VIZZs 1883 ;; ■"„ :■ -/'/■'. iv£-"vx*S'« V;-.- mm : , ■ jfeiScroo^^ NLM005610422 THE SYSTEMATIC TREATMENT NERVE PROSTRATION HYSTERIA. BY / W. S. PLAYFAIR,V\I.l)., F.R.C.P., PROFESSOR OF OBSTETRIC MEDICINE IN KING'S COLLEGE; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO KING'S COLLEGE HOSPITAL; LATE PRESIDENT OF THE OBSTETRIJ SOCIETY OF LONDON. PHILADELPHIA: HENRY C. LEA'S SON & CO. 1883. WM p 122 s l?83 CONTENTS. PAGE Introductory, ........ 17 Notes on the Systematic Treatment of Nerve Prostration and Hysteria connected with Uterine Disease, ....... 26 Further Notes on the Systematic Treatment of Nerve Prostration and Hysteria connected with Tterine Disease,......60 An Introduction to a Discussion on the System- atic Treatment of Aggravated Hysteria and Certain Allied Forms of Neurasthenic Dis- ease, .......... 83 Appendices, ......... 107 NERVE PROSTRATION AND HYSTERIA. INTRODUCTORY. I am tempted to reprint in a collected form the articles contained in this pamphlet, in conse- quence of the numerous inquiries lam constantly receiving on the subject they treat of from prac- titioners in all parts of the country. The possi- bility of curing a class of case we all have been too much in thejiabit of abandoning in despair has "evidently interested a large number of the profession; and I am not without hope that these [tapers may enable many to succeed, as I know that some have already done, in>estoring to health —I might almostwithout exaggeration say to life —some of the miserable and helpless neurasthenic invalids who are so widely scattered over the country. No doubt the systematic treatment of 2 18 THE SYSTEMATIC TREATMENT OF such cases involves an immense amount of trouble, and requires the training of a specially instructed staff of assistants. This latter difficulty, however, is not insuperable, and the striking results to be obtained fully repay the trouble required. In order to facilitate this, I have added in an . appendix a description of the method of perform- ing the massage, which constitutes an important part of the treatment, written for me by one of my rubbers. The details of the massage are not, how- ever, of such consequence, provided the operator produces in his patient the waste of tissue which is essential. Individually I never trouble myself as to how the massage is done; it is soon very easy to see if it is not done effectually; for if, after a sufficient time, the patient is not able to take and to assimilate the large amount of food given to her, most certainly the masseuse is at fault. It is to results, therefore, not to method, that one must look. It would be a great mistake, however, to suppose, as some seem to do, that the systematic treatment here advocated depends altogether, or even chiefly, on the massage. This is only one of the many agencies brought to bear on the patient, the combination of which produces so remarkable NERVE PROSTRATION AND HYSTERIA. 19 an effect in properly selected cases. As a matter of fact, massage is nothing more than a mechanical tonic, and it is no more justifiable to talk of this system as a rubbing treatment, as I have heard it called, than it would be to talk of the occasional administration of a laxative for a definite object as a castor-oil treatment. It is simply a remedial ascent, known from time immemorial, and much practised in the East at the present day, which has been strangely neglected amongst us, and the therapeutic powers of which no one can doubt; and to refuse to employ it, or to look on it with suspicion, is a species of red-tapeism which to me is altogether incomprehensible. This leads me to say a word on the subject of isolation and removal from unwholesome domes- tic surroundings, which is even a more important matter in the successful carrying out of this method than effective massage. The difficulty and expense of this are so great that there is a strong temptation to modify it by treating the patient in her own house, or by admitting the occasional visit of a friend. The more I see of these cases the more satisfied I am that any relax- ation of this rule is an absolute bar to success, and 20 THE SYSTEMATIC TREATMENT OF will infallibly lead to failure. I cannot express too emphatically my conviction on this point. In a second appendix I have briefly referred to the management of a very difficult class of case, in which the patient, although a poor feeder, is unhealthily fat. Such cases are very much more difficult to manage than the more common class of emaciated neurasthenic invalids; but still many of them are not beyond hope of cure, and I have succeeded very satisfactorily on the system indicated in the appendix, although, for the sake of brevity, I did not allude to it in my papers. There is still another class of patients—the fat, comfortable, well-feeding hysterics, who thor- oughly enjoy their life of inert self-indulgence. These had unquestionably be best left alone. A word may be said as to the proper selection of cases. Beyond any doubt, if this method of treatment is indiscriminately employed in cases ill adapted for it, failure and disappointment are certain to result. Individually I never undertake a case except on the full understanding that it must be first treated experimentally, and that if in ten days the patient is not in a thoroughly prom- ising condition, it should not be persevered in, and NERVE PROSTRATION AND HYSTERIA. 21 it is very rarely, indeed, that I find it necessary to avail myself of this proviso. By far the most sat- isfactory results are to be had in the thoroughly broken-down and bed-ridden cases. It is my ex- perience that the worse the case is, the more easy and certain is the cure; and the only disappoint- ments I have had have been in dubious half-and- half cases. Nor is it by any means unimportant that the diagnosis should be very carefully and thoroughly made. It is often a far more difficult matter to distinguish between hysterical and organic diseases of the nervous system than is generally supposed to be the case, and I have heard of more than one instance in which very serious mistakes have been made.1 It is not pretended that many marked cases of hysteria cannot be cured by means other than those here described. This is especially the case with such purely hysterical states as hysterical paralysis, aphonia, and neuro-mimesis in general. But I do not believe that the same can be said of the chronic, bed-ridden neurasthenic. To lecture 1 See especially the admirable chapter on "The Differential Diagnosis between certain Hysterical Conditions and Myelitis," in Buzzard's recent "Diseases of the Nervous System." 22 THE SYSTEMATIC TREATMENT OF such a patient, to force her to make effort, when she has already broken down from effort and strain, is only to make her go on from bad to worse. The success following the opposite plan results, I believe, from throwing a little common sense and sound physiological principle into the treatment. To illustrate the feelings of these patients, a knowledge of which is not in itself an unimpor- tant point in their management, I am tempted to transcribe part of a jeu d'esprit written years ago, after suffering many things from many physicians, by a young lady at present under my care, now, I am happy to sa\% on the high road to recovery. The curious illustration it affords of what such cases go through may excuse the printing of a doggerel composition never intended to be seen. It is taken from a dialogue supposed to take place between the patient and her doctor. PATIENT. Now tell me candidly and as a friend. Say. is there aught that you can recommend, Is there no course of treatment I could follow. For life is now anxiety and sorrow? DOCTOR. Forget it! Laugh it down; raise high the mind Above the feelings. . . . NERVE PROSTRATION AND HYSTERIA. 23 PATIENT. But stay: I have prescriptions tried by scores; G-one out for walks, and sometimes stayed in-doors; Was galvanized till I became much worse; Would ride, but cannot always find a horse; Tried German baths, and much increased my pain. Until I fear all remedies are vain. DOCTOR. Believe it, and from remedies abstain! PATIENT. Ah! then confess that there is yet to find The remedy for sufferings of this kind. Do you not think a cure for every ill That is not mortal there may yet be still, Though 'tis not found by means of drug or pill? Lend me your books; by study will I try To find the undiscovered remedy. DOCTOR. Oh, fight against yourself. This is a way By which you may gain ground from day to day. PATIENT. But this, alas! I have so often tried— Made efforts until I nearly died. DOCTOR. Make more! but as to studying the letter, The less you read about such things the better. Farewell! And to himself he thus observes, 1' Poor thing! her illness is upon the nerves.'' 24 THE SYSTEMATIC TREATMENT OF Now I venture to think that these lines form a really instructive commentary on the general run of these neurasthenic cases. In the vast majority of them some temporary strain or shock has upset a feeble nervous organization; and to call upon it for fresh and renewed efforts, without adopting some rational means to repair the ma- chinery through which it is to act, is as unreason- able as it would be to pile fresh fuel into an engine and to expect it to work while the boiler and wheels are seriously out of repair. The claims of Dr. Weir Mitchell to originality in the introduction of this system of treatment, which I have recently heard contested in more than one quarter, it is not my province to defend ; doubtless Dr. Mitchell is thoroughly well able to do so himself. I feel bound, however, to say that, having carefully studied what has been written on the subject, I can nowhere find anything in the least approaching to the regular, systematic, and thorough attack on the disease here discussed. Certain parts of the treatment have been separately advised, and more or less successfully practised, as, for example, massage and elec- tricity, without isolation; or isolation and judi- NERVE PROSTRATION AND HYSTERIA. 25 cious moral management alone. It is, in fact, the old story with regard to all new things; there is no discovery, from the steam-engine down to chloroform, which cannot be shown to have been partially foreseen, and yet the claims of Watt and Simpson to originality remain practically uncontested. And so, if I may be permitted to compare small things with great, will it be with this. The whole matter was admirably summed up by Dr. Koss, of Manchester, in his remarks in the discussion I introduced at the meeting of the British Medical Association at Worcester, which I conceive to express the precise state of the case. " Although Dr. Mitchell's treatment was not new in the sense that its separate recommendations were made for the first time, it was new in the sense that these recommendations were, for the first time, combined so as to form a complete scheme of treatment." 26 THE SYSTEMATIC TREATMENT OF NOTES ON THE SYSTEMATIC TREATMENT OF NERVE PROSTRATION AND HYSTERIA CON- NECTED WITH UTERINE DISEASE.1 I am anxious to bring very briefly under the notice of the profession in England a method of dealing with certain grave and most intractable forms of nervous disorder familiar to all who see much of the diseases of women, which I first became acquainted with through the study of a remarkable and interesting little work by Dr. Weir Mitchell, of Philadelphia, entitled "Fat and Blood, and how to make them/'' In doing so I have no original contribution to medical science to make; I have simply followed Dr. Mitchell's directions, but with results so astonishing and satisfactory to myself, in cases which were quite heart-breaking from their obstinate resistance to all ordinary management, that I am confident I shall be doing the profession a service if I can secure for Dr. Mitchell's plan, which is based on 1 Lancet, May 28 and June 11, 1881. NERVE PROSTRATION AND HYSTERIA. 27* sound theory and accurate clinical observation, a more extended trial than it has as yet received. I am the more encouraged to do this since Dr. Mitchell informs me that he is not aware that his principles of management have hitherto been tried at all in England, although well known in America. " Here," he writes to me, " the treat- ment has rescued hundreds of women, and is used by men like Perry and Goodell with increas- ing confidence. I hope at some time to write for some English journal a resume of the treatment, but it were far better done by one like you, who could quote cases of success in England." Pending Dr. Mitchell's promised contribution, which will, I am sure, be read with interest, I may, at least, try to prepare the way by the re- cital of a few of the cases in which I have found his plan so useful. The class of cases referred to is not easy to de- fine or describe accurately, and yet they must be perfectly familiar to all. I have called the con- dition, in the heading to these notes, " Xerve Pros- tration and Hysteria connected with Uterine Disease." Goodell, who has an interesting chapter on the subject in his " Lessons on Gynaecology," 28 THE SYSTEMATIC TREATMENT OF heads it " Nerve-tire, or the Relations of Neuras- thenia to Diseases of the Womb." The protean symptoms we have to deal with are such as gradu- ally develop themselves in those confirmed in- valids who are so widely scattered over the country, who have been from one doctor to another, subjected to all sorts of uterine medi- cation, mechanical and other, with no lasting improvement, until eventually they become bed- ridden, or nearly so, sleepless, victims to chloral and morphia, worn and wasted, and burdens to themselves and their families. JSTow, in a large number of these cases there is, or has been, very real uterine mischief. I shall not be accused, I am sure of any disposition to minimize the in- fluence of local uterine disorder on the general health. As a matter of fact, however, many of these cases have drifted far beyond the point at which local treatment, however judicious, is capable of effecting a cure. The pain, the back- ache, the leucorrhaa, the difficulty in progres- sion, the disordered menstruation, which are at- tendants on the local troubles, have ended in producing a state of general disturbance in which all the bodily functions become implicated. The NERVE PROSTRATION AND HYSTERIA. 29 nervous system is profoundly affected, the blood impoverished, and the general nutrition at the lowest ebb. I shall not attempt here to explain the pathol- ogy of this state, but rather to describe the class of case, which, however, all my readers will at once recognize. Such cases have two or three prominent symptoms in common, among the most marked of which are wasting of the fatty tissues, combined with anaemia, the patient hav- ing gradually lost all appetite, professing a total inability to take a healthy amount of food, and often consuming barely enough to support vi- tality. Associated with this are very marked dyspeptic symptoms, too often aggravated by the pernicious habit of deadening pain by chloral, morphia, or stimulants. As a necessary conse- quence of such a state, and partly no doubt from local pain, all exercise is abandoned, and the pa- tient becomes entirely confined to the house, or even to bed. Another group of symptoms which soon show themselves under such conditions are those of a moral character, the patient becoming emotional and hysterical, constantly craving for sympathy, which she often obtains to a degree 30 THE SYSTEMATIC TREATMENT OF most prejudicial to her welfare, until at last the whole household becomes victimized by the mor- bid selfishness thus developed. Every practi- tioner must know of cases of this kind, and must be familiar with the useless endeavors at cure which have been made by tonics, water cure, and a hundred other plans, each of which has proved equally unsuccessful. It is in such cases that Dr. Mitchell's method is applicable, and it is based on the principle, which must be admitted to be perfectly physio- logical and reasonable, of removing the patient from the unwholesome moral atmosphere in which she has been living, combined with the renewal of her vitality by excessive feeding, which, under ordinary circumstances, could not be assimilated, but which is rendered possible by passive muscular exercise obtained through the systematic use of shampooing and electricity. At first sight this sounds, perhaps, chimerical; and, had I not myself witnessed the astonishing success which followed its use, I should doubt- less be as sceptical as others may be as to its value. I propose, however, to relate the first four cases in which I have followed Dr. Mitchell's NERVE PROSTRATION AND HYSTERIA. 31 method, each of which had been for years in a state of hopeless misery, subjected to all sorts of treatment in vain, and I trust that the sim- ple narration of these remarkable cases, which are not selected, but are the first which have come under my observation, may secure for this rational treatment a fair and extended trial. Before relating them, however, I shall shortly describe the method of treatment I used, and in doing this I merely paraphrase Dr. Mitchell's directions. I must necessarily be extremely brief, and I must refer those who are disposed to try it to Dr. Mitchell's book, in which full details for their guidance will be found. The plan involves four principal heads, each of which I shall refer to separately. 1. Seclusion and Rest.—An important element in the treatment—and one which, from what I have seen of these cases, I believe to be absolutely indispensable—is the entire seclusion of the pa- tient under a competent nurse, and her removal from the morbid atmosphere of invalid habits, which has gradually grown up around her. Un- less the patient is entirely removed from the injudicious sympathy and constant tending of 32 THE SYSTEMATIC TREATMENT OF her friends, it will be next to impossible to gain that moral influence over her which is really essential to success. This is a point which in- volves so severe a strain that it may be found very difficult to obtain the consent of the patient and her friends to a measure which will seem to them so harsh and strange. I do not think, however, that any compromise on this point should be admitted; and if it be found impos- sible, from domestic reasons, to secure the re- moval of the patient from her house, it should, at least, be made an absolute sine qua non that she should be placed in a separate room with her nurse, and that she should not be visited by anyone except her medical attendant. On this point Dr. Mitchell's experience is worthy of note. "I have often," he says " made the effort to treat these cases in their own homes, and to isolate them there, but I have rarely done so without promising that I would not again complicate my treatment by such embarrassments. Once sepa- rate the patient from the moral and physical sur- roundings which have become part of her life ot sickness, and you will have made a change which will be, of itself, beneficial, and will enormously NERVE PROSTRATION AND HYSTERIA. 33 aid in the treatment which is to follow." The first step, on commencing, is to place the patient at rest in bed. It will be readily understood that this absolute repose is only intended as a tempo- rary resource, until, by the means presently to be described, the nutrition is improved, and new tissues are built up. Space will not permit of my following Dr. Mitchell in his explanation of the manner in which this proves serviceable; but independently of the physical benefit in patients apt to suffer from exhaustion on the slightest fatigue, there is a distinct moral gain. " From a life of irregular hours, and probably endless drugging, from hurtful sympathy and over-zeal- ous care, the patient passes to an atmosphere of quiet, to order and control, to the system and care of a thorough nurse, to an absence of drugs, and to simple diet." As a rule, in bad cases this repose in bed is continued during the greater part of the treatment, averaging from six to eight weeks; and at first the rest is made absolute, the patient being only allowed to rise for the purpose of passing her evacuations, and is neither allowed to read, to sew, nor to feed herself. Practically there is so much to do with feeding, massage, 3 34 THE SYSTEMATIC TREATMENT OF and electricity, that this is not found so weari- some as might be supposed; but no doubt, the monotony of the life, and the growing strength which accompanies a satisfactory progress towards cure, tend to make the patient the more willing to throw off her old habits of invalidism when the proper time arrives to make the effort. By degrees the period of repose is lessened, and the patient is gradually made to sit up for several hours, until towards the end of the cure she only rests on the bed for three or four hours daily. 2. Massage.—This, combined with faradization, is a very important part of the treatment, and it consists in systematic shampooing and exercise of all the muscles, both of the extremities and trunk, first for half an hour or so twice daily, but very soon for not less than an hour and a half night and morning. By this means the cu- taneous circulation is improved, and the muscles are brought into active exercise without the ex- penditure of nerve force. To do this effectually considerable experience is required, and although in one or two cases I have had it done success- fully by the nurse, it requires so much intelli- gence on her part, and she is besides otherwise NERVE PROSTRATION AND HYSTERIA. 35 so fully occupied by the rest of her work, that I think it preferable to employ a regular rubber. Full details of the method to be adopted, and the best way of exercising the various groups of mus- cles and the joints, Avill be found in Dr. Mitchell's book. It is surprising how soon the patient comes positively to enjoy a manipulation that for the first few days is very trying. Soon all local tenderness disappears, and a pleasant sense of exhaustion, followed by refreshing sleep, is alone experienced. In two of my cases the ab- domen, especially in the ovarian regions, was so tender that the patient at first shrank from the slightest touch, but in a very short time she could be freely handled and kneaded in every part. 3. Electricity.—This forms a valuable subsidiary means of exercising the muscles. The inter- rupted current is employed twice daily from half to three-quarters of an hour. Here, again, some practical skill is necessary, but with a little care- ful teaching on the part of the practitioner, the use of the battery can be safely and efficiently entrusted to the nurse. The poles, armed with wetted sponges, are placed on the muscles to be operated on in turn, about four inches apart, and 36 THE SYSTEMATIC TREATMENT OF slowly moved until the muscle is fully and freely contracted. Commencing with the feet, the whole body, except the head, is thus systemati- cally gone over. There is no doubt that this is painful and disagreeable, but it is of unquestiona- ble utility, especially in cases such as the one to be presently narrated, in which there was long-stand- ing hysterical paralysis, and consequent atrophy from disuse of extensive groups of muscles. 4. Diet and .Regimen.—These form the most important and most characteristic part of the cure. It is perfectly astonishing how, under the conditions above described, a pale, anaemic, and wasted invalid, able to eat next to no food, can be brought to consume, and not only to con- sume but perfectly to assimilate, an amount of nourishment that would appear to be incredible had experience not amply proved the fact, so that she shall gain flesh, weight, and strength so rap- idly that the change is almost apparent to the eye from day to day. The first step, after secluding the patient with the nurse, and before the mas- sage is commenced, is to place her on a diet of milk alone, given at intervals of three hours. At first three to four ounces are given at each NERVE PROSTRATION AND HYSTERIA. 37 feeding, but in a couple of days or so the amount is increased to eight or ten ounces, so that within three or four days she is consuming two or three quarts of milk within the twenty-four hours. No difficulty is experienced in getting the patient to take this quantity, and if she suffers, as so many of these cases do, from dyspeptic symptoms, they rapidly disappear. After the first two days, when the stomach is settled, the massage is commenced, and along with it an increased amount of food is administered, commencing with bread and butter, an egg, or the like, for breakfast; then, in a day or two, a chop finely cut up, with some vege- tables, is given at midday, and so on progres- sively, until in from ten days to a fortnight three full meals daily are given, besides from a quart to two quarts of milk in divided quantities, and a considerable amount of soup made from raw beef, after a receipt given in Dr. Mitchell's book. It seems impossible, but it is nevertheless a fact, that under the use of massage and electricity these large amounts of food are taken readily without the slightest feeling of dyspepsia or dis- comfort. In illustration I copy the food journal on the fourteenth day of treatment of one of my 38 THE SYSTEMATIC TREATMENT OF patients, who had been bedridden for many years, and who all that time had existed on a dietary almost as remarkable from its smallness, fre- quently not taking more than half a tumbler of milk in twenty-four hours, and who could not be persuaded to eat more than one strawberry at a time, as forming a meal too large for her capacity. The treatment was commenced on October 10 with three ounces of milk every third hour. On October 30 this was what she consumed with appetite: 5 a. m., ten ounces of raw meat soup; 8 a. m., cup of black coffee; 9 a. m., plate of oat- meal porridge, with a gill of cream and a tumbler of milk; 12.30 p.m., milk; 1.45p.m., whiting, bread and butter, rumpsteak, cauliflower, ome- lette, and a tumbler of milk; 4 p. m., milk; 5 p. m., milk and bread and butter; 7 p.m., fried had- dock, chicken, cauliflower, apple and cream, and a glass of burgundy; 9.30, milk; 11 p.m., raw meat soup. (The milk between 8 a. m. and 9.30 p. m. amounted to two quarts.) Xor is this excep- tional. In every case I have treated on this plan similar amounts of food were taken, and with the same advantage. Of course, certain difficulties are apt to be met with; but only in one of my NERVE PROSTRATION AND HYSTERIA. 39 cases was any nausea or oppression experienced from the administration of this apparently exces- sive diet, and in that I attributed the sickness rather to too sudden an attempt to stop the hypo- dermic injection of morphia the patient had been accustomed to than to the feeding. At any rate, should sickness supervene, a temporary return to milk alone for a day or two will be sufficient to settle the stomach. I have only attempted to sketch, in very rough outline, the principles on which the treatment is conducted; the results will be better appreciated by a short narration of a few of the cases in which I have employed it with success. Case 1. Early in October of last year I was asked to see a lady thirty-two years of age, with the following history: She had been married at the age of twenty-two, and since the birth of her last child had suffered much from various uterine troubles, described to me by her medical attend- ant as "ulceration, perimetritis, and endome- tritis." Shortly after the death of her husband, in 1876, these culminated in a pelvic abscess, 40 THE SYSTEMATIC TREATMENT OF which opened first through the bladder and afterwards through the vagina. Paralysis of the bladder immediately followed the appearance of pus in the urine, and from that time the urine was never spontaneously voided, and the catheter was always used. Soon after this she began to lose power in the right leg and then in the left, until they both became completely paralyzed, so that she could not even move her toes, and lay on her back with her legs slightly drawn up, the muscles being much wasted. Towards the end of 1877, after some pain in the back of her neck and twitching of the muscles, she began to lose power in her left arm and in her neck, so that she lay absolutely immobile in bed, the only part of her body she was able to move at all being her right arm. Up to this time the pelvic abscess had continued to discharge through the vagina, and occasionally through the bladder, but it now ceased to do so, and there were no further symp- toms referable to the uterine organs. Her gen- eral condition, however, remained unaltered, in spite of the most judicious medical treatment. She was seen, from time to time, by several of our most eminent consultants, all of whom recog- NERVE PROSTRATION AND HYSTERIA. 41 nized the probable hysterical character of her ill- ness, but none of the remedies employed had any beneficial effect. There was almost total anorexia, the amount of food consumed was absurdly small, and the necessary consequence of this inability to take food, combined with four years in bed with paralysis of the greater part of the body, and the habitual use of chloral to induce sleep, had re- duced a naturally fine woman to a mere shadow. In October, 1880, her medical attendant was good enough to bring her to London for the purpose of giving a fair trial to the Weir Mitchell method of treatment, with the ready cooperation of herself and her friends, and she was conveyed on a couch slung from the roof of a saloon carriage, so as to avoid any jolt or jar, since the slightest move- ment caused much suffering. Two days after her arrival my friend Dr. Buzzard saw her with me, and, after a careful and prolonged electrical ex- amination, came to the conclusion that contrac- tility existed in all the affected muscles, and that the paralysis was purely functional. I could find no evidence in the pelvis of the abscess, the uterus being perfectly mobile, and apparently healthy. After a few days' rest the treatment was com- 42 THE SYSTEMATIC TREATMENT OF menced on October 16, the patient being isolated in lodgings with a nurse of my own choosing; and this was the only difficulty I had with her, since she naturally felt acutely the separation from the faithful attendant who had nursed her during her long illness. Her friends agreed not to have communication with her of any sort. It is needless to give the details of the treatment in this and the following cases. A mere abstract will suffice to indicate the rapid and satisfactory progress made. October 16.—Twenty-two ounces of milk were taken, in divided doses, in twenty-four hours; on the 17th, fifty ounces of milk; on the 18th, the same quantity of milk repeated; massage for half an hour; on the 19th, milk as before; bread and butter and egg; massage for an hour and a half; twenty minims of dialyzed iron twice daily; on the 21st, a mutton chop in addition to the above; massage an hour and fifty minutes. To-day she passed water for the first time for four years, and the catheter was never again used. Chloral dis- continued, and she slept naturally all night long. On the 23d, porridge and a gill of cream were added to her former diet; massage three hours NERVE PROSTRATION AND HYSTERIA. 43 daily, and electricity for half an hour, and this was continued until the end of the treatment, Mai tine was now given twice daily. October 30.—She is now consuming three full meals daily of fish, meat, vegetables, cream, and fruit, besides two quarts of milk and two glasses of burgundy. Considerable muscular power is returning in her limbs, which she can now move freely in bed. November 6.—Sat in a chair for an hour. The massage and electricity are being gradually dis- continued, and the amount of food lessened. November'17.—Walked down stairs, and went out for a drive, and henceforth she went out daily in a bath chair. She has increased enormously in size, and looks an entirely different person from the wasted invalid of a few weeks ago. On November 26 she went to Brighton quite convalescent, and on December 11 came up of her own accord to see me, drove in a hansom to my house, and returned the same afternoon. She has since remained perfectly strong and well, and has resumed the duties of life and society. A somewhat curious phenomenon in this case, which I am unable to account for, was the forma- 44 THE SYSTEMATIC TREATMENT OF tion on the anterior surface of the legs, extending from below the patella half way down the tibiae, of two large sacs of thin fluid, containing, I should say, each a pint or more, freely fluctuat- ing, and quite painless. I left them alone, and they have spontaneously disappeared. Case 2. In May, 1880, I saw, with Dr. Julius, of Hast- ings, an unmarried lady, aged thirty-one. Her history was that she had been in fairly good health until five years ago, when, during her mother's illness, she overtaxed her strength in nursing, since which time she had been a con- stant invalid, suffering from backache, bearing- down, inability to walk, disordered menstruation, and the usual train of uterine symptoms. She used to get a little better on going to the seaside, but soon became ill again, and in October, 1879, she was completely laid up. The least standing or walking brought on severe pain in her back and side, and she gave up the attempt, and had since remained entirely confined to her bed or sofa, suffering from constant nausea, complete loss of appetite, and depending on chloral and NERVE PROSTRATION AND HYSTERIA. 45 morphia for relief. Many efforts had been made to break her of this habit, but in vain. Her medical attendant had recognized the existence of a retroflexion, but no pessary remained in situ for more than a day or so, and he suspected that she herself pulled them out. I was unable to do more than confirm the diagnosis that had been made as to her local condition, but the pessary I introduced shared the fate of its predecessors, and she remained in the same condition—in no way benefited by my visit. Things going on from bad to worse, Dr. Julius sent her to London for treatment in the early part of December. I now determined to try the effect of the method I am discussing, of which I knew nothing when I first saw her. It was commenced on December 11, and everything went on most favorably. A week after it was begun, when her attention was fully occupied with the diet, massage, etc., I intro- duced a stem pessary, being tempted to try this instrument, which I rarely use, by the knowledge that she was at perfect rest, and that no form of Hodge had previously been retained. I do not think she ever knew she had it, and it remained in situ for a month, when I removed it and in- 46 THE SYSTEMATIC TREATMENT OF serted a Hodge, which was thenceforth kept in without any trouble. I may say that I do not think the retroflexion had much to do with her symptoms, except, doubtless, at the commence- ment of her illness, and she probably would have done quite as well without any local treatment. She rapidly gained flesh and strength, and very soon I entirely stopped both chloral and morphia, and she never seemed to miss them. On Decem- ber 11, when the treatment was commenced, she weighed 5 st. 9 lbs. On January 20 she weighed 7 st. On January 25 she walked down stairs, and went out for a drive, and from that time she went out twice daily. She complained of no pain of any kind, and, although she wore a Hodge, she did not seem to have any uterine symptoms. On February 1 she went to the seaside, looking rosy, fat, and healthy, and has since returned to her home in the country, where she remains per- fectly strong and well. A few days ago she came to town, a long railway journey, on purpose to announce to me her approaching marriage. nerve prostration and hysteria. 47 Case 3. My third case differed in many respects from the first two, since the patient was not in the state of extreme nervous prostration from which the others suffered. She was not, like them, excessively emaciated, and she was able to con- sume a fair amount of nourishment. It was, in- deed, a case of pure hysteria of an aggravated form, and its cure was, I believe, chiefly due to isolation, and to moral pressure brought to bear on the patient. I commenced its treatment with considerable hesitation, and relate it chiefly with the view of showing how much such cases are influenced by a morbid craving for sympathy, and benefited when this is not within their reach. Mrs.----, aged twenty-six, was sent to me from one of our colonies with the following history : She had had bad labors, followed by bearing- down, backache, and other uterine symptoms, and had been subjected by various medical men to much local treatment, including the use of pes- saries, constant cauterization and the like, most of which had, I believe, a very prejudicial effect on her. I may say that I was unable to detect 48 THE SYSTEMATIC TREATMENT OF any uterine disease requiring topical treatment, although such may no doubt have previously ex- isted. I extract from the full report sent to me by her last medical attendant the following curious account of the nervous phenomena she exhibited: " Her lower limbs are partially para- lyzed, or, at all events, not under the proper con- trol of her will. She is able to walk a short distance with a very uncertain gait, but the knees, after a few paces, suddenly give way, and she falls to the ground. When sitting quietly her hands are frequently affected with slight spasms, and her lips and eyelids are subject to occasional nervous twitches. Each menstrual period is preceded by violent hysterical attacks. In these seizures the body is violently convulsed, and the exhaustion which has followed has been so marked that I have occasionally failed to de- tect the pulse. These attacks are also brought on at other than the menstrual periods by any slight unusual exertion." When the patient presented herself in my consulting-room, although sup- ported by her husband, she fell down on the floor six times, in the manner above described, in walking the length of the room, and this was NERVE PROSTRATION AND HYSTERIA. 49 the only way, I was informed, that she had been able to walk for some two years. She was very pale and anaemic, but fairly well nourished. 1 soon satisfied myself of the hysterical character of these symptoms, but had great difficulty in inducing the patient to submit to my proposed treatment, especially as to separation from her husband, who had got into the way of constantly nursing and tending her, with a result most in- jurious to her health. Within twenty-four hours of the .treatment being commenced she had a violent outburst of hysterical excitement, which, however, soon subsided on my proposing to dis- miss the nurse and give up charge of the case. For ten days everything went on well, food was taken freely, and there was a perceptible increase in size and weight. When, however, faradiza- tion was commenced, it led to a second par- oxysm of excitement, the patient writing piteous letters to her husband declaring that she was going mad, and that the agony produced by the electricity was perfectly unbearable. Under my advice he had the good sense to write and tell her that I was perfectly prepared to stop the treatment the instant she expressed a desire it 4 50 THE SYSTEMATIC TREATMENT OF should be so, but that, as it had been begun, he would not take on himself the responsibility of doing so, and that the decision must be made by her. I then informed the patient that as the object of the electricity was to give strength to her weakened limbs, the moment I was satisfied, by her walking downstairs without falling, that the desired result had been gained, it would, as a matter of course, be stopped. This lady was lodging rather more than a mile from my house, and, to my very great surprise, the next morning after the scene I have narrated, she was shown into my consulting-room, having of her own free will got up and dressed, sent for her husband, and walked without assistance the whole way without once falling. She has since left town apparently quite cured, and I heard from her a few days ago that she was about to start for a prolonged continental tour. It will be obvious that in this case the massage, diet, and electricity had only a secondary effect as part of a whole that was intensely disagreeable to the patient. Clearly the main factor was the removal of injudicious sympathy, but the case seems to me worthy of record as showing the NERVE PROSTRATION AND HYSTERIA. 51 extreme value of a determined effort to break through habits of a morbid character, and the importance of trying to make a weakened will exert itself. Case 4. This case is a typical instance of the kind of nerve debility and exhaustion that may be asso- ciated with old-standing uterine disease. It was placed under my care by Dr. George Kidd, of Dublin, whose account of the case I prefer giving to my own, having his permission to do so. She had long been under his care and that of Dr. McClintock, and the fact that she had been treated by obstetricians so eminent is of itself sufficient proof that all had been done for her that the most advanced science could suggest. I may premise that the patient was a single lady forty-five years of age, that she had never been strong, but had not been completely laid up until 1872, since which time she had been confined to her bed or couch. Dr. Kidd wrote to me as fol- lows: "Miss ---- has been a complete invalid for many years. She suffers from excessive pain during menstruation, and from constant pain in the left side and back, extending down the left 52 THE SYSTEMATIC TREATMENT OF thigh and leg, with loss of muscular power in that side. Some years ago I discovered a fibrous tumor growing from the left side of the uterus, subperitoneal, and with a pedicle long enough to allow of free movements. Mr. Spencer Wells cut down on this tumor, and removed it, but without removing either the menstrual pain or the pain in the side. The tumor has grown again in the same situation, and is nearly as large as before, probably one inch and a half in diameter. All the mucous membranes are del- icate, and she suffers occasionally from vaginitis and endometritis, and also much from piles and prolapse of the rectum. Miss----is of a highly nervous and hyperaesthetic temperament, which is probably exaggerated by the isolated life she has been leading, and by the frequent use of hy- podermic injections of morphia to relieve pain." I may supplement this account with an extract from a letter from the patient herself, which graphically describes the state of her nervous system. "I can hardly tell you what a deep sufferer and how prostrate I have been. For years I have led a completely sedentary life, always lying; it is the position I am easiest in. NERVE PROSTRATION AND HYSTERIA. 53 My back aches sorely. I am peculiarly sensitive to pain. I spend very restless nights. The pain is often then very bad. I have always a sense of great weariness." I found this lady, as might have been anticipated, pale, anaemic, very wasted, and with her nutrition at the lowest ebb. She had no appetite, and consumed hardly any food, a snipe or the wing of a pigeon constituting, with half a cupful of bread and milk, all she took in twenty-four hours. Moreover, she had the morphia crave strongly developed, her maid giving her hypodermic injections of four minims of the pharmacopceial solution ten times, some- times much oftener, daily, equivalent at the least to six grains of solid morphia; besides which she took draughts of chloral and morphia twice daily. I found the fibroid as described by Dr. Kidd, apparently growing from the posterior wall of the uterus, supported by a Hodge, which seemed to give her some comfort. It will be admitted that here was a case sufficiently bad to test the value of the treatment thoroughly, and, inasmuch as there was a distinct uterine lesion which could not be removed, I undertook it with considerable 54 THE SYSTEMATIC TREATMENT OF misgiving. I was, however, encouraged to do so on reflecting that there was nothing per se in such a fibroid to cause much suffering, many women having similar outgrowths which in no way affect them, and I hoped that if I could succeed in im- proving the vital energies and in breaking off the vicious habit of morphia-taking, much good might be done. I accordingly isolated her with a nurse, having sent away her maid who had at- tended her during all her illness. During the first fortnight, or rather more, things went on very badly. It was reported to me that it was quite impossible to administer to her the food that was ordered, the stomach being unable to bear it; the sleeplessness was aggravated rather than lessened, and she was in the lowest state of mental depression, constantly crying and de- claring that she could not possibly bear the treatment. On trying to stop the hypodermic injections, violent vomiting supervened, which lasted the whole of one night, but which was immediately relieved when the morphia was again given. At this juncture I was nearly in as great despondency as the patient, and feared NERVE PROSTRATION AND HYSTERIA. 55 that the treatment must be abandoned. On reflecting on a result so different from that which I had observed in other cases, I came to the conclusion that the fault lay chiefly with the nurse, who, although an amiable and willing woman, had neither the intelligence nor the tact necessary for such a case, and who yielded in everything to the wishes and fancies of the patient, I therefore determined to change her, and secured the services of the nurse who had managed my first case, on whose judgment and skill I could thoroughly rely. From that moment everything went on as well as could be Avished; nothing more was heard of the food dis- agreeing, and within ten days my patient was taking three full meals a day, besides her milk and soup, with relish and appetite. She slept all night long, and began rapidly to put on flesh. As a matter of fact, I believe that the first nurse, who had no experience as a masseuse, entirely mismanaged the shampooing, giving practically no muscular exercise, and, as a matter of course, the increased amount of food could not be assimilated. It was quite surprising to note 56 THE SYSTEMATIC TREATMENT OF how, at the end of a week with her new nurse, the patient had lost her depression, and had become comparatively bright and very hopeful. The hypodermic injections were gradually les- sened in number and quantity; in a fortnight all sedatives were entirely discontinued, and nothing of the kind has been since touched, nor has she any craving for them. It was very curious to watch this patient's progress. From leading a life of complete isolation for so many years she had fallen into a chronic state of dread and alarm, and could not at first bear the idea of meeting any stranger, and was, indeed, some- what like a prisoner brought into the world after a lengthy imprisonment. Every step in advance was a matter of apprehension to her, and it required much encouragement and persuasion to induce her first to leave her room and walk downstairs, then to go out, and so on; but by degrees all difficulties were overcome. I even- tually induced her to remove into one of our largest hotels for the express purpose of bringing her into contact with the life and bustle of such an establishment, and soon she was able to sit in NERVE PROSTRATION AND HYSTERIA. 57 the public room, to dine at the table d'hote, to go out for daily drives, and to go to church. She now looks twenty years younger than when the treatment was commenced, and her friends declare her to be almost unrecognizable, which is indeed the fact. For the last month of her treatment she never mentioned her uterine symp- toms, and I purposely refrained from inquiring about them. She has now left, accompanied only by a maid, for a trip across the Atlantic, with the object of visiting the Falls of Niagara. Perhaps I cannot better contrast this patient's present and past condition than by again quoting from a letter of her own, written as she was leaving town. "I find it impossible to get people to understand the treatment I have lately under- gone, but results have been quite marvellous, and speak for themselves. My brother, whom I saw for the first time yesterday, said I am a miracle. I really do not know myself, and, although I sometimes have a frightened feeling, I have much more self-control, and the aspects of my life have completely changed for me." In a patient of this class it is, perhaps, too much to hope that when left to herself there will be no 58 THE SYSTEMATIC TREATMENT OF relapse—time alone can show; but so far at least the treatment has been successful beyond my utmost hopes and anticipations.1 I trust that the cases I have narrated may suf- fice to show that, by systematic treatment on rational principles, a class of case hitherto found most intractable is really capable of being very satisfactorily dealt with. Of course, it is hopeless to imagine that every case of this kind will be found to improve as much as those I have de- scribed, since there must of necessity be many factors in operation, the action of which can never be determined beforehand, which may ma- terially interfere with the desired results. If, moreover, the medical man, and still more the nurse, cannot succeed in obtaining a certain moral influence over the patient, and in inspiring the confidence which is essential, failure will almost necessarily follow. In Case 4 the influ- ence of an inefficient nurse was very distinctly shown, and I should be inclined to say that a really good nurse of sufficient intelligence to 1 The above was written eighteen months ago. This lady has since been travelling in the Cape and elsewhere, and remains quite well. NERVE PROSTRATION AND HYSTERIA. 59 understand thoroughly what is required, and with the necessary admixture of tact, kindness, and firmness, is by far the most important ele- ment of success, and it is needless to say that nurses of this stamp are not readily found. Short of complete cure, very material improvement in the condition of such cases may be confidently expected; and, at the worst, even if failure fol- lows, no bad results can possibly attend the adop- tion of this plan. My own conviction is that Dr. Weir Mitchell has made a most important contribution to practical medicine by the intro- duction of the method I have been describing, which I trust the perusal of these notes may induce many to try. Beyond doubt the treat- ment is very troublesome, and requires much care and patience; but in cases so distressing no trouble should be considered a bar to its adoption. 60 THE SYSTEMATIC TREATMENT OF FURTHER NOTES ON THE SYSTEMATIC TREAT- MENT OF NERVE PROSTRATION AND HYSTE- RIA CONNECTED WITH UTERINE DISEASE.1 In the Lancet for May 28 and June 11 of this year I published a paper on the subject indicated in the above heading, relating several remarka- ble cases of neurasthenia growing out of old- standing uterine disease, entirely cured by the systematic treatment first brought under the notice of the profession by Dr. Weir Mitchell, of Philadelphia, which had not, so far as I know, previously been tried in this country, although well known and fully appreciated in America. Knowing how widely spread these unhappy cases are, I am not surprised that that communication should have attracted the attention of practi- tioners in all parts of the country who had cases of the kind under their care, and should have brought under my notice many very interesting examples of this form of disease. For the past 1 Lancet, December 10 and 17, 1881. NERVE PROSTRATION AND HYSTERIA. 61 six months I have had many opportunities of carefully studying this subject, with the result of giving me daily increasing confidence in Dr. Weir Mitchell's method as an invaluable aid in managing certain classes of disease in women. I say " an aid," because it is unquestionable that the majority of cases are complicated in their origin, and that the general symptoms, by which I mean such states as nerve prostration, wasting, sleeplessness, hysteria, and the like, are inextrica- bly mixed up with local uterine disease, and that too exclusive attention to the one or the other may lead to failure. I am anxious to lay stress on this point, since I should not wish to be considered as dwelling too exclusively on the importance of general treatment, or as under- rating the influence of localized disease of the sexual organs, of which no one can be more fully convinced than I am. It is a fact, however, which all will admit who have much experience in gynaecology, that in the cases which are spe- cially under consideration, the local disease, how- ever important in its inception, has led to a sec- ondary general disturbance of the whole system, which at last completely overshadows it, and the 62 THE SYSTEMATIC TREATMENT OF continuance of which renders every endeavor at cure, by local treatment alone, futile. It is the neurotic element, which at last is the dominant one; and it is too frequently the case that over- much local treatment, rushing from one doctor to another, and incessant change in topical medi- cation according to the special views of each succeeding physician, have, in time, a most prej- udicial effect. The adoption of this method does not, however, in any degree prevent such topical treatment as is really indicated; on the contrary it affords an admirable opportunity of carrying it out, since it involves a lengthy period of enforced rest, which is excellently suited for any operative or other local measures that may be necessary. My object at present, however, is simply to give a few practical hints from my own increased experience, which the numerous inquiries that have reached me lead me to hope may be of use to those who have cases of the kind under their care. The first point I would particularly insist upon is that these cases should be carefully selected. I am the more tempted to say this on account of a remark made by Dr. Coghill in his excellent NERVE PROSTRATION AND HYSTERIA. 63 address on " Obstetric Medicine " at the annual meeting of the British Medical Association at Ryde, who says: "It seems to me that the sys- tematic treatment of neurasthenic disorders, prac- tised with such success by Dr. Weir Mitchell, of Philadelphia, and so recently brought to the notice of the profession with such a corrobora- tive record of success by Professor Play fair, offers an alternative to Battey's operation of the most promising kind.'' Here, I venture to think, is just that sort of misapprehension which is cer- tain to lead to disappointment. If a case is purely neurasthenic it cannot, under any con- ditions, I apprehend, be one even for the con- sideration of oophorectomy. If, on the other hand, there exist those chronic organic changes in the ovaries which afford the most justifiable grou ^d for this operation, any attempt at their cure by this treatment will inevitably fail. I cannot better illustrate my opinion on this point than by stating that a lady, sent to me from Northumberland as a good case for treatment, who had been entirely confined to her bed or sofa for years from severe and intractable pelvic pain, was found to have large, swollen, and ex- 64 THE SYSTEMATIC TREATMENT OF cessively tender ovaries, acutely painful on touch. I at once stated my conviction that this was not a suitable case for treatment, inasmuch as I be- lieved the patient's sufferings to be very real, and to be caused by definite organic disease. At her own urgent request, however, I carried on the treatment for a month, with marked im- provement of the nutrition but with no relief to her sufferings. At the end of that time I was fully satisfied that nothing short of oophorec- tomy would give any chance of cure, and I at last removed the ovaries by abdominal section. They were found to be thoroughly disorganized, and everywhere bound down by old-standing adhesions; and, although too short a time has elapsed to judge completely of the result, I trust it may prove satisfactory. It is certain, therefore, that no case of this kind can fairly be considered suitable for the treatment, although the diagno- sis may be sufficiently difficult and obscure to jus- tify an experimental trial of it, before any more radical measures are seriously contemplated. Another class of case likely to lead to dis- appointment is that in which there is some definite mental disease. On this point I speak NERVE PROSTRATION AND HYSTERIA. 65 with more hesitation, from want of sufficient experience, but in two instances in which the patients were clearly suffering from a form of melancholia, I felt bound, after a short trial, to relinquish the treatment, feeling that it was doing harm rather than good. The typical cases likely to succeed well are those old-standing, bedridden, and wasted in- valids, who have been dragging on for years in a state of chronic helpless invalidism; or those more definitely hysterical patients, who suffer from a variety of simulated diseases, and have become morbidly dependent on the injudicious sympathy and tending of their friends. It is undesirable to narrate a succession of cases, but I am tempted to give a brief notice of two, as they admirably illustrate each of the classes I have alluded to, and may interest those who did not see the cases described in my former paper. Both these patients had been for years subjected to treatment of every kind without the least benefit, and I will ask any candid reader to say whether they were not of a type entirely beyond the reach of any ordinary method of manage- ment. I should say that the passages between 5 66 THE SYSTEMATIC TREATMENT OF inverted commas are from letters I have received concerning these patients, which I prefer to quote to avoid any suspicion of exaggeration on my part. Case 1. On September 10 a gentleman came to consult me on the case of his wife, in consequence of his attention having been directed to my former papers by a relative who is a well-known physi- cian in London. He informed me that his wife was now fifty-five years of age, and that she had passed ten years of her married life in India. At the age of thirty she was much weakened by several successive miscarriages, and then drifted into confirmed ill-health. He wrote, on making an appointment, as follows: "I will give you at once a short outline of her case. We have been married thirty-four years, of which the last twenty have been spent by her in bed or on the sofa. She is unable even to stand, and finds the pain in her back too great to admit of her sitting up. She is utterly without strength, of an in- tensely nervous temperament, and suffers inces- santly from neuralgia. She has, moreover, an outward curvature of the spine. There is not NERVE PROSTRATION AND HYSTERIA. 67 the slightest symptom of paralysis. Fortunately she does not touch morphia, or any narcotic or stimulant, beyond a glass or two of wine in the day. -That she has long been in a state of hysteria is the opinion of nearly all the many medical men who have seen her." Although the attempt to cure so aggravated a case as this was certainly a sufficiently severe test of the treatment, I determined to make the trial, and had the patient removed from her own home, and isolated in lodgings. I found her in bed, supported everywhere by many small pil- lows, and wasted more than, I think, I had ever seen any human being. She really hardly had any covering to her bones, and looked somewhat like the picture of the living skeleton we are familiar with. It may give some idea of her emaciation if I state that, though naturally not a small woman, her height being 5 ft. 5£ in., she weighed only 4 st. 7 lbs., and I could easily make my thumb and forefinger meet round the thick- est part of the calf of her leg. The curvature of the spine said to exist was a deceptive appearance produced by her excessive leanness, and the con- sequent unnatural prominence of the spinous 68 THE SYSTEMATIC TREATMENT OF processes of the vertebrae. I could detect no organic disease of any kind. The appetite was entirely wanting, and she consumed hardly any food beyond a little milk, a few mouthfuls of bread, and the like. From the first the patient's improvement was steady and uniform. The way she put on flesh was marvellous, and one could almost see her fatten from day to day. Within ten days all her pains, neuralgia, and backache, had gone, and have never been heard of since, and by that time we had also got rid of all her little pillows and other invalid appliances. It may be of interest, as showing what this system is capable of, if I copy her food diary on the tenth day after the treatment was begun; and all this, this bedridden patient, who had lived on starvation diet for twenty years, not only con- sumed with relish, but perfectly assimilated. Six a. M.: ten ounces of raw meat soup. 7 a. M.: cup of black coffee. 8 a. m. : a plate of oatmeal porridge, with a gill of cream, a boiled egg, three slices of bread and butter, and cocoa. 11 A. m. : ten ounces of milk. 2 p. m. : half a pound of rumpsteak, potatoes, cauliflower, a savory omelette, and ten ounces of milk. 4 p. m. : NERVE PROSTRATION AND HYSTERIA. 69 ten ounces of milk and three slices of bread and butter. 6 p. m. : a cup of gravy soup. 8 p. m. : a fried sole, roast mutton (three large slices), French beans, potatoes, stewed fruit and cream, and ten ounces of milk. 11 p. m. : ten ounces of raw meat soup. The same scale of diet was continued during the whole treatment, and, from first to last, never produced the slightest dyspeptic symptoms, and was consumed with relish and appetite. At the end of six weeks from the day I first saw her she weighed 7 st. 8 lbs.—that is, a gain of 3 st. 1 lb. It will suffice to indicate her improvement if I say that in eight weeks from the commencement of treatment she was dressed, sitting up to meals, able to walk up and downstairs with an arm and a stick, and had also walked in the same way in the park. Considering how completely atrophied her muscles were from twenty years' entire dis- use, this was much more than I had ventured to hope. She has now left with her nurse for Natal, and I have no doubt that she will return from her travels with her cure perfected. 70 the systematic treatment of Case 2. Early in August I was asked to see a lady, aged thirty-seven, with the following history: " As a girl of sixteen she had a severe neuralgic illness, extending over months; excepting that, she seems to have enjoyed good health until her marriage. Soon after this she had a miscarriage, and then two subsequent pregnancies, accom- panied by albuminuria and the birth of dead children." " During gestation I was not surprised at all sorts of nervous affections, attributing them to uraemia." The next pregnancy terminated in the birth of a living daughter, now nearly three years old; during it she had "curious nervous symptoms—e. g., her bed flying away with her, temporary blindness, and vaso-motor disturb- ances." Subsequently she had several severe shocks from the death of near relatives, and gradually fell into the condition in which she was when I was consulted. This is difficult to describe, but it was one of confirmed illness, of a marked neurotic type. Among other phenomena she had frequently recurring attacks of fainting. NERVE PROSTRATION AND HYSTERIA. 71 " These were not attacks of syncope, but of such general derangement of the balance of the circu- lation that cerebration was interfered with. She was deaf and blind; her face often flushed, some- times deadly cold; her hands clay cold, often blue, and difficult to warm with the most vigor- ous friction. These attacks passed off in from twenty minutes to a couple of hours." Soon " the attacks became more frequent, with the reappearance of another old symptom—acute ten- derness of the spine, especially over the sacrum. Then came frequent and persistent attacks of sciatica, and gradual loss of strength." About this time there appears to have been some uterine lesion, for a well-known gynecologist went down to the country to see her. Eventually " she became unable to do anything almost for herself, for the nervous irritability had distressingly in- creased. To touch her bed, the ringing of a bell, sometimes the sound of a voice, sunlight, etc., affected her so as to make her almost cry out." " If she stood up, or even raised her hands to dress her hair, they immediately became blue and deadly cold, and she was done for." Then followed palpitations of a distressing character, 72 THE SYSTEMATIC TREATMENT OF with loud blowing murmur, and pulse of 120 to 140, for which she was seen by an eminent physician, who diagnosed them to be caused by " slight ventricular asvnchronism, with atonic condition of the cardiac as well as of all other muscles of the body." " She had no appetite whatever." " Any attempt at walking brings on sciatica. She cannot sit because the tip of the spine is so sensitive ; any pressure on it makes her feel faint. She cannot go in a carriage, because it jars every nerve in her body. She cannot lie on her back, because her whole spine is so tender." When consulted about this lady, I gave it as my opinion that any attempt at cure was hopeless as long as she remained at the country house in which she lived. I was informed that it was absolutely impossible to get her away, as she could not bear the motion of any carriage, still less of a railway, without the most acute suffer- ing. Eventually the difficulty was got over by anaesthetizing her, when she was carried on a stretcher to the nearest railway station, and then brought over two hundred miles to London, being all the time more or less completely under NERVE PROSTRATION AND HYSTERIA. 73 the influence of the anaesthetic, administered by her medical attendant, who accompanied her. I found this ladv's state fully justified the account given of her. She was intensely sensitive to all sounds and to touch. Merely laying the hand on the bed caused her to shrink, and she could not bear the lightest touch of the fingers on her spine or any part near it. She lay in a darkened room at the back of the house, to be away from the noise of the streets, which distressed her much. She was a naturally fine and cultivated woman, greatly emaciated, with a dusky, sallow complexion, and dark rims round her eyes. I could find no evidence of organic disease of any kind. Whatever lesion of the uterine organs had previously existed had disappeared, and I there- fore paid no attention to them. Within a week I had the patient lying in a bright, sunlit room in the front of the house, with the windows open, and she complained no longer of the noise. Within ten days the whole spine could be rubbed freely from top to bottom, and from the first I directed the masseuse to be relentless in her manipulation of this part of the body. In a few weeks she had gained flesh largely, the dusky 74 THE SYSTEMATIC TREATMENT OF hue of her complexion had vanished, and she looked a different being. The only trouble complained of was sleeplessness, but it did not interfere with the satisfactory progress of the case, and no hypnotic was given. After the first few days we had no return of the nerve crises, which in the country had formed so characteristic a part of her illness. Her hands and feet also, at first of a remarkable deadly coldness, soon became warm, and remained so. In five weeks she was able to sit up, and before the fifth week of treatment was completed I took her out for a drive through the streets in an open carriage for two hours, which she bore without the slightest inconvenience, and the result of which she thus described in a letter the same evening: " I never enjoyed anything more in my life. I cannot de- scribe my delight and my astonishment at being once more able to drive with comfort. My back has given me no trouble, and I was not really tired." This lady has since remained perfectly well, and I need give no better proof of this than stating that she has started with her husband on a tour round the world, via India, Japan, and NERVE PROSTRATION AND HYSTERIA. 75 San Francisco, and that I have heard from her that she is thoroughly enjoying her travels. The main difficulty in satisfactorily conducting these cases is in securing the surroundings which are essential to success. Individually, I have hitherto been fairly successful with the cases I have undertaken, because I have never, in any instance, agreed to compromise on the following points: 1st. That the case should be conducted away from the patient's own home, either in lodgings or in one of the many institutions for the reception of patients that we have in the metropolis. 2d. That the patient should be placed in charge of a nurse of rny own selection, and that her friends promise me to have no communication with her, except by letter, with- out my knowledge and consent. If the patient or her friends cannot make up their minds to agree to these terms, and faithfully to carry them out, I simply decline to undertake the case. In several instances in which failures have been reported to me these essentials have not been insisted on, and on investigation it has turned out either that an attempt has been made to carry out the treatment in the patient's own 76 THE SYSTEMATIC TREATMENT OF home, or that her friends have been allowed to visit her at their own and her discretion. The latter is especially fatal. In the majority of these cases the removal from hurtful sympathy, the quiet and repose of enforced rest, and the want of opportunity for the discussion of feelings and symptoms, form, perhaps, as potent a part of the treatment as any other, and it is needless to say that all this is lost if total seclusion is not adhered to. The selection of a suitable nurse is a matter of great difficulty. Fortunately nurses of the proper type are not so rare as they were some 37ears ago. What is required is a woman of kindly disposition and pleasant manners, and of sufficient intelligence and education not only to fully appreciate and second the object of the medical attendant, and to report to him the peculiarities of each individual case, but also to form an agreeable companion to the patient during her long seclusion. Hence it is obvious that a vulgar, underbred woman, even if sufficiently intelligent, is likely to do harm to a class of patients who are often of high culture and refinement. Moreover, a certain amount of firmness and decision is essential, for if the NERVE PROSTRATION AND HYSTERIA. 77 patient gets the upper hand of the nurse, all hope of success is at an end. The real difficulty in this respect is to secure a combination of kind- ness with firmness. If I find, as I have done on several occasions, that the nurse lacks these essential qualities, I have no hesitation in chang- ing her; and I have had more than one instance in which a case was going on badly, which immediately altered for the better when a more suitable nurse was provided. Nearly as great a difficulty is the massage, and it has given me infinite trouble to have this properly done. When I first began to carry out this system I tried to train the nurses to act also as masseuses; but, although I was successful in one or two instances, I soon found that a woman might be a very suitable nurse who was quite unfit to be a proper masseuse, since it requires an amount of physical strength, combined with a certain knack, which many otherwise excellent nurses are entirely deficient in. Moreover, the nurse has so much to do in other ways, that to carry out the massage properly requires from her an amount of work that it is really unfair to exact. The so-called professional rubbers, of 78 THE SYSTEMATIC TREATMENT OF whom I have tried several, I have invariably found most unsatisfactory. They have their own preconceived notions, which it is impossible to break them of, and they are unwilling, so far as my experience of them goes, to learn afresh. I have now a sufficient number of strong women whom I have trained de novo, and any one may do the same who takes the trouble to study the full directions contained in Dr. Weir Mitchell's book. It requires, however, an aptitude which few women possess; and one practical hint I may give is, that if after a week's massage the patient is not taking well the large amount of food administered to her, and perfectly assimi- lating it, her massage is undoubtedly being badly done. This, indeed, means that the muscular waste is not being produced, which alone will admit of so much food being assimilated. I therefore do not at all care to see that the mas- sage is being effectually done; the proper test for that is the patient's power of consuming and assimilating food. The faradization would, beyond doubt, be best administered by a medical man. This, however, involves much extra trouble and expense, in a NERVE PROSTRATION AND HYSTERIA. 79 treatment otherwise necessarily costly, so that this course is not generally practicable. For my own cases I have taught the women who act as masseuses to use the battery as well, or in some cases the nurses, and this is not difficult. If they have placed in their hands a chart of Ziemssen's points, they can easily learn how to apply the current, so as to produce the required muscular contraction. If this method is to be successful, it is neces- sary that the medical man who is to carry it out should exhibit certain qualities, which are really very much those which I have already indicated as necessary for an efficient nurse; especially a judicious mixture of kindness and firmness. If he cannot manage to let his patient find out that his is the dominant will, failure is certain; while, on the other hand, anything approaching to harshness or roughness will have the effect of producing dislike on the part of the patient, which will render his best efforts futile. An important question to decide, and one which will naturally suggest itself, is, Are these cases likely to relapse ? This is, of course, a con- sideration of great consequence; for if, in a few 80 THE SYSTEMATIC TREATMENT OF weeks or months, the case is likely to be as bad as before, it may hardly be worth while to subject the patient to so troublesome a course of treatment. My own experience is as yet too recent to admit of positive assertion on this point. So far, how- ever, I have not heard of one of my cases that has not remained permanently well. I under- stand from Dr. Weir Mitchell, Avhom I had the pleasure of seeing in the autumn, that he finds that his cures, with rare exceptions, are perma- nent. It is to be remarked that the large ma- jority of these cases have insensibly slipped into invalid habits, which are fostered and aggravated by injudicious management on the part of the family and friends. It is of no use telling the friends that they are at fault; but when they have a proof of it submitted to them of so strik- ing a character as the rapid restoration to health of the patient when she is removed from home influences, they are likely to be careful not to fall a second time into the same error. Fortu- nately for herself the patient is apt to meet with somewhat scant sympathy for the future, and in this there is good ground for expecting that the NERVE PROSTRATION AND HYSTERIA. 81 recovery will not be imperilled by a return to old habits. In conclusion, I wish to make one or two ob- servations on a criticism that has been made on my former paper, and it is, indeed, in great meas- ure to have the opportunity of doing so that I have written these further notes. One or two of my professional brethren, whose opinion I value highly, have objected to the methods of treat- ment employed, especially to the massage, as savoring, to speak plainly, of quackery; one eminent physician, indeed, has assured me that he thinks it far better to leave patients of the class I have been talking of to drag on a life of suffering, a burden to themselves and to their families, rather than to cure them by such means. Now, I am bound frankly to confess that to me this criticism is absolutely unintelligible. To my mind, quackery does not consist in the thing that is done, so much as in the spirit in which it is done. The most time-honored and orthodox remedies may be employed in such a manner, and by men boasting of the highest qualifications, as to be fairly chargeable with this taint. That we should be debarred from the use of such 82 THE SYSTEMATIC TREATMENT OF potent therapeutic agents as shampooing, mas- sage, or systematic muscular exercise, whichever we may choose to call it, or electricity, or hydro- therapeutics, and the like, because in unworthy hands they have been abused, seems to me al- most worse than an absurdity. The true scien- tific position is, I submit, that we should endeavor to rescue such means of treatment from abuse, and lay down rational rules for their employ- ment. It is with such views, and in such a spirit, that I have endeavored to deal with these dis- tressing and hitherto intractable cases, and I venture to hope that the large majority of the profession will agree with me, that not only are we fully justified in resorting to such treatment, but that the eminent American physician who first introduced and systematized it has done a signal service in teaching us how to deal success- fully and scientifically with a class of case which has hitherto been entirely beyond our skill, and which brings untold misery not only on the suf- ferers, but on all connected with them. NERVE PROSTRATION AND HYSTERIA. 83 AX INTRODUCTION TO A DISCUSSION ON THE SYSTEMATIC TREATMENT OF AGGRAVATED HYSTERIA AND CERTAIN ALLIED FORMS OF NEURASTHENIC DISEASE, IN THE MEDICAL SECTION OF THE BRITISH MEDICAL ASSOCI- ATION AT WORCESTER, ON AUGUST 9, 1882. Gentlemen : When your President did me the honor of asking me to open a discussion on the Systematic Treatment of Hysterical and Neuras- thenic Diseases, to which I had already drawn the attention of the profession in a series of papers in the Lancet in May, June, and Novem- ber, of last year, I suggested to him that he should endeavor to persuade Dr. Weir Mitchell, of Philadelphia, whose method I had adopted and carried into practice, to undertake himself the task he had proposed to me. I much regret, for your sakes, gentlemen, that Dr. Mitchell was unable to accept your President's invitation, for I am sure that it would have been most interesting and profitable to have heard from that distin- guished physician an exposition of his views on a 84 THE SYSTEMATIC TREATMENT OF matter of such great practical moment. Until I had actually put into practice Dr. Mitchell's method, I, in common, I am sure, with the vast majority of the profession, looked upon the distressing and unhappily common cases we are about to discuss as a very opprobrium medicince. Nothing could possibly be more hopeless than the experience of all of us of these wretched instances of broken and shattered lives, these bed-ridden, helpless creatures, who became a burden not only to themselves, but to all around them, making happy homes miserable, and ex- hausting at once the patience and the resources of those who are responsible for their care. Who is there amongst us who cannot point to some typical example of this kind, in which the patient at last, after every sort of treatment and drug has been used; after not one, but twenty doctors have been consulted; after every method, orthodox and heterodox, has been used in vain, has been allowed to drift into the hopeless state to which I have alluded, from pure despair of alleviating her sufferings, which are none the less real because we are satisfied that they are purely functional, and are not associated with any definite organic NERVE PROSTRATION AND HYSTERIA. 85 disease ? To teach us how to lift such cases from the slough into which they had fallen is no slight achievement; and I may say, without exaggera- tion, that, having paid great attention to this subject for the last eighteen months, I have not only acquired a daily increasing confidence in the value of Weir Mitchell's method, but have had more satisfactory and surprising results from it than I have ever before witnessed in any branch of my professional experience, and that I now more confidently undertake the care of a well- selected case of this kind, than I do of almost any malady that comes under my charge. The reason for this confidence and this success is, I think, not far to seek. We have to do with cases which are, to a great extent, psychological in origin. Heretofore, although all well-instructed physicians recognized this fact, they have not been in the habit of trusting to methods of treat- ment which were based on a scientific conception of the nature of the disease. In default of other means, recourse has been had to a useless system of drugging with the so-called nervine tonics, while the patient has been left to the unaltered morbid influence of the psychological causes, 86 THE SYSTEMATIC TREATMENT OF which, in nine cases out of ten, have so large a share in the production of the illness. Although the grave forms of hysterical disease we are considering differ from each other in endless variations, the peculiarities of each requiring most careful study, there is scarcely a single one of them in which unhealthy mental influences do not play a most important part, if not in causing, certainly in keeping up, the disease. The inju- dicious and constant nursing, the craving for sympathy, the fact that the sick-room becomes the centre of interest for the patient and her friends, the constant discussion of feelings and symptoms, all have a most marked and prejudicial effect; and so long as these continue in operation no course of medicine or treatment, however judicious, has any reasonable prospect of success. As I shall presently show, the complete and perfect isolation of the patient from all these unhealthy conditions forms the very foundation and essence of the systematic management of these cases ; and when once this has been accom- plished, an enormous leverage has been obtained for the successful application of other methods of cure. I do not propose to occupy your time with NERVE PROSTRATION AND HYSTERIA. 87 any long description of the forms and symptoms of hysterical disease to which the treatment is applicable, or to their pathology. No study could be more interesting, but the time at my disposal is altogether insufficient for such a task. I shall, therefore, content myself with a very brief outline sketch of the typical instances of neurasthenic disease in which systematic treatment is of most use, and follow this by an equally short sketch of what that treatment consists. And I must beg my hearers to remember that I cannot enter into any but the most elementary details on both these topics, for a fuller account of which I must refer them to the writings of Weir Mitchell and Goodell, as well as to my own former papers. I may say here that while the latter were entitled "The Systematic Treatment of Nerve Prostration and Hysteria Connected with Uterine Disease," this was chiefly because my attention was first di- rected to the subject in consequence of the fre- quent association of these states with disease of the reproductive organs in the female. It would be a great mistake, however, to conclude that there is any necessary or constant connection between the two. Indeed, although very frequently the 88 THE SYSTEMATIC TREATMENT OF nerve state has originated in connection with uterine disease, in a large proportion of the cases I have seen, it has completely overshadowed the originating local disorder. I am not sure that I should not, in common honesty, make the somewhat humiliating confession that in many instances overmuch and injudicious local treat- ment has, in my opinion at least, intensified and kept up the now dominating neurasthenic dis- order, as in a case under my care as I write, in which the patient may fairly be said to be suffering from pessary on the brain—so inces- santly is she thinking of one or other of the seventy-nine different instruments which she has had inserted in the last few years in America and in this country. It is, perhaps, superfluous to recall to your minds the extremely varying and complex forms of the neurasthenic diseases, which may be fairly classed under the heading I have selected for this communication. Still I think it likely that it is only those medical men who have paid special attention to this subject, and who have had op- portunities of watching cases of this description, that have properly realized how multiform, NERVE PROSTRATION AND HYSTERIA. 89 strange, and misleading these nervous diseases really are. As a matter of fact, probably no two cases are ever precisely alike, and every indi- vidual instance calls for the most careful and minute study if we are to hope for a successful result in its management, not only of its physical symptoms, to make sure that we do not confound real but obscure organic lesions with simple func- tional disorder, but also of the special mental character of the patient, since much of our suc- cess must depend on a judicious reading of this, and on our tact in dealing with it. Any one who attempts to treat such diseases without careful study of the psychological characteristics of each individual patient, will inevitably fail. The type of case best adapted for systematic treatment is, in my experience, the worn and wasted, often bedridden woman, who has broken down, either from some sudden shock, such as grief, or money losses, or excessive mental or bodily strain. At first, perhaps, there may have been only a debility, constantly, however, on the increase, daily more and more yielded to, until at last all power of effort is lost, fostered, too often, by injudicious sympathy, and the constant nurs- 90 THE SYSTEMATIC TREATMENT OF ing of devoted relatives and friends. Coincident with this is the total loss of appetite, the profound anaBinia, and the consequent wasting of the tis- sues, so characteristic of these cases. On the soil so prepared are often developed the graver protean forms of hysterical disease, such as pa- resis, or paralysis, vomiting, disorder of motion, hystero-epilepsies, and many others which consti- tute the despair of the physician, and which must be more or less familiar to all of you. Such, in endless variations, are the cases which those of you who have attempted to cure them by ordi- nary medication will, I am sure, admit to have given more unsatisfactory results, and caused more disappointment, than almost any other in your practice. Now, the principal elements in the systematic management of these cases are— 1. The removal of the patient from unhealthy home influences, and placing her at absolute rest. 2. The production of muscular waste, and the consequent possibility of assimilating food by what have been called " mechanical tonics," viz., prolonged movement and massage of the muscles NERVE PROSTRATION AND HYSTERIA. 91 by a trained shampooer, and muscular contrac- tions produced by electricity. 3. Supplying the waste so produced by regular and excessive feeding, so that the whole system, and the nervous system in particular, shall be nourished in spite of the patient. On each of these I shall offer one or two brief observations. 1. The removal of the patient from her home surroundings, and her complete isolation in lodg- ings with only a nurse in attendance, is a matter of paramount importance. This is a point on which I am most anxious to lay stress, since it is the great crux to the patient and her friends; and constant appeals are made to modify this, which I look upon as an absolute sine qua non. I attrib- ute much of the success which I have been fortu- nate enough to obtain in my cases to a rigid adherence to this rule. In almost every instance of failure in the hands of others of which I have heard, some modification in this rule has been agreed to, in deference to the wishes of the friends; as, for example, treating the case in one room by herself in her own house, or in admitting the occasional visits of some relatives 92 THE SYSTEMATIC TREATMENT OF or friends. While, however, the patient is to be rigidly secluded, it is incumbent to secure the attendance of a judicious nurse, with sufficient intelligence and education to form an agreeable companion. To shut up a refined and intellectual woman for six weeks with a coarse-minded stupid nurse, can only lead to failure. I have had more difficulty in obtaining suitable nurses sufficiently firm to ensure the directions being carried out, and yet not over-harsh and unsympathetic, than in any other part of the treatment. Whenever my case is not doing well, I instantly change the nurse—often with the happiest results. In addi- tion to the isolation, the patient is put at once to bed, to secure absolute rest. In many cases she is already bedridden, in others there has been a weary protracted effort, and the complete repose is in itself a great gain and relief. 2. Under the second head comes systematic muscular movement, having for its object the production of tissue waste. This is administered by trained rubbers, and here again is a great practical difficulty. The so-called professional rubbers are, in my experience, worse than use- less, and I have had to teach de novo a sufficient NERVE PROSTRATION AND HYSTERIA. 93 number of strong, muscular young women; and the aptitude for the work I find to be very far from common, since a large proportion of those I have tried have turned out quite unsuited for it, I cannot attempt any description of this process. I need only say that it consists in a systematic and thorough kneading and movements of the whole muscular system for about three hours daily, the result of which at first is to produce great fatigue, and subsequently a pleasant sense of lassitude, Subsidiary to this is the use of the faradic current for about ten to twenty minutes, twice daily, by which all the muscles are thrown into strong contraction, and the cutaneous circu- lation is rendered excessively active. The two combined produce a large amount of muscular waste, which is supplied by excessive feeding; and, in consequence of the increased assimilation and improved nutrition, we have the enormous gain in weight and size which one sees in these cases, it being quite a common thing for a patient to put on from one to two stones in weight in the course of five to six weeks. The feeding, at regular intervals, constitutes a large part of the nurse's work. At first from three to five ounces 94 THE SYSTEMATIC TREATMENT OF of milk are given every few hours; and for the first few days the patient is kept on an exclusively milk diet. By this means dyspeptic symptoms are relieved, and the patient is prepared for the assimilation of other food. This is added by de- grees, pari passu with the production of muscular waste by massage, which is commenced on the third or fourth day. By about the tenth day the patient is shampooed for an hour and a half, twice daily, and by this time she is always able to take an amount of food that would appear almost preposterous, did not one find by experi- ence how perfectly it is assimilated, and how rapidly flesh is put on. It is the usual thing for patients to take, when full diet is reached, in addition to two quarts of milk daily, three full meals, viz.: breakfast, consisting of a plate of porridge and cream, fish or bacon, toast and tea, coffee, and cocoa; a luncheon, at 1 p. m., of fish, cutlets or joints, and a sweet, such as stewed fruit and cream, or a milky pudding; dinner, at 7 p. m., consisting of soup, fish, joint, and sweets ; and, in addition, a cup of raw meat soup at 7 a. m. and 11 p. m. It is really very rare to find the slightest inconvenience result from this apparently enor- NERVE PROSTRATION AND HYSTERIA. 95 mous dietary. Should there be an occasional attack of dyspepsia, it is at once relieved by keeping the patient for four-and-twenty hours on milk alone. Such is a brief outline of the method to which I am here to direct your attention. As to the results, I have already published several remarka- ble illustrative cases, so that it is perhaps not nec- essary to do much more in this direction. I may say, on looking back at my cases, that the only ones with which I have any reason to be disap- pointed are those in which the primary selection has been bad; and in the few in which the re- sults were not thoroughly satisfactory, I had doubts as to their suitability for the treatment, which I expressed beforehand. These include one case of chronic ovarian disease, and one of bad anteflexion with fibroid enlargement of the uterus, in both of which the local disease pre- vented any really beneficial results. In a third case, I had to stop the treatment in a week, in consequence of cardiac mischief; two others were cases of positive mental disease; and in one case there was true epilepsy. I have no doubt that any positive co-existent organic disease of this 96 THE SYSTEMATIC TREATMENT OF kind should be considered a contra-indication. In my other cases, the results have been all that could be wished, and in many of them the pa- tients have been restored to perfect health after having been helpless bedridden invalids for years; in one case twenty-three without ever putting a foot to the ground, in others sixteen, nine, six, and so on. In two instances my pa- tients were in such a state, that it was found absolutely impossible to move them except when anaesthetized; and they were brought to Lon- don by their medical men long distances under chloroform, in each case leaving in six weeks perfectly cured. I am not desirous of occup}Ting your time by long details of cases, having already published several; but, as many of my hearers have probably not seen my former papers, I shall conclude by a short notice of some of my recent cases, which will illustrate the classes of disease in which this method is so useful; and I select them not only for their own interest, but because the uselessness of all ordinary treatment in such conditions is proved by the fact that I have with regard to each of them a list of their former medical attendants, amounting in one to no fewer NERVE PROSTRATION AND HYSTERIA. 97 than twenty-five in number, and including the names of many of the most eminent consultants in the country—of itself a sufficient proof that all that the most advanced medical knowledge and skill could do had been tried in vain. Case 1. On April 24 last, I was consulted on the case of a young lady from the North of England, suffering from intense hysterical vomiting. This had commenced six years previously, after severe mental strain. Latterly, she could keep nothing but a single mouthful of milk on her stomach, and this only when mixed with whiskey, so that in this way she was taking three to four glasses of spirit daily. She was terribly emaciated— weighing only 4 st. 7 lbs. Her mother wrote of her: "It is just five years last Christmas-day since she has ever retained a single meal. Her symptoms have been most distressing, and have resisted every kind of treatment. Her young life has been completely blighted, and I have long since given up her case as quite hopeless." The rapidity of the cure, in this instance, was almost ludicrous. In three days after she was 7 98 THE SYSTEMATIC TREATMENT OF isolated, she was keeping down two quarts of milk, it is needless to say no longer with the aid of whiskey. In ten days she was eating with an enormous appetite, and in six weeks she left town weighing 7 st. 8 lbs., a gain of 3 st. 1 lb., and has since remained quite well. Case 2. The next case is illustrative of the evil effects of overmuch education and mental strain, in a clever girl of highly developed nervous organiza- tion. It was placed under my care by the advice of one of our most eminent metropolitan physi- cians, who had been seeing her frequently in consultation with her own medical attendant for several years, and besides him many other physi- cians, equally eminent, had been consulted. This young lady was seventeen years of age. At the age of fourteen, when working, she had suddenly broken down, got complete hysterical hemiplegia, and for four years had never been out of bed, or moved either of her lower limbs. In addition, she- had a loud barking cough, which could be heard all over the house, and which had resisted every kind of medication. No food could be NERVE PROSTRATION AND HYSTERIA. 99 taken beyond milk, or a biscuit, and an orange. This case was placed under my care as a sort of test, and I was particularly anxious that it should turn out well. As to the result, I need only say that at the end of a month I drove her out in my carriage, dropped her at the top of the street in which she lived, and made her walk down to pay her parents a visit. She has since remained per- fectly well. It was a curious and characteristic point that her cough, which had resisted for years all sorts of energetic treatment at home, entirely ceased forty-eight hours after she was removed, and was never again heard. Case 3. The next instance is one out of many of the same sort I have had under my care, and is a typical example of the kind of case best suited for this treatment. In this, there was no definite ill- ness, no simulated disease, as in the last lady, but a general and complete break-down. Her medi- cal man sent her to me with the following note: " She has all her life been an invalid, with no well-defined symptoms; sometimes headache and nausea; at others spinal irritability, giddiness, 100 THE SYSTEMATIC TREATMENT OF etc. In fact, she is a typical hysteric or neu- ralgic patient. She never stirs out of the house, or moves from her bed or sofa, eats next to nothing, and is never happy unless seeing a doctor, or taking physic." I found, as was to be expected, that this young lady was wasted to a skeleton. Her chief complaints were nausea, headache, backache, intense nervous depression, and timidity (so that she was unable to speak to a stranger), and absolute anorexia ; skin dry and rough; menstruation irregular; entirely depend- ent on chloral and morphia for sleep. She was twenty-nine years of age, and for nine years had been entirely on her back. I need say no more about this case, than that it was as successful as the rest of the same type I have had to deal with, any one of which I might have selected as an illustration. In six weeks she was walking about; in two months she started on a sea- voyage with her nurse, with directions that she should be forced to mix as much as possible with the passengers, to overcome her dread of society. Only two days ago, she came to report herself to me, having travelled alone from the country by rail; and I positively did not at first recog- NERVE PROSTRATION AND HYSTERIA. 101 nize her—so different was the well-dressed, healtlry-looking woman, from the wretched in- valid of a few months ago. She tells me that she now plays tennis; goes out to picnics and parties; and enjoys life like anyone else. Case 4. The last example with which I shall trespass on your patience, I am tempted to relate, because it is one of the most remarkable instances of the strange and multiform phenomena which neu- rotic disease may present, which it has ever been my lot to witness. The case must be well known to many members of the profession, since there is scarcely a consultant of eminence in the metrop- olis who has not seen her during the sixteen years her illness has lasted, besides many of the leading practitioners in the numerous health-re- sorts she has visited in the vain hope of benefit. My first acquaintance with this case is somewhat curious. About two months before I was intro- duced to the patient, chancing to be walking along the esplanade at Brighton with a medical friend, my attention was directed to a remarkable party at which every one. was looking. The chief 102 THE SYSTEMATIC TREATMENT OF personage in it was a lady reclining at full length on a long couch, and being dragged along, look- ing the picture of misery, emaciated to the last degree, her head drawn back almost in a state of opisthotonos, her hands and arms clenched and contracted, her eyes fixed and staring at the sky. There was something in the Avhole procession that struck me as being typical of hysteria, and I laughingly remarked, " I am sure I could cure that case if I could get her into my hands." All I could learn at the time was, that the patient came down to Brighton every autumn, and that my friend had seen her dragged along in the same way for ten or twelve years. On January 14 of this year, I was asked to meet my friend, Dr. Behrend, in consultation, and at once recog- nized the patient as the lady whom I had seen at Brighton. It would be tedious to relate all the neurotic symptoms this patient had exhibited since 1864, when she was first attacked with paralysis of the left arm. Among them—and I quote these from the full notes furnished by Dr. Behrend—were complete paraplegia, left hemi- plegia, complete hysterical amaurosis, but from this she had recovered in 1868. For all these NERVE PROSTRATION AND HYSTERIA. 103 years she had been practically confined to her bed or couch, and had not passed urine sponta- neously for sixteen years. Among other symp- toms, I find noted "awful suffering in spine, head, and eyes," requiring the use of chloral and morphia in large doses. " For many years she has had convulsive attacks of two distinct types, which are obviously of the character of hystero- epilepsy." The following are the brief notes of the condition in which I found her, which I made in my case-book on the day of my first visit. " I found the patient lying on an invalid couch, her left arm paralyzed and rigidly contracted, strapped to her body to keep it in position. She was groaning loudly at intervals of a few sec- onds, from severe pain in her back. When I attempted to shake her right hand, she begged me not to touch her, as it would throw her into a convulsion. She is said to have had epilepsy as a child. She has now many times daily, fre- quently as often as twice in an hour, both during the day and night, attacks of sudden and abso- lute unconsciousness, from which she recovers with general convulsive movements of the face and body. She had one of these during my 104 THE SYSTEMATIC TREATMENT OF visit, and it had all the appearance of an epilep- tic paroxysm. The left arm and both legs are paralyzed, and devoid of sensation. She takes hardly any food, and is terribly emaciated. She is naturally a clever woman, highly educated, but, of late, her memory and intellectual powers are said to be failing." It was determined that an attempt should be made to cure this case, and she was removed to the Home Hospital in Fitzroy Square. She was so ill, and shrieked and groaned so much on the first night of her admission, that next day I was told that no one in the house had been able to sleep ; and I was informed that it would be im- possible for her to remain. Between 3 p. m. and 11.30 p.m., she had had nine violent convulsive paroxysms of an epileptiform character, lasting, on an average, five minutes. At 11.30 she be- came absolutely unconscious, and remained so until 2.30 a. m., her attendant thinking she was dying. Next day, she was quieter, and from that time her progress was steady and uniform. On the fourth day, she passed urine spontaneously, and the catheter was never again used. In six weeks, she was out driving and walking; and NERVE PROSTRATION AND HYSTERIA. 105 within two months she went on a sea-voyage to the Cape, looking and feeling perfectly well. When there, her nurse, who accompanied her, had a severe illness, through which her ex-patient nursed her most assiduously. She has since remained, and is at this moment, in robust health, joining with pleasure in society, walking many miles daily, and without a trace of the ill- ness which rendered her existence a burden to herself and her friends. In conclusion, I may remark that it seems to me that the chief value of this systematic treatment, which is capable of producing such remarkable results, is that it appeals, not to one, but many influences of a curative character. Everyone knew, in a vague sort of way, that if an hysterical patient be removed from her mor- bid surroundings, a great step towards cure is made. Few, however, took the trouble to carry this knowledge into practical action; and, when they did so, they relied on this alone, combined with moral suasion. Now, I am thoroughly con- vinced that very few cases of hysteria can be preached into health. Judicious moral manage- ment can do much; but I believe that very few 106 NERVE PROSTRATION AND HYSTERIA. hysterical women are conscious impostors; and the great efficacy of the Weir Mitchell method seems to me to depend on the combination of agencies which, by restoring to a healthy state a weakened and diseased nervous system, cures the patient in spite of herself. APPENDICES. APPENDIX A. MASSAGE. The patient lying in a blanket, I begin at the feet by taking up the skin over the whole surface and firmly pinching it, twisting the toes in all directions, kneading the small muscles with the ends of my fingers and thumb, the large muscles of the leg with both hands grasping alternately, frequently running the hand firmly up the leg and striking the muscles very often with the side of the hand. Before commencing the kneading of any of the limbs I rub them freely with neat's-foot oil, and I find the more oil a patient's skin absorbs the sooner does she begin to make flesh. The hands and arms are manipulated in the same way, working upwards. The patient, lying flat upon her back with the knees up, the abdomen is first pinched all over, and then the abdominal walls are firmly grasped in both hands, one hand grasping as the other relaxes. This part of the body is finished by the hands being placed one on each side, just below the ribs, and 108 APPENDIX A. firmly drawing the flesh forward, especially in the direction of the colon. Great attention should be paid to this part of the body if the patient is troubled with indigestion. The patient now lies quite flat upon her face. I commence at the nape of the neck and pinch up the muscles on either side of the vertebrae and the whole of the back. Then I place the first two fingers of my right hand, one on each side of the spine, and make a sweep downwards the length of the spine; this I do several times quickly. By working at tender spots longer, and gently, I find the tenderness soon disappears. The patient must be taught to relax all the muscles of the body and to lie perfectly passive, otherwise she will be much bruised, and the massage, instead of being a pleasure, will be a source of pain. Towards the end of the treatment the limbs are exer- cised by movements of flexion and extension, especially the legs in the case of a patient who has not walked for years. For the first day or two I give about twenty minutes, but in about a week I find the patient able to bear the full time (an hour and a half) twice a day, and she should then be left in the blanket for about an hour to rest quietly. E. M. APPENDIX C 109 APPENDIX B. RAW MEAT SOUP. Take one pound of raw fillet of beef, chop it finely, and place it in a bottle with a pint of water and five drops of hydrochloric acid. Stand the mixture in ice all night, and in the morning set the bottle in a pan of water at 110° F., and keep it two hours at this tem- perature. It is then to be thrown on a stout cloth, and strained, until the remaining mass is nearly dry. The filtrate is given in two or three doses in the course of twenty-four hours. If the raw taste prove very ob- jectionable, the beef to be used may be quickly roasted on one side, and then the process is completed in the manner above described. The soup thus made is for the most part raw, but has also the flavor of cooked meat. 110 APPENDIX C. APPENDIX C. In a few exceptional cases, neurasthenic patients, although very anaemic and indifferent feeders, are over- burdened with an excess of unhealthy adipose tissue. Under these circumstances it is advisable before com- mencing the treatment by massage, electricity, and feeding, to reduce the weight with the view of getting rid of the unwholesome fat with which the tissues are loaded. When this is done, experience has proved that the time so occupied is really well spent, and a more complete and satisfactory result obtained. For this purpose the patient is put to bed and completely at rest, and at first is placed on a diet consisting solely of two quarts of skimmed milk, given in small quanti- ties every two hours. After this amount has been given for a day or two, it is gradually lessened, until not more than a quart a day, or even less, is consumed. Under the absolute rest, and the absence of any mus- cular exertion, this apparently starvation diet does not, so far as I have seen, cause any discomfort or incon- venience. Of course it is necessary to watch the pa- tient closely to see that no ill effects result, but in the cases in which I have tried this plan it has answered admirably. If the stomach should rebel, or there APPENDIX C. Ill should be any appearance of undue weakness, some beef-tea, or good soup may be substituted for the milk. After the amount of milk has been reduced to a daily quantity of a quart or even less, the weight will gradu- ally lessen at the rate of about half a pound a day. The length of time on which the patient may be safely treated in this way, will, of course, vary according to circumstances; and it is essential that she should be weighed daily. Probably two to three weeks will be about the outside time that this process should be em- ployed, and from fourteen to sixteen pounds taken off the weight. When this has been effected, pure milk may be substituted for skim milk, and the treatment conducted from this point precisely as in the case of an originally emaciated patient. My experience of this plan is, as yet, limited to four cases, in all of which, however, it succeeded admirably. One of them especially, a fat unwieldy woman, who had been quite bedridden, and had not used her limbs in any way for many years, eventually made a perfect recovery, and is now able to walk about and exert her- self like anyone else. CATALOGUE OF BOOKS PUBLISHED BY HENRY C. LEA'S SON & CO. (LATE HENRY C. LEA.) The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. No risks of the mail, however, are assumed, either on money or books. Gen- tlemen will, therefore, in most cases, find it more convenient to deal with the nearest bookseller. In response to a large number of inquiries for a finer binding than is usually placed on medical books, we now finish many of our standard puhlications in half Russia, using, in the manufacture none but the best materials. To foster the growing taste, the prices have been fixed at so small an advance, over the cost of leatlier binding as to bring it within the reach of all to possess a library attractive to the eye as well as to the mind. Detailed catalogues furnished or sent free by mail on application. HENRY C. LEA'S SON & CO., Nos. 706 and 708 Sansom Street, Philadelphia. THE MEDICA.L NEWS, A WEEKLY JOURNAL OF MEDICAL SCIENCE, Is published every Saturday, and contains 28 large double-columned quarto pages, the contributors to which include the most able writers of the day. FI V E DOLLARS ($5) per annum, in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by I. MINIS HAYS, A.M., M.D., Is published quarterly, on the 1st of January, April, July and October. Each number contains over 300 large octavo pages. FIVE DOLLARS ($5) per annum, in advance. COMMUTATION RATES. The Medical News The American Journal of Medical Sciences "i Nine dollars per > annum, in ad- ) vance. ALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY. WITH AN INTRODUCTORY CHAPTER ON HISTOLOGY, by E. 0. Shakespeare, M.D. To be completed in one large and hand- some quarto volume of about 600 double-columned pages, with 380 engravings on stone on 109 plates, and 250 woodcuts in the text. In six sections, each in a portfolio Section I. (Histolopy), Section II. (Bones and Joints) and Section III. (Muscles nnd Fascias) just ready. Section IV. (Arteries, Veins and Lymphatics) in press. Section V. (Nervous System) in press. Section VI. (Organs of Sense, of Digestion and Genito-Urinnry Organs) in press Price per section, $3 50. Sold by subscription only. ASHHURST (JOHN, Jr.) THE PRINCIPLES AND PRACTICE OF SURGERY. FOR THE USE OF STUDENTS AND PRACTI- TIONERS. Third and revised edition. In one large and handsome octavo volume of 1060 pages, with 555 woodcuts. Cloth, $6; leather, $7 ; very handsome half Russia, raised bands, $7 50. 2 HENRY C. LEA'S SON & CO.'S PUBLICATIONS. ASHTON (T. J.) ON THE DISEASES, INJURIES AND MALFOR- MATIONS OF THE RECTUM AND ANUS. With remarks on Habitual Constipation. Second American from the fourth Lon.lon edition, with illustrations. One 8vo. vol. of 287 pp. Cloth, $3 25. ASHWELL (SAMUEL). A PRACTICAL TREATISE ON THE DIS- EASES OF WOMEN. Third American from the third London edi- tion. In one octavo volume of 520 pages. Cloth, $3 50. ATTFIELD (JOHN). CHEMISTRY; GENERAL, MEDICAL AND PHARMACEUTICAL. Eighth edition, revised by the Author. In One 12mo. vol. of 701 pages, with 87 illus. Clo., $2 50 ; leather, $3 00. BAIRD (ROBERT). IMPRESSIONS AND EXPERIENCES OF THE WEST INDIES. 1 vol. royal 12mo. Cloth, 75 cents. BARLOW (GEORGE H.) A MANUAL OF THE PRACTICE OF MEDICINE. In one 8vo. volume of 603 pages. Cloth, $2 50. BARNES (FANCOURT). A MANUAL OF MIDWIFERY FOR MID- WIVES. In one royal 12mo. vol., with numerous illustrations. Cloth, $125. (Just issued.) BARNES (ROBERT). A PRACTICAL TREATISE ON THE DIS- EASES OF WOMEN. Third American from third English edition. In one handsome octavo volume of about 800 pages, with about 200 illustrations. (Preparing.) BA.RTHOLOW (ROBERTS). A PRACTICAL TREATISE ON ELEC- TRICITY AS APPLIED TO THE PRACTICE OF MEDICINE. Second edition. In one very handsome octavo volume of 292 pages, with 109 illustrations. Cloth, $2 50. BASHAM (W. R.) RENAL DISEASES ; A CLINICAL GUIDE TO THEIR DIAGNOSIS AND TREATMENT. In one 12mo. volume of 304 pages, with illustrations. Cloth, $2 00. BELLAMY'S MANUAL OF SURGICAL ANATOMY. In one royal 12uio. volume of 300 pages, with 50 illustrations. Cloth, $2 25. BLOXAM (C. L.) CHEMISTRY, INORGANIC AND ORGANIC. With Experiments. New edition. In one handsomeoctavo volume of about 700 pages, with about 300 illustrations. (Preparing.) BRISTOWE (JOHN SYER). A TREATISE OF THE PRACTICE OF MEDICINE. Second American edition, revised by the Author. Edited with additions by James H. Hutchinson, M.D. In one handsome 8vo. volume of 1085 pages. Cloth, $5 00 ; leather, $6 00; very handsome half Russia, raised bands, $6 50. (Just issued.) BROWNE (EDGAR A.) HOW TO USE THE OPHTHALMOSCOPE. Elementary instruction in Ophthalmoscopyfor theUseof Students. In one small 12mo. volume of 116 pages, with 35 illust. Cloth, $1. BROWNE (LENNOX). THE THROAT AND ITS DISEASES. New edition. In one handsome imperial 8vo. volume, with 12 colored plates, 120 typical illust. in color and 50 woodcuts. (Preparing.) BRYANT (THOMAS). THE PRACTICE OF SURGERY. Third ■D American from the third English edition. Edited, with additions, by J. B. Roberts, M.D. In one imperial octavo volume of 1009 pages, with 735 illustrations. Cloth, $6 50 ; leather, $7 50 ; very handsome half Russia, raised bands, $8. (Just issued.) BUMSTEAD (F. J.) THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES. Fifth edition, revised and enlarged, by II. W. Taylor, M.D. In one very handsome octavo volume of 850 pages, with about 150 illustrations. (Inpress.) ---ANDCULLERIER'S ATLAS OF VENEREAL. See "Cullerier." HENRY C. LEA'S SON & CO.'S PUBLICATIONS. 3 BURNETT (CHARLES H.) THE EAR : ITS ANATOMY, PHYSI- OLOGY AND DISEASES. A Practical Treatise for the Use of Students and Practitioners. In one handsome octavo volume of 619 pages, with 87 illustrations. Cloth $4 50; leather, $5 50; very handsome half Russia, raised bands, $6. (Lately issued.) CAMPBELL'S LIVES OF LORDS KENYON, ELLENBOROUGH AND TENTERDEN. Being the third volume of " Campbell's Lives of the Chief Justieesof England." In one crown octavo vol. Cloth, $2, CARPENTER (WM. B.) PRINCIPLES OF HUMAN PHYSIOLOGY. A new American, from the eighth English edition. In one large 8vo. volume of 1083 pages, with 373 illustrations. Cloth, $5 50; leather, raised bands, $6 50 ; very handsome half Russia, raised bands, $7. (Lately issued.) ----- PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New Edition, with a Preface by D. F. Condie, M.D. One 12mo. volume of 178 pages. Cloth, 60 cents. CARTER (R. BRUDENELL). A PRACTICAL TREATISE ON DIS- EASES OF THE EYE. With additions and test-types, by John Green, M.D. In oneSvo. vol. of 500 pages, with 124 illustrations. CENTURY OF AMERICAN MEDICINE.—A History op Medicine im America. 1776-1876. In one I2mo. vol. of 366 pages. Cloth, $2 25. CHADWICK (JAMES R.) A MANUAL OF THE DISEASES PECU- LIAR TO WOMEN. In one 12mo. vol , with illust. (Preparing.) CHAMBERS (T. K.) A MANUAL OF DIET IN HEALTH AND DISEASE. In one handsome 8vo. vol. of 302 pages. Cloth, $2 75. CHURCHILL (FLEETWOOD). ESSAYS ON THE PUERPERAL FEVER. In one octavo volume of 464 pages. Cloth, $2 50. CLASSEN'S QUANTITATIVE ANALYSIS. Translated by Edgar F. Smith, Ph.D. In one 12mo. volume of 324 pp., with 36 illustrations. Cloth, $2 00. CLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF THE HUMAN BODY. In one 12mo. vol. of 178 pp. Cloth, $125. CLOWES (FRANK). AN ELEMENTARY TREATISE ON PRAC- TICAL CHEMISTRY AND QUALITATIVE INORGANIC ANA- LYSIS. FromtheThirdEne. Ed. In one 12mo. vol. Cloth, $2 50. COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY AND PATHOLOGY. With Notes and Additions to adapt it to American Practice. By Thos. C. Stellwagen, M. A., M.D., D.D.S. In one hand- some 8vo. vol. of 412 pp , with 331 illus. Cloth, $3 25. (Just ready.) GONDIE (D.FRANCIS). A PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and enlarged. In one large 8vo. vol. of 800 pages. Cloth, $5 25 ; leather, $6 25. COOPER (B.B.) LECTURESON THE PRINCIPLES ANDPRACTICE OF SURGERY. In one large 8vo. vol. of 767 pages. Cloth, $2 00. 00RNIL (V.) SYPHILIS: ITS MORBID ANATOMY, DIAGNOSIS AND TREATMENT. Translated, with notes and additions, by J. Henry C Simes, M.D , and J. William White, M.D. In one 8vo. volume of 461 pages, with 84 illust. Cloth, $3 75. (Just ready.) G0RNIL (V.), AND RANVIER(L.) MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by E. O. Shakespeare, M.D., and J. Henry C. Simes, M.D. In one octavo volume of 800 pages, with 360 illustrations. Cloth, $5 50; leather, $6 50,- very handsome half Russia, raised bands, $7. (Just issued.) 0ULLERIER (A.) AN ATLAS OF VENEREAL DISEASES. Trans- lated and edited by Freeman J. Bumstead, M.D., LL.D. A large imperial quarto volume, with 26plates containingaboutl50 figures, beautifully colored, many of them life-siae. In one vol., strongly bound in cloth, $17. In five parts, paper covers, $3 per part. 4 HENRY C. LEA'S SON & CO.'S PUBLICATIONS. DALTON (J. C.) A TREATISE ON HUMAN PHYSIOLOGY. Sev- enth edition, thoroughly revised, and greatly improved. In one very handsome 8vo. vol. of 722 pages, with 252 illustrations. Cloth, $5 ; leather, $6 ; very handsome half Russia, $6 50. (Just ready.) DANA (TAMES D.) THE STRUCTURE AND CLASSIFICATION OF ZOOPHYTES. With illust. on wood. In oneimp. 4to. vol. Clo.,$4. DAVIS (F. H.) LECTURES ON CLINICAL MEDICINE. Second ed., revised and enlarged. In one 12mo. vol. of 287 pp. Cloth, $175. DE LA BECHE'S GEOLOGICAL OBSERVER. In one large 8vo. vol. of 700 pages, with 300illustrations. Cloth, $4. DON QUIXOTE DE LA MANCHA. Illustrated edition. In two hand- some crown 8vo. vols. Cloth, $2 50 ; half moroceo, $3 70. DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MO- DERN SURGERY. A revised American, from the eighth London edition. In one octavo volume of 687 pages, with 432 wood en- gravings. Cloth, $4; leather, $5. DUNCAN (J. MATTHEWS) CLINICAL LECTURES ON THE DIS- EASES OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1 50. (Just issued.) DUNGLISON (ROBLEY). MEDICAL LEXICON; A Dictionary of Medical Soience. Containing a concise explanation of the various subjects and terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medi- cal Jurisprudence and Dentistry ; notices of Climate and of Mineral AVaters ; FormulaeforOfficinal, Empirical and Dietetic Preparations; with the accentuation and Etymology of the Terms, and the French and other Synonymes. New edition. In one very large royal 8vo. vol. Cloth, $6 50; leather, $7 50; half Russia, raised bands, $8. EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Stu- dents and Practitioners. In one handsome 8vo. vol., of 576 pp., with 148 illustrations. Cloth, $3 ; leather, $4. (Just ready.) ELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. Being a Guide to the Knowledge of the Human Body by Dissection. From theeighth and revised English edition. In one very handsome octavo volume of 716 pages, illustrated by 249 engravings on wood. Cloth, $4 25 ; leather, $5 25. ( Lately issued.) EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRACTICE OF GYNECOLOGY, for the use of Students and Practitioners. Sec- ond edition, enlarged and revised. In one large 8vo. vol. of 879 pp., with 133 original illustrations. Cloth, $5; leather, $6; very handsome half Russia, raised han