Chapter 8. Dietetics And Therapeutics

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_ CHAPTER VIII. 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 anaemia, 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 anaemia with obesity, and in the latter state uncomplicated by defective haemic 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 deg., 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 faecal 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 lithaemic 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 anaemic 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 anaemic 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.

[Footnote 26: Harvey on Corpulence.]

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 anaemia 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 haemoglobin, 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 anaemic and overloaded with fat.

Mrs. P., aet. 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 anaemia.

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., aet. 40, came under my care with partial hysterical paralysis of the right and hemi-anaesthesia 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 anaemic cases, because, while rare, they have been, to me at least, among the most difficult to manage of all the curable anaemias, 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.

[Footnote 27: The management of the morphia or chloral habit becomes much more easy under a milk diet, massage, and absolute rest, and I can with confidence commend their use in these difficult cases. Massage in the morning is liked, and general surface-rubbing without muscle-kneading at night very often proves remarkably soothing, while the rest in bed cuts off many opportunities to indulge in the temptation to secure the desired drugs.]

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 deg. 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]

[Footnote 28: I have found that this may be usefully replaced by one of the numerous peptonized foods described in the pamphlets issued by the manufacturers of the peptonizing powders. The ready-made peptonized preparations vary very much, like some of the beef extracts, but a trial will discover which of them is best fitted for an individual case.]

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, aet. 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 deg. 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]

[Footnote 29: Nerve Prostration and Hysteria.]

"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 patellae half-way down the tibiae, 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 vertebrae. 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 uraemia.' 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 gynaecologist 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 anaesthetizing 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 anaesthetic, 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, _via_ 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." _

Read next: Chapter 9. Dietetics And Therapeutics--(continued)

Read previous: Chapter 7. Electricity

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