The Relation of Chronic Fatigue Syndrome and Neurasthenia
Some medical historians consider neurasthenia to be the diagnostic predecessor of Chronic Fatigue Syndrome (CFS). The following commentary on neurasthenia is a section from a book entitled, “A Handbook of Practical Treatment” edited by John H. Musser, M.D. and O. A. Kelly, M.D. which was published in 1912. The first sentence sets the tone for the whole discussion and provides a link to modern CFS research: “When we come to study the symptoms of neurasthenia, we find that they are essentially those of chronic fatigue.”
The significance of this documentation with regard to the Meridian Institute research project on Chronic Fatigue Syndrome (CFS) is that the general approach to treatment is consistent with that found in the Edgar Cayce readings on neurasthenia. The medical treatment provided for neurasthenia included nutrition, massage, mild exercise, electrotherapy, hydrotherapy, mental hygiene and a therapeutic (healing) environment. A central theme in this historic treatment model is the importance of improving eliminations to help the body to cleanse itself (“Fatigue is as much an effect of the presence of waste substances as it is of the consumption of tissue.”).
Edgar Cayce’s readings on neurasthenia (and fatigue in general) also focused on the role of toxicity and the importance of improving eliminations. Cayce’s approach as presented by Harold Reilly’s C.A.R.E. model is very consistent with the traditional medical treatment of neurasthenia.
From A Handbook of Practical Treatment edited by John H. Musser, M.D. and O. A. Kelly, M.D., (1912); excerpted from the section entitled “The Treatment Of So-Called Functional Nervous Disorders” (pp. 858 – 873).
When we come to study the symptoms of neurasthenia, we find that they are essentially those of chronic fatigue. On the surface they appear to be hopelessly multiple and complex, but it soon becomes evident that they possess unequal value. This indeed was recognized years ago by Charcot, who separated a group of symptoms which he spoke of as the cardinal symptoms. He grouped them roughly as follows: Headache, sleep disturbances, rachialgia, spinal hyperesthesia, muscular weakness, dyspepsia, genital and psychic disturbances. All other symptoms he termed secondary or tertiary. Charcot evidently selected as his cardinal symptoms those which present themselves with a certain degree of frequency. He does not appear to have made use of any other guiding principle. However, if we conceive of neurasthenia as being the neurosis of chronic fatigue, the clinical picture becomes very clear. All affections which present themselves in such generalized forms as neurasthenia, hysteria, and hypochondria, present symptoms which are readily classifiable as sensory, motor, psychic, and somatic. As soon as we begin to analyze the symptoms of neurasthenia in a systematic manner, we find that the sensory symptoms express themselves, first, in generalized fatigue sensations — e. g., a general sense of tire, a general sense of weakness; secondly, as localized fatigue sensations — e. g., headache, backache, and limbache. When we turn our attention to the motor symptoms, we find present, in varying degree, muscular fatigue, muscular weakness, and, above all, ready muscular exhaustion. When we turn our attention to the psychic symptoms, we find a diminution in the capacity for sustained mental effort, ready mental exhaustion, and diminution in the spontaneity of thought. When we turn our attention to the somatic symptoms, we note especially atony of the digestive tract, atony of the circulatory apparatus, anomalies of the secretions, and disturbances of the sexual functions, which can be interpreted only as signs of weakness and deficient innervation. The symptoms just enumerated I have termed the primary or essential symptoms of neurasthenia; all other symptoms are secondary or adventitious symptoms. The essential symptoms are always those of chronic and persistent fatigue, while the adventitious symptoms are, as we shall see, secondary outgrowths.
The sensory symptoms consist, first, of vague fatigue sensations, generalized in character. There is present a general sense of tire or fatigue which is very persistent. It is one of the primary or essential symptoms, and may dominate the picture as long as the neurasthenia lasts. Not infrequently there are present associated or secondary symptoms, direct outgrowths of this generalized fatigue; for instance, the patient not infrequently presents a feeling of uncertainty in regard to his movements or in regard to his environment — i. e., he sometimes complains of being giddy or dizzy, without presenting any symptoms of real vertigo. Indeed, mild forms of dizziness are very frequently noted. This symptom is undoubtedly one directly referable to the asthenia, and it appears to be due to the lessened vasomotor tone of the cerebral vessels, so that slight efforts or changes of position affect the intracranial circulation. It is not impossible, on the other hand, that at times this symptom is due to an actual weakness of the various centers concerned in coordinated movement. At any rate, this dizziness is a secondary and not a primary symptom.
In addition to the general sense of tire, there are sensations of fatigue, more or less distinctly localized, such as headache, backache, or limbache. These localized achings are to be regarded as exaggerated fatigue sensations, and are also among the primary symptoms of neurasthenia. In early cases they disappear upon rest, as do other fatigue sensations, though in cases of long standing they may only be relieved and not disappear altogether upon the cessation of work. For instance, concerning headache the average statement by the patient is that mental effort of any kind brings it on, or if it be already present, makes it worse. The headache is diffuse in character, and is usually most pronounced in the occipital region, though it may be frontal or widely diffused. Not infrequently we have, associated with this headache, sensations of pressure or constriction, more especially drawing sensations in the occiput and in the back of the neck, or, on the other hand, of heaviness and fullness. These associated sensations are to be classed among the secondary or adventitious symptoms they are probably to be referred to secondary vasomotor changes, and are in themselves only indirectly the outcome of the chronic fatigue.
The backache is usually referred to the small of the back, sometimes to the mid-scapular region, and at times to the sacrum. This diffuse aching, like the headache, must be regarded merely as the expression of an exaggerated fatigue sensation, and constitutes unquestionably one of the primary symptoms of neurasthenia. Not infrequently, however, we have, as in the case of headache, secondary symptoms also making their appearance. Thus, there may be present tenderness over the spine to pressure, tenderness which is, as a rule, most marked in one or more of the following regions: over the seventh cervical spine, over the mid-dorsal region, over the dorso-lumbar juncture, over the mid-lumbar region, over the sacrum, or over the coccyx. These regions of tenderness constitute the symptoms which gave rise to the term “spinal irritation,” employed by the physicians of a previous generation. Sometimes there is present, in addition to these symptoms of spinal tenderness, also spontaneous pain or aching referred by the patient to the substance of the spine itself. It is extremely probable that these secondary symptoms are merely the indirect outgrowths of greatly exaggerated fatigue sensations. Occasionally other areas or points of tenderness are noted in neurasthenia. such as tenderness of the teeth or gums, and sometimes diffuse tenderness of the entire head; never, however, the localized tenderness of the clavus of hysteria.
The aching of the limbs, like headache and backache, is, as already stated, to be considered a primary symptom. Not infrequently this aching bears a direct relation to the occupation of the patient; as, for instance, aching in the legs in a collector, letter-carrier, or salesman, or aching in the arms in persons with occupations in which the arms are used excessively. In addition to the simple aching, other symptoms, secondary in value, are occasionally noted; for instance, subjective numbness, pricking, formication, velvety sensations, or a subjective sense of heat or cold. The adventitious character of such symptoms is self-evident. It is to be especially noted that sensory loss, anesthesia, is never present.
When we turn our attention to the special senses, we find a similar interesting aggregation of symptoms, readily divisible into primary and secondary phenomena. As regards vision, we have first and foremost the symptoms of ready fatigue. This fatigue is. as a rule, complex in its origin. Various elements, muscular, retinal, and cortical, play a role. Thus, weakness and ready fatigue of the intrinsic and extrinsic muscles of the eye, weakness and irritability of the retina, and ready cortical exhaustion play roles varying in degree in different cases. It is for this reason, doubtless, that mere correction of the eyes by glasses, as a rule, fails to relieve the eye symptoms of which the neurasthenic complains.
Disorders of hearing present the symptom of localized fatigue less plainly than do the disorders of vision. However, neurasthenic patients will often say that they cannot ” hear right”; though this symptom, when investigated, proves as a rule to be psychic and not directly referable to the ear — that is, it is due to lack of the power of sustained attention and not to any true difficulty of hearing. However, there is frequently present auditory hyperesthesia, and this may be pronounced in degree. The patient may suffer exquisitely from noises, even when the latter are insignificant. Secondary auditory symptoms are also prominent; especially is this true of tinnitus, of which a very large number of patients complain.
With regard to smell and taste, fatigue symptoms are not obvious; however, olfactory hyperesthesia is not an infrequent symptom, the patient complaining inordinately of odors, not especially noticed by healthy persons. Again, neurasthenic patients are notoriously peculiar in regard to their eating, often presenting an extreme dislike of various wholesome articles of food. It is not impossible that these dislikes are, in part at least, owing to modifications of the sense of taste, similar to those presented by the other special senses.
When we turn our attention to the motor symptoms in detail, we find, as already stated, as the primary symptom, ready exhaustion. The sense of weakness is, as a rule, referred to the legs and small of the back. There is, however, never any local weakness, nothing in the faintest degree suggesting a paresis or paralysis. Among the secondary motor symptoms we note especially tremor. This tremor is an intention tremor, and is usually fine in quality. There may also be noted at times slight spasms or twitchings in small muscular bundles here and there; for instance, in a few fibers of the frontalis of the one side, or perhaps of one or both orbiculares palpebrarum, or in other facial muscles.
The tendon reactions of the neurasthenic may be normal. More frequently, however, they present the symptom of irritability, and we find, therefore, that in the majority of cases the knee-jerks are decidedly increased. Now and then, owing doubtless to lowered muscular tone, the knee-jerks are diminished; they can, however, always be well reinforced. Occasionally also an ankle clonus is noted; it is, however, never so marked nor so prolonged as we find it in organic disease. It is most frequently faint and disappearing. The cutaneous reflexes may be pronounced or may remain unchanged; they are never altered in quality. Thus, a Babinski sign is never present.
When we turn our attention to the psychic disturbances, we find again, as the most striking symptom, a diminished capacity for sustained effort. just as the patient is incapable of long-continued physical effort, so is he incapable of long-continued mental effort. The attempt to do brain work sooner or later brings on symptoms of exhaustion. The patient finds it more and more difficult to sustain. his attention. This often alarms the patient greatly, as it gives rise to the idea that he is about to lose his mind or to lose his memory. Further, ideas do not present themselves as readily as in health. There is a true lack of spontaneity of thought, and this the patient makes known to the physician by the familiar expression, “I cannot think.” Like the failure of the power for sustained attention, it is only another sign of fatigue.
The secondary psychic symptoms of neurasthenia are intensely interesting, and would justify a much more elaborate consideration than is here possible. We note, first, that the man who is chronically tired loses some of his personal force, aggressiveness, and will-power. Secondly, coupled with this lack of will-power, hesitation, uncertainty, indecision, sooner or later make their appearance. Thirdly, there is also a markedly increased irritability. That the tired man is cross is as well known to the laity as to ourselves, and this irritability is merely the expression of a more or less marked loss of self-control or inhibition. Fourthly, the man who is chronically tired is also afraid, for weakness and fear inevitably go hand in hand. Indeed, it is a well-known fact that neurasthenics are subject to spontaneous attacks of fear- this fear is causeless in origin and generalized in character. Sometimes these attacks of fear are accompanied by pallor of the face and palpitation of the heart, just as is normal fear. More rarely they are accompanied by the most pronounced signs, the patient suffering from sudden weakness, pallor, coldness of the surface, excessive tachycardia, and even relaxation of the sphincters. Such attacks are commonly mistaken for attacks of hysteria, but they bear no resemblance whatever to the latter affection. It should be added that occasionally the attack of fear is not accompanied by any physical symptoms.
If the neurasthenia occurs in a patient who does not possess a normal nervous system to start with, but who is already neuropathic by heredity, — that is, possesses a nervous system structurally defective, feeble in resistance, and prone to degenerative change, — certain special symptom groups may present themselves. These have been variously termed by different writers the neurasthenic insanities, and have been described collectively by Janet as psychasthenia. They clearly have not to do with neurasthenia proper, for in a non-neuropathic subject a neurasthenia will always remain a neurasthenia simplex, and true and uncomplicated neurasthenia never terminates in mental disease.
In addition to the psychic symptoms here described, the patient also suffers from insomnia. Mostly he has but little difficulty in falling asleep, but the sleep is broken, especially toward the morning hours, and the patient finds difficulty in falling asleep again. If be does, the second sleep is likely to be heavy and the awakening to be accompanied by a feeling of more or less marked prostration. Occasionally the sleep is interrupted a number of times, and often is accompanied by a desire to empty the bladder. Less frequently the patient has difficulty in falling asleep, the oncoming of the first sleep being delayed for an hour or more. The sleep of neurasthenics is rarely refreshing. The patient usually awakens with a feeling of lethargy and depression, and feels but little inclined to activity, especially in the early part of the day.
The somatic symptoms of neurasthenia, like the other symptoms thus far detailed, present as their essential characteristics ready exhaustion. Thus we have, as the cardinal symptoms of the indigestion of neurasthenia, atony, delay, and enfeeblement. The disturbances of digestion may be intestinal as well as gastric, while constipation is almost the rule. Secondary symptoms are, of course, present here ag well as elsewhere. The indigestion may become so pronounced as to lead to the production of a secondary gastric catarrh. On the other hand, the nervous weakness may manifest itself not so much by atonicity of the bowel — that is, constipation — as by looseness, and the patient may not infrequently present the symptoms of sudden and precipitate bowel movements, accompanied by sudden faintness and prostration.
The disturbances of the circulatory apparatus consist in modification of the force and rhythm of the heart’s action, in the character and frequency of the pulse, and in more or less marked alterations of vasomotor tonus. Perhaps the most striking, if not indeed the most common, symptom of circulatory disturbance is palpitation of the heart. While frequently associated with digestive disturbances, it is by no means dependent upon the latter, and frequently comes spontaneously. We note also coldness of the hands and feet. Sometimes lividity, local flushings, and other signs of vasomotor disturbance are noted. The circulatory disturbances, like the digestive disturbances, are to be referred to diminished or defective innervation, and are as much the expression of fatigue as are the other symptoms already considered.
The disturbances of the secretions, more especially of the skin and of the kidneys, are to be referred to deficient innervation, and cannot be more than alluded to here. The disturbances noted in the skin consist of undue moisture of hands and feet, undue sweating upon exertion, or, on the other hand, of unusual dryness. As regards the urine, the quantity may be increased or diminished. The secretions, both perspiration and urine, may, in addition, show chemical modifications and other changes secondary in character which space will not permit us to consider.
The sexual disturbances of neurasthenia are notably those of ready exhaustion, weakness, and irritability. The patient may complain of diminished sexual power, of premature ejaculation, and of diminution of the sensations normally accompanying the sexual act. Numerous variations of these symptoms, depending upon the sex and habits of the patient, may also be present. They are of the nature of secondary manifestations.
Treatment. — The above outline of symptoms is that of simple and uncomplicated neurasthenia, that which the writer has termed neurasthenia simplex. It is, as far as we are able to determine, a purely functional disease, and yet there is reason to believe that if neurasthenia simplex lasts for a long time — that is, many years — actual changes may supervene in the tissues and the signs of a premature senescence may make their appearance. The writer has spoken of such cases as instances of neurasthenia terminalis.
The conception of neurasthenia as a state of chronic fatigue leads to clear conceptions of its pathology. In the normal exercise of function, such as leads to normal fatigue, there are changes, chemical and morphologic, which indicate a consumption of tissue — a consumption which depends directly upon the increased oxidation attendant upon functional activity. The expenditure of energy means loss of substance, and that this conception is not entirely theoretic is evidenced by the researches of Hodge, Vas, Nissl, Mann, Lugaro, and others, in the changes in the nerve-cells which occur from function. The excessive exercise of function leads to the excessive consumption of tissue, and there can be no doubt that here we have a factor which plays a r6le in the pathology of chronic fatigue. Secondly, we must bear in mind the role played by the products of tissue waste. It is extremely probable that waste products circulating in the blood in normal amount are not toxic in their action. and in reality exercise an important and beneficial function in the economy. In order to obtain an idea as to the action of such substances, we need but recall the following experiment: It is well known to physiologists that if a frog muscle which has been completely exhausted by electric stimulation, and refuses any longer to respond, is washed out by injecting into its artery ordinary salt solution, the muscle again reacts to the electric current, and almost as well as before. Evidently the action of the waste products restrains or inhibits the muscular contraction; and the question arises, may it not be that this is one of nature’s methods of preventing undue or excessive fatigue? If it be true that the action of the muscles is inhibited by the waste products resulting from functional activity, the same is probably true of the r6le played by waste products in other organs, more especially in the nerve-centers. Here, again, the probable physiologic action of waste products present in normal amount is to induce rest by retarding activity. Considered in this light, the various fatigue substances normally thrown into the circulation act as sedatives upon the nerve-centers, and are among the direct causes of rest and of sleep. Fatigue is as much an effect of the presence of waste substances as it is of the consumption of tissue.
Excessive exercise of function leads primarily to the excessive consumption of tissue. Under these circumstances the waste substances thrown into the circulation are present in abnormal amount, and instead of a sedative or retarding influence, exert a toxic action. They no longer act as gentle restrainers of function, as preventives of unphysiologic waste, but as poisons. In all probability their effect upon the nerve-centers is now that of irritants and excitants, and instead of inducing rest, they disturb or prevent it. Here we have, I believe, the explanation of the nervousness and the irritability of exhausted states’ and of the insomnia of overfatigue. However, it is extremely probable that excess of function, if persisted in, leads eventually to a perversion of the chemical changes that accompany normal function; and thus arises an additional element of toxicity.
In the treatment of neurasthenia, therefore, two problems present themselves: first, the restitution of tissue; and, secondly, the elimination of waste substances. The first implies rest and the administration of food; the second, the maintenance of the action of the skin, of the kidneys, and of the bowels. The special methods adopted in given cases are, of course, subject to a great variety of detail.
The first indication is to remove, if possible, the cause of the fatigue symptoms. If the case be one of simple and uncomplicated neurasthenia, it will generally be found that the case owes its origin to some infraction of physiologic living. In the civilization of our day no cause is more potent than overwork and nervous overstrain. In many cases, if merely so much of the strain be taken off as is in excess of the patient’s strength, nature will gradually reestablish a normal equilibrium, provided, of course, that the overstrain has not been too long continued. The cessation of overwork of itself brings about a degree of relative rest. In searching for the cause of a neurasthenia, all possible etiologic elements should be inquired into, and in this connection we should remember not only overwork, but also worry, sexual excess, and the abuse of stimulants. It can readily be comprehended that rest of itself may fail to bring relief, so long as the various unphysiologic strains to which the nervous system has been subjected are not removed. Rest, too, has a very wide application, as has already been implied, for it may vary from the slight degree of relative rest just mentioned, to the profound degree of rest that is obtained by placing the patient in bed for a more or less prolonged period of time.
Partial Rest Methods. — When the neurasthenia is not pronounced, or when the patient happens to be one who is actively engaged in business and whose obligations and responsibilities cannot be laid aside, or whose circumstances negative a treatment by rest in bed owing to the expense, it is wise to have recourse to the so-called partial rest methods. Of course, as far as possible such a patient should diminish the amount of work that he does. Secondly, he should increase the hours of rest as much as possible. He should retire early, say at nine o’clock, and rise as late as his engagements permit. He should lie down immediately after the midday meal, resting for an hour, or if possible for two hours. By following this plan, the number of hours spent in actually lying down may be greatly increased; the more, of course, the better. For this excessive rest a certain amount of complementary exercise must be prescribed, and this exercise should be taken in the open air. It may consist at first of a twenty-minute walk taken between the hours of eleven and one, or between the hours of three and five. Gradually the amount of exercise should be increased until the patient is walking upward of an hour once, or it may be twice, daily. Care, however, should be taken not to permit the patient to take too much exercise at first. In any event the amount of exercise should in the beginning be very slight. Fatigue should always be avoided, for if fatigue be induced, the very object of our treatment is defeated.
Having prescribed the proper proportion of rest and exercise, we should next take up the matter of food. The amount of this should be, if possible, large. As a rule, the quantity of nourishment can readily be increased by a very simple expedient, namely, by instructing the patient to add a definite quantity of milk, say from 4 to 8 ounces, to each meal, and to drink an equal amount between meals and on going to bed. The amount should be small at first and gradually increased until even 10 or 12 ounces at a time are taken. We should bear in mind also that the red meats are not, as a rule, suitable for neurasthenic patients. In the latter, either the output of alloxuric bodies is increased, or their elimination is interfered with, so that a diet containing meat in large quantities is contraindicated. Starchy foods and sweets are also to be avoided, first, because they favor the formation of alloxuric bodies; secondly, because they may give rise to more or less marked digestive disturbances; and, thirdly, because their tissue-building value is comparatively low. The carbohydrates are of value when muscular energy is to be eliminated, and are not indicated in periods of rest. With regard to meats, we should, therefore, advise the patient to take the red meats, beef and lamb, sparingly. It is not wise, however, to interdict the use of the red meats absolutely in patients treated by partial methods. For a similar reason the carbohydrates should not be withdrawn altogether, but their quantity should be regulated. Fats also should be avoided for a time, and the patient restricted to small quantities of butter. The white meats, chicken, fish and oysters, and eggs should be taken freely, as should also the succulent vegetables. Celery, lettuce, and water-cress and ripe or stewed fruits should be added. Neurasthenic patients do best on a mixed diet. We should remember also that liberal feeding, that feeding in excess, is indicated.
Stimulants, alcohol, tobacco, tea, and coffee, are best withdrawn absolutely. In given cases, however, if the patient is placed under such circumstances that he cannot lessen his work, that he is burdened with imperative engagements, carries great responsibilities which must be discharged, the cup of morning coffee may be allowed, or perhaps a cup of tea may be substituted. Usually, however, the coffee can be withdrawn and replaced by a cup of hot cocoa or hot milk. With regard to patients who are in the middle or advanced period of life, and who have been accustomed to the use of wines, it may be wise to permit the use of a small quantity of claret or Burgundy at dinner. This, however, is a distinct exception to the rule. Usually neurasthenics are very susceptible to the use of alcohol. It makes them dull and heavy, and renders the discharge of their duties more difficult. Tobacco, other things being equal, should also be withdrawn entirely.
The next point we have to consider is the elimination of waste products. Many of the vague aches and distressing sensations from which neurasthenic patients suffer are doubtless due to the retention of waste substances, notably uric acid and its salts, or perhaps one should say, more generally, the alloxuric bodies. So far as possible, therefore, we should add to the plan of living simple methods by means of which the elimination of these substances is facilitated. We should, therefore, increase the amount of liquid which the patient takes. The neurasthenic quite commonly suffers from a deficient thirst, and if left to himself, drinks an insufficient amount of water. It is necessary not only to instruct him to drink water, but at times to fix the amount, usually a liberal amount, which he is to consume at stated intervals. The various table waters may here be made use of with advantage. The free addition of milk to the diet, of course, accomplishes the same object, and often renders the addition of water in large quantities less imperative.
Next it is in order to secure free elimination by the skin, by the kidneys, and by the bowels. The skin can be stimulated very readily, of course, by a liberal use of baths and by simple rubbing. Baths, however, if used too freely, may exaggerate the general weakness and relaxation from which the patient already suffers. As a rule, the use of a simple warm sponge-bath daily, followed by gentle friction, is all that is required. A brief immersion bath will, of course, answer the same purpose. As the circulation in neurasthenics is already somewhat enfeebled, as evidenced by the coldness and lividity of the extremities, they do not react, as a rule, to cold baths, and, as a matter of actual experience, it is found that warm baths are not only well tolerated, but are productive of the best results. Finally, the time of day at which the bath is taken is of importance. Usually, in cases treated by the partial rest method, the bath should be taken in the evening, shortly before retiring. At this time it aids in relieving the fatigue of the day and also quiets the patient and prepares him for sleep. In mild cases of neurasthenia or in convalescent cases cold water is well borne, and is followed by a healthy reaction, but this is not the case when the neurasthenia is at all marked or the vasomotor tone is at all deficient. However, the patient who has been using the warm bath for a time may gradually reduce the temperature of the bath from day to day, and finally take a bath of from 600 to 500 F., which in proper cases is followed by a prompt and healthy reaction. The arterial tension, which is especially low in neurasthenics in the early hours of the day, is by this means raised, and many of the fatigue symptoms either disappear or are lessened for the time being. Tissue metabolism is also actively promoted, for observation has shown that the stimulus of the cold bath increases the consumption of oxygen and the elimination of carbon dioxide. Elaborate hydrotberapeutic apparatus to secure such results is unnecessary. The latter is usually not at the command of the patient, and only infrequently at the command of the physician, but excellent results can be achieved by very simple means.
In partial rest methods massage may, of course, also be employed, and often with advantage. It has the advantage of taking the place of exercise, which it is otherwise incumbent upon the patient to take.
Full Rest Methods. — When neurasthenia is pronounced, it becomes imperative, whenever practicable, to order the patient to bed and to institute a radical course of rest treatment. It is usually necessary to give close attention to the carrying out of the details lest the purpose of the treatment be defeated by some apparently trifling neglect. If rest is imperative, this rest must be made as nearly absolute as possible. The patient is instructed to lie quietly, not to sit up except for the special purpose of taking food, nor is the patient to leave the bed except for the purpose of emptying the bowels or the bladder. Such a degree of rest, maintained for a number of weeks, is usually sufficient for ordinary cases. However, cases of neurasthenia are met with which are so profound that the mere effort of sitting up in bed or turning from side to side is sufficient to cause distress. Such a patient must be fed by the nurse, and when he desires to change his position, he should be gently moved by the attendant. Cases requiring such stringent methods as these are infrequent, however.
It should be home in mind that the patient should have not only physical rest, but also rest of mind, and all source of mental and emotional excitement should be avoided. With this object in view, it is necessary to cut off, or strongly to advise the patient to cut off, communication with the outside world either absolutely or in a very large degree. This necessitates the exclusion of relatives and others, as well as the interruption of all correspondence. The patient, !in other words, should be isolated, and the isolation should be rigid m proportion to the severity of the case. . The isolation is sometimes, though not often, actively resisted by the patient. More frequently, however, it is the relatives who are insistent, and it is against them especially that isolation is a protection. The exhibition of anxiety by relatives and friends and the constant watching of symptoms by them serve only to convince the patient that he is seriously ill, perhaps hopelessly so; in other words, they keep up the constant suggestion of illness without meaning to do so. Isolation, however, must now and then be modified. The circumstances surrounding the patient may be such that absolute isolation is neither feasible nor wise. Occasionally it may be expedient and safe to permit a child to visit its mother at intervals, or the mother perhaps to visit the daughter. At other times facts of a business nature, especially in the case of a male patient, may necessitate modifications of the principle of isolation. With due precautions, however, these modifications are bereft of harm.
In patients treated by partial rest methods a properly proportioned amount of exercise may counterbalance the effects of the excessive rest. However, in patients treated by full rest methods exercise is not possible, and must be substituted by other means. The only measure especially at our command is, of course, massage. In the bed treatment of neurasthenia the employment of massage is imperative. It can never be dispensed with. It should, in the beginning of the treatment, be carried out gently or superficially, and should be applied for a relatively short time. Severe or deep massage given at first may greatly increase the general sense of fatigue from which the patient suffers, while local soreness or rapid action of the heart may add to his distress. Gentle massage having been instituted in the beginning, it may little by little be increased, in both depth and vigor, so that after the expiration of a variable period, say from a week or ten days, full massage is given for about an hour’s duration. We should bear in mind, however, that some patients are never able to endure a very hard or prolonged rubbing.
Electricity is an adjuvant to treatment which is much inferior to the value of massage. However, it also stimulates nutrition and enables us to combat the unfavorable effects of prolonged rest in bed. It should rarely, if ever, be used in the early stage of the treatment. The patient is already very nervous, and is frequently afraid of the electric apparatus. Indeed, in many cases the excitement and the irritation which the application of the electricity causes compel its discontinuance. As a rule, it should not be employed at all, save weeks after treatment is well under way, and in some cases not until the last weeks of the treatment, preparatory to getting the patient out of bed. At this period the exercise which it gives the muscles is undoubtedly beneficial. As a rule, it is found that the slowly interrupted faradic current is the most valuable. The nurse is previously instructed as to the important motor points, so that each group of muscles undergoes a given number of contractions. It is wise also to begin by limiting the application to the flexors and extensors of the legs; later the applications should include the thighs, arms, and trunk. The duration of the treatment should not be more than twenty to forty minutes.
The diet applicable to neurasthenia has already been outlined in describing partial rest methods. Suffice it to say that in the treatment by rest in bed it is wise to begin with a moderate amount of food only. Sometimes it is wise to begin with milk alone, giving this in exceedingly moderate quantities — 4 to 6 ounces at meal-times, between meals, and just before the hour for sleep. However, in most patients some solid food can be given in the beginning. As regards meats, the white meats should, as before, be preferred. The succulent vegetables, spinach, squash, stewed celery, and later peas, string-beans, and other vegetables, may be added until a full diet is reached. Eggs may, of course, also be given. Potatoes should for a long time be excluded, as should also wheat bread in any quantity. The neurasthenic, however, is preeminently in need of a mixed diet, one capable of furnishing all that the tissues require — proteids, fats, carbohydrates, vegetable acids, and salts; but this full diet should be approached gradually. The milk should be increased gradually in quantity until 8, 10, 12, or more ounces are taken six times daily. Not infrequently the patient objects to the milk. Sometimes this objection is based upon an actual idiosyncrasy, so that milk is digested with great difficulty. In such instances we may make a trial of various forms of modified milk. At times the difficulty is overcome by the addition of some alkaline water, still or effervescing, such as Vichy or Selters, or Apollinaris or artificial plain soda-water. At times the addition of a little table-salt makes the milk palatable. Finally, the milk may be predigested, or, what is often a better plan, a small. quantity of some digestive powder, such as pancreatin or sodium bicarbonate, may be added to the cold milk just before the latter is taken. Buttermilk, if it can be obtained, is also of great advantage, especially if there is marked constipation. In other cases whey can be employed with benefit ; it does not, however, answer as a substitute for milk for any lengthy period. Kumiss, or rather imitation kumiss, is of much more value than whey, and is frequently well digested when milk, even modified, fails. Occasionally it is necessary to abandon milk altogether and under such circumstances we may resort to egg feeding. Eggs are best given raw, and should be given in increasing number daily. The procedure is as follows: A raw egg is carefully opened and dropped into a cup in such a way that the yolk is not broken. The patient is then directed to swallow the egg whole and with a single effort. It is best to administer the egg without salt, lemon-juice, or other attempt at flavoring. At first it is wise to begin with one egg between meals, the number being increased to two, three, or four, and even more, as circumstances permit. Later on a raw egg is given after each meal, — sometimes two, and thus the number of raw eggs is increased so that in many instances quite a large number are taken. As a rule, the limit is reached at eight or ten eggs. There are patients, however, who take as many as a dozen, eighteen, or even more eggs in a day. As a rule, these large quantities, are well borne. Exceptionally, however, if a patient has taken a large number of eggs, the skin acquires a yellowish tinge. This is possibly related to the proteid of the yolk, which contains a certain amount of sulphur. The coloring of the skin sometimes alarms the patient, as it suggests an attack of jaundice. However, there is- no discoloration of the conjunctiva. The tint, too, is of a brighter yellow than that seen in jaundice. The staining of the skin can be made to disappear by simply withdrawing the yolk and restricting the egg feeding to the whites of the eggs only. In a few days the coloring becomes distinctly less pronounced and finally fades altogether.
The quantity of food which it is possible to administer to neurasthenic patients at rest in bed is sometimes astonishingly large, and is attended by a rapid increase in weight. If proper precautions are taken, no digestive disturbances, gastric or intestinal, accompany this surcharge of the digestive tract. Great care should, of course, be taken under massive feeding to keep the bowels open, to see that the skin is kept active by bathing, and to see that the massage is given thoroughly. No undue distention of the stomach or of the abdomen results, and when the amount is again reduced to normal, no untoward consequences are observed.
It is indispensable to give the patient a special nurse, one whose function it is to devote her entire time to her one patient. She should sleep upon a cot either in the same room as the patient or in a room immediately communicating. She should spend, counting her own sleep, twenty-two hours out of the twenty-four with her patient. As a rule, the patient is quieted and prepared for an afternoon sleep or absolute rest during the hours of from two to four. During this time the nurse may seek recreation in the open air. Furthermore, the introduction of a special nurse into the room of a patient modifies the isolation. The nurse, if properly trained and adapted to her work, may in various ways divert the nosophobic thoughts of her patient into pleasant and healthful channels. Finally, it is imperative to add that a male patient should have a male nurse.
Other things equal, the nurse had best give the massage and make the electric applications herself. The introduction of a masseuse into the room very frequently disturbs the patient. The masseuse, if she be not a very tactful person, may create havoc by the gossip and injudicious communications which she may bring into the room.
If the details of a rest treatment be properly carried out, various changes are noted, provided, of course, that the case progresses favorably. It is noted that the patient increases in weight, the muscles become firm, the extremities cease to be cold, and the patient begins to lose her pallor. The patient gradually passes into a condition of placidity and contentment. Nervousness and restlessness give way to quiet and an increasing sense of physical well-being. The patient usually remains in this condition until a large degree of improvement has been reached and maintained for some time. Sooner or later, however, mental indifference and placidity give way to spontaneity of thought and action, and to a desire for activity, both mental and physical, and the patient begins to ask permission to sit up, to leave the bed, or to begin exercising. It is found also, if the patient is weighed, that he has gained in weight. Often this gain is so marked as to bring the weight a little above the normal average.
As soon as the maximum degree of improvement has been attained, — a period which ensues at the end of six to ten weeks or more, — the patient should be permitted to leave the bed for a few minutes daily, say, five or ten minutes at a time. The process of getting the patient out of bed should be a very gradual one; otherwise the effort of sitting up may bring on a sense of weakness, trembling in the extremities, faintness, or giddiness. Symptoms such as these are, however, never observed in patients in whom proper care is exercised. Little by little the time is increased until the patient sits up five or six hours out of the twenty-four. Light passive exercises, later calisthenics, and finally a full course of Swedish movements with resistance, should be instituted. Exercise in the open air by walking or an occasional carriage-ride is added. Finally the patient is up the greater part of the day, rising late, say at 10:30 in the morning, lying down between two and four, and going to bed again sometime after the evening meal. It is a good plan to complete the treatment not by sending the patient directly home, but to some nearby point in the country or at the seashore, where exercise in the open air can still further be carried out, and, if possible, among pleasant and stimulating surroundings. As a rule, a stay of two weeks at the seashore answers every purpose. During this period also the patient may gradually resume communication with her friends. The nurse should accompany the patient.
The importance of active exercise subsequent to a course of rest treatment cannot be too strongly insisted upon. The error, however, must be avoided of allowing the patient to take too much exercise, especially at first. The exercise should be little at first and steadily increased, but should always stop well within the limit of fatigue. After returning home the patient should be instructed to live conservatively, and a strictly physiologic method of living should be insisted upon. Permanent results follow a radical course of rest treatment, especially if the subsequent conduct of the case be well carried out. It is of very great consequence, before the patient finally passes from under the influence of the physician, to induce her to take up or in some way bring about the filling of her time with some agreeable and suitable occupation. Work, both mental and physical, is the best guarantee of health. Work should, of course, be within physiologic limits, and adapted to the physical and mental make-up of the patient. A too prolonged period of idleness after a course of rest treatment may favor the formation of invalid and slothful habits.
It will be noted that thus far nothing has been said as to medication, and indeed in many cases no medication is required. However, the constipation frequently present, and at times the insomnia, when marked, may demand treatment by medicines. Constipation is frequently combated by the diet and by the massage. Mild laxatives, such as sodium phosphate, preferably the effervescent preparation, or Hathorn or Friedrichshall water, may be administered in the morning, a half-hour or more before the first feeding. We should, however, not make the mistake of using salines, even when mild, for too long a period. Often a vegetable laxative, such as cascara, which is so extensively used at present, answers the purpose well. Indeed, in an atonic condition of the digestive tract cascara is especially indicated. It is best given in the form of a liquid preparation, in small doses after meals, rather than in a single dose at bedtime. At other times a pill containing small doses of compound extract of colocynth, nux vomica, and hyoscyamus, or a pill of aloes, belladonna, or strychnine or, when a more decided laxative is desired, a pill containing small doses of podophyllin, may be administered. Generally, the laxative should be given at night. Again, atony of the stomach may suggest the use of some simple bitter. As a rule, however, this is not required. The neurasthenic, fortunately, has usually a good appetite. At times catarrh of the stomach is present as a complication, and may suggest special medication. Here the various preparations of bismuth, resorcinol, charcoal, or perhaps a pill containing nitrate of silver, administered a short time before feeding, may be used. Now and then the presence of an unusual amount of intestinal fermentation may suggest the employment of beta-naphthol or other intestinal antiseptic.
Occasionally persistent fatigue sensations, more especially fatigue pains, may indicate the employment of the various salicylates, more especially salophen or aspirin, and possibly sodium salicylate.
Not infrequently the insomnia is so pronounced that it does not yield to the massage or simple hydrotherapeutic measures, such as the warm bath or the drip-sheet. In such cases it may be necessary to employ small doses of sedatives for a time, such as the bromids, trional, sulphonal, medinal, or veronal. For obvious reasons these drugs should not be continued long, nor should they be given in unnecessarily large doses. The stronger hypnotics, such as morphin and chloral, are rarely indicated. Finally, it may be repeated that it is often possible to conduct a rest treatment from beginning to end with very little and often no medication.
Psychotherapy, unless combined with the physiologic and other remedial methods detailed above, is of little or no service. That the suggestion of returning health is of real value in neurasthenia there can be no doubt, and that an air of cheerfulness and brightness should pervade the sick-room goes without saying. Direct and indirect suggestion may both be employed with advantage in the control of special symptoms as they arise, but hypnotic or complex psychoanalytic procedures are but rarely indicated or of value.