Fig. I. Showing the points most liable to muscular irritation and soreness- posterior view. Altered from Inman. Fig. II. Showing the points most liable to muscular irritation and soreness- anterior view. "SPINAL IRRITATION;" OR, THE Causes rf AMONG AMERICAN WOMEN. FROM THE TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK FOR 1864. BY CHARLES FAYETTE TAYLOR, M.D., OF NEW YORK. NEW YORK: WILLIAM WOOD & CO., PUBLISHERS, 61 WALKER STREET. 1870. Entered, according to Act of Congress, in the year 1864, by CHARLES FAYETTE TAYLOR, M.D., In the Clerk's Office of the District Court of the United States for the Southern District of New York. Davies & Kent, STEBEOTYPERS, 188 William-st., 2f. K "SPINAL IRRITATION;" OK THE CAUSES OF BACK-ACHE AMONG AMERICAN WOMEN. At the last Annual Meeting of the New York State Medical Society I had the honor of reading a paper on one form of spinal disease. In that paper I took occasion to urge the importance of a more careful observation of hitherto less regarded symptoms, and an earlier detection of. actual disease of the vertebrae, than was believed to be generally attained. And in the hope of somewhat relieving that large class of sufferers who are afflicted with Pott's dis- ease of the spine from the irreparable damage of delay, con- siderable space was given to what were thought to be im- portant contributions to our means of early diagnosis in those cases. It is one thing to early detect actual disease of the spinal column, and quite another to pronounce every per- sistent back-ache to be a disease of the spine. Diseases, like all things else, have their fashions, and of all fashion- able names, "spinal irritation" has been most generally adopted to represent a certain class of cases. I make use of the common term, " spinal irritation," in order to condemn it. It indicates no lesion, describes no pathological condition, is vague, indefinite, and incompre- hensible. If it were used simply as a technical phrase, as a name for a certain sensitiveness along the back, there would be less objection to it; but used as a pathological expres- sion, it leads to the gravest errors of treatment, attended by continual failure. I repeat, there is no known patholog- 4 ical condition which may-justly be called "spinal irrita- tion," and it is the adoption of a term indicating a local disease to represent symptoms by no means local or con- fined to the spinal column, and which, wherever found, de- pend entirely on general conditions, which leads to confused pathological conceptions and erroneous views of treatment. It is with the view of calling attention to the inadequacy as well as the incorrectness of the use of this term that I have dwelt upon it. It arose, no doubt, from observing that certain pains and a soreness in the back; with a heightened sensibility to the touch, were generally accom- panied with increased irritability of the whole nervous system. But the mistake is made of confounding the effect of this state of the nervous system in causing local symp- toms, with a supposed (impossible) condition of the spine or spinal cord near which these symptoms accidentally exist. I believe, and think I shall be able to show, that this whole category of symptoms, from the simple persistent back-ache to the extremest sensibility which can not bear even a touch, is entirely muscular, wherever lo- calized, and arises wholly from a peculiarly susceptible condition of the nervous system in certain constitutions. It is no more unreasonable to admit that muscular action may be painful than that any other function may be manifested with pain. The same high-wrought and sus- ceptible condition of the nervous system which may make digestion painful in one case and menstruation painful in another, may also make muscular action pain- ful in a third ; while in still another, all of these functions may be performed with suffering, and yet without organic disease in either case. It should ever be borne in mind that the amount of suffering one feels is not always an indication of the extent of disease producing it. It may simply indicate increased ability to suffer. The seat of pain is in the nervous system, and the quantity which we feel de- 5 pends quite as much on the condition of the nervous sys- tem as on the amount of actual disease. Indeed, pain .without disease is quite as possible as disease without pain, which we all know constantly exists. It is the highly developed condition of brain and nerv- ous system, in comparison with the inadequate develop- ment of the muscular, or, more properly, the organic system, which makes American women peculiarly liable to -painful functional manifestations. I say comparative development of brain and nervous system as opposed to the organic system, for I do not admit that there can be actual development of one part at the expense of another without resulting weakness instead of strength, even to the relatively superior development. That our American women are especially characterized by great activity of brain and nervous system and corre- sponding weakness of bodily organs is no more apparent than should be the corollary that heightened capacity for emotion and pleasure carries with it increased suscepti- bility to pain. No wonder that, while every portion of a girl's being is subordinate to intellectual and emotional, the or- ganic system being left entirely out of sight, the result of this one-sided development is an assemblage of organs nearly incapable of performing their functions, and a nerv- ous system especially prepared to translate those mani- festations into the language of pain instead of that of pleasure, which is the normal result of well-balanced con- ditions. The American girl is subjected to a system of hot-house culture equally well-calculated to produce early and fra- grant blossoming and imperfect and feeble maturity ; and nowhere do we see the extent of the injury done her as in the shattered nervous system ; schooled, indeed, to pleasure, but thereby made equally capable of increased pain. Indeed, to such an extent is this exaltation of the 6 nervous over the organic system carried, that it may be said to have developed another temperament-what may be called, perhaps, the impressible temperament, a temper- ament in which the intellectual, emotional, and sensational are exalted above every other attribute. Our very climate, with its extremes of hot and cold, bright sunshine and stim- ulating atmosphere, making the normal pulse considerably more frequent than in Europe, predisposes to greater act- ivity of brain ; which, with the rewards of enterprise and effort which our institutions insure, keeps up and favors increased disproportion of the mental over the organic functions. This tendency is transmitted to the offspring ; and so we have children with big heads and small legs-revers- ing the order of nature, which would get the bodily growth well on its way before the nervous system is called into special activity. Born with an abnormal ac- tivity of the nervous system, instead of being subjected to conditions favoring the correction of this inherited ten- dency, they are immediately brought in contact with whatever will increase and excite activity of mind, and cultivate emotion and sensation, while the muscular and organic systems are entirely subordinated, as of no con- sequence whatever. Indeed, the American child is treated as though it were solid intellect, of which the body is a convenient but scarcely necessary appendage. And to this condition our schools-which should be the instructors of men, rather than of minds merely-have contributed their full share. And though there is a little improvement in some quarters, the change is not yet gen- eral enough or radical enough to produce any noticeable alteration of the main result. Not only are these big- brained children put to school too young-and all the younger if they display uncommon brightness, which should be just the reason for greater delay-but studies are crowded on, one after another, to a fearful extent- Fig ITT. An improperly made chair, showing the faulty position assumed in order to get some support for the spinal muscles, which however are weakened by being kept on the stretch. Fig. IV. An improperly made chair, giving no support to the lower part of the back, and hence keeping the muscles of the lumbar region in continuous action in order to maintain the trunk erect. 7 studies, too, which properly belong to twice their years. But worse than all, there is no relief, no remis- sion, scarcely any intermission to the ceaseless strain to which the brain and nervous system are subjected. It is the constant pressure in one direction, after all, more than severity, amount, or even early application, which produces most evil. There is no relaxation, no let-up, which deserves the name. There seems to be an infatuation among our peo- ple on this point. To allow a child to lose a few months at school seems to be felt as the unpardonable sin. Cu- rious illustrations of this have come under my observa- tion ; and in many instances I have seen parents deliber- ately weigh in their minds whether it were more desir- able to let a delicate daughter take the chances of grow- ing up with disease or hopeless deformity rather than lose a few months at school! Of course, in such a case, the object of superior mental development is defeated by the means employed to secure it. We have smartness instead of strength; memory in place of judgment; appreciation and criticism instead of origi- nality, and a structure narrow and superficial rather than broad and deep, as it might be made by a more compre- hensive development. The same is true of both sexes, and the same impressible temperament is developed by the same causes in boy and girl as well. By virtue of greater powers of endurance, and better and more abun- dant counteracting influences, the boy escapes, it is true, with fewer injuries ; but he by no means escapes entirely. I do not wish to be understood as laying the entire blame to the process of education in the schools, much as they are responsible for the state of public health among our women. Whatever in the constitution of society fa- vors the unnatural stimulation of the brain and nervous system, with a corresponding tendency to neglect the or- ganic powers, has its appropriate effect in making an 8 American woman what she is-a beautiful, bright, charm- ing, suffering human being ! Emotional literature, ener- vating devotion to fashion and dress, and above all, early introduction to what is called "society," where the young girl, who should be rolling hoop with her brothers, is called upon to entertain admirers with a mental effort enough to tax the powers of maturity, all combine to lit- erally sap the vital powers, while exciting the mental to the highest pitch of endurance. The American girl does what no other girl of the same age is capable of doing ; but at what a fearful cost in future suffering! It is said that the Esquimaux feels pricks and bruises much less sensibly than men of other nations, the expla- nation being that in his case the organic functions have sub- ordinated the sensational; and it is well known that for the same reason the excessive and really abnormal develop- ment of the muscular system in the case of prize-fighters enables them to receive, without serious injury, a blow which previous to their training might be fatal. This is simply another illustration (only on the other extreme) in the relations of the nervous and organic functions un- der discussion.* I have dwelt at perhaps wearisome length on the ele- ments of our subject, in order that we may fully realize all their bearings with respect to the cases under consid- eration. Let me now recur to the question, " Why are Ameri- can women especially liable to back-ache ?" I answer, * A striking illustration of the physiological principle that excessive develop- ment is simply a transferring of force in one direction to the certain damage of other attributes, is shown in the case of Heenan, an account of the result of whose en- counter with King is given in the London Lancet. His nervous system was so weakened in consequence of the severe training and enormous development of mus- cle, that he had neither resolution nor endurance left, and hence became an easy prey to his less muscular antagonist. I have watched the result of these brutal encounters with much professional interest, and have learned many important les- sons from them; one is, that mere volume of muscle is no indication of either health or endurance. . Fig. V. Improper and injurious manner of lying, with 'spinal muscles in continuous extension, and abdominal and pelvic organs correspondingly cramped. 9 Simply because the necessary action of the muscles in sustaining the trunk is accomplished by a painful effort. With an over-wrought, and by consequence more suscep- tible condition of the nervous system, and a correspond- ingly diminished organic capacity, especially of the mus- cles, we have just the conditions by which any increased action on the part of any organ may be rendered painful. And such is the case with the muscles of the back. Their labor is relatively much greater in sedentary persons than in any others ; sufficiently so to concentrate upon them- selves, in consequence of this relatively increased labor, the painfulness with which, in these cases, all increased functional action is likely to be accompanied. But let me insist that in these cases the action of the muscles is no more likely to be accompanied with pain than the action of other organs of the body. Any organ is just as likely to be thus affected. Hence we have dyspepsia, neuralgia, dysmenorrhea, head-aches, etc., etc., caused, not by any actual disease of the organs themselves, but simply by want of tone in the organ, and especially by the pe- culiarly irritable condition of the nervous system. And any one at all familiar with so-called " bed-ridden" wo- men, who are only extreme samples of the class of cases under consideration, though often having in addition some local disease, knows full well that many of them perform no single function without extreme suffering. Even the senses often partake of this general condition. I have seen those who could neither see, nor hear, nor touch, much less perform the various active bodily func- tions without exquisite agony. And yet, in some of them, it could not be said that there was a particle of actual disease, as the fact that they finally recovered entirely would seem to prove. And allow me to remark in passing, that it is a grave mistake, in the light of the foregoing observations, to sup- pose that every woman who has painful menstruation 10 has necessarily actual disease of the uterus. It is true that conditions favoring painful menstruation might, car- ried still further, induce uterine disease, but it is my ex- perience that painful menstruation is more often attribu- table to the causes under consideration than to actual dis- ease of the uterus. Certainly the one should never be inferred from the existence of the other. Neither must it be understood that the muscles of the back are alone affected by this state of the nervous system. Any muscle or group of muscles, when subjected to greater strain than the rest, or than usual, will complain in precisely the same manner. This soreness and sensitive- ness is quite as often found affecting the muscles of the ab- domen and chest, the only difference being that the muscles in tlie front of the body are so situated that any strain which would be painful can be easily avoided by relaxing them, which is not the case with the muscles of the back. We find the points at which this aching and soreness exist to correspond with the insertions of the greatest number of muscles ; the most sensitive portion of any muscle being at the musculo-tendinous union. Beginning below (Fig. 1), we have the broad aponeurosis across the hips-the origin of the erectores spin® ; again in the lum- bar region, and especially above the region of the sacro- iliac synchondrosis, extending forward and upward over the crests of the ilia. The middle dorsal region is more apt to be affected than just above or below it. About the seventh cervical vertebra, extending one or two ver- tebrae above and below it and on each side toward the shoulders, is almost always affected in these cases, and so also is it under the occiput, close up to the skull. In- deed, the sore spot will be at any point or region which is subjected to a greater strain or where there is naturally greater susceptibility, as near the insertion of muscles. Thus there is good reason why the lower part of the Fig. VI. Shows how the dress may be very loose and yet very bad. Dotted lines (co) show the union of arms to the trunk, while (ab) the usual form of waist and sleeve effectually circumscribes every movement, contracting the chest and wearying the back. 11 back should be most frequently and most severely affected, as the muscles of that portion have to support a greater pro- portion of the weight of the trunk than those higher up. In the front of the body (Fig. 2) we have, beginning below as before, the origin of the recti muscles at the pubis ; the attachments of the muscles along Poupart's ligaments, and even in the side, over the crests of the ilii. The line® transvers® of the recti are sometimes the seat of the soreness; along the ensiform carti- lage and the origin of the pectorales majores, correspond- ing nearly with the borders of the mammae, the latter sometimes alarming the sufferer with fears of cancer of the breast or disease of the heart. Show me a case of so-called "spinal irritation," and I will show you the same symptoms, both in kind and de- gree, in any other part of the body, if only it be subjected to the same strain. The difficulty is quite as annoying when occurring in the lower part of the abdomen as when affecting the muscles of the back. Is this soreness over the pubis and along Poupart's ligament ever mistaken for disease of the uterus or ovaries ? Although the pain along the back is not found more frequently than on the anterior aspect of the trunk, it certainly is more severe and more persistent, and for that reason, undoubtedly, has attracted chief attention. As before said, it is easy to relax all the muscles of the front of the body, which immediately relieves them from any strain which might be painful if persisted in ; and this may be done so instinctively that the patient herself may not recognize the action. But put them in any po- sition where the abdominal muscles can no more be re- laxed than can those of the back, and the result will be precisely the same • an aching and painfulness fully as hard to bear. Indeed, cases are of constant occurrence in which simply lying flat on the back produces such painful tension of the recti abdominis that the patient complains 12 of a sensation as of being torn apart in the lower part of the abdomen. But besides all this, the muscles of the back are un- fortunately subjected to the greatest abuse from incor- rect and inconsiderate habits of life. They are subject to almost unending, unvarying, and unresting strain. The more sedentary the person, all the worse for the poor muscles of the back. All day long they must hold the trunk erect, without a moment of relaxation, and when they begin to complain by aching, the person wonders " why her back aches so ? She has done nothing!" They would ache less if she had done more, for in vari- ety of motion there would have been relief. Society seems to have conspired against the backs cf our women. After bequeathing them the smallest and softest of muscles, and an impressibility of the nervous system which renders any undue action painful, it has conspired to prevent any remedy of this state of things, by making it almost impossible* that they shall not over- tax the muscles of the back. Search from house to house an avenue through, and you will not find a single seat (Figs. 3 and 4) which gives any adequate rest or support to that part of the body most needing it. Even when the victim retires at night there is still often no rest for the wearied back. Feather pillows, billowing up on each side of the face, make' breathing next to impossible except she lie continuously on the back, while not unfrequently the "patent spring bed;' allows the middle of the body, which should be most supported, because it is most weighty, to sink low down in the form of a curve, thus keeping up through the night the extra strain on the spinal muscles which is ceas-eless through the day (Fig. 5). And as if this were not enough, the very dress, from neck-yoke to boot-heels, all conspires to increase the downward drag on the aching back. Not one dress in ten is so fitted that the wearer can Fig. VII. Showing how elevating the heels produces corresponding changes in the mechanics of locomotion, increasing the muscular effort by destroying the perpendicularity of the legs and trunk. 13 comb her hair without first half undressing. No matter how loose the waist may be, if the arms are pinioned (Fig. 6) to the sides by the dress, the effect is to contract the chest and throw it forward, thus increasing the weight which must be supported by the back. Again, to elevate the heels, destroys at once the mechanical arrangement by which we are supported erect in ease and comfort, by the osseous framework, and throws the weight of the body directly on the muscles, requiring a constant renewal of effort to sustain their action (Fig. 7). In this, also, the muscles of the back come in for an extra share of abuse. One half of these cases of back-ache may be cured or greatly relieved by correcting their habits and giving them a chair (Figs. 8 and 9) which will support the lower part of the back during the day, and a bed which will continue to support it during the night, with hair pillows, which will allow the possibility of lying on all sides of the body by turns. If to this be added a small pillow, about the size of one's arm, or just enough to fill up and support the small of the back when lying on a flat surface, as a mat- trass or even the carpet, with the directions to so use it four or five times a day, for five or ten minutes each time, there are few cases which would not be sensibly relieved (Fig- 10). Of course a radical cure would embrace more radical measures ; but these simple observances would, in most cases, be sufficient to prevent the undue strain on the muscles of the back, and of course prevent the undue concentration of symptoms there. The patient will not be cured, but the so-called " spinal irritation" will disap- pear on adopting any course which relieves the spinal muscles from the disproportionate amount of labor to which they are ordinarily subjected.' I am well aware that, in many cases, all the symptoms here enumerated may exist with disease or displacement of the uterus. When there is uterine disease, the symp- 14 toms characteristic of such a condition can not be mis- taken ; they are entirely distinct from, and should never be confounded with, those of the muscular back-ache or the aching at the origin of the abdominal muscles which we are now considering. I fear sad mistakes are sometimes carelessly made through confounding of these symptoms. It is true that the same want of firmness and strength in the muscles, and the same over-wrought condition of the brain and nervous system are 'prolific sources of various forms of uterine disorder. But actual disease of the uterus, or serious dislocation of that organ, though it may depend on the same general conditions, should by no means be considered the direct cause of all the symptoms which usually accompany it. We have but few cases of simple uterine disease, and hence few cases which are not accom- panied with the muscular back-ache ; and though the latter may be indirectly aggravated by the former, it is through the increased general prostration rather than as a direct result. Thus, while we have few cases of uterine disease without the back-ache, there are scores of cases of the back-ache, in all its stages, with no disease of the uterus whatever. I wish to speak strongly on this point, for I can not but reprehend that other narrow view which sees only uterine disease in every woman who complains of pain in the lower part of the back, and especially the disposition, too often manifested, of considering every slight disloca- tion of the uterus as the origin and sole cause of all the symp- toms which may happen to exist in every part of the body. The fact is, there may be a great deal of variation in the position of the uterus without the slightest inconve- nience being produced. Simply because the uterus may be found farther forward or backward, or more on one side, or lower down than is usual, it by no means follows that its position is abnormal. There may be considerable variation of the position of that organ in the pelvic cav- Fig. VIII. Sitting with lower part of back well supported. Fig. IX. Properly constructed chair. Invented by a Lady. Made by Shearer and Paine, Boston, Mass. 15 ity in different individuals, or at different times in the same person, without being beyond the limits in which it was designed to freely move. The question is not, " Does the uterus occupy the most usual position ?" but, " Is its position really abnormal ?" If the latter be true, we shall not have to go far for evidence of the fact. Do not let me incur the possibility of being misunder- stood. I would not for a moment discredit local treat- ment for serious displacement or actual disease of the ute- rus, for I believe such treatment both necessary and right, and constantly see patients who require and receive it at my hands. But it is not well to be mad on any subject. Because local treatment is often useful, it does not follow that it always is. It is a matter in which we should be very circumspect; and having seen quite a. number of patients who had been subjected to severe and injurious local treatment because there happened to be found a slight variation from the usual position cf the uterus in connection with a troublesome back-ache, while there was really no abnormal condition or position of that organ what- ever, I wish to urge the idea that slight displacements, if un- complicated, do not require local treatment, and that the back-ache does not depend at all on these slight and tem- porary modifications of the position of the uterus. A cure must be sought in another direction. What- ever will diminish the irritability of the nervous system and develop the tone and strength of the organic system will effect a cure. A single extreme case-several such might be cited- will sufficiently illustrate and establish my general posi- tion :- A lady about twenty-five years old, married two years, menstruating rather irregularly, always troubled more or less with pain in the back, about eight months before I saw her was obliged to take to her bed on account of the great and rather sudden increase of this pain. When ly- 16 ing, she was comparatively free from pain, but she found that all effort to get up only increased the trouble ; and so she had lain for the length of time above specified, when, through the recommendation of Dr. Vanderpoel, of Albany, I was called to see her. She had consulted several eminent physicians of New York, all of whom agreed in pronouncing an anteflexion of the uterus to be the origin of all her symptoms. She was accordingly treated with some severity with a view of correcting this condition. Dr. Vanderpoel differed from the attending physician, and with the former I entirely agreed, that, without call- ing in question the correctness of the diagnosis as to the particular dislocation of the uterus, there was no evidence that it had anything to do with her inability to walk or that it affected her in any manner whatever. A treat- ment based upon the hypothesis that the gain was muscu- lar, originating in a peculiar state of the nervous system, was entirely successful. In five weeks she was going everywhere, apparently as well as ever. And, on the other hand, all these facts should not excuse us from closely watching all those symptoms which have an unmistakable uterine origin, or for a moment deter us from giving local treatment wherever and whenever indi- cated. As physicians, we are simply interpreters of nature. In what has been said, it is not denied that actual dis- ease of the uterus (like disease of other of the viscera) does cause aching in the lower part of the back ; it is only asserted that the ordinary back-ache, as well as those se- verer symptoms collectively called "spinal irritation," are not the direct result of either disease or displacement of that organ. And still further, it is asserted that they exist oftener without than with the uterine complication. With regard to treatment, the inference, if our premises are accepted, is irresistible. No local treatment can cure a disease of the spine which does not exist. Nor can I Fig. X. ' Lying with back well supported-complete rest for spinal muscles. 17 regard setons, blisters, and counter-irritation with croton oil or moxas, which are sometimes used, as being of the slightest advantage. On the contrary, they must tend still further to perturb the nervous power, and thus directly aggravate the condition they are intended to cure. If under their use a patient does get well, it must be from the operation of other causes, and in spite of the applica- tions to the back. To absolutely cure the back-ache, however it may be palliated by local rest, we must correct the conditions which have caused it. We have found that these condi- tions are : 1st. A peculiarly susceptible condition of the nervous system as an accompaniment of over-activity of the same ; and 2d. A corresponding feebleness of the or- ganic system, especially the muscular, as a consequence of the excessive waste of vital force through nervous irri- tability. Thus with excessive innervation, and consequent deficient organic power, we have the conditions favoring painful functional manifestation. Any organ is liable to suffer, and will suffer, whenever its action is hindered or put to undue stress ; the muscles of the back simply and only because they are habitually subjected to relative over-action. Now the remedy which has been so often proposed, namely, more muscular exercise, in consideration of the manifest deficiency of muscular power, does not fully reach the indications ; for it is not so much in action of the muscles as over-action of the nerves which is the es- sential condition to be met. A few cases may be cured by any judicious general exercise of the muscles ; but the greater number are not, and can not be, for the simple and sufficient reason that gymnastics and most active ex- ercises require an exhaustive effort of the nervous system out of all proportion greater than the muscular action, which increases rather than corrects the difficulty. The fact is, it is not so much muscular exercise the 18 patient needs, as the stopping of the waste of strength through the over-action of the nervous system. The sys- tem can generate only a certain amount of force, and if this force has been already expended through the brain and nervous system, there is nothing left with which to develop muscle. The over-worked business or profes- sional man grows thin in the legs in spite of long walks and gymnastics. Only repose-in the country, at the sea-side, or at the springs-where his brain first has rest, will enable him to accumulate reserve material, which may then be elaborated into muscle by exercise. So with our women ; we must first rest them,-curtail the expenditure of the nervous force,-and then begin our muscular exercise in the most careful and judicious man- ner. It makes little practical difference whether feeble- ness of bodily organs has been engendered by enervating habits, neglect of physical exercise when young, or by other causes ; we have to treat the patient as we find her, and it is not the absolute but the relative activity of the nervous and organic systems which constitutes the condi- tion these patients present. Our object is to correct this disproportionate action. While w'e do it-and in order to do it-we must keep the expenditure of nervous force at its lowest point. All care and mental occupation, further than the merest amuse- ment, must be temporarily thrown off; and even the or- dinary occupations, though not in themselves harmful, had better be for the time set aside. And or the reason that gymnastics or other adequate muscular exercises require a large expenditure of nervous force, we must use such ex- ercises as can be taken with very little such expenditure. This is the rule ; how completely it shall be applied in a given case will, of course, depend on the circumstances of that case. But it must never be forgotten that in this-class of cases, and in all cases of over-action of the brain and nervous sys- 19 tem which have gone on to exhaustion, our material for the development of muscle must be first saved by diminishing the expenditure of the nervous force. To suppose that an over-expenditure of nervous force, and also an over-expendi- ture of muscular force could go on at the same time, would be to suppose an absurdity, and is, besides, contrary to daily experience. We have abundant illustrations of this truth on every hand. The race-horse, by virtue of excessive nervous development, can have but small muscles; and on the other hand, the draught-horse, in consequence of excessive muscular development, is slow and spiritless, and bears the whip without flinching. Such is the law. In the treatment of a case of so-called "spinal irrita- tion" or back-ache, according to the physiological views just expressed, we must secure three conditions in the order in which they are named : 1st. A temporary dimi- nution of the loss of nervous force, by curtailing the action of the brain and nervous system • 2d. Rest for the rela- tively over-used muscles of the back ; 3d. Exercise of the whole muscular system, in order to increase organic de- velopment out of material saved from the nervous system. Thus, as we increase physical endurance, we diminish nervous irritability in the same ratio. But we shall find that the last condition would be entirely inadequate with- out previously securing the first. We are restricted in our choice of exercises only by the necessities of the first condition, viz., that they shall be such as do not seriously tax the nervous system. In very many cases there need be no special exercises whatever ; but the organic system will begin to increase in strength by the mere fact of ar- resting the disproportionate waste of nervous force ; for the same reason that infantile paraplegia is followed by increased development of the non-affected upper extremi- ties, because the nutrition is as much increased in the up- per as it is diminished in the lower extremities. Our object, then, is to transfer a certain amount of force hus- 20 banded from the nervous, into the organic system. We can not create-we can only save and use to better ad- vantage. The idea of treatment, then, is to irritate the muscles without fatiguing the nerves. This can be best accom- plished by simple stretchings of the muscles ; if special exercises are to be prescribed, those that require the smallest effort of the patient compared to the amount of muscular force employed. Instead of dumb-bells, which drag down and rather increase the strain on the back, or calisthenics and gymnastics, require violent, and therefore exhausting effort, slow but strong action of the muscles is indicated, such as we have in stretching, climbing, etc. But to gain the full benefit of muscular exercise in these cases, the exercise should be given by another person. An excellent method (Fig. 11) is to stand behind and above the patient and slowly and strongly draw up the arms. Or a simple and easy mode of accom- plishing the same result is by means of a cord passing over pulleys, as shown in the accompanying illustration'(Fig. 12). We relieve the back, first, by letting it alone, and secondly, by exercising the extremities ; or at least by using such exercises as bring less stress on the back than on muscles at a distance from it. As irritation is diminished and endur- ance increased, all the muscles of the body, including those of the back, may be brought into action. The par- ticular form of the exercises is of much less consequence than that we keep constantly in mind that the main idea of the treatment is to irritate the muscles without exciting the nerves. For this purpose strong but slow and pro- longed muscular action is particularly indicated ; and the principle can be carried much farther-we are enabled to secure much greater irritation of the muscles with less fatigue-if the action be localized ; that is, if only portions of the muscular system be brought into action at the same moment. Fig1' XI. Stretching the upper extremities. Fig. XII. Development of chest and upper extremities. 21 An excellent method of acting on the muscles of the lateral halves of the trunk is shown in the figure (Fig. 13). I show such movements as can be done in any dwelling by members of the family assisting. But in contriving methods of exercise for the cases under consideration, es- pecially those to be employed at home, we are con- stantly beset by the difficulty of ascertaining how much the patient may do without over-doing, and still avoid doing too little. In order to fully appreciate the difficul- ties of the case, let us take, for example, a bed-ridden woman, who has been confined to her bed for months and perhaps years. Many cases, without local disease suffi- cient of itself to confine them, are kept on their backs from year to year, from the simple fact that they gain no strength while they lie there without using their powers ; and yet every attempt to get up involves so much more strength than they possess, that they are overwhelmed by the effort. There seems to be no middle ground for them-no point where they can begin without the cer- tainty of doing too much or too little. After many en- deavors, fruitless of good, but prolific of relapses and in- creased suffering, they, lose all confidence in themselves and refuse to make further effort. I believe the popular impression is, that a woman who has been " bed-ridden" for a time, at last comes to prefer it to the duties of active life. It is generally considered that if she would only try she could walk about like other people, and that she does not try because she does not wish to. It is certain that long confinement tends to make one morbid on all subjects, and especially so on mat- ters pertaining to one's self. But that these cases deliber- ately prefer to be shut out from the light and joys of the world, and all hope of usefulness to themselves or others, I do not believe. I have had to do with quite a num- ber of them, and either those whom I have seen are ex- ceptions to the general rule, or else these unfortunate per- 22 sons have been often wrongfully censured. I have never yet seen one who was not ready to do any reasonable thing to promote her recovery, and who did not long for freedom like an imprisoned captive. All they need is reasonable intelligent management • a skillful piloting through the difficult channel; and when we have secured their confidence by never requiring any unreasonable thing of them, they are ever ready to render a cordial co- operation in whatever is proposed. Whatever they might be able to do under other circumstances, or whatever may be their latent capacities, like a child, who, though possess- ing the physical strength, must be first taught how to use it, they must be brought gradually and easily to re-possess their functions if we would not incur the risk of over- whelming them with sudden and violent efforts. The matter is very simple. If they gain no strength while lying supine, and if to get up is beyond their pow- ers, all that we have to do is to give such exercises as shall be neither below or above their capacity. We must find their level, and there begin. Gentle, gradual use of the muscles, with avoidance of all over-action and shocks to the nervous system, is the rule. I have never yet seen a woman bed-ridden with so-called "spinal irritation," un- accompanied with serious local disease, which could not be reclaimed. And happier persons than such reclaimed ones, after gaining their liberty, it has never been my lot to see. I confess that my sympathies are all on their side, rather than with those who are inclined to blame them. But they must be managed with great caution and discretion. We gently use their muscles, not so much to develop them, as to quiet and soothe the nervous system, and to form the habit in the patient of mak- ing effort without the exhaustion which follows her ordi- nary endeavors. But we must never go beyond their strength. If we do, we shall be pretty apt not only to temporarily overwhelm their feeble powers, but what is Fig. XIII. Developing the strength of the lateral halves of body. ' Fig. XIV. Apparatus for securing a regulated amount of exercise of the muscles of back or abdomen, in the horizontal position, with passive motion of the abdominal and pelvic organs. 23 of more importance, we shall lose their confidence. We shall need all our caution. The difference between lying down and standing up is very great. The muscles of the back, enfeebled by long inaction and the heat of room and bed, if too suddenly called upon to act in the erect posi- tion, may find themselves incapable of sustaining the hun- dred pounds, more or less, which may come upon them. We must be quite sure that they are fully capable of doing, without harm, all we allow them to do at every stage of the patient's progress. There are no exercises which are of themselves specially curative for such cases. As our object is simply to excite assimilation, any proper stretching of the muscles, or causing the patient gently to pull with the arms or push with the feet, if carefully done and persisted in, will be all that is necessary ; there will be a gradual increase in strength, and decrease of nervous irritability. We must let the back pretty much alone till the treatment be far advanced. There are other cases, not confined to the bed, for whom it is very desirable to give a graduated exercise of the back. There are many who walk about in continual suffering, and are only tolerably easy on lying down. There are many others who find ordinary exercise, to any adequate extent, impossible, because of uterine complications. And in all these cases it is desirable to be able to regulate, within very narrow limits, the arnowd of labor which the back shall do. In ordinary exercise the amount must be always the same, viz., enough to support the trunk. In order to meet these indications, we have devised an apparatus for the purpose of exercising the muscles of the back and abdomen, with the patient in the horizontal po- sition (Fig. 14). It is so contrived as to be exceedingly adjustable, and enables the physician to prescribe any amount, from the most gentle to the most severe, at will. There always is a point, which it is our object to find, up 24 to which exercise is beneficial, and beyond which it might be injurious. So far as the spinal or abdominal muscles are concerned, we are enabled to ascertain their point of endurance with the greatest ease. Besides the regulated action of the abdominal and spinal muscles, the motion itself through the lower part of the abdomen has the most direct and happy effect in giving tone and action to the abdominal and pelvic organs, insomuch that cases of con- stipation which have resisted all other means have yielded readily to this motion. I need not enlarge upon the utility of this apparatus in all cases of displacement or even con- gestion of the uterine organs. As a remedy for the back- ache, in connection with such other treatment as may be indicated, it is almost sovereign. The gentle, easy man- ner of using the spinal muscles seems to remove their harassing pain almost as if by magic. The apparatus which we use is somewhat complicated, as it must be very adjustable to be continually shifted to accommodate different patients. It will be seen that either end may have motion, or both at the same time, ac- cording as we wish the action in the lower or upper part of the back, or along its whole course. But a very sim- ple affair may be made, which will answer every purpose, by hinging a strong board to a common goods-box, af- ter the manner shown in the accompanying cut (Fig. 15). Such an apparatus could be set up in the attic of any house with very little trouble, and when once properly adjusted would want very little alteration. But all these things, to the minutest detail, must be under the immedi- ate supervision of the physician himself, if he would not be subjected to disappointment. A number of extreme cases, illustrative of the various phase's and complications of this affection, will now be given. They are mostly selected with direct reference to illustrating the principle of differential diagnosis in these cases. Fig. XV. Specimen of home-made apparatus for exercising muscles of back fa.-same principle as Fig. XIV. 25 In June, 1860, I was called to see a patient in Dela- ware Co., in this State. I found a young woman of twenty years laboring under the most aggravated form of nervous prostration and irritability. Her history was this : One year before she was a member of the village academy ; the daughter of a farmer, she assisted morning and evening in the household duties, studied in the late evening and early morning hours ; was a good scholar, and not only went ahead of her class but reviewed the primary branches in anticipation of examination before the county commissioners as a candidate for teacher- about which she had a great dread. Besides all this, she prepared to take part in the annual teachers' benefit, called a school "exhibition," writing a dialogue or play for the occasion. The result was that the mind was in continuous action month after month without a moment of actual rest or even temporary cessation from thought. Constant ten- sion will snap the cord at last. On the last day of the term she fainted and showed other signs of complete ex- haustion ; but rallied, went through her part in the exer- cises of the examination and exhibition, went home and to bed, from which she had never got up when I saw her! During the year in which she had lain prostrate, there had been little or no change of her general symp- toms. There was so great intolerance of light that the room was constantly darkened ; ordinary sounds were painful to her, insomuch that the rooms over her could not be used, and the greatest care had to be taken in speaking and walking even in distant parts of the house. Digestion and every other function was attended with distress, and the back, as is.usual, was exceedingly sensa- tive along the whole length of the spine. The most careful examination failed to discover any local disease. The treatment had to be intrusted to a sister, and well did she persevere under many discouragements. It con- 26 sisted iii the simple stretching of the muscles by pulling carefully at the hands and feet, and such other simple movements as could be made by a patient in such prostra- tion. Notwithstanding they had been cautioned against at- tempting too much, in their anxiety to make a show of improvement they several times committed the usual error of going beyond her strength, which resulted in the in- evitable back-set; so that it was nearly two year,s before the cure was fully realized. What makes this case of still more interest is the circumstance that after examin- ing her, the door was opened into the adjoining room, where lay an elder sister as she had lain for twelve years! For eight years she had not ever sat in a chair. Her case was very similar to the first. So far as the fam- ily could carry out the treatment, with their limited means, away from professional aid, she has improved un- der it. At last accounts she was able to take some exer- cise and sit in a rocking-chair. The first case represents a class of patients, the most intelligent and worthy of all our young women, who are ruined-yes, literally ruined at school; and New Eng- land, for obvious reasons, has, probably, most victims. Nearly all the bed-ridden cases, and the most of the worst cases of back-ache, are those who, on inquiry, admit that they have studied excessively at some time, from which they generally date the first symptoms of their disorder.* * There is a class of schools, of which Mt. Holyoke Female Seminary, at South Had- ley, Mass., is the model, which themselves and through their influence have done incalculable harm. Under the plea of thoroughness and discipline they under- take to regulate or methodize almost every hour in the twenty-four in such a man- ner that there is scarcely an unoccupied moment. Intense mental application is not necessarily injurious, provided it be accompanied by seasons of as complete mental repose. But continuous occupation, even where little is accomplished, is exhausting and, if persisted in, ruinous. Where the whole time is divided off, like bars in music, with what are to be the thoughts written down like notes-all pre-determined-the very recreations refuse their office and become a labor. Very few girls educated at such institutions can hope to escape the back-ache in after-life, even if they do not take it direct from the seminary with their diplomas. 27 The next case, Miss C., was a patient of Dr. J. M. Sims. She was attending school, and while menstruating, in taking the usual morning walk with the class, got her skirts drabbled in a new snow then on the ground, and her feet wet, and took a cold which suspended the catamenia, and threw her into a state of extreme prostration. She was for the first six or seven months under homeopathic treat- ment, and ultimately came into Dr. Sims' hands, at whose request I took her case. She had recovered somewhat from the first shock of the disease, though the catamenia had not reappeared. She looked bright, was cheerful, but possessed no ability to get out of the recumbent position. She had been in this condition about eight months. There was slight irritation in the left ovary, but, according to Dr. Sims, no other complication. She was engaged to be married, and was exceedingly anxious to get well; and though she frequently tried at the instance and with the assistance of Dr. Sims, he at last became satisfied that it was utterly impossible for her to get up. Fainting, fol- lowed by great prostration, was always the result of every effort. There was little or no emaciation, and all that was wanted was to teach her how to use her strength without exhausting it on the first effort. By beginning with the simplest and gentlest movements, literally at the toes, she soon acquired the art of econ- omizing her forces, and she rapidly regained the use of all her powers. The weakness of the back, especially of the upper portion, which made it impossible for her to raise her head from the pillow, rapidly disappeared, and at the end of three weeks she was discharged entirely well. My connection with this case occurred in June, 1857, and the lady, now the mother of several children, has had no recurrence of any similar condition. Mrs. R., about thirty years old, of small size, the mother of four children, who were very large at birth, had suf- 28 fered more and more at each confinement, from loss of strength and slow convalescence. After the last confine- ment, which took place in the summer of 1862, she re- covered still more slowly, but after about three months got out, over-exerted herself, and suffered a relapse. This shock, added to the previous one of parturition, com- pletely prostrated her, and she continued in the same bed-ridden condition till June, 1863, when I saw her. She suffered intensely in the back, was much prostrated, and easily agitated by little causes. There seemed to be no uterine complication ; she had recovered from all spe- cial functional disturbance, except some indigestion, and the source of all her symptoms seemed to be the prostra- tion of the nervous system. I recommended the usual kneading of the muscles, with quiet, absence from mental'excitement, etc. The treatment was carried on by the family physician. She progressed satisfactorily, and even got so that she could walk about a little, when her mother, who had been with her, going home, she took an undue amount of household cares upon herself, which soon brought all the back-ache on again. Her friends and herself were unnec- essarily discouraged, and she grew morbid and hysterical. But it only wanted a steady hand at the helm, some one to control the manner in which she should expend her nervous force, or rather to prevent her from frittering it away and to direct it into organic development. A few weeks sufficed to complete the cure and place her beyond danger of relapse. Hers was one of those cases which, probably, would have been bed-ridden for years, for there was great prostration and the most excessive irritability of the nervous system. This lady had been a night stu- dent. These last two cases represent another class, viz., those prostrated by attacks, more or less acute, which leave them with great nervous prostration, perverted sensations, and 29 inability to discover or know their own actual strength. The cure consists in teaching them how to use the capa- city which has, unknown to themselves, been restored to them. It is not to be supposed that so much actual strength can be developed in so short a time as will suffice to restore some of these cases. The last two cases which I shall introduce here, are those complicated with uterine disease. Miss VV., aged twenty, of a very bright, active, nervous temperament, for a year previous to her coming to New York had been suffering from a serious dislocation of the uterus. She was placed under the care of Dr. J. M. Sims, who treated her successfully for ante-flexion of the uterus. I say she was treated successfully, for when, after six months' treatment, at the request of Dr. Sims I took charge of her case, there was no malposition of the uterus to be detected. So far as the uterus was concerned, she was cured ; but notwithstanding she was able to be about when she came-though suffering severely from the local affection-at the end of sisc months' successful treatment (successful so far as correcting the dislocation of the uterus is concerned) she was utterly unable to raise her head from her pillow, and had been in that condition for two or three months previously. She had all the symptoms of aggravated "spinal irritation,'' utter prostration and intense back-ache, and soreness along the spine. The treatment previously described, of irritating the muscles, was only partially successful in this case ; that is, after three months' treatment she was able to walk about and ride, and has been slowly but steadily gaining since. I first saw her in March, 1862. The case is only important as demonstration that the back-ache, usually associated with uterine disease, does not necessarily depend on it as direct cause. Here was a case of uterine disease progressing toward a cure, while the back-ache as progressively increased. The explana- 30 tion is easy. The local disease first, and the severe oper- ations she was subjected to to cure it, operated as shocks to her susceptible nervous system, thus aggravating the condition of the system favoring the back-ache. I have had at least two other bed-ridden cases similar to the above. The next and last case illustrates the same general principle. A young lady, aged about seventeen, in tolerable, but not perfect health, about the first of December, 1860, on a sudden alarm of fire, caught a large pailful of water out of the hands of the servant, and ran with it up two flights of stairs to where the fire was burning. She was attending school at the time, and was obliged to go up and down many flights of stairs during the day. She soon be- gan to feel a slight pain and heaviness in the left groin, sinking at the stomach, and other evidence of serious dis- placement of the uterus, and in about a month was pretty much confined to her bed. From January ( 61) to the close of April she made no whatever, except with assistance, to move from one bed to another. From the first it was impossible for her to sit even for a moment. In the beginning of the summer ('61) "spinal irritation" was suggested, and an apparatus was provided for her to wear. With the apparatus on she could walk about somewhat, and she continued to wear it till the middle of November fol- lowing, during all which time she was unable to sit down a moment without pain, except by using a cushion which was made for her, with a vacant space in the center so large that there could not be the slightest pressure on the perineum, the weight resting wholly on the ischii. By November she was so much worse, particularly as to the spinal symptoms, that she was obliged to take entirely to her bed again, where she remained till the 28th of May, 1862, when I saw her for the first time. On learning her history, my diagnosis was, serious downward and back- ward dislocation of the uterus, and that the spinal symp- 31 toms were induced by the prostrating effects of the dis- ease and the confinement, aggravated possibly by too much effort while wearing the spinal apparatus. Examination disclosed the uterus resting on the floor of the pelvis, to the left of the rectum, and bearing almost directly on the end of the coccyx. This position accounted for her inability to sit, for the slightest pressure on the perineum impinged directly on the uterus. There was but little enlargement, and menstruation had gone on regularly through the whole time. There were two ideas to be taken into consideration in the treatment of this case. There was the obvious one of reducing the uterine dislocation ; but though in ordinary cases the constitu- tional symptoms, which have been induced by the local disease, mostly disappear on removal of the cause, it is by no means uniformly so, as the preceding case demon- strates. Nor is it generally so in these extreme cases. There are, in fact, two tolerably distinct conditions to be treated, namely, the local disease and the constitutional condition ; whether the latter has been the remote cause of the former, or has been produced by it. In this case, on replacing the uterus there was immediate relief to the local symptoms, the tension on the perineum was relieved, and the sense of heaviness in the left side of the pelvis was removed • but the sensitiveness along the spinal col- umn, which had, since wearing the instrument, extended into the neck so that she could not lift her head from the pillow, was not materially alleviated. It was only by a continuous course of treatment-by irritating the muscles- that the prostration of the nervous system was gradually overcome, and the weakness and irritation of the back slowly subsided. It is not to be denied that the local treat- ment for uterine displacements or disease is itself much more efficacious when accompanied by the treatment here indicated. Not only the allaying of nervous irritability is highly favorable to healthful action, but the strengthening 32 of the muscles of the abdomen and loins has a direct influ- ence in sustaining the contents of the abdomen, and pre- venting them from pressing down into the. pelvis. In-this case the uterus was made to retain its proper position with some difficulty ; but under the combined local and general treatment both the local and constitutional conditions were corrected, and on the 28th of August she arrived at home completely restored, and has remained ever since in per- fect health. I should have said that soon after her arri- val in New York she had an attack of tonsillitis, through which she was safely carried by the family physician of the friend with whom she stopped-Dr. Vermilye. This last case is principally interesting as still further illustrating the principle of differential diagnosis. These two cases represent a very large and important class of patients affected with uterine disease and displacements in various forms and stages, which are almost invari- ably associated with the constitutional condition of over- active nervous system and consequent feeble organic power, which has been under discussion in this paper. Note.-I wish to call the attention of the profession to the alarm- ing increase of infantile paralysis. The explanation can be found only in the irritable and susceptible nervous and feeble organic sys- tems which have been developed in parents and transmitted to chil- dren, as is always the case, in an exaggerated form. These cases of paralysis in small children occur almost entirely among the highest and most intellectual classes, and very many of them are children of mothers who have suffered from back-ache from girlhood up. With such antecedents and such a temperament no wonder that the slight- est causes are liable at any time to overwhelm them with some form of paralysis.