Chapter 9. Dietetics And Therapeutics--(continued)

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_ CHAPTER IX. DIETETICS AND THERAPEUTICS--(CONTINUED)

As additional illustrations I shall now state a few cases of my own, without entering into minute details of treatment.

The following case is reported by Dr. John Keating, who watched it with care throughout:

P.D., male, aet. 53, after more than thirty years of close attention to business, which severely tried both mental and physical endurance, found himself, in January, 1877, at the close of some months of gradually increasing feebleness, absolutely unable to fulfil his usual duties, and the most alarming symptoms manifested themselves. There was a remarkable loss of nervous and muscular force; his limbs refused their support; his appetite failed; the recollection of ordinary phrases involved distinct and painful effort; sleep became unattainable, except under the influence of powerful narcotics, and even that brief slumber was rendered valueless by the incessant convulsive twitching of the muscles.

His physician prescribed iron and strychnia; ordered an immediate abandonment of all business, and instant departure to a point where telegraph-wires were unknown and mails infrequent. He went at once to the Bahamas, passing a month in that delicious climate in absolute inaction; more than another month was consumed in slowly returning; but, though some flesh had been gained, there was only a trifling improvement in the nervous condition.

May 1, 1877, Dr. Mitchell examined Mr. P.D. The patient was sallow and emaciated, and coughed every few moments. He had night-sweats, nervous twitching, and slight dulness on percussion at the apex of the right lung, with prolonged expiration and roughened inspiration, and some increase of vocal resonance.

Mr. P.D. was allowed to be out of bed once a day four hours, and to spend one hour at his place of business. The treatment was as follows:

At 6 A.M., a tumbler of strong, hot beef-tea, made from the Australian extract.

At 8 A.M., half a tumbler of iron-water, and breakfast, consisting of fruit, steak, potatoes, coffee, and a goblet of milk. At 8.30 A.M., a goblet of milk mixed with a dessertspoonful of Loefland's extract of malt, with six grains of citrate of iron and quinine.

At 10 o'clock Dr. Keating administered the electricity.

At 12 o'clock Mr. P.D. might be dressed, making as little personal effort as possible. The second goblet of milk and malt was administered, and a carriage took him to his office, where he might remain till two o'clock, when the carriage brought him for dinner, preceded by half a tumbler of iron-water. All walking was forbidden.

After dinner (which included a goblet of milk) the third goblet of milk and malt was swallowed; then a short drive might be taken, but by four o'clock the patient must be undressed and in bed.

At 6 P.M. the third dose of iron-water presented itself, and a light supper of fruit, bread-and-butter, and cream, followed by the fourth goblet of milk and malt. Two quarts of milk were thus swallowed every day in addition to all other food.

At 9 P.M., massage one hour, with cocoa-oil, followed by beef-soup, four ounces.

At the fourth week the soup was given up; dialyzed iron was substituted for all other forms. June 4, electricity was given up. The malt was continued until June 20.

May 6, Mr. D. weighed in heavy winter dress one hundred and twenty-five pounds; June 20, in the lightest summer garb, he weighed one hundred and thirty-three pounds; in August his weight rose to one hundred and forty pounds, and he has continued to gain. When last I saw him, a year later, he was strong and well, had no cough, and had ceased to be what he had been for years--a delicate man.

I am indebted to the late Professor Goodell for the following case, which I never saw, but which was carried on with every detail of my treatment. As the testimony of an admirable observer, it is valuable evidence. Professor Goodell writes as follows:

"Some four years ago, Mrs. Y., a very highly intelligent lady, from a neighboring city, came to consult me. She suffered dreadfully at each monthly period, and had constant ovarian pains and a wearying backache, which kept her on a lounge most of the day. She was also barren, and altogether in a pitiable condition. After a two months' treatment she returned home very much better, and soon after conceived. As pregnancy advanced, many of her old symptoms came back, but it was hoped that maternity would rid her of them. The shock of the labor, however, proved too great for her already shattered nervous system. She became far more wretched than before, and again sought my advice.

"At this time I found all her old pains and aches running riot. She got no relief from them night or day without large doses of chloral. The slightest exertion, such as sewing, writing, and reading for a few minutes, greatly wearied her. Even the simple mental effort of casting up the weekly housekeeping expenses of a very small household upset her, and she had to give it up. The act of walking one of our blocks, or of going down a short flight of stairs, or of riding for an hour in a well-padded carriage, gave her such 'unspeakable agony'--to use her own words--that she would have an hysterical attack of screams and tears. So emotional had this constant nerve-strain made her that she could not sustain an ordinary conversation without giving way to tears. Much of her time was spent in bed; in fact, she was practically bedridden.

"I tried in vain to wean her from her anodynes, and failed altogether in doing her any good, although many remedies were resorted to, and various modes of treatment adopted. Finally, in sheer despair, I put her to bed, and began your treatment of rest, with electricity, massage, and frequent feeding. The first trace of improvement showed itself in a greater self-control, and in a lessening of her aches and pains. Next, smaller doses of the anodyne were needed, until it was wholly withheld. Then she began to pick up an appetite, which, towards the close of the treatment, became so keen that, between three good meals every day, she drank several goblets of milk and of beef-tea. At the outset I had stipulated for six weeks of this treatment, and it was with reluctance that my patient yielded to my wish. But when the time was up she had become so impressed with the wonderful benefits she had received and was receiving, that she begged to have the treatment continued for two weeks more. At the end of that time she had gained at least thirty pounds in weight, and had lost every pain and ache. Her night-terrors, which I forgot to mention as one of her distressing symptoms, had wholly disappeared, and she could sleep from nine to ten hours at a stretch. I now sent her into the country, where she is continuing to mend, and is astonishing her friends by her scrambles up and down the steep hills.

"Such were the salient features of this case; and I can assure you that I was as much impressed by the happy results of the treatment as were a host of anxious and doubting friends.

"Very faithfully yours,
"WM. GOODELL."

* * * * *

Miss C., an interesting woman, aet. 26, at the age of 20 passed through a grave trial in the shape of nursing her mother through a typhoid fever. Soon after, a series of calamities deprived her of fortune, and she became, for support, a clerk, and did for two years eight hours' work daily. Under these successive strains her naturally sturdy health gave way. First came pain in the back, then growing paleness, loss of flesh, and unending sense of tire. Her work, which was a necessity, was of course kept up, steadily at first, but was soon interfered with by increase of the menstrual flow, with unusual pain and persistent ovarian tenderness. Very soon she began to drop her work for a day at a time. Then came an increasing asthenopia, with evening headaches, until her temper changed and became capricious and irritable. When I saw her, she had been forced to abandon all labor, and had been treated by an accomplished gynaecologist, and was said to be cured of a prolapsus uteri and of extensive ulceration, despite which relief she gained nothing in vigor and endurance and got back neither color nor flesh.

She went to bed December 10, and rose for the first time February 4, having gained twenty-nine pounds. She went to bed pale, and got up actually ruddy. In a month she returned to her work again, and has remained ever since in health which enables her, as she writes me, "to enjoy work, and to do with myself what I like."

Miss L., aet. 26, came to me with the following history. At the age of 20 she had a fall, and began in a week or two to have an irritable spine. Then, after a few months, a physician advised rest, to which she took only too kindly, and in a year from the time of her accident she was rarely out of bed. Surrounded by highly sympathetic relatives, to whom chronic illness was somewhat novel, she speedily developed, with their tender aid, hyperaesthetic states of the eye and ear, so that her nurses crept about in a darkened room, the piano was silenced, and the children kept quiet. By slow degrees a whole household passed under the selfish despotism of an hysterical girl. Intense constipation, anorexia, and alternate states of dysuria, anuria, and polyuria followed, and before long her sister began to fail in health, owing to the incessant exactions to which she too willingly yielded. This alarmed a brother, who insisted upon a change of treatment, and after some months she was brought on a couch to this city.

At the time I first saw her, she took thirty grains of chloral every night and three hypodermic injections of one-half grain of morphia daily. As to food, she took next to none, and I could only guess her weight at about ninety pounds. She was in height five feet two and a half inches, and very sallow, with pale lips, and the large, indented tongue of anaemia. I made the most careful search for signs of organic mischief, and, finding none, I began my treatment as usual with milk, and added massage and electricity without waiting. Her digestion seemed so good that I gave lactate of iron in twenty-grain doses from the third day, and also the aloes pill thrice a day. It is perhaps needless to state that I isolated her with a nurse she had never seen before, and that for seven weeks she saw no one else save myself and the attendants. The full schedule of diet was reached at the end of a fortnight, but the chloral and morphia were given up at the second day. She slept well the fourth night, and, save that she had twice a slight return of polyuria, went on without a single drawback. In two months she was afoot and weighed one hundred and twenty-one pounds. Her change in tint, flesh, and expression was so remarkable that the process of repair might well have been called a renewal of life.

She went home changed no less morally than physically, and resumed her place in the family circle and in social life, a healthy and well-cured woman.

I might multiply these histories almost endlessly. In some cases I have cured without fattening; in others, though rarely, the mental habits formed through years of illness have been too deeply ingrained for change, and I have seen the patient get up fat and well only to relapse on some slight occasion.

The intense persistency with which some women study and dwell upon their symptoms is often the great difficulty. Even a slight physical annoyance becomes for one of these unhappily-constituted natures a grave and almost ineradicable trouble, owing to the habit of self-study.

Miss P., aet. 29, weight one hundred and eleven pounds, height five feet four inches, dark-skinned, sallow, and covered with the acne of bromidism, had had one attack which was considered to have been epileptic, and which was probably hysterical, but on this matter she dwelt with incessant terror, which was fostered by the tender care of a near relative, who left her neither by night nor by day. Vague neuralgic aches in the limbs, with constant weariness, asthenopia, anaemia, loss of appetite, and loss of flesh, followed. Then came spinal pain and irregular menstruation, a long course of local cauterizations of the womb, spinal braces, and endless tonics and narcotics.

I broke up the association which had nearly been fatal to both women, and, confidently promising a cure, carried out my treatment in full In three months she went home well and happy, greatly improved in looks, her skin clear, her functions regular, and weighing one hundred and thirty-six pounds.

It is vain to repeat the relation of such cases, and impossible to put on paper the means for deciding--what is so large a part of success in treatment--the moral methods of obtaining confidence and insuring a childlike acquiescence in every needed measure.

Another class of cases will, however, bear some further illustration. We meet with women who are healthy in mind, but who have some chronic pain or some definite malady which does not get well, either because the usual tonics fail, or because their occupations in life keep them always in a state of exhaustion. If by rest we slow the machinery, and by massage and electricity deprive rest of its evils, we can often obtain cures which are to be had in no other way. This is true of many uterine and of some other disorders.

Miss B., aet. 37, height five feet five inches, weight one hundred and fifteen pounds, a schoolteacher, without any notable organic disease, had a severe fall, owing to an accident while driving. A slight swelling in the hurt lumbar region was followed by pain, which became intense when she walked any distance. Loss of color, flesh, and appetite ensued, and, after much treatment, she consulted me. I could find nothing beyond soreness on deep pressure, and she was anything but hysterical or emotional.

Two months' rest with the usual treatment brought her weight up to one hundred and thirty-eight pounds, and she has been able ever since to do her usual work, and to walk when and where and as far as she wished.

Several years ago I treated with some reluctance a lady who had extensive bronchitis and a slight albuminuria. This woman was a mere skeleton, with every function out of order. I undertook her case with the utmost distrust, but I had the pleasure to find her fattening and reddening like others. Her cough left her, the albumen disappeared, and she became well enough to walk and drive; when a sudden congestion of the kidneys destroyed her in forty-eight hours.

The following case of extreme anaemia, with striking resemblance to the pernicious type in some of its features, is especially interesting for the ease and rapidity of improvement under rest and massage without electricity or excessive amounts of food.

Mrs. T., aet. 40, the mother of several children, had been unwell for years, and almost totally incapacitated for exertion for two years before admission, in January, 1894. She complained of extreme feebleness, distaste for and inability to digest food, a great and constant difficulty in swallowing, shortness of breath, dropsy of the ankles if she walked or stood, hemorrhoids from which some bleeding often occurred, extreme constipation, constant chilliness, and frequent violent headaches. Her appearance was that of a person with pernicious anaemia, a very yellow muddy skin, dry and harsh to the touch, and the hands and feet cold, almost to the point of pain.

On examination the spleen was decidedly large; the lower border of the stomach reached to the level of the umbilicus. Two cardiac murmurs were present, the one a sharp and well-defined mitral regurgitant sound, confirmed by the dyspnoea and dropsy as organic, the other a loud musical murmur of haemic origin. The trouble in deglutition proved to be due to an oesophageal narrowing. The blood examination bore out the suggestion of probable pernicious anaemia, the red cells being only 1,500,000, haemoglobin 18 per cent.: the microscope showed microcytes, megaloblasts, nucleated red cells, and a large increase in white corpuscles. In order to study the effect of massage alone upon the blood no other treatment was used, though of course the patient was kept at "absolute rest." No drugs were given, electricity was not used, and extra food was omitted, as the irritability of the oesophagus made her unwilling to attempt the exertion and annoyance of frequent feeding. The general chilliness was at once helped by massage, and in a few days only felt in the small hours of the night, and the patient gained weight from the first. After one week of treatment a blood count was made: red cells were 3,800,000, more than double the former figure; haemoglobin, 35 per cent., almost double its original value. On the same day, one hour after the completion of an hour's massage, the corpuscular count had attained 5,400,000, the haemoglobin remaining 35 per cent.

At the end of two weeks the haemic murmur had faded into a faint soft bruit, though the mitral murmur was unchanged, the skin had improved in color, the aches and weariness were gone, and the blood count had reached nearly five million cells, with 50 per cent. of haemoglobin. The extraordinary results of the blood examination were confirmed by observations made by Professor Frederick P. Henry, Dr. Judson Daland, and Dr. J.K. Mitchell, who all practically agreed. Professor Henry made several studies and stained a number of slides, verifying in his report the statements of the presence of megaloblasts and nucleated red cells made above.

Owing to the necessity for an operation on the hemorrhoids, which caused loss of blood, the patient was somewhat retarded in her progress to recovery, but by the tenth week was so far better that the blood showed no microscopic abnormalities, the count was full normal, and the haemoglobin over 70 per cent. Her color and strength were good, the heart was perfectly strong, the anaemic murmur was gone, and the oesophagus was so much less irritable that it was possible to begin dilatation of the stricture.

I have heard within a year that though occasionally annoyed by this last trouble if she becomes much fatigued, she has remained in other ways well.

Mrs. G., the daughter of nervous parents, was always a nervous, over-sensitive, serious child, worked hard at Vassar, broke down, recovered, returned to college, was attacked with measles, which proved severe, and by the time she graduated had been made by her own tendencies and the anxious attention of her family into a devoted member of the class which I may permit myself to describe as health-maniacs.

Health-foods, health-corsets, health-boots, the deeply serious consideration of how to eat, on which side to sleep, profound examination of whether mutton or lamb were the more digestible flesh,--these were her occupations,--and two or three years before her panic about her health had been made worse by the discovery of an aortic stenosis, of which an over-frank doctor had thought it best to inform her. When I saw her she had been three years married, was childless, and, between the real cardiac disease and her own anxieties about it, had driven herself into a state of great physical debility and a mental condition approaching delusional insanity.

A too restricted diet, lacking both in variety and appetizingness, had had its usual result of upsetting digestion and destroying desire for food. Even with the small amounts which she ate she considered it necessary to chew so carefully and to feed herself so slowly that from one hour to an hour and a half was used for each meal. The heart, under-nourished, beat feebly, there was constant slight albuminuria with evidences of congested kidneys, and she could only rest in a semi-erect position.

The heart condition, with its renal results, proved the most rebellious part of the trouble. A firm and intelligent nurse soon overcame the difficulties and delays about food, and my final refusal to discuss them disposed for the time of some of the fanciful theories about digestion and so on. Her meals were ordered in every detail, and she was told that they were prescribed and to be taken like medicine, and, fed by the nurse, she began to take more nourishment. Massage relieved some of the labor of the heart, and gradually the semi-erect posture was exchanged inch by inch for a semi-recumbent one. Not to prolong the relation of details, it was found needful to keep this lady in bed for five months before the heart seemed to recover sufficiently to allow her to get up. Even then, although improved in color, flesh, and blood condition, she had to attain an erect station almost as slowly as she had had to reach recumbency. Slow, active Swedish movements, to which gentle resistance movements were very gradually added, helped the heart. Her cure was completed by five or six months' camp-life in the woods, and she is now the mother of a healthy child and herself perfectly well, the valvular disease only to be detected by the most careful examination, and never, even during pregnancy and parturition, causing any annoyance.

The surgeons, who once thought a floating kidney could be permanently fixed in its place by stitching, have now concluded that this is very doubtful, and the treatment of this displacement is never very satisfactory by any method. Still, some success has followed long rest in the supine position, which encourages the kidney to return to its normal place, until careful full feeding has renewed or increased the fatty cushions which hold it up. It is best during the first weeks of treatment not to allow the patient to sit or stand, or if she should be unable to avoid the occasional need for these positions, an abdominal binder must be applied by the nurse and drawn tightly before she moves. The masseuse is directed to avoid any movements which might further displace the organ, and may cautiously push it upward and hold it there with one hand while with the other the manipulation of the abdomen is performed. However long it may require, the patient should not get up until examinations, supine, lateral, prone, and erect, combine to assure us that the kidney is replaced. Repeated investigation of this point will be required,--for the kidney will sometimes be in place for a little while and next day or even a few hours later have slipped down again. Before any exertion is permitted, even ordinary walking, an accurate close-fitting abdominal belt with a kidney-pad should be applied. Those kept in stock are seldom properly adjusted, and usually have the pad in the wrong place. If rightly made, they can be worn with comfort and tight enough to be useful. If not rightly made, they are useless instruments of torture.

Mrs. Y., aet. fifty-six, was sent to Dr. J.K. Mitchell by Professor Osler for treatment. She had all the usual intestinal derangements and discomforts attendant upon a floating kidney: constipation alternated with diarrhoea, or rather with a sort of intestinal incontinence; vague pains in the back, flanks, and stomach were frequent; attacks of acute pain began in the right hypogastrium and ran down to the symphysis or into the groin; she had constant flatulence, weight, and oppression after food; was pale, flabby, and emaciated, but had no emotional or nervous symptoms except an annoying amount of insomnia. The lower border of the stomach was fully two inches below the navel in the middle-line, even when only a glass of water had been taken. It was a little lower after a small meal. The colon was distended and very variable in position, probably changing its relations with the landmarks as it happened to be more or less filled with food or gases. The abdominal walls were flabby, relaxed, and pendulous, and the whole surface tender. The patient gave a history of sudden loss of flesh with almost no reason some three years before, and increasing indigestion in all forms ever since. The tenderness made careful abdominal study difficult, but lessened enough after a few days in bed to permit the perception of a displacement of the right kidney, whose lower edge could be felt on a level with the umbilicus and two inches to the right of it. No change of position would bring it any lower. Examined with the patient prone, two-thirds of the kidney could be outlined, extremely tender, and causing nausea and sinking if pressed upon.

The chief trouble in treatment proved to be the irritability of the intestines, which was brought on in most unexpected fashion by foods of the simplest kind. For some time it was so persistent that the suspicion of intestinal tuberculosis was entertained; but it finally disappeared, and after that the case progressed more favorably and she was out of bed with a tight belt and kidney-pad in a little more than twelve weeks. The kidney was then, and has remained since, in its normal position. The patient gained twelve pounds in weight, and should have gained more, but she found the hot weather during the latter weeks of her treatment very trying. The intestinal indigestion was only partially relieved, but the gastric symptoms, the general pains, and weakness all disappeared, and with precaution she will continue to improve. It is best to advise the constant use of the belt in such a case. In a patient who has made a large gain in flesh, as this one did not, and who has been found after some months to maintain the increased weight, the belt might gradually and experimentally be left off; but repeated examinations should be made for a year or two to be sure that no displacement results.

I could relate cases of gain in flesh without manifest relief. As I have said, these are rare; but it is less uncommon to see great relief without improvement in weight at all, or until the patient is up and afoot for some weeks; and I could also state several cases in which a repetition of the treatment won a final and complete success after the first effort at cure had failed or but partially succeeded; and of this, I believe, Professor Goodell has seen several examples.

I have mentioned more than once the singular return of menstruation under this treatment, and as examples I add a brief list of some notable instances.

Mrs. N., aet. 29, no menstruation for five years; return of menstruation at thirtieth day of treatment; continued regularly ever since during three years.

Mrs. C., aet. 42, eight years without menstruation; return at fourteenth day of treatment; now regular during five months.

Miss C., aet. 22, no menstruation for eight months; return at close of sixtieth day of treatment; regular now for four months.

Miss A., aet. 26, irregular; missing for two or three months, and then menstruating irregularly for two or three months. No flow for two months. Menstruated at nineteenth day of treatment, and regular during thirteen months ever since.

I had at one time intended to give, in the first edition of this work, a summary of all my cases, with the results; but what is easy to do in definite maladies like typhoid fever becomes hard in cases such as I here relate. In fevers the statistics are simple,--patients die or get well; but in cases of nervous exhaustion, so called, it is impossible to state accurately the number of partial recoveries, or, at least, to define usefully the degrees of gain. For these reasons I have not attempted to furnish full statistics of the large number of cases I have treated.

In the debate before the British Medical Association the question of the permanence of cures by this method was the subject of discussion. I have lately been at some pains to learn the fate of many of my earlier cases, and can say with certainty that every case then treated was selected because all else had failed, and that I find relapses into the state they were in when brought to me to have been very uncommon. A vast proportion have remained in useful health, and a small number have lost a part of their gains. I now make it a rule to keep up some relation with patients after discharge, by occasional visits or by letter, and believe that in this way many small troubles are hindered from becoming large enough to cause relapses.

I said in my first edition that I did not doubt that the statements I made would give rise in some minds to that distrust which the relation of remarkable cures so naturally excites; and this I cannot blame. Every physician can recall in his own practice such cases as I have described, and every medical man of large experience knows that many of these women are to him sources of anxiety or of therapeutic despair so deep that after a time he gets to think of them as destined irredeemably to a life of imperfect health, and finds it hard to believe that any method of treatment can possibly achieve a rescue.

I am fortunate now in having been able to show that in other hands than my own, both here and abroad, this treatment has so thoroughly justified itself as to need no further defence or apology from its author. It has gratified me also to learn that in many instances country physicians, remote from the resources of great cities, have been able to make it available. As I have already said, I am now more fearful that it will be misused, or used where it is not needed, than that it will not be used; and, with this word of caution, I leave it again to the judgment of time and my profession. _

Read next: Chapter 10. Treatment Of Locomotor Ataxia, Ataxic Paraplegia, Spastic Paralysis, And Paralysis Agitans

Read previous: Chapter 8. Dietetics And Therapeutics

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