doubtful if any movement of the +intestinal muscle-fibres is thus caused, but that it is a useful method +of stimulation in obstinate cases may be taken as proved.</p></div> + +<div class="footnote"><p><a name="Footnote_26_26" id="Footnote_26_26"></a><a href="#FNanchor_26_26"><span class="label">[26]</span></a> Harvey on Corpulence.</p></div> + +<div class="footnote"><p><a name="Footnote_27_27" id="Footnote_27_27"></a><a href="#FNanchor_27_27"><span class="label">[27]</span></a> The management of the morphia or chloral habit becomes +much more easy under a milk diet, massage, and absolute rest, and I can +with confidence commend their use in these difficult cases. Massage in +the morning is liked, and general surface-rubbing without +muscle-kneading at night very often proves remarkably soothing, while +the rest in bed cuts off many opportunities to indulge in the temptation +to secure the desired drugs.</p></div> + +<div class="footnote"><p><a name="Footnote_28_28" id="Footnote_28_28"></a><a href="#FNanchor_28_28"><span class="label">[28]</span></a> I have found that this may be usefully replaced by one of +the numerous peptonized foods described in the pamphlets issued by the +manufacturers of the peptonizing powders. The ready-made peptonized +preparations vary very much, like some of the beef extracts, but a trial +will discover which of them is best fitted for an individual case.</p></div> + +<div class="footnote"><p><a name="Footnote_29_29" id="Footnote_29_29"></a><a href="#FNanchor_29_29"><span class="label">[29]</span></a> Nerve Prostration and Hysteria.</p></div> + +<div class="footnote"><p><a name="Footnote_30_30" id="Footnote_30_30"></a><a href="#FNanchor_30_30"><span class="label">[30]</span></a> It is worth mentioning that where ataxic patients have to +use canes, a crutch-cane with a base some six or eight inches long and +well shod with roughened rubber is far more useful and safer than the +ordinary stick.</p></div> + +</div> + + + + + + + +<pre> + + + + + +End of the Project Gutenberg EBook of Fat and Blood, by S. 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Fat and Blood + An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria + +Author: S. Weir Mitchell + +Editor: John K. Mitchell + +Release Date: July 7, 2005 [EBook #16230] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK FAT AND BLOOD *** + + + + +Produced by Kathryn Lybarger, Janet Blenkinship and the +Online Distributed Proofreading Team at https://www.pgdp.net + + + + + + +FAT AND BLOOD: + +AN ESSAY ON THE TREATMENT OF CERTAIN FORMS OF + +NEURASTHENIA AND HYSTERIA. + + + +BY + +S. WEIR MITCHELL, M.D., LL.D. HARV., + +MEMBER OF THE NATIONAL ACADEMY OF SCIENCES. + + + +_EIGHTH EDITION._ + + +EDITED, WITH ADDITIONS, BY + +JOHN K. MITCHELL, M.D. + + + +PHILADELPHIA: + +J.B. LIPPINCOTT COMPANY. + +LONDON: 5 HENRIETTA STREET, COVENT GARDEN + +1911. + + + +Copyright, 1877, by J.B. LIPPINCOTT & CO. + +Copyright, 1883, by J.B. LIPPINCOTT & CO. + +Copyright, 1891, by J.B. LIPPINCOTT COMPANY. + +Copyright, 1897, by J.B. LIPPINCOTT COMPANY. + +Copyright, 1900, by J.B. LIPPINCOTT COMPANY. + +Copyright, 1905, by S. WEIR MITCHELL. + + +ELECTROTYPED AND PRINTED BY J.B. LIPPINCOTT COMPANY, PHILADELPHIA, +U.S.A. + + + + +PREFACE TO THE EIGHTH EDITION. + + +The continued favor which this book has enjoyed in Europe as well as in +this country has rendered me doubly desirous to make it a thorough and +clear statement of the treatment of the kind of cases which it discusses +as carried out in my practice to-day. + +In the endeavor to do this, the present edition, like the last two, has +been carefully revised by my son, Dr. John K. Mitchell, and there is no +chapter, and scarcely a page, where some alteration or addition has not +been made, besides those of the sixth and seventh editions, as the +result of added years of experience. Especially in the chapters on the +means of treatment some details have been thought worth adding to help +the statement so often repeated in the book that success will depend on +the care with which details are carried out. The chapter on massage, +rewritten for the last edition, has been once more revised and somewhat +extended, in order to make it an accurate as well as a scientific, if +brief, statement of the best method which use and observation have +taught us. A chapter on the handling of several diseases not described +in former editions has been added by the editor. + +S. WEIR MITCHELL. + +SEPTEMBER, 1899. + + + + +CONTENTS. + + PAGE +CHAPTER I. +INTRODUCTORY 9 + +CHAPTER II. +GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED 14 + +CHAPTER III. +ON THE SELECTION OF CASES FOR TREATMENT 33 + +CHAPTER IV. +SECLUSION 50 + +CHAPTER V. +REST 67 + +CHAPTER VI. +MASSAGE 80 + +CHAPTER VII. +ELECTRICITY 108 + +CHAPTER VIII. +DIETETICS AND THERAPEUTICS 119 + +CHAPTER IX. +DIETETICS AND THERAPEUTICS--(_Continued_) 171 + +CHAPTER X. +THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC +PARAPLEGIA, SPASTIC PARALYSIS, AND PARALYSIS +AGITANS 197 + +INDEX 233 + + + + +CHAPTER I. + +INTRODUCTORY. + + +For some years I have been using with success, in private and in +hospital practice, certain methods of renewing the vitality of feeble +people by a combination of entire rest and excessive feeding, made +possible by passive exercise obtained through the steady use of massage +and electricity. + +The cases thus treated have been chiefly women of a class well known to +every physician,--nervous women, who, as a rule, are thin and lack +blood. Most of them have been such as had passed through many hands and +been treated in turn for gastric, spinal, or uterine troubles, but who +remained at the end as at the beginning, invalids, unable to attend to +the duties of life, and sources alike of discomfort to themselves and +anxiety to others. + +In 1875 I published in "Seguin's Series of American Clinical Lectures," +Vol. I., No. iv., a brief sketch of this treatment, under the heading +of "Rest in the Treatment of Nervous Disease," but the scope afforded +me was too brief for the details on a knowledge of which depends success +in the use of rest, I have been often since reminded of this by the many +letters I have received asking for explanations of the minutiae of +treatment; and this must be my apology for bringing into these pages a +great many particulars which are no doubt well enough known to the more +accomplished physician. + +In the preface to the second edition I said that as yet there had been +hardly time for a competent verdict on the methods I had described. +Since making this statement, many of our profession in America have +published cases of the use of my treatment. It has also been thoroughly +discussed by the medical section of the British Medical Association, and +warmly endorsed by William Playfair, of London, Ross of Manchester, +Coghill, and others; while a translation of my book into French by Dr. +Oscar Jennings, with an introduction by Professor Ball, and a +reproduction in German, with a preface by Professor von Leyden, have +placed it satisfactorily before the profession in France and Germany. + +As regards the question of originality I did not and do not now much +concern myself. This alone I care to know, that by the method in +question cases are cured which once were not; and as to the novelty of +the matter it would be needless to say more, were it not that the charge +of lack of that quality is sometimes taken as an imputation on a man's +good faith. + +But to sustain so grave an implication the author must have somewhere +laid claim to originality and said in what respect he considered himself +to have done a totally new thing. The following passage from the first +edition of this book explains what was my own position: + +"I do not wish," I wrote, "to be thought of as putting forth anything +very remarkable or original in my treatment by rest, systematic feeding, +and passive exercise. All of these have been used by physicians; but, as +a rule, one or more are used without the others, and the plan which I +have found so valuable, of combining these means, does not seem to be +generally understood. As it involves some novelty, and as I do not find +it described elsewhere, I shall, I think, be doing a service to my +profession by relating my experience." + +The following quotation from Dr. William Playfair's essay[1] says all +that I would care to add: + + "The claims of Dr. Weir Mitchell to originality in the introduction + of this system of treatment, which I have recently heard contested + in more than one quarter, it is not my province to defend. I feel + bound, however, to say that, having carefully studied what has been + written on the subject, I can nowhere find anything in the least + approaching to the regular, systematic, and thorough attack on the + disease here discussed. + + "Certain parts of the treatment have been separately advised, and + more or less successfully practised, as, for example, massage and + electricity, without isolation; or isolation and judicious moral + management alone. It is, in fact, the old story with regard to all + new things: there is no discovery, from the steam-engine down to + chloroform, which cannot be shown to have been partially foreseen, + and yet the claims of Watt and Simpson to originality remain + practically uncontested. And so, if I may be permitted to compare + small things with great, will it be with this. The whole matter was + admirably summed up by Dr. Ross, of Manchester, in his remarks in + the discussion I introduced at the meeting of the British Medical + Association at Worcester, which I conceive to express the precise + state of the case: 'Although Dr. Mitchell's treatment was not new + in the sense that its separate recommendations were made for the + first time, it was new in the sense that these recommendations were + for the first time combined so as to form a complete scheme of + treatment.'" + +As regards the acceptance of this method of treatment I have to-day no +complaint to make. It runs, indeed, the risk of being employed in cases +which do not need it and by persons who are not competent, and of being +thus in a measure brought into disrepute. As concerns one of its +essentials--massage--this is especially to be feared. It is a remedy +with capacity to hurt as well as to help, and should never be used +without the advice of a physician, nor persistently kept up without +medical observation of its temporary and more permanent effects. + + + + +CHAPTER II. + +GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED. + + +The gentlemen who have done me the honor to follow my clinical service +at the State Infirmary for Diseases of the Nervous System[2] are well +aware how much care is there given to learn whether or not the patient +is losing or has lost flesh, is by habit thin or fat. This question is +one of the utmost moment in every point of view, and deserves a larger +share of attention than it receives. In this hospital it is the custom +to weigh our cases when they enter and at intervals. The mere loss of +fat is probably of small moment in itself when the amount of restorative +food is sufficient for every-day expenditure, and when the organs are in +condition to keep up the supply of fat which we not only require for +constant use but probably need to change continually. The steady or +rapid lessening of the deposits of hydro-carbons stored away in the +areolae of the tissues is of importance, as indicating their excessive +use or a failure of supply; and when either condition is to be suspected +it becomes our duty to learn the reasons for this striking symptom. Loss +of flesh has also a collateral value of great import, because it is +almost an invariable rule that rapid thinning is accompanied soon or +late with more or less anaemia, and it is uncommon to see a person +steadily gaining fat after any pathological reduction of weight without +a corresponding gain in amount and quality of blood. We too rarely +reflect that the blood thins with the decrease of the tissues and +enriches as they increase. + +Before entering into this question further, I shall ask attention to +some points connected with the normal fat of the human body; and, taking +for granted, here and elsewhere, that my readers are well enough aware +of the physiological value and uses of the adipose tissues, I shall +continue to look at the matter chiefly from a clinical point of view. + +When in any individual the weight varies rapidly or slowly, it is nearly +always due, for the most part, to a change in the amount of adipose +tissue stored away in the meshes of the areolar tissue. Almost any grave +change for the worse in health is at once betrayed in most people by a +diminution of fat, and this is readily seen in the altered forms of the +face, which, because it is the always visible and in outline the most +irregular part of the body, shows first and most plainly the loss or +gain of tissue. Fatty matter is therefore that constituent of the body +which goes and comes most easily. Why there is in nearly every one a +normal limit to its accumulation we cannot say, nor yet why this limit +should vary as life goes on. Even in health the weight of men, and still +more of women, is by no means constant, but, as a rule, when we are +holding our own with that share of stored-up fat which belongs to the +individual we are usually in a condition of nutritive prosperity, and +when after any strain or trial which has lessened weight we are slowly +repairing mischief and laying by fat we are equally in a state of +health. The loss of fat which is not due to change of diet or to +exercise, especially its rapid or steady loss, nearly always goes along +with conditions which impoverish the blood, and, on the other hand, the +gain of fat up to a certain point seems to go hand in hand with a rise +in all other essentials of health, and notably with an improvement in +the color and amount of the red corpuscles. + +The quantity of fat which is healthy for the individual varies with the +sex, the climate, the habits, the season, the time of life, the race, +and the breed. Quetelet[3] has shown that before puberty the weight of +the male is for equal ages above that of the female, but that towards +puberty the proportional weight of the female, due chiefly to gain in +fat, increases, so that at twelve the two sexes are alike in this +respect. During the child-bearing time there is an absolute lessening on +the part of the female, but after this time the weight of the woman +increases, and the maximum is attained at about the age of fifty. + +Dr. Henry I. Bowditch[4] reaches somewhat similar conclusions, and shows +from much more numerous measurements of Boston children that growing +boys are heavier in proportion to their height than girls until they +reach fifty-eight inches, which is attained about the fourteenth year. +Then the girl passes the boy in weight, which Dr. Bowditch thinks is due +to the accumulation of adipose tissue at puberty. After two or three +years more the male again acquires and retains superiority in weight and +height. + +Yet as life advances there are peculiarities which belong to individuals +and to families. One group thins as life goes on past forty; another +group as surely takes on flesh; and the same traits are often inherited, +and are to be regarded when the question of fattening becomes of +clinical or diagnostic moment. Men, as a rule, preserve their nutritive +status more equably than women. Every physician must have been struck +with this. In fact, many women lose or acquire large amounts of adipose +matter without any corresponding loss or gain in vigor, and this fact +perhaps is related in some way to the enormous outside demands made by +their peculiar physiological processes. Such gain in weight is a common +accompaniment of child-bearing, while nursing in some women involves +considerable gain in flesh, and in a larger number enormous falling +away, and its cessation as speedy a renewal of fat. I have also found +that in many women who are not perfectly well there is a notable loss +of weight at every menstrual period, and a marked gain between these +times. + +I was disappointed not to find this matter dealt with fully in Mrs. +Jacobi's able essay on menstruation, nor can I discover elsewhere any +observations in regard to loss or gain of weight at menstrual periods in +the healthy woman. + +How much influence the seasons have, is not as yet well understood, but +in our own climate, with its great extremes, there are some interesting +facts in this connection. The upper classes are with us in summer placed +in the best conditions for increase in flesh, not only because it is +their season of least work, mental and physical, but also because they +are then for the most part living in the country under circumstances +favorable to appetite, to exercise, and to freedom from care. Owing to +these fortunate facts, members of the class in question are apt to gain +weight in summer, although many such persons, as I know, follow the more +general rule and lose weight. But if we deal with the mass of men who +are hard worked, physically, and unable to leave the towns, we shall +probably find that they nearly always lose weight in hot weather. Some +support is given to this idea by the following very curious facts. Very +many years ago I was engaged for certain purposes in determining the +weight, height, and girth of all the members of our city police force. +The examination was made in April and repeated in the beginning of +October. Every care was taken to avoid errors, but to my surprise I +found that a large majority of the men had lost weight during the +summer. The sum total of loss was enormous. As I have mislaid some of +the sheets, I am unable to give it accurately, but I found that three +out of every five had lessened in weight. It would be interesting to +know if such a change occurs in convicts confined in penitentiaries. + +I am acquainted with some persons who lose weight in winter, and with +more who fail in flesh in the spring, which is our season of greatest +depression in health,--the season when with us choreas are apt to +originate[5] or to recur, and when habitual epileptic fits become more +frequent in such as are the victims of that disease. + +Climate has a good deal to do with a tendency to take on fat, and I +think the first thing which strikes an American in England is the number +of inordinately fat middle-aged people, and especially of fat women. + +This excess of flesh we usually associate in idea with slothfulness, but +English women exercise more than ours, and live in a land where few days +forbid it, so that probably such a tendency to obesity is due chiefly to +climatic causes. To these latter also we may no doubt ascribe the habits +of the English as to food. They are larger feeders than we, and both +sexes consume strong beer in a manner which would in this country be +destructive of health. These habits aid, I suspect, in producing the +more general fatness in middle and later life, and those enormous +occasional growths which so amaze an American when first he sets foot in +London. But, whatever be the cause, it is probable that members of the +prosperous classes of English, over forty, would outweigh the average +American of equal height of that period, and this must make, I should +think, some difference in their relative liability to certain forms of +disease, because the overweight of our trans-Atlantic cousins is plainly +due to excess of fat. + +I have sought in vain for English tables giving the weight of men and +women of various heights at like ages. The material for such a study of +men in America is given in Gould's researches published by the United +States Sanitary Commission, and in Baxter's admirable report,[6] but is +lacking for women. A comparison of these points as between English and +Americans of both sexes would be of great interest. + +I doubt whether in this country as notable a growth in bulk as +multitudes of English attain would be either healthy or desirable in +point of comfort, owing to the distress which stout people feel in our +hot summer weather. Certainly "Banting" is with us a rarely-needed +process, and, as a rule, we have much more frequent occasion to fatten +than to thin our patients. The climatic peculiarities which have changed +our voices, sharpened our features, and made small the American hand and +foot, have also made us, in middle and advanced life, a thinner and +more sallow race, and, possibly, adapted us better to the region in +which we live. The same changes in form are in like manner showing +themselves in the English race in Australia.[7] + +Some gain in flesh as life goes on is a frequent thing here as +elsewhere, and usually has no unwholesome meaning. Occasionally we see +people past the age of sixty suddenly taking on fat and becoming at once +unwieldy and feeble, the fat collecting in masses about the belly and +around the joints. Such an increase is sometimes accompanied with fatty +degeneration of the heart and muscles, and with a certain watery +flabbiness in the limbs, which, however, do not pit on pressure. + +Alcoholism also gives rise in some people to a vast increase of adipose +tissue, and the sodden, unwholesome fatness of the hard drinker is a +sufficiently well known and unpleasant spectacle. The overgrowth of +inert people who do not exercise enough to use up a healthy amount of +overfed tissues is common enough as an individual peculiarity, but there +are also two other conditions in which fat is apt to be accumulated to +an uncomfortable extent. Thus, in some cases of hysteria where the +patient lies abed owing to her belief that she is unable to move about, +she is apt in time to become enormously stout. This seems to me also to +be favored by the large use of morphia to which such women are prone, so +that I should say that long rest, the hysterical constitution, and the +accompanying resort to morphia make up a group of conditions highly +favorable to increase of fat. + +Lastly, there is the class of fat anaemic people, usually women. This +double peculiarity is rather uncommon, but, as the mass of thin-blooded +persons are as a rule thin or losing flesh, there must be something +unusual in that anaemia which goes with gain in flesh. + +Bauer[8] thinks that lessened number of blood-corpuscles gives rise to +storing of fat, owing to lessened tissue-combustion. At all events, the +absorption of oxygen diminishes after bleeding, and it used to be well +known that some people grew fat when bled at intervals. Also, it is said +that cattle-breeders in some localities--certainly not in this +country--bleed their cattle to cause increase of fat in the tissues, or +of fat secreted as butter in the milk. These explanations aid us but +little to comprehend what, after all, is only met with in certain +persons, and must therefore involve conditions not common to every one +who is anaemic. Meanwhile, the group of fat anaemics is of the utmost +clinical interest, as I shall by and by point out more distinctly. + +There is a popular idea, which has probably passed from the +agriculturist into the common mind of the community, to the effect that +human fat varies,--that some fat is wholesome and some unwholesome, that +there are good fats and bad fats. I remember well an old nurse who +assured me when I was a student that "some fats is fast and some is +fickle, but cod-oil fat is easy squandered." + +There are more facts in favor of some such idea than I have place for, +but as yet we have no distinct chemical knowledge as to whether the +fats put on under alcohol or morphia, or rapidly by the use of oils, or +pathologically in fatty degenerations, or in anaemia, vary in their +constituents. It is not at all unlikely that such is the case, and that, +for example, the fat of an obese anaemic person may differ from that of a +fat and florid person. The flabby, relaxed state of many fat people is +possibly due not alone to peculiarities of the fat, but also to want of +tone and tension in the areolar tissues, which, from all that we now +know of them, may be capable of undergoing changes as marked as those of +muscles. + +That, however, animals may take on fat which varies in character is well +known to breeders of cattle. "The art of breeding and feeding stock," +says Dr. Letheby,[9] "is to overcome excessive tendency to accumulation +of either surface fat or visceral fat, and at the same time to produce a +fat which will not melt or boil away in cooking. Oily foods have a +tendency to make soft fats which will not bear cooking." Such +differences are also seen between English and American bacon, the former +being much more solid; and we know, also, that the fat of different +animals varies remarkably, and that some, as the fat of hay-fed horses, +is readily worked off. Such facts as these may reasonably be held to +sustain the popular creed as to there being bad fats and good fats, and +they teach us the lesson that in man, as in animals, there may be a +difference in the value of the fats we acquire, according as they are +gained by one means or by another. + +The recent researches of L. Langer have certainly shown that the fatty +tissues of man vary at different ages, in the proportion of the fatty +acids they contain. + +I have had occasion, of late years, to watch with interest the process +of somewhat rapid but quite wholesome gain in flesh in persons subjected +to the treatment which I shall by and by describe. Most of these persons +were treated by massage, and I have been accustomed to question the +masseur or masseuse as to the manner in which the change takes place. +Usually it is first seen in the face and neck, then it is noticed in the +back and flanks, next in the belly, and finally in the limbs, the legs +coming last in the order of gain, and sometimes remaining comparatively +thin long after other parts have made remarkable and visible gain. +These observations have been checked by careful measurements, so that I +am sure of their correctness for people who fatten while at rest in bed. +The order of increase might be different in people who fatten while +afoot. + +Facts of this nature suggest that the putting on of fat must be due to +very generalized conditions, and be less under the control of local +causes than is the nutrition of muscles, for, while it is true that in +wasting from nerve-lesions the muscular and fatty tissues alike lessen, +it is possible to cause by exercise rapid increase in the bulk of muscle +in a limb or a part of a limb, but not in any way to cause direct and +limited local increment of fat. + +Looking back over the whole subject, it will be well for the physician +to remember that increase of fat, to be a wholesome condition, should be +accompanied by gain in quantity and quality of blood, and that while +increase of flesh after illness is desirable, and a good test of +successful recovery, it should always go along with improvement in +color. Obesity with thin blood is one of the most unmanageable +conditions I know of. + +The exact relations of fatty tissue to the states of health are not as +yet well understood; but, since on great exertion or prolonged mental or +moral strain or in low fevers we lose fat rapidly, it may be taken for +granted that each individual should possess a certain surplus of this +readily-lost material. It is the one portion of our body which comes and +goes in large amount. Even thin people have it in some quantity always +ready, and, despite the fluctuations, every one has a standard share, +which varies at different times of life. The mechanism which limits the +storing away of an excess is almost unknown, and we are only aware that +some foods and lack of exertion favor growth in fat, while action and +lessened diet diminish it; but also we know that while any one can be +made to lose weight, there are some persons who cannot be made to gain a +pound by any possible device, so that in this, as in other things, to +spend is easier than to get; although it is clear that the very thin +must certainly live, so to speak, from hand to mouth, and have little +for emergencies. Whether fat people possess greater power of resistance +as against the fatal wasting of certain maladies or not, does not seem +to be known, and I fancy that the popular medical belief is rather +opposed to a belief in the vital endurance of those who are unusually +fat. + +That I am not pushing too far this idea of the indicative value of gain +of weight may be further seen in persons who suffer from some incurable +chronic malady, but who are in other respects well. The relief from +their disease, even if temporary, is apt to be signalled by abrupt gain +in weight. A remarkable illustration is to be found in those who suffer +periodically from severe pain. Cessation of these attacks for a time is +sure to result in the putting on of flesh. The case of Captain +Catlin[10] is a good example. Owing to an accident of war, he lost a +leg, and ever since has had severe neuralgic pain referred to the lost +leg. These attacks depend almost altogether on storms. In years of +fewest storms they are least numerous, and the bodily weight, which is +never insufficient, rises. With their increase it lowers to a certain +amount, beneath which it does not fall. His weight is, therefore, +indirectly dependent upon the number of storms to the influence of which +he is exposed. + +At present, however, we have to do most largely with the means of +attaining that moderate share of stored-away fat which seems to indicate +a state of nutritive prosperity and to be essential to those physical +needs, such as protection and padding, which fat subserves, no less than +to its aesthetic value, as rounding the curves of the human form. + +The study of the amount of the different forms of diet which is needed +by people at rest, and by those who are active, is valuable only to +enable us to construct dietaries with care for masses of men and where +economy is an object. In dealing with cases such as I shall describe, it +is needful usually to give and to have digested a surplus of food, so +that we are more concerned now to know the forms of food which thin or +fatten, and the means which aid us to digest temporarily an excess. + +As to quantity, it suffices to say that while by lessening food we may +easily and surely make people lose weight, we cannot be sure to fatten +by merely increasing the amount of food given; something more is wanted +in the way of digestives or tonics to enable the patient to prepare and +appropriate what is given, and but too often we fail miserably in all +our means of giving capacity to assimilate food. As I have said before, +and wish to repeat, to gain in fat is, in the feeble, nearly always to +gain in blood; and I hope to point out in these pages some of the means +by which these ends can be attained. + + _Note_.--The statements made on page 21 and the following + paragraphs about obesity in England and with us are no longer + exact, but have been allowed to stand in the text as recording + facts true at the time of writing them, in 1877. At the present a + medical observer familiar with both countries must note several + decided changes: more fat people, more people even enormously + stout, are seen with us than formerly, and fewer of the + "inordinately fat middle-aged people" in England than used to be + encountered. With us the over-fat are chiefly to be found among the + women of the well-to-do classes of the cities, and from thirty + years old onward. They persecute the medical men to reduce their + weight, and the vast number of advertisements of quack and + proprietary remedies against obesity indicate how wide-spread the + tendency must be. + + Among women somewhat younger, as indeed among men, the American + observer whose recollection takes him back twenty-five years must + note a more hopeful change, a very decided average increase of + stature, not merely in height but in general development. This + change is to be seen throughout the whole country, and must be + taken first as a sign of improved conditions of food and manner of + life, and next, if not more largely, of the new interest and + partnership of girls in the wholesome activities of field and wood. + + + + +CHAPTER III. + +ON THE SELECTION OF CASES FOR TREATMENT. + + +The remarks of the last chapter have, of course, wide and general +application in disease, and naturally lead up to what I have to say as +to the employment of the systematic treatment to describe which is my +chief desire. Its use, as a whole, is limited to certain groups of +cases. In some of the worst of them nothing else has succeeded hitherto, +or at least as frequently. In others the need for its application must +depend on convenience and the fact that all other and readier means have +failed. It is, of course, difficult to state now all the groups of +diseases in which it may be of value, for already physicians have begun +to find it serviceable in some to which I had not thought of applying +it,[11] and its sphere of usefulness is therefore likely to extend +beyond the limits originally set by me. It will be well here, however, +to state the various disorders in which it has seemed to me applicable. +As regards some of them, I shall try briefly to indicate why their +peculiarities point it out as needful. + +There are, of course, numerous cases in which it becomes desirable to +fatten and to make blood. In many of them these are easy tasks, and in +some altogether hopeless. Persons who are recovering healthfully from +fevers, pneumonias, and other temporary maladies gather flesh and make +blood readily, and we need only to help them by the ordinary tonics, +careful feeding, and change of air in due season. + +It may not, however, be out of place to say here that when the +convalescence from these maladies seems to be slower than is common, and +ordinary tonics inefficient, massage and the use of electricity are not +unimportant aids towards health, but in such cases require to be handled +with an amount of caution which is less requisite in more chronic +conditions of disordered health. + +In other and fatal or graver maladies, such as, for example, advanced +pulmonary phthisis, however proper it may be to fatten, it is almost an +impossible task, and, as Pollock remarks, the lung-trouble may be +advancing even while the patient is gaining in weight. Nevertheless, the +earlier stages of pulmonary tuberculosis are suitable cases, and with +sufficient attention to purity and frequent change of air in their rooms +tubercular sufferers may be brought by this means to a point of +improvement where open-air and altitude cures will have their best +effects. + +There remains a class of cases desirable to fatten and redden,--cases +which are often, or usually, chronic in character, and present among +them some of the most difficult problems which perplex the physician. If +I pause to dwell upon these, it is because they exemplify forms of +disease in which my method of treatment has had the largest success; it +is because some of them are simply living records of the failure of +every other rational plan and of many irrational ones; it is because +many of them find no place in the text-book, however sadly familiar they +are to the physician. + +The group I would speak of contains that large number of people who are +kept meagre and often also anaemic by constant dyspepsia, in its varied +forms, or by those defects in assimilative processes which, while more +obscure, are as fertile parents of similar mischiefs. Let us add the +long-continued malarial poisonings, and we have a group of varied origin +which is a moderate percentage of cases in which loss of weight and loss +of color are noticeable, and in which the usual therapeutic methods do +sometimes utterly fail. + +For many of these, fresh air, exercise, change of scene, tonics, and +stimulants are alike valueless; and for them the combined employment of +the tonic influences I shall describe, when used with absolute rest, +massage, and electricity, is often of inestimable service. + +A portion of the class last referred to is one I have hinted at as the +despair of the physician. It includes that large group of women, +especially, said to have nervous exhaustion, or who are defined as +having spinal irritation, if that be the prominent symptom. To it I must +add cases in which, besides the wasting and anaemia, emotional +manifestations predominate, and which are then called hysterical, +whether or not they exhibit ovarian or uterine disorders. + +Nothing is more common in practice than to see a young woman who falls +below the health-standard, loses color and plumpness, is tired all the +time, by and by has a tender spine, and soon or late enacts the whole +varied drama of hysteria. As one or other set of symptoms is prominent +she gets the appropriate label, and sometimes she continues to exhibit +only the single phase of nervous exhaustion or of spinal irritation. Far +more often she runs the gauntlet of nerve-doctors, gynaecologists, +plaster jackets, braces, water-treatment, and all the fantastic variety +of other cures. + +It will be worth while to linger here a little and more sharply +delineate the classes of cases I have just named. + +I see every week--almost every day--women who when asked what is the +matter reply, "Oh, I have nervous exhaustion." When further questioned, +they answer that everything tires them. Now, it is vain to speak of all +of these cases as hysterical, or as merely mimetic. It is quite sure +that in the graver examples exercise quickens the pulse curiously, the +tire shows in the face, or sometimes diarrhoea or nausea follows +exertion, and though while under excitement or in the presence of some +dominant motive they can do a good deal, the exhaustion which ensues is +out of proportion to the exercise used. + +I have rarely seen such a case which was not more or less lacking in +color and which had not lost flesh; the exceptions being those +troublesome instances of fat anaemic people which I shall by and by speak +of more fully. + +Perhaps a sketch of one of these cases will be better than any list of +symptoms. A woman, most often between twenty and thirty years of age, +undergoes a season of trial or encounters some prolonged strain. She may +have undertaken the hard task of nursing a relative, and have gone +through this severe duty with the addition of emotional excitement, +swayed by hopes and fears, and forgetful of self and of what every one +needs in the way of air and food and change when attempting this most +trying task. In another set of cases an illness is the cause, and she +never rallies entirely, or else some local uterine trouble starts the +mischief, and, although this is cured, the doctor wonders that his +patient does not get fat and ruddy again. + +But, no matter how it comes about, whether from illness, anxiety, or +prolonged physical effort, the woman grows pale and thin, eats little, +or if she eats does not profit by it. Everything wearies her,--to sew, +to write, to read, to walk,--and by and by the sofa or the bed is her +only comfort. Every effort is paid for dearly, and she describes herself +as aching and sore, as sleeping ill and awaking unrefreshed, and as +needing constant stimulus and endless tonics. Then comes the mischievous +role of bromides, opium, chloral, and brandy. If the case did not begin +with uterine troubles, they soon appear, and are usually treated in vain +if the general means employed to build up the bodily health fail, as in +many of these cases they do fail. The same remark applies to the +dyspepsias and constipation which further annoy the patient and +embarrass the treatment. If such a person is by nature emotional she is +sure to become more so, for even the firmest women lose self-control at +last under incessant feebleness. Nor is this less true of men; and I +have many a time seen soldiers who had ridden boldly with Sheridan or +fought gallantly with Grant become, under the influence of painful +nerve-wounds, as irritable and hysterically emotional as the veriest +girl. If no rescue comes, the fate of women thus disordered is at last +the bed. They acquire tender spines, and furnish the most lamentable +examples of all the strange phenomena of hysteria. + +The moral degradation which such cases undergo is pitiable. I have heard +a good deal of the disciplinary usefulness of sickness, and this may +well apply to brief and grave, and what I might call wholesome, +maladies. Undoubtedly I have seen a few people who were ennobled by long +sickness, but far more often the result is to cultivate self-love and +selfishness and to take away by slow degrees the healthful mastery which +all human beings should retain over their own emotions and wants. + +There is one fatal addition to the weight which tends to destroy women +who suffer in the way I have described. It is the self-sacrificing love +and over-careful sympathy of a mother, a sister, or some other devoted +relative. Nothing is more curious, nothing more sad and pitiful, than +these partnerships between the sick and selfish and the sound and +over-loving. By slow but sure degrees the healthy life is absorbed by +the sick life, in a manner more or less injurious to both, until, +sometimes too late for remedy, the growth of the evil is seen by +others. Usually the individual withdrawn from wholesome duties to +minister to the caprices of hysterical sensitiveness is the person of a +household who feels most for the invalid, and who for this very reason +suffers the most. The patient has pain,--a tender spine, for example; +she is urged to give it rest. She cannot read; the self-constituted +nurse reads to her. At last light hurts her eyes; the mother or sister +remains shut up with her all day in a darkened room. A draught of air is +supposed to do harm, and the doors and windows are closed, and the +ingenuity of kindness is taxed to imagine new sources of like trouble, +until at last, as I have seen more than once, the window-cracks are +stuffed with cotton, the chimney is stopped, and even the keyhole +guarded. It is easy to see where this all leads to: the nurse falls ill, +and a new victim is found. I have seen an hysterical, anaemic girl kill +in this way three generations of nurses. If you tell the patient she is +basely selfish, she is probably amazed, and wonders at your cruelty. To +cure such a case you must morally alter as well as physically amend, and +nothing less will answer. The first step needful is to break up the +companionship, and to substitute the firm kindness of a well-trained +hired nurse.[12] + +Another form of evil to be encountered in these cases is less easy to +deal with. Such an invalid has by unhappy chance to live with some near +relative whose temperament is also nervous and who is impatient or +irritable. Two such people produce endless mischief for each other. +Occasionally there is a strange incompatibility which it is difficult to +define. The two people who, owing to their relationship, depend the one +on the other, are, for no good reason, made unhappy by their several +peculiarities. Lifelong annoyance results, and for them there is no +divorce possible. + +In a smaller number of cases, which have less tendency to emotional +disturbances, the phenomena are more simple. You have to deal with a +woman who has lost flesh and grown colorless, but has no hysterical +tendencies. She is merely a person hopelessly below the standard of +health and subject to a host of aches and pains, without notable organic +disease. Why such people should sometimes be so hard to cure I cannot +say. But the sad fact remains. Iron, acids, travel, water-cures, have +for a certain proportion of them no value, or little value, and they +remain for years feeble and forever tired. For them, as for the whole +class, the pleasures of life are limited by this perpetual weariness and +by the asthenopia which they rarely escape, and which, by preventing +them from reading, leaves them free to study day after day their +accumulating aches and distresses. + +Medical opinion must, of course, vary as to the causes which give rise +to the familiar disorders I have so briefly sketched, but I imagine that +few physicians placed face to face with such cases would not feel sure +that if they could insure to these patients a liberal gain in fat and in +blood they would be certain to need very little else, and that the +troubles of stomach, bowels, and uterus would speedily vanish. + +I need hardly say that I do not mean by this that the mere addition of +blood and normal flesh is what we want, but that their gradual increase +will be a visible result of the multitudinous changes in digestive, +assimilative, and secretive power in which the whole economy inevitably +shares, and of which my relation of cases will be a better statement +than any more general one I could make here. + +Such has certainly been the result of my own very ample experience. If I +succeed in first altering the moral atmosphere which has been to the +patient like the very breathing of evil, and if I can add largely to the +weight and fill the vessels with red blood, I am usually sure of giving +general relief to a host of aches, pains, and varied disabilities. If I +fail, it is because I fail in these very points, or else because I have +overlooked or undervalued some serious organic tissue-change. It must be +said that now and then one is beaten by a patient who has an +unconquerable taste for invalidism, or one to whom the change of moral +atmosphere is not bracing, or by sheer laziness, as in the case of a +lady who said to me, as a final argument, "Why should I walk when I can +have a negro boy to push me in a chair?" + +It will have been seen that I am careful in the selection of cases for +this treatment. Conducted under the best circumstances for success, it +involves a good deal that is costly. Neither does it answer as well, and +for obvious reasons, in hospital wards; and this is most true in regard +to persons who are demonstratively hysterical. As a rule, the worse the +case, the more emaciated, the more easy is it to manage, to control, and +to cure. It is, as Playfair remarks, the half-ill who constitute the +difficult cases. + +I am also very careful as to being sure of the absence of certain forms +of organic disease before flattering myself with the probability of +success. But not all organic troubles forbid the use of this treatment. +Advanced Bright's disease does, though the early stages of contracted +kidney are decidedly benefited by it, if proper diet be prescribed; but +intestinal troubles which are not tubercular or malignant do not; nor do +moderate signs of chronic pulmonary deposits, or bronchitis.[13] + +Some special consideration needs to be given to the subject of +heart-disease. Especially in cases of broken compensation, by lessening +the work required of the heart so that it needs to beat both less often +and with less force, the simple maintenance of the recumbent position is +a great aid to recovery, and massage properly used will still further +relieve the heart. Disturbed compensation is usually accompanied by +failure of nutrition, often by distinct anaemia, and these and the +anxiety which naturally enough affects the mind of a person with cardiac +disorder are all best handled, at first at least, by quiet and rest. +Later, the methods of Schott, baths and resistance movements, may carry +the improvement further. Even in old and established cases of valvular +disease much may be done if the patient have confidence and the +physician courage enough to insist upon a sufficient length of rest. The +palpitation and dyspnoea of exophthalmic goitre are promptly helped by +rest and massage, and with other suitable measures added, cures may be +effected even in this intractable ailment. + +In former editions I have advised against any attempt to treat the true +melancholias, which are not mere depression of spirits from loss of all +hope of relief, by this method, but wider experience has convinced me +that rest and seclusion may often be successfully prescribed to a +certain extent and in certain cases. + +Those in which the most good has been done have been the cases of +agitated melancholia with attacks, more or less clearly periodic, of +excitement, during which their delusions take acuter hold of them and +drive them to wild extravagance of noisy talk and bodily restlessness. +Whether such patients must be put to bed or not one must judge in each +instance, taking into account the general nutrition. In my own practice +I certainly do put them to bed now much oftener than formerly. It is not +desirable to keep them there for the six or eight weeks which full +treatment would demand. Usually it will be of advantage to order, say, +two weeks of "absolute rest," observing the usual precautions about +getting the patient up, prescribing bed again when the early signs of an +attack of agitation appear, and keeping him there for a couple of days +on each occasion, during which the full schedule of treatment is to be +minutely carried out. + +Goodell and, more recently, Playfair have pointed out the fact that some +cases of disease of the uterine appendages such as would ordinarily be +considered hopeless, except for surgical treatment, have in their hands +recovered to all appearances entirely; and my own list of patients +condemned to the removal of the ovaries but recovering and remaining +well has now grown to a formidable length. Playfair observes also that +he believes it possible that in even very severe and extensive disease +the health of the patient may be sufficiently improved to render +operation unnecessary.[14] + +In cases of floating kidney some very satisfactory results have been +reached by long rest; and although it may be necessary to keep the +patient supine for three months or more, the reasonable probability of +permanent replacement of the organ is much greater than from operative +attempts at fixation, apart from the danger and pain of surgical +procedures. Persons with floating kidney are nearly always thin, often +giving a history of rapid loss of weight, have usually various symptoms +of gastric and intestinal disturbance, and present therefore subjects in +all ways suitable for a fattening and blood-making _regime_ which shall +furnish padding to hold the kidney firmly in its normal place. + +The treatment of locomotor ataxia and some allied states by this method, +with certain modifications, has yielded such good results that I now +undertake with reasonable confidence the charge of such patients; and +the subject is so important and has as yet influenced so little the +futile drugging treatment of these wretched cases that it seems worth +while to devote a special chapter to it, although the affections named +can scarcely be said to be included under the head of neurasthenic +disease. + +In the following chapters I shall treat of the means which I have +employed, and shall not hesitate to give such minute details as shall +enable others to profit by my failures and successes. In describing the +remedies used, and the mode of using them in combination, I shall relate +a sufficient number of cases to illustrate both the happier results and +the causes of occasional failure. + +The treatment I am about to describe consists in seclusion, certain +forms of diet, rest in bed, massage (or manipulation), and electricity; +and I desire to insist anew on the fact that in most cases it is the +combined use of these means that is wanted. How far they may be modified +or used separately in some instances, I shall have occasion to point out +as I discuss the various agencies alluded to. + + + + +CHAPTER IV. + +SECLUSION. + + +It is rare to find any of the class of patients I have described so free +from the influence of their habitual surroundings as to make it easy to +treat them in their own homes. It is needful to disentangle them from +the meshes of old habits and to remove them from contact with those who +have been the willing slaves of their caprices. I have often made the +effort to treat them where they have lived and to isolate them there, +but I have rarely done so without promising myself that I would not +again complicate my treatment by any such embarrassments. Once separate +the patient from the moral and physical surroundings which have become +part of her life of sickness, and you will have made a change which will +be in itself beneficial and will enormously aid in the treatment which +is to follow. Of course this step is not essential in such cases as are +merely anaemic, feeble, and thin, owing to distinct causes, like the +exhaustion of overwork, blood-losses, dyspepsia, low fevers, or nursing. +There are but too many women who have broken down under such causes and +failed to climb again to the level of health, despite all that could be +done for them; and when such persons are free from emotional excitement +or hysterical complications there is no reason why the seclusion needful +to secure them repose of mind should not be pleasantly modified in +accordance with the dictates of common sense. Very often a little +experimentation as to what they will profitably bear in the way of +visits and the like will inform us, as their treatment progresses, how +far such indulgence is of use or free from hurtful influences. Cases of +extreme neurasthenia in men accompanied with nutritive failures require +as to this matter cautious handling, because, for some reason, the ennui +of rest and seclusion is far better borne by women than by the other +sex. + +Even in cases whose moral aspects do not at once suggest an imperative +need for seclusion it is well to remember, as regards neurasthenic +people, that the treatment involves for a time daily visits of some +length from the masseur, the doctor, and possibly an electrician, and +that to add to these even a single friendly visitor is often too much +to be readily borne; but I am now speaking chiefly of the large and +troublesome class of thin-blooded emotional women, for whom a state of +weak health has become a long and, almost I might say, a cherished +habit. For them there is often no success possible until we have broken +up the whole daily drama of the sick-room, with its little selfishness +and its craving for sympathy and indulgence. Nor should we hesitate to +insist upon this change, for not only shall we then act in the true +interests of the patient, but we shall also confer on those near to her +an inestimable benefit. An hysterical girl is, as Wendell Holmes has +said in his decisive phrase, a vampire who sucks the blood of the +healthy people about her; and I may add that pretty surely where there +is one hysterical girl there will be soon or late two sick women. If +circumstances oblige us to treat such a person in her own home, let us +at least change her room, and also have it well understood how far we +are to control her surroundings and to govern as to visitors and the +company of her own family. Do as we may, we shall always lessen thus our +chances of success, but we shall certainly not altogether destroy them. + +I should add here a few words of caution as to the time of year best +fitted for treatment. In the summer seclusion is often undesirable when +the patient is well enough to gain help by change of air; moreover, at +this season massage is less agreeable than in winter, and, as a rule, I +find it harder to feed and to fatten persons at rest during our summer +heats. That this rule is not without exception has been shown by Drs. +Goodell and Sinkler, both of whom have attained some remarkable +successes in midsummer. + +One of the questions of most importance in the carrying out of this +treatment is the choice of a nurse. Just as it is desirable to change +the home of the patient, her diet, her atmosphere, so also is it well, +for the mere alterative value of such change, to surround her with +strangers and to put aside any nurse with whom she may have grown +familiar. As I have sometimes succeeded in treating invalids in their +own homes, so have I occasionally been able to carry through cases +nursed by a mother, or sister, or friend of exceptional firmness; but to +attempt this is to be heavily handicapped, and the position should never +be accepted if it be possible to make other arrangements. Any firm, +intelligent woman of tact, a stranger to the patient, is better than +the old style of nurse, now, happily, disappearing. The nurse for these +cases ought to be a young, active, quick-witted woman, capable of firmly +but gently controlling her patient. She ought to be intelligent, able to +interest her patient, to read aloud, and to write letters. The more of +these cases she has seen and nursed, the easier becomes the task of the +doctor. Young, I have said she ought to be, but youthful would be a +better word. If, as she grows older, the nurse loses the strenuous +enthusiasm with which she made her first entrance into her work, +scarcely any amount of conscientious devotion or experience will ever +replace it; but there are fortunate people who seem never to grow old in +this sense. It is always to be borne in mind that most of these patients +are over-sensitive, refined, and educated women, for whom the +clumsiness, or want of neatness, or bad manners, or immodesty of a nurse +may be a sore and steadily-increasing trial. To be more or less isolated +for two months in a room, with one constant attendant, however good, is +hard enough for any one to endure; and certain quite small faults or +defects in a nurse may make her a serious impediment to the treatment, +because no mere technical training will dispense in the nurse any more +than in the physician with those finer natural qualifications which make +their training available. Over-harshness is in some ways worse than +over-easiness, because it makes less pleasant the relation between nurse +and patient, and the latter should regard the former as her "next +friend." Let the nurse, therefore, place upon the doctor the burden of +decision in disputed matters; his position will not be injured with the +patient by strict enforcement of the letter of the law, while the +nurse's may be. But one nurse will suit one patient and not another: so +that I never hesitate to change my nurse if she does not fit the case, +and to change if necessary more than once. + +The degree of seclusion should be prescribed from the first, and it is +far better to find that the original rules may be profitably relaxed +than to be obliged to draw the lines more strictly when the patient has +at first been indulged. For instance, it is well to forbid the receipt +of any letters from home, unless anxious relatives insist that the +patient must have home news. In that case the letters should be mere +bulletins, should contain nothing, no matter how trifling, that might +annoy a too sensitive person, and, most important of all, should come to +the nurse and by her be read to the patient. + + + + +CHAPTER V. + +REST. + + +I have said more than once in the early chapters of this little volume +that the treatment I wished to advise as of use in a certain range of +cases was made up of rest, massage, electricity, and over-feeding. I +said that the use of large amounts of food while at rest, more or less +entire, was made possible by the practice of kneading the muscles and by +moving them with currents able to effect this end. I desire now to +discuss in turn the modes in which I employ rest, massage, and +electricity, and, as I have promised, I shall take pains to give, in +regard to these three subjects, the fullest details, because success in +the treatment depends, I am sure, on the care with which we look after a +number of things each in itself apparently of slight moment. + +I have no doubt that many doctors have seen fit at times to put their +patients at rest for great or small lengths of time, but the person who +of all others within my knowledge used this means most, and used it so +as to obtain the best results, was the late Professor Samuel Jackson. He +was in the habit of making his patients remain in bed for many weeks at +a time, and, if I recall his cases well, he used this treatment in just +the class of disorders among women which have given me the best results. +What these are I have been at some pains to define, and I have now only +to show why in such people rest is of service, and what I mean by rest, +and how I apply it. + +In No. IV. of Dr. Seguin's series of American Clinical Lectures, I was +at some pains to point out the value of repose in neuralgias, and +especially sciatica, in myelitis, and in the early stages of locomotor +ataxia, and I have since then had the pleasure of seeing these views +very fully accepted. I shall now confine myself chiefly to its use in +the various forms of weakness which exist with thin blood and wasting, +with or without distinct lesions of the stomach, womb, or other organs. + +Whether we shall ask a patient to walk or to take rest is a question +which turns up for answer almost every day in practice. Most often we +incline to insist on exercise, and are led to do so from a belief that +many people walk too little, and that to move about a good deal every +day is well for everybody. I think we are as often wrong as right. A +good brisk daily walk is for well folks a tonic, breaks down old +tissues, and creates a wholesome demand for food. The same is true for +some sick people. The habit of horse-exercise or a long walk every day +is needed to cure or to aid in the cure of disordered stomach and +costive bowels, but if all exertion gives rise only to increase of +trouble, to extreme sense of fatigue, to nausea, to headache, what shall +we do? And suppose that tonics do not help to make exertion easy, and +that the great tonic of change of air fails us, shall we still persist? +And here lies the trouble: there are women who mimic fatigue, who +indulge themselves in rest on the least pretence, who have no symptoms +so truly honest that we need care to regard them. These are they who +spoil their own nervous systems as they spoil their children, when they +have them, by yielding to the least desire and teaching them to dwell on +little pains. For such people there is no help but to insist on +self-control and on daily use of the limbs. They must be told to exert +themselves, and made to do so if that can be. If they are young, this +is easy enough. If they have grown to middle life, and created habits of +self-indulgence, the struggle is often useless. But few, however, among +these women are free from some defect of blood or tissue, either +original or acquired as a result of years of indolence and attention to +aches and ailments which should never have had given to them more than a +passing thought, and which certainly should not have been made an excuse +for the sofa or the bed. + +Sometimes the question is easy to settle. If you find a woman who is in +good condition as to color and flesh, and who is always able to do what +it pleases her to do, and who is tired by what does not please her, that +is a woman to order out of bed and to control with a firm and steady +will. That is a woman who is to be made to walk, with no regard to her +complaints, and to be made to persist until exertion ceases to give rise +to the mimicry of fatigue. In such cases the man who can insure belief +in his opinions and obedience to his decrees secures very often most +brilliant and sometimes easy success; and it is in such cases that women +who are in all other ways capable doctors fail, because they do not +obtain the needed control over those of their own sex. I have been +struck with this a number of times, but I have also seen that to be too +long and too habitually in the hands of one physician, even the wisest, +is for some cases of hysteria the main difficulty in the way of a +cure,--it is so easy to disobey the familiar friendly attendant, so hard +to do this where the physician is a stranger. But we all know well +enough the personal value of certain doctors for certain cases. Mere +hygienic advice will win a victory in the hands of one man and obtain no +good results in those of another, for we are, after all, artists who all +use the same means to an end but fail or succeed according to our method +of using them. There are still other cases in which mischievous +tendencies to repose, to endless tire, to hysterical symptoms, and to +emotional displays have grown out of defects of nutrition so distinct +that no man ought to think for these persons of mere exertion as a sole +means of cure. The time comes for that, but it should not come until +entire rest has been used, with other means, to fit them for making use +of their muscles. Nothing upsets these cases like over-exertion, and the +attempt to make them walk usually ends in some mischievous emotional +display, and in creating a new reason for thinking that they cannot +walk. As to the two sets of cases just sketched, no one need hesitate; +the one must walk, the other should not until we have bettered her +nutritive state. She may be able to drag herself about, but no good will +be done by making her do so. But between these two classes, and allied +by certain symptoms to both, lie the larger number of such cases, giving +us every kind of real and imagined symptom, and dreadfully well fitted +to puzzle the most competent physician. As a rule, no harm is done by +rest, even in such people as give us doubts about whether it is or is +not well for them to exert themselves. There are plenty of these women +who are just well enough to make it likely that if they had motive +enough for exertion to cause them to forget themselves they would find +it useful. In the doubt I am rather given to insisting on rest, but the +rest I like for them is not at all their notion of rest. To lie abed +half the day, and sew a little and read a little, and be interesting as +invalids and excite sympathy, is all very well, but when they are bidden +to stay in bed a month, and neither to read, write, nor sew, and to have +one nurse, who is not a relative,--then repose becomes for some women a +rather bitter medicine, and they are glad enough to accept the order to +rise and go about when the doctor issues a mandate which has become +pleasantly welcome and eagerly looked for. I do not think it easy to +make a mistake in this matter unless the woman takes with morbid delight +to the system of enforced rest, and unless the doctor is a person of +feeble will. I have never met myself with any serious trouble about +getting out of bed any woman for whom I thought rest needful, but it has +happened to others, and the man who resolves to send any nervous woman +to bed must be quite sure that she will obey him when the time comes for +her to get up. + +I have, of course, made use of every grade of rest for my patients, from +repose on a lounge for some hours a day up to entire rest in bed. In +milder forms of neurasthenic disease, in cases of slight general +depression not properly to be called melancholias, in the lesser grades +of pure brain-tire, or where this is combined with some physical +debility, I often order a "modified" or "partial rest." A detailed +schedule of the day is ordered for such patients, with as much +minuteness of care as for those undergoing "full rest" in bed. Here the +patient's or the household's usual hours may be consulted, a definite +amount of time allotted to duties, business, and exercise, and certain +hours left blank, to be filled, within limits, at the patient's +discretion or that of the nurse. + +So many nervous people are worried with indecision, with inability to +make up their minds to the simplest actions, that to have the +responsibility of choice taken away greatly lessens their burdens. It +lessens, too, the burdens which may be placed upon them by outside +action if they can refuse this or that because they are under orders as +to hours. + +The following is a skeleton form of such a schedule. The hours, the +food, the occupations suggested in each one will vary according to the +sex, age, position, desires, intelligence, and opportunities of the +patient. + +7.30 A.M. Cocoa, coffee, hot milk, beef-extract, or hot water. Bath +(temperature stated). Rough rub with towel or flesh-brush: bathing and +rubbing may be done by attendant. Lie down a few minutes after +finishing. + +8.30 A.M. Breakfast in bed. (Detail as to diet. Tonic, aperient, malt +extract as ordered.) May read letters, paper, etc., if eyes are good. + +10-11 A.M. Massage, if required, is usually ordered one hour after +breakfast; or Swedish movements are given at that time. An hour's rest +follows massage. Less rest is needed after the movements. (Milk or broth +after massage.) + +12 M. Rise and dress slowly. If gymnastics or massage are not ordered, +may rise earlier. May see visitors, attend to household affairs, or walk +out. + +1.30 P.M. Luncheon. (Malt, tonic, etc., ordered.) In invalids this +should be the chief meal of the day. Rest, lying down, not in bed, for +an hour after. + +3 P.M. Drive (use street-cars or walk) one to two and a half hours. +(Milk or soup on return.) + +7 P.M. Supper. (Malt, tonic, etc., ordered; detail of diet.) + +Bed at 10 P.M. Hot milk or other food at bedtime. + +This schedule is modified for convalescent patients after rest-treatment +by orders as to use of the eyes: letter-writing is usually forbidden, +walking distinctly directed or forbidden, as the case may require. It +may be changed by putting the exercise, massage, or gymnastics in the +afternoon, for example, and leaving the morning, as soon as the rest +after breakfast is finished, for business. Men needing partial rest may +thus find time to attend to their affairs. + +If massage is not ordered, there is nothing in this routine which costs +money, and I have found it apply usefully in the case of hospital and +dispensary patients. + +In carrying out my general plan of treatment in extreme cases it is my +habit to ask the patient to remain in bed from six weeks to two months. +At first, and in some cases for four or five weeks, I do not permit the +patient to sit up, or to sew or write or read, or to use the hands in +any active way except to clean the teeth. Where at first the most +absolute rest is desirable, as in cases of heart-disease, or where there +is a floating kidney, I arrange to have the bowels and water passed +while lying down, and the patient is lifted on to a lounge for an hour +in the morning and again at bedtime, and then lifted back again into the +newly-made bed. In most cases of weakness, treated by rest, I insist on +the patient being fed by the nurse, and, when well enough to sit up in +bed, I order that the meats shall be cut up, so as to make it easier +for the patient to feed herself. + +In many cases I allow the patient to sit up in order to obey the calls +of nature, but I am always careful to have the bowels kept reasonably +free from costiveness, knowing well how such a state and the efforts it +gives rise to enfeeble a sick person. + +The daily sponging bath is to be given by the nurse, and should be +rapidly and skilfully done. It may follow the first food of the day, the +early milk, or cocoa, or coffee, or, if preferred, may be used before +noon, or at bedtime, which is found in some cases to be best and to +promote sleep. + +For some reason, the act of bathing, or even the being bathed, is +mysteriously fatiguing to certain invalids, and if so I have the general +sponging done for a time but thrice a week. + +Most of these patients suffer from use of the eyes, and this makes it +needful to prohibit reading and writing, and to have all correspondence +carried on through the nurse. But many neurasthenic people also suffer +from being read to, or, in other words, from any prolonged effort at +attention. In these cases it will be found that if the nurse will read +the morning paper, and as she does so relate such news as may be of +interest, the patient will bear it very well, and will by degrees come +to endure the hearing of such reading as is already more or less +familiar. + +Usually, after a fortnight I permit the patient to be read to,--one to +three hours a day,--but I am daily amazed to see how kindly nervous and +anaemic women take to this absolute rest, and how little they complain of +its monotony. In fact, the use of massage and the battery, with the +frequent comings of the nurse with food, and the doctor's visits, seem +so to fill up the day as to make the treatment less tiresome than might +be supposed. And, besides this, the sense of comfort which is apt to +come about the fifth or sixth day,--the feeling of ease, and the ready +capacity to digest food, and the growing hope of final cure, fed as it +is by present relief,--all conspire to make most patients contented and +tractable. + +The intelligent and watchful physician must, of course, know how far to +enforce and when to relax these rules. When it is needful, as it +sometimes is, to prolong the state of rest to two or three months, the +patient may need at the close occupation of some kind, and especially +such as, while it does not tax the eyes, gives the hands something to +do, the patient being, we suppose, by this time able to sit up in bed +during a part of the day. + +The moral uses of enforced rest are readily estimated. From a restless +life of irregular hours, and probably endless drugging, from hurtful +sympathy and over-zealous care, the patient passes to an atmosphere of +quiet, to order and control, to the system and care of a thorough nurse, +to an absence of drugs, and to simple diet. The result is always at +first, whatever it may be afterwards, a sense of relief, and a +remarkable and often a quite abrupt disappearance of many of the nervous +symptoms with which we are all of us only too sadly familiar. + +All the moral uses of rest and isolation and change of habits are not +obtained by merely insisting on the physical conditions needed to effect +these ends. If the physician has the force of character required to +secure the confidence and respect of his patients, he has also much more +in his power, and should have the tact to seize the proper occasions to +direct the thoughts of his patients to the lapse from duties to others, +and to the selfishness which a life of invalidism is apt to bring +about. Such moral medication belongs to the higher sphere of the +doctor's duties, and, if he means to cure his patient permanently, he +cannot afford to neglect them. Above all, let him be careful that the +masseuse and the nurse do not talk of the patient's ills, and let him by +degrees teach the sick person how very essential it is to speak of her +aches and pains to no one but himself. + +I have often asked myself why rest is of value in the cases of which I +am now speaking, and I have already alluded briefly to some of the modes +in which it is of use. + +Let us take first the simpler cases. We meet now and then with feeble +people who are dyspeptic, and who find that exercise after a meal, or +indeed much exercise on any day, is sure to cause loss of power or +lessened power to digest food. The same thing is seen in an extreme +degree in the well-known experiment of causing a dog to run violently +after eating, in which case digestion is entirely suspended. Whether +these results be due to the calling off of blood from the gastric organs +to the muscles, or whether the nervous system is, for some reason, +unable to evolve at the same time the force needed for a double +purpose, is not quite clear, but the fact is undoubted, and finds added +illustrations in many of the class of exhausted women. It is plain that +this trouble exists in some of them. It is likely that it is present in +a larger number. The use of rest in these people admits of no question. +If we are to give them the means in blood and flesh of carrying on the +work of life, it must be done with the aid of the stomach, and we must +humor that organ until it is able to act in a more healthy manner under +ordinary conditions. It may be wise to add that occasional cases of +nervousness or of nervous disturbance of digestion are seen in which the +patient assimilates food better if permitted to move about directly +after a meal; and I recall one instance of very persistent gastric +catarrh where the uncomfortable symptoms following meals only began to +disappear when as an experiment the patient was ordered to take a quiet +half-hour's stroll after each meal, instead of the rest usually ordered. + +I am often asked how I can expect by such a system to rest the organs of +mind. No act of will can force them to be at rest. To this I should +answer that it is not the mere half-automatic intellectuation which is +harmful in men or women subject to states of feebleness or neurasthenia, +and that the systematic vigorous use of mind on distinct problems is +within some form of control. It is thought with the friction of worry +which injures, and unless we can secure an absence of this, it is vain +to hope for help by the method I am describing. The man harassed by +business anxieties, the woman with morbidly-developed or ungoverned +maternal instincts, will only illustrate the causes of failure. Perhaps +in all dubious cases Dr. Playfair's rule is not a bad one, to consider, +and to let the patient consider, this mode of treatment as a hopeful +experiment, which may have to be abandoned, and which is valueless +without the cordial and submissive assistance of the patient. + +The muscular system in many of such patients--I mean in ever-weary, thin +and thin-blooded persons--is doing its work with constant difficulty. As +a result, fatigue comes early, is extreme, and lasts long. The demand +for nutritive aid is ahead of the supply, or else the supply is +incompetent as to quality, and before the tissues are rebuilded a new +demand is made, so that the materials of disintegration accumulate, and +do this the more easily because the eliminative organs share in the +general defects. And these are some of the reasons why anaemic people are +always tired; but, besides this, all real sensations are magnified by +women whose nervous systems have become sensitive owing to a life of +attention to their ailments, and so at last it becomes hard to separate +the true from the false, and we are thus led to be too sceptical as to +the presence of real causes of annoyance. Certain it is that rest, under +proper conditions, is found by such sufferers to be a great relief; but +rest alone will not answer, and it is needful, as I shall show, to bring +to our help certain other means, in order to secure all the good which +repose may be made to insure. + +In dealing with this, as with every other medical means, it is well to +recall that in our attempts to help we may sometimes do harm, and we +must make sure that in causing the largest share of good we do the least +possible evil. + +"The one goes with the other, as shadow with light, and to no +therapeutic measure does this apply more surely than to the use of rest. + +"Let us take the simplest case,--that which arises daily in the +treatment of joint-troubles or broken bones. We put the limb in splints, +and thus, for a time, check its power to move. The bone knits, or the +joint gets well; but the muscles waste, the skin dries, the nails may +for a time cease to grow, nutrition is brought down, as an arithmetician +would say, to its lowest terms, and when the bone or joint is well we +have a limb which is in a state of disease. As concerns broken bones, +the evil may be slight and easy of relief, if the surgeon will but +remember that when joints are put at rest too long they soon fall a prey +to a form of arthritis, which is the more apt to be severe the older the +patient is, and may be easily avoided by frequent motion of the joints, +which, to be healthful, exact a certain share of daily movement. If, +indeed, with perfect stillness of the fragments we could have the full +life of a limb in action, I suspect that the cure of the break might be +far more rapid. + +"What is true of the part is true of the whole. When we put the entire +body at rest we create certain evils while doing some share of good, and +it is therefore our part to use such means as shall, in every case, +lessen and limit the ills we cannot wholly avoid. How to reach these +ends I shall by and by state, but for a brief space I should like to +dwell on some of the bad results which come of our efforts to reach +through rest in bed all the good which it can give us, and to these +points I ask the most thoughtful attention, because upon the care with +which we meet and provide for them depends the value which we will get +out of this most potent means of treatment. + +"When we put patients in bed and forbid them to rise or to make use of +their muscles, we at once lessen appetite, weaken digestion in many +cases, constipate the bowels, and enfeeble circulation."[15] + +When we put the muscles at absolute rest we create certain difficulties, +because the normal acts of repeated movement insure a certain rate of +nutrition which brings blood to the active parts, and without which the +currents flow more largely around than through the muscles. The lessened +blood-supply is a result of diminished functional movement, and we need +to create a constant demand in the inactive parts. But, besides this, +every active muscle is practically a throbbing heart, squeezing its +vessels empty while in motion, and relaxing, so as to allow them to fill +up anew. Thus, both for itself and in its relations to the areolar +spaces and to the rest of the body, its activity is functionally of +service. Then, also, the vessels, unaided by changes of posture and by +motion, lose tone, and the distant local circuits, for all of these +reasons, cease to receive their normal supply, so that defects of +nutrition occur, and, with these, defects of temperature. + +"I was struck with the extent to which these evils may go, in the case +of Mrs. P., aet. 52, who was brought to me from New Jersey, having been +in bed fifteen years. I soon knew that she was free of grave disease, +and had stayed in bed at first because there was some lack of power and +much pain on rising, and at last because she had the firm belief that +she could not walk. After a week's massage I made her get up. I had won +her full trust, and she obeyed, or tried to obey me, like a child. But +she would faint and grow deadly pale, even if seated a short time. The +heart-beats rose from sixty to one hundred and thirty, and grew feeble; +the breath came fast, and she had to lie down at once. Her skin was +dry, sallow, and bloodless, her muscles flabby; and when, at last, after +a fortnight more, I set her on her feet again, she had to endure for a +time the most dreadful vertigo and alarming palpitations of the heart, +while her feet, in a few minutes of feeble walking, would swell so as to +present the most strange appearance. By and by all this went away, and +in a month she could walk, sit up, sew, read, and, in a word, live like +others. She went home a well-cured woman. + +"Let us think, then, when we put a person in bed, that we are lessening +the heart-beats some twenty a minute, nearly a third; that we are +causing the tardy blood to linger in the by-ways of the blood-round, for +it has its by-ways; that rest in bed binds the bowels, and tends to +destroy the desire to eat; and that muscles at rest too long get to be +unhealthy and shrunken in substance. Bear these ills in mind, and be +ready to meet them, and we shall have answered the hard question of how +to help by rest without hurt to the patient." + +When I first made use of this treatment I allowed my patients to get up +too suddenly, and in some cases I thus brought on relapses and a return +of the feeling of painful fatigue. I also saw in some of these cases +what I still see at times under like circumstances,--a rapid loss of +flesh. + +I now begin by permitting the patient to sit up in bed, then to feed +herself, and next to sit up out of bed a few minutes at bedtime. In a +week, she is desired to sit up fifteen minutes twice a day, and this is +gradually increased until, at the end of six to twelve weeks, she rests +on the bed only three to five hours daily. Even after she moves about +and goes out, I insist for two months on absolute repose at least two or +three hours daily, and this must be understood to mean seclusion as well +as bodily quiet, free from the intrusion of household cares, visitors, +or any form of emotion or excitement, pleasureable or otherwise. In +cases of long-standing it may be desirable to continue this period of +isolation and to order as well an hour's lying down after each meal for +many months, in some such methodical way as is suggested in the schedule +on page 64. + +The use of a hammock is found by some people to be a very agreeable +change from the bed during a part of the day. + +The physician who discharges his patient when she rises from her bed +after her two or three months' treatment, or who neglects to consider +the moral and mental needs and aspects of each case, will find that many +will relapse. Even when the patient has left the direct care of the +doctor and returned to home and its avocations she will find help and +comfort in the knowledge that she can apply to him if necessary, and it +is well to hold some sort of relation by occasional visits or +correspondence, however brief, for six months or a year after treatment +has been completed. + + + + +CHAPTER VI. + +MASSAGE. + + +How to deprive rest of its evils is the title with which I might very +well have labelled this chapter. I have pointed out what I mean by rest, +how it hurts, and how it seems to help; and, as I believe that it is +useful in most cases only if employed in conjunction with other means, +the study of these becomes of the first importance. + +The two aids which by degrees I learned to call upon with confidence to +enable me to use rest without doing harm are massage and electricity. We +have first to deal with massage, and I give some care to the description +of details, because even now it is imperfectly understood in this +country, and because I wish to emphasize some facts about it which are +not well known, I think, on either side of the Atlantic. + +Massage in some form has long been in use in the East, and is well known +as the _lommi-lommi_ of the slothful inhabitants of the Sandwich +Islands. In Japan it is reserved as an occupation for the blind, whose +delicate sense of feeling might, I should think, very well fit them for +this task. It is, however, in these countries less used in disease than +as the luxury of the rich; nor can I find in the few books on the +subject that it has been resorted to habitually as a tonic in Europe, or +otherwise than as a means of treating local disorders. + +It is many years since I first saw in this city general massage used by +a charlatan in a case of progressive paralysis. The temporary results he +obtained were so remarkable that I began soon after to employ it in +locomotor ataxia, in which it sometimes proved of signal value, and in +other forms of spinal and local disease. At first I had to train nurses +to use it, but I soon found that, although it was of some service to +their patients, no one could use massage well who was not continually +engaged in doing it. Some men do it better than any woman; but I prefer, +nevertheless, for obvious reasons, to reserve men for male patients, +except that in cases where _strength_ is of moment, as in the forced +movements and the very hard rubbing needed for old articular adhesions, +in which force must be exercised without violence, it is usually +impossible to secure the necessary power in a feminine manipulator. + +A few years later I resorted to it in the first cases which I treated by +rest, and I very soon found that I had in it an agent little understood +and of singular utility. + +It will be necessary, in pursuance of my plan, to describe as minutely +as the limits of a chapter will allow how and why this means is +employed. The process and order of what is known to the manipulator as +"general massage" follows. + +After three or four days in bed have somewhat accustomed the patient to +the general routine of treatment, a masseur or masseuse is set to work. +If any special care is needed,--the avoidance of manipulating one part +or added attention to another, tender handling of a sensitive or timid +patient,--these matters have been ordered in advance by the physician. +An hour midway between meals is chosen, and, the patient lying in bed +between blankets, the manipulator begins, usually with the feet. A few +rapid rubs of the whole foot and leg are given to start with; then the +leg, except the foot and ankle, is covered up, and the operation +commences upon the foot, of which the skin is picked up and rolled +between the fingers, the whole foot receiving careful attention,--the +toes are pulled, bent, and moved in every direction, the inter-osseous +groups worked over with the thumbs and fingers or finger-tips, the +larger muscles and subcutaneous tissues squeezed and kneaded, and last +the whole mass of the foot rolled and pressed against the bones with +both hands. A few rapid upward strokings with some force complete the +treatment of the part, and the ankle is next dealt with. The joint is +moved in every possible direction, slowly but firmly, the crevices +between the articulating bones sought out and kneaded with the +finger-tips, and the foot and ankle are then carefully covered. After +the same rapid stroking upward of the leg with which it began has been +repeated for the sake of the slight stimulation of the skin-vessels and +nerves, the muscles of the leg are treated, first by friction of the +more superficially placed masses, then by careful deep kneading +(_petrissage_) of the large muscles of the calf, twisting, pressing, and +rolling them about the bone with one hand while the other supports the +limb. In fat or heavily-muscled subjects it may be necessary to use both +hands to get sufficient grasp of the muscles. The tibialis anticus and +muscles of the outer side of the leg are operated upon by rolling them +under the finger-tips and by pressing with the thumb while firmly +pushing upward from the ankle to the knee. At brief intervals the +manipulator seizes the limb in both hands and lightly runs the grasp +upward, so as to favor the flow of the venous blood-currents, and then +returns to the kneading of the muscles,--and each part is finished by +light yet firm upward stroking, the hand returning downward more +lightly, yet without breaking its contact with the skin. + +Care must be taken as the different groups of muscles are treated that +the leg is placed in the position which will most completely relax the +ones to be operated upon. Any tension of muscles wholly defeats the +effort of the masseur. + +After completing the process upon both legs, the arm is next treated in +the same manner, the hand receiving somewhat more detailed attention +than the foot. Pains must be taken to reach the several groups of the +forearm by operating from both sides of the arm. The ordinary +manipulation of the shoulder can be accomplished with the patient lying +down; but if special conditions, such as articular stiffening, call for +unusual care or unusual force, it will be found best to treat the +shoulder with the patient seated. The treatment of the arms is concluded +with upward stroking (_effleurage_), as with the leg. + +In the order usually pursued, the back is the next region treated. The +patient lies prone, folding the arms under the head; a firm pillow is +put under the epigastric region, so as to the better relax the back +muscles, which are too tense when a person lies flat. Beginning from the +occiput, both hands stroke firmly and rapidly downward and outward to +the spines of the scapulae, at first lightly, then with increasing force. +Then the whole back is vigorously rubbed--scrubbed one might call +it--with up-and-down strokes, as a preliminary application. The erector +spinae masses are treated by careful finger-tip kneading. Working from +the spine outward to the axillary line, the muscles of the ribs are +acted upon with flat-hand rubbing. The groups of the upper back and +shoulder-blades are kneaded and squeezed, the arms being partly +abducted so as to separate the shoulder-blades and allow the operator to +reach the muscles underlying them. The lumbar regions receive their +manipulation last. If it is desirable to give special attention or an +extra share of manipulation to any part of the spinal region, this is +done as the physician may have ordered, and the whole process is +completed by downward friction over the spine, given vigorously and as +rapidly as possible. + +The chest is the next region to be handled, the patient turning from the +prone to the supine position. In women the breasts are usually best left +untouched unless special conditions demand their treatment. + +The last and perhaps most important part of the process of general +massage is the rubbing of the abdomen. Particular care is needed to +secure complete relaxation, as nervous patients and, still more, +hysterical patients are apt to present extreme rigidity of the abdominal +muscles. The head is raised by pillows, the knees are slightly flexed +and sometimes supported by a folded pillow also. With this position the +rigidity generally yields to gentle persistence, at any rate after a +few treatments. If it does not do so, a lateral decubitus may be tried, +a position in which the intestinal regions may be very thoroughly +treated, and in which, if there be gastric dilatation, the stomach-walls +can be best reached. Sweeping circular frictions about the navel as a +centre begin the process; the abdominal walls are then kneaded and +pinched[16] with one or both hands; deep, firm kneading of the whole +belly with the heel of the hand follows, the movements following the +course of the colon. Next, the fingers of one hand are all held together +in a pyramidal fashion and thrust firmly and slowly into the abdomen, in +ordinary cases both hands being used thus alternately, in fat or +resisting abdomens one hand pressing upon and aiding the other, and +travelling thus over the ascending, transverse, and descending colon. +To conclude, the whole belly is shaken by a rapid vibratory motion of +the hands (to which is sometimes added succussion by slapping with the +flat or cupped hand), and the whole process ends with quick, circular +rubbing of the surface. + +In cases of troublesome constipation or where other special indications +exist, treatment of the abdomen may be much extended beyond the limits +here suggested, and indeed it must be remembered that the process of +"general massage" as described is capable of a great variety of useful +modification to meet individual needs, and is so modified daily by the +careful physician and the watchful masseur. It would not be possible or +desirable here to describe all the movements which a skilful rubber +makes in his treatment, and I have only attempted a skeleton-statement. +It will perhaps be noticed by those familiar with the technique of +massage that nothing is here said about the use of the movements classed +under the general head of "tapotement," the tapping and slapping +motions. They have no proper place in the treatment of cases of +nervousness, and usually will serve only to irritate and annoy the +patient, and often greatly to increase the nervous excitement. Their +routine use or over-use constitutes one of the defects of the system of +massage as usually practised by the Swedish operators; and when patients +tell me, as many do, that "they cannot stand massage," it is often found +that the performance of a great deal of this useless and fretting +manipulation has constituted a great part of the treatment, and that +deep, thorough, quiet kneading can be perfectly borne. + +A few precautions are necessary to observe. The grasping hand should +carry the skin with it, not slip over the skin, as the drag thus put +upon the hairs will, if daily repeated, cause troublesome boils. The use +of a lubricant avoids this, and is a favorite device of unskilful +manipulators. It also does away with much of the good effected by +skin-friction, is uncleanly, very annoying to many patients, promotes an +unsightly growth of hair, and should be avoided except where it is +desired to rub into the system some oleaginous material. There are +exceptional cases where a very dry, harsh skin or a tendency to +excessive sweating during massage makes the use of some unguent +desirable. Cocoa-oil may be used, or what is perhaps more agreeable, +lanolin softened to the consistency of very thick cream by the addition +of oil of sweet almonds. As little as possible should be made to serve. + +Too much care cannot be used to cover with stockings and warm wraps the +parts after in turn they have been subjected to massage. As to time, at +first the massage should last half an hour, but should be increased in a +week to a full hour. I observe that Dr. Playfair has it used twice a day +or more, and I have since had it so employed in some cases, letting the +masseuse come before noon, and allowing the nurse to use it at night if +it does not interfere with sleep, which is a matter to be tested solely +by experiment. Commonly, one hour once daily suffices. I was at one time +in the habit of suspending the use of both massage and electricity +during menstruation, because I found occasionally that these agents +disturbed or checked the normal flow. Of late, however, I continue to +employ both agents, but confine them to the limbs. I have met with rare +cases in which almost any massage gave rise to a uterine hemorrhage, and +in which the utmost caution became necessary. + +Women who have a sensitive abdominal surface or ovarian tenderness have +of course to be handled with care, but in a few days a practised rubber +will by degrees intrude upon the tender regions, and will end by +kneading them with all desirable force. The same remarks apply to the +spine when it is hurt by a touch; and it is very rare indeed to find +persons whose irritable spots cannot at last be rubbed and kneaded to +their permanent profit. + +Sometimes when the patient is found to be much exhausted by massage, it +is well to give some stimulating concentrated food afterwards; +occasionally it may be necessary both before and after. In this case it +would be well to see that the rubbing was not being made too severe. + +Very rarely I find a patient to whom all massage is so disagreeable or +produces such annoying nervousness as to make manipulation impossible; +sometimes, though very rarely, massage, especially frictional movements, +causes sexual excitement when applied in the neighborhood of the genital +organs, or even on the buttocks and lower spine, and this may occur in +either sane or insane patients: if the rubber observe any signs of this, +it will of course be best to avoid handling the areas which are thus +sensitive. + +Another complaint sometimes made is of chilliness after treatment, and +especially of cold feet. If this is not lessened after a few days, the +lower extremities may be rubbed last instead of first, or as is now and +then useful, the whole order of massage may be changed so as to begin +with the abdomen, chest, and upper extremities and conclude with the +back and legs.[17] + +Beginning with half an hour and gradually increasing to about an hour (a +little more for very large or very fat people,--a little less for the +small or thin) the daily massage is kept up through at least six weeks, +and then if everything seems to be going along well, I direct the rubber +or nurse to spend half of the hour in exercising the limbs as a +preparation for walking. This is done after the Swedish plan, by making +very slowly passive and extreme extensions and flexions of the limbs for +a few days, then assisted movements, next active unassisted movements, +and last active movements gently resisted by nurse or masseuse. When the +patient is able to sit and stand, it is well to keep up and extend the +number of these gentle gymnastic acts and to encourage the patient to +make them habitual, or at least to keep them up for many months after +the conclusion of treatment.[18] + +At the seventh week massage is used on alternate days, and is commonly +laid aside when the patient gets up and begins to move about. + +In 1877, several of the members of the staff of the Infirmary for +Nervous Disease, and especially my colleague, Dr. Wharton Sinkler, +obliged me by studying with care the influence of massage on +temperature, and some very interesting results were obtained. In +general, when a highly hysterical person is rubbed, the legs are apt to +grow cold under the stimulation, and if this continues to be complained +of it is no very good omen of the ultimate success of the treatment. But +usually in a few days a change takes place, and the limbs all grow warm +when kneaded, as happens in most people from the beginning of the +treatment.[19] The extremely low temperature of the limbs of children +suffering with so-called essential paralysis is well known. I have +frequently seen these strangely cold parts rise, under an hour's +massage, six to ten degrees F. In such small limbs, the long contact of +a warm hand may account for at least a part of this notable rise in +temperature. In adults this can hardly be looked upon as a cause of the +rise of temperature produced by massage, first, because the long +exposure of large surfaces incident to the process is calculated to +lessen whatever increase of heat the contact of the hand may cause, and +secondly, because this rise is a very variable quantity, and because +occasionally some other and less comprehensible factors actually induce +a fall rather than a rise in the thermometer as a result of massage. + +In very nervous or hysterical women, ignorant of what the act of +kneading may be expected to bring about, and especially in such as are +thin and anaemic and have either a somewhat high or an unusually low +normal temperature, we may find at first a slight fall of the +thermometer, then a fairly constant rise, with some irregularities, and +at last, as the health improves, a lessening effect or none at all. + +The most notable rise is to be found in persons who, owing to some +organic disease, have acquired liability to great changes of +temperature. + +It is impossible to observe the increase of heat which follows both +massage and electricity without inferring that these agents must for a +time, like exercise and other tonics, increase the tissue-waste by the +stimulus they cause of the general and interstitial circulations, and by +the direct influence they seem to have on the tissues themselves. I have +sought to study this matter carefully by placing patients on a fixed and +competent diet of milk alone, and by estimating the waste of tissues as +shown in the secretions before and after the use of massage. This study, +although it was never completed in a satisfactory manner, would seem to +show that massage does not much alter the total elimination of the +entire day, but causes a large and abrupt increase within three hours, +followed by a compensatory decline.[20] + +I add a number of tables, which very well illustrate the facts above +stated as to rise of temperature. + +Mrs. J., at rest, on the usual diet. Manipulation at 11, daily: + +Before Massage. After Massage. + +100 100 + +100 100-1/5 + +99-2/5 99-4/5 + +99-4/5 100 + +99-2/5 100 + +100 100 + +99-4/5 100 + +99-4/5 100 + +Miss P., aet. 24, hysteria: + +Before Massage. After Massage. + +99-1/4 99-1/4 + +98-1/4 99 + +98-1/2 99 + +98-1/4 99 + +98-1/4 98-1/4 + +99 99-3/4 + +100-1/5 100-2/5 + +100-2/5 101-2/5 + +100-2/5 100-3/5 + +100-3/5 100 + +Mrs. L., a very thin, feeble, and bloodless woman, aet. 29 years: + +Before Massage. After Massage. + +99 100 + +98-1/2 99-1/5 + +98 98-2/5 + +99 100 + +98-2/5 98-4/5 + +99 99-4/5 + +100 100-1/5 + +99 99-4/5 + +Mrs. P., aet. 31, feeble and anaemic, nervous, slight albuminuria and +chronic bronchitis. Liable to fever. 3 P.M.: + +Before Massage. After Massage. + +101-3/5 102 + +100 100-4/5 + +99 99-4/5 + +100 101 + +99-2/5 100-1/5 + +99-4/5 100-3/5 + +100-3/5 101-3/5 + +100-2/5 99-4/5 + +100-3/5 100-2/5 + +100-3/10 100-9/10 + +99-1/5 99-4/5 + +These temperatures were taken always before 4 P.M., and at intervals of +three days. Her morning temperature was usually 99 deg. to 99-4/5 deg., and in +the evening, 9 to 10 o'clock, it always rose to 100 deg., 101 deg., and at times +to 102 deg.. + +As I have said already, there are persons who, under circumstances +seemingly alike, have from massage a large rise of temperature, and +others who experience none. I give a single case of what is rare but not +exceptional,--an almost constant fall of temperature. + +Miss N., aet. 21, hysteria, good condition: + +Before Massage. After Massage. + + 98 97-3/5 + + 98-1/2 98-1/2 + + 98 98 + + 98-2/5 98 + + 98-4/5 98 + +These facts are, of course, extremely interesting; but it is well to add +that the success of the treatment is not indicated in any constant way +by the thermal changes, which are neither so steady nor so remarkable as +those caused by electricity. + +If now we ask ourselves why massage does good in cases of absolute rest, +the answer--at least a partial answer--is not difficult. The secretions +of the skin are stimulated by the treatment of that tissue, and it is +visibly flushed, as it ought to be, from time to time, by ordinary +active exercise. Under massage the flabby muscles acquire a certain +firmness, which at first lasts only for a few minutes, but which after a +time is more enduring and ends by becoming permanent. The firm grasp of +the manipulator's hand stimulates the muscle, and, if sudden, may cause +it to contract sensibly, which, however, is not usually desirable or +agreeable. The muscles are by these means exercised without the use of +volitional exertion or the aid of the nervous centres, and at the same +time the alternate grasp and relaxation of the manipulator's hands +squeezes out the blood and allows it to flow back anew, thus healthfully +exciting the vessels and increasing mechanically the flow of blood to +the tissues which they feed. It is possible also that a real increase in +the production of red corpuscles is brought about by repeated +applications of massage, as will be seen later on. + +The visible results as regards the surface-circulation are sufficiently +obvious, and most remarkably so in persons who, besides being anaemic and +thin, have been long unused to exercise. After a few treatments the +nails become pink, the veins show where before none were to be seen, +the larger vessels grow fuller, and the whole tint of the body changes +for the better. + +In like manner the sore places which previously existed, or which were +brought into sensitive prominence by the manipulation, by degrees cease +to be felt, and a general sensation of comfort and ease follows the +later treatments. + +Although this plan of acting on the muscles seems to dispense with any +demands upon the centres, it is not to be supposed that it is altogether +without influence on these parts. In fact, extreme use of massage +occasionally flushes the face and causes sense of fulness in the head or +ache in the back. The actual large increase in the number of corpuscles +in the circulation brought about by massage may be one of the reasons +for this. We have added, perhaps, millions of cells to the number in the +vessels in a very short time, and need not be astonished if some signs +of plethora follow. Moreover, in some spinal maladies it has effects not +to be altogether explained by its mechanical stimulation of the muscles, +nerves, and skin. + +That the deep circulation shares in the changes which are so obvious in +the superficial vessels has been shown by various observers of +experimental and clinical facts. Firm deep muscle-kneading of the +general surface will almost always slow and strengthen the pulse. If the +abdomen alone is thoroughly rubbed the same effect appears in the pulse, +but less in degree, and massage of the abdomen has also a distinct +effect in increasing the flow of urine, a fact worth remembering in +cases of heart-disease. In a case of albuminuria from exercise, W.W. +Keen has shown that massage did not cause the return of the albumin +after rest, though exercise did, a difference due to the opposite +effects upon blood-pressure of the two forms of activity. Lauder-Brunton +has shown that more blood passes through a masseed part after treatment. +Dr. Eccles and Dr. Douglas Graham both found a decided decrease in the +circumference of a limb after massage, showing how completely the veins +must have been emptied, for the time at least,--an emptying which would +surely be followed by an increased flow of arterial blood into the +treated region. Dr. J.K. Mitchell, in 1894,[21] made a large number of +examinations of the blood before and after massage, some in patients +under treatment for a variety of disorders affecting the integrity of +the blood, and a few in perfectly healthy men. With scarcely an +exception there was a large increase in the number of corpuscles in a +cubic millimetre, and an increase, though of less extent, in the +haemoglobin-content. Studies made at various intervals after treatment +showed that the increase was greatest at the end of about an hour, after +which it slowly decreased again; but this decrease was postponed longer +and longer when the manipulation was continued regularly as a daily +measure.[22] The author's conclusions from these examinations were +interesting, and I quote them somewhat fully. The fact that the +haemoglobin is less decidedly increased than the corpuscular elements +makes it seem at least probable that what happens is, that in all the +conditions in which anaemia is a feature there are globules which are not +doing their duty, but which are called out by the necessities of +increased circulatory activity brought about by massage. If this is the +first effect, yet as it is observed that the increase of corpuscles, at +first passing, soon becomes permanent, we must conclude that massage has +the ultimate effect of stimulating the production of red corpuscles. + +One sometimes hears doubts expressed whether a patient with a high-grade +anaemia is not "too feeble for such strong treatment" as massage. This +study of one of the ways in which massage affects such cases may fairly +be taken as proof of the certainty and safety of its effect on them, +provided always it be done properly and with intelligence. Some check +upon this may be had, as is said elsewhere, by the general effect upon +the patient. It may be repeated that the pulse should be slower and +stronger after an hour of deep massage, and that this effect will not be +produced by superficial rubbing (indeed, with light or too rapid +manipulation the pulse may become both less strong and more rapid), and +finally the flow of urine should be increased. With these easily +observed facts to aid, it may readily be judged whether massage is being +rightly applied or not without the need of a visit from the physician +during the hour of treatment. A final test might readily be made by +examination of the blood and counting the red corpuscles before and +after treatment. No doubt in very bad cases a small increase or none +would be found at first, but a week of daily manipulation should show a +distinct addition to the blood count. A striking instance in which this +examination was repeatedly made is related on p. 184. + +"It is evident that our present definitions of anaemia are insufficient. +An essential part of the description in all of them is that there are +defects of number, of color, or of both in the blood. This is not +necessarily or always true. The fault may lie in a lack of activity or +of availability in the corpuscles. The state of things in the system may +be like the want of circulating money during times of panic, when gold +is hoarded and not made use of, and interference with commerce and +manufactures results. + +"Neither an anaemic appearance nor a blood-count is alone enough for a +certain diagnosis. Other signs must be used as a check on the blood +examination for the establishment of the existence of anaemia. For +instance, many cases here recorded had full normal or even supra-normal +corpuscle-count, with a good percentage of haemoglobin. Yet they +presented every external sign of poverty of blood: pallor of skin and, +more important still, of mucous membranes, cold extremities, anorexia, +indigestion, dyspnoea on trifling exertion. In such cases we must suppose +either that the total volume of the blood is reduced, or that the +usefulness of the corpuscles is in some way impaired, or that both these +troubles exist together."[23] + +I have said above that the face was not touched in the course of the +rubbing. There are cases, however, in which massage of the head and face +may be usefully practised. Some obstinate neuralgias are helped by it +temporarily, and very often it is of use with other means to aid in a +permanent cure. Many headaches of a passing character may be dissipated +promptly by careful massage of the head or by downward stroking over the +jugular veins at the sides of the neck to lessen the flow of blood into +the cerebral vessels, where the pain is due to congestion or distention, +and careful manipulation of the facial muscles in paralysis is of +service in restoring loss of tone and improving their nutrition. It is +worth adding here, as women patients frequently say that during their +illness the hair has become thin or shown a great tendency to fall, that +daily firm finger-tip massage of the head for ten or twelve minutes, +followed by rubbing into the scalp of a small amount of a tonic, either +a bland oil or if need be of some more stimulating material, will in a +great majority of the instances where loss of hair is due to general +ill-health perfectly restore its vigor and even its color. + +I am accustomed to pay a good deal of attention to the observations made +on these and other points by practised manipulators, and I find that +their daily familiarity with every detail of the color, warmth, and +firmness of the tissues is of great use to me. + +A great deal of nonsense is talked and written as to the use and the +usefulness of massage. The "professional rubber" not unnaturally makes a +mystery of it, and patients talk foolishly about "magnetism" and +"electricity;" but what is needed is a strong, warm, soft hand, directed +by ordinary intelligence and instructed by practice; and this is the +whole of the matter, except in the massage of such obscure conditions +as need full knowledge of the anatomical relations and physiological +functions of the parts to be rubbed. It is a fact that I have known +country physicians who, desiring to use massage and not having a +practitioner of it within reach, have themselves trained persons to do +it, with considerable resultant success. + +It is not, perhaps, putting it too strongly to say that bad massage is +better than none in those cases in which manipulation is needed. Very +little harm can result from its use even by unskilled hands, provided +that reasonable intelligence direct them. + + + + +CHAPTER VII. + +ELECTRICITY. + + +Electricity is the second means which I have made use of for the purpose +of exercising muscles in persons at rest. It has also an additional +value, of which I shall presently speak. + +In order to exercise the muscles best and with the least amount of pain +and annoyance, we make use of an induction current, with interruptions +as slow as one in every two to five seconds, a rate readily obtained in +properly-constructed batteries.[24] This plan is sure to give painless +exercise, but it is less rapid and less complete as to the quality of +the exercise caused than the movements evolved by very rapid +interruptions. These, in the hands of a clever operator who knows his +anatomy well, are therefore, on the whole, more satisfactory, but they +require some experience to manage them so as not to shock and disgust +the patient by inflicting needless pain. The poles, covered with +absorbent cotton well wetted with salt water, which may be readily +changed, so as not to use the same material more than once, are placed +on each muscle in turn, and kept about four inches apart. They are moved +fast enough to allow of the muscles being well contracted, which is +easily managed, and with sufficient speed, if the assistant be +thoroughly acquainted with the points of Ziemssen. The smaller electrode +should cover the motor-point and the larger be used upon an indifferent +area. After the legs are treated, the muscles of the belly and back and +loins are gone over systematically, and finally those of the chest and +arms. The face and neck are neglected. About forty minutes to an hour +are needed; but at first a less time is employed. The general result is +to exercise in turn all the external muscles.[25] + +No such obvious and visible results are seen as we observe after +massage, but the thermal changes are much more constant and remarkable, +and show at least that we are not dealing with an agent which merely +amuses the patient or acts alone through some mysterious influence on +the mental status. + +A half-hour's treatment of the muscles commonly gives rise to a marked +elevation of temperature, which fades away within an hour or two. This +effect is, like that from massage, most notable in persons liable to +fever from some organic trouble, and it varies as to its degree in +individuals who have no such disease. + +The first case, Miss B., aet. 20, is an example of tubercular disease of +the apex of the right lung. She had a morning temperature of 98-1/2 deg. to +99-1/2 deg., and an evening temperature of 100 deg. to 102 deg.. + +Electricity was used about 11 o'clock daily, with these results: + + Before Electricity. After Electricity. + +November 25 99 99-3/5 + " 27 97-3/5 100 + " 28 98 99 + " 29 98-4/5 99-4/5 + +December 2 100-1/5 101-3/5 + " 4 99-1/5 100-1/5 + " 5 99-2/5 99-1/5 + +Mrs. R., aet. 40, the next case, was merely a rather anaemic, feeble, and +thin woman, who for years had not been able to endure any prolonged +effort. She got well under the general treatment, gaining thirteen +pounds on a weight of ninety-eight pounds, her height being five feet +and one inch. The facts as to rise of temperature are most remarkable, +and, I need not say, were carefully observed. + +Temperature taken in the mouth while at rest in bed. + + Before Electricity. After Electricity. + +April 2 98-2/5 98-4/5 + " 3 98-1/5 98-2/5 + " 4 98-1/5 98-2/5 + " 5 98 98-3/5 + " 6 97-9/10 98-7/10 + " 7 98 98-5/10 + " 8 98 98-3/5 + " 9 98 98-1/10 + " 10 98-2/5 98-3/5 + " 11 98-5/10 98-7/10 + " 12 98-3/5 99-1/10 + " 13 98-1/5 99-5/10 + " 14 98-2/5 99-1/5 + " 16 98-4/10 99-1/10 + " 17 98-5/10 99-2/10 + " 18 98-7/10 99-1/10 One hour later, 99-1/10 + " 19 98-9/10 99-3/10 " " " , 98-4/5 + + Before Electricity. After Electricity. + +April 20 99 99-1/10 + + " 21 98-9/10 99-2/10 + Menstrual period. + + " 30 98-3/5 98-3/5 + +May 1 98 98-5/10 + + " 2 98 98-3/10 + +The third case, Miss M., aet. 33, was that of a pallid woman, the +daughter of a well-known physician in the South. She suffered for six +years with "nervous exhaustion," headaches, pain in the back, intense +depression of spirits, nausea, and repeated attacks of hysteria. She +slept only under anodynes, and used stimulants freely. Under the use of +rest and the adjuvant treatment described, Miss M. made a thorough +recovery, and was restored to useful active life. + +Miss M. Thermometer held in mouth. + + Before Electricity. After Electricity. + +May 14 99-1/10 99-1/10 } Menstruating; general + } faradization only. + " 15 99 99-1/5 } + + " 16 99-1/5 99-1/5 Gen'l faradization and limbs. + + " 17 98-4/5 99-1/5 + + " 18 98-4/5 99-1/5 + + " 19 98-1/5 98-4/5 + + " 21 98-3/5 99 + + " 22 98-4/5 99-1/10 + + Before Electricity. After Electricity. + +May 25 98-1/10 98-4/10 + + " 26 98-1/10 99-1/10 + + " 29 98-3/5 99 + + " 30 98-5/10 99-1/10 + + " 31 98-9/10 99-1/10 + +Mrs. P., aet. 38, was a rather nervous woman, easily tired, but not +anaemic and not very thin. She improved greatly under the treatment. + + Before Electricity. After Electricity. + +January 27 98-3/5 99-1/5 Thermometer in axilla ten + + " 29 98-2/5 99-1/5 minutes before and after. + + " 30 99-1/5 99-3/5 + + " 31 98-4/5 99-2/5 + +February 1 99 99-2/5 + Menstrual period. + +February 8 98-2/5 99-1/5 + + " 9 98-3/5 99 + + " 10 98-2/5 99 + + " 12 98-1/5 99-3/5 + + " 13 98-2/5 99 + + " 14 98-2/5 98-3/5 + + " 15 98-2/5 98-4/5 + + " 19 99 98-2/5 + + " 20 98 99 + + " 23 98-3/5 99-4/5 Thermometer in mouth five + + " 24 99 99-2/5 minutes before and after. + + " 27 99-1/5 99-3/5 + + " 28 98-4/5 99-4/5 + Menstrual period. + +Menstrual period. + + Before Electricity. After Electricity. + +March 13 99 99-2/5 + + " 14 98-4/5 98-4/5 + + " 15 99 99-1/5 + +Miss R., aet. 27, was a fair case of hysterical conditions; over-use of +chloral and bromides; anorexia and loss of flesh and color. + +Thermometer in mouth. + + Before Electricity. After Electricity. + +May 15 100 100 } + } General faradization + " 16 100 100 } for fifteen minutes. + } + " 17 100-1/5 100-2/5 } + + " 18 98-2/5 98-3/5 } General faradization, + } fifteen minutes, also of + " 19 99-4/5 100-1/10 } arm muscles, twenty minutes. + +May 20 100-1/10 100 + General faradization, ten + " 22 99-2/5 99-3/5 minutes; arms and legs + twenty minutes. + " 26 99-1/10 99-2/10 + + " 27 99-3/10 99-4/10 + + " 28 99-2/5 99-2/5 + + " 29 99-3/10 99-3/10 + + " 30 99-1/10 99-4/10 + + " 31 99-1/10 99-2/10 + +June 2 99-3/5 99-4/5 + + " 4 99-5/10 99-6/10 + + " 6 99-3/10 99-5/10 + + " 7 99-3/10 99-5/10 + +I have given these full details because I have not seen elsewhere any +statement of the rather remarkable phenomena which they exemplify. It +may be that a part at least of the thermal change is due to the muscular +action, although this seems hardly competent to account for any large +share in the alteration of temperature, and we must look further to +explain it fully. No mental excitement can be called upon as a cause, +since it continues after the patient is perfectly accustomed to the +process. I should add, also, that in most cases the subject of the +experiment was kept in ignorance of the fact that a rise of the +thermometer was to be expected. Is it not possible that the current even +of an induction battery has the power so to stimulate the tissues as to +cause an increase in the ordinary rate of disintegrative change? Perhaps +a careful study of the secretions might lend force to this suggestion. +That the muscular action produced by the battery is not essential to the +increase of bodily heat is shown by the next set of facts to which I +desire to call attention. + +Some years ago, Messrs. Beard and Rockwell stated that when an induced +current is used for fifteen to thirty minutes daily, one pole on the +neck and one on either foot, or alternately on both, the persistent use +of this form of treatment is decidedly tonic in its influence. I believe +that in this opinion they were perfectly correct, and I am now able to +show that, when thus employed, the induced current causes also a decided +rise of temperature in many people, which proves at least that it is in +some way an active agent, capable of positively influencing the +nutritive changes of the body. + +The rise of temperature thus caused is less constant, as well as less +marked, than that occasioned by the muscle treatment. I do not think it +necessary to give the tables in full. They show in the best cases, rises +of one-fifth to four-fifths of a degree F., and were taken with the +utmost care to exclude all possible causes of error. + +The mode of treatment is as follows: At the close of the +muscle-electrization one pole is placed on the nape of the neck and one +on a foot for fifteen minutes. Then the foot pole is shifted to the +other foot and left for the same length of time. + +The primary current is used, as being less painful, and the +interruptions are made as rapid as possible, while the cylinder or +control wires are adjusted so as to give a current which is not +uncomfortable. + +It is desirable to have electricity used by a practised hand, but of +late I have found that intelligent nurses may suffice, and this, of +course, materially lessens the cost. In very timid or nervous people, or +those who at some time have been severely "shocked" by the application +of electricity in the hands of charlatans, it is common to find the +patient greatly dreading a return to its use. In this case, if the +battery be started and the poles moved about on the surface as usual, +but without any connection being made, one of two things will +happen,--either the patient will naturally find it very mild, and will +submit fearlessly to a gentle and increasing treatment, or else her +apprehensions will so dominate her as to cause her to complain of the +effects as exciting or tiring her, or as spoiling her sleep. A few words +of kindly explanation will suffice to show her how much expectation has +to do with the apparent results, and she will be found, if the matter be +managed with tact, to have learned a lesson of wide usefulness +throughout her treatment. + +However, there are occasional, though very rare, cases in which it is +impossible to use faradism at all by reason of the insomnia and +nervousness which result even after very careful and gentle application +of the current. On the other hand, some patients find the effect of the +electric application so soothing as to promote sleep, and will ask to +have it repeated or regularly given in the evening. + +I have been asked very often if all the means here described be +necessary, and I have been criticised by some of the reviewers of my +first edition because I had not pointed out the relative needfulness of +the various agencies employed. In fact, I have made very numerous +clinical studies of cases, in some of which I used rest, seclusion, and +massage, and in others rest, seclusion, and electricity. It is, of +course, difficult, I may say impossible, to state in any numerical +manner the reason for my conclusion in favor of the conjoined use of all +these means. If one is to be left out, I have no hesitation in saying +that it should be electricity. + + + + +CHAPTER VIII. + +DIETETICS AND THERAPEUTICS. + + +The somewhat wearisome and minute details I have given as to seclusion, +rest, massage, and electricity have prepared the way for a discussion of +the dietetic and medicinal treatment which without them would be neither +possible nor useful. + +As to diet, we have to be guided somewhat by the previous condition and +history of the patient. + +It is difficult to treat any of these cases without a resort at some +time more or less to the use of milk. In most dyspeptic cases--and few +neurasthenic women fail to be obstinately dyspeptic--milk given at the +outset, and given alone by Karell's method for a fortnight or less, +enormously simplifies our treatment. Even after that, milk is the best +and most easily managed addition to a general diet. As to its use with +rest and massage as an exclusive diet in obesity alone or in extreme +fatness with anaemia, I spoke in a former edition with a confidence +which has been increased by the added experience of physicians on both +sides of the Atlantic. Finally, there are exceptional cases of +intestinal pain of obscure parentage or seemingly neuralgic, of +dyspepsia incorrigible by other treatments, which, having resulted in +grave general defects of nutrition, are best treated by several weeks of +milk diet, combined with rest, massage, and electricity. Milk, +therefore, must be so much used in these cases in connection with the +general treatment I am describing that it is perhaps as well to say more +clearly how it is to be employed when given alone or with other food. I +am the more willing to do this because I have learned certain facts as +to the effects of milk diet which have, I believe, hitherto escaped +observation. In fact, the study of the therapeutic influence and full +results of exclusive diets is yet to be made; nor can I but believe that +accurate dietetics will come to be a far more useful part of our means +of managing certain cases than as yet seems possible. + +We are indebted chiefly to Dr. Karell, of St. Petersburg, for our +knowledge of the value of milk as an exclusive diet, and to Dr. Donkin +for the extension of Karell's treatment to diabetes. I shall formulate +as curtly as possible the rules to be followed in using milk as an +exclusive diet in dyspeptic states, and in anaemia with obesity, and in +the latter state uncomplicated by defective haemic conditions. + +For fuller statements as to the reasons for the various rules to be +observed in using milk, I must refer the reader to Karell's paper and to +Donkin's book. + +Have the utmost care used as to preservation of the milk employed, and +as to the perfect cleansing of all vessels in which it is kept. Use +well-skimmed milk, as fresh as can be had, and, if possible, let it be +obtained from the cow twice a day. Or if this is not possible, or where +any doubt exists as to the condition of the milk, or any difficulty is +experienced in keeping it fresh, it may be pasteurized as soon as +received by heating it to 160 deg., keeping it some minutes at this point, +and at once chilling on ice. For this purpose it is best to have the +milk in bottles, and to heat by immersing the bottles in a water-bath. +For longer preservation, as, for example, when travelling, sterilizing +may be more thoroughly done by greater heat and lengthened immersion. +Still, these should be expedients for use only when milk cannot be +secured fresh and in good order, as it is more than doubtful if the milk +is so well borne when it has been altered by these processes. + +For ordinary daily use it might be better to let all the milk for the +day be peptonized in the morning with pancreatic extract, to the extent +which is found to be agreeable to the patient's taste, and then preserve +it by placing it upon ice. In this way milk may be kept for several +days. Then, too, it has been found that where even skimmed milk upsets +the stomach of patients, milk prepared in this manner can be taken +without trouble. In peptonizing, the directions which accompany the +powders to be used for that purpose should be followed carefully. It is +to be remembered that if the patient desires to take the milk warm, the +process of conversion into peptones, which has been stopped by the cold, +will be promptly started again when the fluid is warmed, and then a very +few minutes will suffice to make it disagreeably bitter. At first the +skimming should be thorough, and for the treatment of dyspepsia or +albuminuria the milk must be as creamless as possible. The milk of the +common cow is, for our purposes, preferable to that of the Alderney. It +may be used warm or cold, but, except in rare cases of diarrhoea, should +not be boiled. + +It ought to be given at least every two hours at first, in quantities +not to exceed four ounces, and as the amount taken is enlarged, the +periods between may be lengthened, but not beyond three hours during the +waking day, the last dose to be used at bedtime or near it. If the +patient be wakeful, a glass should be left within reach at night, and +always its use should be resumed as early as possible in the morning. A +little lime-water may be added to the night milk, to preserve it sweet, +and it should be kept covered. + +The milk given during the day should be taken at set times, and very +slowly sipped in mouthfuls; and this is an important rule in many cases. +Where it is so disagreeable as to cause great disgust or nausea, the +addition of enough of tea or coffee or caramel or salt to merely flavor +it may enable us to make its use bearable, and we may by degrees abandon +these aids. Another plan, rarely needed, is to use milk with the general +diet and lessen the latter until only milk is employed. If these rules +be followed, it is rare to find milk causing trouble; but if its use +give rise to acidity, the addition of alkalies or lime-water may help +us, or these may be used and the milk scalded by adding a fourth of +boiling water to the milk, which has been previously put in a warm +glass. Some patients digest it best when it has the addition of a +teaspoonful of barley-or rice-water to each ounce, the main object being +to prevent the formation of large, firm clots in the stomach,--an end +which may also be attained by the addition at the moment of drinking of +a little carbonated water from a siphon. For the sake of variety, +buttermilk may be substituted for a portion of the fresh milk, and +though less nourishing it has the advantage of being mildly laxative. + +When used as an exclusive diet, skimmed milk gives rise to certain very +interesting and what I might call normal symptoms. Since at first we can +rarely give enough to sustain the functions, for several days the +patient is apt to lose weight, which is another reason why exercise is +in such cases undesirable. This loss soon ceases, and in the end there +is usually a gain, while in most rest cases an exclusive milk diet may +be dispensed with after a week. Where milk is taken alone for weeks or +months, it is common enough to observe a large increase in bodily +weight. I have seen several times active men, even laboring men, live +for long periods on milk, with no loss of weight; but large quantities +have to be used,--two and a half to three gallons daily. A gentleman, a +diabetic, was under my observation for fifteen years, during the whole +of which time he took no other food but milk and carried on a large and +prosperous business. Milk may, therefore, be safely asserted to be a +sufficient food in itself, even for an adult, if only enough of it be +taken. + +During the first week or two, exclusive milk diet gives rise to a marked +sense of sleepiness. It causes nearly always, and even for weeks of its +use, a white and thick fur on the tongue, and often for a time an +unpleasant sweetish taste in the early morning, neither of which need be +regarded. Intense constipation and yellowish stools of a peculiar odor +are usual. Of the former I shall speak in connection with the use of +milk in special cases. The influence of milk on the urinary secretion is +more remarkable, and has not been as yet fully studied. + +There is, of course, a large flow of urine; and in dropsical cases due +to renal maladies this may exceed the ingested fluid and carry away very +rapidly the dropsical accumulations. It is sometimes annoying to nervous +persons because of the frequent micturition it makes necessary. I have +discovered that while skimmed milk alone is being taken, uric acid +usually disappears almost entirely from the urine, so that it is +difficult to discover even a trace of this substance; nor does it seem +to return so long as nothing but creamless milk is used. Almost any +large addition of other food, but especially of meat, enables us to find +it again. Creatine and creatinine also seem to lessen in amount, but of +the extent of this change I am not as yet fully informed. + +A yet more singular alteration occurs as to the pigments. If after a +fortnight or less of exclusive milk diet we fill with the urine a long +test-tube, and, placing it beside a similar tube of the ordinary urine +of an adult, look down into the two tubes, we shall observe that the +milk urine has a singular greenish tint, which once seen cannot again be +mistaken. If we put some of this urine in a test-tube carefully upon hot +nitric acid, there is noticed none of the usual brown hue of oxidized +pigment at the plane of contact. In fact, it is often difficult to see +where the two fluids meet. + +The precise nature of this greenish-yellow pigment has not, I believe, +been made out; but it seems clear that during a diet of milk the +ordinary pigments of the urine disappear or are singularly modified. A +single meal of meat will at once cause their return for a time. + +These results have been carefully re-examined at my request by Dr. +Marshall in the Laboratory of the University of Pennsylvania, and his +results and my own have been found to accord; while he has also +discovered that during the use of milk the substances which give rise to +the ordinary faecal odors disappear, and are replaced by others the +nature of which is not as yet fully comprehended. The changes I have +here pointed out are remarkable indications of the vast alterations in +assimilation and in the destruction of tissues which seem to take place +under the influence of this peculiar diet. Some of them may account for +its undoubted value in lithaemic or gouty states; but, at all events, +they point to the need for a more exhaustive study both of this and of +other methods of exclusive diet. + +As regards milk, enough has here been said to act as a guide in its +practical use in the class of cases with which we are now concerned; but +I may add that it is sometimes useful, as the case progresses, to employ +in place of milk, or with it, some one of the various "children's +foods," such as Nestle's food, or malted milk. + +Before dealing with the treatment of the anaemic and feeble and more or +less wasted invalids who require treatment by rest and its concomitant +aids, I desire to say a few words as to the use of rest, milk dietetics, +and massage in people who are merely cumbrously loaded with adipose +tissues, and also in the very small class of anaemic women who are +excessively fat and may or may not be hysterical, but are apt to be +feeble and otherwise wretched. + +Karell has pointed out that on creamless milk diet fat people lose +flesh; and this is true; so that sometimes this mode of lessening weight +succeeds very well. But it does not always answer, because, as in +Banting, loss of weight is apt to be accompanied with loss of strength, +so that in some cases the results are disastrous, or at least alarming. +I do not know that this is ever the case if the directions of Mr. +Harvey[26] are followed with care and the weight very deliberately +lessened. But for this few people have the patience; and, even if they +can be induced to follow out a strict diet, it is often useful to be +able to cut off very rapidly a large amount of weight, and so shorten +the period of strict regimen, or at least put over-fat persons in a +condition to exercise with a freedom which had become difficult, and +thus to provide them with a healthful means of preventing an +accumulation of adipose matter. This can be done rapidly and with safety +by the following means. The person whose weight we decide to lessen is +placed on skimmed milk alone, with the usual precautions; or at once we +give skimmed milk with the usual food, and in a week put aside all other +diet save milk and all other fluids. When we find what quantity of milk +will sustain the weight, we diminish the amount by degrees until the +patient is losing a half-pound of weight each day, or less or more, as +seems to be well borne. Meanwhile, during the first week or two rest in +bed is enjoined, and later for a varying period rest in bed or on a +lounge is insisted upon, while at the same time massage is used once or +twice a day, and later in the case Swedish movements. At the same time, +the pulse and weight are observed with care, so that if there be too +rapid loss, or any sign of feebleness, the diet may be increased. In +many such cases I allow daily a moderate amount of beef- or chicken- or +oyster-soup,--more as a relief to the unpleasantness of a milk diet than +for any other reason. + +When the weight has been sufficiently lowered, we add to the diet beef, +mutton, oysters, etc., and finally arrange a full diet list to include +but a moderate amount of hydro-carbons. Meanwhile, the milk remains as a +large part of the food, and the active Swedish movements are still kept +up as a habit, the patient being directed by degrees to add the usual +forms of exercise. + +If we attempt to make so speedy a change in weight while the patient is +afoot, the loss is apt to be gravely felt; but with the precautions here +advised it is interesting and pleasant to see how great a reduction may +be made in a reasonable time without annoyance and with no obvious +result except a gain in health and comfort. + +Cases of anaemia in women with excess of flesh have to be managed in a +somewhat similar fashion, but with the utmost care. In such persons we +have a loss of red blood-globules, perhaps lessened haemoglobin, weak +heart, rapid pulse, and general feebleness, with too much fat, but not, +or at least rarely, extreme obesity. The milder cases may profit by +iron, with rest and very vigorous massage, but in old cases of this +kind--they are, happily, rare--the best plan is to put the patient at +rest, to use massage, restrict the diet to skimmed milk, or to milk and +broths free from fat, and with them, when the weight has been +sufficiently lowered, to give iron freely, and by degrees a good general +diet, under which the globules rise in number, so that even with a new +gain in flesh there comes an equal gain in strength and comfort. The +massage must be very thoroughly done to be of service, and it is often +difficult to get operators to perform it properly, as the manipulation +of very fat people is excessively hard work. As to other details, the +management should be much the same as that which I shall presently +describe in connection with cases of another kind. + +I add two cases in illustration of the use of rest, milk, and massage +in the treatment of persons who are both anaemic and overloaded with +fat. + +Mrs. P., aet. 45, weight one hundred and ninety pounds, height five feet +four and a half inches, had for some years been feeble, unable to walk +without panting, or to move rapidly even a few steps. Although always +stout, her great increase of flesh had followed an attack of typhoid +fever four years before. Her appearance was strikingly suggestive of +anaemia. + +She was subject to constant attacks of acid dyspepsia, was said to be +unable to bear iron in any form, and had not menstruated for seven +months. She had no uterine disease, and was not pregnant. Two years +before I saw her she had been made very ill owing to an attempt to +reduce her flesh by too rapid Banting, and since then, although not a +gross or large eater, she had steadily gained in weight, and as steadily +in discomfort. + +She was kept in bed for five weeks. Massage was used at first once +daily, and after a fortnight twice a day, while milk was given, and in a +week made the exclusive diet. Her average of loss for thirty days was a +pound a day, and the diet was varied by the addition of broths after +the third week, so as to keep the reduction within safe limits. Her +pulse at first was 90 to 100 in the morning, and at night 80 to 95, her +temperature being always a half degree to a degree below the normal. At +the third week the latter was as is usual in health, and the pulse had +fallen to 80 in the morning, and 80 to 90 at night. + +After two weeks I gave her the lactate of iron every three hours in full +doses. In the fourth week additions were made to her diet-list, and +Swedish movements were added to the massage, which was applied but once +a day; and during the fifth week she began to sit up and move about. At +the seventh week her pulse was 70 to 80, her temperature natural, and +her blood-globules much increased in number. Her weight had now fallen +to one hundred and forty-five pounds, and her appearance had decidedly +improved. She left me after three and a half months, able to walk with +comfort three miles. She has lived, of course, with care ever since, but +writes me now, after two years, that she is a well and vigorous woman. +Her periodical flow came back five months after her treatment began, and +she has since had a child. + +Early in the spring of 1876, Mrs. C., aet. 40, came under my care with +partial hysterical paralysis of the right and hemi-anaesthesia of the +left side. She had no power to feel pain or to distinguish heat from +cold in the left leg and arm, though the sense of touch was perfect. The +long strain of great mental suffering had left her in this state and +rendered her somewhat emotional. Her appetite was fair, but she was +strangely white, and weighed one hundred and sixty-three pounds, with a +height of five feet five inches. As she had had endless treatment by +iron, change of air, and the like, I did not care to repeat what had +already failed. She was therefore put at rest, and treated with milk, +slowly lessened in amount. Her stomach-troubles, which had been very +annoying, disappeared, and when the milk fell to three pints she began +to lose flesh. With a quart of milk a day she lost half a pound daily, +and in two weeks her weight fell to one hundred and forty pounds. She +was then placed on the full treatment which I shall hereafter describe. +The weight returned slowly, and with it she became quite ruddy, while +her flesh lost altogether its flabby character. I never saw a more +striking result. + +I have been careful to speak at length of these fat anaemic cases, +because, while rare, they have been, to me at least, among the most +difficult to manage of all the curable anaemias, and because with the +plan described I have been almost as successful as I could desire. + +Let us now suppose that we have to deal with a person of another and +different type,--one of the larger class of feeble, thin-blooded, +neurasthenic or hysterical women. Let us presume that every ordinary and +easily attainable means of relief has been utterly exhausted, for not +otherwise do I consider it reasonable to use so extreme a treatment as +the one we are now to consider. Inevitably, if it be a woman long ill +and long treated, we shall have to settle the question of uterine +therapeutics. A careful examination is made, and we learn that there is +decided displacement. In this case it is well to correct it at once and +to let the uterine treatment go on with the general treatment. If there +be bad lacerations of the womb or perineum, their surgical relief may +await a change in the general status of health,--say at the fourth or +fifth week. If there be only congestive or other morbid states of the +womb or ovaries, they are best left to be aided by the general gain in +health; but in this as in every other stage of this treatment it is +unwise, and undesirable therefore, to lay down too absolute laws. Having +satisfied ourselves as to these points, and that rest, etc., is needful, +we begin treatment, if possible, at the close of a menstrual period, +because usually the monthly flow is a time at which there is little or +no gain, and by starting our treatment when it is just over we save a +week of time in bed. + +The next step is, usually, to get her by degrees on a milk diet, which +has two advantages. It enables us to know precisely the amount of food +taken, and to regulate it easily; and it nearly always dismisses, as by +magic, all the dyspeptic conditions. If the case be an old one, I rarely +omit the milk; but, although I begin with three or four ounces every two +hours, I increase it in a few days up to two quarts, given in divided +doses every three hours. If a cup of coffee given without sugar on +awaking does not regulate the bowels, I add a small amount of watery +extract of aloes at bedtime; or if the constipation be obstinate, I give +thrice a day one-quarter of a grain of watery extract of aloes with two +grains of dried ox-gall. I find the simple milk diet a great aid +towards getting rid of chloral, bromides, and morphia, all of which I +usually am able to lay aside during the first week of treatment.[27] Nor +is it less easy with the same means to enable the patient to give up +stimulus; and I may add that in the treatment of the congested stomach +of the habitual hard drinker the milk treatment is of admirable +efficacy. As I have spoken over and over of the use of stimulus by +nervous women, I should be careful to explain that anything like great +excess on the part of women of the upper classes, in this country at +least, is, in my opinion, extremely rare, and that when I speak of the +habit of stimulation I mean only that nervous women are apt to be taught +to take wine or whiskey daily, to an extent that does not affect visibly +their appearance or demeanor. + +Meanwhile, the mechanical treatment is steadily pursued, and within +four days to a week, when the stomach has become comfortable, I order +the patient to take also a light breakfast. A day or two later she is +given a mutton-chop as a mid-day dinner, and again in a day or two she +has added bread-and-butter thrice a day; within ten days I am commonly +able to allow three full meals daily, as well as three or four pints of +milk, which are given at or after meals, in place of water. + +After ten days I order also two to four ounces of fluid malt extract +before each meal. The fluid malt extracts which now reach us from +Germany have become less trustworthy than they formerly were. Some of +them keep badly, and are uncertain in composition, one bottle being +good, another bad. The more constant, and at the same time most +agreeable, extracts are those now made in this country. Although their +diastasic powers are usually less than is claimed for them, and vary +greatly even in the best makes, they so far have seemed to me on the +whole more satisfactory than the imported malts. It is very desirable +that a thorough chemical study should be made of the various malt +extracts, solid and liquid. I am sure that some of them are defective +in composition, or vary notably as to the amount of alcohol they +contain. + +No troublesome symptoms usually result from this full feeding, and the +patient may be made to eat more largely by being fed by her attendant. +People who will eat very little if they feed themselves, often take a +large amount when fed by another; and, as I have said before, nothing is +more tiresome than for a patient flat on her back to cut up her food and +to use the fork or spoon. By the plan of feeding we thus gain doubly. + +As to the meals, I leave them to the patient's caprice, unless this is +too unreasonable; but I like to give butter largely, and have little +trouble in getting this most wholesome of fats taken in large amounts. A +cup of cocoa or of coffee with milk on waking in the morning is a good +preparation for the fatigue of the toilet. + +At the close of the first week I like to add one pound of beef, in the +form of raw soup. This is made by chopping up one pound of raw beef and +placing it in a bottle with one pint of water and five drops of strong +hydrochloric acid. This mixture stands on ice all night, and in the +morning the bottle is set in a pan of water at 110 deg. F. and kept two +hours at about this temperature. It is then thrown on to a stout cloth +and strained until the mass which remains is nearly dry. The filtrate is +given in three portions daily. If the raw taste prove very +objectionable, the beef to be used is quickly roasted on one side, and +then the process is completed in the manner above described. The soup +thus made is for the most part raw, but has also the flavor of cooked +meat.[28] + +In difficult cases, especially those treated in cool weather, I +sometimes add, at the third week, one half-ounce of cod-liver oil, given +half an hour after each meal. If it lessen the appetite, or cause +nausea, I employ it thrice a day as a rectal injection; and in cases +where the large doses of iron used cause intense constipation, I find +the use of cod-oil enemata doubly valuable, by acting as a nutriment and +by disposing the bowels to act daily. This may be given as an emulsion +with pancreatic extract. This will suit some people well, and result in +a single passage daily, but in others may be annoying, and be either +badly retained or not retained at all, and may give rise to tenesmus. + +The question of stimulus is a grave one. In too many cases which come to +me, I have to give so much care to break off the use of all forms of +alcoholic drinks that I am loath to resort to them in any case, although +I am satisfied that a small amount is a help towards speedy increase of +fat. Its use is, therefore, a matter for careful judgment, and in +persons who have never taken it in excess, or as a habit, I prefer to +give, with the other treatment, a small daily ration of stimulus: an +ounce a day of whiskey in milk, or a glass of dry champagne or red wine, +seems to me useful as an adjuvant, and as increasing the capacity to +take food at meals. Nevertheless, alcohol is not essential, and for the +most part I give none, except the small amount--some four per +cent.--present in fluid malt extracts. Even this is found to excite +certain persons, and it is in such cases easy to substitute the thicker +extracts of malt, or the Japanese extract, made from barley and rice. + +So soon as my patient begins to take other food than milk, and +sometimes even before this, I like to give iron in large doses. In +hospital practice the old subcarbonate answers very well, being cheap, +and not unpalatable when shaken up in water or given in an effervescent +draught of carbonated waters. In private practice large doses of salts +of iron, as four to six grains of lactate at meal-time, are +satisfactory; but the form of iron is of less moment than the amount. + +Very often I meet with women who cannot take iron, either because it +disturbs the stomach, causes headache, or constipates, or else because +they have been told never to take iron. In the latter case I simply add +five grains of the pyrophosphate to each ounce of malt, and give it thus +for a month unknown to the patients. It is then easy to make clear to +them that iron is not so difficult to take as they had been led to +believe, and when it has ceased to disagree mentally I find that I am +able to fall back on the coarser method. If iron constipate, as it may +and does often do when used in these large doses, the trouble is to be +corrected by fruit, and especially pears, by the pill of the watery +extract of aloes and ox-gall already mentioned, by extracts of cascara +or of juglans cinerea, which may be added to the malt extract ordered +with the meals, or by enemata of oil, or oil and glycerin, or a glycerin +suppository. The instances in which iron gives headache and sense of +fulness are very rare when the patient is undergoing the full treatment +described, and, as a rule, I disregard all such complaints, and find +that after a time I cease to hear anything more of these symptoms. + +Unless some especial need arises, iron, in some form, is the only drug I +care to use until the patient begins to sit up, when I order nearly +always sulphate of strychnia, in rather full doses, thrice a day, with +iron and arsenic. + +Probably no physician will read the account I have here detailed of the +vast amount of food which I am enabled to give, not only with impunity +from dyspepsia, but with lasting advantage, without some sense of +wonder; and, for my own part, I can only say that I have watched again +and again with growing surprise some listless, feeble, white-blooded +creature learning by degrees to consume these large rations, and +gathering under their use flesh, color, and wholesomeness of mind and +body. It is needless to say that it is not in all cases easy to carry +out this treatment. + +When the full treatment has been reached, and kept up for a few days, I +begin to watch the urine with care, because if the patient be overfed +the renal secretion speedily betrays this result in the precipitation of +urates. When this occurs at all steadily, I usually give directions to +lessen the amount of food until the urine is again free from sediment. + +Nearly always at some time in the progress of the case there are attacks +of dyspepsia, when it suffices to cut down the diet one-half, or to give +milk alone for a day or two. Diarrhoea is more rare, and has to be met +in like manner; or, if obstinate, it may be requisite to give the milk +boiled. Occasionally the rapid increase of blood is shown by nasal +hemorrhage, which needs no especial treatment. + +Perhaps I shall make myself more clear if I now relate in full the +diet-list of some of my cases, and the mode of arranging it. + +I take the following case as an illustration from my note-book: + +Mrs. C., a New England woman, aet. 33, undertook, at the age of sixteen, +a severe course of mental labor, and within two years completed the +whole range of studies which, at the school she went to, were usually +spread over four years. An early marriage, three pregnancies, the last +two of which broke in upon the years of nursing, began at last to show +in loss of flesh and color. Meanwhile, she met with energy the +multiplied claims of a life full of sympathy for every form of trouble, +and, neglecting none of the duties of society or kinship, yet found time +for study and accomplishments. By and by she began to feel tired, and at +last gave way quite abruptly, ceased to menstruate five years before I +saw her, grew pale and feeble, and dropped in weight in six months from +one hundred and twenty-five pounds to ninety-five. Nature had at last +its revenge. Everything wearied her,--to eat, to drive, to read, to sew. +Walking became impossible, and, tied to her couch, she grew dyspeptic +and constipated. The asthenopia which is almost constantly seen in such +cases added to her trials, because reading had to be abandoned, and so +at last, despite unusual vigor of character, she gave way to utter +despair, and became at times emotional and morbid in her views of life. +After numberless forms of treatment had been used in vain, she came to +this city and passed into my care. + +At this time she could not walk more than a few steps without flushing +and without a sense of painful tire. Her morning temperature was 97.5 deg. +F., and her white corpuscles were perhaps a third too numerous. After +most careful examination, I could find no disease of any one organ, and +I therefore advised a resort to the treatment by rest, with full +confidence in the result. + +In this single case I give the schedule of diet in full as a fair +example: + +Mrs. C. remained in bed in entire repose. She was fed, and rose only for +the purpose of relieving the bladder or the rectum. + +October 10.--Took one quart of milk in divided doses every two hours. + +11th.--A cup of coffee on rising, and two quarts of milk given in +divided portions every two hours. A pill of aloes every night, which +answered for a few days. + +12th to 15th.--Same diet. The dyspepsia by this time was relieved, and +she slept without her habitual dose of chloral. The pint of raw soup was +added in three portions on the 16th. + +17th and 18th.--Same diet. + +19th.--She took, on awaking at 7, coffee; at 7.30, a half-pint of milk; +and the same at 10 A.M., 12 M., 2, 4, 6, 8, and 10 P.M. The soup at 11, +5, and 9. + +23d.--She took for breakfast an egg and bread-and-butter; and two days +later (25th) dinner was added, and also iron. + +On the 28th this was the schedule: + +On waking, coffee at 7. At 8, iron and malt. Breakfast, a chop, +bread-and-butter; of milk, a tumbler and a half. At 11, soup. At 2, iron +and malt. Dinner, closing with milk, one or two tumblers. The dinner +consisted of anything she liked, and with it she took about six ounces +of burgundy or dry champagne. At 4, soup. At 7, malt, iron, +bread-and-butter, and usually some fruit, and commonly two glasses of +milk. At 9, soup; and at 10 her aloe pill. At 12 M., massage occupied an +hour. At 4.30 P.M., electricity was used for an hour in the manner which +I have described. + +This heavy diet-list, reached in a few days by a woman who had been +unable to digest with comfort the lightest meal, seemed certainly +surprising. I have not given in full the amount of food eaten at +meal-time. Small at first, it was increased rapidly owing to the +patient's growing appetite, and became in a few days three large meals. + +It is necessary to see the result in one of these successful cases in +order to credit it. Mrs. C. began to show gain in flesh about the face +in the second week of treatment, and during her two months in bed rose +in weight from ninety-six pounds to one hundred and thirty-six; nor was +the gain in color less marked. + +At the sixth week of treatment the soup was dropped, wine abandoned, the +iron lessened one-half, the massage and electricity used on alternate +days, and the limbs exercised as I have described. The usual precautions +as to rising and exercise were carefully attended to, and at the ninth +week of treatment my patient took a drive. At this time all mechanical +treatment ceased, the milk was reduced to a quart, the iron to five +grains thrice a day, and the malt continued. At the sixth week I began +to employ strychnia in doses of one-thirtieth of a grain thrice a day at +meals, and this was kept up for several months, together with the iron +and malt. The cure was complete and permanent; and its character may be +tested by the fact that at the thirtieth day of rest in bed, and after +five years of failure to menstruate, to her surprise she had a normal +monthly flow. This continued with regularity until eighteen months +later, when she became pregnant. The only drawback to her perfect use of +all her functions lay in asthenopia, which lasted nearly a year after +she left my care. Fatigue of vision for near work is a common condition +of the cases I am now describing, and is apt to persist long after all +other troubles have vanished. When there is no asthenopia I usually +think well of the general chance of recovery; but in no case of feeble +vision do I omit at some period of the treatment to have the optical +apparatus of the eye looked at with care, because pure asthenopia, apart +from all optical defects, is a somewhat rare symptom. + +Neither am I always satisfied with the ophthalmologist's dictum that +there is a defect so slight as to need no correction, being well aware, +as I have elsewhere pointed out, that even minute ocular defects are +competent mischief-makers when the brain becomes what I may permit +myself, using the photographer's language, to call sensitized by +disease. + +The following illustrations of success in this mode of treatment are +taken from Dr. Playfair's book:[29] + +"Early in October of last year I was asked to see a lady thirty-two +years of age, with the following history. She had been married at the +age of twenty-two, and since the birth of her last child had suffered +much from various uterine troubles, described to me by her medical +attendant as 'ulceration, perimetritis, and endometritis.' Shortly after +the death of her husband, in 1876, these culminated in a pelvic abscess, +which opened first through the bladder and afterwards through the +vagina. Paralysis of the bladder immediately followed the appearance of +pus in the urine, and from that time the urine was never spontaneously +voided, and the catheter was always used. Soon after this she began to +lose power in the right leg, and then in the left, until they both +became completely paralyzed, so that she could not even move her toes, +and lay on her back with her legs slightly drawn up, the muscles being +much wasted. Towards the end of 1877, after some pain in the back of +her neck and twitching of the muscles, she began to lose power in her +left arm and in her neck, so that she lay absolutely immobile in bed, +the only part of her body she was able to move at all being her right +arm. Up to this time the pelvic abscess had continued to discharge +through the vagina, and occasionally through the bladder, but it now +ceased to do so, and there were no further symptoms referable to the +uterine organs. Her general condition, however, remained unaltered, in +spite of the most judicious medical treatment. She was seen, from time +to time, by several of our most eminent consultants, all of whom +recognized the probable hysterical character of her illness, but none of +the remedies employed had any beneficial effect. There was almost total +anorexia, the amount of food consumed was absurdly small, and the +necessary consequence of this inability to take food, combined with four +years in bed with paralysis of the greater part of the body, and the +habitual use of chloral to induce sleep, had reduced a naturally fine +woman to a mere shadow. In October, 1880, her medical attendant was good +enough to bring her to London for the purpose of giving a fair trial to +the Weir Mitchell method of treatment, with the ready co-operation of +herself and her friends, and she was conveyed on a couch slung from the +roof of a saloon carriage, so as to avoid any jolt or jar, since the +slightest movement caused much suffering. Two days after her arrival my +friend Dr. Buzzard saw her with me, and, after a careful and prolonged +electrical examination, came to the conclusion that contractility +existed in all the affected muscles, and that the paralysis was purely +functional. I could find no evidence in the pelvis of the abscess, the +uterus being perfectly mobile, and apparently healthy. After a few days' +rest the treatment was commenced on October 16, the patient being +isolated in lodgings with a nurse of my own choosing; and this was the +only difficulty I had with her, since she naturally felt acutely the +separation from the faithful attendant who had nursed her during her +long illness. Her friends agreed not to have communication with her of +any sort. It is needless to give the details of the treatment in this +and the following cases. A mere abstract will suffice to indicate the +rapid and satisfactory progress made. + +"_October_ 16.--Twenty-two ounces of milk were taken, in divided doses, +in twenty-four hours; on the 17th, fifty ounces of milk; on the 18th, +the same quantity of milk repeated; massage for half an hour; on the +19th, milk as before; bread-and-butter and egg; massage for an hour and +a half; twenty minims of dialyzed iron twice daily; on the 21st, a +mutton-chop in addition to the above; massage an hour and fifty minutes. +To-day she passed water for the first time for four years, and the +catheter was never again used. Chloral discontinued, and she slept +naturally all night long. On the 23d, porridge and a gill of cream were +added to her former diet; massage three hours daily, and electricity for +half an hour, and this was continued until the end of the treatment. +Maltine was now given twice daily. + +"_October_ 30.--She is now consuming three full meals daily of fish, +meat, vegetables, cream, and fruit, besides two quarts of milk and two +glasses of burgundy. Considerable muscular power is returning in her +limbs, which she can now move freely in bed. + +"_November_ 6.--Sat in a chair for an hour. The massage and electricity +are being gradually discontinued, and the amount of food lessened. + +"_November_ 17.--Walked down-stairs, and went out for a drive, and +henceforth she went out daily in a Bath-chair. She has increased +enormously in size, and looks an entirely different person from the +wasted invalid of a few weeks ago. + +"On November 26 she went to Brighton quite convalescent, and on December +11 came up of her own accord to see me, drove in a hansom to my house, +and returned the same afternoon. She has since remained perfectly strong +and well, and has resumed the duties of life and society. + +"A somewhat curious phenomenon in this case, which I am unable to +account for, was the formation on the anterior surface of the legs, +extending from below the patellae half-way down the tibiae, of two large +sacs of thin fluid, containing, I should say, each a pint or more, +freely fluctuating, and quite painless. I left them alone, and they have +spontaneously disappeared." + +"In May, 1880, I saw with Dr. Julius, of Hastings, an unmarried lady, +aged thirty-one. Her history was that she had been in fairly good health +until five years ago, when, during her mother's illness, she overtaxed +her strength in nursing, since which time she has been a constant +invalid, suffering from backache, bearing down, inability to walk, +disordered menstruation, and the usual train of uterine symptoms. She +used to get a little better on going to the sea-side, but soon became +ill again, and in October, 1879, she was completely laid up. The least +standing or walking brought on severe pain in her back and side, and she +gave up the attempt, and had since remained entirely confined to her bed +or sofa, suffering from constant nausea, complete loss of appetite, and +depending on chloral and morphia for relief. Many efforts had been made +to break her of this habit, but in vain. Her medical attendant had +recognized the existence of a retroflexion, but no pessary remained _in +situ_ for more than a day or so, and he suspected that she herself +pulled them out. I was unable to do more than confirm the diagnosis that +had been made as to her local condition, but the pessary I introduced +shared the fate of its predecessors, and she remained in the same +condition,--in no way benefited by my visit. Things going on from bad to +worse, Dr. Julius sent her to London for treatment in the early part of +December. I now determined to try the effect of the method I am +discussing, of which I knew nothing when I first saw her. It was +commenced on December 11, and everything went on most favorably. A week +after it was begun, when her attention was fully occupied with the diet, +massage, etc., I introduced a stem pessary, being tempted to try this +instrument, which I rarely use, by the knowledge that she was at perfect +rest, and that no form of Hodge had previously been retained. I do not +think she ever knew she had it, and it remained _in situ_ for a month, +when I removed it and inserted a Hodge, which was thenceforth kept in +without any trouble. I may say that I do not think the retroflexion had +much to do with her symptoms, except, doubtless, at the commencement of +her illness, and she probably would have done quite as well without any +local treatment. She rapidly gained flesh and strength, and very soon I +entirely stopped both chloral and morphia, and she never seemed to miss +them. On December 11, when the treatment was commenced, she weighed 5 +st. 9 lbs. On January 20 she weighed 7 st. On January 25 she walked +down-stairs, and went out for a drive, and from that time she went out +twice daily. She complained of no pain of any kind, and, although she +wore a Hodge, she did not seem to have any uterine symptoms. On February +1 she went to the sea-side, looking rosy, fat, and healthy, and has +since returned to her home in the country, where she remains perfectly +strong and well. A few days ago she came to town, a long railway +journey, on purpose to announce to me her approaching marriage." + +"On September 10 a gentleman came to consult me on the case of his wife, +in consequence of his attention having been directed to my former papers +by a relative who is a well-known physician in London. He informed me +that his wife was now fifty-five years of age, and that she had passed +ten years of her married life in India. At the age of thirty she was +much weakened by several successive miscarriages, and then drifted into +confirmed ill health. He wrote, on making an appointment, as follows: 'I +will give you at once a short outline of her case. We have been married +thirty-four years, of which the last twenty have been spent by her in +bed or on the sofa. She is unable even to stand, and finds the pain in +her back too great to admit of her sitting up. She is utterly without +strength, of an intensely nervous temperament, and suffers incessantly +from neuralgia. She has, moreover, an outward curvature of the spine. +There is not the slightest symptom of paralysis. Fortunately, she does +not touch morphia, or any narcotic or stimulant, beyond a glass or two +of wine in the day. That she has long been in a state of hysteria is the +opinion of nearly all the many medical men who have seen her.' + +"Although the attempt to cure so aggravated a case as this was certainly +a sufficiently severe test of the treatment, I determined to make the +trial, and had the patient removed from her own home and isolated in +lodgings. I found her in bed, supported everywhere by many small +pillows, and wasted more than, I think, I had ever seen any human being. +She really hardly had any covering to her bones, and looked somewhat +like the picture of the living skeleton we are familiar with. It may +give some idea of her emaciation if I state that, though naturally not a +small woman, her height being five feet five and a half inches, she +weighed only 4 st. 7 lbs., and I could easily make my thumb and +forefinger meet round the thickest part of the calf of her leg. The +curvature of the spine said to exist was a deceptive appearance, +produced by her excessive leanness, and the consequent unnatural +prominence of the spinous processes of the vertebrae. I could detect no +organic disease of any kind. The appetite was entirely wanting, and she +consumed hardly any food beyond a little milk, a few mouthfuls of bread, +and the like. From the first the patient's improvement was steady and +uniform. The way she put on flesh was marvellous, and one could almost +see her fatten from day to day. Within ten days all her pains, +neuralgia, and backache had gone, and have never been heard of since, +and by that time we had also got rid of all her little pillows and other +invalid appliances. + +"It may be of interest, as showing what this system is capable of, if I +copy her food diary on the tenth day after the treatment was begun; and +all this, this bedridden patient, who had lived on starvation diet for +twenty years, not only consumed with relish, but perfectly assimilated. + +"Six A.M.: ten ounces of raw meat soup. 7 A.M.: cup of black coffee. 8 +A.M.: a plate of oatmeal porridge, with a gill of cream, a boiled egg, +three slices of bread-and-butter, and cocoa. 11 A.M.: ten ounces of +milk. 2 P.M.: half a pound of rump-steak, potatoes, cauliflower, a +savory omelette, and ten ounces of milk. 4 P.M.: ten ounces of milk and +three slices of bread-and-butter. 6 P.M.: a cup of gravy soup. 8 P.M.: +a fried sole, roast mutton (three large slices), French beans, potatoes, +stewed fruit and cream, and ten ounces of milk. 11 P.M.: ten ounces of +raw meat soup. + +"The same scale of diet was continued during the whole treatment, and, +from first to last, never produced the slightest dyspeptic symptoms, and +was consumed with relish and appetite. At the end of six weeks from the +day I first saw her she weighed 7 st. 8 lb.,--that is, a gain of 3 st. 1 +lb. It will suffice to indicate her improvement if I say that in eight +weeks from the commencement of treatment she was dressed, sitting up to +meals, able to walk up and down stairs with an arm and a stick, and had +also walked in the same way in the park. Considering how completely +atrophied her muscles were from twenty years' entire disuse, this was +much more than I had ventured to hope. She has now left with her nurse +for Natal, and I have no doubt that she will return from her travels +with her cure perfected." + +"Early in August I was asked to see a lady, aged thirty-seven, with the +following history:--'As a girl of sixteen she had a severe neuralgic +illness, extending over months: excepting that, she seems to have +enjoyed good health until her marriage. Soon after this she had a +miscarriage, and then two subsequent pregnancies, accompanied by +albuminuria and the birth of dead children.' 'During gestation I was not +surprised at all sorts of nervous affections, attributing them to +uraemia.' The next pregnancy terminated in the birth of a living +daughter, now nearly three years old; during it she had 'curious nervous +symptoms,--_e.g._, her bed flying away with her, temporary blindness, +and vaso-motor disturbances.' Subsequently she had several severe shocks +from the death of near relatives, and gradually fell into the condition +in which she was when I was consulted. This is difficult to describe, +but it was one of confirmed illness of a marked neurotic type. Among +other phenomena she had frequently-recurring attacks of fainting. 'These +were not attacks of syncope, but of such general derangement of the +balance of the circulation that cerebration was interfered with. She was +deaf and blind; her face often flushed, sometimes deadly cold; her hands +clay-cold, often blue, and difficult to warm with the most vigorous +friction. These attacks passed off in from twenty minutes to a couple +of hours.' Soon 'the attacks became more frequent, with the reappearance +of another old symptom,--acute tenderness of the spine, especially over +the sacrum. Then came frequent and persistent attacks of sciatica, and +gradual loss of strength.' About this time there appears to have been +some uterine lesion, for a well-known gynaecologist went down to the +country to see her. Eventually 'she became unable to do anything almost +for herself, for the nervous irritability had distressingly increased. +To touch her bed, the ringing of a bell, sometimes the sound of a voice, +sunlight, &c., affected her so as to make her almost cry out.' 'If she +stood up, or even raised her hands to dress her hair, they immediately +became blue and deadly cold, and she was done for.' Then followed +palpitations of a distressing character, with loud blowing murmur, and +pulse of 120 to 140, for which she was seen by an eminent physician, who +diagnosed them to be caused by 'slight ventricular asynchronism, with +atonic condition of the cardiac as well as of all other muscles of the +body.' 'She has no appetite whatever.' 'Any attempt at walking brings on +sciatica. She cannot sit, because the tip of the spine is so sensitive; +any pressure on it makes her feel faint. She cannot go in a carriage, +because it jars every nerve in her body. She cannot lie on her back, +because her whole spine is so tender.' + +"When consulted about this lady, I gave it as my opinion that any +attempt at cure was hopeless as long as she remained in the country +house in which she lived. I was informed that it was absolutely +impossible to get her away, as she could not bear the motion of any +carriage, still less of a railway, without the most acute suffering. +Eventually the difficulty was got over by anaesthetizing her, when she +was carried on a stretcher to the nearest railway station, and then +brought over two hundred miles to London, being all the time more or +less completely under the influence of the anaesthetic, administered by +her medical attendant, who accompanied her. I found this lady's state +fully justified the account given of her. She was intensely sensitive to +all sounds and to touch. Merely laying the hand on the bed caused her to +shrink, and she could not bear the lightest touch of the fingers on her +spine or any part near it. She lay in a darkened room at the back of the +house, to be away from the noise of the streets, which distressed her +much. She was a naturally fine and highly-cultivated woman, greatly +emaciated, with a dusky, sallow complexion, and dark rims round her +eyes. I could find no evidence of organic disease of any kind. Whatever +lesion of the uterine organs had previously existed had disappeared, and +I therefore paid no attention to them. Within a week I had the patient +lying in a bright sunlit room in the front of the house, with the +windows open, and she complained no longer of the noise. Within ten days +the whole spine could be rubbed freely from top to bottom, and from the +first I directed the masseuse to be relentless in her manipulation of +this part of the body. In a few weeks she had gained flesh largely, the +dusky hue of her complexion had vanished, and she looked a different +being. The only trouble complained of was sleeplessness, but it did not +interfere with the satisfactory progress of the case, and no hypnotic +was given. After the first few days we had no return of the nerve-crises +which in the country had formed so characteristic a part of her illness. +Her hands and feet also, at first of a remarkable deadly coldness, soon +became warm, and remained so. In five weeks she was able to sit up, and +before the fifth week of treatment was completed I took her out for a +drive through the streets in an open carriage for two hours, which she +bore without the slightest inconvenience, and the result of which she +thus described in a letter the same evening: 'I never enjoyed anything +more in my life. I cannot describe my delight and my astonishment at +being once more able to drive with comfort. My back has given me no +trouble, and I was not really tired.' This lady has since remained +perfectly well, and I need give no better proof of this than stating +that she has started with her husband on a tour round the world, _via_ +India, Japan, and San Francisco, and that I have heard from her that she +is thoroughly enjoying her travels." + +"The last example with which I shall trespass on your patience I am +tempted to relate because it is one of the most remarkable instances of +the strange and multiform phenomena which neurotic disease may present, +which it has ever been my lot to witness. The case must be well known to +many members of the profession, since there is scarcely a consultant of +eminence in the metropolis who has not seen her during the sixteen +years her illness has lasted, besides many of the leading practitioners +in the numerous health-resorts she has visited in the vain hope of +benefit. My first acquaintance with this case is somewhat curious. About +two months before I was introduced to the patient, chancing to be +walking along the esplanade at Brighton with a medical friend, my +attention was directed to a remarkable party at which every one was +looking. The chief personage in it was a lady reclining at full length +on a long couch, and being dragged along, looking the picture of misery, +emaciated to the last degree, her head drawn back almost in a state of +opisthotonos, her hands and arms clenched and contracted, her eyes fixed +and staring at the sky. There was something in the whole procession that +struck me as being typical of hysteria, and I laughingly remarked, 'I am +sure I could cure that case if I could get her into my hands.' All I +could learn at the time was that the patient came down to Brighton every +autumn, and that my friend had seen her dragged along in the same way +for ten or twelve years. On January 14 of this year, I was asked to meet +my friend Dr. Behrend in consultation, and at once recognized the +patient as the lady whom I had seen at Brighton. It would be tedious to +relate all the neurotic symptoms this patient had exhibited since 1864, +when she was first attacked with paralysis of the left arm. Among +them--and I quote these from the full notes furnished by Dr. +Behrend--were complete paraplegia, left hemiplegia, complete hysterical +amaurosis, but from this she had recovered in 1868. For all these years +she had been practically confined to her bed or couch, and had not +passed urine spontaneously for sixteen years. Among other symptoms, I +find noted 'awful suffering in spine, head, and eyes,' requiring the use +of chloral and morphia in large doses. 'For many years she has had +convulsive attacks of two distinct types, which are obviously of the +character of hystero-epilepsy.' The following are the brief notes of the +condition in which I found her, which I made in my case-book on the day +of my first visit. 'I found the patient lying on an invalid couch, her +left arm paralyzed and rigidly contracted, strapped to her body to keep +it in position. She was groaning loudly at intervals of a few seconds, +from severe pain in her back. When I attempted to shake her right hand, +she begged me not to touch her, as it would throw her into a +convulsion. She is said to have had epilepsy as a child. She has now +many times daily, frequently as often as twice in an hour, both during +the day and night, attacks of sudden and absolute unconsciousness, from +which she recovers with general convulsive movements of the face and +body. She had one of these during my visit, and it had all the +appearance of an epileptic paroxysm. The left arm and both legs are +paralyzed, and devoid of sensation. She takes hardly any food, and is +terribly emaciated. She is naturally a clever woman, highly educated, +but, of late, her memory and intellectual powers are said to be +failing.' + +"It was determined that an attempt should be made to cure this case, and +she was removed to the Home Hospital in Fitzroy Square. She was so ill, +and shrieked and groaned so much, on the first night of her admission, +that next day I was told that no one in the house had been able to +sleep, and I was informed that it would be impossible for her to remain. +Between 3 P.M. and 11.30 P.M. she had had nine violent convulsive +paroxysms of an epileptiform character, lasting, on an average, five +minutes. At 11.30 she became absolutely unconscious, and remained so +until 2.30 A.M., her attendant thinking she was dying. Next day she was +quieter, and from that time her progress was steady and uniform. On the +fourth day she passed urine spontaneously, and the catheter was never +again used. In six weeks she was out driving and walking; and within two +months she went on a sea-voyage to the Cape, looking and feeling +perfectly well. When there, her nurse, who accompanied her, had a severe +illness, through which her ex-patient nursed her most assiduously. She +has since remained, and is at this moment, in robust health, joining +with pleasure in society, walking many miles daily, and without a trace +of the illnesses which rendered her existence a burden to herself and +her friends. + +"In conclusion, I may remark that it seems to me that the chief value of +this systematic treatment, which is capable of producing such remarkable +results, is that it appeals, not to one, but many influences of a +curative character. Every one knew, in a vague sort of way, that if an +hysterical patient be removed from her morbid surroundings a great step +towards cure is made. Few, however, took the trouble to carry this +knowledge into practical action; and when they did so they relied on +this alone, combined with moral suasion. Now, I am thoroughly convinced +that very few cases of hysteria can be preached into health. Judicious +moral management can do much; but I believe that very few hysterical +women are conscious impostors; and the great efficacy of the Weir +Mitchell method seems to me to depend on the combination of agencies +which, by restoring to a healthy state a weakened and diseased nervous +system, cures the patient in spite of herself." + + + + +CHAPTER IX. + +DIETETICS AND THERAPEUTICS--(CONTINUED). + + +As additional illustrations I shall now state a few cases of my own, +without entering into minute details of treatment. + +The following case is reported by Dr. John Keating, who watched it with +care throughout: + +P.D., male, aet. 53, after more than thirty years of close attention to +business, which severely tried both mental and physical endurance, found +himself, in January, 1877, at the close of some months of gradually +increasing feebleness, absolutely unable to fulfil his usual duties, and +the most alarming symptoms manifested themselves. There was a remarkable +loss of nervous and muscular force; his limbs refused their support; his +appetite failed; the recollection of ordinary phrases involved distinct +and painful effort; sleep became unattainable, except under the +influence of powerful narcotics, and even that brief slumber was +rendered valueless by the incessant convulsive twitching of the muscles. + +His physician prescribed iron and strychnia; ordered an immediate +abandonment of all business, and instant departure to a point where +telegraph-wires were unknown and mails infrequent. He went at once to +the Bahamas, passing a month in that delicious climate in absolute +inaction; more than another month was consumed in slowly returning; but, +though some flesh had been gained, there was only a trifling improvement +in the nervous condition. + +May 1, 1877, Dr. Mitchell examined Mr. P.D. The patient was sallow and +emaciated, and coughed every few moments. He had night-sweats, nervous +twitching, and slight dulness on percussion at the apex of the right +lung, with prolonged expiration and roughened inspiration, and some +increase of vocal resonance. + +Mr. P.D. was allowed to be out of bed once a day four hours, and to +spend one hour at his place of business. The treatment was as follows: + +At 6 A.M., a tumbler of strong, hot beef-tea, made from the Australian +extract. + +At 8 A.M., half a tumbler of iron-water, and breakfast, consisting of +fruit, steak, potatoes, coffee, and a goblet of milk. At 8.30 A.M., a +goblet of milk mixed with a dessertspoonful of Loefland's extract of +malt, with six grains of citrate of iron and quinine. + +At 10 o'clock Dr. Keating administered the electricity. + +At 12 o'clock Mr. P.D. might be dressed, making as little personal +effort as possible. The second goblet of milk and malt was administered, +and a carriage took him to his office, where he might remain till two +o'clock, when the carriage brought him for dinner, preceded by half a +tumbler of iron-water. All walking was forbidden. + +After dinner (which included a goblet of milk) the third goblet of milk +and malt was swallowed; then a short drive might be taken, but by four +o'clock the patient must be undressed and in bed. + +At 6 P.M. the third dose of iron-water presented itself, and a light +supper of fruit, bread-and-butter, and cream, followed by the fourth +goblet of milk and malt. Two quarts of milk were thus swallowed every +day in addition to all other food. + +At 9 P.M., massage one hour, with cocoa-oil, followed by beef-soup, four +ounces. + +At the fourth week the soup was given up; dialyzed iron was substituted +for all other forms. June 4, electricity was given up. The malt was +continued until June 20. + +May 6, Mr. D. weighed in heavy winter dress one hundred and twenty-five +pounds; June 20, in the lightest summer garb, he weighed one hundred and +thirty-three pounds; in August his weight rose to one hundred and forty +pounds, and he has continued to gain. When last I saw him, a year later, +he was strong and well, had no cough, and had ceased to be what he had +been for years--a delicate man. + +I am indebted to the late Professor Goodell for the following case, +which I never saw, but which was carried on with every detail of my +treatment. As the testimony of an admirable observer, it is valuable +evidence. Professor Goodell writes as follows: + +"Some four years ago, Mrs. Y., a very highly intelligent lady, from a +neighboring city, came to consult me. She suffered dreadfully at each +monthly period, and had constant ovarian pains and a wearying backache, +which kept her on a lounge most of the day. She was also barren, and +altogether in a pitiable condition. After a two months' treatment she +returned home very much better, and soon after conceived. As pregnancy +advanced, many of her old symptoms came back, but it was hoped that +maternity would rid her of them. The shock of the labor, however, proved +too great for her already shattered nervous system. She became far more +wretched than before, and again sought my advice. + +"At this time I found all her old pains and aches running riot. She got +no relief from them night or day without large doses of chloral. The +slightest exertion, such as sewing, writing, and reading for a few +minutes, greatly wearied her. Even the simple mental effort of casting +up the weekly housekeeping expenses of a very small household upset her, +and she had to give it up. The act of walking one of our blocks, or of +going down a short flight of stairs, or of riding for an hour in a +well-padded carriage, gave her such 'unspeakable agony'--to use her own +words--that she would have an hysterical attack of screams and tears. So +emotional had this constant nerve-strain made her that she could not +sustain an ordinary conversation without giving way to tears. Much of +her time was spent in bed; in fact, she was practically bedridden. + +"I tried in vain to wean her from her anodynes, and failed altogether in +doing her any good, although many remedies were resorted to, and various +modes of treatment adopted. Finally, in sheer despair, I put her to bed, +and began your treatment of rest, with electricity, massage, and +frequent feeding. The first trace of improvement showed itself in a +greater self-control, and in a lessening of her aches and pains. Next, +smaller doses of the anodyne were needed, until it was wholly withheld. +Then she began to pick up an appetite, which, towards the close of the +treatment, became so keen that, between three good meals every day, she +drank several goblets of milk and of beef-tea. At the outset I had +stipulated for six weeks of this treatment, and it was with reluctance +that my patient yielded to my wish. But when the time was up she had +become so impressed with the wonderful benefits she had received and was +receiving, that she begged to have the treatment continued for two weeks +more. At the end of that time she had gained at least thirty pounds in +weight, and had lost every pain and ache. Her night-terrors, which I +forgot to mention as one of her distressing symptoms, had wholly +disappeared, and she could sleep from nine to ten hours at a stretch. I +now sent her into the country, where she is continuing to mend, and is +astonishing her friends by her scrambles up and down the steep hills. + +"Such were the salient features of this case; and I can assure you that +I was as much impressed by the happy results of the treatment as were a +host of anxious and doubting friends. + +"Very faithfully yours, +"WM. GOODELL." + + * * * * * + +Miss C., an interesting woman, aet. 26, at the age of 20 passed through a +grave trial in the shape of nursing her mother through a typhoid fever. +Soon after, a series of calamities deprived her of fortune, and she +became, for support, a clerk, and did for two years eight hours' work +daily. Under these successive strains her naturally sturdy health gave +way. First came pain in the back, then growing paleness, loss of flesh, +and unending sense of tire. Her work, which was a necessity, was of +course kept up, steadily at first, but was soon interfered with by +increase of the menstrual flow, with unusual pain and persistent +ovarian tenderness. Very soon she began to drop her work for a day at a +time. Then came an increasing asthenopia, with evening headaches, until +her temper changed and became capricious and irritable. When I saw her, +she had been forced to abandon all labor, and had been treated by an +accomplished gynaecologist, and was said to be cured of a prolapsus uteri +and of extensive ulceration, despite which relief she gained nothing in +vigor and endurance and got back neither color nor flesh. + +She went to bed December 10, and rose for the first time February 4, +having gained twenty-nine pounds. She went to bed pale, and got up +actually ruddy. In a month she returned to her work again, and has +remained ever since in health which enables her, as she writes me, "to +enjoy work, and to do with myself what I like." + +Miss L., aet. 26, came to me with the following history. At the age of 20 +she had a fall, and began in a week or two to have an irritable spine. +Then, after a few months, a physician advised rest, to which she took +only too kindly, and in a year from the time of her accident she was +rarely out of bed. Surrounded by highly sympathetic relatives, to whom +chronic illness was somewhat novel, she speedily developed, with their +tender aid, hyperaesthetic states of the eye and ear, so that her nurses +crept about in a darkened room, the piano was silenced, and the children +kept quiet. By slow degrees a whole household passed under the selfish +despotism of an hysterical girl. Intense constipation, anorexia, and +alternate states of dysuria, anuria, and polyuria followed, and before +long her sister began to fail in health, owing to the incessant +exactions to which she too willingly yielded. This alarmed a brother, +who insisted upon a change of treatment, and after some months she was +brought on a couch to this city. + +At the time I first saw her, she took thirty grains of chloral every +night and three hypodermic injections of one-half grain of morphia +daily. As to food, she took next to none, and I could only guess her +weight at about ninety pounds. She was in height five feet two and a +half inches, and very sallow, with pale lips, and the large, indented +tongue of anaemia. I made the most careful search for signs of organic +mischief, and, finding none, I began my treatment as usual with milk, +and added massage and electricity without waiting. Her digestion seemed +so good that I gave lactate of iron in twenty-grain doses from the third +day, and also the aloes pill thrice a day. It is perhaps needless to +state that I isolated her with a nurse she had never seen before, and +that for seven weeks she saw no one else save myself and the attendants. +The full schedule of diet was reached at the end of a fortnight, but the +chloral and morphia were given up at the second day. She slept well the +fourth night, and, save that she had twice a slight return of polyuria, +went on without a single drawback. In two months she was afoot and +weighed one hundred and twenty-one pounds. Her change in tint, flesh, +and expression was so remarkable that the process of repair might well +have been called a renewal of life. + +She went home changed no less morally than physically, and resumed her +place in the family circle and in social life, a healthy and well-cured +woman. + +I might multiply these histories almost endlessly. In some cases I have +cured without fattening; in others, though rarely, the mental habits +formed through years of illness have been too deeply ingrained for +change, and I have seen the patient get up fat and well only to relapse +on some slight occasion. + +The intense persistency with which some women study and dwell upon their +symptoms is often the great difficulty. Even a slight physical annoyance +becomes for one of these unhappily-constituted natures a grave and +almost ineradicable trouble, owing to the habit of self-study. + +Miss P., aet. 29, weight one hundred and eleven pounds, height five feet +four inches, dark-skinned, sallow, and covered with the acne of +bromidism, had had one attack which was considered to have been +epileptic, and which was probably hysterical, but on this matter she +dwelt with incessant terror, which was fostered by the tender care of a +near relative, who left her neither by night nor by day. Vague neuralgic +aches in the limbs, with constant weariness, asthenopia, anaemia, loss of +appetite, and loss of flesh, followed. Then came spinal pain and +irregular menstruation, a long course of local cauterizations of the +womb, spinal braces, and endless tonics and narcotics. + +I broke up the association which had nearly been fatal to both women, +and, confidently promising a cure, carried out my treatment in full In +three months she went home well and happy, greatly improved in looks, +her skin clear, her functions regular, and weighing one hundred and +thirty-six pounds. + +It is vain to repeat the relation of such cases, and impossible to put +on paper the means for deciding--what is so large a part of success in +treatment--the moral methods of obtaining confidence and insuring a +childlike acquiescence in every needed measure. + +Another class of cases will, however, bear some further illustration. We +meet with women who are healthy in mind, but who have some chronic pain +or some definite malady which does not get well, either because the +usual tonics fail, or because their occupations in life keep them always +in a state of exhaustion. If by rest we slow the machinery, and by +massage and electricity deprive rest of its evils, we can often obtain +cures which are to be had in no other way. This is true of many uterine +and of some other disorders. + +Miss B., aet. 37, height five feet five inches, weight one hundred and +fifteen pounds, a schoolteacher, without any notable organic disease, +had a severe fall, owing to an accident while driving. A slight swelling +in the hurt lumbar region was followed by pain, which became intense +when she walked any distance. Loss of color, flesh, and appetite ensued, +and, after much treatment, she consulted me. I could find nothing beyond +soreness on deep pressure, and she was anything but hysterical or +emotional. + +Two months' rest with the usual treatment brought her weight up to one +hundred and thirty-eight pounds, and she has been able ever since to do +her usual work, and to walk when and where and as far as she wished. + +Several years ago I treated with some reluctance a lady who had +extensive bronchitis and a slight albuminuria. This woman was a mere +skeleton, with every function out of order. I undertook her case with +the utmost distrust, but I had the pleasure to find her fattening and +reddening like others. Her cough left her, the albumen disappeared, and +she became well enough to walk and drive; when a sudden congestion of +the kidneys destroyed her in forty-eight hours. + +The following case of extreme anaemia, with striking resemblance to the +pernicious type in some of its features, is especially interesting for +the ease and rapidity of improvement under rest and massage without +electricity or excessive amounts of food. + +Mrs. T., aet. 40, the mother of several children, had been unwell for +years, and almost totally incapacitated for exertion for two years +before admission, in January, 1894. She complained of extreme +feebleness, distaste for and inability to digest food, a great and +constant difficulty in swallowing, shortness of breath, dropsy of the +ankles if she walked or stood, hemorrhoids from which some bleeding +often occurred, extreme constipation, constant chilliness, and frequent +violent headaches. Her appearance was that of a person with pernicious +anaemia, a very yellow muddy skin, dry and harsh to the touch, and the +hands and feet cold, almost to the point of pain. + +On examination the spleen was decidedly large; the lower border of the +stomach reached to the level of the umbilicus. Two cardiac murmurs were +present, the one a sharp and well-defined mitral regurgitant sound, +confirmed by the dyspnoea and dropsy as organic, the other a loud +musical murmur of haemic origin. The trouble in deglutition proved to be +due to an oesophageal narrowing. The blood examination bore out the +suggestion of probable pernicious anaemia, the red cells being only +1,500,000, haemoglobin 18 per cent.: the microscope showed microcytes, +megaloblasts, nucleated red cells, and a large increase in white +corpuscles. In order to study the effect of massage alone upon the blood +no other treatment was used, though of course the patient was kept at +"absolute rest." No drugs were given, electricity was not used, and +extra food was omitted, as the irritability of the oesophagus made her +unwilling to attempt the exertion and annoyance of frequent feeding. The +general chilliness was at once helped by massage, and in a few days only +felt in the small hours of the night, and the patient gained weight from +the first. After one week of treatment a blood count was made: red cells +were 3,800,000, more than double the former figure; haemoglobin, 35 per +cent., almost double its original value. On the same day, one hour after +the completion of an hour's massage, the corpuscular count had attained +5,400,000, the haemoglobin remaining 35 per cent. + +At the end of two weeks the haemic murmur had faded into a faint soft +bruit, though the mitral murmur was unchanged, the skin had improved in +color, the aches and weariness were gone, and the blood count had +reached nearly five million cells, with 50 per cent. of haemoglobin. The +extraordinary results of the blood examination were confirmed by +observations made by Professor Frederick P. Henry, Dr. Judson Daland, +and Dr. J.K. Mitchell, who all practically agreed. Professor Henry made +several studies and stained a number of slides, verifying in his report +the statements of the presence of megaloblasts and nucleated red cells +made above. + +Owing to the necessity for an operation on the hemorrhoids, which caused +loss of blood, the patient was somewhat retarded in her progress to +recovery, but by the tenth week was so far better that the blood showed +no microscopic abnormalities, the count was full normal, and the +haemoglobin over 70 per cent. Her color and strength were good, the heart +was perfectly strong, the anaemic murmur was gone, and the oesophagus +was so much less irritable that it was possible to begin dilatation of +the stricture. + +I have heard within a year that though occasionally annoyed by this last +trouble if she becomes much fatigued, she has remained in other ways +well. + +Mrs. G., the daughter of nervous parents, was always a nervous, +over-sensitive, serious child, worked hard at Vassar, broke down, +recovered, returned to college, was attacked with measles, which proved +severe, and by the time she graduated had been made by her own +tendencies and the anxious attention of her family into a devoted member +of the class which I may permit myself to describe as health-maniacs. + +Health-foods, health-corsets, health-boots, the deeply serious +consideration of how to eat, on which side to sleep, profound +examination of whether mutton or lamb were the more digestible +flesh,--these were her occupations,--and two or three years before her +panic about her health had been made worse by the discovery of an aortic +stenosis, of which an over-frank doctor had thought it best to inform +her. When I saw her she had been three years married, was childless, +and, between the real cardiac disease and her own anxieties about it, +had driven herself into a state of great physical debility and a mental +condition approaching delusional insanity. + +A too restricted diet, lacking both in variety and appetizingness, had +had its usual result of upsetting digestion and destroying desire for +food. Even with the small amounts which she ate she considered it +necessary to chew so carefully and to feed herself so slowly that from +one hour to an hour and a half was used for each meal. The heart, +under-nourished, beat feebly, there was constant slight albuminuria with +evidences of congested kidneys, and she could only rest in a semi-erect +position. + +The heart condition, with its renal results, proved the most rebellious +part of the trouble. A firm and intelligent nurse soon overcame the +difficulties and delays about food, and my final refusal to discuss them +disposed for the time of some of the fanciful theories about digestion +and so on. Her meals were ordered in every detail, and she was told that +they were prescribed and to be taken like medicine, and, fed by the +nurse, she began to take more nourishment. Massage relieved some of the +labor of the heart, and gradually the semi-erect posture was exchanged +inch by inch for a semi-recumbent one. Not to prolong the relation of +details, it was found needful to keep this lady in bed for five months +before the heart seemed to recover sufficiently to allow her to get up. +Even then, although improved in color, flesh, and blood condition, she +had to attain an erect station almost as slowly as she had had to reach +recumbency. Slow, active Swedish movements, to which gentle resistance +movements were very gradually added, helped the heart. Her cure was +completed by five or six months' camp-life in the woods, and she is now +the mother of a healthy child and herself perfectly well, the valvular +disease only to be detected by the most careful examination, and never, +even during pregnancy and parturition, causing any annoyance. + +The surgeons, who once thought a floating kidney could be permanently +fixed in its place by stitching, have now concluded that this is very +doubtful, and the treatment of this displacement is never very +satisfactory by any method. Still, some success has followed long rest +in the supine position, which encourages the kidney to return to its +normal place, until careful full feeding has renewed or increased the +fatty cushions which hold it up. It is best during the first weeks of +treatment not to allow the patient to sit or stand, or if she should be +unable to avoid the occasional need for these positions, an abdominal +binder must be applied by the nurse and drawn tightly before she moves. +The masseuse is directed to avoid any movements which might further +displace the organ, and may cautiously push it upward and hold it there +with one hand while with the other the manipulation of the abdomen is +performed. However long it may require, the patient should not get up +until examinations, supine, lateral, prone, and erect, combine to assure +us that the kidney is replaced. Repeated investigation of this point +will be required,--for the kidney will sometimes be in place for a +little while and next day or even a few hours later have slipped down +again. Before any exertion is permitted, even ordinary walking, an +accurate close-fitting abdominal belt with a kidney-pad should be +applied. Those kept in stock are seldom properly adjusted, and usually +have the pad in the wrong place. If rightly made, they can be worn with +comfort and tight enough to be useful. If not rightly made, they are +useless instruments of torture. + +Mrs. Y., aet. fifty-six, was sent to Dr. J.K. Mitchell by Professor Osler +for treatment. She had all the usual intestinal derangements and +discomforts attendant upon a floating kidney: constipation alternated +with diarrhoea, or rather with a sort of intestinal incontinence; vague +pains in the back, flanks, and stomach were frequent; attacks of acute +pain began in the right hypogastrium and ran down to the symphysis or +into the groin; she had constant flatulence, weight, and oppression +after food; was pale, flabby, and emaciated, but had no emotional or +nervous symptoms except an annoying amount of insomnia. The lower border +of the stomach was fully two inches below the navel in the middle-line, +even when only a glass of water had been taken. It was a little lower +after a small meal. The colon was distended and very variable in +position, probably changing its relations with the landmarks as it +happened to be more or less filled with food or gases. The abdominal +walls were flabby, relaxed, and pendulous, and the whole surface tender. +The patient gave a history of sudden loss of flesh with almost no +reason some three years before, and increasing indigestion in all forms +ever since. The tenderness made careful abdominal study difficult, but +lessened enough after a few days in bed to permit the perception of a +displacement of the right kidney, whose lower edge could be felt on a +level with the umbilicus and two inches to the right of it. No change of +position would bring it any lower. Examined with the patient prone, +two-thirds of the kidney could be outlined, extremely tender, and +causing nausea and sinking if pressed upon. + +The chief trouble in treatment proved to be the irritability of the +intestines, which was brought on in most unexpected fashion by foods of +the simplest kind. For some time it was so persistent that the suspicion +of intestinal tuberculosis was entertained; but it finally disappeared, +and after that the case progressed more favorably and she was out of bed +with a tight belt and kidney-pad in a little more than twelve weeks. The +kidney was then, and has remained since, in its normal position. The +patient gained twelve pounds in weight, and should have gained more, but +she found the hot weather during the latter weeks of her treatment very +trying. The intestinal indigestion was only partially relieved, but the +gastric symptoms, the general pains, and weakness all disappeared, and +with precaution she will continue to improve. It is best to advise the +constant use of the belt in such a case. In a patient who has made a +large gain in flesh, as this one did not, and who has been found after +some months to maintain the increased weight, the belt might gradually +and experimentally be left off; but repeated examinations should be made +for a year or two to be sure that no displacement results. + +I could relate cases of gain in flesh without manifest relief. As I have +said, these are rare; but it is less uncommon to see great relief +without improvement in weight at all, or until the patient is up and +afoot for some weeks; and I could also state several cases in which a +repetition of the treatment won a final and complete success after the +first effort at cure had failed or but partially succeeded; and of this, +I believe, Professor Goodell has seen several examples. + +I have mentioned more than once the singular return of menstruation +under this treatment, and as examples I add a brief list of some +notable instances. + +Mrs. N., aet. 29, no menstruation for five years; return of menstruation +at thirtieth day of treatment; continued regularly ever since during +three years. + +Mrs. C., aet. 42, eight years without menstruation; return at fourteenth +day of treatment; now regular during five months. + +Miss C., aet. 22, no menstruation for eight months; return at close of +sixtieth day of treatment; regular now for four months. + +Miss A., aet. 26, irregular; missing for two or three months, and then +menstruating irregularly for two or three months. No flow for two +months. Menstruated at nineteenth day of treatment, and regular during +thirteen months ever since. + +I had at one time intended to give, in the first edition of this work, a +summary of all my cases, with the results; but what is easy to do in +definite maladies like typhoid fever becomes hard in cases such as I +here relate. In fevers the statistics are simple,--patients die or get +well; but in cases of nervous exhaustion, so called, it is impossible to +state accurately the number of partial recoveries, or, at least, to +define usefully the degrees of gain. For these reasons I have not +attempted to furnish full statistics of the large number of cases I have +treated. + +In the debate before the British Medical Association the question of the +permanence of cures by this method was the subject of discussion. I have +lately been at some pains to learn the fate of many of my earlier cases, +and can say with certainty that every case then treated was selected +because all else had failed, and that I find relapses into the state +they were in when brought to me to have been very uncommon. A vast +proportion have remained in useful health, and a small number have lost +a part of their gains. I now make it a rule to keep up some relation +with patients after discharge, by occasional visits or by letter, and +believe that in this way many small troubles are hindered from becoming +large enough to cause relapses. + +I said in my first edition that I did not doubt that the statements I +made would give rise in some minds to that distrust which the relation +of remarkable cures so naturally excites; and this I cannot blame. Every +physician can recall in his own practice such cases as I have +described, and every medical man of large experience knows that many of +these women are to him sources of anxiety or of therapeutic despair so +deep that after a time he gets to think of them as destined irredeemably +to a life of imperfect health, and finds it hard to believe that any +method of treatment can possibly achieve a rescue. + +I am fortunate now in having been able to show that in other hands than +my own, both here and abroad, this treatment has so thoroughly justified +itself as to need no further defence or apology from its author. It has +gratified me also to learn that in many instances country physicians, +remote from the resources of great cities, have been able to make it +available. As I have already said, I am now more fearful that it will be +misused, or used where it is not needed, than that it will not be used; +and, with this word of caution, I leave it again to the judgment of time +and my profession. + + + + +CHAPTER X. + +THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC PARAPLEGIA, SPASTIC PARALYSIS, +AND PARALYSIS AGITANS. + + +In my earliest publication on the treatment of diseases by rest, etc., +locomotor ataxia was alluded to as one of the troubles in which +remarkable results had been obtained. Rest alone will do much to +diminish pain and promote sleep in tabes, rest with massage and +electricity will do more. It is not necessary to order complete +seclusion for such cases, but some special measures will be needed in +addition to those already described as of use in various disorders, and +these will be discussed in this chapter. + +While this is not a treatise on diagnosis, some brief +symptom-description is needed to enable one to define clearly the +methods of treatment at different stages. + +In the middle or late stages there need be little uncertainty in +uncomplicated cases; in the earlier periods diagnosis is by no means +easy. A history may usually be elicited of important heralding +symptoms, such as former or present troubles with the muscles of the +eyes, the occurrence of vague but sharp and recurring pains, vertigo, an +impairment of balance, unnoticed perhaps, except when walking in the +dark or when stooping to wash the face, or especially when going down +stairs. Attacks of 'dyspepsia,' as unrecognized visceral crises are +often called, should render one suspicious. If, on examination, loss or +impairment of knee-jerk be shown, contraction of the pupil with +Argyll-Robertson phenomenon and defective station, but little doubt can +exist. The discovery by the ophthalmoscope of some degree of beginning +optic neuritis would make assurance more sure, and this can often be +detected in a very early stage of the disease. + +Much controversy has been spent on the question of the share of syphilis +in producing tabes, and out of the battle but two facts emerge fairly +certain, the one that syphilis often precedes the disease, the other +that anti-syphilitic medication is commonly of no service. But syphilis +is so frequently antecedent that a history of that infection may make +certain the diagnosis when doubt exists. This may be an important +point, for some of the cardinal symptoms are occasionally absent; cases +are seen with no incooerdination, sometimes with the station unaffected, +even, though rarely, with the knee-jerk preserved. + +The diagnosis established, treatment will somewhat depend upon the stage +which the disease has reached. + +In the pre-ataxic stage, where slight unsteadiness, often not +troublesome except in the dark or with closed eyes, sharp stabbing pains +here and there, numbness of the feet, girdle-sense in the region of +chest, waist, or belly, some recurrent difficulty in emptying the +bladder, a fugitive partial palsy of the external muscles of the eye, +are the chief or, perhaps, the only complaints, it would not be +justifiable to put the patient to bed at complete rest. This early stage +calls for a different plan of treatment, to be presently described. + +In the middle or more distinctly ataxic period long rest in bed should +be prescribed, and will be gratefully accepted by a patient whose +sufferings from incooerdination, pains, and numbness of the extremities +are often so great as to incapacitate him. + +The bladder muscles share in the ataxia, and the consequent retention +of urine frequently causes cystitis, and may endanger life by the +involvement of the kidneys. + +The bowels cannot be emptied or are moved without the patient's +knowledge, and these annoyances combine with the pain and nervous +apprehension to drive the victim into a melancholic or neurasthenic +state. He suffers, too, from want of occupation, from the absence of +exercise, from the anticipation of worse changes in the near future, and +usually by the time he reaches the specialist has been more or less +poisoned with iodide of potash and mercury, and perhaps with morphia. + +In the third, the paralytic stage, which seldom comes on until the +symptoms have lasted for years, there is gradual loss of power and +ataxia, increasing until he is totally unable to walk. If a patient is +not seen until this condition of things has been reached, but little can +be hoped from any treatment, though in a few cases energetic measures +may bring about a marked improvement, which is rarely lasting. + +A combination of tabes with lateral sclerosis, or with general paralysis +of the insane, is sometimes seen, but needs no special consideration. + +The first or pre-ataxic stage is, to the great detriment of patients, +too seldom recognized. The pains are called rheumatic, the eye symptoms +are lightly passed over or glasses are ordered, the difficulty of +micturition is treated by drugs, and the slightly impaired balance +unnoticed or unconsidered. + +When such a patient comes into our hands the history, and especially the +history of predisposing causes, needs the most careful examination. It +is well established that syphilis is a common precedent of ataxia, +occurring in at least two-thirds of the cases; it is even more firmly +settled that iodide and mercury in large doses do no good in advanced +ataxia. I say in advanced ataxia, because a few cases are seen in which +the syphilis has been of recent occurrence, or where the spinal symptoms +are of decidedly acute character, and in these anti-syphilitic +medication is needed and useful; but such cases should be described as +acute or subacute spinal syphilis, not as ataxia. When nerve +degeneration has once begun, iodide will do little good and mercury may +do positive harm, if used in large doses. The other common predisposing +causes, exposure to cold, over-exertion, sexual excess, need concern us +only as they suggest warnings to be given, especially when the patient +is improving. Until he does improve not much need be said about them; he +cannot indulge in venery, as sexual power is usually (though not always) +lost early in the disease; and the incooerdination lessens his +opportunities of exposure or over-exertion. + +During this stage some patients complain most of the numbness, +girdle-sense, and incooerdination; others of the stabbing pains or the +bladder weakness. The general treatment must be much the same, however, +in all, with special attention besides to the special needs of each +individual. + +Fatigue makes all the symptoms worse, increases pain, and impairs still +more the muscular incooerdination; it is, therefore, of the first +importance in every instance to forbid all over-exertion. Walking, more +than any other form of exercise, hurts these cases. The patient should +not walk beyond his absolute necessities. To get the needed fresh air, +let him, according to his situation in life, drive out or use the +street-cars. In some cases the use of a tricycle on a level floor or on +good roads is not so harmful as walking, for obvious reasons; this +tricycle exercise may at first be made a passive or mild exercise by +having the machine pushed by an attendant. To replace the effects upon +the circulation and bowels of physical activity massage may be used, and +the masseur must have directions as to gentle handling of the tender +places at first. These are usually in fixed positions, and can be +avoided or only lightly touched. The shooting pains may be lessened by +deep, slow massage in the tracks of the nerves affected. If, as +generally happens, there are also regions of defective sensation, these +should receive after the general manipulation active, rapid circular +friction, and, perhaps, experimentally, open-hand slapping. As +constipation is one of the troublesome features, the abdomen should have +particular attention, and an unusual amount of time be given to +manipulations of the colon, as described in the chapter on massage. A +full hour's rest in bed, preferably in a darkened room, must follow the +rubbing. + +A schedule for the day on about the lines of the "partial rest" +schedule, as described on a previous page, should be followed. A +prolonged warm bath, with cool sponging after, if the latter be well +borne, is useful in lessening pains and nervous irritability,--and this +may begin the day or be used at any convenient hour. + +At an hour as far from the massage as possible lessons in co-ordinate +movements are given, after a week or ten days of massage has prepared +the muscles, and baths and a quiet life have steadied the nerves. For +many years past, certainly fifteen or sixteen, the students and +physicians who have followed my service at the Infirmary for Nervous +Diseases have seen this systematic training given, and no doubt they +received with some amusement the excitement about it as a new method of +treatment when it was proclaimed in Europe two or three years ago. + +The indication for this teaching appeared too obvious to publish or talk +much about. The patient has incooerdination; one, therefore, does one's +best to teach him to co-ordinate his movements by small beginnings and +by small increases. + +The lessons may be given by the physician at first and be executed +under his eye. After a few days any tolerably intelligent patient should +be able to carry them out alone, but still each new movement should be +personally inspected to make sure that it is done correctly. + +In patients in the first stage of ataxia the most striking result of +incooerdination is the impairment of station. We therefore begin with +balancing lessons. The patient is directed to stand at "Attention," head +up and chest out, not looking at his feet, as the ataxic always wishes +to do. At first this is enough to require; it will not do to be too +particular about how his feet are placed, so long as he does not +straddle. He can repeat this effort for himself a dozen times a day, for +a minute or two each time. Next we try the same position with a little +more care about getting the feet pretty near together and parallel, or +with the toes turned out only a very little. In another couple of days a +little more severity may be exercised about maintaining the correct +attitude,--heels touching, hands hanging down, and eyes looking straight +forward,--and until he is able to do this _easily_ it is best to ask +nothing more. Then he is requested to stand on one foot, being permitted +just to touch a chair-back or the attendant's hand to give confidence. +This is practised until he can keep his erect station for a few seconds +without difficulty. This point of improvement may be reached in three +days or a week or may take a fortnight. Women, as I have before +observed, although rarely in America the victims of tabes, when they do +have it have far less disturbance of balance than men, and this is to be +attributed to their life-long habit of walking without seeing their +feet. I have found in the few cases of ataxia in women that I have seen +that they benefited much more quickly by these balance instructions than +did men, though their other symptoms were in no way different. + +Continuing every day the practice of all the previous lessons, movements +are rapidly added as soon as station is better. A brief list of them +follows. When the exercises grow so numerous as to take overmuch time, +the simpler early ones may be omitted. + +When the learner is able to stand on one foot, let him slowly raise the +other and put it on a marked spot on the edge of a chair. This, like all +the other exercises, must be practised with both feet. + +Stand erect without bending forward and put one foot straight back as +far as possible. + +Do the same sideways. + +Stand and bend body slowly forward, backward, and sideways, with a +moment's rest after each motion. + +Having reached this point, I usually order the patient to practise all +these with closed eyes. When he can do this, he begins to take one or +two steps with shut eyes, first forward, then sideways, then backward. +If he falter or move without freedom, he is kept at this until he does +it confidently. Then exercises in following patterns traced on the floor +are begun. In hospitals, or where bare floors are to be found, the +patterns may be drawn with chalk. In carpeted rooms, which by the way +are less suited for the work than plain boards or parquet floors, a +piece of half-inch wide white tape may be laid in the required pattern, +first in a straight line, later, as proficiency is gained, in curved, +figure-of-eight, or angular patterns. The patient must be made to walk +_on_ the line, putting one foot directly in front of the other, with the +heel of the forward foot touching the toe of the one behind. + +Walking over obstacles is tried next. Wooden blocks measuring about six +by twelve inches and two inches thick are stood on edge at intervals of +eighteen inches and the patient walks over them, thus training several +groups of muscles; the blocks are at first set in straight lines, then +in curving patterns. An ordinary octavo book makes a good substitute for +a block. + +If the trunk muscles are affected by the ataxia, further exercises are +ordered for them, bending and twisting movements, picking up objects +from the floor, etc. For the hands and arms, which, except in those very +rare cases where the ataxia first shows itself in the upper extremities, +seldom exhibit much incooerdination in the primary and middle stages, the +movements are the picking up of a series of different-shaped small +articles, arranging objects like dominoes, marbles, or the kindergarten +sticks in patterns, bringing the fingers of the two hands one after +another together, or touching a finger to the ear or the nose, at first +with open and then with shut eyes. + +With these methods, needing not more than twenty minutes three times a +day, the ataxic symptoms sometimes rapidly diminish. In certain cases no +other improvement will be observed, showing that what has taken place +is of course not an alteration of the diseased nerve-tissues for the +better, as no treatment can restore sclerotic spinal tissue to a normal +state, but is merely a substitution of function, in which other and +associated nerve-tracts have replaced in control the ones affected. + +As to the pains and bowel and bladder disturbances, their handling will +be discussed in considering the treatment of the next or middle stage of +tabes. In this period the ataxic symptoms are most prominent; the gait +has become so unsteady that the patient needs canes to walk at all and +must constantly watch his feet. He walks a little better when well under +way, but at starting or when standing still he sways and totters. The +girdle-sense is severe and constant, various pains assail the body and +limbs; the numbness of the feet, often described as a feeling "like +walking with a pillow under the foot," still further incommodes his +walking.[30] The bladder control may be so enfeebled as to require +daily catheterization, and the bowels move only with enemas or +purgatives, and often without the patient's knowledge, owing to the +anaesthesia which affects the rectum and its vicinity. + +One of the first things to attend to when patients are in this stage is +the bladder, as the retention is the only condition likely to produce +serious disorder. Cystitis is or may be present, and with the retention +is a constant threat to the kidneys. Catheterization and washing out +with an antiseptic must be regularly practised while treatment is used +to improve the condition. + +For these patients rest in bed is a prime necessity in order to remove +all excuse for exertion. The method of application of massage has +already been suggested. Care must be taken that the patient eats well +and of the best food. Except for occasional gastric or intestinal crises +of pain, sometimes with vomiting, sometimes with diarrhoea, the +digestive functions are usually well performed, unless the stomach has +been greatly upset by over-use of iodide. The most liberal feeding +consistent with good digestion is indicated, for it must be remembered +that we are dealing with a disease in which degenerative changes play +an important part. The usefulness of electricity in ataxia has been +denied by some authors, while others praise it indiscriminately. Perhaps +a reason for this difference of opinion may be found in its different +effects upon individual patients; but I see few in whom I do not find +electricity in one or another form helpful. For pains I order the +galvanic current through the affected nerves as strong as the man is +able to bear. If after a few days of this the pains are unchanged, a +rapidly interrupted faradic current is tried, and failing to do good +with this, I use light cauterization or a series of small blisters to +the spine at the point of exit of the painful nerves. Galvanization of +the bladder with an intravesical electrode is sometimes of service to +strengthen its capacity for contraction. Faradism is applied in the form +just described, using a wire brush as an electrode to the areas of +numbness and anaesthesia. Lately I have found that this current in a +strength which would be very painful to the normal skin will in some +instances relieve the feeling of pressure and dull discomfort about the +rectum and perineum, and it has been successful when galvanism did no +good. In patients within reach of a static machine, this form may be +used for the numbness if the others do not help it. + +For the attacks of pain, if general, a prolonged hot bath lasting from +ten to twelve minutes, at a temperature of 100 deg. F. or even more, should +be first tried; if this fail, antipyrin, phenacetin, acetanilid, or +cannabis indica may be used, or, as a last resort, morphia. For the +local pains hot water is also useful, and in the intervals I order +applications of hot water to the tender points, as hot as can be borne, +alternating with ice-water, each rapidly applied three or four times. In +severe attacks, and with all due caution to avoid habituation, cocaine +injections may be given. In cases with high arterial tension the daily +administration of nitroglycerin in full doses will not only lower the +tension but decrease the pains in force and frequency. + +For several years past in all patients with the general lowering of +nervous force and vitality so common in this disease I have habitually +used the testicular elixir of Brown-Sequard. The ridiculous length to +which organic therapeutics have been carried, the extravagant +advertising claims, and an absurd expectation of impossible results have +combined to make the profession shy of those organic preparations which +have not very good evidence in their favor, and for some time I shared +in this prejudice against the Brown-Sequard fluid. A talk with that most +distinguished physician and an examination of some of his cases led me +to a trial for myself, and I am at present very well convinced that, +whether a physiologic basis can reasonably be assumed or not, we have in +the fluid a tonic remedy of great power. While I have used it with good +effect in other conditions, it is in ataxia that I have found it of most +value. + +The glycerin extract is freshly prepared from bulls' testicles in exact +accordance with the directions of the discoverer. It is used +hypodermatically every other day, beginning with a diluted ten-minim +dose and increasing by two or three drops up to about forty minims. The +effect is at its height twelve to twenty-four hours after the +administration in most patients, hence the reason for using it only once +in two days. The skin is prepared, the needles and syringe disinfected, +and the tiny puncture sealed afterwards with as minute care as would be +given to a surgical operation. By these precautions the danger of +abscess, always considerable if hypodermics are carelessly given, is +minimized. As the dose is large, a site must be selected for the +injection where the tissue is loose, otherwise the pain will interfere +with the desired frequency of use. The buttocks serve best, or the outer +masses of the pectoral muscles, or the abdominal muscles. If the +administration causes pain (due in part to the large quantity used and +in part to the local effect of glycerin), a fraction of a grain of +cocaine may be added to the solution when measured out for use. + +It may at once be said, emphatically, that in some cases remarkable +results have followed the use of this material, while in others no good +has been done; but the same may be said of most plans of treatment in +this disorder. As to possible danger from it, no harm has been done to +any patient known to me, except that abcesses have occurred sometimes, +though very rarely, for in many hundreds of injections it has been my +good fortune to see abscesses form only three or four times, two of +these instances, by curious ill luck, being in physicians. Patients +describe a stimulating effect not unlike that of strong coffee, +following a few hours after use and lasting for a day. The sexual +appetite, if present, is increased; if absent, it is often renewed, +sometimes in elderly men to an inconvenient extent. In one tabetic +subject who had lost desire and ability for more than three years both +returned in sufficient force to allow him to beget a child. This +patient, like most of the others, was ignorant of what drug was being +used and of what effects might be expected, so suggestion played no +part. Apart from this special effect, the solution acts only as a highly +stimulating tonic. + +The full dose of forty minims or thereabouts is maintained for a +fortnight or less, and then gradually diminished in the same way that it +was increased. Sometimes, when the effect has been good, a second +"course" may be given after two or three weeks' interval. + +During the treatment by hypodermic the masseur should be told to avoid +rubbing where the injections have been given. A few trials with the +fluid internally have produced so little result of any kind that I am +inclined to think the gastric juices must alter it so as to lessen or +wholly destroy its power. + +As to other drugs, experience has not given me much confidence in any +of those usually recommended. Strychnia, belladonna, and those +antiseptic drugs which are eliminated chiefly by the kidneys are of use +when cystitis has to be treated and the bladder muscles urged to +activity. Arsenic, the chloride of gold and sodium, and chloride of +aluminium are suggested by various authorities, but they have not been +of any value in my hands. In hopeless cases, where all treatment fails, +as will sometimes happen, or in patients in whom the paralytic stage is +already far advanced, if other measures are unsuccessful, morphia is +left as a forlorn hope, which will at least relieve their pains. + +An outline report of several cases of different types and degrees is +appended: + +M.P. of North Carolina, aet. thirty-seven, general health excellent until +syphilis in 1894, was admitted to the Infirmary in 1898. He had had for +two years recurrent attacks of paralysis of the external rectus muscle +of the right eye, slight gastric crises, and stabbing pains in the legs; +station very poor, but strength unimpaired, and he was able to walk +after being a few minutes on his feet; when first rising he was very +unsteady. Knee-jerk lost, no reinforcement. No sexual power. Some +difficulty in emptying the bladder. Examination showed slight atrophy of +both optic nerves, Argyll-Robertson pupil, and myosis. He was ordered +two weeks' rest in bed, with massage, cool sponging daily, and +galvanization of the areas of neuralgia. After two weeks he was allowed +to get up gradually, to occupy himself as he pleased, but not to walk. +Lessons in balance and co-ordination were begun in the fourth week of +treatment, and supervised carefully for two weeks more. When his station +and gait were both improved, he was permitted to walk, always with care +not to fatigue himself. At this time, six weeks from commencement of +treatment, his eyes were glassed by Dr. de Schweinitz. He had gained +some pounds in weight, and walked on straight lines without noticeable +incooerdination, but in turning short or walking sharp curves he was +still unsteady. He found walking much easier than formerly and was less +easily tired. After nine weeks he could stand or walk, even backward, +with closed eyes. He was sent home for the summer, with directions to +continue his co-ordination movements, to walk very little, and take +such exercise as he needed on horseback, riding quietly. He had still +some stabbing pains two or three times daily. + +He reported in one month, and again in six months, "No improvement in +the pains, but I walk well and briskly, can jump on a moving street-car, +and have ridden a horse twenty miles in a day without fatigue." + +This case was in one way favorable for treatment: the patient, an +educated and intelligent man, helped in every way, carrying out minutely +all orders, and had the good sense to begin treatment early. But the +acuteness and rapidity of onset of the tabetic symptoms were so great +that in a little more than two years they had reached a condition which +most cases only attain in from five to ten years, and this makes the +prognosis somewhat less favorable. + +In the instance to be next related there was also antecedent syphilis, +and the patient had already been heavily dosed with iodides and +repeatedly salivated with mercury. His recovery was and has remained +remarkably complete. + +H.B., travelling salesman, from New York, aet. forty, single, a large, +strongly-made man, a hard worker, given to excesses in sexual +indulgence and alcohol for years. Syphilis was contracted fifteen years +before the first traceable symptoms of ataxia, which had shown +themselves after an attack of grippe, in 1890, in sudden remittent +paralysis of the external muscles of the right eye, followed within a +few months by gastric crises, general lightning pains appearing a few +months later. During the two years succeeding he was drenched with drugs +and grew steadily worse. When admitted to the hospital in 1892 he was +very ataxic in the legs, suffered greatly from gastric and other pains, +difficulties with bladder and rectum, loss of sexual power, various +anaesthetic areas, could not stand with eyes open unless he had help, +total loss of knee-jerk, paralysis of right rectus, indigestion from the +irritation of the stomach from medicines as well as from the disease, +and, though muscular and over-fat, was flabby and pallid. He had no +ataxia or loss of sensibility in the upper half of the body. He was in +bed for two weeks, on milk diet, with warm baths and massage. Systematic +movements were begun and massage continued. After the stomach improved +he grew better with unusual rapidity. He is now able to work hard again, +travels extensively, can walk strongly, but wisely takes his exercise +more in the form of massage and systematic gymnastics. He appears to +report himself once or twice a year. There has been a partial return of +sexual ability. + +The next case has points of interest in the later history, but the first +examinations and early treatment may be passed over briefly. X.Y., aet. +forty-two, a steady, sober merchant, closely confined by his business, +always of excellent habits, with no possible suspicion of syphilis, was +seen first in 1894 in a somewhat advanced stage of tabes, but with no +optic or gastric disturbances. His station was very bad, but when once +erect and started he could walk without a stick. Girdle-pains very +marked; bowels very constipated; some trouble in emptying bladder; +several points of fixed sharp pain; lightning pain occasional and +severe, but not frequent. He was ordered to bed for six weeks. +Galvanism, alternate hot- and cold-water applications to the tender +spots, careful massage, and a two-months' course of Brown-Sequard fluid +after getting up made a new man of him. Massage and systematic exercise +were kept up together for six months. The massage was stopped and the +exercises continued, and improvement went on steadily, though the fixed +pains kept up in only slightly less severity. + +In a year the patient was better in general health, looks, and spirits +than he had been for many years before, and remained in good order, +except for the daily recurrences of paroxysms of pain of varying but not +unbearable severity for two years. He then presumed for a month on his +strength, and took much more exercise afoot than was wise, worked late +at night over his books, had some additional nervous strain from +business worries, and came to Dr. J.K. Mitchell in October, 1898, barely +able to crawl with two canes, having lost weight, become sleepless, +suffered great increase of pain, and grown so ataxic that he could +scarcely walk. This change had all occurred in three or four weeks. He +became steadily worse for two or three weeks till he could not stand or +walk at all, had cystitis from retention, violent attacks of rectal +tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with +almost total anaesthesia of the sacral region, buttocks, scrotum, and +perineum, inability to retain faeces, while passages from the bowels took +place without his knowledge. He found that an increase in the rectal +and abdominal pain followed lying down. He therefore spent day and night +sitting up. At the end of three weeks there was total paralysis of the +legs, and the outlook seemed most unfavorable. + +Massage was begun again, strychnia and salol were administered, and a +short course of full doses of the testicular fluid was given. A rapidly +interrupted faradic current, with an uncovered electrode, to the +neighborhood of the rectum, bladder, and buttocks, greatly relieved the +anaesthesia, upon which galvanism had no effect; and, in brief, from a +state which looked almost as if the last paralytic stage of tabes had +suddenly come upon him, he recovered in two months, and is now (July, +1899) better than he was a year ago, before the relapse, and will +probably remain so, as he has had his warning. + +Without multiplying case histories, it may be said that ataxic +paraplegia (a combination of lateral and posterior sclerosis) may be +treated in much the same manner. In this disease there is usually much +less pain than in ataxia, but greater weakness, and late in its course +some rigidity in the extensor groups of the legs; the knee-jerk is +preserved or exaggerated. The disease is a rare one. But two recent +distinct cases are in my list, and one of these, the one here reported, +seems rather more like an ataxia with some anomalous symptoms. The +second one had the symptom, uncommon in this malady, of very frequent +and excessively severe stabbing pains, and though his co-ordination grew +somewhat better, he improved very little in any other way, which, as his +trouble was of fourteen years standing, was not astonishing. + +The other patient, seen in 1897, was a rancher from New Mexico, +thirty-three years old, who had led an active, hard-working, +much-exposed life, but had been perfectly well until 1891, when he was +said to have had an attack of spinal meningitis, from which he recovered +very slowly. Four years later he noticed numbness of feet and weakness +of legs, great enough to make it hard for him to get a leg over his +horse. Some pains were felt in the limbs, and a constriction about the +chest and abdomen, which had steadily increased in severity. Sharp +attacks left distinct bruise-marks at the seat of pain each time. Could +not empty bladder. Gait feeble, spastic, and paralytic, could not mount +steps at all or stand without aid, sway very great. Knee-jerks and +muscle-jerks increased, especially on left; ankle-clonus; very slight +loss of touch-acuity in lower half of body. Eyes: muscles and +eye-grounds negative; pupils equal and active. Bladder could not be +emptied; cystitis. Ordered rest, massage, electricity, and full doses of +iodide in skimmed milk. In this way he was able to take without distress +or indigestion amounts as large as four hundred and forty grains a day. +When education in balance, etc., was begun he could not walk without +aid, or more than a few steps in any way. In three months from the time +he went to bed he walked out-of-doors alone with no stick, and in five +months went back to work. The bladder did not improve much until after +regular washing out and intravesical galvanism were used, with full +doses of strychnia. He was soon able to empty the organ twice a day, and +since leaving the hospital writes that it gives him very little +annoyance, though as a measure of precaution he uses a catheter once +daily. His pains have entirely disappeared, and he is daily on horseback +for many hours. + +In spastic paralysis, whether in the slowly-developing forms in which it +is seen in adults, due sometimes to multiple sclerosis, sometimes to +brain tumor, sometimes following upon a transverse myelitis, or in the +central paraplegia or diplegia of "birth-palsies," some very fortunate +results have followed the careful application of the principles of +treatment already described. Absolute confinement to bed is seldom +required or in adults desirable, though exercise should be carefully +limited to an amount which can be taken without fatigue, and some hours' +rest lying down is usually advantageous. + +Assuming that the necessary treatment for the disease originating the +paralysis is to be carried on in the ordinary way, I will only describe +the special forms and methods of exercise I have found serviceable. +Whatever the cause, this will be much the same, though in birth-palsies +the teaching may have to include groups of muscles and instruction in +the co-ordination of actions which are not affected in adult subjects. + +First, as to massage: the operator must direct his efforts primarily to +the relaxation of the tense muscles, secondarily to the strengthening of +the opponent groups, this last being of special importance where actual +contraction has taken place. He should make frequent attempts by +stretching the rigid groups to overcome the spasm, which in large +muscle-masses may be done by grasping with both hands, taking care not +to pinch, and pulling the hands apart in the line of the muscle's long +axis, thus stretching the muscles. Pressure will sometimes accomplish +the same end, and it will be found in certain cases that by kneading +_during action_,--that is, while the patient endeavors to produce +voluntary contraction,--the result will be better. Except in the most +spastic states, a certain degree of relaxation is possible by effort, +though not without practice, and this has to be constantly inculcated +and encouraged. After a period varying in length according to the case, +lessons in co-ordinating movements are begun. It is best for the +patient's encouragement to start with the least affected muscles, so +that, seeing the good results, he may be stimulated to persistent +effort. The lessons differ only in detail from those given in the list +under tabes. Improvement is slower than in ataxia. + +In birth-palsy cases not much can be accomplished in the way of +education, beyond the attempt by such means as ordinary gymnastics and +lessons in drill and walking offer, until the child shall have reached +an age when he is able to comprehend what is being attempted. For the +imbecile, idiotic, or backward a training-school is the proper place, +where mental and bodily functions may both receive attention and where +constant intelligent supervision is available. + +Many children the subjects of cerebral diplegia are credited with less +intelligence than they really possess, partly because they are +necessarily backward, and partly because of their difficulty in +expressing themselves, the speech-muscles sharing in the disease. These +muscles need to be carefully educated, and this might almost be made the +subject of a treatise by itself. Each case will require study as to the +special difficulties in the way of speech. Some experience most trouble +with the vowel sounds, more find the consonants the worst obstacles. +Patient practice in forming the sounds soon produce some results; the +pupil must be taught, like the deaf mute, to watch and imitate the +movements of the lips and tongue. + +Seguin's books and the numerous special works should be consulted by the +physician or parent desiring to pursue these methods to their fullest +development. + +When once the control of muscular movement begins to improve, more +elaborate exercises may be set. In speech, if the patients be +intelligent, they will sometimes be amused and profitably trained at the +same time by the effort to learn and repeat long words or nonsensical +combinations of difficult sounds, like the "Peter Piper" nursery rhymes. + +B.M., aet. fourteen, an intelligent lad, of Jewish parentage, suffered a +forceps-injury at birth, and had convulsive seizures later. He began to +make futile attempts at walking when five or six years of age, when the +spastic rigidity was first noticed. His speech was better at this time +than later, and a sort of relapse seemed to be precipitated by a fall in +which he struck his head when seven years of age. His mother, finding it +almost impossible to teach him to walk, devoted herself faithfully to +improving his mind, so that at fourteen years of age he read well and +enjoyed books, and was mentally clear, observant, and docile. His speech +was almost incomprehensible,--stuttering, thick, and nasal. He stood, +swaying in every direction, though not apt to fall, with bent knees, +rounded shoulders, every muscle in the extremities rigid, the mouth +half-open, the head projected forward, and, upon attempting to move, +the toes turned in, the legs almost twined around one another, and, +unless supported, he would stumble and twist about, scarcely able to get +forward at all. With a guiding hand he did a little better. His first +lessons were in "setting-up drill," while the feeble, disused muscles +were strengthened by massage, which served at the same time to help his +very irritable and imperfect digestive apparatus, so that it was soon +possible to give him a greater variety and more nourishing kinds of food +than he had before been able to take. He was kept in bed up to three +o'clock in the afternoon, the morning hours occupied with massage and a +half-hour's lesson in erect standing, with slow trunk movements +afterwards. An hour after dinner he was dressed and taken for two hours +in a carriage or street-car. He did his reading and some study on his +return, and had another half-hour's drill, superintended by his mother. +In two or three weeks some improvement began to be observable in his +attitude, and a great change in his color and general expression, but it +was three months before it was thought wise to attempt education in +small co-ordinate movements. At about the same time speech-drill was +commenced. + +In all these lessons the greatest care was taken that adequate rest +should intervene between each series of efforts, and it was always found +that fatigue distinctly impaired his co-ordination, as did emotion or +indigestion. When his speech grew clearer he was set tasks of learning +many-syllabled words and also began to practise drawing patterns. Every +new lesson was first given under medical supervision and then continued +by his mother or by the masseur. To shorten the history it will suffice +to say that in six months he was able to go to school, where with +certain allowances made for his thick speech by a kindly master he did +well, and returned to his home in the South able to walk without +attracting attention, to speak comprehensibly, to write a good letter, +and with every prospect fair for a still greater improvement, which I +learn he has since made. + +The important things to be recognized in the treatment of these cases +are, first, that rest in proper proportion allows of the patients doing +an amount of exertion which, ungoverned, or performed in wrong ways +would harm them; secondly, that full feeding is of value, because these +disorders are mostly of the character of degenerations and involve +failure of nutrition in various directions; and, lastly, that the +exactness of routine is of the highest moral and mental as well as +physical importance. + +Paralysis agitans needs scarcely more than to be mentioned as amenable +to the same methods, with small differences in the application of +details. Body movements to counteract the tendency to rigidity in the +flexor groups of spinal muscles will be especially useful, as the +stiffness of these is one of the causes of displacement forward of the +centre of gravity, a displacement which results in the festination +symptom usually seen in such cases. Prescriptions of special exercises +for the muscle-masses particularly involved in each instance must be +given, remembering that contraction of the affected muscles will to a +certain degree overcome their rigidity even at first, and to a still +greater extent as the patient reacquires voluntary control. + + + + +INDEX. + + +Acne, caused by massage, 89. + +After-treatment, importance of, 79, 195. + +Albuminuria, from exercise, 101. + +Alcoholism producing fat, 23. + +American race peculiarities, 17, 21, 32. + +Anaemia. _Vide_ Cases. + blood-count in, 102. + diagnosis of, 104. + effects of massage in, 101. + fatigue in, 72. + +Anaemic obesity, 24, 128. + +Asthenia. _Vide_ Cases. + +Asthenopia, 67, 145, 149. + +Ataxia. _Vide_ Cases. + bathing in, 204, 212. + co-ordinate movements in, 204. + symptoms of, 197. + treatment of, 197. + + +Bathing, effects of, 67. + in ataxia, 204, 212. + +Birth-palsy. _Vide_ Cases. + +Bleeding, causing increase of fat, 24. + +Blood changes from massage, 99, 101, 185. + +Bowditch on weight at different ages, 17, 23. + +Bright's disease, a contraindication, 45. + +Brown-Sequard's elixir, 212. + +Brunton on effects of massage, 101. + + +Cases: + albuminuria, 183. + amenorrhoea, 149, 193. + anaemia, extreme, 184. + aortic stenosis, 187. + asthenia, 111, 172, 182. + ataxia, 216, 218, 220. + birth-palsy, 226. + chloral habit, 150, 154, 174, 178. + hysteria, 76, 114, 154, 157, 160, 165, 181. + hysteria and neurasthenia, 112. + hystero-epilepsy, 165. + kidney, floating, 191. + morphia habit, 154, 165. + neurasthenia, 144, 171, 174. + neurasthenia and pulmonary disease, 149, 160. + obesity, anaemic, 132, 134. + paralysis, hysterical, 134, 150. + paraplegia, ataxic, 223. + paraplegia, spastic, 228. + tabes. _Vide_ Ataxia. + uterine disease and chloral habit, 150, 154. + +Cases, selection of, 33, 60. + +Chloral habit. _Vide_ Cases. + treatment of, 137. + +Chorea, 33. + +Cod-liver oil enema, 140. + +Constipation caused by milk diet, 125. + +Contraindications to rest, etc., 45. + +Corpulence, Harvey on, 129. + + +Diet-list, 144, 146, 159. + +Dietetics, 119, 171. + +Drug-habits, treatment of, 137. + + +Eccles on massage, 101. + +Electricity, 108. + Beard on, 115. + causing insomnia, 118. + during menstruation, 90. + in ataxia, 211. + in constipation, 109. + mode of using, 108, 116. + rise of temperature from, 110, 116. + when needed, 118. + + +Face, massage of, 105. + +Fat in alcoholism, 23. + in its relation to health, 16. + increased by bleeding, 24. + milk-diet in, 128. + mode of accumulation of, 27. + reduction of, 128. + varieties of, 25. + +Food, amount of, 146, 159. + in obesity, 130. + + +Goitre, exophthalmic, 46. + +Gymnastics, Swedish, 92. + + +Harvey on corpulence, 129. + +Head, massage of, 105. + +Headache from massage, 100. + massage for, 105. + +Heart-disease, treatment of, 45. + +Hysteria. _Vide_ Cases. + + +Introduction, 9. + +Iodide in ataxia, 201. + +Iron, use of, 142. + + +Jackson on rest, 58. + + +Karell on milk-treatment, 120, 128. + +Keen on albuminuria, 101. + +Kidney, floating. _Vide_ Cases. + belt for, 190. + treatment of, 48, 66, 189. + + +Letheby on fattening stock, 26. + + +Malt extract, 138. + Japanese extract of, 141. + +Marshall on urinary changes, 127. + +Massage, 80. + abdominal, 86. + amount of, 92. + blood-changes from, 101. + causing acne, 89. + causing headache, 100. + chilliness from, 91. + during convalesence, 34. + during menstruation, 90. + Eccles on, 101. + effect on temperature, 93. + effects of general, 98, 101. + frequency of use, 90. + in anaemia, 101. + in heart-disease, 46. + in spastic paralysis, 225. + Lauder-Brunton on, 101. + lubricant undesirable in, 89. + of face, 105. + of head, 105. + order of application, 82, 91. + sexual excitement from, 91. + why useful, 98. + +Melancholia, treatment of, 46. + +Menstruation, effects of rest on, 149, 193. + electricity during, 90. + massage during, 90. + +Milk, in alcoholism, 137. + in chloral habit, 137. + pasteurized, 121. + peptonized, 122. + quantity to be used, 123. + sterilization of, 121. + +Milk diet, 119. + constipation caused by, 125. + disappearance of uric acid during use of, 126. + effects of, on urinary pigments, 126. + general effects of, 124. + in obesity, 128. + in obesity with anaemia, 128. + Karell on, 120, 128. + precautions in using, 123. + sleepiness from, 125. + stools during use of, 125. + urinary changes from, 126. + +Morphia habit, treated by rest, etc., 137, 154, 165. + +Movements, co-ordinate, in ataxia, 204. + in paralysis agitans, 231. + in paraplegia, 223. + in spastic paralysis, 226. + Swedish, 92. + + +Neurasthenia. _Vide_ Cases. + +Nurse, choice of, 53. + + +Obesity, milk diet in, 128. + with anaemia, 128. + with anaemia. _Vide_ Cases. + +Ovarian disorders treated by rest, etc., 47. + + +Paralysis agitans, 231. + +Paraplegia, ataxic, 223. + spastic, 228. + +Partial rest, 63. + schedule for, 64. + +Peculiarities of American race, 17, 21, 32. + +Phthisis, gain of weight in, 35. + Pollock on, 35. + +Playfair on nerve-prostration, 12, 150. + + +Quetelet on gain of weight at different ages, 17. + + +Rest, 57. + definition of, 62. + effects of, on menstruation, 149, 193. + in ataxia, 203, 210, 230. + in neuralgia, 58. + in spinal disease, 58, 197, 230. + Jackson on, 58. + length of, 66, 68. + mental, 71. + mode of terminating, 63, 78. + moral uses of, 69. + partial, 62. + reasons for, 61, 70, 182. + + +Schedule for partial rest, 64. + +Seclusion, 50. + +Selection of cases, 33, 60. + +Soup, raw, mode of making, 139. + +Spine, irritable, 163, 178. + +Syphilis preceding tabes, 198, 201. + + +Tabes. _Vide_ Ataxia. + +Temperature after electric treatment, 110, 116. + after massage, 93. + +Treatment, season for, 53. + selection of cases for, 33. + + +Urinary pigments, changes in, during milk diet, 126. + + +Weight at different ages, Bowditch on, 17, 23. + gain or loss of, 14. + loss of, relation to an anaemia, 15. + Quetelet on, 17. + + + + +THE END. + +FOOTNOTES: + +[Footnote 1: The Systematic Treatment of Nerve Prostration and Hysteria. +London, 1883.] + +[Footnote 2: The Pennsylvania Orthopaedic Hospital and Infirmary for +Diseases of the Nervous System.] + +[Footnote 3: Sur l'Homme, p. 47, et seq.] + +[Footnote 4: Growth of Children, p. 31.] + +[Footnote 5: See a valuable paper by Dr. Gerhard, Am. Jour. Med. Sci., +1876. Also Lectures on Diseases of the Nervous System, especially in +Women. S. Weir Mitchell. Phila., 1881, p. 127. See also the papers by +Dr. Morris J. Lewis on the seasonal relations of chorea, analyzing seven +hundred and seventeen cases of chorea as to the months of onset (Trans. +Assoc. Amer. Phys., 1892), and Osler On Chorea (1894).] + +[Footnote 6: Statistics (Anthropological) Surgeon-General's +Bureau--1875.] + +[Footnote 7: This excess of corpulence in the English is attained +chiefly after forty, as I have said. The average American is taller than +the average Englishman, and is fully as well built in proportion to his +height, as Gould has shown. The child of either sex in New England is +both taller and heavier than the English child of corresponding class +and age, as Dr. H.I. Bowditch has lately made clear; while the English +of the manufacturing and agricultural classes are miserably inferior to +the members of a similar class in America.] + +[Footnote 8: Zeitschrift fuer Biol., 1872. Phila. Med. Times, vol. iii., +page 115.] + +[Footnote 9: Letheby on Food, pp. 39, 40, 41.] + +[Footnote 10: Am. Jour. Med. Sci.; Proc. Phil. Coll. of Phys., 1883; +Phil. Med. News, April, 1883.] + +[Footnote 11: Chorea. See Lancet, Aug. 1882.] + +[Footnote 12: "Nurse and Patient." S. Weir Mitchell. Lippincott's +Magazine, Dec. 1872.] + +[Footnote 13: See Philip Karell's remarks on the use of treatment by +milk in cardiac hypertrophy. Edin. Med. Jour., Aug. 1866.] + +[Footnote 14: Trans. Obst. Soc. of London, vol. xxxiii.] + +[Footnote 15: Seguin Lecture, _op. cit._] + +[Footnote 16: "Pinch" is used to avoid the use of a technical term, but +should be understood to mean the grasping and squeezing of a part with +the whole hand, using the palmar portion of the fingers to press the +grasped mass against the "heel" of the hand. Fuller technical details of +the massage process and consideration of its effects will be found in +the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham, +Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's +"System of Medicine" (1896), by Dr. John K. Mitchell.] + +[Footnote 17: Dr. Symon Eccles in "The Practice of Massage" recommends +this order.] + +[Footnote 18: Some care is needed not to overwork patients. For details +I must refer to manuals of Swedish Gymnastics.] + +[Footnote 19: See also page 91.] + +[Footnote 20: A number of observations in late years have been made upon +the effect of massage upon elimination. Among the articles to which the +practitioner desiring further to study this subject may be referred +are,-- + +_Edin. Clin. and Path. Jour_., Aug., 1884. + +_Jour, of Physiol._, vol. xxii., p. 68. + +_Centralbl. f. Inner. Med._, 1894, No. 40, p. 944. + +_Munch. Med. Woch._, April 11 and April 18, 1899 (Influence of bodily +exercise upon temperature in health and disease). + +Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque +and Marette, and Maggiora.] + +[Footnote 21: American Journal of the Medical Sciences, May, 1894.] + +[Footnote 22: Numerous examinations made since have quite uniformly +agreed with the former remarkably constant results.] + +[Footnote 23: J.K. Mitchell, _loc. cit._] + +[Footnote 24: Most induction batteries are without any arrangement for +making infrequent breaks in the current.] + +[Footnote 25: In the extreme constipation of certain hysterical women, +good may be done by placing one conductor in the rectum and moving the +other over the abdomen so as to cause full movement of the muscles. This +means must at first be employed cautiously, and the amount of +electricity carefully increased. It is doubtful if any movement of the +intestinal muscle-fibres is thus caused, but that it is a useful method +of stimulation in obstinate cases may be taken as proved.] + +[Footnote 26: Harvey on Corpulence.] + +[Footnote 27: The management of the morphia or chloral habit becomes +much more easy under a milk diet, massage, and absolute rest, and I can +with confidence commend their use in these difficult cases. Massage in +the morning is liked, and general surface-rubbing without +muscle-kneading at night very often proves remarkably soothing, while +the rest in bed cuts off many opportunities to indulge in the temptation +to secure the desired drugs.] + +[Footnote 28: I have found that this may be usefully replaced by one of +the numerous peptonized foods described in the pamphlets issued by the +manufacturers of the peptonizing powders. The ready-made peptonized +preparations vary very much, like some of the beef extracts, but a trial +will discover which of them is best fitted for an individual case.] + +[Footnote 29: Nerve Prostration and Hysteria.] + +[Footnote 30: It is worth mentioning that where ataxic patients have to +use canes, a crutch-cane with a base some six or eight inches long and +well shod with roughened rubber is far more useful and safer than the +ordinary stick.] + + + + + +End of the Project Gutenberg EBook of Fat and Blood, by S. 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