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
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.
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 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.
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., 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 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.