Part 2 (1/2)
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 finis.h.i.+ng.
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.