In getting the history of patients for diagnostic purposes the safest way is to begin with the getting up in the morning and then to follow out the various actions of the day. The hour and mode of rising should be inquired into. Practically all nervous people, and nearly all those beyond middle life, feel less fit in the morning hours than at any other time in the day. Apparently as a consequence of their will having been allowed to lose its hold during sleep, it does not secure thorough command over the organism for some time. Nervous people, as a rule, wake up with a tired feeling, a dread of the day, wondering whether life is worth living. They dread—for it is a real dread—to get up and tackle the daily round of life once more.

If they have nothing very definite to do, then slight tired feelings or discomfort, even of very minor degree, may lead them to think that they cannot get up. Any yielding in this matter is almost sure to do harm. When there are no objective signs, that is, when there is no fever recognizable by the thermometer and there has been no diarrhea or any physical weakness, nervous patients should get up promptly at a particular hour every morning, because, as a rule, within a half hour after getting up they feel better, and by the time they are washed and have had their breakfast, life has grown not only quite possible but even plausible, and the day's work does not seem such a nightmare as it was at first. It is not advisable to tell people all this as soon as they confess their habit of dawdling in the morning, for they must be gradually brought to discipline themselves. The detail emphasizes the necessity of knowing how they get up as well as when.

Mode of Awaking.—It is often valuable to know how patients awake. Sometimes it will be found that they are anxious and solicitous to be at work at a particular hour, or to catch a train at a particular time, and that as a consequence their sleep is disturbed in the early morning hours. At best it may be fitful and when they awake they fear to go to sleep again lest they oversleep. An alarm clock will sometimes remedy this state of affairs. Better still is an arrangement by which someone, who can be depended on, will wake them at a particular time. Occasionally patients cannot content themselves in spite of the assurance that they will be waked. They dread that the alarm clock may not go off, or that the awakener may make a mistake, and so they go to bed with a dominant idea, which is more or less constantly present in their mind during all their sleeping hours, disturbing sleep and preventing complete rest. It may be necessary to insist on a change of occupation for such persons, or a change of residence that will do away with the necessity for early rising. When this is done, many a neurotic condition that has before proved intractable will disappear.

Amount of Sleep.—It is of cardinal importance to know how long patients sleep. In our large cities most people have too little sleep. A comparison of the hours when they get to bed with those when they get up will often show that at least three or four nights in the week some patients who are complaining of nervous symptoms, especially nervous indigestion, are {166} sleeping less than seven hours. There are but few men, and still fewer women, who will retain their health under such conditions. Some men have been able to do it, but they are comparatively rare. King Alfred's rule of dividing the day into three eight-hour periods—one for sleep, one for work, and the third for bodily necessities and recreation, still remains the best for human nature. Whenever people try to live the strenuous life and get along on less than eight hours of sleep, they are almost sure, sooner or later, to render themselves uncomfortable, to make themselves liable to all sorts of neurotic symptoms and, above all, to detract from their efficiency for whatever work they are engaged in. Whether they sleep or not, they should be in bed for nearly eight hours.

Bathing.—Morning Bath.—In our larger cities at least, many of the inhabitants begin the day with a bath. In this matter one finds all sorts of harmful fads that need to be corrected. Many men take a cold bath, and unless they are particularly strong and vigorous, this is rather an exhausting experience for the beginning of the day, when the last nutrition the body absorbed is twelve hours before. On the other hand, large, athletic men who manufacture a great deal of heat, their muscles—the heat-making organs—being well developed, will be benefited by having a cold bath because of the abstraction of heat that it involves. It is not, however, infrequent to find that the man for whom it will be good is not taking it, while the thin, neurotic individual, already exhausting more of his vitality by worry and dieting and in various fads with regard to his health than is good for him, is regularly taking his cold plunge or douche. Unless especially asked about it, few men give particulars in this matter, yet they are extremely important.

Women, on the other hand, are likely to take hot baths more frequently than is good for them. Especially when they have maids to assist in dressing and undressing, it is not unusual to find that women take two, and sometimes even three, hot baths in a day. They take them in the early morning when they first get up, and in the evening before dressing for dinner. I have known cases where some took a third hot bath before going to bed and sometimes even put in a fourth before luncheon in case they had had any exercise in the morning hours—tennis, or horseback riding, or the like—that made them perspire. These are details which the physician will learn only if he asks particularly about them. Until he has actually had the experience of finding that they play an important role in some ailment he is almost sure not to think of it. It is probable that even two hot baths a day are too many. I have known women to begin at once to get better of neurotic symptoms that before had proved quite intractable, when their hot baths were limited or when they were changed for a single warm bath with a cold rub after it in the morning, or sometimes just before dinner.

Bathing is more liable to abuse than is usually thought to be possible. While the habits of modern life call for it often, and many people are quite sure that they would not be healthy without it, the people who live longest, and who have had the best health far beyond three score years and ten, have usually not been noted for bathing proclivities. The human body is composed of nearly seven-eighths water, and so our cells are constantly bathed in it, but the making of the whole organism a marine animal once more, as seems to be the definite tendency of some people, is not nearly so hygienic as {167} it is often thought to be. Enough bathing for thorough cleanliness, but not for luxury, must be the rule for people who have active work and want to retain their health.

Bathing Fads.—While such mistakes are usually made only by the wealthy and leisure classes, the physician will sometimes be surprised to find that women who have no maids for personal service are indulging themselves in these over-frequent bathing practices. They have heard that it softens the skin and renews youth, or they have heard that the Japanese take hot baths and are revivified when they are very fatigued, and so they go to great lengths in bathing. Often this is the main reason for the relaxation of muscle tissue and the sense of prostration that has come over them. Neurotic people are constantly going to extremes. Even delicate women will sometimes be found to take very cold baths which are surely doing them harm. Over frequent washings of hands and face are sometimes responsible for skin lesions, especially if the soap used is one of the varieties so scented that the manufacturer is enabled to conceal the impurities in its ingredients. Some women easily run into what is really a misophobia, an exaggerated morbid fear of dirt, and need to be restrained from washing themselves over frequently. Many a chapped hand would be saved by avoiding unnecessary washings, and especially in warm water just before one goes out, for it leaves the skin without its proper oily protection.

Clothing.—Then comes the question of clothing. It is curious how irrationally many people clothe themselves. People complain of cold hands and feet when they are wearing thin cotton undergarments, and who need only to have these changed for wool for their feelings to be at once improved. In the meantime they have been persuaded that they have a defective circulation. The usual excuse for not wearing wool is that it produces hyperemia of the skin with itchy discomfort, but this, as a rule, is only passing and is due to unaccustomedness. The coarser wools should not be worn by the sensitive. A thin cotton garment may, if absolutely necessary, be worn next the skin. There is too little variety in the underclothing that people wear. Some change from light to heavy weight and only that, but there should be a medium weight worn, and occasionally, when there is a spell of mild weather in the winter time, even during the season when heavy weight is usually worn, medium weight should be substituted for comfort's sake.

It is even more common to find that neurotic individuals, who fear to catch cold, wear too much clothing, especially around the chest. Very often they alternate from this during the day to next to nothing in the evening, and by so doing subject themselves to special risks of internal congestions. When the skin is covered with too much clothing it loses the habit of reacting, and the warmth and the irritation of wool keep up an artificial hyperemia which gradually lowers the tone of the peripheral vessels. Many people wear "chest protectors," as is evident from the prominent display of these abominations in the drug-store windows. By leaving certain portions of the chest unprotected while other parts are kept over-warm, these add greatly to the risk of such disturbances of circulatory equilibrium as predispose to the infections grouped under the term "taking cold." It is not heavy clothing that keeps people warm so much as the layers of non-conducting air between the skin and the outer air. It is better, therefore, to wear three thin {168} garments than two heavy ones because of the additional layers of air that are thus confined. A paper vest, if one is driving in the wind, will probably protect better than the heaviest woolen garment worn. The wearing of chamois garments is not, as a rule, advisable because chamois does not permit free access of air and it hampers transpiration.

Before Breakfast.—After dressing comes breakfast, with regard to which it may be advisable to ask many questions. It is well to begin with a query as to whether liquids are taken before breakfast. Many people have taken to the fad of drinking a large quantity of warm water, sometimes as much as a pint, before breakfast. Surely this never does any good and, in most cases, just as surely does harm. Plain water will not dissolve mucus that may have collected in the stomach, and warm water merely dilates that organ, relaxes its fibers, and renders the whole gastric digestive system atonic. If cold water can be borne, it will often be found that a glass of cold water the first thing in the morning stimulates peristalsis, and serves to lessen the necessity for laxatives. Many people complain that cold water is too much of a shock. Usually, if they are reminded that when we want to warm our hands we rub them vigorously with cold water and that the reaction after this gives a healthy glow, the effect of the supposed shock, which was merely an unfavorable suggestion, will disappear. Sometimes delicate people cannot drink cold water. If there is any reason to suspect an accumulation of mucus in the stomach, a small bouillon cup of very hot water, just as hot as it can be borne, in which a pinch of salt and a pinch of bi-carbonate of soda have been dissolved will prove an excellent aperitive for the day. This is physiological and appropriately chemical, as well as naturally stimulating. Mucus does not dissolve in ordinary water but dissolves readily in an alkaline salt solution, and this is just what is thus recommended. This drink is quite grateful to the palate. Indeed, it tastes very much like clear soup, and, if the eyes are closed, cannot, as a rule, be distinguished from some of the bouillon commonly served. I have known this cup of hot water to stimulate an appetite when drug tonics had failed.

It is better to take the glass of cold water from fifteen to twenty minutes before the morning meal—say immediately on rising. If, instead, the small cup of hot water is chosen, it should come immediately before eating, and will usually prove an appetizer.

Breakfast.—The exact details of the amount of breakfast taken and how it is eaten should be known. Nervous people eat little breakfast. When ordered to eat, they find it difficult at first, but the habit is easily formed, and then they want their breakfast like anyone else. It is surprising how often physicians will find that nervous persons, who are under weight, are not taking enough breakfast. They will ordinarily say that they are eating breakfast about as other people do and will, perhaps, mention eggs and rolls, but it will be found that their ordinary breakfast consists of a roll and piece of toast and coffee, and only occasionally do they have any of the other things mentioned.

Breakfast is ordinarily the meal which those who work are likely to eat too hurriedly. Those who are neurotically inclined are especially victims of the habit. They lie abed until there is only a few minutes left to get the train so as to reach their place of occupation in time, and thus their breakfast is {169} skimped. Their oatmeal or other soft cereal is fairly shovelled in, coffee is gulped, toast is unchewed, the coffee softening it; if they have creamed potatoes they are swallowed in such large pieces that, as every physician knows, if for some reason they vomit they are surprised, beyond all measure, at the large portions they have been able to pass down into their stomachs. A breakfast thus eaten makes a bad beginning for a nervous man's day, and the more that is so eaten the worse for the victim. With a habit like this, it will be utterly impossible by means of drugs or directions as to diet to relieve the discomfort of neurotic indigestion, or to keep the patient from suffering that stomach discomfort so often complained of in the morning.

Working Women.—Working women are even more prone than are men to take a hurried breakfast, and having, as a rule, less appetite than men, their meal is likely to be deficient. It is not unusual to find that a young woman who is under weight and who needs three meals a day, is taking so little for the first meal that even she hesitates to regard it as a meal. Very often her last previous meal has been taken before seven o'clock the night before, so that she goes out ill prepared for her day's work. Much more than men, women are annoyed in the morning by our transportation systems, and by worry as to whether they will get to the office on time. Suggestions as to the modification of this unfortunate routine, the taking of an earlier train, the using of a quiet local instead of a crowded express, a short walk at least before taking the train, will often help in producing a marked change in the general health.

Home Keeping Women.—For those who really have homes, the morning duties are usually sufficient to rouse their activities and make them begin the day well. For those who live in apartment-hotels, however, and for those who have the luxury of many servants, the morning hours are often a serious problem. Madame does not get up, or if she does, it is only to lie around in dressing gown for most of the morning. Breakfast is easily neglected or may be eaten hurriedly because the head of the house is rushing to business. The lack of an incentive requiring them to rise, and get outside for a time every morning, is probably at the root of more feminine symptoms among leisure class patients than anything else. As we grow older all of us are likely to note the lowered physiological cycle of the morning hours, so that unless there is some sharp reason to compel action, we are rather prone to persuade ourselves that it is better to lie abed, or at least to loll around. This leads to a concentration of attention on self and on one's feelings that easily gives rise to neurotic conditions.

Interest in life.—In my special clientÉle I have often found that going to church in the early morning hours was an excellent remedy for many of these patients. It gives them a definite reason for rising promptly, the service provides motives to rouse them to activity, they are likely to think during it of how they shall make their life a little bit more livable for others as the result of their trying to be better, and so the apathy that is so fruitful of ill feeling is shaken off. This can only serve for those who have faith in the service. For others, the old-fashioned going out to market, or the making of appointments at morning hours that will tempt them to regular activity early in the day, is of special significance. It is always ominous for health when a woman can look forward to a whole long day without any particular duties {170} in it until the late afternoon or evening hours. This has become so frequently the case for the women of our large cities, particularly those who live in apartment hotels, it is no wonder that neuroses and psychoneuroses of various kinds have grown in frequency. The best prophylaxis for them is occupation of mind. The cure for them is the securing of many interests and such diversion of mind as will prevent concentration of attention on self.

Mail Before Breakfast.—Many people receive their most important mail in the early morning, and personal mail, in cities especially, is likely to be placed beside the breakfast plate. Not infrequently, letters contain serious matters that are likely to disturb people, and occasionally even important business finds its way to the side of the plate at breakfast time. Authors often find their rejected manuscripts sent back in the morning's mail. Occasionally bad news of other kinds comes in this way, and, as a rule, it is the very worst time for its reception. The human system—it cannot be too often repeated—is at its lowest physiological term in the morning, the temperature is lower than during the rest of the day, all the nervous vitality is below the normal. Half an hour after breakfast the reception of bad news, or the coming of important matters requiring decision, would not make so much difference. Hence, the necessity for knowing whether the mail is ordinarily read in the early morning, in order to know something about people, and about the consumption and digestion of their breakfast.

Company at Breakfast.—Pleasant company during meals is an important factor that makes for good digestion. At the other meals there is much more likelihood of having such pleasant company, while the morning meal is often a solitary, and quite as often as not, a rather glum quarter of an hour, preoccupied with the business cares of the day. As may be readily understood from our discussion of this problem of mental preoccupation during digestion, this may seriously hamper digestive processes. Often men take refuge in their paper. The thoughts aroused by reading the modern newspaper are not the pleasantest in the world and consist, very often, of the following out of details of hideous crimes and scandals. When, as is sometimes the case, these scandals concern relatives, friends or acquaintances in whom we are interested, and with regard to whom we feel poignantly because of the publicity involved, nearly the same effect is produced as when bad news is received in letters, or when business worries are thus brought to the breakfast table.

The best conditions for the eating of breakfast are those in which it becomes like the other meals, a family matter. When father, mother and children eat their breakfast together, nearly always family interests and especially the enlivening effect of the joyousness with which children face a new day is the best possible tonic for a business man in whom a solitary breakfast starts a day of digestive disturbance. Sociability and sufficient time must be insisted on, whether at home or in a boarding house, at breakfast as well as the other meals, and it will often be surprising to find how much difference this makes both as regards the quantity eaten and the digestion of the food.

Morbid Habits.—In matters of diet, it is important to ask for details, for it is surprising what unexpected things may be discovered after weeks of treatment. That was illustrated for me once by a case of persistent acne in a young girl, which all the ordinary remedies failed to cure. I felt sure that {171} I had given her such explicit directions with regard to diet that I knew exactly what she was taking and that nothing could be hoped for from any change. As a last resort, I asked once more with regard to all that she ate and only then discovered that before breakfast every day she ate a baked banana. It had been recommended to her by a friend as a sure cure for constipation, she had formed the habit of taking it as a medicine, and so had not spoken of it. Baked bananas agree with many people well, but just as soon as this was eliminated from her diet her acne began to improve and before long had disappeared almost entirely. The taking of large amounts of warm water, already spoken of, is another of these morbid habits. Then many people take a glass of salt water, or laxative water, and some have curious habits with regard to the eating to excess of salt on cereal or on fruit, or sometimes they eat too great a variety of fruit. All this should be known, but often will not be ascertained unless particularly inquired about.