It has been said that only those who have been victims of neurasthenia are competent to treat it. However valuable may be the experience, it cannot be regarded as essential, though only those who are capable of appreciating the sufferings of their patients should undertake their treatment. To some minds the illness seems to be quite incomprehensible, and so it comes about that not all masseurs are temperamentally fit to deal with this class of case. For their own credit, no less than for the sake of their patients, they would be well advised to recognise their incapacity and refuse to undertake the work.

For treatment to be effective there must be a clear understanding of the condition that exists, how it has developed, and what progress should be expected.

There is a tendency, not only among the laity, but even among medical men, to despise the neurasthenic. The idea seems to be deep-rooted that, because a patient fails to produce physical signs to account for the symptoms, therefore the whole illness is imaginary. Those who hold this view would be not a little incredulous if they were told that they had suffered from neurasthenic symptoms themselves, yet so it is. We are all neurasthenics at times, though for most of us the attack is transient, thanks to the provision of recuperative power by a merciful Providence. The most unlikely subject for an attack may go for a long day's tramp, shoot, or golf. He comes home, has a hot bath and a good dinner, and then sits down in front of the fire to read. He feels in his pocket for a pipe and finds it is upstairs. A wave of irritation passes over him totally out of proportion to the cause, and he experiences for a brief moment one of the symptoms of neurasthenia. This victim goes to bed, has a good night's sleep, and the attack is over; but let him pass a restless night, and his irritability next day will be very marked. Repetition of a few more strenuous days without adequate rest, and appetite will fail, trifles will begin to worry, and many of the symptoms of a neurasthenic attack will be well established.

Most of us know the "good-for-nothing" feeling that follows an attack of influenza, tonsilitis, or other infective illness, and have experienced the irritability that accompanies it. Any trifle is liable to annoy, everything fatigues. If recuperative power is good, these symptoms soon vanish. But imagine the poison to have bitten a little deeper, magnify this irritability and fatigue, and we can appreciate that the neurasthenic symptoms might be very serious. If people would only realise the necessity of allowing adequate time to pass in order to ensure complete recovery after an attack of influenza before resuming work, there would be less neurasthenia.

The psychical state produced by anxiety or trouble can supply symptoms which exactly correspond to those that follow sepsis, and are more or less familiar to most of us. Magnify the experience common to us all, and we see the picture of neurasthenia.

Neurasthenia is not an illness of imagination, and, if we want to discover the cause of the illness, we must take into consideration the whole of the patient's circumstances, his whole life, which Herbert Spencer described as consisting of "the definite combination of heterogeneous circumstances, both simultaneous and successive, in direct combination with external co-existences and sequences." If we take the trouble to do this, a careful study has shown that, far from despising the neurasthenic, we are often compelled to admire the pluck and determination that has postponed the final crash for, it may be, years. In the first place, then, if we wish to treat neurasthenics at all, let us extend to them sympathy begotten of a full understanding of the cause of their attack; and our respect when, as is so often the case, they have merited it by the fight they have put up against their symptoms. There must of course be no maudlin sentimentality in our attitude to our patients, which must be moulded only by appreciation of their past and present state.

Most writers on neurasthenia are agreed that the diagnosis cannot bo justified unless there is fatigue. This may be due to physical or psychical exhaustion, or to any cause that saps vitality, the chief being chronic sepsis or some acute general infection. Fatigue of the nervous system simply amounts to this, that the nervous energy remaining is inadequate for all the needs of the mind and body. The highest centres, being the last to develop, and therefore being the most intricate, suffer first; and so the mentality of the patient "gives out" and the perspective of life is lost. To quote from Lewis Carroll, the neurasthenic tends "to look at all things with a sort of mental squint."

As the illness advances, the "lowering of the amount of the nervous potential that is available for the use of the organism," as Maurice Wright expresses it, leads to "deficiency in the innervation of the bodily functions," and we find that such troubles as indigestion and constipation develop. The stomach is not diseased. The deficient innervation has led to loss of muscular tone, the stomach fails to empty itself as it should, and the patient suffers from flatulent dyspepsia, often apparently accompanied by hyperacidity. The patients at any rate very commonly dose themselves freely with bi-carbonate of soda, and most claim that they have benefited from it. Whether this is due to "faith" or to the actual action of the alkali I do not know. The muscles of the lower bowel also lose their tone, simply from lack of adequate nerve control. Then we see the possibility of two of the vicious circles of neurasthenia. The nerve fatigue interferes with digestion, absorption is deficient, nutrition fails, and the nervous system fails further in consequence. So, too, the nerve fatigue interferes with normal defaecation, septic absorption takes place, and the poison further lowers the vitality of the nervous system. The onset of insomnia adds another very serious item, which can take its place as a potent factor in any of the numerous vicious circles it is possible to describe.