S. Weir (Silas Weir) Mitchell.

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FAT AND BLOOD:



AN ESSAY



TREATMENT OF CEKTAIK POEMS OF



NEURASTHENIA AND HYSTERIA.



BY



S. WEIR MITCHELL, M.D.,

111



MEMBER OF THE NATIONAL ACADEM'if OF SCIENCES; PHYSICIAN TO THE ORTHOPCEDIC



HOSPITAL AND INFIRMARY FOR DISEASES OF THE NERVOUS SYSTEM ; VICE-
PRESIDENT OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; HONORARY
CORRESPONDING MEMBER OF THE BRITISH MEDICAL ASSOCIA-
TION ; HONORARY' MEMBER OF THE LONDON MEDICAL
SOCIETY ; FOREIGN ASSOCIATE OF THE ROYAL
MEDICAL SOCIETY OF NORWAY, ETC.



FOURTH EDITION, REVISED, WITH ADDITIONS.



P H I li A D E L P H I A :

J. B. LIPPINCOTT COMPANY.
LONDON: 15 RUSSELL STREET, COVENT GARDEN.

1885.



Copyright, 1877, by J. B. Lippincott k Co.



Copyright, 1883, by J. B. Lippincott & Co.







TO

SAMUEL LEWIS, M.D. EDIN., M.KC.S. LOND.,

EX-PRESIDENT PHILADELPHIA COLLEGE OF PHYSICIANS.



The profession in Philadelphia owes chiefly to
your unceasing liberality the great library of our
College of Physicians. Personally, I owe to you a
friendship which the passing years have made more
valuable. As a physician and a friend, therefore,
I gratefully dedicate to you the fourth edition of
this little book.

THE AUTHOE.



CONTENTS.



CHAPTEE I.

PAGE

Introductoky 7



CHAPTER II.
Gain or Loss of Weight Clinically Considered 14

CHAPTEE III.

On the Selection of Cases for Treatment . . 33

CHAPTEE IV.
Seclusion 47

CHAPTEE V.
Eest . . 52

CHAPTEE VI.
Massage . . . . 71

CHAPTEE VII.
Electricity 86

CHAPTEE Vlil.
Dietetics and Therapeutics 97

Index 168

1* 5



PREFACE TO THE FOUETH EDITION.



I HAVE made some slight changes in this edi-
tion, and have added a few not unimportant
points in regard to treatment.

S. WEIR MITCHELL.



CHAPTER I.

INTRODUCTORY.

For some years I have been using with suc-
cess, in private and in hospital practice, certain
methods of renewing the vitality of feeble people
by a combination of entire rest and of excessive
feeding, made possible by passive exercise ob-
tained through the steady use of massage and
electricity.

The cases thus treated have been chiefly women
of a class well known to every physician, — ner-
vous women, who, as a rule, are thin and lack
blood. Most of them have been such as had
passed through many hands and been treated in
turn for gastric, spinal, or uteriB£_ troubles, but
who remained at the end as at the beginning, in-
valids, unable to attend to the duties_of^ife, and
sources alike of discomfort to themselves and
anxiety to others.

In 1875 I published in " Seguin's Series of
American Clinical Lectures," Yol. I., ^o. iv., a



10 JNTR OD UCTOR V.

brief sketch of this treatment, under the heading
of " Rest in the Treatment of Nervous Disease,"
but the scope afforded me was too brief for the
details on a knowledge of which depends success
in the use of rest. I have been often since re-
minded of this by the many letters I have
received asking for explanations of the minutiae
of treatment ; and this must be my apology for
bringing into these pages a great many particu-
lars which are no doubt well enough known to
the more accomplished physician.

In the preface to the second edition I said
that as yet there had been hardly time for a
competent verdict on the methods I had de-
scribed. Since making this statement, many
of our profession in America have published
cases of the use of my treatment. It has also
been thoroughly discussed by the medical sec-
tion of the British Medical Association, and
warmly endorsed by William Playfair, of Lon-
don, Ross, of Manchester, Coghill, and others;
while a translation of my book into French by
Dr. Oscar Jennings, with an introduction by
Professor Ball, has placed it satisfactorily before
the profession in France.

As regards the question of originality I did



INTRODUCTORY. H

not and do not now much concern myself. This
alone I care to know, that by the method in
question cases are cured which once were not ;
and as to the novelty of the matter it would be
needless to say more, were it not that the charge
of lack of that quality is sometimes taken as an
imputation on a man's good faith.

But to sustain so grave an implication the
author must have somewhere laid claim to ori-
ginality and said in what respect he considered
himself to hav-e done a totally new thing. The
following passage from the first edition of this
book explains what was my own position :

" I do not wish," I wrote, " to be thought of
as putting forth anything very remarkable or
original in my treatment by rest, systematic
feeding, and passive exercise. All of these have
been used by physicians ; but, as a rule, one or
more are used without the others, and the plan
which I have found so valuable, of combining
these means, does not seem to be generally un-
derstood. As it involves some novelty, and as
I do not find it described elsewhere, I shall, I
think, be doing a service to my profession by
relating my experience."

The following quotation from Dr. William



1 2 INTROD UCTOR F.

Plajfair's essay ^ says all that I would care to
add :

" The claims of Dr. "Weir Mitchell to origi-
nality in the introduction of this system of treat-
ment, which I have recently heard contested in
more than one quarter, it is not my province to
defend. 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 dis-
cussed.

" Certain parts of the treatment have been
separately advised, and more or less successfully
practised, as, for example, massage and electri-
city, without isolation ; or isolation and judicious
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 chloro-
form, which cannot be shown to have been par-
tially foreseen, and yet the claims of Watt and
Simpson to originality remain practically un-
contested. And so, if I may be permitted to



* The Systematic Treatment of Nerve Prostration and Hys-
toriti. London, 1883.



INTRODUCTORY, 13

compare small things witli great, will it be with,
this. The whole matter was admirably summed
up by Dr. Ross, 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.' ''

As regards the acceptance of this method of
treatment I have to-day no complaint to make.
It runs, indeed, the risk of being employed in
cases which do not need it and by persons who
are not competent, and of being thus in a measure
brought into disrepute. As concerns one of its
essentials — massage — this is especially to be
feared. It is a remedy with capacity to hurt as
well as to help, and should never be used with-
out the advice of a physician, nor persistently
kept up without medical observation of its
temporary and more permanent effects.



CHAPTEE 11.

GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED.

The gentlemen who have done me the honor
to follow my clinical service at the State Infirm-
ary for Diseases of the I'Tervous System ^ are well
aware how much care is there given to learn
whether or not the patient is losing or has lost
flesh, is by habit thin or fat. This question is
one of the utmost moment in every point of
view, and deserves a larger share of attention
than it receives. In this hospital it is the cus-
tom to weigh our cases when they enter and at
intervals. The mere loss of fat is probably of
small moment in itself when the amount of re-
storative food is sufficient for every-day expendi-
ture, and when the organs are in condition to
keep up the supply of fat which we not only
require for constant use but probably need to



^ The Pennsylvania Orthopaedic Hospital and Infirmary for

Diseases of the Nervous System.
14



GAIN OR LOSS OF WEIGHT. I5

change continually. The steady or rapid lessen-
ing of the deposits of hydro-carbons stored away
in the areolae of the tissues is of importance,
as indicating their excessive use or a failure of
supply ; and when either condition is to be sus-
pected it becomes our duty to learn the reasons
for this striking symptom. Loss of flesh has
also a collateral value of great import, because
it is almost an invariable rule that rapid thin-
ning is accompanied soon or late with more or
less anaemia, and it is uncommon to see a person
steadily gaining fat after any pathological reduc-
tion of weight without a corresponding gain in
amount and quality of blood. We too rarely
reflect that the blood thins with the decrease of
the tissues and enriches as they increase.

Before entering into this question further, I
shall ask attention to some points connected with
the normal fat of the human body; and, taking,
for granted, here and elsewhere, that my readers
are well enough aware of the physiological value
and uses of the adipose tissues, I shall continue
to look at the matter chiefly from a clinical point
of view.

When in any individual the weight varies rap-
idly or slowly, it is nearly always due, for the



J



16 QAIB OR LOSS OF WEIGHT.

most part, to a change in tlie amount of adipose
tissue stored away in the meshes of the areolar
tissue. Almost any grave change for the worse
in health is at once betrayed in most people by a
diminution of fat, and this is readily seen in the
altered forms of the face, which, because it is the
always visible and in outline the most irregular
part of the body, shows first and most plainly the
loss or gain of tissue. Fatty matter is therefore
that constituent of the body which goes and
comes most easily. Why there is in nearly every
one a normal limit to its accumulation we cannot
say, nor yet why this limit should vary as life
goes on. Even in health the weight of men, and
still more of v^omen, is by no means constant,
but, as a rule, when we are holding our own with
that share of stored-up fat which belongs to the
individual we are usually in a condition of nu-
tritive prosperit}^, and when after any strain or
trial which has lessened weight we are slowly re-
pairing mischief and laying by fat we are equally
in a state of health. The loss of fat which is
not due to change of diet or to exercise, espe-
cially its rapid or steady loss, nearly always goes
along with conditions which impoverish the
blood, and, on the other hand, the gain of fat



GAIN OR LOSS OF WEIGHT, 17

up to a certain point seems to go hand in hand
with a rise in all other essentials of health, and
notably with an improvement in the color and
amount of the red corpuscles.

The quantity of fat which is healthy for the
individual varies with the sex, the climate, the
habits, the season, the time of life, the race, and
the breed. Quetelet^ has shown that before pu-
berty the weight of the male is for equal ages
above that of the female, but that towards pu-
berty the proportional weight of the female, due
chiefly -to gain in fat, increases, so that at twelve
the two sexes are alike in this respect. During
the child-bearing time there is an absolute less-
ening on the part of the female, but after this
time the weight of the woman increases, and the
maximum is attained at about the age of fifty.

Dr. Henry I. Bowditch^ reaches somewhat
similar conclusions, and shows from much more
numerous measurements of Boston children that
growing boys are heavier in proportion to their
height than girls until they reach fifty-eight
inches, which is attained about the fourteenth



1 Sur rHomme, p. 47, et seq.

2 Growth of Children, p. 31.



18 GAIN OR LOSS OF WEIGHT.

year. Then the girl passes the boy in weight,
which Dr. Bowclitch thinks is due to the accu-
mulation of adipose tissue at puberty. After
two or three years more the male again acquires
and retains superiority in weight and height.

Yet as life advances there are peculiarities
which belong to individuals and to families. One
group thins as life goes on past forty ; another
group as surely takes on flesh ; and the same
traits are often inherited, and are to be regarded
when the question of fattening becomes of clini-
cal or diagnostic moment. Men, as a rule, pre-
serve their nutritive status more equably than
women. Every physician must have been struck
with this. In fact, many women lose or acquire
large amounts of adipose matter without any
corresponding loss or gain in vigor, and this fact
perhaps is related in some way to the enormous
outside demands made by their peculiar physi-
ological processes. Such gain in weight is a
common accompaniment of child-bearing, while
nursing in some women involves considerable
gain in flesh, and in a larger number enormous
falling away, and its cessation as speedy a re-
newal of fat. I have also found that in many
women who are not perfectly well there is a



GAIN OR LOSS OF WEIGHT. 19^

notable loss of weight at every menstrual period,
and a marked o^ain between these times. — -

I was disappointed not to find this matter
dealt with fully in Mrs. Jacobi's able essay on
menstruation, nor can I discover elsewhere any
observations in regard to loss or gain of weight
at menstrual periods in the healthy woman.

How much influence the seasons have, is not
as yet well understood, but in our own climate,
with its great extremes, there are some inter-
esting facts in this connection. The upper
classes are with us in summer placed in the best
conditions for increase in flesh, not only because it
is their season of least work, mental and physical,
but also because they are then for the most part
living in the country under circumstances favor-
able to appetite, to exercise, and to freedom from
care. Owing to these fortunate facts, members
of the class in question are apt to gain weight in
summer, although many such persons, as I know,
follow the more general rule and lose weight.
But if we deal with the mass of men who are
hard worked, physically, and unable to leave the
towns, we shall probably find that they nearly
always lose weight in hot weather. Some support
is given to this idea by the following very curi-



20 GAIN OR LOSS OF WEIGHT.

ous facts. Yerj many years ago I was engaged
for certain purposes in determining the weight,
height, and girth of all the members of our city
police force. The examination was made in
April and repeated in the beginning of October.
Every care w^as taken to avoid errors, but to my
surprise I found that a large majority of the
men had lost weight during the summer. The
sum total of loss was enormous. As I have mis-
laid some of the sheets, I am unable to give it
accurately, but I found that three out of every
^YQ had lessened in weight. It would be inter-
esting to know if such a change occurs in con-
victs confined in penitentiaries.

I am acquainted with some persons who lose
weight in winter, and with more who fail in
flesh in the spring, which is our season of great-
est depression in health, — the season when with
us choreas are apt to originate^ or to recur, and
when habitual epileptic fits become more frequent
in such as are the victims of that disease.

Climate has a good deal to do with a tendency

* See a valuable paper by Dr. Gerhard, Am. Jour. Med.
Sci., 1876. Also Lectures on Diseases of the Nervous System,
especially in Women. S. Weir Mitchell. Phila., 1881, p.
127.



GAIN OR LOSS OF WEIGHT. 21

to take on fat, and I think the first thing which
strikes an American in England is the numhe}
of inordinately fat middle-aged people, and es-
pecially of fat women.

This excess of flesh we usually associate in
idea with slothfulness, hut English women ex-
ercise more than ours, and live in a land where
few days forbid it, so that probably such a ten-
dency to obesity is due chiefly to climatic causes.
To these latter also we may no doubt ascribe the
habits of the English as to food. They are larger
feeders than we, and both sexes consume strong
beer in a manner which would in this country
be destructive of health. These habits aid, I
suspect, in producing the more general fatness
in middle and later life, and those enormous
occasional growths which so amaze an American
when first he sets foot in London. But, what-
ever be the cause, it is probable that members
of the prosperous classes of English, over forty,
would outweigh the average American of equal
height of that period, and this must make, I
should think, some difierence in their relative
liability to certain forms of disease, because the
overweisrht of our trans-Atlantic cousins is
plainly due to excess of fat.



22 GAIN OR LOSS OF WEIGHT.

I have sought in vain for English tables giving
the weight of men and women of various heights
at like ages. The material for such a study of
men in America is given in Gould's researches
published by the United States Sanitary Com-
mission, and in Baxter's admirable report/ bul
is lacking for women. A comparison of these
points as between English and Americans of
both sexes would be of great interest.

I doubt whether in this country as notable a
growth in bulk as multitudes of English attain
Avould be either healthy or desirable in point
of comfort, owing to the distress which stout
people feel in our hot summer weather. Cer-
tainly " Banting" is with us a rarely-needed
process, and, as a rule, we have much more fre-
quent occasion to fatten than to thin our patients.
The climatic peculiarities which have changed
our voices, sharpened our features, and made
small the American hand and foot, have also
made us, in middle and advanced life, a thinner
and more sallow race, and, possibly, adapted us
better to the region in which we live. The same

* Statistics (Anthropological) Surgeon-General's Bureau —
1875.



GAIN OR LOSS OF WEIGHT. 23

changes in form are in like manner showing
themselves in the English race in Australia.^

Some gain in flesh as life goes on is a frequent
thing here as elsewhere, and usually has no un-
wholesome meaning. Occasionally we see people
past the age of sixty suddenly taking on fat and
becoming at once unwieldy and feeble, the fat
collecting in masses about the belly and around
the joints. Such an increase is sometimes ac-
companied with fatty degeneration of the heart
and muscles, and with a certain watery flabbi-
ness in the limbs, which, however, do not pit
on pressure.

Alcoholism also gives rise in some people to a
vast increase of adipose tissue, and the sodden,
unwholesome fatness of the hard drinker is a
sufficiently well known and unpleasant spectacle.



^This excess of corpulence in the English is attained chiefly
after forty, as I have said. The average American is taller
than the average Englishman, and is fully as well built in
proportion to his height, as Gould has shown. The child of
either sex in New England is both taller and heavier than
the English child of corresponding class and age, as Dr. H. I.
Bowditch has lately made clear ; while the English of the
manufacturing and agricultural classes are miserably inferior
to the members of a similar class in America.



24 GAIN OR LOSS OF WEIGHT.

The overgrowth of inert people who do not ex-
ercise enough to use up a healthy amount of
overfed tissues is common enough as an indi-
vidual peculiarity, but there are also two other
conditions in which fat is apt to be accumulated to
an uncomfortable extent. Thus, in some cases of
hysteria where the patient lies abed owing to her
belief that she is unable to move about, she is apt
in time to become enormously stout. This seems
to me also to be favored by the large use of
morphia to which such women are prone, so that
I should say that long rest, the hysterical consti-
tution, and the accompanying resort to morphia
make up a group of conditions highly favorable
to increase of fat.

Lastly, there is the class of fat anaemic people,
usually women. This double peculiarity is rather
uncommon, but, as the mass of thin-blooded per-
sons are as a rule thin or losing flesh, there nmst
be something unusual in that anaemia which goes
with gain in flesh.

Bauer ^ thinks that lessened number of blood-
corpuscles gives rise to storing of fat, owing to

iZeitschrift fur Biol., 1872. Phila. Med. Times, vol. iii.,
page 115.



GAIN OR LOSS OF WEIGHT. 25

lessened tissue -combustion. At all events, the
absorption of oxygen diminishes after bleeding,
and it used to be well known that some people
grew fat when bled at intervals. Also, it is said
that cattle-breeders in some localities — certainly
not in this country — bleed their cattle to cause
increase of fat in the tissues, or of fat secreted as
butter in the milk. These explanations aid us
but little to comprehend what, after all, is onl}^
met with in certain persons, and must therefore
involve conditions not common to every one who
is ansemic. Meanwhile, the group of fat ansemics
is of the utmost clinical interest, as I shall by
and by point out more distinctly.

There is a popular idea, which has probably
passed from the agriculturist into the common
mind of the community, to the effect that human
fat varies, — that some fat is wholesome and some
unwholesome, that there are good fats and bad
fats. I remember well an old nurse who assured
me when I was a student that " some fats is fast
and some is fickle, but cod-oil fat is easy squan-
dered."

There are more facts in favor of some such
idea than I have place for, but as yet we have
no distinct chemical knowledge as to whether the



26 GAIN OR LOSS OF WEIGHT.

fats put on under alcohol or morplda, or rap-
idly by the use of oils, or pathologically in fatty
degenerations, or in anaemia, vary in their con-
stituents. It is not at all unlikely that such is
the case, and that, for example, the fat of an
obese angemic person may differ from that of a
fat and florid person. The flabby, relaxed state
of many fat people is possibly due not alone to
peculiarities of the fat, but also to want of tone
and tension in the areolar tissues, which, from
all that we now know of them, may be capable
of undergoing changes as marked as those of
muscles.

That, however, animals may take on fat which
varies in character is well known to breeders
of cattle. ^' The art of breeding and feeding
stock," says Dr. Letheby,^ " is to overcome ex-
cessive tendency to accumulation of either sur-
face fat or visceral fat, and at the same time to
produce a fat which will not melt or boil away in
cooking. Oily* foods have a tendency to make
soft fats w^hich will not bear cooking." Such
differences are also seen between English and
American bacon, the former being much more

»Letheby on Food, pp. 39, 40, 41.



GAIN OR LOSS OF WEIGHT. 27

solid ; and we know, also, that the fat of different
animals varies remarkably, and that some, as
the fat of hay-fed horses, is readily worked oft*.
Such facts as these may reasonably be held to sus-
tain the popular creed as to there being bad fats
and good fats, and they teach us the lesson that
in man, as in animals, there may be a difference
in the value of the fats we acquire, according as
they are gained by one means or by another.

The recent researches of L. Langer have cer-
tainly shown that the fatty tissues of man vary
at different ages, in the proportion of the fatty
acids they contain.

I have had occasion, of late years, to watch
with interest the process of somewhat rapid but
quite wholesome gain in flesh in persons sub-
jected to the treatment which I shall by and
by describe. Most of these persons were treated
by massage, and I have been accustomed to
question the masseur or masseuse as to the man-
ner in which the change takes place. Usually
it is first seen in the face and neck, then it is
noticed in the back and flanks, next in the belly,
and finally in the limbs, the legs coming last in
the order of gain, and sometimes remaining
comparatively thin long after other parts have



28 GAIN OR LOSS OF WEIGHT.

made remarkable and visible gain. These ob-
servations have been checked by careful meas-
urements, so that I am sure of their correctness
for people who fatten while at rest in bed. The


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