When the attack is established there are three main features - fatigue, depression, and irritability.

The fatigue of the neurasthenic is genuine; there is a real muscular asthenia due to deficient innervation. It is true that the neurasthenic can, in a moment of emergency, exhibit considerable powers of endurance; but so can a patient who is failing in the later stages of diabetes, consumption, or other chronic conditions. But whereas in the latter instances the effort may hasten the end, in the neurasthenic it only tends to increase the severity of the symptoms. Thus the common advice of "pull yourself together" is really the worst that can be offered, and many victims owe their downfall to the mistaken sense of duty which has impelled them to "pull themselves together" instead of "giving in" while the condition was not yet serious. The fact that the muscular asthenia is present tempts us to strengthen the muscles by the prescription of exercises. There could be no greater error in treatment. The muscles themselves are healthy, it is their innervation that is at fault. The expenditure of nervous energy in the performance of exercises will inevitably push the patient further down the hill. When the nervous system is rested and its tone restored, muscular strength will return, and the general toning up of the muscles may be completed by exercises or, preferably, by the use of the Bergonie chair, which entails no risk of tiring a nervous system that has only recently recovered its stability.

It has been stated that the depression of the neurasthenic "is the reflection in consciousness of the plaint of the cellular aggregate, suffering from the deficiency of vegetative life." This supposes each cell of the body to be endowed with the mental attribute of a complete and separate entity - that each cell, conscious of weariness and the depression which accompanies it unless counteracted by some all-satisfying attainment, sends up, as it were, its plaint of weariness to the brain. There, under this theory, is received an overwhelming avalanche of ceaseless complaining from millions of cells. Small wonder, then, that there is depression and that life is surveyed with "a sort of mental squint." The depression is often reflected in the facial expression; so much so, indeed, that Charcot recognises it as the casque neurasthenique.

The irritability is also similarly explained. It is incredible that the mind should not suffer thus, and, unless exhaustion is too great, it is necessary that physical irritability should be its outward sign.

It is easy to understand that the combination of fatigue and depression should lead to fantastic ideas to account for the sensations experienced; and, when we add thereto the constant liability to perverted somatic stimuli, nothing should surprise us in the way of phantasms, phobias, doubts, or misgivings. These patients are not mad; they are merely victims of their sensations. When vaso-vagal storms are added, the sufferers' condition is parlous indeed, and well may they adopt what we may call the neurasthenic's creed: "This too is vanity and vexation of spirit. Vanity of vanities: all is vanity!"

If this is the picture of the neurasthenic, how can we compass alleviation of the symptoms? The first obvious thing to do is to enforce rest. Bed, and bed alone, may suffice. But bed alone may only serve to aggravate the mental symptoms, whereas sometimes peace and comfort can be attained without insisting upon absolute rest in bed. It is often a most unwise move, and particularly if we are dealing with severe insomnia, to dump a patient straight into a nursing-home. Not infrequently this unexpected course acts most deleteriously. If "home conditions" are possible it is often well to make a start, at least, without change. It is, however, essential to insist upon the minimum expenditure of physical energy.

The faulty innervation of the stomach, and the consequent inability of the organ properly to empty itself, renders digestion difficult and there is loss of appetite. Hence all these patients require to be "fed-up." But many have been under-fed for weeks, or it may be months, and over-feeding may do much more harm than good in the early stages of treatment. Encouragement will succeed: force will fail. So, too, the nurse who reports, "The patient made a poor breakfast but really seemed to do her best, and I am sure she will do better in a few days," will succeed; but failure will be the reward of the report "I could not get the wretched creature to make the smallest attempt to eat anything, although I badgered away for half an hour."

The patient invariably is endowed with the disconcerting idea that "no one ever had such an illness as this," and is therefore convinced that no one understands the condition. Hence follows distrust of doctor and nurse alike. Only too often previous experience of both has justified the opinion. So our next duty is to win the patient's confidence, and, to do this, conversation must be encouraged. As the "tale of woe" is unfolded in a "pitiful minor key" it is possible to point out how natural has been the sequence of events and how simple in reality is the explanation of the symptoms. There are three golden rules: - never to lie to a patient, never to forget what the patient has said or what has been said to the patient, and never to promise the impossible. Let us also remember that the average neurasthenic is no fool, but is usually a most highly intellectual individual for the state of life to which he or she has been called.

The illness is characterised by wave-like variations, and it is well to forewarn the patient of the fact. Peace and happiness will return in the evenings before they do so in the mornings; good days will become more and more frequent, bad days fewer and further between. The disappointment of a "bad day" after a few "good days" may throw a patient right back unless warning of the inevitable "wave" has been given. The barometer has a potent bearing upon "waves."