An acute case of short duration dating from a serious crisis (such as an operation or accident), which is now over, will get well quickly; a chronic case of long standing, with, it may be, the main cause (such as trouble in family life) still operative, will recover very slowly.

It is usually possible to convince a patient of complete understanding of the condition, and to promise some alleviation. Then the moment any trace of improvement has been admitted we must play it for all it is worth; for, as a rule, the true neurasthenic welcomes any vestige of improvement, which the hysterical patient would equally resent.

So far we have considered what almost amounts to the psychical aspect of treatment. Without it purely physical treatment will rarely succeed, though the converse holds equally good, that psychical treatment without the physical is usually a failure also. In psychasthenia physical treatment is, of course, useless: in hysteria, physical treatment which falls short of physical punishment will only tend to confirm the hysterical phenomena.

In treatment it is a fatal mistake to confuse hysteria and neurasthenia. For a hysterical patient by all means let the physical treatment approach as near punishment as may be in safety. A really heavy pummelling at the hands of an expert masseur may be beneficent, and the patients should get all they can stand, short of precipitating an outbreak. "Let us have no nonsense about it; I have got to give you a thorough good dose and you have got to lump it" may suffice to cure an attack of hysteria, though the writer prefers psychical treatment to physical for these patients.

In the treatment of neurasthenia these tactics are fatal. The illness is due to fatigue: the massage must soothe and rest, it must not add to the fatigue. No neurasthenic should ever require to rest after massage owing to fatigue or exhaustion; the desire for rest should be based on the wish for freedom to enjoy to the uttermost the luxurious sense of ease, comfort, and peace that follows the visit of the masseur. The visit and the subsequent hour or more should be the brightest spot in the patient's day. If we wish to attain this end the first law in treatment must be: -

Only the most gentle movements possible are to be performed; any irritating (so-called stimulating) movements are to be prohibited.1 A necessary corollary may be called the second law of treatment: -

Any point that is tender or hypersensitive is the last that should receive attention. Many cases have been brought under the author's notice in which treatment has failed owing to neglect of this law. Most neurasthenics have some area of the body on which it is impossible to perform any massage movement without producing a sensation of irritation. A single touch on this area may undo the good of half an hour's previous work. A patient who develops neurasthenic symptoms after an abdominal operation serves as an example. The symptoms will probably be attributed by the patient to pain in the scar. There may be pain of course, but its measure is central, not peripheral. Abdominal massage is ordered; it may well suffice to render the patient's condition far worse. Massage treatment should begin on the back, and, if necessary, the legs, arms, and head may be treated. Not until the patient can submit in perfect tranquillity should the abdomen be touched, and even then the site of operation must be avoided till the last. One of the signs of progress is the gradual approach to the area of chief discomfort. It is a progress the patient can note, and the "I could not have let you touch me there a week ago" is a sure sign of future success.

1 This and the following two laws of treatment are quoted from a paper by the author read before the Medical Society of London, and published in the Practitioner, January, 1914. Much of this paper is here epitomised; the paragraphs placed in quotation marks are quoted in extenso.

Details as to the exact nature of the movements which should be employed cannot be given, as of necessity they vary with each case.

The third great law of treatment is: -

The actual nature of the massage movement performed is of minor importance provided it is rhythmical.1

"'I shall never forget the marvel of the rhythm,' was the farewell remark of one of my patients, and I would submit that herein lies the whole secret of success in the treatment of neurasthenic patients by massage.

"An American physician . . . wrote to me recently to say, that if a patient complained of any obscure pain, his one test as to whether or no it was due to organic trouble rested on the result of massage such as I advocate. 'If,' says he, 'the pain persists in spite of massage, some organic lesion must be present.' I do not venture as far as this, but there is much truth in the statement. If we remember a fact, the truth of which I have proved in many hundreds of cases, viz., that the pain even of fracture can be relieved by massage, then the claim to give relief if no organic lesion is present seems less ambitious.

"The massage I advocate consists solely of a rhythmical stroking of the surface of the skin, and the lighter the stroke the more effective the massage. 'Light as a caress'. . .is the description given by the great author of this method of treatment. He invented the treatment for cases of fracture only, and has left it to his disciples to develop his method for the treatment of other complaints. I am proud to recall that he referred to me as his 'English disciple,' and deputed to me the task of preaching his gospel of healing in this country. He knew my views intimately, and I had hoped to submit this paper to him for approval, and to claim his endorsement of the statement that the rhythmical nature of the movements is not less important than their gentleness. The death of Lucas-Championniere has dissipated that hope, so I can only give you the assurance that, under happier circumstances, his approval would not have been withheld.