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 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.
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 anæmia, 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, gynæcologists,
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 anæmic 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, 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
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 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.
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.