CHAPTER II
THE MORNING HOURS

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 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 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 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.