wp, C458b 1860 vs^x BED CASE: ITS HISTORY AND TREATMENT. By WALTER CHANNING, M.D. Honorary Fellow ok the ObstetrTcal SoaETY of Londox. Impotbnt and Bed-bid. Hamlet. BOSTON: PUBLISHED BY TICKNOR AND FIELDS, D. Clapp, Printer......Med. and Surg Journal Office. MDCCCLX. BED CASE: ITS HISTORY AND TREATMENT By WALTER CHANNING, M. D. Honorary Fellow of the Obstetrical Society of London. Impotent and Bed-bid. Hamlet. &1SLW BOSTON: PUBLISHED BY TICKNOR AND FIELDS, D. Clapp, Printer......Med. and Surg. Journal Office. MD C CC LX. WP £4581 I860 THE BED CASE. This affection gets its name from a symptom. Its subjects live in bed. They may be taken up daily, weekly, or monthly, But not as others take themselves up, to stay up, and to live up. They are taken up mainly to be put into bed again; or, in other words, to have the bed moved and made anew, that it may do the most and the best for its patient tenant for the four-and-twenty hours next ensuing. Few things would strike the observer more than the cheerful endurance of exile from the outward world, its enjoy- ments, its excitements—did he not see in it intellectual and moral features which are often singularly attractive. It is a life entirely by itself. It is an experience which nothing but itself presents. It is a whole life, and yet the most unchanged of all lives. The patient does not go from the blue room to the green one; that change of place which figures so largely in an old novel. The chamber, on the contrary, is the whole and sole home—the journey is from bed to chair. The business of life consists in being taken daily out and put back into the same two places, the bed and the chair, and which at length become as one, the difference being too slight to raise a suspicion that they are other than the same. But how-fares it with the Bed Case ? What is its life ? These questions are specially pertinent, for in their answers may be found the history of the case itself. This is a perfectly natural way of telling such a story, for wc are literally to look into itself for its own and whole history. Its physiognomy is peculiarly striking, so that he who has once really seen it—for many observers do not see what they look at—he or she who has seen a genuine Bed Case 4 will hardly fail to recognize it, even under the various and seem- ingly different phases which it may present. It repeats itself in a thousand cases, and though the remark will be again and again made, " How strange all this is ! why does not Miss or Mrs. Blank get up ?" etc. etc.—he who makes it, does it often only from habit, or from as common a motive, viz., that it is as easy to say it as anything else. But let us go into detail, and speak of this affection as it de- clares itself in the body, the mind, the heart—in other words, of its physical, its intellectual, and its moral aspects. I. Physical.—Painless quiet and repose; a good appetite, good food, and good digestion—a tranquil mind, and no sense of re- sponsibleness concerning active duty—the present absorbing the future—kind offices from others which know no interval nor abate- ment ; with these and other ministries to comfortable existence, it is not at all to be wondered at, that the body in the Bed Case is often well conditioned, the flesh abundant, and the complexion excellent. I have met with this physical condition in many cases, and in those of the longest continuance. The state of repose, of living in bed, has been gradually induced. Its cause may have been some slight uneasiness on motion; or it may be the advice of the physician. It has not at once taken entire possession of its subject. There has been occasional exercise—a journey, it may be. But the intervals have insensibly increased, until locomotion has ceased almost entirely, the confinement being first to the house, next to the chamber, and lastly to the bed. It will be seen in this history, how little violence has been done to the newly acquired habit of rest in the progress of the case, or during the passage through its stages. The body, which has become gradually accustomed to its discipline, experiences no shock; in other words, its func- tions proceed without disturbance, and the result, the general bodily result, is in the mouths of all. I have spoken of this good appearance of the Bed Case because it is not rare, and, in some patients, it is very striking. I occa- sionally see a case of fourteen years growth. It began about pu- berty with weariness, lassitude, both increased by exercise. At length the spine was diseased, or thought to be so. It was when such diseases occupied a large amount of professional interest, and institutions were forming for their cure. This case went through 5 its earlier stages—the bed was at last reached, and it has never been forgotten or forsaken. The appearance of health in this case is striking. In another of four years standing, and following the birth of a child, the bed was taken early, or it was not left during convalescence from child-birth, and had been perseveringly adhered to till I was called in. In this instance the external cha- racters of perfect, rude health, were more remarkable than have presented themselves in any case before seen, and this is almost the latest. The flesh was abundant—extravagant. The complex- ion of the healthiest bloom. The expression of the face full of contentment, passive enjoyment, and in the extreme, agreeable. This appearance of health, and the fact, may exist, along with a belief in, or the actual existence of some functional or organic lesion, and which is most frequently referred to the womb, or to the spine. Pain—uneasiness—complaining—a state, in short, is induced in these cases by the distinct placing a symptom in some part of the body, in consequence of something felt there, which especially characterizes the Bed Case when existing in its inten- sity, and which separates it from all other chronic troubles. In these cases the health is not good. The appetite fails, is capri- cious—the rich tit-bit is too rich, and the plainer food is too plain. The stand is at the bed-side, covered with luxury in detail, each specimen it may be small, but to the medical eye too large to al- low of a favorable prognosis, or a hope that his patient will very soon dispense with his attendance, unless it be to secure the ser- vices of another. In such cases we may have symptoms in masses which exist as individuals in others, but which embarrass treatment, prevent a true prognosis, and make the whole medical relation with the patient as uncomfortable as possible. Thus the Bed Case, if a genuine specimen of this affection—made by time and kindness very com- plete—will of necessity avail itself of any and every circumstance to produce comfort. Position is selected with care, and to this end. One limb is drawn up and at length fixed in a position which it seems at first sight almost impossible for it to have acquired. A lower limb, rarely both, and more rarely an upper one—I have never known an upper one attacked—a lower limb will gradually be found fixed in some position, sometimes the most awkward, and so it will remain for months if not for years. You must not touch it. You are hardly allowed to look at it. The result of either 6 touch or sight, worse if combined in the examination, may be spasm, more or less violent and alarming, or an expression of pain so intense, that in any other than the Bed Case might be to some medical men alarming. At times the head becomes fixed, and is never moved, or attempted to be moved. The jaws become locked —sometimes fall, and mechanical means, or the hand of a friend, may be always required to keep it in place. I have met with but one case in which the upper extremities were so much affected as to make them useless—the patient, though looking in perfect health, being fed by a nurse. The exception here may prove the rule. At times other troubles are complained of, but it is extremely rare to find those present which threaten life. Or if there be, compensating healthy functions present will show that there is no danger. Thus we may have cough—expectoration—pains in the chest in various parts—very rarely, however, do they affect those regions which are ordinarily the seats of fatal pulmonary le- sions. But let them be never so severe—never so racking, you will find along with them a good pulse—good sleep at night—no sweats—fair appetite—good digestion, and no striking emaciation —sometimes no emaciation at all. On the other hand, you may have much emaciation, a most morbid aspect every where, but ac- companied by no special local trouble to attract your notice or your apprehension. So far from this, I think I have found as speedy, if not speedier recovery occur in the most exaggerated cases, where limbs have been most rigidly bent, and the emacia- tion has been most declared. As if in the acme of the disease was its crisis, and its sure prophecy of recovery. In none of these cases have any physical signs been discovered which for a moment suggested the existence of any such pulmonary lesion as threaten- ed life. With regard to the position in lying, or the decubitus, a word may be said. It is for the most part on the back. This may be the case, even where one or both of the lower limbs are contracted— a position, one would think, of all others the most awkward and painful. The shoulders are sometimes raised more or less, pro- ducing a sort of half-sitting, half-lying recumbency. The patient may lie upon the side; but whatever the position may be, if it be at all established by time, choice, or whim, it will be continued with a persistency which can hardly fail to attract the attention of the physician, and become to him an important means of diag- 7 nosis. But whatever the position, and however faithfully persisted in, it very rarely produces a lesion which is very often met with in diseases which keep the patient in bed. Among these lesions are " bed sores," so called. I have never met with one in the genuine Bed Case, nor is soreness of the back a complaint. The word soreness is underscored, as it must be dis- tinguished from pain. It is thus very carefully distinguished in the popular use of the word, there being great pain^ where there is no soreness, and vice versa. Whence this exemption from lesions of the skin, ulcers about the hips, sacrum, &c, in the Bed Case ? There is long-continued pressure endured by the skin, and on the same points too, but no sores are produced. The exemption must proceed from the general good health. The processes of nutri- tion are well performed. Waste and supply are in harmony, and the skin is healthful, and retains the condition, the result of such state perfectly. It does not give way. Face—Features and Expression.—The variety in regard to these is very striking. It depends upon the time of the disease, sometimes, at which the observation is made—much upon the character of the disease itself, whether painful, or the manner in which total want of exercise is borne—and much upon the temperament, whether physical, moral, or intellectual. In some cases, face, features, ex- pression, and even complexion, remain unaltered, or so little changed, that it passes unnoticed. The features retain their out- line, fulness—the color is good, perhaps becoming more delicate from being withdrawn from light, air, heat, cold, for the tempera- ture of the Bed Case is a matter of prime interest, and fully re- ceives the demanded attention. The expression will attract the attention of the observing physician. This, at times, is like the face which manifests it, perfectly natural. Placid, cheerful, it takes its part in the communicating that gratitude for daily and hourly kindnesses, which so often is conveyed by words. Habit has made resignation hardly a virtue, and the hourly regards of friends, ex- pressed often very substantially, completes the catalogue of those causes which concur to give to the face the happiest, and even sweet- est expression. In other cases, we find other effects of Chamber life. Suppose we are called early, see the patient from the beginning, and mark the progress of the case. Rest is not well borne. It produces irritability. The body suffers and declares its troubles. A febrile 8 state comes on; the secretions are disturbed. Functions which, in tlieir regular performance, are indexes of the health which they preserve or produce—these are irregular. The senses become morbidly acute. Sleep is disturbed. Dyspepsia in some form or degree exists. Now such a state hath its language. It utters it- self by the tongue, and by the face. There may be dissatisfaction with all you do—fickleness, qucrulousness. The children must be quiet—the servants speak in whispers—and friends "come in with- out ringing." The light must be carefully excluded, and the east wind unknown. Visits must be short, and conversation be carried on by pressure of the hand, or the motion of the fingers. Under the pressure of these and like circumstances, it is not to be wondered at that the face and its expression, nay, and the whole form and bearing of the patient, should be changed from that which was before more or less natural to it, and indicate dis- ease ; giving to friends and plrysicians the idea of alarming maladies. The skin gets dark; its secretions insensibly accumulate, in and about the glands; spots, brown, strongly defined and ephilus, ap- pear on the forehead, neck, and elsewhere. The skin looks dirty, soiled, and may be thence concealed. The forehead is wrinkled and contracted. The face and body are thin. There is, indeed, but little daily waste, but the food craved and taken is not the best to repair what waste happens. The nose gets pinched; the eyes are sunken; the lips grow thin, and the ordinary expression of the mouth is wanting. The bowels are torpid, and, as more or less of agony comes of stirring the body, costiveness, which was at first accidental, becomes habitual, and so is easily tolerated. In short, the whole livery of chronic disease is gradually put on, and in no long time becomes "the only wear." The Senses.—These show strikingly the characters of the Bed Case. To the eyes, light is, it was said, very annoying, and must be carefully shut out. But the light seems changed. It is of various colors. At times there is partial, at others total blindness. There may be sight of one eye only. Flashes of light only are seen in some cases. Objects are imperfectly seen, half of one for instance, or one only when many are together. The hearing. It is often very acute, as before observed. It may be dull. Deafness may occur. The taste and touch and smell do not escape. Sometimes by 9 excess, sometimes by diminution of power, is their disturbance de- clared. In some cases so exquisite is the sensibility of the organs of these functions as to add greatly to the discomfort of the patient- The slightest touch approaches to torment, while the taste and smell add to the general discomfort, and this too in regard to ar- ticles which in ordinary health may be agreeable. The Head.—Pain in the head is very frequently complained of. There is throbbing often, and if an anaemic state be induced, the noises in the ears which attend that condition become almost in- tolerable. Sometimes the pain is confined to some small spot in the forehead over the eye, one eye; sometimes in the temple. This pain is often intense, sometimes intermitting, and at others constant. The Chest and Lungs.—We find various symptoms in the lungs. There is dyspnoea; elaborate, painful breathing; at times it is sighing. Cough—dry, hacking, painful cough, and this with much distress, and disturbed sleep. The emaciation and rapid pulse which may attend, might lead one to fear coming or present phthi- sis. In such a case physical signs are invaluable, and the patient and friends may have their minds put at rest. The patient may bo the latest" to give up the belief in existing consumption, since it is a character or sign of the Bed Case to despair of recovery, and it seems even to seize with avidity upon such occasions as may contain or give the strongest evidence, furnish the best proof, of the reason of their faith. But as belief in recovery, a hope which the sure progress of consumption cannot weaken, is among the strongest moral proofs of this disease where it exists, the en- tirely opposite state in regard to it, in the Bed Case, would go far to diminish in the professional mind the belief that phthisis, how- ever closely imitated, is present. Pain in one or both sides of the chest—extensive, or occupying but a small space—may be present, and will greatly annoy the pa- tient. But the seats of pain are peculiar, or are not in those parts of the chest which most frequently are the places of that pain which marks the local occurrence of inflammation, and which is accompanied by more or less increased general disturbance. It is the special duty of the physician to make use of all the means which will aid him to a true diagnosis in cases like these. If he neglect to do this, or fail in reaching accurate knowledge, his patient may be abandoned to a fate which might have been 10 avoided; means will be omitted which might have restored health, and the examination after death may discover a perfectly healthful condition of the lungs, and of all other organs. The Heart.—Few of the symptoms of the Bed Case are more strongly marked, or more likely to mislead, than those which refer to the heart. The sensibility may be increased, and pain is a com- mon and distressing symptom. Much of the time may be passed in severe suffering in the region of the heart. It is sometimes confined to a spot, as if organic lesion existed there. At others, or in other cases, it is diffused, much or all of the organ being complained of. In some instances the action of the heart becomes excessive; violent palpitation exists, and the motions of the heart become visible; its sounds audible, and its movements are perceived by the touch, and over a surface rarely exceeded by its gravest or- ganic affections. I have met with a case of this affection, in which the tumultuous action of the heart suggested to the patient the idea that it was turned over and over, in its contractions, the ut- most confusion in its functions being supposed to exist. In this case, such was the agony of the heart, and so fruitless were found all remedies, both ordinary and extraordinary, that blood-letting was at last tried. It gave great, and immediate relief. The dis- tress was paroxysmal, and the patient soon demanded blood-let- ting in every attack. To such an extent was this demand made and indulged, that when the young woman came under my care, she reported ninety-seven bleedings in two and a half years. She was now perfectly anaemic—the whitest living person I ever saw. She was not emaciated, or was suffering from some morbid ful- ness, the skin not affording the ordinary tint of oedema. I directed such means as might diminish irritability and gradu- ally give tone, and in an improved general condition looked for amendment in the restoration and establishment of healthful func- tions. She was not to be blooded unless everything else failed and circumstances should clearly indicate that death was at hand. The quantity was not to exceed eight ounces. I now know enough of such paroxysms to teach me that the condition was misplaced. Death is not hazarded in such cases, at least such is now my opin- ion, and an extreme remedy for a self-limited suffering was the most dangerous treatment. A paroxysm did not occur until a longer time than usual from the preceding one. It was a very se^ 11 vere one—the most severe, according to the patient's account, that she had ever experienced, its force being increased by the interval. It was thought necessary to bleed, to prevent death. The blood spirted from the opening in the vein as if a large artery had been opened. It was not of the color of venous blood, but of a bright though pale arterial color. I was told it flew nearly across the ward. The quantity directed was almost at once got, with much waste; but before the haemorrhage could be checked, a great deal more was lost. Perfect relief, and entire exhaustion, followed immediately on the operation. A full statement was now made to the patient of her condition, of the liability of return of the paroxysms, and the utter wrong that was done to her by blood-letting, and that I could not permit its being done again. She soon declined my further attendance, returned home, was again and again bled, and died. Upon examination after death, the heart was found of natural size, and free from every trace of organic disease. The same was found to be the case with every other organ which was examined. I have given this rapid sketch of a most important case, in this place, because though it presents an extreme instance of the condi- tion of the heart in the Bed Case, it may the better become a key to the various forms of cardiac disturbances which are met with in it. We may rarely meet with a case of equal violence. The treatment may rarely be carried so far. Present relief may not always be re- garded as the only present indication. Experience and careful observation will pretty surely show that ultimate recovery is hardly to be looked for from the continuance of such treatment for such an end. The Bed Case furnishes various degrees and different forms of heart trouble. It imitates the gravest, as above, as well as the less severe, and so perfect are its imitations in all, that if rational symptoms alone be relied on, we are liable to fall into the saddest mistakes in practice. Of the Abdominal Viscera.—The organs of nutrition suffer in the Bed Case. The entire absence of exercise; the capricious, and sometimes craving appetite; the indulgence of friends, and the very natural feeling to make such a life tolerable in any way, and if in no other or better, by feeding; the tolerance of costiveness, and of overloaded organs, arising from undue activity of others; the small waste, and the small demand for supply; the daily employment of 12 medicines for the relief of pain, or to promote sleep, and espe- cially opium—all that is necessary or contingent to the disease, tends more or less to produce disturbance in the abdominal or- gans, and actually does as much or more than auy other agency to produce suffering, and to perpetuate disease. We sometimes find* that notwithstanding all sorts of embarrass- ments to the healthy performance of the function of the organs of the abdomen, the Bed Case is not only not emaciated but is fat, very fat. I rarely meet with more positive marks of excellent health than in this disease. The skin may be clear, complexion excellent, and the habitual expression natural, kindly, without the smallest evidence of ill-health. I have known this to happen when the Bed Case phenomena, beginning in absolute girlhood, as in the " spine in the back " case, and extending hence over full fourteen years or more, would have led one to look for the extrcmest ema- ciation. In one instance in which this condition of more than average nutrition manifested itself, all other members of the fami- ly, the mother and sisters, were striking for their want of all embon- point, presenting the marks of deficient nutrition, amounting to ex- treme morbid emaciation. In other instances the opposite to all this exists. No matter what may be the appetite, no matter how kindly and faithfully it be provided for, emaciation occurs to an extent only paralleled in the advanced stages of phthisis. Along with this we have all other symptoms of the Bed Case in extreme forms, and out of them all, patients have come into full health and active life. I have a case in mind which came under my observation in 1851, in which, when the woman left her chamber to begin what she thought an impos- sible journey, she weighed 70 pounds, but who, in about three months after, called on me at my house and said she weighed 106, and seemed in perfect health. The change in this instance was the more remarkable, as not only her body but the mind had yield- ed to her disease, so that it seemed impossible for her long to survive. Thus are we presented in this disease with the greatest variety and contrariety of symptoms. We have apparently rude health, the mind clear, and active; the affections declaring them- selves in gratitude, cheerful submission, strong hope of recovery; the body perfectly well nourished, sometimes unusually fat; color- good, skin clear, functions perfectly performed. In other cases we have the reverse of all this—emaciation, querulousncss, unhealthy 13 skin, feeble intellect, entire absorption in one's self—hopeless, help- less, wholly wretched. Now, however it may be in all these re- spects, whatever antagonisms cases may present, there is no differ- ence in the essential nature of the disease. The pathology is the same in them all. The cases are all alike—there is one " spirit,' whatever may be its " manifestations." Few facts in the Bed Case require more carefully to be kept in mind than these. They will save us alike from errors in diagnosis and in treatment. The Pelvic Viscera.—The womb and its appendages are particu- larly in view in our notice of these organs; though from the vici- nity of the rectum and bladder to these, they will also demand regard. Some one says that a woman is what she is, on account of the womb. It is very certain that her pathological condition gets much of its character and importance from the state of the womb and appendages. There has been at times a disposition in the profession to ascribe many or most of the chronic affections of women to various disturbances in place, organism and function, of the womb, with which such affections are not unfrequently associated. Their precise relations, however, have not been al- ways sufficiently accurately traced, and certain transpositions of causes and effects have been made which must often have led to useless if not injurious practice. Modern discoveries have done much to diminish the chances of such error. It is in regard to the anatomy, and especially the functions of the great nervous centres, when acting in perfect health, and particularly when dis- turbed by disease, that we have obtained knowledge, light, which is slowly removing the obscurity which wrapt up, as by an impene- trable veil, the true pathology of the womb and its appendages. The Bed Case has its origin frequently, I might almost say always, in uterine trouble. How rare is it to see this disease in the male ! I have not met with the first case. We meet with it in the married and in the unmarried female. I have more fre- quently seen it in the latter. In some striking cases it has fol- lowed labor. This may have been protracted and severe, or other- wise. The '■' getting up " has been slow. Lameness has been dis- covered in attempts to leave the bed. This has made rest a ne- cessity in severe cases, and a choice in others. Rest is often prescribed where the patient thinks it quite unreasonable, and when this is the case the rule is not always recollected. This lameness may depend on many circumstances. The ligaments 14 which keep the bones of the pelvis together, may have been put strongly on the stretch by the labor.- The relaxation which the joints of the pelvis undergo during pregnancy, as a preparation for delivery, it is easy to understand is a condition which may be followed by such lesion of the connecting ligaments as will pro- duce the lameness referred to. By premature attempts to get about, the uterus, not yet returned to its size and weight in the unimpregnated state, and its natural supports being still weak or relaxed, may undergo so much dislocation as to lead to pain in the erect posture, which pain at once subsides on horizontal rest. At times the lameness after delivery follows the severe pressure to which the back has been subjected to relieve the suf- fering of uterine contractions; or rather of the pressure of the child or the presenting part during such contractions, sometimes referred to the hollow of the sacrum, sometimes higher up, or to the spine. However lameness, or suffering on motion, or in the sitting or erect position, may be produced by, or after labor, it soon becomes an obstacle to motion. It is properly yielded to at first with a view to relief, or rest is prescribed as a remedy. Much comfort is expe- rienced. Rest is continued. At length, functions which depend upon exercise are disturbed. The mind is depressed. Appetite fails, and more or less rapidly a state of invalidism is produced, which makes the state of the woman most miserable. Emaciation occurs. The milk disappears. We may have ceased to visit the patient, so gene- rally was she doing well in the first week or fortnight after confine- ment. We are called to-see her, and are struck and greatly sur- prised at the changes which have occurred. We prescribe such remedies as are indicated, and especially exercise. We are told that it is impossible to try this remedy—that pain, lameness, weak- ness, are such that almost the least attempt to move, certainly to sit up, produces an agony that cannot be borne. We see our pa- tient as often as we may think necessary. No improvement oc- curs, or only some transient amendment. Our visits become more and more rare, and at length very much lose their professional objects and character, and the Bed Case is in no long time present, with all that belongs to it. Whatever, then, tends to produce local embarrassment, and to interfere with or prevent motion after delivery, may be followed by the disease. Continued rest diminishes the power of the muscular system—disturbs the rela- 15 tions between voluntary muscles and the will, so that in time there is present not only pain on attempting motion, but absolutely want of ability to move. The nervous system falls into the condition of its organs, and from disuse becomes disturbed and enfeebled. What has now been said of the puerperal state in connection with the Bed Case, will aid us in tracing other conditions of the uterine system in their relations to the same disease. The con- nection may be less obvious because there is more or less compli- cation with what may not always be reached, or which may seem less important than it really is. Thus, I have known paroxysms of distress in the Bed Case to be directly produced by moral causes; as may be those of insanity, by referring to some one sub- ject ; and in other cases I have found motion impossible or intole- rable because of an indescribable distress referred to some point in the hollow of the sacrum, or low down, or midway, or high up in the back, the true explanation of which, can only be found in late discoveries concerning the functions of the nervous system. Spinal Irritation, so called, is not unfrequently a grave trouble in the Bed Case. This differs from common pain in the back, and which may, as just remarked, be the consequence of mechanical causes. This last rarely produces suffering, unless motion be at- tempted. As a symptom of the Bed Case, spinal irritation de- serves special attention. It does most to produce, and infinitely the most to perpetuate. To it have been addressed all manner of treatment, and which treatment has, for the most part, only done harm. Leeches, blisters, caustics, issues, et id omne genus, have been resorted to again and again, and by the year too, in the same case, and with an ill success which might have been well predicted but for the pathological mistakes concerning the affection—I can- not call it disease—the spinal affection itself. Then again, relief of this trouble has been sought in various mechanical arrange^ ments, which have done as much good, and no more, than have the local appliances just partially enumerated. The object of these instruments has been to fix the spinal column, to take from it the weight, or a part of it, of the trunk, to straighten it if bent out of line, and to enable the patient to take exercise. It has been found that in exact proportion as the instrument has done all these things, perhaps only excepting the last, so much the more injurious lias the instrument been. The more perfectly it has fixed the back and relieved it from pressure, so much more harm has come 1G of its use. And why? Because it has substituted for natural supports—which under wise direction will act, and act truly, viz., the living muscles—it has substituted, I say, for these, dead matter, which has no power of motion, and which cannot get such power from the muscles, as the very instrument itself, which is looked to, to do so much good, destroys, or suspends muscular power alto- gether. In spinal irritation the treatment has hitherto proceeded on the ground, first, that the spine is diseased; second, that the muscles are diseased; and, third, that the spinal column itself, its bones, its intervertebral substance, are diseased. 1. The spinal cord is diseased. The proof? Tenderness or pain on pressure in some one part; in two or more parts; or through the whole length of the column. This pressure was much in vogue sometime since, and as it was sometimes performed, the pain was not a mystery. There was a will, and a correspondent force, in the pressor, which gave to his manipulation a determi- nate character which led at once to the audible expression of a sensitiveness, if not tenderness—for the words do not in physio- logy or pathology mean precisely the same thing—to an expres- sion of suffering as natural as it was loud. A benevolent diagnost substituted a gentler mode of diagnosis. This consisted in pass- ing up and down the spine a bit of sponge, or of rag, which had just been dipped in hot water. If the water were hot enough, pain might be looked for. Now there was no use in these methods—the pressure, the punch, or the hot water—that is, as far as the spine was concerned, for it is notorious, at least abundantly well known, not only that pressure or heat will produce uneasiness, pain, and what not, over the spine in such cases, but over the whole back also, nay, almost over the whole body. A firm pressure of the radial artery for the pulse, or for learning its strength, as well as its frequency, will as surely give pain, as pressing or scalding the integuments over the spine. How often have I seen tested, and tested myself in this way, the question of spinal irritation, as a cause of the pain on mo- tion, &c, complained of by the Bed Case having this symptom. Pressure has been made on each side of the spine, above and be- low the scapula, over the sacrum, in short, everywhere, and uni- formly with like effects. Now in these cases there may be no disease of the spine; there is 17 only a perfectly natural tenderness under the circumstances. There is functional or organic disease of some tissue or organ far away, it may be, from the spine. With these there is a nervous connection. The reflex function contains and explains the whole causation. The spine, and every other texture to which this function can reach, tells the whole story. Let it here be borne carefully in mind, that the disease may not be in its apparent seat. Especially let it be borne in mind, that remedies applied to the spine may do harm exactly in proportion to their power, and that protracted dis- ease and increased suffering must be their results. 2. The muscles are weak, it is said, and must be supported. There is hardly less truth in this defence of the popular treatment of spinal irritation, than for the earlier leeching, blistering, and caustics. The muscles are not weak. They are unused to motion; or to contraction, for motion. They have long been out of use, for the Bed Case is not the product of a day. They have ceased to obey the will readily, and without an effort. They have rested wrongly, and they rebel when called on to work. In a word, they are lazy; the mind, too, is lazy, too much so for hearty, or even ordinary volition. Here is the whole story. We shall see in the sequel that when the occasion—the " hour," if not the " man "— comes, these diseased muscles of the back, and of the legs too, will act, and accomplish everything that the present demand, how- ever great, may require. The " Arise, take up thy bed and walk," will be enacted before our very eyes. Let it be remembered that in the Bed Case, the muscles about the spine are no more diseased than they are anywhere else, and require neither brass, iron, whale- bone or leather, to help them to perform their proper uses. They are to be exercised. They have been still for months or years. They must be moved. Somebody must move them. The patient, who has been kept in bed that recovery might be found in rest, is incapable of self-motion, or to apply the remedies wdiich her case mainly requires. Balfour's method I suppose now pretty much out of fashion, which rules physic as it does everything else—Bal- four's method will do much to put into use neglected and useless muscles. They can be exercised thus with the very best benefit. Look at the success of practitioners out of the profession, medical « outsiders," who set bones by instinct, and rub, and scrub, and knead, old effete muscles into the best uses. We of the regular file may learn much from these, who so often eclipse, displace and 3 is replace us ; and bring a true science into harmonious action with a so-far wise empiricism. We are then to work with and for mus- cles, and to bring them into independent action. Above all, we are to have, and to feel that we have, a just influence with the will of the patient, for. in the will, or out of it, is to spring true power as well as occasion for action. I have thought, sometimes, that the '■' outsider " was clean ahead of us in this matter. The muscles are, thus, to be taught, as honest industrious servants, to do their own work; and when we have taught them this, and how to do it, we may e'en let them take care of themselves. We are told, as the latest defence of the brazen and iron in- struments for weak back, that with the apparatus, exercises of va- rious kinds may be employed, as of the arms and legs. This is true, and it may happen that the tone given by action to certain muscles may come to be distributed to the system generally, and so reach the stomach, liver, bowels, and even the brain, and thence be communicated to the muscles, " though thrice locked up in steel," of the back and trunk, and gradually put the whole machinery in harmonious action. For myself, I should much prefer the other, which is the more natural, and hence should be the shorter method with these recusant muscles, and make them work for themselves. 3. Organic Lesions of the Spinal Column.—Alleged muscular weakness, accompanied with more or less suffering, even in the horizontal posture, has been spoken of as a frequent attendant on the Bed Case. Another condition deserves special notice. This is the change in shape, or rather direction, which the spine some- times manifests. Lateral and other curvatures may exist, and give an additional feature to our already complicated, or very ex- pressive malady. This may be confounded with curvatures or de- formities which have for their causes various lesions of the spine itself. It is very important that the diagnosis here be correct. When lesion of structure exists, we have an exaggeration of symptoms which no merely functional disturbance imitates. In the first place, the constitutional symptoms are very strongly mark- ed. The general features of a very grave disease are present. Emaciation is declared. A febrile state, it may be, marked by a daily paroxysm, may exist. The heat, pulse, complexion, are striking. The latter gets, and keeps, that dark, thick, sallow, if the expression may be allowed, dirty hue, which is so distinctive of malignant disease. Such disease of the uterine system is remarka- 19 ble for this appearance of the skin. Positive rest in the horizon- tal posture is not only demanded for comfort, but any other posi- tion becomes absolutely intolerable. In such condition of the general system, the effect of organic spinal disease, we have cur- vatures, and angular projections, with shortening in height, which occur under no other circumstances. I have seen nothing of this kind in the genuine Bed Case, and there is nothing in its rise, pro- gress, and termination, which at all allies it with malignant spinal disease. Now it is perfectly well known that curvatures may exist with- out any organic lesion of the spinal column. They occur in the Bed Case, and are a source of much mental uneasiness as well as physical suffering. They are thus matters of much interest in the study and treatment of this case. To what are such curvatures owing ? First, to muscular action. This may be accidentally induced. The weight of the body, the habit of lying in one position, disease, these may produce curvature, each of them bringing into action certain muscles, and allowing others entirely to rest. Various occupations which require fixed positions of the body—in early life long confinement in the same posture, as in schools—rapid growth—hereditary weakness of organization. The contracted muscles constantly acquire strength of action by this state being continued. They grow hard, strongly developed, and resist all attempts to overcome their contractions. It is not a passive re- sistance, or rest in the existing state of things which relate to this muscular condition, of permanent contraction on the one hand, and of relaxation on the other, or to the resulting curvatures. More than one curvature generally exists. Curvature may begin without notice, being slight, or lost sight of in the midst and pressure of other symptoms. The patient continues to sit, to stand, to walk, with a view to strength. In the mean time the curvatures increase, and are at length discovered. The muscles have acted in perfect harmony with the circumstances. Change of place has been made in the spinal column, which in health its muscles support, by infinitely complicated contractions, and which they now distort by truly functional, but irregular contractions. Forces acting in various directions, and different forces, produce their effects on the spine, which become permanent by muscular ac- tion. In their disturbed functions, produced by disease of remote 20 organs, the mupcles may act to the same end where no force is di- rectly in operation to distort the spine This may and does hap- pen in a state of permanent recumbency. But disease of organs in the neighborhood of the spine, in the organs of the chest or abdomen, may come to produce curvatures, very much by its own agency. Thus aneurisms and other tumors may by pressure pro- duce absorption of the bones of the spine, and various lesions of its other tissues, and the resistance to irregular action of the mus- cles being removed, we shall have curvatures or projections of dif- ferent kinds, and in different places, induced. A case was formerly under my care, in which a curvature—there was only one—was directly produced by disease. This was a young man of about 16, who had rapidly reached great height, and who in November, 1850, had severe pleurisy, with very large effusion into the left pleural cavity. I did not see him till mid- summer of the following year, and found him a perfect cripple, passing most of his time in bed, and suffering severely from pain in various parts of the trunk, mostly, however, referred to the seat of the pleurisy. Upon examination, the physical signs of effusion declared the disease. The left chest was larger than the right, pro- tuberant ; the heart was felt strongly pulsating in the right chest, being forced quite out of its natural position. No sonnd or impulse in the ordinary seat of the organ. Strong' lateral curvature to the right side- Measures were adopted for the removal of the effusion, which so far succeeded as to diminish and nearly remove the fulness of the left chest, and along with this the curvature of the spine gradually lessened, so that at length it was not to be compared with the distortion which existed when the treatment was begun. This case is brought in here, because it shows, in the first place/ how readily the spinal column yields to mechanical forces, even when laterally applied; and especially how ready it is, in some cases, to recover its natural direction if such forces are removed. The whole muscular apparatus of the anatomical region implicated in the young man's disease, was disturbed both in place and in func- tion, and the curvature seemed as much fixed for life, as in other cases. But the cause of the dislocation, for such existed, the col- umn being clearly out of place—this cause being removed, it well nigh recovered its natural direction, and promised to do this com- pletely. As the case passed out of my hands in September, I am 21 not able to state the whole result. In the second place, this case shows that no permanent or organic muscular lesion occurred in consequence of the unnatural position into which the muscles were forced by the curvature of the spine, and that they were ready at any moment to regain their natural situations and func- tions whenever the spine became straight. It is to this point I will ask particular attention in the Bed Case which is accompa- nied by lateral curvatures. Guerin taught the same thing in the remarkable case in which curvatnres were removed by the division of dorsal muscles in a space of time hardly credible, aud certainly unequalled by any other experience. In Guerin's case the mus- cles returned to their place, on dividing their tendons, with ex- plosions which were audible at some distance. In a Bed Case recently under my care, and in appearance the most hopeless one I have met with, the right lower extremity had gradually become contracted at the knee and pelvis, especially at the former place, as completely as I have ever found it. The tendons in the ham were hard and sharp, and resembled inorganic cords, ropes, more than anything else. It seemed impossible that motion should ever again be manifested by this limb. Upon attempted extension, ex- quisite pain was complained of. The limb and whole frame were completely emaciated. After a few weeks' use of pressure, of rubbing and kneading the muscles of pelvis and limb, this contraction gave way. The limb could be extended, and at length the will of the patient could control its motions. In no long time the perfect use of the limb Was acquired; next, of the whole body, and finally recovery. The question recurs, What is to be done in the Bed Case for the removal of various deformities which lying in bed, certain posi- tions, and an incidental, but unnatural action of muscles may pro- duce. This can best be done, and only done, by disturbing the whole conditions on which curvature and other deformities have been produced* In the first place, position is to be changed. The patient is to get, or be moved out of bed. It is there she has had her disease formed and ministered to, and out of this she must come. It may not be possible to accomplish this at once, but by degrees, positive degrees, it will be. done. It will be painful, exceedingly painful; so It is with the man who has been on his back for three months on account of compound fracture of the thigh or leg, and all the 22 time subjected to antagonistic forces to keep the limb straight. He has got to move, and to use his leg as freely as before the fracture; and to begin this must be painful, it may be exquisitely so. It is begun, of course, and always succeeds. A contraction, however, which nearly resembles those of the Bed Case, is that which occurs to the muscles of the lower jaw, and by which the mouth becomes gradually, but completely and permanently shut. Here is no disease of the muscles. Their action is exaggerated, simply because they have nothing else to do but to contract. It is quite curious to observe that however slow such a process may be, it will surely in time be perfect. Now this contraction may be overcome, and by pressure applied in the only way it can be used in this particular case. It may be interrupted or continuous pressure, as circumstances indicate, or rather permit. Prof. Mott, of New York, has been successful in the use of violent force, in overcoming the obstacles to recovery in cases of chronic shut-mouth, and has proved how true is that principle which finds relief in natural living functions, rather than in artificial supports. As soon as a morbidly contracted muscle is straightened, the muscles which have been useless are called into action. They must and will act if alive, and in this action is the first and most important step to recovery. But how preserve them in tlieir places ? The straightened muscle will contract as soon as the power is removed, and the an- tagonist muscles have not regained power enough in their temporary contraction to prevent this. Habit, continued action in a certain direction, is in such a case a paramount power, and must be obey- ed. There is much apparent truth in this, and it becomes for the most part practical truth by the manner in which the patient is left after the painful trial to remove distortion has been made, and this successfully. In such a case the will of the patient must be brought into activity, however painful its exercise, and its organs made to obey it. The position must be such, however difficult it may be voluntarily to sustain it, as will tend to bring into line that which has been so long crooked, and to keep it straight. But there is apparatus by which to accomplish it. True. We have apparatus of brass, of steel, of wood, and cord. I have looked at such with surprise that human ingenuity had been so tasked to accom- plish an end for a being in whom is ever living, and ready to act, an apparatus which Infinite Wisdom has contrived and executed, 23 and which is equal to all the demands that can ever be made upon it. And now what has been the result of the human contrivance ? Not the universal result, as recovery may often happen in spite of it, and would have occurred without it. What is the known result ? Where is the apparatus, or the principle, upon which it acts ? It is for extension and counter-extension. The points of support (lespoints d'appui) are not bed rails or boards, but living textures—the arm-pits or the hips. One result is excoriation, ul- ceration of these points. At times, the patient suffers extreme pain. I have now in mind a young woman who has been fourteen years bed-rid, who ascribes the continuance and increase of her disease to an apparatus, which produced extreme distress on the points of support of the hips, and ultimately such a loss of power as almost to prevent, for a time, motion altogether. Other effects are there. There*may be straightness of the spine and comfort in motion while the apparatus is applied. But as soon as it is re- moved, the column bends at once, and the old agony invariably returns. How true is this last result in regard to abdominal sup- porters, so called. They never cure. They may give temporary relief, though not always ; but as soon as they are removed, the old suffering returns. Our Bed Case may leave the bed in her casings, but she gets no cure by them. As far as the means of recovery are concerned, she too " Is naked, though locked up in steel." Whence the failure ? The organs of support, and of motion, have acquired no power, no use by the apparatus. They have been quiet, though the body may have been in motion. Had they been free to move, the old suffering would have existed, and the old deformity would, as far as the machine is concerned, have come back again. Attempts have been made to combine rest and motion in the same arrangement. But to useful practical ends, can such union be made ? Is not the good destroyed by the evil—their co- partnership, or exact balance, leaving things precisely as they were before ? The true apparatus for such cases exists within. It is not used, because pain attends and may follow its use. After a time, though the original trouble may have been greatly lessened or removed, the lono- absence of use—permanent contractions—and quiescence of antagonists, will make motion as painful as it ever has been. The a<>'ents in the recovery are the muscles, that living apparatus 2-1 which survives such long neglect, and which so often shows itselt ready for use, and under circumstances, too, which astonish both patients and friends. The motive power is the will—the will ol the patient, or the will of others. The causes of its exercise are various, and often declare themselves active when least looked for. The body, which has been at rest for years, which has never been expected to move again, as if imbued by some new principle of motion leaves its long resting-place, and at once lives again with the moving world. The performances of Mesmerism have been said to be quite wonderful. It has said, " take up thy bed and walk," and half the miracle, at least, has been performed. No apparatus has been used. No preparatory exercises have been enacted. The bird has been drawn from its nest, and has flown away. One is unconsciously moved to rhetoric, sometimes, even in physic. The reader may find an apology for this unusual burst, when I come to the cases. It was while speaking of the womb in its relation to the Bed Case, that I became involved in spinal troubles and treatment. The whole uterine system itself, and its appendages, are allied to this case. Functional and many organic affections accompany, produce, and give to it its characteristics. Among these are va- rious morbid conditions of the mouth and neck of the organ. Such are chronic inflammation, induration, ulceration and enlarge- ment of these portions of this organ. Morbid irritability, neural- gia, with or without changes in structure, are closely related to the Bed Case. So are displacements, especially when accompa- nied by enlargements, and when in consequence of this, or by po- sition of the organ in its healthy size and state, pressure come to be made upon parts of the pelvic cavity, which ordinarily are not subjected to that pressure. It may be this pressure is made upon the ovaries or an ovary, upon the rectum and hollow of the sacrum, or forward upon the bladder and symphysis, on the sides of the pelvis, or against the muscles, bloodvessels, nerves, which belong to or have their courses through the pelvis to the lower extremities. Such lesions of place may farther, and do, put upon the stretch the natural supports of the womb and its append- ages, and thus may come to disturb the natural condition and re- lations of these supports. Many and most of these agencies and conditions are accompanied with more or less pain or uneasiness. This pain or uneasiness is constant, or, at least, one or the other is 25 in some degree for the most part perceived. Especially is this the case in the erect posture. Even when not felt, there is a con- sciousness perpetually disturbing the patient that she is not well— that she is not as others who have none of her troubles—that she cannot exert herself—that she must give up—that she must go to bed. We have already treated of the symptoms of the Bed Case, and which come of sympathy or of reflex action. These are believed to have more or less connection, or dependence, on functional or or- ganic disturbances of the uterine system. The disease in question shows how intimate may be the connections of important general disease, or disorder, with uterine disease. It was just shown that local pain or uneasiness is a most frequent attendant on certain uterine diseases, with or without displacement, and that the Bed Case is, for the mdst part, the result of such morbid sensibility of the parts concerned. I say, certain uterine troubles, for our dis- ease is by no means a consequence of, or necessary attendant on, malignant disease of the organs concerned. We indeed find that in the progress of some maladies, the bed at length comes to be demanded. But iu such, it is the demand of the disease, the stern necessity of utter prostration, or of inability to sustain the erect posture—as in the case of a broken limb—which forces the pa- tient to bed; the last stage in the malignant malady before the grave. Such patients resist to the last, and go to the bed to die. It is in non-malignant uterine diseases, we find the most frequent causes of the Bed Case. These are frequently accompanied by functional disturbances which add greatly to their agencies in pro- ducing the Bed Case. We have leucorrhcea—bloody, serous, puru- lent, muco-purulent, and other secretions. These are drains, ex- hausting drains from a system which may not be well nourished, and which add greatly to the general debility. Pain was spoken of as a very common and persistent symptom of the Bed Case. It may not be severe, and is most troublesome in the erect posture—while walking—in attempts to stand, to walk, to ride—in short, in every species of exercise in which there is motion of the trunk and extremities attempted, and especially if performed in the erect posture. Long-continuous pain, or merely uneasiness, will come gradually to produce effects which are very striking to patient and friends. The perpetual conscious- ness of the existence of organs, or of separate portions of the 4 2(i living body, though this consciousness may not be constituted or kept up by severe pain, will at length come to show itself, and in a great variety of ways. No one at all acquainted with the laws of life, with the results of agencies which disturb living organs, and the existence of which is only declared by morbid sensa- tions, especially when long-continued—no one will be surprised at these effects. The constant dropping will wear the stone. A constant fret will wear the garment. So will the body and the mind give way—be conquered, by such agencies as we have been considering, and present the characteristic features of the Bed Case. The known existence of a disease which is unaccompanied with pain, and of an organ whose healthful state is not necessary to life, will come at last to produce uneasiness, discomfort, morbid mental conditions, very disturbing to their subject, but which dis- appear, often at once, whenever the offending part is removed, or by the cure of the malady. II.—The Mind.—We have now reached a very interesting question in our inquiries. What are the mental phenomena pre- sented by the Bed Case ? These are various. Sometimes they indicate a mental condition, which is the direct product of the dis- ease. Sometimes they get their character from individual pecu- liarities, or intellectual habits, and moral idiosyncrasies. The pa- tient is of literary habits—a student, or a writer, or both. The sick-room becomes a study. It is selected with care as to aspect, and especially the prospect. Sun, air, and view, are studied, until the most perfect arrangements are made which circumstances per- mit. Books, pictures—whatever will make the interior more agreeable—are collected. Society has been provided for in the choice social relations and habits of the individual. Preparations for a sort of moral and intellectual hibernation have been made (the winter lasting through the year, and it may be many years too), and the sufferer enters upon a new life, with the sole pros- pect of passing from " bed to sofa " and from sofa to bed, it may be for life, as a refuge from a thousand annoyances, and, at all events, as presenting the best chances for any portion of physical comfort. The sick life corresponds with the sick room. Books are writ- ten and read. Friends are assiduous with their attentions to pre- vent such a life from becoming intolerable, and to render it even 27 agreeable. The nicest fruits, and the most exquisite flowers, are selected. The whole of nature and of art are put under contribu- tion. Everything is done, and beautifully done, too, and year after year glides by, leaving behind them pleasant memories, and gilding the future with hopes, if not of better things, of freer and brighter days. This, to be sure, is the golden side of the shield. It has its reverse, as all other and like things have. There are pain, discomfort, depression, in this sick life. Motion is so intolerable, often, that it is rarely attempted, except under the strongest mo- tives from the physician and friends. And these sometimes suffer some abatement in the qualities of kindness and considerateness, in consequence of their vain attempts to serve the sufferer. Opium, however, comes in, to such cases, with its promises and performan- ces of solace and sleep; and if the time of disease is lengthened by it, the days and years are made less wretched. In this class of Bed Cases, which, to be sure, has but few exam- ples, the bodily condition may undergo but slight changes. The complexion may become fairer, more delicate by an always in-door life, and the weight may be increased by varieties of nourishing food, and by the slight waste which entire rest, and the absence of grave care, often involve. Intellectual habits secure varied and grateful occupation. There is talking, and reading, and writ- ing it may be. The life may be passed much in the past, but when its pleasant is at our call, the present may be agreable enough. The religious sentiment may be entire, and this, even in its occa- sional exaggerations, as with all other circumstances of the Bed Case, it is likely to be, brings with it enough of resignation to make the patient comfortable, and a willing waiter upon the future. The temper is preserved in the present class ; fretfulness, dissatis- faction, impatience, are rarely present, or, should either or all of them occur, there is a wide garment of charity for such infirmities, and they are soon covered up and forgotten. I have spoken now of an extremely interesting class of patients. They do not constitute the whole or the greater number. Still, in their various modifications, these elements are frequently met with. From what is here affirmed, may be gathered the circum- stances or symptoms of other cases. In these, from their length, from their hopelessness, effort for cure is gradually given up, and the bed is the home of the sick. In these we have sometimes oreat emaciation; some symptom—it may be cough—is gradually 2s established, and some of the imitative signs of phthisis may be present. In these, the mind may suffer with the body; weak- ness extends to this, and moral manifestations made, and grow habitual, which are anything else but agreeable. Often in these, dissatisfaction and discontent declare themselves very strongly; and, as is common in some other forms of mental weakness, the friends of the patient, those who, by night and by day, do most to make their sufferings less, are the patient or impatient recipi- ents of most of the current complaints. One tact in this history deserves notice, as it has some bearing on diagnosis,- prognosis, a,nd treatment. It is the force—the in- tensity—let us use the best word—the exaggeration, which cha- racterizes the expression of the whole views of the patient. No matter what may be the subject of conversation, this characteristic of it is very generally present. It doubtless has effects beyond itself. It may be upon the patient, or on friends. The former comes to estimate the severity of her case by her habitual de- scriptions of it, and as these grow in strength, her consciousness of the hopelessness of her condition is increased. The physician and friends are in great danger of a like influence until, at length, the case is abandoned; or, what most frequently happens, it passes into the current quackery, and drifts about into whatever direc- tions such an agency, or mere accident, may impel it. There is another fact in this connection which deserves notice,, being involved in others enumerated. The Bed Case becomes thoroughly acquainted with whatever may be done for relief. The prescriptions are all inquired into and studied, and their effects are stored. Suppose, now, a new physician is called in. He exa- mines the case, but as the pa,tient is thoroughly versed in symp- toms, he will find himself anticipated by the rapid enumeration of symptoms he may be quietly hunting for, and a continuous story come of his first question, as it were a text on which the patient was to discourse. He suggests remedies. « 0, I have used that most thoroughly. That never agreed with me, I do not under- stand that, and it has been a rule with me, never, never to use what I do not_ perfectly understand." Galvanism is suggested. " I have studied Golding Bird, and in my case he would never re- commend that,"—and so on for hours; for the time of visits to such cases are almost without end, certainly without one on which any safe calculation can be made. 29 How perfectly natural is this, and how illustrative is this part of our history of the disease. The mind has become, in a sense, a part of the body. Its activity, which in health controlled its own faculties, and the physical over which the intellectual has rule, has its power in the service of the body, and its whole ope- rations acknowledge the legitimacy of the usurping empire. This exists, the whole of it, and consists with the perfect consciousness of what is precisely the mental relation with the physical. The reasoning is perfect, and the conduct is entirely harmonious. Dif- ferent, and especially opposing views are argued out and down, and with a force which leaves very little chance for successful reply. The whole of the mind, and its greater activity, which may be the consequence of physical inability, comes into the service of the patient, and in its paramount development leaves the field in her hands. Every physician at all conversant with the Bed Case in full expression, must have been struck with what has so often and strongly been impressed upon the writer. In this view of it, no disease makes a stronger claim on the best regards of the medical man than this. It is not insanity; and yet the mind has so far lost its prerogative, as to demand of the physician the best reme- dial management of a disease which has so far led it captive, and which has in itself no certain means of relief. An important fact in the history of this disease has not been stated. It is this:—In few, if any diseases, does recovery take place so suddenly, so unexpectedly, and so perfectly as in this. The circumstances under which recovery happens are as striking as is the recovery itself. It would seem that it could be hardly otherwise than that a preparation for this has been making or made a long, or at least some time before, and that there has been only some one thing wanting—that special agency, which has been so suddenly followed by cure. Let us offer some examples. Mrs.____had been a-bed between one and two years. The disease followed labor. She had been treated by different physi- cians, but without any benefit. It was impossible for her to move, or to'be moved, without such suffering as to lead her friends to put off another experiment of the kind as long as possible. When I was called in consultation in this case, Mrs.----presented just such an appearance as her previous state would be most likely to produce. She had, in the first place, passed through a very severe labor, and had never recovered from its immediate effects. 30 The most pressing trouble in this case was a sense of "giving way,'* "falling to pieces," upon every attempt to move. This state of things was referred to the pelvis as its principal scat. A belt of strong webbing, with an interposition of India rubber, and a pad for the symphysis pubis, was prepared, and on my second visit it was applied, and Mrs.----at once taken out of bed. Her general health was slowly regained; but from this time it was ob- vious that recovery was in progress, and the usual characters of the Bed Case soon disappeared. Here mechanical means were used to prevent the alleged immediate effects of motion. Confidence soon came, that effort was possible, and practical results daily added to confidence, and the patient was thus saved from a disease which might have made a long life miserable. Mrs. ----gave birth to her first child between four and five years before I was called to see her. She had kept her bed for most of the time since. The disease had slowly made progress, but had for years been confirmed. Time enough had elapsed for all the direct effects of labor to have passed away. She was young, and had always before delivery been in excellent health. She present- ed to me every appearance of perfect health. Her complexion was clear, the skin smooth, and well colored. The flesh was abun- dant. In its fulness, it might have been thought morbid. Appe- tite good. Bowels regular. Pulse natural. I could discover no symptom of disease. Yet she could not move, or if motion was attempted, spasms came on which so alarmed the attendants by tlieir violence, that attempts to move were rare, and soon no more was done than was made absolutely necessary by circumstances which could not be neglected. The simple act of feeding, or of being fed, required the most skilful management, or alarming spasms would be produced. A very careful examination was made into the whole facts of this case, and I became satisfied that the only chance of cure here, was in doing what seemed so dangerous, namely, getting Mrs.----out of bed, and obliging her to use her own will, and her own muscles in getting back to it again. This was, at first, only hinted at. It was declared to be impossible, or, that life would be endangered by it. Several visits were made and medicines were prescribed, and taken. At length it seemed to me the time had come for action. I was alone with Mrs.____ in her chamber, and stated that I could no longer attend her, unless she would follow my directions; and that she must leave her bed. I 31 should have said that her house was in a large field, with no house near it, and nobody in her house. All the doors were left open. She consented; and with great trouble, and after much time, she was persuaded to make the attempt. With great difficulty she was brought to the edge of the bed. She of course aided in ac- complishing this, for it would have been utterly impossible for me, or for any one person, to have moved such a mass of helpless matter. Mrs.----reached the middle of her chamber, and there I left her. I did not see Mrs. ----, professionally, from this time. I was sitting in my book-room one day, when a medical acquaint- ance was showed in. After some chat on matters and things in general, said he, " Have you seen Mrs.----lately ?" I said I could not bring her to mind. " 0," said he, " she is the person you saw some months ago, in---------. She was bed-rid. Being a townsman of mine, she called on me after your last visit, and I had her removed to my house in---------, and I have cured her." I remembered that last visit, and Mrs.,---- came up in her am- plest proportions, standing alone, in that lone house. I answered indifferently, I was glad; how did it happen ? &c. &c. " I cured her mesmerically," said Dr.----. " How ?" asked I. " Mesmerically; and I have called to tell you all about it." " How did she get to your house ? She lived some two or three miles off. She did not walk, surely; and to have carried her must have been a caution. Did she retain her old admeasurements as when I last saw her ?" " I will tell you. We got her to---------, of course. I found her perfectly helpless; spasms upon the least motion." Said I, " 'twas strange she survived that drive from----, and af- ter having been taken out of bed as above narrated, and left alone." " A terrible journey was that day's travel. She remained in bed till she was thoroughly rested, you know, and then I set about the cure. We first got her out of bed. It was something to do it I assure you. She was bent upon being sick, or upon keeping in bed. At length I succeeded, and she was put into the chair. I told her to move. It is no use, Mrs.----; move you must. She would do no such thing. At length I began with mesmerism. In the first place, I excited the organ of veneration by putting my fingers upon it with a will. When this was perfectly done, or 32 Mrs.----had come entirely under my power, I excited the organ of locomotion, and bade her to ' walk.' [Mrs.----, by this time, , had become a loco-motive.] Straightway she rose and walked; and walked has she ever since." I do not question a word of this narrative, and how can I ? For, a short time after, I saw Mrs.----, as fairly restored to her legs as was ever any body to anything or things. She was not as heavy as when I last saw her. Exercise had done something to bring her within some compass. She was very glad to see me, and stated her own notions of the case with great pleasure. I said I did not question a word of this narrative. I am not one of your credat judceus class, but have respect for the doctrine of human credibility, or that other word, credulity, which so nearly resembles it in sound, that they may be very conveniently used, the one for the other. I do not know that I should go so far in the matter of faith, in the popular use of the word, as did Sir Thomas Browne, which you doubtless recollect, but in certain uses of it I should not be far behind him. This case strongly reminds me of one which made a very great noise in the time of it—that of Harriet Martineau. In her case mesmerism had its perfect work. Miss M., it is said, had not much faith in some other matters, but her faith in Mesmer was without a shadow of doubt. Several years ago she was ill, as it was said, of cancer. Before, or since that, she has suffered more from a disappoint- ment. And since both, she has climbed the " proudest pyramid of them all, and which has lost its apex, and stands obtruncated on the traveller's horizon." She has listened to the music of the sun's rays, as the early morning breezes sweep by the statue of Memnon. And above all, she has been a Bed Case. Her Life in a Sick Room—I think that is the title—is the moral history of her case. If there were ever any one, nursed, petted, coddled, it was Miss Harriet Martineau. Friendship lived and moved and had its be- ing for her. For her was spring and summer, autumn and winter. The sun shone for her. The spring spread out its offering of blos- som ; and autumn, for her, garnered all its harvests. How patient she was. How patient her friends. Exquisite suffering brought with it no complaint, and privation was better than enjoyment. Every- thing was tried for her cure. Who could withhold skill from such a claim ? Who could deny drugs, if drugs promised any good ? 33 Years and years passed by, and Miss M. pined and smiled in lier sufferings. I think five years were completed, when the light began to dawn upon that long moral polar night. It came in the shape of Mr. Surgeon Atkinson, and its beaming was Mesmerism. The passes were made. " I still live," in almost dying utterances, came sighing from her. Mr. Atkinson broke down under the weight of his accomplishments. He was, in the popular language, •"used up." An Irish girl succeeded, a servant of all work in the family. She was full of animal magnetism, and bestowed it as freely and as successfully upon Miss Harriet as she had upon the grate hob, or any other object of her professional care or skill. It is quite unnecessary to pursue this matter any further. Miss Martineau recovered perfectly, and ceased to be a Bed Case, by the mysterious agencies of mesmerism. She has lost all her old prejudices, or left them all in her sick room; so that in regard to affairs of faith, popularly so called, I suppose she remains pretty much what she was before. Mrs.____, aged between 25 and 30, mother of one child, did not recover well after her confinement, and gradually became a confirmed Bed Case. I was not called to see her until many medi- cal men had already seen and prescribed for her. My professional history contains many such facts. Within the year in which I write, I have, in two cases of disease, been the ninth physician consulted, just the ninth. The younger and the older gentlemen of the call- ing had already seen the patients. Sometimes this leads to much amusement for me. Being called when the patient is thought hope- lessly ill, everybody else having been tired out, how often has my -visit been thus greeted:—" Why ! have you sent for him ? Then it must be pretty much over with me, for he is never called till people are just dying." The earnestness of the appeal shows that death is not so nigh the door as apprehended. But let this pass. Distinction comes through various channels—now suicide, now murder, &c. &c. Its pursuit, and its attainment, would make one of the saddest and most interesting of human histories. I was called at last, and last, to see Mrs.----, and certainly of all Bed Cases her's was the worst. " The trail of the serpent was over it all." Not an organ had escaped. From head to foot, everywhere there was disturbance. Vision was always indistinct, sometimes 5 34 wanting. Light and air were intolerable. The hearing, taste, and smell, all were perverted. The heart, the lungs, but especially the stomach, had most yielded to the power of the disease. The appe- tite was coaxed by every species of the most delicate food. From one friend came daily a potato, which was cooked as nobody else could cook a potato. And so of everything else. The right low- er limb was permanently bent at the knee. To move it was ago- ny ; and it may be understood how miserable was this state of things, when it is added that Mrs.----was always on her back, and had, in this position, to keep the knee elevated, and bent almost at a right angle. The uterine system was disturbed in its func- tions, and these were painful. A morbid vaginal secretion was the substitute for its healthy one. Emaciation existed in the ex- treme. Suffering had worn the patient almost to a skeleton. The skin had acquired that peculiar hue, of sallow and dark, which is so characteristic of long and painful disease, and which so often indicates its malignant character. It was not believed, however, that this was the tendency, or state of this case. The mind had yielded to the body. That absorption into one's self, which comes of such maladies, was complete. Complaint had become a natural language, and spoke out on all occasions. The mind was weakened in regard to its best uses. Its whole pow- er had come to be directed to the disease, and to a perpetual effort to show how grave it was, and how impossible it was for the patient to be other than she was. The tone of the voice got its character from the mind, and was querulous, repining, or sad, as the moral state determined. The sleep was every night dis- turbed, or often wanting; and this added greatly to the general discomfort, or misery. The treatment was to be directed to the mind and body. As to the first, it was clear that argument would have no weight. Intellectual habits, the product of long experience of suffering, had become the natural, daily life of the mind; and attempts to alter, or to replace this by anything else would only serve to give to it strength. Persuasion or any other moral agency could do nothing here; and no relation of other individuals could be so near as was the patient to herself. The only safe sympathy for her was in a quiet, patient hearing of the daily repeated story; or in mak- ing such inquiries concerning it as would show to the sufferer that the daily repetition of the same was patiently received. 35 I remember years ago I had a conversation with the late Dr. Chaplin, who was so deservedly distinguished by his management of the insane. Said he, " I never argue with them, for as you can never refute or convince them, your argument gives them support in all the views they may entertain. I always receive what they say respectfully, and leave its absurdity or whole wrong, to exert its power upon their own minds. I remember," said he, further, " that a lady from the South, of very ancient and proud descent, and much wealth, was placed under my care. Her insanity turned mainly upon the idea that she was a drunkard, and a daily dis- grace and insult to her family. I agreed with her perfectly that to be a drunkard was all she said of it—that I was surprised that a lady of her appearance and relations should so disgrace herself, &c. The first appearance of improvement in this case was a dis- inclination to have the subject of drunkenness referred to, and at length the cure declared itself by the patient denying that she was or ever had been a drunkard, and manifesting the greatest displeasure at any allusion to the subject." In another case, a pa- tient whom I had placed under his care, declared herself to be a ghost. The idea was admitted by Dr. Chaplin, and one day at din- ner was alluded to in the surest way to reach the mind most favor- ably, namely, that, for a ghost, she seemed to have a remarkably good appetite, and eat an excellent dinner. In the cases we are now proposing to treat, the mind is in a condition of such unsoundness—such weakness—that all attempts to disprove its beliefs and notions, add to existing discomfort, and directly tend to its increase. The great object should be to get the confidence of the patient, as the only and best means for the application of remedies to physical conditions. Such a use of the mind is a perfectly legitimate one, and he who fails to make it may never cure the disease. In the physical treatment of Mrs.----, the indications were to regulate the diet—relieve pain—procure sleep—-restore tone— straighten and restore motion to the bent and stiffened limb—to bring the senses into healthful exercise—admit to the lungs fresh ajr__(Mrs.----always living in close, shut-up rooms)—to take her out of her bed, and finally out of her house. I. To regulate the diet.—This was begun by exclusion. The lit- tle table at the bed-side, with its multifarious and multitudinous luxurious articles of food, with its nice white covering napkin, 36 which hid all from the profane, was gradually to be withdrawn. The hours of eating were to be gradually reduced to their usual number. All this was accomplished after so much trial and time as the circumstances of the case demanded. II. To relieve pain.-^This was not easily done; or rather it was done at more or less risk of making the bowels more torpid than the entire want of exercise, and other difficulty-regulated things produced. The valerianate of morphia, the liquid extract of valerian, and various subnarcotics, were tried, and the object more or less accomplished; and the next indication, III. To procure sleep, answered. IV. To increase strength.—The ordinary means to do this Were used. Chalybeates were much relied on; while a powder of bis- muth and calombo, quinine, gentian, &c, was also given. V. To straighten the limb.—The left limb was bent upon the pelvis at the hip-joint, and at the knee; while the foot had long remained in the same position—the knee being drawn high enough for it to rest on the sole. This was the most important indication, viz., to straighten this limb, which would be to give it power of motion, and this it had in its present state only in the smallest degree. To touch, to rub, or to attempt to move it, oc- casioned great suffering. The treatment was begun by fomenta- tions, liniments, the stereotyped course in such cases. But upon this followed a method which accomplished the object, and in the most thorough manner. A string was attached to the foot by a band passed over the instep and under the sole, which played free- ly over the foot of the bedstead as over a pully; to this was at- tached a weight. The apparatus was allowed to be put on, and to be used. The weight was gradually increased, and the limb wag straightened. The most important object was thus accomplished, and while proceeding, the other indications were also slowly get- ting to be answered. VI. The senses were next, or rather with other things, receiv- ing attention. The room had been kept perfectly dark. The light was now permitted to enter it. This required great caution, and was, perhaps more than any other indication, difficult to be begun or pursued. Should by chance any portion of the treat- ment produce trouble, give pain, or produce any annoyance what- ever, mental or physical, the chances were that the whole course would have been rejected, and Mrs.----reduced to helplessness 37 for life. The will loses nothing of its strength in the Bed Case, and only array it or get it arrayed against physician or treatment, and their function and influence at once will cease* The sense of hearing was managed just as was that of seeing, and noises came to be tolerated, which before had been annoying in the extreme. With the return of tone of general strength, the senses acquired the power of use. VII. Ventilation.—It \vas pretty clear if the brain was to get tone, and exert a healthful influence over the organic functions, that it must be visited by pure blood. The purifier of the blood is the air, and the purer the air the better the blood. But Mrs. —— having lived so long in such perfect seclusion from light and air, and the attention having been so long directed to every part of the body, especially the surface—the skin—and every change in sensation over every inch of it at once noted, and provided against, that a most difficult thing was to be done when the outer air was to be admitted into her almost hermetically sealed chamber. This was accomplished. The key-hole was unstopped, The bags of sand, or what not, were taken from the bottom of the doors and Windows, and the air found its way into the room again. VIII. The last indication was to remove Mrs. —- from her bed, and from her house. The first was attempted soon after mo- tion was restored to the limbs, and it was soon done. Mrs. ----- had acquired a more healthful consciousness of power, and a will- ingness to exert it, which so often accompanies the acquisition. She was willing that an attempt should be made to remove her from one place to another, and this was both prophecy and promise of recovery. She was taken from bed. This was well borne. In a short time it was proposed that she should go abroad. This, too, was acceded to. Mrs.----suggested that she should at- tempt a visit to some friends, some forty miles off, stopping by the way whenever she was so fatigued that she could proceed no farther. The suggestion was adopted. She soon undertook the journey by rail, and, to her entire surprise, found herself at its end before fatigue demanded her to stop. Mrs.----remained at home some weeks, gaining flesh, strength, and true pleasure every day; and called on me when she returned to the city in possession of ap- parently perfect health. This was to me, and more especially to the patient, a case ot the deepest interest. The question was, if it should be abandoned 38 by the profession as hopeless, and the patient left to gradually ac- cumulating suffering aud helplessness j or whether further attempt should not be made to prevent all this, and apparently to save life. It was agreed to try. An encouraging circumstance it wag that Mrs. — became gradually conscious that power to be better remained, and acknowledged it. Few facts in all recoverable chro- nic diseases arc more encouraging than this, and especially in such as get most of their symptoms, and all their adhesiveness, from having their source mainly in the lesions of the nervous system. It is hence comes their hopelessness—their utter helplessness— the extreme difficulty of their management—the exhaustion of friends—the frequent changes of nurses and physicians. In other, and in the gravest chronic diseases, consumption, for instance, hope ceases only with life, and cheerfulness and effort for recovery mark its whole course. One of the severest forms of the disease occurred in the per- son of Mrs.----, some years ago. She was of a family in which the nervous temperament had the fullest development, and in which insanity had shown itself. Our disease, Bed Case, followed occurrences which deeply affected the mind, the natural power and good culture of which, did not save it from the injurious influ- ences of strong moral agencies. She took to her bed when she felt no longer able to keep out of it; and the Bed Case became established. Nothing could induce her to move. Her friends were among the kindest people living, and paid her the most de- voted attention. Months and years came and went by, but brought with them no relief of this terrible malady. At length her father —a merchant—failed, and was left without property. It became necessary for him at once to leave his house, and to take his fami- ly some thirty miles into the country, where he had friends who would receive him amongst them. The great question was, how Mrs.----should be disposed of. She had become a fixture; for years she had not been moved—she could not be moved. A nice point was to settle how she should be got down stairs; and it was decided that a window frame in her chamber should be taken out, and she lowered down in a chair to the carriage. This plan, how- ever, was abandoned. Arrangements were next made for Mrs. ----'s best accommodation on the road. She was to go so many miles the first day, so many the second, third, &c. The day of departure came. Mrs.----was brought from her chamber in the 39 most legitimate manner to the coach, and started on her journey. Strength came as she tried it. She drove by the first stopping place, the second—stopped for lunch and dinner, and towards evening reached, in excellent condition, her new, country home. From this day, Mrs.----went to bed at the same hour with oth- ers ; and, better, got up when they did; in other words, was radi- cally cured. Another Bed Case has been partially reported to me, which be- gan entirely in mental cause—which lasted, I think, longer than did the last—in which the mind was as striking for its power and growth, and from which the patient, Miss----, rose from her bed most unexpectedly, and by her own will, and has enjoyed most excellent health ever since. I regret that I cannot give the de- tails of a case which was deeply interesting to the friends of this long and patient sufferer, and the recovery from which gave the sincerest pleasure. A professional friend, of the highest reputation among his breth- ren for his knowledge of disease, and of its treatment, related to me the last case but one, and some others of the affection under consideration, of singular interest. The first of these was in a lady, the mother of two daughters. She gradually sank, and, after a long confinement to bed, and much suffering, she died. One of her daughters sickened, and took to the bed, which at length became her only dwelling place. She died after long suffering, and without manifesting any other symptoms than those which have marked my own narrated cases of the disease. The surviving daughter, not long after, gave indications of the approach of Bed Case, and at its earliest appearance my friend labored to prevent its establish- ment. There was the same apparently unconquerable disposition to go to bed, and to continue in it, as in the preceding cases. He succeeded in preventing the gratification of this intense longing; and for a short time the young lady seemed to be doing well. Pulmonary consumption, however, gradually showed itself in its severest signs, and was fatal. A question suggested itself to the narrator, how far the prevention of Bed Case was the cause of consumption; and almost regret was expressed at the course which was adopted when it first showed itself. But the result in the two first cases was a demand for prevention of the Bed Case; and the means used were successful. This did not save from death. The form only was changed under which death came. 40 I was called, three or four }-ears ago, to see a young lady who was represented as having been bed-ridden for some years. I reached the address, and was introduced to the patient, Miss-----, who seemed about twenty, and was lying on a low bedstead, as if for the convenience of being tended. Her appearance was of perfect health; with that addition to a natural delicacy of skin which long seclusion from light and air brings with it. The eyes had that expression of cautious use, which probable morbid sensi- tiveness of the retina from her darkened room, was likely to pro- duce. The hand and arm were as white as snow, and of extreme softness. The amount of flesh showed excellent appetite, good food, and " good digestion." The manner was very pleasing, and had not in any degree the character which long confinement and much suffering commonly bring with them. Upon inquiry of my patient, and of her friends, I learned that the uterine and spinal systems had mainly suffered in the early days of the malady, but that the whole nervous and muscular sys- tems had gradually become impaired, and for the most important purposes of the economy were now useless. Miss----could not move. She was lying on her left side, a position which made the necessary service of attendants easy. She was fed, it being im- possible for her to use the hands and arms in the office of self- feeding; and the movements of the jaw took part in the general embarrassment. There was universal soreness, or rather tender- ness, from the entire disuse of the body. The spine suffered most. This was represented as exquisitely tender, and all pressure to ascertain its actual state was carefully prevented, or very slight pressure was allowed to be made upon it, or its neighborhood. No deviation in direction was detected. As to what had been done, I learned that all sorts of methods had been faithfully tried. The patient had been at various insti- tutions, and had been submitted to all sorts of treatment. Espe- cially had she tried apparatus of brass, of wood, of steel, of leath- er—electricity and galvanism—Mesmerism—the seashore and the interior—the wet and the dry—baths, fumigations, fomentations— hot, cold, lukewarm. Of internal remedies, the name was le- gion. Note had been taken of every recipe, and books had been read of pathology and of treatment, and faithfully, and understand- ingly read. Rarely have I met with so full, so minute, and, let me say, so accurate an account of a disease before; and when it is recol- 41 lected that it went back for many years, and in their experience there was much that might be considered exhausting to the memo- ry, still there was the story, as perfect in its first, as in its latest page. I saw Miss ----a number of times. I gave to her case, and to its investigation, a willing leisure. There was every- thing in it to move to any and to all effort which might bring recovery with it, or mere relief. I truly regret that so little was accomplished. Attempts were made again and again to induce her to leave her bed; and chairs, and sofas, and couches, of all sorts, were put in requisition, but without any benefit. At times there was unwillingness to try novel methods, so distressing had all motion become. At others, the attempt was made, but ever with the same general and particular failure. I left her, without her having experienced any change from my ministries. Some time after, I heard of her death. In my inquiries for cases, many have reached me. In one Bed Case which had lasted many years, the lady succeeded to a large fortune. A change in her whole style of living was at once made. She wanted a carriage—the coach was built, the horses bought, the coachman found. Her orders in all kinds were of course obeyed, for in the schemes of such causation, volition and action are in such immediate proximity, that one includes the other. The intervening processes are merely nascent states, which, in their birth, have reached their perfection. But what was most remarka- ble in this case, was this: Mrs.----'s recovery became nascent and complete, too, in her new fortune, and she was at once ready for the new coach, &c. &c. From this moment her hours ran even with the current of every-day time, and she was as early up, and as wide awake, and as happy, as were any of her peers. Diagnosis.—The disease attempted to be described in the pre- ceding pages is neither a rare, nor a new one. It has not received so distinct a consideration before; at least, the writer has met with no work devoted to it. He has given it a name. This is not remarkable for its euphony, but it expresses just what the writer means it should express. Patients having this disease, have been long said to be "bed-ridden," "bed-rid," &c. These terms designate states, conditions, symptoms. They present no distinct disease to the mind, and hence what has incidentally fallen on the subject has been little more than the recital of separate cases, or 6 42 instances of the disease; never those generalizations which con- tain, or rather arc, theories, or principles; and which present the disease as a pathological being, having all the elements which per- tain to any other affection. The Bed Case may be confounded with many other diseases. Still it has characters of its own; while it wants those which mark others with which it may be confounded. Hysteria is essen- tially paroxysmal in its invasions, and nature; leaving the subject free at other times from all its characteristics. Neuralgia is per- manent, indeed, but it is physical in its elements, and leaves the mind quite alone. And so rheumatism, which is so painful, and often keeps its subjects in bed so long; still this last is not its characteristic state or symptom—its proximate cause—itself. I shall never forget an instance in which the Bed Case exactly imi- tated another disease, consumption. It lasted a great while, the pa- tient dying between ninety and a hundred. The great and pressing symptom of Bed Case was here present in a very striking manner. This was its persistency in one stay, one condition. The patient never changed. She grew older, and when perfectly emaciated, which she was many years before death—dried up, and wrinkled in the extreme—she changed not otherwise. She eat with excel- lent appetite and good digestion. She drank wine, as a medicine, and was evidently comforted by the remedy. She was very reli- gious, and manifested great resignation in the midst and pressure of suffering, and most touching gratitude for the genuine kindness and respect which followed her all the years of her long life. The Bed Case may have the helplessness of palsy, but it is not paralysis. The limbs are under the power of the will, though they may not always obey it, or the will is withheld from this function by its uses for another, or for others. There is no change of tem- perature, sensibility, or size, in any part or limb. The functions may proceed in their best order, and still the Bed Case be as perfectly consistent—true to itself—as if accompanied by the occasional disturbances by which it may be attended. The fail- ure of the will in these cases is owing to this. The motives to move are less powerful than those which enjoin rest. As soon as the former become paramount, the bed is forsaken—and this some- times immediately, as by a miracle—the lame rise up and walk. Bed Case, it was said, is not insanity or monomania. The pa- tient reasons perfectly well, from true premises. The whole con- 43 duct is consistent with a perfectly healthy mind. The patient is content with her situation. She does not ask or wish to be mov- ed. She has the moral in fair exercise. She is grateful and affec- tionate. If otherwise, or querulous, or hard to please, she may have taken to bed with her, what belonged to common life, and manifests it under the new circumstances, just as she did under the old. While this is said, in treating of diagnosis, it is conceded that moral power may be, not in the ascendant, or so far direct the patient as in her ordinary health. The mind has become con- centrated on a peculiar physical state, and because of the para- mount influence of the latter. This is a state of suffering, of suf- fering greatly exaggerated by motion, or its attempt. At length pain may be felt only on motion. How powerless may healthful moral motives be in such a case 1 And how powerful, when strong enough to overcome the hitherto imperative rulings of disease! Our disease is in the mind, just so far forth as the motive to keep the bed is stronger than any present, common, every-day mo- tive can become to leave it. I say " can become," because every one at all acquainted with the disease has witnessed, every day, it may be, the utter failure of any present, ordinary inducement to influence the conduct of the sufferer. But let the moral appear— it may be a new physician—let some extraordinary, unexpected change in condition occur, and suddenly—let the attention of the patient, the direction of consciousness, be detached, so to speak, from herself, and given, heart and soul, under a sufficient cause, to some- thing out of herself—objective—and we may find a change produced which we might, under other circumstances, have regarded almost as miraculous. At times all this may be spontaneous. Very re- markable cases of this have been witnessed, which seemed to be the promptings of the Bed Case's own agency, and a like health- ful revolution may be made.* The state of the mind here referred to, is so unlike what com- monly prevails in the disease, or rather is so inconsistent with it, * Direction of consciousness is given above as the equivalent expression for attention. For the use of this phrase, see the admirable work of Dr. Holland, recently published, entitled " Chap- ters on Mental I'li\ Mology." This, and the earlier work by the same author, " Medical Notes and Reflections," deserve the study of every physician who would understand and use philoso- phy in its true relations to medical theory and practice. Is there an American reprint of these im- portant works 1 Wo have plenty of books of Practice, so called, in every department of the profession. But of what value is the rule to him who has never reached to its reason ? Without Hie principle, how can he know anything of the case—the occasion for its application 1 44 that it has led some to regard the Bed Case as a form of insanity. The mind, as we have seen, may be habitually active, clear, cheer- ful, studious, contented, so that it is not easy to convince some that any disease whatever can exist. The appetite, digestion, nu- trition, may be in perfect harmony with the mental condition, and yet there is the patient, there she has been for years, and there she is likely to remain. Why is it so ? We answer, the disease began in some morbid mental or physical occurrence or state. It was gradually yielded to, when proceeding from the first, but more suddenly when from the last, as bodily disease so commonly de- mands repose, or makes motion, or the erect or even the sitting position, difficult or impossible. Absolute recumbency is the rule, which neither gets nor asks an exception for its proof. With a mind in its ordinary and best uses, apparently so sound, how ex- plain the disease—Bed Case ? One use of the mind, and which involves its widest reach, and most important relations, is through the will, as again and again said. This is powerless in regard to the physical being and state; and so the bed, which was taken from whatever cause, comes to be kept with a pertinacity, and ar- gument, which entirely convince the sufferer that she is right, and make her suspect the whole outside motive, come whence it may, which desires or insists upon a change of place. The diagnosis may be aided by further considerations. The disease does not always disappear with its cause. The patient remains in bed. The Bed Case continues when its causes have been removed. Some parallels may be found in other diseases or states. A joint has been injured, inflamed, and for cure has been kept without motion. The disease at length is removed, or leaves the part. But the man does not move. He has will, and its functions are perfect. But the joint will not obey. And why not ? Because a condition has been induced, and left by disease, which does not permit motion; and as pain accom- panies the attempt, it is soon abandoned. Now this state of things may become permanent. The surgeon is called in, and so imita- tive is the condition of the joint of new, acute disease, that active treatment may again be instituted. At length an outsider is called in; one whose only teacher has been experience, and that very roughly gained. He takes the limb in his strong hands, bends it forcibly backwards and forwards, tells the patient to go out of doors—which he does, and very soon he does the same himself. I 45 have in memory a most striking instance of such a state—such treatment, and such recovery. Bed Case, in its continuance after the removal of its cause, does not proceed so, or present such phenomena. The limbs have not become stiff; the muscles have not become palsied; the circulation has not been disturbed, and the nervous energy is very well distributed. But the will is pow- erless 1 There is no will, no true volition. The effort begins with " I can't," and is pretty sure to end as it began. Sometimes it uses another, and as short monosyllable, which is very apt to close the colloquy. The will and the muscles have suffered such long divorcement—• they have so entirely lost sight of each other—have so forgotten each other, that it is not easy for a spontaneous reconcilement to take place between them, or for mutual relations to be established. Now let any unusual occasion for motion, for action, arise—let a new and powerful motive be presented, from without—nay, let it arise from within, as we have said and seen, and the will and the muscles come together again, are married, so to speak, without rite. Another class of diseases, and a very long one, too, with which the Bed Case may be confounded, is that which arises from the dislocations, the diseases, the functional and organic lesions, to which the uterine system is so prone. One of the symptoms of these imitates our disease very exactly. It is the inclination for the bed—the eagerness with which it is sought, and the extreme reluctance with which it is left. The deep pain in the lower part of the back—the pain which accompanies spine sympathy—the reflex function—with uterine disturbances, and which sometimes is so severe as to lead to apprehensions of grave spinal disease— the dragging sensations in the hips—the painful pressure upon the bladder, and demands for micturition—the dysuria—these, and others becoming ten fold more severe in the erect position, con- strain the patient to do what may be done for relief. The bed furnishes the surest means of this relief. It is sought, and the pleasurable result is found. There is this marked distinction to be observed between the two classes of diseases, the Bed Case and the uterine. In the last, aid is eagerly sought for. The phy- sician is confided in, and is obeyed. Means are used. The ute- rine trouble is removed, and artificial supports compensate, for the time, for the natural. The patient is willing, nay, chooses, to try 46 what she may have gained. She crawls out of the bed—she walks about the chamber—she runs down stairs—she is abroad again. So pleased with such results is she, that without great caution, she will do much more than it is safe for her to do, and relapse, and find it a much harder task to submit to requisite treatment again, than at first. The whole history of this case furnishes the ready means to distinguish it from the genuine Bed Case. Instances are fresh in my mind, the old and the new. I was consulted in one from a distance. The patient was single, about 20. She could not come to me, and circumstances prevented my visiting her. A description of the case was sent to me, which showed that chronic ovaritis existed, and along with it was morbid menstruation, with uterine dislocation. The treatment was directed accordingly. This young lady recovered perfectly under the treatment. She was taken from her bed. She began to walk. She gradually ex- tended her walks. She drove. She was well. Her first move- ments were embarrassed and painful. But practice made them easy. For years had this patient been confined to bed. She had cough, dyspepsia, emaciation. The kindest offices were done her. Recovery was not thought of. There is no doubt she would have died without leaving her bed—the victim of Bed Case. When I was consulted, she had no regular medical attendance, and my communications were made through friends. The symptoms were too clear to leave it doubtful what was the disease. How differ- ent was all this from the history of the Bed Case. A second consideration is, that the cure or removal of Bed Case is often rapid, sometimes instantaneous. The truth of our diagnosis is often established in this way. I know of no disease in which this is so strikingly shown. The patient is literally helpless, hopelessly ill one day, and the next is well. There seems to have been no moment between cause and effect, and in some of the more striking cases there does not seem to have been any time between them. Between a volition, and the action of a voluntary muscle or muscles, there is strictly no time. With regard to many muscular movements, we are wholly uncon- scious. The mind, in these, takes no notice of its own agencies, and they are as sure in themselves, as they are unerring in their results. Think, for a moment, if we were conscious in directing the movements of those muscles on which intonation of the voice depends, and which, when not so directed, become convulsive, spas- 47 modic; and suppose that conscious volition directed the action of the muscles concerned in walking. The labor of life would soon exhaust itself. Now in the Bed Case it may become—it does be- come, positively necessary that this minute consciousness of voli- tions should exist. The patient has the severe task in hand of doing this as the condition of loco-motion. Are we surprised that she should so frequently fail if the attempt be made ? or that from such failure, she at length abandons the effort altogether ? And are we surprised that when cure is reached, it has been, as it were, at a bound, and the patient, with the quickness of lightning, has willed, and has acted ? Of the Treatment.—This must come of the case. It is moral in its cause, wholly moral. The evidence of this which has been fur- nished to me, is as large as has been the basis of assent in any of my professional engagements. My mind has been in many cases wholly made up by this evidence, and the mode of their termina- tion has shown the correctness of the judgment. In the Bed Case of the son of the Persian monarch—a very rare instance, being in a man—Hippocrates, with that wisdom which marked the profes- sional life of the Father of Medicine, and which has placed him at its head in all the succeeding time—Hippocrates discovered, at a glance, what was the cause of the malady, and as soon, and as suc- cessfully, prescribed for it. When I speak of the moral origin of the Bed Case, in relation to its treatment, it is not to deny or to lose sight of a closely related fact, namely, that what began in the mind will often reach the body—clothe it in its own livery, and so present all the features and the fact, too, of grave functional and organic disease. Nay, I recollect a case which seemed to have had the clearest moral origin, in which, after many years, recovery happened suddenly; the lady found herself lame in one limb, and which lameness remains, so that she walks with a cane to this day. This is the only case in which this result has happened; or which has been reported to me. When the question of treatment arises in such cases, one is very strongly reminded of a similar one which occurs in the play:— " Canst thou not minister to a mind diseased ? Pluck from the memory a rooted sorrow ?" How full of wisdom was the physician's answer: " In that the patient must minister to himself." As the case is so often moral in its cause, it very rarely happens IS that the physician is called in until some physical trouble is present. The patient may have kept about, lmd much as do others around her, until weariness, weakness, or some local disturbance, has be- come pressing enough to prevent further effort. The mental ma- lady may have been concealed. The physical rarely is. It comes as an addition to that weight, which has become less and less tole- rable every day, and at length the bed is sought as the only com- fort, or is resorted to by an irresistible necessity. Now, under such circumstances, aid may be asked for, or friends may call for it. The physician will hardly direct his attention to the mental ma- lady as directly demanding his care. The great moral indication to his mind would be to direct the consciousness of the patient— to transfer interest from the mind to the body—in other words, to divide the responsibility between the body and the mind. There is local disorder, or local disease. It may be of long continuance. It may have become the habit, the mode of life of the individual, or of the organ which is its seat. The physician is called, on its account. Before it had showed itself, the family, the friends, could manage the mental trouble. They may even have concealed it. But at length domestic resources, patience amongst the rest, are exhausted by the demands made upon them by so much suffering, so much morbid sensitiveness. The medical man assumes, and does what his professional position calls upon him to do, and with a facility, a felicity of manner, which knowledge always brings with it; and in this way gets and secures so much of the confidence of the patient as will bring with it that acquiescence in regard to his directions which can alone make it sure they will be followed. Having to do with local trouble, and this having occupied the at- tention of the patient for a longer or shorter time, remedies will be directed to this. The interest will gradually be turned to this, and its gradual removal will bo the surest precursor of hope in other directions. The mind will at length be reached. Assent, unwilling, it may be, will be given to professional opinion. Bene- fit has been received, and is acknowledged. What surer step to- wards compliance with further directions—even to leave the bed, the chamber, the house. All this has occurred again and ao-ain and in the great majority of cases may result in the same way. The remedies for local disease depend upon its scat, its nature, its relaujns. They are often external, and where this use of them is possible, it is believed they will answer a better purpose than 49 when internally used. They produce sensible effects—the blister, the embrocation, the ointment, &c. &c. The patient knows, feels, that something is in hand for her relief. The mind takes part with the remedy; and, than this, nothing tends more surely to cure. At times, there is no organic difficulty, the whole disease exist- ing in the nerves. Now nothing is more intolerable or more per- sistent than the pain which accompanies functional lesions of the nerves. The pain may be general—every part of the body, every region, having its own suffering. At other times it is local— in the head, the senses, in the thorax, abdomen, extremities. No matter where it is, and hardly how slight it may be, you may en- tirely fail to induce such a patient to move, or seriously to enter into any plan of relief. Now it unhappily may be that it is in troubles like these that the whole disease exists. There is no grave organic lesion. Life is not threatened. You may have spasms, convulsions, delirium, trance, and what not, and sympathy in its extreme may declare itself; but death is not in such condi- tions, nor will it come of them. The physician of any experience in such maladies as these, understands this, and governs himself accordingly. But remedies are demanded from some quarter, and must be used. Suppose much general debility—with pale skin, cold extremities, ringing ears, hurried respiration and circulation, emaciation—attend, or come of the watchfulness and pain, and dyspepsia of the neuralgia. These things are to be especially regarded. For the hysteric symptoms, nothing in my hands has succeeded so well as the treatment—moral, and physical, and medi- cal—recommended by Mr. Roberton, of Manchester* The hyste- rical so completely takes the lead in the Bed Case, that it is of great benefit to the patient that means be at hand, and used, which, • The work in which this recommendation will be found, is entitled "Essay and Notes on the Physiolo-v and Diseases of Women and of Midwifery. By John Koberton, formerly Surgeon in Ordinary "to the Manchester and Salford Lying-in Hospital, &c. London : 1854," a copy of which I had the pleasure and* honor to receive from its distinguished author a year or two ago. The only other copy amongst us, within my knowledge, was recently received by my fnend, Dr. C G Putnam of this city. This work should be in the hands of every medical man in the coun- try It is one'of the most practically useful books which has appeared for many years ; and as .philosophical and scientific work, deserves the highest commendations. It has not to my know- ledge been printed here. This is to be regretted. The profession deserves it. It should be w.th- in the easy reach of every one. It wants neither note nor comment. It tells its own story, and so cleverly and so well, that it asks not for the addition to bulk and cost which editor.al labors so generally bring with them, and which labors are so rarely used by the reader. It may be that this work is not known amongst us. If so, and if this communication does no more than to g.ve notice of its existence and secure a republication, it will not have been written wholly in vain. 7 50 while they act favorably, at the same time make the least possible demand upon the system generally—remedies which, while they are active, are not destructive. The use of the word active here suggests a caution, namely, that such states as are best expressed by the term hysterics are always best treated by means which occu- py time, are looked to with some confidence, and which, especially, do not waste power. Every symptom is morbid action in such a case, and uses power. Let not the physician, by active medication, diminish what seems already so small. For quiet, and to relieve pain, much benefit has been derived from the valerianate of mor- phia and the valerianate of ammonia, which have been added to the Materia Medica here. Very small doses of these only are needed, and the effect is often excellent. I have never known them do harm, which is certainly no small recommendation for new re- medies. Tonics are often indicated. The color of the skin and other symptoms may show that the blood in these cases has undergone changes which require attention. If anaemia be present, the skin, the lips, inside of the mouth, show it. But there is another mark which to me is most distinctive of this state of the blood, and of which I gave an account, in a pamphlet on Anseniia, several years ago. I mean the color of the blood in the veins, at the wrists, or wherever seen. This color is pink. The Modena red of venous blood is replaced by the bright color of arterial blood. At least it is much nearer to this color than to that in the veins in health. I have been led to think, from this fact in the history of the circu- lation in anaemia, that it may have its pathological condition in a lesion of the capillary system; in other words, in that system, what- ever it may be; for the question of the kind of connection seems unsettled, by which the veins and arteries intercommunicate. An instance illustrating this idea has already been given, in which the Bed Case, hysteria, and anaemia, existed together, and in which, when a vein was opened, the blood burst forth as from an artery, with a force which for a time successfully resisted all efforts to stop it. In this case the arterial color of the venous blood was very striking. I am aware that the blood in anaemia differs, in its physical liv- ing, and chemical characters from healthy blood—that its color differs, that it does not coagulate on rest, that the results of analy- sis differ. Still, from the facts stated, I cannot but think there is 51 reason for the belief that the two bloods, the arterial and the ve- nous, are blended, and the two systems of vessels have relations which, in their degree at least, differ from perfectly healthy con- ditions. As the blood, in the disease of which I am speaking, and in its congeners, undergoes such important changes—the loss of fibrin, &c.—is it at all surprising that its influence upon the brain and nervous system should be so remarkable as their attendant symptoms authorize us to suppose it to be ? The brain depends upon the blood for its functions. If the blood be diseased, how can the brain act healthily ? Of the pathological relations of the blood, we have much yet to learn. Of Tonics, the mineral have the most reputation. Among these are the salts of iron, of manganese, of nickel. Quinine is also very useful. Prof. Simpson thinks he has found most benefit from the sulphate of nickel in the same doses in which the iron and manganese are given. Vegetable tonics, especially from their efforts on the stomach in restoring appetite, are often very useful. Diffusible stimuli are often in place; but any important dependence upon them, or daily recurring use, must be carefully avoided, as from the whole condition of the patient, demands for such stimu- lants may come to be irresistible, and the last state of that wo- man be worse than the first. The rapidity, the suddenness with which cure has so often de- clared itself in Bed Case, has been shown in many instances in this Chapter.* This is easily explained, and should be constantly borne in mind in the treatment of the disease. This manner of disappearance of symptoms, especially keeping the bed, shows that the causes of the disease, whether moral or physical, or both unit- ed, have probably been absent some time, or for an uncertain one, and that habit alone has kept the patient in bed. Means, then, must be used, and varied ones, too, and at various intervals, for getting the patient out of bed, for whenever this has been fairly accomplished, no matter how, the chain of habit is broken, and will not be re-united. I have never known such a patient take to bed again. The attempt to get out of bed, to stand, sit, or walk, will be, as we have seen, painful, and to overcome this suffering, or the fear of it, the strongest motives are to be presented, and * It might have been said before, that this communication is from a work which has long been in preparation by the writer, which may be entitled An Autobiography of a Physician, as it w.ll be mainly filled with a history of his relations with medicine. 52 such have been successful in instances too numerous to be ques- tioned. Let the patient be consulted, of course, but in just such a manner, and with just such circumstance, as will satisfy her that the experiment of motion must be made. Who loves to take physic ? and yet it is taken every hour and every day; and in case of the child, volition is not consulted. Violence is not to be used in the Bed Case, and yet the motive for action must be sufficient to overcome the natural opposition which may be made to effort, and to bring the will into harmony with what is attempted, or to be put to the proof. It is the abandonment of these cases by physicians, and friends, which is most to be deplored. The most obstinate ones have been overcome, and by means so gentle, so easily understood, as to prove that the cure is to be regarded as the rule, not the exception; and in place of looking to accident for the remedy, it must be found in the use of the mind, both of physician and patient, just as is the case in the treatment of all other diseases. h H «? .' '.1- V: , >'. ■> ^v'l.,* . . , y , . ' \ .- M'iV'l'jlW-.l*, ,,<■■- ■ .•;■ i'£:!i*-±}*K\ *'&ai rfctfl m "■,.. 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