Irregularities of eating are at this and at all times to be superseded by the most rigid regularity of meals. The traditional and conventional three-meal system, however well adapted to the needs of a vigorous man or woman, does not agree with the neurasthenic patient. It is much better that these should eat oftener; four times a day is best in most cases, for the simple reason that in this way a patient, while eating less at a time, consumes more food in the aggregate.
As neurasthenic patients are rarely troubled with absolute aversion to wholesome food, they are generally able to consume a liberal quantity, about which it is only needful to remark here that the food should be selected from among the articles and dishes which the patient likes, provided they belong to the order of good, normal articles of food, to the exclusion of those which simply please the taste without being digestible. A dish entirely of meat or “animal food” is as far from being a good diet for neurasthenics as one consisting entirely of “vegetable” food. As a rule, the diet list should comprise one-third of nitrogenous material and two-thirds of carbohydrates.
Together with these, it is a great mistake to neglect the fats, such as good butter and the fats of meats. And, lastly, every patient of this kind should be made to drink some water often, a dietetic feature too often neglected.
During this stage, actually fatiguing exercise of body and mind should be avoided, while, on the other hand, the patient’s mind should be directed away from herself, in which she is much assisted by withholding a certain kind of emotional sympathy, quite as natural as it is difficult to repress on the part of affectionate persons. Of this, a few words further on.
There is no definite time for the duration of this stage, which, however, depends largely on the time during which the exciting causes have acted, either aided by or without a predisposition. It is certain, however, that the sooner it is recognized and the exciting causes eliminated, so much the sooner recovery will begin. But there is a stage at which the best of experience and judgment often fail, especially in very inveterate cases. If the case is one of a patient whom the physician has had opportunity of watching at least since the earlier stages, the difficulty is not so great as it is in old cases months or even of several years’ duration which come to treatment late.
In these, the line between the intermediate stage and incipient convalescence cannot be drawn. The patient is as neurasthenic and hypochondriacal as ever; cannot bear the slightest mental or bodily exertion, not even a word or a look, without sings of apparent exhaustion, while nearly the whole time is spent in bed under anxious care of sympathetic attendants.
In such cases, having become assured, by careful physical examination, of the absence of organic disease, seeing the patient generally well nourished and in fair muscular condition, the physician is warranted in assuming that the disease has run its course, that whatever morbid (pathological) process there may have been progressing in the nervous system, this process has now come to and end, but it has left the patient’s mental condition habituated to the moods of the past months or years, and fixed, as it were, indelibly in the memory. It is the habit that now remains, not the disease.
If reasonably sure of this, and calling to mind the rapid recoveries and the circumstances attending them, as above detailed, the physician is now safe in ordering a more energetic treatment, calculated to rouse the self-reliance of the patient. All visible signs of sympathy must now be set aside; the actins and demeanor of the attendants should, from this time, if not before, be changed so as to give the patient the impression that she is no longer an invalid, but expected to rely on her own exertion.
Instead of being fed, the food should be placed where she must go for and eat it. She should now be expected to dress and attend, without assistance, to her natural wants. This, with some temperaments, is almost impossible, with al extremely difficult. The best course to pursue is to remove such patients from sympathetic relatives or friends, and to place them in charge of kind, reliable, but eminently practical nurses.
The first effect of this is either to throw the patient into a stage of helpless despondency, which, again appealing powerfully to the sympathies of those nearest to her, often frustrates the physician’s plans which, if firmly but kindly adhered to, would, ere long, prove of their superiority by signs of returning self-reliance and absence of complaints on the part of the patient. A second form of effect is that occurring in patients of obstreperous, selfish disposition, whose opposition and even anger is aroused by being thrown on their own resources after the removal of depressing and unpractical sympathy.
This opposition or temper, often manifested in all sorts of intrigues and subterfuges on the part of the patient, if not supinely yielded to by sympathetic persons, will finally be replaced by a more rational disposition. On the whole, anger or active opposition are signs of returning energy, which, once coming to the consciousness of the patient, takes the form of self- reliance. it is this way that the cures of chronic cases above related can be explained, and physicians should profit by such experience for the benefit of their patients.
The general dietetic management now readily follows from what has been said, and needs only a few general modifications. The first duty of the physician will be to test the degree of reliance to be placed on the patient and her friends, ad to win them over if possible to his plans, and his success will be in proportion to the degree of confidence he is able to inspire. This personal confidence should not degenerate into a mere personal liking or attachment of a sympathy-craving neurasthenic who should discover henceforth that all sentimental expressing of sympathy are about to take a practical form, aiming at a definite result-the patient’s health-which she wishes but cannot exert her will to attain.
The best and often the only way to do away with sentiment and to reach practical kindness is to remove the patient from certain home influence, and to place her in a hospital or elsewhere under the management of competent nurses who, without being selfish, know how to exert a certain amount of wholesome push as fast as the patient can bear it. Without the removal of sentimental sympathy, all efforts at counteracting the purely hypochondriacal side of neurasthenia are useless.
In these cases of neurasthenia as yet uncomplicated with the hypochondriacal element of introspective nosomania, there is only one unconditional rule to be followed, especially in acquired cases whose evident cause was incessant, conscientious work of mind and body, together with insufficient food and sleep. Such cases come on very insidiously, the loss of strength-that is, the actual waste of nerve-substance-being just a trifle grater than the quantity restored, the patient unconsciously using up a minute part of her capital every day. Here the rule should be to reverse matters to insuring a supply of nourishment and time for its assimilation greater than was the case heretofore.
The case of young school-girls belong in this class. The time of food and rest should be carefully controlled at home, the duty of the physician being to educate indifferent and ignorant parents up to an appreciation of the nature of the case. It is generally not difficult to open their eyes through the medium of their anxiety concerning their children’s health. Having thus insured sufficient rest and food at home, the physician’s next object of attention should be the regulations of the school. Here is the point where teachers have an opportunity of exerting their most practical influence. It should be made obligatory on the part of teachers to institute inquiry as to whether pupils have had their meals before coming to school.
This they could often ascertain without a question, by reading the pupil’s condition in her emaciated form, pale face and nervous manner. To guard against neglect at home, it would be an easy matter to insist that all pupils of public and private schools should bring with them some proper food. The few who do so generally bring sweets-an apple, orange or a few dry crackers-when a piece of good bread and slice of cold meat would be what they actually need. All pupils should pass inspection, and if remiss in this important particular, the delinquent should be dismissed with several marks against her. To expect this of teachers would be a great advance in the place of futile innovations of endeavoring to send forth from our common schools graduates in arts and sciences.
Sudden Effects.-A large number of cases of neurasthenia, especially those complicated with inveterate Hypochondriasis, are frequently traced to some sudden occurrence, having the effect of a mental or physical shock. In one patient, a vigorous girl, used to romping, climbing and running lie a boy, the cause was supposed to be a slight thump she received during a game of blindman’s-buff. She thought nothing of it at the time, but it was suggested long after the patient’s illness began. In another case some mental shock of joy or grief, not very severe and such as is often experienced in every person’s life, is the beginning of months of nervous prostration.
