Nursing in Nervous Disease, particularly in Hysteria. By Guy Hinsdale, N.I). • 
'VltOy, 314 
GUY HINSDALE, M.D., ON 
NURSING IN NERVOUS DISEASE, PARTICULARLY IN 
HYSTERIA.1 
Assistant Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases; Physician to Out- 
Patients, Presbyterian Hospital; Lecturer on Climatology in the University of 
Pennsylvania, Philadelphia. 
GUY HINSDALE, M.D., 
The term nervous disease covers a very wide range of affections: the 
case of apoplexy with its rapidly fatal course or the slow, lingering, partial 
recovery with the paralytic arm or leg; the epileptic spasm that may be the 
forerunner of a series of convulsions which render a nurse or an attendant 
necessary to the safety of the subject; the sufferer from neuralgia in its 
various forms, where the slightest exertion will set the facial or sciatic nerve 
throbbing with pain ; the ataxic or spastic paralytic, whose form of locomo- 
tion is impaired and whose sufferings it is almost impossible to relieve for 
any length of time; finally, the hysterical and insane, whose erratic mental 
condition requires the highest quality of medical art to deal with, and for 
whom often far more can be done by the good judgment, tact, patience, 
and properly-directed kindness of a nurse than by all the medicines in the 
drug-shop. 
It is this last class of affections, particularly the hysterical, that I wish 
to call your attention to this evening. 
The supply of good nurses in nervous disease is not equal to the demand ; 
the ranks are constantly being depleted by various causes. Those who have 
nursed a patient after a surgical operation, be it cceliotomy or amputation, 
will find very much the same thing required in a second case of cceliotomy 
or amputation; but no matter how many cases of hysteria you may have to 
deal with, every one will be found different and will call for very different 
treatment. At any rate, the successful nurse as well as the successful physi- 
cian will never undertake to adopt routine methods in such cases. The 
moment the patient discovers that she is being put through a routine system 
without consideration for individual needs and peculiarities, from that time 
she loses faith in the medical director. 
Obhe most successful plan of treating these cases is by a combination of 
various agencies, which were first grouped together and applied simul- 
taneously to the treatment of neurasthenics by Dr. S. Weir Mitchell of this 
city. Indeed, the plan of treatment is usually known in this country and 
in Europe by his name. It is sometimes charged against the system that 
1 Delivered before the class of nurses in training at the Presbyterian Hospital, 
Philadelphia. Fig. 2.-Appearance of the same patient after complete recovery was established. 
Fig. 1.-Appearance of a nervous patient before commencing treatment. NURSING IN NERVOUS DISEASE, PARTICULARLY IN HYSTERIA. 
315 
it consists of routine, but, although the various agencies may be continued 
in use from one to two or even, in exceptional cases, three months, it is the 
personal influence, tact, and maintenance of authority founded on a thorough 
appreciation of the various and often deceptive features of the case that 
make the line of treatment the farthest degree removed from routine 
method. If it has failed in the hands of many of those who have under- 
taken it, the lack of success has not been due, as a rule, to the fact that the 
physical agencies have not been properly applied; these can be reduced to 
a more or less constant element of practice; they conform pretty closely to 
the written page; it is that'unwritten, inexpressible personality that avails. 
This is the field for the exercise of what is sometimes spoken of as 
" will power," and it is in this class of cases that occur those extraordinary 
instances of " faith cure" and which offer a field for the so-called " Christian 
scientists." 
The general treatment of a typical case of hysteria will involve a great 
deal of time and money. Hysteria is usually seen in women from fifteen 
to fifty years of age, although these limits may be exceeded, and in excep- 
tional cases hysteria may be observed in boys and men. 
Specialists in nervous disease are usually consulted after the hysterical 
condition has been well established. The history is usually somewhat as 
follows: 
The patient has perhaps undergone a season of trial or has encountered 
some prolonged strain. Perhaps it has been in nursing a relative during 
months of anxiety. She has denied herself air, food, and refreshment of 
mind ; she becomes thin and pale; has a poor appetite; is easily wearied, and 
finds a refuge finally on the sofa or bed. 
Aches and pains develop and sleep is poor. By this time unwise medi- 
cation may have added to the trouble and actual dyspepsia or constipation 
may have to be contended with. It will be a mistake for you to conclude, 
because the diagnosis of hysteria has been made, that the affections which 
are apparent in the patient are, after all, imaginary. This is by no means 
true. There are actual disorders; there may be even a true paralysis as 
well as a false paralysis of hysteria. Most of the real affections that hys- 
terical patients suffer from are the results of misdirected treatment. An 
effort should be made to raise the standard of health generally, to revolu- 
tionize the entire manner of life, and give the patient the opportunity of 
making a fresh start on a different plane. 
Without discussing the causes that have brought the patient to bed, 
whether it may have been overstudy, devotion to society, disappointment 
in love, bereavement, or the care of the household,-whatever the cause is, 
you will find that they have usually exhausted the resources of many 
physicians, worn out various nurses, or overtaxed in their selfishness the 
various members of their unfortunate families. 
Instead of being ennobled by sickness they become self-centred, and 
lose that control of their emotions and wants, that regard for others which 316 
GUY HINSDALE, M.D., ON 
it is the duty of every one to observe in this world. In the typical case 
the invalid has become a tyrant surrounded by a group of slaves. It often 
happens that hysterical invalids complain greatly of a sensitive spine. 
Exertion is therefore considered to be harmful. Reading may be given up 
because the eyes are weak, and others have to read to her. The light finally 
is painful, and the invalid's room has to be darkened. That I may not 
seem extravagant I will quote what Dr. Mitchell says of these cases: "A 
draught of air is supposed to do harm, and the doors and windows are 
closed, and the ingenuity of kindness is taxed to imagine new sources of 
like trouble, until at last, as I have seen more than once, the window cracks 
are stuffed with cotton, the chimney is stopped, and even the keyhole is 
guarded. It is easy to see where all this leads to: the nurse falls ill, and 
a new victim is found. I have seen an hysterical, anaemic girl kill in this 
way three generations of nurses. If you tell the patient she is basely 
selfish, she is probably amazed and wonders at your cruelty. To cure such 
a case you must alter as well as physically amend, and nothing else will 
answer. The first step needful is to break up the companionship, and to 
substitute the firm kindness of a well-trained nurse." 
The patient should be carefully examined for the existence of any 
organic disease. In certain instances, such as advanced Bright's disease or 
in tubercular conditions, malignant disease, or in the case of true melan- 
cholia, the rest treatment is unadvisable. 
Cardiac affections or stomach disorders are, as a rule, incidentally relieved. 
The essential features of the treatment are,- 
I. Seclusion. 
II. Certain forms of diet. 
III. Rest in bed. 
IV. Massage (or manipulation). 
V. Electricity. 
It is the combination of these five measures that brings success. 
I.-SECLUSION. 
Not only is it obviously impossible to treat these cases in a general hos- 
pital ward, but it is not desirable to undertake the treatment of hysteria 
within the patient's home, no matter how remote and quiet a room may be 
proposed and no matter how strict a quarantine may be promised by mem- 
bers of the family. It is against the whole spirit and plan of treatment. 
Homfe connections must be severed for the time being; the interests of 
family, the accustomed sounds, anxiety for the comfort of others, petty 
annoyances, had better be left hundreds of miles behind. The patient must 
consent to be placed under a new authority as implicitly as the soldier who 
leaves home and business behind and obeys the order to halt, or march, 
with perfect confidence in his general's ability to direct and unquestioning 
loyalty even in the darkest hours. 
Seclusion is a feature of the treatment which a patient at first often Fig, 4.-Same patient after complete recovery. 
Fig. 3.-Patient's appearance before treatment was commenced. NURSING IN NERVOUS DISEASE, PARTICULARLY IN HYSTERIA. 
317 
objects to strenuously, but which she herself will after a while admit is 
essential to success. 
Seclusion does not mean, by any means, solitary confinement, nor should 
a room be chosen that is so dark or unattractive as to give the slightest 
ground for calling it a prison. It should be sunny, especially in autumn 
and winter, which, by the way, is the better portion of the year to conduct 
the treatment. 
The patient requires the entire time of one nurse. As previously stated, 
she should be a well-trained hired nurse. She ought to be a stranger to the 
patient, "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, and to write letters. The more of these cases she has 
seen and nursed, the easier becomes the task of the doctor. It is always 
to be borne in mind that most of these patients are over-sensitive, refined, 
and educated women, for whom the clumsiness, or want of neatness, or bad 
manners, or immodesty of a nurse may be a sore and steadily-increasing 
trial. To be more or less isolated for two months in a room with one con- 
stant 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 im- 
pediment to the treatment, because no mere technical training will dispense, 
any more in the nurse than in the physician, with those finer natural quali- 
fications which make her training available. But one nurse will suit one 
patient and not another, so that I never hesitate to change my nurse if she 
does not fit the case." These are Dr. Mitchell's words, and certainly no 
one is better qualified to speak. 
The daily visit from the doctor in charge brings with it encouragement, 
strength, perhaps a firm but gentle remonstrance, but never argument with 
the patient. The nurse makes a note of all directions given, and shows the 
physician the schedule which is her guide in the performance of the duties 
of the day. If any omissions or irregularities have occurred, it is her duty 
to report upon them at that time, not, however, in the presence of the patient. 
At another hour there is a visit from a physician who administers elec- 
tricity, and at another hour there is a visit from the masseuse. Thus there 
are by day no long intervals in which the patient can grow lonely. 
II.-CERTAIN FORMS OF DIET. 
Early in the morning, on waking, there is given a glass of milk or 
cocoa, in some cases coffee. The patient is sponged after this, usually every 
day, but in some cases, where it seems to be fatiguing, only three times a 
week. Milk is not only the chief but for the first fortnight the only article 
of diet. It is given in small quantities at frequent intervals, and according 
to the plan of Dr. Karell, of St. Petersburg. 
The milk is kept with the greatest care in clean vessels. It is used 
skimmed, and is better if obtained from the cow twice a day. At first the 318 
GUY HINSDALE, M.D., ON 
skimming should be thorough, and it is therefore not desirable to have the 
rich milk of the Alderney cow. 
At first the amount given is not over four ounces every two hours. The 
amount taken may be increased, but the interval may not be lengthened 
beyond three hours. The last glass of milk should be given at bedtime, 
and if the patient be wakeful a glass may be left beside the bed, covered, 
so that it may be taken at night if awake. It may be administered either 
warm or cold. 
In taking milk the patient does not drain the glass in a few draughts, 
but sips it in mouthfuls. Sometimes a trifle of tea or coffee or caramel is 
used to flavor it if the taste is seriously objected to. But they are abandoned 
later. Lime-water may be used if acidity ensues. Sometimes a little 
barley-water or rice-water may be given with advantage. The patient, 
and I may add the nurse, need not be disappointed if there should be a 
slight loss of weight at first. Patients have been weighed while undergoing 
treatment, but of course this is not practicable, as a rule. 
Sleepiness may be present during the first week or two after the new 
aspect of the treatment has worn off. Constipation usually has to be treated 
with a gentle laxative. The frequent passage of urine must also be expected 
and need not excite comment by the nurse. For constipation, a quarter of 
a grain of aloes and two grains of dried ox-gall may be given in a pill at 
night. The amount of milk taken in a day will run up from two to four 
quarts. After the tenth day malt is also given before meals. Johann 
Hoff's is advised, and the quantity should be from two to four ounces. 
Many persons eat little because of the fatigue of feeding. If there is 
no exertion and the patient is fed by the nurse, much larger quantities than 
usual may be taken. 
At the close of the first week of treatment, a pound of raw beef made 
into a soup may be given in addition to the milk. It is make by chop- 
ping up one pound of raw beef and placing it in a bottle with one pint of 
water and five drops of strong hydrochloric acid. This mixture stands all 
night, and in the morning the bottle is set in a pan of water at 110° F. 
and kept two hours at about this temperature. Strain through a stout 
cloth and squeeze the mass till nearly dry. The resulting fluid is given in 
three portions daily. If the taste be objected to, the meat may be roasted 
a trifle on one side. 
Alcohol is generally not essential excepting as found in the malt pre- 
scribed! 
Iron is given to the anaemic in the form of subcarbonate of iron or 
lactate of iron in doses of four to six grains. Sometimes five grains of 
pyrophosphate of iron may be added to the malt and it is not recognized 
by the patient. 
When the patient begins to sit up, strychnine may be added with iron 
and arsenic. Fig. 6.-Appearance of the same patient after full recovery. 
Fig. 5.-Appearance before treatment was instituted. Fig. 8.-After complete recover; 
Fig. 7.-Condition before treatment. NURSING IN NERVOUS DISEASE, PARTICULARLY IN HYSTERIA. 
319 
This will seem somewhat strange to those who have been accustomed to 
go about the house although in a languid manner. It will be far better 
also for invalids who recline on sofas and yet have not cared to relinquish 
all opportunity of seeing friends and hearing of the outer world. By going 
to bed in earnest and under no pretext walking about the room,-not even 
sitting up, and in some cases noteven feeding herself,-the patient realizes 
that a new era has begun in her life history. The result is that she appre- 
ciates highly the opportunity to feed herself when the permission is given, 
perhaps after a fortnight or more of denial. At the end of a month or so 
she sits up a few minutes each day; the time is lengthened ; at the end of 
two months perhaps she is allowed to sit in a chair. Every added privi- 
lege is appreciated as never before ; liberty never seemed such a boon. It 
is like the hunger of a convalescent from typhoid fever. The whole aim 
in life, if you have maintained the case successfully, is now to occupy a 
sphere that before seemed impossible to attain, and with timely assurance 
you will have the satisfaction of seeing the patient launched upon the world 
made over anew. I am not drawing on my imagination or magnifying the 
results attained. They are matters of actual experience. I have witnessed 
the most extraordinary cures of what had been given up as hopeless 
invalids, and it is in these cases that so-called miracles are wrought. 
But how is the bodily health maintained during this period of enforced 
rest and excessive feeding? This brings us to the fourth and fifth divisions 
already incidentally alluded to. 
III.-REST IN BED. 
IV.-MASSAGE. 
Massage is instituted to establish and maintain a good circulation; to 
secure nourishment of all the tissues; to prevent coldness of the extremi- 
ties, and to insure a certain amount of passive exercise each day to compen- 
sate for the loss of opportunity for voluntary movement. This occupies 
an hour. It should not be given sooner than an hour after a meal, and 
should be followed by from one-half to one hour of quiet. There is one 
point that should be mentioned in regard to massage as well as electricity, 
and that is that during a menstrual period they should be administered only 
to the extremities. In some cases massage has given rise to uterine hemor- 
rhage, and the possibility of this should be recognized. 
Massage usually becomes more agreeable as the patient has more experi- 
ence of it. Even the tender spines and sensitive abdomens can be gradu- 
ally rubbed until these abnormal conditions disappear and are forgotten. 
Massage is kept up for six weeks at least, and then the manipulator 
should spend awhile in exercising the limbs according to the Swedish 
system. A few movements of extension and flexion, at first assisted, then 
unassisted, and finally active movements gently resisted by the nurse are 
added, and by the seventh week massage is given only on alternate days. 320 
GUY HINSDALE, M.D., ON 
V.-ELECTRICITY. 
Electricity accomplishes somewhat the same result as does massage, but 
is more deep in its effect. 
The battery for this purpose should be a faradic battery which is pro- 
vided with a slow interrupter, automatic in its movement, as in the larger 
faradic battery of Flemming. 
The disks of the electrodes should be circular, about one inch and a 
quarter to an inch and a half in diameter, and covered neatly with absorbent 
cotton, which should be renewed at frequent intervals. As in the case of 
massage, the operator should follow a centripetal method. The poles moist- 
ened with hot water, which need not contain salt, are placed about four 
inches apart upon the muscles in turn, beginning with the feet, legs, and 
thighs, and are moved about so as to move groups of muscles and indi- 
vidual muscles. Care must be taken to avoid placing the electrode over 
bony prominences, such as the shinbone, but always over a cushion of 
muscle. Tendons will, of course, give no reaction to the current, but the 
electrodes when properly placed cause a gentle muscular contraction unat- 
tended with pain. By being familiar with the so-called "motor points," 
the most advantageous positions for moving the muscles may be recognized 
and much time saved. 
After the legs, the muscles of the abdomen, back, and loins are taken 
systematically, then those of the chest and arms. The neck and head are 
not touched. It is immaterial with regard to the position of the positive 
and negative pole; but the primary current is probably the better to 
employ. After the various muscles are treated so as to give four or five 
contractions to each, the battery is adjusted for the rapid interruption, 
and a flat electrode about two and a half by three inches is placed under 
the neck, and one of the ordinary disks is held at the sole of one of 
the feet. At the end of seven minutes the other foot is brought into the 
circuit, fifteen minutes being shared between the two feet. 
It will be found that the bodily temperature will be raised from three- 
quarters to one degree Fahrenheit, and the muscles will grow stronger 
and rounder as the treatment progresses. In very nervous persons it is 
safe to begin very cautiously. Many have been shocked by electricity at 
various times, and have a dread of it. It is advisable to start by using 
electrodes disconnected with the battery, then gradually an imperceptible 
perhaps waiting an entire day before giving any current whatever. 
A thorough knowledge of the construction and operation of a battery, as 
well as of the anatomy of the surface of the body, is essential, for difficul- 
ties will arise in the best of hands, and when the current stops or goes with 
sudden starts, or hurts, or the electrodes chill, or the process fatigues, the 
value of the treatment is largely lost. Of all the elements in the treat- 
ment electricity may best be spared. It is decidedly best to intrust it to a 
physician. I do not advise a nurse to try it unless specially trained. I do Fig. 10.-Appearance of same patient after full recovery. 
Fig. 9.-Appearance of patient before treatment was commenced. Fig. 12.-The same patient after full recovery. 
Fig. 11.-A nervous patient previous to treatment. NURSING IN NERVOUS DISEASE, PARTICULARLY IN HYSTERIA. 
321 
not mean to say that there are not many other kinds of cases where a 
nurse can safely use it, but the difficulties that arise in these cases are great 
and must be promptly met, for it would be humiliating to acknowledge 
ignorance or defeat. 
The difficulties that arise in using a battery are : 
1. In the fluid. This grows weak after ten or twelve hours of use, 
and the battery gives notice by working irregularly. 
2. In the liability of the zinc to come in actual contact with the carbons 
instead of hanging freely between them. 
3. In the connections between the battery and the coil of wire in the 
interior of the battery. 
4. The liability of the various metallic bearings and connections to 
become corroded by the acid. 
5. In a defect in the silk-covered cords so that no current passes through 
them. 
6. In not noticing that the connecting cords have become loosened from 
their proper attachments. This is very liable to occur, and must be 
watched. 
7. In keeping the absorbent cotton wet enough to moisten the skin, but 
not so as to drip over the patient. 
To illustrate the great advantages of the rest treatment I will show 
you photographs of six patients treated in this way; the changes are 
striking, but hardly more so than in a case now about to be discharged 
from the Infirmary for Nervous Diseases. The patient is a girl of four- 
teen, whose life was without doubt saved by these general measures and 
without the use of any special medication. 
Mamie L. was admitted to Dr. Weir Mitchell's ward on November 20, 
1891 ; a well-marked case of hysterical starvation. She had excited a great 
deal of interest in the town in which she lived, and was apparently near 
the grave. She was absolutely without appetite, would scarcely speak, and 
was a mere bundle of skin and bones, weighing forty pounds. 
She was placed on complete rest in bed, gentle massage, milk diet, and 
an occasional laxative. House diet was soon added. In ten days she was 
allowed to sit up in bed; at the end of two -weeks she ate of her own 
accord ; in four weeks she commenced sitting up one hour out of bed, and 
there was no fatigue; in five and a half weeks she was allowed to be up 
and walk at will. Her appetite and digestion were good, and her bowels 
were usually regular, although she required an occasional laxative. Her 
body was much better nourished, and on the thirty-fourth day she showed 
a gain of thirty-two and a half pounds; on the day of her discharge, 
January 14, she showed marked improvement; she was bright, obedient, 
and willing, and she had gained in weight thirty-nine pounds. 
On May 9 she was readmitted in somewhat a similar condition, and 
after forty days of treatment upon the same lines as before she was 
discharged much improved. 
Vol. II.-21 322 
J. E. THOMPSON, M.B., B.S. LOND., F.R.C.S. ENG., ON 
On August 22, 1892, she was admitted for the third time to the In- 
firmary, with all her symptoms repeated and at a weight of sixty-two and 
a half pounds. She was put to bed and placed on the usual house diet, 
with the addition of eight ounces of milk at and between meals. She was 
given massage, but, as before, electricity was not given. Her record is as 
follows : 
August 22.-Weight sixty-two and a half pounds. 
August 29.-Weight seventy-two pounds. 
September 9.-Weight seventy-nine and a half pounds. 
September 11.-Allowed to sit up half an hour and increase ten 
minutes daily. 
September 16.-Weight eighty-one and a half pounds. 
September 30.-Weight ninety-eight and a half pounds. 
October 18.-Weight one hundred and ten pounds. 
October 30.-Weight one hundred and seventeen and a half pounds. 
The patient's gain is thus fifty-five pounds in sixty-nine days, and her 
weight is nearly three times what it was a year ago. We sincerely trust 
that, since her body has been raised to such a high plane of nourishment, 
her mind and brain will preserve their normal powers, and forbid in 
the future any such hysterical demonstrations as we have seen in this 
remarkable case.