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Title: Fat and Blood

An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria

Author: S Weir Mitchell

Editor: John K Mitchell

Release Date: July 7, 2005 [EBook

#16230]

AN ESSAY ON THE TREATMENT OF CERTAIN FORMS OF

NEURASTHENIA AND

HYSTERIA.

BY

S WEIR MITCHELL, M.D.,

Copyright, 1897, by J.B LIPPINCOTTCOMPANY.

Copyright, 1900, by J.B LIPPINCOTTCOMPANY.

Copyright, 1905, by S WEIRMITCHELL

ELECTROTYPED AND PRINTED BYJ.B LIPPINCOTT COMPANY,PHILADELPHIA, U.S.A

PREFACE TO THE EIGHTH EDITION.

The continued favor which this book hasenjoyed in Europe as well as in thiscountry has rendered me doubly desirous

to make it a thorough and clear statement

of the treatment of the kind of caseswhich it discusses as carried out in mypractice to-day

In the endeavor to do this, the presentedition, like the last two, has beencarefully revised by my son, Dr John K.Mitchell, and there is no chapter, andscarcely a page, where some alteration

or addition has not been made, besidesthose of the sixth and seventh editions,

as the result of added years ofexperience Especially in the chapters onthe means of treatment some details havebeen thought worth adding to help thestatement so often repeated in the bookthat success will depend on the carewith which details are carried out Thechapter on massage, rewritten for thelast edition, has been once more revisedand somewhat extended, in order tomake it an accurate as well as ascientific, if brief, statement of the bestmethod which use and observation havetaught us A chapter on the handling ofseveral diseases not described in formereditions has been added by the editor

S WEIR MITCHELL.SEPTEMBER, 1899.

EDITION.

CHAPTER I INTRODUCTORY CHAPTER II GAIN OR LOSS OF

CONSIDERED

TREATMENT

CHAPTER IV SECLUSION

CHAPTER V REST

CHAPTER VI MASSAGE

CHAPTER VII ELECTRICITY

CHAPTER VIII DIETETICS AND THERAPEUTICS

CHAPTER IX DIETETICS AND

THERAPEUTICS—(Continued)

CHAPTER X THE TREATMENT

ATAXIC PARAPLEGIA, SPASTIC

AGITANS

INDEX.

CHAPTER I.

INTRODUCTORY.

For some years I have been using withsuccess, in private and in hospitalpractice, certain methods of renewingthe vitality of feeble people by acombination of entire rest and excessivefeeding, made possible by passiveexercise obtained through the steady use

of massage and electricity

The cases thus treated have been chieflywomen of a class well known to everyphysician,—nervous women, who, as arule, are thin and lack blood Most ofthem have been such as had passedthrough many hands and been treated inturn for gastric, spinal, or uterinetroubles, but who remained at the end as

at the beginning, invalids, unable toattend to the duties of life, and sources

alike of discomfort to themselves andanxiety to others.

In 1875 I published in "Séguin's Series

of American Clinical Lectures," Vol I.,

No iv., a brief sketch of this treatment,under the heading of "Rest in theTreatment of Nervous Disease," but thescope afforded me was too brief for thedetails on a knowledge of whichdepends success in the use of rest, I havebeen often since reminded of this by themany letters I have received asking forexplanations of the minutiæ of treatment;and this must be my apology for bringinginto these pages a great many particularswhich are no doubt well enough known

to the more accomplished physician

In the preface to the second edition Isaid that as yet there had been hardlytime for a competent verdict on themethods I had described Since makingthis statement, many of our profession inAmerica have published cases of the use

of my treatment It has also beenthoroughly discussed by the medicalsection of the British MedicalAssociation, and warmly endorsed byWilliam Playfair, of London, Ross ofManchester, Coghill, and others; while atranslation of my book into French by

Dr Oscar Jennings, with an introduction

by Professor Ball, and a reproduction inGerman, with a preface by Professorvon Leyden, have placed it satisfactorilybefore the profession in France and

As regards the question of originality Idid not and do not now much concernmyself This alone I care to know, that

by the method in question cases arecured which once were not; and as to thenovelty of the matter it would beneedless to say more, were it not that thecharge of lack of that quality issometimes taken as an imputation on aman's good faith

But to sustain so grave an implicationthe author must have somewhere laidclaim to originality and said in whatrespect he considered himself to havedone a totally new thing The followingpassage from the first edition of this

book explains what was my ownposition:

"I do not wish," I wrote, "to be thought

of as putting forth anything veryremarkable or original in my treatment

by rest, systematic feeding, and passiveexercise All of these have been used byphysicians; but, as a rule, one or moreare used without the others, and the planwhich I have found so valuable, ofcombining these means, does not seem to

be generally understood As it involvessome novelty, and as I do not find itdescribed elsewhere, I shall, I think, bedoing a service to my profession byrelating my experience."

The following quotation from Dr

William Playfair's essay[1] says all that Iwould care to add:

"The claims of Dr Weir Mitchell

to originality in the introduction ofthis system of treatment, which Ihave recently heard contested inmore than one quarter, it is not myprovince to defend I feel bound,however, to say that, havingcarefully studied what has beenwritten on the subject, I cannowhere find anything in the leastapproaching to the regular,systematic, and thorough attack onthe disease here discussed

"Certain parts of the treatmenthave been separately advised, and

more or less successfullypractised, as, for example,massage and electricity, withoutisolation; or isolation andjudicious moral managementalone It is, in fact, the old storywith regard to all new things:there is no discovery, from thesteam-engine down to chloroform,which cannot be shown to havebeen partially foreseen, and yet theclaims of Watt and Simpson tooriginality remain practicallyuncontested And so, if I may bepermitted to compare small thingswith great, will it be with this Thewhole matter was admirablysummed up by Dr Ross, of

Manchester, in his remarks in thediscussion I introduced at themeeting of the British MedicalAssociation at Worcester, which Iconceive to express the precisestate of the case: 'Although Dr.Mitchell's treatment was not new

in the sense that its separaterecommendations were made forthe first time, it was new in thesense that these recommendationswere for the first time combined

so as to form a complete scheme

of treatment.'"

As regards the acceptance of this method

of treatment I have to-day no complaint

to make It runs, indeed, the risk of beingemployed in cases which do not need it

and by persons who are not competent,and of being thus in a measure broughtinto disrepute As concerns one of itsessentials—massage—this is especially

to be feared It is a remedy with capacity

to hurt as well as to help, and shouldnever be used without the advice of aphysician, nor persistently kept upwithout medical observation of itstemporary and more permanent effects

CHAPTER II.

GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED.

The gentlemen who have done me thehonor to follow my clinical service atthe State Infirmary for Diseases of theNervous System[2] are well aware howmuch care is there given to learnwhether or not the patient is losing orhas lost flesh, is by habit thin or fat Thisquestion is one of the utmost moment inevery point of view, and deserves alarger share of attention than it receives.

In this hospital it is the custom to weighour cases when they enter and atintervals The mere loss of fat isprobably of small moment in itself whenthe amount of restorative food issufficient for every-day expenditure, andwhen the organs are in condition to keep

up the supply of fat which we not only

require for constant use but probablyneed to change continually The steady

or rapid lessening of the deposits ofhydro-carbons stored away in the areolæ

of the tissues is of importance, asindicating their excessive use or afailure of supply; and when eithercondition is to be suspected it becomesour duty to learn the reasons for thisstriking symptom Loss of flesh has also

a collateral value of great import,because it is almost an invariable rulethat rapid thinning is accompanied soon

or late with more or less anæmia, and it

is uncommon to see a person steadilygaining fat after any pathologicalreduction of weight without acorresponding gain in amount and

quality of blood We too rarely reflectthat the blood thins with the decrease ofthe tissues and enriches as they increase.Before entering into this question further,

I shall ask attention to some pointsconnected with the normal fat of thehuman body; and, taking for granted,here and elsewhere, that my readers arewell enough aware of the physiologicalvalue and uses of the adipose tissues, Ishall continue to look at the matterchiefly from a clinical point of view.When in any individual the weight variesrapidly or slowly, it is nearly alwaysdue, for the most part, to a change in theamount of adipose tissue stored away inthe meshes of the areolar tissue Almost

any grave change for the worse in health

is at once betrayed in most people by adiminution of fat, and this is readily seen

in the altered forms of the face, which,because it is the always visible and inoutline the most irregular part of thebody, shows first and most plainly theloss or gain of tissue Fatty matter istherefore that constituent of the bodywhich goes and comes most easily Whythere is in nearly every one a normallimit to its accumulation we cannot say,nor yet why this limit should vary as lifegoes on Even in health the weight ofmen, and still more of women, is by nomeans constant, but, as a rule, when weare holding our own with that share ofstored-up fat which belongs to the

individual we are usually in a condition

of nutritive prosperity, and when afterany strain or trial which has lessenedweight we are slowly repairing mischiefand laying by fat we are equally in astate of health The loss of fat which isnot due to change of diet or to exercise,especially its rapid or steady loss,nearly always goes along withconditions which impoverish the blood,and, on the other hand, the gain of fat up

to a certain point seems to go hand inhand with a rise in all other essentials ofhealth, and notably with an improvement

in the color and amount of the redcorpuscles

The quantity of fat which is healthy forthe individual varies with the sex, the

climate, the habits, the season, the time

of life, the race, and the breed.Quetelet[3] has shown that beforepuberty the weight of the male is forequal ages above that of the female, butthat towards puberty the proportionalweight of the female, due chiefly to gain

in fat, increases, so that at twelve thetwo sexes are alike in this respect.During the child-bearing time there is anabsolute lessening on the part of thefemale, but after this time the weight ofthe woman increases, and the maximum

is attained at about the age of fifty

Dr Henry I Bowditch[4] reachessomewhat similar conclusions, andshows from much more numerous

measurements of Boston children thatgrowing boys are heavier in proportion

to their height than girls until they reachfifty-eight inches, which is attainedabout the fourteenth year Then the girlpasses the boy in weight, which Dr.Bowditch thinks is due to theaccumulation of adipose tissue atpuberty After two or three years morethe male again acquires and retainssuperiority in weight and height

Yet as life advances there arepeculiarities which belong toindividuals and to families One groupthins as life goes on past forty; anothergroup as surely takes on flesh; and thesame traits are often inherited, and are to

be regarded when the question of

fattening becomes of clinical ordiagnostic moment Men, as a rule,preserve their nutritive status moreequably than women Every physicianmust have been struck with this In fact,many women lose or acquire largeamounts of adipose matter without anycorresponding loss or gain in vigor, andthis fact perhaps is related in some way

to the enormous outside demands made

by their peculiar physiologicalprocesses Such gain in weight is acommon accompaniment of child-bearing, while nursing in some womeninvolves considerable gain in flesh, and

in a larger number enormous fallingaway, and its cessation as speedy arenewal of fat I have also found that in

many women who are not perfectly wellthere is a notable loss of weight at everymenstrual period, and a marked gainbetween these times.

I was disappointed not to find this matterdealt with fully in Mrs Jacobi's ableessay on menstruation, nor can Idiscover elsewhere any observations inregard to loss or gain of weight atmenstrual periods in the healthy woman.How much influence the seasons have, isnot as yet well understood, but in ourown climate, with its great extremes,there are some interesting facts in thisconnection The upper classes are with

us in summer placed in the bestconditions for increase in flesh, not only

because it is their season of least work,mental and physical, but also becausethey are then for the most part living inthe country under circumstancesfavorable to appetite, to exercise, and tofreedom from care Owing to thesefortunate facts, members of the class inquestion are apt to gain weight insummer, although many such persons, as

I know, follow the more general rule andlose weight But if we deal with themass of men who are hard worked,physically, and unable to leave thetowns, we shall probably find that theynearly always lose weight in hotweather Some support is given to thisidea by the following very curious facts.Very many years ago I was engaged for

certain purposes in determining theweight, height, and girth of all themembers of our city police force Theexamination was made in April andrepeated in the beginning of October.Every care was taken to avoid errors,but to my surprise I found that a largemajority of the men had lost weightduring the summer The sum total of losswas enormous As I have mislaid some

of the sheets, I am unable to give itaccurately, but I found that three out ofevery five had lessened in weight Itwould be interesting to know if such achange occurs in convicts confined inpenitentiaries

I am acquainted with some persons wholose weight in winter, and with more

who fail in flesh in the spring, which isour season of greatest depression inhealth,—the season when with uschoreas are apt to originate[5] or torecur, and when habitual epileptic fitsbecome more frequent in such as are thevictims of that disease.

Climate has a good deal to do with atendency to take on fat, and I think thefirst thing which strikes an American inEngland is the number of inordinately fatmiddle-aged people, and especially offat women

This excess of flesh we usuallyassociate in idea with slothfulness, butEnglish women exercise more than ours,and live in a land where few days forbid

it, so that probably such a tendency toobesity is due chiefly to climatic causes.

To these latter also we may no doubtascribe the habits of the English as tofood They are larger feeders than we,and both sexes consume strong beer in amanner which would in this country bedestructive of health These habits aid, Isuspect, in producing the more generalfatness in middle and later life, andthose enormous occasional growthswhich so amaze an American when first

he sets foot in London But, whatever bethe cause, it is probable that members ofthe prosperous classes of English, overforty, would outweigh the averageAmerican of equal height of that period,and this must make, I should think, some

difference in their relative liability tocertain forms of disease, because theoverweight of our trans-Atlantic cousins

is plainly due to excess of fat

I have sought in vain for English tablesgiving the weight of men and women ofvarious heights at like ages The materialfor such a study of men in America isgiven in Gould's researches published

by the United States SanitaryCommission, and in Baxter's admirablereport,[6] but is lacking for women Acomparison of these points as betweenEnglish and Americans of both sexeswould be of great interest

I doubt whether in this country asnotable a growth in bulk as multitudes of

English attain would be either healthy ordesirable in point of comfort, owing tothe distress which stout people feel inour hot summer weather Certainly

"Banting" is with us a rarely-neededprocess, and, as a rule, we have muchmore frequent occasion to fatten than tothin our patients The climaticpeculiarities which have changed ourvoices, sharpened our features, andmade small the American hand and foot,have also made us, in middle andadvanced life, a thinner and more sallowrace, and, possibly, adapted us better tothe region in which we live The samechanges in form are in like mannershowing themselves in the English race

in Australia.[7]

Some gain in flesh as life goes on is afrequent thing here as elsewhere, andusually has no unwholesome meaning.Occasionally we see people past the age

of sixty suddenly taking on fat andbecoming at once unwieldy and feeble,the fat collecting in masses about thebelly and around the joints Such anincrease is sometimes accompanied withfatty degeneration of the heart andmuscles, and with a certain wateryflabbiness in the limbs, which, however,

do not pit on pressure

Alcoholism also gives rise in somepeople to a vast increase of adiposetissue, and the sodden, unwholesomefatness of the hard drinker is asufficiently well known and unpleasant

spectacle The overgrowth of inertpeople who do not exercise enough touse up a healthy amount of overfedtissues is common enough as anindividual peculiarity, but there are alsotwo other conditions in which fat is apt

to be accumulated to an uncomfortableextent Thus, in some cases of hysteriawhere the patient lies abed owing to herbelief that she is unable to move about,she is apt in time to become enormouslystout This seems to me also to befavored by the large use of morphia towhich such women are prone, so that Ishould say that long rest, the hystericalconstitution, and the accompanyingresort to morphia make up a group ofconditions highly favorable to increase

of fat.

Lastly, there is the class of fat anæmicpeople, usually women This doublepeculiarity is rather uncommon, but, asthe mass of thin-blooded persons are as

a rule thin or losing flesh, there must besomething unusual in that anæmia whichgoes with gain in flesh

Bauer[8] thinks that lessened number ofblood-corpuscles gives rise to storing offat, owing to lessened tissue-combustion At all events, the absorption

of oxygen diminishes after bleeding, and

it used to be well known that somepeople grew fat when bled at intervals.Also, it is said that cattle-breeders insome localities—certainly not in this

country—bleed their cattle to causeincrease of fat in the tissues, or of fatsecreted as butter in the milk Theseexplanations aid us but little tocomprehend what, after all, is only metwith in certain persons, and musttherefore involve conditions not common

to every one who is anæmic.Meanwhile, the group of fat anæmics is

of the utmost clinical interest, as I shall

by and by point out more distinctly

There is a popular idea, which hasprobably passed from the agriculturistinto the common mind of the community,

to the effect that human fat varies,—thatsome fat is wholesome and someunwholesome, that there are good fatsand bad fats I remember well an old