A fourth case, still very vividly impressed on the writer’s mind, was one of a healthy, romping girl of 14, who, as happen in this remarkably capricious disease, in the midst of perfect health, one day took to her bed and remained there with all the symptoms of neurasthenia, involving first the spinal and finally the cerebral nerves. This patient was very amiable, conscientious, and sensible, never loquacious, and not troubled with hypochondriacal thoughts or sensations. Tiredness was the only expression she used in describing her feelings. There was literally no variation from this condition, which confined her to her bed for years, till she grew from a girl to a woman.
Eating and sleeping well, and improving perceptibly in personal appearance and character, yet she lay on her couch tired and watched over with unremitting care by a most anxious mother, showing her solicitude and sympathy in every feature. Once, in the second year of the disease, a favorable interruption occurred. The mother, still a young woman, gave birth to another child. During her confinement the neurasthenic patient was in charge of her mother’s nurse, assisted by other servants. The nurse, while devoted to the daughter, agreed with the writer that excess of sympathy was injurious, and used her best and judicious endeavors gradually to persuade the patient to make some physical effort at walking and standing.
In this she was so successful that in two weeks she accompanied the girl on half-mile walks up and down hill, finally without assistance. Thus, recovery seemed assured, and everything was favorable progressing towards it when the mother, having fully recovered, again took charge of her daughter, with the result that she at once took to her lounge and remained there two years longer. About that time other advice was urged and gladly acceded to, with the result that the case was diagnosed by an eminent surgeon as spinal paralysis in consequence of concussion, though it could never be shown when and where it occurred.
Salves, plasters, anodynes, nervines, and electricity did no good, but effectually destroyed appetite and digestion, which higher to had been normal. So this adviser resigned in favor of a third, who, being a younger and less prejudiced man, agreed perfectly with the writer’s original opinion. He advised return to moderate exercise, avoidance of drugs, and less display of sympathy. This, though formerly rejected as “unkind,” was now acceded to as coming from a nerve- specialist, fresh from Europe, at that time very rare.
Still attending the other members of the family, the writer had sample opportunity of observing the course of the case. Improvement was very slow and uncertain till financial misfortune overtook the family. Almost with a bound our patient left her cough, and, organizing a kindergarten, strove energetically in supporting herself and assisting her mother. The change came about in less than three weeks, and resulted in perfect recovery.
At this point another very instructive case of very speedy recovery, after six or seven years of neurasthenic prostration, deserves to be mentioned. A woman of 35 had been in bed and on the lounge most of the time for nearly seven years, at the end of which time she became my patient, her regular medical attendant having gone to Europe. She was of very amiable disposition and as sensitive as she was weak. Her symptoms, as in the other cases, were instantaneous exhaustion on the least physical exertion.
She could give herself up to no mental occupation beyond directing her house-hold affairs, the education of her son, and the rehearsal of her numerous sensations. She had not been my patient long when her husband failed in business, so that the family was reduced from very comfortable circumstances to a condition which made it necessary for the patient to make her own living and that of the family.
This she almost at once proceeded to do, setting aside all other considerations and establishing a boarding-house, where she did most of the work herself. This she has done now for ten or twelve years without a serious relapse. The time involved in the period of convalescence was scarcely more than three weeks, a although her work maybe said to have begun at the moment her resolution was taken.
Prognostics.-From these and other cases in and outside of the writer’s practice, it is safe to say that the majority of cases of neurasthenia recover, though years may elapse before that period. We learn, furthermore, that recoveries, especially of very inveterate cases, depend on conditions beyond the control of the physician, as was the case in the above-recorded instances, where circumstances forced the patient to cases to wish for recovery and to make an effort of the will. This having been once accomplished self-confidence, for a long time in abeyance, was permanently restored.
Curability, further, depends very much on the temperament of the patient, whether amiable, tractable and confiding in the honest endeavors of the physician, or whether refractory, suspicious, untruthful, selfish and antagonistic, of a disposition impossible to win over on account of unnatural distrust of every well-meaning person. The degree of intelligence of patients also has a pronounced influence on the result. The most readily curable cases are those acquired without hereditary predisposition, where the cause is found in the absence of food and sleep, also where sorrow and anxiety can be averted or counteracted by judicious conduct of near relatives and friends.
Dietetic Treatment.-This, as medicinal treatment, must be governed by the stage at which the case comes into the physician’s hands-whether yet in its prodromal, its acute or its chronic phase. The prodromal stage of the disease has no very decided pathognomonic signs. The most that can be recognized in this stage is that the patient’s habits or duties are of a kind which will eventually lead to obdurate neurasthenia if not arrested in time by removing the exciting causes. Too much pleasure, as well as too much care, especially in girls and woman, tends to neglect of food and rest, in the absence of which, excitements, whether of pleasure or care, begets a state of unrest in which repose is disagreeable.
With such a condition comes a list of incipient casual complaints of headache, imperfect sleep, notional ways of eating, working or playing. A few questions will determine whether the patient is living according to normal or abnormal habits with regard to appetite, sleep and occupation. Where these are found, their alteration to normal ways must be instead on. It is unnecessary to say that this is easier said than done, for it will probably meet with serious objections on the part of the patient, if not on that of her relatives; for most likely she has examinations for college to prepare for, involving several months of dose and careful study at night, and the patient cannot waste time in sleeping and eating while cramming that little excited and ambitions brain.
A failure in the examinations would be as much of a disappointment to parents as to patient, who proves, as usual, that this appellation is a misnomer. She accordingly goes in as she please, lied by an increasing morbidly ambitions impulse, and the result is likely to be the mournful satisfaction on the part of the physician of being obliged to say, “I told you before what would happen.”
Of course, all regret the now evident nerve-prostration, while, if the doctor had succeeded in enforcing his rules, he would in many cases experience the still more painful reproach of having been too severe. Nevertheless, absolute firmness and a kindly but unflinching exertion of his will, without the least compromise, reward the physician with the best results in such cases.
When the case, after the stage of excitement and untiring restlessness (at which it would still be speedily curable by simple dietetic rules) has, after weeks or months, entered upon the phase of painful prostration, here we encounter backache, oppressive headache, and absolute loss of mental or bodily endurance, measures of dietetic management are much less effective and much more difficult to find. it is at this stage that slight rise of temperature will occur, especially towards evening; then the backache and headache disappear, the pallor is replaced by a flush of color, the eyes lose their listless look, and the patient is inclined to enter upon some diversion or excitement, followed by a restless night and a morning of exhaustion and a renewal of all painful sensations. Most of such patients feel much better in the evening when they are ready for some entertainment, while in a normal state this would be the time for relaxation and repose.
The dietetic treatment of this stage is methodical rest. In severe cases the patient will do well to remain in bed for several days or even for weeks. It is well to shorten this period as much as possible and to insist on walking about, or, at least. sitting for a specified time every day. This may be varied b equally specified periods of rest in the recumbent position.
