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Fat And Blood, treatment of Neurasthenia And Hysteria, S. Weir Mitchell, 1902 AD
An Essay On The Treatment Of Certain Forms Of Neurasthenia And Hysteria.
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 de-scribe 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,' and its sphere of usefulness is therefore likely to extendChorea. See Lancet, Aug. 1882.
34 SELECTION OF CASES FOR TREATMENT. SELECTION OF CASES FOR TREATMENT. 35
beyond the limits originally set by me. It will be well here, however, to state the various dis-orders 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 whirl; 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 re-covering 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, how- 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.
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
36 SELECTION OF CASES FOR TREATMENT. SELECTION OF CASES FOR TREATMENT. 2'7
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 value-less ; 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 amemia, 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, gynecologists, 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 fol-lows exertion, and though while under excite-
38 SELECTION OF CASES FOR TREATMENT. SELECTION" OF CASES FOR TREATMENT. 39.
ment or in the presence of some dominant mo-tive 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 trouble-some instances of fat anemic people which 1 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 under-taken 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 need-ing 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 re-mark 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 kind-ness 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 prob-ably 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.'
Another form of evil to be encountered in these eases 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. Life-long 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
" Nurse and Patient." S. Weir Mitchell. Lippincott's Magazine, Dec. 1872.
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 pro-portion 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 clay 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 in-sure 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
44 SELECTION OF CASES' FOR TREATMENT. SELECTION OF CASES FOR TREATMENT. 45
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 over-looked or undervalued some serious organic tis-sue-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 in-volves 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 who constitute the difficult cases.
I am also very careful as to being sure of the absence of certain forms of organic disease before slattering 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.'
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
1 See Philip Karell's remarks on the use of treatment by milk in cardiac hypertrophy. Edin. Med. Jour., Aug. 1866.
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used will still further relieve the heart. Dis-turbed compensation is usually accompanied by failure of nutrition, often by distinct anmmia, and these and the anxiety which naturally enough affects the mind of a person with car-diac 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 dyspncea 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
48 SELECTION OF CASES FOR TREATMENT.
SELECTION OF CASES FOR TREATMENT. 49
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.'
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 replace-ment of the organ is much greater than from operative attempts at fixation, apart from the danger and pain of surgical procedures. Per-sons 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 rt'vinie which shall furnish pad-ding to hold the kidney firmly in its normal place.
The treatment of locomotor ataxia and some allied states by this method, with certain modifi-cations, has yielded such good results that I
1 Trans. Obst. Soc. of London, vol. xxxiii.
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 of 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 en-able others to prosit 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 fail-ure.
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 modisied or used separately in some instances, I shall have occasion to point out as I discuss the various agencies alluded to.
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 en-tire, was made possible by the practice of knead-ing the muscles and by moving them with cur-rents 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 especi-ally 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 ?t-- 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 opin-ions and obedience, to his decrees secures very often most 1TriTir(mt 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 nmn ber of times, but I have also seen that to be too long and too habitually in the hands of one phy-sician, even the wisest, is for some cases of hys-teria the main difficulty in the way of a cure,—it is so easy to disobey the familiar friendly attend-ant, so hard to do this where the physician is a stranger. But we all know well enough the per-sonal 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 en-tire rest has been used, with other means, to sit them for making use of their muscles. Nothing upsets these cases like over-exertion, and the at-tempt 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. 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
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minuteness of care as for those undergoing " full rest" in bed. Here the patient's or the house-hold'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 re-sponsibility of choice taken away greatly les-sens 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 op-portunities 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 AM. 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.11. P.11. 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
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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 al-ways 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.-7 But many neuras-thenic 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 anemic 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, what-ever 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 per-manently, 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 of 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 nct in a more healthy manner under ordinary con-ditions. It may be wise to acid that occasional cases of nervousness or of nervous disturbance of digestion are seen in which the patient as-similates food better if permitted to move about directly after a meal; and I recall one in-stance 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-auto-
matic intellectuation which is harmful in men or women subject to states of feebleness or neuras-thenia, 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 har-assed by business anxieties, the woman with morbidly-developed or ungoverned maternal in-stincts, 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 hope-ful 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 diffi-culty. As a result, fatigue comes early, is ex-treme, 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 sensa-tions are magnified by women whose nervous systems have become sensitive owing to a life of attention to their ailments, and so at last it be-comes 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
74 REST. REST. 75
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 re-member 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 cer-tain 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 treat-
"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."'
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, be-sides this, every active muscle is practically a
1Stuin Lecture, op. cit.
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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 de-fects 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., mt. 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 sirm 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 fee-ble; 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 de-stroy 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 hyw 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, pleasure- able or otherwise. In cases of long-standing it may be desirable to continue this period of iso-lation 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.
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