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 ma.s.sage is less agreeable than in winter, and, as a rule, I find it harder to feed and to fatten persons at rest during 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 exceptional 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 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. Young, I have said she ought to be, but youthful would be a better word. If, as she grows older, the nurse loses the strenuous enthusiasm with which she made her first entrance into her work, scarcely any amount of conscientious devotion or experience will ever replace it; but there are fortunate people who seem never to grow old in this sense. 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 hard 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. Over-harshness is in some ways worse than over-easiness, because it makes less pleasant the relation between nurse and patient, and the latter should regard the former as her "next friend." Let the nurse, therefore, place upon the doctor the burden of decision in disputed matters; his position will not be injured with the patient by strict enforcement of the letter of the law, while the nurse's may be. 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, and to change if necessary more than once.

The degree of seclusion should be prescribed from the first, and it is far better to find that the original rules may be profitably relaxed than to be obliged to draw the lines more strictly when the patient has at first been indulged. For instance, it is well to forbid the receipt of any letters from home, unless anxious relatives insist that the patient must have home news. In that case the letters should be mere bulletins, should contain nothing, no matter how trifling, that might annoy a too sensitive person, and, most important of all, should come to the nurse and by her be read to the patient.

CHAPTER V.

REST.

I have said more than once in the early chapters 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, ma.s.sage, electricity, and over-feeding. I said that the use of large amounts of food while at rest, more or less entire, was made possible by the practice of kneading the muscles and by moving them with currents able to effect this end. I desire now to discuss in turn the modes in which I employ rest, ma.s.sage, 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 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 cla.s.s 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 No. IV. of Dr. Seguin's series of American Clinical Lectures, I was at some pains to point out the value of repose in neuralgias, and especially 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 accepted. 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 answer almost every day in practice. Most often we incline to insist on exercise, and are led to do so from a belief that many people walk too little, and that to move about a good deal every day is well 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 systems 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 be. If they are young, this is easy enough. If 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 pa.s.sing 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 opinions 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 not obtain the needed control over those of their own s.e.x. I have been struck with this a number of times, but I have also seen that to be too long and too habitually in the hands of one physician, even the wisest, is for some cases of hysteria the main difficulty in the way of a cure,--it is so easy to disobey the familiar friendly attendant, so hard to do this where the physician is a stranger. But we all know well enough the personal 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 succeed according to our method of using them. There are still other cases in which mischievous tendencies to repose, to endless tire, to hysterical 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 entire 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 attempt to make them walk usually ends in some mischievous 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 cla.s.ses, 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, 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 repose on a lounge for some hours a day up to entire rest in bed. In milder forms of neurasthenic disease, in cases of slight general depression not properly to be called melancholias, in the lesser grades of pure brain-tire, or where this is combined with some physical debility, I often order a "modified" or "partial rest." A detailed schedule of the day is ordered for such patients, with as much minuteness of care as for those undergoing "full rest" in bed. Here the patient's or the household's usual hours may be consulted, a definite amount of time allotted to duties, business, and exercise, and certain hours left blank, to be filled, within limits, at the patient's discretion or that of the nurse.

So many nervous people are worried with indecision, with inability to make up their minds to the simplest actions, that to have the responsibility of choice taken away greatly lessens their burdens. It lessens, too, the burdens which may be placed upon them by outside action if they can refuse this or that because they are under orders as to hours.

The following is a skeleton form of such a schedule. The hours, the food, the occupations suggested in each one will vary according to the s.e.x, age, position, desires, intelligence, and opportunities of the patient.

7.30 A.M. Cocoa, coffee, hot milk, beef-extract, or hot water. Bath (temperature stated). Rough rub with towel or flesh-brush: bathing and rubbing may be done by attendant. Lie down a few minutes after finishing.

8.30 A.M. Breakfast in bed. (Detail as to diet. Tonic, aperient, malt extract as ordered.) May read letters, paper, etc., if eyes are good.

10-11 A.M. Ma.s.sage, if required, is usually ordered one hour after breakfast; or Swedish movements are given at that time. An hour's rest follows ma.s.sage. Less rest is needed after the movements. (Milk or broth after ma.s.sage.)

12 M. Rise and dress slowly. If gymnastics or ma.s.sage are not ordered, may rise earlier. May see visitors, attend to household affairs, or walk out.

1.30 P.M. Luncheon. (Malt, tonic, etc., ordered.) In invalids this should be the chief meal of the day. Rest, lying down, not in bed, for an hour after.

3 P.M. Drive (use street-cars or walk) one to two and a half hours.

(Milk or soup on return.)

7 P.M. Supper. (Malt, tonic, etc., ordered; detail of diet.)

Bed at 10 P.M. Hot milk or other food at bedtime.

This schedule is modified for convalescent patients after rest-treatment by orders as to use of the eyes: letter-writing is usually forbidden, walking distinctly directed or forbidden, as the case may require. It may be changed by putting the exercise, ma.s.sage, or gymnastics in the afternoon, for example, and leaving the morning, as soon as the rest after breakfast is finished, for business. Men needing partial rest may thus find time to attend to their affairs.

If ma.s.sage is not ordered, there is nothing in this routine which costs money, and I have found it apply usefully in the case of hospital and dispensary patients.

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. Where at first the most absolute rest is desirable, as in cases of heart-disease, or where there is a floating kidney, I arrange to have the bowels and water pa.s.sed 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 order 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 always 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 bathing, 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.

Most of these patients suffer from use of the eyes, and this makes it needful to prohibit reading and writing, and to have all correspondence carried on through the nurse. But many neurasthenic 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 interest, 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 ma.s.sage 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 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 to 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 pa.s.ses 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, whatever it may be afterwards, a sense of relief, and a remarkable and often a quite abrupt disappearance 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 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 permanently, he cannot afford to neglect them. Above all, let him be careful that the ma.s.seuse 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 dyspeptic, 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 food. The same thing is seen in an extreme degree in the well-known experiment of causing a dog to run violently after eating, in which case digestion is entirely suspended. Whether these results be due to the calling off 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 ill.u.s.trations in many of the cla.s.s 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 conditions. It may be wise to add that occasional cases of nervousness or of nervous disturbance of digestion are seen in which the patient a.s.similates food better if permitted to move about directly after a meal; and I recall one instance of very persistent gastric catarrh where the uncomfortable symptoms following meals only began to disappear when as an experiment the patient was ordered to take a quiet half-hour's stroll after each meal, instead of the rest usually ordered.

I am often asked how I can expect by such a system to rest the organs of mind. No act of will can force them to be at rest. To this I should answer that it is not the mere half-automatic intellectuation which is harmful in men or women subject to states of feebleness or neurasthenia, 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 vain to hope for help by the method I am describing. The man hara.s.sed by business anxieties, the woman with morbidly-developed or ungoverned maternal instincts, will only ill.u.s.trate 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 hopeful experiment, which may have to be abandoned, and which is valueless without the cordial and submissive a.s.sistance 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 difficulty. As a result, fatigue comes early, is extreme, 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 acc.u.mulate, and do this the more easily because the eliminative organs share in the general defects. And these are some of the reasons why anaemic people are always tired; but, besides this, all real sensations are magnified by women whose nervous systems have become sensitive owing to a life of attention to their ailments, and so at last it becomes 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 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 remember 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 certain 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 shall, in every case, lessen and limit the ills we cannot wholly avoid. How to reach these ends I shall by and by state, but for a brief s.p.a.ce I should like to dwell on some of the bad results 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 treatment.

"When we put patients in bed and forbid them to rise or to make use of their muscles, we at once lessen appet.i.te, weaken digestion in many cases, constipate the bowels, and enfeeble circulation."[15]

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, besides this, every active muscle is practically a throbbing heart, squeezing its vessels empty while in motion, and relaxing, so as to allow them to fill up anew. Thus, both for itself and in its relations to the areolar s.p.a.ces 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 defects 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., aet. 52, who was brought to me from New 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 week's ma.s.sage 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 feeble; 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, 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 destroy 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 times under like circ.u.mstances,--a rapid loss of flesh.