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FAT AND BLOOD: 
 
 AN ESSAY 
 
 TREATMENT OF CEKTAIK POEMS OF 
 
 NEURASTHENIA AND HYSTERIA. 
 
 BY 
 
 S. WEIR MITCHELL, M.D., 
 
 111 
 
 MEMBER OF THE NATIONAL ACADEM'if OF SCIENCES; PHYSICIAN TO THE ORTHOPCEDIC 
 
 HOSPITAL AND INFIRMARY FOR DISEASES OF THE NERVOUS SYSTEM ; VICE- 
 PRESIDENT OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; HONORARY 
 CORRESPONDING MEMBER OF THE BRITISH MEDICAL ASSOCIA- 
 TION ; HONORARY' MEMBER OF THE LONDON MEDICAL 
 SOCIETY ; FOREIGN ASSOCIATE OF THE ROYAL 
 MEDICAL SOCIETY OF NORWAY, ETC. 
 
 FOURTH EDITION, REVISED, WITH ADDITIONS. 
 
 P H I li A D E L P H I A : 
 
 J. B. LIPPINCOTT COMPANY. 
 LONDON: 15 RUSSELL STREET, COVENT GARDEN. 
 
 1885. 
 
Copyright, 1877, by J. B. Lippincott k Co. 
 
 Copyright, 1883, by J. B. Lippincott & Co. 
 
 
TO 
 
 SAMUEL LEWIS, M.D. EDIN., M.KC.S. LOND., 
 
 EX-PRESIDENT PHILADELPHIA COLLEGE OF PHYSICIANS. 
 
 The profession in Philadelphia owes chiefly to 
 your unceasing liberality the great library of our 
 College of Physicians. Personally, I owe to you a 
 friendship which the passing years have made more 
 valuable. As a physician and a friend, therefore, 
 I gratefully dedicate to you the fourth edition of 
 this little book. 
 
 THE AUTHOE. 
 
CONTENTS. 
 
 CHAPTEE I. 
 
 PAGE 
 
 Introductoky 7 
 
 CHAPTER II. 
 Gain or Loss of Weight Clinically Considered 14 
 
 CHAPTEE III. 
 
 On the Selection of Cases for Treatment . . 33 
 
 CHAPTEE IV. 
 Seclusion 47 
 
 CHAPTEE V. 
 Eest . . 52 
 
 CHAPTEE VI. 
 Massage . . . . 71 
 
 CHAPTEE VII. 
 Electricity 86 
 
 CHAPTEE Vlil. 
 Dietetics and Therapeutics 97 
 
 Index 168 
 
 1* 5 
 
PREFACE TO THE FOUETH EDITION. 
 
 I HAVE made some slight changes in this edi- 
 tion, and have added a few not unimportant 
 points in regard to treatment. 
 
 S. WEIR MITCHELL. 
 
CHAPTER I. 
 
 INTRODUCTORY. 
 
 For some years I have been using with suc- 
 cess, in private and in hospital practice, certain 
 methods of renewing the vitality of feeble people 
 by a combination of entire rest and of excessive 
 feeding, made possible by passive exercise ob- 
 tained through the steady use of massage and 
 electricity. 
 
 The cases thus treated have been chiefly women 
 of a class well known to every physician, — ner- 
 vous women, who, as a rule, are thin and lack 
 blood. Most of them have been such as had 
 passed through many hands and been treated in 
 turn for gastric, spinal, or uteriB£_ troubles, but 
 who remained at the end as at the beginning, in- 
 valids, unable to attend to the duties_of^ife, and 
 sources alike of discomfort to themselves and 
 anxiety to others. 
 
 In 1875 I published in " Seguin's Series of 
 American Clinical Lectures," Yol. I., ^o. iv., a 
 
10 JNTR OD UCTOR V. 
 
 brief sketch of this treatment, under the heading 
 of " Rest in the Treatment of Nervous Disease," 
 but the scope afforded me was too brief for the 
 details on a knowledge of which depends success 
 in the use of rest. I have been often since re- 
 minded of this by the many letters I have 
 received asking for explanations of the minutiae 
 of treatment ; and this must be my apology for 
 bringing into these pages a great many particu- 
 lars which are no doubt well enough known to 
 the more accomplished physician. 
 
 In the preface to the second edition I said 
 that as yet there had been hardly time for a 
 competent verdict on the methods I had de- 
 scribed. Since making this statement, many 
 of our profession in America have published 
 cases of the use of my treatment. It has also 
 been thoroughly discussed by the medical sec- 
 tion of the British Medical Association, and 
 warmly endorsed by William Playfair, of Lon- 
 don, Ross, of Manchester, Coghill, and others; 
 while a translation of my book into French by 
 Dr. Oscar Jennings, with an introduction by 
 Professor Ball, has placed it satisfactorily before 
 the profession in France. 
 
 As regards the question of originality I did 
 
INTRODUCTORY. H 
 
 not and do not now much concern myself. This 
 alone I care to know, that by the method in 
 question cases are cured which once were not ; 
 and as to the novelty of the matter it would be 
 needless to say more, were it not that the charge 
 of lack of that quality is sometimes taken as an 
 imputation on a man's good faith. 
 
 But to sustain so grave an implication the 
 author must have somewhere laid claim to ori- 
 ginality and said in what respect he considered 
 himself to hav-e done a totally new thing. The 
 following passage from the first edition of this 
 book explains what was my own position : 
 
 " I do not wish," I wrote, " to be thought of 
 as putting forth anything very remarkable or 
 original in my treatment by rest, systematic 
 feeding, and passive exercise. All of these have 
 been used by physicians ; but, as a rule, one or 
 more are used without the others, and the plan 
 which I have found so valuable, of combining 
 these means, does not seem to be generally un- 
 derstood. As it involves some novelty, and as 
 I do not find it described elsewhere, I shall, I 
 think, be doing a service to my profession by 
 relating my experience." 
 
 The following quotation from Dr. William 
 
1 2 INTROD UCTOR F. 
 
 Plajfair's essay ^ says all that I would care to 
 add : 
 
 " The claims of Dr. "Weir Mitchell to origi- 
 nality in the introduction of this system of treat- 
 ment, which I have recently heard contested in 
 more than one quarter, it is not my province to 
 defend. I feel bound, however, to say that, 
 having carefully studied what has been written 
 on the subject, I can nowhere find anything in 
 the least approaching to the regular, systematic, 
 and thorough attack on the disease here dis- 
 cussed. 
 
 " Certain parts of the treatment have been 
 separately advised, and more or less successfully 
 practised, as, for example, massage and electri- 
 city, without isolation ; or isolation and judicious 
 moral management alone. It is, in fact, the old 
 story with regard to all new things : there. is no 
 discovery, from the steam-engine down to chloro- 
 form, which cannot be shown to have been par- 
 tially foreseen, and yet the claims of Watt and 
 Simpson to originality remain practically un- 
 contested. And so, if I may be permitted to 
 
 * The Systematic Treatment of Nerve Prostration and Hys- 
 toriti. London, 1883. 
 
INTRODUCTORY, 13 
 
 compare small things witli great, will it be with, 
 this. The whole matter was admirably summed 
 up by Dr. Ross, of Manchester, in his remarks in 
 the discussion I introduced at the meeting of the 
 British Medical Association at Worcester, which 
 I conceive to express the precise state of the case: 
 ' Although Dr. Mitchell's treatment was not new 
 in the sense that its separate recommendations 
 were made for the first time, it was new in the 
 sense that these recommendations were for the 
 first time combined so as to form a complete 
 scheme of treatment.' '' 
 
 As regards the acceptance of this method of 
 treatment I have to-day no complaint to make. 
 It runs, indeed, the risk of being employed in 
 cases which do not need it and by persons who 
 are not competent, and of being thus in a measure 
 brought into disrepute. As concerns one of its 
 essentials — massage — this is especially to be 
 feared. It is a remedy with capacity to hurt as 
 well as to help, and should never be used with- 
 out the advice of a physician, nor persistently 
 kept up without medical observation of its 
 temporary and more permanent effects. 
 
CHAPTEE 11. 
 
 GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED. 
 
 The gentlemen who have done me the honor 
 to follow my clinical service at the State Infirm- 
 ary for Diseases of the I'Tervous System ^ are well 
 aware how much care is there given to learn 
 whether or not the patient is losing or has lost 
 flesh, is by habit thin or fat. This question is 
 one of the utmost moment in every point of 
 view, and deserves a larger share of attention 
 than it receives. In this hospital it is the cus- 
 tom to weigh our cases when they enter and at 
 intervals. The mere loss of fat is probably of 
 small moment in itself when the amount of re- 
 storative food is sufficient for every-day expendi- 
 ture, and when the organs are in condition to 
 keep up the supply of fat which we not only 
 require for constant use but probably need to 
 
 ^ The Pennsylvania Orthopaedic Hospital and Infirmary for 
 
 Diseases of the Nervous System. 
 14 
 
GAIN OR LOSS OF WEIGHT. I5 
 
 change continually. The steady or rapid lessen- 
 ing of the deposits of hydro-carbons stored away 
 in the areolae of the tissues is of importance, 
 as indicating their excessive use or a failure of 
 supply ; and when either condition is to be sus- 
 pected it becomes our duty to learn the reasons 
 for this striking symptom. Loss of flesh has 
 also a collateral value of great import, because 
 it is almost an invariable rule that rapid thin- 
 ning is accompanied soon or late with more or 
 less anaemia, and it is uncommon to see a person 
 steadily gaining fat after any pathological reduc- 
 tion of weight without a corresponding gain in 
 amount and quality of blood. We too rarely 
 reflect that the blood thins with the decrease of 
 the tissues and enriches as they increase. 
 
 Before entering into this question further, I 
 shall ask attention to some points connected with 
 the normal fat of the human body; and, taking, 
 for granted, here and elsewhere, that my readers 
 are well enough aware of the physiological value 
 and uses of the adipose tissues, I shall continue 
 to look at the matter chiefly from a clinical point 
 of view. 
 
 When in any individual the weight varies rap- 
 idly or slowly, it is nearly always due, for the 
 
J 
 
 16 QAIB OR LOSS OF WEIGHT. 
 
 most part, to a change in tlie amount of adipose 
 tissue stored away in the meshes of the areolar 
 tissue. Almost any grave change for the worse 
 in health is at once betrayed in most people by a 
 diminution of fat, and this is readily seen in the 
 altered forms of the face, which, because it is the 
 always visible and in outline the most irregular 
 part of the body, shows first and most plainly the 
 loss or gain of tissue. Fatty matter is therefore 
 that constituent of the body which goes and 
 comes most easily. Why there is in nearly every 
 one a normal limit to its accumulation we cannot 
 say, nor yet why this limit should vary as life 
 goes on. Even in health the weight of men, and 
 still more of v^omen, is by no means constant, 
 but, as a rule, when we are holding our own with 
 that share of stored-up fat which belongs to the 
 individual we are usually in a condition of nu- 
 tritive prosperit}^, and when after any strain or 
 trial which has lessened weight we are slowly re- 
 pairing mischief and laying by fat we are equally 
 in a state of health. The loss of fat which is 
 not due to change of diet or to exercise, espe- 
 cially its rapid or steady loss, nearly always goes 
 along with conditions which impoverish the 
 blood, and, on the other hand, the gain of fat 
 
GAIN OR LOSS OF WEIGHT, 17 
 
 up to a certain point seems to go hand in hand 
 with a rise in all other essentials of health, and 
 notably with an improvement in the color and 
 amount of the red corpuscles. 
 
 The quantity of fat which is healthy for the 
 individual varies with the sex, the climate, the 
 habits, the season, the time of life, the race, and 
 the breed. Quetelet^ has shown that before pu- 
 berty the weight of the male is for equal ages 
 above that of the female, but that towards pu- 
 berty the proportional weight of the female, due 
 chiefly -to gain in fat, increases, so that at twelve 
 the two sexes are alike in this respect. During 
 the child-bearing time there is an absolute less- 
 ening on the part of the female, but after this 
 time the weight of the woman increases, and the 
 maximum is attained at about the age of fifty. 
 
 Dr. Henry I. Bowditch^ reaches somewhat 
 similar conclusions, and shows from much more 
 numerous measurements of Boston children that 
 growing boys are heavier in proportion to their 
 height than girls until they reach fifty-eight 
 inches, which is attained about the fourteenth 
 
 1 Sur rHomme, p. 47, et seq. 
 
 2 Growth of Children, p. 31. 
 
18 GAIN OR LOSS OF WEIGHT. 
 
 year. Then the girl passes the boy in weight, 
 which Dr. Bowclitch thinks is due to the accu- 
 mulation of adipose tissue at puberty. After 
 two or three years more the male again acquires 
 and retains superiority in weight and height. 
 
 Yet as life advances there are peculiarities 
 which belong to individuals and to families. One 
 group thins as life goes on past forty ; another 
 group as surely takes on flesh ; and the same 
 traits are often inherited, and are to be regarded 
 when the question of fattening becomes of clini- 
 cal or diagnostic moment. Men, as a rule, pre- 
 serve their nutritive status more equably than 
 women. Every physician must have been struck 
 with this. In fact, many women lose or acquire 
 large amounts of adipose matter without any 
 corresponding loss or gain in vigor, and this fact 
 perhaps is related in some way to the enormous 
 outside demands made by their peculiar physi- 
 ological processes. Such gain in weight is a 
 common accompaniment of child-bearing, while 
 nursing in some women involves considerable 
 gain in flesh, and in a larger number enormous 
 falling away, and its cessation as speedy a re- 
 newal of fat. I have also found that in many 
 women who are not perfectly well there is a 
 
GAIN OR LOSS OF WEIGHT. 19^ 
 
 notable loss of weight at every menstrual period, 
 and a marked o^ain between these times. — - 
 
 I was disappointed not to find this matter 
 dealt with fully in Mrs. Jacobi's able essay on 
 menstruation, nor can I discover elsewhere any 
 observations in regard to loss or gain of weight 
 at menstrual periods in the healthy woman. 
 
 How much influence the seasons have, is not 
 as yet well understood, but in our own climate, 
 with its great extremes, there are some inter- 
 esting facts in this connection. The upper 
 classes are with us in summer placed in the best 
 conditions for increase in flesh, not only because it 
 is their season of least work, mental and physical, 
 but also because they are then for the most part 
 living in the country under circumstances favor- 
 able to appetite, to exercise, and to freedom from 
 care. Owing to these fortunate facts, members 
 of the class in question are apt to gain weight in 
 summer, although many such persons, as I know, 
 follow the more general rule and lose weight. 
 But if we deal with the mass of men who are 
 hard worked, physically, and unable to leave the 
 towns, we shall probably find that they nearly 
 always lose weight in hot weather. Some support 
 is given to this idea by the following very curi- 
 
20 GAIN OR LOSS OF WEIGHT. 
 
 ous facts. Yerj many years ago I was engaged 
 for certain purposes in determining the weight, 
 height, and girth of all the members of our city 
 police force. The examination was made in 
 April and repeated in the beginning of October. 
 Every care w^as taken to avoid errors, but to my 
 surprise I found that a large majority of the 
 men had lost weight during the summer. The 
 sum total of loss was enormous. As I have mis- 
 laid some of the sheets, I am unable to give it 
 accurately, but I found that three out of every 
 ^YQ had lessened in weight. It would be inter- 
 esting to know if such a change occurs in con- 
 victs confined in penitentiaries. 
 
 I am acquainted with some persons who lose 
 weight in winter, and with more who fail in 
 flesh in the spring, which is our season of great- 
 est depression in health, — the season when with 
 us choreas are apt to originate^ or to recur, and 
 when habitual epileptic fits become more frequent 
 in such as are the victims of that disease. 
 
 Climate has a good deal to do with a tendency 
 
 * See a valuable paper by Dr. Gerhard, Am. Jour. Med. 
 Sci., 1876. Also Lectures on Diseases of the Nervous System, 
 especially in Women. S. Weir Mitchell. Phila., 1881, p. 
 127. 
 
GAIN OR LOSS OF WEIGHT. 21 
 
 to take on fat, and I think the first thing which 
 strikes an American in England is the numhe} 
 of inordinately fat middle-aged people, and es- 
 pecially of fat women. 
 
 This excess of flesh we usually associate in 
 idea with slothfulness, hut English women ex- 
 ercise more than ours, and live in a land where 
 few days forbid it, so that probably such a ten- 
 dency to obesity is due chiefly to climatic causes. 
 To these latter also we may no doubt ascribe the 
 habits of the English as to food. They are larger 
 feeders than we, and both sexes consume strong 
 beer in a manner which would in this country 
 be destructive of health. These habits aid, I 
 suspect, in producing the more general fatness 
 in middle and later life, and those enormous 
 occasional growths which so amaze an American 
 when first he sets foot in London. But, what- 
 ever be the cause, it is probable that members 
 of the prosperous classes of English, over forty, 
 would outweigh the average American of equal 
 height of that period, and this must make, I 
 should think, some difierence in their relative 
 liability to certain forms of disease, because the 
 overweisrht of our trans-Atlantic cousins is 
 plainly due to excess of fat. 
 
22 GAIN OR LOSS OF WEIGHT. 
 
 I have sought in vain for English tables giving 
 the weight of men and women of various heights 
 at like ages. The material for such a study of 
 men in America is given in Gould's researches 
 published by the United States Sanitary Com- 
 mission, and in Baxter's admirable report/ bul 
 is lacking for women. A comparison of these 
 points as between English and Americans of 
 both sexes would be of great interest. 
 
 I doubt whether in this country as notable a 
 growth in bulk as multitudes of English attain 
 Avould be either healthy or desirable in point 
 of comfort, owing to the distress which stout 
 people feel in our hot summer weather. Cer- 
 tainly " Banting" is with us a rarely-needed 
 process, and, as a rule, we have much more fre- 
 quent occasion to fatten than to thin our patients. 
 The climatic peculiarities which have changed 
 our voices, sharpened our features, and made 
 small the American hand and foot, have also 
 made us, in middle and advanced life, a thinner 
 and more sallow race, and, possibly, adapted us 
 better to the region in which we live. The same 
 
 * Statistics (Anthropological) Surgeon-General's Bureau — 
 1875. 
 
GAIN OR LOSS OF WEIGHT. 23 
 
 changes in form are in like manner showing 
 themselves in the English race in Australia.^ 
 
 Some gain in flesh as life goes on is a frequent 
 thing here as elsewhere, and usually has no un- 
 wholesome meaning. Occasionally we see people 
 past the age of sixty suddenly taking on fat and 
 becoming at once unwieldy and feeble, the fat 
 collecting in masses about the belly and around 
 the joints. Such an increase is sometimes ac- 
 companied with fatty degeneration of the heart 
 and muscles, and with a certain watery flabbi- 
 ness in the limbs, which, however, do not pit 
 on pressure. 
 
 Alcoholism also gives rise in some people to a 
 vast increase of adipose tissue, and the sodden, 
 unwholesome fatness of the hard drinker is a 
 sufficiently well known and unpleasant spectacle. 
 
 ^This excess of corpulence in the English is attained chiefly 
 after forty, as I have said. The average American is taller 
 than the average Englishman, and is fully as well built in 
 proportion to his height, as Gould has shown. The child of 
 either sex in New England is both taller and heavier than 
 the English child of corresponding class and age, as Dr. H. I. 
 Bowditch has lately made clear ; while the English of the 
 manufacturing and agricultural classes are miserably inferior 
 to the members of a similar class in America. 
 
24 GAIN OR LOSS OF WEIGHT. 
 
 The overgrowth of inert people who do not ex- 
 ercise enough to use up a healthy amount of 
 overfed tissues is common enough as an indi- 
 vidual peculiarity, but there are also two other 
 conditions in which fat is apt to be accumulated to 
 an uncomfortable extent. Thus, in some cases of 
 hysteria where the patient lies abed owing to her 
 belief that she is unable to move about, she is apt 
 in time to become enormously stout. This seems 
 to me also to be favored by the large use of 
 morphia to which such women are prone, so that 
 I should say that long rest, the hysterical consti- 
 tution, and the accompanying resort to morphia 
 make up a group of conditions highly favorable 
 to increase of fat. 
 
 Lastly, there is the class of fat anaemic people, 
 usually women. This double peculiarity is rather 
 uncommon, but, as the mass of thin-blooded per- 
 sons are as a rule thin or losing flesh, there nmst 
 be something unusual in that anaemia which goes 
 with gain in flesh. 
 
 Bauer ^ thinks that lessened number of blood- 
 corpuscles gives rise to storing of fat, owing to 
 
 iZeitschrift fur Biol., 1872. Phila. Med. Times, vol. iii., 
 page 115. 
 
GAIN OR LOSS OF WEIGHT. 25 
 
 lessened tissue -combustion. At all events, the 
 absorption of oxygen diminishes after bleeding, 
 and it used to be well known that some people 
 grew fat when bled at intervals. Also, it is said 
 that cattle-breeders in some localities — certainly 
 not in this country — bleed their cattle to cause 
 increase of fat in the tissues, or of fat secreted as 
 butter in the milk. These explanations aid us 
 but little to comprehend what, after all, is onl}^ 
 met with in certain persons, and must therefore 
 involve conditions not common to every one who 
 is ansemic. Meanwhile, the group of fat ansemics 
 is of the utmost clinical interest, as I shall by 
 and by point out more distinctly. 
 
 There is a popular idea, which has probably 
 passed from the agriculturist into the common 
 mind of the community, to the effect that human 
 fat varies, — that some fat is wholesome and some 
 unwholesome, that there are good fats and bad 
 fats. I remember well an old nurse who assured 
 me when I was a student that " some fats is fast 
 and some is fickle, but cod-oil fat is easy squan- 
 dered." 
 
 There are more facts in favor of some such 
 idea than I have place for, but as yet we have 
 no distinct chemical knowledge as to whether the 
 
26 GAIN OR LOSS OF WEIGHT. 
 
 fats put on under alcohol or morplda, or rap- 
 idly by the use of oils, or pathologically in fatty 
 degenerations, or in anaemia, vary in their con- 
 stituents. It is not at all unlikely that such is 
 the case, and that, for example, the fat of an 
 obese angemic person may differ from that of a 
 fat and florid person. The flabby, relaxed state 
 of many fat people is possibly due not alone to 
 peculiarities of the fat, but also to want of tone 
 and tension in the areolar tissues, which, from 
 all that we now know of them, may be capable 
 of undergoing changes as marked as those of 
 muscles. 
 
 That, however, animals may take on fat which 
 varies in character is well known to breeders 
 of cattle. ^' The art of breeding and feeding 
 stock," says Dr. Letheby,^ " is to overcome ex- 
 cessive tendency to accumulation of either sur- 
 face fat or visceral fat, and at the same time to 
 produce a fat which will not melt or boil away in 
 cooking. Oily* foods have a tendency to make 
 soft fats w^hich will not bear cooking." Such 
 differences are also seen between English and 
 American bacon, the former being much more 
 
 »Letheby on Food, pp. 39, 40, 41. 
 
GAIN OR LOSS OF WEIGHT. 27 
 
 solid ; and we know, also, that the fat of different 
 animals varies remarkably, and that some, as 
 the fat of hay-fed horses, is readily worked oft*. 
 Such facts as these may reasonably be held to sus- 
 tain the popular creed as to there being bad fats 
 and good fats, and they teach us the lesson that 
 in man, as in animals, there may be a difference 
 in the value of the fats we acquire, according as 
 they are gained by one means or by another. 
 
 The recent researches of L. Langer have cer- 
 tainly shown that the fatty tissues of man vary 
 at different ages, in the proportion of the fatty 
 acids they contain. 
 
 I have had occasion, of late years, to watch 
 with interest the process of somewhat rapid but 
 quite wholesome gain in flesh in persons sub- 
 jected to the treatment which I shall by and 
 by describe. Most of these persons were treated 
 by massage, and I have been accustomed to 
 question the masseur or masseuse as to the man- 
 ner in which the change takes place. Usually 
 it is first seen in the face and neck, then it is 
 noticed in the back and flanks, next in the belly, 
 and finally in the limbs, the legs coming last in 
 the order of gain, and sometimes remaining 
 comparatively thin long after other parts have 
 
28 GAIN OR LOSS OF WEIGHT. 
 
 made remarkable and visible gain. These ob- 
 servations have been checked by careful meas- 
 urements, so that I am sure of their correctness 
 for people who fatten while at rest in bed. The 
 order of increase might be different in people 
 who fatten while afoot. 
 
 Facts of this nature suggest that the putting 
 on of fat must be due to very generalized condi- 
 tions, and be less under the control of local causes 
 than is the nutrition of muscles, for, while it is 
 true that in wasting from nerve-lesions the mus- 
 cular and fatty tissues alike lessen, it is possible 
 to cause by exercise rapid increase in the bulk 
 of muscle in a limb or a part of a limb, but not 
 in any way to cause direct and limited local 
 increment of fat. 
 
 Looking back over the whole subject, it will 
 be well for the physician to remember that in- 
 crease of fat, to be a wholesome condition, should 
 be accompanied by gain in quantity and quality 
 of blood, and that while increase of ftesh after 
 illness is desirable, and a good test of successful 
 recovery, it should always go along with improve- 
 ment in color. Obesity with thin blood is one of 
 the most unmanageable conditions I know of. 
 
 The exact relations of fatty tissue to the states 
 
GAIN OR LOSS OF WEIGHT. 29 
 
 of health are not as yet well understood ; but, 
 since on great exertion or prolonged mental or 
 moral strain or in low fevers we lose fat rap- 
 idly, it may be taken for granted that each indi- 
 vidual should possess a certain surplus of this 
 readily-lost material. It is the one portion of 
 our body which oomes and goes in large amount. 
 Even thin people have it in some quantity always 
 ready, and, despite the fluctuations, every one 
 has a standard share, which varies at different 
 times of life. The mechanism which limits the 
 storing away of an excess is almost unknown, 
 and we are only aware that some foods and lack 
 of exertion favor growth in fat, while action and 
 lessened diet diminish it; but also we know that 
 while any one can be made to lose weight, there 
 are some persons who cannot be made to gain a 
 pound by any possible device, so that in this, as 
 in other things, to spend is easier than to get; 
 although it is clear that the very thin must cer- 
 tainly live, so to speak, from hand to mouth, 
 and have little for emergencies. Whether fat 
 people possess greater power of resistance as 
 against the fatal wasting of certain maladies or 
 not, does not seem to be known, and I fancy that 
 
 the popular medical belief is rather opposed to 
 
 3* 
 
30 OAIN OR LOSS OF WEIGHT. 
 
 a belief in the vital endurance of those who are 
 unusually fat. 
 
 That I am not pushing too far this idea of the 
 indicative value of gain of weight may be further 
 seen in persons who suffer from some incurable 
 chronic malady, but who are in other respects 
 well. The relief from their disease, even if tem- 
 porary, is apt to be signalled by abrupt gain in 
 weiofht. A remarkable illustration is to be found 
 iu those who suffer periodically from severe pain. 
 Cessation of these attacks for a time is sure to 
 result in the putting on of flesh. The case of 
 Captain Catlin^ is a good example. Owing to an 
 accident of war, he lost a leg, and ever since has 
 had severe neuralgic pain referred to the lost 
 leg. These attacks depend almost altogether on 
 storms. In years of fewest storms they are least 
 numerous, and the bodily weight, which is never 
 insufficient, rises. "With their increase it lowers 
 to a certain amount, beneath which it does not 
 fall. His weight is, therefore, indirectly de- 
 pendent upon the number of storms to the in- 
 fluence of which he is exposed. 
 
 1 Am. Jour. Med. Sci. ; Proc. Phil. Coll. of Phys., 1883; 
 Phil. Med. News, April, 1883. 
 
GAIN OR LOSS OF WEIGHT. 31 
 
 At present, however, we have to do most 
 largely with the means of attaining that mod- 
 erate share of stored-away fat which seems to 
 indicate a state of nutritive prosperity and to be 
 essential to those physical needs, such as protec- 
 tion and padding, which fat subserves, no less 
 than to its aesthetic value, as rounding the curves 
 of the human form. 
 
 The study of the amount of the different forms 
 of diet which is needed by jDeople at rest, and 
 by those who are active, is valuable only to en- 
 able us to construct dietaries with care for masses 
 of men and where economy is an object. In 
 dealing with cases such as I shall describe, it is 
 needful usually to give and to have digested a 
 surplus of food, so that we are more concerned 
 now to know the forms of food which thin or 
 fatten, and the means which aid us to digest 
 temporarily an excess. 
 
 As to quantity, it suffices to say that while by 
 lessening food we may easily and surely make 
 people lose weight, we cannot be sure to fatten 
 by merely increasing the amount of food given ; 
 something more is wanted in the way of digest- 
 ives or tonics to enable the patient to prepare 
 and appropriate what is given, and but too often 
 
32 GAIN OR LOSS OF WEIGHT. 
 
 we fail miserably in all our means of giving 
 capacity to assimilate food. As I have said be- 
 fore, and wish to repeat, to gain in fat is nearly 
 always to gain in blood ; and I hope to point out 
 in these pages some of the means by which these 
 ends can be attained when all usual methods 
 have failed. 
 
CHAPTER III. 
 
 ON THE SELECTION OF CASES FOR TKEATMENT. 
 
 The remarks of the last chapter have, of course, 
 wide and general application in disease, and nat- 
 urally lead up to what I have to say as to the 
 employment of the systematic treatment to de- 
 scribe 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 suc- 
 ceeded 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, diffi- 
 cult 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,^ and its 
 sphere of usefulness is therefore likely to extend 
 
 ^ Chorea. See Lancet, Aug. 1882. 
 
 33 
 
34 SELECTION OF CASES FOR TREATMENT. 
 
 beyond the limits originally set by me. It will 
 be well here, however, to state the various dis- 
 orders 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. 
 
 There are, of course, numerous cases in which 
 it becomes desirable to fatten and to make blood. 
 In many of them these are easy tasks, and in 
 some altogether hopeless. Persons who are re- 
 covering healthfully from fevers, pneumonias, 
 and other temporary maladies gather flesh and 
 make blood readily, and we need only to help 
 them by the ordinary tonics, careful feeding, and 
 change of air in due season. 
 
 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 inefl&cient, massage and the 
 use of electricity are not unimportant aids to- 
 wards health, but in such cases require to be 
 handled with an amount of caution which is less 
 requisite in miore chronic conditions of dis- 
 ordered health. 
 
 In other and fatal or graver maladies, such as, 
 for example, advanced pulmonary phthisis, how- 
 
SELECTION OF CASES FOR TREATMENT. 35 
 
 ever 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. 
 
 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 phj'sician. If I pause to dwell upon 
 these, it is because they exemplify forms of dis- 
 ease 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 t] j 
 physician. 
 
 The group I would speak of contains that large 
 number of people who are kept meagre and often 
 also ansemic 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-con- 
 tinued 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 
 
56 SELECTION OF CASES FOR TREATMENT. 
 
 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 value- 
 less; 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, and 
 'which I have yet to describe, 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 de- 
 fined as having spinal irritation, if that be the 
 prominent symptom. To it I must add cases in 
 which, besides the wasting and anaemia, emo- 
 tional manifestations predominate, and which are 
 
 ' then called hysterical, whether or not they ex- 
 
 ^)iibit 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 
 
SELECTION OF CASES FOR TREATMENT. 37 
 
 continues to exhibit only the single phase of 
 nervous exhaustion or of spinal irritation. Far 
 more often she runs the gauntlet of nerve-doc- 
 tors, 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. l!^ow, 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 fol- 
 lows exertion, and though while under excite- 
 ment or in the presence of some dominant mo- 
 tive 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 trouble- 
 
 4 
 
38 SELECTION OF CASES FOR TREATMENT. 
 
 some 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 under- 
 taken the hard task of nursing a relative, and 
 have gone through this severe duty with the ad- 
 dition 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 ef- 
 fort, 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 b}^ 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 sleep- 
 
SELECTION OF CASES FOR TREATMENT. 39 
 
 ing ill and awaking un refreshed , and as need- 
 ing: 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 em- 
 ployed to build up the bodily health fail, as in 
 many of these cases they do fail. The same re- 
 mark 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. JSTor is this less true of 
 men ; and I have many a time seen soldiers who 
 had ridden boldly with Sheridan or fought gal- 
 lantly with Grant become, under the influence 
 of painful nerve-wounds, as irritable and hys- 
 terically emotional as the veriest ^irl. 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 un- ' 
 dergo is pitiable. I have heard a good deal of 
 the disciplinary usefulness of sickness, and this , 
 
40 SELECTION OF CASES FOR TREATMENT. 
 
 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 
 
 j growth of the evil is seen by others. Usually 
 
 (the individual withdrawn from wholesome duties 
 
 to minister to the caprices of hysterical sensi- 
 
 /tiveness is the person of a household who feels 
 
 most for the invalid, and who for this very 
 
 Ireason suffers the most. The patient has pain, 
 
 — a tender spine, for example ; she is urged to 
 
SELECTION OF CASES FOR TREATMENT. 4X 
 
 give it rest. She cannot read; the self-consti- 
 tuted 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 kind- 
 ness 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 prob- 
 ably amazed, and wonders at your cruelty. To 
 cure such a case you must morally alter as well 
 as physically amend, and nothing less will an- 
 swer. The first step needful is to break up the 
 companionship, and to substitute the firm kind- 
 ness of a well-trained hired nurse.^ 
 
 Another form of evil to be encountered in 
 these cases is less easy to deal with. Such an 
 
 ^" Nurse and Patient." S. Weir Mitchell. Lippincott'a 
 Magazine, Dec. 1872. 
 
 4* 
 
42 SELECTION OF CASES FOR TREATMENT. 
 
 invalid has by unhappy chance to live with some 
 near relative whose temperament is also nervous 
 and who is impatient or irritable. Two such 
 people produce endless mischief for each other. 
 Occasionally there is a strange incompatibility 
 which it is difficult to define. The two people 
 who, owing to their relationship, depend the 
 one on the other, are, for no good reason, made 
 unhappy by their several peculiarities. Life- 
 long annoyance results, and for them there is 
 no divorce possible. 
 
 in a smaller number of cases, which have less 
 tendency to emotional disturbances, the phe- 
 nomena are more simple. You have to deal 
 with a woman who has lost flesh and grown 
 colorless, but has no hysterical tendencies. She 
 i 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 pro- 
 portion of them no value, or little value, and 
 i 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 
 
SELECTION OF CASES FOR TREATMENT. 43 
 
 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 dis- 
 orders 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 in- 
 sure 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 ' 
 
44 SELECTION OF CASES FOR TREATMENT, 
 
 I can add largely to the weiglit and fill the ves- 
 sels with red blood, I am usually sure of giving 
 \ general relief to a host of aches, pains, and 
 jvaried disabilities. If I fail, it is because I fail 
 in these very points, or else because I have over- 
 looked or undervalued some serious organic tis- 
 sue-change. 
 
 f. 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 in- 
 volves a good deal that is costly. ISTeither does 
 it answer as well, and for obvious treasons, 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 Play fair remarks^the half-ill who 
 constitute the difiicult 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 dis- 
 ease does; but intestinal troubles which are not 
 tubercular or malignant do not ; nor do moder- 
 ate signs of chronic pulmonary deposits, or bron- 
 
SELECTION OF CASES FOR TREATMENT. 45 
 
 chitis, nor, as a rule, heart disease in its milder 
 forms.^ 
 
 On the other hand, the true melancholias, which .' 
 are not merely depression of spirits from loss of 
 all hope of relief, are best let alone, as far as 
 this treatment is concerned. The nutritive fail- 
 ures which so often accompany them must be 
 met by other means than rest, seclusion, etc. ;f 
 and in this opinion I am sustained by some fail- 
 ures on my own part, and by the opinions of 
 Goodell and PI ay fair. 
 
 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 en- 
 able 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 fail- 
 ure. 
 
 The treatment I am about to describe consists 
 in seclusion, certain forms of diet, rest in bed, 
 massage (or manipulation), and electricity ; and 
 
 * See Philip Karell's remarks on the use of treatment by 
 milk in cardiac hypertrophy. Edin. Med Jour., Aug. 1866. 
 
46 SELECTION OF CASES FOR TREATMENT. 
 
 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 
 j used separately in some instances, I shall have 
 I occasion to point out as I discuss the various 
 \ agencies alluded to. 
 
CHAPTER lY. 
 
 SECLUSION. 
 
 It is rare to find any of the class of patients I 
 have described so free from the influence of their 
 habitual surroundings as to make it easy to treat 
 them in their own homes. It is needful to dis- 
 entangle them from the meshes of old habits and 
 to remove them from contact with those who 
 have been the willing slaves of their caprices. 
 I have often made the effort to treat them 
 where they have lived and to isolate them there, 
 but I have rarely done so without promising 
 myself that I would not again complicate my 
 treatment by any such embarrassments. Once 
 separate the patient from the moral and physical 
 surroundings which have become part of her life 
 of sickness, and you will have made a change 
 which will be in itself beneficial and will enor- 
 mously aid in the treatment which is to follow. 
 Of course this step is not essential in such cases 
 
 as are merely ansemic, feeble, and thin, owing to 
 
 47 
 
48 SECLUSION. 
 
 distinct causes, like tlie exhaustion of overwork, 
 blood-losses, dyspepsia, low fevers, or nursing. 
 There are but too many women who have broken 
 down under such causes and failed to climb again 
 to the level of health, despite all that could be 
 done for them ; and when such persons are free 
 from emotional excitement or hysterical compli- 
 cations there is no reason why the seclusion need- 
 ful to secure them repose of mind should not be 
 pleasantly modified in accordance with the dic- 
 tates of common sense. Very often a little ex- 
 perimentation as to what they will profitably bear 
 in the way of visits and the like will inform us, 
 as their treatment progresses, how far such in- 
 dulgence is of use or free from hurtful influences. 
 Cases of extreme neurasthenia in men accom- 
 panied with nutritive failures require as to this 
 matter cautious handling, because, for some 
 reason, the ennui of rest and seclusion is far 
 better borne by women than by the other sex. 
 
 Even in cases whose moral aspects do not at 
 once suggest an imperative need for seclusion it 
 is well to remember, as regards neurasthenic peo- 
 ple, that the treatment involxes for a time daily 
 visits of some length from the masseur, the doc- 
 tor, and possibly an electrician, and that to add 
 
SECLUSION. 49 
 
 to these even a single friendly visitor is often too 
 much to be readily borne ; but I am now speak- 
 ing chiefly of the large and troublesome class of 
 thin-blooded emotional women, for whom a state 
 of weak health has become a long and, almost I 
 might say, a cherished habit. For them there is 
 often no success possible until we have broken 
 up the whole daily drama of the sick-room, with 
 its little selfishness and its craving for sympathy 
 and indulgence. ISTor should we hesitate to in- 
 sist upon this change, for not only shall we then 
 act in the true interests of the patient, but we 
 shall also confer on those near to her an inesti- 
 mable benefit. An hysterical girl is, as Wendell 
 Holmes has said in his decisive phrase, a vam- 
 pire who sucks the blood of the healthy people 
 about her; and I may add that ]3retty surely 
 where there is one hysterical girl there will be 
 soon or late two sick women. If circumstances 
 oblige us to treat such a person in her own home, 
 let us at least change her room, and also have it 
 well understood how far we are to control her 
 surroundings and to govern as to visitors and the 
 company of her own family. Do as we may, we 
 shall always lessen thus our chances of success, 
 but we shall certainly not altogether destroy them. 
 
50 SECLUSION. 
 
 I should add here a few words of caution as 
 to the time of year best fitted for treatment. In 
 the summer seclusion is often undesirable when 
 the patient is well enough to gain help by change 
 of air ; moreover, at this season massage is less 
 agreeable than in winter, and, as a rule, I find it 
 harder to feed and to fatten persons at rest dur- 
 ing our summer heats. That this rule is not 
 without exception has been shown by Drs. 
 Goodell and Sinkler, both of whom have attained 
 some remarkable successes in midsummer. 
 
 One of the questions of most importance in the 
 carrying out of this treatment is the choice of a 
 nurse. Just as it is desirable to change the 
 home of the patient, her diet, her atmosphere, so 
 also is it well, for the mere alterative value of 
 such change, to surround her with strangers and 
 to put aside any nurse with whom she may have 
 grown familiar. As I have sometimes succeeded 
 in treating invalids in their own homes, so have 
 I occasionally been able to carry through cases 
 nursed by a mother, or sister, or friend of ex- 
 ceptional firmness ; but to attempt this is to be 
 heavily handicapped, and the position should 
 never be accepted if it be possible to make other 
 arrangements. Any firm, intelligent woman of 
 
SECLUSION. 51 
 
 tact, a stranger to the patient, is better than the 
 old style of nurse, now, happily, disappearing. 
 The nurse for these cases ought to be a young, 
 active, quick-witted woman, capable of firmly 
 but gently controlling her patient. She ought to 
 be intelligent, able to interest her patient, to read 
 aloud, and to write letters. The more of these 
 cases she has seen and nursed, the easier becomes 
 the task of the doctor. It is always to be borne 
 in mind that most of these patients are over- 
 sensitive, refined, and educated women, for 
 whom the clumsiness, or want of neatness, or 
 bad manners, or immodesty of a nurse may be a 
 sore and steadily-increasing trial. To be more 
 or less isolated for two months, in a room with, 
 one constant attendant, however good, is hardl 
 enough for any one to endure ; and certain quite • 
 small faults or defects in a nurse may make her a 
 serious impediment to the treatment, because no 
 mere technical training will dispense in the nurse 
 any more than in the physician with, those finer 
 natural qualifications which make their training 
 available. But one nurse will suit one patient 
 and not another : so that I never hesitate to 
 change my nurse if she does not fit the case. 
 
CHAPTER Y. 
 
 REST. 
 
 I HAVE said more than once in the early chap- 
 ters of this little volume that the treatment I 
 wished to advise as of use in a certain range of 
 cases was made up of rest, massage, electricity, 
 and over-feeding. I said that the use of large 
 amounts of food while at rest, more or less en- 
 tire, was made possible by the practice of knead- 
 ing the muscles and by moving them with cur- 
 rents able to effect this end. I desire now to 
 discuss in turn the mode' in which I employ rest, 
 massage, and electricity, and, as I have promised, 
 I shall take pains to give, in regard to these three 
 subjects, the fullest details, because success in the 
 treatment depends, I am sure, on the care with 
 which we look after a number of things each in 
 itself apparently of slight moment. 
 
 I have no' doubt that many doctors have seen 
 
 fit at times to put their patients at rest for great 
 
 or small lengths of time, but the person who of 
 52 
 
REST. 53 
 
 all others within my knowledge used this means 
 most, and used it so as to obtain the best results, 
 was the late Professor Samuel Jackson. He was 
 in the habit of making his patients remain in bed 
 for many weeks at a time, and, if I recall his 
 cases well, he used this treatment in just the class 
 of disorders among women which have given me 
 the best results. What these are I have been at 
 some pains to define, and I have now only to 
 show why in such people rest is of service, and 
 what I mean by rest, and how I apply it. 
 
 In 'Eo. lY. of Dr. Seguin's series of American 
 Clinical Lectures, I was at some pains to point 
 out the value of repose in neuralgias, and especi- 
 ally sciatica, in myelitis, and in the early stages 
 of locomotor ataxia, and I have since then had 
 the pleasure of seeing these views very fully ac- 
 cepted. I shall now confine myself chiefly to its 
 use in the various forms of weakness which exist 
 with thin blood and wasting, with or without 
 distinct lesions of the stomach, womb, or other 
 organs. 
 
 Whether we shall ask a patient to walk or to 
 take rest is a question which turns up for an- 
 swer almost every day in practice. Most often 
 
 we incline to insist on exercise, and are led to do 
 
 5* 
 
54 REST. 
 
 SO from a belief that many people walk too little, 
 and that to move about a good deal every day is 
 w^ell for everybody. I think we are as often 
 wrong as right. A good brisk daily walk is for 
 well folks a tonic, breaks down old tissues, and 
 creates a wholesome demand for food. The 
 same is true for some sick people. The habit of 
 horse-exercise or a long walk every day is needed 
 to cure or to aid in the cure of disordered stomach 
 and costive bowels, but if all exertion gives rise 
 only to increase of trouble, to extreme sense of 
 fatigue, to nausea, to headache, what shall we 
 do ? And suppose that tonics do not help to 
 make exertion easy, and that the great tonic of 
 change of air fails us, shall we still persist? And 
 here lies the trouble : there are women who 
 mimic fatigue, who indulge themselves in rest on 
 the least pretence, who have no symptoms so 
 truly honest that we need care to regard them. 
 These are they who spoil their own nervous sys- 
 tems as they spoil their children, when they have 
 them, by yielding to the least desire and teaching 
 them to dwell on little pains. For such people 
 there is no help but to insist on self-control and 
 on daily use of the limbs. They must be told to 
 exert themselves, and made to do so if that can 
 
REST. 65 
 
 be. If they are young, this is easy enough. K 
 they have grown to middle life, and created 
 habits of self-indulgence, the struggle is often 
 useless. But few, however, among these women 
 are free from some defect of blood or tissue, 
 either original or acquired as a result of years of 
 indolence and attention to aches and ailments 
 which should never have had given to them more 
 than a passing thought, and which certainly 
 should not have been made an excuse for the 
 sofa or the bed. 
 
 Sometimes the question is easy to settle. If 
 you find a woman who is in good condition as 
 to color and flesh, and who is always able to do 
 what it pleases her to do, and who is tired by 
 what does not please her, that is a woman to 
 order out of bed and to control with a firm and 
 steady will. That is a woman who is to be made 
 to walk, with no regard to her complaints, and 
 to be made to persist until exertion ceases to 
 give rise to the mimicry of fatigue. In such 
 cases the man who can insure belief in his opin- 
 ions and obedience to his decrees secures very 
 often most brilliant and sometimes easy success ; 
 and it is in such cases that women who are in all 
 other ways capable doctors fail, because they do 
 
56 ^^'^^• 
 
 not obtain the needed control over those of their 
 own sex. I have been struck with this a num- 
 ber of times, but I have also seen that to be too 
 long and too habitually in the hands of one phy- 
 sician, even the wisest, is for some cases of hys- 
 teria the main difficulty in the way of a cure, — it 
 is so easy to disobey the familiar friendly attend- 
 ant, so hard to do this where the physician is a 
 stranger. But we all know well enough the per- 
 sonal value of certain doctors for certain cases. 
 Mere hygienic advice will win a victory in the 
 hands of one man and obtain no good results in 
 those of another, for we are, after all, artists who 
 all use the same means to an end but fail or suc- 
 ceed according to our method of using them. 
 There are still other cases in which mischievous 
 tendencies to repose, to endless tire, to hysteri- 
 cal symptoms, and to emotional displays have 
 grown out of defects of nutrition so distinct that 
 no man ought to think for these persons of mere 
 exertion as a sole means of cure. The time 
 comes for that, but it should not come until en- 
 tire rest has been used, with other means, to fit 
 them for making use of their muscles. Nothing 
 upsets these cases like over-exertion, and the at- 
 tempt to make them walk usually ends in some 
 
REST. 57 
 
 miscliievous emotional display, and in creating a 
 new reason for thinking that they cannot walk. 
 As to the two sets of cases just sketched, no one 
 need hesitate; the one must walk, the other 
 should not until we have bettered her nutritive 
 state. She may be able to drag herself about, 
 but no good will be done by making her do so 
 But between these two classes, and allied by 
 certain symptoms to both, lie the larger number 
 of such cases, giving us every kind of real and 
 imagined symptom, and dreadfully well fitted to 
 puzzle the most competent physician. As a rule, 
 no harm is done by rest, even in such people as 
 give us doubts about whether it is or is not well 
 for them to exert themselves. There are plenty 
 of these women who are just well enough to 
 make it likely that if they had motive enough 
 for exertion to cause them to forget themselves 
 they would find it useful. In the doubt I am 
 rather given to insisting on rest, but the rest I 
 like for them is not at all their notion of rest 
 To lie abed half the day, and sew a little and 
 read a little, and be interesting as invalids and 
 excite sympathy, is all very well, but when they 
 are bidden to stay in bed a month, and neither to 
 read, write, nor sew, and to have one nurse, — 
 
58 REST. 
 
 who is not a relative, — then repose becomes for 
 some women a rather bitter medicine, and they 
 are glad enough to accept the order to rise and go 
 about when the doctor issues a mandate which has 
 become pleasantly welcome and eagerly looked 
 for. I do not think it easy to make a mistake in 
 this matter unless the woman takes with morbid 
 delight to the system of enforced rest, and unless 
 the doctor is a person of feeble will. I have 
 never met myself with any serious trouble about 
 getting out of bed any woman for whom I 
 thought rest needful, but it has happened to 
 others, and the man who resolves to send any 
 nervous woman to bed must be quite sure that 
 she will obey him when the time comes for her 
 to get up. 
 
 I have, of course, made use of every grade of 
 rest for my patients, from insisting upon repose 
 on a lounge for some hours a day up to entire 
 rest in bed. In carrying out my general plan of. 
 treatment in extreme cases it is my habit to ask 
 the patient to remain in bed from six weeks to 
 two months.- At first, and in some cases for four 
 or five weeks, I do not permit the patient to sit 
 up, or to sew or write or read, or to use the hands 
 in any active way except to clean the teeth. 
 
REST. 59 
 
 "Where at first the most absolute rest is desirable, 
 I arrange to have the bowels and water passed 
 while lying down, and the patient is lifted on to 
 a lounge for an hour in the morning and again 
 at bedtime, and then lifted back again into the 
 newly-made bed. In most cases of weakness, 
 treated by rest, I insist on the patient being fed 
 by the nurse, and, when well enough to sit up in 
 bed, I insist that the meats shall be cut up, so as 
 to make it easier for the patient to feed herself. 
 
 In many cases I allow the patient to sit up in 
 order to obey the calls of nature, but I am al- 
 ways careful to have the bowels kept reasonably 
 free from costiveness, knowing well how such a 
 state and the efforts it gives rise to enfeeble a sick 
 person. 
 
 The daily sponging bath is to be given by the ' 
 nurse, and should be rapidly and skilfully done. 
 It may follow the first food of the day, the early \ 
 milk, or cocoa, or coffee, or, if preferred, may be 
 used before noon, or at bedtime, which is found 
 in some cases to be best and to promote sleep. 
 
 For some reason, the act of bathings or even 
 the being bathed, is mysteriously fatiguing to 
 certain invalids, and if so I have the general 
 sponging done for a time but thrice a week. 
 
60 REST. 
 
 Most of these patients suffer from use of the 
 eyes, and this makes it needful to prohibit read- 
 ing and writing, and to have all correspondence 
 carried on through the nurse. But many neuras- 
 thenic people also suffer from being read to, or, 
 in other words, from any prolonged effort at 
 attention. In these cases it will be found that if 
 the nurse will read the morning paper, and as 
 she does so relate such news as may be of in- 
 terest, the patient will bear it very well, and will 
 by degrees come to endure the hearing of such 
 reading as is already more or less familiar. 
 
 Usually, after a fortnight I permit the patient 
 to be read to, — one to three hours a day, — but I 
 am daily amazed to see how kindly nervous and 
 anaemic women take to this absolute rest, and 
 how little they complain of its monotony. In 
 fact, the use of massage and the battery, with 
 the frequent comings of the nurse with food, and 
 the doctor's visits, seem so to fill up the day as 
 to make the treatment less tiresome than might 
 be supposed. And, besides this, the sense of 
 comfort which is apt to come about the fifth or 
 sixth day, — the feeling of ease, and the ready 
 capacity to digest food, and the growing hope 
 of final cure, fed as it is by present relief, — all 
 
REST. 61 
 
 conspire to make most patients contented and 
 tractable. 
 
 The intelligent and watchful physician must, 
 of course, know how far to enforce and when 
 to relax these rules. When it is needful, as it 
 sometimes is, to prolong the state of rest to two 
 or three months, the patient may need at the 
 close occupation of some kind, and especially 
 such as, while it does not tax the eyes, -gives 
 the hands something to do, the patient being, 
 we suppose, by this time able tQ sit up in bed 
 during a part of the day. 
 
 The moral uses of enforced rest are readily 
 estimated. From a restless life of irregular 
 hours, and probably endless drugging, from 
 hurtful sympathy and over-zealous care, the 
 patient passes to an atmosphere of quiet, to 
 order and control, to the system and care of a 
 thorough nurse, to an absence of drugs, and to 
 simple diet. The result is always at first, what- 
 ever it may be afterwards, a sense of relief, and 
 a remarkable and often a quite abrupt disap- 
 pearance of many of the nervous symptoms with 
 which we are all of us only too sadly familiar. 
 
 All the moral uses of rest and isolation and 
 
 change of habits are not obtained by merely 
 
 6 
 
62 REST. 
 
 insisting on the physical conditions needed to 
 effect these ends. If the physician has the force 
 of character required to secure the confidence 
 and respect of his patients, he has also much 
 more in his power, and should have the tact to 
 seize the proper occasions to direct the thoughts 
 of his patients to the lapse from duties to others, 
 and to the selfishness which a life of invalidism 
 is apt to bring about. Such moral medication 
 belongs to the higher sphere of the doctor's 
 duties, and, if he means to cure his patient per- 
 manently, he cannot afford to neglect them. 
 Above all, let him be careful that the masseuse 
 and the nurse do not talk of the patient's ills, and 
 let him by degrees teach the sick person how 
 very essential it is to speak of her aches and 
 pains to no one but himself. 
 
 I have often asked myself why rest is of value 
 in the cases of which I am now speaking, and 
 I have already alluded briefly to some of the 
 modes in which it is of use. 
 
 Let us take first the simpler cases. We meet 
 'now and then with feeble people who are dys- 
 peptic, and who find that exercise after a meal, 
 or indeed much exercise on any day, is sure to 
 cause loss of power or lessened power to digest 
 
REST. 63 
 
 food. The same thing is seen in an extreme 
 degree in the well-known experiment of causing 
 a dog to ran violently after eating, in which case 
 digestion is entirely suspended. "Whether these 
 results be due to the calling oiF of blood from 
 the gastric organs to the muscles, or whether the 
 nervous system is, for some reason, unable to 
 evolve at the same time the force needed for a 
 double purpose, is not quite clear, but the fact 
 is undoubted, and finds added illustrations in 
 many of the class of exhausted women. It is 
 plain that this trouble exists in some of them. 
 It is likely that it is present in a larger number. 
 The use of rest in these people admits of no 
 question. If we are to give them the means in 
 blood and flesh of carrying on the work of life, 
 it must be done with the aid of the stomach, and 
 we must humor that organ until it is able to act 
 in a more healthy manner under ordinary con- 
 ditions. 
 
 I am often asked how I can expect by such a 
 system to rest the organs of mind. I^o act of 
 will can force them to be at rest. To this I 
 should answer that it is not the mere half-auto- 
 matic intellectuation which is harmful in men or 
 women subject to states of feebleness or neuras- 
 
64 REST. 
 
 thenia, and that the systematic vigorous use of 
 mind on distinct problems is within some form 
 of control. It is thought with the friction of 
 worry, which injures, and, unless we can secure 
 an absence of this, it is in vain to hope for help 
 by the method I am describing. The man har- 
 assed by business anxieties, the woman with 
 morbidly-developed or ungoverned maternal in- 
 stincts, will only illustrate the causes of failure. 
 Perhaps in all dubious cases Dr. Playfair's rule 
 is not a bad one, to consider, and to let the 
 patient consider, this mode of treatment as a hope- 
 ful experiment, which may have to be abandoned, 
 and which is valueless without the cordial and 
 submissive assistance of the patient. 
 
 The muscular system in many of such patients 
 — I mean in ever-weary, thin and thin-blooded 
 persons — is doing its work with constant diffi- 
 culty. As a result, fatigue comes early, is ex- 
 treme, and lasts long. The demand for nutritive 
 aid is ahead of the supply, or else the supply is 
 incompetent as to quality, and before the tissues 
 are rebuilded a new demand is made, so that 
 the materials of disintegration accumulate, and 
 \ do this the more easily because the eliminative 
 organs share in the general defects. And these 
 
REST. 65 
 
 are some of the reasons why angemic people are 
 always tired; but, besides this, all real sensa- 
 tions are magnified by women whose nervous 
 systems have become sensitive owing to a life of 
 attention to their ailments, and so at last it be- 
 comes hard to separate the true from the false, 
 and we are thus led to be too sceptical as to the 
 presence of real causes of annoyance. Certain 
 it is that rest, under proper conditions, is found 
 by such sufferers to be a great relief; but rest 
 alone will not answer, and it is needful, as I shall 
 show, to bring to our help certain other means, 
 in order to secure all the good which repose may 
 be made to insure. 
 
 In dealing with this, as with every other 
 medical means, it is well to recall that in our 
 attempts to help we may sometimes do harm, 
 and we must make sure that in causing the 
 largest share of good we do the least possible 
 evil. 
 
 " The one goes with the other, as shadow 
 with light, and to no therapeutic measure does 
 this apply more surely than to the use of rest. 
 
 "Let us take the simplest case, — that which 
 
 arises daily in the treatment of joint-troubles or 
 
 broken bones. We put the limb in splints, and 
 e 6* 
 
QQ BEST. 
 
 • thus, for a time, check its power to move. The 
 bone knits, or the joint gets well ; but the 
 muscles waste, the skin dries, the nails may for 
 a time cease to grow, nutrition is brought down, 
 as an arithmetician would say, to its lowest 
 terms, and when the bone or joint is well we 
 have a limb which is in a state of disease. As 
 concerns broken bones, the evil may be slight 
 and easy of relief, if the surgeon will but re- 
 member that when joints are put at rest too long 
 they soon fall a prey to a form of arthritis, which 
 is the more apt to be severe the older the patient 
 is, and may be easily avoided by frequent motion 
 of the joints, which, to be healthful, exact a cer- 
 tain share of daily movement. If, indeed, with 
 perfect stillness of the fragments we could have 
 the full life of a limb in action, I suspect that the 
 cure of the break might be far more rapid. 
 
 " What is true of the part is true of the whole. 
 
 When we put the entire body at rest we create 
 
 certain evils while doing some share of good, 
 
 and it is therefore our part to use such means as 
 
 i shall, in every case, lessen and limit the ills we 
 
 ( cannot wholly avoid. How to reach these ends 
 
 I I shall by and by state, but for a brief space I 
 
 ' should like to dwell on some of the bad results 
 
REST. 67 
 
 which come of our efforts to reach through rest 
 in bed all the good which it can give us, and to 
 these points I ask the most thoughtful attention, 
 because upon the care with which we meet and 
 provide for them depends the value which we 
 will get out of this most potent means of treat- 
 ment. 
 
 " When we put patients in bed and forbid ' 
 them to rise or to make use of their muscles, 
 we at once lessen appetite, weaken digestion inj 
 many cases, constipate the bowels, and enfeeble 
 circulation."^ 
 
 When we put the muscles at absolute rest ■ 
 we create certain difficulties, because the normal 
 acts of repeated movement insure a certain rate 
 of nutrition which brings blood to the active 
 parts, and without which the currents flow more 
 largely around than through the muscles. The 
 lessened blood-supply is a result of diminished 
 functional movement, and we need to create a 
 constant demand in the inactive parts. But, be- 
 sides this, every active muscle is practically a 
 throbbing heart, squeezing its vessels empty 
 while in motion, and relaxing, so as to allow 
 
 ^Soguin Lecture, op. cif. 
 
68 REST. 
 
 them to fill up anew. Thus, both for itself and 
 in its relations to the areolar spaces and to the 
 rest of the body, its activity is functionally of 
 service. Then, also, the vessels, unaided by 
 changes of posture and by motion, lose tone, and 
 the distant local circuits, for all of these reasons, 
 cease to receive their normal supply, so that de- 
 fects of nutrition occur, and, with these, defects 
 of temperature. 
 
 " I was struck with the extent to which these 
 evils may go, in the case of Mrs. P., set. 52, who 
 was brought to me from Kew Jersey, having 
 been in bed fifteen years. I soon knew that 
 she was free of grave disease, and had stayed 
 in bed at first because there was some lack of 
 power and much pain on rising, and at last 
 because she had the firm belief that she could 
 not walk. After a wreck's massage I made 
 her get up. I had won her full trust, and she 
 obeyed, or tried to obey me, like a child. But 
 she would faint and grow deadly pale, even if 
 seated a short time. The heart-beats rose from 
 sixty to one hundred and thirty, and grew fee- 
 ble; the breath came fast, and she had to lie 
 down at once. Her skin was dry, sallow, and 
 bloodless, her muscles flabby ; and when, at last, 
 
REST. 69 
 
 after a fortnight more, I set her on her feet 
 again, she had to endure for a time the most 
 dreadful vertigo and alarming palpitations of the 
 heart, while her feet, in a few minutes of feeble 
 walking, would swell so as to present the most 
 strange appearance. By and by all this went 
 away, and in a month she could walk, sit up, 
 sew, read, and, in a word, live like others. She 
 went home a well-cured woman. 
 
 " Let us think, then, when we put a person in 
 bed, that we are lessening the heart-beats some 
 twenty a minute, nearly a third; that we are 
 causing the tardy blood to linger in the by-ways 
 of the blood-round, for it has its by-ways ; that 
 rest in bed binds the bowels, and tends to de- 
 stroy the desire to eat ; and that muscles at rest 
 too long get to be unhealthy and shrunken in 
 substance. Bear these ills in mind, and be 
 ready to meet them, and we shall have answered 
 the hard question of how to help by rest without 
 hurt to the patient." 
 
 "When I first made use of this treatment I 
 allowed my patients to get up too suddenly, and 
 in some cases I thus brought on relapses and a 
 return of the feeling of painful fatigue. I also 
 saw in some of these cases what I still see at 
 
70 REST. 
 
 times under like circumstances, — a rapid loss of 
 flesh. 
 
 I now begin by permitting the patient to sit 
 up in bed, then to feed herself, and next to sit 
 up out of bed a few minutes at bedtime. In a 
 week, she is desired to sit up fifteen minutes 
 twice a day, and this is gradually increased until, 
 at the end of six to twelve weeks, she rests on 
 the bed only three to five hours daily. Even 
 after she moves about and goes out, I insist for 
 two months on absolute repose at least two or 
 three hours daily. 
 
 The use of a hammock is found by some 
 people to be a very agreeable change from the 
 bed during a part of the day. 
 
CHAPTER YL 
 
 MASSAGE. 
 
 How to deprive rest of its evils is the subject 
 with which I might very well have labelled this 
 chapter. I have pointed out what I mean by 
 rest, how it hurts, and how it seems to help ; 
 and, as I believe that it is useful in most cases 
 only if employed in conjunction with other 
 means, the study of these becomes of the first 
 importance. 
 
 The two aids which by degrees I learned to 
 call upon with confidence to enable me to use 
 rest without doing harm are massage and elec- 
 tricity. "We have first to deal with massage, and 
 I willingly give to it a chapter of careful detail, 
 because as yet it is little understood in America, 
 and because I have some facts to relate in regard 
 to it which are not known, I think, on either 
 side of the Atlantic. 
 
 Massage in some form has long been in use in 
 
 the East, and is well known as the lommi-lommi 
 
 71 
 
72 MASSAGE. 
 
 of the slothful inhabitants of the Sandwich 
 Islands. In Japan it is reserved as an occupa- 
 tion for the blind, whose delicate sense of feel- 
 ing might, I should think, very well fit them for 
 this task. It is, however, in these countries less 
 used in disease than as the luxury of the rich ; 
 nor can I find in the few books on the subject 
 that it has been resorted to habitually as a tonic 
 in Europe, or otherwise than as a means of 
 treating local disorders. 
 
 It is many years since I first saw in this city 
 general massage used by a charlatan in a case 
 of progressive paralj'sis. The temporary results 
 he obtained were so remarkable that I began 
 soon after to employ it in locomotor ataxia, in 
 which it sometimes proved of signal value, and 
 in other forms of spinal and local disease. At 
 first I had to train nurses to use it, but I soon 
 found that, although it was of some service to 
 their patients, no one could use massage well 
 who was not continually engaged in doing it. 
 Some men do it better than any woman ; but 
 I prefer, nevertheless, for obvious reasons, to 
 reserve men for male patients. 
 
 A few years later I resorted to it in the first 
 cases which I treated by rest, and I very soon 
 
MASSAGE. 73 
 
 found that I had in it an agent little understood 
 and of singular utility. 
 
 It will be necessary, in pursuance of my plan, 
 to describe exactly how this means is employed, 
 and why it is employed. 
 
 I can better speak of what it does after care- 
 fully specifying the manner of its use. 
 
 After a few days of the milk diet, with which 
 my treatment ordinarily begins, or from the out- 
 set, the masseur or masseuse is set to work. An 
 hour is chosen midway between two meals, and, 
 the patient lying in bed, the manipulator starts 
 at the feet and gently but firmly seizes the skin, 
 rolling it lightly between his fingers and going 
 carefully over the whole foot ; then the toes are 
 bent and moved about in every direction, and 
 next, with the thumbs and fingers, the little 
 muscles of the foot are kneaded more largely, 
 and the interosseous groups worked at with the 
 finger-tips between the bones. At last the 
 whole tissues of the foot are seized with both 
 hands and somewhat firmly rolled about. !N'ext 
 the ankles are dealt with in like fashion, all the 
 crevices between the articulating bones being 
 sought out and kneaded, while the joint is put in 
 every possible position. The leg is next treated, 
 
74 MASSAGE. 
 
 first as to the skin, then hy deeper grasping 
 of the areolax tissue, and last by industrious 
 and more profound pinching^ of the large mus- 
 cular masses, which for this purpose are put in 
 a position of the utmost relaxation. The grasp 
 of the muscles should be firm, and for the large 
 muscles of the calf and thigh both hands should 
 act together, the masses of muscle being, as it 
 were, twisted around the bone while the hands 
 alternately contract upon them. In treating the 
 firm muscles in front of the leg, the fingers or 
 the two thumbs are made to roll the muscle 
 under the cushions of the finger-tips. At brief 
 intervals the manipulator seizes the limb in both 
 hands and lightly runs the grasp upw^ards, so as 
 to favor the flow of venous blood-currents, and 
 then returns to the kneading of the muscles. 
 
 The same process is carried on in every part 
 of the body, and especial care is given to the 
 muscles of the loins and spine, while usually the 
 face is not touched. The abdomen is first treated 
 
 1 The word " pinch" is here used for lack of a better. It is, 
 oddly enough, associated in the minds of many persons with 
 the idea of pain, which, of course, is not borne out by its true 
 meaning. The process here described is such as I have seen 
 used by one of the most skilful of masseurs. 
 
MASSAGE. 75 
 
 by pinching the skin, then by deeply grasping 
 and rolling the muscular walls in the hands, and 
 at last the entire belly is kneaded with the heel 
 of the hand in a succession of rapid, deep move- 
 ments, passing around in the direction of the 
 colon, while somewhat later the whole belly, 
 relaxed by position, may be shaken by a rapid 
 motion of the grasping hands. 
 
 Pinching or squeezing of the skin is very 
 valuable in certain spinal troubles accompanied 
 with lessened sensation, and in some other cases, 
 if the surface and extremities be very cold; 
 but the best masseurs often omit it and rely 
 solely upon the deeper grip and rolling of the 
 muscles. The process should not be painful or 
 more at first than merely annoying and fa- 
 tiguing, but after a time the muscles may be 
 handled with a good deal of strength without 
 causing other than agreeable results. If the 
 grip be allowed to move much or roughly over 
 the skin, the pull upon the hairs will inevitably 
 cause troublesome and painful boils. In fact, 
 unless the process be well done, it is best in very 
 hairy persons to shave the legs ; but with prac- 
 tised operators this is always needless, or may 
 be avoided by using cocoa-oil or vaseline. These, 
 
76. MASSAGE. 
 
 however, make the work less efficient and more 
 difficult, and I do not order them unless it is 
 considered desirable to rub into the system some 
 oleao;inous material.^ 
 
 Too much care cannot be used to cover with 
 stockings and warm wraps the parts after in turn 
 they have been subjected to massage. As to time, 
 at first the massage should last half an hour, but 
 should be increased in a week to a full hour. I 
 observe that Dr. Playfair has it used twice a day 
 or more, and I have since had it so employed in 
 some cases, letting the masseuse come before 
 noon, and allowing the nurse to use it at night 
 if it does not interfere with sleep, which is a 
 matter to be tested solely by experiment. Com- 
 monly, one hour suffices. I was at one time in 
 the habit of suspending the use of both massage 
 and electricity during menstruation, because I 
 found occasionally that these agents disturbed or 
 checked the normal flow. Of late, however, I 
 continue the employ of both agents, but confine 
 them to the limbs. I have met with rare cases 
 in which almost any massage gave rise to a 
 
 ^ Cocoa-oil is cheap, and keeps well if covered with lime- 
 water ; it is also agreeable in odor. 
 
MASSAGE. 77 
 
 uterine hemorrliage, and in which the utmost 
 caution became necessary. 
 
 "Women who have a sensitive abdominal sur- 
 face or ovarian tenderness have of course to be 
 handled with care, but in a few days a practised 
 rubber will by degrees intrude upon the tender 
 regions, and will end by kneading them with all 
 desirable force. The same remarks apply to the 
 spine when it is hurt by a touch ; and it is very 
 rare indeed to find persons whose irritable spots 
 cannot at last be rubbed and kneaded to their 
 permanent profit. 
 
 Occasionally I meet with feeble persons as to 
 whom the masseurs remark that they " rub wet," 
 — that is, under massage they perspire remarka- 
 bly. If the case proves successful, this peculiarity 
 soon passes away. 
 
 The daily massage is kept up through at least , 
 six weeks, and then, if everything seems to me '] 
 to be going along well, I direct the rubber or 
 nurse to spend half of the hour in exercising 
 the limbs as a preparation for walking. This 
 is done after the Swedish plan, by making very 
 slowly passive and extreme extensions and flex- 
 ions of the limbs for a few days, then assisted 
 
 movements, next active unassisted movements, 
 
 7* 
 
78 MASSAGE. 
 
 and last active movements gently resisted by 
 
 I nurse or masseuse. When able to sit and stand, 
 
 it is well to keep up and extend the number of 
 
 \ these gentle gymnastic acts and to encourage the 
 
 patient to make them habitual.^ 
 
 At the seventh week massage is used on alter- 
 nate days, and is commonly laid aside when the 
 patient gets up and begins to move about. 
 
 During the past year, several of the members 
 of the staff of the Infirmary for !N"ervous Dis- 
 ease, and especially my colleague, Dr. Wharton 
 Sinkler, have obliged me by studying with care 
 the influence of massage on temperature, and as 
 to this some very interesting results have been 
 obtained. In general, when a highly hysterical 
 person is rubbed, the legs are apt to grow cold 
 under the stimulation, and if this continues to 
 be complained of it is no very good omen of 
 the ultimate success of the treatment. But usu- 
 ally in a few days a change takes place, and the 
 limbs all grow warm when kneaded, as happens 
 in most people from the beginning of the treat- 
 ment. The extremely low temperature of the 
 
 1 Some care is needed not to overwork patients. For do- 
 tails I must refer to manuals of Swedish Gymnastics. 
 
MASSAGE. 79 
 
 limbs of cliildren suffering with so-called essen- 
 tial paralysis is well known. I have frequently 
 seen these strangely cold parts rise, under an 
 hour's massage, six to ten degrees F. In such 
 small limbs, the long contact of a warm hand i 
 may account for at least a part of this notable 
 rise in temperature. In adults this can hardly 
 be looked upon as a cause of the rise of tem- 
 perature produced by massage, first, because the 
 long exposure of large surfaces incident to the 
 process is calculated to lessen whatever in- 
 crease of heat the contact of the hand may 
 cause, and secondly, because this rise is a very 
 variable quantity, and because occasionally some 
 other and less comprehensible factors actually 
 induce a fall rather than a rise in the ther- 
 mometer as a result of massage. 
 
 In very nervous or hysterical women, ignorant 
 of what the act of kneading may be expected to 
 bring about, and especially in such as are thin and 
 anaemic and have either a somewhat high or an 
 unusually low normal temperature, we may find 
 at first a slight fall of the thermometer, then a 
 fairly constant rise, with some irregularities, and 
 at last, as the health improves, a lessening effect 
 or none at all. 
 
go MASSAGE. 
 
 I The most notable rise is to be found in per- 
 kons who, owing to some organic disease, have 
 (acquired liability to great changes of tempera- 
 Ture. 
 
 It is impossible to observe the increase of heat 
 which follows both massage and electricity with- 
 ^out inferring that these agents must for a time, 
 like exercise and other tonics, increase the tissue- 
 waste by the stimulus they cause of the general 
 and interstitial circulations, and by the direct 
 influence they seem to have on the tissues them- 
 selves. I have sought to study this matter care- 
 fully by placing patients on a fixed and com- 
 petent diet of milk alone, and by estimating the 
 waste of tissues as shown in the secretions before 
 and after the use of massage. This study is as 
 yet too incomplete for full statement, but so far 
 it would seem that massage does not much alter 
 the total elimination of the entire day, but causes 
 a large and abrupt increase within three hours, 
 followed by a compensatory decline. 
 
 I add a number of tables, which very well 
 illustrate the facts above stated as to rise of 
 temperature. 
 
 Mrs. J., at rest, on the usual diet. Manipu- 
 lation at 11, daily : 
 
MASSAGE. 
 
 81 
 
 Before Massage. After Massage. 
 
 100 100 
 
 100 100| 
 
 99| 99^ 
 
 99f 100 
 
 99| 100 
 
 100 100 
 
 99^ 100 
 
 99| ....... 100 
 
 Miss P., set. 24, hysteria : 
 
 Before Massage. After Massage. 
 
 99| 99J 
 
 98^ 99 
 
 98i 99 
 
 98| 99 
 
 98^ ....... 98| 
 
 99 99f 
 
 100^ . lOOf 
 
 lOOf . lOlf 
 
 lOOf lOOf 
 
 lOOf • . 100 
 
 Mrs. L., a very thin, feeble, and bloodless 
 woman, set. 29 years : 
 
 Before Massage. After Massage. 
 
 99 100 
 
 98| 99^ 
 
 98 98| 
 
 99 100 
 
 / 
 
i 
 
 32 MASSAGE. 
 
 Before Massage. After Massaga 
 
 98f 98f 
 
 99 ... . . . 99| 
 
 100 100^ 
 
 99 99| 
 
 Mrs. P., set. 31, feeble and ansemic, nervous, 
 slight albuminuria and chronic bronchitis. Li- 
 able to fever. 3 p.m. 
 
 Before Massage. After Massage. 
 
 lOlf 102 
 
 100 lOOf 
 
 99 99| 
 
 100 101 
 
 ^ 99| 100^ 
 
 99f 100| 
 
 lOOf lOlf 
 
 lOOf 99f 
 
 > lOOf lOOf 
 
 lOOxV I00j\ 
 
 99i 99| 
 
 t;^ These temperatures were taken always before 
 V j 4 P.M., and at intervals of three days. Her 
 morning temperature was usually 99° to 99|-°, 
 and in the evening, 9 to 10 o'clock, it always 
 rose to 100°, 101°, and at times to 102°. 
 y As I have said already, there are persons who, 
 lunder circumstances seemingly alike, have from 
 
MASSAGE. 33 
 
 massage a large rise of temperature, and others 
 who experience none. I give a single case of 
 what is rare but not exceptional, — an almost 
 constant fall of temperature. 
 
 Miss ]Sr., set. 21, hysteria, good condition : 
 
 Before Massage. After Massage. 
 
 98 ....... 97f 
 
 981 98i 
 
 98 98 
 
 98| 98 
 
 98f 98 
 
 These facts are, of course, extremely interest- 
 ing ; but it is well to add that the success of 
 the treatment is not indicated in any constant 
 way by the thermal changes, which are neither 
 so steady nor so remarkable as those caused by 
 electricity. 
 
 If now we ask ourselves why massage does \ 
 good in cases of absolute rest, the answer — at 
 least a partial answer — ^is not difficult. The 
 secretions of the skin are stimulated by the 
 treatment of that tissue, and it is visibly flushed, 
 as it ought to be, from time to time, by ordi- 
 nary active exercise. Under massage the flabby 
 muscles acquire a certain firmness, which at first 
 lasts only for a few minutes, but which after a 
 
84 MASSAGE. 
 
 itime is more enduring -and ends by becoming 
 I permanent. The firm grasp of the manipulator's 
 hand stimuhites the muscle, and, if sudden, may 
 cause it to contract sensibly, which, however, is 
 j not usually desirable or agreeable. The muscles 
 are by these means exercised without the use of 
 volitional exertion or the aid of the nervous cen- 
 tres, and at the same time the alternate grasp and 
 relaxation of the manipulator's hands squeezes 
 out the blood and allows it to flow back anew, 
 •^ thus healthfully exciting the vessels and increas- 
 ing mechanically the flow of blood to the tissues 
 which they feed. 
 
 Although this plan of acting on the muscles 
 seems to dispense with any demands upon the 
 centres, it is not to be supposed that it is alto- 
 -gether without influence on these parts. In 
 fact, extreme use of massage occasionally flushes 
 the face and causes sense of fulness in the head 
 , or ache in the back. Moreover, in some spinal 
 ^ maladies it has effects not to be altogether ex- 
 plained by its mechanical stimulation of the 
 i muscles, nerves, and skin. 
 The visible results as regards the surface-cir- 
 . culation are sufficiently obvious, and most re- 
 markably so in persons who, besides being 
 
MASSAGE. 35 
 
 ansemic and thin, have heen long unused to exer- 
 cise. After a few treatments the nails become 
 pink, the veins show where before none were 
 to be seen, the larger vessels grow fuller, and 
 the whole tint of the limbs chans-es for the 
 better. 
 
 In like manner the sore places which previ-( 
 ously existed, or which are brought into sensi- 
 tive prominence by the manipulation, by degrees 
 cease to be felt, and a general sensation of com- 
 fort and ease follows the later treatments. 
 
 I am accustomed to pay a good deal of atten- 
 tion to the observations made as to these and 
 other points by practised manipulators, and I 
 find that their daily familiarity with every detail 
 of the color, warmth, and firmness of the tissues 
 is often of great use to me. 
 
CHAPTER YIL 
 
 ELECTRICITY. 
 
 Electricity is the second means which I have 
 made use of for the purpose of exercising mus- 
 cles in persons at rest. It has also an additional 
 value, of which I shall presently speak. . 
 
 In order to exercise the muscles best and with 
 the least amount of pain and annoyance, we 
 make use of an induction current, with interrup- 
 tions as slow as one in every two to five seconds, 
 a rate readily obtained in properly-constructed 
 batteries.^ This plan is sure to give painless 
 exercise, but it is less rapid and less complete 
 as to the quality of the exercise caused than the 
 movements evolved by vp.ry rapid in»terruptions. 
 These, in the hands of a clever operator who 
 knows his anatomy well, are therefore, on the 
 whole, more satisfactory, but they require some 
 experience to manage them so as not to shock 
 
 ^ Most induction batteries are without any arrangement for 
 
 making infrequent breaks in the current. 
 86 
 
ELECTRICITY. 87 
 
 and disgust the patient by inflicting needless 
 pain. The poles, covered with sponges well 
 wetted with salt water, are placed on each mus- 
 cle in turn, and kept about four inches apart. 
 They are moved fast enough to allow of the 
 muscles being well contracted, which is easily 
 managed, and with sufficient speed, if the assist- 
 ant be thoroughly acquainted with the points of 
 Ziemssen. After the legs are treated, the mus- 
 cles of the belly and back and loins are gone 
 over systematically, and finally those of the chest 
 and arms. The face and neck are neglected. 
 About forty minutes to an hour are needed; 
 but at first a less time is employed. The gen- 
 eral result is to exercise in tarn all the external 
 muscles.^ 
 
 1^0 such obvious and visible results are seen 
 as we observe after massage, but the thermal 
 changes are much more constant and remark- 
 
 ^ In the extreme constipation of certain hysterical women, 
 good may be done by placing one conductor in the rectum 
 and moving the other over the abdomen so as to cause full 
 movement of the muscles. This means must at first be 
 employed cautiously, and the amount of electricity carefully 
 increased. 
 
88 
 
 ELECTRICITY. 
 
 able, and show at least that we are not dealing 
 with an agent which merely amuses the patient 
 or acts alone through some mysterious influence 
 on the mental status. 
 
 A half-hour's treatment of the muscles com- 
 monly gives rise to a marked elevation of tem- 
 perature, which fades away within an hour or 
 two. This effect is, like that from massage, 
 most notable in persons liable to fever from 
 some organic trouble, and it varies as to its 
 degree in individuals who have no such disease. 
 
 The first case, Miss B., set. 20, is an example 
 of tubercular disease of the apex of the right 
 lung. She had a morning temperature of 98J° 
 to 99J°, and an evening temperature of 100° to 
 102^ 
 
 Electricity was used about 11 o'clock daily, 
 with these results : 
 
 Before Electricity. After Electricity. 
 
 November 25 . 
 
 . 99 
 
 99f 
 
 " 27 . . 
 
 . . 97f 
 
 100 
 
 " 28 . 
 
 . 98 
 
 99 
 
 " 29 . 
 
 . . 98| 
 
 99| 
 
 December 2 . 
 
 . . lOOi 
 
 lOlf 
 
 '» 4 . . 
 
 . . 99^ 
 
 100^ 
 
 " 5 . . 
 
 . . 99f 
 
 99^ 
 
 Mrs. R., set. 40, the next case, was merely a 
 
ELECTRICITY. 
 
 89 
 
 rather anaemic, feeble, and thin woman, who for 
 years had not been able to endure any prolonged 
 effort. She got well under the general treat- 
 ment, gaining thirteen pounds on a weight of 
 ninety-eight pounds, her height being five feet 
 and one inch. The facts as to rise of tempera- 
 ture are most remarkable, and, I need not say, 
 were carefully observed, the observations having 
 been made by Dr. Sinkler. 
 
 Temperature taken in the mouth while at rest 
 in bed. 
 
 Before Electricity. After Electricity. 
 
 April 2 
 
 . . 98| 
 
 981 
 
 " 3 
 
 . . 98i 
 
 98| 
 
 u 4 
 
 . .98^ 
 
 98| 
 
 " 5 
 
 . 98 
 
 98| 
 
 *' 6 
 
 . . 97^ 
 
 98,^ 
 
 u 7 
 
 . . 98 
 
 98^ 
 
 " 8 
 
 . 98 
 
 98f 
 
 " 9 
 
 . 98 
 
 99^ 
 
 «' 10 
 
 . . 98f 
 
 98f 
 
 " 11 
 
 . . 98^^^ 
 
 98tV 
 
 " 12 
 
 . . 98f 
 
 99tV 
 
 " 13 
 
 . . 98i 
 
 99^ 
 
 " 14 
 
 . 98| 
 
 99i 
 
 " 16 
 
 . 98^4^ 
 
 99^ 
 
 « 17 
 
 . 98^ 
 
 99x% 
 
 " 18 
 
 . 98xV 
 
 99,2jr 
 
 « 19 
 
 . 98^ 
 
 99^ 
 
 One hour later, 99^ 
 
 8* 
 
90 
 
 
 ELECTRICITY, 
 
 Before Electricity. After Electri 
 
 April 
 
 20 
 
 . 99 99iV 
 
 (( 
 
 21 
 
 . . 98^ 99^2^ 
 Menstrual period. 
 
 (( 
 
 30 
 
 . 98| 98f 
 
 May 
 
 1 
 
 . 98 98^5^ 
 
 (( 
 
 2 
 
 . 98 98x8^ 
 
 The third case, Miss M., set. 33, was that of 
 a pallid woman, the daughter of a well-known 
 physician in the South. She suffered for six 
 years with " nervous exhaustion," headaches, 
 pain in the back, intense depression of spirits, 
 nausea, and repeated attacks of hysteria. She 
 slept only under anodynes, and used stimulants 
 freely. Under the use of rest and the adju- 
 vant treatment described. Miss M. made a 
 thorough recovery, and was restored to useful 
 active life. 
 
 Miss M. Thermometer held in mouth. 
 
 Before Electricity. After Electricity. 
 
 May U 
 
 . 99,,V 
 
 99J^ -» Menstruating ; general fara- 
 99^ / dization only. 
 
 " 15 
 
 . 99 
 
 " 16 
 
 . 99^ 
 
 99|^ Gen'l faradization and limbs 
 
 u 17 
 
 . 98f 
 
 99i 
 
 " 18 
 
 . 98| 
 
 99i 
 
 '' 19 
 
 . 98i 
 
 98| 
 
 " 21 
 
 . 983 
 
 99 
 
 » 22 
 
 . 98f 
 
 99tV 
 
ELECTRICITY. 
 
 91 
 
 Before Electricity. After Electricity. 
 
 May 25 
 
 . 98^V 
 
 98A 
 
 " 26 
 
 . 98tV 
 
 99tV 
 
 » 29 
 
 . 98f 
 
 99 
 
 " 30 
 
 . 98x% 
 
 99tV 
 
 " 31 
 
 . 98f^ 
 
 99xV 
 
 Mrs. P., set. 38, was a rather nervous woman, 
 easily tired, but not ansemic and not very thin. 
 She improved greatly under the treatment. 
 
 Before Electricity. After Electricity. 
 
 January 27 
 " 29 
 " 30 
 " 31 
 
 February 1 
 
 February 8 
 9 
 10 
 12 
 13 
 U 
 15 
 19 
 20 
 23 
 24 
 27 
 28 
 
 984 
 
 99i 
 98| 
 99 
 
 99i 
 99i 
 99f 
 99| 
 99f. 
 
 Thermometer in axilla ten 
 minutes before and after. 
 
 Menstrual period. 
 
 98f 
 
 98f 
 
 98| 
 
 98i 
 
 98| 
 
 98f 
 
 98| 
 
 99 
 
 98 
 
 98| 
 
 99 
 
 99i 
 
 99i 
 
 99 
 
 99 
 
 99 
 
 98f 
 
 98f 
 
 98f 
 
 99 
 
 99| 
 
 99| 
 
 99| 
 
 Thermometer in mouth five 
 minutes before and after. 
 
 Menstrual period. 
 
92 
 
 ELECTRICITY. 
 
 Before Electricity. After Electricity. 
 March 13 . 99 99f 
 
 " 14 . 98| 98f 
 
 " 15 . 99 99^ 
 
 Miss K., 8et. 27, was a fair case of hysterical 
 conditions; over-use of chloral and bromides; 
 anorexia and loss of flesh and color. 
 
 Thermometer in mouth. 
 
 Before Electricity. 
 May 15 .100 
 " 16 . 100 
 u 17 
 
 After Electricity. 
 
 " 18 
 
 " 19 
 
 May 20 
 
 " 22 
 
 " 26 
 
 " 27 
 
 " 28 
 
 " 29 
 
 " 30 
 
 " 31 
 
 June 2 
 
 u 4 
 
 " 6 
 
 " 7 
 
 lOOi 
 
 98| 
 99| 
 
 99| 
 
 99rV 
 99^ 
 99§ 
 
 99x% 
 
 99tV 
 
 99t\t 
 
 99| 
 
 99^ 
 
 99A 
 
 99xV 
 
 100 
 100 
 lOOf 
 
 98| 
 lOO^V 
 
 1 
 
 100 
 
 99| 
 oq 6 
 
 99x17 
 99f 
 
 99x^3 
 99x1^ 
 99t% 
 99| 
 
 99x«Ty 
 99x^^ 
 99^ 
 
 General faradization for fif- 
 teen minutes. 
 
 General faradization, fif- 
 teen minutes, also of arm 
 muscles, twenty minutes. 
 
 General faradization, ten 
 minutes ; arms and legs, 
 twenty minutes. 
 
 I have given these full details because I have 
 
ELECTRICITY. 93 
 
 not seen elsewhere any statement of the rather 
 remarkable phenomena which they exemplify. 
 It may be that a part at least of the thermal 
 change is due to the muscular action, although 
 this seems hardly competent to account for any 
 large share in the alteration of temperature, and 
 we must look further to explain it fully. ]N"o 
 mental excitement can be called upon as a cause, 
 since it continues after the patient is perfectly 
 accustomed to the process. I should add, also, 
 that in most cases the subject of the experiment 
 was kept in ignorance of the fact that a rise of 
 the thermometer was to be expected. Is it not 
 possible that the current even of an induction 
 battery has the power so to stimulate the tissues 
 as to cause an increase in the ordinary rate of 
 disintegrative change? Perhaps a careful study 
 of the secretions might lend force to this sugges- 
 tion. That the muscular action produced by the 
 battery is not essential to the increase of bodily 
 heat is shown by the next set of facts to which I 
 desire to call attention. 
 
 Some years ago, Messrs. Beard and Kockwell 
 stated that when an induced current is used for 
 fifteen to thirty minutes daily, one pole on the 
 neck and one on either foot, or alternately on 
 
94 ELECTRICITF. 
 
 both, the persistent use of this form of treatment 
 is decidedly tonic in its influence. I believe 
 that in this opinion they were perfectly correct, 
 and I am now able to show that, when thus 
 employed, the induced current causes also a de- 
 cided rise of temperature in many people, which 
 proves at least that it is in some way an active 
 agent, capable of positively infl.uencing the nutri- 
 tive changes of the body. 
 
 The rise of temperature thus caused is less 
 constant, as well as less marked, than that occa- 
 sioned by the muscle treatment. I do not think 
 it necessary to give the tables in full. They 
 show in the best cases rises of one-fifth to four- 
 fifths of a degree F., and were taken with the 
 utmost care to exclude all possible causes of 
 error. 
 
 The mode of treatment is as follows : At the 
 close of the muscle-electrization one pole is 
 placed on the nape of the neck and one on a 
 foot for fifteen minutes. Then the foot pole is 
 shifted to the other foot and left for the same 
 length of time. 
 
 The primary current is used, as being less 
 painful, and the interruptions are made as rapid 
 as possible, while the cylinder or control wires 
 
ELECTRICITY. 95 
 
 are adjusted so as to give a current which is not 
 uncomfortable. 
 
 It is desirable to have electricity used by a 
 practised hand, but of late I have found that in- 
 telligent nurses may suffice, and this, of course, 
 materially lessens the cost. In very timid or 
 nervous people, or those who at some time have 
 been severely '' shocked" by the application of 
 electricity in the hands of charlatans, it is com- 
 mon to find the patient greatly dreading a return 
 to its use. In this case, if the battery be started 
 and th.e poles moved about on the surface as 
 usual, but without any connection being made,; 
 one of two things will happen, — either the patient 
 will find it naturally very mild, and will submit 
 fearlessly to a gentle and increasing treatment, or 
 else her apprehensions will so dominate her as to! 
 cause her to complain of the effects as exciting 
 or tiring her, or as spoiling her sleep. A few 
 words of kindly explanation will suffice to show 
 her how much expectation has to do with the 
 apparent results, and she will be found, if the 
 matter be managed with tact, to have learned a 
 lesson of wide usefulness throughout her treat- 
 ment. 
 
 I have been asked very often if all the means 
 
96 ELECTRICITY. 
 
 here described be necessary, and I have been 
 \ criticised by some of the reviewers of my first 
 edition because I had not pointed out the relative 
 needfulness of the various agencies employed. 
 In fact, I have made very numerous clinical 
 studies of cases, in some of which I used rest, 
 seclusion, and massage, and in others rest, seclu- 
 sion, and electricity. It is, of course, difficult, 
 I may say impossible, to state in any numerical 
 manner the reason for my conclusion in favor 
 of the conjoined use of all these means. If one 
 is to be left out, I have no hesitation in saying 
 that it should be electricity. 
 
CHAPTER YIIL 
 
 DIETETICS AND THERAPEUTICS. 
 
 The somewliat wearisome and minute details 
 I have given as to seclusion, rest, massage, and 
 electricity have prepared the wslj for a discus- 
 sion 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 neuras- 
 thenic women fail to be obstinately dyspeptic^ 
 milk given at the outset, and given alone by 
 Karell's method for a fortnight or less, enor- 
 mously 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 
 
 E ^r 9 97 
 
98 DIETETICS AND THERAPEUTICS. 
 
 in a former edition with a confidence which has 
 been increased by the added experience of phy- 
 sicians on both sides of the Atlantic. Finally, 
 there are exceptional cases of intestinal pain of 
 obscure parentage or seemingly neuralgic, of dys- 
 pepsia incorrigible by other treatments, which, 
 having resulted in grave general defects of nu- 
 trition, 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 within 
 two years certain facts as to the effects of milk 
 diet which have, I believe, hitherto escaped ob- 
 servation. 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 
 
DIETETICS AND THERAPEUTICS, 99 
 
 tlie 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 dj^speptic states, and in anseraia with obesity, 
 and in the latter state uncomplicated by defec- 
 tive hsemic 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 i 
 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. 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 Al- 
 derney. 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 
 
100 DIETETICS AND THERAPEUTICS. 
 
 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 re- 
 sumed 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 dis- 
 gust 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 gen- 
 eral 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 
 
DIETETICS AND THERAPEUTICS. IQl 
 
 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. 
 
 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 ex- 
 ercise 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. 
 
 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 
 
 9^ 
 
102 DIETETICS AND THERAPEUTICS. 
 
 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 some- 
 times annoying to nervous persons because of 
 the frequent micturition it makes necessary. I 
 have discovered that while alone skimmed milk 
 is being taken, uric acid usually disappears al- 
 most entirely from the urine, so that it is difli- 
 cult 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 addi- 
 tion of other food, but especially of meat, enables 
 us to find it asrain. 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 ordi- 
 nary 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 
 
DIETETICS AND THERAPEUTICS. 103 
 
 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 ox- 
 idized 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 is now a matter under study, but so 
 far it seems clear at least that during a diet of 
 milk the ordinary pigments of the urine disap- 
 pear or are singularly modilied. 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 re- 
 sults 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 de- 
 struction of tissues which seem to take place 
 under the influence of this peculiar diet. Some 
 
104 DIETETICS AND THERAPEUTICS. 
 
 of them may account for its undoubted value 
 in lithsemic 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 Kestle's food or that of the Anglo-Swiss 
 Company. 
 
 Before dealing with the treatment of the anae- 
 mic and feeble and more or less wasted invalids 
 who require treatment by rest and its concomi- 
 tant 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 
 
DIETETICS AND THERAPEUTICS. 105 
 
 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^ are fol- 
 lowed with care and the weight very deliber- 
 ately lessened. But for this few people have the 
 patience ; and, even if they can be induced to fol- 
 low 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 diffi- 
 cult, 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 
 
 ^ Harvey on Corpulence. 
 
106 DIETETICS AND THERAPEUTICS. 
 
 amount by degrees until the patient is losing a 
 half-pound of weight each day, or less or more, 
 as seems to be well borne. Meanwhile, during 
 the first week or two rest in bed is enjoined, 
 and later for a varying period rest in bed or 
 on a lounge is insisted upon, while at the same 
 time massage is used once or twice a day, and 
 later in the case Swedish movements. At the 
 same time, the pulse and weight are observed 
 with care, so that if there be too rapid loss, or 
 any sign of feebleness, the diet may be increased. 
 In many such cases I allow daily a moderate 
 amount of beef- or chicken- or oyster-soup, — 
 more as a relief to the unpleasantness of a milk 
 diet than for any other reason. 
 
 When the weight has been sufficiently lowered, 
 we add to the diet beef, mutton, oysters, etc., 
 and finally arrange a full diet list to include but 
 a moderate amount of hydro-carbons. Mean- 
 while, 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 
 desrrees 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 
 
DIETETICS AND THERAPEUTICS. ]07 
 
 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 re- 
 sult except a gain in health and comfort. 
 
 Cases of ansemia 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 imperfect blood-pigment, weak heart, 
 rapid pulse, and general feebleness, with too 
 much fat, but not, or at least rarely, extreme obe- 
 sity. 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 mas- 
 sage, 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. 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 
 
108 DIETETICS AND THERAPEUTICS. 
 
 rest, milk, and massage in the treatment of per- 
 sons who are both anaemic and overloaded with 
 fat. 
 
 Mrs. P., set. 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 appear- 
 ance 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. Mas- 
 sage 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 
 
DIETETICS AND THERAPEUTICS. 109 
 
 diet was varied bj the addition of broths after the 
 third week, so as to keep the reduction within 
 safe limits. Her pulse at first w^as 90 to 100 in 
 the morning, and at night 80 to 95, her tempera- 
 ture 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 w^eek 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 im- 
 proved. 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 
 ^YQ months after her treatment began, and she 
 
 has since had a child. 
 
 10 
 
110 DIETETICS AND THERAPEUTICS. 
 
 Early in the spring of 1876, Mrs. C, set. 40, 
 came under my care with partial hysterical pa- 
 ralysis of the right and hemi-ansesthesia 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 suiFering 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-trou- 
 bles, 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. 
 
DIETETICS AND THERAPEUTICS. m 
 
 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, neuras- 
 thenic 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 w^e 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 ex- 
 amination 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 
 
112 DIETETICS AND THERAPEUTICS. 
 
 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 di- 
 vided doses every three hours. If a cup of 
 coff'ee 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 
 
DIETETICS AND THERAPEUTICS. 113 
 
 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.^ ITor 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 effi- 
 cacy. 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 ex- 
 cess 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 afiect 
 visibly their appearance or demeanor. 
 
 1 The management of the morphia or chloral habit be- 
 comes much more easy under a milk diet, massage, and abso- 
 lute rest, and I can with confidence commend their use in 
 these diflScult 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. 
 
 h 10* 
 
114 DIETETICS AND THERAPEUTICS. 
 
 Meanwhile, the mechanical treatment is stead- 
 ily 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 daj^s 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 badjy, 
 and are uncertain in composition, one Dottle 
 being good, another bad. Of the English ex- 
 tracts I know but little. The more constant, 
 and at the same time the most agreeable, extracts 
 are those now made in this country. They have 
 not as yet been subjected to examination by un- 
 interested chemists, and may not prove on analy- 
 sis to be all that is required, but so far have 
 seemed to me on the whole more satisfactory 
 than the imported malts. It is very desirable that 
 
DIETETICS AND THERAPEUTICS. 115 
 
 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 compo- 
 sition, or vary notably as to the amount of alco- 
 hol they contain. 
 
 '^o 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 them- 
 selves, 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 
 wdth milk on waking in the morning is a good 
 preparation for the fatigue of the toilet. 
 
 At the close of the first w^eek 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 ^YQ drops of strong hydrochloric acid. This 
 
116 DIETETICS AND THERAPEUTICS. 
 
 mixture stands on ice all night, and in the morn- 
 ing the bottle is set in a pan of water at 110° F, 
 and kept two hours at about this temperature. 
 It is then thrown on to a stout cloth and strained 
 until the mass which remains is nearly dry. 
 The filtrate is given in three portions daily. If 
 the raw taste prove very objectionable, the beef 
 to be used is quickly roasted on one side, and 
 then the process is completed in the manner 
 above described. The soup thus made is for the 
 most part raw, but has also the flavor of cooked 
 meat. 
 
 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. When given thus, I like to 
 use it in an emulsion made with the juice drained 
 oflf after crushing the fresh pancreas of the beef 
 in warm water. Enough of water to cover a half- 
 pound of chopped pancreas is allowed to stand 
 
DIETETICS AND THERAPEUTICS, 117 
 
 for an hour in a warm kitchen, and then squeezed 
 through a towel. An ounce is mixed with half 
 that amount of oil and injected slowly thrice a 
 day, or the pancreatic emulsions of commerce 
 may be used with the oil. These preparations 
 suit some people well, and may result in a single 
 passage daily, but in others they are annoying, 
 and are either badly retained or not retained at 
 all, and sometimes 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 re- 
 sort to them in any case, although I am satis- 
 fied 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 increas- 
 ing the capacity to take food at meals. Never- 
 theless, 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. 
 
118 DIETETICS AND THERAPEUTICS. 
 
 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 v^^ell, being cheap, and not unpalatable 
 when shaken up in water or given in an effer- 
 vescent draught of carbonated waters. In pri- 
 vate practice large doses of salts of iron, as four 
 to six grains of lactate at meal -time, are satisfac- 
 tory ; 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 pyro- 
 phosphate 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 
 
DIETETICS AND THERAPEUTICS. 119 
 
 method. If iroD 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, or by the enemata 
 of oil. The instances in which iron gives head- 
 ache 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 str^^chnia, 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 im- 
 punity from dyspepsia, but with lasting advan- 
 tage, 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 
 
120 DIETETICS AND THERAPEUTICS. 
 
 gathering under their use flesh, color, and whole- 
 sorneness 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 over- 
 fed the renal secretion speedily betrays this re- 
 sult 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 
 mi-Ik 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 : 
 
DIETETICS AND THERAPEUTiCS. 121 
 
 Mrs. C, a ITew England woman, set. 33, under- 
 took, 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 sh« 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. ligature had at last its 
 revenge. Everything wearied her, — to eat, to 
 drive, to read, to sew. Walking became impos- 
 sible, and, tied to her couch, she grew dyspeptic 
 and constipated. The asthenopia which is al- 
 most 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 
 p 11 
 
122 DIETETICS AND THERAPEUTICS. 
 
 emotional and morbid in her views of life. After 
 numberless forms of treatment had been used 
 in vain, she came to this city and passed into my 
 care. 
 
 At this time she could not walk more than a 
 few steps without flushing and without a sense 
 of painful tire. Her morning temperature was 
 97.5° F., and her white corpuscles were perhaps 
 a third too numerous. After most careful exam- 
 ination, 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 re- 
 lieving the bladder or the rectum. 
 
 October 10. — Took one quart of milk in di- 
 vided doses every two hours. 
 
 11th. — A cup of coflfee 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. 
 
DIETETICS AND THERAPEUTICS. 123 
 
 ITth and 18tli. — 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 Qgg 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., mas- 
 sage 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 sur- 
 prising. I have not given in full the amount of 
 
124 DIETETICS AND THERAPEUTICS. 
 
 food eaten at meal-time. Small at first, it was 
 increased rapidly owing to the patient's growing 
 appetite, and became in a few davs 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 waa 
 dropped, wine abandoned, the iron lessened one- 
 half, the massage and electricity used on alter- 
 nate days, and the limbs exercised as I have de- 
 scribed. 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, 
 tosrether with the iron and malt. The cure was 
 complete and permanent; and its character may 
 
DIETETICS AND THERAPEUTICS. 125 
 
 be tested by tbe 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. Fa- 
 tigue of vision for near work is a common con- 
 dition 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 appa- 
 ratus of the eye looked at with care, because pure 
 asthenopia, apart from all optical defects, is a 
 somewhat rare symptom. 
 
 E^either am I always satisfied with the ophthal- 
 mologist's dictum that there is a defect so slight 
 as to need no correction, being well aw^are, as I 
 have elsewhere pointed out, that even minute 
 ^ ocular defects are competent mischief-makers 
 w^hen the brain becomes what I may permit my- 
 self, using the photographer's language, to call 
 
 sensitized by disease. 
 
 11* 
 
126 DIETETICS AND THERAPEUTICS. 
 
 The followino^ illustrations of success in this 
 mode of treatment are taken from Dr. Play fair's 
 book '} 
 
 " Early in October of last year I was asked to 
 see a lady thirty-two years of age, with the fol- 
 lowing 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 attend- 
 ant as ' ulceration, perimetritis, and endome- 
 tritis.' 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 cathe- 
 ter 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 para- 
 lyzed, 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 
 
 ^ Nerve Prostration and Hysteria. 
 
DIETETICS AND THERAPEUTICS. 127 
 
 of her neck and twitching of the muscles, she 
 hegan 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 blad- 
 der, but it now ceased to do so, and there were 
 no further symptoms referable to the uterine 
 organs. Her general condition, however, re- 
 mained unaltered, in spite of the most judicious 
 medical treatment. She was seen, from time to 
 time, by several of our most eminent consult- 
 ants, all of whom recognized the probable hys- 
 terical 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 
 
128 DIETETICS AND THERAPEUTICS. 
 
 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 ex- 
 amination, came to the conclusion that contrac- 
 tility 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 
 health}^ 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 
 
DIETETICS AND THERAPEUTICS. 129 
 
 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 Qgg] 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 natu- 
 rally all night long. On the 23d, porridge and a 
 gill of cream were added to her former diet ; mas- 
 sage three hours daily, and electricity for half an 
 hour, and this was continued until the end of the 
 treatment. Mai tine 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 powder 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 
 
130 DIETETICS AND THERAPEUTICS. 
 
 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 as^o. 
 
 " On I^ovember 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 for- 
 mation on the anterior surface of the legs, ex- 
 tending from below the patellae half-way down 
 the tibiae, of two large sacs of thin fluid, con- 
 taining, 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, 1 saw with Dr. Julius, of Hast- 
 ings, 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 con- 
 stant invalid, suffering from backache, bearing 
 down, inability to walk, disordered menstruation, 
 
DIETETICS AND THERAPEUTICS. 131 
 
 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 
 
132 DIETETICS AND THERAPEUTICS. 
 
 week after it was begun, when her attention wa? 
 fully occupied with the diet, massage, etc., I in- 
 troduced 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 com- 
 menced, 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 com- 
 plained 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 he^althj^, and 
 
DIETETICS AND THERAPEUTICS. 133 
 
 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 ap- 
 proaching marriage." 
 
 " On September 10 a gentleman came to con- 
 sult 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-know^n 
 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 ir. not 
 the slightest symptom of paralysis. Fortunately. 
 
 12 
 
134 DIETETICS AND THERAPEUTICS. 
 
 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 hys- 
 teria is the opinion of nearly all the many medi- 
 cal men \vho 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 pil- 
 lows, 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 ^yq 
 and a half inches, she weighed only 4 st. 7 lbs., 
 and I could easily make my thumb and fore- 
 finger 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 un- 
 natural prominence of the spinous processes of 
 the vertebrre. I could detect no orsranic disease 
 
DIETETICS AND THERAPEUTICS. I35 
 
 of any kind. The appetite was entirely wanting, 
 and she consumed hardly any food beyond a little 
 milk, a few moiitlafuls 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 assim- 
 ilated. 
 
 " Six A.M. : ten ounces of raw meat soup. 7 
 A.M. : cup of black cofifee. 8 a.m. : a plate of 
 oatmeal porridge, with a gill of cream, a boiled 
 Qgg^ 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 
 
136 DIETETICS AND THERAPEUTICS. 
 
 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 symp- 
 toms, and was consumed with relish and appe- 
 tite. 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. Consider- 
 ing 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 !N'atal, 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-sev^en, with the following historj^ : — 
 ' As a girl of sixteen she had a severe neuralgic 
 
DIETETICS AND THERAPEUTICS. 137 
 
 illness, extending over months : excepting that, 
 she seems to have enjoyed good health until her 
 marrias^e. Soon after this she had a miscarriao:e, 
 and then two subsequent pregnancies, accom- 
 panied by albuminuria and the birth of dead 
 children.' ' During gestation I was not sur- 
 prised at all sorts of nervous affections, attrib- 
 uting 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 sev- 
 eral severe shocks from the death of near rela- 
 tives, 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 
 
 12* 
 
138 DIETETICS AND THERAPEUTICS. 
 
 attacks passed off in from twenty minutes to a 
 couple of hoars.' 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 anj^thing 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 palpita- 
 tions of a distressing character, with loud blow- 
 ing murmur, and pulse of 120 to 140, for which 
 she was seen by an eminent physician, who diag- 
 nosed them to be caused by * slight ventricular 
 asynchronism, with atonic condition of the car- 
 diac 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. 
 
DIETETICS AND THERAPEUTICS. 139 
 
 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 hope- 
 less 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 suffer- 
 ing. Eventually the difficulty was got over by 
 anjfisthetizing 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 
 
140 DIETETICS AND THERAPEUTICS. 
 
 the noise of the streets, wliicli distressed her 
 much. She was a natural!}- fine and highly-culti- 
 vated woman, greatly emaciated, with a dusky, 
 sallow complexion, and dark rims round her 
 eyes. I could find no evidence of organic dis- 
 ease 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 difterent being. The 
 only trouble complained of was sleeplessness, 
 but it did not interfere wdth 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. 
 
DIETETICS AND THERAPEUTICS. 141 
 
 III 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 re- 
 sult 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 wxll, 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 thor- 
 oughly enjoying her travels." 
 
 " The last example with which I shall trespass 
 on your patience I am tempted to relate be- 
 cause 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 w^ho has not seen her during the six- 
 
142 DIETETICS AND THERAPEUTICS. 
 
 teen 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 look- 
 ing. The chief personage in it was a lady re- 
 clining 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 hj^steria, 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 consul- 
 tation, and at once recognized the patient as the 
 
DIETETICS AND THERAPEUTICS. I43 
 
 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 prac- 
 tically confined to her bed or couch, and had 
 not passed urine spontaneously for sixteen years. 
 Among other symptoms, I find noted ' awful 
 sufifering 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 w^as groaning loudly at inter- 
 vals 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 
 
144 DIETETICS AND THERAPEUTICS. 
 
 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 sensa- 
 tion. 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 im- 
 possible 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 be- 
 came absolutely unconscious, and remained so 
 
DIETETICS AND THERAPEUTICS. I45 
 
 until 2.30 A.M., her attendant thinking she was 
 dying. IS'ext 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 rohust 
 health, joining with pleasure in society, walking 
 many miles daily, and without a trace of the ill- 
 nesses 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 treat- 
 ment, which is capable of producing such re- 
 markable 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 mor- 
 bid surroundings a great step towards cure is 
 made. Few, however, took the trouble to carry 
 this knowledge into practical action ; and when 
 
 G k 13 
 
146 DIETETICS AND THERAPEUTICS. 
 
 they did so they relied on this alone, combined 
 with moral suasion. JSTow, I am thoroughly 
 convinced that very few cases of hysteria can be 
 preached into health. Judicious moral manage- 
 ment 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." 
 
 As additional illustrations I shall now state 
 a few cases of my own, without entering into 
 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 se- 
 verely 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 them- 
 selves. There was a remarkable loss of nervous 
 and muscular force; his limbs refused their 
 support; his appetite failed; the recollection of 
 
DIETETICS AND THERAPEUTICS. I47 
 
 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 busi- 
 ness, and instant departure to a point where 
 telegraph-wires were unknown and mails infre- 
 quent. He went at once to the Bahamas, pass- 
 ing a month in that delicious climate in absolute 
 inaction; more than another month was con- 
 sumed 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. 
 
148 DIETETICS AND THERAPEUTICS. 
 
 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 for- 
 bidden. 
 
 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 pre- 
 sented 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. 
 
DIETETICS AND THERAPEUTICS. I49 
 
 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 Professor Goodell for the fol- 
 lowing 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 suiFered dreadfully at each 
 monthly period, and had constant ovarian pains 
 and a wearying backache, which kept her on a 
 
 13* 
 
150 DIETETICS AND THERAPEUTICS, 
 
 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 w^as hoped that maternity 
 would rid her of them. The shock of the labor, 
 however, proved too great for her already shat- 
 tered nervous system. She became far more 
 wretched than before, and again sought my ad- 
 vice. 
 
 *' 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 eifort 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 w^ords — that she would have an hysterical 
 attack of screams and tears. So emotional had 
 this constant nerve-strain made her that she 
 
DIETETICS AND THERAPEUTICS. 151 
 
 could not sustain an ordinary conversation with- 
 out giving way to tears. Much of her time was 
 spent in bed : in fact, she was practically bed- 
 ridden. 
 
 " I tried in vain to wean her from her ano- 
 dynes, 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 
 
152 DIETETICS AND THERAPEUTICS. 
 
 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 im- 
 pressed 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, set. 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 natu- 
 rally sturdy health gave way. First came pain 
 in the back, then growing paleness, loss of flesh, 
 and unending sense of tire. Her work, which 
 
DIETETICS AND THERAPEUTICS. I53 
 
 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. Yery soon she 
 began to drop her work for a day at a time. 
 Then came an increasing asthenopia, with even- 
 ing 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 gynsecol- 
 ogist, 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." 
 
 Two years ago. Miss L., set. 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 
 
154 DIETETICS AND THERAPEUTICS. 
 
 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 devel- 
 oped, with their tender aid, hypersesthetic states 
 of the eye and ear, so that her nurses crept 
 about in a darkened room, the piano was si- 
 lenced, and the children kept quiet. Bv 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 be- 
 fore long her sister began to fail in health, owing 
 to the incessant exactions to which she too will- 
 ingly yielded. This alarmed a brother, who in- 
 sisted upon a change of treatment, and after 
 some months she w^as brought on a couch to this 
 city. 
 
 At the time I first saw her, she took thirty 
 grains of chloral every night and three hypo- 
 dermic 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 
 
DIETETICS AND THERAPEUTICS. I55 
 
 the large, indented tongue of ansemia. I made 
 the most careful search for signs of organic mis- 
 chief, and, finding none, I began my treatment 
 as usual with milk, and added massage and elec- 
 tricity 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 end- 
 
156 DIETETICS AND THERAPEUTICS. 
 
 lessly. In some cases I have cured without fat- 
 tening; 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 physi- 
 cal annoyance becomes for one of these unhap- 
 pily-constituted natures a grave and almost in- 
 eradicable trouble, owing to the habit of self- 
 study. 
 
 Miss P., set. 29, weight one hundred and eleven 
 pounds, height five feet four inches, dark-skinned, 
 sallow, and covered with the acne of bromidism, 
 consulted me last year. She had had one at- 
 tack which was considered to have been epi- 
 leptic, 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 day. 
 Vague neuralgic aches in the limbs, with con- 
 stant weariness, asthenopia, anaemia, loss of ap- 
 petite, and loss of flesh, followed. Then came 
 spinal pain and irregular menstruation, a long 
 
DIETETICS AND THERAPEUTICS. I57 
 
 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 prom- 
 ising 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 con- 
 fidence 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 maladj^ 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. K by rest we 
 slow the machinery, and by massage and elec- 
 tricity 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. 
 
 14 
 
158 DIETETICS AND THERAPEUTICS. 
 
 Miss B., set. 37, height five feet five inches, 
 weight one hundred and fifteen pounds, a school- 
 teacher, 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, a year and a half ago. 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. 
 
 A year 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 disap- 
 peared, and she became well enough to walk and 
 
DIETETICS AND THERAPEUTICS. I59 
 
 drive; when a sudden congestion of the kidneys 
 destroyed her in forty-eight hours. 
 
 I have ventured, without much hope, to treat 
 three cases of phthisis in the same manner. 
 There are cases of this nature in which exercise 
 wearies ; there are others which we cannot, for 
 various reasons, send away to more genial cli- 
 mates; and in such instances we are driven to 
 stand by and, with no more hope than oil and 
 tonics give, merely watch the slow decline of our 
 patients. I believe that sometimes, and especially 
 in the very earliest stages of consumption, my 
 treatment will save a small percentage of such 
 people; but as yet I only venture to make the 
 suggestion, and wish distinctly to state that my 
 experience in this form of its usefulness is 
 limited. 
 
 One of the cases treated got well and remained 
 well. There w^as every evidence of pulmonary 
 trouble. 
 
 A second improved enormously in all re- 
 spects, but relapsed hopelessly, owing to large 
 and repeated bleeding from piles and rectal 
 fissure. 
 
 The third, a male, set. 24, was treated by rest 
 and massage without electricity, and improved 
 
160 DIETETICS AND THERAPEUTICS. 
 
 SO as to resume his work. He still has slight 
 cough, and has to be careful, and there are, as 
 jet, distinct evidences of inactive disease at the 
 summit of the left lung. 
 
 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 with- 
 out 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 repeti- 
 tion of the treatment won a final and complete 
 success after the first efibrt 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 sin- 
 gular return of menstruation under this treat- 
 ment, and as examples I add a brief list of some 
 notable instances. 
 
 Mrs. X., set. 29, no menstruation for five years ; 
 return of menstruation at thirtieth day of treat- 
 ment; continued regularly ever since during 
 three years. 
 
 Mrs. C, set. 42, eight years without menstru- 
 ation ; return at fourteenth day of treatment; 
 now regular during five months. 
 
 Miss C, set. 22, no menstruation for eight 
 
DIETETICS AND THERAPEUTICS. \Q\ 
 
 months ; return at close of sixtieth day of treat- 
 ment ; regular now for four months. 
 
 Miss A., set. 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 defi- 
 nite 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 Asso- 
 ciation 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 
 
 I 14* 
 
162 DIETETICS AND THERAPEUTICS. 
 
 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 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 re- 
 call in his own practice such cases as I have 
 described, and every medical man of large ex- 
 perience knoAvs 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 be- 
 lieve 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 thor- 
 oughly justified itself as to need no further de- 
 fence or apology from its author. It has grati- 
 fied me also to learn that in many instances 
 
DIETETICS AND THERAPEUTICS. Ig3 
 
 country physicians, remote from the resources 
 of great cities, have been able to make it avail- 
 able. 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. 
 
INDEX. 
 
 Acne, caused by massage, 75. 
 Alcoholism producing fat, 23. 
 American race-peculiarities, 17, 
 
 21. 
 Anaemia, fatigue in, 64. 
 Anaemic obesity, 107. 
 Asthenopia, 60, 126. 
 
 Banting, objections to, 105. 
 Bathing, effects of, 59. 
 Bleeding, causing increase of fat, 
 
 24. 
 Bowditch on weight at different 
 
 ages, 17, 23. 
 
 Cases : 
 
 anaemic obesity, 108, 110. 
 chloral habit, 131. 
 hysteria, 133, 149, 153, 156. 
 hysteria and neurasthenia, 
 
 136. 
 hysterical paralysis, 126. 
 hystero-epilepsy, 141. 
 neurasthenia, 121, 158. 
 neurasthenia and pulmonary 
 
 disease, 146. 
 pulmonary disease, 159. 
 simulated paralysis, 68. 
 uterine disease, 152. 
 uterine disease and chloral 
 habit, 130. 
 Chorea, 33. 
 
 Constipation caused by milk diet, 
 101. 
 
 Corpulence, Harvey on, 105. 
 
 Dietetics, 97. 
 
 Electricity, 86. 
 
 in constipation, 87. 
 
 mode of using, 86. 
 
 rise of temperature from, 88. 
 
 when needed, 55. 
 
 Fat in alcoholism, 23. 
 
 in its relation to health, 16. 
 
 increased by bleeding, 24. 
 
 mode of accumulation of, 27. 
 
 varieties of, 25. 
 Food, amount of, 114. 
 
 Gymnastics, Swedish, 77. 
 
 Harvey on corpulence, 106. 
 
 Hysteria, vide Cases. 
 
 Introduction, 9. 
 Iron, use of, 118. 
 
 Jackson on rest, 53. 
 
 Earell on milk-treatment, 45, 97, 
 
 99. 
 
 Letheby on fattening stock, 26. 
 
 Malt extract, 114. 
 Malt, Japanese extract of, 118. 
 165 
 
166 
 
 INDEX. 
 
 Menstruation, effect of rest on, 
 
 160. 
 Massage, 71. 
 
 amount of, 76. 
 
 business of the blind in 
 
 Japan, 72. 
 causing acne, 75. 
 effect on temperature, 78. 
 effect on tissue-change, 80. 
 in Sandwich Islands, 72. 
 mode of, 73. 
 why useful, 83. 
 Milk diet, 97. 
 
 constipation caused by, 101. 
 disappearance of uric acid 
 
 during use of, 102. 
 effects on urinary pigments 
 
 of, 102. 
 general effects, 101. 
 in obesity, lOi. 
 in obesity with anaemia, 107, 
 
 108. 
 Karell on, 45, 97, 99. 
 precautions in using, 99. 
 sleepiness from, 101. 
 stools during use of, 101, 103. 
 Morphia habit, treated by rest, 
 (.to., 113. 
 
 Neurasthenia, hysterical, 111. 
 
 treatment of, 111. 
 Nurse, choice of, 50. 
 
 Oleum morrhuae, 116. 
 Obesity with anaemia, 107. 
 milk diet in, 104. 
 
 Peculiarities of American race, 
 17, 21. 
 
 Permanence of relief after treat- 
 ment, 162. 
 Phthisis, gain of weight in, 35. 
 
 Pollock on, 35. 
 Playfair on nerve-prostration, 
 126. 
 quotations from, 126 et seq. 
 
 Quetelet on gain of weight at 
 different ages, 17. 
 
 Rest, 52. 
 
 definition of, 57. 
 effects of, 62, 65. 
 effects of, on menstruation, 
 
 160. 
 in neuralgia, 53. 
 in s-pinal disease, 53. 
 Jackson on, 53. 
 mental, 63. 
 
 mode of terminating, 70. 
 moral uses of, 61. 
 reasons for, 52, 62. 
 
 Seclusion, 47. 
 
 Soup, raw, mode of making, 115. 
 
 Stimulus, 117. 
 
 Therapeutics, 97. 
 Treatment, season for, 50. 
 
 selection of cases for, 33. 
 
 Urinary pigments, changes in 
 during milk diet, 102. 
 
 Weight at different ages. Bow- 
 ditch on, 17, 23. 
 Quetelet on, 17. 
 Weight, gain or loss of. 14. 
 
 loss of, relation to anaemia, 
 15. 
 
 THE END. 
 
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