In order to maintain the functions of the skin the patient should be well sponged in bed every morning after breakfast. A strong solution of salt, or, better, sea-brine, is to be preferred to simple water, and frequently it may be followed by the use of alcohol. In very feeble cases the alcohol may be employed alone. I have seen very good effects from momentarily rubbing each portion of the skin with ice just after the bathing.
The question of feeding is one of great importance, and requires the utmost care and attention from the physician. The end to be attained is to feed the patient as much as can be digested, but not to overdo and derange the digestion. Food should be given at intervals of two or three hours, and must be both light and nutritious. It should, at least at first, largely consist of milk, except in those rare cases in which that fluid does really disagree, and not merely is thought to do so. The milk should be skimmed or given in the form of koumiss. Beef and other concentrated meat-essences are valuable as stimulants, and may be used, especially as the basis of soups. Various farinaceous articles of food may be added to them, or if an egg be broken into the concentrated bouillon or beef-essence just as it ceases boiling a nutritious, and to many persons palatable, dish is obtained. When constipation exists, oatmeal porridge, Graham bread, fresh or dried fruits may be allowed if readily digested by the patient. In order to give an idea of the general plan of the dietary, the following schedule of the daily life is given. Such a schedule should always be put into the hands of the nurse, who should be required to follow it strictly. It must be altered from day to day, so as not to weary the patient with monotony. It is especially important to remember that the diet must be carefully studied for each patient, and be adapted to the individual requirements of the case. Success will in a great measure depend upon the practical skill and tact of the physician in this adaptation:
| 8 | A.M. | Rolls or toast; cocoa or weak coffee, or roasted wheat coffee; beefsteak tenderloin or mutton chop. |
| 9 | A.M. | Bathing. |
| 11 | A.M. | Oatmeal porridge, with milk, or else a pint of koumiss. |
| 12 | M. | Massage. |
| 2 | P.M. | Dinner: Bouillon with or without egg; beefsteak; rice; roast white potatoes; dessert of bread pudding, blanc mange, or similar farinaceous article of diet. |
| 4 | P.M. | Electricity. |
| 5 | P.M. | Milk toast. |
| 9 | P.M. | Half pint of skimmed milk or koumiss. |
In many cases the patient at first can take very little food, and it is very frequently best to begin the treatment with an entirely liquid diet, giving milk every two hours, or using Liebig's raw-meat soup, with milk or plain farinaceous food, and only after a time gradually accustoming the patient to solid food. Not rarely a prolonged treatment by the so-called milk diet is of avail. The rest-cure is indeed largely based upon a careful regulation of the food; but a full discussion of the various dietaries to be used would require a treatise upon dietetics.
Passive exercise is to be obtained by the use of electricity and massage, the object being to get the effects of exercise upon the nutrition and circulation without the expenditure of the patient's nerve-force. By the use of electricity muscular contractions are secured which simulate those which are voluntary and more or less thoroughly replace them. By the general application of the current to the whole body we probably affect the tone of all of the minute blood-vessels, and certainly in this or some other way stimulate the general nutrition, and, as has been shown by S. Weir Mitchell, for the time being elevate the bodily temperature.
The faradic current is alone used. It is applied in two ways: first, to the individual muscles; second, to the whole body. The séances should be daily, the operator beginning at the hand or foot, and systematically faradizing each muscle of the extremities and trunk.
The slowly-interrupted current is generally preferable, but advantage is sometimes gained by varying the rapidity of the interruptions. The general rule is to select that current which produces most muscular contraction with the least pain. The poles should be applied successively to the motor points of the muscles, so as to contract each firmly and thoroughly. This process should occupy from thirty to forty minutes. The electrodes are then to be replaced by large sponges well dampened with salt water: one of these should be put at the nape of the neck and the other against the soles of the feet, and a rapidly-interrupted current, as strong as the patient can bear, should be sent through the body for twenty minutes or half an hour. It is not necessary for the operator to remain during this time. In some cases the electrical programme may be varied so as to get a local stimulant action from the general current; thus, when digestion is enfeebled and the bowels costive for a portion of the time one of the sponges may be placed upon the epigastric region. In women when there is great abdominal and pelvic relaxation one pole may be placed high up in the vagina. I have seen old-standing prolapses cured in this way. Some electro-therapeutists claim great advantage from galvanization of the cervic sympathetic ganglia, but I do not myself believe that they ever succeeded in reaching these ganglia with the current.
Massage, like electricity, affects greatly the peripheral circulation, empties the juice-channels, and gives tone to the muscular system. It must be clearly distinguished from rubbing of the skin. It consists in manipulations of such of the muscles as are not too deep to be reached, and of the cellular tissue: in order to lessen as much as may be the skin friction by these manipulations, it is often well to anoint the surface with cocoanut or other bland oil. As sold in the drug-stores, cocoanut oil is very often rancid, and at any time it is well substituted by the cheaper cottonseed oil. In practising massage it is essential to remember that the natural course of the venous blood and the juices of the cellular tissue is toward the centre of the body; therefore, all general movements should be practised in this direction.
The manipulations are percussion, rolling, kneading, and spiral. They consist of movements made with the pulpy ends of the fingers and thumbs, and spiral movements with the whole hand so folded as to adapt its palm to the limb. In percussion the strokes should be from the wrist, and should be quick and short. It is probably not possible, even by long strong strokes, to affect deep muscles. In the rolling manipulation the effort is to roll the individual muscles beneath the pulps of the fingers. This manipulation may be varied by pinching the muscles, not the skin, and kneading. In each case it is intermittent pressure upon the muscles which is aimed at. The circular movements are to be in opposite directions with both hands simultaneously, the limb being grasped by one hand a little above the other, and a spiral sweep made up the limb, the ball of the thumb and the palm of the hand resting upon the patient, and the pulpy parts of the thumb and the fingers grasping the limb. It is especially such motions as these which affect the circulation of the flesh-juices.
The length of time the patient is to be kept in bed and treated in the manner described varies of course with the individual case, but usually less than four weeks is not sufficient, and rarely are more than six weeks required. In getting up, the patient should begin by sitting up one or two hours a day, increasing daily, but not too rapidly, the time of being out of bed and the amount of exertion made. The electrical treatment should be gradually intermitted: in many cases massage twice a week seems to be of service even after the patient is about. In the going back to ordinary daily life great care is to be exercised to proportion the amount of exertion to the newly-obtained strength, so as not to lose what has been gained. In cases of natural or of long-standing acquired severe neurasthenia the mode of life must be arranged to correspond with the small daily product of nervous energy.