DIETETICS AND THERAPEUTICS.
The somewhat wearisome and minute details I have given as to seclusion,
rest, massage, and electricity have prepared the way for a discussion of
the dietetic and medicinal treatment which without them would be neither
possible nor useful.
As to diet, we have to be guided somewhat by the previous condition and
history of the patient.
It is difficult to treat any of these cases without a resort at some
time more or less to the use of milk. In most dyspeptic cases--and few
neurasthenic women fail to be obstinately dyspeptic--milk given at the
outset, and given alone by Karell's method for a fortnight or less,
enormously simplifies our treatment. Even after that, milk is the best
and most easily managed addition to a general diet. As to its use with
rest and massage as an exclusive diet in obesity alone or in extreme
fatness with anæmia, I spoke in a former edition with a confidence
which has been increased by the added experience of physicians on both
sides of the Atlantic. Finally, there are exceptional cases of
intestinal pain of obscure parentage or seemingly neuralgic, of
dyspepsia incorrigible by other treatments, which, having resulted in
grave general defects of nutrition, are best treated by several weeks of
milk diet, combined with rest, massage, and electricity. Milk,
therefore, must be so much used in these cases in connection with the
general treatment I am describing that it is perhaps as well to say more
clearly how it is to be employed when given alone or with other food. I
am the more willing to do this because I have learned certain facts as
to the effects of milk diet which have, I believe, hitherto escaped
observation. In fact, the study of the therapeutic influence and full
results of exclusive diets is yet to be made; nor can I but believe that
accurate dietetics will come to be a far more useful part of our means
of managing certain cases than as yet seems possible.
We are indebted chiefly to Dr. Karell, of St. Petersburg, for our
knowledge of the value of milk as an exclusive diet, and to Dr. Donkin
for the extension of Karell's treatment to diabetes. I shall formulate
as curtly as possible the rules to be followed in using milk as an
exclusive diet in dyspeptic states, and in anæmia with obesity, and in
the latter state uncomplicated by defective hæmic conditions.
For fuller statements as to the reasons for the various rules to be
observed in using milk, I must refer the reader to Karell's paper and to
Donkin's book.
Have the utmost care used as to preservation of the milk employed, and
as to the perfect cleansing of all vessels in which it is kept. Use
well-skimmed milk, as fresh as can be had, and, if possible, let it be
obtained from the cow twice a day. Or if this is not possible, or where
any doubt exists as to the condition of the milk, or any difficulty is
experienced in keeping it fresh, it may be pasteurized as soon as
received by heating it to 160°, keeping it some minutes at this point,
and at once chilling on ice. For this purpose it is best to have the
milk in bottles, and to heat by immersing the bottles in a water-bath.
For longer preservation, as, for example, when travelling, sterilizing
may be more thoroughly done by greater heat and lengthened immersion.
Still, these should be expedients for use only when milk cannot be
secured fresh and in good order, as it is more than doubtful if the milk
is so well borne when it has been altered by these processes.
For ordinary daily use it might be better to let all the milk for the
day be peptonized in the morning with pancreatic extract, to the extent
which is found to be agreeable to the patient's taste, and then preserve
it by placing it upon ice. In this way milk may be kept for several
days. Then, too, it has been found that where even skimmed milk upsets
the stomach of patients, milk prepared in this manner can be taken
without trouble. In peptonizing, the directions which accompany the
powders to be used for that purpose should be followed carefully. It is
to be remembered that if the patient desires to take the milk warm, the
process of conversion into peptones, which has been stopped by the cold,
will be promptly started again when the fluid is warmed, and then a very
few minutes will suffice to make it disagreeably bitter. At first the
skimming should be thorough, and for the treatment of dyspepsia or
albuminuria the milk must be as creamless as possible. The milk of the
common cow is, for our purposes, preferable to that of the Alderney. It
may be used warm or cold, but, except in rare cases of diarrhoea, should
not be boiled.
It ought to be given at least every two hours at first, in quantities
not to exceed four ounces, and as the amount taken is enlarged, the
periods between may be lengthened, but not beyond three hours during the
waking day, the last dose to be used at bedtime or near it. If the
patient be wakeful, a glass should be left within reach at night, and
always its use should be resumed as early as possible in the morning. A
little lime-water may be added to the night milk, to preserve it sweet,
and it should be kept covered.
The milk given during the day should be taken at set times, and very
slowly sipped in mouthfuls; and this is an important rule in many cases.
Where it is so disagreeable as to cause great disgust or nausea, the
addition of enough of tea or coffee or caramel or salt to merely flavor
it may enable us to make its use bearable, and we may by degrees abandon
these aids. Another plan, rarely needed, is to use milk with the general
diet and lessen the latter until only milk is employed. If these rules
be followed, it is rare to find milk causing trouble; but if its use
give rise to acidity, the addition of alkalies or lime-water may help
us, or these may be used and the milk scalded by adding a fourth of
boiling water to the milk, which has been previously put in a warm
glass. Some patients digest it best when it has the addition of a
teaspoonful of barley-or rice-water to each ounce, the main object being
to prevent the formation of large, firm clots in the stomach,--an end
which may also be attained by the addition at the moment of drinking of
a little carbonated water from a siphon. For the sake of variety,
buttermilk may be substituted for a portion of the fresh milk, and
though less nourishing it has the advantage of being mildly laxative.
When used as an exclusive diet, skimmed milk gives rise to certain very
interesting and what I might call normal symptoms. Since at first we can
rarely give enough to sustain the functions, for several days the
patient is apt to lose weight, which is another reason why exercise is
in such cases undesirable. This loss soon ceases, and in the end there
is usually a gain, while in most rest cases an exclusive milk diet may
be dispensed with after a week. Where milk is taken alone for weeks or
months, it is common enough to observe a large increase in bodily
weight. I have seen several times active men, even laboring men, live
for long periods on milk, with no loss of weight; but large quantities
have to be used,--two and a half to three gallons daily. A gentleman, a
diabetic, was under my observation for fifteen years, during the whole
of which time he took no other food but milk and carried on a large and
prosperous business. Milk may, therefore, be safely asserted to be a
sufficient food in itself, even for an adult, if only enough of it be
taken.
During the first week or two, exclusive milk diet gives rise to a marked
sense of sleepiness. It causes nearly always, and even for weeks of its
use, a white and thick fur on the tongue, and often for a time an
unpleasant sweetish taste in the early morning, neither of which need be
regarded. Intense constipation and yellowish stools of a peculiar odor
are usual. Of the former I shall speak in connection with the use of
milk in special cases. The influence of milk on the urinary secretion is
more remarkable, and has not been as yet fully studied.
There is, of course, a large flow of urine; and in dropsical cases due
to renal maladies this may exceed the ingested fluid and carry away very
rapidly the dropsical accumulations. It is sometimes annoying to nervous
persons because of the frequent micturition it makes necessary. I have
discovered that while skimmed milk alone is being taken, uric acid
usually disappears almost entirely from the urine, so that it is
difficult to discover even a trace of this substance; nor does it seem
to return so long as nothing but creamless milk is used. Almost any
large addition of other food, but especially of meat, enables us to find
it again. Creatine and creatinine also seem to lessen in amount, but of
the extent of this change I am not as yet fully informed.
A yet more singular alteration occurs as to the pigments. If after a
fortnight or less of exclusive milk diet we fill with the urine a long
test-tube, and, placing it beside a similar tube of the ordinary urine
of an adult, look down into the two tubes, we shall observe that the
milk urine has a singular greenish tint, which once seen cannot again be
mistaken. If we put some of this urine in a test-tube carefully upon hot
nitric acid, there is noticed none of the usual brown hue of oxidized
pigment at the plane of contact. In fact, it is often difficult to see
where the two fluids meet.
The precise nature of this greenish-yellow pigment has not, I believe,
been made out; but it seems clear that during a diet of milk the
ordinary pigments of the urine disappear or are singularly modified. A
single meal of meat will at once cause their return for a time.
These results have been carefully re-examined at my request by Dr.
Marshall in the Laboratory of the University of Pennsylvania, and his
results and my own have been found to accord; while he has also
discovered that during the use of milk the substances which give rise to
the ordinary fæcal odors disappear, and are replaced by others the
nature of which is not as yet fully comprehended. The changes I have
here pointed out are remarkable indications of the vast alterations in
assimilation and in the destruction of tissues which seem to take place
under the influence of this peculiar diet. Some of them may account for
its undoubted value in lithæmic or gouty states; but, at all events,
they point to the need for a more exhaustive study both of this and of
other methods of exclusive diet.
As regards milk, enough has here been said to act as a guide in its
practical use in the class of cases with which we are now concerned; but
I may add that it is sometimes useful, as the case progresses, to employ
in place of milk, or with it, some one of the various "children's
foods," such as Nestle's food, or malted milk.
Before dealing with the treatment of the anæmic and feeble and more or
less wasted invalids who require treatment by rest and its concomitant
aids, I desire to say a few words as to the use of rest, milk dietetics,
and massage in people who are merely cumbrously loaded with adipose
tissues, and also in the very small class of anæmic women who are
excessively fat and may or may not be hysterical, but are apt to be
feeble and otherwise wretched.
Karell has pointed out that on creamless milk diet fat people lose
flesh; and this is true; so that sometimes this mode of lessening weight
succeeds very well. But it does not always answer, because, as in
Banting, loss of weight is apt to be accompanied with loss of strength,
so that in some cases the results are disastrous, or at least alarming.
I do not know that this is ever the case if the directions of Mr.
Harvey[26] are followed with care and the weight very deliberately
lessened. But for this few people have the patience; and, even if they
can be induced to follow out a strict diet, it is often useful to be
able to cut off very rapidly a large amount of weight, and so shorten
the period of strict regimen, or at least put over-fat persons in a
condition to exercise with a freedom which had become difficult, and
thus to provide them with a healthful means of preventing an
accumulation of adipose matter. This can be done rapidly and with safety
by the following means. The person whose weight we decide to lessen is
placed on skimmed milk alone, with the usual precautions; or at once we
give skimmed milk with the usual food, and in a week put aside all other
diet save milk and all other fluids. When we find what quantity of milk
will sustain the weight, we diminish the amount by degrees until the
patient is losing a half-pound of weight each day, or less or more, as
seems to be well borne. Meanwhile, during the first week or two rest in
bed is enjoined, and later for a varying period rest in bed or on a
lounge is insisted upon, while at the same time massage is used once or
twice a day, and later in the case Swedish movements. At the same time,
the pulse and weight are observed with care, so that if there be too
rapid loss, or any sign of feebleness, the diet may be increased. In
many such cases I allow daily a moderate amount of beef- or chicken- or
oyster-soup,--more as a relief to the unpleasantness of a milk diet than
for any other reason.
When the weight has been sufficiently lowered, we add to the diet beef,
mutton, oysters, etc., and finally arrange a full diet list to include
but a moderate amount of hydro-carbons. Meanwhile, the milk remains as a
large part of the food, and the active Swedish movements are still kept
up as a habit, the patient being directed by degrees to add the usual
forms of exercise.
If we attempt to make so speedy a change in weight while the patient is
afoot, the loss is apt to be gravely felt; but with the precautions here
advised it is interesting and pleasant to see how great a reduction may
be made in a reasonable time without annoyance and with no obvious
result except a gain in health and comfort.
Cases of anæmia in women with excess of flesh have to be managed in a
somewhat similar fashion, but with the utmost care. In such persons we
have a loss of red blood-globules, perhaps lessened hæmoglobin, weak
heart, rapid pulse, and general feebleness, with too much fat, but not,
or at least rarely, extreme obesity. The milder cases may profit by
iron, with rest and very vigorous massage, but in old cases of this
kind--they are, happily, rare--the best plan is to put the patient at
rest, to use massage, restrict the diet to skimmed milk, or to milk and
broths free from fat, and with them, when the weight has been
sufficiently lowered, to give iron freely, and by degrees a good general
diet, under which the globules rise in number, so that even with a new
gain in flesh there comes an equal gain in strength and comfort. The
massage must be very thoroughly done to be of service, and it is often
difficult to get operators to perform it properly, as the manipulation
of very fat people is excessively hard work. As to other details, the
management should be much the same as that which I shall presently
describe in connection with cases of another kind.
I add two cases in illustration of the use of rest, milk, and massage
in the treatment of persons who are both anæmic and overloaded with
fat.
Mrs. P., æt. 45, weight one hundred and ninety pounds, height five feet
four and a half inches, had for some years been feeble, unable to walk
without panting, or to move rapidly even a few steps. Although always
stout, her great increase of flesh had followed an attack of typhoid
fever four years before. Her appearance was strikingly suggestive of
anæmia.
She was subject to constant attacks of acid dyspepsia, was said to be
unable to bear iron in any form, and had not menstruated for seven
months. She had no uterine disease, and was not pregnant. Two years
before I saw her she had been made very ill owing to an attempt to
reduce her flesh by too rapid Banting, and since then, although not a
gross or large eater, she had steadily gained in weight, and as steadily
in discomfort.
She was kept in bed for five weeks. Massage was used at first once
daily, and after a fortnight twice a day, while milk was given, and in a
week made the exclusive diet. Her average of loss for thirty days was a
pound a day, and the diet was varied by the addition of broths after
the third week, so as to keep the reduction within safe limits. Her
pulse at first was 90 to 100 in the morning, and at night 80 to 95, her
temperature being always a half degree to a degree below the normal. At
the third week the latter was as is usual in health, and the pulse had
fallen to 80 in the morning, and 80 to 90 at night.
After two weeks I gave her the lactate of iron every three hours in full
doses. In the fourth week additions were made to her diet-list, and
Swedish movements were added to the massage, which was applied but once
a day; and during the fifth week she began to sit up and move about. At
the seventh week her pulse was 70 to 80, her temperature natural, and
her blood-globules much increased in number. Her weight had now fallen
to one hundred and forty-five pounds, and her appearance had decidedly
improved. She left me after three and a half months, able to walk with
comfort three miles. She has lived, of course, with care ever since, but
writes me now, after two years, that she is a well and vigorous woman.
Her periodical flow came back five months after her treatment began, and
she has since had a child.
Early in the spring of 1876, Mrs. C., æt. 40, came under my care with
partial hysterical paralysis of the right and hemi-anæsthesia of the
left side. She had no power to feel pain or to distinguish heat from
cold in the left leg and arm, though the sense of touch was perfect. The
long strain of great mental suffering had left her in this state and
rendered her somewhat emotional. Her appetite was fair, but she was
strangely white, and weighed one hundred and sixty-three pounds, with a
height of five feet five inches. As she had had endless treatment by
iron, change of air, and the like, I did not care to repeat what had
already failed. She was therefore put at rest, and treated with milk,
slowly lessened in amount. Her stomach-troubles, which had been very
annoying, disappeared, and when the milk fell to three pints she began
to lose flesh. With a quart of milk a day she lost half a pound daily,
and in two weeks her weight fell to one hundred and forty pounds. She
was then placed on the full treatment which I shall hereafter describe.
The weight returned slowly, and with it she became quite ruddy, while
her flesh lost altogether its flabby character. I never saw a more
striking result.
I have been careful to speak at length of these fat anæmic cases,
because, while rare, they have been, to me at least, among the most
difficult to manage of all the curable anæmias, and because with the
plan described I have been almost as successful as I could desire.
Let us now suppose that we have to deal with a person of another and
different type,--one of the larger class of feeble, thin-blooded,
neurasthenic or hysterical women. Let us presume that every ordinary and
easily attainable means of relief has been utterly exhausted, for not
otherwise do I consider it reasonable to use so extreme a treatment as
the one we are now to consider. Inevitably, if it be a woman long ill
and long treated, we shall have to settle the question of uterine
therapeutics. A careful examination is made, and we learn that there is
decided displacement. In this case it is well to correct it at once and
to let the uterine treatment go on with the general treatment. If there
be bad lacerations of the womb or perineum, their surgical relief may
await a change in the general status of health,--say at the fourth or
fifth week. If there be only congestive or other morbid states of the
womb or ovaries, they are best left to be aided by the general gain in
health; but in this as in every other stage of this treatment it is
unwise, and undesirable therefore, to lay down too absolute laws. Having
satisfied ourselves as to these points, and that rest, etc., is needful,
we begin treatment, if possible, at the close of a menstrual period,
because usually the monthly flow is a time at which there is little or
no gain, and by starting our treatment when it is just over we save a
week of time in bed.
The next step is, usually, to get her by degrees on a milk diet, which
has two advantages. It enables us to know precisely the amount of food
taken, and to regulate it easily; and it nearly always dismisses, as by
magic, all the dyspeptic conditions. If the case be an old one, I rarely
omit the milk; but, although I begin with three or four ounces every two
hours, I increase it in a few days up to two quarts, given in divided
doses every three hours. If a cup of coffee given without sugar on
awaking does not regulate the bowels, I add a small amount of watery
extract of aloes at bedtime; or if the constipation be obstinate, I give
thrice a day one-quarter of a grain of watery extract of aloes with two
grains of dried ox-gall. I find the simple milk diet a great aid
towards getting rid of chloral, bromides, and morphia, all of which I
usually am able to lay aside during the first week of treatment.[27] Nor
is it less easy with the same means to enable the patient to give up
stimulus; and I may add that in the treatment of the congested stomach
of the habitual hard drinker the milk treatment is of admirable
efficacy. As I have spoken over and over of the use of stimulus by
nervous women, I should be careful to explain that anything like great
excess on the part of women of the upper classes, in this country at
least, is, in my opinion, extremely rare, and that when I speak of the
habit of stimulation I mean only that nervous women are apt to be taught
to take wine or whiskey daily, to an extent that does not affect visibly
their appearance or demeanor.
Meanwhile, the mechanical treatment is steadily pursued, and within
four days to a week, when the stomach has become comfortable, I order
the patient to take also a light breakfast. A day or two later she is
given a mutton-chop as a mid-day dinner, and again in a day or two she
has added bread-and-butter thrice a day; within ten days I am commonly
able to allow three full meals daily, as well as three or four pints of
milk, which are given at or after meals, in place of water.
After ten days I order also two to four ounces of fluid malt extract
before each meal. The fluid malt extracts which now reach us from
Germany have become less trustworthy than they formerly were. Some of
them keep badly, and are uncertain in composition, one bottle being
good, another bad. The more constant, and at the same time most
agreeable, extracts are those now made in this country. Although their
diastasic powers are usually less than is claimed for them, and vary
greatly even in the best makes, they so far have seemed to me on the
whole more satisfactory than the imported malts. It is very desirable
that a thorough chemical study should be made of the various malt
extracts, solid and liquid. I am sure that some of them are defective
in composition, or vary notably as to the amount of alcohol they
contain.
No troublesome symptoms usually result from this full feeding, and the
patient may be made to eat more largely by being fed by her attendant.
People who will eat very little if they feed themselves, often take a
large amount when fed by another; and, as I have said before, nothing is
more tiresome than for a patient flat on her back to cut up her food and
to use the fork or spoon. By the plan of feeding we thus gain doubly.
As to the meals, I leave them to the patient's caprice, unless this is
too unreasonable; but I like to give butter largely, and have little
trouble in getting this most wholesome of fats taken in large amounts. A
cup of cocoa or of coffee with milk on waking in the morning is a good
preparation for the fatigue of the toilet.
At the close of the first week I like to add one pound of beef, in the
form of raw soup. This is made by chopping up one pound of raw beef and
placing it in a bottle with one pint of water and five drops of strong
hydrochloric acid. This mixture stands on ice all night, and in the
morning the bottle is set in a pan of water at 110° F. and kept two
hours at about this temperature. It is then thrown on to a stout cloth
and strained until the mass which remains is nearly dry. The filtrate is
given in three portions daily. If the raw taste prove very
objectionable, the beef to be used is quickly roasted on one side, and
then the process is completed in the manner above described. The soup
thus made is for the most part raw, but has also the flavor of cooked
meat.[28]
In difficult cases, especially those treated in cool weather, I
sometimes add, at the third week, one half-ounce of cod-liver oil, given
half an hour after each meal. If it lessen the appetite, or cause
nausea, I employ it thrice a day as a rectal injection; and in cases
where the large doses of iron used cause intense constipation, I find
the use of cod-oil enemata doubly valuable, by acting as a nutriment and
by disposing the bowels to act daily. This may be given as an emulsion
with pancreatic extract. This will suit some people well, and result in
a single passage daily, but in others may be annoying, and be either
badly retained or not retained at all, and may give rise to tenesmus.
The question of stimulus is a grave one. In too many cases which come to
me, I have to give so much care to break off the use of all forms of
alcoholic drinks that I am loath to resort to them in any case, although
I am satisfied that a small amount is a help towards speedy increase of
fat. Its use is, therefore, a matter for careful judgment, and in
persons who have never taken it in excess, or as a habit, I prefer to
give, with the other treatment, a small daily ration of stimulus: an
ounce a day of whiskey in milk, or a glass of dry champagne or red wine,
seems to me useful as an adjuvant, and as increasing the capacity to
take food at meals. Nevertheless, alcohol is not essential, and for the
most part I give none, except the small amount--some four per
cent.--present in fluid malt extracts. Even this is found to excite
certain persons, and it is in such cases easy to substitute the thicker
extracts of malt, or the Japanese extract, made from barley and rice.
So soon as my patient begins to take other food than milk, and
sometimes even before this, I like to give iron in large doses. In
hospital practice the old subcarbonate answers very well, being cheap,
and not unpalatable when shaken up in water or given in an effervescent
draught of carbonated waters. In private practice large doses of salts
of iron, as four to six grains of lactate at meal-time, are
satisfactory; but the form of iron is of less moment than the amount.
Very often I meet with women who cannot take iron, either because it
disturbs the stomach, causes headache, or constipates, or else because
they have been told never to take iron. In the latter case I simply add
five grains of the pyrophosphate to each ounce of malt, and give it thus
for a month unknown to the patients. It is then easy to make clear to
them that iron is not so difficult to take as they had been led to
believe, and when it has ceased to disagree mentally I find that I am
able to fall back on the coarser method. If iron constipate, as it may
and does often do when used in these large doses, the trouble is to be
corrected by fruit, and especially pears, by the pill of the watery
extract of aloes and ox-gall already mentioned, by extracts of cascara
or of juglans cinerea, which may be added to the malt extract ordered
with the meals, or by enemata of oil, or oil and glycerin, or a glycerin
suppository. The instances in which iron gives headache and sense of
fulness are very rare when the patient is undergoing the full treatment
described, and, as a rule, I disregard all such complaints, and find
that after a time I cease to hear anything more of these symptoms.
Unless some especial need arises, iron, in some form, is the only drug I
care to use until the patient begins to sit up, when I order nearly
always sulphate of strychnia, in rather full doses, thrice a day, with
iron and arsenic.
Probably no physician will read the account I have here detailed of the
vast amount of food which I am enabled to give, not only with impunity
from dyspepsia, but with lasting advantage, without some sense of
wonder; and, for my own part, I can only say that I have watched again
and again with growing surprise some listless, feeble, white-blooded
creature learning by degrees to consume these large rations, and
gathering under their use flesh, color, and wholesomeness of mind and
body. It is needless to say that it is not in all cases easy to carry
out this treatment.
When the full treatment has been reached, and kept up for a few days, I
begin to watch the urine with care, because if the patient be overfed
the renal secretion speedily betrays this result in the precipitation of
urates. When this occurs at all steadily, I usually give directions to
lessen the amount of food until the urine is again free from sediment.
Nearly always at some time in the progress of the case there are attacks
of dyspepsia, when it suffices to cut down the diet one-half, or to give
milk alone for a day or two. Diarrhoea is more rare, and has to be met
in like manner; or, if obstinate, it may be requisite to give the milk
boiled. Occasionally the rapid increase of blood is shown by nasal
hemorrhage, which needs no especial treatment.
Perhaps I shall make myself more clear if I now relate in full the
diet-list of some of my cases, and the mode of arranging it.
I take the following case as an illustration from my note-book:
Mrs. C., a New England woman, æt. 33, undertook, at the age of sixteen,
a severe course of mental labor, and within two years completed the
whole range of studies which, at the school she went to, were usually
spread over four years. An early marriage, three pregnancies, the last
two of which broke in upon the years of nursing, began at last to show
in loss of flesh and color. Meanwhile, she met with energy the
multiplied claims of a life full of sympathy for every form of trouble,
and, neglecting none of the duties of society or kinship, yet found time
for study and accomplishments. By and by she began to feel tired, and at
last gave way quite abruptly, ceased to menstruate five years before I
saw her, grew pale and feeble, and dropped in weight in six months from
one hundred and twenty-five pounds to ninety-five. Nature had at last
its revenge. Everything wearied her,--to eat, to drive, to read, to sew.
Walking became impossible, and, tied to her couch, she grew dyspeptic
and constipated. The asthenopia which is almost constantly seen in such
cases added to her trials, because reading had to be abandoned, and so
at last, despite unusual vigor of character, she gave way to utter
despair, and became at times emotional and morbid in her views of life.
After numberless forms of treatment had been used in vain, she came to
this city and passed into my care.
At this time she could not walk more than a few steps without flushing
and without a sense of painful tire. Her morning temperature was 97.5°
F., and her white corpuscles were perhaps a third too numerous. After
most careful examination, I could find no disease of any one organ, and
I therefore advised a resort to the treatment by rest, with full
confidence in the result.
In this single case I give the schedule of diet in full as a fair
example:
Mrs. C. remained in bed in entire repose. She was fed, and rose only for
the purpose of relieving the bladder or the rectum.
October 10.--Took one quart of milk in divided doses every two hours.
11th.--A cup of coffee on rising, and two quarts of milk given in
divided portions every two hours. A pill of aloes every night, which
answered for a few days.
12th to 15th.--Same diet. The dyspepsia by this time was relieved, and
she slept without her habitual dose of chloral. The pint of raw soup was
added in three portions on the 16th.
17th and 18th.--Same diet.
19th.--She took, on awaking at 7, coffee; at 7.30, a half-pint of milk;
and the same at 10 A.M., 12 M., 2, 4, 6, 8, and 10 P.M. The soup at 11,
5, and 9.
23d.--She took for breakfast an egg and bread-and-butter; and two days
later (25th) dinner was added, and also iron.
On the 28th this was the schedule:
On waking, coffee at 7. At 8, iron and malt. Breakfast, a chop,
bread-and-butter; of milk, a tumbler and a half. At 11, soup. At 2, iron
and malt. Dinner, closing with milk, one or two tumblers. The dinner
consisted of anything she liked, and with it she took about six ounces
of burgundy or dry champagne. At 4, soup. At 7, malt, iron,
bread-and-butter, and usually some fruit, and commonly two glasses of
milk. At 9, soup; and at 10 her aloe pill. At 12 M., massage occupied an
hour. At 4.30 P.M., electricity was used for an hour in the manner which
I have described.
This heavy diet-list, reached in a few days by a woman who had been
unable to digest with comfort the lightest meal, seemed certainly
surprising. I have not given in full the amount of food eaten at
meal-time. Small at first, it was increased rapidly owing to the
patient's growing appetite, and became in a few days three large meals.
It is necessary to see the result in one of these successful cases in
order to credit it. Mrs. C. began to show gain in flesh about the face
in the second week of treatment, and during her two months in bed rose
in weight from ninety-six pounds to one hundred and thirty-six; nor was
the gain in color less marked.
At the sixth week of treatment the soup was dropped, wine abandoned, the
iron lessened one-half, the massage and electricity used on alternate
days, and the limbs exercised as I have described. The usual precautions
as to rising and exercise were carefully attended to, and at the ninth
week of treatment my patient took a drive. At this time all mechanical
treatment ceased, the milk was reduced to a quart, the iron to five
grains thrice a day, and the malt continued. At the sixth week I began
to employ strychnia in doses of one-thirtieth of a grain thrice a day at
meals, and this was kept up for several months, together with the iron
and malt. The cure was complete and permanent; and its character may be
tested by the fact that at the thirtieth day of rest in bed, and after
five years of failure to menstruate, to her surprise she had a normal
monthly flow. This continued with regularity until eighteen months
later, when she became pregnant. The only drawback to her perfect use of
all her functions lay in asthenopia, which lasted nearly a year after
she left my care. Fatigue of vision for near work is a common condition
of the cases I am now describing, and is apt to persist long after all
other troubles have vanished. When there is no asthenopia I usually
think well of the general chance of recovery; but in no case of feeble
vision do I omit at some period of the treatment to have the optical
apparatus of the eye looked at with care, because pure asthenopia, apart
from all optical defects, is a somewhat rare symptom.
Neither am I always satisfied with the ophthalmologist's dictum that
there is a defect so slight as to need no correction, being well aware,
as I have elsewhere pointed out, that even minute ocular defects are
competent mischief-makers when the brain becomes what I may permit
myself, using the photographer's language, to call sensitized by
disease.
The following illustrations of success in this mode of treatment are
taken from Dr. Playfair's book:[29]
"Early in October of last year I was asked to see a lady thirty-two
years of age, with the following history. She had been married at the
age of twenty-two, and since the birth of her last child had suffered
much from various uterine troubles, described to me by her medical
attendant as 'ulceration, perimetritis, and endometritis.' Shortly after
the death of her husband, in 1876, these culminated in a pelvic abscess,
which opened first through the bladder and afterwards through the
vagina. Paralysis of the bladder immediately followed the appearance of
pus in the urine, and from that time the urine was never spontaneously
voided, and the catheter was always used. Soon after this she began to
lose power in the right leg, and then in the left, until they both
became completely paralyzed, so that she could not even move her toes,
and lay on her back with her legs slightly drawn up, the muscles being
much wasted. Towards the end of 1877, after some pain in the back of
her neck and twitching of the muscles, she began to lose power in her
left arm and in her neck, so that she lay absolutely immobile in bed,
the only part of her body she was able to move at all being her right
arm. Up to this time the pelvic abscess had continued to discharge
through the vagina, and occasionally through the bladder, but it now
ceased to do so, and there were no further symptoms referable to the
uterine organs. Her general condition, however, remained unaltered, in
spite of the most judicious medical treatment. She was seen, from time
to time, by several of our most eminent consultants, all of whom
recognized the probable hysterical character of her illness, but none of
the remedies employed had any beneficial effect. There was almost total
anorexia, the amount of food consumed was absurdly small, and the
necessary consequence of this inability to take food, combined with four
years in bed with paralysis of the greater part of the body, and the
habitual use of chloral to induce sleep, had reduced a naturally fine
woman to a mere shadow. In October, 1880, her medical attendant was good
enough to bring her to London for the purpose of giving a fair trial to
the Weir Mitchell method of treatment, with the ready co-operation of
herself and her friends, and she was conveyed on a couch slung from the
roof of a saloon carriage, so as to avoid any jolt or jar, since the
slightest movement caused much suffering. Two days after her arrival my
friend Dr. Buzzard saw her with me, and, after a careful and prolonged
electrical examination, came to the conclusion that contractility
existed in all the affected muscles, and that the paralysis was purely
functional. I could find no evidence in the pelvis of the abscess, the
uterus being perfectly mobile, and apparently healthy. After a few days'
rest the treatment was commenced on October 16, the patient being
isolated in lodgings with a nurse of my own choosing; and this was the
only difficulty I had with her, since she naturally felt acutely the
separation from the faithful attendant who had nursed her during her
long illness. Her friends agreed not to have communication with her of
any sort. It is needless to give the details of the treatment in this
and the following cases. A mere abstract will suffice to indicate the
rapid and satisfactory progress made.
"_October_ 16.--Twenty-two ounces of milk were taken, in divided doses,
in twenty-four hours; on the 17th, fifty ounces of milk; on the 18th,
the same quantity of milk repeated; massage for half an hour; on the
19th, milk as before; bread-and-butter and egg; massage for an hour and
a half; twenty minims of dialyzed iron twice daily; on the 21st, a
mutton-chop in addition to the above; massage an hour and fifty minutes.
To-day she passed water for the first time for four years, and the
catheter was never again used. Chloral discontinued, and she slept
naturally all night long. On the 23d, porridge and a gill of cream were
added to her former diet; massage three hours daily, and electricity for
half an hour, and this was continued until the end of the treatment.
Maltine was now given twice daily.
"_October_ 30.--She is now consuming three full meals daily of fish,
meat, vegetables, cream, and fruit, besides two quarts of milk and two
glasses of burgundy. Considerable muscular power is returning in her
limbs, which she can now move freely in bed.
"_November_ 6.--Sat in a chair for an hour. The massage and electricity
are being gradually discontinued, and the amount of food lessened.
"_November_ 17.--Walked down-stairs, and went out for a drive, and
henceforth she went out daily in a Bath-chair. She has increased
enormously in size, and looks an entirely different person from the
wasted invalid of a few weeks ago.
"On November 26 she went to Brighton quite convalescent, and on December
11 came up of her own accord to see me, drove in a hansom to my house,
and returned the same afternoon. She has since remained perfectly strong
and well, and has resumed the duties of life and society.
"A somewhat curious phenomenon in this case, which I am unable to
account for, was the formation on the anterior surface of the legs,
extending from below the patellæ half-way down the tibiæ, of two large
sacs of thin fluid, containing, I should say, each a pint or more,
freely fluctuating, and quite painless. I left them alone, and they have
spontaneously disappeared."
"In May, 1880, I saw with Dr. Julius, of Hastings, an unmarried lady,
aged thirty-one. Her history was that she had been in fairly good health
until five years ago, when, during her mother's illness, she overtaxed
her strength in nursing, since which time she has been a constant
invalid, suffering from backache, bearing down, inability to walk,
disordered menstruation, and the usual train of uterine symptoms. She
used to get a little better on going to the sea-side, but soon became
ill again, and in October, 1879, she was completely laid up. The least
standing or walking brought on severe pain in her back and side, and she
gave up the attempt, and had since remained entirely confined to her bed
or sofa, suffering from constant nausea, complete loss of appetite, and
depending on chloral and morphia for relief. Many efforts had been made
to break her of this habit, but in vain. Her medical attendant had
recognized the existence of a retroflexion, but no pessary remained _in
situ_ for more than a day or so, and he suspected that she herself
pulled them out. I was unable to do more than confirm the diagnosis that
had been made as to her local condition, but the pessary I introduced
shared the fate of its predecessors, and she remained in the same
condition,--in no way benefited by my visit. Things going on from bad to
worse, Dr. Julius sent her to London for treatment in the early part of
December. I now determined to try the effect of the method I am
discussing, of which I knew nothing when I first saw her. It was
commenced on December 11, and everything went on most favorably. A week
after it was begun, when her attention was fully occupied with the diet,
massage, etc., I introduced a stem pessary, being tempted to try this
instrument, which I rarely use, by the knowledge that she was at perfect
rest, and that no form of Hodge had previously been retained. I do not
think she ever knew she had it, and it remained _in situ_ for a month,
when I removed it and inserted a Hodge, which was thenceforth kept in
without any trouble. I may say that I do not think the retroflexion had
much to do with her symptoms, except, doubtless, at the commencement of
her illness, and she probably would have done quite as well without any
local treatment. She rapidly gained flesh and strength, and very soon I
entirely stopped both chloral and morphia, and she never seemed to miss
them. On December 11, when the treatment was commenced, she weighed 5
st. 9 lbs. On January 20 she weighed 7 st. On January 25 she walked
down-stairs, and went out for a drive, and from that time she went out
twice daily. She complained of no pain of any kind, and, although she
wore a Hodge, she did not seem to have any uterine symptoms. On February
1 she went to the sea-side, looking rosy, fat, and healthy, and has
since returned to her home in the country, where she remains perfectly
strong and well. A few days ago she came to town, a long railway
journey, on purpose to announce to me her approaching marriage."
"On September 10 a gentleman came to consult me on the case of his wife,
in consequence of his attention having been directed to my former papers
by a relative who is a well-known physician in London. He informed me
that his wife was now fifty-five years of age, and that she had passed
ten years of her married life in India. At the age of thirty she was
much weakened by several successive miscarriages, and then drifted into
confirmed ill health. He wrote, on making an appointment, as follows: 'I
will give you at once a short outline of her case. We have been married
thirty-four years, of which the last twenty have been spent by her in
bed or on the sofa. She is unable even to stand, and finds the pain in
her back too great to admit of her sitting up. She is utterly without
strength, of an intensely nervous temperament, and suffers incessantly
from neuralgia. She has, moreover, an outward curvature of the spine.
There is not the slightest symptom of paralysis. Fortunately, she does
not touch morphia, or any narcotic or stimulant, beyond a glass or two
of wine in the day. That she has long been in a state of hysteria is the
opinion of nearly all the many medical men who have seen her.'
"Although the attempt to cure so aggravated a case as this was certainly
a sufficiently severe test of the treatment, I determined to make the
trial, and had the patient removed from her own home and isolated in
lodgings. I found her in bed, supported everywhere by many small
pillows, and wasted more than, I think, I had ever seen any human being.
She really hardly had any covering to her bones, and looked somewhat
like the picture of the living skeleton we are familiar with. It may
give some idea of her emaciation if I state that, though naturally not a
small woman, her height being five feet five and a half inches, she
weighed only 4 st. 7 lbs., and I could easily make my thumb and
forefinger meet round the thickest part of the calf of her leg. The
curvature of the spine said to exist was a deceptive appearance,
produced by her excessive leanness, and the consequent unnatural
prominence of the spinous processes of the vertebræ. I could detect no
organic disease of any kind. The appetite was entirely wanting, and she
consumed hardly any food beyond a little milk, a few mouthfuls of bread,
and the like. From the first the patient's improvement was steady and
uniform. The way she put on flesh was marvellous, and one could almost
see her fatten from day to day. Within ten days all her pains,
neuralgia, and backache had gone, and have never been heard of since,
and by that time we had also got rid of all her little pillows and other
invalid appliances.
"It may be of interest, as showing what this system is capable of, if I
copy her food diary on the tenth day after the treatment was begun; and
all this, this bedridden patient, who had lived on starvation diet for
twenty years, not only consumed with relish, but perfectly assimilated.
"Six A.M.: ten ounces of raw meat soup. 7 A.M.: cup of black coffee. 8
A.M.: a plate of oatmeal porridge, with a gill of cream, a boiled egg,
three slices of bread-and-butter, and cocoa. 11 A.M.: ten ounces of
milk. 2 P.M.: half a pound of rump-steak, potatoes, cauliflower, a
savory omelette, and ten ounces of milk. 4 P.M.: ten ounces of milk and
three slices of bread-and-butter. 6 P.M.: a cup of gravy soup. 8 P.M.:
a fried sole, roast mutton (three large slices), French beans, potatoes,
stewed fruit and cream, and ten ounces of milk. 11 P.M.: ten ounces of
raw meat soup.
"The same scale of diet was continued during the whole treatment, and,
from first to last, never produced the slightest dyspeptic symptoms, and
was consumed with relish and appetite. At the end of six weeks from the
day I first saw her she weighed 7 st. 8 lb.,--that is, a gain of 3 st. 1
lb. It will suffice to indicate her improvement if I say that in eight
weeks from the commencement of treatment she was dressed, sitting up to
meals, able to walk up and down stairs with an arm and a stick, and had
also walked in the same way in the park. Considering how completely
atrophied her muscles were from twenty years' entire disuse, this was
much more than I had ventured to hope. She has now left with her nurse
for Natal, and I have no doubt that she will return from her travels
with her cure perfected."
"Early in August I was asked to see a lady, aged thirty-seven, with the
following history:--'As a girl of sixteen she had a severe neuralgic
illness, extending over months: excepting that, she seems to have
enjoyed good health until her marriage. Soon after this she had a
miscarriage, and then two subsequent pregnancies, accompanied by
albuminuria and the birth of dead children.' 'During gestation I was not
surprised at all sorts of nervous affections, attributing them to
uræmia.' The next pregnancy terminated in the birth of a living
daughter, now nearly three years old; during it she had 'curious nervous
symptoms,--_e.g._, her bed flying away with her, temporary blindness,
and vaso-motor disturbances.' Subsequently she had several severe shocks
from the death of near relatives, and gradually fell into the condition
in which she was when I was consulted. This is difficult to describe,
but it was one of confirmed illness of a marked neurotic type. Among
other phenomena she had frequently-recurring attacks of fainting. 'These
were not attacks of syncope, but of such general derangement of the
balance of the circulation that cerebration was interfered with. She was
deaf and blind; her face often flushed, sometimes deadly cold; her hands
clay-cold, often blue, and difficult to warm with the most vigorous
friction. These attacks passed off in from twenty minutes to a couple
of hours.' Soon 'the attacks became more frequent, with the reappearance
of another old symptom,--acute tenderness of the spine, especially over
the sacrum. Then came frequent and persistent attacks of sciatica, and
gradual loss of strength.' About this time there appears to have been
some uterine lesion, for a well-known gynæcologist went down to the
country to see her. Eventually 'she became unable to do anything almost
for herself, for the nervous irritability had distressingly increased.
To touch her bed, the ringing of a bell, sometimes the sound of a voice,
sunlight, &c., affected her so as to make her almost cry out.' 'If she
stood up, or even raised her hands to dress her hair, they immediately
became blue and deadly cold, and she was done for.' Then followed
palpitations of a distressing character, with loud blowing murmur, and
pulse of 120 to 140, for which she was seen by an eminent physician, who
diagnosed them to be caused by 'slight ventricular asynchronism, with
atonic condition of the cardiac as well as of all other muscles of the
body.' 'She has no appetite whatever.' 'Any attempt at walking brings on
sciatica. She cannot sit, because the tip of the spine is so sensitive;
any pressure on it makes her feel faint. She cannot go in a carriage,
because it jars every nerve in her body. She cannot lie on her back,
because her whole spine is so tender.'
"When consulted about this lady, I gave it as my opinion that any
attempt at cure was hopeless as long as she remained in the country
house in which she lived. I was informed that it was absolutely
impossible to get her away, as she could not bear the motion of any
carriage, still less of a railway, without the most acute suffering.
Eventually the difficulty was got over by anæsthetizing her, when she
was carried on a stretcher to the nearest railway station, and then
brought over two hundred miles to London, being all the time more or
less completely under the influence of the anæsthetic, administered by
her medical attendant, who accompanied her. I found this lady's state
fully justified the account given of her. She was intensely sensitive to
all sounds and to touch. Merely laying the hand on the bed caused her to
shrink, and she could not bear the lightest touch of the fingers on her
spine or any part near it. She lay in a darkened room at the back of the
house, to be away from the noise of the streets, which distressed her
much. She was a naturally fine and highly-cultivated woman, greatly
emaciated, with a dusky, sallow complexion, and dark rims round her
eyes. I could find no evidence of organic disease of any kind. Whatever
lesion of the uterine organs had previously existed had disappeared, and
I therefore paid no attention to them. Within a week I had the patient
lying in a bright sunlit room in the front of the house, with the
windows open, and she complained no longer of the noise. Within ten days
the whole spine could be rubbed freely from top to bottom, and from the
first I directed the masseuse to be relentless in her manipulation of
this part of the body. In a few weeks she had gained flesh largely, the
dusky hue of her complexion had vanished, and she looked a different
being. The only trouble complained of was sleeplessness, but it did not
interfere with the satisfactory progress of the case, and no hypnotic
was given. After the first few days we had no return of the nerve-crises
which in the country had formed so characteristic a part of her illness.
Her hands and feet also, at first of a remarkable deadly coldness, soon
became warm, and remained so. In five weeks she was able to sit up, and
before the fifth week of treatment was completed I took her out for a
drive through the streets in an open carriage for two hours, which she
bore without the slightest inconvenience, and the result of which she
thus described in a letter the same evening: 'I never enjoyed anything
more in my life. I cannot describe my delight and my astonishment at
being once more able to drive with comfort. My back has given me no
trouble, and I was not really tired.' This lady has since remained
perfectly well, and I need give no better proof of this than stating
that she has started with her husband on a tour round the world, _viâ_
India, Japan, and San Francisco, and that I have heard from her that she
is thoroughly enjoying her travels."
"The last example with which I shall trespass on your patience I am
tempted to relate because it is one of the most remarkable instances of
the strange and multiform phenomena which neurotic disease may present,
which it has ever been my lot to witness. The case must be well known to
many members of the profession, since there is scarcely a consultant of
eminence in the metropolis who has not seen her during the sixteen
years her illness has lasted, besides many of the leading practitioners
in the numerous health-resorts she has visited in the vain hope of
benefit. My first acquaintance with this case is somewhat curious. About
two months before I was introduced to the patient, chancing to be
walking along the esplanade at Brighton with a medical friend, my
attention was directed to a remarkable party at which every one was
looking. The chief personage in it was a lady reclining at full length
on a long couch, and being dragged along, looking the picture of misery,
emaciated to the last degree, her head drawn back almost in a state of
opisthotonos, her hands and arms clenched and contracted, her eyes fixed
and staring at the sky. There was something in the whole procession that
struck me as being typical of hysteria, and I laughingly remarked, 'I am
sure I could cure that case if I could get her into my hands.' All I
could learn at the time was that the patient came down to Brighton every
autumn, and that my friend had seen her dragged along in the same way
for ten or twelve years. On January 14 of this year, I was asked to meet
my friend Dr. Behrend in consultation, and at once recognized the
patient as the lady whom I had seen at Brighton. It would be tedious to
relate all the neurotic symptoms this patient had exhibited since 1864,
when she was first attacked with paralysis of the left arm. Among
them--and I quote these from the full notes furnished by Dr.
Behrend--were complete paraplegia, left hemiplegia, complete hysterical
amaurosis, but from this she had recovered in 1868. For all these years
she had been practically confined to her bed or couch, and had not
passed urine spontaneously for sixteen years. Among other symptoms, I
find noted 'awful suffering in spine, head, and eyes,' requiring the use
of chloral and morphia in large doses. 'For many years she has had
convulsive attacks of two distinct types, which are obviously of the
character of hystero-epilepsy.' The following are the brief notes of the
condition in which I found her, which I made in my case-book on the day
of my first visit. 'I found the patient lying on an invalid couch, her
left arm paralyzed and rigidly contracted, strapped to her body to keep
it in position. She was groaning loudly at intervals of a few seconds,
from severe pain in her back. When I attempted to shake her right hand,
she begged me not to touch her, as it would throw her into a
convulsion. She is said to have had epilepsy as a child. She has now
many times daily, frequently as often as twice in an hour, both during
the day and night, attacks of sudden and absolute unconsciousness, from
which she recovers with general convulsive movements of the face and
body. She had one of these during my visit, and it had all the
appearance of an epileptic paroxysm. The left arm and both legs are
paralyzed, and devoid of sensation. She takes hardly any food, and is
terribly emaciated. She is naturally a clever woman, highly educated,
but, of late, her memory and intellectual powers are said to be
failing.'
"It was determined that an attempt should be made to cure this case, and
she was removed to the Home Hospital in Fitzroy Square. She was so ill,
and shrieked and groaned so much, on the first night of her admission,
that next day I was told that no one in the house had been able to
sleep, and I was informed that it would be impossible for her to remain.
Between 3 P.M. and 11.30 P.M. she had had nine violent convulsive
paroxysms of an epileptiform character, lasting, on an average, five
minutes. At 11.30 she became absolutely unconscious, and remained so
until 2.30 A.M., her attendant thinking she was dying. Next day she was
quieter, and from that time her progress was steady and uniform. On the
fourth day she passed urine spontaneously, and the catheter was never
again used. In six weeks she was out driving and walking; and within two
months she went on a sea-voyage to the Cape, looking and feeling
perfectly well. When there, her nurse, who accompanied her, had a severe
illness, through which her ex-patient nursed her most assiduously. She
has since remained, and is at this moment, in robust health, joining
with pleasure in society, walking many miles daily, and without a trace
of the illnesses which rendered her existence a burden to herself and
her friends.
"In conclusion, I may remark that it seems to me that the chief value of
this systematic treatment, which is capable of producing such remarkable
results, is that it appeals, not to one, but many influences of a
curative character. Every one knew, in a vague sort of way, that if an
hysterical patient be removed from her morbid surroundings a great step
towards cure is made. Few, however, took the trouble to carry this
knowledge into practical action; and when they did so they relied on
this alone, combined with moral suasion. Now, I am thoroughly convinced
that very few cases of hysteria can be preached into health. Judicious
moral management can do much; but I believe that very few hysterical
women are conscious impostors; and the great efficacy of the Weir
Mitchell method seems to me to depend on the combination of agencies
which, by restoring to a healthy state a weakened and diseased nervous
system, cures the patient in spite of herself."