Home > Authors Index > S. Weir Mitchell > Fat and Blood: Treatment of Certain Forms of Neurasthenia and Hysteria > This page
Fat and Blood: Treatment of Certain Forms of Neurasthenia and Hysteria, essay(s) by S. Weir Mitchell |
||
Chapter 3. On The Selection Of Cases For Treatment |
||
| < Previous |
Table of content |
Next > |
|
________________________________________________
_ CHAPTER III. ON THE SELECTION OF CASES FOR TREATMENT The remarks of the last chapter have, of course, wide and general application in disease, and naturally lead up to what I have to say as to the employment of the systematic treatment to describe which is my chief desire. Its use, as a whole, is limited to certain groups of cases. In some of the worst of them nothing else has succeeded hitherto, or at least as frequently. In others the need for its application must depend on convenience and the fact that all other and readier means have failed. It is, of course, difficult to state now all the groups of diseases in which it may be of value, for already physicians have begun to find it serviceable in some to which I had not thought of applying it,[11] and its sphere of usefulness is therefore likely to extend beyond the limits originally set by me. It will be well here, however, to state the various disorders in which it has seemed to me applicable. As regards some of them, I shall try briefly to indicate why their peculiarities point it out as needful.
It may not, however, be out of place to say here that when the convalescence from these maladies seems to be slower than is common, and ordinary tonics inefficient, massage and the use of electricity are not unimportant aids towards health, but in such cases require to be handled with an amount of caution which is less requisite in more chronic conditions of disordered health. In other and fatal or graver maladies, such as, for example, advanced pulmonary phthisis, however proper it may be to fatten, it is almost an impossible task, and, as Pollock remarks, the lung-trouble may be advancing even while the patient is gaining in weight. Nevertheless, the earlier stages of pulmonary tuberculosis are suitable cases, and with sufficient attention to purity and frequent change of air in their rooms tubercular sufferers may be brought by this means to a point of improvement where open-air and altitude cures will have their best effects. There remains a class of cases desirable to fatten and redden,--cases which are often, or usually, chronic in character, and present among them some of the most difficult problems which perplex the physician. If I pause to dwell upon these, it is because they exemplify forms of disease in which my method of treatment has had the largest success; it is because some of them are simply living records of the failure of every other rational plan and of many irrational ones; it is because many of them find no place in the text-book, however sadly familiar they are to the physician. The group I would speak of contains that large number of people who are kept meagre and often also anaemic by constant dyspepsia, in its varied forms, or by those defects in assimilative processes which, while more obscure, are as fertile parents of similar mischiefs. Let us add the long-continued malarial poisonings, and we have a group of varied origin which is a moderate percentage of cases in which loss of weight and loss of color are noticeable, and in which the usual therapeutic methods do sometimes utterly fail. For many of these, fresh air, exercise, change of scene, tonics, and stimulants are alike valueless; and for them the combined employment of the tonic influences I shall describe, when used with absolute rest, massage, and electricity, is often of inestimable service. A portion of the class last referred to is one I have hinted at as the despair of the physician. It includes that large group of women, especially, said to have nervous exhaustion, or who are defined as having spinal irritation, if that be the prominent symptom. To it I must add cases in which, besides the wasting and anaemia, emotional manifestations predominate, and which are then called hysterical, whether or not they exhibit ovarian or uterine disorders. Nothing is more common in practice than to see a young woman who falls below the health-standard, loses color and plumpness, is tired all the time, by and by has a tender spine, and soon or late enacts the whole varied drama of hysteria. As one or other set of symptoms is prominent she gets the appropriate label, and sometimes she continues to exhibit only the single phase of nervous exhaustion or of spinal irritation. Far more often she runs the gauntlet of nerve-doctors, gynaecologists, plaster jackets, braces, water-treatment, and all the fantastic variety of other cures. It will be worth while to linger here a little and more sharply delineate the classes of cases I have just named. I see every week--almost every day--women who when asked what is the matter reply, "Oh, I have nervous exhaustion." When further questioned, they answer that everything tires them. Now, it is vain to speak of all of these cases as hysterical, or as merely mimetic. It is quite sure that in the graver examples exercise quickens the pulse curiously, the tire shows in the face, or sometimes diarrhoea or nausea follows exertion, and though while under excitement or in the presence of some dominant motive they can do a good deal, the exhaustion which ensues is out of proportion to the exercise used. I have rarely seen such a case which was not more or less lacking in color and which had not lost flesh; the exceptions being those troublesome instances of fat anaemic people which I shall by and by speak of more fully. Perhaps a sketch of one of these cases will be better than any list of symptoms. A woman, most often between twenty and thirty years of age, undergoes a season of trial or encounters some prolonged strain. She may have undertaken the hard task of nursing a relative, and have gone through this severe duty with the addition of emotional excitement, swayed by hopes and fears, and forgetful of self and of what every one needs in the way of air and food and change when attempting this most trying task. In another set of cases an illness is the cause, and she never rallies entirely, or else some local uterine trouble starts the mischief, and, although this is cured, the doctor wonders that his patient does not get fat and ruddy again. But, no matter how it comes about, whether from illness, anxiety, or prolonged physical effort, the woman grows pale and thin, eats little, or if she eats does not profit by it. Everything wearies her,--to sew, to write, to read, to walk,--and by and by the sofa or the bed is her only comfort. Every effort is paid for dearly, and she describes herself as aching and sore, as sleeping ill and awaking unrefreshed, and as needing constant stimulus and endless tonics. Then comes the mischievous role of bromides, opium, chloral, and brandy. If the case did not begin with uterine troubles, they soon appear, and are usually treated in vain if the general means employed to build up the bodily health fail, as in many of these cases they do fail. The same remark applies to the dyspepsias and constipation which further annoy the patient and embarrass the treatment. If such a person is by nature emotional she is sure to become more so, for even the firmest women lose self-control at last under incessant feebleness. Nor is this less true of men; and I have many a time seen soldiers who had ridden boldly with Sheridan or fought gallantly with Grant become, under the influence of painful nerve-wounds, as irritable and hysterically emotional as the veriest girl. If no rescue comes, the fate of women thus disordered is at last the bed. They acquire tender spines, and furnish the most lamentable examples of all the strange phenomena of hysteria. The moral degradation which such cases undergo is pitiable. I have heard a good deal of the disciplinary usefulness of sickness, and this may well apply to brief and grave, and what I might call wholesome, maladies. Undoubtedly I have seen a few people who were ennobled by long sickness, but far more often the result is to cultivate self-love and selfishness and to take away by slow degrees the healthful mastery which all human beings should retain over their own emotions and wants. There is one fatal addition to the weight which tends to destroy women who suffer in the way I have described. It is the self-sacrificing love and over-careful sympathy of a mother, a sister, or some other devoted relative. Nothing is more curious, nothing more sad and pitiful, than these partnerships between the sick and selfish and the sound and over-loving. By slow but sure degrees the healthy life is absorbed by the sick life, in a manner more or less injurious to both, until, sometimes too late for remedy, the growth of the evil is seen by others. Usually the individual withdrawn from wholesome duties to minister to the caprices of hysterical sensitiveness is the person of a household who feels most for the invalid, and who for this very reason suffers the most. The patient has pain,--a tender spine, for example; she is urged to give it rest. She cannot read; the self-constituted nurse reads to her. At last light hurts her eyes; the mother or sister remains shut up with her all day in a darkened room. A draught of air is supposed to do harm, and the doors and windows are closed, and the ingenuity of kindness is taxed to imagine new sources of like trouble, until at last, as I have seen more than once, the window-cracks are stuffed with cotton, the chimney is stopped, and even the keyhole guarded. It is easy to see where this all leads to: the nurse falls ill, and a new victim is found. I have seen an hysterical, anaemic girl kill in this way three generations of nurses. If you tell the patient she is basely selfish, she is probably amazed, and wonders at your cruelty. To cure such a case you must morally alter as well as physically amend, and nothing less will answer. The first step needful is to break up the companionship, and to substitute the firm kindness of a well-trained hired nurse.[12]
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]
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]
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. _ |
||