On examination the spleen was decidedly large; the lower border of the stomach reached to the level of the umbilicus. Two cardiac murmurs were present, the one a sharp and well-defined mitral regurgitant sound, confirmed by the dyspnoea and dropsy as organic, the other a loud musical murmur of hæmic origin. The trouble in deglutition proved to be due to an oesophageal narrowing. The blood examination bore out the suggestion of probable pernicious anæmia, the red cells being only 1,500,000, hæmoglobin 18 per cent.: the microscope showed microcytes, megaloblasts, nucleated red cells, and a large increase in white corpuscles. In order to study the effect of massage alone upon the blood no other treatment was used, though of course the patient was kept at "absolute rest." No drugs were given, electricity was not used, and extra food was omitted, as the irritability of the oesophagus made her unwilling to attempt the exertion and annoyance of frequent feeding. The general chilliness was at once helped by massage, and in a few days only felt in the small hours of the night, and the patient gained weight from the first. After one week of treatment a blood count was made: red cells were 3,800,000, more than double the former figure; hæmoglobin, 35 per cent., almost double its original value. On the same day, one hour after the completion of an hour's massage, the corpuscular count had attained 5,400,000, the hæmoglobin remaining 35 per cent.
At the end of two weeks the hæmic murmur had faded into a faint soft bruit, though the mitral murmur was unchanged, the skin had improved in color, the aches and weariness were gone, and the blood count had reached nearly five million cells, with 50 per cent. of hæmoglobin. The extraordinary results of the blood examination were confirmed by observations made by Professor Frederick P. Henry, Dr. Judson Daland, and Dr. J.K. Mitchell, who all practically agreed. Professor Henry made several studies and stained a number of slides, verifying in his report the statements of the presence of megaloblasts and nucleated red cells made above.
Owing to the necessity for an operation on the hemorrhoids, which caused loss of blood, the patient was somewhat retarded in her progress to recovery, but by the tenth week was so far better that the blood showed no microscopic abnormalities, the count was full normal, and the hæmoglobin over 70 per cent. Her color and strength were good, the heart was perfectly strong, the anæmic murmur was gone, and the oesophagus was so much less irritable that it was possible to begin dilatation of the stricture.
I have heard within a year that though occasionally annoyed by this last trouble if she becomes much fatigued, she has remained in other ways well.
Mrs. G., the daughter of nervous parents, was always a nervous, over-sensitive, serious child, worked hard at Vassar, broke down, recovered, returned to college, was attacked with measles, which proved severe, and by the time she graduated had been made by her own tendencies and the anxious attention of her family into a devoted member of the class which I may permit myself to describe as health-maniacs.
Health-foods, health-corsets, health-boots, the deeply serious consideration of how to eat, on which side to sleep, profound examination of whether mutton or lamb were the more digestible flesh,—these were her occupations,—and two or three years before her panic about her health had been made worse by the discovery of an aortic stenosis, of which an over-frank doctor had thought it best to inform her. When I saw her she had been three years married, was childless, and, between the real cardiac disease and her own anxieties about it, had driven herself into a state of great physical debility and a mental condition approaching delusional insanity.
A too restricted diet, lacking both in variety and appetizingness, had had its usual result of upsetting digestion and destroying desire for food. Even with the small amounts which she ate she considered it necessary to chew so carefully and to feed herself so slowly that from one hour to an hour and a half was used for each meal. The heart, under-nourished, beat feebly, there was constant slight albuminuria with evidences of congested kidneys, and she could only rest in a semi-erect position.
The heart condition, with its renal results, proved the most rebellious part of the trouble. A firm and intelligent nurse soon overcame the difficulties and delays about food, and my final refusal to discuss them disposed for the time of some of the fanciful theories about digestion and so on. Her meals were ordered in every detail, and she was told that they were prescribed and to be taken like medicine, and, fed by the nurse, she began to take more nourishment. Massage relieved some of the labor of the heart, and gradually the semi-erect posture was exchanged inch by inch for a semi-recumbent one. Not to prolong the relation of details, it was found needful to keep this lady in bed for five months before the heart seemed to recover sufficiently to allow her to get up. Even then, although improved in color, flesh, and blood condition, she had to attain an erect station almost as slowly as she had had to reach recumbency. Slow, active Swedish movements, to which gentle resistance movements were very gradually added, helped the heart. Her cure was completed by five or six months' camp-life in the woods, and she is now the mother of a healthy child and herself perfectly well, the valvular disease only to be detected by the most careful examination, and never, even during pregnancy and parturition, causing any annoyance.
The surgeons, who once thought a floating kidney could be permanently fixed in its place by stitching, have now concluded that this is very doubtful, and the treatment of this displacement is never very satisfactory by any method. Still, some success has followed long rest in the supine position, which encourages the kidney to return to its normal place, until careful full feeding has renewed or increased the fatty cushions which hold it up. It is best during the first weeks of treatment not to allow the patient to sit or stand, or if she should be unable to avoid the occasional need for these positions, an abdominal binder must be applied by the nurse and drawn tightly before she moves. The masseuse is directed to avoid any movements which might further displace the organ, and may cautiously push it upward and hold it there with one hand while with the other the manipulation of the abdomen is performed. However long it may require, the patient should not get up until examinations, supine, lateral, prone, and erect, combine to assure us that the kidney is replaced. Repeated investigation of this point will be required,—for the kidney will sometimes be in place for a little while and next day or even a few hours later have slipped down again. Before any exertion is permitted, even ordinary walking, an accurate close-fitting abdominal belt with a kidney-pad should be applied. Those kept in stock are seldom properly adjusted, and usually have the pad in the wrong place. If rightly made, they can be worn with comfort and tight enough to be useful. If not rightly made, they are useless instruments of torture.
Mrs. Y., æt. fifty-six, was sent to Dr. J.K. Mitchell by Professor Osler for treatment. She had all the usual intestinal derangements and discomforts attendant upon a floating kidney: constipation alternated with diarrhoea, or rather with a sort of intestinal incontinence; vague pains in the back, flanks, and stomach were frequent; attacks of acute pain began in the right hypogastrium and ran down to the symphysis or into the groin; she had constant flatulence, weight, and oppression after food; was pale, flabby, and emaciated, but had no emotional or nervous symptoms except an annoying amount of insomnia. The lower border of the stomach was fully two inches below the navel in the middle-line, even when only a glass of water had been taken. It was a little lower after a small meal. The colon was distended and very variable in position, probably changing its relations with the landmarks as it happened to be more or less filled with food or gases. The abdominal walls were flabby, relaxed, and pendulous, and the whole surface tender. The patient gave a history of sudden loss of flesh with almost no reason some three years before, and increasing indigestion in all forms ever since. The tenderness made careful abdominal study difficult, but lessened enough after a few days in bed to permit the perception of a displacement of the right kidney, whose lower edge could be felt on a level with the umbilicus and two inches to the right of it. No change of position would bring it any lower. Examined with the patient prone, two-thirds of the kidney could be outlined, extremely tender, and causing nausea and sinking if pressed upon.