HX64121925 RC341 .As3 The problem of nervo " NERVOUS BREAKDO EDWIN ASH, M. D, RECAP m 'f^dSA R' Culimtbia ^nito^itp itttlieCttp 0t Jletogorh THE PROBLEM OF NERVOUS BREAKDOWN Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/problemofnervousOOashe THE PROBLEM OF NERVOUS BREAKDOWN BY EDWIN LANCELOT ASH DOCTOR OF MEDICINE NEW YORK THE MACMILLAN COMPANY 1920 Copyright in the British Empire by Mills & Boon, Ltd. FOREWORD rriHE concern alike of doctors, nurses, social workers, -L care committees, schoolmasters, military authori- ties, prison ofl&cials, and others who have frequently before them questions which can only be efficiently answered in the light of some understanding of its vari- ous bearings the problem of nervous breakdown is to-day of great importance. Hence, anyone who has had special opportunities of studying the mind and nervous system in health and in disorder may weU feel desirous of placing his experiences and conclusions before the widest possible circle just now. The kind reception of my earlier work, Nerves and the Nervous — out of print for some time since — has encouraged me to write this book, the purpose of which is to review the problem as it affects the individual and as it concerns the State ; to discuss the origin of the more common disorders, and to indicate in what direc- tions it is possible for us to redress the balance in favour of nerve and efficiency. Throughout I have particularly borne in mind the difficulties of the family doctor, the trained nurse, and the anxious relative upon whose shoulders faUs the grave responsibility of bringing back those stricken in " nerve " to useful life and work. THE AUTHOR. London, W., January, 1919. CONTENTS PART I THE ORIGINS OF NERVOUS BREAKDOWN CHAPTER I THE PROBLEM STATED A_ nation's worth is based on individual nerve — The new age — ■ Efficiency the hey to success — Nerve health the key to effici- ency — Nervous breakdown a question of national importance — Stress and stram of modern life — Fo'an.dations of nervous breakdown — Inherent hardiness of human nerves — Indica- tions of failing nerve — The problem to be solved — Importance of mental control — Economic aspect of nervous breakdown page 3 CHAPTER II THE EMOTIONS Hiunan feelings — Emotional stress and nervoiis breakdown — Definition of emotion — Feeling and action — Physical accom- paniments of emotional excitement — Anger — Grief — Fear — Our feelmgs stamped on our bodies — -Higher emotions — Heart versus head — Intellectuahzing one's feelings — Personal reactions of emotions — Ways in which emotional stress causes nervous disorder — Illustrations . . . , . .17 CHAPTER III NERVOUS TEMPERAMENT Nervousness — Temiperament and character — Reaction to en- vironment — Types of temperament — The nervous tempera- ment — Temperamental blends — Normal and abnormal nerv- ousness — Eccentricity — National temperaments — Degeneracy — Genius and morbidity — The ex-Kaiser as an interesting study in temperament . . . . . . .38 viii THE PROBLEM OF NERVOUS BREAKDOWN kchapter IV SOME FACTORS DETERMINING BREAKDOWN Stresses of daily life — Work and worry — Common anxieties — Household worries — The worrjdng habit — Nerve weakness and a burdened mind — Nerves and domesticities — Strain of development ........ fage 51 CHAPTER V CONDITIONS PREDISPOSING TO BREAKDOWN [A) Occupation, Climate and Constitution Predisposing as opposed to determining causes — The prevalence of breakdown among brain workers — Influence of occupation — Strain of modern conditions — Motoring — Telephone work — Occupational breakdown in America — Climate and nemras- thenia — Debilitated effects of residence in Tropical countries — Heredity — Ancestral indiscretions — ^larriage and consan- guinity — Depleted stocks ....... 60 CHAPTER VI CONDITIONS PREDISPOSING TO BREAKDO\VN [B) Poisons, Shocks and Some Others Nerve poisons — Autointoxication — Tea, coffee, alcohol and tobacco — Drug taking — Influenza — Trench fever — Accidents and injiu-ies — Traixmatic neurasthenia — Nervous breakdown after operations — Race — Age . . . . . .71 PART II THE VARIETIES OF NERVOUS BREAKDOWN CHAPTER I FORMS OF NERVOUS BREAKDOWN Harmony of functions necessary for health — Basis of control — Central nervous system — The brain the seat of government — Ramification of nerve fibres — The term " nerves " — Nerves in disorder — The nervous tj^e — Classification of nervous diseases — Relations of nervous breakdown — Three chief groups — Neurasthenia — Hysteria — The so-called borderland — Terms in common use — Psycho-neurosis — Psychasthenia . CONTENTS ix CHAPTER II THE NEtTRASTHENIC STATE ' Neurasthenia — L'homme a petits papiers — Common neuras- thenic symptoms — The question of subgroups — Le casquet neurasthenique — Other head troubles — ^Weakening of self- control — Fear of losing reason — Stevenson's picture of col- lapse from over-work — General consequences of neurasthenia — Heart and circulation — Over-sensitiveness — Some typical examples. ..,,,... fage 89 CHAPTER III MORBID FEARS AND DOUBTS Obsessions — Psychasthenia — Obsessional neurasthenia — Web- ster's definition of " obsession " — Common forms of obses- sional thoughts — Morbid fears — Their physical accompani- ments — Agoraphobia — Claustrophobia — Siderophobia — An- thopophobia — Morbid flushing and self-consciousness — Patho- phobia — Astrophobia — Batophobia — Fears about health — Morbid anxieties — Doubts and scruples — Over-conscientious- ness — Fear of impulsive action — Some examples . . . 107 CHAPTER IV NERVOUS nSTDIGESTION Dyspepsia a common accompaniment of nervous disorder — Tone and its failtire — Digestive processes susceptible to mental influences — Definitions of nervous indigestion — Consequences of dyspepsia — Vicious circle — Characteristics of nervous dys- pepsia — Auto-intoxication — Secondary consequences — Classi- fication of cases — Mucous colitis — Common misconceptions — Treatment must be mental as well as physical. • . . 124 CHAPTER V HYSTERIA A psychological riddle — Hysteria known to the ancients — Pithiatism — Sydenham's definition — Bygone theories — Common signs of hysteria — Basis of the hysterical state — 3 ' Disorders of movement — Curious reactions — Disorders of sensation — Witch's marks — Disturbances of general health — Hysterical attacks — La grande hysterie — Illustrations . .138 X THE PROBLEM OF NERVOUS BREAKDOWN CHAPTER VI MXTLTIPIiB PERSONALITY A simple case — Morbid desire for notoriety — Dual personality — An interesting problem — Consequences — Alternating person- ality — The case of Felida X — -A clergyman's experience — Loss of Memory — The famous Sally Beauchamp — Dr. Morton Prince's analysis — Professor Janet's investigations — Simula- tion of demoniacal possession — Dangers of dissociation . page 153 CSAPTER VII WHAT THEN IS HYSTERIA ? The hysterical temperament — Its characteristics — Deficient powers of attention — Morbid emotionalism — Abnormal sug- gestibility — The spoiled child — Unliealthy dreaminess — Vain imaginings — What is hysteria ? — Discarded views — No physical basis found — Eabinski's theory — Auto-suggestion — Charcot — Janet's hj'phothesis — The Freudian School — Other theories .......... 162 PAUT III THE HYGIENE OF NERVE CHAPTER I REDRESSING THE BAIANCE Prevention of nervous breakdown — A special problem of hygiene — Not a question of destroying germs — ^Modern requirements for treatment — Difficulties of family practitioner — So-called nerve tonics — Principles of physical treatment — Electrical methods — Massage — The sick soul — Morbid introspection — Suggestion of right ideas — Other methods of treatment through mind — Fuiactional and organic diseases — The search for a reliable principle of mind treatment — Prayer . . .173 CHAPTER II THE REST CTTRE {A) General Principles Natiiral recuperative forces — The great vis medicatrix naturae — Medieval and modern medicine contrasted — The principle of rest — Weir Mitchell's rest cure — Modern modifications — Planning a rest ciu-e — Attitude of invaUd — Dta-ation — Place of treatment — Home or institution — Nursing — Qualifications of the ner^e nurse — General sui foundings - . . .188 CONTENTS xi CHAPTER IIIj THE BEST CtTRE {B) Routine Daily Routine — Sleep — Nourisliment — Massage — Occupation — A typical programme . . ~ . . . . page 201 CHAPTER IV DIET AND SOME OTHER POINTS IN CONVALESCENCE Nerve energy dependent on nutrition — Diet in nervous maladies — Personal idiosyncrases— Advantages and disadvantages of milk — A mixed diet — General principles of diet — Sugar — Cheese — Stimulants — Baths — Effects on nervous system — " Reaction " — ^Important rules — Clothing — Natural heat — Exercise and body temperature ..... 209 CHAPTER V SLEEP AND SLEEPLESSNESS The mystery of sleep — Effects on brain — An interesting experi- ment — Ability to sleep at will — Insomnia — Common forms — Causes — Fear and insomnia — Simple sleep-bringing devices — The restful mind — Some maxims . . . . .220 CHAPTER VI REST AND RECBEATION Rest apart from sleep — The rest hour — Ways of securing rest — Husbanding resources — Unhealthy restlessness — The proper ordering of spare time — Over-exercise — Common-sense and nerve energy — Rest and over- work — Recreation — Walking — Cycling — Golfing — Change of air — Sea voyages — Smoking . 230 CHAPTER VII CHILDHOOD AND YOUTH Child father to the man — Plasticity of early Ufe — The nervous temperament in childhood — Childhood fears — Night terrors — Enuresis nocturna — Hygiene of children's nerves — Diet in childhood — Mental hygiene in the nursery — Morbid sensitive- ness — Powers for work and play — Dangers of over-strain — A reasonable programme — Sensitiveness of early life^ Youth — Critical period of adolescence — Its characteristics and dangers — The psychology of young men and maids . . 240 xii THE PROBLEM OF NERVOUS BREAKDOWN CHAPTER VIII PBINCIPLES OF SBLF-HEUP The will to be well — Misconceptions about self-help — Importance of co-operation between patient and doctor — Conscientious- ness in carrying out instructions — Holding on during set-backs — Self-reverence, self-knowledge, self-control — Strengthening self-control — Exercising inhibitory power — Self-denial — Getting rid of f etir — Nerve-health and religious faith . page 268 PART IV THE BREAKDOWNS OF WAR CHAPTER I THE EFFECTS OF WAR STRAIN Strain of modern warfare — Shock from explosion — The strain of battle — Brain liable to both mental and physical assaults — Determining facts of war-strain and civilians — General worries — Raids and bombardment ...... 269 CHAPTER II SHBLL-SHOCK The wounded in mind — No new disease — A convenient term — Battle-field breakdown — Characteristics of war-neurasthenia — Typical examples — Mental shock and its consequences — Paralysis — Other limitations of movement — Astasia-abasia — Dumbness — Blindness — Deafness — Further illustrations — Mental breakdown — War-hj-steria — Psj'^chological basis of shell-shock — The outlook in war-breakdowns . . .277 Indbs . . . , . . . • • . 291 PART I THE ORIGINS OF NERVOUS BREAKDOWN THE PROBLEM OF NERVOUS BREAKDOWN CHAPTER I THE PROBLEM STATED A nation's worth is based on individual nerve — The new age — Effi- ciency the key to success — Nerve health the key to efficiency — Nervoiis breakdowii a question of national importance — Stress and strain of modern life — Foundations of nervous breakdown — Inherent hardiness of human nerves — ^Indications of failing nerve — The problem to be solved — Importance of mental control — Economic aspect of nervous breakdown. AS a field of wheat is made up of separate ears, as tlie Jl\- strength of a chain rests in its links, as the majesty of a forest resides in the trees forming it, as the beauty of a garden embraces the fairness of its flowers — so does the efficiency of a nation depend on the worth of its individual sons and daughters. And the value of the individual is in the ultimate a question of nerve. Our merit as children of empire is a matter of nerve to per- severe, to lift up OUT hearts, to endure through all that fortune brings ; and to enjoy sanely the great rewards our efforts gain. Health, nerve and efficiency — ^these constitute the grand triumvirate of human power, in- separable in their mutual influences, failing together when one fails, unconquerable when together each strengthens the other. And so it is that any prevalent set of circumstances that threatens one of these three pillars of our individual well-being threatens the security of the commonwealth and presents a problem for very 3 4 THE PROBLEM OF NERVOUS BREAKDOWN serious consideration. To-day the ubiquitous occurrence of nervous breakdown constitutes just such a problem. We stand on the threshold of a new age in which man- kind may well achieve greater triumphs than any known in the past ; we are at the beginning of an era when, inspired by the spirit of liberty, the race may take a long step forward. In this great age that is before us each individual will be weighed according to the worth of that which he can do for his fellows, and his patriotism will be expressed not only by his sense of duty towards his native country, but by the value of his contribution to the welfare of the Greater State of the World. Thus there never was a time when the capacity for work possessed by each of us had greater worth and greater potentialities for good, or when the call for efficiency in our daily lives was more urgent. For the development of aviation alone it is of the utmost national importance that a high-level of nerve be main- tained. The Prime Minister has warned us that we cannot maintain a splendid State with inferior national health ; it is quite certain that British youth can only make its grand inheritance in the air if its health and nerve be assured. Every one is agreed that the future possibili- ties of flying in the times of peace before us are immeasur- able ; let us make certain -then that no slackness prevents us helping every young man who wishes and who has any reasonable chance of becoming a good aviator from overcoming natural disabilities of nerve that at first hamper him. From the wider outlook let us remember that an improved state of nerve -health in the coming generations means in the matter of flying alone an incalculable national asset. There is no need to labour the point that any dis- cord in the workings of the nervous system — which is the centre of control — is at once reflected in lowered efficiency, as well as impaired health. From which it follows that every one should know how to care for his THE PROBLEM STATED 5 nervous system and to promote his nerve ; that every one should have some knowledge of the chief rules for keeping mind, brain and nervous system in proper and harmonious action and reaction. Nerve health is the key to efficiency, and efficiency is the key to success. No man whose nerve ceUs are tked or poisoned, or strained, or impaired in any way, can attain a full measure of working efficiency, and, therefore, no one thus disabled can do his or her best for family, self, country, or humanity. On the other hand, the stronger the nerve the higher the level of efficiency- — the easier the road to success and the better the opportunities for doing one's duty as a think- ing, working, human being. The world has recently suffered so much strain, sorrow and anxiety that it is not to be wondered at if there is a tendency for general nerve health to be rather below par. Consequently the author hopes that the observations he has to make will serve as useful sign-posts both to those who have the care of invahds and to some who have felt then nerves waver a Httle and their strength flag— sign-posts point- ing to the twm-goals of health and efficiency. The problem we have to solve is how best we can minimise the common drags and hindrances to the satisfactory workings of the nervous system, how life should be lived to get the best results by those who are unfortunately handicapped with some nervous clehcacy, and how those should be encouraged who have been cast down by some shock or blow of outrageous fortune, and who are now striving to struggle back to then' old level of strength. Certainly in considering this problem we shall be very careful to remember the victims of nervous troubles brought about through their services to their country in time of war. So increasingly evident that akeady in the decades immediately preceding the Great War writers caUed attention to them as the " disease of the age," nervous disorders have now with war-time's impetus assumed a 6 THE PROBLEM OP NERVOUS BREAKDOWN prominent place in questions of national health and economics. In some ways they are the penalty exacted of civilized mankind for the daring advances of the past fifty or sixty years ; claiming victims on all sides and among the followers of a thousand callings. In the study, the office and council chamber men have fallen under the nerve-strain caused by the rush and emotional tension of modern life. Women formerly withdrawn from the major stresses of the world have come out from their sheltered paths to share in the rough and tumble of the fight in the open fields. India, Africa and other tropical countries also have contributed their quota of neurasthenics drawn from those unable to withstand the enervating influences of the tropics. The pace grows and the brain reels under the stimulation of rapid transit, quick communication, and competitive stress. Only the fit can survive the turmoil. Constitutional make-up, inherited strength or weak- ness, temperament, occupation, cu'cumstances and friends all influence the individual's reaction to the strains and stresses of life ; hkewise they are deciding factors in the all-important question as to whether he will suffer breakdown or not. At the outset it stands out clearly that a man's nervous system may collapse from causes inherent in it or from stress brought to bear from with- out. He may suffer neurasthenia because his brain cells are delicate through inherited transmission of weakness, or his nerves may fail through exhaustion or the shock of an explosion. Often enough the failure depends on some comparatively moderate stress from without proving too much for a system that has been strong enough to bear life's ordinary burdens but no stronger. In any case, the nervous organisation is, of all systems, particularly un- favourably situated in that it has to bear the brunt of stresses coming from two directions. Not only is it liable to exhaustion, poisoning or damage from physical causes, but it is continually swept by emotional waves that set THE PROBLEM STATED 7 it vibrating. That emotion may be as tiring as running a race, that playing chess may take as much out of the body as mowing a lawn, are things proved. Consequently the problem of nervous breakdown repeatedly confronts us with the interaction of two Idnds of influence, physical and mental, the sensitive nervous system being the scape- goat of both. Not a few writers have endeavoured to solve the prob- lem by referring everything back to disturbances of the well-being of nerve-cells and nerve-fibres, making the question entirely one of physical state. Brain, spinal cord, nerve-cells and nerve-fibres we know, they have cried ; we can see them, dissect them out and subject them to microscopic examination. Mind we know not. We grant that it is an all-important function of human life, because unless a man thinks and is conscious he has no proper existence. But we have decided that mind is secondary to brain-action ; it must be a sort of electrical current generated by batteries of brain-cells ; a briUiant flame that waxes and wanes Avith the physical health of the nervous system. We have, in fact, come to the con- clusion that mind cannot primarily interfere with or influence bodily functions and reactions. Mental trouble spells physical disorder somewhere. If it cannot be found blame our methods of investigation rather than our theory ! And so one has said that nervous breakdown is always due to poisoning from the bowel, another that poisoning from the teeth is its origin ; others say that it is a case of simple physical fatigue of nerve-centresremediable by rest ; yet others find the cause in errors of hygiene, weakened circulation, faults of diet and what not else besides. That the physical state of the brain does influence mental out- look is sure enough ; every drunkard show^s this clearly. But against that one has to put the results of modern investigations proving how emotional trouble alone will precipitate a breakdown, and demonstrating how treat- 8 THE PROBLEM OF NERVOUS BREAKDOWN ment through mind alone will not infrequently serve to clear up a host of neurasthenic troubles largely expressed by physical disturbances. Indeed, however much physi- cal causes may contribute to a nervous breakdown, or however much physical disorders may figure in the results, the deciding factor is very often psychological. Were nervous breakdown merely a material result of a depleted nervous system, and its remedy just the strength- ening of exhausted elements, the problem would be more simple ; it is the complicated mind reactions occurring simultaneously with the organic troubles that make its solution difficult. As a matter of fact, delicate in structure as they are, nervous-tissues are remarkably hardy, and possess re- markable powers of recuperation. It is an astonishing thing that after prolonged strain such as is often ex- perienced in warfare men will frequently recover their nerve and mental power after one long sleep. One is not now referring to instances of " shock," but to those of extreme fatigue where temporary mental disability, evidenced by impaired memory, depression and " vacancy," as well as other signs, has indicated great fatigue of nerve-elements. Again, where for experi- mental reasons persons have been kept awake for a long period it has been found that quite a small extra allow- ance of sleep subsequently at once restored their mental vigour. Again, consider the impunity with which nar- cotic and sedative drugs are administered daily with the direct object of medicinally " poisoning " the brain- ceUs, Patients recover from chloroform, " gas," ether or morphia without harm ; and it is a rare and noteworthy occurrence should any sign of brain-cell damage appear after such administrations, which are made in millions every year. This applies not only to constitutionally strong people, but to those in whom the nervous system admittedly shares in or exhibits inherent delicacy. Regarded as a physical problem, the marvel would be THE PROBLEM STATED 9 not that some persons break down under modern stresses — ^particularly those of recent years — but that any avoid collapse. Looked at as a mental problem we see that mind has qualities that enable it — when properly ex- pressed — to maintain serenity even amidst the most appalling conditions, and not only to do this, but actually to protect over-sensitive brain-cells from the disastrous consequences of emotional disturbance. In a word, it takes a good deal to brea.k down the average nervous system, and even those possessed of constitutionally delicate brains have inherent means of protection and a greater capacity for lessening stress than is generally understood. Even delicate nervous systems rarely collapse at the first storm. Usually several tempests rage through the sensitive brain before it wilts and breaks. True enough, a " nervous attack " often appears to be of sudden onset, but the close observer notes that heralds of a coming storm had been pointing to danger for those wise enough to understand. So often friends seem careless and rela- tives not a little unsympathetic, and the burden of increasing fatigue is borne until some possibly trifling incident becomes the last straw to break the back of nervous fibre. Many breakdowns might be prevented did friends show more common sense, more charity and more consideration. One wonders how it is that this can be. Is it that the medical profession have discouraged people from taking " nerves " at aU seriously ? Is it that the healthy man or woman is naturally unsympathetic towards those abnormally sensitive ? Or is it that as a characteristic of his state the individual so carefully hides all signs of the nervous tension within him that every one is deceived into thinking him secure ? It ought to be open and easy for every nervous person to know where to seek sympathetic and experienced advice, so that whenever he feels that loss of control which so often presages the impending brain-storm, he can obtain help 10 THE PROBLEM OF NERVOUS BREAKDOWN and be protected from harm until the stress of mind and nerves has been relieved. It stands to reason that on any delicately balanced nervous system continual worry or harassing circumstances must exert a steadily increasing effect of tension ; that eventually this tension must reach a point which to the nervous is breaking-point ; and that a crisis which would be safely passed through by an individual with a healthy brain is likely to disturb others very seriously. When this storm takes the form of depression, the patient suffers all the terrible agonies of the melancholic, and tends to get deeper and deeper into the slough of despond. Sometimes a passing storm has remote con- sequences of a kind which may be conveniently illus- trated by such an example as the following : A business man of moderate means finds himself persistently em- barrassed by an unlucky chain of circumstances, and suffers crisis after crisis, each being accompanied by a small nerve-storm that is not big enough to ruffle the outward surface of his calm, collected demeanour. Apparently he stands firm and safely passes through this troublesome time ; apparently his embarrassments have ceased before his nerve-strength had become ex- hausted. Some time later a trifling iUness — a chill, mild influenza, or an attack of rheumatism — occurs, and breakdown quickly follows. The stress which he had been able to bear up against successfully is now unbearable, and the overwrought brain is unable to withstand longer the blows of adverse fortune. Instances occur in which the collapse is not evidenced by severe exhaustion or other definite sign so that its true significance may well be overlooked. It may be expressed in irrational actions which do not attract any particular attention. On close investigation these may be found extravagant, wanting in balance, but no close observer is there to make a report. This hitherto quiet man may embark on some wild scheme of finance, or expansion, and precipitate THE PROBLEM STATED 11 himself into sudden ruin. Or, on the other hand, he may actually succeed vnth his plans and find himself in un- dreamed-of prosperity. In either case, neither he nor his friends will understand how their changed circumstances are due to nervous instabihty — in short to a brain-storm. It m&,y be said there is no point in its being recognized. But there is, because for one success there are many failures, and no prosperity is worth the price of a damaged brain. In the individual sudden waves of brain-disturbance frequently cause a good deal of misery by giving rise to impulsive thoughts. In certain circumstances sudden impulses arise in the mind of even the healthiest people. Thus there are many, without experience of nervousness, under the ordinary conditions of life, who, if they find themselves at the edge of a high chff, or on the roof of a high house, or walking along an elevated bridge, feel an impulse to throw themselves over. This is not at all uncommon, and one sees the same kind of thing in an exaggerated and more distressing form in instances in which the impulse takes the thought of precipitation underneath a train or other vehicle. It should be some comfort to those who are bothered with such impulses to know that of aU the thousands of individuals who are afflicted in this way but a very small proportion ever yield thereto. The great thing is to lend such aid and sympathy to persons bothered with impulses as to prevent them getting worse. Unfortunately, impulsive thoughts sometimes tend to suggest others of the same kind, and unless counteracted by strong suggestion from without they may go on and render the patient's fife increasingly miserable. Only those who have experienced the torture of these things can appreciate what it is always to be subject to the sudden promptings of an impish thought, that suggests that they shall do harm to then friends or relatives, never to be able to free oneseK permanently from these promptings, and in consequence never to be 12 THE PROBLEM OF NERVOUS BREAKDOWN absolutely sure of what one really will do. It is my ex- perience that when such a person understands that he or she does not stand alone, but is a member of a fairly large group of other unfortunate sufferers tortured in a similar way, a certain amount of rehef comes from a true appreciation of this position. Nervous children are particularly subject to brain-storms which are repre- sented by the terrible rages some Httle people, v.ho are natm'ally over-strung, get into on occasions ; and if one follows the lives of such nervous children, it will be found that in many cases when they grow up into adult hie then' brain-storms persist although in somewhat different forms. In addition to these things, the problem under con- sideration demands of us that we should make some further attempt to understand those prevalent nervous maladies which caU for repeated periods of rest, and are admittedly beyond the reach of drugs. Those who enjoy good health are hard put to it to understand the con- dition of anyone who in spite of keenness and ambition is constantly weighed doT\ai by this feehng of slackness. Such tnedness hamiting its victim from morning till night, restricting work and preventing enjoyment, is one of the conditions that have most commonly to be dealt with in nervous breakdoAra. Then, again, we want to know more about the mental depression which for no apparent reason attacks neurasthenic persons. We want to know why sense of fatigue and depression so often go hand in hand, and why it is that in their tm^n they lead to other morbid signs and to the building up of a huge pile of crippling nerve symptoms. Our inquiry must have a Wide range. The peculiarities of the neurasthenic head- ache — typically giving sensation of a heavy weight pressing on the top of the head, or of a band tied tightly round the temjDles, or of a vice gripping the forehead — require investigation ; so also do the innumerable sensa- tions that occur with broken nerve — sharp pains, prick- THE PROBLEM STATED 13 ings, numbness, and neuralgia. Why should a busy man carry with him through life a sense of weight upon his head which rarely lifts, suffering it for perhaps twenty or thirty years, and then finding one day that for very little apparent cause it suddenly lifts and frees him from his burden ? Racing thoughts, cm'ious buzzings and other noises in the head, distressing attacks of sudden giddi- ness, want of self-confidence, morbid flushings of the face, and obsessing thoughts, aU have to be considered. In no other class of illness have such elusive and mysteri- ous disturbances to be examined. What strange and partly hidden chain of thought, or what disturbance of the normal thought stream, leads to such terrors as claustrophobia, or agoraphobia ? To say that a person is claustrophobic is to give a high sounding name to an incomprehensible state of mind, but does not explain why he should be reduced to a trembling and uncon- trolled condition just because he finds himself in a locked room, a lift, a tube railway, or other confined space. Neither does the term agoraphobia in any way help us to understand why a similar state of nervous collapse overcomes some individuals when they have to cross a field, square, or other open space. The list of anxieties, fears, and doubts thus suffered can never be completed, because they are as infinite in variety as the patients whose nerves are disordered, and those who have to help them are always adding to their notes fresh descriptions of various mental tortures which no other class of individuals is ever caUed upon to suffer. One has known a man of strong physique and sturdy intellect who has been like a terrified child when he found himself in a wide, empty street, or even in a large, empty room ; and others who would never be suspected of nerve- weakness by their friends who suffer the acutest mental agony if they have to travel in an underground tube railway, or are confined for a few minutes in a lift which refuses to act. There are capable brain-workers who are 14 THE PROBLEM OF NERVOUS BREAKDOWN tormented all day about some such absurd thing as whether they have touched a certain lamp-post on walking to and from their destination ; or as to whether they have looked up a particular street on passing it. It is, of course, clear that many manifestations of acute or chronic nervous breakdown depend upon loss of mental control ; not only the unreasonable fears, shyness, con- fusion, and sense of unworthiness, morbid blushing, obsessing thoughts and alike which bother nervous people, but many of the digestive and other physical disturbances are based on this failure of control. More- over, associated with this particular want of mental power is a morbid predominance of fear. Not only is there slackness in the power of thought direction, but there is a usurpation of the mental field by sense of terror, and it is characteristic of the fear that it is beyond reach of reason. Certainly it may be said that in some ways serious and obsessing nervous fears are not unlike the common dislike of certain colours, horror of various creeping animals, dread of darkness, shown by many people in ordinary health. Indeed, one can learn some- thing about nervous " phobias " by paying a little atten- tion to these very common fears. Thus, taking the not unusual dread of thunderstorms, the individual of sound nerve knows by experience that under ordinary circumstances the thunderstorm will not harm him in any way, and in spite of disliking the experience, pulls himself together and bothers no more about it ; but the nervous individual, although knowing that the thunderstorm is harmless, is unable to control the fear it inspires. The nervous subject is often fully aware that many of his complaints are unreasonable, but that makes him suffer all the more. For the time being he cannot help them, though they are unreasonable. He is unable to inhibit the fear — failure of capacity to inhibit. He has lost in part or wholly the power of inhibition that has won^ for Man his pre-eminent position in the animal kingdom. THE PROBLEM STATED 15 Nervous people do not fear cats or mice because they reasonably consider that such animals may harm them. Certainly not. Their expressions of alarm are due to wild, unreasoning terrors which fly up in their minds at the sight of these creatures ; terrors which they are unable to crush down if their power of inhibition is at all weak. Take, for example, the indecision that torments many neurasthenic persons, and causes many a victim of shattered nerves to explain, " I cannot make up my mind to do anything " ; or to utter the bitter complaint, thoughts being out of control — ^that the " brain won't work." The average person probably never realizes the cease- less loss which is incurred to the nation by the premature breakdown of men who would unquestionably do lasting work of the greatest public importance as lawyers, social reformers, preachers, journahsts, physicians or surgeons, were they able to recover their lost health. Every year men of these classes may be seen to give up their work without hope of ever taking it up again in the same way, and the national loss from these cases of nervous break- down is incalculable. We talk much about increasing and preserving the physical strength of the nation, but we do nothing to preserve or strengthen its nerve -force. Perhaps one day the State will see the wisdom of founding sanatoria for such people, where the brilliant scientist shall be able to recuperate his lost nerve-strength mth- out undue anxiety, and be made fit to continue his studies to the advantage of the race as a whole ; where the rising barrister, who has exhausted himself in the pursuit of legal wisdom, shall be able likewise to regain his strength and once more devote himself to the career which will, in its own way, be of public advantage ; where the writer who has a great message to dehver shall be able to get back his impaired vitality, and resume the lofty task laid upon him. It would, of course, be absurd to place all brain-workers 16 THE PROBLEM OF NERVOUS BREAKDOWN in the category of the unfit ; but the fact remains that such a large proportion of them at the present time are hampered by the results of nervous instability that it is becoming a matter of real importance to consider some such provision for them as that referred to. One cannot suggest that any overworked professional man should be able to gain free rest and treatment in a sanatorium just whenever he likes, but it should be possible for any worker whose work can be shown to be of real benefit to the public at large to obtain, when his condition demanded it, such rest and attention at the expense of the State. CHAPTER II THE EMOTIONS Human feelings — Emotional stress and nervous breakdown — Definition of emotion — Feeling and action — Physical accompaniments of emotional excitement — -Anger — Grief — Fear — Our feelings stamped on our bodies — Higher emotions — Heart versus head — Intellectual- izing one's feelings— Personal reactions to emotions — Ways in wliich emotional stress causes nervous disorder- — Illustrations. IT is part of our daily experience — as every one who takes the trouble to study his thought-processes will quickly observe — that the rnental states that occasion, or are invariably accompanied by, disturbances of our sense of well-being are those which are concerned with our feehngs. It is not so much what we think as what we feel about things that disturbs the steady beat of our hearts, or hurries our breathing ; although, of course, our feeling is really about what we think of things. The very fact that our feehngs so obviously move us has led to the more scientific term given to them in psychology ; our feehngs are, indeed, our emotions, the word emotion being quite a transparent modern representation of the Latin emovere : to move out, to shako up. And the one thing that stands out clearly when one studies the causa- tion of nervous breakdown in its full development, as exemphfied by those invalids who are so ill that they consult a specialist, is the prominence of the emotive factor. ' Undoubtedly, a number of familiar conditions operating in the sphere of physical well-being often predispose or appear directly to cause nervous break- -down — these, including exhausting diseases, accidents, and nerve -poisons, will be discussed later under special 17 18 THE PROBLEM OF NERVOUS BREAKDOWN headings — but even when this is so it is more often than not that a strong psychological factor is found to be operating at the same time. As a matter of practical experience one usually finds causes both mental and physical in any particular case, and it is difficult to disentangle the separate causative ailments, but an entkely wrong conception of nervous conditions will be obtained by those who over-estimate the influence of either cause. Usually distm-bing mind-states — ^that is emotional stresses — are the deter- mining factors in the final breakdown of the nervous machinery. So much has this impressed some authorita- tive investigators that more than one theory of purely psychological causation has been put forward by eminent writers. Thus, those distinguished French observers, Professor Dejerme and Dr. Gauckler, hold that neuras- thenia is entirely psychological in origin, although they do not extend this observation to those types of nervous breakdown which exhibit psychasthenic symptoms such as obsessions, or those allied to so-called mental diseases. They " hold that neurasthenia is due whoUy to psycho- logical factors, and these psychological factors are essenti- ally, if not exclusively, determined by emotion." ^ More- over, they go so far as to say that physical fatigue or overstrain by itself never occasions neurasthenia, a state- ment which appears to be at variance with daily experi- ence, although it is quite true that nervous breakdown due to over-work unaccompanied by such mental stress as worry or grief is comparatively uncommon. " Over- work and fatigue are no more a cause of neurasthenia than they are of tuberculosis. They create a condition which predisposes to tuberculosis, and which favours the sowing and the proHferation of the tubercle baciUus which remains the only true pathogenic cause. In the same way, by the lowered psychic and physical tone to ^ Prof. J. Dejerine and Dr. E. Gauckler, P sycho-neuroses and Psycho- therapy, p. 218. THE EMOTIONS 19 which they subject the patient thej may become factors of a greater emotionalism on the one hand, as they also constitute by themselves true causes of emotion on the other hand. But without emotion there are no psycho- neuroses."^ On the contrary, an equally eminent French neurologist, Professor Babinski, some years ago wrote : " The typical form of the disease [neurasthenia] is repre- sented by what is called constitutional neurasthenia, which appears in youth, in subjects who until that time were able to work intellectually and physically in a normal way. The least effort tires them ; they are exhausted after reading a few pages or writing a letter. This form of affection may be developed without there having been any preKminary over-work, and in individuals who are not especially susceptible to emotion." One notes also that the late Dr. Savill, who strongly upheld a theory of physical causation, was impressd by the emotive factor as a determining agent. " Overwork is one of the most familiar causes [of neurasthenia] in the experience of us all ; too long hours, too close attention to work without a break, and an inordinate desire to finish an allotted task. One finds it in busy city life, in the keen struggle for existence, and one finds it also most frequently in the autumn months, when men have not been away for some time. Overwork of the mind is what I am chiefly referring to, but physical exertion is also a strain upon the nervous systeni. Prolonged forced functioning of any nervous structures undoubtedly results in their malnutrition or atrophy. But it is surprising what the nervous system will tolerate, and how quickly and readily it will recuperate provided the mind be free from worry and anxiety ^^ It is clear, then, that any attempt to solve the problem of nervous breakdown requires full consideration of the part played by human emotions in everyday life. Hence ^ Prof. J. Dejerine and Dr. E. Gauckler, Psycho -neuroses and Psycho- therapy, p. 232. ^ T. D. Savill, M.D., Lectures on Neurasthenia, p. 60. 20 THE PROBLEM OF NERVOUS BREAKDOWN we must for the moment digress from our main theme to study just how far emotional feeling influences mental rest or unrest, and, therefore, to what extent it affects the question of nervousness or nervous instability. Of course, everyone knows what is meant by the emotions in a wide sense ; but familiar as are these states of feeling it is not easy to construct a comprehensive but simple definition of them. Webster defines emotion as " any of the feelings of joy, grief, fear, hate, love, awe, reverence, etc. ; any of the feelings aroused by pleasure or pain, activity or repose, in their various forms, or the type of consciousness characterized by such feelings." This sufficiently indicates as an introduction to what follows the particular mind states with which we have to deal, and is a useful enough definition, especially when read in conjunction with Webster's qualifying statements, namely, that " emotion is consciousness attendant upon other forms of consciousness (as perception and ideation) to which it gives their feeling tone ; and emotions are separable and classifiable apart from these other forms because the same object of thought may at different times have a different feefing tone, as a person may be now loved, now hated. Sensations of pain and pleasure pass insensibly into pure emotion. As compared with affection and feeling, emotion is a narrower term in psychology, though in non-technical usage both of these terms have the narrower meanings." From the practical point of view the first thing to be realized is the very close connection that exists between emotional feeling and bodily state ; indeed, the ways in which a man's feelings are reflected in his face and general attitude are familiar enough. See how the countenance fights up when some friend approaches ; see how the brow lowers and the skin flushes with anger when an adversary comes on the scene. The grief -stricken man's bent head and bowed shoulders, the love-lit maiden's radiant face, shining eyes and dancing footsteps, are THE EMOTIONS 21 common contrasts of daily life ; antitheses that time and again have moved poet, painter and playwright. Dignity and pride are shown in the upright bearing, harmonious movements, the sedate speech, and firm expression of those who worthily occupy responsible posts. Ambition is shown in set of chin and cast of face, vigour of action, and trenchant voice. Do we not in daily conversation speak of a determined face, an expression of weakness, an angry countenance, a proud demeanour, an ambitious bearing ? And do we not equally often note jealousy in a twisted smile, treachery in a furtive glance, and honesty in an open face ? Descriptions of men and women gripped by strong emotion have called forth some of the greatest efforts of great ^vriters ; it is truly a theme for the genius of novelist or poet. And the skill of the artist is no less seldom exercised with conspicuous success in depicting the play of some profound f eehng through the human face and body. How graphically Macbeth's scornful ex- clamations to his frightened servant limns with the touch of a master -hand a phase of panic : " Thou cream- faced loon ! . . . Thou lily-livered boy . . . those linen- cheeks are counsellors to fear ! . . . Whey -face ! " ^ Whilst where Agamemnon says to Nestor, " What grief hath set the jaundice on your cheek ? " 2 one notes the subtle difference between the facial expression of the two emotions. Many observers of human nature have essayed the task of describing in detail the interplay of mental and bodily processes which goes to make up the familiar picture in various emotional states. Thus, of anger, Mantegazza has written : " Withdrawal of the head back- wards, withdrawal of the trunk ; projection forwards of the hands, as if to defend one's self against the hated object ; contraction or closure of the eyes ; elevation of the upper lip and closure of the nose — these are all elementary movements of turning away. Next threaten- ^ Shakespeare's Macbeth, Act V, Sc. 3. ^ Shakespeare's Troilus and Greasida, Act I, Sc. 3. 22 THE PROBLEM OF NERVOUS BREAKDOWN ing movements, as : intense frowning ; eyes wide open display of teeth ; grinding teeth and contracting jaws opened mouth with tongue advanced ; clenched fists threatening action of arms ; stamping with the feet deep inspirations — ^panting ; growling and various cries automatic repetition of one word or syllable ; sudden weakness and trembling of voice ; spitting. Finally, various miscellaneous reactions and vaso-motor symp- toms : general trembling ; convulsions of lips and facial muscles, of Umbs and of trunk ; acts of violence to one's self, as biting fist or nails ; sardonic laughter ; bright redness of face ; sudden pallor of face ; extreme dilata- tion of nostrils ; standing up of hair on head."^ Yet the descriptions of scientific men are not usually so much to the point as are popular phrases and proverbs. Thus, to say as we do that someone shook with fear, his hair stood on end with fright, she was white with anger, she trembled with rage, his heart stood still, his heart was in his mouth or in his boots, his tongue clove to the roof of his mouth — ^to speak phrases such as these is to give a touch of realism more dramatic and descriptive than any scientific analysis ever can. Still, analysis does help us to understand the close association between feeling and physical reaction. Thus examining the effects of grief one finds that they are manifested somewhat differently in relation to the tem- porary or settled nature of the sorrow felt. In the early stage there is an attitude of general prostration. The whole system is overcome by the storm that sweeps over it, every function is depressed, even the hair tells the tale of trouble, and the floodgates of the eyes being opened, torrents of tears complete the spectacle of desolation. So great is the depression of vitality that appetite and digestion fail for the time being ; the heart may wilt under the blow so far that fainting occurs ; and in any ^ Mantegazza, La Physiognomie et V expressions des sentiments quoted by Wm. James, Principles of Psychology. THE EMOTIONS 23 case the exhausted brain usually yields to a soothing sleep that automatically descends and enfolds the sufferer in the calm of oblivion. On the other hand, when the first spasms of grief are over and full realization of loss brings a settlement of misery, the picture is still one of depressed vitaUty, but of a far less prostrating character. Nevertheless, even then the devitalizing of the system is shown by weakness or weariness resulting in bent head, bowed shoulders, and di'agging gait ; whilst the sagging muscles of the face give the characteristic expression of dejection. The " v/eight of sorrow "is, indeed, a burden which the system has to " bear up " against. Let us now see what happens in fear. Here the picture is at first one of intense alertness. The senses being wide awake, the fear-stricken man stands or crouches quite still- with eyes widely open and eye-brows raised in signification of heightened visual intent, whilst the mouth is open as commonly happens when one wishes to hear better. Breath comes quickly and the heart bangs against the ribs. The skin pales, and a cold sweat breaks out, whilst the hairs are raised by spasm of the tiny muscles at their roots. Other small superficial muscles also contract, "goose-fiesh" being thus produced. Dry mouth and husky voice complete the picture. Increasing emotion then hastens the violent action of the heart, rigidity gives way to trembluig of limbs and chattering teeth. "Lysander, look how I do quake with fear,"^ cries Hermia, awaking from her fearsome dream of a serpent eating her heart away whilst " you sat smiling at his cruel prey." The Psalmist sang : " My flesh trembleth for fear."2 As fear deepens to overwhelming terror the eyes start forwa,rd, the lips move convulsively, the nostrils dilate, and the breath comes with difficulty. At the same time, the whole frame is either again stiffened like a statue — ^ Shakespeare's Midsummer Night's Dream, Act II, Sc. 2. 2 Psalm cxix. 120. 24 THE PROBLEM OF NERVOUS BREAKDOWN frequently some striking attitude being fixed in this way — or alternatively there may be wild movement of the arms and hands. Moreover, fear is an emotion that when felt intensely not uncommonly distm'bs the tranquil action of the abdominal organs so that the normal move- ment of stomach and bowel may be seriously disordered. Sickness may occur, or, on the other hand, there may be sudden failm'e to retain the bowel contents. There are few, if any, finer descriptions of what fear means to us than is to be found in those telling phrases of the Book of Job : "In thoughts from the visions of the night, When deep sleejo falleth on men, Fear came upon me, and trembling, Which made all my bones to shake. Then a sjoirit pa^ssed before my face ; The hair of my flesh stood up : It stood still, but I could not discern the form thereof : An image was before mine eyes."^ And so, with all other emotions, every feeling is accom- panied by a corresponding movement in the physical being and every response of this kind vibrates in the nervous system primarily. When we are cast down by grief, exalted in devotion, torn by disappointment ; whether our hearts sweU with love, or our senses are pleasantly thrilled by a fine day, the emotional feehng is most assuredly reflected in our bodies. Frequently the bodily response is but fleeting, but there are some of us so constituted — so impressionable — that feehng quite readily stamps our organic make-up \\ith a firm and lasting impress. Mary Tudor, of doleful memory, spoke more truly than she knew, if she did indeed exclaim in a moment of bitter disappointment, that after her death the word " Calais " would be fomid engraved on her heart. That poignant cry may be taken as a picturesque expression of a physical impress that inevitably occurs when we are very deeply stirred. The emotions are legion — love, joy, 1 Book of Job, iv. 13-10. THE EMOTIONS 25 pride, grief, fear, rage, jealousy, disappointment, ambi- tion, amusement, admiration, devotion, and a hundred others — every minute of the day influences the spinning thread that is being woven into the pattern of our lives. The world may be the loom, and life the spinner, but the emotions vary the pattern according as they are much or little controlled. Even when there appears to be no link between sense of feeling and bodily reaction — even when our thoughts move freely on light levels of intellect and emotion seems absent — it is true that, as William James put it so well, " The bodily sounding-board is at work, as careful introspection will show, far more than we usually suppose." ^ And out of his great experience Dubois wi'ites : " There is no movement of the mind without its echo on the organism. We are only able to detect in ourselves and in others the most obvious, the coarsest phenomena. Moreover, we see emotions that are whoUy diverse expressed by the identical phenomena of blushing, growing pale, or by ordinary gestures. We see tears accompanying smiles as well as sobs. These are gross macroscopic reactions. But there are more delicate and less perceptible phenomena, which, under the influ- ence of an idea, present themselves within the very tissues themselves. It is this microscopic psychophysiology that should be studied in mental pathology. If we can, by a healthy philosophy of life and by moral hygiene, suppress this toxic element of emotion, we shall rid the greatest physical and intellectual fatigue of its harmful influence." ^ The practical point, then, is that our feelings are so closely associated with our bodily reactions that the latter — ^particularly when our bodies are inherently deli- cate — become thrown out of gear just as any other sensi- tive mechanism, a watch, a magneto, a compass, may be disturbed by an electrical storm. Further, the cruder the emotion, the more it is concerned with primitive ^ Wm. James, Principles of Psychology, Vol. II, p. 471. * Paul Dubois, M.D., Psychic Treatment oj Nervous Disorders, p. 155. 26 THE PROBLEM OF NERVOUS BREAKDOWN animal feeling, the more closely associated is it with organic function, the more violently it shakes the body. Hence it is the storms of passion, hatred and jealousy ; the reactions of love, courtship and marriage ; the tremors of fear — it is these that shake the nervous system to pieces far more commonly than the reactions of ambi- tion, pride, aesthetic emotion, intellectual feeling, and the hke. Body and subconsciousness, that mysterious combination of evolving human phases — possibly just two phases of one and the same thing — act and interact so closely when it is a question of primitive feeling that it is not to be wondered at that some psychologists have believed that the coarser emotions at any rate are them- selves occasioned by, and in consequence of, particular bodily reactions in the presence of special conditions . The author finds himself in agreerhent with others who hold that the emotion — sense of feeling — comes first, and that bodily changes follow. But even extremists of the former school have been of opinion that the higher emotions are primarily founded in ideas ; recognizing that the more intellectual the mental process the more removed from crude bodily and subconscious reactions. This is borne out every day of our lives. Who has not observed, time after time, the failure of an intellectual appeal to reach the foundation of some nervous trouble or functional bodily disorder, when the same difficulty at once responds to a crude " suggestion " which is given an emotive impetus ? Intellect soars high above body and subconsciousness — too high at times for our practical convenience, and the intelligent man of affairs often finds himself unable to reach unaided some troublesome " phobia " or symptom which reason teUs him is baseless and ridiculous, for subconsciousness blunders on its way unheeding. How often do we say of a man that his heart has run away with his head ; meaning that his emotions have blurred, or warped his judgment. Pascal well said, THE EMOTIONS 27 " the heart has many reasons which reason never knows," thus simply expressing a profound psychological truth. Mankind in our present state of development is tremend- ously swayed by the emotions ; even those comparative few who rely on their heads rather than on then hearts are time and again shaken out of their intellectual calm by some rude storm at lower levels to which their very disdain and neglect have largely contributed. The whole point of education and training should be to establish control of feehng, whilst developing abihty to express all feelings in the most spuitual way. That education so often fails to guarantee our heads against the riot of our hearts, and to show us how to protect ourselves against the nerve-racking storms which result when heads and hearts come into violent conflict, is one of the most glaring defects of this present civilization. Every one should endeavour to obtain control of feelings throughout the whole gamut of the emotional scale — from raging anger, deadly fear, passionate love, to the highest levels of spiritual and aesthetic feeling. Fortu- nate are those who by training or temperament are able to be captains of their souls in all weathers. Around us we see the difference of individual reaction to feeling at various points of the scale. The gradation of crude emotion to intellectual feeling may well be illustrated by a comparison of the points of view of the critic and the sentimentalist. The former has a cold, practical non- emotional sense of value. The latter loses his intellectual concept in a wave of emotion based on a set of percep- tions rendered in terms of his senses ; his pleasure is that of romance, that is appreciation of things expressed in pleasurable bodily effects, and hence much more dis- turbing to nerve and bodily function. Conversely it foUows that the more a man can elevate his feeling — the more he can spirituaMze, or intellectualize his thought — the more his nervous system is protected agamst storms that threaten its security. This is on all 28 THE PROBLEM OF NERVOUS BREAKDOWN fours with the observation that it is not simple mental work that leads to breakdown, but mental work accom- panied by emotional strain — worry, grief, jealousy, dis- appointment and the rest. The clearer the thought — the more our thinking processes are kept apart from bodily feeling, particularly in an emergency — the stronger the nerve. There are many particular illustrations and applications of this. Thus, take the doctor's attitude towards disease and suffering, often a matter of popular comment. He cannot feel deeply with all who come to him for help, it is said ; surely familiarity with pain brings callousness. But what happens is this. The doctor gradually exchanges his lower emotional feeling for a higher intellectual emotional conception which does not disturb the harmony of his body, and the latter thus freed from disturbance his " nerve " no longer suffers. And so the surgeon works out his sympathy in a height- ened intellectual process which creates an appearance of unsympathetic detachment. He intellectualizes — spiritualizes — his emotions to the very great interest of his patient. Doctors would be in a quandary were this not so. What a state of things if every sad case roused those less intellectual emotions which cause his face to pale, his heart to beat violently, his hands to sweat, his eyes to fill with tears. His judgment, his professional capacity would be centred in his heart and his stomach instead of in his head ! His fine discrimination — his saving nerve — where would they be, and what about his skill ? Obviously the stronger the emotion the more difRcult to intellectualize it. There comes a point when lower centres will respond and that bodily sounding- board vibrate violently. Herein lies the scientific ex- planation of the circumstance that medical men feel themselves to be i)oor doctors to their families. Suffering in one very dear occasions such strong response of all centres that bodily disturbance will occur and the intel- lectual processes — judgment, and so forth— become THE EMOTIONS 29 depreciated thereby. It requires vevy strong will — a very practised nerve^ — to keep eniotional feeling entirely in the realm of intellect when the future happiness or even life of a loved friend or relative hangs on one's pro- fessional opinion. As another illustration, let us take the tremendous case of the general upon whose judgment depends not only the lives and bodies of thousands of his fellows but the fate of nations. His capacity to serve his country well is a matter of his nerve, and is to be measured by his ability to lift his feelings as far as possible out of the realm of bodily disturbance and to intellectualize them. Freed from the weakening con- sequences of visuahzing the horrors resulting to friends and individual units under his command, v/hich must inevitably occur in v/arfare whatever be his decision ; and freed from the contemplation of individual agony by working mentally in the realm of the intellect, he carries on his great task in the most efficient way. He is not callous ; not wantmg in feeling. Far from it. But he raises his emotions above the level at which they would send waves of disorder rushing through his nervous system and so hamper his powers of reasoning. Not a few of those tragic failures in life where the trusted man suddenly fails, to the consternation of his friends, and is overwhelmed by a crisis everyone thought him capable of handling, are due to some unexpected inability to keep feeling-tone on the intellectual plane. And here let it be remembered that the body is insis- tent enough all the time that it should be allowed to share in feeling. Body is insistent enough and requires firm mastery at the best of times, but when it is ill or tired or getting rather old it manages to hamper intellect. The brain, of course, shares in aU physical states of body ; intellect depends on a healthy nervous system for its ordinary expressions, and is clogged by a tired or sick brain. 30 THE PROBLEiM OF NERVOUS BREAKDOWN When the surgeon finds that his operative skill is hampered by excessive emotional feeling on lower levels, so that his hand trembles, his temper becomes irritable and his voice high-pitched — ^let him take a hohday. When no holiday suffices to restore the calm harmony of intel- lectual control, then let him think of handing over his scalpel to a younger colleague and devoting himself to work of a purely consultant kind. When the experienced officer finds his will no longer able to keep his feehngs on intellectual levels and his judgment becoming mixed up with his heart, his breathing, or his bowel — ^let him pause and consider his state one for review by a sympathetic medical board. Whether a man controls an army or a business, whether he orders the destinies of a thousand fellow-workers, or is the legal or medical adviser of a single fellow-creature, he can only do his best work when he has intellectualized — given the spiritual values of clear thought and sound reasoning — to his mental work. The merit of William Tell's historic feat was that he did not allow his emotional feehngs to run riot over his bod}' and so destroy his nerve as to upset his true aim. To have shown more feeling in the popular sense — because the only way that feeling shows is through the bodily disturbance it sets up — would have led to his missing the apple and transfixing his son ; yet the issue of the ordeal to which he was committed was nothing less than the fife or death of his beloved child. The practical application of our understanding of the emotions in regard to the problem of nervous breakdown rests in its enablhig us better to understand just under what conditions emotional storms must try a sensitive nervous system. To be thus forewarned is to be better forearmed against neurasthenic and similar states when adverse circumstances arise. Unless we comprehend how emotions influence bodily worldngs and disturb the balance of the mind, we cannot follow the beginning of nervous disorder, nor ca,n we satisfactorily estimate the THE EMOTIONS 31 true value of the various mental factors contributing to a neurasthenic, hysterical, or allied illness. Conse- quently, our next concern must be with the ways in which emotional reactions commonly disturb health. And we may at once note that some people are naturally pre- disposed to distressing emotional waves as compared with their less highly-strung brothers and sisters. On the other hand, we will leave for the present the detailed study of the nervous temperament in its many implica- tions. Let it be understood at once that each of us exhibits a particular personal response to emotion. Just as it is rare to find any two people exactly alike in face and physique, so it is equally rare to find two individuals alike in emotional response. Fairly close resemblances appear to be common, but careful examination shows how deep are the differences between the feelings of individuals. If this is so in regard to the famUiar things of life, how much greater are the barriers between us in the more unusual relations. Let it be repeated that each one of us reacts in his own peculiar way to emotional disturbance, and that in this fact lies the explanation of many strange nerve disorders. Moreover, the under- standing of this enables us to find ways of protecting ourselves, and seeing to it that ascertained tendencies to excessive reactions of feeling do not run away with us, but are kept well in hand. To be forewarned against particular emotional response is to be protected against overwhelming storms threatening us from these special quarters. Anyone who wants proof that the individual always has his own ways and tendencies in expression of and response to feeling has only to look at incidents of life around him. Thus, Smith can lose his money cheer- fully, but is prostrated by a story of his wife's infidelity. Jones, on the other hand, shrugs his shoulders at obvious domestic irregularities — ^jealousy seems unknown to him — but becomes iU with anxiety should a breath of 32 THE PROBLEM OF NERVOUS BREAKDOWN misfortune threaten his investments. Robinson, again, seems able to bear anything but the diminution of his personal position in the world. Indeed, each of us can recall instances in his own circle exemplifying the special predispositions of individuals to particular emotional reactions. Is it not often noted how " touchy " some people are on certain points, whilst being comparatively reasonable on most others. The jealous husband or wife is a common example of this. Emotional reactions, questions of temperament, and temperamental differences will be discussed at length later on. Given favourable predisposing circumstances, the ways in which emotion may seriously disturb health are for all practical purposes four in number. Sometimes the intensity of feeling is so great that it may straightway wreck the whole delicate organization by which through the medium of the brain the mind-body system is kept in harmonious action ; or, it may serve as the last straiv breaking the hack of resistance, and topple off its throne some already shaken human reason. On the other hand, whilst an individual's nerves may have been strong enough to resist the original storm, or partly protected from it by some chance side-tracking of its violence, the subsequent memory of it may be so vivid as one day to assume almost the fury of its originator ; indeed, memories of 'past emotions quite commonly act as disorganizers of nerve-harmony, especially where remembrance of the original emotion comes back repeatedly. Thirdly, emotions are dangerous when they are repressed. When strong feeling finds expression so that the bursting storm wears itself out its harmful possibilities are minimised, but emotion bottled-up is liable to ferment and bubble in the depths of thought. It is stifled feelings that " work like madness in the brain." Does not a good cry relieve pent-up grief ? Does not anger quicldy spend itself when it has a speedy outlet. Even bad-tempered people find it difficult to maintain their angriness at a really THE EMOTIONS 33 impressive level for long at a time. The soft answer that undoubtedly turns away wrath works its soothing magic by refusing to feed the flames of fury and letting the fire burn itself out quickly, whilst by contrast showing the rightness of peace as against the fooHshness of a negative thing. Lastly, the effort to keep feeling in its place not unseldom results in a mental confhct that is extremely exhausting, and unless definitely settled without diffi- culty may lead to disaster. The over-tired man or woman who finds some animal emotion struggling against higher conceptions, or experiences a sense of losing control over morbid desires, suffers very great strain until the fight is won. Facilis descensus Averni ! It is an axiom of psychology and a rule of life, as many a proverb tells, that to win ground may be hard indeed, but to hesitate always means a grave set-back. The stage being set, it is our Httle personal responses that give the accents to the great picture of life's drama. It is the myriad unexpected reactions of individuals to the common interests of life that give endless oppor- tunities for poet, dramatist and novehst to weave their fascinating skeins. It is the excessive and often morbid response in certain directions that gives the practical psychologist inexhaustible material for study — a most interesting field of work — and exceptional occasions for helping many a sick soul out of the Slough of Despond. But in the wrecking of nerves it is emotional responses and conflicts tha.t excel over all other reactions. Hard as it is to understand how a thing that has been forgotten, how a M^ave of feehng that has been quickly thrust aside, can persist as an active agent — and steadily undermine health — ^the fact remains that this is so. Analysis of thought, intuitions and dreams has proved bej^ond the possibility of doubt that there are dark caverns of men- tality — subconscious depths — in which lurk horrid shapes and monsters of crude emotion. Further psychological research has proved no less surely that these goblins and 34 THE PROBLEM OF NERVOUS BREAKDOWN phantasms of past experience and unfulfilled passion are powerful for our ■ destruction under certain conditions. Particularly if we fear them, or excite them by sending them companions of their kind, do they become restless and seek to devour us. But to bring them out into the light of full consciousness, to demonstrate that they have no real power, is to show them up for what they are worth. Wraiths and ghosts of a transient hate, a flash of anger suppressed, a consuming love unfulfilled — these spectres vanish into smoke when confronted with the eye of under- standing and confidence. Conflicts distract the thought and tear the nervous system when the higher cannot hold the lower and help is not sought to sway the balance in favour of our better nature. Such struggles may occur round memories and repressions as round immediate emotional disturbances. As soon as a conflict is set up, that is to say as soon as the individual can only maintain his nerve by a constant fight for his intellectual position, then he is no longer fit for good work. Where the officer, or the surgeon, or the lawyer is able to make his decisions without any very noticeable effort of will being required to suppress his emotion, without, indeed, those emotions tending to display themselves on lower levels', then excellent work can be done. But as soon as an effort is required it means that nerve is impaired and a rest should be taken. If responsible duties are persisted with under such condi- tions of mental conflict as are herein indicated, then, if the individual is not capable of almost superhuman effort, emotional feeling will eventually overflow the barriers of Will and send such violent waves of reaction throughout the body that the nervous system will no longer be able to perform its work and general coUapse will occur. This, in a word, is the story of a thousand nervous breakdowns in men and women who have previ- ously done good work. We have Dr. Charles Burr's authority for the state- THE EMOTIONS 35 ment that in the United Sta.tes, just as in this country, emotional stress is a much more important factor than physical overv/ork in the production of neurasthenia. He states : " Mental work, even if carried to excess, pro- vided it is not accompanied by worry, is not a frequent cause, but when\vorryis present neurasthenia is frequent." ^ As illustra-ting the prominence of the emotional factor in bringing about particular breakdo\vTi or " nervous attacks " one may note the following examples of operative mental causes : 1. A young married woman had been neurasthenic for some years with particular " attacks." During the latter she exhibited violent temper. Inquiry eUcited the facts that she had had violent disagreements with her husband, and that there was great incompatibility of temperament betiveen them,. 2. A middle-aged tradesman became afflicted with depression, giddiness, indigestion and neuralgia with domestic trouble, luhich ended in his having to divorce his wife, of whom he luas apparently very fond. 3. A journalist became neurasthenic after suffering the combined strain of overwork and worry about re- sponsibilities. 4. Numerous instances appear in one's notes of people developing neuralgia or headache when having to follow distasteful occupations or to work with uncongenial com- panions. 5. A superstitious young woman became sleepless and ill through constant fear that a sujjposed omen ivoidd be fulfilled to her detrrnient. 6. A business man became highly nervous and fatigued after a period of do^nestic ivorry, in the course of which he separated from his wife. 7. Serious and persistent neurasthenia invalided a very active woman after the sudden and entirely unex- pected death of her husband. ^ Osier's System oj Medicine, Vol, V, p. 626. 36 THE PROBLEM OF NERVOUS BREAKDOWN 8. Concerning a successful business man suffering from numerous neurasthenic symptoms the note was made, " obvious emotional factor relating to anxiety about his affairs." 9. A man experienced an accident in which a wall fell on him and a fellow-worker ivas hilled. Although very little hurt, he developed a serious and persistent neurasthenia. 10. Widow, aged 43, became neurasthenic with dis- turbed sleep, depression, mental and physical fatigue, loss of memory and digestive trouble following a great deal of domestic worry. 11. Young unmarried woman complained of mental and physical fatigue, severe headache, digestive trouble and attacks of faintness. Herself attributed the iOness to domestic worry. 12. A tradesman suffered from neurasthenia, fatigue, a sense of " specks " in front of eyes. He had much business worry. 13. A lady complained of loss of confidence, depression, fatigue, sense of failing in interest and severe headache, said she had had much private worry. 14. A young woman said that she attributed her neurasthenic state (including depression, and want of interest), to having kept to herself an anxiety about frequent flushing in public. 15. Severe neurasthenia occurred in a married woman following prolonged overwork combined with domestic worry. Was apparently still in love with her first husband, from whom she was divorced. 16. Professional man, aged 52, broke down after shock and domestic worry. 17. In the case of a young married woman in whom neurasthenic symptoms appeared it was surmised that the morbid conditions present were due to a suppressed emotional conflict. She was married to a man older than herself, and, although particularly wishing for a son, had no children. THE EMOTIONS 37 18. Numerous cases have appeared to be largely due to a sense of disappointment or dissatisfaction with the sufferer's position in life. Retirement from official work, and want of occupation following, would come under this heading. 19. A young woman suSering from mental and physical exhaustion with attacks of anxiety, great restlessness and neuralgic pains had previously been greatly upset by a love affair. 20. In the case of a widow between 50 and 60 years of age, breakdown followed immediately on her husband's death. 21. A man who had successfully borne the strain of many years hard official work broke down when his affairs became complicated by a disturbing love affair, he being a married man. 22. In many instances a neurasthenic condition has been observed to develop after the death of a near friend or relative. CHAPTER III NERVOUS TEMPERA^klENT Nervousness — Temperament and character — Reaction to euviron- meat — -Types of temperament — The nervous temperament^ — Tem- peramental blends — Normal and abnormal nervousness — Eccen- tricity — National temperaments — Degeneracy — Genius and mor- bidity — The ex-Kaiser as an interesting study in temperament. THERE are numerous ]Deople who by reason of cer- tain familiar characteristics we say are " nervous " ; meaning by this they are quick in response, highly-strung, over-sensitive in both mind 8.nd body, subject to dis- turbances of sleep and digestion, greatly bothered by aches and pains that do not trouble theh' fellows, in- capable of very prolonged exertion, yet withal frequently intellectual, ambitious and successful. In other words, this nervousness shows all our most live qualities raised to a high power ; its intense emotionalism separating it out as a type. And as in the preceding chapter we have seen how emotional reaction so commonly over-strains the nervous system, now we are to see how certain people are so temperamentally constituted that they are especi- ally predisposed to excessive feeluig response, and con- sequently are more than their feUows liable to neuras- thenic and similar troubles. To understand how this is so necessitates a brief study of what we understand by temperament. Variously defined, temperament is really the inherent tendency of the individual to react to particular influ- ences and conditions. It is therefore personal. We have, indeed, already noted that each of us exhibits his own 38 NERVOUS TEMPERAMENT . 39 special ways of responding to emotional waves, and it is the sum-total of our personal reactions that forms that general response to the calls of the world and society that constitutes temperament. Deeply rooted in all those factors that have gone to help in constructing the fabric of the human soul, moulded by those which have differentiated one race-mind from another, and then one tj^e of individual from another, our temperaments are to-day the basis of our lives. Far from being hopelessly unpliable, personal mental constitution as expressed by temperament is certainly hard to remould, and on this innate and notably firm foundation of temperament each of us builds the super-structure of character. Moreover, as the latter is the last to develop so it is inevitably the less resistant to internal or external influences. Character can be so trained as to minimize the dis- advantages of temperament, where it is found too hard a task to modify the latter ; character so formed in opposition to morbid kinds of temperament then acts as a steady influence modifying its own foundations for good. It follows, then, that an important aspect of our problem is that which concerns the character-building of nervous children, so that their education shall give them a sound protection against the deleterious tenden- cies they start life with. To make our characters masters of our temperaments should be our ideal ; where we are of nervous predisposition it must be an early goal. To form a fine character always denotes a victory of mind ; to conquer a vile temperament is always a great spiritual triumph. For character to be the servant of tempera- ment is always unfortunate ; for the neurasthenic it is disastrous. Temperamental peculiarities bring it about that various people show such remarkable aptitude for certain work and offices that we say they are " born to " their occupations. These are they who so successfully " fit into " the envu-onment in which they find themselves— 40 THE PROBLEM OP NERVOUS BREAKDOWN or wherein opportunity leads them or chance thrusts them — that they go straight ahead and achieve success with meteoric rapidity. They occupy the centre of the stage and are the cynosure of all eyes. Cromwell was a born leader and a born statesman ; Napoleon was born to leadership and strategy. The born doctor, actor, lawyer, we see all round us ; their fitness for their opportunities gives them a headlong start in life's handicap. But it is no good being " born to " certain work if opportunity never comes to exercise inherent gifts, or if, in sportive vein. Nature has denied the ability of making opportunities for individual ends. At the other end of the scale we find those who, sadly enough, do not fit into their environment. Some, indeed, are so miserably situated that they find themselves always unsuited. Misfits are for ever with us ; they are for the most part the poor in nerve. The solution of our problem must include the consideration of these, for amongst them are many who with help would certainly play a useful if small part, and so contribute that much to the commonwealth. They include, of course, those who owing to stress of war quickly break down under the conditions of military service ; the " martial misfits," as some one has dubbed them. The fault is certainly not theirs. The remedy for nervous misfits is to secure them work they feel capable of and which will enable them to do their best as units in the great machine of State, instead of crushing whatever abilities they may possess in unwise attempts to fit these square pegs into round holes. Only bj?^ studying temperament as well as physique can we see to it that we always have the best man for the job. Estimation of general physique and the state of the physical nervous system is not enough. Temperament is the physique of the individual mind, and much greater attention should be given to it in selecting candidates for posts of any kind. Now that our future lies largely in the air there are going to be endless opportunities for NERVOUS TEMPERAMENT 41 mistakes ; many misfits may be given work that will endanger their own lives as well as those of their fellows if this question of temperament is not properly taken up. Temperament in relation to aviation opens a new field of research that is of vital importance to national welfare in commerce and security in war. Already one can estimate with a little more accuracy than was possible two or three years ago, some of those temperamental factors which point to the successful aviator and to the aerial unfit. Differences of temperament have been observed from very ancient times, and, indeed, in the early days of medicine temperament played as important a part in the diagnostic reckonings of physicians as do our scientific instruments to-day. Doctors of old times knew nothing of X-rays, chemical analysis, microscopes or apparatus for testing the heart or other organs, but they were studi- ous observers of human nature. And, as a result of look- ing closely for divergencies of temperament, they eventu- ally classified mankind according to sanguine, bilious, melancholic and phlegmatic temperaments. To-day, whilst perhaps not recognizing quite the same character- istics in these types, we are, nevertheless, familiar enough with many of the features which led to this division. Thus it is interesting to recall how one associates the sangume temperament with fairness of skin, reddish hair and blue eyes ; accompanied on the mental side with quick emotions, active brains, but, sad to say, often some lack of persistency in thought and conduct. Contrast this with the more sober and steady qualities of those who, dark in eyes, hair and complexion, exhibit the mental characteristics of depth, caution, determination, and ambition ; or, again, with those heavy persons, pasty in face, slow in movement, very cautious but plodding in all mental activities and readily depressed, who would come within the ancient definition of phlegmatic. To- day, as already noted, we recognize the nervous constitu- 42 THE PROBLEM OF NERVOUS BREAKDOWN tion — which Hippocrates and his fellows would probably have called the melancholic temperament. Ribot, in his interesting work on the emotions, endea- vom'ed to simplify matters by distinguishing two broad tjrpes : sensitive and active. Of these the sensitive really represents a combination of the nervous and bilious, and the active a blend of sanguine, bilious and nervous. But the learned professor then found that he had to admit a third type, which he called the apathetic, corresponding to the old phlegmatic temperament ; and eventually found himself unable to place that very common make- up which expresses moderation in all things, and so actually added a fomth which he called temperate. Thus one sees that if it is attempted to define definite types of temperaments too closely it is very hard to improve on the division into sanguine, bilious, phlegmatic, and melancholic v/hich satisfied ancient philosophy and the great Greek doctors who founded medical science. In- deed, one could go on making classifications indefinitely without coming to any better understanding of the problem, particularly when one realizes that modern man by virtue of his mixed descent exhibits a blend of many previous race characteristics. Daniel Defoe well said of ourselves, " a true born Englishman's a contra- diction, in speech an irony, in fact a fiction," Unquestionably in studying the part played by tempera- ments in favouring or protecting against nervous break- down the best thing to do is to realize that the classifica- tion into definite tjrpes is simply a matter of academic convenience, enabling us to recognize the common association of certain mental and physical differences and also helping us to recognize blends of these associa- tions. We must not go out into the street expecting everyone we meet to exemj)lify pure types of particular temperaments according to some enthusiast's classifica- tion. Mixtures we are, and mixtures shaU remain until some future century produces that perfect type towards NERVOUS TEaiPERAMENT 43 which one may hope the evolution of mankind is tending. For each individual the actual self at any moment as related to the world represents a combination of three interdependent factors : (1) Physical state ; (2) Emotional condition ; (3) Intellectual attitude. Of these the first two are very closely related, as we have seen, whilst the third is to some extent independent. Within certain limits this combination is recognized as normal, but when there is such want of balance that one is out of harmony with the others, or that 1 and 2 are found in conflict with 3, breakdown occurs, as shown by neurasthenic and morbid mental states. " The practically real world for each one of us, the effective world of the individual, is the com- pound world, the physical facts and emotional values in indistinguishable combination. Withdraw or pervert eitlier factor of this complex resultant, and the kind of experience we call pathological ensues." In studying this question one should note just what are those characteristics which commonly stand out so boldly as definitely to colour specific temper amxcnts. They include hopefulness, optimism, cheerfulness, or sen- sitiveness, i.e. impressionabihty which may be (a) superficial, (b) deep — a very important matter ; pessimism, desire for action, determination and persistency, caution, phlegm as exhibited by slowness in thought and deed, mischievousness. Each individual's temperament is really a resultant ; and the features by which he is best kno'wai to his fellows are emphasized by just those charac- teristics which are most prominently present. It is when some happy blend of temperament occurs that we find a man or woman outshine the rest in thought, word, or deed. Some of the world's greatest men and women have been compounded of the dark, cautious type, admixed with sanguine and nervous features. To those who are fortunate enough to be brightly sanguine in out- look whilst strong in build, sure in thought, but neverthe- less quick, comprehensive and imaginative, all things are 44 THE PROBLEM OF NERVOUS BREAKDOWN possible. These are they who successfully carry out enterprises requiring dash and swift virility. They have no fear, and on land, on the sea or in the air will always do great deeds. One thinks of Harold the Saxon King, of Richard Cceur de Lion, of Francis Drake, of Nelson and of many a brave boy lately " gone west." Similarly, a blend of the nervous constitution will change one who would otherwise have been a phlegmatic individual into a dashing hero or heroine, or into an inventive genius who becomes a national asset. One knows that many weU-known men have owed their success, or been influenced at critical stages of their careers, by particular temperamental characteristics. Thus one finds many famous leaders of men have been either primarily of the choleric type, whilst truly sanguine and sensitive (nervous) at the same time, or primarily nervous with just sufficient blending of phlegm to steady them. Amongst the former one thinks of Julius Caesar, Oliver Cromwell and Cardinal Wolsey ; amongst the latter William of Orange. Where the nervous temperament has run riot, controlled merely by a degenerate cunning, such monsters as Richard III of England, and Ivan the Terrible of Russia have scourged humanity. One finds that writers of fiction like to endow their heroes with just that satisfactory admixture of the firm choleric type and a certain sanguine nervousness sufficient to make them noble, adventurous, energetic and magnificent. Of just the right temperament for a hero, D'Artagnan holds the field in The Three Mus- keteers, and captures all hearts. Shakespeare's Hotspur and splendid Prince Hal are equally gallant ; whilst King Arthur and his Knights of the Round Table stand out for all time as the most perfect examples of this fortunate type. One would like to survey at length the representations of temperament as portrayed by some famous novelists. In the pages of Dickens alone one can find enough NERVOUS TEMPERAMENT 45 material for a whole volume. There we encounter different types depicted with a masterhand and ex- emplifying every familiar mixture of those innate mental qualities which, as we have seen, go to make up temperaments. So true to life, indeed, are these types that the names of many Dickensian characters stand as household equivalents of various ways of reacting to life. The kindly benevolence of Mr. Pickwick, the undaunted optimism of Mr. Micawber, the irrepressible jolHty of Mark Tapley, the unctuous meanness of Mr. Pecksniff, and the insidious humility of Uriah Heep at once come to mind. Exaggeration of certain temperamental characteristics far more often leads to an individual being obviously — and therefore abnormally — " nervous " than it does to noticeable breakdown. But it is none the less true that where there is a diversion of thought and physical energy to the setting up of eccentricities or other forms of mental defensive machinery, there is to greater or less extent a breakdown of that smooth harmonious relationship between the individual and his environment that is the ideal of happy healthy life. Of course it is only when the jars and disharmonies are such that the nervous system is unable to maintain harmony of thought and action that the resultant mind-body condition is recog- nised as an indication of actual breakdown. It is thus, then, that the individual concerned becomes definitely a " patient " suffering from " neurasthenia," or some allied trouble. It has been said that the nervous are the salt of the earth, but that is not to say the neurasthenic. What is true is that a blend of nervousness often gives just that fire and force that enables a man to manifest his finest characteristics and do his best work. Just as, on the other hand, the bright, happy life of the sanguine may be spoiled by a dash of viciousness ; its sweetness soured by selfishness and morbid jealousies. Similarly too great a preponderance of lively emotionalism obscures 46 THE PROBLEM OF NERVOUS BREAKDOWN any possible advantages of the nervous temperament, and if uncontrolled results in failure and ill-health. Eccentricity often represents a self -defensive mechanism set up by morbidly sensitive people who directly or indirectly- — usually quite unconsciously — have elabo- rated this means of getting away from the things of ordinary life that worry and irritate them. Eccen- tricity is so commonly found in nervous persons because it is just those who manifest over-sensitiveness and react abnormally on the emotional side. Hence then' eccentricities tend to protect them from what is to them the unbearable rough and tumble of the work-a-day world and they develop habits of seclusion, of compara- tive irregularity, of devious ways of living. In detail, eccentricity is governed by a number of secondary factors which, in course of time, frequently lose their original force, but, nevertheless, leave habits behind them when this particular form of nervous self-defence originally set up no longer is needed. Many eccentricities of conduct are in the first place quite consciously per- formed by nervous people who have a perfectly sensible reason from their point of view ; but the same over- sensitiveness that led to the eccentricity prevents — by fear of unsympathetic criticism — the indi\Hdual con- cerned from confiding the reason for his little tricks even to his closest friends. It is, after all, his business, and he lets outside opinion go hang ! One recognizes national as well as individual tem- peraments. National temperamental tendencies be- come modified by training and environment. It has been said that " the long and severe training of the tribes of Central and Northern Europe explains their pugnacious qualities, which compare so strongly with the people of China and India who embraced Buddhism, the religion of peace and inertia." ^ In many countries ^ T. Claye Shaw, M.D., The Psychological Influences Affecting War. a. Medical Press and Circular, May 19th, 1915. NERVOUS TEMPERAMENT ' 47 to-day the fighting temperament has been so modified by training that it has been transformed into the gentler experience of industrial competition and friendly rivalry in sport. According to those conceptions which we and our allies in the great war feel must be representative of the best types of civilization so far attained this is a definite advance in the evolution of national tempera- ments. That it is not so considered by those tribes of Central Europe just referred to has been unpleasantlj'^ forced on our attention. How prominently the morbid developments of the nervous temperament have figured in the lives of many who have left their mark upon the world, is amply illustrated in the pages of history. Certainly it often has happened that when a family constitution is largely based on the nervous temperament, the further blending has led to both flights of brilliant genius and depths of depression and despair in individual members. Nevertheless, brilliancy of intellect is by no means always or necessarily associated with mental degeneracy. Shelley, Sheridan, Sn Walter Scott, Robert Burns, Wordsworth, and Byron all shone in a firmament of neuroticism. Cowper, who is said to have written John Gilpin when suffering from intense melancholia, came of a family previously exhibiting both mental instability and great fame. Of the family of another famous poet, we are told that " his father was eccentric and absent-minded, and his mother is stated to have been uneducated and simple. He himself ran away from coUege, he quarrelled with his brother as a boy, and left home, being absent all night without apparent reason. Later in life he left his wife and children and v/ent off to Malta. At the age of thirty he was broken down, and he died a wreck whilst his son drank himself to death and died demented." ^ Yet another shone as the brilliant star of ^ Sir Robert Armstrong-Jones, M.D., Temperaments : la there a Neurotic One ? Cf. The Lancet, Jiily let, 1911. 48 THE PROBLEM OF NERVOUS BREAKDOWN a highly unstable family, amongst his uncles being one who left his estate to a footman. On tracing inheritance and mental reaction in the biographies of some of the most eminent musicians, we can find the same penalty exacted from families which have produced geniuses. " The genealogy of the Bach family has been traced for 200 years, from the founder, who was a baker, to Sebas- tian Bach, the climax of musical talent. Bach had twenty children, but no issue remains to perpetuate the distinctions of the father. Although many of the Bachs married musical people, the family record is one of sick- ness, bhndness, drunkenness and mental defect. Although we can breed Arab horses, Derby winners, and prize cattle, it has hitherto not been possible to produce a " musical breed," showing the unfitness of genius to survive in a world requiring many adaptations, and the incapability of genius to continue its own dis- tinctions. Schumann suffered from recurrent melan- cholia. . . . Wagner, wild and erratic in youth, in later years exhibited a violent temperament, and often lost control of himself. He had a mania for silks and satins, with which he always dressed himself to compose music. When travelling he also carried these to decorate his rooms, and when he died he requested that his room should be upholstered in pink and pale blue satin. Schubert was worn out and died at thirty-one. Beethoven . . . was always changing his rooms and was paying for three or four different lodgings at the same time. He seems to have alienated his best friends through suspicious jealousy and false accusations."^ The ex-Kaiser offers an interesting study of a tem- perament which illustrates the controlled nervous type admixed with callousness and influenced by the unique position in which he has found himself as undisputed arbiter of millions of intelligent people. Allowed free 1 Sir Robert Armstrong-Jones, M.D., Temperaments : Is there a Neurotic One ? Cf. The Lancet, July 1st, 1911. NERVOUS TEMPERAMENT 49 rein, the general tendency of the over-sensitive mind is to become more and more centred on self, the extreme case being that of the deeply depressed person who has given up the struggle against overwhelming sensations of distress that have culminated in a grand depression. Having reached this melp.ncholic level the sufferer then sees everything through the fog of the morbid atmo- sphere that surrounds him, and refuses to be comforted. It is often enough a hard task getting people to fight their way through such negative phases. Particularly physi- cal disorders have in the first place destroyed mental comfort through their reverberations in the chambers of the brain. But the egoism of neuroticism by no means always finds expression in depression. The self-centring may focus round an idea or group of ideas that dominates the field of thought. In the fanatic and the devotee we only too often find the results of over-centring of this kind. An obsession may be a nuisance, but an obsession that so possesses its victim that he or she feels an irre- sistible urge to play a special part may become a source of danger to society. However, there are many medium expressions of egocentricity which lead to harmless enough happenings however troublesome they may be to a man's friends. The crank is commonly an innocuous illustration of the nervous temperament morbidly developing in the brain an obsessing idea. The founders of a thousand and one " isms," political systems and creeds have also been illustrations of this trend. Where the highly-strung individual is also ambitious, powerful and unchecked megalomania — that is " sweUed-head " carried to its highest power — may result. Of the Prussian despot we have for years been told of his ceaseless activities ; his constant tension and frequent explosions ; of his sudden plans, his goings out and his comings in ; aU carried out against a background of fixed behef in his divine authority* Some fifteen years ago a psychologist of repute in the 50 THE PROBLEM OF NERVOUS BREAKDOWN English-speaking world expressed the considered opinion that this exponent of the divine right of kings was so far neuropathic as to be on the borderland between sanity and insanity. Long ago one of his own subjects found him not unlike a notorious and cruelly unstable Roman Emperor. The first mentioned observer declared that " his childhood and youth were characterized by pecu- liarities of conduct that may safely be said to be psycho- pathic, while his early manhood was punctuated with frequent instances of decidedly insane behaviour." ^ Quoting this in recent times, a leading medical journal remarked of the Kaiser that " there is enough in his megalomaniac proclamations about his destructive sword, and his alliance with the old God of the Prussians, to justify us in pronouncing him a man of abnormal mind." ^ More recently we have had the testimony of Mr. Davis, the Kaiser's dentist for fourteen years, that in his imperial patient he found " a man of unparalleled egotism, of wide reading " ; yet one who " was im- patient of correction and who would brook no opposi- tion," 2 a man who hid the egoism of the abnormally self-centred, and the obsessions of the fanatic, behind a mask of courtesy, affability and gentleness. Clearly this is a graphic picture of the nervous temperament in one of its worst developments. ^ Dr. McLane Hamilton, quoted by The British Medical Journal, August 28th, 1915. '^ Arthiir N. Davis, The Kaiser as I Kneiv Him for Fourteen Years. Cf.- The Times, August 24th, 1918. CHAPTER IV SOME FACTORS DETERMINING BREAKDOWN Stresses of daily life — Work and worry — Common anxieties — House- hold worries — The worrying habit — Nerve weakness and a burdened mind — Nerves and domesticities— Strain of development. HAVING considered the relations between the emo- tions and nervous breakdown in general terms it is desirable to apply our observations to everyday Hfe. Granted that in anyone emotional storms react hardly on the brain, and that in those of nervous temperament the whole system is constantly vibrating violently in response to waves of feeUng, we still want to know just in what particular directions the conditions of daily life favour the occurrence of these stresses. After aU, few of us live for long on high levels of feeling ; even those excitable folk who are continually running up emotional ladders come down to ordinary levels for the routine business of life. Consequently, we shaU expect to find — and shall, indeed, do so — ^that although the grand passions tear people's nerves to shreds often enough, in the great majority of cases the emotional factor operates in a more insidious way. Love, hate, anger and disappointment, as many other emotions, wreck the brain when felt strongly and deeply — ^particularly if there are successive waves of heightened feeling at short intervals — but for the most part it is the insidious reactions of smouldering fires, of gnawing envy, bitter jealousy, long-nursed grievance, unrequited affection and their fellows that wreck most nervous systems. Certainly it is the mental 51 52 THE PROBLEM OF NERVOUS BREAKDOWN strain of these things rather than physical stress that finally and in favourable soil determines most break- downs. In practical life, indeed, it means, as abeady noted, that it is worry rather than work, that is responsible for the tired faces one sees so commonly about us. A man's brain can stand a remarkable amount of work without becoming over-strained, but as soon as worry is added to work nerves begin to fail. Life is such that many people who have to work hard find it necessary to worry at the same time ; a temperamental predis- position to worry leading astray some who even from the most material standpoint have nothing to be anxious about. We live in a time when few are content to leave off in more or less the same way as they began. Few are satisfied with their positions. Many who would be better off if content with a moderate success, strive and struggle against odds to gain worldly advance which can never be theirs. In business circles the pressure of competition leads many men to worry day after day and year after year, with the consequence that their capacity for work is impaired, whereas if each had only to do his work in the certainty that it would bring him a moderate living and a comfortable reward, he would quite easUy be able to carry it on many more hours a day than he is able to do when worry is added. The stimulus of brain-work is good for the nervous system, and the harder a man uses his brain up to a cer- tain point the better wiU it respond. But worry soon tires. Thoughts that race backwards and forwards through the head, thoughts that will not be dismissed ; the uncertainties of position, employment, and so forth, wear out the brain of many a man who could do most excellent work if his bare living were certainly and always secured to him. Many a man living in circumstances suggesting prosperity is made ill through the canker of worry gnaw- ing at his nervous system ; not through overwork, as his friends suppose, but through the anxieties attendant SOME FACTORS DETERMINING BREAKDOWN 53 upon a self-enforced maintenance of his household in a luxurious position. It is the man whose expenses are large, and whose income is large, and whose interests are large, who is often beset with fatiguing anxieties which leave untouched the man of smaU interests and certain income. The constant strain on people born in moderate circumstances of keeping up appearances beyond their position has carried worry and ill-health into many a household. Financial adventm^es bring much worry. Gambling in stocks and shares, rubber booms, oil specu- lations, gold mines, and similar ventures have been, and may be again, responsible for a good deal of nervous disorder. Financial speculation cannot be carried on without strain ; and the anxieties born of gambling have worn out many. Again, there are persons in important administrative posts, won by their own determination and energy, who, jQlHng positions of authority in which great strength of mind is required to deal adequately with the duties pre- sented to them, not infrequently find themselves in- herently incapable of assuming the bm-den thus thrust upon them. To some a position of great responsibility brings with it terrors of uncertainty and doubt. Uncer- tainties as to course of action, as to attitude to subor- dinates, as to confidence in servants, or as to the results of action, gradually undermine their nerve. Sometimes we are sm^prised to hear of an important post being given up not long after it has been hardly won by a keen worker. Only the victim and intimate friends know the story of how the final ruin of ambition has depended on nerve failure in face of unaccustomed responsibility. House- hold worries often determine nervous breakdown. Some women are so temperamentally constituted that they cannot run a large household without suffering stress ; others through want of method bring needless anxieties on themselves. Many through no fault of their own are unable to support the burden of those difficulties of 54 THE PROBLEM OF NERVOUS BREAKDOWN service which have been prominent of late years. Here, also, we must consider incompatibility of marriage ; incompatibility of friendship ; ill-chosen companion- ships ; and the unfortunate congregation in families of persons who are absolutely unsuited to live together. Sometimes, of course, people worry because they have no interesting occupation ; others worry over imaginary grievances between themselves and their neighbours ; yet others worry because they cannot get enough amuse- ment, and after a certain age tend to worry about every- thing they possibly can. Such persons are tempera- mentally predisposed to worry. Seme worry themselves into a state of hypochondriasis, in which they are con- tinually thinking of some illness or other ; their worry- ing, becoming concentrated upon health, turns them into confirmed valetudinarians. It is then very difficult to distract their attention from their bodily troubles. One meets people who have been for years worrying about trifles, small domestic affairs, little business transactions, even about their hoHdays, who eventually concentrate their worrying minds upon their health in this way. Some seem to spend the greater part of their lives in going from doctor to doctor about little aches and pains, small symptoms of one kind or another, which should never be noticed at all by healthy individuals. When influenza is rife they worry lest the infection catch them ; when gout is popular they worry about their supposed gouti- ness ; when insanity is talked about, they worry as to the state of their own brains. A goodly number finally and persistently concentrate attention on their stomachs. Hundreds go about seeking relief from stomachic troubles which, if present at all, they owe entirely to their own morbid habits of mind, and for which the sole hope of cure lies in an elevation of general health and nerve- tone. These people make difficult patients, and it requires a good deal of moral force and self-confidence to stir them up sufficiently to break the morbid habits of mind SOME FACTORS DETERMINING BREAKDOWN 55 and body upon which depend their chronic ill-health. In fact they are self-hypnotized. A man's nerves often reflect the state of his conscience. The knowledge of having deliberately done wrong can only be a heavy burden ; a load that may be too heavy to be borne even by the strongest. Secret misdeeds bring their own punishment. Remorse is a cbeadful penalty and bears hardly on human nerve, which not unseldom gives way beneath the strain. Yet again there is such a thing as morbid conscientiousness. In this state of mind people suffer tortures in theu' vain regret for some trifhng action which has really no importance ; they magnify molehills into mountains and needlessly torment themselves about smaU personal and domestic happenings to which the healthy-minded man would give no thought. Wrongdoers sometimes sm'render themselves to the police rather than go on suffering the strain of unconfessed misdeeds. The victim of a bur- dened conscience is well-advised to get rid of his load as soon as possible, pouring out his trouble into sympa- thetic ears. That way relief comes, and the explosion of too-long restrained emotion is obviated. A classic example of the morbid conscience is the figure so power- fully portrayed by Borrow as the man who had sinned against the Holy Ghost. Hatred, envy, or mahce secretly nursed against others invariably react on those who encourage these bitter thoughts. They act like a poison upon the system, and are responsible for many disturbances of health. The mind that nm^ses a secret hatred against somebody else is bound to suffer from the recoil of the cruel thoughts it formulates ; and the neurasthenia of the bitter thinker is by no means uncommon. Little malicious thoughts, small subterfuges, trivial advantages gained over some trusting comrade are, indeed, despicable ; but there are few human beings who are entirely blameless in these things, which are the measure of how far we are from the 56 THE PROBLEM OF NERVOUS BREAKDOWN realization of man the image of God. Still, lamentable as are these signs of our bondage to false beliefs they are far from crimes and the healthy minded — the right- thinkers — should use them as sign-posts pointing the way to a better sense of life and living. The morbid con- science takes those peccadilloes too seriously and leads the neurasthenic to become imbued by the terrible thoughts of deadly sin. More than that, the thing often grows morbid, the obsessed victim believes he has com- mitted an unpardonable sin, that there is no hope for him in this world or the next. Lucky are those who are pulled up by a friendly warning ere they have descended the hill to the pit of black depression waiting for them at the bottom. Free discussion of the mental difficulty is their best hope of relief, but it must be discussion with some one who is not unaccustomed to deal with these matters. The morbid outlook on life may be quickly changed from misery to brightness when the situation is properly explained to them. In states of lowered nerve -tone domestic or financial troubles which are really not very important may seem big and overwhelm- ing, but they commonly lose their terror when discussed with a true friend. Issues fearfully avoided frequently appear small when braved, or confronted in company with a helping confidant — ^the biggest bogey vanishes when we face it bravely. When a staunch friend stands by difficulties are never so appalling. Sensitive nerves figure more prominently than is generally reahzed in the ordinary relations of family life. The story of the petty squabbles and jealousies which mar the life of many families is a very sad one. As a matter of fact, many of the little family upsets which are treated so seriously, and which often lead to serious breaches of harmony, are due to a nervous state — over-sensitiveness. Homes are broken up, and the happiness of domestic life is marred through indi- vidual reactions which are misapprehended. In large SOME FACTORS DETERMINING BREAKDOWN 57 families there is often some one who is particularly high-strung, and it is this unfortunate individual who somehow or other becomes the focus of discord. Given a suitable setting inflammable material may lead to a domestic explosion. Storms of this kind are character- ized by increasing waves which ultimately reach a certain height and then decrease, in much the same way as a tempest at sea. Furious distm'bances are often recog- nized because they place the patient in a serious posi- tion ; but little nerve-storms, not understood as such, produce many jars and quarrels in home life and between friends. Nervous irritabihty is responsible for many of the squabbles which disturb domestic peace. Bad temper in many cases really represents an iUness ; often it is a troublesome psychological disorder. Sulkiness, abrupt- ness of manner, and sudden rudeness often belong also to the same category. If this were more generally under- stood, people would be more inclined to settle their differences amicably. Home quarrels are often a tragic consequence of wrong-thinking. It may be said that as a matter of fact serious squabbles and quarrels and dis- agreements between friends are not really very common in comparison v/ith the opportunities for their occur- rences, but any doctor who has opportunities of con- stantly observing the home -life of weU-to-do people, and, in fact, the home -life of all classes above the ex- tremely poor, knows that home quarrels are remarkably common. There is little doubt that many of these quarrels depend upon the morbid irritability, the ex- cessive tension, the unhealthy excitability in some one's nervous system which, under stress of circumstances, has resulted in a little brain-storm, expressing itself as an attack of bad temper which has been misunderstood and has led to most unfortunate consequences. There are thousands of cases which are now dealt with in the public courts the proper place for which is the consulting-room 58 THE PROBLEM OF NERVOUS BREAKDOWN of the specialist. There are hundreds of instances in which separations and divorces are sought on the ground of incompatibility of temper, or similar circumstances, in which the right course of action would have been for the parties concerned to consult a doctor before resorting to drastic measures. Why should not an irritable husband or a nagging wife take such a reasonable step, before seek- ing legal advice which may lead to irreparable misery and disaster for them both ? Matters of sex are often determining factors in pro- ducing nervous unrest or breakdown, but there is a ten- dency to-day to take extreme views of the relations between these and nervous disorders. Certainly many seek rehef from nerve symptoms who have at some time or other been bothered with primary sex emotions, but human nature being what it is the same might be said of any other kind of malady. Still, the effects of strain inseparable from unfortunate love affah's, from jealousy, from loss of husband or wife, are always incalculable and often far-reaching in their consequences. It is not surprising that where health is impaired from such causes the nervous system should bear the brunt of the dis- turbance ; and often enough one can trace the effects of some amatory crisis in originating a serious condition. Any consideration of this factor of causation touches that great problem of the unmarried which concerns a lament- able number of women who are prevented from entering the state of matrimony. The crux of this problem can- not be put into better words than those of the late Sir Thomas Clouston, M.D., who wi'ote : " Intense and complete outward repression and inhibition of certain physiological cravings required by our morals and civiliza- tion causes, no doubt, a dangerous strain on the brain functions, and a reaction in other dnections where there is hereditary neurotic weakness." Then, again, the special period of development of the reproductive functions throws a tremendous strain on SOME FACTORS DETERMINING BREAKDOWN 59 the system during the years of puberty and adolescence. Hence so many neuroses develop in girls who are budding into womanhood. In this also can be found ^he reason why for young men the ten years from fifteen to twenty-five are so productive of neurasthenic ailments. This is the time when the boisterous mamier of the boy gives way to a more dreamy attitude of mind, when young women are no longer regarded just as gentle com- panions, but are viewed in a somewhat mystical light ; when poetry becomes of some interest ; and when, with strange pulses beginning to beat within him, the youth's soul awakens to the full reality of life and life's work. To many this is a time of ever-increasing joy in the knowledge of growing manhood ; to the deli- cate the changes going on within the organism may prove too much for the nervous system. It is thus under- standable why neurasthenic ailments are so common amongst students and others who have to do a great deal of brain- work during the period of development. The natural way of spending adolescence is out of doors in occupations that will not throw any strain on the nervous system. The student lives too much indoors and thinks too much, often paying dearly for his temerity in out- raging Nature's laws. Herein partly lies the explanation of the paradox that many of those who acquit themselves brilliantly as students have but moderate success in after-life. Exhausting their nervous systems at a critical time, they are unable to make up for their spendthrift output of nervous energy. CHAPTER V CONDITIOXS PREDISPOSING TO BREAKDOWN {A) Occupation, Climate and Constitution Predisposing as opposed to determining causes — The prevalence of breakdown among brain workers — Influence of occupation — Strain of modem conditions — Motoring — Telephone work — Occupational breakdown in America — Climate and neurasthenia — Debilitated effects of residence in Tropical countries — Heredity — Ancestral indiscretions — Marriage and consanguinity — Depleted stocks. THE circumstances of daily life referred to in the preceding chapter as often determining the onset of signs of nerve disorder are, of course, frequently modi- fied by conditions partly or wholly operating on the physical side. It will be convenient now to consider these, which for purposes of classification may be regarded as predisposing rather than determining factors. On occa- sion it is difficult, indeed, to say which happenings have predisposed as distinct from those which have actually determined a breakdown. Where the event follows the working of a combination of many possible causes the dis- tinction perhaps cannot be made. But for present pur- poses, and with these reservations, the grouping here made can well stand as being convenient. Occupation, climate, heredity, nerve-poisons, wasting diseases and accidents are some of the things predisposing to nervous trouble which we can now proceed to study. As might be expected, nerv- ous maladies are prevalent among brain workers ; but it must not be supposed that it is especially predisposed to by the work of journahsts, barristers or doctors for example. On the contrarj^ the reason why the vast army of neuras- thenics is so constantly recruited from the professions is 60 CONDITIONS PREDISPOSING TO BREAKDOWN 61 because many who foUow them are of nervous tempera- ment from the outset. People of the nervous type, rather highly-strung, and quick in thought often find their natural bent in a professional career rather than in any- thing wherein they would have to display more physical than mental activity. But wherever there is a predis- position to neurosis mental strain is necessarily liable to bring out latent tendencies to neurasthenic conditions. The great orator, the tragedian, the fluent advocate, the priest or missionary consumed with spiritual fire are types of those whose occupations predispose to collapse. On the other hand, however, there is a good deal of nerve-disorder amongst those who never do much hard work at the best of times. It is a fact that lack of occupation is often responsible for nerve-symptoms in people who have no definite object in life, and are very often bored to distraction with the mere effort of seeking fresh amusements. Persons of this kind are readily relieved of their troubles by being made to take up some serious occupation. In such cases a hobby is not usually sufficient to bring about the mental change required ; it is absorption in some useful pursuit which is so bene- ficial. Far more serious are the cases of breakdown which one finds in elderly men who have retired or been retired from their occupations ; men who are strong mentally and physically, but have to retire from some responsible position because they have reached the age at which officialdom considers it necessary to consign them to the shelf. The effect of sudden cessation of work and mental activity in such instances is to throw a remarkably severe strain on the nervous system, and, out- side absorbing distractions having gone, the indi- vidual tends to become introspective and nervous. Further, a mind unused not infrequently becomes quickly disordered, and the corresponding loss of nerve-tone is not uncommonly reflected in physical infirmity. Not only is such an unfortunate strain of 62 THE PROBLEM OF NERVOUS BREAKDOWN circumstances seen in the case of retired officials, but there are not a few instances, which many can recall, in which the successful business man has decided to retire under his prosperity, and having done so quickly breaks down through sheer brain inaction. This question of occupation, or rather lack of occupa- tion in retired people is a very difficult one. It is not always easy to replace the absorbing interests of a life- long career, indeed, of a lifework itself, by some satis- fying substitute. It is aU very well to tell a man who has governed half a continent to play golf and to read novels, or to write to the papers or to take up gardening, or to fill up his time in a hundred other trivial ways, but he may not be able to throw the same energies and interest into growing roses as he did into governing a colony. One may set a man who has achieved success in the con- duct of a commercial undertaking to coUect stamps in the days of his retirement, but he may be quite unable to occupy himself properly in any such direction. StUl one has to make the best of things, and there are many useful occupations which can be suggested. Anyone who is contemplating retnement after a busy and active career should seriously consider how time is to be occu- pied when the change has been made, and not wait until arrives the deadly depression arising from the feeling that there is nothing to do, that he is no longer an important link in the chain of active existence. Certainly it is the intellectuals who suffer mostly from nerve troubles at the present day, but quite commonly such ailments occur amongst uneducated manual workers. Artisans, labourers, porters, women who probably never open a book or write a line, domestic servants and navvies, are by no means free from such affections, and some very severe cases occur amongst them ; thus showing that monotony of life, poor circumstances, and the in- numerable worries associated therewith, are just as potent to cause nervous disorder in the less-favoured CONDITIONS PREDISPOSING TO BREAKDOWN 63 ranks of society as amongst those who are better off. Obviously, such factors as alcoholism, shock from acci- dents, exhausting diseases, grief, and disappointment are just as likely to occur amongst the poor as amongst the rich. During the last ten years or so a new occupational factor in the production of nervous disorders has become prominent, namely, the effect of modern methods of locomotion. Thus, the control of motor-vehicles often throws great strain on the nervous system, severe re- actions occurring particularly where there is predisposi- tion to nervous instability. Especially is this important for those who have to drive motor vehicles through crowded traffic. Chauffem^s driving taxi-cabs tell one that their capacity for work is not unseldom seriously limited by the effects of nerve-strain. Some time ago a taxi-driver pointed out that his wage-earning possibiHties were always limited by the fact that after a certain number of hours — far short of the number he might have been expected to work — he found it abso- lutely necessary to take his cab back to the garage owing to the nervous feeling which bothered him when tired. Habitual motoring in a big city is bound to be attended by a certain number of accidents of varying degree. For every one person who is seriously injured by motors in the streets there are a considerable number who are knocked down and escape with very little hurt. But the effect and the shock to the chauffeur in all these cases must be very much the same. One can often see the painful signs of great shock in the pallid face of some chauffeur who has been unfortunate enough to run into something and who has subsequently had to stand by while an account of the case was jotted down by a police official. Such jars leave a permanent mark on the nervous system. Many accidents are due to hesitation on the part of drivers whose co-ordinating faculties are paralysed by an accumulated nerve-strain 64 THE PROBLEM OF NERVOUS BREAKDOWN and the sudden necessity for quick decision. Among amateurs it is not at all rare to find people who from this cause have had to give up driving. One often finds that even one sHght accident or " close shave " is quite suffi- cient to upset nerves seriously. Hence we should extend a little more thought and sympathy to the professional driver, who has to continue his arduous occupation, however much his nerves may have been jangled by his adventures. It is a question whether some system of health inspection of public chauffeurs, especially directed to the matter of nerve, will not ultimately have to be carried out. Efficient treatment and rest wiU do much to remedy any nervousness that may handi- cap a chauffeur, provided his weakness is taken in time. It is no good letting a man's nervous system go all to pieces before taking any notice of him, and then find it necessary to tell him that he must give up his job. A little forethought may preserve him in capable health. Much the same might be said about railway workers. Careful investigation has proved beyond doubt that some of the worst accidents have not been due to panic or loss of nerve under exciting conditions, but to a temporary failure of judgment in ordinary routine. Monotony of work carried out day after day under the same conditions of unrelieved routine may lead to such a blunting of capacity. Indeed, in the official report on a tragic acci- dent that occurred a few years ago this was practically admitted as a factor influencing the want of judgment that had led to the catastrophe. Again, telephone work is carried out under conditions that are most " trying " to people's nerves. A telephone operator is subjected to a constant strain of attention, and it is to be feared that the stress of the harassing work carried out is not always lessened by the sympathy of the public. Every one agrees that it is irritating to be foiled in one's attempts at quick communication, especially so if after a long wait and much curious stimulation of one's CONDITIONS PREDISPOSING TO BREAKDOWN 65 ear nothing better than a " wrong number " results ! Such experiences combine the nerve-strain of gambling without its possibly compensating excitements. This may be trying enough. But the operator is bombarded by calls hour after hour, and passes her time changing many pegs into a host of holes whilst having to preserve her equanimity through all the bustle of the day. It is not to be wondered at that some years ago it was found necessary to institute an official inquiry into the preva- lence of " nerves " amongst telephone operators. Of conditions leading to nervous breakdown in America we are told : " Occupations are important causative factors. Those causing great emotional stress are most dangerous. Thus, actors, business promoters, specula- tors (financial, not philosophical), and clergymen of the intense type are especially liable to breakdown. The fault is not altogether with the work. It is partly due to the fact that emotionalists are prone to be drawn to it." 1 The relations of occupation to nervous breakdown are sometimes influenced by climatic considerations. There is no doubt that local circumstances of work and living quite often determine the onset of a breakdown. In our own country the differences of climate are not so marked as to be commonly a potent influence of this kind ; nevertheless, one does from time to time find people whose nervous predispositions are brought out in par- ticular districts. Certainly there are quite a number who seem unable to live or work with comfort in the bracing ail' of the east and north-easterly district particularly near the coast. On the other hand, there are some who become neurasthenic in the softer atmosphere of the west country. Where local cHmate is adverse to an individual and his work is also antagonistic to his nervous balance there is clearly all the more chance of incapacitating dis- order occurring. However, whilst not of primary import- ^ Osier's System of Medicine, Vol. V, pp. 620-627, 66 THE PROBLEM OF NERVOUS BREAKDOWN ance to the average person of nervous temperament in this country, the question of climate is one of definite signifi- cance in relation to existence in tropical countries. It has been said that all white men worldng for years in hot coun- tries tend to deterioration of health ; indeed, it is recorded that whole peoples have become debilitated after migra- tion to tropical climates. One thinks of Baber, a sovereign who descended upon India with conquering hosts about the time when Henry VIII reigned in these islands. It is related that this potentate found it necessary to send his people home wholesale ; only in this way could he counter- act the enervating consequences of their change of country. At this distance of time it is difficult to say what other factors might have been at work in producing this neuras- thenia of a host, but there is further evidence in the history of other invaders of the Indian Peninsula that the conditions of the plain produced nervous exhaustion in races who went thither as conquerors. Some years ago an eminent authority on the health conditions of our Indian Empire drew attention to this weakening of peoples invading India. He did so as an introduction to an account of the exhausting effects of hot climates on the nervous system of European officials, stating that : " An officer otherwise in every way a good fellow, be- comes short-tempered ; forgets names ; is troubled with sleeplessness ; feels his work too much for him ; shirks responsibility ; given to making molehills into moun- tains ; procrastinating ; susceptible on slight exertion, mental or physical, to fatigue, and with a loss of con- centration." ^ An excellent description of the sort of malady one sees time after time in men who come home from India or Africa in a neurasthenic state. The preva- lence of such disorders is, indeed, indicated by the fact that typical names have actually been given to it in differ- ent parts of the world ; certainly in addition to the well- 1 Sir Havelock Charles, M.D., " Neurasthenia Among Europeans in India ' {British MedicalJournal, March 28th, 1914). CONDITIONS PREDISPOSING TO BREAKDOWN 67 known " tropical liver " — a term which often attributes to a much maligned organ, troubles which are really centred in the nervous system — one has heard of " Bengal head," " Sudan head," " Burmese head," and " Punjab head." It may well be asked, as suggested by a leading medical journal some time back in reference to this sub- ject, if we are not by our system of education, and the strain of competition, breeding a race of a nervously pre- disposed people who cannot live under the conditions of work in the tropics. A graphic description of nervous breakdown in Indian heat is to be found in Mr. Rudyard Kiplhig's At the End of the Passage. Heredity is often a vital factor in predisposing to nervous breakdown, and we can now see how far an inherited delicacy causes the production of nem'asthenic troubles ; noting at once that many suffer in this way through no fault of their own. Time after time it has been shown that nervous disorder is predisposed to in certain families, the history of which records instances of instability in preceding generations. It is a circum- stance that should not be ignored, but faced boldly, so that by right education and due precaution the worst threats of instability may be brought to naught. Un- doubtedly that nervous delicacy in one generation which so commonly becomes reflected in the next has been accentuated in our time by certain factors in the lives of our ancestors. Perhaps the Victorian era was in some respects good for the nation's nerves, but at an earlier period health must have been shattered by the habits of drink, gambling and other excitements then rife. We have to pay for the extravagances of our gay predecessors who from the time of the Restoration developed the excitements of life to their utmost, and now know that past consumption of strong Liquors has sown the seeds of nervous weakness in our generation. On the other hand, the opinion has been expressed that in those Good Old Days people lived 68 THE PROBLEM OF NERVOUS BREAKDOWN quietly and comfortably, laughed often and grew fat, thus stormg energy which is to be found useful in a more active time. Of course, this may react in either of two directions, for our immediate predecessors may have so drawn on the family store that we are now feeling a lack ; or it may be our irresponsibility in draining present reserves that is going to penalize the generations to come. " One generation may, by living at high pres- sure, and thereby disregarding hygienic laws, exhaust and use up more than its share of the ancestral energy transmitted to it. It may draw a bill on posterity and not hand on to the next generation enough to pay it. I believe many of us are now having the benefit of the calm, lazy lives of our forefathers of past generations who stored up energy for us. We, in this too strenuous generation, are using it up."^ At all events, inherited weakness of the tissues composing the brain is a highly important predisposing cause of all kinds of nervous derangement ; nevertheless, it is wrong to say that neurasthenia is inherited, because even a dehcate nerv- ous system will not break down unless some overbearing strain is placed upon it. The strain may be of a kind that stronger people would regard as negligible ; never- theless, it is stress enough for the predisposed person. It is not the disease which is inherited, but the tendency to it. It is weU that this should be fully understood, as there is no more lamentable sight than that of the person who sits down crushed under the weight of a supposedly inevitable inheritance of nerve trouble. The man who knows of his inherent nerve -weakness should use that knowledge to protect himself against its becoming an inconvenience to him. Certainly he should not assume the inevitabihty of a breakdown. The problem of heredity touches the question of consanguinity as marriage of closely related persons fre- quently produces in their offspring a dangerous delicacy 1 The late Sir Thomas Clouston, M.D., The Hygiene oj Mind, p. 169. CONDITIONS PREDISPOSING TO BREAKDOWN 69 of nerve -tissues. Thousands of families suffer in their nervous derangement the penalty of too strict an observ- ance of caste, as witnessed by the tragic story of several famous royal houses. On the Continent inter-marriage has brought houses like that of Wittelsbach to a tragic pass of nervous instability, whilst Bismarck's scornful reference to Austria's idiot archdukes was not without point in the matter of nervous inheritance due to con- sanguinity. Allied to the factor of consanguinity is that of de- pleted stock apparently resulting from exhaustion after centuries of activity. As in animals and plants, so with men, a stock tends to wear out in time unless renewed by infusion of fresh energy from without. The aristocrat may have to pay dues for his aristocracy in the form of neurasthenic troubles. Among parental causes of a constitutionally weak nervous system, we find many which in themselves might appear to be preventable. Thus the marriage of two persons themselves of nervous temperament is very likely to result in nerve-weakness in the next generation ; similarly the marriage of two persons whose nervous system has been weakened from various causes is not likely to augur well for the nervous stability of their children. And this question as to the advisabihty of the marriage of people whose nervous systems are unstable is one of the most important prob- lems which practical eugenists will have to deal with in the future. Any discussion of this matter must, of course, take into consideration the question of degree. The marriage of two people either of whom suffers from temporary nerve-weakness is obviously of nothing like the same importance as a marriage where one of the con- tracting parties is afSicted with constitutional failure of nerve-strength, or where one of "the marrying persona is so far weakened in regard to the nervous system as to lose at times entire control of the mental faculties. Taking the worst case first, we know that an appalhng 70 THE PROBLEM OF NERVOUS BREAKDOWN amount of nerve-weakness is transmitted from one genera- tion to another through the marriage of unstable individuals. Yet, although our duty seems clear in regard to these extreme cases, it is by no means so clear when one comes to consider the marriages of individuals who, although obviously of nervous temperament, or even with very greatly impaired nervous vigour, are quite able to take care of themselves, and can scarcely be interfered with in regard to such matters. The mar- riage of cousins is also a potent cause of nervous in- stability. It is not uncommon for the children of such marriages to be subject to nervous disorder throughout their lives. Here again we have a cause of the origin of a nervous generation which is in itself essentially pre- ventable, although it may be a long while before as a nation we insist upon its practical prevention. Other direct causes of inherited nerve-weakness are the trans- mission of constitutional disorder which especially affects the nervous system ; the marriage of elderly people ; or the marriage of an old man and a young wife. In all these conditions there are factors which tend to under- mine the nerve-force of the next generation, and these are among the problems which eugenists will have to deal with satisfactorily before they can make much progress in their great work of benefiting the nation's future physique. CHAPTER VI CONDITIONS PREDISPOSING TO BREAKDOWN (B) Poisons, Shocks and Some Others Nerve poisons — Auto-intoxication — Tea, coffee, alcohol and tobacco — ■ Drug taking — Influenza — -Trench fever — Accidents and injuries— Tratunatic neurasthenia — Nervous breakdown after operations — Race — Age. BUILT up as it is of the most delicate tissues of the human body the brain quickly responds to deleteri- ous matters circulating in the system, and many nervous disorders are maintained or initiated on the physical side by nerve poisons. Let it be noted at once that these health-destroying substances are not always introduced from without, but are frequently manufactured within ourselves owing to the breakdown of some other part of the general machinery of organic life. At least as many instances of nerve -poisoning exemplify the effects of self-poisoning — auto -intoxication — as those of extraneous poisons. Moreover, when nerves fail as a result of serious infective illness, say influenza or trench fever, the injury is brought about by the poisons set free within the body by the germs of the respective diseases. In the consideration of chronic illness of any kind, one should always be on the look out for possibly hidden microbes that may be persistently poisoning the sick man. Full discussion of this, as of auto-intoxication, does not come within the scope of this book, suffice it to say that there is nowadays general agreement that the stomach and bowel — particularly the colon — are the sites of poison manufacture in many instances. 71 72 THE PROBLEM OF NERVOUS BREAKDOWN From without, the nervous system often suffers on the one hand from the result of excess in consumption of such commodities as tea, coffee, alcohol, and on the other from morbid habits of self-drugging. Tobacco also must not be overlooked as a not unknown source of nerve poisoning. Under ordinary conditions of health and moderate use, tea, coffee, and alcohol are harmless enough, but, welcome as they may be on our table, let us remember that they are detrimental to those whose nervous systems are impaired in vitality. Even com- paratively weak tea or coffee may produce added dis- comfort in neurasthenic people, thus showing how in ill-health nerve tissues are peculiarly sensitive to their action. As with healthy people the question of indi- vidual susceptibility comes in here, so that in a few deli- cate persons tea or coffee will actually produce great excitement, distressing palpitation, giddiness, or gastro- intestinal disturbance. This is on all fours with the familiar observation that there are people in the best of health who cannot take a cup of tea without sub- sequent discomfort, whilst others cheerfully drink a strong brew knowing themselves to be immune. Signs of tea poisoning include disturbed sleep, irritability, trembl- ing, indigestion, poor appetite, palpitation. In excess tea drinking has been known to produce a state — tea in- ebriety — which in some respects resembles drunkenness. To avoid ill-effects from tea it should be made by pouring the boiling water on to the leaves placed in a strainer, or if made in a tea-pot the infusion should be ^Doured off after it has stood not more than two or three minutes. China tea is certainly less harmful than the coarser varieties in common use. Where tea is injurious to the nerves, coffee is still more so. The active elements in tea and coffee — respectively theine and caffeine — may for all practical purposes be considered identical, and consequently they resemble each other in their effects on the nervous system. Tired brain-workers should beware of resorting to tea or CONDITIONS PREDISPOSING TO BREAKDOWN 73 coffee to stimulate their flagging energy ; even should they succeed by this means in keeping up for a time their out-put of good work, the price they have to pay is dangerously high. All that these stimulants do is to unlock and use up stores of nerve-energy that Nature has accumulated in view of some emergency. When these stores have been recklessly squandered Nature comes down with a severe punishment, usually in the form of a serious attack of nervous exhaustion. Much the same may be said of alcohol in relation to the nervous system. Alcohol taken habitually adds to the prevalence of neurasthenic troubles in two ways ; by sapping the energy and poisoning the brains of many who generally realize that they are taking more than is good for them ; consequently by emphasizing ner- vous tendencies in constitutionally predisposed persons. Alcohol attacks nerve tissues with special virulence in some people, producing three common types of disorder due to its deleterious action on nerve-cells and fibres, namely, true neurasthenia (exhaustion), nemitis and insanity. The last-named results from the direct de- structive effect on the brain-cells which in chronic alcohohsm gradually degenerate and sometimes lose their vitality altogether. Promiscuous drug taking is responsible for a good deal of nervous trouble. Curiously enough, many of those whose nerves have been deranged by drugs have in the first place resorted to them for the relief of nervous symptoms ; the craving for rest or increased energy becomes so insistent at times that sedatives or stimu- lants are thoughtlessly taken. Because morphia both soothes and stimulates it is the drug that has claimed most victims, but there are numerous other poisons which from their direct and powerful action on the nervous system secure many worshippers. They seize readily on delicate people, and those who take them without medi- cal advice incur great danger. 74 THE PROBLEM OF NERVOUS BREAKDOWN Debilitating illness of a general kind very frequently depresses vitality so much that the nervous system gives way and convalescence is interrupted and prolonged by the onset of distressing nerve symptoms. Among ill- nesses that have a special tendency to produce a secondary neurasthenia, influenza holds the leading place. Since its first invasion of this country influenza has been re- sponsible for a definite increase in the prevalence of nerve disorders. Whatever the special form its attack has taken the influenzal poisoning has always proved par- ticularly virulent to the tissues of the brain. Weeks after what has appeared to be a minor illness, its victims have often found nervous instabihty, depression, headache, lassitude, and impaired mental vigour bothering them. When, as sometimes happens, influenza attacks the nervous system at the very outset of the illness all these symptoms quickly appear and are greatly accentuated. Severe mental depression following influenza is one of its most serious sequels, and no manifestation of post- influenzal neurasthenia can be regarded lightly. All acute fevers deplete the nervous system, and may lead to some degree of nervous weakness. The longer the febrile state, that is, of course, the longer the poisoning, the worse for the nervous system ; thus typhoid fever with its acute stage of three weeks is not at all unlikely to leave neurasthenia behind it. Even a common cold may be sufliciently severe to induce considerable im- poverishment of nerve energy. At the present time two acute diseases must be given a prominent place here. Both are associated with war conditions, although one — malaria — has always been productive of a certain num- ber of neurasthenic cases amongst those working in tropical climates. The other is trench fever, which although often mild in the acute stage, nevertheless frequently leaves a weakened nervous system behind it. Indeed, the neurasthenia resulting from this war- disease is one of its most troublesome possibilities, and CONDITIONS PREDISPOSING TO BREAKDOWN 75 in part accounts for the importance which it has achieved in the sight of the medical world. AU exhausting conditions such as abscesses, boils, and carbuncles, will if prolonged reduce nerve-energy and bring about a neurasthenic state ; and so will all chronic infections resulting in persistent poisoning. Of these, pus-forming at the roots of the teeth — pyorrhoea alveolaris or Rigg's disease — has perhaps been blamed more severely than necessary for bringing about neuras- thenia. Where any source of persistent formation of, poisonous matter can be demonstrated we may be cer- tain that health in general, and nerve-health in par- ticular, must be prejudiced thereby. But it is a serious matter to have all one's teeth out for a slight pyorrhoea on the supposition that it alone is the cause of a neur- astlienic state. Strangely enough, it is often forgotten that severe nervous debility of itself represents a state of impoverishment which gives germs a good opportunity for attacking the roots of the teeth. Time and again pyorrhoea is demonstrably secondary to neurasthenia. It is stated that we must have all our teeth out to cure our nerves ; why are we never advised to have our nervous system toned up to save our teeth ? The fact is • there can be no general rule, but this word of precaution may save some from unnecessary discomfort and incon- venience. Of other common infections tuberculosis is one that sometimes leads to nervous debility ; on the whole, the poison of tuberculosis does not specially impair nerve tissues, but it must not be overlooked as a possible cause of instability. On the other hand, the poison of syphilis is deadly to every ceU and fibre in the brain and nervous system ; countless are the wrecks that result from this special action of syphilitic infection. Many nervous breakdowns are caused by accidents. Shocks sustained through being thrown out of a carriage, caught in a railway disaster, or through some mischance of motoring not infrequently produce a collapse of nerv- 76 THE PROBLEM OF NERVOUS BREAKDOWN ous function that it is very difficult to remedy. The chief features of this condition are loss of memory and physical power expressed in all degrees from slight diminution to complete paralysis or aberration of mind. Trembling, local pain, sleeplessness, depression, inability to read, indigestion and sensations of all kinds persis- tently tormenting the sufferer are also commonly seen. The incapacitating effects of nervous instability due to accidents are well known to employers of labour, and traumatic neurasthenia — as It is technically known — occasions many difficult problems in regard to insurance and compensations. Very often the shock to the nervous system is out of all proportion to the actual injury, as one sees when the victim of a railway accident comes through physically whole, but soon after develops signs of severe nerve shock. One of the most curious features of traumatic neurasthenia is the occasional delay in the appearance of the worst symptoms. Thus, after a blow on the head the injured person may feel comparatively well for a da.y or two and then collapse with many dis- tressing symptoms. Similarly, after a railway or motor- ing accident there may be a considerable interval between the shock and the developing of the illness. Increasingly complicated methods of transit more and more expose us to the chances of small accidents ; the cumulative effects of these small jars and accidents must be taken into serious consideration as a cause of nervous disorder, as they gradually lower nerve-tone until one more precipitates breakdown. Shell-shock, of which we now see so many distressing examples, is essentially a form of traumatic neurasthenia with special relations. These are discussed at length in a subsequent chapter. The miracles of modern surgery are amongst the most marvellous achievements of present-day science. Thou- sands of people owe health, happiness and prosperity to the operative sldll of some master of surgical craft ; indeed, operations are a common necessity of life to-day, CONDITIONS PREDISPOSING TO BREAKDOWN 77 and until the time comes when some other branch of therapeutic medicine can banish disease we shall have to rely on and be grateful for them. Nevertheless, an operation is always a serious thing, and, however small, produces some nerve shock. More frequently than is generally understood operations cause considerable and lasting nerve shock, so that instead of passing into health through a short convalescence the invalid is caught in the miseries of a neurasthenic state and suffers much therefrom. Post-operative neurasthenia must be reckoned with nowadays as an important, if not very common, caiise of nervous breakdown. Care in pre- venting shock, and in lessening strain after an operation, must be our chief means of obviating this unfortunate result. There are interesting differences in the response of different races to conditions predisposing to neurasthenia. Dr. Burr, of Philadelphia, states that until recently the American negro did not suffer from neurasthenia, but nowadays nervous breakdown quite commonly occurs amongst the dark citizens of the United States. He makes the interesting comment that " apart from organic disease and bad morals, the mere struggle of the best specimen of an inferior race to attain the plane of a superior leads often to theii* downfall." ^ As an excep- tion to this, it has often been noted that the Jews wherever they may be settled are very prone to nervous disorders. Some writers have suggested that this is a consequence of stabihty being weakened by centuries of oppression. Lately we have had the word of an army consultant that the Turks, in military life at any rate, rarely, if ever, suffer from nervous breakdown. No time of life of itself guarantees protection from nervous distress. Octogenarians troubled with morbid thoughts are not unknown — indeed the neurasthenia of ^ Dr. Burr, of Pliiladelphia, Osier's System oj Medicine, Vol. V, p. 628. 78 THE PROBLEM OF NERVOUS BREAKDOWN old age should be recognized more definitely than it is, whilst at the other extreme of life indications of instability in infancy are often met with, and attacks of excitement as well as morbid fears and fancies are quite common between three and twelve years. Of special periods, that from eighteen to about thirty-five years of age is very pro- lific of breakdown. Many men of nervous temperament go through a time of particularly bad nerve-health be- tween eighteen and twenty-five, and then again fail at about thirty-five if they are not careful. Certainly after this age every year of good health argues well for increas- ing freedom from nerve -weakness. Special distinction between the manifestations of nervous instability at different times of life may be made by saying that in childhood they are characterized chiefly by excitement and in senility by depression. Of hysteria it is true that it is so rare after fifty that if occurring in later life it may very likely be mistaken for some other malady. Cases of severe hysterical disturbances in advancing years are recorded from time to time as matters of interest. PART II THE VARIETIES OF NERVOUS BREAKDOWN CHAPTER I FORMS OF NERVOUS BREAKDOWN Harmony of fiinction necessary for health — Basis of control — Central nervous system — The brain the seat of government — Ramification of nerve fibres — The term " nerves " — Nerves in disorder — The nervous type — Classification of nervous diseases — Relations of nervous breakdown — Tlu'ee chief groups— Nem'asthenia — Hysteria — The so-called borderland — Terms in common use — Psycho - neurosis — Psychasthenia. WE breathe and eat, think and speak, work and play, whilst all the time a multitude of active processes are being carried out within our bodies ; somewhere there is a governing power that Hnks up in harmony the mjn^iad transactions of countless glands and ceUs, selecting and separating the gases we breathe in and out, eliminating waste products, destroying poisons, buUding up chosen elements into the various tissues. Somewhere there is a controller who prevents undue supplies of nourishment being sent to areas where they are not needed, or toxic substances accumulating in others ; whilst all the time providing increased supplies where there is a call for them. Somewhere there is a censor checking the messages that ceaselessly fly along the nerve-fibres which are the tele- graph wires of the body. Were it not for this power which governs and controls supply and demand — this higher command — ^the workings of the human system would soon end in chaos. Soon, for example, would the diges- tive juices turn against the living tissues which produce them ; quickly, indeed, would the body break up and dissolve under the impact of its own forces. No large effort of imagination is required to realize the necessity of a mentally active agent to look after these things so G 81 82 THE PROBLEM OF NERVOUS BREAKDOWN ably, and to conceive some mechanism by which its orders can be carried out and co-ordinated. The con- trolling power is, of course, a term of mind, and the mechanical apparatus which acts as the switch-board and telegraphic exchange for the whole vast business is that miracle of miracles we call the brain. In some form or another a nervous system central board of control can be found in all grades of animal life ; even where, as in the lowest tjrpes, the whole organism consists of but a single cell, that cell directly responds to its sur- roundings, and apart from its other properties exhibits those particular characteristics which we call nervous. As one traces development in the animal kingdom, the more complicated does the nervous system become, until in mankind one finds it in its highest stage of development, consisting of large nerve centres respectively controlling such vital functions as respiration, circulation, balance, movement, and sensation ; the whole governed through the brain, which not only co-ordinates the various organs of the body, but is the seat of consciousness and of all mental faculties — will, understanding, memory, imagination and attention. Actual connection between the brain, nerve- centres, and remote parts of the body is secured through the maze of nerve-cords that extend to every corner, and some idea of the ramifications and intricacies of the nerve-fibres linking up the different tissues with each other and with the brain may be obtained by comparing them to the skeleton of a leaf. The delicate net-work of fibres that constitute the ground-work of a leaf is familiar to everyone, and if one could free the nerve-cords through- out the body just as children sometimes dissect out a leaf's fibrous skeleton, which in itself retains the shape and outline of the leaf, so should we find that the nerve-tissues would give the shape and outline of the human body. ^ 1 For detailed description of the structure and functions of the central nervous system the reader may be referred to the author's book for nurses and students entitled Notes on the Nervous System, published by the Scientific Press, Ltd. FORMS OF NERVOUS BREAKDOWN 83 So dolicate in structure and far-reaching in connection, it would certainly be surprising were the human nervous system not very responsive to adverse conditions ; it is, indeed, this extreme sensitiveness that leads to those unpleasant and incapacitating troubles which we familiarly and collectively call " nerves." Be it noted, however, that the popular and medical use of the term " nerves " is not in conformity with its meaning in physiological or anatomical nomenclature. Strictly speaking, the scientific use of the word " nerves " is to indicate those particular strands, strings, or wires of nervous tissue which are the main connecting links of the body, and which have just been particularly referred to. However, in the sense of a general disturbance of the nervous system expressed both by mental and physical manifestations — as, for example, the equivalent of neurasthenia, or nervous breakdown — " nerves " has come to stay. It has the merit of conveying a meaning well known to everyone ; it certainly is brief and to the point. When we come to study the characteristics of people suffering from nervous breakdown, it is found that two main groups of cases present themselves. The first consists of those who from early years have suffered from troubles of all kinds ; the second includes people whose stores of energy have proved sufficient for many years, yet who one day find themselves unable to main- tain nerve health. Those of the first group are the more unfortunate ; constitutionally weak in regard to their nerve-strength they are habitually subject to a series of -troubles which are exceedingly distressing and persistent. They suffer all sorts of pains and penalties for enjoying themselves ever so little ; they are in many cases tor- tured by the knowledge that they possess great mental ability without having the necessary nerve-energy to produce work of a high order without extreme fatigue. Indeed, as a rule, the nervous subject is able to do much 84 THE PROBLEM OF NERVOUS BREAKDOWN less steady work than a normal individual, but, at the same time, he is often able to accomplish three or four times as much in a short spell of activity. In fact, monumental labours have been accomplished, in spite of their natural infirmity, by people whose nerves were never properly ordered. As was noted in a previous chapter persons of nervous temperament form a fairly definite type, and one which can readily be recognized amongst those around us. Thej are frequently thin and delicately formed. Quick and intelligent beyond their fellows, they enter into whatever they take up with the utmost zeal, but tire rapidly before they have gone very far with it. Their minds are active, and jump quickly from one subject to another. Moreover, they have a greater capacity for enjoyment, and a greater ability for misery than the ordinary phleg- matic individual. These are the people who disagree with their relations, and whose friends fail to understand them. The fact is, their quickness of intellect is often difficult to follow for the ordinary individual who would understand them if he could, and only fails to do so through want of attention rather than want of intention. Again, their natural sensitiveness often leads them to think much about themselves, whilst their friends are thinking comparatively little about them. It is one of the most difficult things for a person of nervous tempera- ment to realize that he himself tends to over-estimate his own importance in the eyes of those around him. Many such, when once they appreciate the fact that they are morbidly sensitive, begin to talk much less about being misunderstood. Practical consideration of the varieties of nervous breakdown necessitates an attempt at classifying a num- ber of allied conditions that, indeed, do not conveniently fall into definite groups. From the point of view of scientific description there is far too much overlapping of characteristics, and at best it will not be found possible FORMS OF NERVOUS BREAKDOWN 85 to divide our different types in such a way as to provide the proper pigeon-hole for each case. After all, nervous breakdown varies from a trivial sense of discomfort or abnormal uneasiness after work to such complete collapse that mental and physical functions are for the time being in abeyance. Between these two extremes are to be found a host of grades of disability. Some of these are expressed chiefly in terms of physical disorder, some cause emotional mental inconvenience, whilst yet others trouble their victims in both mind and body. In a word, at one end of the scale are to be found the simple ex- haustion cases, the obsessing thoughts, the functional paralysis and similar disturbances ; while at the other lies mental collapse. Let it be said at once that our consideration of nervous breakdown stops short of those iQstances where the derangement of mind is so great that insanity results. There are necessarily affinities between all forms of disorder affecting any particular system ; all kinds of heart disease, or aU kinds of lung trouble are to some extent expressed by similar signs. But just as a man may suffer from pleurisy, for example, without ever being in danger of becoming consumptive, so thousands of people are brought down by kinds of nervous disorder which never really endanger their sanity. Mental disorders which inevitably and always occasion insanity form a large and important gToup of maladies which do not come within the scope of this work. We have sufficient to concern us in the con- sideration of those varieties of nervous disorder which come within the ordinary designations of neurasthenia, psychasthenia, and hysteria. In many cases these ill- nesses are so severe as to take those suffering from them into the dangerous " borderland " between sanity and insanity ; sometimes, but not commonly, that border- land is crossed with disastrous consequences. In everyday usage the expression nervous breakdown is, 86 THE PROBLEM OF NERVOUS BREAKDOWN indeed, used at times to indicate every possible kind of nervous and mental disorder ; nowadays it appears to be more and more frequently employed when the sole justification for this is consideration of the feelings of invalids suffering from insanity or their friends. It is desirable to point out that here such a wide extension of the employment of the term is not contemplated. It may be said at once that cases of nervous break- down as it commonly presents itself fall into two hroad groups. Of these one is made up of maladies expressing exhaustion or inherent weakness of the nervous system with certain associated conditions of mind. Such are the neurasthenic cases. The other class of case exhibits a peculiar mental instabihty accompanied by excessive suggestibility and those remarkable reactions between mind and body which make up the condition we know of as hysteria. These terms are not enthely satisfactory in that they signify recognizable combinations of nervous symptoms rather than definite and readily describable diseases ; but as they are commonly in use we may as well keep them until we are provided with something better. Certainly they are better than the designation " mental," which is still not infrequently used to mdicate a variety of disorders difficult to diagnose, particularly by nurses and students who have not yet become accus- tomed to differentiating the various groups. For junior practitioners there is the doubtful excuse for the hap- hazard use of such indefinite terms that without consider- able experience mental and nervous maladies are difficult to understand, opportunities given for studying them m student years are usually Hmited, and the stress laid upon them at examinations is trivial. Owing to the common combination of mental with physical symptoms in the conditions under notice the expression psycho-neurosis has come into increasing use of late years ; beyond the fact that it is a more imposing title it would appear to have no advantages over that FORMS OF NERVOUS BREAKDOWN 87 just considered. After all, psycho-neurosis merely con- veys an indication of some condition in which the physi- cal nerve-trouble is combined mth signs of disorder in the field of thought, and therefore takes us no further. Again, many writers make a separation of nerve cases according to the predominance of mental symptoms or physical troubles, using the term psychasthenia for the former, whilst reserving neurasthenia for the latter. As a general rule, psychasthenia is employed to indicate an inherent neurasthenic tendency ultimately expressed by head symptoms, obsessions, and morbid fears. To repeat, then, the term neurasthenia is used herein as a convenient expression — made still more convenient by usage, but with certain hmitations — to signify that kind of impaired physical health or disturbed mental har- mony which is found when the brain or central nervous system generally is deficient in vitahty, whether such deficiency is primarily dependent on causes operating in the body or in the mind. And to understand just what sort of abnormality neurasthenic conditions indicate it must be realized that the crux of the whole matter lies in the condition of the brain and dependent nervous centres. Both body and mind depend for their harmoni- ous working on fitness of these. Thus under the heading neurasthenia are to be considered all the common forms of nervous exhaustion with mental and physical fatigue after comparatively little exertion, and varied subjective sensations ; also those curious, but very troublesome, states of anxiety — the " anxiety neuroses " — which stand out so promi- nently that there is a tendency to-day to gToup them apart from neurasthenic troubles proper. Nervous indigestion, a common manifestation of nem'asthenia and a bane of innumerable chronic invalids, will be dis- cussed in a separate chapter, as will also the obsessional conditions, including the various morbid fears, doubts, and scruples. After the difficult subject of neurasthenia 88 THE PROBLEM OF NERVOUS BREAKDOWN has been reviewed in its various relations consideration will be given to the problem of hysteria which will then be seen to have characteristics which definitely separate it from the neurasthenic type of nervous breakdown. Finally, and in a special part, will be grouped those forms of disorder particularly attributable to the special conditions of war-strain and shell-shock. CHAPTER II THE NEURASTHENIC STATE Nexiraathenia — L'homme a petits papiers — Common neurasthenic symptoms — The question of subgroups — Le casquet neurasthenique — Other head troubles — Weakening of self-cofitrol — Fear of losing reaison — Stevenson's picture of collapse from over-work — General consequences of ne\irasthenia — Heart and circulation — Over- sensitiveness — Some typical examples. OUR endeavour now must be to comprehend the essential features constantly appearing in neuras- thenic states, particularly that state of irritable fatigue which so often evidences a disturbed and tired nervous system, and in knowing this characteristic of irritable fatigue one begins at once to understand why it is that this form of nervous breakdown presents such varied pictures ; one sees that the exhausted nervous system responds just as does an over-strained violin which gives out all sorts of strange disharmonies. At the outset it may be noted that infinite in their variety as are the symptoms of neurasthenia they tend to appear time and again in particular combinations ; hence writers have found it convenient to speak of such different types as cerebral nem-asthenia, spinal neurasthenia, gastric neurasthenia, sexual neurasthenia, and cardiac neuras- thenia. As all the symptoms which occur in these so- caUed types are dependent upon a lowering of vitality in the nervous system as a whole, the description of such subgroups as distinct types of neurasthenia is not scientific. Neither, indeed, does it accord with experi- 89 90 THE PROBLEM OF NERVOUS BREAKDOWN ence. No invalid is ever neurasthenic as regards head, heart, spine, or stomach, without being neurasthenic in other respects also. There is a danger that in dwelling too closely on the symptoms most prominent in any particular instance the ilhiess as a whole may be mis- understood. As the term suggests, neurasthenia is essentially a manifestation of fatigue. Exhaustion of body and limbs, tiredness of mind, failure of attentive power, characterize the neurasthenic state and are responsible, individually or in combination, directly or indnectly, for all its troubles. Fatigued nerve centres show theu- state by enfeebled work and over-quick reaction ; they are in a state of " irritable weakness." The neurasthenic is certainly a weakened and excitable individual. Loss of strength is expressed in every line of his body as he walks into one's room either with faltering steps or with a swift jerky manner that is quickly changed for one of slack- ness as he collapses weakly into a comfortable chair. Otherwise the nerveless grip and tired face give a clue to his want of nerve energy. Then, again, he is, as the great Charcot used to say, " I'homme a petits papiers," and, indeed, he may well be sympathised with for so often bringing a sheaf of little slips of paper, for his discom- forts are innumerable, his symptoms legion, and his miseries great. Little wonder that in reasonable anxiety to get rid of this persistent incapacity that is hampering him at every turn, the neurasthenic is careful to make a written record of his troubles lest in the anxieties of the moment he may omit to tell the doctor something of importance. The typical story of neurasthenia is that the sufferer is harassed by a tiredness that never leaves him ; even by night he is not rested, for he wakes continually and in the intervals of broken sleep feels the oppressing sense of his fatigue still with him. Aiter the restless night the day dawns without hope that the load will be lightened THE NEURASTHENIC STATE 91 and he may well feel inclined to exclaim with the . Dauphin, in King John : " There's nothing in this world can make me joy. Life is as tedious as a twice-told tale. Vexing the dull ear of a drowsy man." '^ Headache or distressing sensations of some kind refer- able to the head, difficulties with digestion, and mental depression commonly find their place in the list of primary symptoms. Added to this, one is invariably told of a host of other distressing things, and as just remarked, according to then distribution and combination it has been customary to divide neurasthenia into a series of subgroups labelled with the names of those symptoms which are most prominently associated with them in individual cases. Certainly under some circumstances it may be very convenient to note that cases tend to fall into groups in which particular symptoms predominate, but let it be repeated, neurasthenia must be treated as a breakdown of the nervous system and its relations to the body as a whole, rather than regarded as a weakness that can pick out brain, heart, stomach, for example, without distm'bing other parts. Taking the most prominent troubles of the neuras- thenic in further detail one may at first consider symptoms referred to the head, which are of wide range, an infinite variety of aches, pains, or sensations in the head being described. Typically, the nem^asthenic headache is felt rather as a weight or pressure than as a sharp pain. Those afflicted say that they feel as if their ^ heads were being gripped in a vice, or as if a heavy iron helmet were weighing them down ; hence, French writers have used the term " le casquet neurasthenique." Sometimes, instead of a wide area of pressure, the sensa- tion is as if a smaU ring or plate of hard material were pressed on to the scalp. This " pressure headache " is ^ Shakespeare's The Life and Death of King John, Act III, Sc. 4. 92 THE PROBLEM OF NERVOUS BREAKDOWN very persistent, and some people suffer from it on and off for many years. However, it is by no means the only form of head sensation suffered by neurasthenics, who not infrequently complain of sharp pains darting through the scalp. The persistence of the ache, or the sharpness of the "shooting pains," often leads the invalid to suppose that his brain is seriously diseased, and one has known instances in which the victim of a chronic localized headache has consulted doctor after doctor until he has persuaded a surgeon to operate under the im- pression that there has been something to be removed. Under such circumstances, however, nothing will be found, although it does sometimes happen that the mental or moral effect of the experience is to banish the headache for a time. So various are other head sensa- tions commonly met with in neurasthenia that they can best be described in the actual words of some who have suffered from them. Thus, one has had to note at times such definitions as the following : Sense of emptiness ; feeling as if the top of the head was coming off ; sensa- tions of distension of head ; head feeling light ; sense of constriction ; sensation of water rushing about in the head ; as if the " nerve running in the centre of the head " was inflamed ; a band tied round the forehead. So closely associated with these head sensations are certain mental annoyances that some of the latter can be conveniently reviewed at once, consideration in detail of others being reserved for another chapter. They include great fatigue and " brain fag " as soon as an attempt is made to attend to anything requiring per- sistent attention ; mental depression ; impairment of memory ; sense of confusion and feeling that the sufferer has " lost control of his thoughts." Particularly where he has the not uncommon sensation of thoughts racing through the head or going " round and round," is this distressing s^ense of lost control very prominent. When it is then feared that these things portend loss of reason there THE NEURASTHENIC STATE 93 is for this reason added misery. The following notes illustrate some of the more common and pressing mental troubles of the neurasthenic state ; they are given verbatim : " Very impressionable and emotional and suffered aD. his life from subjective symptoms and attacks of depression." "Mental fatigue " (an expression which occurs time after time in one's case books). " Disturbed sleep." " Troubled with thoughts, chiefly at bed time, songs, tunes, and so forth obsessing his mind." " Thoughts constantly dwelling on health." " For many years bothered with nerve storms, attacks of temper and nervousness." " Nervous, imaginative, and introspective." " Mental confusion and nervousness." " Depression, with morbid ideas." " Attacks in which he felt he must rush out of the room, being then filled with great apprehension and sense of acute depression." " Morbid thoughts always associated with unpleasant things." " A state of mind in which he felt strained and excited." There are other mental miseries in neurasthenia. Very distressing are the morbid fears and doubts or other obsessing thoughts. So frequent and so troublesome are these that, as with the gastric accompaniments of the neurasthenic state, a special chapter is given to their detailed consideration. Whether or not nervous debiUty brings with it special obsessions, severe mental depres- sion, or other well-defined mental torment, it invariably occasions a sense of irritability which is quite charac- teristic. The sufferer from neurasthenia is irritated by a host of things which would not be noticed in health, 94 THE PROBLEM OF NERVOUS BREAKDOWN and not uncommonly gives way to emotional reactions expressing displeasm^e. Hence, a leading object in treat- ment must always be the regaining of self-control ; the resumption of mastery over manner, method and temper. It is a matter of interest that in neurasthenia irritability of temper commonly seems to be most troublesome in those of the dyspeptic tjrpe. Mental discomforts of a nem-asthenic order often occm^ because people do not soon enough heed warnings which should be sufficient to tell them that they are over-taxiQg their strength. The over-pressed man of affairs who has been through a time of considerable anxiety begtas to find that when he goes to bed at night he becomes more wideawake than ever, instead of falling asleep ; and the matters with which he has been concerned in the day- time will recur to his mind. He begins to go through interviews, to review columns of figures, to think out transactions and go over new plans, whilst all the time he feels that his brain is "on fire " and that sleep will never come. The continued repetition of ideas is a constant torture ; he mentally dictates the same letter over and over again ; or adds up the same figures time- after time ; he becomes nauseated with the recurring thought of plans and prospects. A few nights of this sort of thing rapidly lowers anyone's store of nerve-energy, and not only is control of thoughts lost at night, but in the daytime many things keep bothering which there is really no need to worry about. If he disregards these warnings, the sufferer soon finds that his work becomes extremely exhausting ; that he takes a very long time to get through what should be an ordinary day's routine ; that his days are miserable, and his nights wretched. Moreover, feeling that thoughts are " getting beyond control," he may be further tormented by the idea that he is " going mad." Unfortunately, once people get this idea that troubled nights and racing thoughts are a sign of oncoming mental trouble, it is very difficult to reassure THE NEURASTHENIC STATE 95 them ; they know they have seriously overtaxed their strength, and they are not at all certain that one's hope- ful opinion as to the future is not expressed merely to comfort them in the face of threatening disaster. But, as a matter of fact, people who think they are " going mad " very rarely fulfil theii' tragic expectations. Conse- quently, when they make this terrifying suggestion, and ask if the sensation of strain so often present means that something is about to snap, the safe thing is to tell them candidly that their very fear is almost a guarantee of safety in this respect. When a neurasthenic person says : " My one dread is that I am going mad," then one can reply with confidence, " You may be quite certain that you are not." It takes a very gi'eat deal of prolonged stress and strain, or some sudden shock of quite excep- tional magnitude, to unhinge the human mind suddenly ; and it is a matter of considerable importance that this should be realized more generally, if only for the peace of mind which such knowledge will bring to hundreds, per- haps thousands, of people who are continually haunted by this dread of becoming mentally deranged. Nevertheless, reckless abuse of one's nervous system may exhaust it, just as harsh usage will wear out any other delicate mechanism, or neglect of an electrical battery result in its failure. The vivid pen of R. L. Stevenson has given us a picture of collapse from foolish overwork that stands unrivalled. He relates how " a student, ambitious of success by that hot, intemperate manner of study that now grows so common, read day and night for an examination.^ Day after day and night after night he kept up the strain until the dawn of his test, when on going to the wdndow to^ see the sun rise, ' nameless terror seized his mind.' ^ Rushing out into the street he felt restored. ' Nothing troubled him but the memory of what had passed, and an abject fear of its return.' " ^ ^ R. L. Stevenson, Memories and Portraits, p. 21. 2 Ibid. 3 Jiid.— p. 22. 96 THE PROBLEM OF NERVOUS BREAKDOWN Nevertheless, persistent over-strain — evidently coupled with a strong emotional factor, be it noted — hot-headed ambition and anxiety to succeed spurring him on — had done its work. This over-anxious student had brought upon himself the miseries of nervous breakdown, as can be best told in Stevenson's own vivid words : " He dared not retm-n to his lodging ; he could not eat ; he sat down, he rose up, he wandered ; the city woke about him with its cheerful bustle, the sun climbed overhead ; and still he grew but the more absorbed in the distress of his recollection and the fear of his past fear. At the appointed hour he came to the door of the place of ex- amination ; but when he was asked, he had forgotten his name. Seeing him so disordered, they had not the heart to send him away, but gave him a paper and admitted him, still nameless, to the hall. Vain kindness, vain efforts. He could only sit in a still growing horror, writing nothing, ignorant of all, his mind filled with a single memory of the breaking day and his own intoler- able fear. And that same night he was tossing in a brain /V fever." ^ Such a story can only have been obtained from someone who could recount the facts from actual experience ; it could scarcely have been written as an exercise of imagination. Stevenson's moral therefrom is also true in that " we all have by our bedsides the box of the Merchant Abudah, thank God, securely enough shut ; but when a young man sacrifices sleep to laboiu", let him have a care, for he is playing with the lock." 2 Among disturbances of general health associated with neurasthenia, indigestion and secondary results there- from are often conspicuous, as has been already noted. In addition, disorders affecting heart and circulation are commonly responsible for pressing physical symp- toms. Inevitably, the heart and blood-vessels share both 1 R. L. Stevenson, Memories and Portraits, p. 22, 2 Ibid., p. 23. THE NEURASTHENIC STATE 97 in the slackness of the neurasthenic state and in its quickness of response to impressions of all kinds. Thus, on the one hand, people who suffer from nervous debility often complain of palpitation, sense of breathlessness or sense of oppression after quite a little effort ; and, on the other hand, attacks of palpitation, feeling as if the heart is going to stop, and irregularities of rhythm. Often, indeed, in neurasthenia, the heart is so sensitive that it starts beating wildly for very little cause ; almost any- thing, going upstairs, drinkhig a glass of water, taking a Httle coffee, smoking a cigarette, meeting somebody unexpectedly, hearing bad news, sudden noises, are all quite sufficient to occasion an attack of palpitation and distress. It is not surprising, therefore, that the neuras- thenic who has not obtained some understanding of his trouble often sends for the doctor or rushes off to see a speciaUst after one of these attacks, in deadly fear that something has gone seriously wrong with his heart. The associated slackness and irritability of blood-vessels, and the nerve-centres controlling them, fully account for the flushings and palings, the sensations of faintness, as well as much of the giddiness, and other unpleasant head dis- comforts suffered by neurasthenic people. Where the receipt of a telegram, the sudden ringing of a bell, the slamming of a door, or other trifling incident of every- day life sends the heart off into a run, that causes a feehng of half-suffocation with a distressing throbbing in the throat followed by prostration with sweating and sense of coUapse, it is hardly to be wondered at that great alarm is caused in the family circle until the true facts of the case are made manifest. Even where these acute attacks do not occur to occasion distress nervous people are often bothered with that irregularity of heart-beat which causes them to know that a beat is missed every now and then. But always heart jumpiness ex- perienced in neurasthenia is distressing in proportion to the anxieties it occasions. The sense of " missing a •98 THE PROBLEM OF NERVOUS BREAKDOWN beat," so often complained of, is never pleasant. Once it is understood to be of no special significance, and cer- tainly not to suggest heart weakness, the thing loses its value and becomes easily regarded as one of those minor discomforts of general state that have to be put up with until a better level of nerve health is secured. As a matter of fact, it is not so muchthe missing of the beat that causes alarm as the sudden " thump " experienced immediately after ; such occasional thumping may affect anyone who is tired or suffering from indigestion, but particularly troubles those whose nervous energies are impoverished. Again, the extreme sensitiveness of some neurasthenic patients occasions them a great deal of physical dis- comfort which, being difficult to avoid, further depresses them. This hypersensitiveness is often so extreme that the sufferer suffers agonies through quite slight noises, and is unable to face bright daylight without the assist- ance of tinted glasses. No doubt the same sensitiveness is responsible for the morbid attention which some of those debilitated in nerves give to their internal organs. Once they become aware of an occasional palpita- tion or of some irregular movement of stomach and bowels — magnified by their sensitiveness — ^they fasten their attention on it and build up a host of morbid imaginations about what is going on inside them. Associated with head symptoms, mental or physical, are attacks of giddiness which occasion much distress. The vertigo of neurasthenia is one of its most incapaci- tating manifestations. Taking the form of attacks of giddiness which come on quite suddenly, it leads to a sense of uncertainty and apprehension which often causes those afflicted to require the services of a constant com- panion. Moreover, simulating as it does grave forms of ear and brain disease, it adds its quota of fear to the burden already carried. Not unnaturally, the attacks of giddiness, the curious sensations, and the strange noises / THE NEURASTHENIC STATE 99 in their ears which bother many neurasthenics lead them to suppose that some serious disorder is proceeding within their heads, and this fear of impending disaster adds greatly to their nervousness. Instances in which neurasthenia is characterized by undue attention to sex questions are well kno^vn to every medical man. At this stage a few personal histories will best help to illustrate further the neurasthenic state. Let us con- sider at the outset the case of a young professional man, intelhgent and anxious to get on, but who has had to give up work owing to neurasthenia. For some months past a condition of increasing mental and physical fatigue has incapacitated him ; at the same time he has been a martyr to indigestion and, therefore, unable to keep his weight up by an ample diet. In addition, he has been bothered by attacks of giddiness and sense of " spinal irritation." Of temperate habit and a steadj'^ worker who has done well in his profession, he had married two or three years previously ; then, on going to live in a tropical country, had broken down. The picture is that not uncommon one of a man somev/hat delicate in physique and nervous in temperament who has not realized his limitations until they have been forced upon him. Another man gives the following clear account of his condition and its onset. " Three years ago I had a bad fainting attack, and since then I have suffered from nervous dyspepsia, vertigo, and faintness, inability to concentrate my attention without my head swimming, and complete exhaustion after a two-mile walk. I had hopes that I should throw it off, but after thjxe years it stiU clings tenaciously to me, although I am better than I was. No drugs seem to do any good." Yet another, this time a middle-aged woman, requires help for removal of fear of traveUing ; for self-confidence ; to stop shaking of limbs ; to do away with bitter, [ealous and suspicious thoughts ; to remove introspection, to 100 THE PROBLEM OF NERVOUS BREAKDOWN " clear head " and remove " contracted feeling " ; to give spirit and interest for life and work. A list of require- ments evidencing the tjrpe of neurasthenia. A professional man writing as a neurasthenic of sixteen years' standing, gives the following history : "I am neurotic, of neurotic parents ; age forty -nine — very nervous. I served twenty-three years in the tropics, and had to do a lot of railway travelling, and that ruined my sleep. Confined with anxious work during the day and no sleep at night, my health broke down, and I had to come home. I cannot stand a cold bath. I have atonic dyspepsia, and have had weak digestion all my life." Here is the story of a young man who has been ill for some years with " almost every nervous symptom one could mention." He has no power of " concentration," and is, therefore, unable to read for long. After attend- ing closely to anything he gets an " intense feeling with jumpy heart " and a sensation that he is about to lose consciousness. Even a conversation is sufficient to bring on these feelings. Attacks of palpitation in which his heart " hammers away," with shivermg and feeling of apprehension, add to his burden. The history of this case from early years is typical of that of many neuras- thenics. As a child he was very " nervy," but seemed to grow stronger for a time. In youth his inborn nerv- ousness began to be more troublesome. The attempt to take up useful work brought out his limitations, so that only a few hours' attention to business was possible each day. Then followed a series of " rests " and " cures " in various places and under various speciahsts. Drugs, massage, electricity, nm'sing homes, hospitals, con- valescent homes, were all tried in turn and in various combinations. Resort was then had to a meatless regime, in which a forlorn hope was made to sustain nerve energies on a dietary in which such things as " puffed rice," " grape nuts with a little honey," and " twelve lightly boiled raisins " seem to have figured promi- THE NEURASTHENIC STATE 101 nently. At the age of twenty-five he was found still seeking a purely physical remedy, making no effort to use his own will power, and not at aU pleased at being told that the cure for his troubles was to be sought in mind rather than in matter. A clerk of delicate appearance complains of " nervous attacks," in which he becomes cold and shivering, with perspiring palms. He has had poor health lately ; his digestion has been bad, and sore throat has bothered him. In these circumstances the nervous attacks coming on suddenly at the slightest jar or shock — for example, if in a train which has stopped unexpectedly — ^have been particularly distressing. Here the over- worked, ill- nourished state, and anxious temperament give obvious clues for the lines on which treatment must be carried out. A man between fifty and sixty years of age says that he has suffered from neurasthenia for nearly twenty years ; qualifying this by adding that he gets spells of good health between the attacks. Attributing the onset of his symptoms to the loss of a near relative, he gives a list of present troubles which include constant sense of apprehen-sion — " fear of everything " ; disturbed sleep ; neuralgic pains ; constipation and loss of appetite ; worrying thoughts and depression which he cannot throw off. Inquiry shows that his present state of lowered nerve-tone follows special anxiety in connection with his financial affairs. A man of some thirty-five years of age says : " All my life I have had some nerve disorder or trouble connected therewith, but I am unable to get much benefit from doctors, although I have consulted several." Without venturing to make it clear why he should nevertheless have decided to consult yet another, he describes the following distressing symptoms : " Irritation of stomach," head troubles, unpleasant sensations as if being struck in various parts of the body, digestive discomforts, 102 THE PROBLEM OF NERVOUS BREAKDOWN which he describes with more regard for accuracy of details than for the feelings of his auditor, (He illus- trates that morbid dwelling on symptoms with uncon- scious exaggeration displayed by some invahds, who are inclined to rely more and more on their own exhaustive studies of neurasthenia than on the advice of those whose experience is really valuable ; it is always well to point out to such as kindly as possible that whilst he bases his knowledge on one case of neurasthenia — his own — the doctor advises from an experience of many.) Yet another man still on the right side of forty relates a story of some fifteen years' varying health. He writes that his symptoms began with " a general slackness felt chiefly on waking in the morning, and the alimentary business got upset — I used to get a lot of flatulence and a dirty tongue. These attacks used to pass off with the help of a tonic. About six years ago I began to get another symptom coming with the attack — an upsetting of the heart's action. This came on two hours or so after violent exertion. About this time I began to feel tired with severe exercise. My condition got rather chronic, and I had a regular breakdown. I got then, and I get now at times, what seems to be a kind of nerve storm. My face flushes and my hands go cold, and I get a nasty sensation about the stomach. The heart sometimes thumps, but generally goes weak and I feel faint. Brandy always reheves, but I do not want to take this. Whilst the attack lasts I am very irritable. I am not depressed or seemingly nervous at all, but these things incapaci- tate one from getting the best out of life." After some jT^ears of ill-health, including several opera- tions, a lady writes to say that she finds her powers of self-control, memory and mental grasp are considerably impahed. " I get very, very easily'' irritated and put out " — " I tried to use self-control and make up my mind to do so, but when the time comes I absolutely seem not to be able to remember my resolution or have power to THE NEURASTHENIC STATE 103 carry it out. 1 also get very apprehensive, and inclined to worry over past failures. I have longed for some sort of treatment or help to enable me to make a real start." The following tortuous account of disordered sensa- tions shows how the same process of introspection and endeavour to find a basis for mental discomfort leads to an environment of thought that absorbs the whole time and interest. In this case the sufferer was perfectly sane, but entirely concentrated on his troubles. About these he writes : "I feel sure I have at last put my hand at the root of the trouble — ^the cause of all the irritations I have every day ; and I want to put it to you that the whole thing is practically aU physiological and not psychical. I feel sure now that the trouble is due to the state or physical condition of the brain or nerves ; and I will give you my reasons for this conclusion. Every irritating thought and feeling is accompanied with a physical sensation — either of a very minute character as the slightest touch of a pin's head, or else in a greater degree as of pressure on a nerve. The physical sensation can in general be classed in two divisions : (1) In a mild degree as irritation, (2) in an acute degree as pressure ; but for the present purpose I will always refer to this sensation as irritation. There is a vital point, namely, that whenever I have this irritation (except when very slight) the brain is obviously to myself not working prox:)erly — or better, perhaps, is not co-ordinating. And certainly when the irritation is bad, the Ego seems quite disconnected from the brain and has no influence for the time being." The whole point of this rigmarole is an endeavour to explain the extreme discomfort of nem'as- thenia in a particular instance. Always a Httle know- ledge is a dangerous thing, but hardly ever more so than when the victim of nervous disorder endeavours to sort out his symptoms. When he will remember that neuras- thenia is the great malady of disordered sensation, and 104 THE PROBLEM OF NERVOUS BREAKDOWN realizes that it is useless as well as a hopeless task for him to try and fit his physical feelings to supposed physical foundations, he will take a good step forward towards recovery. To attempt analysis, to try and worry the thing out, only leads to more and more intro- spection and ultimately to confusion worse confounded. An over-worked professional man writes : " My present physical symptoms are as follows : Constant flatulence, dyspepsia, this occasionally gives rise to acute attacks of gastric distension, causing severe palpitation of the heart, and great terror, which I cannot get rid of. In so far as the terror is associated with an idea it seems to be a fear of sudden death. I occasionally when alone get attacks of terror without palpitation and with no defi- nite associa,ted idea — but generally I do not get beyond uneasiness and apprehension. I have lost a good deal of flesh — my heart is very irritable and ' runs away ' at the least nervous excitement. A pretty sharp attack was occasioned about a jeaY ago by the guns at a firework representation. Apart from physical symptoms of indi- gestion, loss of weight, etc., I suffer from a good deal of depression, but most of all from most unrear^onable fears. I am always obsessed by a fear of sudden death. I am very anxious when I am left alone in the house and am quite unable to travel or even to go out alone. It is not exactly a fear of being alone, but a fear of being taken ill whilst there." A man of middle-age described his troubles as " the sensation of a threatened loss of consciousness, which comes over me every few minutes, lasting a second or so. This is continuous. I have been affected in this way for a very long time. I never actually go unconscious, but feel almost on the verge of it sometimes. I have been told that I have a dilated stomach, and I wish particu- larly to emphasize that there are constant rumbling noises about the stomach, and if I press my fingers there these noises continue. One doctor has suggested an THE NEURASTHENIC STATE 105 operation for this, in order to widen the passage from the stomach to the bowels. Further, I have a great deal of flatulence. Again, I would point out that the circulation appears to be very poor indeed — hands and feet being almost cold with hands often blue — and sometimes one portion of a limb will be cold. I am also very nervous and startled with the slightest noise, and sometimes wonder whether the nerves of the stomach are defective as any startling noise seems to affect the stomach first. I have consulted several medical men, and on advice I have had teeth replaced by artificial ones and have had eyes examined and fitted vdth spectacles." Another neurasthenic sufferer says : " The periods of weakness and depression which have characterized my illness began first ten or twelve years ago. The first following a very bad attack of influenza. At first they only came at fairly long intervals, but within the last five years I have had two other severe attacks of infiuenza and the prostration, insomnia, and depression have been so much worse and have necessitated giving up my work. About two and a half years ago I had a nasty fright, and since then I have suffered very much from depression and all sorts of nervous fears with bad spells of insomnia." Histories such as the above show that neurasthenia is a disease of disordered function ; an exhaustion of nerve- centres and a weakening of thought-control opening the way to a breakdown — or at best a serious incapacitation — of various vital functions and including diminished brain-power. At the same time, one notes that we have here a malady prohfic in heightened and disturbed sensa- tion. Discord in both function and sensory reaction combine to cause these discomforts and illness that are so graphically described by those they trouble, who find words fail them to express their symptoms accurately. Often enough one has heard neurasthenic people derided for the care and wealth of detail mth which they describe their difficulties. This is unfair to them, because the supposed 106 THE PROBLEM OF NERVOUS BREAKDOWN selfishness on which this condition is based in itself a symptom of the nervous state. It is the effort to get at the bottom of his troubles that turns the invalid's thoughts more and more inwards, and leads to those prolonged self-analyses and expression in those closely written notes and lengthy narratives with which he is so often armed ; or in many-paged descriptions of symptoms with which an endeavour is made to assist his doctor's quest for the som-ce of his ill-health. Those who spurn the personal stories of nervous people frequently in so doing pass over the very information that holds the key to the individual's problem. Both patient and those who would help him only too often lose their way in a forlorn pursuit after physical causes. The former analyses, describes, writes and rewrites his story with a steady attention to minutiae that is intended to reveal the full waywardness of heart, appendix, stomach, brain, or whatever organ he feels must be "to blame for the whole thing." Whilst the doctor, relying on his methods of physical- diagnosis, may pay little heed to the written narrative which usually contains the psychological clue to the situation. True enough, there is a school to-day that encourages accounts of thoughts, feelings and even dreams to an extent that may well be emba^rrassing, but its followers are few enough, and one has rather in mind the task of the practitioner who wishes to maintain a level of common-sense, and estimate judiciously both physical and psychological factors. In neurasthenia above all illnesses it is wise and just to attend carefully to the invalid's own story. One should do so if only to point out fallacious suppositions and erroneous deductions. The only way to free people from a network of crippling sensations is to show them how and where they can break their bonds by under- standing the true facts of the case. CHAPTER III MORBID FEARS AND DOUBTS Obsessions — Psychastheiiia — Obsessional neiu'asthenia — Webster's definition of " obsession " — Common forms of obsessional thoughts — Morbid fears — -Their physical accompaninaents — Agoraphobiti — Claustrophobia — Siderophobia — Anthropophobia — Morbid flushing and self-conscioasness — Pathophobia — Astrophobia — Batophobia — Fears about health — Morbid anxieties — Doubts and scruples — Over-conscientiousness — Fear of impulsive action — Some examples. THERE is a particular type of neurasthenic state which requires special consideration in that it is characterized by special mental difficulties. In addition to the mental fatigue and depression common in neuras- thenia the form of disorder in view always exhibits ob- sessions ; that is thoughts and ideas which continually recur and will not be dismissed. Of such a kind as by their nature or persistence seriously to disquiet those bothered with them, they end by dominating every other interest. Their victim thereby becomes preoccupied, is unable to work properly, and wastes a vast amount of nerve-energy in combating his obsessions. Owing to this some observers now write and speak of psychasthenia as opposed to neurasthenia, by this term indicating people who from earliest years have shown signs of nervous disposition. At the outset excitable and suffering from night terrors or other neuroses of childhood, they later enter the class of dreamy, delicate yet inteUigent boys and girls who in one way or another commonly are a source of anxiety to parents and others ; in adolescence they begin to evince more definite signs of instability ; in adult life they are often ailing though 107 108 THE PROBLEM OF NERVOUS BREAKDOWN rarely ill, and all the time harassed by a ceaseless ever- changing series of nervous difficulties which their inborn sensitiveness and emotionalism make it hard for them to fight successfully. These indeed are the so-called " psychasthenics." But obsessions may bother anyone whose nerves get out of order, and by their appearance only one cannot define psychasthenia. For the rest it is a matter of degree, and although future observation may persuade us to split up " neurasthenia " into sub-groups there is scarcely yet sufficient ground for so sharply separating psychasthenia as some would do. For one's notes, or as a convenience in indicating predominance of symptoms, it may be useful to make a sub-heading of " obsessional neurasthenia," but such should only be used when it is clearly understood not to exclude the coincidence of other common disorders — subjective sen- sations and so forth — with the obsessions, in the particu- lar instances thus kept in a separate file or note-book. Obsessing thoughts are of all kinds, from little haunting phrases and questions to tormenting ideas that seriously influence their victim's life. Few there are who have not on occasion been troubled with a curious feeling of being compelled to carry out some little act. Frequently the triffing thing is done, and no more thought about it. Less hardy thinkers admit an element of fear with the compulsion, and once they do so the impulsive tendency becomes accentuated. How foolish it seems to want to touch a lamp-post, or kick a particular stone or move a pair of boots ; especially when the want is felt so strongly that to resist it causes real mental discomfort. To realize this funny side of the impulse, to give way and to laugh, indeed, will take away its sting. To resist, to fear, and finally to give way, is to submit to a sad tyranny. One may not be able to give way when the impulse points to danger, but one can always laugh, and ridicule is the best treatment possible for a haunting thought. Many who think they know not " nerves " become anxious as MORBID FEARS AND DOUBTS 109 soon as they find themselves at the edge of a tall cliff, or on the roof of a house, or walking on a high bridge, lest they be impelled to throw themselves over. However, those thus bothered with impulsive thoughts may take comfort in the knowledge that in face of laughter the impulse commonly loses its significance. See it in its true light, reahze the power of Will and the thing loses its terror. Webster defines an obsession " as the persistent and unescapable influence of an idea or emotion " ; ^ that exactly expresses the relation of the tormenting thoughts in neurasthenia to their victims. All day long the sufferer is haunted by their presence ; however he occupies him- self there just in the background of his mental field are the tiresome ideas. It may be noted that the term obsession is derived from two Latin words together meaning to sit upon. Truly obsessions sit upon those they attack, one of the most unpleasant features of these trying thoughts being that the more one fights against them the more firmly do they maintain their seat ; the more seriously they are taken the more do they puff themselves up. If one traces them back in any particu- lar case it is nearly always found that they had small beginnings ; sometimes coming suddenly, but as a rule without much force. Subsequently the neurasthenic realizes that the same thought has been bothering him, and often it is the shock due to fear lest he may not be able to get rid of it that actually establishes the obsession. The persistence, intensity, and personal character of common obsessing thoughts is such as to excuse a less educated generation in supposing that they were im- planted in human minds by evil spirits. In those days the term obsession had a more sinister meaning than that which we now ascribe to it, and many a man of weak nerve suffered terrible misery from the added fear that he was in the grip of dark forces. ^ Webster's New International Dictionary. 110 THE PROBLEM OF NERVOUS BREAKDOWN As a matter of practical experience obsessions com- monly follow certain familiar lines, and at once it may be noted that they can be readily classified under the headings of fears, doubts, scruples, haunting phrases, or questions and impulses. Of these the morbid fears and doubts are by far the most common. Scruples have, of course, been a source of psychological discussion for centuries, and used to be considered a matter rather for the priest than the physician. To-day the individual who finds his conscience troubling him about trifles often realizes that his nerves may be out of order, although there are still many people going to the confessional who ought to be going to the consulting-room. Let us then consider in some detail the nature and conseq4iences of these obsessing thoughts, taking the morbid fears first of all. At once it must be noted that these compelling fears or " phobias," so commonly met with as an accompani- ment of nervous instability, work in the brain indepen- dently of reason. However much their victim knows, and confirms his knowledge by reasoning, that there is no ground for his fear, nevertheless when it comes upon him he is swept along like chaff before the wind. In the calm- ness of his study he reasons out the baselessness of his fear, and feels that he can conquer it. Sadly enough, when the thing he has greatly feared comes upon him reason gives way to panic ; a nerve-storm breaks up the tranquillity of his steady calm, and deadly fear possesses his pulses. With thumping heart, hastened breath, and sweating palms, he is for the nonce turned into the sem- blance of a shivering poltroon. The agony oi mind suffered by men and women of strong moral fibre, who, far from cowards at heart, yet are habitually overcome by specific fear storms, is great indeed. In the presence of the things feared the very fiood-gates of unreasoning terror are let loose, and calm judgment is swept away in the torrent. MORBID FEARS AND DOUBTS 111 There are many nervous dreads or phobias characteristic of the neurasthenic state. Thus, wide spaces are a hete noire to many, in the sense that being out in the open renders them liable to that particular morbid panic we term agoraphobia. It is named agoraphobia, indeed, only because it has become customary to give these fears high- sounding titles compounded out of Greek names indicat- ing the things feared and the idea of fear itself. The agoraphobic person, indeed, fears greatly the field or the wide market place. To suffer in this way means that outside the house there is no peace of mind except in crowded streets and narrow roads. Under such conditions, the crossing of a wide space is always an escapade, and a walk in the country an impossibility, the mere thought of whida occasions mental distress. Every visit to a strange place puts the victim of this fear on tenterhooks lest he shall precipitately be faced with the crossing of an open space. No invitation can be accepted until the ground has been prospectively sur- veyed by many a furtive question and much diligent inquiry. The confirmed victim of agoraphobia becomes an expert on the face of the landscape. He knows he can play golf at one place because the. course is secluded and overshadowed with many trees, or broken by natural features that interrupt its spacioueness, but he has a dozen others on his black list as places where the wide sweep of ground spells for him nothing but misery. But in this matter of obsessional fears conditions favourable to one man mean acute anxiety for others. Thus the sense of space so shunned by the agoraphobic is welcomed by him who fears morbidly all closed spaces. The narrow street, or the small room which brings balm to the one brings unrest to the other. Claustrophobia, the fear of closed spaces, is indeed, the second of the two most common morbid terrors, and in some respects it is a far greater handicap than its fellow. After all, most of the day's work can be got through quite com- 112 THE PROBLEM OF NERVOUS BREAKDO\VN fortably without wide spaces having necessarilj' to be negotiated, but life in big cities is largely a matter of living amongst crowds in smallish rooms, whilst when moving from place to place one goes through a maze of tubes and tunnels, lifts and passages that of?er conditions most appalling to claustrophobic people. When no journey can be decided upon until the possibility of tunnels has been prospected ; when the use of a lift has to be avoided on every possible pretext ; when to travel on the Under- ground is always a perilous venture, and when no ticket can be taken for a pubhc entertainment until the seat it gives is known to be situated near the door, life has an added complexity that is a serious handle aj). Another common fear causes its victim to think twice before taking a railway journey. Dignified by the name siderophobia, it is often so intense as to prevent people for years at a time from going far from their homes, the morbid dread of railway traveUing most certainly ranks as a serious manifestation of nervous dis- order. As it is a curious circumstance about the fear of open spaces that sometimes those hampered by it will cross a square. or field or common when in company of some one else or, indeed, at times even when possessed of a stick or umbrella, or preceded by a dog, so is it the case with those afraid of trains that the presence of someone else in the compartment will for the time being take away their panic. On the other hand, there comes to mind an extreme instance in which a nervous individual having to keep an important engagement some thirty miles away was so far unable to spend an hour in the train as to have to plan out an adventurous journey, in which by cycle, motor-bus, tram and taxi-cab he succeeded in accom- plishing his purpose, and at the same time evading the dreaded railway. A few miles on a bicycle took him to the terminus of a motor-bus route ; then fifteen miles on the road brought him mthin reach of a tramway service ; a long and weary journey in a succession of trams landed MORBID FEARS AND DOUBTS 113 the patient traveller at a stand for taxi-cabs ; thence he concluded the Journey in dignified haste. Nothing daunted by the fatigue and discomfort of his strange passage, and beyond reach of persuasion that he should return by train, this unfortunate, victim of obsessing fear reversed his method of travel, and ultimately arrived home none the worse for the adventure. The knowledge that some people are constantly having these experiences leads one to see how far Hfe can be carried on without trains, for example, and it is, indeed, interesting to note what a long way it is possible to go without using the railway at all so long as one is a patient observer of road- way services, a cyclist, and withal not afraid of a few miles on foot to complete a necessary connection here and there. It might be supposed that the convenience of being free from such fears would determine every one who is bothered by them to give up hours, weeks, or even months to that patient mental re-education and self -training which wiU invariably minimize, where it will not drive away, the morbid dread. Strange to say, the majority are too pessimistic about their difficulty to set out seriously upon the path of self -treatment. Neverthe- less, there is probably no obsessional fear that will not yield to perseverance and patient training of thought in the right way. Nervousness in the presence of other people sometimes acquires the character of an obsessional fear. Brought into line with the rest under the name of anthropophobia it drives its victim into solitude, and is responsible for some of those curious instances of hermitage v/hich interest the public from time to time. In less degree, it is often the cause of that morbid blushing and flushing which so very much distresses sensitive people. Here there is usually a mixture of extreme self-consciousness and sense of uneasiness in the presence of other people ; the two things having a different psychological basis, but working together towards the same end, namely 114 THE PROBLEM OF NERVOUS BREAKDOWN that those troubled by them labour under the false im- pression that everyone is looking at them or that they have some peculiarity of expression that attracts atten- tion. Morbid flushing is very common among abnormally sensitive people, whilst quite a number of nervous persons suffer miseries from false beliefs that their eyes are pecuhar, their expressions strange, their noses not quite straight, or their appearance in some way bizarre. Many of these spend a good deal of time going round to ophthal- mic surgeons and oculists in an endeavour to obtain some form of spectacles that will either hide or correct the supposed curious expression. Nothing but a full under- standing that the whole thing is based on a morbid mis- conception will free them from their troubles. Dread of catching some infectious disease or developing a deadly illness — pathophobia — obsesses not a few. When in full possession this phobia affects conduct to such an extent that those influenced by it may fear to shake hands with their friends. Often they refuse to handle letters lest they may have come from an infected household ; and suffer agonies of mind in pubhc conveyances lest fellow passengers should be disseminatmg the seeds of disease. They wiU not go within a mile of a hospital, and they are quite ready to remove from their Ust of ac- quaintances anyone who has lately suffered from one of the common infections, or even has been in contact to the second and third removed with a friend or relative who has. This is a phobia not very different from that in which a morbid dread of having unclean hands leads its victim to be constantly washing, and having washed to wash yet again, until the day's routine becomes largely a matter of ablution. Fear of thunder and lightning, sometimes caUed astro- phobia, and batophobia, fear that ceilings will come down or otjier high things faU, are both forms of nervous dread which one comes across from time to time. The latter is matched by the still more common anxiety that MORBID FEARS AND DOUBTS 115 the individual may fall from exalted places such as bridges, cliffs or even railway-platforms. Yet again we meet with a host of nervous dreads touching various con- ditions and circumstances of everyday life. Mice, cats, insects, or other animals produce acute fear in some over- sensitive people ; plants, colours, food and weather all add their quota to the list of phobias which, indeed, would be difficult to complete in that the final and morbid differences of temperament responsible for these reac- tions are infinite in their varieties. Thus a whole chapter might be written about the fears of illness, apart from the morbid dread of infectious disease just referred to. Apjjrehension with regard to the heart, to apoplexy, appendicitis, tuberculosis, and other not uncommon ills to which the flesh is heir haunt some nervous people from morning till night. Persistently translating un- pleasant sensations, which really have but the shghtest significance, into signs of oncoming disaster, the obsessed neurasthenic may make his own life and that of his rel- tives unbearable. Instead of accepting the ordinary accidents and happenings of life as the lot of humanity in this present phase some jDcople of nervous tempera- ment display their tendencies by making everything into a personal matter, and thinking that every untimely event in their own circle must needs be also worked out for them- selves. Many people of nervous temperament complain of feehngs of anxiety about the most trivial things. They are tormented all night with anxious thoughts as to whether they have left the gas on in some part of the house, or as to whether the kitchen fir© is safely low, or the house doors are securely locked, and so forth. Where they are unable to break free from their petty worries they spend time and money in telegraphing and telephoning and sending special messages to satisfy themselves as to whether they have, or have not, done certain things at the places they have left. This sort of thing varies only in degree from that of the obsessed 116 THE PROBLEM OF NERVOUS BREAKDOWN doubter who centres his mistrust around special things, and whose difficulties may now be considered. Morbid doubts commonly concern things of religion and conscience. When so strong as to become obsessions they influence the whole life and conduct of their victim just as do the phobias just discussed. Expressed in myriad forms, and through the medium of lengthy human documents, they can, however, nearly always be reduced to a simple term, namely, into fear lest duty has not been fulfilled towards self and others. In a word, the neurasthenic doubter suffers from a morbid over- conscientiousness which leads him to parson or doctor according to his bent, and frequently to both. It is characteristic of these doubts and scruples that those who suffer from them are so under the influence of the morbid idea that they cannot judge correctly about it. The difficulty in trying to help them is that there is often just a million-to-one chance that their doubt has some substantial basis. For example, a man tells one that he has just carried out a business transaction in which he has gained a slight advantage which might not have been his had he emphasized a particular point in the dealing. He then mentions something which is a matter of common sense, such as would occur, it might be said, to every one carrying out business of the kind. The idea has fastened upon our conscience-stricken friend that he has been very unscrupulous, and he is now suffering torments of remorse. One reassures him by pointing out how every man of the world would naturally have taken the point in doubt into consideration, but he traverses one's argu- ments at once by saying " Yes ; but can you assure me absolutely that no one would overlook it ? " Obviously, one cannot truthfully say that there is not a remote possibility that a man might overlook the point, and this contingency is at once fastened on as legitimate ground for doubt. It is a false judgment, of course, for the healthy-minded man who had not intended to take MORBID FEARS AND DOUBTS 117 advantage of his fellow would shrug his shoulders and say, "Well, it is his look out, but I will drop him a line about it." Not so the doubter, who continues suffering agonies over his supposed unscrupulousness, and wdll not clear the matter up by going and having a straight- forward talk with the other man because he fears by so doing he will be finally branded as a scoundrel. The same morbid trend of reasoning is followed by those who are always on tenterhooks lest they may be the medium of transmitting infectious disease to others. Thus a man who had to send a parcel to a doctor serving with the army could not bring himself to do so without much apprehension because he feared that in handling it he might convey some germ -laden dust or dirt thereto and this might lead to the poisoning of wounds at the hands of the medical man to whom the package was to be sent. Obsessed by apprehensions about fire a man was troubled with a particularly bad attack of doubt under the follow- ing circumstances. He had to go to a wedding and, think- ing his silk hat was not smart enough, proceeded to polish it up with some petrol. After this he feared to take it up to his office because it still smelled of petrol and thought that in some way it might lead to a fire there. As illus- trating the peculiar limitations of some obsessing ideas, it may be noted that in this instance the doubts about fire only occurred in relation to this man's office. Con- sequently, he could leave the petrolized hat at home with- out any discomfort, but he dared not take it to the city. Subsequently questioned as to his " fire " doubts, he said that, although improved on the whole, he still had to pick up a match if he saw it at the door of the office. Similarly he often had to touch the switch con- trolling the current of his electric stove to make sure that it was really turned off before he could leave for home. Sometimes having got home in the evening, he would telephone to his clerks or caretaker asking them to make sure that he had turned off the switch. 118 THE PROBLEM OF NERVOUS BREAKDOWN Doubts about promises and engagements of all kinds are a constant source of worry to predisposed people, A man who had agreed with his partner to have three weeks' holiday wanted to return home a little earlier, but dared not do so without medical authority for breaking what he took to be an important promise. In an attempt to solve his difficulty he wrote as follows : " Do you think I ought to stay in honour bound until next Mon- day week, or would I be as well at home ? In any case, I should have been here over two weeks if I went on Tuesday. The real point that worries me is as to whether I actually promised to stay as long as possible or not, and if I did so am I bound to stay until Monday week ? I have an idea that I may have done so, but also think that it is about the last thing I should have done. In any case there would be no harm done if I let him (the part- ner) know. The length of time was usually spoken of as three weeks, which expires on Saturday week. I am better again, but not quite fit, but all the ideas are very silly like this one. You must wish me in Jericho. P.S. — I do not want to feel compelled to stay. P.S.S. — Please assume that I did promise to stay as long as possible." Here we have a typical epistle with doubt, hesitation, and over-conscientiousness showing in every line. The following story speaks for itseH : " Was talking to my sister last night about being so sensitive re speaking the exact truth — or she was teUing me — at any rate, she said she cm'ed herself by saying to herself ' Nobody is so particular, so why should I be.' Soon afterwards I went to my sister's house, where my parents were dining, and, although my mother said to me, ' We shall see you to- morrow,' to which I could easily have answered ' Yes,' my father suddenly said to me, ' Are you going to the concert to-morrow.' I had very little time to think, but said, ' Aye,' as a sort of mind substitute for ' yes.' Now thia was rather a lie, because I had not made up my mind re Ascension Day, and I immediately feared that one of my MORBID FEARS AND DOUBTS 119 horrible ideas would appear, but, telling myself that I did not fear them, or something of that sort, they did not corq,e in any violent way, and, I think, not at all — any- how not to hurt. I- was relieved and pretty happy again, but the whole episode came again to my mind some minutes later, and this time a horrible idea did come. It worried me, because it was founded on a more or less lie. But I see that the whole sin was saying ' Aye ' when I did not really know, to save a discussion which Ishould not have liked, being on religious matters, and that the other part had really nothing to do with it, and that if I had had time to think I could easily have said something indefinite. When at its worst my morbid mind tells me tha-; I preferred avoiding an unpleasant discussion to avoiding blasphemy. [When troubled so-called blas- phemous thoughts would flash through his mind and torment him with sense of responsibility for them.] I am not even sure that I anticipated blasphemy, so short was the time. I did not sleep well, and was worried rather badly about it — ^the whole thing hinged, of course, or. to-day being Ascension Day." The fate of the nervous doubter is to be continually swept away by " attacks " of particularly over-scrupu- lousness arising from various incidents of everyday life. He gets over one and feels a little better, only to be caught in the mazes of fresh argument in a few days' time. Well may many a sufferer from obsessions exclaim with Macbeth, " There comes my fit again. . . . Now I am cabined, cribb'd, confined, bound in to saucy doubts and fears. "^ Short of understanding the nature of the trouble, and re-educating himself so as to be able to strike at the root of the whole thing, the obsessed indi- vidual may be troubled and haunted with these dis- turbing thoughts for most of his fife. Obsessions may be further illustrated by glancing at the chief points noted in a series of case records taken 1 Shakespeare's Macbeth, Act III, Sc. 4, 120 THE PROBLEM OF NERVOUS BREAKDOWN haphazard ; in these the following morbid fears and doubts have been emphasised : Fear of impulsive action, losing control or of "going mad ;" sense of panic on going far from home ; on getting to a strange place is obsessed by feeling that he must get back ; songs and tunes haunt- ing the mind every evening to an unbearable extent, habits as to touch and repeating things ; fear of travelling alone ; fear of thunderstorms to such a degree that when- ever the day becomes dark and cloudy there is inoense anxiety lest there should be a storm ; intense fear of meet- ing people; haunting ideas which, if voluntary, would have been blasphemous; similar haunting ideas associ- ated with obscene things ; fear of harming other people ; inability to sign name in public. Among other examples one finds a man of nervous temperament who was obsessed with the feeling that he was going to be sick ; when visiting friends this idea be- came so strong as to dominate his thought and pro- duced such a state of apprehension that he often had to go home. In spite of experience that the sickness never happened the obsession remained. Also a middle-aged woman who suffered mental torture from a persistent fear that she might develop meningitis, or sore throat ; other illnesses did not interest her, but of these two she had the greatest horror. Again, a yomig woman's work was hampered by her mind continually dwelling on the false idea that she was wanting in mental power and would probably one day "go out of her mind "; a prey to numerous obsessions, she also suffered from doubts about words, questions, and many trifling things requir- ing decision in daily life, whilst closed spaces were ab- horrent to her. The following is an example of the great annoyance obsessions sometimes occasion. Out of a host of tire- some fears and troublesome thoughts the following were given as typical instances : "I have feared to omit, after signing my name, to draw a line from the signature to the MORBID FEARS AND DOUBTS 121 bottom of the paper and up again, touching the paper three times with the pen in the upstroke, repeating the whole of the performance three times. If this were not done I feared to let the signature go out of my hands or be posted. By slow degrees, and cautious attempts, I reduced this to apply only to cases where the signed article was posted without mentioning the posting to someone. I have feared to omit to turn a bolt-handle three times before going to bed after first looking at three windows, and stretching upward. This has been broken to the extent of not going to bed till about one o'clock next morning, when I did it. I have feared to omit taking a certain walk for three (or four) Sundays in succession , and it is difficult to omit it at all on a Sunday. This is a great hindrance from leaving home, and is a burden when I am not weU on Sunday. I have feared to omit to wash out my mouth nine times with izal after smoking, before eating. I have feared to finish smoking a cigarette except in a certain room. These are some of the worst fears, but there are many smaller fears such as the speaking of certain words under certain conditions, the not laying down of pins in certain places, the spending of pennies which have not been changed from one pocket to another and afterwards to a third, which idea originated in a fear of spending know- ingly a penny with a king's head on it instead of a queen's. In aU these cases the thing that is feared is the production by fear of some disease which would end fataUy, com- mencing either immediately or at a prescribed time after the breaking of the inhibition. I have been through three days, a fortnight, and even twice through eighteen- month periods after the partial breaking of inhibitions, but have escaped iQ-consequences, I am thankful to say. I once deliberately broke an inhibition of walking along a path in which I feared I should have a fit. My heart beat furiously for some time afterwards, but got quieter. This was some twenty years ago. A doctor informed me 122 THE PROBLEM OF NERVOUS BREAKDOWN that the palpitation was probably due to the fact that I had gone out of my way to break the inhibition." As if these things were not enough to hamper seriously the business of life, the following was subsequently added : " Then there is that difficulty about signing a letter and posting. I am afraid of signing a letter without making certain marks and strokes after my name, even with an empty pen. By dint of hard work and friends' assistance I got as far as signing my name with hut small marks so long as I did not post it, except when I told my wife beforehand." He could send it by hand or carry it, but this meant that (without having made the large marks — although not showing) he could not post a letter without referring to his wife. When she was not at home, there- fore, " my difficulty became great." " This began when my first nervous breakdown occurred (some six or seven years ago), the first obsession being the drawing of a line from the signature to the bottom of the paper and up again — some three times (see above). This difficulty is to-day much the same." Once whilst his wife was abroad a friend asked him to sign a paper which he did, without making large marks, and the friend then went and posted it. No undue fear attacked him, although he was a little uneasy on this account, But further relief was afforded by informing his wife, who was in Switzerland, that the letter had been posted. The fear was of disease — " the worst disease " — contmgent on not fulfilling the require- ments of the obsession. " Although I understand it would be safe to omit the marks, I camiot brmg myself to believe it sufficiently to act on it in practice." Thus obsessing thoughts take many forms, but always have their tormenting influence based on an element of fear. Without this they are merely a nuisance, and the quickest way to attack them, therefore, is to assail the dread that lurks behind them. A simple effort of will commonly makes them worse in that it accentuates a desire to get away from them, as if they mattered. On MORBID FEARS AND DOUBTS 123 the other hand, to strive for some understanding of their nature, and to realize that they are bogies which have no power which their victim does not himself ascribe to them is to extract their sting. Of varieties of obsessions not above mentioned passing reference may be made to the haunting phrases and sentences — often in the form of questions — which sometimes occur. Just as sometimes a tune will ring in one's head annoyingly, but with a thousand times greater insistence, will particular phrases haunt some people ; such are : Why is the earth round ? Where is heaven ? What are the evidences of survival ? I am the man ! and so on and so forth. When the haunt- ing idea is of a repellent character the torture it occasions is necessarily aU the greater. CHAPTER IV NERVOUS INDIGESTION Dyspepsia a common accompaniment of nervous disorder — Tone and its failure — Digestive processes susceptible to mental influences — Definitions of nervous indigestion — Consequences of dyspepsia — Vicious circle — Characteristics of nervous dyspepsia — Auto-intoxi- cation — Secondary consequences — Classification of cases — Mucous colitis — Common misconceptions — Treatment must be mental as weiras physical. INDIGESTION is one of the commonest ailments for which people consult a doctor, and remarkably often the dyspepsia has a neurasthenic basis. Consequently, one of the commonest misconceptions of illness is that which leads people to be treated for a primary disturbance of the digestive organs when all the time the root of their indigestion is to be found in a failing nervous system. Certainly amongst those who are admittedly suffering from " nerves " one finds that indigestion is one of the discomforts most frequently complained of. So common, indeed, that many writers have felt compelled to describe " gastric neurasthenia " as a special variety of the malady ; although as previously noted, it is neither necessary nor desirable to try and divide so protean a disorder into too definite sub-groups. Nevertheless, the frequency with which neurasthenia is associated with digestive troubles makes it convenient to give separate consideration to this combination which has, be it noted, achieved rank as a popularly recognized form of illness under the names of " nervous indigestion " or " nervous dyspepsia." Let us see how it is that failure of nerve -strength so 124 NERVOUS INDIGESTION 125 readily leads to weakened digestive powers> Apart from the general want of muscular power associated with neurasthenia, the question of tone has to be con- sidered. In health the nervous system is continually sending out impulses which serve to maintain efficient elasticity in all muscular organs. These messages not only maintain '* tone," in the voluntary muscles of the limbs and body, but keep up to the right pitch of elasticity the automatical working of muscles of stomach, intestines, and other internal organs. If an accident or operation severs the nerve -trunks supplying the muscles of the arm, for example, the individual muscle groups, apart from loss of power, become slack and wanting in tone. It is the same with aU other muscular parts. Tone is important in that it holds the muscle - fibres in a position of readiness to act. Where through iUness or other cause there is great slackness in arm or leg, the ability to move quickly is handicapped by want of tone. On the contrary, in health the tonicity main- tained enables movements to be carried out with great swiftness. In short, tone is an alertnees of the body a.nd its organs, which makes for efficiency on all occasions.^ When the nature of bodily tone is understood, it is easy to see how ability to respond quickly to the calls of daily life must fail when debility reaches those wonderful central batteries — ^the brain and spinal cord. On the physical side the neurasthenic state represents a slack nervous system, hence associated with it one fre- quently finds poor elasticity in stomach and bowel. Slack nerve -cells mean slackness not only of the whole physical man, but of his digestive organs ; feeble diges- tive apparatus means a variety of dyspeptic troubles. - Webster defines physiological tone as " that state of the body or of any of its organs or parts, in which the animal functions are healthy and performed with due vigour." By the same authority physiological tonicity is defined as " state of mind ; temper ; mood." Also atony as " want of tone or vital energy, weakness of the system, or of^any, especially contractile^organ." 126 THE PROBLEM OF NERVOUS BREAKDOWN In a word, nervous indigestion is a particular local mani- festation of the total flabbiness which is at the root of the neurasthenic person's troubles, and therefore often depends primarily on those emotional disturbances which play such a leading part in producing the nervous dis- turbance. This view is supported by many competent observers, whilst years ago Sir Lauder Brunton called attention to the way in which worry or other mental disturbance profoundly affects digestion. He said: " The effect of emotion upon the stomach is well known. A piece of bad news takes away the appetite, and may even bring on sickness. Mental work immediately after a meal is very apt to disturb digestion, and if carried on regularly may lead to dyspepsia. I was once staying at a hydro- pathic establishment near a large commercial town, when I observed that one of the rules was that any patient taking up a newspaper within an hour after dinner was fined one shilling. The reason for this was that the patients who came there were chiefly engaged in business, and the first thing they turned to in a news- paper was the money column ; thus their minds became occupied with commercial affairs after meals, and diges- tion was not so good. Excessive weariness tends to cause indigestion, because the worried stomach and nervous systems do not respond to the stimulus of food. Worry, anxiety, disappomtments, and especially a love affair, all tend to cause dyspepsia." The same author wrote : "It is important, as far as possible, to avoid fatigue before meals, and to get rid of all worry and thoughts about business during meals. Some people damage their digestion by walking from their work with the notion of getting an appetite. The extra labour caused by this finishes up the patient, already exhausted by his daily work, andjessens the digestive powers still more. Twenty minutes' restfat|least after getting home is a useful re- storative, and is advisable for dyspeptics, especially for NERVOUS INDIGESTION 127 patients at or above middle age. On the other hand, if the occupation be of a harassing or anxious kind, it is sometimes useful for the patient to walk home instead of driving, in the hope of getting rid of his anxiety and worry by exercise. If rest can be taken on arrival the disadvantage caused by the extra bodily work in such cases may be more than compensated by the relief to the mind. After the meal is over, rest is required both for body and mind, and active exertion, either bodily or mental, is injurious ; it is advisable to rest half an hour or more if possible. During this time pleasant conversa- tion or light reading or a pipe may direct the thoughts from care." Dubois goes so far as to declare that " ninety per cent of dyspeptics are psychoneurotics, and that all these patients should have nothing to do with restricted diet and stomachic medication." ^ He emphasizes his belief that our method of approaching all manifestations of nervous indigestion should be constant, and "the same in the various dyspepsias with eructations, vomitings, sharp pain and heaviness in the stomach, dilatation and gastroptosis. It is bad to begin the treatment by admit- ting, in such cases, a primary affection of the stomach, or ' stomachic nervousness.' It is, on the contrary, the stomach which suffers from the counter effect of the nervous condition." ^ The late Dr. George HerscheU, who devoted special attention to the study of this condition, defined it as " an affection of the stomach of nerve origin, accompanied by an indigestion resembling very much the flatulent dys- pepsia of chronic gastritis. It is evidently due to abnor- mality of function in the nerves which preside over the stomach and intestines, more than two-thirds of all the cases of this complaint met with in practice being part of a general neurasthenia." ^ ^ Paul Dubois, M.D., The Psychic Treatment of Nervous Disorders, p. 258. 2 jfji^^ * George HerscheU, M.D., Indigestion, p. 159. 128 THE PROBLEM OF NERVOUS BREAKDOV/N However, one must not forget that some specialist investigators, the late Dr. T. D. Savill prominently among them, have considered that in very many instances the nervous illness is a result rather than a cause of the stomach disorder. But this view does not account for the early failure of digestive power as expressed by the slackening stomach wall ; nor does it square with the common observation that so often the development of the indiges- tion has been preceded many years previously by signs of constitutionally low-level of nervous vitality which has necessarily included the digestive organs in its general effects. Dr. Savill held " that gastric disorder produces neurasthenia by an autotoxic condition of the blood acting on the nervous system. There can be no doubt that gastric disorder results in a defective elaboration of the products of digestion, and the pouring into the blood of a large quantity of imperfectly elaborated and toxic products. Constipation is capable of acting detri- mentally in the same way owing to the reabsorption of many materials which are intended for excretion." ^ He further wrote : " Bad food or a dietary containing a deficiency or excess of certain articles, even without indigestion, are some of the other errors which, in persons otherwise predisposed may, I believe, give rise to neuras- thenia." ^ At the same time, he qualified these state- ments as follows : " It may be that, in some cases, a contributory cause is necessary to render the nervous system inherently weak ; but such a cause does not seem to be always necessary ; certainly in many cases it cannot be revealed, and one is almost led to infer that the toxic products of digestion have a specifically poisonous effect on nerve structures." ^ What is true enough is that once the nervous indiges- tion has well developed it of itself reacts severely on the nervous system, and it is then that the fermentation 1 T. D. Sa\'ill, M.D., Lectures on Neurasthenia, p. 83. 2 Ibid. - » Ibid. NERVOUS INDIGESTION 129 products of deficient action in fetomach and bowel further poison and weaken the already debilitated nerve -cells. Thus is set up a species of " vicious circle " which is very commonly observed. Here the sequence of events is that a delicate nervous system through overstrain leads to weakened digestion ; impaired work of stomach and intestines permits fermentation, and fermentation in- variably results in the production of substances highly poisonous to the "nerves," whUst the poor state of the digestive organs allows them to be all the more quickly absorbed into the system, and so to attack the central nervous system directly. These poisons, strongly re- acting on the debilitated nerve-centres, lead to further weakening of stomach and bowel, so that the debilitating process goes round in that morbid circle which so com- monly leads to chronic invalidism and great emaciation. To cure the sufferer the circle must be cut somewhere, and the task is a hard one, although in the early stages there are no insurmountable difficulties. The late Sir James Goodhart used to draw attention to the nervous element in so many misunderstood cases of stomach and bowel disorder, and also to the way in which worry, for example, will occasion furring of the tongue, tilting against the time-honoured convention that such furring necessarily sign?Js important digestive trouble. In his usual spirited manner, he derided this popular medical " obsession," suggesting that " there is no more ineradicable idea in the mind of the doctor than that the furred tongue is essentially an indication of a deranged stomach, and it is probably an attempt to kick against the pricks to say otherwise. That a dirty tongue is an indication that the liver is out of order, and that a purge of some sort is the one and only remedy will, I suppose, never cease to be thought- as long as the world lasts, and in a fair proportion of cases I am not prepared to traverse the practice. But it is by no means always so ; a dirty tongue does not always mean a foul stomach. . . . Nerv- 130 THE PROBLEM OF NERVOUS BREAKDOWN ous fears and nervous tastes are common enough, and they demand a special thought." ^ Sir James aptly- reminded us that " Quinney squirmed at the remote possibility of being merged and lost. He muttered un- easily, ' It fair furs my tongue to think o' that.' " The question of disturbed taste is, indeed, interesting. One finds over-sensitiveness to certain flavours, loss of taste to others, or complete loss of taste and smell as results of a disordered nervous system. Sometimes one has to deal with persistent tastes that are found trouble- some. There comes to mind a man who always had a sweet taste in his mouth ; nothing to bother about, it might be said, but he became so anxious lest this should portend something about to happen to his brain that his sleep and capacity for work were seriously influenced for a time. Here, as so often, it was the fear of the unknown that was the main trouble, and probably the sweet taste itself was " fixed " by just some such fear set up in the thought of an over-active and rather tired individual. The chief characteristics of nervous indigestion are its persistency and the variety of symptoms it occasions. Flatulence and distress after food are common, as also is sense of great hunger satisfied by very little food, but recurring again within a couple of hours. The actual dis- comfort experienced may be anything from slight sense of weight or fulness, to disturbing pain ; sensations of gnawing or burning felt at the pit of the stomach are quite common. Sour eructations into the throat often occur, and may be associated with a sore, red tongue. In long-standing cases, where there is dilatation of the stomach, a considerable quantity of fluid may be brought up from time to time. Even where there is no distension, the bringing up of a small quantity of mucus and undigested food is a troublesome feature that bothers many neurasthenic people, and in itseK signifies the 1 Sir James Goodhart, M.D., " On Nervous Furring of the Tongue and Disturbed Taste," The Lancet, September 25th, 1915. NERVOUS INDIGESTION 131 unhealthy state into which the lining mucous membrane of the stomach has fallen. Indigestion is not necessarily centred in the stomach, but may be manifested mainly in the intestines when some or all of the following symptoms may indicate that the bowel is not functioning properly : flatulence, rumblings, spasmodic pain, irregu- lar action of the bowels, intermittent mucous discharges, and abnormal character of the motions. It helps us to understand the difficult problems of nervous dyspepsia if we realize that the abdominal organs share in the general morbid hypersensitiveness, and that in con- sequence minor discomforts or pain which in an individual of strong nervous fibre would scarcely be noticed may be felt as acute distress when troubling a neurasthenic person. A particularly unpleasant feature of neurasthenic indigestion is the disturbed nights it often leads to. The sufferer wakes up in the early morning hours feeling low- spirited, chilly, and very hungry. There may be trouble- some intestinal squirms and rumblings. Then, unless food of some kind is taken, the discomfort persists, or may increase, so that no more rest is obtained, and the morning dawns on a thoroughly unhappy and disgruntled individual, who feels quite unfit to take up his daily task. Many dyspeptics keep a few biscuits by their bedside with which to combat the early morning attack. Others make a habit of rising and brewing a cup of tea or making some cocoa. Best of all is the use of a heat-retaining flask in which a warm drink can be kept ready to hand. Often enough a glass of water serves to restore ease and sleep. Considering the subject in more detail, it is to be noted that sufferers from nervous indigestion — ^the dyspeptic neurasthenics — usually come with a history of many years' chronic Hi-health, which has been combated with varying success and assistance from numerous qualified and unqualified practitioners of healing arts. Birds of passage from one consulting room to another, and from 132 THE PROBLEM OP NERVOUS BREAKDOWN one treatment to another, they have largely lost con- fidence in anything that may be suggested for their health, yet must needs seek a little more advice for a condition of things which hampers their work, upsets their domestic happiness, and bids fair to rob them of that considerable success in life which the neurasthenic quite often finds within his reach. Commonly below weight, and of delicate appearance, the sufferer plunges straightway into a story of persistent discomfort after meals, with flatulence, abdominal dis- tension and pain ; however careful he is in regard to meals, he suffers from sharp " attacks of indigestion," usually accompanied by a feeling of biliousness, furred tongue, lassitude, headache and want of spirits. Fre- quently enough there is constipation ; but it is also quite common for the patient to be unaware that the bowels are really sluggish in action. Again, not infre- quently one is told that indigestion and flatulence are sometimes accompanied with or varied by colicky pains, with numerous loose slimy motions. When this is the case, it is usual to be told that such abdominal attacks are separated by periods of obstinate constipation. Further questioning commonly reveals clues to the nervous element in the case. Thus it is perhaps revealed that the invalid sleeps badly, gets " brain fag " after comparatively little work, finds himself breathing heavily after a little sharp physical exercise, or bothered by general nervousness and sense of mental discomfort in various ways. Examination shows that no gross organic disease is present, but there are evidences of slackness and irregularity of action in the muscular coats of stomach and bowel. Splashing and distension show that instead of being normally elastic and properly contracted the alimentary passages are flabby and contain much gas. This picture is as familiar in the consulting-room of the general physician and family doctor as in that of the specialist. There are two main factors at work in pro- NERVOUS INDIGESTION 133 ducing it, namely, the constitutional neurasthenia, and a state of poisoning commonly secondary thereto and asso- ciated with the debilitated condition of stomach and bowel. Of this poisoning a number of familiar signs gives evidence, particularly headache, disturbed sleep with morning tiredness, foul brea,th, tired eyes, indefinite pains in back and limbs, dull cadaverous -like skin, and presence of indican and aUied products of faecal decomposition in the urine ; whilst obstinate constipation and furred tongue may indicate an obvious physical basis for it. But as in the majority of cases we can trace a history of fatigue on slight exertion back to early years, and very often on account of some adolescent psycho-neurosis, youthful nervousness or childhood's nerve-storm, there is some difficulty in estimating to what extent the ex- haustion and functional nervous disturbance is due to primary asthenia, and to what extent it is a secondary result of gastro-intestinal poisoning. Nowadays there is an inclination to attribute all the neurasthenic symp- toms characteristic of such cases to the poisoning, re- gardless of the fact that so many patients suffering in this way bear in themselves the obvious signs of a delicate constitution, including, of course, a weak nervous system. For in my experience instances are comparatively rare in which a strong, healthy man or woman, free from nervous taint, becomes so injured in health as to develop a chronic auto-intoxication, which reacts on the nervous system so as to bring about a prolonged neurasthenic state. On the other hand, cases are extremely common in which a rather delicate person who has always been inclined to undue fatigue after exertion, and whose energies have never given enough margin for the ordinary demands of daily work and pleasure, gradually finds digestion and bowel action diminishing in efficiency ; there being at the same time indications that the natural want of vigour is being further increased by auto-intoxication. The 134 THE PROBLEM OF NERVOUS BREAKDOWN difficult|cases are those in which physical signs are not much in evidence, and where there is all the difference between suspicion and confirmation. Fortunately, by careful X-ray examination after a bismuth meal, or by other tests, it is possible to detect sluggish peristalsis action without difficulty, and it may be taken as a cer- tain axiom that when there is such alimentary langour, poisoning is a possibility that requires serious con- sideration. But the very facility with which modern technique has provided us in the matter of detecting bowel stasis, and suggesting physical grounds for a diagnosis of chronic auto-intoxication, is in itself a trap to the unwary medical man who, carried away by local conditions, may be in- clined to forget the primary neurasthenic state at the root of the illness. This essential want of vitality per- sists, however efficiently the muscles of the stomach and intestines may be ' toned ' up by massage, electricity, or what not, and however thoroughly the sluggish bowel be drained. It is owing to this common misunderstand- ing of the factors producing the vicious circle which drags down the health of the dyspeptic neurasthenic that in one consulting-room the invalid is said to be suffering from gastric trouble — catarrh, dilatation, gastroptosis, and so on ; in another, his case is diagnosed ' neuras- thenia ' ; and in yet another he is said to be suffering from intestinal auto -intoxication ; whilst in a fourth he may be told that ' colitis ' is the main source of all his troubles. These things may be true enough, but they represent parts and not the whole malady. It is because an illness of this kind is often not understood in its entirety, and is believed to depend wholly on some local disturbance, that so many dyspeptic neurasthenics receive but temporary benefit from treatment. This is unfortunate, because when one takes the broad view a great deal can be done to increase the total efficiency and usefulness of such semi-invalids, to say nothing of NERVOUS INDIGESTION 135 vastly adding to their family happiness and comfort in life. When the indigestion resists all remedies and becomes a constant source of impairment there gradually arises a train of secondary consequences, other than those already specified, which tends to confirm the invalidism and to make efiective treatment more and more difficult. In two directions especially does this tendency manifest itself. On the one hand, the persistent pain, or other local distress, often leads the sufferer to conclude that he is reaUy the victim of some grave disease that has been overlooked. To the misery of previous discomfort be- comes added a hopeless feeling of being outside the reach of the doctor's skill. People are reluctant to beHeve that so pressing a malady can possibly be dependent on some mind disturbance, or disorder of their " nerves," and seize on the slightest excuse for assuming that they have a deep-seated organic disease. The worst of it is that the more a conscientious doctor endeavours to make certain of his diagnosis by resorting to X-ray examinations, estimation of stomach contents, or opinions of physicians specializing in abdominal troubles, the more do they secretly decide that he is searching for that dire disease that they feel sure must be present. Thus the first important step in helping those sufferers must be to give them a clear understanding of the nature of their trouble ; and to convince them that no growth, obstruc- tion or other gross change is at the root of it. Emphasis must be laid on the fact that sensations are most mis- leading both as to the nature of the actual disturbance and as to where it is reaUy taking place. Thus pain very frequently occurs a long way from the seat of trouble, maybe on the opposite side of the body. That is because the automatic, " sympathetic," nervous system that links up the abdominal organs is characterized in one respect by an inability to render an accurate account of direction and place. As a consequence, a disturbance on the right 136 THE PROBLEM OF NERVOUS BREAKDOWN side may be expressed by pain on the left ; or spasmodic contractions of the bowel may be reflected in discomfort apparently referable to the stomach. It may be said at once that it is an important point in treatment to explain these possible fallacies about pain and local sensations, as it encourages invalids to become less fearful of their symptoms when they realize how untrustworthy first appearances may be. The other morbid tendency is towards attempted self- cure by gradually cutting out of their diet special things that are considered to increase the local distress. Oblivi- ous of the fact that the true remedy for a tired stomach is to train it to digest more and more they faU into the error of encouraging the refractory organs. Admitted that one comes across peculiar and undoubted personal difficulties in different people, cheese, cucumber, and shell-fish being familiar examples, that does not alter the fact that the neurasthenic digestive tract has to be treated first like the neurasthenic patient himself. It must be rested at the outset, but subsequently re-educated and coaxed into fresh life and activity. There is a story of a fine old octogenarian who at a late supper party astonished a neighbour by eating lobster salad. On bemg asked with surprise how he could eat lobster for supper at his time of life, and if his stomach would not rebel, retorted, " Sn, my stomach has to eat what it is told to at all times." The object of the dyspeptic neurasthenic must be to treat his fatigued organs fairly, but never to forget that it is intended that ultimately they shaU dispose of whatever meals he may decide on. And in dealing with his stomach fairly the invalid may well bear in mind the reference to rest just made. At the outset of a " cure " for severe nervous indigestion, especially where there is an acute attack or sudden increase of symptoms, there is nothing better than a few days' rest of the whole system. Three days in bed on the lightest diet compatible with proper nourishment will often work wonders and form a NERVOUS INDIGESTION 137 good starting-point from which a systematic routine of treatment may be carried out. In dealing with cases of this kind, the great outstanding fact should at once be realized that the problem is one of income and expenditm-e. That is to say, the patient has to adjust his life to suit his avera.ge coefficient of energy, otherwise the nervous depletion wiU obstruct any attempt at successful treatment. Clearly this raises a difficulty, for it is not open to every one to change life's routine at the bidding of the physician, although fortunately one's task is rendered less arduous the more the principle of conservation of nerve energy is understood. Hard as it is to augment the natural vitality of the neurasthenic, it is nevertheless possible to enable him to make greater use of the vigom' that is in him by practismg the most strin- gent economy in regard to his nervous expenditure. Regu- lar hours for work and rest, scrupulous routine in the matter of meals and sleep, are useful energy-saving measures. Where the system flags, brain, stomach and muscles should not have to contend at any particular moment for the comparatively small amount of energy available for distribution among them ; but when one has to take up the tale of daily duty, the others should rest for that v/hile. CHAPTER V HYSTERIA A psychological riddle — Hysteria known to the ancients — Pithiatism— Sydenham's definition — Bygone theories — Common signs of hysteria — Basis of the hysterical state — Disorders of movement — Curious reactions — Disorders of sensation — Witch's marks — Dis- turbances of general health — Hysterical attacks — La grande hysterie — Illustrations. WE have seen that neurasthenia is one great enigma of medical science, but, truth to tell, this remark- able group of maladies is eclipsed in point of singularity by hysteria. The peculiar state of mind that was a puzzle for the ancients, and a question of demonology in the middle ages, remains the great riddle of medico-psych- ology in the twentieth century. Certainly Hippocrates was familiar with this baffling disorder of mind and body, the name we now use being given to it in his day, whilst Pliny wrote about hysteria as a special disease of women. Thus it is, indeed, an interesting example of a common malady recognized at the dawn of medicine and described in the medical schools of to-day in the same terms, and under the same name that was applied to it in the halls of the great Greek philosophers. Now, as a matter of fact, after occupying a recognized place in medical nomencla- ture for so many centuries, the term hysteria seems likely to be ousted by a new title — ^pithiatism — coined in the modem schools of French neurology. Be it noted, that in spite of its time-honoured use as a scientific expression it has, curiously enough, been popularly used in a mean sense, confusing the issue and failing to distinguish one of the gravest nervous diseases from malingering. No 138 HYSTERIA 139 true conception of the problem of nervous breakdown can be obtained unless it be clearly recognized that in hysteria we have a very real disease which, although frequently enough indefinite in outline, is, nevertheless, accompanied by definite mental and physical characteris- tics. To make this quite clear it wiU be helpful to review the manifestations which occur in this particular nervous disorder. Sydenham, the great physician of Cromwellian times, described hysteria in terms that have become classical. He said : " Hysteria imitates almost every disease which befalls mankmd. Whatever part of the body it attacks, it wiU create the proper symptom of that part. Hence, without skill and sagacity the physician will be deceived, so as to refer the symptoms to some essential disease of the part in question and not to the effects of hysteria." And in regard to the mental states of hysterics the same able observer wrote : "All is caprice. They love without measure those whom they will soon hate without reason. Now they will do this, now that, ever receding from their purpose." Such a picture drawn by a master hand makes it easier for us to understand how hysteria has not only puzzled doctors, but been seriously dealt with by priests, philosophers, and law-givers at various times in the world's history. Physicians have always been con- cerned with hysterical disturbances, rightly enough considering them in the nature of an illness. Philosophers have been fascinated by the problems presented because of the possibility that the extraordinary mental reactions and apparent phases of spiritual exaltation and insight might afford a key to their own researches. Priests have been continually worried by hysteria, not knowing whether to welcome its manifestations on occasion as opening up communications with heaven, or, alterna- tively, as demonstrating the agency of the evU one. Judges have been called in by perplexed priests and frightened people to settle these matters in so far as they 140 THE PROBLEM OF NERVOUS BREAKDOWN have been thought to imperil the lives and welfare of respectable men and women. Sadly enough for sufferers from hysteria, priests, philosophers, doctors, and lawyers actually found themselves in agreement about these matters some three hundred years ago ; they were of one opinion that the peculiar stigmata of hysterical persons represented possession by Satan or his minions. Witch hunting became rife and for a few years almost elevated into the position of a national sport, as those who have read the mournful story of the witches know full well. Even to-day in a few remote hamlets it seems likely that hysteria has not yet been finally divorced from witch- craft in the folk-mind. The main physical disturbances commonly resulting from hysteria may be indicated in a few words, although their combinations, degrees, and detailed character vary so much that one could speak indefinitely about them. Of the mental state of hysteria volumes have indeed been written, and with the best intentions in the world it is difficult to compress all one would like to say about it within the compass of a few pages. Briefly the more usual outward signs which occur in hysteria are paralysis, varying from inability to move the fingers or a hand to complete loss of movement in all limbs ; abnor- malities of sensation, commonly inability to feel pain or pressure, heat, or cold over particular areas of the body, with or without neuralgic pains ; irregularities of the special senses and involuntary movements of all kinds. It is sufficiently obvious that were these the only troubles brought about by hysteria it would still deserve to rank high as an important disease. But whilst these disorders may be such as entirely to incapacitate the individual affected, in addition one has frequently to deal with acute states of mental excitements, violent convulsive attacks, severe fevers, serious changes in the skin, swellings, and hsemorrhages. Moreover, all sorts of combinations of symptoms imitating other diseases HYSTERIA 141 have to be included in our survey and kept in mind as not infrequent accompaniments of this form of nerv- ous breakdown. It would be difficult, therefore, to overestimate the importance of the matter we have now under consideration. Subsequent analysis of the factors leading up to hji^teria will show us that nervous instability in the family tree, and, in the individual, over-emotionalism and abnormal suggestibility are three important influences ; that wherever there are conditions favouring their action and interaction hysteria soon appears. Thus in com- munities, large or small, when feeling tone is raised to an abnormal level hysterical outbreaks become prominent. Religious revivals, political disturbances, crazes of all kinds, and acute international situations, obviously provide a setting favourable for the reaction of emotion- alism and suggestion on large masses of people ; all the more so during the com'se of so stupendous a conflict as that which has lately shaken civilization. Further, as the strain of war falls for the most part on armies in the field so it is not surprising that in the nervous disorders of active service hysteria occupies an important place. When we come to discuss the psycho-neuroses of war more detailed consideration will be given to this aspect of the question. Amongst the most readily observable of hysterical states, weakness of limbs figures prominently. In its most advanced development there is paralysis of one side of the body (hemiplegia) — the arm and leg, with possibly the face muscles on the same side, being thrown out of action ; or, more commonly, there may be paralysis of both arms or both legs (paraplegia). Not infrequently hysterical paralysis affects single limbs, muscles, or groups of muscles (monoplegia). The usual type of this condition is paralysis of one arm following an injury which has not really produced actual physical damage (brachial monoplegia). Accidents in which 142 THE PROBLEM OF NERVOUS BREAKDOWN sudden shock occurs with considerable emotional stress frequently produce a paralysis of this type. Mishaps with motor-cars, bicycles, or in railway trains, are thus productive of loss of movement in this way ; whilst paralysis of an arm, for example, may be brought about by sudden shock produced by unexpected contact with a strong electrical current, or other violent and miexpected stimulation. There is one peculiar form of limb weakness which deserves special mention ; in this there is ability to move the limbs whilst the patient is lying down with collapse and failure to control movement or support the body as soon as an attempt is made to stand up or walk. This peculiar condition (astasia-abasia), whilst occa- sioning very great distress to those thus afEected, never- theless calls forth an amount of sympathy out of all pro- portion to the real nature of the case ; a state of things which is particularly disadvantageous in that it confirms the invalid in those very morbid self-suggestions of paralysis which are the mainsprmgs of the iUness itself.^ Be it noted that facial palsy, in effect exactly resembUng that produced by cold, ear trouble, or other condition damaging the facial nerve, may occur. Paralysis of the vocal apparatus, producing complete loss of voice (aphonia) is comparatively common. Equally typical hysterical manifestations affecting muscular movements are the contractures. The common type is that of a partially or completely clenched fist which resists aU attempts to open it, and if of long duration may even remain closed during the administration of chloroform. Amongst the war neuroses we shall find that contractures are fairly common, and determined in their locality and extent by the nature of the wound or injury which has originated or accompanied the nervous condition. Wounds and injuries being many in their variety and distribution, the hysterical contractures of war are correspondingly various. ^ See also Part IV, chap. ii. p. 28X. HYSTERIA 143 Whilst many hysterics are crippled by weakness and paralysis there are some whose muscular powers are influenced in the opposite direction ; they suffer from rather too much than too little muscular activity. Such morbid excitability is evidenced by a variety of move- ments which are beyond the control of the sufferer. Tremors and tremblings, jerks and spasms of all kinds, convulsive actions in various parts of the body, some- times general restlessness, occasionally conditions re- sembling St. Vitus dance occur at one time or another as hysterical manifestations. Amongst the explosive muscu- lar phenomena of this malady must be included as facial accompaniments the violent outbursts of crying and laughing which not infrequently mark the hysteric, and in the same order must be mentioned the peculiar running or jumping actions, and the curious grimaces sometimes seen in hysterical people. For centuries one characteristic of hysteria has excited the wonder of all who have investigated this protean disease, and, unfortunately for those suffering from it, has formed the great sign by which the witch-hunters recog- nized their prey. One refers to the curious patches of numbness and diminished sensibility which so often occur as hysterical phenomena. When zealous villagers aflame with excitement sought out the children of the devU they were confirmed in their suspicions when some unfortunate creature suspected of traffic with the powers of darkness was found to be insensible to proddings ia various parts of the body. These "witch's marks " were hailed as the sign manual of Satan, and often enough the sufferer from hysterical anaesthesia was lucky if she were led to the nearest pond for a ducking instead of to the stake. Times change, and witch's marks, once potent to rouse popular frenzy, to-day excite the interest of the medico-psychological laboratory rather than of the countryside. Nevertheless, the disturbance of sensation that was a mystery to priests and parishioners in a 144 THE PROBLEM OF NERVOUS BREAKDOWN more ignorant age still remains a mystery to modern science. Curiously enough, the loss of ability to feel anything touching the skin, so characteristic of hysteria, quite commonly affects an arm or leg just as if a glove or stock- ing of non-conducting material were drawn over it. When this occurs the area of anaesthesia can be readily mapped out and -Rdll be found to have a regular upper- border just as does a glove or stocking. On all fours with this lessened skin sensitiveness one often finds duninished sensibility of the throat and eye ; so much so that an observant medical man will sometimes become aware of the hysterical basis of an illness when on examining the throat he finds that manipulations which would occasion retching and choking under ordinary circumstances cause no discomfort ; or when, on touching the eye-ball, the invalid does not flinch. Amongst disturbances of sensation must be included neuralgic pains. These may be widespread in distribution, and not infrequently felt in the joints. Sometimes there are definite areas of the body in which pain is felt constantly ; also a state of increased sensitiveness of the skin (hypersesthesia) is quite common, so that the slightest touch is felt as a painful stimulus. It is just as difficult to explain how it is that without any physical cause people may become blind and deaf, or divested of their ability to taste and smell, as it is to give definite unchallengeable reasons for the patches of ansesthesia referred to above. The modem theory of hysteria propounded by the French school under the leadership of Babinski holds that these phenomena are not inherent in the disease itself, hut are alivays due to suggestion from without ; an interesting hypothesis that can be discussed at length when we come to sum up the basis of the illness. It is noteworthy that, although the disorders of sensation — including peculiar variations in regard to sight, hearing, smell, and taste HYSTERIA 145 that one comes across in examining hysterical patients — are fairly common in civil life, the war has afforded us much greater opportunities of studying these derange- ments of the special senses than we have ever had before, as will be observed when the question of war neuroses comes up for detailed consideration. It has already been pointed out that hysteria is a great imitator of other diseases, and, if this is borne in mind, we shall never be surprised at those remarkable conditions of ill-health in which without any ascertainable physical foundation most serious changes of function and struc- ture occur, suggesting that there must be present some grave underlying physical trouble. Heart, lungs, abdo- minal organs, skin, and general processes of wear and tear, all come within the scope of the interfering influence of hysteria from time to time. Gastric ulcer, anaemia, consumption, tuberculous disease of the joints, intes- tinal disorders, and progressive degeneration of the brain and spinal cord are aU imitated by hysteria with con- summate skill. From time to time doctors are puzzled by an attack of persistent fever in which day after day there is a rise of temperature to as much as 106° F. when no cause is to be found, and eventually the whole thing turns out to be a freak of hysteria. Finally, one remem- bers that this extraordinary condition has for ages been known as a producer of "living skeletouE." Hysterics sometimes manage to live on incredibly small quantities of food, but in the process become so reduced in weight and flesh that it is marvellous how body and soul manage to maintain company. A few years ago one of these living skeletons flgured prominently when, at a famous Well of Heahng, a wonder cure occurred as a result of the psychological stimulus provided by the ceremonies there. Last, but not least, in our review of the general signs of hysteria may be taken the strange attacks that so often move hysterical persons. Comparatively simple emo- 146 THE PROBLEM OF NERVOUS BREAKDOWN tional attacks in whicli the sufferer is carried away by a fit of laughing or an outburst of weeping are well known ; still these, together with outbreaks of bad temper and excitement, although common, constitute but the minor, manifestations of the hysterical attack. On the other hand, the great convulsive seizures, representing a tre- mendous storm sweeping over mind and body, have from earliest times of recorded history occasioned great interest. Responsible for many wild scenes in medieval days, the cause of many strange riots and religious happenings, the despair of physicians, and the terror of respectable persons ; represented on the stage, pictured in poetry, and described in a thousand works on all subjects, it has remained for a great physician of our own day to interpret and describe in classical terms the features of these strange seizures. It was the great Charcot who described for all time the characteristics of " la grande hysteric," and it was through those demonstrations, to see which the medical world flocked to Paris some years ago, that the modem medical man became acquainted with the full significance of the great hysterical convulsions. Certainly in recent times no clinic has been so prolific of the real thing as that directed by Charcot, it being, of course, unquestionably by a constant process of suggestion — maintained at that time entirely without the knowledge of the physicians concerned — ^that the phenomena became so multiplied and magnified. But that this occurred does not in the least detract from the masterly descriptions which eman- ated from Charcot's clinic, whilst in one respect it hap- pily or unhappily accentuated those particular expres- sions of hysteria with which we are now concerned. Briefly, the grand hysterical attack consists of three stages. There is a period of general unrest in which the individual influence becomes gradually stored up with a sense of something being about to happen. Next, after a matter of minutes, hours, or days as the case may be, the body becomes strung up into a state of great tension. HYSTERIA 147 It is then that certain well-known bodily attitudes are assumed, and the hysteric throws herself as if sculptured in marble into one of those strange positions of which the " crucifixion " attitude and " ecstatic " pose are famous. In the former the legs are extended, the head bent over, the arms thrown out as if the body was being stretched on a cross. When the position of ecstasy is assumed the attitude is that of being absorbed in prayer. On bended knee the hysteric throws up her clasped hands, and with wide staring eyes and uplifted face shows every sign of intense devotion. That at this stage she may dream dreams, see visions, or hear voices, adds to the interest of the psychological problem to-day just as it roused wonder- ment, admiration, jealousy, enmity, or fear in priests and people in times gone by. Following the positional stage there is a period of terrible convulsion, in which the sufferer throws herself about screaming, kicking, and fainting ; and, whilst a hundred different poses are assumed, every now and then the main position previously noted is taken up for a short time. During this stage of the grand seizure anything may happen. Under such an influence the hysteric becomes a great actress, and may portray such scenes of agony and passion as are only dreamed of by professional tragedians in their most exalted moments. It is here that suggestion plays such an important part in in- fluencing action, and in individual instances it may be difficult to iollow the train of suggested thought. Never- theless, there is often sufficiently obvious evidence as to the nature of many of the ideas underlying the dramatic performance witnessed. After this stupendous nerve-storm comes gradually a calm. Sometimes a wild cry may end the attack. Often enough nothing further occurs that is worthy of note, but on the other hand, it sometimes happens that a strange state of mind persists for some little time after the con- vulsion. When this is so a variety of happenings may 148 THE PROBLEM OF NERVOUS BREAKDOWN occur. It is in this period that one witnesses the remark- able automatic actions which often place the hysteric in a false position. Automatism may lead to the perform- ance of such habitual actions as midi^essing or putting on more clothes ; of walking or resting ; of going to shops and buying things, even of stealing things, without the person thus under subconscious control bemg in the least aware of what is being done. On the other hand, in the stage following the convul- sion the sufferer will often pass into a dream-state, in which she rests with closed eyes for days at a time as if poised between life and death. Under such circum- stances, the hysteric becomes an object of intense interest to wonder -seekers, and it is from such material that are made the reported cases of persons being buried alive without food or drink for some days which from time to time excite the multitude. Occasionally the showman has had his chance and exploited the victim of hysteria ; it is hard to blame him for having been deceived by a phenomenon that has puzzled the wisest heads of all ages, nor for his anxiety to bring his wonderful discovery of " living death " or " trance " before the eyes of the astonished world. Illustrative notes. — ^The following extracts illustrate some of the more common manifestations of hysteria : 1. A young girl, after a railway accident, in which her left shoulder was bruised, experienced weakness in her left arm, which readily became tked and " gave way readily," 2. A widow had recently great anxiety and grief through her husband's fatal illness. Experienced difficulty in swallowing eohd food ; indigestion with distressing flatulence ; jtimpiness of limbs and head, particularly movements of the head before speaking. 3. A young woman, aged 25, was very dissatisfied with life and complained chiefly of mental and physical fatigue ; neuralgic pain in the head ; difficulty in vision (could HYSTERIA 149 only read very large type, and was Bupposed by relatives, supported by medical opinion, to be " going blind ") ; depression at times. Examination revealed no organic disease, but there was distinct diminution in the field of vision. In spite of the bad forecast which had been given she gradually improved under systematic treat- ment in which mental therapeutics played the chief part. 4. A married woman for some years had been affected with functional spinal weakness, so that she was unable to stand without support, owing to " giving way " of the body muscles on the left side. Consequently, was unable to get about without immediately falling down. On inquiry, it appeared that patches of anaesthesia (witch's marks) and hjrpersesthesia had occurred at times, but nothing of this kind was to be found on examin- ation. A very interesting case in regard to the rapidity of improvement under static electricity supported by suggestion and persuasion. 5. A school teacher, after a long period of over-work, was attacked by nervous symptoms. There was right - sided weakness said to vary from time to time and definite diminution of sensation of the left leg as compared with the right. 6. A Government employee, after a long period of over- work, complained of jumpitiess of limbs — attacks of nose bleeding — patches of numbness and pains in the legs and feet. Examination revealed no organic disease, but there were definite patches of numbness. Over these places there was a feeling that the skin had gone " to sleep." One was at the back of little and fourth fingers, another about two inches below the left hip-joint covering an area the size of haK-a-crown ; excessively sensitive to pricks, but apparently insensitive to deep pressure. Also on the lower surface of left big toe there was weU defined insensitivity to both prick and touch. Patient was of a nervous and introspective temperament, inclined to be depressed and to withdraw from friends 150 THE PROBLEM OF NERVOUS BREAKDOWN and relatives. Under treatment by rest, persuasion and static electricity made a good recovery ; normal sensa- tion retm'ning in the various patches. 7. Girl, aged 17, previous to being seen had been troubled by loss of voice and hoarseness, particularly after singing. After a holiday she recovered the strength of her voice, but towards the end of the term much in- convenienced, and her future career greatly jeopardized. On this account had been told by a doctor she must change her vocation. No organic abnormality was found. She was perfectly healthy both mentally and physically. After explanation and firm conversational persuasion she had very little subsequent trouble, being only bothered occasionally after singing. 8. A young man lost the use of an arm after an electri- cal shock. On examination it was found that there was loss of sensibility (anaesthesia) of the whole limb. Ex- haustive investigation failed to demonstrate any sign of physical injury. Subsequently recovered. 9. A young woman suffered from mental excitement and convulsive attacks. In one of these she was seen to throw herself on the ground and go off into a trance -like state, in which her body and limbs assumed the classical " crucifixion attitude." (See account of hysterical attacks.) 10. A young woman had been going about on crutches, being unable to use the right leg for walking or standing. Complained of pain and intense throbbing sensation below the knee. Both the patient and relatives reported occasional swelling of knee. This case is particularly interesting in that she had been sent to London with a view to having her right leg taken off above the knee for supposed tubercular disease. Electricity and sug- gestion were advised. As a result there was immediate improvement, and within a fortnight she was able to walk without crutches. l\. A young woman complained of involuntary move- HYSTERIA 151 ments of "neck muscles," disturbed sleep, headaches, palpitation and hot flushes. . Said that her head twisted round to the left involuntarily and remained there some minutes during which she was unable to move it back again. Recently whilst practising elocution suddenly had an attack in which she became semi-conscious, whilst the head twisted as usual ; also said that the front of the head felt as if " the thinking part " was full up with a gathering of water. 12. A young girl had been suffering from attacks of loss of voice (aphonia). Unable to speak even in a whis- per. Cured by two or three suggestion treatments. 13. ^ married woman, suffering from attacks of cata- lepsy of half -hour's duration, sometimes more frequent than others, but usually more common about the time of the period. Also indigestion, inertia, headache. 14:. A middle-aged woman sought advice for aphonia with vocal cord spasm of four years' duration. Apparently had had previously an attack of functional paralysis in the right arm. Treated psychologically without success. 15. ^ girl, aged 20, troubled with neuralgia of the left hip (pain constant) following upon a fall. No organic lesion to be found. Treated by suggestion with imme- diate relief. Three treatments given. No subsequent return of pain. 16. A married ivoman, troubled with general nervous- ness, fatigue, disturbed sleep, and morning sickness. History by medical man that she had suffered from subjective symptoms for some time, and on one occasion had exhibited patches of numbness and insensitivity to pain. 17. A man suffered from attacks in which he ex- perienced numbness of one or other limb, with simultane- ous sense of confusion as to locality. 18. ^ young woman with a history of two years' alco- holism. The chief interest in this case was the occurrence of catalepsy. According to report of medical man, in 152 THE PROBLEM OF NERVOUS BREAKDOWN these attacks she lay rigid and still ; pale with very shallow breathing; "like a corpse," according to sister. Duration of each several hours as a rule. Formerly attacks ensued nearly every day, but latterly at intervals of a few months. 19.-4 young woman apparently suffered from ulcer of the stomach. Pain and tenderness, constant sickness directly after taking food ; frequently " bringing up blood." White furred tongue. Lay in bed with legs drawn up ; said that this attitude relieved pain. A few days later patient complained of pain being very bad. Careful examination showed diminished sensation of skin of arms and legs, also considerable limitation of fields of vision laterally. Subsequently diagnosed as hysteria. 20. A woman complamed of attacks of emotional excitement. Pains and tinghngs in arms and hands. Occasional attacks ia which she "lost herself." Mental and physical fatigue. Made good progress under treat- ment, but relapsed through over -work. 21. Unmarried woman sought advice for mental and physical fatigue and general nervousness. Very self- centred. Functional aphonia. Appeared to be a suitable case for treatment by suggestion, but, as a matter of fact, the method was unsuccessful, as was aU else tried. CHAPTER VI MULTIPLE PERSONALITY A simple case — Morbid desire for notoriety — Dual personality — An interesting problem — Consequences — Alternating personality — The case of Felida X — A clergyman's experience — Loss of memory— The famous Sally Beauchamp — Dr. Morton Prince's analysis — Professor Janet's investigations — Simulation of demoniacal posses- sion — ^Dangers of dissociation. OOME years ago great interest was aroused by a case KJ in which an entirely innocent individual was actually imprisoned on a charge of writing anonymous letters making all sorts of dreadful statements about a young woman. In the course of the trial it suddenly transpired that the supposed victim of this anonymous corre- spondence had, indeed, written the communications herself ! Once this was discovered it was not difficult to find medical and other evidence that she was subject to hysteria and had suffered in previous years from hysteri- cal disturbances. Whether or not this unfortunate young woman became for the time being dominated by a secon- dary personality was not made clear ; probably it was not a case of dual personality, but rather an example of that hysterical mental state which causes those influenced by it to seek notoriety at all costs. When possessed by such a morbid and furious desire to be known to the whole world the hysteric regards neither her own charac- ter nor the honour of those dragged into her schemes. From time to time innocent and unsuspecting persons have aspersion cast on their fair name by hysterical women. Curiously enough, the mentally deranged fame- eeeker at times endeavours to drag down into the mud 153 154 THE PROBLEM OF NERVOUS BREAKDOWN a man to whom — quite unbeknown to himself — she has taken a great fancy. It seems that realization of the futility of her amorous propensities leads to a violent reaction which seeks merely to destroy, and in destroy- ing to bring herself into the limehght of publicity. Reference to such cases leads us directly to further consideration of the problem of dual personality ; the occurrence of which is, indeed, one of the most extra- ordinary of all the many remarkable manifestations of hysteria. Certain temperaments are predisposed to the exhibition of what is termed by medico-psycho- logists "multiple personality," which means that they are liable to exhibit at times such widely differing charac- teristics as to constitute separate individualities. That is to say, the victim of this temperament may appear to one set of people and under one set of circumstances a perfectly good - natured and healthy - minded person, whilst in another place or at another time he or she may manifest all the evidences of a bad-tempered and morbid disposition. In extreme cases, of which numbers have been reported and examined, the change of personality is such that at different periods different names even are assumed, and sometimes different occupations pursued ; whilst living an ordinary Hfe to all outward appearances, the subject of this strange condition is at the same time pursuing a second life hidden from friends and relatives. Indeed, sometimes the subject of dual personality actually deceives herself as to what is going on ; thus, whilst obsessed by the idea of the second personality, she may do things wilfully intended to deceive the self which she recognizes as her ordinary self, but yet as a separate self, and vice versa. And so it is that from time to time some one who is respected and known as a straightforward, kindly, honourable young woman, is suddenly found to be the author of libellous postcards or anonymous letters which have persecuted a whole district. Often enough MULTIPLE PERSONALITY 155 the double-faced dealing is not recognized as a mani- festation of mental illness, but regarded as a form of moral perversion, for which the individual concerned is reaUy responsible. As a matter of fact, the victims of hysteria and double personality are not responsible for their actions. Where the spHt or division between the two personahties shown is complete, the hysteric thinks and behaves as one individual at one time and an- other at another, without there being any correlation between the two mental states. Doctors who have much to do with nervous and mental cases are familiar with patients in whom, without there being a complete split of personality, two entirely different characters are exhibited at different times. A common example is that of the young woman who, outside her own family, is sweet and lovable, — famous for her cleverness and careful thought for others, — whilst at home she is subject to most violent outbursts of ungovernable fury, and suffers from attacks in which the violence of her actions is only equalled by the coarseness of her language. Such outbreaks are for the most part entirely beyond the control of the individual concerned, and represent a sudden ascendancy in the mind of passionate ideas, which for the time being possess the whole mental field. In very bad cases the terrible anger and physical violence are so great that the sufferer throws herself on the ground, writhing with contorted limbs and twisting her face into horrible expressions. Some understanding of the subject may be arrived at if one reduces it to its simplest terms, and considers the case of a man who has received a blow on the head, or for the time being is the victim of poisoning by a drug which excites the brain. As is well known, under these circumstances a gap in memory may occur, so that for a short while life is approached from a new point of view, usually abnormal when judged by common stan- dards of conduct. The holiday-maker who worships too 166 THE PROBLEM OF NERVOUS BREAKDOWN devotedly at the shrine of Bacchus may for a few hours behave in a manner entirely different from the ordinary, and this without exhibiting any of the recognized signs of drunkenness. As he comes to himself memory brings it home to him that his conduct is strange, and leads his will to take up again the rems of government which were slipping from his grasp. Should the dour and parsimonious individual, who has for the time being become benevo- lent and happy-go-lucky through taking a few glasses of wine, now be unable to regain the memory of his previous mode of living, he might persist m the new personality. Similarly on a minor scale unexpected good news, the sudden acquirement of wealth, or realization of duty may work marvellous changes. Where the new characteristics do not persist, but only appear from time to time, then we have a definite example of " alternating personality." One of the most extraordinary cases of alternating personality ever recorded was that of Felida X, investi- gated by a well-known French psychologist some forty years ago. Here was an instance in which, at the age of fourteen, a girl more or less suddenly changed her dis- position and became a new being. After a time the new personality was lost, and the original one assumed again, an interesting point being that as Felida II she remem- bered Felida I, but in her normal state (I) she knew nothing of her secondary personality. The great dis- advantage to this individual was that the changes would sometimes come on with startling rapidity ; and when living as FeUda I she would suddenly find herself in surroundings very confusing to her, because she could not remember the circumstances that had led up to her then position, for, as just mentioned, Felida I knew nothing of the life of Felida II. The conclusion of the case was equally interesting, because when she was between forty and fifty-five years of age she one day became Felida II, and remained as such for the remainder of her days. MULTIPLE PERSONALITY 157 A still more interesting and astounding case of alternating personality was that of an American clergy- man, whose experiences were carefully investigated by the late Professor WiLLLam James and other eminent persons interested in these matters. The Rev. A. B. became a clergyman at about the age of thirty, and took missionary work in his own country, preaching from town to town. One day he drew money from his bank to make a certain purchase, transacted some business, and got into a tram-car. Having done this, he apparently lost knowledge of himself, so to say, and nothing was heard of him for a couple of months, when he suddenly found himself the proprietor of a small general shop in a town far from that in which he remem- bered having taken the tram-car. He said then that his name was the Rev. A. B., that he did not know the town he was in, nor how he got there, and that how it was that he had apparently become the proprietor of a shop in the name of Brown surpassed his comprehension. Natur- ally, everyone thought he was mad, including the doctors who were asked to see him. However, the distracted clergyman insisted upon telegraphing to his alleged friends, and in a short time one of his relatives came along and identified him. What he did in the interval between taking the car at one town and arriving in another no one could ascertain. But the undoubted fact remains that the Rev. A. B. did arrive at the second locahty, and possess himself of a business in which he behaved as a perfectly rational shopkeeper, making his living and conducting his affairs in the name of Brown for some little time. Amongst other features of interest in this case was the circumstance that Mr. " Brown " attended a local church, and at a devotional meeting made a speech, during which he actually gave an account of something which had happened when he was the Rev. A. B., without recalling his real individuahty. Something of the same kind, but of a far less dramatic 158 THE PROBLEM OF NERVOUS BREAKDOWN character, was once brought to the notice of the writer in the case of a man engaged as a clerk in London, who set out for his office one morning, and some days later wandered into a provincial hospital sixty or seventy miles away, saying he did not know who he was nor where he had come from. Gradually memory returned and identification was secured. This individual had evidently lived for two or three days in apparent comfort, although he had probably walked a gTeat many miles, in the guise of a secondary personality, without doing anything to call particular attention to himself. Dr. Morton Prince, a well-known American psycho- logist, has pubhshed some very interestmg mvestiga- tions about the case of " Sally Beauchamp," a secon- dary personality who has thus become famous in the scientific world. In this case, by a process of careful analysis, aided by hynoptism, Dr. Prince discovered that an unfortunate girl was possessed by no less than five and possibly more distinct personalities, each of which appeared to have very little understanding, or, at any rate, kindly feeling towards the others. Thus it is that where a temperament is capable of manifesting distinct personalities, Personality II, for example, may plan a plot and carry out a series of vicious acts intended to damage PersonaHties I or III, and so forth, as the case may be. In Dr. Morton Prmce's remarkable case, a Miss Beauchamp was obsessed by a personality calling herself SaUy, who manifested intense disUke of the normal individual, and did various things to annoy her. Thus it is related that on one occasion, when Sally was in the ascendant, this unfortunate woman went out and gathered some insects, snakes, and other creepy things, and put them into a box addressed to Miss Beauchamp — that was, of course, to herself as the normal personahty. In due course Miss Beauchamp came to herself, received the parcel, and was terrified to distraction on reaUzing its contents. It must be noted that here the same woman, MULTIPLE PERSONALITY 159 as Sally, handled live things that were most obnoxious to herself as the real Miss Beauchamp. The possibilities of such JekyU and Hyde combinations, together with the misunderstandings and miseries that may be thereby occasioned, are sufficiently obvious. Trouble is particularly likely to arise, where, for example, a young woman obsessed for the time being conceives an attachment to one of the opposite sex, of whose existence in her normal state of mind she is scarcely aware. In one of the cases of the remarkable series collected by Professor Janet, of Paris, was a young woman known as Leonie, who exhibited many extraordinary features. Here, not only was a second Leonie revealed in the hyp- notic trance, but on one occasion a Leonie III appeared, who was quite a different person from the other two. It was found that Leonie II had not arisen in the course of ordinary Ufe, but because in early years this girl had permitted herseK to be the subject of hypnotism in the hands of numerous individuals, who, finding her very susceptible, had made sport of her for many years with a resulting mental dissociation. Another subject investi- gated by the same authority was a girl named Lucie, in. whom also three personalities were revealed ; but here, again, the change did not occur in ordinary life, but only as the result of experiment. Janet has also reported an extraordinary case of double personahty simulating demoniacal possession ; and further serving as an ex- ample of his own psychological acumen. This was a case in which a man called Achille was obsessed by a person- ality claiming aU the powers of an attacking demon. The curious thing was that the subject of the " possession " was quite unconscious of the presence of the invading personality, so that when the latter was told to move AchiUe's limbs the resulting movements were made, and greatly surprised the man concerned. Professor Janet's Bkill in curing this sphtting of personality was shown by hie final experiment, in which he sought to hypnotiseTthe 160 THE PROBLEM OF NERVOUS BREAKDOWN patient. Owing to the difficulty of this, he hit upon the device of putting it to the obsessing personality that it could not send AchOle to sleep. Fortunately, the split- o£f part of this man's temperament, which was then in ascendancy as a " demon," carried out the suggested idea to show its strength, and in a moment Achille went to sleep. Immediately the experimenter made the necessary suggestions to bring together the dissociated parts of the victim's mind, and a cure resulted. There is little doubt that in times gone by the cases of supposed demoniacal possession, which our ancestors sought to cure by a combination of physical violence and spiritual ministration, were often instances of double personality. At one time it was the practice to plunge the victim of such attacks into cold water, or to beat her with sticks, after which resort was had to the services of the Church to complete the cure. It is interesting to remember this in view of the fact that at the present time the medico-psychologist re- commends the physical stimulus of electricity, backed up by the mental effect of hypnotic or simple suggestion, as the best means of combating the evil thing. It is certainly true that a secondary personality, manifesting itself in one of the ways indicated above, may exhibit the most diaboHcal characteristics, and plan aU sorts of things for harming the invalid himseK or those about him. From the practical point of view these cases are important at the present day, when so much attention is being given by educated persons to the production of trance -states in connection with spiritualism ; because the psychologist who has studied these things is very well aware that the personalities which are said to control the medium in such trance-states may be nothing more than spHt-off parts of his or her personality, which assume the characteristics of " possessing " spirits, and the mani- festation of which necessarily becomes intensified through habit. Whatever may be the final verdict of science upon MULTIPLE PERSONALITY 161 the phenomena of the spiritualistic seance, it must be borne in mind that every one who seeks to cultivate for himself the faculty of automatic writing or automatic speaking, either when in a semi-trance or during waking life, opens the way to a splitting — dissociation — of personality that may have a very serious bearing on future mental health. As already noted, it sometimes happens that a shock, physical or mental, wiU readjust things so that the " split " no longer persists, and the personality remains constant ; but the psychologist of to-day rehes mostly on the effects of persuasion or suggestion to bring about the restoration of balance. Hypnotism has been used with success in a few cases, but the difficulty here is that many persons afflicted by disorders of personality are not amenable to that in- fluence. CHAPTER VII WHAT THEN IS HYSTERIA? The hysterical temperament — Its characteristics — Deficient powers of attention — Morbid emotionalism, — Abnormal suggestibility — The spoiled child — Unhealthy dreaminess — Vain imaginings — "ViTiat is hysteria ? — Discarded \'iews — No physical basis found — Babinski's theory — Auto-suggestion- — Charcot — Janet's hypothesis — The Freudian School — Other theories. TO suffer from hysteria one must in the first place be hysterical ; to be hysterical one must come from a nervous stock, and at the outset of our inquiry it will be as well to note straightway those particular features which obviously, and admittedly, are characteristic of hysterics. These are caprice, emotional instability, poor attentive power, a tendency to dreaminess, and inability to refuse ideas strongly presented to their minds. In other words, the hysterical temperament is characterized by great emotionalism, abnormal suggestibility, and deficient powers of attention. Owing to the latter defect the mind of the hysteric habitually wanders, and a wandering mind invites such abnormal mental phenomena as automatism, visions, day-dreams, and multiple person- ality. How very much these particular mental attri- butes are those of a child ! Do we not see evidences of the ready suggestibility, the quick emotionalism, and the rapid play of thought from one object of interest to another displayed by our little ones every day ? The hysterical mind then may be said to be the child mind, but whereas the latter is responsive to routine processes of education and so has minimized for it the danger for its limitations, the hysteric is not commonly subject to 162 WHAT THEN IS HYSTERIA ? 163 similar beneficial influences and suffers from lack of moral training. Do we not frequently see the child become a hysteric when over-fond but foolish parents, loosening instead of tightening the reins of mental control owing to some noticeable sensitiveness, so develop their spoiled child into one of those young terrors with which doctors are only too well acquainted instead of into a useful member of society ? Time after time the fate of a child — whether it is to become a spoiled and impossible fury or a useful citizen — is governed by a chance combination of circumstances which in these days should never be permitted to arbitrate in such an important matter. Let us now examine the particular men.tal charac- teristics of hysteria in further detail, taking the abnormal emotionalism first of all. How changeable is the mood of the hysterical person — so sensitive as to turn every possible remark into adverse criticism, so morbid as to detect supposed slights in a dozen turns of ordinary conversation. Violent in temper if thwarted, and yet passionate in passing devotion if attracted, the hysteric lives always in a mental maelstrom. Storms, showers, and sunshine pass and repass, ever shaking into greater instabihty a nervous system unfitted at the outset to bear tremors of any kind. To a-ttempt to follow the emotional vagaries of people of this type is a task beyond ordinary powers of observation ; it is difficult enough for the psychological expert to keep touch with a train of thought that is so bewildering in its wanderings and versatile in its expression, but it is quite hopeless for parents, friends, or relatives to essay this task. Do they try to do so they will most certainly add fuel to the flame, and sympathy will often be converted into harsh misunderstanding by the mobile thought of the individual to whom it is addressed. Now as to the absent-mindedness characteristic of hysterical persons. One has not to be long in contact with those of hysterical temperament to note their 164 THE PROBLEM OF NERVOUS BREAKDOWN incapacity for prolonged attention. In conversation or in occupation they cannot keep to the point for long. Their interest wanders along aU sorts of side channels, and it is difficult for them to pursue a sustained line of thought. Watch the hysterical girl as she sits over her book. For quite long periods she reads nothing, the pages may be turned over in a half-hearted way ; more often they are not turned at all. She has wandered off into the land of make-believe and, content with a passing array of satisfying dreams, is lost to the world and its hard ways. To the ordinary individual she is m a day- dream, a brown study, a reverie ; to the psychologist she has let go those reins of conscious control which it should be our proudest attribute to hold, and in so surren- dering her powers of quick judgment lies open to every passing suggestion. To be open to suggestion in this way is to become the victim of nervous manifestations, the dupe of self-deceits, and the prey of the unscrupulous. In such a state of mind the hysteric is quite unable ever to perform that operation of intellectualizing the emotions that is desirable for all who have to take a practical place in daily life. She never inteUectualizes her emotions ; on the contrary, she lets them run riot throughout her responsive body. There ha,ve been times and places where a fascinating personality — and the vagaries of her emotional make-up frequently make the hysteric a fascinating person in certain moods — combined with dreaminess and an oracular manner have made the fortune of hysterical people who have been elevated into the position of pythoness or prophet. Associated with the constant dreaminess goes a sense of dissatisfaction with surroundings. Castles built in the air are only too seldom impotent to keep out " the slings and arrows of outrageous fortune." Most of us are con-- tent to use our dream castles as resting places in which for a short space we can be free from the troubles of this present time. The hysteric wants to bring her dream- WHAT THEN IS HYSTERIA ? 165 land to earth ; she strives to materialize her dreams. Human nature is such that it is quite normal for us in our dreams and reveries to play the part of kings, princes, and governors. Everyone to his bent. The humble writer pictures himself swaying a most powerful pen ; dreams of the day when his next volume will be a " best seller." The struggling artist builds his castle as a studio in which amidst luxurious surroundings he wiU receive the highest in the land. The rising lawyer sees himself in the full bottomed wig and splendid gown of a great judge. The soldier becomes the general ; the sailor treads the quarter-deck in the panoply of the admiral. The keen politician sees himself ushered into his sove- reign's presence to receive from majesty the keys of office. All these things and more, are dreamed by day and by night, but their dreamers come back to earth and take up the stem task of the moment ; to pursue undis- mayed the hard road that alone leads to fame and fortune. All but the castle-builder of hysterical temperament who will not be put off ui this way. She wishes to be a queen for always and not the queen of a day-dream only ; and "in this we find the explanation of those extraordinary aberrations of conduct which not infrequently horrify friends and startle the world. To originate the most fantastic rumour ; to tell the most outrageous lie ; ruthlessly to take away someone else's character ; to steal ; to accuse ; to resort even to self-mutilation ; or to carry out a dramatic act of specious — but never in- tended suicide ; such are the ways in which the hysteric endeavours to transfer the limelight of her dreams to the world's stage. What, then, is hysteria ? Certainly it cannot be said that the conclusions arrived at about hysteria by the medical schools of to-day are satis- factory. A multitude of irreconcilable opinions are held by authorities of equal eminence, and out of the welter of fact and theory comes no clear guiding light. Hysteria remains the great enigma of medicine and psychology ; 166 THE PROBLEM OF NERVOUS BREAKDOWN as always fickle in feature, uncertain in behaviour,, and elusive as to cause. With the exception, indeed, of the countless hysterical disorders that have tem- porarily incapacitated so many soldiers and sailors through war-strain and shell-shock. When thus occa- sioned hysteria certainly seems fairly weU behaved, following certain lines with almost monotonous regu- larity and yielding to treatment so well that the majority recover completely, and it may be confidently antici- pated that the minority will sooner or later follow them to health. The only definite step forward one can take when theorizing about hysteria is to discard some of the old views that clearly were based on misconceptions. There is no object to be served by reviewing those fancies of past days which have been decently buried and may be left to rest with those wiseheads that originated them. The steady procession of discarded medical theories to the graveyard of lost reputations makes one pause to think. To-day the bells sound as cheerfully and the mourners chatter as merrily at these strange funerals as at any time. Still everyone is now agreed that hysteria is not really due to the wandermgs about the body of certain essential organs of procreation ; nor do we any longer believe that hysterical people are possessed of the devil. On the positive side, whilst there are still some who seem to think that one day a primary physical cause will be found at the root of all forms of nervous disorder, including even hysteria ; for the most part there is agreement that this condition is entirely based on disturbances in human mind. On the one hand, the tendency to mind-wandermg — Pleading to certain thought -groups apparently getting out of control, and becoming dissociated — and on the other, the abnormal suggestibility of hysterical people taken m consideration with their excessive emotionalism, form the basis of the most generally accepted modern theories of hysteria. WHAT THEN IS HYSTERIA ? 167 Indeed, that which is most rapidly gaining ground just now is that hysterical symptoms are solely and finally due to passing " suggestions " which have been caught, as it were, and transferred to the realm of action. According to this idea, which has been most diligently fathered by the famous French neurologist, Babinski, hysteria has no identity at all as a disease or nervous disorder ; what we find is the result of particular suggestions, some self- administered by the patient, some coming from friends, or even from the doctor himself ! Followers of Babinski say, in effect, that we are all potential hysterics ; that according to our degree of suggestibility so are we more or less likely one day to show signs of what is known as hysteria ! An American authority amusingly writes that " everyone has hysterical small coin in the bank of his personality." In a word, the suggestion theory says that when a doctor examines a hysterical patient he can find practi- cally whatever he looks for unless he takes the very greatest care not to give any indication of what he is after. Thus, it is said that if one asks the patient, " Do you feel me touch you ? " the question at once acts as a suggestion that one rather expects a negative answer, and, in consequence, the part in question is actually found to be insensitive. This modem school practically holds that Charcot actually manufactured — quite un- knowingly, of course — ^the classical types of hysteria which have become so familiar to us from the experiments and observations under his direction at the Saltpetriere hospital in Paris some few years ago. Of a rather different order, but stUl centred round the characteristic of ex- treme suggestibility, is the theory of Janet, which, up to quite recently, has probably had more modern sup- porters than any other. Janet, another brilliant worker in the French schools, holds that the hysteric is to aU intents and purposes a hypnotized person, in whom particular sets of ideas dominate the field of conscious- 168 THE PROBLEM OF NERVOUS BREAKDOWN nese on their owii account as it were. Certainly such a supposed " dissociation " can readily be invoked to ex- plain many things in hysteria. It is quite true that the hysteric often seems to be playing a part, to have lost normal personality for the time being ; witness the " grand attacks," and more particularly the cases of dual and multiple personality to which reference has been made. Janet started from the observation that hysterical people are not able to take so much in at a time as others ; they are tired in mind and can only grasp a proportion of what is presented to them at any given moment. He evidenced their dreaminess, and poverty of attentive power in support of this. Under these cixcTunstances the supposition is that the hysteric attends to what she can and lets the rest go. Conse- quently, she commonly exhibits such signs as diminished sensibiHty of the skin, contraction of the field of vision, and so forth. In the realm of ideas this same contraction of consciousness operates so that she neglects some things altogether. But so weak is her general thought - control that such neglected thought-groups — ^perhaps suggested from without — actually make a centre of their own and manifest as secondary phenomena. In this way a secondary personality may be built up which at times dominates and excludes the normal personality so that a new individual seems to appear. Thus we get the remarkable phenomenon of two lives lived alterna- tively, to which attention has already been called. In a word, the hysteric varies from the normal to the extent to which she is dominated by some hypnotizing idea. Janet holds that the hypnotic state and the hysterical state are the same thing. To free the hysteric one must, there- fore — ^according to the schools of both Babinski and Janet — ^free her from the false beliefs which have forced their way between her and the truth of things. Of recent years the school of Freudians has tried to take us back to the old sex-theory. Extraordinary WHAT THEN IS HYSTERIA ? 169 as was the ancient sex view that held hysteria to be due to wanderings of the womb it was scarcely as remarkable as its modem representative which finds sex in every thought, and sex in every action. Awake or asleep, the Freudians haunt us with sex. Our conscious lives are but the results of endless struggles with sex- instincts ; our conscious thoughts but the bubble and froth of cauldrons of iniquity. That emotions based on sex matters disturb all human beings and make some ill is a truism. But that aU nervous troubles — ^hysteria amongst them — have a sex basis is an extreme view. Put briefly, the theory of Freud and his school is that ideas of a sexual order, offensive to the better feelings of the individual, arise and are sternly repressed. Sub- sequently they act as a focus of irritation in subconsci- ousness and give rise to nervous troubles. The man who loves and is unable to achieve the object of his desires represses his passion, and then lives over a volcano as it were. Other conditions favouring it, one day an erup- tion will occur ; some day an explosion may shake the very foundations of his reason. There is a good deal in this, of course, but whilst it may be an explanation of particular cases it can be by no means applied in general. The exponents of psycho-analysis, which pro- fesses to cure the disease by getting rid of the morbid focus of thought, have managed to attract a good deal of attention, but it is likely that the high-watermark of their popularity was reached some time since, and that the tide of favour wiU now recede more and more rapidly. Nevertheless, it leaves behind a monument of literature, often hysterical in more senses than one, which will attract the degenerate by its obscenity long after the psychologist has turned his back on it. There is yet another of the many views of hysteria which may be mentioned in passing, the theory that the hysterical mind is always the child-mind, and that where the individual does not mentally grow-up as it were, his or 170 THE PROBLEM OF NERVOUS BREAKDOWN her reactions to Burroundings become those that we call hysterical. This theory ascribes hysteria to " the per- sistence in adult life of the childish type of reaction to the facts of life. It is a mode of reaction in persons of naive, simple and elementary mentality. It is a men- tality lacking in development and defective in judgment and critique. Such mentalities, when placed in new environments to which they cannot adapt, or adapt with difficulty, develop the hysterical reaction. They go back to primitive methods of escaping difficulties." ^ The fact is the truth is not yet known about this pecu- liar variety of nervous breakdown. It is easy to theorize glibly in psychological terms, but we want a clearer understanding of what we mean by mind, for example, before we can solve these problems of causation satis- factorily. To the author hysteria seems but a particular group of ailments due to the blmTing of true appre- hension of things as they are by that false mind which seems continually to be interfering in human affairs , From what we vaguely call subconsciousness there come to bother us all sorts of false beliefs, and many of these become so impressed on the system that ill-health results. The key to the problem must be sought in the evolution and foundation of human mind. For the present we must see through the mists just as far as we can, being thank- ful, indeed, that modern investigations have certainly enabled us to cope more satisfactorily and certainly with hysterical troubles than ever before. After all, to cure without knowing why is perhaps better than to know why without curing. 1 Osier's System oj Medicine ; art. " Hysteria." PART III THE HYGIENE OF NERVE CHAPTER I REDEESSING THE BALANCE Prevention of nervous breakdown — A special problem of hygiene — Not a question of destroying germs — Modem requirements for treat- ment — Difficulties of family practitioner — So-called nerve tonics — Principles of physical treatment — Electrical methods — Massage — The sick soul — Morbid introspection — Suggestion of right ideas — Other methods of treatment through mind — Functional and organic diseases — The search for a reliable principle of mind treatment — Prayer. THE national importance of nervous breakdown, as with all other prevalent forms of Ul-health, lies in the steady drain of energy which it occasions. But whereas in the case of germ-borne diseases and infec- tions^tuberculosis, small-pox and typhoid fever, for example — ^the solution of the problem rests mainly in methods of destroying the microbes as well as their habitat, and of preventing those not destroyed from spreading amongst human beings, with nervous break- down the matter is more complicated from the fact that we have neither a definite disease nor a specific bacillus causing it. Indeed, we have an entirely different set of circumstances, for, as our study of the origin and mani- festation of the psycho-neuroses has shown us, we have in them to deal with disorder affecting an association of delicate nerve -structures with over-sensitive mental make-up. Moreover, as a weakness of brain cells and a tendency to mental discord can actually become an inherent family failing, the quickest way of strengthening national nerve is to be found not in rooting out some morbid fungus, but in building up the weakly on the one hand, and on the other, in strengthening impoverished 173 174 THE PROBLEM OF NERVOUS BREAKDOWN stocks by the infusion of fresh vitality wherever possible. The latter is an object that can only be secured when heart and head agree as to the desirability of an alliance between a man and a woman. Certainly it does seem that Nature herself attempts this feat of strengthening stock often enough when she brings about a mysterious affinity between two young people whose friends cannot make out what they "see in each other." Not always do " affinities " make for health and happiness, but, as we have noted once before, the heart has many reasons that reason never knows, and sometimes it seems as if heart instinctively pointed in the right direction for the better- ment of a family stock when the head has been unable to see the way so quickly. A satisfactory solution of our problem lies then in taking the requisite means to reduce, generation by generation, racial Hability to nervous and mental unfitness. The goal is one worthy of much striving and special State help to reach it. Certain it is that every nation that deliberately sets out to conserve and improve the nerve energies — and therefore the nerve — of its sons and daughters is going to score in a thousand ways over those that neglect this question. Ca,re of body and hygiene of mind are the twin foundation-stones of that department of nerve, which, however described, must be an important element in the looked-for Ministry of Health. Priest and physician ; pa.rent and school- master ; press and people, are all closely concerned with its success. As we have seen, it is the strain of mind, the waves of anger, fear, the storms of passion as weU as the insidious cankers of doubt, jealousy, envy and their feUow sprites that swing over the scales from nerve-health to neurosis ; whilst a delicate physical basis handicaps the nervous system in resisting the effects of these storms and bHghts. Restoration of health from nervous breakdown is an aSair of both mind and matter, physical measures, indeed, being directly related to certain definite physical REDRESSING THE BALANCE 175 needs, but our difficulty in restoring peace to the troubled system is not found so much in regard to securing greater strength of nerve-cells as in comforting the tortured soul and banishing the morbid thought. How best we can overcome the combined disability of body and mind and so redress the balance may well be our next consideration. At the outset it should be recognized that the modern requirements of treatment in nervous disorders make exceptionally difficult the task of a doctor called in to deal with them. In the first place, he frequently finds himself handicapped by want of equipment and time to deal with the illness as he would Uke to. Thus on the physical side alone the modern treatment of nervous disorders often demands special apparatus — chiefly electrical — a,nd what is more difficult to obtain, experience in using it ; whilst, again, from the mental point of view the practitioner is often handicapped through want of facili- ties for becoming acquainted with psychological methods. It is owing to this that attempts are often made to carry the patient through with drugs. However, with an ill- ness which exhibits so surprising a range of symptoms tbe doctor finds it no easy task to select suitable prepara- tions out of our voluminous pharmacopoeia. Often enough the attempt to cure nervous breakdown by drugs results in something like a return to the medical blunder- bus of our ancestors, although the mixtures of to-day no longer contain powdered stones, crushed toads, dried blood, curious herbs, and other extraordinary things such as were once poured down patients' throats. A prescription of proved efficacy for the relief of particu- larly urgent symptoms is justifiable, but it is a thousand pities that a medical man should ever waste energy on the compounding of comphcated concoctions for a "shot in the dark," when all the time he has within his own personality means more helpful in treating nervous maladies than all the chemicals m the druggist's store. 176 THE PROBLEM OF NERVOUS BREAKDOWN It is true that inasmuch as the nervous system is in a highly sensitive condition the sedative effects of bromide are frequently very useful in lessening some of the most disturbing symptoms and sensations during such time as the sufferer is able to make a start on the road to recovery. But bromides are by no means to be regarded as curative. So-called " nerve tonics " are for the most part a snare and a delusion ; phosphorus, strych- nine, valerian, arsenic, and many another find advocates who extol their wonderful capacities for strengthening the nervous system ; but no proof has ever been adduced that these things have any specific. action in nervous and mental disabihties. It is related that a child once wisely asked how can one put medicine on a thought ! The truth of the ma.tter is that anything that will improve general health reacts favourably on the nervous system. Iron and arsenic ; quinine, phosphorus and strychnine ; as weU as many another medicament have general tonic properties, and therefore can often be made to play a part when one frames a general attack upon neurasthenia. To rely on either, or aU, as " cures " is to rely on a broken reed. Occasionally one of the common tonics will aet with almost magical efficacy in improving health in a few individual cases. Where this is so let every advan- tage be taken of the happy fact. Certainly of all tonic remedies iron is the most reliable ; whilst improving the blood, it helps to restore the nerve system to a healthier state. Still, there yet remains to be discovered an elixir that will restore the tissues of the flagging brain, and build up those minute corpuscles — ^the so-called " Nissl's granules" — normally present within healthy nerve-cells, which have been found to break up or disappear coincidentaUy with profound exhaustion. It is well that these things should be understood, for one finds numbers of neurasthenic people persistently taking " nerve tonics," hoping against hope that sooner or later permanent benefit wiU be derived from REDRESSING THE BALANCE 177 them. Let them look upon sedatives and nerve tonics as useful temporary remedies, helpful in tiding over a diffi- cult passage, but by no means able to get at the root of their troubles, then they will be in a far better position to carry out a successful offensive against their illness. People who rely too much on medicines find the day comes when the sickness borne of deferred hope further adds to their load. They begin to think their plight hopeless, to believe that health is irretrievably lost ; energy gone for ever, and mental comfort no longer possible ; this is to initiate a process of morbid self-suggestion leading directly to that state of chronic invalidism which is the sad lot of many who, properly piloted, might long ago have reached a haven of health. There are many ways in which physical means can be used for the assistance of some neurasthenics, and often of nervous people suffering from serious but ill-defined states threatening their mental well-being. But for the majority of functional conditions treatment through mind is everything, and time after time when one comes to analyse an alleged cure through matter it is found that " suggestion " has been strongly at work through the very physical medium which is being ex- tolled. Particularly is this the case when hysteria yields to electricity. The comparative results lately obtained by various workers in the military hospitals show that with the right mental attitude on the part of the doctor the cure of many war-neuroses can be just as quickly brought about through mind alone as through mind plus some material infiuence brought in as a persuasive instru- ment. If we honestly believe that a mind cure is indi- cated then let us decide to carry it out honestly, and not shirk the main issue or trick the sufferer by saying that electricity, massage or a lotion is the curative agent. So to do is really only curing one false conception by another. To review the physical measures that can be used to 178 THE PROBLEM OF NERVOUS BREAKDOWN assist recovery in the psycho-neuroses would be to con- sider the whole range of modern medical and surgical procedures. Drugs, operations, injections, vaccines — all these things find a useful place at one time and another. The point being that anything that will improve physical health in general wiU help recovery ; particularly when in neurasthenia physical disabilities figure prominently. But there is no specific drug, injection, vaccine, or opera- tion that will certainly help the neurasthenic or the hysteric. On the other hand, there are two modes of physical treatment more constantly helpful than any others in restoring nerve-tone and reinvigorating an exhausted nervous system from the material side. One is electricity ; the other is massage, which wiU be referred to again when considering the " rest-cure," in the routine of which it finds its most useful place. Electricity is the agent which in our experience most closely 8.pproaches our conception of life-force itself. Invisible and intangible, known only by its results, and demonstrable solely by the wonderful things it does, electricity seems the main-spring of aU hving processes, and, moreover, according to modern investigations is possibly the foundation of matter itself. This is no place for speculation on the fascinating problems of electricity ; let it suffice to say that it has been shown to have very close relations with everything that goes on in the human body, and is to-da,y considered by various able investigators to have close affinities with that equally subtle influence which we speak of as nerve-force or nerve-energy. Living tissues in all directions have been shown particularly susceptible to this influence, being strengthened under some conditions and weakened under others. Under the influence of electrified atmo- spheres plants have been shown to grow with greater vigour, whilst their seeds have under the same exposure developed exceptional vitality. Again, sensitive galvano- meters attest the currents generated in human organs REDRESSING THE BALANCE 179 during their activities. Thus it is accepted to-day as quite certain that action of brain-cells and nerve -cells generally is accompanied by electrical disturbances. Hence, it is not surprising that amongst physical means helpful in the treatment of neurasthenic and other nervous states electricity must be highly esteemed. In its range of possibilities and general effects the electri- cal current opens numerous roads through which we can pour fresh energy into the devitahzed nervous system ; whilst at the same time it enables us to soothe or stimu- late special areas with ease. In spite of this, however, the uses of electricity in the treatment of nervous mala- dies remain much misunderstood. It is by no means uncommon to hear people seeking help say " We have tried electricity " ; nor is it rare to hear from doctors that they have failed to give help by electrical methods. Electricity is no panacea in neurasthenia, but is, nevertheless, very helpful in treatment. Success in the use of electricity can only come through a grasp of the wide scope of its employment ; misconception of the prin- ciples on which its use in nervous disorders should be based leads to a foolish and unscientific handling of apparatus. Curiously enough, one sometimes finds ignorant exercise of electrical methods by some who think this a legitimate method of mental treatment ; their intention being to convey a suggestion of some- thing being done, and so to produce a health-giving impression. Such methods offend against a funda- mental rule, for mental treatment should be based on truth and not on falsehood, and the less false sugges- iiions are reHed upon to help one's feUows the better for all concerned. Electrical applications to be helpful should be pre- scribed with due regard to several important points, including particularly the special form to be used, the quantity to be given, and the length of time for which the treatment is to continue. There are other considera- 180 THE PROBLEM OF NERVOUS BREAKDOWN tions, such as the number of treatments to be given a week, the hour of their administration, and the relation that electricity is to bear to the rest of the remedial campaign. Scientific apparatus gives ample means of measuring the dosage in those forms where accurate measurement is essential, whilst experience of one's instruments enables one to make a suitable calcula- tion where instrumental estimation is not available. Scientific use of electrical methods has been greatly developed by war-time requirements, and many doctors who have had experience of work with the Army will take back into private practice a much greater apprecia- tion of this powerful agent for treatment than they would otherwise have achieved. Detailed discussion of the merits and technique of the different ways of ad- ministering electricity is beyond the scope of this book, but a general knowledge of the chief principles to be observed in its administration is nowadays of public importance. It is highly desirable that people should be able to protect themselves from the false claims and dangerous service of ignorant pretenders. Holes burnt in a man's arm by the careless handling of a well-meaning individual who thought he knew " all about electricity," for example, help to convince one that the medical pro- fession has a duty to perform in educating the public as to the potentialities and common use of electricity in healing. Such an instance of misguided zeal and ignorant technique comes to mind. It is to be noted that one meets with the greatest divergency of opinion about electricity as a remedy for nervous disorders. Some neurologists appear to pass through three phases of experience. At first sceptical, they subsequently become impressed by electro-thera- peutic results and for a period place considerable rehance on electrical methods. Finally, they come to realize how difficult it is to estimate how much of the benefit is obtained from the current itself and how much is reaUy REDRESSING THE BALANCE due to the psychological influence of those carrying out the treatment. My own view is that electricity is an extremely useful secondary agent, having both tonic and sedative properties according to the method of application, but that its accomplishments are poor where the psychological factor is neglected. Medicines, electricity, massage, with, of course, rest and good food, offer ample means of building up a depleted nervous system. But success in treatment depends on the fulfilment of three other conditions also. These are that physical drains and strains shall be checked ; that stresses acting through the feeUngs shall be ehminated ; that a general adjustment of thought and mental outlook shaU take place. Just as assisting from the physical side means making use of the routine measures of medical practice, as already noted, so the checking of physical disorders bearing hardly on the brain and other nerve-centres belongs to the daily pro- gramme of the family doctor. In so far as it is desirable to discuss this side of the question in the present volume these matters wiU be referred to when dealing with the •" rest-cure " where they have not already been touched upon. It is the psychological task to be accomplished in restoring harmony to a shaken system that offers the most difficulties, and is withal the essential part of the plan of treatment in most instances. Always in ill- health the individual is to be considered as well as his malady ; in a nervous breakdown the individual com- monly requires more attention than his illness. William James used to discuss at length and in his own enchanting way, the psychology of the " sick soul." It is a fact that the victims of nervous breakdown are, either tempera- mentally or for the time being, sick souls. They see things through a glass darkly, A fog of jaundiced thought seems to come between them and happiness of outlook. Of two things one ; and that the negative for the neurasthenic as a rule, and for the hysteric often. 182 THE PROBLEM OF NERVOUS BREAKDOWN The surest foundation of mental health is faith in things unseen — ^the sense that God is in His Heaven and all's right with the world no matter what appear- ances may be. Most emphatically it is this sense of the essential " all-rightness " of things that the neuras- thenic lacks. Many are like this from earliest years. To attain health of mind means for them nothing less than a new birth ; these are they to whom " conversion " or sudden realization of things spiritual brings with it a new lease of life in which for the first time happiness is genuinely present. Others fail in later life, losing the optimism and mental comfort they have hitherto known. Born into the grace of health they forfeit their birth- right, sometimes sacrificing it to pagan gods. The inherently sick in soul are those of the morbid nervous temperament. As we have seen, nervousness, as a temperamental characteristic may serve to liven up an otherwise dull person ; it may add zest and sparkle to life ; it may, indeed, supply just that element which makes for fame and fortune in many walks of fife. To be nervous is not necessarily to be morbid, but it is true that in many the nervous temperament has an unhealthy tendency, and it is these who are the confirmed worriers, wrong- thinkers, and anxiety-mongers. They constitute the bulk of the sufferers from constitutional nervous instability. With vision turned in upon themselves they habitually contract their whole lives until within the limits of an ever-narrowing morbid circle they eke out their fear-fraught lives. For such, indeed, health of mind and nerve can come only through a great psychologi- cal upheaval — " conversion " — as a result of which locks are broken, bars are sundered and the whole machinery of life and thought is allowed to run free. Then with quickening pulses and rising health the erst- while prisoner looks out on to the world which he sees with normal vision perhaps for the first time for many years — perhaps for the first time in his life. To gain REDRESSING THE BALANCE 183 an understanding of life, to get feet firmly planted on some sound rock of religion or philosopliy is the essen- tial condition of such a change. Sometimes coming from within — or seemingly as a spiritual message — commonly the process is initiated by the " suggestion " of some new and bond-breaking idea conveyed by book, sermon or talk with a friend. In these days such ideas are now quite often utilised deliberately as a form of treatment. Sometimes they are suggested forcibly and with a take- no-denial manner ; sometimes based on reason ; some- times to assist analysis of the morbid idea until it is proved false ; occasionally on rehgious observance. And so we have the methods of suggestion, hypnotism, persuasion and psycho-analysis used so commonly to- day by medico -psychologists, corresponding to the first three of these forms of attack. Lastly, we have the increasing attempts to find a medium for the healing powers of spirit, and to uplift suffering humanity towards the source of all life, health, and power so that our iUs must -be dispelled like mist before the sun's rays. The merit of this mind-heaHng carried to its highest possible terms is, of course, that it seeks not merely to remove ills and discomforts of nerves and body, but to uplift physi- cally and spiritually the whole individual. As worry, grief, anxiety, fear and mental shock play so conspicuous a part in weakening our " nerves " it follows that if one can obtain the confidence of the sufferer and by judicious and tactful conversation sug- gest ideas which will enable him to overcome his morbid thoughts and feelings one can thus remove causes operat- ing from the mental side. Moreover, from the admitted proof of this the further conclusion is derived that wher- ever a mental cause for ill-health can be diagnosed the rational method of attack must always be through mind. As the operation of psychological factors is most clearly seen, and has been most closely studied, in nervous disorders, mitid-cure must occupy a prominent place in 184 THE PROBLEM OF NERVOUS BREAKDOWN any discussion of the problem of nervous breakdown. In no other form of illness is it so urgent that we — . . . minister to a mind diseased, Pluck from the memory a rooted sorrow, Raze out the written troubles of the brain. And with some sweet oblivious antidote Cleanse the stuff'd bosom of that perilous stuff Which weighs upon the heart ! ^ Indeed, so closely is the scientijfic study and appHcation of treatment through mind bound up with the relief of mental and nervous troubles that it is quite customary to-day to make the success of such treatment diagnostic of the Idnd of malady remedied. A remarkably sharp line is thus quite arbitrarily drawn between the " func- tional " ailments held to be curable by mental thera- peutics and the " organic " diseases supposed to be beyond reach of mind. When it is related that someone suffering from an incapacitating illness of some years' duration has suddenly recovered after prayer, suggestion or other means working in thought, medical orthodoxy at once welcomes the recovery, but says " Oh ! So-and- so's troubles were ' functional ' (or nervous) after all ! " Moreover, in some cases of impaired strength or sensa- tion the effect of " suggestion " is not infrequently relied on to indicate the extent of the damage in brain or spinal cord. If improvement occurs the diagnosis of " functional " is finally made, otherwise the case-sheet is marked " organic." This is without doubt an unscien- tific way of looking at the question. The admitted dis- tinction between " functional " (nervous) and " organic " troubles is that in the latter structural damage is demon- strable, and in the former unrecognizable even by the microscope. Improved methods of microscopic examina- tion are continually revealing fine structural changes previously unknown in obscure diseases, and it is not an unreasonable supposition that such modes of investiga- 1 Macbeth, Act V, So. 3. REDRESSING THE BALANCE 185 tion will probably demonstrate similar departures from healthy state of the tissues in most or all maladies. Judging from the recent results of microscopic inquiry one may suppose that every condition of illness, " functional " or " organic " — ^including nervous break- down in all its varied forms — is accompanied i^by abnormal states of nerve-cells and nerve fibres in the brain or elsewhere. This is, of course, the position of the materialistic school as to the physical bases of disease, and one may readily admit it. And to do so really widens rather than narrows the possible scope of treatment through mind from the scientific point of view. Assum- ing that neurasthenia, hysteria, and other functional disorders are associated with structural damage — some injury in the tiny cells of the brain or other nerve-centres let us suppose — ^then, in the light of admitted successes of mind treatment, does not this very circumstance prove that thought, " suggestion," ideas can and do actually react on the tissues of the nervous system ? And if directly on the nervous system, why not directly or indirectly on other organs ? Even now we have cases where the disorder is such that it is difficult enough to say whether the trouble is due to disseminated patches of degeneration in the spinal cord — a definite enough " organic " condition if present — or whether it is due to hysteria — ^the very type of a purely " functional " ail- ment. To say that if in such a case cure follows " sug- gestion " it must be the latter, and if not the former, is an unsound method of reasoning. The quest for a reliable principle of mental heaKng has been persistently pursued for at least three thousand years, and probably from much earlier days of human endeavour. At all times mankind seems to have ex- hibited two intellectual types ; one tending to a material- istic outlook, and the other to a spiritual view of things as they are. It is the latter who have maintained the active pursuit of our finest powers and whose burning 186 THE PROBLEM OF NERVOUS BREAKDOWN enthusiasm has kept alight the fires of faith in the spirit and its works, even during the darkest ages of thought. With regard to the problem of treatment it appears that at no time during recorded history was loiowledge of healing through mind ever entirely lost ; on the contrary, there are many records of its practice under various forms in many countries. There were healing rites in ancient Egypt ; and in the great days of Greece sumptuous temples of healing received count- less thousands of the sick who rested under the supposed influence of the gods until restored in health. The prophet healers of Israel had no doubt of the powers of spirit in this direction. The Bible is, indeed, a wonderful chronicle of miracles of healing. And it is interesting to note that from the most ancient times down to the present day there has been a tendency for the methods used to evolve from the grossest rites of superstition to an increasing realization of spiritual power as an expres- sion of a divine principle of love. At first centred round the invocation of helpful gods to exorcise and destroy evil demons, a process assisted by an elaborate ceremonial ; later regarded as the flowing out of a healing fluid from one to another, particularly under the blessing of a beneficent deity ; ultimately conceived as the work- ings of pure spirit in matter, this evolutionary process has left its traces in various practices of healing to-day. For those who have followed the upward path super- stition has given way to sublime faith ; magic has yielded to mysticism. The seal was set on this understanding of spiritual power when in his healings Jesus rebuked the superstitious " casters out of devils," and showed that all healing is really of God and that in healing as in aU else we have not to rely on magical placations of evil spirits, but on faith in that God who is Spirit, and is Love. Thus it is to-day that the study of treatment through mind must embrace a wide range of practices, and in regard to its special application to the alleviation of REDRESSING THE BALANCE 187 nervous disorders must not only take into account the suggestive therapeutics, the medical hypnotism, and the psycho-analyses of orthodox psychology, but go farther and attempt to understand how and on what basis prayer and appeals to the highest spiritual instincts of mankind have curative value. CHAPTER II THE REST CURE {A) General Principles Natiiral recuperative forces — The great vis medicatrix naturae — Medieval evil and modern medicine contrasted — The principle of rest— Weir Mitchell's rest-cure — Modem modifications — Planning a rest cure — Attitude of invalid — Duration — Place of treatraent — Home or institution — Nursing — Qualifications of the nerve nurse — General surroundings. THE knowledge that there are forces within us con- stantly striving to renew worn-out tissues, to build up broken down organs, to combat germs and to restore lost nerve-energy, is a paramount influence in all branches of treatment to-day. It is one of the great concepts of modern science. In old times an invalid's main support was found in a pill, plaster, or potion. Surgical operation was a thing of horror only to be faced under circumstances of extreme need. lUnesses were considered to be of various specific kinds, curable only when the correspond- ing specific remedy could be exhibited. An important part of the medical student's education was understood to be the steady pursuit of specific antidotes ; and people had little doubt that one doctor was more skilled than another because his memory contained a longer list of suitable cures. The idea that Nature is always doing her best to help a sick person, and that the doctor could do some of his best work by assisting Nature, at last came to irradiate many dark places. Certainly the great truth had been dimly perceived during the ages by a few masters of medicine. Thus several hundred years ago 188 THE REST CURE 189 the great French surgeon, Ambrois Pare, exclaimed on a stricken battlefield, " I dress the sufferer ; God heals him," a sentiment that cuiiously enough was, cen- turies later, expressed in keen-edged irony by another great Frenchman, MoHere, who remarked that the physician amused the invalid whilst God healed him. But it was long before this great truth became plain to the majority. Nowadays recognition of the great natural heahng forces working in each one of us — ^the great vis medicatrix naturae — points the way for us ; we now know that much of the doctor's work should be strenuous endea- vour to remove obstructions to Natm-e's healing balm. In many illnesses the physician, who not so very many years ago would have put his patient through a terrible ordeal of drugs, blisters and bleeding, is now content to pursue what has been called a policy of masterly in- activity. He watches beside the sick man's bed, waiting for an opportunity to guide the inherent life-forces ; to assist a flagging organ here, to relieve a tired system there ; using his drugs as useful aids in his work and not placing sole reliance upon them as infallible remedies. When breakdown threatens any part of the human machine the best way to give Nature an opportunity of exercising her wonderful powers to the utmost is by taking some of the load of daily work off the strained chains and cogs. In a word, rest of overburdened organs must be a leading principle of treatment. When one has to deal with an organism so closely bound up with the activities of the body as the nervous system, the appHcation of rest necessarily includes a pro- gramme of diminished work for both body and mind ; and it has been the recognition of this that has led to the advocacy of the " rest-cure " as a means of restoring health in nervous debility. As originally carried out under the auspices of its most celebrated exponent, the late Dr. Weir Mitchell, an American savant, the rest-cure was chiefly intended to enable the body to make physical 190 THE PROBLEM OF XERVOUS BREAKDOWN leeway. NeuraBtlieiiia. for example, was regarded primarily as an exhaustion of nervous tissues, and an endeaTour made to restore from the physical side the lost energies, to rest the body by committing it to bed for a long time, to reduce brain activity to a minimum by shutting off all business and private worries : to get rid of even the little strain put on the nerves by letters from or intercourse with, friends : and to build up the physical system by supplying it to repletion with rich, digestible food — such were the essential principles of what has come to be known as the Weir Mtchell treatment. In this regime the disadvantages of too much bodily inactivity were fully recognized, and massage was ordered as a means of keeping the muscles of the body and Hmbs in a state of proper tonicity. It was realized that when people lie in bed their muscles become flabby, whilst the want of movement favoured sluggishness of the circulation. The invalid was massaored dailv to obviate these disadvantages. The full Weir ]\IitcheU rest-cure is by no means as popular to-day as it was a few years ago. Under some practitioners it always gives excellent results : by many others it has not been found very successful. Where it fails, failure is invariably due to the one weak point in the method. The fact is that the Weir Mitchell rest cure depends for its success upon the degree to which the mental factor is taken into consideration. In the hands of its originator and his immediate disciples, the im- portance of support through mind was fully recognized ; the isolation insisted upon, and the regular visits from the physician whose duty was understood to consist partly of encouraging the invahd, aU implied that sug- gestion and persuasion were to be used as a matter of routine. On the other hand, those who have merely copied the mechanical details have never found its results as satisfactory or as lasting as those who have realized that, to be complete, Weu' ]\Iitchell's methods include psychological as well as physical treatment. THE REST CURE 191 Where one finds a practitioner using the plan with constant success there one as certainly finds a doctor who reaKzes that his patients have souls as well as bodies. A rest-cure to-day commonly takes note of the require- ments indicated above, but is less strict in regard to isolation, to the drinking of large quantities of milk, and long apphcations of massage. Details vary a good deal in individual hands, according to the point of view of the practitioner. Some lay more stress on the physical than on the mental features of the treatment ; whilst others take the opposite view. Then, again, the part to be played by such methods as electrical applications, vac- cines and so forth, also influences the routine in individual cases. The most important point to be appreciated is that whilst there is little difiiculty about resting a tired body, and little trouble in feeding up an invalid so that weight is put on, it is by no means as easy to eradicate the de- pression and morbid thoughts usually associated with the physical symptoms in nervous breakdown. Time after time one sees people who have been through a " suc- cessful " rest-cure, looking fat and well, sleeping properly, and apparently restored to health, but who, nevertheless, within a short time rapidly lose weight and quickly sink into the depths once more. Apart from the fact that there are many active-minded persons to whom the mechanical routine of a rest-cure in which the mental factor is ignored is extremely irritating, the omission of measures intended to restore the invalid's confidence in himself and to give him a bright outlook is almost certain to bring about ultima.te failure. Let us now study the requirements of a m^odern rest-cure designed to restore the victim of " nerves " to a really satisfactory state of health. When advice has been given that someone is to under- go a rest-cure three very important things have to be settled at once. In the first place, one wants to know if 192 THE PROBLEM OF NERVOUS BREAKDOWN the invalid is really willing ; for it is always unsatisfactory to treat those who are averse from the particular method of giving assistance that is suggested. All the more so when it is a matter of lengthy and somewhat tiresome routine the hearty co-operation of the patient is all the more essential to success. Those who definitely protest and only agree to rest whilst so protesting had much better be either left to work out their own salvation in their own way, or invited to co-operate on other lines. Those who say, " I am not very hopeful, and don't think anything can cure me," but will willingly and obediently carry out the programme advised, take up a not entirely unreasonable attitude, and are usually found to co-operate more and more heartily as time goes on. The invalids who say, "We will willingly do our best to help you to help us," and will look forward and upward to health and success, make the best patients. The second thing to be decided is the minimum length of time to be given up to the treatment. Various circum- stances influence this decision. Where there is great debility the question has to be decided solely on grounds of the health interest of the patient, but in many less severe cases interests and occupations, matters of ex- pense, family duties, and so forth, all have to be con- sidered. Unfortunately, there is always a risk that, in trying to save the invalid expense, the physician may err in advising too short a time for the " cure," which then fails. People forget that when their nervous systems have been losing strength for perhaps two or three years, it is unreasonable to expect health and tone to be restored within a month or six weeks. Sometimes a great deal can be done within a month ; more often six weeks is a minimum and three months desirable. It all depends on individual conditions, but on an average three months rather than one is necessary to achieve a really happy ending to the illness. Relatives should be careful not to THE REST CURE i - embarrass the doctor by an endeavour to persuade bim to reduce the time he has advised, remembering that if they persuade him against his better judg- ment the result will probably be unfortunate for everyone concerned. Time is a great factor in the treatment of all mental and nervous troubles. The exhausted brain-cells require not only rest to enable natural recuperative forces to restore them, but time for the healing action to proceed in full, and time for the tormented mind to replace its depressing thoughts by healthy and cheerful ideas. Moreover, when the task has been accomplished a little extra time enables the good work to be consolidated on a sound foundation of mental health and physical well-being. The third point that has to be discussed and decided upon is place. Where is the invalid to undergo treatment ? The choice of place is, after all, limited. There is the patient's own home, a nursing home or allied institution, rooms in an hotel, or the hospitality of some sympa- thetic friend. But the point must not be overlooked that the decision as to where the cure shall be carried out must be influenced by the question of nursing. Someone has to look after the invalid systematically. Nothing will avail if personal attention be haphazard and in- different ; nothing can be more unsatisfactory than for the care of a neurasthenic individual to be irregularly shared by a number of friends or relatives, however kind they may be. On the contrary, it is essential that one particular person, chosen for special personal qualities and abilities, shall be responsible for the nursing and every- thing incidental thereto, and it is rare for the right quali- ties for the particular patient to be found in his or her immediate circle. The very anxiety of near and dear ones to help hinders the carrying out of their good intentions ; too strong a personal interest in the sufferer tends to make their conduct of the case unsatisfactory. Our previous observations about emotional feeling and judg- 194 THE PROBLEM OF NERVOUS BREAKDOWN ment again apply here.^ Many reasons occur why one might have thought that this would not be so, but the hard facts of experience show that kindly rela^tives and friends make the worst nurses, in average circum-stances, for those dear to them. Of course, we all know of brilliant exceptions by which this harsh rule is lovingly proved, and when the experienced physician has reason for believing that some devoted friend ca.n safely be entrusted with the difficult task of restor- ing his patient to health, he will wisely act in accor- dance with his observations ; but it remains an axiom that a stranger is to be responsible for the nursing, and the services of a trained nurse must, therefore, be obtained. Again, what has been said about help from relatives during treatment equally applies to one's experience as to the effects of home surroundings. People suffering from nervous disorders certainly do not get on so quickly in their own homes as they do elsewhere. Exceptions admitted, this is a serious consideration. In practice it amounts to this, that it is in the best interest of the in- vahd that he makes up his mind to part from family conditions for the time being and undergo treatment away from home. If away from home, and in charge of a nurse, it is difficult to find anything better than a good nursing home or special home for nervous troubles. Very often, of course, the question of expense has to be closely considered, but on this point there is little to be said in favour of rooms in a private house or hotel. In convalescence it is sometimes advantageous for the invahd to go away under such conditions, but during the early part of the rest-cure routine it is very unsatisfac- tory for patient and nurse to be boxed up in limited accommodation day after day. Then, again, in a proper home there is a certain amount of beneficial change in 1 Cf. Part I, chap, ii, THE REST CURE 195 regard to nursing ; when the special nurse goes off duty some other trained person takes her place, and thus the danger of harm being done through the good in- tentions of a kindly visitor who may be called in to help is obviated. But let it be particularly noted that the home chosen must be up-to-date in its equipment, and managed in a thoroughly efficient way. Much as one may sympathize with the directors of nursing homes who endeavour to accommodate invalids inexpensively, one cannot overlook the fact that to administer an in- valid institution in a fu-st -class manner is an expensive matter ; therefore people must not expect to get efficient nursing, dieting and attention unless they are prepared to meet a heavy biU. Disappointing as frequently are the results of treatment carried out at home, neverthe- less, where expense is a difficulty, it is better to secure the services of a good nurse, and make the best of things, than to seek the indifferent assistance of an inefficient home. Sometimes a friend will come to the rescue and accommodate nurse and patient, but in any case it is very necessary that the place chosen shall, if possible, be acces- sible to the doctor supervising the treatment. If things cannot be arranged so that the physician who has advised the rest-cure can see that it is carried out properly, then he should arrange that some other practitioner who can visit the invalid regularly is deputed to take charge. It is most helpful to the invalid to know that professional help is always at hand should it be needed urgently. Confidence is strained if the doctor supervising the treat- ment is not readily accessible. Having considered the question of locality, let us now see wha,t cii'cumstances have to be considered in securmg the services of a reliable nurse. At once let it be said that the nursing of neurasthenic or mentally disturbed patients calls for so much special experience that it is fair neither to nurse nor to patient to employ anyone who has not taken charge of similar cases before. In nursing, as in other pro- 196 THE PROBLEM OF NERVOUS BREAKDOWN fessions, individual workers follow out their own special tendencies. It has to be remembered that the nursing of nervous people calls for considerable self-confidence, tact and persuasiveness. There are many difficult passages to be negotiated, many little irritations that will want soothing down. The morbid mental outlook has to be met with just the right amount of sympathy. Fear has to be overcome, anxious relatives must be dealt with kindly but firmly. The doctor only sees the patient for relatively a very short time ; the nurse is there practi- cally all the time, not only helping the patient with troublesome symptoms, but also superintending special treatments, such as massage and electricity. Then, again, the nurse has the responsibility of seeing that sufficient rest and sleep are obtained ; she has to report accurately as to the amount and kind of sleep that is being secured ; also as to the effects of any sedatives that may be given. Thus, whilst her personality and strength of mind are two great assets, nevertheless it is not for her to overawe her tired and distressed charge, nor to exert and control by sheer force of human will. Strength has to be coaxed back and health demons- trated ; thought has to be led into right channels, and not forced willy-nilly. Naturally, the factor of suggestion is as helpful to the nurse as to the doctor, but it should^ be the suggestion of restfulness and confidence conveyed by her general mental atmosphere. She must calm by her tranquillity, brighten by her cheerfulness and win confidence by straight dealing. The happy medium of just enough sympathy associated with the right manifestation of authority is necessary. As any illness may so react as to produce a neurasthenic condition, it follows that every trained nurse should know how to deal with nervous disorders. Whatever the nature of the case to which she is called " nerves " may be found to figure prominently. It is because nurses so often find themselves at a loss when confronted by THE REST CURE 197 neurasthenia that one sometimes hears of patients criticising them adversely. The invalid instinctively feels that however excellent the nurse's attention may be in regard to material routine, she has failed to grasp his difficulties in the ultimate field of mind. It sometimes happens that a nurse successfully looks after an operation case, and, although the technical details of surgical nursing are efficiently carried out, yet the patient does not seem to make progress satisfactorily. Then perhaps a more understanding, although less highly trained, attendant takes charge of the case, and rapid progress is at once made. Nm^ses should be careful to study sick persons not only as cases but as human beings. Sick people are not machines to be cared for without thought of their anxieties and mental difficulties. Patients frequently ask for a nurse who will under- stand them, meaning thereby not merely that she should be proficient in technical nursing, but that she should have a sympathetic comprehension of their tempera- ment and feehngs. The very thorough training which invalid nurses undergo to-day, excellent as it is in many special branches, would nevertheless be greatly improved if more special attention were given to instruction as to the functions and common vagaries of the mind and nervous system. By no means is it suggested that exact- ing patients should have things all their own way on the ground that their sensitive feelings must be respected. Selfish people who think only of themselves and make no attempt to help the doctor or nurse should be dealt with firmly. But, on the other hand, the nurse who knows iter work can well afford to modify the details of strict routine to suit her charge, where there are nervous diffi- culties existing. To give way a little in the matter of arrangement of bed and furniture, as also in regard to the general regime of the sick room, may be a gTeat source of comfort to the invahd and not in the least interfere with essentials. The nurse may maintain her authority weU, 198 THE PROBLEM OF NERVOUS BREAKDOWN letting the sufferer see she thoroughly understands his point of view. If anything has to be done that is un- pleasant to the invalid, it need not be done roughly, and he may weU be told beforehand what is going to be done, and how it is in his best interests that it should be done. Patients have every reason to complain when they are made uncomfortable for the sake of some routine measure which has no real importance. Apart from the questions of locaUty and nursing, success of the rest-cure depends on the general sur- roundings and daily programme. To-day the physician studies the effects of environment in illness much more closely than formerly, reahzing how important it is that the tired nervous system shall be assisted in attaining renewed activity by just the right kind of impressions from without. He knows that cheerful surroundings and the companionship of bright healthy attendants are essential for the purpose in view. Again, special con- ditions require special modifications of environment. Thus a highly excitable patient requires quiet and sooth- ing surroundings, whilst one suffering from depression is best helped by conditions designed to stimulate the nervous system. In any case, to isolate an invalid in dull and unsympa/thetic surroundings, whilst overwhelming him with milk and slops, is but a poor parody of a cure. An uninteresting routme impresses the sufferer with morbid suggestions and makes for ill-health instead of health. The question of seeing friends during a rest-. cm'e is a matter of some importance. Unfortunately, as already noted, it commonly happens that the mfluence of near friends and relatives is disadvantageous to patients suffering from nem-asthenic conditions. As a matter of experience one finds they are mclined to be pessimistic ; that they are so impressed by the distressing symptoms that theh anxiety is conveyed to the invahd. Thus they continually subject him to bad suggestions, and help him to persuade himself that his case is more serious and com- THE REST CURE 199 plicated than it really is. Certainly nervous breakdown is a serious and comj)licated condition, but it is a com- paratively straightforward malady to those who under- stand it ; there is all the difference betv/een realizing the serious nature of a situation and regarding it as practically beyond hope. The VvT^ong kind of sympathy may prolong a nervous illness for many unnecessary months. Invalids are very sensitive as to what is thought about them, and quickly estimate what those about them really think. Success in treatment so largely depends on the will and determination to get well, that every adverse suggestion must be barred out and every possible source of pessimism ehminated. On the other hand, one sometimes comes across a very careless flippancy that in its way is just as harmful as undue pessimism. It. still sometimes happens that healthy people scornfully express their intolerance of " nerves." To scoff at nervous maladies is merely an expression of ignorance about a matter of urgent pubhc importance. To speak contemptuously of nerves is to insult every man who has suffered sheU-shock dua^ing the great fight for freedom. As to relatives their attitude should be one of watch- ful sympathy. Under the guidance of the physician they should endeavour to support the patient through his trouble whUst they have to look after him. Over- whelming sympathy should be avoided, on the one hand, and, on the other, cruel attempts to laugh him out of his illness are to be deprecated. Recognizing that treatment invariably takes some time, friends should avoid frequent questioning as to feelings and symptoms. The patient obviously is ill and, therefore, feels it. When he feels well and strong he will no longer need to be under treat- ment ; the fact that he is mider treatment indicates that he is still unwell. No good at all can be done, and progress will not be hastened by repeated questioning and endea- vours to obtain detailed information in the first few 200 THE PROBLEM OF NERVOUS BREAKDOWN weeks of the cure. It is for these reasons that visits and letters from friends have to be stringently regulated. Relatives are naturally anxious to have good news as soon as possible ; in the interests of the sick person they must restrain their solicitude for the time being. CHAPTER III THE REST CURE {B) Routine Daily routine — Sleep — Nourishment — Massage — Occupation — A typical programme. THE patient having been installed in a bright and restful room with a reliable nurse in charge, the daily programme has next to be drawn up, and one of our objects being to rest the tired nervous system, the question of how long the invaUd shall stay in bed comes up for immediate decision. Under the influence of the natural desire of patient and friends to shorten the treatment as much as possible, the ten- dency is to order too little rather than too much rest. As a rule six weeks may be regarded as the minimum time for thorough rest where a neurasthenic condition is so advanced as to make a rest cure advisable ; in other forms of breakdown the time required necessarily varies accord- ing to circumstances. This does not necessarily mean that he is to stay in bed all the time. It often happens that the same end can be secured by allowing a portion of the day to be spent on a couch, or, during the summer, on a reclining chair out of doors. In many ways it is better for patients to rest and have meals out of doors, where this can be arranged without bringing them into contact with too many other people. Towards the end of the time allotted for complete rest a little more walking about the room, or up and down the 201 202 THE PROBLEM OF NERVOUS BREAKDOWN stairs, or in the course of the journey to and from the garden, may be permitted. Although complete rest of body is so necessary, it is equally important that rest of mind be considered from the point of view of its own special requirements. The latter can be obtained either by sleep, or by mental occupation. Never can it be obtained by mental in- activity. But the right activity must be secured. The whole point of mental rest is to change the stream of thought which has been morbidly centred in certain directions into fresh and health-bringing channels. The mental process which ensures rest through action and new thought finds its counterpart on the physical plane, for when groups of brain cells have been exhausted by one particular kind of mental work, the exercise of the mental faculties in a new direction diverts the strain from the tired cells and brings into activity new sets that have hitherto not borne stress. Of course when the brain is tired the fatigue reacts through the v/hole nervous system, so that any form of intellectual activity must at first be regulated with care. Each day the invalid must have a definite programme of occupation, covering every hour, and allowing no time for morbid thoughts to take possession. Often it is difficult at first to per- suade the suSerer that he can do anything at all ; some- times it does happen that exhaustion is so profound as to prevent all activity for a day or two. Nevertheless, even when this is so the day must not be allowed to pass in a. slipshod manner ; gentle conversation, being read to from suitable books, as much sleep as can be secured, massage, meals and the routine of the bedroom, must be made between them to fill up every moment. Sleep is often enough a difficulty. So far as possible drugs are to be avoided, but experience must guide us here, and each physician will act according to his own judgment in individual instances. Patients should not embarrass the doctor by crying out for sleeping draughts. THEIREST CURE 203 Granted that a sleepless night is a distressing experience, it should, however, be pointed out that most of the dis- tress in insomnia comes from the fear which arises from it. As previously noted, where no special activity is called for on the following day a sleepless night is com- paratively harmless ; and, indeed, where rest can be secured during the day several bad nights can be borne in succession without the least danger of anything un- toward happening. It is remarkable how a few minutes' restful persuasion from some understanding individual enables a sleepless person to " settle down for the night " and secure rest. Sometimes sleep itself will quickly come if the right word be spoken at the last moment. Comfort in bed, the right degree of warmth, and a judiciously filled stomach are all important factors in making for sleep. All digestive disturbances tend to cause insomnia, so that flatulence and constipation — particularly the latter — must be alleviated by suitable remedies. Again, common sense tells us that unpleasant medicines or preparations likely to set up violent action in the stomach should not be given at bed-time ; a point in nursing that should be more carefully noted than often is the case. Such matters as having a light in the room, or a fiire, must be decided by individual requirements, but, in any case, the best possible ventilation is desirable, and one knows of instances in which sleeplessness has been cured by the simple expedient of opening wide the bedroom windows. Then, as to nourishment, inva/Uds undergoing a rest cure should have three meals a day, irrespective of afternoon tea. Vv^e v/ant our patients to put on weight ; we want them to fill out, and to be stouter in every way. Therefore, we give them a full diet, and see to it that they have plenty of fat. It is for this reason that it has been a custom to give large quantities of milk during a rest cure, although there are notable disadvantages in so doing both from the point of view of digestion and appetite. Besides, 204 THE PKOBLEM OF NERVOUS BREAKDOWN neurasthenic people require more fat in their brains as well as in then bodies. Extra milk up to a pint or two daily is often found helpful, but there is no better way of administering additional fat than by giving such preparations as ohve oil and cod-hver oil. Some people prefer the former and can take it without difficulty, but as a rule, cod-liver oil is better borne. It may be given two or three times a day, but there are advantages in giving one large dose, say up to two table - spoonfuls at bed-time nightly. Those who find them- selves unable to take oils in simple form can usually ingest one of the emulsions without difficulty. There is this to be said about oils as helpful in building up a broken down nervous system. Nerve-cells depend in part for their successful working on a delicate film of fatty substance. This is, indeed, a phosphcrised fat — lecithin — and contains most of the phosphorus held in the nervous system. One may consider this lecithin as part of the insula,ted material which separates the tiny nerve-fibres in the same way as silk and india- rubber coverings separate the wires of electrical apjDaratus. The next point to be observed is that in the absence of regular exercise, means must be adopted to main- tain the limbs and muscular system generally in a healthy state, as well as to assist the circulation. When people remain recumbent for a long time, the muscles become flabby, whilst the circulation becomes sluggish and there is a corresponding slackness in the discharge of waste matters from the system. For these reasons, therefore, energetic stimulation which does not over-tne the invahd must be regarded as a useful part of the rest-cure routine. Of aH means of securing this effect, massage is the most helpful and convenient. There is no mystery about it, as it is simply a scientific method of rubbing and kneading. People sometimes talk about massage as if it had special healing properties, and often one hears it said that some one who has been ill for a THE REST CURE 205 long time has, among other things, " tried massage," as if that were a specific remedy. Rubbing and pounding are time-honoured methods of restoring life to flagging human bodies ; such processes cause con- traction in muscular fibres and help to drive the blood through areas where there is a tendency to stagnation. In addition to these simple results, massage may be carried out in such a way as to be very sedative, and is then useful in allaying restlessness and promoting sleep. Moreover, rubbing the abdomen is very useful in setting up regular healthy contractions of stomach and bowels, thereby aiding digestion and preventing constipation ; whilst achieving this it also disperses accumulations of gas and, therefore, alleviates uncomfortable symptoms occasioned by flatulence. Special points to be, observed in making use of massage as an aid to other methods of treatment in neurasthenic conditions are that it should not be too vigorous or given for too long a time ; also that where there is great excitement the strokes should be light and rhythmical. On the contrary when a sedative effect is desired, these long rhythmical movements should be apphed to the spine rather than to the Hmbs. Com- prehensive general rules cannot well be laid down as individual requirements vary so very much ; but it may well be remembered that long contin.ued vigorous handling will cause fatigue, restlessness and disturbed sleep. However, difficult though it may be to express in words the difference between gentle and vigorous massage, one can be more definite about time. As a rule, it is well to commence with ten minutes' rubbing, after a few days increasing by five minutes every third day until haK an hour's treatment can be comfortably borne. The best time for the application is in the morning, unless a special sedative effect is required later on in the day. As to occupation emphasis has been laid on the necessity for keeping patients continually occupied during their rest cure, but it is by no means easy to find 206 THE PROBLEM OF NERVOUS BREAKDOWN suitable tasks in the ea.rly stages. The patient has to be impressed with the importance of doing something, but not infrequently raises objections whilst admitting the fact. Sometimes one is told that using the eyes produces terrible fatigue, accompanied perhaps by head sensations. If this is accepted, it rules out almost every- thing one can suggest for the patient to do himself. But the impasse has to be overcome somehow or other. Fortunately it seldom happens that patients will assert that they cannot give attention to an object or to a book for a few minutes at any rate. Even this short time serves as a foundation upon which to build. Let them be assured that the use of their attentive powers for even a few minutes daily is better than nothing, 'and all that is required for the time being ; then it is usually easy by sympathetic encouragement to increase the time given to attentive tasks as the days pass by. The fact remains, however, that where concentration is found to be distressing, the few minutes given to a task represent an inappreciable fraction of the day's routine, and, therefore, some continuous com- panionship is essential. Someone must be at hand to read, to write letters, to dkect the invalid's attention into the right channel dming these first trying days. Nevertheless we may now consider a few occupations that are suitable for patients who can, without difficulty, devote an appreciable time to them daily. Reading, of course, is a great resource, but its disadvantages must not be overlooked. Although useful in diverting thoughts from illness, it nevertheless frequently results in the invalid thinking about himself in relation to what he has been reading. The right books being selected, the patient should be allowed to read only for periods of thirty to forty minutes at a time during the day, and not for hour after hour. Those which occupy hand as well as brain are the most helpful of all. Anything that calls for manipulation as THE REST CUHE 207 well as thought helps in the recovery of nerve-tone sooner than any purely mechanical process such as knitting. Only too often, when people seem to be engaged in needlework, their thoughts are all the time dwelling on their troubles. The movements for knitting, stitching, or embroidery, are largely automatic, and do not serve to divert the mind. But where a task is given that requires attention as well as manual move- ments for its accomplishment a twofold result is achieved. For these reasons such occupations as putting together jig-saw puzzles, learning new kinds of needle- work, drawing, painting or type-writing, are very useful ; all except the latter can be conveniently carried out in bed and even type-writing is not impossible to those who possess one of the lighter makes of machines. Such occupations may be varied by various other kinds of fancy work, such as making baskets or mats. But the disadvantages about automatic movements previously noticed applies to some of these things as soon as the patieiit becomes proficient at them. The great thing is to secure variety and avoid automatism. Once the invaUd is able to get up and about a variety of health-giving interests come within his scope. Light gardening jobs, out-door sketching, the collection of flov/ers and grasses, carpentry and so forth, can all be undertaken. V/hether in bed or out of it the invalid should ha.ve a daily programme upon which to work ; where he is difficult to deal with in this respect, the special tasks ordered should be written down ; but as time ^oes on the pa.tient becomes able to suggest his own little jobs, and such co-opera,tion between him and his doctor is very desirable and a sure sign of improvement. We are now in a position to draw up a programme for a typical d£iy under rest-cure routine, and the follow- ing represents daily programmes in constant practical use. It is to be noted that the active day is of some thirteen to fourteen hours duration, with a two hours 208 THE PROBLEM OF NERVOUS BREAKDOWN break in the afternoon. Breakfast at 8.0 is followed by an hour or so for looking at papers or any letters that may have been permitted. From 9.30 to 11.0 is occu- pied by the routine of getting up, for those who are able to do so, whilst a process corresponding to dressing fills up the time for patients remauiing in bed. The little inci- dentals of the toilet, when performed 'vvithout haste, take up a surprising amount of time, and people seldom find they have many spare moments in the early morning where a regular method is pursued daily. No slackness must be permitted, and things such as shaving, hair- dressing and tidying up generally must be conscientiously carried out. Where electricity or massage is ordered it is usually at least 11.30 before the morning's preparation is finished. At 11.0 or 11.30, as the case may be, wa,rm milk or special food is taken with a few biscuits. With the mid- day meal at 1.0 o'clock there remains an hour and a half to be spent in one of the occupations lately considered. Luncheon occupies about half an hour, and is followed by a period of half an hour, durmg which papers or books may be looked at. Each afternoon between 2.0 and 4.0 o'clock — in winter from 1.45 to 3.0 — the patients rest, lying down with drawn curtains intent to sleep if possible. A short period of getting up again precedes a good tea at 4.15. From 5.0 to 7.0 o'clock time is given to reading, v/riting, doing a jig-saw puzzle, or a little light work, and early evening passes so quickly that under well-directed conditions the hour for the evening meal arrives before the invalid has time to be bored, or to think about himself. At 9.0 o'clock pre- parations for the night begm, and by 10.0 p.m. the room should be darkened. CHAPTER IV DIET AND SOME OTHER POINTS IN CONVALESCENCE Nerve energy dependent on nutrition — Diet in nervous maladies — Personal idiosyncrasies — Advantages and disadvantages of milk — A mixed diet — General principles of diet — Sugar — Cheese — Stimu- lants — Baths — Effects on nervous system — " Reaction " — Impor- tant rules — Clothing — Natural heat — Exercise and body tempera- ture. IT is helpful for people convalescent from nervous breakdown or subject to failure of nerve -tone to know what to eat and to drink, what to do about baths and to what extent their clothing shall be arranged to meet their special requirements. Nerve-energy is the active force on which every part of the body depends for its power to carry out its part in the grand chain of physical life ; and nerve-energy is dependent on what nourish- ment is taken into the system. Nature, indeed, protects the nervous system in the matter of nourishment, indi- cating its paramount position in the human body ; so much so that in starvation all other organs suffer first, and what little food remains in the system is reserved and given to the brain. Observations have been made showing that where people have been starving the muscles, large glands, and even the heart itself shrink and lose substance long before the brain suffers in this way, thus evidencing Nature's protective influence. However, when it is a matter of nourishment under conditions of ample diet, there is no indication that a selective action is exercised on behalf of the nervous system ; that is to say the popular supposition that certain p 209 210 THE PROBLEM OF NERVOUS BREAKDOWN principles are extracted from the food and given to it is fallacious. Certainly it is true that the brain contains phosphorus, but it does not contain more phosphorus than can be obtained from an ordinary mixed diet ; moreover, its requirements in this respect being very limited extra phosphorus in the food serves no useful purpose. It is popularly understood that certain articles of diet, such as fish, are particularly nourishing to the nervous system, owing to the fact that they con- tain a rather higher percentage of phosphorus than other things. But there is not the slightest evidence that these particular food substances are especially valuable in the treatment of neurasthenic states. The fact is that with a mixed diet the various organs of the body receive their nourishment in a general way from the blood stream, and that each can obtain from such a diet everjrthing that is required for its particular purpose, and to sustain its own particular constitution. In other words, every- thing that is good food for one part of the body is good food for aUthe rest ; any ample nourishing diet is a good nerve diet. Preparations that enable us to give the essential principles of a mixed diet in concentrated form are, of course, good invalid foods ; any good invaUd food nom'ishes the brain and nerve tissues excellently. All the reUable food preparations advertised as being helpful in neurasthenic states are virtually concentrations of such things as milk, eggs, or meat. Let it be noted that to be effective a diet must contain fats, carbohydrates and proteids. If a concentrated food preparation is deficient in fats, sugars, or flesh principles it must to that extent fail as an aU-round nutritive for the nervous or any other system. It follows, then, that the nerve patient's diet must be as full and varied as possible, being supplemented as may be decided by whatever concentrated prepara- tion is convenient. Many such preparations are very useful in their way. Thus it is not necessary to lay down DIET IN CONVALESCENCE 211 very rigid rules of diet for those who are neurasthenic, or to trouble them with a diet-sheet that will make their meals a burden to them or destroy the peace of the kitchen. Leaving out of consideration, for the present, those -unfortunate persons whose state of health is such that they are practically confined to their rooms, I may say at once that neurasthenic people should partake plentifully of a good mixed diet. Certainly limitations of digestive capacity must not be overlooked, but, having made a note of the particular articles of diet that upset him, he should proceed to exclude them rigidly from his table, and enjoy his meals without bothering more about them. One person can eat anything except cheese ; another cannot digest shell-fish ; yet others are upset by cucumber ; a few even find eggs disagree with them. Such idiosyncrasies are innumerable, and some appear trivial. But it is foolish to risk a disturbance of digestion which may influence health and work for some days. Far better to make it a rule of life to avoid those particular foods that always disagree. It is not at ail easy to prescribe successfully a nourishing diet for people who tell you that they cannot eat this and cannot eat that without being upset by it, and in this connection one has to utter a word of warning. The neurasthenic person who is bothered by dyspeptic symptoms is often inclined to over-estimate their importance and the sufferings he is subject to from them, with the result that he will un- necessarily reduce the list of things he feels he can digest. Of course, milk is always useful in dyspepsia, but it is a mistake to think that by the consumption of a certain number of glasses of milk daily great progress will neces- sarily be made in either building up the nervous system or fattening the body. By itself milk is not very easy of digestion ; for when it comes into contact with the diges- tive juices a heavy curd is formed which takes time to dissolve. Where this curd, as sometimes happens, is not thoroughly digested, the residue ferments, with the pro- 212 THE PHOBLEM OF NERVOUS BREAKDOWN duction of further distressing symptoms. This is why eo many people cannot take milk and find that it is " too heavy," and therefore disagrees with them. But this is, indeed, easily remedied, because the addition of a small proportion of soda-water to the milk before it is taken will result in the formation of a much lighter curd which is more readily digested. This process can be carried even further by the addition of sodium citrate, which, in the proportion of one grain to one ounce of milk, will produce a curd which is light and very readily dealt with by the digestive juices. Thus there is no reason why a great many people who are now debarred from the benefits of milk through misunderstanding its proper use should not be enabled to take it with the greatest advan- tage to their general strength and nourishment. For some others peptonised milk or " sour " milk, will be found more suitable preparations. For the rest let the nerve patient take as mixed a diet as he possibly can of things that experience has taught him will not be pro- ductive of unfortunate consequences. If the number of these things be small, then let him begin with the milk preparations, eggs lightly boiled, fish, thin bread and butter, and similar things, till such time as the course of treatment he is undergoing so far nerves the tone of the stomach that he can digest a heavier diet. Unfortunately for themselves, many neurasthenic people allow themselves to be led away by fads and crazes in the matter of diet. Their malady predisposes them to in- fluences from without which in health they would be proof against, and in the endeavour to gain better health they are inclined to listen rather favourably to the strongly-expressed views of cranks. The study of rational dietetics, with the object of keeping up general and nerv- ous health, as also the adjustment of diet to the conditions of life as it is lived in our big cities and business centres, is perfectly reasonable, but why is it that so many dietists rush away to extreme views ? The most elementary study DIET IN CONVALESCENCE 213 of Man, the organs with which he is provided, and, per- haps even more, the realization of his accepted place in the animal kingdom, should convince us of the impor- tant fact that he is evidently adapted for a thoroughly mixed diet. Still, this tendency to dietetic fads exists, and is productive of many wrong attempts at construct- ing a rational diet-sheet on the part of people who realize that they have made progress in this direction, and honestly wish to benefit their fellows. There is no doubt that many of the existing food fads, such as vegeta- rianism, fruitarianism and the anti-salt crusade, owe their origin to amateur experiments in dietetics on the part of neurasthenic people who have been unsatisfied in their demands for directions from their doctors. The complaint is sometimes made that doctors are content with giving a bare general outline of the principles of diet, leaving the bewildered inquirer in a more hopeless state of mind than he was before ; but people are often very exacting in their questions as to diet. The average patient who inquires as to his diet wants to know exactly how much bacon he may have for breakfast, and how many eggs he must take. He wants to know whether he is to have a four-course lunch with a bottle of wine in the middle of the day, and, if so, what each course shall consist of. He is even more anxious to know how he can have a good dinner after the day's work without having to suffer for it. It is, of course, a little difficult to answer all these questions in a general manner, because the indi- vidual has to be studied and modifications must be made to suit his requirements, bearing in mind the condition s of his occupation and symptoms. One must enter a special plea on behalf of sugar and cheese as foods that might weU be partaken of by delicate persons more frequently than they are at the present time. The consumption of considerable quantities of sugar for those whom it does not upset by any sensation of sickness or nausea, is always followed by 214 THE PROBLEM OF NERVOUS BREAKDOWN increased energy. Sugar need not always be eaten in the crude form ; indeed, there are many ways in which it can be taken pleasantly. Sugar in all forms is a splen- did nerve food, is pleasant to take and is easily carried about in portable form. Cheese is usually rejected by neurasthenic persons on the ground of its indigestibility, but, as a matter of fact, it is digestible enough if eaten in the right way. Cheese affords considerable resistance to the action of the diges- tive juices if swallowed in lumps ; if well masticated, so that the digestive fluids can come into thorough contact with its constituents, it will give no trouble on this account. Thus it is that the popular combination of bread and cheese, which necessarily requires a good deal of chewing, is really an ideal one from the point of view of the dietist. Furthermore, cheese can be artificially rendered very digestible by serving it as fine scrapings mixed with milk or cream, to which a small quantity of bi-carbonate of soda has been added. No doubt every good cook knows this, a,lthough unaware of the fact that the bi-carbonate greatly aids in the dissolving process of digestion. It is worth noting that an authority on the subject has said that one pound of cheese is able to provide as much energy as three pounds of beef. Owing to the fact that alcohol stimulates flagging energies many nervous people are inclined to resort to it as a medicinal measure which may tide them over par- ticularly depressing periods. They are inclined to forget that the stimulating effect of the alcoholic beverage will inevitably be followed by a reaction which may be even more depressing than the original feeling of lassitude which it was sought to relieve. Consequently, one may lay it down as the axiom that for persons of neurasthenic tendency alcohol is rarely beneficial — and is frequently harmful. The fact that in a few instances the habitual consumption of wine or spirits in moderate amounts is not apparently harmful should not permit laxity in DIET IN CONVALESCENCE 215 regard to this rule, and alcohol in every form should be studiously avoided by anyone whose nervous system is inclined to give him trouble, unless specifically ordered. Neurasthenia is, indeed, at times responsible for in- ebriety. The tired nervous system responds gaily to the cheering cup, but when the temporary effect of the stimu- lant has passed, it needs yet another stimulus of the same kind to enable it to continue its work at an adequate level of utility. In which lies an obvious danger. Here and there it may be advisable to allow a certain daily quantity of whisky or v/ine, but that does not in the least mean that it is always essential to the nervous system. Of course there are various light wines and beers that can be partaken of even by people of nervous tempera- ment without detriment to health, because in these the quantity of alcohol is so small that the amount usually taken can scarcely have any appreciable effect one way or the other. In any case, let it be borne in mind that there are many unstable people to whom even the smallest percentage of alcohol will act as a deadly poison, leading to excitabihty, irrational judgment, and subsequent slacliness. It is a well-known fact that many people who have had severe shocks such as head injuries or sun- stroke bear alcohol badly, and may be seized with all the symptoms of drunkenness after drinking quite a small quantity. The influence of hot and cold baths on the nervous system is another matter of importance to the convales- cent. There is a popular idea in certain quarters that a sure cure for a disordered nervous system is to take an ice-cold bath first thing every morning and, in conse- quence of this, there are not a few people who make a habit of further exhausting their none too strong nervous systems by a daily plunge which is entkely unsuitable for their strength. When anyone plunges into cold water a series of events occur in his system which, if completed, makes for health ; but if, through any con- 216 THE PROBLEM OF NERVOUS BREAKDOWN stitutional weakness, the full response to the bath be not obtained, the result may be very detrimental to well-being. This becomes clear if one traces the effects of sudden contact of cold water with the skin. Firstly, there is certainly a shock to the system in general, fol- lowed immediately by lowering of the circulation through- out the body, as evidenced by the shivering which im- mediately occurs ; this may be called the " stage of depression," and in the healthy bather should be quite short, lasting not more than half a minute or so. The second stage is the all-important one, and depends on what physiologists call " reaction of tissues " ; in it the full benefits of the cold j^lunge are experienced, for this reaction manifests itself by results which are just the opposite of those of the first period. In the " stage of reaction " the skin is flushed and becomes warm, the cir- culation is stimulated, and a general sense of fitness and well-being pervades the body. Knowing these things, and thus understanding the way in which a cold plunge acts on the system, anyone should be able to judge for himself the advisability of indulging in this popular early morning habit. The individual who at all seasons and in all weathers finds that he " reacts " very quickly and feels warm and re- freshed even whilst in the bath, can most certainly bathe without fear of harming " nerves " or constitution. But others who find that they shiver on stepping out of the bath, or notice from other evidences, such as blueness of the hands and feet, or feeling of general depression, that they are not reacting properly, should at once give up the habit. Of course, there are not a few people who " react " thoroughly throughout the summer months, and yet have difficulty in getting warm after a cold plunge on a wintry morning ; it is probable that in all such cases the bath does more harm than good whether the water is found to be "too cold" for comfort, or the " reaction " is delayed. This being understood, DIET IN CONVALESCENCE 217 it may at once be said that, where they can be taken with comfort, cold morning baths are good for those whose nerve-tone is low, or who tend to suffer from " nerves " in any form. To those who can stand it, a bath which is just a few degrees below the average temperature of the morning air is certainly a powerful tonic, but it is a great mistake for anyone to persist in taking a cold bath when he feels it is an effort to do so, and when he knows that his system does not respond to the considerable shock which is given to it in this way every morning. Most delicate people vnR find that they will be very much better by substituting appUcation with a damp towel for the actual bath. In the case of the rnajority whose nerve-energy is below par, a really cold bath further increases their exhaustion, although it may appear to give temporary fillip to the jaded system. But a brisk rub down with a towel never fails to invigorate, to warm and to strengthen. One has known a good many people to make this substitute with the very greatest advantage. In regard to one peculiar effect of the morn- ing plunge a note of warning must be given. There are some who are remarkably elated and stimulated as the immediate result of their morning " tub " no matter how slack they feel on getting out of bed, the contact with the stinging water brightens them at once ; they splash about joyfuUy and often feel constrained to sing or whistle lustily as they finish their toilet. But, alas, a sad reaction quickly overtakes them, and in half an hour or so the bright, invigorated feehng has gone, and in its place has come a sense of lassitude and fatigue. This sequence of events is by no means rare in persons of nervous constitution ; it is quite certain that where it occurs the cold bath does more harm than good. On the whole, it may be said that very hot baths are certainly very bad for the nervous, and they exhaust far more than they strengthen. Warm baths, on the other hand, are sedative and as such are useful to soothe 218 THE PROBLEM OF NERVOUS BREAKDOWN an over-tired system, especially when excessive physical exercise has been the chief factor in bringmg about the fatigue. Again, clothes play a more important part in the lives of nervous people than is generally reahzed. In the first place, many neurasthenics feel the cold very much ; their skins are pale and bloodless, so that the surface of the body always tends to feel colder than general circum- stances may warrant. Thus, except in the warmest weather, they commonly feel chiUy unless clothed to an extent that the normal person regards as unreasonable. In this country, where cold winds so often prevail, this failure to resist the cold is accentuated ; hence, on these grounds alone, the lot of the neurasthenic is an unhappy one. Not until he can assimilate sufficient nerve-energy to enable the circulation to be so adjusted that the warm blood is sent to the skin in due proportion, in consequence of which the body-surface ceases to feel unduly cold, does he become independent of superabundant clothes. People who suffer thus are quite right to wear extra clothes to keep them warm ; but they are unwise to put on so much clothing that the proper functions of the skin are interfered with. It must be remembered that the body gives out exhalations through the skin, and it is most desirable for health's sake that the air immediately surrounding each individual — ^that is, be- tween skin and clothes, or between the different layers of clothing — should be in free communication with the outside atmosphere. Moreover, the packing on of heavy clothes, far from reducing the normal balance between heat -production and heat-loss, actually tends to pro- duce further chiUing ; for this reason that the neuras- thenic person who feels the cold has lost the quick normal reaction of the skin found in healthy people by which a due supply of warm blood is sent to it m chiUy weather. Now the more he endeavours to warm the air next the skin the more will the nervous mechanism thereof DIET IN CONVALESCENCE 219 shirk its task of properly v/arming it. Consequently, the more a habit is made of pandermg to this fault of the skin, the worse will be its behaviour. Persons who rely on many layers of heavy clothing to keep them warm forget the part played by exercise in the natural main- tenance of body-heat. Man in his early days had to rely chiefly on muscular exercise to keep him warm, and even after untold ages during which he has been gradually accustoming himself to artificial methods of keeping warm he is still very dependent on the working of his muscles to keep up the life-heat of his body. Neuras- thenic persons naturally shrink from taking much physi- cal exercise ; it exhausts them a.nd makes them miser- ably tired — but, unfortunately, they usually go to ex- tremes and take too much on occasion and too little habitually. A brisk walk each morning is very desirable for those who are strong enough to get out. This stimu- lates the circulation at the outset, and brings about a rise of surface-temperature which can afterwards be more readily maintained by moderate clothing. The daily walk or walks can be graduated, according to the requirements of the individual, from a hundred yards or so up to a few miles. CHAPTER V SLEEP AND SLEEPLESSNESS The mystery of sleep— Effects on brain^ — -An interesting experiment — Ability to sleep at will — Insomnia — Common forms — Causes — Fear and insomnia — Simple sleep-bringing devices — The restful mind — Some maxims. WE spend a third of our lives asleep, yet none has discovered just what it is that happens when sleep comes. That it is an affair of the brain we all know. Sleep — or a state of coma — occurs if the brain be Jarred, or pressed upon, or poisoned beyond a certain point. Undoubtedly sleep results directly from something which temporarily influences the brain cells — something which is natural, rhythmical and sure in action. But mystery envelops that something. Perhaps it is a folding up of the little tentacles by v/hich cell makes contact with cell ; perhaps it is a shutting off of the supply of nourishment to certain nerve-centres, or even a rise and fall in the tide of blood flowing through the brain. Who knows ? All these things have been suggested but none proved. The one thing we are all agreed upon is that sleep is the greater restorer. Behind the dark curtain which it so mercifuUy throws over human activities, Natiu-e works miracles of healing. Time after time when fighting for a Hfe the doctor knows that victory will be his if only sleep will be his ally ; no drug, no cure, no operation will help so much as a few hours' natural sleep in many crises of disease. As brain work not only uses up energy, but wears out a certain amount of vital tissue — a fact that has been 220 SLEEP AND SLEEPLESSNESS 221 proved by scientific experiment — it follows that sleep must lead to actual restoration of the nervous system. There was once a physician who devoted himself to estimating small losses or gain of weight in his own body under varying conditions of health and work ; he found that just as there is a small diminution of weight after ordinary exercise, so there is after a period of brain work. Then, again, physiologists have shown by dehcate measurements that activity of the brain is actually accompanied by a fractional, but measm^able rise of temperature ; the popular and poetic fancy of a heated brain is thus, indeed, a scientific fact. Conversely it is true that to cool one's brain — another colloquialism — ^the best thing to do is to sleep. It is sufficiently evident, then, that in respect of tissue waste, loss of weight, and heat, mental work has a very definite effect on the general conditions of the body. Bacon showed himself once more a shrewd and accurate observer of man- kind when he remarked that sleeplessness threatened fife. Sometimes under pressure of work men voluntarily do without sleep to finish an appointed task, and occasion- ally one comes across a man of affairs or literary interest who has been able to make a habit of working until two or three o'clock in the morning or even later without impunity, whilst commencing each day at the same time as his fellows. It is very dangerous for the ordinary man to make an endeavour to emulate these excej^tional powers. The irrevocable breakdown of Southey, who sacrificed sleep to write not only poetry, but essays on historical and general matters, may well serve as a warning. Nature's activities during sleep are well illustrated by the rapidity with which an exceptionally long bout of work wiU be compensated by a little extra slumber. In emergency we may be called upon to forfeit a night's rest, but a sound sleep the next night wipes out the balance 222 THE PROBLEM OF NERVOUS BREAKDOWN owing, and we start again fresh and fit ; a not uncommon experience once scientifically tested by an experiment carried out in an American University. In this three educated men were kept awake for some ninety hours — representing a succession of rather more than four days and three nights. After this long vigil each felt quite well after only a few hours' more sleep than he would usually have had on going to bed. It is evident that the willing victims of this scientific insomnia were in very good health to start with ; had they been neurasthenic the experiment might have led to many bad nights and inability to regain the natural habit of sound sleep. It is, indeed, always dangerous to play tricks with one's rest, for though one here and there finds someone who needs but little sleep — Frederick the First and Napoleon are said to have been of this order — most of us require to slumber at least eight hours if we are to carry on in health ; a fact that has been made use of by races excelling in the invention of diabolical forms of torture. Punished by being kept from sleep — spear-points, forced exercise, blows and noise all being made to play a part — the victim of this abominable cruelty loses sense of place and time and then succumbs. This same torment of preventing sleep has also been used in the prolonged interrogation of suspected criminals by relays of questioners carrying on a requisition by day and by night until some sort of confession is wrung from the exhausted prisoner. Under such circumstances the sufferer is bound to give all kinds of abnormal resi3onses, and the value of evidence obtained in such a way must always be doubtful. The great war has given us ma-ny examples of the wonder- ful restorative powers of sleep to men exhausted by exceptional strain. Of these one recalls how the old British Army, exhausted as it was in the great retreat from Mons, nevertheless was far from being as knocked out as the enemy probably supposed. Fitness and train- ing told, the men slept well, and, restored to strength in SLEEP AND SLEEPLESSNESS 223 a remarkably short time, tm^ned on their foes with all their old fire and beat them. There are people so constituted as to be able to obtain refreshing sleep whenever they feel inclined. In the midst of work, after a meal, or on a railway journey they can compose themselves and sleep soundly for a while, awaking clear enough in head and feeling all the better for their nap. It requires a temperament far more equ- able than that enjoyed by the average person of nervous predisposition to have such fortunate command of Nature's heaKng balm. Possibly the small amount of sleep required by Napoleon, already noted, can be accounted for in part by his ability of stopping work and " dropping off " into a dose when.ever he wished. Gladstone is said also to have had this power of stopping the machinery of mental effort at will, and to have been able to go home and fall asleep at once after having left the House of Commons in a blaze of excitement following a speech of his own. The soothing effects of sleep on the body generally are clearly seen in the soft regular breathing, the relaxation of the body, and, if one examines for it, in the gentler beat of the heart and the steadier pulse. Whilst consciousness is lost or perhaps focussed elsewhere, whilst voluntary movements cease, and the nervous system is eased of outward strain, the automatic processes, nevertheless, still pursue their normal course, and in health the mechanism of the body works smoothly and unchecked. On the contrary, when sleep is disturbed there is commonly a reflected dis- turbance of function, whilst again if there is disturbed digestion, for example, sleep is often broken. Ample sleep is very necessary where inborn delicacy or nervousness make the individual dependent on restful nights for the maintenance of those slender energies which are all they have to face the world with. But, indeed, few people of nervous temperament manage to escape periods of indifferent sleep. Digestive dis- 224 THE PROBLEM OF NERVOUS BREAKDOWN turbances alone are responsible for many restless nights in neurasthenic persons. Again, whilst any emotional disturbance readily occasions insomnia in some, there are many delicate people whose sleep very readily becomes impaired, and who consequently have to be especially careful not to permit any variation of their daily routine which experience has shown them is likely to unsettle their nights. Where sleep is disturbed the disorder is either one of defective quality or deficiency in duration. Some find it difficult to go to sleep in the first instance, but, having once lost consciousness, rest comfortably throughout the night ; others fall asleep readily enough, but wake in the early morning hours, and then find it difficult to sleep again. When the rest is deficient in quality the individual manages to sleep for the greater part of the night, but suffers from a multitude of dreams and sensa- tions of semi-consciousness. He is asleep, yet he is awake. Sometimes he wakes in the early morning hours with a sense of weariness, and rouses himself out of the trouble- some state of muddled dreaminess which bothers him, with the object of making a fresh start. Sure enough he falls off to asleep again only to find himself once more caught in the mazes of that mixed mentaUty which so many neurasthenics know too well. When the wakefulness is persistent or the muddled dreams prevent proper rest night after night then it is time for some steps to be taken to improve this unhappy state of affairs. On the other hand, those occasional periods of disturbed rest which trouble over-sensitive people are not necessarily to be regarded seriously. Such bouts of indifferent rest should never be permitted to become the starting point for morbid fears about possible disastrous consequences. Important as sleep is it is nevertheless true — as the experiment previously quoted shows — that several sleep- less nights in succession may be experienced without danger. Several hours at rest in bed in a quiet darkened room SLEEP AND SLEEPLESSNESS 225 sufficiently relieve the periods of daily activity as to protect the nervous system from immediate disorder ; it is possible to obtain sufficient rest to maintain mental health for some time by spending one's nights in a state of mental restfulness, although sleep does not ensue. Nervous persons cannot appreciate this point too fully, for many let their fears of imminent disaster work far more harm to them than would ever be occasioned by the loss of sleep about which they worry. Unfor- tunately nothing tends to banish sleep so quickly as nervousness and apprehension about it. Far better to brave the discomfort and wait for the disturbed balance of rhythm between wakefulness and somnolence to be naturally restored than immediately to resort to seda- tives. When nights are disturbed people should judge their condition by the state of their general health and not anticipate trouble by over-estimating the importance of the matter. When all is said and done, quite sleepless nights are rare, and even the worst sleepers usually succumb to Natm'e's anaesthetic in the early hours of the morning. In any event, those who manage to sleep for some three hours or so during the night obtain quite enough to maintain strength for an indefinite period. Sleep soon after going to bed may be more restful and natural, but if it will not come then we must be grateful for the rest obtained later on. On no account let us worry about it. It is certainly not suggested that there is any advantage in such a state of things, and if it persists the time comes when the question of doing something to remedy it will necessarily arise. Until then patience must be exercised. Cases often occur in which sleep has become reduced to a minimum and health suffers com- paratively little. On the other hand, it must be remem- bered that people often sleep for longer than they know, it being difficult to estimate accurately how long one has slept. Quite honest people report they have scarcely slept at aU, when the evidence of observers — ^relatives or 226 THE PROBLEM OF NERVOUS BREAKDOWN nurses — ^is quite to the contrary. Again, invalids will say that they hear the clock strike every hour throughout the night, thus seemingly proving a case for serious insomnia. Nevertheless, one knows that light sleepers sometimes get into the habit of waking sufficiently to hear the clock strike and immediately dropping ofi to sleep again. A habit of this kind is by no means difficult to estabUsh, and, where fear disturbs judgment as well as sleep, totally erroneous accounts may be given by the best intentioned people. There are again some who whilst sleeping badly at night, are able to get an hour or two's sleep in the after- noon or late evening ; this is all to the good, although they are wise to make every effort to get all their sleep at the right time if possible, so as to be able to forget all about the question of having a good night's rest. Assur- ance as to the relative significance of occasional or even periodic disturbed nights is always helpful and enables sufferers to get rid of their morbid and groundless anxie- ties. Several instances come to mind of people who have established a periodic phase of wakefulness. That is to say, that they have got into the habit of a bad night at fairly regular intervals. Two good nights followed by a poor one is a not uncommon sequence. Where this is so it is often found that a definite routine has been deve- loped. Great preparations are made for getting through the night. Not only the victim of all this morbid self suggestion is concerned, but the whole household knows that it is so-and-so's " bad night." Books, food, lights, apparatus for making tea or cocoa are all arranged for. Going to bed without the least thought of sleeping — under the influence of a suggestion that sleep is not coming — with all the paraphernalia just indicated — and with every one else in the house dominated with the same fear-thought, is it to be expected that the periodic sleeplessness will be easily remedied ? A word as to simple means of inducing sleep, remem- SLEEP AND SLEEPLESSNESS 227 bering that the more we seek it the more elusive it may be, whilst the less we bother about it the more quickly it win come. To Ke dowii with the expressed intention of forcing oneself to sleep is only too likely to be followed by the reverse effect. Similarly, the old-fashioned ways of seeking sleep by such devices as counting imaginary sheep going over a stile ; counting up to ten thousand, or counting backwards ; reciting things mentally back- wards or forwards, and so forth, are aU open to the same criticism that they direct attention too strongly to the question of going to sleep. At the end of the mental task, when innumerable sheep have been watched over the stile, or counting has soared into the thousands, should sleep not have closed the exercise an anticlimax will have been reached, and the last state of the sufferer be worse than the first. Far better is it to take a journey in thought, recalling various scenes of some excursion that has been enjoyed in times past — noting the varying phases of experience, the towns visited, the scenery passed by, the people met. Alternatively, a tour can be planned by car or on foot and the pleasures of the road anticipated stage by stage. One is, of course, in some- thing of a quandary when wakeful people teU us that nightly they have arrived at the end of many journeys, but never yet found themselves in the Land of Nod ! In any case, it is essential to assume as comfortable a position as possible in bed, carefully relaxing the whole body. A relaxed restful body mirrors a relaxed and peaceful mind. Let feet, legs, and arms be restfully relaxed so that no portion of the body is strained. Get the tightness out of the muscles and feel the restfulness that comes when tension is undone. Relaxation having been secured, the matter of sleep should be dismissed and the thought occupied with any pleasant subject that occurs. The journey may find a place here, but it wiU not help if the suggestion — " At the end of the journey I shall sleep " — is to the fore. These voyages of conveni- 228 THE PROBLEM OF NERVOUS BREAKDOWN ence should have no goal. Certainly professional or business problems should be excluded and opportunity taken for letting thoughts dwell on the spiritual values of life ; it is clear that those who have spiritual interests, and who are accustomed to rely on spiritual meditation or prayer, have an advantage over those whose lives are differently ordered. To know that through the veil of appearances the true world of love, beauty, and harmony is to be seen however dimly ; to hold fast to the thought that in all times and through all distresses Man as Spirit is unconquered and unconquerable ; to feel assurance of Divine Love, is to have a sure protection from insomnia's terrors. Fear conscious or subconscious in one guise or another is at the root of all nervous sleeplessness. To know God is to banish fear. " I will both lay me down in peace, and sleep : for thou. Lord, only makest me dwell in safety," sang the Psalmist. That is the attitude of calm trust that dispels fears, quiets turbulent emotion, soothes the weary thought and brings sleep. Maxims for the sleepless — The following general axioms may well be noted : 1. One hour of sleep before one o'clock in the morning is better than three hours taken later on. 2. To stay up after eleven o'clock at night is to expend nervous energy that will probably be needed on the morrow. 3. To go to bed early one night and late the next, with- out any method, rhyme, or reason, is to tempt the mind to form bad habits in regard to sleep, and so favour the onset of a sleeplessness that may be very difficult to get rid of. 4. Even when constantly wakeful sedative drugs should be the very last thing thought of. 5. One hour of natural sleep is at any time worth several hours of unconsciousness produced by drugs. 6. To sleep with the aid of drugs is merely to avoid the main issue, and the latter, however, may be helpful, if continued. SLEEP AND SLEEPLESSNESS 229 7. To go to bed with the mind full of worrying thoughts or business matters is consciously to make an attempt to thwart the onset of sleep, and consequently a very bad habit. When the brain is very active it is well to spend half an hour reading poetry or sedative literature before seeking sleep. 8. Regula,rity in the time of retiring, and regularity in the number of hours spent in bed, make for the preserva- tion of energy. 9. The habit of taking extra naps after once waking in the morning is a bad one at any time, and specially tends to produce a feeling of lassitude. 10. Such simple things as having a well- ventilated bedroom, not piling up too many bed-clothes, having a hot-water bottle if cold, keeping a few biscuits, or a little cocoa in a vacuum flask by the bedside are more helpful than medicines for securing sleep. 11. As a rule, brain-workers should have seven hours' — and preferably eight hours' — sleep each night. CHAPTER VI EEST AND KECREATION Rest apart from sleep — The rest hour — Ways of seeimng rest — Hus- banding resources — Unhealthy restlessness — The proper ordering of spare time — Over-exercise — Common-sense and nerve energy — Rest and over-work — Recreation — Walking — Cycling— Golfing — Change of air — Sea voyages — Smoking. IT is possible for delicate people to obtain a great deal of recuperative and properly regulated rest, apart from actual sleep ; although the more nervous or excit- able anyone is the less he is capable of obtaining ample repose. Clearly rest may be obtained simply by lying down in a quiet room, or lounging in a comfortable chair, but more than this it is rest of thought and freedom from strain that is the important thing. Every one who suffers from nervous symptoms should make a rule of having a time of retirement during the day, an hour that should be given up to drowsiness and quiet meditation. During this time nothing that is worrying or too absorbing should be done, nor physical exercise taken. In such a " rest-hour " all muscles should be relaxed and the work- ings of the mind and body brought to their lowest ebb. Thus considerable recuperation can be obtained which helps to preserve precious nerve-energy. Many people steadily squander their nerve-force throughout the day without a pause ; they say that it is impossible to get a " rest-hour " in the course of the day. They are too busy, they have so many social engagements or too many calls upon their time to indulge in such a luxury. But if they will only apportion their programme for the day 230 REST AND RECREATION 231 in the right manner, and with a calm regard for the actual necessities of life, they will quite easily be able to find one hour to set aside for rest and solitude. Is it not a fact that the busiest people often have the most time ? Their business-like habits are orderly, and orderliness makes for leisure. Solitude is a desirable attribute of the rest-hour, for nervous peoeple when moving about in society and amongst friends — or even about the streets — seem readily to lose theii' vitality, and retirement from their fellows frees them from this outside drain for the time being. Some highly strung individuals become exhausted after merely passing through a crowd of people, and these ought to be careful to take their " rest-hour " regularly every day of their lives. Rest can be secured in many other ways ; rest in the little things which tend to strain the nerves. It is, indeed, the little habits and actions of life which are largely responsible for reducing the nerve-energy of the delicate ; they represent far more perhaps than the reaUy big tasks, which after aU are not so very common in the life of the average individual. What is meant by this is that there are many people who carry on their conversa- tions, and perform all their actions with a superfluous expenditure of energy which is inevitably exhausting their reserve stores of nerve-force — although they seem quite unconscious of this obvious fact. They put a thousand times as much vitality into the performance of a simple action, such as writing a letter, or catching a train, or speaking to somebody on the telephone, or ordering the dinner, as does the ordinary phlegmatic person who knows not what nerves are. It is here that the regaining of lost control is so very helpful, and when increased control has been secured the first and best way the nervous individual can put it to use is in exercising strict supervision over the daily expenditure of nerve- energy in small coin. In conversation, in going about the house, in work at the office, or in walking along the 232 THE PROBLEM OF NERVOUS BREAKDOWN street, increasing control should be obtained over the excessive flow of nerve -energy which invariably charac- terises highly-strung people. If such control be carefully built up and wisely exercised, the conservation and pre- servation of nerve-force can be carried out to a remark- able extent with the greatest benefits to health, work, and life in general. The preservation of nerve -force in the little things of life makes a great difference to the ultimate happiness of nervous people. We all know people who have no method, no system, no definite out- look upon life ; if they want to write a letter they have to collect their material from aU parts of the house, they find they have to get fresh paper, or they have run out of ink, or they have no stamps, or they have lost the address of the person to whom they wish to write, or a dozen and one other things crop up which prevent the simple, easy carrying out of a simple normal act. Such people tire themselves out in simple things of this kind. On the other hand, by exercismg seK-control they can so get the better of their excitable nerves, that they can form methodical habits which will prevent all this lamentable waste of nerve-energy. The cultivation of muscle-control, control of the expression, of the habit of decision, and of the habit of taking things easUy, is of the very greatest value to anyone who suffers from nervous excitability. Overhaste, want of method, indecision, are the enemies of every sensitive and highly responsive person. The proper ordering of spare time is a matter of con- siderable importance to those whose nerve energies are miduly limited as it is to those whose tendency is to turn their thought inward and dwell upon depressing things. For both the consistent pm^suit of the right relaxation means far more than to the ordinary robust individual. Paradoxically enough, many delicate people take far too much active exercise, and through this further deplete their slender stores of strength. There is no greater fallacy than to suppose that hard work out of doors wiU REST AND RECREATION 233 relieve nerve strain. No one can have too much fresh air, or, in this climate too much sunshine, but benefits of both these can be for many far better obtained by resting or sleeping out of doors than by over-activity when vitahty is low. It is not at aU uncommon for a breakdown to be finally precipitated by the mistaken attempts of the sufferer to regain nerve strength by severe exercise. From the physical point of view the energies of the body are drawn from a common source, namely, the air and food taken in. Where a man works with his muscles, his brain, or other organs there is only a certain amount of energy available for him at any given moment. In the ordinary course of daily Hfe the common stock of vitaUty is being continually drawn upon for the requirements of digestion, absorption of food, and excretion of waste matters. The human body is a great factory in which profound chemical processes are always being carried out ; whilst for their complete maintenance a multitude of physical changes for the most part consisting in muscu- lar contractions — of heart, stomach, intestines, Hmbs, and a host of other muscles — are being performed. In addition to this the system has to supply on demand energy for extra muscular work or brain work. Accus- tomed to its routine demands the body fulfils these requirements according to the habit of the individual, but it is only under exceptional circumstances of health and vigour that all these requirements can be fulfilled at a high level at the same time. As has been noted already, brain work uses up a great deal of energy being accom- panied by considerable physical and chemical changes. Wastage due to use of the brain requires making up. Just as does wastage from the use of the muscle. It amounts to this, then, that where one goes for a long walk, writes an article, or digests a heavy meal, there is wastage in the body and consumption of energy which have to be made good. The athlete has his demands for energy satisfied by a habitual and automatic regulation of energy 234 THE PROBLEM OF NERVOUS BREAKDOWN distribution which meets his requirements ; similarly, the brain worker or the gourmand. But it goes hard with either if he should suddenly change his mode of living, substituting mental for physical exercise or sacrificing both to the pleasures of the table to which he has hitherto been a stranger. The average individual avoids trouble by making varying use of the reserves of energy present in normal health. Should he be indiscreet in exercise, brain work, or diet he makes up for it by a rest or short " cure " which enables an adjustment to be effected in his favour. Not so with those v»^hose nervous systems are delicate and whose balance at the bank of energy is customarily low. They are always in danger of over- drawing, and an overdraft means a dangerous expendi- ture of capital. In neurasthenia reserves quickly become depleted, and consequently the use of further vital energy in unwise physical activities is not only to prevent that restoration of wastage which the nervous system so urgently requires, but actually to increase the overdraft. Time after time one finds a condition of serious debility brought about by misunderstanding of the fact that the body has only a certain amount of income and reserve in the matter of vitality, a^nd, particularly when the balances are low, cannot supply persistent demands for all quarters. True it is that change of occupation and fresh mental atmosphere is good for people suffering from overstrain, but it is equally true, and of even greater importance, that rest, not activity, is the rule in nervous exhaustion. The place for the overworked man who has become neurasthenic is not the golf links, tennis courts, the road or the river, but bed. It follows, then, that those who whilst in health know from experience that their nerve-strength is comparatively poor should be equally careful to avoid indulgence in recreation that will certainly make serious demands upon their vitality. These considerations from the physical point of view must be taken into account with the necessity of securing REST AND RECREATION 235 absorbing interests for those of introspective turn of mind. Whilst recreation must be taken in such a way as not further to deplete strength, yet occupation apart from work is a paramount necessity to everyone of nervous tendency. In a word, recreation is useful and important to those Hable to nervous trouble, but a hobby is an urgent necessity. It may, then, be well to give a little thought to the advantages and disadvantages of various sports and pastimes in special relation to the problem of nervous breakdown. Walking is splendid for neurasthenic people, but it must be graduated intelligently. To be health-giving walks should not be aimless ; they should be taken on definite plan and with an object. A walk that is taken for a certain distance, or for a certain time, just because the doctor advises it, is not going to be worth anything, and if it bores to the invahd may do more harm than good. But where a walker can evince an interest in places visited or make a hobby of noting various features of Nature, walks are always beneficial. Always care should be taken not to take too long walks, but particu- larly when convalescence is being estabhshed after a period of considerable exhaustion. Only too often one sees good work spoilt and a relapse brought about through neglect of this simple precaution. After some weeks of quiet routine invalids find themselves with a new sense of buoyancy and health which they want to make the best of, and in their delight do not spare themselves. One need scarcely say that sympathetic and bright companionship make for the success of walking in town or country. Indeed, depressed or introspective persons should avoid lonely walks. All outdoor games and pastimes are helpful when undertaken with due regard to considerations already noted. Cycling may be made very helpful if common sense governs the use of the bicycle, but must be avoided where ready exhaustion is already troublesome. As with cycling and 236 THE PROBLEM OF NERVOUS BREAKDOWN with the same reservations one finds that riding is extremely beneficial to a large number of people whose nerves tend to be disordered. Golf is popularly supposed to be a splendid recreation for the nervous, and so it is for those who can go round the links without undue anxiety ; but it is equally certain that the golfer who worries over the game loses more than he gains from the point of view of health. To be in a state of tension all the way through the green ; to worry over every stroke and round each hole is only to harass the nervous system. Hence, where natural excitability makes it difficult for a course to be negotiated without mental discomfort goK should be given up for a time. Among lighter recreations, the development of carpentering, wood-carving, modelling, book-binding, painting, drawing, and so forth are to be encouraged. Hobbies that occupy both hands and brain are by far the most valuable. Music, typewriting, the microscope, collection and arrangement of natural objects may be all employed in systematic nerve-hygiene. There is a popular idea that the sea is a sure remedy for nervous fatigue or irritability, but, indeed, the seaside is by no means always the best place when nerves are troublesome. Bracing air often tends to aggravate sleeplessness, indigestion, headache, and other common symptoms of the neurasthenic state. Certainly where poor health is directly associated with a short spell of overwork, a journey to the seaside often does good and tones up the system generally. But as a general rule, neurasthenic persons should not go to the sea without due consideration of individual circumstances. It is a com- mon mistake of people who need rest to go to places well known for their social advantages and excitements in the hope of distracting their thoughts. A " rest " under such circumstances becomes a farce, for at fashionable seaside resorts the regularity of daily life and the quiet surroundings that are necessary for those suffering from nerve-exhaustion are difficult to obtain. The most suit- EEST AND RECREATION 237 able conditions for recovery from neurasthenia and its congeners are to be found inland ; particularly in well- wooded districts where there are hills to protect from cold and irritating winds, and trees to lend their soothing influence. There is balm and healing in old English gardens, fields and woods for those of nervous tempera- ment. Londoners and other town-dwellers in this land are fortunate in that beautiful country with quiet and helpful natural surroundings can be obtained with little trouble. Health is often sought through a sea vovage ; often, indeed, with lamentable consequences. When possible strength should be restored under the conditions in which the life of the patient has to be led. The less interruption of daily life and work the better for all concerned. One may well hesitate to send the victim of a nervous breakdown into strange countries, where he will have to eat food that is foreign to his digestion, keep all sorts of irregular hours that are bad for him, and be harassed by the excitement of meeting new people and seeing strange sights. To the great majority of persons the question of leaving their work for a long period, as well as the expense involved by long voyages, is a matter for very grave consideration. It is of little value to tell a man whose nerves are seriously out of order through over-anxiety and worry to go away to South Africa, or the West Indies, or to Timbuctoo, when to do this he would have to leave affairs which probably need his constant attention. To give up work for a time is bad enough, but to be thrown right out of touch with home interests, desirable on occasion, is commonly very disadvantageous to health. On the con- trary, rest in the country can often be taken without seriously jeopardising prospects. Although smoking is so extremely common in aU grades of society no general conclusive opinion ever seems to have been arrived at about alleged injurious effects of this habit. Medical men differ on this point so far as con- 238 THE PROBLEM OF NERVOUS BREAKDOWN cerns moderate indulgence, although they all agree that excess is distinctly injurious to health. The fact is, individuals vary so remarkably in their susceptibilities to tobacco that no general rule can be framed as to what is moderation and what is excess. Consequently, those who happen to have come across some instances in which smoking appears certainly to have impaired health are inclined to condemn the habit, whilst ardent smokers retort by bringing forward some nonagenarian who has thrived on tobacco throughout his long life. As a matter of fact, adverse criticism of one of our most popular habits seems scarcely to be supported by the results one sees in everyday life, for apart from a few susceptible individuals the great majority of fairly heavy smokers do not appear to be on the way to physical ruin, nor does expert examination contradict this impression. On the other hand, it would be foolish to say tobacco is always quite harmless, as every physician has before him from time to time objective evidences of the disturbances of health to which smoking may lead. Whatever can be said, nicotine remains a deadly poison, although it occurs in very small quantities in the actual smoke inhaled. With those who are particularly susceptible to nicotine poisoning, even the minute particles absorbed may exercise serious effects on heart and nerves ; indeed, the nerve- poisoning is the chief factor, because a considerable proportion of the symptoms due to "tobacco-heart " are unquestionably due to derangement of nerve -balance. Common symptoms due to tobacco poisoning are trembling hands, tremors of the lips on speaking, staggering of gait, giddiness, and neuralgic pains through the head. Con- sequently, whilst the majority of moderate smokers are very unlikely to be injured by the tobacco-habit, there are certainly some who ought not to smoke. Obviously if anyone is so susceptible to tobacco poisoning that very slight indulgence in smoking produces giddiness, or palpitation, he had best be warned in time and give up REST AND RECREATION 239 the habit altogether. If he does not he will be liable to the more serious results of nicotine intoxication. Undoubtedly the risk of nicotine poisoning varies with the mode of indulgence. Thus the habit of inhaling smoke right down into the lungs is much more hkely to lead to iU effects than the simpler methods of just draw- ing it into the mouth. Again, there are important differences between pipe, cigar, or cigarette ; whilst there are considerable variations owing to individual reaction. It may be taken as a general rule that a pipe is least harmful, owing to the fact that condensation occurs in the stem and thus prevents a good proportion of the bi-products from reaching the mouth ; on the other hand, a cigar is most likely to cause injurious effects owing to the fact that it most readily conveys moisture laden with nicotine and other products into the mouth. This theoretical consideration is supported by the practi- cal observation that excessive cigar smoking certainly is the most injurious of all three ways of consuming tobacco. Necessarily, it is particularly injurious to smoke right down to the end of the cigar -stump, or to hold it for long in the mouth. The friendly cigarette occupies a middle place as being distinctly less harmful than a cigar, and possibly more likely to lead to poisoning than a pipe. It follows, then, that nervous people need not be forbidden to smoke where they do not exhibit signs of special susceptibility to tobacco, but as we know that nicotine is liable to "go for " the nerves, one is natur- ally more careful in watching the effects of smoldng in neurasthenic individuals than in others. CHAPTER VII CHILDHOOD AND YOUTH Child father to the man— Plasticity of early life — ^The nervous tempera- ment in childhood — Childhood fears — Night terrors — Enuresis nocturna — Hygiene of children's nerves — ^Diet in childhood — Mental hygiene in the nursery — Morbid sensitiveness — Powers for work and play— Dangers of over-strain — A reasonable programme — Sensitiveness of early life — Youth — Critical period of adolescence — Its characteristics and dangers — The psychology of young men and maids. IT has been well said that the child is father to the man. Certainly careful inquiry into the life history of sufferers from nervous disorders very often reveals the fact that from earliest years there have been manifesta- tions of instability. The pity of it is that these warnings so often have not been recognized, or if noted have been disregarded. Prevention as much as cure is one of the great aims of medical science to-day, and in the due recognition and firm handling of the early signs of un- steadiness are to be found reliable means of preventing subsequent disaster. By training the weakly nervous system to bear more and more easily the burden of life, and by educating the will so as to develop its fullest powers of self-control, much can be done to enable those who would otherwise suffer breakdown to fight their way successfully through the battle of life. The plasticity of early life is still not sufficiently realized by parents and educational authorities. The appearance of any of those signs by which the nervous temperament invariably betrays itself in child- hood should be taken as an urgent call for special care. Such early evidences include St. Vitus' dance (chorea), 240 CHILDHOOD AND YOUTH 241 or other persistent twitching movements, convulsions, vacant expression, drooping head, dropping of hands when arms are extended, slow response in carrying out imitative actions to order, stammering, or other speech impediments not due to local disease, mental confusion, difficulty in recognizing familiar objects, or in remember- ing simple events, names, days, or dates, deficient bladder control, sudden flushing, occurrence of sudden pallor, " dead " fingers, persistent and extensive chilblains, night terrors. Again, nervous children are very sensitive, and in consequence react abnormally to conditions that do not bother a normal child. Thus, the morbidly sensitive youngster dwells unduly on snubs and punishments, brooding over these inevitable drawbacks of childhood, and magnifying quite small matters into affairs of im- portance. In this way false ideas of injustice and harsh treatment, or sense of having done some dreadful thing render the little victim pitiably miserable. Days of haunting thought, in which little interest is taken in lessons, meals or play, are succeeded by dreamful nights which stiU further prejudice mental physical health. Similarly, nervous children often ponder on tragic events they have heard about and conjure up all sorts of horrors and gruesome possibilities that would never enter the mind of a healthy adult. The greatest care should be given to getting rid of these fears. They are nearly always present although a little coaxing and sympa- thetic conversation may be required to elicit them, for children are very reticent about their fancies, and hesitate to describe them lest they be misunderstood. Many nurse secret terrors of such simple things as black patches or marks on a wall or ceiling, a badly stained bath, a cracked looking glass, or a broken piece of furniture. Others do not like woolly things, or fm:ry surfaces, some are apprehensive of anything that moves suddenly, whilst most little ones are agitated by unfamihar shape or appearance. Colour " phobias " are by no means rare 242 THE PROBLEM OF NERVOUS BREAKDOWN amongst children, and when present are manifested by screaming and signs of panic at the sight of the par- ticular colom* objected to. Childhood's fears have been well described by Charles Lamb, who as a child suffered greatly from nervous dreads. In one of his essays, he tells of the horror born in him through looking at the picture of Samuel resisting the Witch of Endor, in an old Stackhouse Bible, and of consequent terrors which dis- tressed his childish mind at night. " I was dreadfully alive to nervous terrors. The night time, solitude, and the dark were my hell. The sufferings I endured in this nature would justify the expression. I never laid my head on my pillow, I suppose, from the fourth to the seventh or eighth year of my life — so far as memory serves in things so long ago — without an assur- ance, which realized its own prophecy, of seeing some frightful spectre. Be old Stackhouse then acquitted in part if I say that to this picture of the Witch raising up Samuel — (0 that old man covered with a mantle !) — I owe, not my midnight terrors, the hell of my infancy, but the shape and manner of their visitation. It was he who dressed up for me a hag that nightly sat upon my pUlow, a sure bedfellow, when my aunt or my maid was far from me. All day long, while the book was permitted me, I dreamed waking over his delineation, and at night (if I may use so bold an expression) awoke into sleep, and found the vision true. I durst not, even in the dayUght, once enter the chamber where I slept, without my face turned to the window, aversely from the bed where my witch-ridden piUow was. Parents do not know what they do when they leave tender babes alone to go to sleep in the dark. The feeling about for a friendly arm, the hoping for a famiHar voice when they wake screaming, and find none to soothe them ; what a terrible shaking it is to their poor nerves ! The keeping them up till mid- night, through candle-light and the unwholesome hours, as they are called, would, I am satisfied, in a medical CHILDHOOD AND YOUTH 243 point of view, prove the better caution. That detestable picture, as I have said, gave the fashion to my dreams — if dreams they were — for the scene of them was invari- ably the room in which I lay. Had I never met with the picture the fears would have come self-pictured in some shape or other : Headless Bear, Black Man or Ape, but as it was, my imaginations took that form. It is not book or picture, or the stories of foolish servants, which create these terrors in children. They can at most but give them a direction. Dear little T. H., who of all children has been brought up with the most scrupulous exclusion of every taint of superstition — who was never allowed to hear of goblin or apparition, or scarcely to be told of bad men, or to read or hear of any distressing story — finds all this world of fear, from which he has been so rigidly excluded, ah extra, in his own 'thick-coming fancies'; and from his little midnight pillow, this nurse-child of optimism will start at shapes, unborrowed of tradition, in sweats to which the reveries of the ceU-damned mur- derer are tranquillity. "^ Children who wake screaming in fear must be dealt with very gently and lulled into a knowledge of personal security by loving hands and sympathetic words. Con- fusion, parental severity, crowding round of relatives, and sharp orders to be quiet, can only increase distress ; and whatever be the cause, predisposing or exciting, the greatest care should be taken to avoid undue shock when a screaming attack occurs. It is foolish to suppose that a child can be cured of night terrors by slapping and scolding. Such crude measures only cause further nerve disturbance, and so lead to worse attacks. Fears may haunt a child in the daytime, and cause sudden attacks and visions. Day-terrors, though by no means so com- mon as night -terrors, nevertheless may be just as severe. An important practical point is that sensitive children may nurse fears in their waking hours, leading lives ^ Cliarles Lamb, on " Witches and other Fears." See Essays oj Elia. 244 THE PROBLEM OF NERVOUS BREAKDOWN full of terror, never confiding in their parents or nurses ; whilst all the time resultant nerve tension impoverishes general health, impairs their appetite, and hinders their proper physical and mental development. Such children are pale and listless with dark rings under their eyes ; they are sullen and suspicious, look thoroughly unhappy, and cannot be got to take an interest in games or other childish pleasures. Next to these dreads and other results of over-sensi- tiveness, nervous children probably suffer most misery from deficient control of the bladder. Inabihty to regu- late the passage of water causes a sensitive child infinite distress, in that it constantly feels under a cloud for having committed a misdemeanour. Too often it in- evitably becomes the butt of playmates who laugh and jeer at this misfortune. Parents also are sometimes to blame for treating the matter as a misdeed. Shoulder- ing the responsibility thus thrown upon them, and being often in great physical discomfort, life becomes a burden to these children who thereby become more and more nervous. Inability to hold water is a common manifesta- tion of nervous instability in early years. Happily enough, it sometimes represents only a transient state of nerve weakness. The disability is far more common at night than during the day time, and when allowed to persist into later years seriously affects life and work ; consequently efforts should be made to get rid of the weakness. A policy of drift based on the experience of the minority and the supposition that the child will " grow out of it " is much to be deprecated. When a chlid gets to the age for boarding school, or still later when a career has to be chosen, the fact that morning after morning the bed is found wet produces a sense of infirmity that is highly detrimental to development, and may prevent important work being taken up. Parents should pursue a definite line of action in regard to this weakness. First of all, they should ascertain CHILDHOOD AND YOUTH 245 whether or no organic disease is the cause of it, and, having been satisfied that no gross disease is present, should take the little sufferer into their confidence and explain how the trouble is due to a loss of control that is remediable. It is very hard on a child already sufficiently persecuted by such a troublesome condition to ascribe its difficulties to carelessness. It is sad to hear of unedu- cated mothers punishing some little thing who is strug- gling with nightly enuresis. Indeed, such ignorance of children's ailments ought no longer to be possible in these days of schools for mothers and health propaganda which afford ample facilities for parents to become ac- quainted with the chief features of delicacy in their children. Fortunately most cases are curable without much difficulty if systematically treated on the right lines. Mothers or nurses can often aboHsh the distressing condi- tion by encouraging their small charges to wake once or fcwice each night. Simple suggestion and explanation of what is required usually succeeds in achieving the desired end. When punishment is said to have been successful in getting rid of the disability, it is because the penalty inflicted happens to have implanted in the child's mind the necessity of waking during the night — a cruel method of mental treatment. Various physical remedies, in- cluding drugs, and electricity, are sometimes advocated, but there should be no need to have recourse to this means. In the nursery, at school, and then in that often diffi- cult period when youth is passing into the full fruition of adult life, a great deal can be accomplished in protecting and strengthening delicate nerves. Let us take the hygiene of the nursery first a/ud dwell on such issues as are particularly important from our present point of view, at once dealing with some physical considerations. In the first place, one notes that many mistakes are made in regard to the feeding of children of the neurotic 246 THE PROBLEM OF NERVOUS BREAKDOWN type, with the result that they so often become thin and ill from want of nom'ishment. Sometimes they become dyspeptics because they consistently bolt food that is un- palatable to them once they realize that they are not to be "let off " by unwise parents ; sometimes they suffer from being left too much to their own wishes. The first rule for a mother to follow when arranging the diet of a nervous child is to close her ears to popular absiu-dities and rely on common sense and expert advice when it is needed. Common sense wiU obviate too strict rules and combine firmness with due consideration for the child's individual requirements. If a child does best on a diet of sweet things, why not let him have it. If he craves for pure cold water, what harm will it do him ? Yet for some reason there is a general tendency to feed children on the most plain and tasteless fare, which, although acceptable enough to the strong, healthy youngster whose nerves are not likely to trouble him then or thereafter, is simply revolting to the highly strung. Again, people insist on children sitting over a meal until they have finished up whatever may have happened to have been provided. The " finishing up " process may be completed aU right, but probably through the method of " bolting." Thus the child's delicate stomach is filled with a mass of unmasticated food that is most difficult to digest, and by the irritation it sets up may impair health in many ways. Another point about diet is that care should be taken to dissociate the idea of powders and medicines from any of the foods that are in common use. A nasty tasting powder concealed in a spoonful of jam may engender such a dislike for jams of all kinds that the child once victimized in this way will refuse to touch them again ; and this is an important consideration when we remem- ber how useful a part jams play in making the simple fare of the nm"sery and schookoom more appetizing than it otherwise would be. Similarly, cod-liver oil thought- CHILDHOOD AND YOUTH 247 lessly given in milk may result in giving great dislike for that most nourishing commodity. Cod-liver oil is a most valuable support for delicate children, but it should always be given as an emulsion, preferably with iron, or in one of the palatable forms prepared by so many well- known jfirms of chemists. In a word, children require plenty of light, good nourishing food. Milk must not be given in super- abundance, but the writer likes to see cream on the nursery table daily. Fruit and sweets also have their proper place not merely as extras but as regular elements of nourishment and children's feeding. It is mainly a question of common sense, moderation, and regularity as to whether a child gets the right food and the right nourishment. The delicate nervous child is in danger of Buffering through too much unsuitable food rather than the reverse. He really wants small amounts of very digestible food at regular intervals, and is more dependent on taking something between the chief meals of the day than are his stronger brothers and sisters. Moreover, as he is very often constipated, the regulation of his bowels must be made a matter of very careful routine. When digestion is so disturbed that night terrors are thereby encouraged or accentuated, special care must be given to drawing up a daily diet table suitable for the little sufferer, no heavy meal being given later than at most three hours before bed time. Turning now to the mental side of hygiene in the nursery, let us note at once it is the over-sensitiveness of the nervous child that requires primary consideration. Thus, unwholesome brooding often follows where chil- dren are threatened with dire penalties for small mis- deeds. The quick thought of the sensitive child at once grasps the full horror of being turned into a cat or dog ; spirited away by a black man, fetched by a policeman, or burned eternally in the hereafter. One only hopes that modern educational methods and the better training 248 THE PROBLEM OF NERVOUS BREAKDOWN of children's nurses will soon banish these silly threats from our nurseries. Such suggested terrors not infre- quently give rise to distressing nightmares causing the excited child suddenly to wake up screaming, trembling, and obviously in deadly fear. It is tragic that such attacks should ever be occasioned by the careless threats of irresponsible people. That the latter have no idea of the dread they are suggesting to the little ones in their care is no excuse for stupid cruelty. Let all thoughts of relentless punishment, bogies, and ghosts be kept out of the nursery. Even fairy tales and fables should always be qualified by teaching that ghosts and goblins have no real power ; that the smallest child is stronger than the biggest bogey. Once unhealthy thoughts get root in childish thought it is difficult to uproot them, and every one who thinks to make a child good by threats of hob- goblins merits severe censure. In the minds of some children terrifying thoughts produce wide-spread results not infrequently leading to nerve disturbances that may persist and prove a handicap throughout adult life. Many a neurasthenic is tormented by obsessing thoughts that have their origin far back in some mental crisis of childhood. Let the child-mind be filled with beautiful ideas symbolized by fairies, guardian angels, and good sprites, and for the sake of grown-up nerves, if for no more worthy reason, let it be spared terrors that are often thoughtlessly inflicted on it. Children who fear the dark and lie panting in terror when left alone at night owe their alarms to some false fear -thought working their minds. Let it be remembered that where such fearful- ness is not dealt with sympathetically the fear-thought may soon develop to such a degree that terrifying hal- lucinations occur, and the child go nearly mad with fright at some supposed apparition. There are, indeed, some nern'otic children whose mobile minds evolve fear-thoughts out of very little. So long as they talk about them openly the ill effects of these terrors is minimized, but once, CHILDHOOD AND YOUTH 249 through misunderstanding or other cause, they keep their fears secret, there is risk of serious excitement. Suppressed horrors sooner or later become manifested as night terrors, general ill health, sometimes convul- sions, and in later life by neurasthenic or hysterical states. Although it is so clear that particularly in childhood does care in training enable us to dispel or, at any rate, to minimize latent possibilities of neurotic disturbance in later life, the fact remains that many people over-estimate the strength of the growing nervous system, and the capacity of the child-mind for assimilating knowledge without strain. A mistake of this kind may and does frequently result in irreparable damage. The whole tendency of natural processes in childhood is towards nutrition, whilst all through growing years Nature makes increasing efforts to develop the brain. Any undue stress on the developing nervous system not only strains a particularly delicate organ, but leads to excessive calls on general bodily energy to compensate the over-worked brain. At a time when Nature is making great efforts towards building up the body generally, risk is incurred when the balance is seriously disturbed by undue demands on behalf of some particular part of the system. If a child is made to take too much muscular exercise, or to indulge too freely in out-door games and exercise, the growing brain and nervous system has to suffer ; on the other hand, where excessive mental work is asked for the developing body is thereby deprived of some of the nutriment that is its due. Where a careless system of education and training leads to excessive demands on both brain and body the most serious dangers are run, and the whole process of successful evolution may be frustrated. Some rather delicate children naturally tend to be studious, and where a wise training does not see that the demands made upon their bodies and minds are reasonable and balanced they usually drift into a routine 250 THE PROBLEM OF NERVOUS BREAKDOWN in which they learn too quickly and too much. Thus is developed a not unfamiliar type of youngster with puny body and quick excitable mind. The pity of it is that it is just the more finely constructed and so particularly plastic brains that get imposed on. The quick child is regarded joyfully and triumphs of genius foretold for it ; the unfortunate victim of mistaken praises is en- couraged to pass test after test, whilst an ever-growing pile of useless rewards blinds the parents' eyes to the danger incurred. Many individuals can attribute a serious mental handicap in after life to strain from over-study in childhood. There is far too great a tendency, especially in small schools, for children of quick brains to be over-trained mentally at the expense of little bodies which require more, rather than less, attention. Competitions and school tests have their uses, but there is a great deal of mischief done by study for examinations between the ages of twelve and seventeen years. There is no reason why any child should have to undergo unreasonable strain of body or mind during school life, but it is par- ticularly urgent that those who are delicate should have their physiological requirements carefully studied. The maximum amount of work which a boy or girl should have to do during school years is about thirty hours a week ; that means an average of just under five hours a day, which may be divided up into three hours in the morning, one for the afternoon, and one for preparation for the next day's work. This should be the maximum for this particular period, but is commonly exceeded in the ordinary routine of school life. Moreover, if " pre- paration " for the next day's work is not carefully mapped out, it may mean a serious and unnecessary draft on Nature's bank of nerve-energy. Hours that ought to be devoted to recreation, rest and sleep, should never be encouraged for school preparation. Then there is the question of sleep for school children. CHILDHOOD AND YOUTH 251 They should spend at least nine hours out of the twenty- four asleep, and as they usually have to get up at about seven o'clock in the morning, it is clear that the older ones should be in bed by ten o'clock at night, and therefore should certainly cease work at least an hour before that every evening ; for it is quite unreasonable for children to go to bed with thoughts full, alert and excited by recent lessons. Again, under proper conditions of mental hygiene, every boy and girl ought to have some hobby which should occupy him or her for an hour daily so as to rest the mind from thoughts of school. In the matter of physical exercises for school children one often finds ignorance of natural laws. Sometimes it is considered that sufficient fresh air and exercise are obtained if the youngsters over-exert themselves at violent games twice a week; a few days' mental stress, relieved by physical strain is a system that has been only too common, and is cited here merely as an example of what should be avoided. The fact that numbers of young people break down in early adult hfe is sufficient warning that in any case greater attention should be given to the training of children of the nervous type. Even now it is insufficiently reahzed how often the mental catastrophies of early adult life are largely due to faulty school conditions. The question therefore arises as to what we are going to do to remedy faults in our educational system which tend to bring out rather than eradicate tendencies to nervous disorders. How are we going to ensure that our nervous youngsters shall be protected and fostered mentally and physically ? Clearly, the remedy is to be found in the establishment of a rational system of school hygiene. Thus the daily programme for delicate boys and girls should be on the following lines. An early breakfast followed by half an hour's gentle exercise in the open air ; the morning work should then consist of not more than four periods of not more than three-quarters of an hour 252 THE PROBLEM OF NERVOUS BREAKDOWN each ; the last lesson should be verbal instruction by a good teacher, this entailing much less effort than reading class-books or working out mathematical prob- lems. The afternoon should be spent in the open air as far as possible, exercises and games being carefully super- vised and graduated according to the capacity of indi- viduals. During the late afternoon and evening there should be one, or at most two further periods of forty-five minutes for study, whilst the time between the last meal of the day and bed-time should be given up to pleasant relaxation. In this way the evening hour of study is, in the case of nervous children, finally eliminated ; there should, indeed, be no hesitation in omitting late study for neurotic boys and girls. The highly-strung child best conserves his energies whilst strengthening his mental control and developing his faculties, when giving up his evenings to such occupations as drawing, developing photo- graphs, or other instructive hobbies. Then, apart from details of daily routine, everything should be done to avoid making school a place of mental torture or physical discomfort for nervous children. Life there should be made as bright and homely as possible so that the difficulties of adaptation to environment which so constantly trouble the possible neurasthenic may be minimized. It really comes to this, then, that where a child exhibits signs of brain instability it is better away from the rough and tumble of ordinary school life. On the other hand, the dangers of fixing the nervous habit by coddling and too much morbid sympathy at home must certainly be avoided. We want a few more centres where the educational care of the nervous child is especially undertaken by those who have studied these matters. Given a fair chance, the nervous child will often develop into a highly successful man or woman ; let it be remembered that each child starts life with an inherent personality that will ultimately make good if properly fostered and guided in the right way. Here we touch CHILDHOOD AND YOUTH 253 upon problems of real national importance, and matters which it is to be hoped will, in the future, receive much more attention from public authorities than they have done in the past. When nursery and school life are based upon true principles of mental and physical hygiene the nervous tendencies of child life will far more often be prevented, than is the case at present, from developing into the psycho-neuroses of adult life. No training in after-life can provide the reserve of nerve-energy that can be built up during school days by reasonable attention to Nature's laws and needs. R. L. Stevenson has said that we write our diaries " in airy characters " upon our brains. It is certain that child- hood's experiences leave their permanent mark on the developing nervous system, and many a delicate brain is ruined through exposure to over-rough stimuli and un- necessary stress during the period of growth. Similarly, protection is not often enough given to girls and boys who need it during the years that lead them from irresponsible youth to responsible maturity. This period of adolescence is most critical for everyone, and where there is inherent deUcacy of nerve tissues or abnormal mobility of mind the passage to adult life only too often ends in, or is inter- rupted by a wreck. The decade between seventeen and twenty-seven is productive of many sad breakdowns, not a few of which could be prevented. It ought to be one of the proud claims of applied psychology and neurology in the future that our over-sensitive young people are far more often given a safe voyage through the troubled waters of adolescence than is the case to-day. There has been far too strong a tendency to treat the nervous discomforts of youth as negligible quantities, and to urge their minor importance by telling young men and maidens just to pull themselves together and not be foolish. Thus, instead of gaining that confidence and analytical understanding of dangerous mental states and 254 THE PROBLEM OF NERVOUS BREAKDOWN nervous weakness, the whole point of the problem has been missed, and, indeed, the problem itself ignored. One of the characteristics of youth and maidenhood is over-sensitiveness to personal criticism, and the unsym- pathetic handling of nervous difficulties quickly leads to reticence about them. There is nothing worse for those troubled in this way than the constant bottling up of their perplexities. Many a man and woman suffers from distressing breakdown in later life as a result of pent-up emotional stress during the period of adolescence ; whereas careful analysis of the difficulty with sympa- thetic directions would have prevented the setting up of a chronic source of mental irritation. Similarly, one can trace many breakdowns, or states predisposing to breakdown, to misunderstanding of misery suffered by little children of nervous temperament. We need a greater understanding of the psychology of youth ; we need to study a good deal more closely the impetuous fire, the fascinating way of them and the subtle sensitivity of those who assume a natural course over the threshold that leads to the full inheritance of manhood and womanhood. Particularly do we want a better understanding of the unwholesome channels into which youthful thought sometimes tends to wander, especi- ally in those of nervous temperament and delicate physique. Increasing pursuit of the answers to the riddles thus suggested will enable us to give more and more help to those who find youth not so much a time of joyous life as an age of uncertainty and discontent. Often enough adolescence is a period of extravagance, and those of matm-e years are sometimes inclined to judge too harshly those who, in the wildness of youth, let their behaviom? offend the conventions. Let it be re- membered that when in early life eccentricities of conduct pass a certain point, it brmgs those concerned within the category of nervous disorder, and really occasions them CHILDHOOD AND YOUTH 255 to merit sympathy rather than censure. Apropos of this the " flapper " whose particular phase of adolescence has lately attracted popular attention. The true facts are that the " flapper," who, by uncon- trolled spirits and occasionally immodest behaviour, sometimes shocks her seniors, is carried away by the exuberance of developing youth. It is, indeed, quite normal for the profound changes that proceed in the human mind and body between the years of childhood and adult life to be accompanied by emotional outbursts. The emotions are not yet curbed by that judgment which takes its place as an important part of the individual's mental make-up in later life. It is these changes and varjdng mind attitudes, indeed, that go to make the periods of puberty and adolescence so interesting to the student of human nature. Particularly is it to be expected that the changes which accompany preparation for the great function of woman- hood should, as a matter of course, produce both reflec- tions in the body and echoes in the mind. The bodily reflections are recognized by the physician as hysteria, headaches, anaemia, and nerve troubles of all degrees of gravity ; the mental echoes and accompaniments thereof present themselves as those emotional phases beloved by the novelist. It may be said at once that were it not for these cataclysms in the sphere of the emotions due to the general disturbance of adolescence the world would miss both in romance and real life many of the tragedies and comedies of affairs of love, hatred and jealousy in daily life. The subject of adolescent changes really is, of course, the unwitting victim of her mental and physical vagaries ; and society has erected safeguards to the con- duct and mentality of maidenhood in the shape of chaperons and conventions that subject her possibly unwise inclinations to the rule of a more mature judg- ment than she herself possesses. Heightened emotions lead to increased suggestibility, and the new and odd 256 THE PROBLEM OF NERVOUS BREAKDOWN interest which the adolescent boy or girl suddenly becomes possessed of in regard to members of the opposite sex, unquestionably achieves such dominance for a time that they are, as it were, hypnotized and unable to exercise full discretion in their friendships. Taking the characteristics of feminine adolescence in great detail one finds that there is an increasing self- interest which arises paradoxically enough from the scarcely conscious wish to become interesting in the eyes of the other sex ; definite wish to marry has not yet arisen, but, at the same time, instinct strongly prompts behaviour which tends to make its subject an object of attraction to men. The emotional outlook quite over- shadows the none too strongly developed reason and judgment of a girl. As secondary results selfishness; obstinate following of lines of conduct which may appear irrational or even scandalous to parents ; determination to secure as much admiration as possible tend to make the enchanted young woman an unstable and unreliable member of society for the time being. Unable to exercise judgment for herself, she is only too liable to behave in a way that scandalizes her friends and relatives, although she is not in the least possessed of vicious tendencies. In times of great emotional strain, when social rules are to some extent temporarily allowed to lapse, ex- aggeration of the normal characteristics of developing maidenhood are only to be expected, for the maiden can- not help reflecting the excitements of the days in which she finds herself. It is obvious, then, that in the indis- cretions and apparent immodesty of flapperdom we have nothing but the irresponsible conduct of adoles- cence involuntarily aggravated by its representatives without immoral intent. Indeed, unkind critics of the flapper should note that by her very fickleness she illus- trates the characteristics of her peculiar mental condi- tion, for the swift emotions of adolescence have little depth, and her friend of one day and her sweetheart the CHILDHOOD AND YOUTH 257 next may be the object of complete indiSerence yet a little later. As the late Sir Thomas Clouston observed : " We know that the love-making, the flirting, the engage- ments to marry, and the broken hearts of the adolescents are not really very serious affairs. The cataclysms of life do not happen then." CHAPTER VIII PEINCIPLES OF SELF-HELP The will to be well — Misconceptions about self-help — Importaaice of co-operation between patient and doctor — Conscientiousness in carrying out instructions — Holding on during set-backs — Self- reverence, self-knowledge, self-control — Strengthening self-control — Exercising inhibitory power — Self-denial — Getting rid of fear — Nerve-health and rehgious faith. IN aU forms of ill-health, but particularly when cora- bating nervous troubles, the doctor welcomes the will to be well as a most valuable aUy, To obtain the co-operation of the invahd is, indeed, a very important step forward. As disturbed thought-control plays such a leading role in all forms of nervous breakdown, it is clear that any determined effort by the individual con- cerned to order his thoughts and carry out a systematic plan of mental self-help is going to be an invaluable aid to recovery. But so often is it found that people believe all their difficulties both in mind and body come from some physical source that it is well to exercise tact in approaching the question of self-help. When the sick person is under the impression that only a physical remedy can help he entirely fails to grasp the significance of trying to help himself by thought-control. Moreover, often he is not at aU sure that requests to him to help in the treatment by using his own will-power do not imply a suggestion that his illness is in part due to his own slack- ness, a suggestion he sharply resents. Consequently, the doctor may often spend a quarter of an hour usefully in explaining just why self-help is so valuable in this 258 PRINCIPLES OF SELF-HELP 259 class of malady, and in what directions it is most likely to b6 most successful. The invalid seems to argue fret- fully : " Here am I crippled by a miserable condition that makes life a burden, prevents my doing the work I very much want to get on with, and now you come along and talk about self-help ! Gracious Heavens ! If I could have helped myself out of this state of torment I would have been weU long ago. Not at all. I am tired of the whole thing — it must have a definite physical basis. I wash my hands of all responsibility in the matter. To get me weU is my doctor's task entirely." This not unusual attitude can only be combated suc- cessfully by patient conversation in which the relation of the invalid's will and thought to his iUness is carefully explained. In addition to this, it should be pointed out .how, after all, self-help is by no means only a question of mind discipline, but concerns such things as regulation of rest, carrying out prescribed recreations, conscientiously following any rules of hygiene that may be laid down, or making an effort, where effort is necessary, to persevere with a dietary or remedies that are not particularly palat- able. God helps those who help themselves, says the old proverb. Never was a truer word spoken about those exhausted in nervous system ; no better saying can they find as their daily watchword. Self-help means exercise of mind, and exercise of mind takes us nearer to or further from God, just as we will. To walk healthward is to go Godward. To attempt to go Godward is to find help. Let those bothered by nerves remember that every possible influence has to be brought to bear in restoring health ; let them bear in mind how the balance sways for weeks and months between recovery and relapse, particularly let experience remind them how true it is that the last straw of help breaks the back of the illness — then, holding in mind these things, they will realize clearly how quite a small effort of self-help may finally tip the balance in their favour. In a word, the more the 260 THE PROBLEM OF NERVOUS BREAKDOWN invalid will carry out things suggested for helping himself the more thorough is the attack on his troublesome malady. Infinitely more hopeful are the prospects of speedy recovery when the patient pulls his full weight in the contest ; by so doing he not only does useful work directly but encourages doctors, nurses, friends and relatives in their efforts to bring him through the slough of despond we know as nervous breakdown, and so in- duces them to redouble their own efforts. In matters of detail it is extremely important for people to carry out conscientiously any simple tasks set as self-help exercises. Be it a Jig-saw puzzle to strengthen attentive control, be it a game of patience to assist concentration, or a light gardening job, some copy- ing, a little carpentering, or some painting — be it a slight task or a reaily useful one — ^it must be carried out with a will and intention to do the best, and leave the rest. That is all one asks ; that the one helped shall himself do his bit in the work of getting him weU. Never mind if it is a poor " best " or a good " best '* — it is the inten- tion and attempt that counts and really helps. Show us the nerve-sufferer v,^ho is making very slow progress, but nevertheless is doing his " best " to co-operate — then you will be showing one who is most certainly going to get weU. Time after time does it happen that in one of those familiar crises which come to disturb steady progress and, without warning, thrust the invalid back to sullen misery, does it occur that the victim's ability to hold on — to make use of self-help principles — takes the sting out of these " nervous attacks," and prevents that tragic sur- render which is only too often the fate of those who struggle without proper support or instruction. To pre- vent the hopelessness that leads to such surrenders must always be one of our leading aims, for we know that a letting-go of this kind may need weeks of good work, whilst, on the contrary, the conquest of such threatened PRINCIPLES OF SELF-HELP 261 set-backs enormously strengthens the foundation for future health which is laboriously being built up. Bacon said, " The fit man and the right man is he who has constancy of mind, so that he enjoys the good without disdain and endures the bad without impatience." What an ideal for those of over-active thought and feeling ! Such an ideal that if we take it as a standard of the normal as opposed to the nervous few people would be acquitted of neurosis. Nevertheless, that is the sort of balance of mind that we should all aim at ; it is the attitude pointed to by philosophers as the pearl beyond price ; the goal sought by ascetics for centuries ; the ideal of priest, prophet and poet. Stevenson's old sheriff showed to perfection the calm dignity, the stately certainty, the graceful equanimity of those who feel their feet on a rock and their minds unthrilled by the storms and troubles of the world. The very antithesis of the neurasthenic, yet withal exhibiting quickness of thought and mental ability with his tranquillity. Of Mr. Hunter's room — he was Robert Hunter, Sheriff of Dumbarton — we are told that no " young man could have found else- where a place so set apart from envy, fear, discontent, or any of the passions that debase ; a life so honest and com- posed ; a soul like an ancient violin, so subdued to har- mony, responding to a touch in music — as in that dining- room, with Mr. Hunter chatting at the eleventh hour, under the shadow of eternity, fearless and gentle." We want, then, a firmness of thought, a control of feeling, such that emotional storms beat harmlessly over our heads, or better, die down before they are really aroused. Tennyson epitomized a volume of self-help instruc- tions when he wrote : "SeK- reverence, self-knowledge, self-control. These three alone lead life to sovereign power." His beautiful couplet makes a golden rule for the nerv- ous to live by ; something definite to keep in view, a 262 THE PROBLEM OF NERVOUS BREAKDOWN triple goal always increasing in worth and glory the nearer we get to it ; a triple crown for those who have well stayed the course in life's great race. But in the splendour of the reward let us not forget its magic powers of protection, for the wearer of the triple crown symboliz- ing self-reverence, self-knowledge, self-control, is thereby rendered proof against the assaults of many of those mental demons which together bolster up the bogey of nervousness. Our preliminary study of the chief mani- festations of nervous disorder showed us how commonly poor self-control weakens the defences against this kind of malady, and how many troublesome symptoms are the direct expression of weakness in self-command. Here, then, is one way in which self-help can be exer- cised with advantage. In a word, if anyone suffering from nervous disorder will do no more than promise to attempt to regain lost control — ^that is, to increase the amount of control over self that happens to be present at the time of illness — ^then a very important step will have been taken towards the ultimate restoration of nerve-harmony. At once it may be said that the first goal to be sought by any one who wishes to increase mental control is improved power of attention. Exercise of attention in itself evidences some degree of mind- control and the degree of nervous disability can to some extent be gauged by the improvement of attentive power as evidenced in general behaviour and conversation. This wonderful power of voluntary and involuntary con- trol — the function of inhibition — is one of man's crowning developments ; it is one of the great points of distinc- tion between man and the lower animals that he has this faculty of forbidding himself, or of making a choice between two actions so strongly developed. To strengthen inhibition, to augment our will-power by every possible means should be one of our daily tasks. This develop- ment should always be one of the leading objects of education, and the training of the will should play a much PRINCIPLES OF SELF-HELP 263 greater part in the up -bringing of young children than has hitherto been the case. Ability to make a decision and maintain it ; the power to follow out persistently a definite Kne of life ; the power to lead and help fellow-creatures — all these depend ultimately on the extent to which one can exercise the great function of inhibition. From the practical point of view, one finds that the best way of strengthening mental control is to make a habit of exercising inhibition to a greater or less extent every day. Indeed, it is remarkable what great benefit the nerves can obtain from daily exercise of self-control ; by no means an original observation or a new thought, for religious systems have noted the importance of exercising inhibition in little ways in the building up of character. Is not this the whole practical point about " self-denial " ? And self-denial has been taught by many Churches in many lands to be a great factor in the progress of the human soul. It is the continued exercise of the power of inhibition, of forbidding, of self-denial that makes so strongly for the regaining of control ; much more so than one or two single acts of great self- denial in which the full power of inhibition have been concentrated on one great deed, as it were. The con- tinued practice of inhibition and of little self-denials steadily strengthens the wiU, and therefore steadily helps the individual towards the longed-for end of complete self-control ; whereas one great act of inhibition, or self-denial, by its very intensity, may go a long way towards further weakening the patient and exhausting his nerve-strength. The mere fact of occasionally re- stricting some habitual pleasure — say, smoking less cigarettes or purchasing a new dress — or the voluntary denial of various good things the world has to offer, goes a long way towards exercising and strengthening the control we ought to have over our thoughts, words, and deeds. Of all things the best exercise for increasing powers of both attention and control is to be found in 264 THE PROBLEM OF NERVOUS BREAKDOWN the practice of watching one's thoughts, and checking each one that points in the direction of surrender, depres- sion, doubt, anxiety or anger. Every thought of a nega- tive kind should at once be made use of to point the way towards its positive counterpart. A persistent habit of seeing the bright side of everything ; of determinedly looking for the silver lining no matter how black the cloud will be found invaluable in self-help. Fear is the great adversary of most nervous persons. Manifesting in a thousand guises, choosing anxiety and worry as its favourite forms, fear haunts many through- out their lives. Anxiety attacks, sense of apprehension, worrying over trifles, fearing things that never come to pass exhausts energy and wears down health. Unreason- able fear about the common possibilities of life is at the bottom of much impairment of nerve strength and vitality. The neurasthenic is essentially a person preoccupied with fear. Often enough he does not realize the extent of his enchainment, and only after careful examination of his outlook begins to understand how fear has held him bound. Where there is fear without due cause sympa- thetic reasoning helps to dismiss the troublesome thoughts, but one's task is harder where, as often happens, the nervous person can point to some definite circumstance in life as a reasonable basis for his anxieties. The point here is, of course, that the abnormally anxious person fears out of due proportion. In other words, he makes a habit of anticipating the worst. If he catches cold he expects pneumonia ; if he has a pain in his chest after a heavy meal he fears heart trouble rather than indigestion ; if a friend is unwell he anticipates the funeral ; if his business gives a little trouble he is haunted by dread of its collapse. As a rule, individuals show a curious partiality for particular anxieties. The man who is always worrying about his health may take the success of his career for granted ; the woman who is continually anxious about PRINCIPLES OF SELF-HELP 265 her future takes little heed for her health and so on. Cer- tainly many whose " nerve " is poor are troubled by fear at every turn, and their lot is a sad one. After aU, fear is one of the penalties of being self-centred, and although impaired nerve-health may lead to morbid self-centring for which the subject cannot be held directly re- sponsible, nevertheless, the penalties have in any case to be paid. To get away from self is a troublesome but essential task for aU suffering from nervous disabilities. Their malady turns their thoughts inwards and again inwards to dwell on the myriad discomforts of body and mind to which they are subject. Recovery of health can only be made sure when they can succeed in looking out- wards with interest to the world about them. They have to get out of their tomb of desolation in which self seeks to imprison itself. The way to the goal of freedom can be best lighted by a sound philosophy of life. WUliam James realized this when he boldly recorded his belief that " the sovereign cure for worry is religious faith." ^ Certain it is that the man or woman whose faith in things unseen is so strong that with spiritual eyes they can pierce through the gloom of temporary appearances and see the undying light beyond have within themselves a support in ilbiess that nothing else can equal or approach. To feel safe, to know that God is AU-in-All, and that the service of His creation is all the task we need is indeed to have " cast off the works of darkness, and put on the armour of Ught." 2 ^ Prof. Wm. James. ^ Rom. xdii. 12, PART IV THE BREAKDOWNS OF WAR CHAPTER I THE EFFECTS OF WAR STEAIN Strain of modem warfare — Shock from explosion — The strain of battle — Brain liable to both mental and physical assaults — Determining facts of war-strain and civilians — General worries— Raids and bombardment. AT the outbreak of the great war it was confidently XjL expected by neurologists that the terrible engines of destruction and the high explosives which would figure prominently in a modern conflict would place an over- whelming strain on many combatants. This anticipa- tion was quickly realized when the ambulance trains began to bring in numbers of men suffering from nerv- ous and mental derangements, and it was not long before the public became familiarized with the new term shell- shock or before special arrangements were made for dealing with this class of case. One realized, indeed, that the mentally wounded would require as much atten- tion and care as the physically injured. In the actual area of hostilities stresses and strains — both physical and mental — crowded on the combatants more and more furiously. The fatigue of service, the long watch- ing in the trenches by day and by night, the cunning and remorseless cruelty of the enemy, the stress of actual engagement, piled up a burden so great that the individual has not always been able to bear it. The noise alone is sufficient to cause such vibrations in the brain and special sense organs as not infrequently to overwhelm them ; shells and bombs, mines and aerial torpedoes, bursting with ceaseless din, have combined in 269 270 THE PROBLEM OF NERVOUS BREAKDOWN such an assault of sound as the human nervous system has never before been asked to sustain. The fact that explosions have featured so prominently in war conditions producing nervous breakdown has led to the use of the now popular term " shell-shock " to indicate all the varieties of nerve disturbance thus occa- sioned. It should, however, be clearly understood that many cases of breakdown are not really instances of sudden shock at all, but represent a total exhaustion of the nervous system following a period of strain. Various other terms are used to designate these mental and nerv- ous troubles, but there do not appear to be any phrases so clearly indicative of the issue as war-neurasthenia, and war-hysteria. War-strain, or psycho-neurosis of war, are also terms in common use, but would appear to have no special advantages. All these terms indicate the varied expressions of mental disturbance and nervous breakdown particularly associated with stresses of war conditions. Studying in detaD. the special features of shell-shock clearer understanding is necessary of the fact that the bursting of a shell is often by no means the sole cause of the collapse ; the exhaustion may be — often is — simply the last straw in breaking the camel's back. It frequently happens that the neurasthenic state immediately follows what appears to be a comparatively small shock ; in these cases the exhaustion has come at the end of a series of events tending to upset the balance between mind and body. Men in the front Imes of an army are frequently kept in a state of nervous tension for days at a time. Hunger, exposure, fatigue, and want of sleep aU tend to sap the nervous energy whilst strong emotional waves disturb mental calm. Anticipation of coming events, fear called out by near explosions, horror and distress at the wound- ing or death of comrades, load the mind heavily, but may just be supportable ; yet they stretch the nerves to such a point that very little extra strain causes a break. THE EFFECTS OF WAR STRAIN 271 On the other hand, it is quite true that an explosion of itself may be sufficient to produce severe shell-shock. High explosives produce such a tremendous disturbance that the nervous system may be suddenly exhausted apart from any wounding, and even where the sufferer is in a good state of physical and mental health. The terrific noise, tremendous concussion, and the vast up- heaval of ground — victims of the explosion being thrown headlong many yards away or buried where they stand — present an appalling combination of nerve-breaking conditions. Whilst here again the emotional factor constantly operates and dreadful sights of mutilation and slaughter play their part. To understand shell-shock one must recall the peculiar features of brain action and its characteristic concern with two phases of life. As we have seen, the brain is remarkable for functioning in two spheres ; on the one hand being the organ for the regulation of physical activity, and on the other the medium for the harmoni- ous co-ordination of these two kinds of brain activity ; it is compounded of a psychological as well as of a physio- logical factor, and for the same reason disturbance of mental balance, that is weakening of nerve, may be initiated from both sides. All our ordinary experiences of life are concerned with brain action in regard to both thought and activity. Whatever we do we live this double mind-matter life ; always we live this double life of thought and movement, and there is ceaseless action and reaction between mind and body. Whatever is conceived in thought depends on the brain for its material accomplishment ; whilst on the other hand, activities in body constantly affect mental outlook. These functional peculiarities of the brain and its depen- dent nerve-centres particularly predispose the nervous system to shock and strain, for it is quite clear that they must come in for a double share of stress. The brain is the only organ of the body that does work both mental 272 THE PROBLEM OF NERVOUS BREAKDOWN and physical. Compare it with the lungs, for example ; one can injure these by some direct physical assault — in war one can drive a bayonet or bullet into them, one can reach them by poisoned gas — but one cannot worry them directly by emotional strain. On the other hand, one can not only injure the brain physically, but in addi- tion to material damage or concussion one can harass it by mental worry at the same time. Indeed, frequently the conditions of a head- wound are such that the brain is not only shaken up, but is strained by the anxiety, excitement, and general emotional stress attendant on the circum- stances under which the wound was received. All organs of the body other than the brain can only be directly assaulted by material means. The brain is subject to both mental and physical blows ; even under favour- able material conditions it is continually subject to damage from emotional shocks. Is it not clear that a man under bombardment may come through with his entire physical system apparently undamaged, but a few hours afterwards find that he is seriously incapacitated through disorder of his nervous system which has re- sulted from the mental strain he has undergone and not from material injury ? The flying fragments of bursting bombs did not damage him directly, but the shock of the attack, the horror of seeing others struck, the fear about self, friends, and comrades, anticipation of more intense bombardment, near explosions and the excitement of battle, have combined to produce a volume of mental stress that has proved too much for his nervous system. Even where the breakdown has apparently occurred as the result of one big explosion, the psychological factor commonly determines the resulting nerve disturbance. Often it is a question of acute anxiety, horror, or antici- pation sufficing to overcome the nervous system in face of simultaneous physical shock ; at other times it is a matter of one final mental strain acting as the last straw. In considering this sudden loss of nerve-balance, it THE EFFECTS OF WAR STRAIN 273 must be realized how much the individual is always strained before the final shock hj the exercise of his normal control over emotional states. Up to a point he manages to keep a firm hold over himself, to crush down his fears and anticipations. Be it noted, this control is often maintained for a short while after the final catastrophe ; long enough, indeed, for the shocked soldier to make some attempt to help himself out of difficulties. There is, therefore, often a definite period between shell-explosion and resulting nerve-collapse. The explanation of this is that the intensity of self-preservation so strongly rooted in every human body operates to keep up control when otherwise it would be lost by conscious will. This power- ful instinct takes charge for the time being and forces the individual to act in spite of the shock sustained until he has secured safety. Then it lets go, and, left to his own conscious control, the sufferer collapses. There is yet this further consideration that whatever be the actual happening of series of events that finally determines breakdown on the field of battle, the catas- trophe is enormously favoured by certain predisposing conditions. So much so, indeed, that one is tempted to beheve that a complete record of the past life of each man who suffers from a war neurosis would certainly reveal the occurrence of one or other of these. Certain it is that there has been individual or family tendency to nervous instability in a great many instances of shock or similar states. Predisposition to nervous disorder is un- doubtedly an important factor in the chain of circum- stances which culminates in these maladies . Often enough, the inherent tendency to disturbance of balance between mind and brain is a constitutional matter, but where a man born apparently with a healthy nervous mechanism has for some reason broken down in civil life years before he suffered the strange experiences of war, this earlier breakdown has left its mark in such a way as to make him an easier victim to war strain. In addition to these 274 THE PROBLEM OF NERVOUS BREAKDOWN two important predisposing conditions — constitutional or acquired nerve weakness — intemperate habits or previous injury to the head, particularly where con- cussion of the brain has resulted, must certainly weaken the natural defences against shock and stress ; also a taint of insanity or epilepsy in a family seems to predis- pose the members thereof to the neuroses of war. Yet again, local disabihties. even of a small order, especially those affecting the special senses or limbs, not infre- quently influence the character of local nervous mani- festations resulting from shock and strain ; whilst habitual indulgence in tobacco certainly opens the way to the ready development of certain nervous symptoms, notably that group associated with " soldier's heart." Of course, on the field of battle itself, hunger, privation, and the debilitating effects of poisoned gas help to lower nerve resistance. Again, the question of war-strain has affected the nation in its reactions on civilians. The long struggle has reacted disastrously on many in civilian life, although it must be said at once that in this country at any rate civilian nerves have, on the whole, borne this strain with wonderful stoicism. The shock of the outbreak was very great, and the succession of events which plunged us from peace into horror was bewilderingly rapid. It is a tribute to the stabihty of British nerve that at that time cases of sudden breakdown were few and far between ; the strain at home has been chiefly mental, varying from the sudden shock of receiving bad news to the dreary- watching and waiting that over-strained even the strongest. Nervous breakdowns attributable to war- strain there have been, but it is a fact that there has been no serious increase of mental or nervous illnesses amongst the civilian population in spite of distressing alarms, disappointments, and local bombardments that have been suffered. In no belligerent country has the civilian population THE EFFECTS OF WAR STRAIN 275 entirely escaped the graver consequences of war-strain. All wars necessarily throw an added, stress on the nerves of the people at large ; thoughts of dear ones at the front, anxieties about general developments, financial worries and the inevitably distressing effects of war-time conditions always react on those left at home. But when the conditions of warfare are such that the army is the nation and the battle-front is from time to time carried to the heart of big cities and to the very threshold of the citizens, the stress becomes very great for many indi- viduals and unbearable for some of nervous tempera- ment. Thus, not only has the Great War been pro- ductive of nervous breakdowns that would probably not have occurred otherwise, but it renewed dis- orders that had been remedied, and developed latent weaknesses in not a few nervous systems. The ups and downs of the long struggle were accompanied by corre- sponding waves of emotion in the nation as a whole, and each wave told most heavily on those of weakest nerve. In addition, regulations and inconveniences which never previously hampered people in this country pro- duced a sense of uncertainty and apprehension that again was particularly emphasized in those constitutionally predisposed to neurasthenic conditions. And yet further, it cannot be doubted that unaccustomed restrictions and modifications of diet played a part in debilitating people's nerve tissues. The brain requires plenty of fat for its physical sustenance, and fat was one of the com- modities that was difficult to obtain. Raids by sea and air, in their turn, augmented the burden thrown on the nation's nerves ; but although not a few individuals suffered thereby, it is equally true that the national nerve as a whole was strengthened rather than otherwise by the experiences of red-hot war in our midst. The features of neurasthenic and similar conditions amongst civilians either attributable to, or aggravated by, war strain have not differed as a rule from the ordinary 276 THE PROBLEM OF NERVOUS BREAKDOWN breakdown of peace time, with the exception of a few instances where complete mental unbalance occmTed, and stricken persons became deluded into the false belief that they were pursued by spies, or suspected of spying, or being persecuted by the Government in various mysterious ways, or that they were being burdened with serious responsibilities in regard to the war. On the other hand, where breakdowns occurred primarily as the result of naval or aerial bombardment, the resulting conditions in many instances resembled those of the shell-shock of the battlefield. After all, the conditions of bombardment with the shock of explosions, the ear-splitting crashes, the emotional strain, and only too often the terrible sights are the same, and must react on human beings in the same way, whether they occur in an actual battle or, say, during an air-raid, and so it is that after bombardments civilians suffered from such things as loss of voice, paralysis, persistently rapid heart-beat, sleeplessness, terrifying dreams, trembhngs, mental depression, and digestive disturbances. Still, there is no doubt that the extraordinary adaptability of the human system enables people to get used to even such experiences as bombardment from the air, and, so far as can be judged, the general effects on the nervous system of dropping bombs was not so severe as in the earlier days of raiding, excepting in the case of those immediately concussed by explosions. CHAPTER II SHELL-SHOCK The wounded in mind — No new disease — A convenient term — Battle- field breakdown — Characteristics of war-neurasthenia — Typical examples — Mental shock and its consequences — Paralysis — Other limitations of movement — Astasia- abasia — Dumbness — Blindness — Deafness— Fui'ther illustrations — Mental breakdown — War hysteria — Psychological basis of shell-shock — The outlook in war-break- downs. NERVOUS disorders due to war strain do not differ essentially from those occurring in the breakdowns of ordinary civilian Ufe. Examples of the neurasthenic state in its many phases, of hysteria, and of serious mental derangement are frequent enough as consequences of war-time stresses, and so it may be said at once that, whilst the term shell-shock has been made convenient by usage, there is really no new nor special nervous dis- tm^bance for which such a novel name is required. As remarked in the last chapter, the actual shock of an ex- plosion is often merely the " last straw " in a series of events straining the mind and nervous system ; and the resulting breakdown often has no features associated with the particular shock which finally precipitated the illness. On the other hand, it is quite true that an explo- sion may be the primary as well as the determining event, and the resulting nervous disorder may in its character- istics bear some witness to the occasion of its origin. For the rest, the observations made in regard to the forms of nervous breakdown and the ways in which this disaster is commonly made manifest, apply equally well here.^ Proceeding to the study of the usual appearances of 1 Cf. Part II., Chap. 1. 277 278 THE PROBLEM OF NERVOUS BREAKDOWN battlefield breakdown, it must be borne in mind that the state of things found near the firing line differs consider- ably from that observed in the nearer base hospitals, and still more from that seen in the military institutions at home. There Mdll, however, be no advantage in confining our attention to cases in which there is a definite connec- tion between nervous collapse and the explosion of a shell, bomb, or mine — ^true shell-shock ; it will, indeed, be more convenient to review widely, and without immediate attempt at close analysis, the general manifestations of these breakdowns. It has already been said that the neuroses of war present the same features as the break- downs of civil life ; particularly are there very close re- semblances between them and the nervous maladies with which we are familiar as the result of railway disasters, accidents with machinery, earthquakes, and similar calamities. Certainly the symptoms are often influenced and associated with war happenings, and especially so in regard to mental disturbances, but the fact remains that we have not here to face any new kinds of disease ; a circumstance that has made our task in treatment somewhat less difficult. Where nervous disorder occurs in men subject to the continual strain of modern warfare, headache, sleep disturbed by nightmares, neuralgic pains, haunting thoughts, indigestion and sense of fatigue in mind and body, gradually undermine strength and impair self- confidence. In civil life the over-worked individual has his sleep spoiled by wakefulness, and muddled dreams about things he has been occupied with. In the neuras- thenia of war these dreams become hideous nightmares in which, with vivid detail, gruesome experiences of battle are lived through again and yet again. The more terrible particular experiences have been, the more nerve-racking in view of associations with personal feelings — the loss or mutilation of friends, for example — ^the deeper the imprint on the receptive mind, and the more graphic and SHELL-SHOCK 279 tormenting the subsequent reproduction in the watches of the night. Similarlj^ special conditions commonly accentuate particular symptoms, and so lend a character to neurasthenic states resulting from the strain of active service that superficially distinguishes them from the nervous exhaustion of civil life. The sort of experience that has so often led to war neurasthenia is well exempUfied by the following history. An officer who had been through the hardships of a long retreat following eight or ten weeks of continued fighting came through this ordeal without injury. Then his luck deserted him, and he found himself left badly injured in a trench with only wounded men around him. There he lay for many hours with shells dropping round him sometimes near and sometimes far. Exhausted and in pain, expecting every minute to be his last, he felt certain that if not put out of his miseries by a shell he would be killed by the attacking enemy or left in a sort of no-man's-land to die of starvation. However, as things happened, a counter-attack brought him help, and he was carried back to safety. Neurasthenia resulted, and for weeks and weeks this victim of war stress suffered from broken sleep with terrifying dreams, and was with- out mental or physical energy. In addition, he was frequently obsessed by the false sense of shells dropping round him. Although, under systematic treatment, he ultimately recovered and returned to active service, he was for a long time incapacitated by inability to sustain any mental or physical effort, irritabihty, feehngs of apprehension, and involuntary remembrances of his experiences whilst lying wounded. Such an experience may be compared with that of another officer who was suddenly knocked over by the explosion of a shell close by which fortunately caused neither physical injury nor loss of consciousness. In- deed, he was able to get up and continue his duties. Nevertheless, the shock had told upon his nervous system, 280 THE PROBLEM OF NERVOUS BREAKDOWN and some hours later when fatigue and hunger had further strained his nervous system he became mentally confused, and when given an order by a superior officer was unable to grasp its meaning to execute it. Neuras- thenia developed just as in the preceding instance. Exhaustion, headache, disturbed sleep, and extreme sen- sitiveness of the whole nervous system produced incapacity lasting for months. Over and beyond the onset of a readily recognizable neurasthenic state, with its attendant symp- toms, there have occurred quite commonly a series of disabilities resultmg in the main from mental impressions. Particularly so where the breakdown has been finally deter- mined by the shock of an explosion. To be blown up by a shell, mine or bomb is, indeed, a terrific experience. The general upheaval, the appalling noise, the physical concus- sion and consequences such as being hurled through the air or buried in debris — all these things occurrmg at a time of mental strain — ^result in far-reaching disorder of nervous function. Thus it is that after such experiences men are found unconscious, or mentally confused ; deaf, blind, dumb, or paralysed ; sometimes bereaved of memory ; sometimes gibbering insanely. The paralyses, distortions, and special sense distm^bances of the shell-shocked are so numerous in manifestation, and so varied in combina- tion, that akeady a large descriptive literature has accu- mulated in regard thereto. Commonly loss of power is limited to one or two limbs, and but seldom paralyses the whole body. Often, indeed, in place of complete loss of movement there is weakness with irregular movements of the limbs which proceeds outside the control of the sufferer. Again, it is not uncommon to find lessened ability to co-ordinate the various movements of the body ; when this is so there may be no difficulty in actually moving arms or legs, but the victim thereof is unable to use his limbs in a steady and harmonious manner. Where these disorders chiefly affect the lower extremities they are, of course, manifested by peculiarities of gait. These SHELL-SHOCK 281 vary from lameness to complete collapse of the whole muscular mechanism used in walking. Inability to walk properly is, indeed, a common result of shell-shock and, apart from the more common phases just indicated, some singular abnormalities have been observed, such as where men have for some weeks been doubled up Hke those old labourers one sometimes sees working in the streets of country villages. Fortunately for them, those thus afflicted are usually able to lie in their beds comfortably and straight. It is when they get up and try to walk that their backs become bent and painful. Then there is the remarkable condition known as astasia-abasia, in which there is ability to carry out movements of arms or legs easily when Ijdng down, but complete failure to control limbs when standing or walk- ing is attempted. A good description of this disorder as it appears on the battlefield has been given by IMM. Roussy and Lhermitte, two weU-known French obser- vers, in the follomng terms : "It commonly occurs in a man who has been thrown to the ground more or less violently, and who has rolled into a trench or hollow. He has sometimes been able to get back to the first-aid post either by laborious walking or by crawling along the ground. By the time he gets to the ambulance he is quite unable to walk. When he is examined lying down he exhibits no elementary motor disorders ; all move- ments, muscular power and tendon, osseous and cutane- ous reflexes are normal. If placed in the upright position he either collapses on his flaccid lower limbs or the latter are shaken by a rapid tremor which ends in an indefinite treading movement. When told to walk, his Hmbs are incapable of action, and in spite of an obvious efiort his legs are quite unable to execute a voluntary movement. He is unable to walk, even with the aid of two sticks ; the limbs are dragged along inertly, as in true paraplegia."^ 1 Dr. G. Roussy and M. J. Lhermitte, The Psycho-neuroses oj War, pp. 40, 41. 282 THE PROBLEM OF NERVOUS BREAKDOWN Sometimes these disabilities, particularly where there is complete loss of power in a limb, are due to some actual damage to the nervous system, so that either through an injury to the brain or spinal cord, or through the severing of a nerve trunk connecting the limbs to the central nervous system, there is a complete cutting off of control. But apart from these organic injuries, the study of which finds no proper place here, there have been a far greater number of instances in which the disorders of movement have been entirely functional in nature. That is to say, they come within the category of those disturbances of nervous function which in discussing the psycho-neurosis of civilian life we classify under the comprehensive term of hysteria. They are, therefore, conditions brought about by the action of a powerful suggestion in individuals rendered susceptible to mental impressions by emotional stress. In the same order come those numerous disturbances of speech, sight and hearing that have become familiar to the public through various descriptions and para- graphs in the daily press, apart from an increasing semi- popular literature on the subject. Dumbness has been extremely common as a result of shell-shock. Every one knows that acute emotional stress may deprive an indi- vidual of the power of speech. Sometimes the mere shock of being blown up is sufficient to take away control of vocal organs ; sometimes, added to the shock, there is a strong self-suggestion that the voice has been lost, con- veyed to the stricken man by his sense of incapacity to collect his faculties. Where there is a strong suggestion of this kind recovery of speech is usually deferred longer than where the dumbness is primarily due to shock. For the time being there is complete inability to use the muscles of the larynx. Moreover, the idea of paralysed vocal organs is usuaEy so strong that there is inability even to whisper, although whispering has noth- ing to do with the vocal cords, but is carried out by teeth, SHELL-SHOCK 283 lips, and tongue alone. In many cases there appears to be great impairment of the power to move the tongue properly when it is a question of wishing to speak, although the difficulty does not persist with the part itself. In- stead of complete loss of speech, it sometimes happens that stammering occurs. When this is so we find many personal peculiarities with regard to the stammerer, just as is the case with stammerers in civil life. The blindness of shell-shock at first sight seems even more remarkable than the paralysis or other disabilities, in view of the fact that it occurs so often where there is absolutely no damage to the eyes or optic nerve, and is recovered from time and again with such dramatic suddenness. Commonly the sufferer from this form of war hysteria keeps the eyelids closed, and behind them the eyeballs rolled well upwards ; a process of self- suggestion initiated by darkness following an explosion or aggravated by some slight muscular trouble, such as dust blown into the eyes, is often responsible for the inability to see. Be it noted, that the blindness is quite genuine and the shell-shocked patient behaves quite differently from the man who is malingering. Deafness in one or both ears is another result of shell- shock often observed. Sometimes it is very persistent and its association with actual damage to the structure of the ear may make it difficult to determine whether the inability to hear is functional or irretrievable. As wiU be seen, when reviewing the future of the shell-shocked, whilst dumbness is one of the results most readily treated, deafness is extremely resistant to treatment. In one sense it is fortunate that the deafness of shell-shock is very often associated with inability to speak, because the rehef of the latter encourages the patient to assume an attitude of mind in which he is expectant of being freed from the former. As the cure of these cases must always in principle be psychological there is here an obvious factor operating in favour of recovery. 284 THE PROBLEM OF NERVOUS BREAKDOWN The following notes illustrate how some of the common results of shell-shock of the kind just discussed produce disablement. Sometimes shell-shock results in a combina- tion of the neurasthenic state with one of the more defi- nite local limitations of action, as shown by the case of a gunner who broke down after having been blown up and buried no less than three times. Here the symptoms were severe headache, broken sleep, with terrifying dreams ; general nervousness ; depression ; want of appetite ; pains in the legs ; and also paralysis of the left arm. Under appropriate treatment the last-named symptom disappeared long before he was relieved from the general neurasthenic troubles. Again, a non-commissioned officer who was buried by the explosion of a big shell became deaf and lost all powers in the right lower limb from the hip downwards. The paralysis was accom- panied vv^ith a sense of burning in the right side and leg, whilst disturbed sleep, headache and mental confusion sufficiently expressed the accompanying neurasthenia. A man was hit in the back by a fragment of bomb just as he was getting out of a trench ; he fell forward and found himself paralysed in both legs. This incapaci- tated him for a long time, and six or seven months after- wards he was only able to get about with the aid of two sticks, and with bent back. Another man who was buried by shell explosion lost consciousness and knew nothing more until he found himself in a dressing station. For some hours both legs were completely paralysed, the power to use them then returning gradually. Subse- quently, he was for some time very nervous, sleeping badly, troubled with nightmares, and suffering from headache and mental confusion. The more usual combinations of physical and mental disabilities following shell-shock and war-strain are well illustrated by the following examples : A young private soldier ivas buried in a trench by shell explosion three or four weeks before coming under observation. He had SHELL-SHOCK 285 been unconscious for some time, and for about four days subsequently was quite unable to locate himseK, as he had lost his memory for recent events. For a long time he was incapacitated by severe headache, general nervousness, disturbed sleep, with terrifying dreams about fighting and battlefield experiences. Noises disturbed him greatly, producing considerable emotional disturbance and increasing his headache. His progress towards recovery was seriously incapacitated by the disturbance due to an air-raid. A man who was struck by a bullet on the right temple was unconscious for awhile, but soon recovered sufficiently to be able to walk back to an ambulance. Subsequently suffered from great nervousness and emotionalism, disturbed sleep with nightmares, headaches, giddiness and depression. An artilleryman was standing in a gun emplacement when a shell exploded and buried him. When dug out he was found to be unconscious with a wound on the left side of his head. On regaining consciousness he was dazed and trembled continually. This condition, evi- dently partly due to concussion, led to a neurasthenic state in which considerable depression, want of sleep, and nightmares, figured prominently. For a long time he was very emotional, and when anything occurred to recall his experiences became anxious in manner, per- spiring freely, and trembled violently. An infantryman was just getting out of a trench when a fragment of a bomb hit him in the bach. He fell forward, but did not lose consciousness. His legs were paralysed, and he dragged himself to a shell-hole for safety. He lay between the lines for about three-quarters of an hour, and then dragged himself about a mile and a quarter to the fii'st-aid post. Dm^ing this time he was hit by a bullet. He says the excitement carried him through. The con- dition at that time was complete paralysis from the hips downwards, so that he was quite unable to move his legs ; he suffered much pain in hie back, very bad nights, and 286 THE PROBLEM OF NERVOUS BREAKDOWN severe headaches. The paralysis lasted some weeks, and was eventually relieved by the use of a special psycho- physical method. In another instance the victim was standing on the firing 'platform of a trench when a shell exploded immediately in front of the parapet behind which he was standing. The result of this was that he was blown off the shelf, his head and back coming forcibly in contact with the back of the trench, when he rebounded to the bottom of the trench just in time to receive a mass of earth, sand-bags, and other things, which piled them- selves up and half buried him. When rescued he was in a state of mental confusion and unable to move. For some time he had loss of power in legs, no capacity for mental or physical effort, nightmares, and depression. Eventually he was relieved by a combined treatment of static electricity, conversational suggestion and re- education. Sometimes mental symptoms predominate to the exclu- sion of all other manifestations of shell-shock, and to such an extent that the stricken man is for the time being quite irresponsible for his actions. On occasion the mental breakdown is accompanied by great violent and maniacal outburst. More often the disturbance is of an emotional character with complete loss of self-confidence, severe depression, and loss of interest in everything. Many shell-shocked men complain merely of being mentally confused, sleeping badly, unable to maintain attention, and headache. A private who was buried several times on one particular day eventually lost consciousness. Subsequently was very emotional and had bad head- ache. Memory of the strain through which he had passed had been with him all the time, and wearing him down. Particularly during the nightmares, in which he felt as if he was being suffocated by something pressing closely upon him. The latter caused great disturbance of sleep with struggling and loud calls for help. A Canadian who had been blown up and left buried for some fiiteen SHELL-SHOCK 287 minutes did not immediately collapse, but gradually broke down under the strain of shell-fire on subsequent days. In addition to a neurasthenic state which deve- loped he was very weak in his legs, walking with struggling steps, and attacked by violent trembling whenever he stood still. It is not difiScult to understand how a long period of strain culminated by a specific shock should produce a condition of general neurasthenia with symptoms charac- teristic thereof, nor to comprehend that an explosion may often deprive its victim of speech, sight, hearing and power of movement for the time ; but special explana- tion is needed of why a man should remain dazed, blind, dumb, paralysed, or unable to walk for weeks and months afterwards. We want to know what impression has been made on the nervous system that should make it suffer such prolonged disturbance. Let it be said at once that this riddle can only be read correctly in the light thrown by other side-issues, and particularly by the analysis of the basis of hysteria.^ In the first instance one must recall the persistent dreams and distressing mental pictures that haunt so many shell-shock patients for a long time, and reaKze that just as these pictures have been so firmly impressed on conscious thought so others have become imprinted on the retina of the mind, although the sufferer is not conscious of this. The blindness, deaf- ness, paralysis, and so forth express outwardly the morbid ideas that have thus taken root in subconsciousness. It is a matter of the fixation of the morbid idea by intense suggestion at a moment of greatly increased suggestibility due to emotional tension. Self-control is weakened and the forceful suggestion given ; the morbid idea accepted in consciousness then becomes " buried " and subsequently reacts to produce disturbance of function. Moreover, it goes on reacting in this way until it can either be dis- charged by explanation, or naturalized by counter- 1 See Part II, Chap. V. 288 THE PROBLEM OF NERVOUS BREAKDOWN suggestion. If the paralysed \'ictim of shell-shock could retam in memory the occasion which produced his dis- ability it would not be so difficult to free him from it ; but the more deeply it has been buried in subconscious- ness the more resistant his symptoms. As examples of the sort of powerful suggestion that is operative at a time of acute shell-shock one may note the pressure exerted on limbs by falling earth, or forceful closure of eyes by debris. In each instance at the moment of crisis, or immediately after, the stricken man finds himself from actual force of circumstances unable to move one or aU his limbs ; possibly unable to open his eyes, or if he does open them finding himself in pitch darkness ; perhaps unable to hear. Instantly the idea flashes through his mind — so quickly, perhaps, that he is un- aware of it — "I am paralysed" — "I am blind" — "I am deaf." After rescue his memory of the crisis is blurred or lost, but the effect of the anxiety-reaction remains. There is here no question of malingering. The victim of shell-shock is overwhelmed in mind and unable to extri- cate himseK from the psychological maze into which he has been suddenly thrown. It would scarcely be neces- sary to say this were it not for the fact that the idea of hysteria is stiU associated with fraudulent behaviour by many who completely misunderstand the basis of hysteri- cal troubles. Even among medical men this misconcep- tion is sometimes found, particularly is there failure to realize how completely resulting disturbances, paralysis, and so forth, are beyond the control of those exhibiting them when it is found that collapse occurs from the re- calling to mind of the circumstances originally occa- sioning shell-shock. But, as was noted in our survey of the emotions, the memory of an emotion may cause just as much physical reaction as the emotion itself. Thus, anything that recalls circumstances of the battle- field or even the fact of military service may be sufficient to bring back symptoms that had disappeared SHELL-SHOCK 289 under treatment. And so one finds that the sound of anti-aircraft guns or other disturbing noises, news from the front, or even the receipt of an official document will thoroughly unnerve men who have been previously making good progress. Loss of confidence, lack of interest, failure of elasticity, depression, weakened powers of will and attention — these mental disabilities are the more serious of the wounds in mind caused by war events. The paralyses, contractions and other local disturbances commonly yield to treatment without great difficulty — even where resistant it is commonly found that measures based on a proper understanding of the psychological issues banish these consequences of shell-shock ; but such things as failure of will, loss of self-confidence and depres- sion offer much greater resistance to treatment, and often defy one's best efforts to get rid of them quickly. It is, indeed, a serious matter that for a long time to come many men will be hampered by such limitations to greater or less extent ; their incapacity depending on the stress or strain of work they may take up. Nevertheless, in spite of this there are many reasons for being optimistic about the outlook for those wounded in mind. Catas- trophies there have been so great that one cannot reasonably look for restoration of health or balance, but such are very much in the minority ; everything goes to show that treatment on the lines indicated when we reviewed our methods for redressing the balance suffices to bring back nerve-health ; maybe many months will sometimes be required to effect this happy issue, but there is no reason to be despondent at the length of a " cure " when its fulfilment is certain. Always in nerv- ous maladies treatment through mind is of primary im- portance, but experience shows that, if possible, it has even greater potency in the breakdowns of war than in those of civil life. The only exception to this optimistic outlook is to be 290 THE PROBLEM OF NERVOUS BREAKDOWN made in regard to breakdown accompanied by actual organic damage to brain or nervous system such as permanently to impair the physical mechanism of conduct and reaction. Otherwise one can always hope with due reason — even where there is dire mental derangement — that time and perseverance will in the end help harmony to resume its rightful place. INDEX Accidents, 60, 63, 64, 75, 76 Actors, 65 Adolescence, 59, 107, 253, et seq. difficulties, 253, 254 emotionalism, 255 extravagancies, 253, 254 suggestibility, 255 the flapper, 255, 256 Africa, 6, 66, 67 Agamemnon, 21 Age, and nervous breakdown, 77, 78 old age, 77 Agoraphobia, 13, 111 Air-raid, 276 Alcohol, 72, 73 American negro, 77 Analysis, of thought, 33 Anaesthesia, 148 Anger, 20, 21, 22 Anthropophobia, 113 Anxiety, 13, 19, 36, 37, 51, et seq., 148, 264 Aphonia, 142, 150, 151, 152, 282 Aristocracy, and nervous weakness, 69 Armstrong- Jones, Sir Robert, M.D., 47 Artisans, and nervous breakdown, 62 Astasia-abasia, 28, 142. Astrophobia, 114 Attacks — hysterical, 143, et seq. nervous, 9, 35, 101, 260 of giddiness, 13, 98 of indigestion, 132 At the End of the Passage, 67 Attentive control, 260 Austria, and inherited nerve weak- ness, 69 Automatism, 148 Automatic writing, 161 Automatic speaking, 161 Auto-intoxication, 71, 128 Aviation, 4 B Baber, and nervous breakdown, 66 Babinski, Prof., 19 theory of hysteria, 144, 167, 168 Bach, family of, 48 Bacon — on sleeplessness, 221 on fitness, 261 Baths, 215, 216, 217 Batophobia, 114 Beethoven, 48 Bismarck, 69 Blindness, 280, 283 Blushing, 14 morbid, 14 Borrow, Chas., 55 Borderland, 85 Bowel, 71, 131 Brain cells — - and alcoholism, 73 inherited delicacy, 6 Brain, 82 wear and tear, 220, 221, 233 Brain-work — good for the nervous system, 52 and adolescence, 59 Brain-workers — and nervous breakdown, 60, 61 Brain-storms, 9, 10, 12, 57 Breakdown, premature, 15 British Medical Journal, 50, 66 Brunton, Sir Lauder, M.D., on worry and indigestion, 126 Buddhism, 46, 47 Burns, Robert, 47 Burr, Dr. Chas., 34 on emotional stress, 35 on racial response in nervous breakdown, 77 Business man, breakdown of, 10 Byron, 47 291 292 THE PROBLEM OF NERVOUS BREAKDOWN c Caffeine, 72 Calais, Mary Tudor and, 24 Casquet neurasthenique, 91 Catalepsy, 151 Causes of nervous breakdown, 17, 18 Central Europe, tribes of, 46, 47 Charcot — and the hysteric, 146, 167 and the neurasthenic, 90 Character, 39 Charles, Sir Havelock, M.D., on nervous breakdown in India, 66 Chauffeurs, and nervous breakdown, 63 Children, 12 nervous, 12 Childhood, 240, et seq. day terrors, 243 diet, 246, 247 enuresis, 244, 245 hours of work, 250 hygiene of nursery, 245, et seq, mental hygiene, 247, et seq. morbid fears, 241, 242 night terrors, 242, 243 physical exercise, 251 signs of nervous temperament, 240, 241, 242 sleep, 250, 251 suggested routine, 251, 252 China, 46 Clergymen, 65 Climate, 60, 65 Africa, 66, 67 India, 66 Clothes, 218, 219 Clouston, Sir Thomas, M.D., 58 on adolescence, 257 on inherited nerve weakness, 68 Coffe, 72, 73 Colon, 71 CoUtis, 134 Common cold, as a cause of nervous breakdown, 74 Conflict, mental, 33, 34 Confusion, 14, 92 Consanguinity, 68, 69, 70 Conscience, 55 morbid, 56 nerves and, 55 Consciousness, 20 Constipation, 132, 133 Constitution, 6 Control, 14 mental, 14, 260, et seq. Convalescence, 209, et seq. Convulsions, hysterical, 147, 150 Cowper, 47 Cromwell, OUver, 40, 44 Crucifixion attitude, 147 Cycling, 235 D Daniel Defoe, 42 D'Artagnan, 44 Davis, Mr. Arthur N., on the ex- Kaiser, 60 Day terrors, 243 Deafness, 280, 283 Dejerine, Prof. J., 18 Depression, 10, 12, 35, 56, 76, 92, 101- 105, 284, 295 influenza, 74 Demoniacal possession, alleged, and hysteria, 160 Dickens, Chas., 44 Diet, 136, 209, et seq. alcohol. 214, 215 cheese, 14, effective constituents, 210 fads, 211 fish, 210 idiosyncrasies, 211 in childhood, 246, 247 milk, 212 phosphorus, 200 Dignity, 21 Disappointment, 24, 37, 51 Disease — abscesses, 75 boils, 75 chronic infection, 75 common cold, 74 carbuncles, 75 functional, 184, 185 general, and nervous breakdown, 60,74 infiuenza, 74 common cold, 74 organic, 184, 185 pyorrhoea (Rigg's disease) 75 syphilis, 75 trench fever, 74 typhoid fever, 74 tuberculosis, 75 Dissociation, 168 Doctors, and nervous breakdown, 60 INDEX 293 Domestic servants, and nervous breakdown, 62 Domestic worry, 35, 36, 37 difficulties, 56, 57 Doubts — about fire, 117 about promises, 118 conscientious, 116 nervous, 3, 116, et seq. religion, 116 Dreams, in sbell-shock, 284, 286 Drugs in nervous breakdown, 175 Drug taking, 73 Dubois, Prof., 25 on indigestion, 127 on the emotions, 25 Dumbness, 280, 282 Dyspepsia, 124 E Eccentricity, 46 Ecstatic pose, 147 Efficiency — and nervous discord, 4 and nerve health, 4 nerve and, 3 of a nation, 3 Egocentricity, 49 Egoism, morbid, 49 Electricity, 178, 179, 180, 245 Emotion, 6, 7, 17, et seq. and body reaction, 20, et seq. and intellect, 27 and nervous breakdown, 17 emotional storms, 51 example of emotional stress in- fluencing breakdown, 35, 36, 37 intensity of, 32 memory of, 32 repression of, 32 Enuresis, 244, 245 Environment, 39, 40 misfits — " martial " and others, 40 Envy, 55 Essays of Elia, 242 Eugenics, and nervous breakdown, 15, 16, 17 Explosives, 269, et seq. F Faith, and foundation of mental health, 182, 265 and recovery, 186 Fatigue, 7, 12 90, 93, 99, 102, 148, 151 " brain fag " 92 and war, 269 Fear, 1, 3, 22, 23, 264 of animals, 14, 115 of cats, 15 of closed spaces, 111 of colours, 14 of darkness, 14 of disease, 114, 120 of everything, 101 of harming people, 120 of high places, 115 of illness, 115 of impulsive action, 120 of insanity, 95, 120 of lifts, 13 of mice, 15 of miscellaneous things, 115 of open spaces, 13, 111 of people, 113, 120 of railway journeys, 112 of sudden death, 164 of sudden iLkiess, 120 of things falling, 115 of thunderstorms, 14, 114 of travelling alone, 120 of underground railways, 13 and war-strain, 272, et seq. Fears, 13, 14 agoraphobia, 111 astrophobia, 114 batophobia, 114 claustrophobia. 111 morbid, 197, et seq. pathophobia, 114 Felida X, 156 Fever, 145 Flapper, 255, 256 Flatulence, 131, 148 Francis Drake, 44 Freud, Prof., and hysteria, 169 Fright, 22 Functional, the term, 184 G Gambling, 53 " Gastric neurasthenia "124 Gastroptosis, 134 Gauclder, Dr. E., 18 Giddiness, 13, 35, 72, 99, 238, 284 in neurasthenia, 89 Gladstone, and sleep, 223 294 THE PROBLEM OF NERVOUS BREAKDOWN Golf, 236 Goodhart, Sir James, M.D., on nervous indigestion, 129 Goose-flesh, 23 Grief, 20, 23, 24 H Hamilton, Dr. McLane, 50 Harmony in the human system, 81 Hate, 51, 55 Head, 13 noises in, 13 Headache, 12, 36, 91, 133, 151, 284 Head-wounds, 272 Heart, in neurasthenia, 97, 98, 102, 104 Henry VIII, 66 Heredity, 6, 60, 67, et seq. HerscheU, George, M.D„ on nervous dyspepsia, 127 Hippocrates, 42 Hygiene — errors of, 7 nerve, 172, et seq. Hygiene of Mind by Sir Thomas Clouston, M.D., quoted 68 Hypersensitiveness in neurasthenia, 98 Hypersesthesia, 144 Hypnotism, 161, 183, 187 Hysteria, 85, 138, et seqi anaBsthesia, 143, 144, 150 and age, 78 aphonia, 142, 150, 152 attacks of, 145, et seq. automatism, 148 automatic writing, 161 catalepsy, 151 Charcot, 146 crucifixion attitude, 147, 150 day dreams of the hysteric, 144, 145 ecstatic pose, 147 factors leading up to, 141 fever, 145 general signs, 140 hemiplegia, 141 hypersesthesia, 144, 149 hysterical temperament, 1 62,et seq. illustrative notes, 148 imitative phenomena, 145, 152 la grande hysterie, 146 living skeleton, 145 monoplegia, 141 Hysteria — multiple personaUty, 151 neuralgia, 144 paralysis, 141 paraplegia, 141, 150 spasmodic phenomena, 143, 147, 150 Sydenham, description of, 139 theories of, 166, et seq. witch's marks, 143 Impulses, 11, 110 Indecision, 15 India, 6, 46, 66 Indigestion, 35, 72, et seq., 124, 148, 151 Individual, reaction, 27 Influenza, 74 and neurasthenia, 74, 105 Inhibition, 14, 262, 263 Insanity, 85 and alcohol, 73 Intermarriage, 68, 69, 70 Intellect, 26 and emotion, 27 Irritable weakness, 90 Ivan the Terrible, 44 James, Wm., 25, 157 on the emotions, 25 on faith, 265 on the "sick soul," 181 Janet, Prof. P., 159, 167, 168 Jealousy, 21, 51, 58 Jews, 77 John Gilpin, 47 JournaUsts, and nervous breakdown, 60 Juhus Caesar, 44 K King Harold, 44 KipUng, Mr. Rudyard, 67 description of nervous breakdown noted, 67 Knights of the Round Table, 44 La grande hysterie, 146 Labourers and nervous breakdown, 62 INDEX 296 Lamb, Charles, on children's fears, 242, 243 Lamp-post, obsession about, 14 Lancet, The, 130 Living skeleton, 146 M Malaria, as a cause of nervous breakdown, 74 Malice, 55 Man, 14 pre-eminence of, 14 Manual workers, and nervous breakdown, 63 Mantegazza on anger, 21 Mark Tapley, 45 Mary Tudor, 24 Massage, 178, 181, 204, 205 Megalomania, 49 Memory, loss of, 76, 92, 155 Memories and Portraits, by R. L. Stevenson, 85, 96 Mental Control, 7, 14 loss of, 14 importance of, 94 Mental — the term, 86 dissociation, 168 confusion, 92 Micawber, Mr., 46 Midsummer Nights Dream, 23 Mind, 7, 82 certain qualities of, 9 Mind cure, 183, 185 MitcheU, Dr. Weir, 189, 190 Moliere, 189 Monoplegia, 141 Morbid, 14 conscience, 56 egoism, 49 emotional response, 33 fear, 14, 107, et seq. flushing, 14, 114. thoughts, 77 Morphia, 73 Motoring,and nervous breakdown,63 Multiple personahty, 163, et seq. and alleged " possession," 160 Dr. Morton Prince's investigation, 158 FeHda X, 166 Leonie, 169 Prof. Janet's investigation, 159 Rev. A. B., 157 Sally Beauchamp, 158 N Napoleon, 40 on sleep, 223 Navvies, and nervous breakdown, 62 Negroes, and nervous breakdown, 77 Nelson, 44 Nerve, and efficiency, 3 Nerve-energy, 59 Nerve-cells, 7 and alcohol, 73 Nerve-centres, 7, 82 fatigue of, 90 Nerve-fibres, 7 and alcohol, 73 Nerve-force, 15 of nation, 15 Nerve-tonic, 176 Nerve-poisons, 60, 71, et seq. influenza, 74 morphia, 73 tea, 72 typhoid fever, 74 Nerves — and family life, 56 a popular term, 83 sensitive, 56 Nervous — dyspepsia, 124, et seq. fears, 14 indigestion, 124, et seq. Nervous attacks, 9, 101, 260 Nervous children, 12 character building, 39 Nervous indigestion, attacks of, 132 characteristics of, 130, et seq. Nervous system — and control, 82 and general disease, 74 and high explosives, 271 and influenza, 74 and tjrphoid fever, 74 development of, 82 exhaustion of, 95 functions of, 82 How subject to stress, 6, 59 inherited weakness, 67, 68, 69 Nervous tissues — hardiness of, 8, 9 irritabihty, 67 seaside, 236 sea voyages, 237 seK-help, 258, et seq. sleep, 220, et seq. siderophobia, 112 296 THE PROBLEM OF NERVOUS BREAKDOWN Nervous tissues- smoking, 237, 238, 239 some theories, 7 Turks, 77 types of, 83 ubiquitous occurrence, 4 United States, 77 vicious circle, 129 war-strain, 269, et seq. Nestor, 21 Neuralgia, 13, 35, 101, 144, 148, 151, 238 Nervous breakdown, 1, 14, 19, 50 agoraphobia. 111 alcohol, 214, 215 American negro, 77 and ancestry, 67, 68 and accidents, 75, 76 and intermarriage, 69 and the " Good Old Days/' 67 and the emotions, 19, 30 and temperament, 42, 45 anthropophobia. 111 astrophobia, 113 auto-intoxication, 71, 128 batophobia, 114 baths, 21, 57, 216, 217 causes, 60, 78 childhood, 240, et seq. classification, 84, et seq claustrophobia. 111 climate, 65 clothes, 218, 219 diet, 209, et seq. disturbed taste, 130 electricity, 178, 179, 180 exercise, 219 faith, and mental health, 182 house of Wittelsbach, 69 hysteria, 85, 138, et seq. impulses, 110 in America, 65 in India, 66, 67 in prof essional men, 15,16,60,61,65 indigestion, 124 Jews, 77 massage, 178, 179, 180 mind cure, 183 morbid doubts, 13, 116, et seq. Mr. Rudyard Kipling's descrip- tion of, 67 nuerasthenic state, 89, et seq. neurasthenia. See rcf. obsessing phrases, 123 obsessions, 107, et seq. Nervous breakdown — occupation, 6, 15, 16, 60, et seq. pathophobia, 114 persuasion, 183 phobias, 110 physical causes, 8 physical remedies, 178 psychasthenia, 107, 108 racial response, 77 recreations, 235, 236, 237 rest cure, 188. et seq. Neurasthenia, 18, 19, 45, 85 abscesses, 75 amongst students, 59 and alcohol, 73 and influenza, 74 and malaria, 74 and particular ages, 78 and trench fever, 74 and tropics, 66, 67 and typhoid fever, 74 and wrong thoughts, 55 " attacks," 101 boils, 75 breathlessness, 97 carbuncles, 75 detailed description of, 89, et seq. disturbed sleep, 90, 93, 94, 100, 101, 105, 223, et seq. examples of, 99, et seq. examples of — associated with em- tional disturbance, 35, 36, 37 fatigue, 90, 99, 93, 102 fear, 264 gastric, 124 general health disturbance in, 96, et seq. giddiness, 98, 99 heart, 97, 98, 102, 104 hypersensitiveness, 98 illustrative notes, 93 indigestion, 99, et seq. in old age, 78 irritabihty, 102 morbid fears, 95, 101 neuralgia, 101 obsessional, 108 of war, 278 operations as a cause of, 77 palpitation, 97, 100 pyorrhoea (Rigg's disease), 75 racial response, 77 sensation, 91, et seq. sex questions, 99 special mental symptom8,93, et seq. INDEX 297 Neurasthenia — sjrphilis, 75 the term, 87 traumatic, 76 tuberculosis, 75 typical headache, 91 typical story of, 90 visional troubles, 36 Neuritis, 73 Night terrors, 242, 243 Nissl's granules, 176 Noises in head, 13 Northern Europe, tribes of, 46 Nursing, 195, 196, 197 Obsessional neurasthenia, 108 Obsessions, 197, et seq. Octogenarian, and nervous break down, 77 Octogenarian, story of, 136 Occupations, and nervous break- down, 6, 60, et seq. actors, 65 business promotors, 65 clerifymen, 65 dangers of lack, 61 in America, 65 motoring, 63 railway workers, 64 speculators, 65 telephone workers, 64 the professions, 15, 16, 60, 61, 65 Operations, and nervous breakdown, 77 Organic, the term, 184 Osier, Prof. W., System of Medicine, quoted, 35, 77, 170 Over-emotionalism, 141 P Pain, 76, 101 Palpitation, 72, 100 Paraplegia, 141 Paralysis, 141, 150 Pare, Ambroise, 189 Pascal, 27 on the emotions, 27 Pathophobia, 114 Pecksniff, Mr., 45 Personality — alternating, 156 Fehda X, 156 Leonie, 159 Rev. A. B., 156 Sally Beauchamp, 158 Persuasion, 183 Phobias, 110 Phosphorus, 216 Phrases — obsessing, 103 Pickwick Mr., 45 Pithiatism, 138 Pliny, 136 Poisoning, 7, 8, 71, et seq. abscesses, 75 auto-intoxication, 71 boils, 75 chronic infection, 75 carbuncles, 75 from stomach, bowel and colon, 71 influenza, 74 morphia, 73 of nervous system, 60 pyorrhoea (Rigg's disease), 75 syphilis, 75 tea, 72 tobacco, 238, 239 tuberculosis, 75 typhoid fever, 74 Pressure headache, 91 Pride, 21 Prince, Dr. Morton, 158 Prince, Hal, 44 Prosperity, and damaged brain, 11 Psalm scix, 23 Psychasthenia, 85, 107, 108 the term, 87 Psychoanalysis, 169, 183, 187 Psychoneurosis — the term, 86, 87 and the war, 270, 281 Psychoneurosis of war, 281 Psychological causes, 18 Dejerine and Gauckler, 18 Babinski, 19 SaviU, 19 physical, 19 Puberty, 59 Punjaub Head, 67 Pyorrhoea alveoraUs (Rigg's disease), 75 Rage, 22 ^ Railway workers, and nervous breakdown, 64 Reaction, individual, 27 Recreations, 230, et seq. cycling, 235 golf, 236 hobbies, 235, 236 walking, 235 298 THE PROBLEM OF NERVOUS BREAKDOWN Redressing the balance, 173, et eg. Remorse, 55 Resj)onse, emotional, 17, et seq, excessive, 33 individual, 31, 33 morbid, 33 Rest, 7, 188, et seq, 230, et seq, in nervous dyspepsia, 136 rest hour, 230 seaside, 236 Rest cure, 187, et seq. attitude of invalid, 192 daily programme, 208 daily routine, 201 duration, 192 exercise, 204 friends, 199 general surroundings, 198 massage, 204, 205 mental occupation, 202 nourishment, 203, 204 nursing, 195, 196, 197 place, 193, 194, 199 principles of, 191 relatives, 194, 199 sleep, 202, 203 tasks, 206, 207 Weir MitcheH, 189, 1^90 Retirement,and nervous breakdown. 61, 62 Ribot, Prof., 42 Richard Coeur de Lion, 44 Richard III, 44 Rigg's disease, 75 Rigg's disease (pyorrhoea), 75 Romans xiii. 12, 265 Roussy and Lhermitte, 281 8 Sally Beauchamp, 158 Sanatoria, for nervous breakdown,15 Savill, the late Dr. T. D., 19, 128 Scott, Sir Walter, 47 Schumann, 48 Schubert, 48 Scruples, 110 Self-confidence, want of, 13 in shell-shock, 289 Self-control. (S'ee Control Self-denial, 263 Self-help, 258, et seq. Self-knowledge, 261 Self-reverence, 261 Sensation — neurasthenic, 27, 91, et seq. head, 92 Sex theory, 58, 168 Shakespeare, Wm., quotationa, 21, 23, 44, 91, 119, 184 Shaw, Dr. T. Claye, 46 SheUey, 47 SheU-shock, 270, et seq. astasia-abasia, 281 dreams, 284, 286 examples of, 284, et seq. general features, 280 head-wounds, 272 _ mental confusion, 280 mental symptoms, 286, et seq. paralysis, 280, 284, et seq. problem of, 287, et seq. special senses, 280, 282 the outlook, 290 unconsciousness, 280 Sheridan, 47 Shock — from accidents, 75 shell-shock, 76 "Shooting pains," 92 Shyness, 14 Siderophobia, 112 Sleep, 220, et seq. Bacon, 221 disturbed, 72, 76, 90, 93, 100, 101, 105, 133, 151, 220, et seq, 284 induction of, 227, 228 maxims, 228, 229 morbid fears, 226 personal idiosyncrasies,, 223 recuperative powers of, 8, 221, 222 Slough of despond, 33 Soldier's heart, 274 Sorrow, 23 Southey, 221 Speculators, 65 Stevenson, R. L., 253, 261 description of nervous breakdown; 95, 96 St. Vitus' dance, 143 Stomach, 71 atony of, 132, 134 Subconsciousness, 26 Suggestion, 11, 26, 144, 149, 161, 160, 167, 177, 183, 187, 245, 288 Suggestibihty — abnormal, 141, 162 in adolescence, 255 Sulkiness, 57 Sydenham on hysteria, 139 INDEX 299 Taste, disturbed, 130 Tea, 72 China, 72 Teeth- decayed, 75 pyorrhoea (Rigg's disease), 75 Telephone workers, and nervous breakdown, 64, 65 TeU, Wm., 30 Temper, bad, 57 Temperament, 6, 38 and aviation, 41 and genius, 47 apathetic,42 bilious, 42 blends of, 42, 45 differences of, 41 phlegmatic, 41 hysterical, 162, et seq. melancholic, 42 nervous, 38, et seq., 84, 182, et seq. sanguine, 41 sensitive, 42 temperate, 42 Tennyson, 261 Theine, 72 Theories of nervous breakdown, 18, 19 Thought processes, 17 Thoughts, 11 impulsive, 11 racing, 13 obsessing, 13, 106, et seq. morbid — in old age, 77 sense of loss of control, 92, 94 Three Musketeers, 44 Tiredness, 12 Tobacco, 72, 237, 238, 239 Tone, 125 Tongue — nervous furring, 129 Traumatic neurasthenia, 76 shell shock, 76 Treatment, 173, et seq. recreation, 235, 236, 237 sea voyage, 237 seaside, 236 self-help, 258 smoking, 237, 238, 239 Trembling, 72, 76, 143 Trench fever, as a cause of nervous breakdown, 74 Troilus and Cressida, 21 Turks, 77 Typhoid fever, as a cause of nervous breakdown, 74 U United States, 35, 77 Uriah Heep, 45 Vicious circle, 129 Victorian era, 67 Vision, disturbances of, 36 W Wagner, 48 Walking, 219, 235 War, and air-raids, 276 and civilians, 274 and nervous disease, 5, 141 breakdowns of, 69, et seq. characteristics of, 278 strain of, 269, et seq. Webster, definitions, 20, 109, 125 wm, 34 William II, ex-Kaiser, 48, 50 William of Orange, 44 Witch-hunting, 140 Witch's marks, 143, 149 Wolsey, Cardinal, 44 Wordsworth, 47 Workers, and nervous breakdown- artisans, 64 brain, 60, 61 chauffeurs, 64 labourers, 64 manual, 62 porters, 64 railway, 64 telephone, 64 Worry, 10, 18, 19, 35, 36, 51, et seq. and faith, 264 and imaginary troubles, 54 domestic, 35, 36, 37 X-ra.ys — and nervous indigestion, 134, 145 PRINTED BY WILLIAM BRENDON AND SON, LTD. PLYMOUTH ENGLAND ^Z)