THE EDUCATIONAL TREATMENT OF 
NEURASTHENIA AND CERTAIN 
HYSTERICAL STATES. THE EDUCATIONAL TREATMENT OE 
NEURASTHENIA AND CERTAIN 
HYSTERICAL STATES. 
By MORTON PRINCE, M.D. 
Physician for Diseases of the Nervous System, Boston City Hospital. Head at the Annual Meeting of the Massachusetts Medical Society, 
June 8, 1898. THE EDUCATIONAL TREATMENT OF 
NEURASTHENIA AND CERTAIN HYSTERICAL 
STATES. 
IN recommending a treatment for neurasthenia and cer- 
tain hysterical states, it must be understood that reference 
is made to the severer types of these neuroses only;—to 
cases which have resisted all the ordinary methods and 
called for more extraordinary ones. Mild cases are usually 
amenable to simple procedures, like change of scene, ces- 
sation of wearing occupations and ordinary hygienic meas- 
ures. As to the more obstinate cases, I think I am right 
in saying that we are still in need of a practical method of 
treatment which shall be applicable to the general run of 
cases. Neurasthenia differs from the organic diseases in 
that while on the one hand it is usually susceptible of cure, 
on the other it is not a self-limited disease, but may con- 
tinue indefinitely, — growing, so to speak, on itself, and, 
like a snowball, taking upon itself bigger proportions from 
its surroundings. 
A marked advance over all other methods was that orig- 
inated by Dr. S. Weir Mitchell and bearing his name. ft 
has unfortunately and mistakenly been called the Rest Cure. 
The logical basis of this method is, or perhaps was, the 
principle that faulty nutrition is the basis of neurasthenia, 
and that by curing faulty nutrition — making " fat and 
blood” — neurasthenic and hysteric symptoms disappeared. 
In the practical making of fat and blood, this primitive idea 4 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
became associated with various other principles, inasmuch 
as the systematic procedure upon which successful treat- 
ment depends, requires the combination of forced feeding, 
absolute rest, passive exercise and isolation. Pest and the 
other three agents are theoretically only devices to secure 
improvement in nutrition. 
It should be noticed that by rest is meant absolute rest, 
so far as it is practically possible to make it. The patient 
is not allowed even to turn over in bed or feed herself. 
Passive exercise (massage and electricity) is only a device 
to prevent the deleterious effects in other ways, of rest, and 
to help the assimilation of food. Isolation is almost a sine 
qua non of the treatment; without it, the rest cure, al- 
though efficient in a certain proportion of cases, is still 
usually abortive in severe cases. This is a most significant 
fact. jMow it is common knowledge that while the influ- 
ence of isolation is complex, its chief mode of action is 
mental. This is so patent and so well recognized that I 
need not take the time to consider its mode of action in 
detail. 
It is therefore apparent at once that along with the prim- 
itive idea of making fat and blood, another and essential 
factor has been introduced, namely, a mental one. And it 
must also be apparent to any one who is practically familiar 
with isolation in mental and nervous diseases, that the effect 
of mental influence can be enormously augmented or im- 
paired according to the individuality and therapeutic atti- 
tude of the physician. As to the assumed pathological 
principle,—faulty nutrition, — I think there has been a 
growing conviction that this is not the real underlying prin- 
ciple of neurasthenia, and that the cures effected by the rest 
treatment are due to other influences, largely moral and 
educational, quite as much as, if not more than, to the nu- 
tritive factor. I do not believe that the observations of the 
best and most experienced clinicians will support the view AND CERTAIN HYSTERICAL STATES. 
5 
that neurasthenic symptoms are wholly dependent on, or 
caused by inanition, whether of tissue or of blood. As to 
my own observations, I can say that in the early years of 
practice, the scales occupied the more conspicuous place in 
the consulting room; I accepted the inanition theory with 
unquestioning faith, and it was a disappointment to find 
that later experience failed to verify it, and that too fre- 
quently the relation between weight and neurasthenic 
symptoms was a very loose one. It frequently turned out 
to be the case that with gain of weight symptoms failed to 
disappear; and with equal frequency, perhaps, that with 
good nutrition marked neurasthenic symptoms were pres- 
ent. It became evident that some other principle was at 
work as a causative factor than that of insufficient nutri- 
tion. 
I find this conclusion now amply verified by a review of 
my cases observed during the last fifteen years, and it seems 
to me also to have been recently verified by a very 
valuable study of " The Relation of Neurasthenic Condi- 
tions to the General Nutrition,” by Dr. Robert T. Edes.* 
Dr. Edes, as a result of a systematic study of his cases, 
has arrived at what seems to me similar conclusions ; that is 
to say, Dr. Edes concludes " that no plan of treatment 
which affords a prospect of anything like enduring success 
can afford to leave .... wholly out of sight ” the improve- 
ment of the nutrition. "So far as body-weight, which, of 
course, depends upon the harmonious work of more than 
one function, is concerned, by far the greater number of my 
cases seem to fully confirm the popular view. In the great 
majority a steady gain in body weight went hand in hand 
with improvement in nervous symptoms.” But this im- 
* The Relation of Neurasthenic Conditions to the General Nutrition, 
with reference to fa) Body-weight; (b) Blood-Measurements '.(c) Excre- 
tion of Urea, Uric Acid, Indican. By Robert T. Edes, M.D., of Jamaica 
Plain, Mass. Transactions of the Association of American Physicians. 
Vol. XII. 1897. 6 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
provement, it should, I think, be pointed out, occurred in a 
sanitarium where it is to be presumed there were the condi- 
tions of rest and isolation as cooperative factors. On the 
other hand, he found special groups of cases which were 
partly incompatible with these ideas, and which went to 
show " that although the two processes of improved general 
nutrition and returning nervous strength do go so nearly 
hand in hand, they are not one and the same, and it is not 
always easy to say which leads.” I think it is quite as 
much the case that improvement in nutrition is an accom- 
paniment of improvement in health and an index of such 
improvement, as it is the cause. As a state of health be- 
gins to return, the body takes on increase of weight. 
The fact may be fairly stated to be that the relation of 
nutrition to health is a general and not a specific one, and 
just about what every one has known from time immemo- 
rial, namely, that people in good health are usually well 
nourished, and when they begin to break down they lose 
fiesh and gain again when they improve. Conversely, 
poorly fed and nourished people break down more easily 
than well nourished people. They cannot stand the strain 
or do the work required of them any more than can a poorly 
fed horse. So, impaired nutrition undoubtedly plays a part 
in neurasthenia, but it is a cooperative part and not the only 
or primary one. Neurasthenic symptoms may exist with or 
without malnutrition ; unquestionably, imperfect nutrition 
tends to increase and encourage fatigue, and fatigue tends 
to perpetuate symptoms. When malnutrition is present, 
fatigue is more easily induced, and in fatigue symptoms are 
more easily excited and tend to persist, habit symptoms are 
less easily broken up, automatic symptoms continue, and 
the tendency to relapse and to a return of former symptoms 
is greater. As Dr. Edes says, we cannot afford to leave 
wholly out of sight the principle of malnutrition. 
I think it would be approximately correct to say that the AXD CERTAIN HYSTERICAL STATES. 
7 
neurasthenic state is primarily one of fatigue, and that as 
a rule it is more easily brought about when malnutrition 
exists, and that when malnutrition comes on secondarily, 
as is apt to be the case, it is more easily cured when the 
nutrition is restored. But increasing the quantity of fat 
and blood does not necessarily cause the nervous system to 
react normally or remove the condition of "fatigue.” It 
does not necessarily increase the quantity of the hypotheti- 
cal energy-holding compounds in the cells. Making fat 
and blood bears the same relation to the act of curing symp- 
toms, that using steam and horse-power does to hand labor ; 
it makes the work more economical, easier and quicker, but 
it also, and here the analogy ceases, it also makes the result 
more permanent. We may not hesitate, then, to accept 
formally what most of us think, that the assumed physio- 
logical principle, that the neurasthenic state is caused by 
faulty nutrition, is unsound. The introduction of the 
device of absolute rest in the treatment — for it is a device 
to aid the purpose of improving nutrition—does not in any 
way strengthen the malnutrition principle. 
More important than the supposed scientific principles 
upon which any particular treatment is based, are the prac- 
tical results which are obtained by it. That the rest treat- 
ment has been successful in experienced hands, and espe- 
cially as practised by its distinguished originator, must be 
accepted, irrespective of any contrary results that may have 
fallen to the lot of individuals. For myself, I can bear tes- 
timony, if at this late date this were necessary, to the bril- 
liant results which have followod Dr. Mitchell’s treatment 
of cases of which I have had personal knowledge. I feel 
myself indebted to Dr. Mitchell for undertaking the care of 
a number of severe cases which have always returned to 
me to bear witness by their restored or improved health, to 
the skill of this eminent physician. Undoubtedly there are 
other members of the profession in whose hands the rest 8 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
cure has given perhaps equally satisfactory results. In its 
general plan it has been adopted with more or less thorough- 
ness in probably all sanitaria for nervous diseases in this 
country, and has had an influence upon the general practice 
of the profession, which can be paralleled only by the late 
discoveries in bacteriological medicine. To its influence 
we probably owe the development of a large number of 
sanitaria which of late years have sprung up throughout the 
country. 
Nevertheless, even if all this be true, there have been 
certain drawbacks, and I may say ill consequences of the 
method, and certain difficulties in carrying it out, that make 
a reinvestigation of the treatment of neurasthenia desira- 
ble. 
The objections and outs of the treatment may be briefly 
stated as follows: (A) While we must recognize that 
the treatment has been brilliantly successful in the hands 
of certain individuals, nevertheless it has been a failure 
in the hands of others. It is not a treatment which is 
calculated to give equal results independent of the personal 
qualifications of the physician ; this largely because its fun- 
damental principle has been wrongly interpreted and there- 
fore the treatment itself has been too often improperly 
carried out. (B) Many cases which are distinctly cura- 
ble, and which later were cured by other methods, have 
failed to be cured by the rest cure, although systematically 
employed. (C) It too often happens that patients im- 
proved by this method fail to stay well, but promptly relapse 
as soon as they are again exposed to their old environments 
and the wear and tear of life. (D) Many patients far from 
being cured are made distinctly worse and become more 
confirmed invalids than ever. The rest cure not only 
makes use of improved nutrition but employs the most pow- 
erful of all therapeutic agents in neurasthenic and hysteri- 
cal conditions, to wit, every moral influence that can be AND CERTAIN HYSTERICAL STATES. 
9 
brought to bear by means of change of surroundings, iso- 
lation, active physical manipulation of the body, and the 
personal influence of the physician. When this moral in- 
fluence has been lost sight of, and reliance has been placed 
by the physician upon the mere physical details of the treat- 
ment, looking mainly to the increase in nutrition for the 
therapeutic effect, the result is apt to be a failure. Under 
such conditions in fact I do not hesitate to say that the rest 
cure has done much harm ; a result which, as I have said, 
has been due to a misunderstanding of the real principles 
involved. When a patient has been for a considerable pe- 
riod of time secluded and absolute rest lias been enjoined, 
and when after the prescribed period the expected freedom 
of symptoms has not been obtained, I think that as a rule, 
a distinct injury has been done the patient; pathological 
habits of the nerve centres have been strengthened, new 
morbid associations formed, and the symptoms have become 
more firmly rooted and more difficult to dispel. In fact, 
the symptoms are worse and the neurasthenic or hysterical 
state more fixed. Under such conditions the tendency is to 
prolong the rest, hoping for an improvement each week, 
and at the end of each additional week of rest the matter 
is made worse. In other words, rest and seclusion under 
such conditions tend to cultivate and strengthen neurasthe- 
nic and hysteric habits, and the last state of that person 
is worse than the first. 
Mere improvement of nutrition cannot be relied upon 
to remove neurasthenic and hysteric symptoms. Mere 
rest alone, without isolation, without improved nutrition, 
without strong moral influences, will not do it. Under 
such a rest it is the too common experience, that so far 
from being removed, they become more persistent then ever 
or, even when they disappear, they at once return after 
restoration to the environment. For this reason I am of 
the opinion that the rest cure is a method that, when not 10 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
properly understood in its real underlying principles, is 
capable of doing the greatest harm, and I do not hesitate 
to say that it is a most dangerous method in inexperienced 
hands. I say this not as a mere unfounded generalization 
or impression, but as a logical induction from an enumera- 
tion of quite a number of cases which I have seen in private 
and hospital practice, treated unsuccessfully by this method. 
Finally, a practical objection to the rest cure, even when 
it would otherwise be effective, is the expense.* In some 
cases this practically debars many patients from its benefit, 
so that for this reason alone it is desirable that we should 
have some effective method applicable in most cases. 
Wh at method, then, can we suggest to take its place? 
I am perforce compelled in a paper of this kind, to limit 
myself to certain'general principles. 
The method of treatment which I have practised during 
the past eight or nine years with satisfactory results and 
which I now bring to your notice, is what may be termed 
for want of a better name, the Educational Treatment, com- 
bined with mental therapeutics and physical hygiene. The 
general mode of procedure may be summarized as follows : 
First. Instruction of the patient in the nature of the 
symptoms and disease. 
Second. Fixed ideas, apprehension and erroneous be- 
liefs counteracted ; faulty habits of temperament and charac- 
ter corrected. 
Third. Individual symptoms suppressed by electricity, 
suggestion and other therapeutic agents. 
Fourth. Rules given for the daily conduct. 
Fifth. Improvement of nutrition, moderate rest, and, in 
extreme cases, isolation from previous surroundings only. 
* Properly carried out it involves the cost of hoard and lodging in a first- 
class boarding-house or hotel for two persons, patient and nurse, for a period 
of six or eight weeks, with one or two months’ further sojourn in hotels at 
the sea-side or country. Then the cost of electricity and massage (some- 
times extra), the wages of the nurse and the physician’s charges for daily 
attendance all mount up to several hundreds of dollars. AND CERTAIN HYSTERICAL STATES. 
11 
I will briefly consider each of these principles, taking 
them in a somewhat different order than I have done. 
Isolation. Perhaps the first question in the treatment 
is to determine how far is isolation necessary. If by isola- 
tation is meant not only the separation of the patient from 
all former surroundings, but a restriction of all intercourse 
to only the nurse and physician for any considerable period 
of time ; if this is meant by isolation, then I doubt extremely 
whether it is necessary or desirable in any class of cases, 
unless it be a few exceptional cases of severe hysteria. 
Separation from previous surroundings and associations, and 
particularly not only from all members of the household but 
from the house itself, is always beneficial and a great help 
in the treatment. I believe this to be one of the strongest 
moral therapeutic agents, and as potent as perhaps any fac- 
tor in bringing about a cure. When therefore there are no 
financial or other difficulties in the way of obtaining a limited 
isolation of this kind, I would always advise it as a great 
help, but it does not seem to me that absolute isolation is 
desirable. On the contrary, I would strongly advise the 
systematic development of new associations and the encour- 
agement of new thoughts and new mental and physical 
habits, which are best brought about, not by complete 
isolation, but by bringing the patient in active contact 
with the new world in which she is brought. Some cases 
require a change of surroundings more than others. The 
more marked the mental symptoms, the more hysterical, 
the more emotional the character of the disability, the 
greater the necessity for a separation of this kind, and a 
change of all external influences. In some extreme cases 
such a separation is absolutely necessary and any attempted 
cure is useless without it. It is for this reason that patients 
do better when they go under a physician’s care in a distant 
city than when they are even under the best of treatment 
in their own place of residence. The familiar associations 12 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
of even the streets and acquaintances work for harm, while 
new scenes, new streets, strange people are strong mental 
factors for good. But practically it is only feasible for a 
limited portion of neurasthenics to be removed from their 
homes, and we therefore have to take the conditions as we 
find them. Fortunately such (separation, although a great 
aid, is not absolutely necessary in the great majority of 
cases, and therefore the rule I would lay down is, " Procure 
separation only where feasible in moderate cases, and insist 
upon it at all costs in the extreme and worst cases.” A 
nurse is not required excepting in the worst cases. 
Education and Mental Therapeutics. The next part 
of the treatment, and at the same time the one that is most 
difficult and interesting, is what I call the education of the 
patient. It is upon this that we must rely for the suppres- 
sion of the individual symptoms, the acquisition of strength 
and the development of habits of body and mind that will 
enable the patient to return to the wear and tear of life 
without breaking down. The preliminary step in the treat- 
ment is the study of the origin, history and groupings 
of individual symptoms. It is surprising to find, after a 
searching enquiry which involves every detail concerning 
the origin and character of the symptoms, and the condi- 
tions under which they arise, how often what seems to be 
a mere chaos of unrelated mental and physical phenomena 
will resolve itself into a series of logical events, and law 
and order be found to underlie the symptomatic tangle. 
By such a study we can determine what symptoms are pure 
habit symptoms of the kind which Dr. Taylor to-day has 
already described and of which he has given us examples; 
what symptoms are pure manifestations of hysteria; what 
are due to faulty ideation or auto-suggestion ; what fatigue is 
due to real physical exhaustion and is true fatigue and what 
is false fatigue ; what pains are due to the diffusion of effort 
and association and what are due to some real underlying AND CERTAIN HYSTERICAL STATES. 
13 
physical cause; what symptoms are due to real disease 
of organs like the heart or stomach and what to mimicry. 
After unravelling the symptoms in this way it will be sur- 
prising to find how much facilitated will be the removal 
of them. 
For example : Miss D. had what ordinarily would be 
called neurasthenia, but what I prefer to call hysterical 
neurasthenia, of two years’ standing. Her general neuras- 
thenic condition was easily cured in a few weeks, but there 
persisted for almost a year after being otherwise well, a 
pain in the left lower abdominal region. This she had had 
for two years. She had had various kinds of treatment, 
gynecological, electrical and drugs without benefit. The 
pain was of sufficient intensity to cause considerable dis- 
tress. Careful physical examination by an eminent gyne- 
cologist and myself failed to find any physical reason for it. 
Finally a searching enquiry previously neglected showed 
that the first appearance of the pain was after the introduc- 
tion of a pessary which had to be removed on account of pain 
and discomfort. The present pain and discomfort are ex- 
actly the same in character as that originally caused by the 
pessary. It is not continuous; it is relieved by exercise 
and by conditions that would aggravate any local patho- 
logical process. The conclusion is then reached that it is 
a habit neurosis originally excited by the pessary and now 
continued by sub-conscious ideation and habit. The expla- 
nation is accepted by the patient and a cure rapidly follows. 
Mrs. R. suffers from neurasthenia which has been un- 
fortunately diagnosed as lead poisoning. Fatigue is a 
prominent symptom; she is capable of very little physical 
exertion, being able to walk perhaps a block. Enquiry 
shows that her treatment has forced upon her the impression 
that there is some distinct but mystical disease of the nerv- 
ous system caused by lead, and she has been unconsciously 
educated to have fatigue after exertion. Every time she 14 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
attempts walking she is apprehensive of doing permanent 
damage. The fatigue is thus shown to be false fatigue and 
easily cured by mental therapeutics and hygiene, so that 
in a week or two she takes quite long walks, etc. 
Mrs. I)., an extreme case of hysterical neurasthenia, 
suffers from extreme dyspepsia and an abdominal neurosis 
or parsesthesia. Careful investigation shows the dyspepsia 
to be mostly false and to be really a hyperesthesia of the 
stomach of probably the same pathology as is the common 
photophobia of the eyes in neurasthenia. The abdominal 
neurosis is also found to be of a similar character. The 
same patient was a notorious sufferer from headaches. 
These after analysis are shown to begin with true megrim 
and then to pass into hysterical headaches. The key to the 
multitude of symptoms exhibited by this patient almost 
always can be found to be apprehension or auto-sugges- 
tion. 
Mrs. S. suffers from attacks of tachycardia, palpitation, 
and syncope if she attempts to go out doors. She has been 
educated to believe she has heart disease, although careful 
examination by a prominent physician showed nothing 
organic. These attacks cease when the true nature of them 
is explained, viz. apprehension and expectation. 
Miss V. This was one of the worst and most inveterate 
cases of cerebro-spinal pain in a neurasthenic of seventeen 
years duration, that I have ever seen. From the pain and 
general fatigue she had been incapacitated for seventeen 
years and deprived of almost all participation in the ordinary 
affairs of life. A careful study of the original conditions 
of occurrence and other peculiarities of the pain showed 
conclusively that it was an association or habit neurosis. 
It finally yielded to prolonged and persistent educational 
treatment. 
The second preliminary step is the study of the personal 
characteristics of the patient, with a view to determining AND CERTAIN HYSTERICAL STATES. 
15 
what part mental influences have in the symptoms, and to 
obtaining the cooperation of the patient. Further, a per- 
son who is sensitive, whose feelings are easily wounded, 
ready to see personal reflections in any criticism of his or 
her habits, must be very differently treated from one who is 
throughly open-minded, not sensitive and indifferent to 
criticism, and ready to cooperate in the treatment without 
regard to personal considerations. This cooperation is a 
very important factor. The attitude of the physician should 
be largely that of the trainer to the athlete. He is to teach 
the patient how to help himself. 
Having gained the patient’s confidence and cooperation, 
the rules 1 would lay down are these: First, remove 
all interfering mental states that prevent the subsidence 
of symptoms; these are: («), a fixed idea or belief in 
the seriousness of the condition and the existence of real 
organic disease. (6), a belief in the danger or incura- 
bility of the state, (c), a fear or apprehension that any 
harm can come to the patient from incautious actions, like 
exercise and doing various things. (e?), sub-conscious 
fixed ideas or memories producing hysteric symptoms. 
One of the commonest hampering mental states is a 
belief on the part of the patient that doing things that 
bring on symptoms, are likely to produce serious harm. 
Most patients do not mind disagreeable feelings so much as 
they fear that anything that produces them might do them 
serious and lasting harm. A patient, for example, refuses 
to go about not because he minds fatigue, but because he 
thinks that fatigue means serious damage. Another fears 
to move because of cardiac symptoms, which he imagines 
or has been told indicate heart disease, but does not mind 
them if he can be assured and really believe there is no 
cardiac trouble. It is surprising sometimes to see the 
almost immediate beneficial effects produced by the mere 
acceptation of the idea that symptoms do not mean disease 16 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
or lasting injury. With the acceptation of this idea, symp- 
toms sometimes subside at once. 
The next point is the instruction of the patient in the 
meaning of symptoms. The patient should be allowed to 
understand the cause and meaning of each discomfort; for 
example, when symptoms are pure habits, due to associa- 
tion of ideas and actions, when fatigue is a false or habit 
fatigue this should be explained. It is my habit to give a 
great deal of time to this instruction. It is important to 
take the patient into your confidence and explain the nature 
of such symptoms as if one were explaining to a colleague ; 
and above all, Avlien the case is of hysteria to say so frankly, 
and not conceal the fact but explain its nature. Next, 
when tendencies to emotional states exist, states of anger 
at trivial tilings, anxiety, fear, worry, nervous shocks, 
accompanied as these usually are by somatic symptoms, to 
educate the patient to control and suppress all such emo- 
tional states. Here tact, character and individuality on the 
part of the physician come in. 
Suppression of individual symptoms by appropriate 
therapeutic agents.—Now comes in one of the most im- 
portant parts of the treatment, namely, the daily suppres- 
sion of individual symptoms by proper therapeutic agents. 
Symptoms should, if possible, be suppressed as fast as they 
arise without being allowed to gather headway and grow, 
in order that faulty habits and reactions of the nervous sys- 
tem may be broken up at once. It is preferable that the 
patient should make visits to the physician’s office rather 
than the reverse. When a patient makes a pilgrimage, as 
it were, for the distinct purpose of being alleviated, the effect 
of the treatment is generally heightened. For the suppres- 
sion of symptoms, one of the most valuable therapeutic 
agents, and one which I find myself making use of more 
and more in practice, is direct suggestion. This occupies 
a very prominent place in every case. It may be used in AND CERTAIN HYSTERICAL STATES. 
17 
various forms and for different purposes. As to the form 
which is used, I have rarely of late been obliged to resort 
to the hypnotic state, but have obtained all the influence 
that I have needed in a waking state, using for the pur- 
pose static electricity where it can be had; the faradic or 
galvanic battery will sometimes answer. At the same time 
that the electricity is applied the suggestion is given, and the 
patient is instructed in the nature and cause of her symp- 
toms and disease, and what is to be expected. In a wak- 
ing state, a suggestion is more efficacious if given symboli- 
cally so to speak, through some material agent. I myself 
rely almost entirely upon some form of electricity. I would 
not overlook the purely physical effect of electricity in neu- 
rasthenia. I believe it has a physical influence especially 
in suppressing painful feelings, and removing fatigue sen- 
sations. I would therefore make use, at one and the same 
time, of both influences, the mental and the physical. In 
some cases the physical and in some cases the mental in- 
fluence predominates. To illustrate, a patient is directed to 
come daily at first to the physician’s office. The patient’s 
symtoms, we will say, are headache, insomnia, backache 
and fatigue. The static douche and sparks are used, the 
present and future effect expected insisted upon ; if possible 
the patient is not allowed to leave until some, or complete 
relief has been obtained. The beneficial effect of drugs 
should not be neglected. Often sedatives like bromide are 
valuable. Gouty and rheumatic tendencies should be cor- 
rected, and the diet carefully regulated of course when dys- 
peptic symptoms exist. 
My plan is to take each symptom individually in turn, 
no matter in what part of the body it may be, and by ap- 
propriate therapeutic agents to endeavor to dispel it as fast 
as it appears. 
In some but rare cases of hysteria it may be necessary to 
go down to the lowest strata of consciousness, and for this 18 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
purpose the hypnotic state may be necessary. One advan- 
tage of hypnosis in such cases as this, is that in this state 
we can often learn from the patient the causes and origin of 
symptoms which in the waking state are forgotten. For 
example, Miss F. suffers from attacks of pain in the left 
side, with various other symptoms, coming on under peculiar 
circumstances. It is related in hypnosis that they all date 
from a certain episode involving an emotional shock. The 
psychical character of such pains is at once demonstrated, 
and their removal facilitated by suggestion. Many such in- 
stances might be cited. 
A further value of hypnotic suggestion is that you are 
sometimes able to make in the hypnotic state criticisms of 
the patient’s habits which will be resented in a waking state. 
Ordinarily hypnosis is not necessary. Besides suggestions 
directed to the individual symptoms, others should be given 
directed to the state itself. For example, that there is no 
real disease at all, only a lack of harmony in the working 
of the system, according to the view taken by the physician, 
always being particular to state the truth and exactly what 
the physician believes. Suggestions should also be given to 
counteract fixed ideas, fears, apprehensions and expectations 
of the patient, and by such suggestions to anticipate future 
accidents that may arise. 
Avoidance of artificial cultivation of symptoms.— 
Just as education is a most potent factor for good, it may 
have an equal influence for evil. Caution is therefore most 
desirable against unintentionally suggesting all sorts of pos- 
sible evil consequences that may result either from the ac- 
tions of the patient or from the disease. The physician 
should be cautious against suggesting himself, or allowing 
others to suggest, either directly or by innuendo, that fa- 
tigue, pain, insomnia, or any discomfort, will be likely to 
supervene under certain circumstances, and above all that 
any real lasting injury can be done the patient by any effort AND CERTAIN HYSTERICAL STATES. 
19 
of any kind. This does not mean that rigid rules of con- 
duet should not be prescribed; on the contrary they should 
be, but it should be done with intelligence and judgment. 
I have seen more than one neurasthenic whose symptoms 
have been the pure result of unintentional cultivation. 
Next, educate the subject’s body and nervous system to 
do whatever it cannot do without symptoms. An educa- 
tional process of this kind is the same as that which is used 
in teaching a person in any of the arts or sports. If a per- 
son cannot walk without fatigue, he must be taught to do 
it. If he cannot go to the theatre without pain, he must be 
taught to do it. If he cannot put food in his stomach with- 
out distress, particularly when this distress represents a feel- 
ing of dyspepsia, the stomach must be taught to bear food 
without resulting discomfort. This is the opposite of the 
system which would suppress every action which cannot be 
accomplished without discomfort. Some physicians, I find, 
have a habit of restricting a patient from doing whatever 
cannot be done without pleasure and comfort. The result 
of this is that the symptoms tend to grow and increase until 
finally the restriction must be proportionately increased. 
For example, a patient who cannot walk without fatigue, a 
fatigue that is evidently false, if cautioned too severely, 
and restricted, will eventually end by becoming confined to 
the house and thus to the bed. If the cooperation of the 
patient is obtained as above, this is unnecessary. 
Finally I would say, in regard to the educational part 
of the treatment of neurasthenia and hysteria, it is most 
important that a methodical regularity of life should be 
enjoined, almost each hour of the day being filled up by 
the physician. This both for its moral and physical effects. 
To summarize once more the daily educational treatment: 
First.—Instruction in the nature of the symptoms and 
disease. 
Second.—Fixed ideas, apprehension and erroneous be- 20 
EDUCATIONAL TREATMENT OF NEURASTHENIA 
liefs counteracted, faulty habits of temperament and char- 
acter corrected. 
Third.—Individual symptoms suppressed by electricity, 
suggestion and other therapeutic agents. 
Fourth.—Rules given for the conduct during the sue- 
ceeding twenty-four hours. 
Food and Nutrition.—When faulty nutrition exists of 
course it must be corrected on general principles of health. 
We cannot expect permanent robust health with endurance 
for bodily activity so long as the body is underfed. For 
this purpose my plan has been to give five to six raw eggs 
daily in addition to the meals, one between each meal and 
one immediately after each meal on leaving the table, and 
one at bedtime. The eggs are to be swallowed whole with- 
out the yolk or albumen being broken. This is a trick 
easily acquired. Any other form of nourishment may be 
substituted, but this is the most practical. Increase of 
weight, it must be remembered, is an adjuvant or cooper- 
ative factor, not the end sought. 
Rest.—A certain amount of rest must be given. What 
amount of rest is required? Absolute and continuous rest 
I have of late years rarely used, excepting in cases that are 
already more or less bed-ridden. I find it not only unne- 
cessary but a distinct disadvantage in the majority of cases. 
The only advantages are : First, the moral effect. This may, 
if properly made use of, be great; but I cannot help thinking 
that the same moral effect can be obtained in a more straight- 
forward way by appealing directly to the intelligence of the 
patient. Second. When severe dyspepsia is present it ena- 
bles us to get along with smaller quantities of food while we 
are educating the stomach to take larger quantities. The 
disadvantages are distinct. (A) At the end of a period of 
four or six weeks we have, in addition to the fatigue of the 
disease to contend with, the weakness from prolonged rest. 
(B) It tends to cultivate habits of fatigue and other ner- AND CERTAIN HYSTERICAL STATES. 
21 
vous symptoms after effort. (C) Absolute rest requires 
the constant attendance of a skilled nurse, whose qualities 
are not easy to obtain, and the more continuous attendance 
of the physician. (D) It requires massage and electricity 
to counteract the deleterious effect of rest. (E) It taxes 
the ingenuity of the physician to fill up the time. (F) We 
lose much time in beo-innino; the educational treatment of 
the patient, in teaching self-control and breaking up faulty 
habits. (6) It is unscientific and unnecessary. 
But some amount of rest above that of a night’s sleep a 
patient must have, and for this reason : there is a limit to 
the endurance of every person. The average person per- 
haps finds eight hours’ sleep sufficient, giving sixteen hours 
to the wear and tear of life, or fatigue-producing occupa- 
tions, including pleasures. Of these sixteen, nine can be 
used for actual work and the remaining seven for recreation, 
exercise, feeding, etc. But the seven thus spent are also 
fatigue-producing hours. Now the essence of neurasthenia 
is a lack of endurance and easily induced fatigue, with 
delayed recuperation, so that a neurasthenic, instead of 
being able to give sixteen hours, can only spare eight or 
ten to fatigue-producing occupations. It is therefore neces- 
sary to cut down the day hours during which a neurasthenic 
is exposed to the wear and tear of life, including pleasures. 
Now when fatigue has been produced it does not matter 
'whether it is true or false fatigue—the patient is incapaci- 
tated for further exertion. I have always found it useless 
to push patients when this point is reached; if it is done 
the result has almost always been disastrous. The patient 
can be educated or trained but not pushed, just as an oars- 
man can be trained to do a double amount of work but he 
cannot be pushed at first beyond his strength. 
The rule I would make then, is this. Divide up the 
day into alternate periods of rest and occupation. See 
that sufficient rest is given, taking the peculiarities of the 22 
EDUCATIONAL TREATMENT OF NEURASTHENIA. 
individual case into consideration; and having done this, 
see that the occupation periods are utilized in training the 
body and mind. Instead of absolute rest then I would 
insist on the opposite or active use of the nervous system 
for certain periods of time. It is important that the hours 
of the day should be actively filled up with little time left 
on the hands of the patient. 
The principle is, see that enough rest is given, and being 
satisfied of that, see that the remainder of the time is spent 
in education and training, and provide as much hygienic 
occupation as the patient will stand. If a neurasthenic can- 
not sit up ten minutes, she can one, which will soon become 
ten. If she cannot drive twenty minutes she can ten.