NEURASTHENIA.
Though the treatment of the hysterical condition and that of neuras thenia often run on lines which arc nearly parallel, much confusion and consequent failure results from lack of appreciation of the fundamental dif ferences between the two states. If the essential element in neurasthenia, which is nervous exhaustion or nervous debility in an abnormally sensitive individual, he prominently kept in view there will be little danger of enforcing an element of treatment on the neurasthenic patient which, though highly beneficial in hysteria, may he fraught with mischief when applied to one whose reserve of vital energy has been used up by some exhausting mental occupation or prolonged application to a wearying routine struggle against time and competition in some strenuous walk in life.
Prophylaxis is a problem of vital importance. The majority of patients who succumb to nervous " breakdown " are middle-aged males inheriting a weak nervous system from parents who have continuously drawn too freely upon their own store of vital energy in the battle of life. The recent war has produced a type of neurasthenia which may be seen in the mixed condition described as Shell-shock.
The prophylactic measures indicated in other neuropathic conditions have been mentioned in the article on Hysteria, and should be carried out in the case of neurasthenic subjects. Of all the exciting causes none is so frequent and powerful as competition, especially competition against time. This is seen in its most typical form in literary men, especially in those pursuing creative work. A labour which could be achieved in leisurely case and safety if pursued under the stress of a time limit often causes a serious breakdown from which the ambitious author never completely recovers. In the case of clergymen this is a common factor, if the preparation of their seventh-day work be crowded into the last day or two of the week. Even the mere " compiler," whose literary achieve ments are not in the creative realm, is liable to succumb to neurasthenia when he wilfully sets himself a daily task which must he accomplished. All such performances should be avoided by every brain-worker and never attempted under any circumstances by the neurasthenic.
Neurasthenia, like other neuropathic tendencies, is often found associated with ambitious and philanthropic desires, and even the hard working clerk may be frequently found struggling in the arena of church work or politics during every possible opportunity when not confined to his ledger.
In every case it will be the duty of the physician to search for evidence of the inherited tendency and insist when possible upon a change of occupation when this is at all practicable. In the same way he should
investigate the cause of the acquired type of the diseased condition and act accordingly.
When once neurasthenia has manifested itself mental rest is imperative; physical rest is, however, seldom necessary and is often harmful, as few cases of this condition arise directly from excess of bodily fatigue, though in the spinal type of neurasthenia marked muscular exhaustion follows the most trifling degree 'of exercise or bodily exertion. There are few situations calling for more skill and tact than in the prescription of a rest cure for the victim of neurasthenia. There is, however, no difficulty in the grave type of the disease where the breakdown is complete and all intellectual exercises are impossible or accompanied by profound mental exhaustion. Here a Weir Mitchell course is clearly indicated, and should be carried out as described in the article on Hysteria, the usual elements in the treatment, as absolute rest of body and mind, isolation, forced feeding, massage, electricity, hydropathy and suggestion, all being re quisitioned for a period of a couple of months, followed afterwards by a long holiday in which physical exercises should play a prominent part.
It is in the milder types of the disorder that the difficulty arises in carrying out treatment. Cessation from all the mental operations which have preceded the breakdown must be insisted upon, but absolute mental rest is as undesirable as it is impracticable. A constant feature in the symptoms being not only the exhaustion which follows intellectual exercise, but a constant restlessness and a burning desire for further mental work, any rigidly enforced system aiming at total intellectual inertia only aggravates the condition. These patients are frequently possessed with the dread of becoming demented or imbecile, and the rigidly enforced commands for mental idleness drive their thoughts inwards upon their abnormal sensations and phobias. The neurasthenic patient usually is incapable of taking mental rest, and the tactful physician, on recognising the individual peculiarities and tastes of the patient, should direct his mental exercises along new channels whereby introspection and concentration of his mind upon his former labours are averted. It is in these cases that the had effects of the so-called " rest cures " are evident; properly adjusted physical exercises, as shown by the results obtained by Rigg's method of graduated exercises and calisthenics at Massachusetts, go a long way in bringing about a complete re-education of the patient.