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 RC343 .G61 On common neuroses; 
 
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ON COMMON NEUROSES 
 
ON 
 
 Common Neuroses 
 
 OR 
 
 THE NEUROTIC ELEMENT IN DISEASE 
 AND ITS RATIONAL TREATMENT 
 
 THREE LECTURES DELIVERED BEFORE THE HARVEIAN SOCIETY 
 OF LONDON, NOVEMBER — DECEMBER, 189I 
 
 JAMES FREDERIC GOODHART 
 
 M.D. Aberd., F.R.C.P. 
 
 PHYSICIAN TO guy's HOSPITAL, AND CONSULTING PHYSICIAN TO THE EVELINA 
 HOSPITAL FOR SICK CHILDREN 
 
 SECOND EDITION 
 
 LONDON 
 H. K. LEWIS, 136 GOWER STREET, W.C. 
 
 MDCCCXCIV. 
 
TO 
 
 SAMUEL WILKS, M.D., LL.D. Edin., F.R.S., 
 
 FOR NOW MANY YEARS THE DEAR AND HONOURED FRIEND 
 
 AND TEACHER OF THOSE WHO HAVE STUDIED MEDICINE 
 
 AT guy's hospital. 
 
 21 
 
 J4b483 
 
PREFACE TO THE SECOND 
 EDITION. 
 
 This edition has been reprinted very nearly in its 
 original form. I have been urged to expand it by 
 adding cases and other additional matter ; but to do 
 this would, in my opinion, be to detract from any 
 value that the book may possess. It aims only at 
 a statement of the principles of management of the 
 many ailments which may be comprehended within 
 the limits of common neuroses. More detail, while 
 all too ready to hand, would be both a burden to the 
 attention and an affront to the intelligence of those 
 who may become my readers. 
 
PREFACE TO THE FIRST 
 EDITION. 
 
 It was not my intention, in reprinting these lectures, 
 to do more than satisfy the needs of private circu- 
 lation amongst the Council and Members of the 
 Society before whom they were delivered. But since 
 their appearance in The Lancet so many have written 
 to me to express the kindly wish that they should 
 be reissued in more accessible form that I could 
 not do otherwise than accept as a command an 
 invitation that was all the more imperative because 
 it has come in great part from those who are per- 
 sonally unknown to me. If, in thus responding, I 
 should seem to any one to have too readily inflicted 
 an injury on medicine by adding yet another book 
 to the existing deluge, I would ask my critic to 
 pause and read it, and to mark well that it is but 
 a little one. 
 
ON COMMON NEUROSES. 
 
 LECTURE I. 
 
 When the President and Council of the Harveian 
 Society did me the honour to invite me to fill for this 
 year the post of their lecturer, I accepted with no 
 more than the momentary hesitation that might be 
 the natural physiological reaction of any surprise. 
 And I did so because it was clear that the request 
 came, not to ine personally so much as to one of the 
 physicians, and therefore to one of the accredited 
 mouthpieces, for the time being, of Guy's Hospital, 
 To have declined such an invitation, however much 
 private inclination so counselled, would have been 
 to run away from an obvious duty, and to cast a 
 slur upon an institution that deserved nothing of 
 that sort at my hands. So I am here relying 
 on, and attempting to personify as best I may,, 
 my nursing mother, dear to me, as those other 
 kindred and not less noble institutions where you 
 severally have studied, and spent, it may be, the 
 freshest years of your lives, are dear to you, my 
 
 I 
 
COMMON NEUROSES. 
 
 hearers. But having thus somewhat impulsively 
 taken up what seemed to be a duty, I am free to 
 confess that it was a case of " Marry in haste and 
 repent at leisure," for only when there was no 
 escape did I realise that a matrimonial project of 
 this sort was neither to be " enterprised nor taken in 
 hand lightly " ; and anxiously did my mind range 
 the wide field of medicine for some subject that 
 might prove not only instructive, but also attractive, 
 at this somewhat somnolent evening hour. 
 
 Ruskin has said in effect, in his "Sesame and 
 Lilies," that in reading a book one should try to get 
 at the author's meaning, rather than interpret him 
 by the light of our own thought. For the poet, 
 the mystic, the moralist, I might allow this to be 
 true, though I am by no means sure that it is so, 
 for the books that have most taken hold of man- 
 kind have ever been those in which the author 
 has dealt with subjects for which no language could 
 be precise enough ; and that hold has been gained, 
 not necessarily by beauty of language — though that 
 has often been conspicuous ; not by wealth of idea — 
 though that may have been abounding ; but chiefly, 
 as I believe, because individual minds of the most 
 varied type and depth of intelligence, each and all, 
 in attempting to unravel the writer's meaning, have, 
 unconsciously it may be, seen in it their own expe- 
 rience, and interpreted it so. Do you believe, by 
 putting Shakespeare on any pinnacle of intellectual 
 
COMMON NEUROSES. 
 
 acquirement you may please, that any single brain 
 ever had within its compass the half of the ideas 
 that have been found by others in his plays ? I 
 believe that if we could piece together all the 
 knowledge that from then till now has been sup- 
 posed to have been put into his work of his own 
 purpose and intention, we should build up an indi- 
 vidual who, even at this advanced period of the 
 nation's history, would be a psychological impos- 
 sibility. Shakespeare is Shakespeare, Milton is 
 Milton — Browning is and will be Browning if you 
 like — it matters not whom of the greatest writers 
 of the past we take — each and all of them, great 
 as they were and are, would yet be comparatively 
 unknown to fame were it not that, in attempting 
 to interpret them, age after age has interpreted 
 itself through them. I question whether it could 
 be otherwise. It is the natural resurrection that a 
 great mind may expect. But let this pass. If 
 what Ruskin says be true for the writers of books, 
 it is hardly so for the audience of a lecturer on 
 medicine, and I seemed to receive my mandate from 
 quite another point of view and from a very dif- 
 ferent source. 
 
 Those of you who have read " Life's Handicap," 
 by Mr. Rudyard Kipling, will remember that in the 
 preface — to my mind the most charming part of 
 the volume — there is a dialogue between an old 
 Indian of eighty years, Gobind the one-eyed, and 
 
COMMON NEUROSES. 
 
 the author, with reference to the art of telling tales. 
 There are one or two passages in that preface, by- 
 the-bye, that seem apt in respect of medical author- 
 ship. For instance : " I write," says the author, 
 " of all matters that lie within my understanding, 
 and of many that do not. But chiefly I write of 
 life and death, and men and women, according to 
 the measure of my ability. Then, by the favour 
 of God, the tales are sold, and money accrues to 
 me that I may keep alive." But with more special 
 reference to the work before me he asks, " ' In what 
 manner is it best to set about the task, O chiefest 
 of those who string pearls with their tongue ? ' 
 ' How do I know ? ' said Gobind. ' Yet ' — he thought 
 for a little — 'how should I not know ? Do thou this : 
 tell them first of those things that thou hast seen 
 and they have seen together. Thus will their know- 
 ledge piece out thy imperfections.'" And this is 
 what I have ever found the readiest way to my 
 hearers' attention. This is what I shall now attempt 
 to do. I propose to give you a plain tale of my 
 own experience, feeling sure that in so doing I 
 shall appeal to similar experiences of your own, 
 and I hope that the piecing-out process may pre- 
 vent the time from being altogether lost. Thinking 
 thus it was that I determined to deal with the 
 subject of neurotic conditions, and here it was that 
 my first difficulty arose — the question of a title to 
 these lectures. All titles and definitions bind one, 
 
COMMON NEUROSES. 
 
 and I want to present the neurotic element in disease 
 to you as it has presented itself to me ; and that 
 presentation does not well allow of any other than 
 the most general definition. " Neurasthenia " would, 
 I think, have been the most fitting term but that in 
 inviting you to listen to lectures comprehended by 
 that name I feared to seem to limit your vision 
 to massage and stuffing, which I have no wish to 
 do. Included within my horizon are such diseases 
 as asthma and angina pectoris ; and indeed the subject 
 is all too wide. " The Common Neuroses of Modern 
 Life " next came to mind ; but some of my friends 
 said that a title of that kind was rather too sug- 
 gestive of a ticket for the play. So at last the 
 heading stands as it does, and if it be somewhat 
 vague, it at any rate sets the lecturer free. 
 
 But modern life is, after all, my chief theme ; 
 and insistence upon it is one of the first points 
 that I wish to make, for it is the very mainspring 
 of my subject, or rather, I ought to say, of my 
 idea of it. As year succeeds to year of life I become 
 more impressed with the widely-prevailing influence 
 of the neurotic element in the production and carriage 
 of disease. And it is my own opinion that this 
 influence is more all-pervading than in former years. 
 I shall not attempt to prove this, for I feel confident 
 that figures could be made to do service either way 
 according to the bias of the manipulator. I there- 
 fore simply give it as my opinion, worth no more 
 
COMMON NEUROSES. 
 
 but worth no less, than that of any other individual 
 who has had an equal opportunity of observing. 
 For, let me remind you, thei conclusion that I had 
 come to has determined the subject of these lectures ; 
 it was not formed after I had settled that question. 
 If I look through the notes of cases that I have 
 .seen there is no group so large as that of the 
 neurotic in one form or another, and I really do 
 not think I have exaggerated this feature. I believe 
 that insanity is on the increase ; but I refuse to be 
 confined, in speaking of mental disease, to those 
 grosser forms that require to be committed to the 
 hospitals set apart for such cases. Incidentally, I 
 may say, too, that I believe that the grit of the 
 English constitution has lessened in robustness ; 
 and if the question, Why, then, is the average 
 duration of life longer ? seems at first all too per- 
 tinent for the maintenance of that contention, a 
 very little reflection will convince any one that no 
 great weight attaches to it ; for in both cases 
 — physical and mental death, to bring both at 
 once into the same line — it is more than probable 
 that the last extremity is averted by our greater 
 care of life at the present day, and that the ave- 
 rage is lengthened out by the large prevention of 
 such diseases as can be prevented. Yet men and 
 women may drag along more self-conscious, more 
 oppressed and weighed down by trivial ailment, 
 less ready to step out with the spontaneity and 
 
COMMON NEUROSES. 
 
 joyous liberty and power of healthy life, so that 
 where one man may say that to-day there is less 
 of capital punishment, there are ten who can make 
 answer, " Even so ! But there is more of penal 
 servitude and of the treadmill." 
 
 I remember, five-and-twenty years ago, when first 
 entering the medical profession, that the late Sir 
 Thomas Watson had given expression in public to 
 the opinion that disease had changed its type. I 
 was surprised to see, even at that early date of my 
 career, how much discussion that opinion excited, 
 and even more so when, after a time, it was practi- 
 cally recanted. I thought then, and I think now, 
 that, unless the world is standing still, disease must 
 change its type — that it has changed its type, and 
 is changing it. Some of you, at any rate, will 
 remember that the discussion turned around the 
 former treatment of pneumonia by bleeding and 
 its then and present management without it. And, 
 surely, the argument in favour of a change of type 
 on that ground was not wanting in strength. Still, 
 I would maintain that it was not the strongest upon 
 which the contention could be supported, for it was 
 quite open for those who had lived years enough 
 to say that the pneumonia of a former generation 
 was, in all essential features, the pneumonia as we 
 know it now ; and that was indeed the line taken, 
 and, many supposed, successfully so. But a quarter 
 of a century has gone by, and almost within that 
 
COMMON NEUROSES. 
 
 time the doctrine of evolution has come into exist- 
 ence and has grown into robust manhood. In those 
 days change of type conjured up the idea of jumps 
 from the disease of one day to that of some suc- 
 cessive one. We can understand now, if we could 
 not at first sight then, that no such demonstration 
 is possible, because it is out of the natural order 
 of things. But the absence of gross changes within 
 the span of a century or two does not touch the 
 assertion that disease has changed and is changing. 
 The process is one of transition, subtle and gradual 
 — as gradual as that by which man himself must 
 be undergoing modification, because this earth is 
 changing ; and unless he accommodates himself |to his 
 altering circumstances the man of to-day will have 
 to make way for some other being more pliable than 
 he, I see no escape from the absolute certainty of 
 the conclusion based on this a priori consideration 
 that disease is becoming modified, and this, too, in 
 all sorts of directions in correspondence with the 
 manifold circumstances to which it is subjected. I 
 need hardly give any illustrations of this, they are so 
 abounding ; but to show the intricacy of the case, 
 let me insist on this maxim : " No man liveth to 
 himself, and no man dieth to himself." Apply the 
 principle — for it is a principle ^to the exanthemata, 
 and to what we are doing for them in all directions, 
 both preventive and curative, at the present day. 
 It is impossible, I take it, to do away with one of 
 
COMMON NEUROSES. 
 
 these scourges, or to render its reaction on the 
 human body less severe, without the change or 
 changes thus produced reacting to a wide extent, 
 and probably far wider than we have any idea of, 
 upon a number of other processes of disease which 
 each involves in its unbridled turmoil. For instance 
 — and there could not be a better one considering 
 my subject, — there is many and many a home now 
 bewailing the ravages of disease in one or other 
 of its members, relighted, or maybe started, by 
 quite another disease — viz., that interesting but ter- 
 rible pest influenza ! I suppose there is not one of 
 us who does not see, even now, almost every day a 
 case of one sort or another that dates its initiation 
 from the first outbreak of that disease of now several 
 years ago. I think it would be difficult to say in 
 how many ways that disease has attacked the human 
 organism and laid it open to attack, or in how many 
 directions its absolute extirpation would better the 
 future of the race. I take it, therefore, that disease 
 is changing its type not only in accordance with the 
 changing circumstances of man and his surroundings, 
 but also with the modifications that are produced in 
 it in its various phases, as each or any of its atoms 
 are made to .submit to the assaults of advancing 
 knowledge. 
 
 However this may be, my chief point now is that 
 man him.self is altering, and if so, so must his dis- 
 eases be, and I believe him to be changing chiefly 
 
lo COMMON NEUROSES. 
 
 as regards his nervous centres, and that these are 
 becoming more prone to fatigue, more easily the 
 prey of morbid sensations, of morbid thoughts, of 
 morbid action, and so on. 
 
 But I am not sure that this is so, at any rate 
 equally so, in all the strata of society. I do not 
 think that it is, and my own experience goes strongly 
 to show that the stress of living tells largely against 
 the middle classes of our world. " Liberte ! EgaHte ! 
 Fraternite ! " is the prevailing cry of the day : we 
 are all men and brothers, and a savage is as good 
 as the most cultivated man. This may be good 
 sociology or political economy, but it is not sound 
 physiology. There can be nothing more sure in 
 physiology than this : that as we go upwards in the 
 scale of creation, so the nervous system becomes 
 more highly strung. But if, on the one hand, it 
 becomes more intense in the enjoyment of pleasure, 
 it must also, on the other hand, be more sensitive 
 to pain and to disturbing sensations of all sorts. 
 
 There can be no doubt that surgical operations 
 can be performed on the lower animals without any 
 of the precautions that are taken in the case of our- 
 selves, and that the results are astonishingly good 
 all the same. I think there can also be no doubt — 
 one has seen illustrations of it so often in the out- 
 patient room and elsewhere — that the differences 
 that are seen in this respect between the lower 
 animals and man are seen in a similar, if less 
 
COMMON NEUROSES. 
 
 marked, way between the lower and upper grades 
 of society. 
 
 Who does not remember to have seen, and even 
 to have often seen, the patient in the hospital out- 
 patient room desperately ill and even within a very 
 few hours of death, yet hardly allowing that there 
 could be anything serious the matter ? I remember, 
 too, to have seen more than once a man come for 
 some ailment confessing to nothing else than that 
 which had brought him there, and yet on being over- 
 hauled he was found to be the unhappy possessor of 
 a huge ulcer of the leg that would certainly have 
 quite incapacitated any one in the upper walks of 
 life, but which he called " nothing." It is said that 
 the working man cannot afford to lie up, and there- 
 fore he does not call attention to things that are 
 chiefly an inconvenience. But this is no adequate 
 explanation ; this would not explain the power he 
 possesses of working under such very adverse cir- 
 cumstances. I feel sure that the reason is none 
 such as this, but that it springs from the fact that 
 the working man is generally far less sensitive to 
 such conditions as would depress and incapacitate 
 those above him in the social scale ; his nervous 
 system reacts with sloth. 
 
 We see the same thing in the deafness that comes 
 of noisy occupations; still better perhaps in the differ- 
 ence in the reaction to drugs that may be seen at the 
 two levels. Give belladonna and nux vomica with an 
 
COMMON NEUROSES. 
 
 equally free hand to the hospital patient and to the 
 delicate lady, and we soon see the difference. It 
 seems obvious that the one who has had to rough it 
 has become deadened to trivial shocks of all kinds ; 
 while the other, pampered in the lap of luxury, 
 has become cultivated into such a state of nervous 
 erethism that the least disturbance upsets her. 
 
 But more than this. Not only does the neurotic 
 state evolve more, as I think, in one stratum of 
 society than in others — it has its lines of special 
 development in some occupations more than others. 
 I wish there were time to develop this subject, for 
 it strikes me as an important one. I have in mind 
 the neurotic tendency as it shows itself in the clergy ; 
 in those whose calling is to deal in stocks ; in those 
 whose occupation is our own. But, interesting as 
 this line of observation is, I must confine myself to 
 saying that, for the most part, the clerical neurotic is 
 irritating to others rather than dangerous to himself ; 
 finance seems to me to be liable to produce a state 
 of nervous instability, such as would seem to threaten 
 an ending in insanity of some form or other, of the 
 frequency of which I should like to hear something 
 from those who by their practice are more familiar 
 with the professions as they are found in asylums 
 than I am ; and of the medical neurotic — well, I am 
 not bound to say anything of my own cloth, so I shall 
 leave him to your kindly judgment, more particularly 
 as he is often youthful and inexperienced. 
 
COMMON NEUROSES. 13 
 
 It is my conviction, then, forced upon me by the 
 experience of now many years, that the maladies 
 which owe their origin to a faulty action of the 
 nervous system are of more frequent occurrence in 
 practice than are even phthisis, heart disease, Bright's 
 disease, or organic hepatic disease, though these are 
 in no small number. 
 
 There are many who combat this view — who point, 
 and correctly so, to the ease of living that now 
 prevails as compared with the insecurity of life in 
 former days ; to the utter want of comfort that 
 prevailed then in almost every one of the activities 
 of daily life, compared with the luxurious ease of 
 to-day. But arguments of this kind seem to me 
 to be beside the question, because it is this very 
 ease — this very luxury — that develops the erethism 
 of nervous centres of which I speak. In this fact lies 
 the essence of the difference that exists between the 
 several strata of society. It is because we have come 
 to require everything to be made so easy for us 
 that we are becoming so sensitive. Every additional 
 luxury that becomes a necessity has its Nemesis of 
 lessened resistance for that system that perceives and 
 enjoys it. 
 
 Now, as time goes on and the subject develops,, 
 some will certainly raise the criticism that the seeing 
 a nervous element in disease largely depends upon 
 the standpoint or the bias of the individual observer ; 
 and I shall admit this risk. But if it is easy to over- 
 
14 COMMON NEUROSES. 
 
 rate an influence of this kind, the influence no less 
 certainly exists, and it is quite as possible to belittle 
 as to exaggerate the sphere of its action. 
 
 We must now proceed to more detail, and I pro- 
 pose to divide the subject into the following groups : 
 the common neurotic conditions which may be said 
 to be essentially central in their whole course ; those 
 that are respiratory ; those that are cardiac and 
 circulatory ; and those that are abdominal, concerning 
 themselves with the stomach and bowel and liver and 
 kidney. 
 
 Of those that are central it is difficult, if not 
 impossible, to give any adequate clinical description, 
 because, concerning themselves as they do so much 
 with subjective sensations, they are as various as 
 the variable mental conditions of the individuals 
 in whom they occur. But, nevertheless, there are 
 certain common methods of disturbance of the healthy 
 cerebral action ; and first of these I will mention 
 the curious dread that some neurotics have of going 
 into society or into any crowded place. Ladies will 
 frequently complain that they cannot go to church 
 because they are afraid that they will faint, or that 
 an attack of what they have generally agreed to 
 call " the fidgets " will come on, and that they will have 
 to leave. I have known this dread to take posses- 
 sion of men, but in them it is perhaps more often 
 a modification of the same thing — viz., a disinclina- 
 tion to go out and see their friends, which, if it be 
 
COMMON NEUROSES. 15 
 
 indulged in, becomes, before long, an " all-overishness " 
 at going into society of any kind that quickly con- 
 verts a man into a recluse. In women there is 
 another common phase of the same malady — viz., 
 where the subject describes herself as turning scarlet 
 all over. Some inborn sensation starts what is 
 usually described as a sudden rush of blood up- 
 wards, and thus they usually suppose themselves 
 to turn colour, although I do not think that they 
 often do. The hot sensation is succeeded by a 
 copious perspiration ; and of this sweating there can 
 be no doubt, for I have been repeatedly told by the 
 subjects of such attacks that their underclothing 
 becomes so saturated that they require to change it. 
 
 This is a short description, but I think it embraces 
 the essentials of a large, very large, group of cases. 
 Now, how are they usually treated? How should 
 they be treated ? The general plan of dealing with 
 them is, I think, to call them hysterical, and to ad- 
 minister assafoetida and valerianate of ammonia. I 
 have nothing to say against these excellent remedies ; 
 they are very good in their way, and I am not pre- 
 pared to say they are not the best in these cases ; but 
 there is a right way and a wrong way of administering 
 even proper remedies, and to offer either as a cure is 
 not the proper way of dealing with any such case as 
 I have depicted. If we should have to do with a 
 frightened horse that will not pass a certain spot, we 
 do not send it to the veterinary surgeon that a bolus 
 
COMMON NEUROSES. 
 
 may be administered, but it is walked up and down 
 before the object that disturbs it until its self-posses- 
 sion is regained, and until it finds that what startled 
 it is, after all, nothing to be alarmed at. So must 
 our patients treat themselves. Their nervous systems 
 revert to a similar state of unreason to that seen in 
 the startled animal, and the only way to cure them 
 is to restore their confidence in themselves; Some- 
 thing may be done by good nerve tonics, sometimes 
 by sedatives judiciously given, to help them to help 
 themselves, but clearly the only way by which they 
 will overcome their weakness is by becoming oblivious 
 to the conditions that are the cause of the self-con- 
 sciousness and distrust. For instance, in the common 
 dread of doing something foolish or coming over ill in 
 church or society, the difficulty is usually surmounted 
 by staying away ; and I say that to deal with it thus is 
 to encourage the malady. The true method is to go 
 and do all that comes to the hand to do, and thus to 
 learn again that what had been thought impossible 
 without a catastrophe is accomplished without any ill 
 result. It is constantly impressed upon us that all 
 this has been done, and without avail, that the patient 
 has struggled against the feeling and has been unable 
 to overcome it ; and this is supposed to be an argument 
 against the advice that is being given. But it is 
 nothing of the sort. There are hundreds of neurotics 
 who fight and struggle and try not to give in, who are 
 really consuming themselves in the bearing, and who 
 
COMMON NEUROSES. 17 
 
 are all the time by so doing kindling the flame of 
 their neurosis by encouraging their self-consciousness. 
 Surely this was so in a young lady I saw the other 
 day, whose mother remarked to me that her daughter 
 was the most absolutely enduring creature that was 
 ever known. This lady little knew my inward 
 response : that she who goes about the house with 
 sweet resignation set upon her face is ofttimes one of 
 the most incorrigible of neurotics. A neurosis is best 
 treated by the cold shade of neglect. Moreover, to 
 struggle against a feeling you cannot help, or to call 
 yourself hard names for being overcome by a distress- 
 ing feeling that was none of your own invitation, is 
 equivalent to flogging the frightened horse, and the 
 result in both cases is the same — the state of panic is 
 made worse. The best way of meeting these ailments 
 is to allow to the full the misery that they cause to 
 the individual, but in doing so to insist (i) that they 
 are always transitory, (2) that they are purely sub- 
 jective and not perceptible to others, and (3) that they 
 never do any real harm or mean any organic disease. 
 As I have said, unconcern at their approach and 
 during their course is the certain cure. But, alas ! I 
 must add, even so, that the remedy is easy to preach, 
 but difficult to put into practice. Remember, though, 
 that this difficulty docs not discredit the certainty of 
 the facts. 
 
 Next there comes a large group of cases where the 
 morbid sensation is chiefly confined to the head. 
 
 2 
 
COMMON NEUROSES. 
 
 Some will complain of headache here or there ; some 
 — and this is extremely common — of a constant, dull 
 weight on the top of the head ; some of peculiar 
 clawings inside the skull. Once this was described to 
 me as like a beetle running about. Some will say 
 their brains feel as if their top stories were converted 
 into wool ; others, again, suffer from what, according 
 to their own descriptions, appears to be a species of 
 mild explosive sensation within the skull ; and then 
 there is a very large group of cases whose trouble is 
 singing in the ears. It is perhaps seldom that one 
 sees a typical case of Meniere's disease ; but, regarding 
 Meniere's description of auditory vertigo, as I do, as 
 a type, in the same way as I shall by-and-by insist 
 that Raynaud's disease and exophthalmic goitre are 
 also, of a large group of cases, the tinnitus aurium and 
 deafness form the very commonest of the neurotic 
 ailments which come before the physician in his daily 
 work. 
 
 But some one will perhaps say. Why call this a 
 neurosis ? It is a definite affection due to an irrita- 
 tive or destructive lesion in the semicircular canals. 
 So it may be, but I am none the less very much 
 concerned to insist that the disease as I know it is 
 very seldom indeed, if at all, a simply local disease, 
 and it is nearly always found in those of markedly 
 neurotic constitution, either of themselves, or more 
 often, I think, as regards their family historj^. For 
 instance, this case comes before me : A lady of my 
 
COMMON NEUROSES. 19 
 
 acquaintance suffered for years from noises in her 
 ears, which could only feebly be kept in the back- 
 ground of her mental activity by the constant playing 
 of a musical box. What was her family history ? 
 Her brother was in an asylum for some years before 
 his death ; another member of the family suffered 
 from harmless delusions, and passed into a state of 
 senile imbecility out of proportion to his years. And 
 this does not tell the half of the neurotic strain in that 
 family ; for, beyond the gross departures such as these, 
 there runs through all the members an indescribable 
 eccentricity such as cannot be put on paper, but which 
 is nevertheless very real and obvious to those with 
 whom they come in contact. 
 
 Here is another case of a gentleman of sixty-three 
 years who was under Sir William Gull many years 
 " for the nerves of his head." He says that his 
 mother suffered greatly from " bile," and was always 
 under the doctor, a history that I shall always con- 
 tend shows a vice of the nervous system ! He has 
 had good health, but every now and again, with 
 complete freedom between the paroxysms, there will 
 come a roaring in his head which he describes as a 
 mill-stream going inside him, and he staggers about 
 as if he had been drinking — and he will also occasion- 
 ally see double. 
 
 In another case you only want to look at the man 
 to see that he is liable to nerve-storms of all sorts, for 
 his head goes almost to a point at the forehead, and 
 
20 COMMON NEUROSES. 
 
 his whole history is that of a highly neurotic man. 
 He keeps well when away from business, which is a 
 large one, and in which he has much to do with figures. 
 He had been to an authority who told him he had a 
 weak heart, which nearly killed him with fright. He 
 appears to have rebounded in consequence into the 
 chair of an ear doctor, who told him he had Meniere's 
 disease, and I suppose that, finding himself between 
 the devil and the deep sea, he came to me for such 
 hope and consolation as I could honestly give him. 
 
 Once more, as showing that these cases form a 
 large group and have relations with other neurotic 
 states, I note the case of a man of fifty-four, in whom, 
 in association with the noises in the head and ears, 
 there come on from time to time attacks of faintness, 
 in which he flushes up, his veins stand out, he 
 becomes a little giddy, and he breaks out into a 
 profuse perspiration, his account being quite like that 
 of the woman so much more commonly seen with 
 flushings to whom I have already alluded. The 
 attacks in this man, although one cannot but think 
 from his whole demeanour that they are subjective 
 entirel}'', are nevertheless clearly very real, for they 
 compel him to sit down wherever he may be until 
 they have passed off. Of twenty of these cases taken 
 from my note-books only one had evidence of local 
 ear disease, and all were people whom I should call 
 very nervous. I may also note in favour of a central 
 origin that these symptoms, certainly in the large 
 
COMMON NEUROSES, 
 
 majority of cases, are paroxysmal in their occurrence 
 at the onset, and may remain more or less so to the 
 end, for many people will tell you that they are better 
 or worse according as their general health is so ; but 
 the tinnitus very generally tends to become confirmed 
 into persistency as years go on, and it is usually 
 associated with a gradually-increasing deafness — a 
 deafness also, be it noted, that manifests itself most 
 in a room when several people are talking at the 
 same time. Again, as pointing in the same direction, 
 according to my experience there are two classes 
 of cases, the one that makes no more than an incon- 
 venience of the malady ; and in these, although it 
 is a serious and, indeed, a distressing affection, it 
 does little harm ; in the other it is ever present — is 
 nursed, so to speak, and brooded over, and day by 
 day a greater degree of mental wretchedness is 
 produced, until, if not actually insane, the sufferer 
 becomes very much of a mental wreck. 
 
 This leads me on to a somewhat different condition, 
 but as regards results a closely-allied one — I mean 
 insomnia. Now what is sleeplessness? I have in 
 former years described it as a bad habit of the 
 nervous system, and so it is in most cases ; but it is 
 also more, for if we go into the history of this trouble 
 we almost always find that it can be traced back to 
 parental tendencies in the same direction, while it is 
 also one of the commonest forms of the manifestation 
 of nervous fatigue and breakdown. There is therefore 
 
COMMON NEUROSES. 
 
 ample evidence for regarding it as a vice of the 
 nervous centres. Yet I hold that it is a vice that is 
 too often detrimental to the patient simply because of 
 an inability to rise above it. It is very much with 
 the sleepless as it is with the subjects of Meniere's 
 disease ; for if we look at the subject from a physio- 
 logical point of view there is nothing so very harmful 
 in sleeplessness. There are plenty of people going 
 about who sleep no more than three or four hours ; 
 there are many more who are the lightest of sleepers, 
 which means that they wake many times in the course 
 of the night ; and those of either class would not dream 
 of considering themselves out of health. They go 
 about and take little heed of what is really not the 
 normal state of things. They take their sleep in 
 snatches, as the heart does, and do fairly well upon it. 
 But as soon as they get it on the brain that the sleep- 
 lessness is a grave matter, that it indicates serious 
 nervous weakness, and that it will end sooner or later 
 in insanity, then it becomes a very serious thing 
 indeed. Then it is that it does become a dread, 
 and every returning night becomes a hot iron entering 
 into the soul, for it is met with the closed teeth of an 
 expectation that will certainly be fulfilled. It is thus 
 I think that the patient tosses about and arises in the 
 morning in ■ such a dilapidated condition. " I am 
 sleepless ! I am sleepless ! " is the night-long refrain ; 
 whereas a dominant thought of this kind should be 
 dismissed for this other, that insomnia is harmful 
 
COMMON NEUROSES. 23 
 
 chiefly in proportion as we feed upon the idea that 
 it is so. 
 
 I pass naturally from such subjects as these to 
 others that are still more purely of mental origin. 
 There are many of these that give much anxiety to 
 individuals, and for which they come to the physician 
 to be reassured. A large number are unhappy 
 because they are losing their memory, or think they 
 are ; others because, comparing themselves with some 
 of their acquaintance, they think they cannot do such 
 and such things as well as their wont was, or as well 
 as they. Others, again, there are who have the time- 
 honoured fits of the blues, and very curious is the 
 persistency of some depressing idea with which the 
 patient is ofttimes possessed. One of the more 
 recent cases that have come before me was a young 
 man who, although he had been assured that there 
 was nothing the matter with him — that is to say, no 
 organic disease, — and although he professed to have 
 a thorough belief in his doctor, nevertheless came for 
 another opinion, because he was certain that there 
 7nust be something the matter because he perspired 
 so much. I talked to him for some time and carefully 
 went over all his organs, just to satisfy him that 
 everything had been done to make certain that there 
 was no disease. But I feel sure that I made little 
 real impression upon his mental condition, for it is 
 the habit of these patients to be a little more cheerful 
 while they are talking to the doctor, but to speedily 
 
24 COMMON NEUROSES. 
 
 relapse as soon as the sound of his voice has passed 
 away. 
 
 Of other common complaints I have jotted down 
 these : Headache ; pains in the back of the head and 
 dreadful depression at the top of the head ; a sensation 
 of going out of one's mind ; inability to concentrate 
 thought ; fits of absent-mindedness ; clouds of depres- 
 sion and sleeplessness. 
 
 Pins-and-needles and numbness claim another 
 large group of victims who die daily in anticipa- 
 tion of paralysis ; others come because their hands 
 shake, others for fainting fits, others for a feeble 
 circulation. 
 
 Another group is formed by people who come 
 and tell you that they are hardly ever free from pain. 
 There is an instinctive dislike in most of us, when a 
 person complains of pain, to say there is no disease ; 
 and it is necessary in such cases to be very careful 
 that we do not . let an idea run away with us. Never- 
 theless, I think that it must be admitted that there 
 are a fair number of people who are always in pain, 
 and who yet have no disease. Many and many a 
 time have I had this complaint of pain made— where 
 upon the most careful examination no disease could 
 be detected. And in some no doubt there has been 
 structural change, that could not be detected ; but 
 allowing for this I have none the less come to the 
 conclusion that there are some people in whom the 
 ordinary processes of life are conducted with pain, 
 
COMMON NEUROSES. 25 
 
 and yet without organic disease. A large number of 
 such seem to affect uterine disease, and find their 
 way into the hands of the gynecologist : some as 
 having ovaries ; others as having flexions ; others as 
 having a general lassitude and dull dragging back- 
 ache, and other ill-defined pains about the pelvis and 
 lower extremities. 
 
 Another large group affect spines, and lie on their 
 backs for months, and lead their friends and their 
 doctor a fine dance, unless some dire necessity steps 
 in, and, by taking them out of themselves, changes 
 the current of their lives. It may seem hard to say 
 that such people must learn to bear their pain, but so 
 it is. Herein is one of the mysteries of pain — there 
 is no standard by which to gauge it. In the abstract 
 it is part of the common lot of man, but there is 
 nothing that is less common between you and me. 
 What is agony to you may be a mere fleabite to me ; 
 and it is obvious, I think, as indeed I have already in- 
 dicated, that in its higher refinements pain is a product 
 or development that marches with the march of the 
 keen nervous susceptibilities of modern life. 1 can- 
 not believe that pain plays upon the same number 
 of strings in the lower animals as it does in man ; I 
 cannot believe that it conveys the same sense of 
 suffering to the savages of equatorial Africa as it does 
 to our country labourer ; I doubt if it is the same 
 to the country labourer as it is to the working-class 
 toilers in our large industrial centres ; I cannot believe 
 
26 COMMON NEUROSES. 
 
 it is the same to these as it is to the higher grades of 
 society. And if there are these differences, as I think 
 there must be, so there must be differences between 
 individuals, and inasmuch as I can only judge of 
 your suffering under given conditions by what I have 
 felt myself under such circumstances as happen to 
 have been most similar, we have no common ground, 
 or next to none, and we must therefore deal with 
 pain in the main upon nature's great principle of 
 strength sufficient for the day. We talk of treating- 
 pain ; but if we think about it, how large a part of 
 physical pain, and all the greater pain of mental 
 anguish, has to be borne. And if this indeed be 
 nature's law, as it appears to be, that the larger part 
 by far of the sum of human pain is thus without 
 remedy, there can be no unkindness in any one if 
 he should say that the best cure for many a lesser 
 pain is to learn to bear it. But so it is. The very 
 effort is a tonic with which no drug in the pharma- 
 copoeia can, all round, compare ; while every potion 
 is a submission to circumstances which, when the 
 next call comes, will necessitate a stronger dose. 
 " The weaker a body is the more it commands ; the 
 stronger it is, the more it obeys." 
 
 I am afraid I am hardly making my meaning clear^ 
 but it is this : that pain is, after all, only one form of 
 morbid sensation. I am not sure that it can rightly 
 be called morbid in many cases, seeing that it is so 
 often but the fag-end of pleasure. Why, then, should 
 
COMMON NEUROSES. 27 
 
 we fly at once to deaden pain by opiates and sedatives 
 any more than we should apply to the same source 
 to relieve some other unusual sensation, such as, for 
 instance, some slight itching of the skin ? An intole- 
 rable itching we should all agree to try to stop, because 
 it is out of the common, and when controlled one may 
 hope, or even confidently expect, that it will not 
 reappear ; but a slight irritation of the skin is so 
 much the lot of all at one time or another that we 
 take it as one of the daily vicissitudes of life. Why 
 do we deal with the slighter forms of pain, as, with 
 some exceptions, I think we are too much in the 
 habit of doing, in a different way ? 1 believe the 
 reason to be that which I have given — that we have 
 no gauge for the degree of pain, and because the 
 advice to grin and bear it is too likely to be resented, 
 unless it be presented with tactful modulations, the 
 power of which we do not all possess. The truth of 
 what I am saying is illustrated well by perhaps the 
 most homely ache that troubles us — viz., toothache. 
 He would be a very unwise physician who for every 
 aching tooth advised extraction, because we all know 
 well that a bad tooth will often ache as a barometer 
 of fatigue or worry or ill-health. A dose of quinine, 
 a dose of rest or sleep, sends many an ache of this 
 sort away ; while I suppose all must remember similar 
 cases to that of the neurotic lady I saw the other day, 
 who, refusing to accept advice and wait for the action 
 of such remedies as these, insisted on having her 
 
^8 COMMON NEUROSES. 
 
 tooth out, and then came back to me with her ache 
 far worse than it was before. 
 
 Now, whatever may be the common practice with 
 each of us, it is quite certain that such cases as I 
 have mentioned of general aches and pains are made 
 ■worse by treatment directed only to relieving their 
 pain or abnormal sensations — I will go further, and 
 •say are certainly ruined by such treatment ; and they 
 are as certainly reliev/^d somewhat, we cannot say 
 by half as much as we could wish oftentimes — be- 
 cause their ailment is the result, one might almost 
 say a part, of their being — by other measures. Job's 
 ■comfort this, some will surely say, but I reply that 
 to recognise the reason of a thing is always the first 
 step towards any real cure. 
 
 And let me enforce my remarks on this head, and 
 perhaps help to make my meaning still clearer, by 
 alluding to another common group of cases. There 
 came into my room one day a year or two ago, on 
 one of the hottest of summer days, a young man, 
 >of whom I had previously heard that he was a martyr 
 to his health. From what had been told to me 
 I was not altogether surprised when a dark-haired, 
 pale-faced, nervous man appeared upon the scene, 
 cloaked in a thick inverness cape and with his collar 
 turned up. But I was surprised when, peering 
 slowly round the room, he espied a window open 
 by a hair's breadth, and immediately asked leave to 
 shut it — this in the middle of summer, mind you. 
 
COMMON NEUROSES. 29 
 
 My wonder grew, too, apace as he next proceeded 
 to divest himself of layer after layer of apparel : 
 first his inverness, next his coat, then, I think, more 
 than one waistcoat, a linen shirt, a flannel shirt, a 
 Jaeger, and last of all a chest protector. Can you 
 wonder that he had developed a subserviency to what 
 he was pleased to call draughts and chills, that made 
 his life not worth the living ? This poor fellow 
 was leading a wasted life, for he had given up, or 
 deemed himself unfit for, the occupation he had 
 wished, and why ? Because, so far as I could find 
 out, he had been nursing his neurotic tendency until 
 he had become a perplexing and anxious burden to- 
 himself and his friends. A straight talk on the- 
 elements of physiological knowledge came as a 
 revelation to him, and I am told that he is now 
 clothed and in his right mind, and lives the life of 
 an ordinary mortal. But the main point is, How 
 come such to this pass ? I hope I shall not be 
 considered uncharitable in attributing something of 
 the bad result to a want of vigour in the professional 
 advice these poor people receive through sometimes- 
 many years. It is the tempering of the wind to the 
 shorn lamb no doubt, but it only makes the animal 
 more subjectively shorn. We are many of us much 
 too afraid of giving advice to patients that we 
 think they will not like : and in being so, a poor 
 neurotic slides on year after year, and only too likely 
 becomes eventually a wreck at the hands of the 
 
so COMMON NEUROSES. 
 
 profession which should have saved him. And if 
 you doubt it, think for a minute of the many women 
 who are only too ready to think they have a spine. 
 There is a halo of sanctity attaching to the spine, 
 such as never has been credited to the skull ; and 
 I really believe there are some who regard a weak 
 spine as an evidence of distinction, they nurse it 
 so long, and even in after-years still seem to regard 
 its former achings with such affectionate, if not re- 
 gretful, tenderness. Well, now, I doubt whether 
 there be such a disease as neuralgia of the spine ; 
 but no doubt the difficulty lies in distinguishing 
 between the early stages of spinal disease and the 
 mere achiness that is best treated, not by rest, but 
 by distraction. This must be so, for I could show 
 you a man now who has been cauterised all down 
 the spine, who has had a running sore made and 
 kept open for weeks, who has been roaming the 
 wide world under " the best medical advice," but 
 who has never had a whit the matter with him save 
 a bad set of nerves, and who has been practically 
 ■well since I told him so. 
 
 And I may here allude to another group, although 
 it has been so often talked about that there is no need 
 to say much. It comprises the large number of cases 
 born of anxiety for a supposed want of virility, or 
 rather for the loss of health that is supposed to 
 accrue from the too frequent involuntary excitement 
 •of the sexual centre and its natural physiological 
 
COMMON NEUROSES. 31 
 
 consequence. I do not know who coined the word 
 " spermatorrhoea," whether it was a quack or an honest 
 man, but I do know that it figures as a disease on 
 the nomenclature of the Royal College of Physicians, 
 and that there are surgeons of repute — physicians 
 also, perhaps, for aught I know — who still make use 
 of the term, and who treat what they consider to 
 be the disease. There is no such disease, and the 
 occurrences that are supposed to indicate its exist- 
 ence are natural and physiological, the absence of 
 which in some degree would be evidence of feebleness 
 or of ill-health, and the more or less of which is 
 the subject of much variation within the range of 
 health. And I have this much to say about seminal 
 discharges, that they are troublesome or complained 
 of in two classes of persons — the very muscularly 
 strong ; and such" as work hard with their brain and 
 in consequence run into a state of nervous erethism. 
 In either case a continent man is likely to suffer 
 more in this way than is natural, but this is not to 
 say that it is a disease that requires to be treated ; 
 it may be allowed to be a matter that admits of one 
 visit to a doctor, but by him it is to be relegated 
 to its proper position in the individual's mind by a 
 short lecture upon the most elementary physiological 
 principles. 
 
 The next condition that requires mention is a very 
 common one, and I can describe it no otherwise than 
 as simple fatigue. This is of course a vague sort 
 
32 COMMON NEUROSES. 
 
 of symptom, likely to lead for that very reason to 
 important errors in diagnosis. I feel constrained 
 to dwell upon it because there is no other class of 
 ailments that I find more difficult to make the public 
 understand than this. " I am always so tired," say 
 these men and women, but more often the latter than 
 the former. " I am tired when I get up in the 
 morning and tired all day, and yet I cannot say 
 that there is anything the matter." Nor is there. 
 "It is better," says the Autocrat of the Breakfast 
 Table, " to lose a pint of blood from your veins than 
 to have a nerve tapped. Nobody measures your 
 nerve force as it runs away." I suppose that any one 
 could give notes of many such cases — people easily 
 knocked up, and yet without any discoverable disease. 
 In such cases it behoves us of course to be very 
 careful not to overlook anything, and it is as well 
 to make several examinations if there be any doubt ; 
 but they pursue the even tenor of their languid way 
 too long for serious disease, and the feeling of fatigue 
 is part of the order of their being. These cases all 
 have this other feature in common : that they are 
 neurotics. Let me note the salienjt features of two 
 or three of them. One is a man^ aged forty-foun 
 He has had rheumatic fever, which in itself is enough 
 to constitute a man a neurotic, for the whole history 
 of that disease betokens its affinities. He was in 
 business, but gave that up, and now is a farmer, but 
 he cannot work long. He is not short of breath, and 
 
COMMON NEUROSES. 33 
 
 his appetite is as good as ever it was ; but he is 
 always tired, and he says he could not walk the ten 
 minutes to his farm if he were given five pounds to 
 do it. In another case it is a woman, again with a 
 history of rheumatic fever, but with no disease. She 
 is a lady of a decidedly intellectual turn, but she de- 
 clares that she never has energy for anything, and her 
 daily duties in her house are a regular burden to her. 
 Another case is a young lawyer whose father's family 
 he calls a decidedly nervous one, and his mother is 
 very gouty. He has had indigestion and a liver 
 for twenty years, and wakes up with a dirty tongue 
 (I wonder who wakes up with a clean one). Of late 
 he had lived in the country and had had plenty of 
 exercise, and had been better, but then he got the 
 influenza, and since then he had felt weak. He came 
 to me because, as he expressed it, he was dead tired 
 from the time he got up in the morning till the 
 time he went to bed at night. He was quite free 
 from disease, he was not wasting, and I attributed 
 all his ailment to the fact that he was hard at brain 
 work from nine till six, that all his vital energy 
 was thus consumed, and he had none to give to his 
 muscular system. Now I hope I shall not be under- 
 stood to say that all those who complain of fatigue 
 and inability to do their ordinary day's work are 
 neurotic. There are of course many causes of 
 muscular fatigue : the man who habitually cats and 
 drinks too much may feel the same lassitude, the 
 
 3 
 
34 COMMON NEUROSES. 
 
 habitually constipated the same, the man with an 
 excess of uric acid in his blood the same ; but, de- 
 ducting these and all other causes of muscular mal- 
 nutrition, such as acute blood-poisoning and the like, 
 I will still maintain that a large number of people 
 come complaining of this symptom, for which the most 
 probable explanation is that their nervous flow is not 
 produced in sufficient quantity to suffice for the needs 
 of the various organs that require it. There are some 
 who generate enough, but they distribute it unequally, 
 or rather the consumption by certain organs is 
 prodigal. The brain holds debenture stock of this 
 investment, and so those who tax their brain unduly, 
 whether by work or worry, are very likely to experi- 
 ence this feeling of fatigue, because their muscular 
 system has not the requisite supply of energy where- 
 with to make it go. On the other hand, there are 
 others who make little nerve force at the best of 
 times, and although their brain power never shows 
 above mediocrity, or something lower, they yet suffer 
 in the same way as those more highly endowed, 
 but at an altogether lower pressure along the whole 
 line. I shall have to utilise, and I think enforce, this 
 explanation when I come to the subject of indiges- 
 tion ; but in the meantime some support may be 
 gained for it from another set of rases perhaps similar 
 and only more pronounced, and of which some of 
 you must have seen examples. I mean the curious 
 conditions of complete nervous collapse seen now 
 
COMMON NEUROSES. 35 
 
 and again after severe mental strain. Here is such 
 an one : A clergyman aged forty-six, the incumbent 
 of a London parish, first began to have peculiar at- 
 tacks some three or four years ago after very hard 
 work. He would be suddenly seized with numbness 
 in his hands, his nose, his tongue, and mouth ; with 
 violent pains in his knees ; a feeling as if he were 
 going to die ; then a violent fit of crying would come 
 on, and this was succeeded by a sleep of eight or 
 ten hours. He had been well for many months, 
 and, indeed, till just before I saw him, when he had 
 other not quite similar seizures, in which breath- 
 lessness was the chief symptom ; but he also had 
 the most acute pain in the right arm, and fainting 
 afterwards, he thinks, from sheer pain. I saw him 
 two or three times, and could not make out much. I 
 never was quite clear about the nature of the attacks ; 
 no medical man saw them, and 1 was therefore obliged 
 to take the statement of the patient and of his wife ; 
 and the latter described them to me as a mixture of 
 cramp and hysteria, but that they ended in a state of 
 complete exhaustion and drowsiness, after which he 
 only slowly regained his strength. I thought at one 
 time that they might have an epileptic taint about 
 them, but I do not now think that such was the 
 case. 
 
 Another case was that of a younger man who 
 had always been subject to headaches, which had 
 of late been on the increase. He had had a sreat 
 
36 COMMON NEUROSES. 
 
 deal of worry before the attack I am about to relate, 
 and, his headaches being worse, he was taking a 
 few days' holiday. When out for a ride he suddenly 
 became quite dazed ; he found his way home, or his 
 horse took him, for he was not conscious of where 
 he was, and his memory for that period was a com- 
 plete blank. He slowly came to himself, but was 
 confused till the next day, and when I saw him, so 
 late as six days afterwards, he still felt stupid, and 
 his head heavy. Except for his headaches, he has 
 remained well ever since. 
 
 Another somewhat different case is as follows : A 
 surveyor of thirty-six years, whose father died of 
 diabetes, while out with the Volunteers one day in 
 August had a " sunstroke." In passing I may remark 
 that a quite mild sunstroke would seem to be a 
 serious thing, for I have seen certainly five or six 
 cases where it was deemed to be the starting-point of 
 a number of morbid nervous actions. He had never 
 been well since the sunstroke ; he had had vertigo 
 since then and curious sensations at the back of the 
 head. Not long afterwards he fell some twelve feet 
 through a trap-door, and th'is greatly prostrated him. 
 I could make out nothing except that he had a slight 
 buzzing noise in his ears ; but he spoke slowly and in 
 a depressed manner, and all his reflexes, knee and 
 wrist, were exaggerated ; and his urine contained 
 sugar in small quantity. 
 
 Last of all of this class of cases I would take that 
 
COMMON NEUROSES. 2>7 
 
 of the woman whose attack may begin in a variety 
 of ways, either by coHc or seeming coHc ; or by 
 violent pain in the side that is referred to the heart, 
 but in all probability not correctly so ; or, it may 
 be, by some indescribable feeling of illness ; but 
 each and all of these are followed by what can only 
 be described as a state of complete exhaustion. Often 
 have I been called to such cases, and found that the 
 medical man in attendance has been sitting with 
 the patient for hours, perhaps all the night, because 
 he was afraid of sudden dissolution, and the heart 
 is the organ that is supposed to be failing ; whereas 
 the truth of the matter is that the heart is perfectly 
 sound, and if one may venture to form an opinion 
 after the crisis is over, I do not suppose there has 
 at any time in the progress of the attack been any 
 danger of death whatever, I cannot think that this 
 is a form of neurosis that receives adequate recogni- 
 tion ; and I believe the real nature of the malady 
 is often overlooked because the household is in a 
 panic, thinking the trouble one of the heart, and the 
 medical man, not quite sure that there may not be 
 some real disease, and not wanting to make a mis- 
 take, first for the sake of his patient and next for 
 his own reputation, acts on the side of caution. 
 There is no danger in these cases ; they only need, 
 they and the friends, who generally cause most of 
 the mischief, a decided assurance by the doctor, in 
 a tone that shows to them that he knows what he 
 
38 COMMON NEUROSES. 
 
 is talking about, that the patient will soon be well. 
 A little valerianate of ammonia or bromide of am- 
 monium and sal volatile will complete the cure. 
 
 Allied, again, to these cases of prostration comes 
 another group, characterised only by emaciation. 
 And here again one has need to be very careful 
 not to overlook anything. But there can be no 
 question that nervous exhaustion, or breakdown, or 
 whatever we choose to call it, is capable of pro- 
 ducing the most extreme wasting, quite apart from 
 the existence of any disease. The most extreme 
 instance of this that I have ever seen was in the 
 case of a young man whom I had already known 
 some ten years or more, and who was much given 
 to worrying over trifles. Some sixteen years ago he 
 walked into my room one day, and in doing so 
 produced an electric sensation throughout me which 
 I have never forgotten, for I could not get away from 
 the idea that I had shaken hands with a corpse. He 
 was an absolute skeleton, and his wizen face had 
 that peculiar appearance of the skin of the fore- 
 head that gives the idea that the skull is showing 
 through it. I examined him with the utmost care, 
 and I could find no evidence of disease of any 
 kind. I think that is good evidence that there was 
 not much wrong so far as gross disease was con- 
 cerned, for in those early days I fancy that the errors 
 we commit are not so much those of omission, but 
 we often find diseases that have no real existence. 
 
COMMON NEUROSES. 39 
 
 Well, I could find nothing, but I did not nevertheless 
 give up my opinion, that had consigned him prema- 
 turely to the grave. I could not find anything ; so 
 much the worse for me, not the better for him. I 
 still held to the idea that, concealed under the lean 
 skirts of his fleshly covering, there lurked a something 
 that was gnawing at his vitals. Indeed, I believe I 
 came the nearest I have ever done to believing in the 
 popular notion that perhaps he had a tapeworm. 
 But in supposing that this man had some hidden 
 disease that could not be discovered I had overlooked 
 the power of the disordered nervous system to 
 produce the symptom that had alarmed me so much. 
 I realised it afterwards to the full when week after 
 week, sometimes day after day, he would come and 
 talk by the half-hour of his ailments, till some- 
 times I think my visage must have caught the 
 reflection of the sickly light that shone so plain in 
 his. However, his worries wore off, and his business, 
 which was a harassing one, prospered, and his flesh 
 came again to him, if not like the flesh of a little 
 child, yet with sufficient plumpness for his needs, 
 and that man is alive and well to-day. Several 
 others might be given of like kind, if not quite so 
 extreme in degree, and there can be no doubt 
 about the influence of the nervous system in modi- 
 fying nutrition in this way, and what is more, it is 
 one of the most interesting subjects in the whole 
 range of medicine and physiology. We talk about 
 
40 COMMON NEUROSES. 
 
 diet influencing the nutrition, and we diet fat people 
 to make them thin, and thin people to make them 
 fat. But I have never heard of this experiment 
 being carried out yet : the taking twenty consecutive 
 cases of obesity, treating them on the same plan, 
 and publishing the results, and doing the fattening 
 process on the lean kind in similar way. We hear 
 of Mr. So-and-so's diet as a good thing because it 
 has reduced one or perhaps two people, but I make 
 bold to say that there is no diet that has ever been 
 suggested that has not failed, and failed absolutely, 
 in many more cases than it has ever succeeded in. 
 There are some people, ay, many, whom you can 
 never make thin, and there are many people, and 
 those usually — and here is the point of its introduc- 
 tion here — of a nervous temperament, whom, do what 
 you will, you can never make fat. Children, for 
 instance, are often brought for an opinion because' 
 they are so' thin ; they are always eating, and 
 yet never do any credit to their victuals, and they 
 are fed up and made to take cod-liver oil, and 
 maltine, and all the latter-day fatteners. But these 
 children are always twitchy, half choreic, or excit- 
 able ; and they are for the most part of a nervous 
 temperament. No good is done by stuffing them ; 
 on the contrary, their urine becomes loaded with 
 solids, their intestine fails to digest properly, and 
 they have repeated bilious attacks. Put them on 
 an ordinary diet, perhaps rather a spare one, and 
 
COMMON NEUROSES. 41 
 
 plenty of water to drink, and though they do not 
 get fat, they keep in much better health, and indeed 
 they cease to give much anxiety to their parents. 
 
 And now that I am on the subject of children, in 
 this regard another condition comes to my mind that 
 is very common ; it is a neurotic condition, and one 
 that is not fully apprehended in many cases. I allude 
 to the pyrexia that is so often produced in young 
 children by falls on the head, or blows of any kind in 
 that region. It is quite common to be called to see a 
 child who has been quite well till a certain day, when 
 it has had an injury to its head by a fall or what not ; 
 and thereafter it has, within a day or two, become 
 feverish, and in consequence the onset of meningitis is 
 feared. I have seen cases of this kind repeatedly, and 
 they have always seemed to be of considerable interest, 
 because they suggest the possibility of an injury of 
 some heat centre or regulator. But I do not think 
 this explanation is so probable as that the injury to 
 the head leads to disordered nerve control over the 
 viscera, which elaborate the blood and depurate it of 
 effete matters, and that in consequence the pyrexia is 
 a direct result of this faulty action of the viscera. 
 And I believe head injuries of this kind are capable 
 of inducing even definite disease in this way. For 
 instance, some three years ago I saw a little boy of 
 two years old who had hitherto been quite well. He 
 had a fall on the 5th of the month. On the next 
 day he was quite well, but on the 7th of the month 
 
42 COMMON NEUROSES. 
 
 he was very sleepy and wanted to stop in bed. He 
 was seen by Mr. Stokes, of Blackheath, on the third, 
 day after his fall, and he then had a retracted neck, 
 had vomited once, and he was still very drowsy. 
 When I saw him his temperature was ioi°, his pupils 
 active, no intolerance, and I regarded it as one of the 
 cases I am discussing. He remained in the same 
 drowsy, irritable, indefinite state for a fortnight, and 
 then slowly developed into a case of apical pneumonia 
 that came on very slowly and obscurely, and which 
 ultimately got quite well. Am I because of the 
 result to alter my opinion of its cerebral origin, and 
 say the fall had nothing to do with the attack? 
 Had I seen no others like it, I might be inclined 
 to think so, but having seen many of somewhat 
 similar character, I incline to believe that injuries 
 to the head are capable, by interfering with the 
 control power of the nervous centres, of leading — 
 to disordered function in the first instance, and in 
 the second to such pronounced organic departures 
 even as an acute pneumonia. I doubtless speak to 
 those whose experience can supply other cases to 
 which a like explanation would be not inappropriate. 
 And here I must break off this section of my 
 subject with the remark that it often strikes me 
 when dealing with such conditions as I have spoken 
 of how intimate is their connection with pronounced 
 insanity. It is a happy thing that one can say 
 for certain that such conditions as these eo on 
 
COMMON NEUROSES. 43 
 
 for many years ; but many of them pass out of 
 notice, and we do not have the opportunity of seeing 
 the result, and one cannot but think that in some 
 of them, at any rate, one must see the beginnings 
 of mental unsoundness, and in some of them probably 
 the incipient stages of that most terrible of all its 
 forms, the disease that goes by the name of general 
 paralysis of the insane. 
 
LECTURE 11. 
 
 We pass next from the neurotic conditions that 
 concern the sentient being as a whole, and which I 
 have in consequence termed " cerebral neuroses " for 
 want of a better term, to others that have for the 
 most part a more local bearing. The distinction is 
 of course an artificial one, but it allows of a better 
 grouping of cases in this lecture, and has other 
 conveniences as well. We shall concern ourselves 
 then now with troubles of the thoracic cavity, or rather 
 with respiratory and circulatory neuroses. And the 
 first group of cases that I have to mention is distin- 
 guished by a disposition to more or less severe 
 attacks of paroxysmal sneezing. Such cases are by 
 no means uncommon, and they are very troublesome. 
 I give a short note of some. A young lady comes of 
 highly neurotic stock. Her mother suffers from bad 
 sick headaches, and as these have become less severe 
 they have been replaced by other neuralgic turns. 
 This patient's brother, whom I saw, has had curious 
 neuralgic pains in the abdomen when a child, the 
 diagnosis of which was only arrived at after some 
 long period of watching. Two other of the children 
 
 44 
 
COMMON NEUROSES. 45 
 
 have bad nightmare. This child is aged fifteen ; she 
 is growing fast. She is brought for what are called 
 bad colds, but when the account of them is detailed, 
 the attack appears to consist of sudden severe 
 paroxysms of sneezing, and her nose runs freely. 
 The seizures are so severe that they make her quite 
 ill, and she has to go to bed for a day or two, by 
 which time she recovers herself, and is well for a 
 time. She has a thin skin, and easily gets chilblains. 
 A second case is that of a lady of thirty, who is much 
 troubled with violent fits of sneezing and nose-run- 
 ning, which last about two hours every morning. 
 There is no doubt that she is a neurotic : she has bad- 
 headaches and noises in the ears, and she already has 
 grey hair. Two others were women, and both were 
 asthm.atic. Another case, a man, has his attacks 
 almost every morning, more in the cold weather than 
 in the warm, and the " cold " passes off as the morning 
 wears on, mostly soon after breakfast ; but before that 
 time is reached he has used up a couple of handker- 
 chiefs. In a little girl of six "such bad colds come 
 on quite suddenly in her nose." A lady of forty is 
 always taking cold. She has been to no end of 
 doctors about her throat, and has used all sorts of 
 vapours and inhalations. Her fingers " die " occasion- 
 ally, and when her body is warm her fingers and toes 
 are cold. She has most bothering attacks of sneez- 
 ing, and is often hoarse. The- sneezing comes on 
 mostly at night, and in consequence of it she wraps 
 
46 COMMON NEUROSES. 
 
 her head in a shawl whenever she goes out, and takes 
 great care of herself ; but whenever she is in a good 
 climate she is quite well. Another case is a woman 
 aged twenty-nine. Her maternal grandfather had 
 hay fever and asthma. She has had bad sneezing 
 attacks for years. They commence in the early 
 morning and go on till about 1 1 a.m., and then 
 cease suddenly ; she has of late had much asthma. 
 The last case I shall allude to is that of a gentleman 
 who has been long in India. He has had malaria 
 once or twice, and an attack of eczema once in India, 
 and for twenty years or more he has had severe 
 periodical attacks of sneezing. He was sent to me 
 for transient glycosuria, and he did not allude to his 
 nose much. I fancy he had had enough treatment 
 for that affection, for he had fallen (unluckily, as I 
 think, for him) into the hands of some one who had 
 done despite to his nasal mucous membrane by means 
 of the galvano-cautery. 
 
 These cases are very interesting ; they are closely 
 allied to hay fever, if they be not part of the disease 
 that goes by that name. They are closely related 
 also to spasmodic asthma, as this case will show. A 
 man of twenty-six has had asthma since three years 
 old. His attack often begins in the early morning by 
 passing from a warm to a cold room, which brings on 
 a violent attack of sneezing. This may last from 
 thirty minutes to two or three hours, and sooner or 
 later seems to pass down his bronchial tubes to his 
 
COMMON NEUROSES. 47 
 
 lungs and then to produce a short attack of asthma, 
 which, however, generally passes off on taking a cup 
 of hot coffee. I am not sure, too, that these cases may 
 not have some relation with Raynaud's disease. But 
 however this may be, the affection is a purely neu- 
 rotic one, and in no one of these cases was there any 
 local disease of the nose. Nor, indeed, if we look at 
 the history of the attack, was there likely to be, for 
 the attack comes on in almost all the cases with the 
 greatest suddenness, reminding one much more of 
 the suddenness of the explosion of a nervous dis- 
 charge than of the onset of an inflammation. And I 
 think, if we study the nature of these attacks, the more 
 one becomes convinced that the real disease cannot 
 be any local organic change, it comes and goes so 
 rapidly. It has been said indeed, and I dare say 
 with truth, that this state is immediately due to an 
 erectile condition of the mucous membrane of the 
 turbinated bones ; but if we allow that this is so, such 
 a state of things is, after all, only an exaggeration of 
 a physiological condition, and in no sense a local 
 disease. I make a great point of this, because these 
 cases are in the present day being treated by local 
 measures of some considerable severity. I hear of 
 turbinated bones being removed for such symptoms 
 as I have narrated, and more often of the galvano- 
 cautcry being applied. Now I must not say that 
 treatment of this kind is never necessary, for " never " 
 is a word that seems to have crept into the language 
 
COMMON NEUROSES. 
 
 of men by mistake, and almost the only time it has 
 justified its existence, and can be used with absolute 
 appropriateness, is when we say of it that it is never 
 absolutely true. But I think we should remember, in 
 making use of severe measures of this kind, that we 
 are only treating a symptom, and from the nature of 
 the case adopting a means that is very unlikely to 
 prove of any permanent good. I feel bound to add 
 that in my own opinion means of this kind are too 
 often meddlesome and bad surgery, and bring us 
 no credit ; I will go further, and say that they may 
 come perilously near trailing an honourable calling 
 in the mire of quackery. 
 
 In saying this, I pass to another neighbouring 
 neurosis that is not altogether above a similar 
 suspicion — the disease that goes by the name of 
 " clergyman's sore-throat." I suppose we all come 
 more or less across this affection, and if your ex- 
 perience is at all like mine, it is of this kind : it 
 occurs in nervous persons ; they are often over- 
 worked, and want a holiday (a not uncommon re- 
 quirement). But it often enough occurs in the country 
 parson who has an easy life and less than enough to 
 do. Now I have talked to many of these people, and 
 the complaint they make is that after a simple reading 
 exercise, such as is required by the church services, 
 the voice goes, or more commonly, I think, that they 
 feel exhausted. I do not remember to have seen it in 
 any one who has been a long-winded preacher, or 
 
COMMON NEUROSES. 49 
 
 in one who had the gift of energetic extempore dis- 
 course ; it is a disease of the feeble lack-lustre man and 
 of the highly nervous. From talking to them I have 
 come to the conclusion that there are some who look 
 upon the exercise of the voice as an exhausting thing, 
 and that when they had gone through the very 
 modest exertion of reading the prayers they were 
 somehow used up and virtue had gone out of them. 
 The idea is expressed in this extract of a letter 
 received only the other day from a young effeminate 
 man, who has a good voice, and is cultivating the 
 art of song. " I forgot to ask you," he writes, " if 
 I may bathe and swim in the season, because I 
 have been told that they are very weakening for one 
 who wishes to cultivate the voice." The idea here 
 obviously is that the act of singing uses up the vital 
 energy, and that there is no sufficiency for any ex- 
 penditure on other calls. So far as my experience 
 goes, I have examined these throats many times, and 
 have never seen anything the matter with them ; and 
 I am certain I have seen these people having a nice 
 time of it on the Riviera, nursing their throats and 
 with an air of respectable delicacy about them, 
 when all they required was a good tonic, with the 
 reassurance that they might with perfect safety 
 return to their work if only they would take care 
 to make it a work of their will^ and not of their 
 emotions. 
 
 Now these arc emphatically not the cases to put 
 
 4 
 
50 COMMON NEUROSES. 
 
 through a course of inhalations, of paints, of electric 
 tickling — worse still, of galvano-cautery. They will 
 go in for anything we advise them, and it is mar- 
 vellous to me how docile, not to say imbecile, some of 
 these patients are in abdicating all the seat of their 
 reason. But in saying thus much it may perhaps be 
 thought that I am speaking in an exaggerated way, 
 for, after all, the voice and the throat are sensitive 
 parts, and we have abundant evidence in great singers 
 that most trivial causes may upset them. I do not 
 think what I have said touches that question. A 
 singing voice brought to the perfection of that of a 
 great public singer is a very touchy thing, no doubt, 
 but the avocations of those who are prone to suffer 
 from their throats — and though I have given it the 
 common name, yet it is by no means confined to the 
 clergy — ask no service that can be compared to the 
 evolutions that a larynx of that kind goes through. 
 The ordinary work of the voice, even for those who 
 are called to address public meetings or talk much, 
 is no such excessive tax. Moreover, it is no un- 
 common thing to find people become hoarse aftei' 
 reading or singing for a short time. But if their 
 nerves are of proper string, they do not for that 
 reason rush off to the throat doctor ; rather do they 
 bear the ills they have than fly to others that they 
 know not of Nor do these things mean any real 
 delicacy. The same person who becomes hoarse by 
 a little reading aloud from a book that has no great 
 
COMMON NEUROSES. 51 
 
 interest for him, may go and lecture for an hour 
 without a shade of huskiness, when the exigencies of 
 the situation or interest of the subject have taken him 
 out of himself I assert most positively that voice 
 failures of this kind are absolutely independent of the 
 general health, and are due no doubt to some local in- 
 coordination of the several structures concerned. This 
 may arise from several causes. It may be from fatigue 
 of the muscles ; may be from inability to adapt the 
 parts properly ; it may be from some little swelling of 
 the mucous surface under the stimulus of use ; from a 
 little hypersecretion under like circumstances ; and so 
 on. My own conception of the disease would perhaps 
 be that it is a mild hybrid between a costermonger's 
 throat on the one hand and the functional aphonia of 
 women on the other. I mean to say that there are 
 perhaps about it both the elements concerned in 
 these diseases : a mild, very mild, catarrh, we may 
 call it, on the one hand, and a want of nerve force on 
 the other. The former element is so slight that treat- 
 ment for it is not required ; and for the latter nothing 
 more is necessary than a good nerve tonic. I have 
 no objection to a poor hard-worked man of business 
 or a clergyman having a health-giving time on the 
 Riviera, or anywhere else. By all means let them 
 have it if it be necessary ; only let it be the remedy 
 for what it is : for a general nerve fatigue. The advice 
 could be then taken or rejected on its merits ; but to 
 say you have a delicate throat and must go here or 
 
52 COMMON NEUROSES. 
 
 there according as the latest fashion dictates, if it 
 means anything, is a sort of verdict of consumption 
 by innuendo that does not allow the man to be a 
 free agent, and he obeys, often at the greatest in- 
 convenience to others as well as himself, and too 
 commonly at considerable sacrifice. And while I 
 am on this subject I will say that advice with 
 reference to residence seems often to be given in 
 the most reckless and ill-considered fashion, when 
 we remember how little we really htow about such 
 matters. 
 
 I must next allude to the people who are always 
 " catching cold." They are common enough, but here 
 is one such, a man of thirty-nine years. He had 
 ague in his youth when he lived down in Essex, but 
 he has got rid of that, and has had very good health 
 until he went to the East a year or two ago and got 
 fever (he thinks not malarial) on his way home at 
 Athens, Ever since then he has been prone to 
 colds, and his subjection in this respect gets worse 
 and worse. Sometimes he has cold in the head, and 
 sometimes it is a sore throat. The slightest chill 
 brings on an attack. Now colds, or rather a tendency 
 thereto, are due to a neurotic susceptibility in almost 
 all cases. The usual treatment for them is shielding 
 the patient in all possible ways from all changes of 
 temperature ; and what is the result ? It must 
 inevitably be that, kept from all experience of 
 changes of temperature, the surface loses its accom- 
 
COMMON NEUROSES. 53 
 
 modative power, and in consequence becomes unduly 
 sensitive to any change. Thus, instead of a cure an 
 ever-increasing liability to " colds " results. The 
 man who attempts to keep himself in an uniform 
 temperature in our English climate engages himself 
 in a struggle with his environment in which he will 
 inevitably get the worst of it, and sooner or later he 
 will be crushed if he does not give up the fight. 
 There cannot be any question that the diseases of 
 which I am speaking are the products of civilisation, 
 and that they are gradually evolved out of the trivial 
 ills and troublesome sensations that are the common 
 lot of mankind by giving way to them in the first 
 instance instead of learning to bear them, which in 
 the end would mean not to mind them. In so far 
 as the inability to bear them is an indication, as it 
 often is, of an enfeebled nervous tone, so far they 
 are proper cases for drugs ; but bear in mind that 
 it is always to be medicine plus good advice and 
 rudimentary lessons in physiology, and that the 
 latter part of the treatment is the more radical of 
 the two. 
 
 And from this I pass to a closely-allied disease, 
 to another product of civilisation — viz., spasmodic 
 asthma. Of course this disease may be produced in 
 several ways, but I shall not be misunderstood when 
 discussing it to speak of the several organic causes 
 by which it is brought about, but simply of what is 
 sometimes called true spasmodic asthma, because, 
 
54 COMMON NEUROSES. 
 
 forsooth, no definite organic cause can be discovered 
 for its existence. I say, again, no true definite 
 organic cause can be discovered for its production. 
 To say that impHes that we have searched for one, 
 and I would not say have searched wrongly, but 
 what I would say is that in searching for a cause of 
 this kind let us beware of becoming engrossed with 
 the idea that there is a structural change, if only we 
 could but find it. In these latter days the search for 
 tangible causes is so successful that it has become 
 absorbing, and there is a definite intolerance abroad 
 of those who talk of functional disease. No doubt, 
 from the point of view of those who attack the citadel 
 of ignorance ab extra, functional disease is a cloak 
 for ignorance, and it is too often made the pretext 
 for the wildest notions, the most shameless quackery, 
 and at the best is too often obstructive to material 
 progress. Nevertheless, grounded as I have been in 
 the coarser facts of morbid anatomy by thirteen 
 years' work in the post-mortem room, I consider I 
 have aright to say that there is still a large place in 
 the practice of medicine that is legitimately filled by 
 functional disease, and that probably there always 
 will be. The huge lunatic asylums that may be seen 
 growing up all around us go a long way towards 
 proving the truth of such a contention, but there 
 are many diseases along the lines of my present 
 subject, and spasmodic asthma is one of them. 
 When I study this complaint in a comprehensive way, 
 
COMMON NEUROSES. 55 
 
 it seems to me as nearly certain as it can be that it is 
 the direct result of cultivation, and in its worst forms 
 often of our methods of its ti^eatmefit. Asthma can 
 be fostered and nursed into a very terrible disease, 
 and often is so. And, on the other hand, I believe 
 that much may be done to mitigate its severity, to 
 eradicate it altogether, or, at any rate, to divert it into 
 more general paths of explosion, if we make ourselves 
 familiar with its history. 
 
 What is the history of spasmodic asthma? The 
 first thing that I learn about it is that it largely occurs 
 in those who have in one form or another a neurotic 
 inheritance, or are themselves clearly of nervous 
 temperament. I have gone over my own cases from 
 this point of view, and this is the result. Of fifty-one 
 cases (twenty-seven males and twenty-four females), 
 nine only were not evidently neurotic. In eight the 
 disease was hereditary ; in ten there was rheumatism 
 in the family ; in five a pronounced history of megrim. 
 For others I have noted the existence of diabetes and 
 somnambulism in the relatives. In the patients I 
 note such things as chorea : " a highly nervous and 
 crotchety lady." " If anything goes wrong in busi- 
 ness the man is sure to have an attack " ; " the attack 
 comes on after any little excitement." A girl of 
 seventeen had convulsions when an infant ; another 
 young lady had hysterical aphonia and urticaria, and 
 bad rheumatism at other times ; another patient has 
 hafl urticaria, headache, and asthma. And so the 
 
56 COMMON NEUROSES. 
 
 story goes all through the list. I need not take up 
 time by going more into details. But as an amusing 
 illustration of the extraordinary mental feebleness 
 that may be sometimes reached where our ailments 
 are in question, I cannot forbear to tell the following : 
 A lady came to me for asthma, and in the course of 
 conversation said she thought she ought to tell me 
 everything. The confession she had to make was 
 that she had put herself under some one who under- 
 takes to treat disease by correspondence. I asked 
 her what had led her to seek advice from so unre- 
 liable a source, and her reply was, " Well, I knew he 
 must be a good man because he advertises in The 
 Christian." 
 
 Another point about asthma has often struck me, 
 too — viz., how seldom, comparatively speaking, it 
 occurs in the lower classes of society. It is chiefly 
 a disease of the middle and upper strata — a disease, 
 I believe, of infancy and childhood as much as of 
 adult life, and, I would add, ought to be confined 
 to those stages of existence. A case of pure spas- 
 modic asthma is quite uncommon in the wards of 
 a hospital, and in so being may be offered as a 
 fact in support of what I advanced in my last 
 lecture — that it is probable that the evolution of 
 neurotic tendencies is proceeding faster in some 
 strata of the people than in others. And when I 
 say this of asthma, I am not sure that in all of 
 what I am going to call its stages of evolution, it 
 
COMMON NEUROSES. 57 
 
 IS much more often absent in the lower than in 
 the upper classes ; and if this is true, then it may 
 go to support my contention that the pronounced 
 disease is eradicated in no small number of cases 
 by the gradual hardening of the nervous system 
 that takes place under the conditions of the struggle 
 for existence that prevail amongst the lower sons 
 of toil. But to make my meaning clear, I must 
 now explain what I consider to be the different 
 phases of spasmodic asthma. 
 
 As I look along the seven stages of human life, 
 from its cradle to its grave, I find nothing that at 
 first sight resembles spasmqdic asthma at the early 
 periods of existence ; that is, under, say, three or four 
 years. And not finding it, and further, not seeing 
 any evident reason for its absence — for there is 
 nothing in its symptoms that would betoken it was 
 a disease of a special period — one not unnaturally 
 scans the wide plain of infantile disease to see if, 
 perchance, from this point of view, some rudiment 
 or embryonic form of the malady can be discovered. 
 I cannot but think that a disease soon suggests itself 
 which has points of great similarity, although want- 
 ing the most characteristic feature of the mature 
 malady, if so I may speak of it. 
 
 The disease I have in my mind you all know 
 well. I mean the common gastro-pulmonary fever 
 that any practitioner sees once or twice in every 
 day. Here is the sort of case I mean : A little 
 
58 COMMON NEUROSES. 
 
 boy four years old, who comes of a decidedly neu- 
 rotic stock, and who, moreover, has given evidence 
 that as are his parents in this respect, so is he — is 
 quite well on a certain day, but ails a little towards 
 night. His mother says he has got a chill ; his 
 father, knowing more of the world, perhaps, and 
 altogether having a more critical disposition, is not 
 so sure that the child has not overeaten himself 
 Anyhow the so-called cold gets worse, a cough 
 comes on, and he develops a sharp fever. The 
 disease, whatever it be, quickly rolls along the bron- 
 chial tubes, and when the doctor arrives the child 
 has all the appearance of being seriously ill with a 
 sharp attack of bronchitis. To make matters worse 
 apparently, he is sick several times in the course of 
 the first twenty-four hours, and at the end of that 
 time he is still breathing rapidly and seems very 
 ill. Within a day or two, however, the temperature 
 drops, the acuteness of the chest disturbance sub- 
 sides, and within three or four days the whole affair 
 is at. an end, leaving the little patient hardly worse 
 than he was before the attack commenced. Now, 
 one acute illness of this sort tells us nothing ; the 
 disease might be many things, and the field is left 
 still contested. " My dear," again says the wife, 
 " I am sure the child caught a chill," and a host of 
 reasons are given to prove it, but the father keeps 
 also to his opinion, and declares that the buns he 
 saw his little glutton eating were enough to do a 
 
COMMON NEUROSES. 59 
 
 great deal more damage than was the case here 
 had not the destroying angel stayed his hand. The 
 doctor looks on at this domestic strife and shrugs 
 his shoulders, and departs well satisfied that the 
 illness that threatened so seriously has proved abor- 
 tive. But by-and-by the same scene comes over 
 again and yet again, and the doctor at any rate 
 grows wiser, for he learns then to know his patient's 
 constitution, and he knows that, whatever may be 
 the exciting cause, the real one lies far deeper in 
 the primordial tendencies of the child. The expe- 
 riences of general practice will tell many that I 
 am not drawing upon my imagination in the least, 
 but that the picture is one of the commonest that 
 is met with in the daily round. 
 
 There can be no question that attacks of this 
 sort occur in particular families and belong to 
 particular children ; and, as I have said elsewhere, 
 they are to my mind paroxysmal neuroses, and they 
 are the representatives in babyhood of spasmodic 
 asthma. For some reason or other, which I shall 
 not even attempt to guess at, the respiratory 
 paroxysmal neuroses put on this form in infancy 
 and early life ; while that of spasmodic asthma is 
 characteristic of older children and adults. I think, 
 to repeat what I said just now, that in comparison 
 with spasmodic asthma the gastro-pulmonary fever 
 of infancy is quite a common affection ; and well 
 it may be, if, as I say, it is the special reaction 
 
6o COMMON NEUROSES. 
 
 of the infantile respiratory system to nerve storms 
 of all sorts. But its prevalence also admits of 
 other explanations : one being that as the embryo 
 nervous system grows in health and education it 
 becomes less explosive, and thus the tendency 
 vanishes ; another that as development goes on 
 other viscera come more into the field, the cyclone 
 is drawn into other regions, and the pulmonary 
 tract escapes. 
 
 Now, dealing first with the treatment of these 
 infantile cases, over and over again these children 
 have been brought to me because their proper 
 treatment has not been rightly apprehended, be- 
 cause their nature has not been recognised. They 
 have been supposed to be due to cold and chills, 
 and the disease has been treated, and not the 
 patient. But to shield these children from every 
 possible draught, and to keep them at home when 
 there is the least suspicion of the wind being in 
 the east, are not the means to cure them ; such 
 only make them worse. It is because they have been 
 getting worse, in spite of treatment, that they are 
 for the most part brought to me. Measures of this 
 kind beget a more irritable state of nervous centres, 
 whereas the only way to cure them is to harden them. 
 I need hardly go into the details of management 
 of such cases, they are so common-sense and plain ; 
 but, in short, they are to have their bath regularly, 
 to be warmly but lightly clad ; they are to be 
 
COMMON NEUROSES. 6i 
 
 taken out into the air as much as possible ; and 
 they are, in fact, to undergo a process of hardening 
 and education by which their nervous susceptibiHties 
 are to be made less susceptible. As regards drugs, 
 if any at all are given, they are to be such as give 
 tone to the nervous system, such as nux vomica 
 and iron. 
 
 The treatment of asthma is not otherwise. You 
 will never cure asthma by coddling. The disease 
 is a local expression of an undue sensitiveness of 
 the nervous system to the changing circumstances 
 of its environment, a phlegmatic power of accom- 
 modation that, reacting slowly, reacts too late ; and 
 in the meantime the higher centres, left unguarded 
 by the laggard signal and bereft of their natural 
 protection, are stimulated too strongly, and a storm 
 or spasm is the result. Put it in what language 
 you like, that, I take it, is, in effect, what happens 
 in spasmodic asthma. Supposing, now, that we 
 elect to treat the disease according to the common 
 fashion, we prescribe some local inhalation to the 
 respiratory mucous membrane, which in some one 
 of several ways leads to the cessation of the spasm. 
 What happens is best illustrated, I think, by the 
 infant who for each new toy drops all its old 
 ones, or perhaps by the old adage. You cannot 
 do two things at once. The bronchial mucous 
 membrane, stimulated by some powerful aromatic, 
 forgets all about its previous excitement, and 
 
62 COMMON NEUROSES. 
 
 between the two stools the patient happily sinks to 
 his much-needed rest. But whether stimulant or 
 sedative, so far as regards the nervous system, the 
 same result accrues — viz., that a sugar-plum is put 
 in its mouth and it is told not to be a bad boy 
 again, and with the usual result that when the 
 sweet is gone the recipient is soon on the look-out for 
 another, and another it gets, and so on. In more 
 prosaic language, the mucous surface receives a 
 something that for the time being causes it to 
 ignore the conditions of the environment at which 
 it had taken offence ; but the effect of the drug 
 having passed off, it is more alive than ever to the 
 original discomfort, and again a spasm is set up. 
 Again the drug is repeated, and the same order 
 is observed, and so on again and again and again, 
 with, however, this important difference : that the 
 interval between the spasmodic attacks grows shorter 
 and shorter as the mucous surface grows more 
 hungry. I take it that the nervous circuit from 
 lung to brain of the old asthmatic who has been 
 addicted to the various " cures " is the exact counter- 
 part of the nervous circuit from nose to brain of 
 the chronic snuffer ; but the pangs of the bronchia 
 are the more urgent. 
 
 As regards children there is something else to be 
 said. They are not quite so often as adults treated 
 by these patent powders ; but they are very gene- 
 rally so by looking on the disease as the result 
 
COMMON NEUROSES. 63 
 
 of cold, and they are confined to an overwarm 
 apartment ; they are smothered in clothes ; they 
 are not allowed to have a decent romp for fear 
 they may get hot and take a chill ; and altogether 
 they are only too liable to live a most unhealthy 
 life. Their most saving power, that of accommo- 
 dating themselves to their environment, is nursed 
 into imbecility, and then the wonder is that they 
 grow worse instead of better. 
 
 I would venture to point to a more excellent 
 way than that, more excellent because it is as- 
 suredly founded upon a physiological basis ; and 
 it is this : to find out by experiment where the 
 child can live best. This is always a matter of 
 experiment ; not the greatest authority in all the 
 world can say for certain, for I say asthma is a 
 functional disease of the nervous system, and it is 
 in diseases of this sort that the individualism of the 
 patient most crops up. Having found a place of 
 residence, turn the child out to grass, in place of 
 keeping it indoors on all doubtful days ; gradually 
 accustom it to be out in all weathers, and make it 
 as perfect an animal as can be in these days, when 
 conventionality is part of the air we breathe, has 
 penetrated to the inmost recesses of our homesteads, 
 and, for aught I know, perhaps even to the pigsty. 
 It is difficult indeed to be a healthy animal in 
 these days ; but that is the way to cure asthma 
 in the child, and it meets with a large measure of 
 
COMMON NEUROSES. 
 
 success. I have seen enough evidence of the ill 
 success of the coddling method to have no doubt 
 which is the better plan had I no other grounds ; 
 but I do believe that those other grounds that I 
 have pressed upon your attention are not unworthy 
 of it. 
 
 When we come to consider the case for adults I 
 cannot say I am so hopeful, and one of the best 
 evidences of the intractability of asthma is to be found 
 in the number of patent medicines that abound for 
 its cure. The diseases of children would not keep a 
 quack in bread-and-cheese for a fortnight, if soothing 
 syrups be excepted. The adults are the patronisers 
 of the various cures for asthma, and who carry 
 a powder in their pockets and call it a cure, when all 
 the while there never was, and never will be, a better 
 illustration of the toils of the charlatan, for with each 
 fresh whiff the sufferer is dragged deeper into the 
 abyss of chronic asthma. This is what they come 
 to. I will take my last case, a young lady aged 
 nineteen. Her mother had suffered much from hay 
 fever, and her mother had had asthma. She had 
 been an asthmatic since the age of eleven, and she. 
 had indicated her neurotic inheritance at a much 
 earlier date by never having been able to eat &^% 
 in any form or combination. She sneezes much and 
 suffers much from catarrh. She is now hardly ever 
 free from asthma, but it is worse at night, and she 
 burns a patent powder three or four times, by which 
 
COMMON NEUROSES. 65 
 
 means she gets a fair amount of sleep, although 
 her nights are very disturbed, and she is unable 
 to lie down much. Here was the note that her 
 medical man sent with her : — " She has suffered 
 almost from infancy from spasmodic asthma. She 
 has taken everything in the legitimate pharmacopceia, 
 and tried with varying success twenty quack remedies, 
 besides other nostrums for smoking. She is a frail, 
 weakly-looking girl, but she has admirable courage 
 and spirits, notwithstanding the years of suffering 
 through which she has struggled. She is, as I am, 
 not oversanguine as to permanent relief" And who 
 could do otherwise than endorse this doleful view? 
 Here was a young lady with years of a baneful habit 
 upon her, a very different thing from a child affected 
 with the same disease, almost the same difference as 
 between a child in its first convulsion and the con- 
 firmed epileptic of twenty years or more. To offer 
 her drugs under such circumstances, or rather drugs 
 alone, as the panacea might well seem a mockery, 
 and I began at the other end. I explained to her 
 that the temporary ease that she undoubtedly 
 procured from her cure — for these remedies are cer- 
 tainly successful in procuring temporary ease from 
 the distress of the paroxysm — was dearly purchased, 
 and that each release so obtained let her more 
 deeply into the slough of despond. She had got 
 into a bad habit that needed to be broken, and in 
 the attempt to break it she would at this time of 
 
 5 
 
66 COMMON NEUROSES. 
 
 the day of her disease realise to the full the meaning 
 of the words " Through much tribulation ye shall 
 enter the kingdom of heaven." If ever there was 
 a heaven to be begun on earth it was to be found 
 for this poor child in the relief of her now constant 
 suffering. 
 
 It has not been my purpose in preparing these 
 lectures to deal in any way with the details of treat- 
 ment by drugs, for there are those here at whose 
 feet I would rather sit in such matters. I have 
 rather aimed at dealing in a comprehensive spirit 
 with the principles that underlie these diseases, and 
 which ought to, and must eventually, energise all 
 our treatment. But lest it should be thought that in 
 taking the patient back to, or rather putting her, 
 perhaps for the first time in her life, face to face 
 with, the problem that she and I had both to deal 
 with — and, as I think, she far more than I — I was 
 giving her a stone when she came for bread, let me 
 say that I did not send her altogether empty away, 
 but that I believe most firmly in the free adminis- 
 tration even in these old cases, and at all times of 
 life at which asthma occurs, of iodide of potassium 
 and the ethereal tincture of lobelia, for the relief of 
 the asthmatic condition, and that I feel certain 
 that arsenic taken in free doses, and with breaks, 
 over a long period of time — several months — is a 
 great help by its action on the nervous centres in 
 preventing the recurrence of the paroxysms. I am 
 
COMMON NEUROSES. 67 
 
 no friend of the as-he-was and as-he-is descriptions 
 of the results of treatment, but it so happens that 
 this young lady, without any asking on my part, 
 thought fit to report her progress thus : — " I am 
 writing to tell you how very much better I am. I 
 can lie down at nights ; I have no asthma after 
 eating ; and I never have to burn anything or smoke. 
 In fact, I have hardly had any asthma for the last 
 two months, and the slight returns of it have gone 
 off after one dose of the medicine." 
 
 Before I have quite done with asthma let me 
 return again to inhalations. I have made a serious 
 charge against them, and I do not doubt for a 
 moment that there are many who will abund- 
 antly confirm all that I have said. But I want 
 to say more — viz., that in the long run they are 
 murderers in the garb of friends, for not only do 
 they confirm this disease of habit, but they do 
 more, for their repeated use leads to enfeeblement 
 of the heart muscle and to its dilatation ; and thus 
 they introduce serious, and often fatal, complications. 
 Mind, I do not say they must never be used — I have 
 seen too much of the distress of bad asthma for 
 that ; but I do say, as I have heard it said of the 
 doctor's brougham that it is the first nail in his 
 coffin, that when an asthmatic takes regularly to such 
 remedies as these they are equal to a good many 
 coffin nails. 
 
 I come now to the neurotic conditions that involve 
 
COMMON NEUROSES. 
 
 the circulatory system, and perhaps chief of these is 
 angina pectoris ; but I will not take that first, be- 
 cause some might be inclined to question the right 
 of this affection to the title of a neurosis, and even 
 if it has that right, as I think it undoubtedly 
 has in some instances, it is still a little off the 
 lines we have hitherto been considering, and there 
 are other neurotic conditions that may well be 
 considered. 
 
 First of all, then, I will allude to that common 
 affection, the being the conscious possessor of a 
 heart. It always strikes me as the most astonish- 
 ing thing that a man may have a heart of twenty, 
 thirty, even forty ounces, and yet be unconscious of 
 its pulsations, although to the bystander the heaving 
 of the chest provokes a recognition of the fact ob- 
 trusively. But this heart conscience occurs in quite 
 other cases, and verily it is a sprig from the garden 
 of Eden, for it is a genuine knowledge of good and 
 evil, the good of it being there, but veiled from 
 sight. It is good knowledge, if only the possessor 
 could believe it, for it mostly tells that there is 
 nothing serious the matter ; and it is evil in that it 
 enshrouds the mind of its possessor in spectral fancies 
 of which he is utterly unable to dispossess himself. 
 Yes ! Once to know you have a heart in this fashion 
 is to become full of an idea that it is well-nigh im- 
 possible to dislodge, and there is no doubt whatever 
 that it takes a good slice out of the happiness of 
 
COMMON NEUROSES. 69 
 
 very many lives. But now comes the point. There 
 are many refuges for the destitute of diagnosis in 
 medicine. A dehcate spine is one, a dehcate chest 
 another, a torpid liver another, consumption of the 
 bowels another, gout another, neurotic — yes ! I will 
 not leave that out — another. We cannot do without 
 them, but there are some that are much more two- 
 edged than others. I do not so much mind a man 
 being told he has a torpid liver, if the doctor does 
 not know what is the matter with him, because the 
 liver is a benevolent deity, and we lay our pills at 
 its shrine without any harmful explosion, and the 
 public have learned to recognise this. But " delicate 
 lungs " or " a weak heart," which run up a sword 
 over the head of the victim, with " Sudden death " 
 or " Consumption " engraved thereon, when there is 
 nothing serious the matter, and often because we are 
 unconsciously looking after our own reputation, and 
 are afraid of making a mistake which some one else 
 may catch us up in, is not a trifling detail, for a 
 " weak heart " to the public is as precise a diagnosis 
 as it is vague and unmeaning to the instructed. To 
 us it means nothing, but there are hundreds of people 
 going about and nursing their hearts because they 
 arc weak, but with nothing really the matter, and 
 that idea they must have got by medical consent in 
 most cases. Then I have to say that the term is 
 applied to all sorts of conditions that have nothing 
 in common. For example, a stout lady of sedentary 
 
70 COMMON NEUROSES. 
 
 habits comes for some trifling ailment, and she starts 
 with the announcement, " 1 know I have a weak 
 heart. Dr. So-and-so said so years ago." I examine 
 her heart, and it is, as far as present means of 
 diagnosis go, absolutely healthy. And I have little 
 doubt that Dr. So-and-so, looking at his patient's 
 physique, and judging her rightly of corpulent habit, 
 plumped for a fatty heart, and that case was ticketed. 
 
 Another lot of hearts are maligned because the 
 first sound is weak, a perfectly worthless criterion, 
 unless hedged round with all sorts of qualifications ; 
 and a still larger number because the pulse is small 
 and feeble ; and then there come all the multitudi- 
 nous causes of irregularity of the heart, which in 
 the absence of any definite disease are all liable to 
 go into the same pot, and a pretty kettle of fish 
 comes out of it all if we take the aggregate of results 
 of misery that is produced. I cannot discuss this 
 question very satisfactorily, because there are so 
 many causes of irregularity ; but I can say this : 
 that no more common condition exists than the ir- 
 regularity of the neurotic heart, and though we all 
 know of it, I do not think that its very frequent 
 occurrence is as generally remembered as it ought 
 to be. 
 
 A great injustice is not infrequently done to can- 
 didates for insurance in this way. A man goes up for 
 examination and is nervous under it. His heart is un- 
 steady, and very likely there may be some slight basic 
 
COMMON NEUROSES. 71 
 
 or apical systolic bruit as well, and he is warned not to 
 pursue his proposal at the time, but to come again in 
 so many months. What is the result ? Naturally the 
 rejected candidate receives a severe shock. Imagining 
 himself sound, he finds there are suspicions about 
 his most vulnerable part — his heart — and off he goes 
 to " another opinion " to know if there is any chance 
 of sudden death — heart disease and sudden death 
 being indissolubly bound together in the mind of 
 the layman. Far be it from me to seem to be 
 wanting to teach the medical officers of insurance 
 societies their business ; they probably know it far 
 better than I, and, moreover, not being attached to 
 any body of this sort, I am very much like the 
 politician out of office, except that I am not trying 
 to get in. But I will confess to having wished, as 
 cases of this kind have come before me, that medical 
 examinations for insurance could be conducted with 
 a little more bilateral poise, for the refusal to grant 
 a policy is really of more moment to the candidate 
 than it is to the shareholders of the company, for 
 I am of course only discussing cases that could add 
 at the most an infinitesimal risk, and yet the one 
 party does not receive a particle of consideration. 
 But having said this, I will let it at once discover 
 my weakness, for it opens up a most interesting 
 question : whether the irregularities of neurotic origin 
 may not in the end lead to some failure of the 
 muscle, and so confirm the fitness of their rejection. 
 
-jz COMMON NEUROSES. 
 
 In 1885 I saw a young man who had been refused 
 at an insurance office for an irregular heart. He 
 was brought to me by his own medical man in 
 consequence, and I certainly could not in that in- 
 stance find fault with the decision, for his heart was 
 tumbling about in a most extraordinary fashion for 
 a man, and such as I have rarely seen in that sex 
 and at that age before or since. I cannot go at 
 length into my reasons for regarding the affection 
 as a functional one ; it must suffice to say that the 
 shape of his head, his whole bearing, and the previous 
 history, given me by the gentleman who brought him, 
 who was an old friend as well as his medical adviserj 
 showed conclusively that he was an extreme neurotic. 
 He wanted to get insured before he went abroad, 
 and he was obliged to start in some ten days or so. 
 I told him that I was convinced that there was 
 no disease of his heart, but as to getting insured 
 before he went, that was impossible, as it was clear 
 that no examiner would look at him with his heart 
 in that state, and it was little likely to quiet down 
 with an ordeal such as that before him under the 
 circumstances of the hurry. So I advised him to 
 go abroad, and as his rejection had much upset him, 
 to go to some medical man near him, and to have 
 his heart examined frequently, thinking that when 
 he got used to the process he would soon be re- 
 ported upon more favourably than we could do at 
 that time. My expectations were quite justified, for 
 
COMMON ATEUROSES. 'ji 
 
 after some months I heard from him, saying that 
 he had got his life insured, and that now his mind 
 was at rest. I do not think that in the end he 
 had any desire for the insurance as an investment, 
 but merely because it gave him a certificate of the 
 soundness of his heart. He comes to England 
 periodically, and I have seen him several times in 
 the course of the eight years that have now elapsed 
 since my first introduction to him, and he has hardly 
 put his foot on shore before he comes to me to 
 get his mind set at rest. ' And here is the point 
 that makes me a little uneasy about him : he has 
 several times had recurrences of extreme irregu- 
 larity of the heart's action, generally after mental 
 worry, and once in this state I sent him to Homburg, 
 and some one who saw him there, not knowing so 
 much as I did about him, shook his head at him, kept 
 him on one floor, made him go about in a Bath chair, 
 and sent him home again more dead than alive from 
 sheer fright. But although I judge the nature of 
 the case to be a neurosis, I cannot but fear that as 
 he advances in years a muscle or nerves of such 
 irritability may fail under the stress of even ordinary 
 existence, and that he may not live out his term. 
 And yet, on the other hand, the case is much like, 
 in all but the sex, the palpitation that is so common 
 in women, and which does not, so far as I know, 
 do much, if anything, to shorten life ; nay more, 
 is a condition that may well excite astonishment 
 
74 COMMON NEUROSES. 
 
 by the small amount of disturbance that it creates. 
 There may be some amount of discomfort, but even 
 that is difficult to speak of accurately, for going 
 with the disturbed cardiac action there is so much 
 nervous erethism that it is uncertain how much 
 of the distress is due to the one and how much to 
 the other ; and how little of anything there may 
 be sometimes is well impressed on my mind by the 
 remembrance of a lady who walked into my room 
 a year or two ago after a morning's shopping in 
 Regent Street, saying that she had had a palpita- 
 tion all that night and morning, and would I please 
 to give her something to stop it. I found her heart 
 beating i6o per minute, and I do not doubt that it 
 had been doing so through all her peregrinations to 
 the shops of the West End. 
 
 There are other cases that seem to suggest more 
 positively that neurotic disturbances may lead to 
 actual organic disease, and the following case seems 
 to me to illustrate this point. A man of about forty- 
 four — so far as is known, in perfect health at the 
 time ; in fact, he was passed first-class for insurance 
 just before he left England — went out to the colonies 
 to assume a very important and anxious financial 
 post. Before he went, he had been in the habit of 
 taking a good deal of exercise, and his new berth 
 kept him so continuously occupied that he had not 
 only no time, but neither had he the energy nor the 
 inclination, for it. His work told upon him severely, 
 
COMMON NEUROSES. 75 
 
 and he felt that it did so, and within six months of 
 his taking up his new post he found himself so short 
 of breath that he was obliged to seek medical advice. 
 He was found to have mitral incompetence, and he 
 has had it ever since ; and, what is more, he was, 
 so long as he remained at his post, slowly going 
 downhill, until he relinquished it and started for home. 
 Since that time he has continuously improved. The 
 evidence of mitral disease remains — and the heart is 
 generally irregular in its action, — but the man is, to 
 all outward appearance, in the best of health, and has 
 been so now for nearly three years. It seems quite 
 possible that the fault here may have been a 
 primarily nervous one ; that the man's whole energy 
 was used up by his brain work, and that for the want 
 of its due supply the heart muscle dilated, and led 
 to the mitral incompetence, the body muscles at the 
 same time being disinclined and incompetent for their 
 wonted exercise. But of course it cannot be denied 
 that there is, at any rate, another explanation ; for 
 the heart that is accustomed to work, as is that of 
 a man who makes it his business to take a good 
 deal of exercise, when thrown into idleness, as it 
 is in great measure when its master changes all his 
 habits of life and betakes himself to a very sedentary 
 occupation, is very likely to grow indolent, and it is 
 the indolent hearts as much as the overworked ones 
 that dilate. As a further point in reference to the 
 influence of nervous failure in producing organic 
 
76 COMMON NEUROSES. 
 
 disease, I would add that I have seen one or two 
 cases, though they are happily rare, where, without 
 any definite disease, yet with some permanent sense 
 of discomfort about the heart, a patient suddenly 
 falls down dead, and all that is found post-mortem 
 is a dilated heart. Again, it cannot be said that 
 such cases have any certain connection with any 
 definite nervous cause, but in the one or two cases 
 that I have seen there was a something about the 
 individuals that led me to class them as belonging 
 to the group of the neurotic. 
 
 Now this subject leads me on to another that 
 has similar risks^ — viz., Graves's disease. I have 
 already said that I regard this disease in what may 
 be called its fullj^ developed form as one that shades 
 off in all directions into conditions that are not 
 generally considered in relation with it, but which 
 ought to be so considered in my opinion. Just now 
 the exophthalmos and the thyroidal enlargement 
 are somewhat at a discount, and we hear more of 
 muscular tremors and some other local phenomena ; 
 but what has long struck me is that the central 
 feature of all these cases is, without any exception, 
 their extreme nervousness. I hope no one will 
 take exception to my making use of this popular 
 term, but it is really an exceedingly useful one. 
 And what do I mean by it? Well, I understand 
 a state of the central nervous system in which the 
 person starts suddenly at the least unexpected noise ; 
 
COMMON NEUROSES. -jy 
 
 in which the least excitement makes him tremble 
 all over or flush, or break out into a perspiration ; 
 in which an impulsive word or a sudden act will send 
 the heart into a state of palpitation. Such people 
 are perpetually in the condition — happily to him a 
 temporary one — of the nervous man who is about to 
 make his first speech : his tongue suddenly dries and 
 sticks to the roof of his mouth, his neck swells, 
 and he feels uncomfortable in his respiration ; his 
 heart is beating so fast that it would seem that it 
 must stop ; and his head throbs so badly that if 
 the memory of pain were not short-lived he would 
 never trouble an audience again. But in this picture 
 of Graves's disease it is not the muscular tremor that 
 is the essential feature ; it is not the enlargement 
 of thyroid that is either, or the protruding eye- 
 balls ; all of them are included in the still more 
 fundamental state of decrepit control on the part 
 of the centres, and, whatever it be, it lies deep in 
 them. So that when I see, as one so often does 
 see, a nervous woman or man with a very rapid 
 heart or excessive pulsation in the neck or abdomen, 
 with undue tendency to sudden sweats, with a want 
 of muscular control, as evidenced by tremor and so 
 on, I see in each of these an outlying symptom 
 of the condition, whatever it be, that causes the 
 assemblage of symptoms we call " Graves's disease," 
 a state that seems to me most aptly likened to a 
 permanent blushing of the centres involved. I 
 
78 COMMON NEUROSES. 
 
 should like, however, to remark that such symptoms 
 are common to many forms of nervous breakdown. 
 For instance, many of them are found in chronic 
 alcoholism ; they are seen in some cases of melan- 
 cholia ; in the decrepit state engendered by overwork, 
 or by excesses of any kind ; sometimes they occur 
 with glycosuria, and no doubt in many other condi- 
 tions also. And herein is another point of interest, 
 if I may judge by my own experience — viz., that all 
 these conditions, more or less, are benefited by the 
 same drug — opium. I believe for patients suffering 
 from Graves's disease there are no remedies com- 
 parable to the rest and absolute freedom from fussing 
 that are to be procured in a hospital, and there is 
 no drug that does them so much good as small doses 
 of opium, combined with strychnia, cod-liver oil, 
 and all remedies that go to build up the nervous 
 centres. 
 
 I can only mention one other condition that has 
 to do with the question of weak hearts — viz., faint- 
 ings that are supposed to own a cause of this kind. 
 They are exceedingly common, far more so in 
 wom.en than in men, and they come for an opinion 
 in numbers because the uninstructed associate the 
 condition of fainting with disease of the circu- 
 latory centre. Now, except occasionally in old 
 people, is it ever so? If it be, I confidently assert 
 that it is a very rare occurrence ; and, for myself, 
 I can say that of the large number of cases of 
 
COMMON NEUROSES. 79 
 
 this kind that have come under my notice, and of 
 which I have notes, in no single instance have I 
 been able to discover any organic disease, and in 
 all there has been ample evidence that they were 
 nerve cases, and not heart cases. I need hardly 
 say that faints are often of an epileptic character 
 I do not wish to assert that all these cases are of 
 that nature, but short of epilepsy there are many 
 conditions that emanate from the nervous system 
 and lead to faints that are altogether outside the 
 heart. The sort of case met with is after this 
 wise : A gentleman aged thirty-three, who has been 
 in the tropics for some years, and has had malaria 
 and rheumatic fever, has had within a short time 
 of returning home two attacks of palpitation, in 
 one of which he fainted for a minute. He has 
 had one slight attack since he came home. He 
 came to me because he thought his heart was 
 affected, but there was nothing discoverable, and 
 as he was very tremulous and nervous, I believe 
 it was all brain, and he became perfectly well by 
 treatment suggested by this diagnosis. Another 
 interesting case of this sort I saw down in the country 
 some years ago. A lady, aged twenty-eight, had 
 been somewhat recently confined, and was ansemic. 
 For some days before I saw her she had been going 
 off into repeated faints, and had kept the whole 
 house in a perpetual panic. I do not know how 
 many nights the doctor had slept in the house to see 
 
8o COMMON NEUROSES. 
 
 an attack, but his presence always seemed to keep 
 them off, and he had never seen one. The patient 
 was a light-haired, lively, neurotic Irishwoman, subject 
 to vertigo, but with no organic disease of any kind. 
 And yet one more, also in a lady of the same age 
 (twenty-eight), who has been subject to attacks of 
 giddiness for years, but who of late has had most 
 curious seizures that come on quite suddenly while 
 she is walking about. She has all the feeling that 
 she may faint, but never goes quite off; sometimes 
 she goes pale, but more usually she flushes and 
 gets into a perspiration. At the onset of the 
 attacks her heart seems to stand still for a second, 
 and then on comes a violent palpitation. The 
 heart sounds were a little irritable, but there was 
 no evidence of organic disease. Of course these 
 cases do not touch the question of fainting in 
 organic disease of the heart, though even there 
 I think it may be said that it is a much rarer 
 thing than is supposed. I remember having a 
 patient of this sort under my care in Guy's Hos- 
 pital some years ago, and I kept him in for some 
 time because the case was so very uncommon in 
 this respect, but even there I was in doubt. He 
 had definite mitral or aortic disease, I forget for 
 the moment which, and he used to have faints ; 
 but I believe in that case the heart disease led in 
 some way to cerebral exhaustion, and that it was 
 not a state of cardiac syncope. People with dilated 
 
COMMON NEUROSES. 
 
 hearts may die suddenly from syncope ; old people 
 with degenerate muscle may die in like manner, 
 but the fact remains that those who are subject 
 to faintings are very seldom sufferers from heart 
 disease, and it is also the outcome of clinical ex- 
 perience that faints of this kind are not dangerous, 
 and need never excite much alarm for the immediate 
 issue. Practically they occur in boys and girls and 
 women, and are a symptom of a deranged or weak 
 or ill-nourished nervous system. 
 
 And now let us pass for a few minutes to 
 peripheral disturbances, which, although we do not 
 know much about their pathology, would yet appear 
 to be largely neuro-vascular in their development. 
 " Vaso-motor " they are more usually called, but as I 
 am more concerned with central causes than with 
 local, I shall look at the affections concerned more 
 especially from that point of view. We have heard 
 a good deal of recent years of what has been called 
 " Raynaud's disease " — a gangrene of more or less 
 of the extreme periphery whether it be of the 
 tips of the fingers, or of the toes, or of the rims of 
 the ears or the nose. This typical or extreme form 
 of Raynaud's disease is decidedly uncommon ; but 
 inasmuch as I do not see where to draw the line 
 between this severe disease and a number of slighter 
 grades, Raynaud's disease as a type seems to me to 
 be a very common affection. For instance, a lady 
 came to me with some rather pronounced irregu- 
 
 6 
 
82 COMMON NEUROSES. 
 
 larity of her heart, and the symptom she made 
 most of, thinking it to be an important one in rela- 
 tion to the heart disease she supposed she had, 
 was that she always had cold feet. " Madam," said 
 I, " you know the old saying, ' A cold hand and warm 
 heart,' and if you remember that heart should be 
 rendered soul or spirit, cold hand or foot spells 
 an active brain. It is never a symptom of heart 
 disease." "It is a good sign to have one's feet grow 
 cold when he is writing," says the Autocrat of 
 the Breakfast Table. This seems to me the very 
 mildest form of Raynaud's disease, so mild indeed 
 that it is no disease at all. And of other conditions 
 that are of the same kind I would mention the thin 
 skin and blue hands, sometimes a little swollen, that 
 are seen quite commonly in young women, and 
 sometimes also in children. Closely allied to these 
 is the proclivity to chilblains ; and then there are 
 the peculiar waxy or corpse-like fingers, that are 
 described as dead fingers. There are, besides, a 
 number of less well-defined conditions of disturbed 
 sensation — pain in some, numbness in others — which 
 go to complete the picture of the disease. 
 
 There are few clinical facts more important to 
 be sure of than this. I should be sorry to say 
 how many people come into my room in anxiety 
 about their heart, because they have what is called 
 " a feeble circulation." And it is supposed by them 
 in consequence that their hearts are weak. But so far 
 
COMMON NEUROSES. 83 
 
 as their inference is concerned it is more true to 
 teach that we are possessed of two circulations, a 
 central and a peripheral, which are independent of 
 one another ; so universal is the rule that these 
 local conditions of flushing or stasis are controlled by 
 agencies outside the circulation. 
 
 Yet, while all these things are at first sight purely 
 local, and while it is of course quite possible that 
 in the future a local pathological process may be 
 assigned to them, for the present the local changes 
 are of no use to us, we cannot treat them locally, and 
 the far more important point for recognition is that 
 they occur in people of ;a certain temperament. 
 Herein appears one of the great difficulties of my 
 subject, for these several manifestations that I have 
 named probably do not all occur in the same kind of 
 person ; the livid blue hands and the tendencies to 
 chilblains occur for the most part in the lethargic 
 neurotic, and in those in whom one may surmise that 
 the play of nerve force is always at a low ebb, the 
 neurosis being one of initial default. In those whose 
 fingers die it is certainly not always so, and I think 
 that this is more an affection of the quick-brained 
 and vivacious. This brings me to remark, as I have 
 not hitherto done, on the wide field occupied by 
 the neurotic temperament. It is seen, indeed, in 
 all sorts and conditions of mental activity — in the 
 most logical ; in the most impulsive ; in the most 
 emotional as well as the most unsympathetic and 
 
COMMON NEUROSES. 
 
 cold ; in the strong-minded as well as in those who 
 are wanting in resolution. But all these atypical 
 forms of Raynaud's disease are found in those who 
 are of this constitution, and the disease must be 
 treated, not by attacking the local change, but by 
 devoting attention to the general vigour of the 
 system. Improve that, and you will do something 
 to better the local distress, though one cannot say 
 that the measure of success is any great thing to 
 boast of, or leaves us with nothing to be desired. 
 
 I have said that such and such symptoms make 
 up the picture of Raynaud's disease, but I am not 
 sure that its connections are not wider even than I 
 have here indicated, for I have in my mind the 
 case of a little child who has had for a period of 
 many months a curious bullous eruption, that seems 
 to be certainly due to some neurotic disturbance,, 
 for it comes on after any little over-excitement. 
 
 And when I think of this case there are several 
 conditions of the skin, notably pemphigus and its 
 curious control, not cure, by arsenic, various pruri- 
 ginous states, and even such pronounced changes as 
 psoriasis also, that are by no means without their 
 interest in this regard. Psoriasis particularly is a 
 disease of the neurotic; and I could quote one or 
 two cases from my notebooks where it and distri- 
 Duted joint lesions have gone with general nerve 
 tremor, such as indicated serious nervous failure, 
 while in a few others the disease has been associated 
 
COMMON NEUROSES. 85 
 
 with mental failure such as threatened actual madness. 
 One cannot, however, fail to remark that psoriasis 
 in one respect is an exception to the rule I am 
 preaching, for it is a disease that is best treated by- 
 local remedies. 
 
 But I must leave these questions to say a few 
 words upon angina pectoris, a more important, be- 
 cause more terrible, disease. And I would repeat 
 here what I said at first : that it is a little off the 
 lines of my present theme, because, although I believe 
 it to be a neurosis in some cases, it is neverthe- 
 less a neurosis that cannot be treated on general 
 principles, nor can it be said that it occurs in those 
 of a neurotic temperament to any marked extent. 
 There was a discussion a few months ago at the 
 Medical Society of London on this subject of angina 
 pectoris, but what I have to say was said several 
 years ago in the Guy's Hospital Reports, and is 
 not in any way inspired by that discussion. I say 
 this because I had independently arrived at certain 
 opinions as the result of my own observation 
 and they are therefore additions to any consensus 
 that may be in course of formation concerning the 
 disease. 1 had it on my lips to say that I have 
 nothing new to add to what I wrote in 1887.* But 
 I have this addition to make : that whereas I thought 
 that there was a neurotic element in the disease 
 
 * " Guy's Hospital Reports." 
 
COMMON NEUROSES. 
 
 then, I think still more so now, with a considerable 
 addition to my experience. Of late years the ex- 
 planation of the attacks has all gone upon one line : 
 that the disease is due to a rise in tension in the 
 arterial system, and this suggestion we owe chiefly 
 to an observation of Dr. Lauder Brunton. The 
 late Dr. Hilton Fagge adopted that explanation, 
 and considered it sufficiently established by the 
 therapeutic results so frequently obtained by adopt- 
 ing the recommendations that followed from it. 
 But Dr. Brunton's observations were made upon 
 a case of angina with aortic regurgitation, and I 
 do not think they carry much weight for the 
 general run of cases. Angina pectoris clearly 
 comes on in some cases of advanced heart disease 
 associated with high tension, and sometimes this 
 is so with aortic disease, sometimes with the large 
 and dilated heart of renal disease. But it is only 
 quite exceptional that this result happens in these 
 diseases : for one case with angina there are many 
 that show no such feature ; and, on the other 
 hand, I consider that the character of the pulse in 
 the greater number of cases of angina enables us 
 to say that the arterial tension is not high. There 
 can be no doubt that angina comes about through 
 a number of conditions, in which the only common 
 factor that I can see is muscular fatigue. Arterial 
 tension will produce this ; dilatation leads to it ; so 
 also does badly-nourished muscle, whether this be 
 
COMMON NEUROSES. 87 
 
 due to starvation from disease of the coronary 
 arteries, to senile degeneration of the muscle, to 
 fatty changes, to ptomaine-poisoning, to the circula- 
 tion of uric acid in the blood, and so on. And the 
 remedies that are so useful, nitrite of amyl and 
 nitro-glycerine, without throwing any doubt on their 
 power of relaxing arterial tension, are none the 
 less also relaxors of muscular spasm and cramp. 
 I believe it is by virtue of this power more parti- 
 cularly that they work their effect in the disease 
 under consideration. This hypothesis of heart cramp 
 consequent upon heart fatigue is one that adapts 
 itself to all the conditions under which angina is 
 known to occur. But I am only concerned now with 
 that form of the disease that occurs without any 
 definite structural change, with those cases in which 
 apparently healthy persons are suddenly seized with 
 pain which may kill them within a very short space 
 of time, and yet the heart's action may be hardly, 
 perhaps not at all, disturbed, and the sounds are 
 practically normal. Supposing even that an attack 
 of this kind passes off, yet it leaves behind it the 
 painful uncertainty, such as hangs over the epileptic, 
 that another may come at any time. Trousseau, with 
 his clinical acumen, seized upon this parallel with 
 epilepsy, and considered some cases to be of the 
 nature of an epileptiform neuralgia, and others also 
 of a neuralgic nature from their frequency in the 
 gouty. There are, indeed, .several features of many 
 
COMMON NEUROSES. 
 
 of the attacks that favour this idea : they are often 
 accompanied by troublesome flatulence, by flushings 
 in the head and face, by tingling in the arms, 
 which all remind one of the erratic performance 
 of electric apparatus during violent atmospheric 
 disturbances. I have suggested, too, that in the 
 crises of tabes dorsalis and diabetes there are in- 
 stances of severe abdominal neuralgia, to which this 
 thoracic crisis or angina is in many respects com- 
 parable. I may further add that it is often associated 
 with a very sudden bronchial storm that can only 
 be called acute bronchitis ; and although we make 
 much of it as a distinct affection, it is closely allied 
 with, and s metimes very difficult to distinguish 
 from, the attacks of air hunger in their more ex- 
 treme degrees that are seen in uraemia and in 
 states of cardiac failure. These and such as these 
 are probably all ordained from a worried nervous 
 centre. 
 
 Now these cases of angina that exhibit a distinctly 
 neurotic type are they that loom more largely as 
 one's experience grows, and which enshroud the whole 
 subject in difficulty. I look up my notes of angina, 
 and where it was obviously due to disease of heart or 
 kidney the patient has already reached that bourn 
 whence no traveller returns ; but where there was 
 no discoverable affection I could give cases where 
 the seizures have been absent several years ; I 
 could give others where their recurrence has been 
 
COMMON NEUROSES. 
 
 frequent, and yet no harm done, the attacks being, 
 it is needless to say, mild ones. And then there 
 is a very large group of cases where one remains 
 in doubt whether the symptoms have any import 
 of serious kind. As a good illustration of this sort 
 I may mention the case of a man who came under 
 my notice only a few days ago. He is forty-seven 
 years old, and this is his tale : His father died of 
 Bright's disease. A year ago he had much worry 
 with the illness and death of his wife, and at that 
 time he had an attack of paralysis of his sixth 
 nerve. His trouble is flatulence. He fills with wind 
 after his meals, generally some two hours after, and 
 it not only wakes him up, but he cannot walk 
 more than a few minutes without stopping. "The 
 wind seems to get up under his heart. If he 
 can rest comfortably in a chair he is free ; but 
 as soon as he gets into action, as he calls it, a 
 fermentation seems to start, and fills the top part 
 of his body." His complaint has upset him and 
 made him nervous, and now if anything worries 
 him an attack comes on. Now, with all this rig- 
 marole poured into my ear, you will not wonder 
 that I thought him a wretched neurotic, and more 
 particularly because he clinched his doleful tale by, 
 " Mother says we are a windy family." But as I 
 talked to him I found that he had frequently had 
 bad pain when out walking and on going up slight 
 hilLs, and that a few seconds' rest relieved the pain ; 
 
90 COMMON NEUROSES. 
 
 and he would then continue his walk. He further 
 volunteers the statement that when the pain is bad 
 he cannot move a step. Add to this that he had 
 a very metallic and ringing second sound, and that his 
 arteries were thick ; and I ended by thinking that we 
 had, under the garb of a rather pronounced neurotic 
 temperament, to do with a true angina. 
 
 And in relation with this case I will mention 
 another where I made a mistake by doubts of this 
 kind. 
 
 A lady aged sixty-one, who had suffered a good 
 deal from fever in India, and who for many years had 
 neuralgia in the ovarian region, which as it passed 
 off was replaced by neuralgia in the head, for some 
 months had had a great deal of discomfort in the 
 chest and throat. She had been seen by a very 
 eminent physician in London, and nothing but in- 
 cipient asthma discovered. She had been treated 
 by bismuth and soda, and such like. But she got 
 worse, and used to sit gasping over the fire at night, 
 with a nasty pain in her chest and a choking feeling 
 in the throat, but no palpitation. She had been 
 decidedly better of late under strychnia and nitro- 
 glycerine tablets, but had again experienced rather 
 a bad pain the night before I saw her. I judged her 
 from her manner to be decidedly neurotic. But she 
 had a quick pulse, and complained of a tingling in her 
 arms down to the tips of her fingers, although she 
 moved about without distress or shortness of breath. 
 
COMMON NEUROSES. 91 
 
 The heart was evidently large and dilated ; and 
 there was a basic systolic aortic murmur of no great 
 intensity. There was no sign in any of the viscera 
 that the heart was failing. But it seemed from all the 
 evidence at my disposal that the heart muscle must 
 have failed of late, and that the angina was due to 
 this cause, and it seemed that, as she had improved 
 under careful treatment, there was every hope that 
 she might continue to do so. Moreover, it was im- 
 possible to be sure how much of the pain and 
 choking sensation she suffered from was due to her 
 neuralgic habit. Altogether I thought she might 
 move about a little more and take her tablets of 
 nitro-glycerine a little less, for I was rather afraid 
 that her nervous circulatory and muscular systems, 
 or whichever of these was acted upon by the remedy, 
 might pass into an unstable or oscillatory condition 
 that might render her recourse to such means of 
 too frequent occurrence. I know not what extent 
 of freedom she considered my advice warranted, or 
 even if she had acted on it in any way ; but anyhow 
 it clearly tended in the wrong direction, and three 
 or four days after I saw her she was suddenly seized 
 with a bad attack of pain on retiring to her room 
 at bedtime, and she died. 
 
 The remedy for the anginal paroxysm is unques- 
 tionably nitro-glycerine or nitrite of amyl, and per- 
 haps in so terrible a disease, and one in many cases 
 of which it will ever be difficult to say whether any 
 
92 COMMON NEUROSES. 
 
 structural change is at the bottom of it or not, it 
 may seem unwise to go behind the fact that in either 
 of these we have a drug that in most cases has 
 a decided power. But it is not really so, because 
 no thoughtful man can have seen many of such cases 
 without having often asked himself the question 
 whether he is doing the best for the patient by 
 keeping him from all exertion and telling him to 
 consume a tablet when his pain threatens. And this 
 much is certain : that, control it as much as the 
 remedy may, it is in a fair proportion of cases only 
 controlling a symptom, and the cause of the disease 
 lies deeper. 
 
 In my opinion then angina sometimes constitutes 
 a disease for which the gastric crises of locomotor 
 ataxy and diabetes afford the nearest parallel ; in 
 other cases perhaps the condition of calf cramp comes 
 nearest to it in likeness. In the one it may possibly 
 be due to the uric acid diathesis, in others to the 
 explosive nervous discharges that are well known to 
 take place in the worried and overworked. 
 
 But I must not take leave of the subject of angina 
 without alluding to that always to me curious and 
 interesting affection of women, the common and 
 well-known pain in the left side. Has it or has 
 it not anything to do with the true disease ? It 
 would appear to be a very troublesome affection ; it 
 lasts so long and is so difficult entirely to displace. 
 It is curious that it should occur so seldom in men, 
 
COMMON NEUROSES. 93 
 
 but one may suppose that this has to do with the 
 associated anaemia with which it so commonly occurs, 
 and which in anything Hke a corresponding degree 
 is so seldom seen in males. 
 
 And the fact that it does so occur in anaemic 
 women only is perhaps an evidence in favour of it 
 being something of the same kind as the true disease, 
 for if, on the one hand, we consider angina as a 
 condition due to fatigue, we have in these women 
 the bloodless condition best suited for its easy pro- 
 duction ; if, on the other, we like the better the 
 neuralgic origin, we have, too, under such circum- 
 stances, all the elements that seem best fitted for 
 the calling out of the pain, and abundant evidence 
 that they are the parents of any number of neuralgic 
 affections. But whether this pain in the left side 
 be related to true angina or not, it is quite certain 
 that, except there be a probable cause for it in the 
 existence of cardiac disease, true, that is dangerous, 
 angina never occurs in young women ; and when I 
 consider that I have several times been asked to see 
 young people supposed to be suffering from this 
 serious disease, I imagine that the fact is not known 
 .so widely as it might be. 
 
 These constitute, I think, the most prominent 
 circulatory conditions that can be fairly contended 
 to be due to neurotic outbursts. But there are 
 others of which it would be interesting to give 
 what evidence there might be in favour of a nervous 
 
94 COMMON NEUROSES. 
 
 fault of some kind being at the bottom of them. 
 And of these other states I should have most to 
 say perhaps in favour of the neurotic element in 
 chlorosis. We are all familiar with the fact that 
 severe shocks occasionally produce a sudden and 
 bad form of ansemia ; that observation is a very 
 old one. But I think I could show that chlo- 
 rosis is a disease that occurs in families, that it is 
 associated with well-marked vagaries of nervous 
 action, and that it is a disease that dogs the patient 
 and is liable to relapse from time to time. I cannot, 
 however, pursue the subject here, for I must in the 
 next lecture pass on to consider the abdominal 
 neuroses. 
 
LECTURE III. 
 
 Of the neuroses that show themselves in the 
 abdominal viscera, there are several that supply- 
 much interesting material bearing on their rational 
 treatment. I shall take in order the stomach, the 
 intestine, the kidney, and the liver. I have much to 
 say about the stomach and the rational treatment of 
 its diseases, for I believe they are often treated most 
 irrationally. And let me take first the common, very 
 common, ailment of flatulent dyspepsia. And here 
 at once I suspect that if any one who has devoted 
 himself to the treatment of the stomach thinks what 
 I have to say worthy of any attention, he will at once 
 fall foul of me when he finds that I am going to have 
 my say on this subject in general, so to speak. " What 
 can any one know about dyspepsia who talks of it as 
 an entity that knows no differences of form ? " Well, 
 I have often said that although there are all sorts of 
 different dyspepsias elaborated out of the heads of 
 individuals, if I were going to write a book on indi- 
 gestion, I should first devote myself to a volume on 
 disea.ses of the nervous system. Surely I cannot be 
 
 95 
 
COMMON NEUROSES. 
 
 wrong when I make this statement : that of the 
 numbers of dyspeptics that fill the doctors' lists the 
 greater proportion by far are neurotics in one form 
 or another. It is really no great exaggeration to say 
 that there are only two forms of indigestion : that 
 produced by over-eating and drinking, and that due 
 to a failure of nervous power. There are other 
 conditions that are met with as rarities, but who 
 knows anything about these ? For instance, there is 
 an acute condition originating in some indiscretion 
 in diet, in which the stomach forms sulphuretted 
 hydrogen in quantity. I have seen three or four such 
 cases, but if I try to find out anything about it the 
 authorities have very little indeed to tell. Then we 
 talk about acid dyspepsia and atonic dyspepsia, as if 
 any dyspepsia were other than acid, and, from my 
 point of view, as if atonic dyspepsia were necessarily 
 something different. " Gouty dyspepsia " is another 
 term in frequent use, but it is no different ; it is often 
 enough a little of both the others, and sometimes the 
 indigestion of over-eating and over-drinking as well. 
 Nor is the classification according to morbid anatomy 
 much better, for here the observer talks of catarrh of 
 the stomach as if the stomach easily catarrhed ; 
 whereas we know as certainly as we know any fact of 
 physiology or medicine that of all the multitudinous 
 sins of commission that are done to its would-be 
 detriment there is happily not one in a hundred, if 
 so many, to which the stomach deems it necessary 
 
COMMON NEUROSES. 97 
 
 to turn a hair. Were it otherwise, civilised humanity 
 would not last out two or three generations. No ! 
 If there is one thing that is certain, it is that the 
 stomach is an organ that has been trained by cen- 
 turies of custom and by the slow process of evolution, 
 to a condition of hardihood that endows it with the 
 special attribute of comparative callousness, and 
 within limits, and mutatis mutandis, I would as soon 
 talk of catarrh of a bird's gizzard. But if, as is 
 assuredly the case, the stomach will stand all this 
 hard work and still come up smiling, it must needs 
 be supplied with an amount of " go " — in other words, 
 of nervous energy — to enable it to do its work ; and 
 it is just this supply that, in this era of high civilisa- 
 tion, is often and often cut short. There is a sort 
 of action abroad that would seem to imply, " Oh ! 
 anything is good enough for the stomach." Men go 
 to business, for example, and, beginning at 9 a.m., go 
 on till 6 or 7 p.m., and often enough bring home their 
 business worries with them, their brains being all 
 the while in a state of turmoil. In the midst of this 
 they eat and drink, and ask their stomachs to digest ! 
 But if they have exhausted their nervous supplies — 
 and more than exhausted, have overdrawn their 
 capital, as they often have to no inconsiderable 
 extent, — where is the stomach to get its motive 
 power ? Take, again, the neurotic woman, in any of 
 the many forms in which she presents herself to 
 your gaze. No lecturer, gifted even with the most 
 
 7 
 
COMMON NEUROSES. 
 
 consummate art of word painting, could depict the 
 many ways in which women of this sort consume 
 their nervous energies ; but consume them they cer- 
 tainly do, and they constantly find themselves in the 
 same case, and their stomachs are called upon to 
 perform the impossible task of making bricks without 
 straw. 
 
 I assert without any fear of contradiction that this 
 is the indigestion of the present day. How do we 
 treat it, and what is its rational treatment? Well, 
 I suppose it is ten to one in favour of the patient 
 getting a little soda and bismuth, and perhaps a 
 little gentian or calumba in addition. If the patient 
 will run to it, he may take some rhubarb and mag- 
 nesia instead, and generally, I believe, it must be 
 said that he at first leaves his doctor's door well 
 satisfied that he has got his money's worth. But 
 time goes on, he has consumed his appointed potions 
 (most of these people take medicines well), and he 
 does not feel any very sensible relief from the 
 vagaries of stomach discomfort to which he has been 
 subjected ; so back he goes to the doctor, and now 
 probably a few drops of mineral acid and nux vomica 
 are ordered, and this time it is precisely prescribed 
 perhaps to be taken an hour before meals, because — 
 well, because — well, I will leave that to the Seers. 
 But time again goes along, and our dyspeptic begins 
 to have qualms whether he is placing his money 
 rightly, and before long he is to be found at some- 
 
COMMON NEUROSES. 99 
 
 body else's door, and No. 2 has his turn, and so 
 on to Nos. 3 and 4, up to the N*^ If the patient, 
 male or fenmale, be a particularly bad case, he or she 
 will produce in the course of consultation with, say, 
 the physician in tenth best repute for diseases of 
 the stomach, a bundle of prescriptions that for 
 thickness may well make his face turn pale and his 
 eye involuntarily seek the clock, while his ears will 
 tingle, I think, with shame that any human being 
 can be so bereft of common sense as not to have 
 got his cure or let it alone ere it has come to this. 
 Will any one say this is an overdrawn picture? I 
 have seen it too commonly not to know. There are 
 two things that I very generally do on such occa- 
 sions ; one is to indulge in a very short-lived regret 
 that I entered the medical profession, and the other 
 to ask the patient to have so valuable a manuscript 
 bound in calf But why do things come to this 
 pass ? Are we only to have a laugh at the ignorance 
 of the uninstructed ? Is there no beam in our own 
 eye? I think there is a very big beam. And it is 
 this : that we are much too fond of giving a prescrip- 
 tion because the individual wants it, and we do 
 not ask ourselves the question. Is a drug the right 
 treatment here ? Will it ever come to pass that the 
 public will habitually pay us for our advice, and 
 receive an order for physic as an evil, which, if 
 it must be, must be ? But I am wandering from 
 my subject. I do not wish to convey that in these 
 
COMMON NEUROSES. 
 
 cases of indigestion we can do without drugs, but 
 I do mean most decidedly that they are not the treat- 
 ment. It does not follow because a man or a woman 
 has dyspepsia that bismuth and soda are forthwith to 
 be shot into his or her stomach. The great majority 
 of the dyspeptics of the present day are so because 
 their nervous power has run down, or has been 
 incontinently consumed in other directions without 
 any regard for the needs of the stomach. The first 
 and foremost treatment in these cases is to take 
 what steps can be taken to lessen the tax upon the 
 nervous centres, and to tone up those that are run 
 down. Often would I, were it not a mockery, write 
 on the prescription paper of many a hard-worked 
 man in business toiling for his bread-and-cheese, 
 " Recipe — ^^;^5oo a year and an eight-hour day " ; 
 often and often for the woman who frets her nerve 
 force into useless fritters, " An occupation that shall 
 give you freedom from yourself" Could one but 
 give these things away, there would be no occupation 
 for us in the way of treating indigestion, and it is 
 the hardest part of a doctor's life to feel what he 
 knows to be the right treatment, and yet to be 
 obliged to give a dose of medicine as the nearest 
 approach to the possible. But such is our life, and 
 we cannot do otherwise than accept its conditions ,' 
 but in doing so it falls to me to say that these are 
 cases for tonics and every available means for invigor- 
 ating the nervous system : and the remedies I have 
 
COMMON NEUROSES. loi 
 
 decried, but have in no way besmirched — for they 
 are good enough in their place — are to come in their 
 proper place, and be only called to our aid to treat 
 symptoms of passing occurrence. 
 
 Next, though not quite in order on my list, I will 
 take anorexia, or want of appetite, because it is 
 closely bound up with this subject of indigestion. 
 There is no more common ailment than this, and 
 it is much more common amongst women than 
 amongst men, although it may be found in either 
 sex. It also is largely the product of our civilisa- 
 tion, and of an improper consumption, or of feeble 
 supplies of nervous energy. Therefore I think the 
 term proposed by the late Sir William Gull of ano- 
 rexia nervosa a very fitting one. But the cases 
 recorded by that distinguished physician were all 
 of extraordinary severity, and it will be in the 
 recollection of some here that such as were nar- 
 rated in the Transactions of the Clinical Society^ and 
 by others now and again since in the medical 
 periodicals, have all been remarkable for being in 
 the last stage of emaciation. Interesting as these 
 cases are, they are comparatively rare, and I want to 
 extend the term to a much commoner class. I think 
 there can be no doubt that the same disease 
 exactly, but not reaching anything like the same 
 extent, may be seen almost daily by any one who 
 chooses to see it in his own practice. I read in one 
 of the daily papers the other day this paragraph : 
 
102 ' COMMON NEUROSES. 
 
 " Almost the only failing of the Englishwoman is 
 that she has no touch of gluttony. She does not 
 take an intelligent interest in what she eats. Any- 
 thing will do, she says. She is incapable of appreci- 
 ating good cookery, and that is one of the reasons 
 why the English cuisine is fraught with so many 
 terrors." I shall express no opinion about the truth 
 of the latter clause, but I am sure about that of the 
 first. There are hundreds, ay, thousands, of women 
 going about who habitually have the smallest of 
 appetites, and they are often enough women of a 
 very active habit of body and brain. Now we all 
 reason from our own experience far more than we do 
 from what we obtain secondhand. And the familiar 
 experience of every one is that when we have gone 
 long without food a stage is soon reached in which 
 we do not care whether we have food or not, and 
 it is easy under such circumstances to reject such 
 food as is put into the stomach. Apply this to the 
 case before us. An individual starts, from whatever 
 cause — for the minute it is not necessary to inquire — 
 with a small appetite ; she gets tired or overdone, as 
 is very easily accomplished, on the small amount of 
 food that is taken. Meal-time comes on, and finding 
 herself without appetite, and thinking, as most people 
 do, that if the appetite be not there the food cannot 
 be necessary, none is taken, or the meal becomes 
 smaller than the one preceding. So the case goes 
 on, and little by little no food worth the name is 
 
COMMON NEUROSES. 103 
 
 taken. Let me give the day's record of one or two 
 of these cases. A small part of an egg and a finger 
 of toast and a cup of tea for breakfast (this is rather 
 a respectable meal for a case of this kind) ; for lunch, 
 a drachm or so of veal cutlet, no vegetable, or bread, 
 or pudding ; a cup of arrowroot and brandy at bed- 
 time. A second case : for breakfast, a little potted 
 meat and dried-up bread, a cup of strong tea with 
 very little milk ; for dinner, a very small slice of meat 
 and a little vegetable and milk pudding or stewed 
 fruit ; for tea, a cup of strong tea, dried-up bread, or 
 a biscuit and fruit ; for supper, milk pudding and a 
 biscuit, and a little soda-water at bedtime, and so on. 
 Now these cases are really very interesting as 
 showing upon how very little life can be sustained, 
 and indeed, not only sustained, but made to do 
 quite a large amount of active work. But what 
 happens, what must happen, to the stomach under 
 such circumstances ? It does not need much labour- 
 ing ; common sense will say at once that, accustomed 
 to gradually-diminishing meals, the stomach little by 
 little diminishes in capacity, and becomes inactive ; 
 and inasmuch as the bodily vigour conforms to this 
 ebbing tide, so each viscus has less and less vigour, 
 until it goes almost to sleep. There are discomforts 
 attending the course of these cases that hasten the 
 process. Friends notice how little food is taken, 
 and all sorts of things are advised and made trial 
 of ; and these spasmodic efforts cause to the languid 
 
104 COMMON NEUROSES. 
 
 stomach a good deal of pain. The patient then 
 argues within herself that something taken at the 
 last meal has disagreed, and it is cut for ever out 
 of the diet list. Another attempt is made with 
 something else, but with no better success, and out 
 goes this also. Nor does she stop here. So by slow 
 degrees the possibles of her digestion become more 
 and more attenuated. This is nothing more than 
 the common history, not of rare cases, but of any 
 number. What is the use of treating these people 
 only by bismuth and soda and all the usual stoma- 
 chics? Granted that they have pain, what is the 
 pain due to ? It is the result of the state of disuse 
 into which the stomach has fallen, and to the irritable 
 state of the nerves which the generally depressed 
 state of body has engendered. The proper method 
 of cure is to first explain to the patient what has 
 happened as the result of the process of gradual 
 starvation, what is the condition and size even to 
 which the digestive apparatus has shrunk ; and it 
 must be fully understood that restoration to health 
 is impossible, or at least unlikely, without a certain 
 amount of discomfort, not to say pain ; that the 
 stomach needs to be educated back to a healthy 
 habit, and to be stretched to a more natural size. 
 These, therefore, are the cases, or one class of them, 
 that undoubtedly derive great benefit from what is 
 now generally called Weir-Mitchell's treatment of 
 feeding and massage. And it is a treatment that in 
 
COMMON NEUROSES. 105 
 
 most cases does these people a great deal of good. 
 They gain weight, and become altogether different 
 creatures. I said just now that we might dismiss 
 for the minute the initial fault in these cases ; but I 
 have now to say that they are neurotics almost all of 
 them, and, what is more, they are neurotics of a rather 
 bad type. By this I mean that, although they are 
 submitted to treatment of this kind and derive much 
 benefit from it, they are exceedingly likely to get 
 back to their old habit again, after a longer or shorter 
 time, and some of the more pronounced of them find 
 their way ultimately into the ranks of the insane. 
 
 This anorexia is the fundamental cause of the 
 ill-health such people suffer, but there is another 
 condition that ought, I believe, to share a good 
 deal of the blame. I allude to the most pernicious 
 practice of taking no breakfast. Small eaters, with 
 their last meal taken at seven or half-past in the 
 evening, and probably all digested, so little has it 
 been, many, many hours before morning dawns, 
 begin the day on a finger of toast and a cup of 
 tea — sometimes, I have been told, in the excep- 
 tionally perverse without even any milk in it. And 
 this to last them till i or 2 p.m. ! How can 
 any one be expected to have any vigour of mind 
 or body under such circumstances? But I daresay 
 some one will be thinking that the no-breakfast plan 
 is .such a common thing that there is no need to 
 make such a fuss over it. I would not do so if the 
 
io6 COMMON NEUROSES. 
 
 meal-time alone were changed. There is no objec- 
 tion that I know to the chief meals being taken at, 
 say, twelve and six, on the foreign plan, but then 
 the two meals are taken, not sniffed at. But I 
 confess to thinking so highly of our English plan^ 
 for our peculiar climate, of starting with a good 
 solid meal, that a cup of tea at half-past seven in 
 the morning, although very nice, is, from a digestive 
 point of view, a mistake ; and if I belonged to the 
 band of medical advisers to insurance societies, 
 although I think I should pass many a heart that 
 is now looked at askance, I doubt if any one would 
 get in as a first-class life under my regime unless he 
 produced evidence that the volume of his breakfast 
 came within measurable distance of 
 
 " Devilled kidneys and sweetbreads and ducks and green peas, 
 Baked sucking-pig, goose, and all viands like these." 
 
 I may enforce these remarks by adding that Dn 
 Wharton Hood tells me that his father used to tell 
 a story of a City merchant who was in advance of 
 the times. Whenever he required a new clerk, he 
 selected a number of the applicants and invited them 
 to breakfast. He watched them carefully during 
 the meal, and engaged the man who ate the most. 
 Dr. Wharton Hood also tells me that the Spaniards 
 have a proverb, " Don't let your daughter marry a 
 man who cannot eat a good breakfast." 
 
 But to return — food, and not medicine, is the prime 
 need of these people ; and yet it may well be doubted 
 
COMMON NEUROSES. 107 
 
 whether this is put before them with all the blunt 
 uncompromisingness and persistency that the occa- 
 sion and their blindness in the matter require. 
 
 Neurotic vomiting is another branch of the same 
 subject, but I shall not discuss it, because it is so 
 well recognised that it rarely fails to receive the 
 appropriate treatment. There is, however, a group 
 of cases in children of which I do not think much 
 is known, so I shall deal with it a little more in 
 detail. I allude to the sudden periodical paroxys- 
 mal vomiting of extreme violence that is occasionally 
 seen in children of four, five, and six years or so of 
 age. It goes on for twenty-four, thirty-six, or forty- 
 eight hours ; everything, often even water, is returned. 
 The child becomes hollow-eyed and choleraic in 
 appearance, and is, indeed, brought to the very verge 
 of death. In a first attack of this kind it is not 
 unnaturally supposed to be due to some error of 
 diet, although it often puzzles the parents to say 
 what that error may have been. It is of course an 
 attack that may very well be set up by an irritant 
 poison in the shape of food, or by ptomaines of one 
 kind or another, but in these cases the irritant is for 
 the most part trivial, and similar attacks tend to recur 
 over and over again in the same child. Moreover, 
 they always lead to the most rigid dieting, and yet 
 the attacks recur. I have notes of six or eight such 
 cases, and I cannot but think that the vomiting is of 
 cerebral origin, and not gastritic. At any rate, I do 
 
io8 COMMON NEUROSES. 
 
 not think such cases should be treated by a too strict 
 diet, for by such means the youthful stomach fails to 
 obtain the requisite amount of experience, and in 
 consequence hereafter takes fright at such trivialities 
 as " one currant in a bun," I believe that bromide 
 of potassium and moderate care in diet are more 
 successful. 
 
 Another common form of neurotic dyspepsia is 
 the condition that is known as flatulence simply, 
 and how closely this condition goes with debilitated 
 states of the nervous system is well illustrated by 
 the following case : A man of forty-two, who volun- 
 tarily called himself " a wretched nervous fellow," 
 had been dyspeptic for many years, and in conse- 
 quence suffered from an irritable heart. His wife 
 died a few months ago, and he got into a very low 
 state. He went to the seaside for seven or eight 
 weeks, and was better ; but as soon as he came home 
 again he relapsed. His attacks are very peculiar in 
 that they always commence with sleeplessness, and 
 when this begins he always knows that in three or 
 four days he will be attacked by flatulence and dys- 
 pepsia. Having mentioned this man, let me tell of 
 another condition, also in the male, because there 
 seems to be some difference between male and female 
 in this respect. It would almost seem that the 
 flatulence of the male sex is chiefly in their stomachs, 
 and that of women in the bowel. This second case 
 was in a highly neurotic man, who had taken himself 
 
COMMON NEUROSES. 109 
 
 out of an honourable calling into that of speculative 
 finance and Monte Carlo-ism. This man came into 
 my room one day, and treated me to the most extra- 
 ordinary musical performance — his stomach being 
 the bellows, and his mouth the pipe — that I ever 
 remember to have heard. The only advice I deemed 
 it necessary to give him was the very simple com- 
 mand to stop it. And I hope it cured him, for bar 
 his stomach, which was temproarily crazy, he seemed 
 sensible enough. 
 
 How often it happens that such are treated as 
 cases of indigestion, and drugs are put into their 
 stomachs as the be-all and end-all of treatment, 
 and they are never told about the mechanism 
 of the flatulent distension. The consequence is 
 that, feeling distended, they dispose of their surplus 
 gas by eructation and are easy for a time. But in 
 so doing they become gas factories ; soon more is 
 secreted, and that is passed off, and so on, and the 
 stomach is enticed to produce more each time, the 
 demand, according to the universal rule, creating 
 the supply. If, on the other hand, you tell them that 
 each return of momentary ease is accentuating a 
 habit and really making them worse, and that if they 
 bear with what, after all, is but a slight and passing 
 discomfort, they will soon be better, and then apply 
 such remedies as the case seems to call for, it will 
 take no time to cure the majority. It will not 
 be so easy with a minority. These betoken the 
 
COMMON NEUROSES. 
 
 intensity of their neurotic degradation first by the 
 dismal setting of their visage and then by the minute 
 and exaggerated description of their woes. For these 
 it is hard to say what treatment will suffice. 
 
 In addition to these cases, or such as these, there 
 is a far larger class of dyspeptics who come com- 
 plaining of a troublesome distension after their food, 
 and who, looking upon it as a symptom of indiges- 
 tion, and due — for this is the common corollary — to 
 something they have eaten, diet themselves, and, 
 meeting with no great measure of success, they apply 
 to us. The old tale of drugs is gone through, and 
 they are dieted and given some pepsine in one form 
 or another. But often enough they are not cured in 
 this way ; and, what is more, they will be fortunate 
 if they ever are. Again I appeal to the experience 
 of any one. Who has not felt the same discomfort 
 more or less when over-worked or harassed in one 
 of the hundred ways that happen to man in this 
 world of every one for himself ? And when you have 
 felt this condition what have you thought of it, and 
 did you take bismuth, or what did you do? Was 
 not this rather the outcome of your deliberations : 
 " Such and such cases have taken it out of me," or 
 " I have been busy lately, and had too little time for 
 meals " ? And those of us to whom this condition 
 is no uncommon thing, have we not rather thought 
 much in the strain to which I have already given 
 vent, that in these days of hurry-scurry our brains 
 
COMMON NEUROSES. in 
 
 run ahead and take no thought for the stomach, and 
 that in consequence there is almost a necessity for 
 many of us to suffer from a slow digestion ? And a 
 slow digestion means that, as regards symptoms, there 
 will be more or less distension after food, maybe 
 after breakfast, maybe after one of the later meals of 
 the day, when the physical energy is more expended. 
 But taken patiently and not thought about, it all 
 passes off after an hour or two. If we have been wise, 
 we have not done much in the way of medicine ; 
 we have perhaps taken a little strychnia and phos- 
 phoric acid; we have not made much alteration in 
 our diet, which has been plain and wholesome before, 
 but we have taken a little more pains with it, and 
 put food under cover more tenderly, and perhaps, as 
 a temporary thing, we have added a little pepsine to 
 the meal. No mystery in all this. We have treated 
 ourselves on plain common-sense principles. Do 
 we always treat our patients by the same approved 
 methods that we deem fitting for ourselves? 
 
 Coming next to constipation, it is hardly neces- 
 sary to insist that there are two predominant factors 
 in its production : the influence of the nervous system 
 direct, and the influence of habit. The influence of 
 the nervous system shows itself by a phlegmatic re- 
 action to the natural stimuli, and this may be either 
 an action natural to the individual, or an unhealthy 
 one, due to a temporarily-lowered vitality of the 
 centres involved. There is no difficulty in establish- 
 
112 COMMON NEUROSES. 
 
 ing the power of the nervous system to determine 
 the complaint when we consider how in several 
 morbid conditions — melancholia in particular, but 
 in hemiplegics, acute and chronic inflammatory con- 
 ditions of the brain, and so on — one and the other 
 keep time together ; and there can be no question 
 that, although the derangement of the bowels is an 
 important element for consideration in promoting 
 the cure, the morbid condition of the nervous system 
 precedes. It is with the bowel as with the stomach 
 in the case already quoted : the sleeplessness always 
 preceded the flatulent dyspepsia. Moreover, who has 
 not seen several times the milder forms of nerve 
 disturbance — the simple depression of spirits, the 
 transient glycosuria that occurs in the overworked, 
 etc. — closely followed by obstinate constipation ? It 
 is often thought that the benefit that accrues on a 
 good clear-out shov/s that some of these states are 
 the result of the fouled flues. No doubt this is so 
 sometimes — it cannot be so always ; and it is certain 
 that the intestine as regards constipation is a highly- 
 sensitive organ, from which we can very often read 
 the temperament or disposition of the man. But 
 that is not all : it is an index of the state of nervous 
 tone and vigour of the patient ; and there is many 
 a state of constipation that is not a case for aperients 
 at all, but requires the liberal use of tonics. 
 
 But I have something to say also on the subject 
 of habit. It is sufficiently obvious that the repeated 
 
COMMON NEUROSES. 113 
 
 recourse to aperients conduces to constipation and 
 engenders a habit ; but perhaps I may say this 
 also : that, impressed, as we all become as years 
 go on, with the primary importance of maintaining 
 the purity of the primce vicB, we sometimes forget 
 in our advice to the patient that aperients are, 
 after all, only a makeshift, and that they are an 
 evil unless the good they do is undoubted. But the 
 point I wish to make is this : that I have often been 
 told by the chronic piller, as an excuse for the per- 
 sistence in his practice of pill-taking, that he cannot 
 leave it off, because if he does he never has a satis- 
 factory evacuation. He appeals, in fact, to the habit 
 that he has cultivated. But I maintain that in some 
 cases he has not fully considered the question, and 
 that he is not always right, and for this reason : 
 the chronic exhibition of aperient drugs, which are 
 in most cases irritating, engenders a state of peri- 
 odical excitement in the peripheral nerve endings 
 of the intestine, and ultimately raises the unnatural 
 condition to a natural one for them. When this 
 time has arrived, the bowel may be described to 
 pass through periods of hunger and periods of satis- 
 faction according as it is being tickled by the drug 
 that has been given or not. The condition is on 
 all fours with the opium-eater's sensorium ; with the 
 bronchial tubes of the chronic asthmatic under the 
 influence of repeated inhalation ; with the mucous 
 membrane of the habitual snuffer. And this state 
 
 8 
 
114 COMMON NEUROSES. 
 
 extends through the whole length of the intestine 
 probably ; but in the present case it is the lower 
 bowel that conveys the sensation of a satisfactory 
 evacuation or not. If it feels the bite of the stimu- 
 lant, then the individual, through his local sensations, 
 describes himself as satisfied ; when the bowel is 
 not under the influence of the stimulant, then there 
 is no adequate sensation of a good clearance, and 
 the patient takes his ease in discomfort. The bowel, 
 like the stomach, takes kindly to good living ; but 
 when it has been used to the luxury of such 
 dainties as compound colocynth pill, calomel, aloes, 
 and such-like, no more than the stomach that has 
 been fed on highly-seasoned foods does it like to 
 be deprived of them. The rectum is a very pretty 
 judge of quality, but a very poor one of quantity. 
 So that when a patient, after such a practice as this, 
 takes to Carlsbad salts and mineral waters and says 
 that they do him no good, and that he must go 
 back to his old remedies, all that he really means 
 is that he cannot control the wishes of his lower 
 bowel, any more than the opium-eater can control 
 the cravings of some other part, or the alcoholic 
 his thirst. 
 
 But it is not only in constipation that the neurotic 
 tendency of the bowel comes into play. It is even 
 more strikingly seen, if not quite so often, in the 
 explosive diarrhoeas that are common in children, 
 and sometimes, dog the steps of the individual even 
 
COMMON NEUROSES. 115 
 
 to adult age. I can well remember having for some 
 time as one of my out-patients at Guy's Hospital 
 a poor feeble neurotic patient who was in this un- 
 happy condition : that if any one suddenly came 
 behind him in the street and clapped him on the 
 back with an " Hulloa ! how are you, old fellow ? " 
 his bowels would promptly act. I have never seen 
 another case so bad as that ; but I have seen several 
 where the individual had to walk circumspectly : 
 and the well-recognised condition where the mucous 
 membrane of the intestine seems to be over-sensitive 
 and reacts energetically as soon as food enters the 
 stomach is a similar state of things, and an indica- 
 tion of a temperament. It is certainly a neurotic 
 condition, and may be remedied, as so many of 
 the too-sensitive conditions of the nervous system 
 may be, by tonics in part, but much more, I think, 
 by tonics with minute doses of opium added to 
 them. 
 
 And this question of diarrhoea leads me on to 
 another very interesting disease that has been called 
 membranous colitis. The term is not a good one 
 because there is no inflammation, but I mean a 
 condition in which casts, more or less perfect, are 
 passed from the bowel. I first made acquaintance 
 with this disease by the kindness of Mr. E. U. Berry, 
 of Gower Street, many years ago. Since then I 
 have seen many such cases, and they have been all, 
 with few exceptions, in women who were of a 
 
ii6 COMMON NEUROSES. 
 
 markedly neurotic disposition. I have rarely seen it 
 in children, and only once, I think, in a man, and 
 then, interesting to relate, it was associated with the 
 presence of ascarides. The cases I have seen have 
 mostly put on similar characters. Here is one : a 
 young married lady, who dates her troubles from 
 blood-poisoning. She is a highly nervous lady, and 
 always afraid she shall be considered hysterical — a 
 very common dread in the over-nervous. She is able 
 to take little food, for when she eats solids they are 
 frequently followed by faintness and sinking sensation 
 in the lower part of the abdomen ; the extremities get 
 cold, and she has peculiar twitchings. She is exces- 
 sively particular about the action of the bowels ; when 
 they do not act she has an enema. Every eight or 
 ten days mucous casts are evacuated, and before they 
 come she turns sick, and feels so ill and all-to-pieces 
 that she wishes she might die. She has wasted in 
 the last year or two. This passage of mucus will 
 go on for years, and it does little apparent harm, 
 although the patient is generally spare and mostly 
 of an over-anxious or unhappy disposition. I am 
 very interested in this affection, because it will be 
 in the recollection of my readers that long ago Dr. 
 Eustace Smith described a condition in children to. 
 which he gave the name of mucous disease, in which 
 an excess of mucus is passed from the bowels. I 
 have always contended that this symptom occurs- 
 in children either of neurotic inheritance or evi- 
 
COMMON NEUROSES. 117 
 
 dently neurotic in themselves, and, in fact, that 
 it is in some way a part of the neurotic con- 
 stitution. And I think it may be said now that 
 the mucous disease of children is represented in 
 adults by membranous colitis, and that in either 
 case the neurotic constitution is a constant feature. 
 What the bond of association may be is a difficult 
 question ; possibly a state of the nervous system 
 that is considered adequate to the production of a 
 torpid liver may produce a torpid intestine too, and 
 in some way the mucous surface becomes coated 
 with its own effete products — a parallel perhaps to 
 that thick and harsh condition of the skin which 
 is seen in many a case of mental aberration. I 
 should be not adverse to some such hypothesis, if 
 only for being able by such a means to avoid the word 
 "catarrh," which, I suppose, would indicate activity, 
 not torpidity. The symptom, at any rate, goes with 
 a state of sluggish abdominal organs, and it is in 
 no sense one that has even the remotest likeness to 
 inflammation. It is of interest, too, that it should 
 be associated sometimes with the presence of asca- 
 rides. This is no more than one would expect, but 
 ascarides are not a common occurrence in adults. 
 And in relation to them I may mention that both 
 for them and mucous disease, when I have oppor- 
 tunity, I advise the trial of the oleo-resin of 
 copaiba as a possible means of relief, on the recom- 
 mendation of my friend Dr. Argles, of Wanstead, 
 
ii8 COMMON NEUROSES. 
 
 who tells me that for ascarides he has found this 
 drug administered in capsules one of the most 
 efficacious of remedies for killing the parasites. But 
 in saying this let me not be supposed to be 
 departing from my affection for principles : in 
 these things, as in others already mentioned, the 
 disease is a neurotic one, and is certainly much 
 relieved by assuring the patient that even if it should 
 go on for years no appreciable harm to the individual 
 results, and that a good tonic of arsenic or strychnia 
 and quinine is almost always beneficial, combined 
 with any local remedies for regulating the working 
 of the abdominal viscera. There are other points of 
 interest in this disease that might well be considered, 
 the emaciation particularly ; but they fall beyond 
 the line of my present purpose, and therefore I 
 must leave them, though reluctantly. 
 
 The consideration of nervous diarrhoea leads on 
 naturally to the subject of stomach ache and ab- 
 dominal neuralgia, of which I have notes of several 
 interesting cases. All I can say is that they are 
 exceedingly puzzling, and in several I have hesitated as 
 to whether there were actual disease, and but slowly 
 came round to the diagnosis of neuralgia. No one 
 feels more than I do that a term of this kind is one 
 of the refuges I have already alluded to and the grave 
 of many a reputation ; nevertheless there is assuredly 
 a severe form of neurosis in the abdominal nerves, 
 sometimes starting in the stomach, sometimes in 
 
COMMON NE UROSES. 1 1 9 
 
 the intestine, small or great, and many times owning 
 a uterine or pelvic cause, and which, as far as one 
 can approach to certainty, is of functional character. 
 I have purposely excluded the kidney from mention, 
 because I want now to make special reference to that 
 organ as a source of abdominal or renal neuralgia, 
 for the subject is a somewhat novel one, and it falls 
 in with what, on the whole, has been the main- 
 spring of these lectures. I am indebted for much 
 of my train of thought on this matter to a 
 single case, seen eighteen or twenty years ago, that 
 made a great impression on me at the time, and 
 has, without doubt, controlled my advice in many 
 a case since. It was that of a woman who was in 
 Guy's Hospital several times, or for a long time, 
 with all the symptoms of renal calculus. She had 
 severe pain of a paroxysmal kind, and repeatedly 
 passed large quantities of blood in her urine, but that 
 she was also a pronounced neurotic no one doubted 
 who saw her, and, I think in consequence, she was 
 subjected to an unusually long period of scrutiny. 
 However, after a long while all who saw her came 
 to the conclusion that she must have a calculus 
 in one kidney — I forget which at this distance of 
 time. It was at the period when the first talk and 
 performance of nephrectomy were beginning in 
 Germany, and after long waiting it was at last 
 decided to operate in her case, and the kidney was / 
 removed. I think it was the first case of nephrec- 
 
120 COMMON NEUROSES. 
 
 tomy in this country. The kidney proved to be 
 perfectly healthy, and no stone or evidence of the 
 previous existence of one was to be found. The 
 patient died within a day or two of the operation, 
 and I made the post-mortem examination, and the 
 other kidney, bladder, and indeed all parts of her 
 body, were absolutely healthy. I have ever since 
 felt obliged to admit that all the symptoms of 
 stone in the kidney may be present, even to the 
 passage of blood from the organ, and yet no stone 
 exist ; and the only explanation that seems possible 
 is that, under the stress of some severe abdominal 
 nerve-storm emanating from the kidney in a neurotic 
 subject, the circulation of the part may become 
 disturbed, and so the passage of blood was to be 
 explained. I admit — for no one nurtured on the 
 rude facts of morbid anatomy as I have been could 
 help doing so — that in such an explanation there is 
 always a lurking spectre of mistake somewhere ; 
 nevertheless, I can but think now that it does fall 
 in with clinical experience. And for that reason 
 tender and movable kidneys form a subject of the 
 greatest practical importance. In the last ten years 
 I have come across many cases of this sort, and I 
 have taken notes of seventeen cases. Two facts call 
 for notice : first, the large preponderance of women 
 affected, thirteen to four ; and secondly, that both 
 women and men were almost without exception 
 definitely neurotic. As regards the preponderating 
 
COMMON NEUROSES. 
 
 influence of the female sex, it may be that the dis- 
 placement is really much more common in women, but 
 it is also possible that it is not so, and that men go 
 about with movable kidneys and do not complain. I 
 suspect, however, that my figures, small though they 
 be, give a pretty accurate idea of the relative frequency 
 of the affection in the two sexes ; and the cause of 
 this preponderance may possibly be the prevailing 
 mode of dress in the female. It is needless to say 
 that tight lacing must be a great influence for its 
 production, but tight lacing as generally interpreted 
 is not necessary. There are many women who would 
 be insulted at the bare suggestion of such a thing, 
 and yet on undressing they have no little difficulty 
 in unfastening their corsets. And if you ask them 
 whether they do not find them tight, they will almost 
 certainly reply that if they had them looser there 
 would be no support. Support therefore means a 
 very fair amount of constriction of the lower part 
 of the chest, and also a considerable power in 
 extruding the kidney from its snug bed under the 
 ribs and liver. Thus far there is, however, no ex- 
 planation of the occurrence of pain ; but in these 
 cases the kidney was not only movable, it was 
 painful ; and unless the mere displacement of the 
 organ was sufficient to cause the pain by dragging, 
 we must apply to the other fact that I have men- 
 tioned to explain it, and I certainly believe it was 
 painful because the patient was neurotic, or, perhaps 
 
COMMON NEUROSES. 
 
 better, that the displacement causes some slight 
 discomfort or tends towards such a thing, and that in 
 the neurotic this is soon transmuted into an intoler- 
 able pain or leads to an explosion in the shape of 
 a violent renal neuralgia. Either way the important 
 fact to be borne in mind is that the pain may be there 
 by reason, not so much of the local displacement, as 
 because of the tem.perament of the individual. And 
 this is a matter of the greatest importance now 
 that movable kidneys are being treated commonly 
 by the operation for their fixation. It might be 
 surmised on a priori grounds that just as has so 
 often happened in dividing, and even in excising, 
 portions of nerves for neuralgic affections elsewhere, 
 after a period of ease the torment has commenced 
 again, so here. For this reason I have been and 
 am averse to having recourse to this operation except 
 as a dernier ressort, and I have seen more than one 
 case that bears this opinion out. Some time ago 
 I saw a patient who had very severe attacks of 
 abdominal neuralgia. They were so bad that she 
 had time after time to be put under the influence 
 of an anaesthetic, and kept under its influence for 
 many hours. She had a movable kidney on one 
 side, and the pain radiated much in the position of 
 the displaced organ. She had a belt made, and it 
 acted fairly well as long as she was in bed ; but 
 what belt can compete against the abdominal wall, 
 when it is required of it that it shall keep up the 
 
COMMON NEUROSES. 123 
 
 organ under the ribs, and it failed eventually, as 
 all such appliances do fail, besides proving very- 
 uncomfortable. It was ultimately determined to 
 operate, as the pain returned, and life under the 
 circumstances was hardly worth the living. The 
 kidney was stitched into position ; and I must admit 
 that for many months she had perfect relief, and be- 
 came quite a different woman. I came therefore to 
 the conclusion that I was wrong, and that fixing the 
 kidney was, after all, a successful operation. But 
 time has gone on, and now I hear that the pain 
 still occasionally recurs. It is therefore quite pos- 
 sible that, although unquestionably great relief was 
 obtained by the operation in this case, it may yet 
 be that the relief was only such as the neuralgic is 
 likely to obtain from the last new form of treatment, 
 whatever it be, and the more decided the measures 
 undergone the more the relief for the time being. 
 I do not of course wish to slight the value of an 
 operation in carefully-selected cases : all I wish to 
 convey is that the patients are neuralgics ; and that 
 to be a neuralgic indicates a vice of nervous action 
 that an operation can seldom hope to cure ; and that, 
 since we are thus only treating a symptom, in no 
 sense attacking the disease, these are cases for great 
 deliberation. Our endeavour should be to encourage 
 the patient to make light of her trouble, and, by 
 improving her nervous tone by such means as are 
 available, to enable her to bear, and so to cure, the 
 
124 COMMON NEUROSES. 
 
 fundamental condition, and only to operate when 
 patient means have failed. 
 
 And here may be said what need be with reference 
 to uterine and ovarian neuralgise, I have said it is 
 a bad day for a man when he first knows he has a 
 heart ; it is a ten times worse day for a woman 
 when the pelvic pains to which so many are subject 
 are focussed for her by medical opinion upon uterus 
 or ovary. If there is anything that curdles my 
 blood it is to hear a woman talk of her ovaries as 
 she might of some intimate acquaintance. One 
 cannot of course suppose (as Sir William Gull used 
 to say of the jejunum that it has no pathology) 
 that organs fulfilling such important functions should 
 have no liability to the aches and pains that all 
 flesh is heir to, or even that they are free from 
 a large measure of disease. We know that it is 
 not so, but there can be no doubt that the ovaries 
 are organs that largely concern themselves with 
 functional disease, and with forms of it, too, that 
 penetrate into the inmost recesses of the patient's 
 being. Do we always remember this at the present 
 day, with all the prevalent means of treating disease 
 locally ? Do we not sometimes undertake local treat- 
 ment hazardously, I mean as regards the chances of 
 real improvement, because it can be effected with so 
 little risk to life ? Is it not too often, " It cannot 
 do any harm, and it may do good " ? Surgery can 
 happily accomplish now much of what it undertakes ; 
 
COMMON NEUROSES. 125 
 
 but it needs to remember that it has not yet attained 
 to the enucleation of the neurotic constitution. And 
 when I see, as I have seen, the uterine appendages 
 removed for an apparently incurable neuralgia, I see 
 in the measures adopted not the advance of scientific 
 surgery, as some might suppose, but the abasement 
 of the patient, who has been obliged to yield to the 
 force of circumstances. It is a poor result. Opera- 
 tions of this kind are on a par with some of those 
 upon a painful kidney, or with the destruction of 
 Meckel's ganglion for tic. They may be necessary, 
 just as war is necessary. But they are nothing to 
 be proud of ; they often leave a lot of " bad blood " 
 behind them, and they are conspicuous for the failure 
 of those higher and more fundamental arts of treat- 
 ment that should have lifted the patient over this 
 necessity. To criticisms of this kind it is often said, 
 " But the people love to have it so " ; and true this 
 is. But for us the thought should ever be. With 
 the kidney gone, the ovaries removed, the Meckel's 
 ganglion destroyed, and the pain returned, what will 
 ye do in the end thereof? 
 
 With one other subject only do I propose to trouble 
 you, and I have done. It is one perhaps most dear 
 to the neurotic of any I have named, and, must I 
 not say, most indispensable of all as a shelter to the 
 doctor ? I need hardly add that I allude now, in its 
 own right, to the torpid liver. Ah ! what, indeed, 
 should we doctors do without this sluggard of an 
 
126 COMMON NEUROSES. 
 
 organ to treat ? What would many a patient do 
 without a vital of this kind to nurse and think about ? 
 " Well, doctor, it is my liver," falls so commonly on 
 the ear that blue pill if we are old-fashioned, or 
 podophyllin, euonymin, etc., if we are sensitive to the 
 breath of the trade winds, comes as an automatic 
 response, which hardly, if at all, stirs our sensorium. 
 How often, I wonder, do we really think outside this 
 groove, and question for the particular individual that 
 is at the moment seeking our aid whether we shall 
 take his diagnosis or make our own ? I shall ven- 
 ture to maintain that the liver is a much-abused 
 organ, and that there are thousands of people in the 
 civilised vforld — the savage has his knowledge of good 
 and evil to come — who are being physicked for their 
 livers with nothing the matter with them, save a dulled 
 or flabby nervous system. But do not let it be sup- 
 posed from what I have said that I disbelieve in the 
 existence of a torpid liver. Quite the contrary. But 
 I am trying to shift the responsibility of its supposed 
 crimes on to the back of the real offender. All I am 
 contending for is that the torpidity is not a disease, 
 but a symptom, and that in nine cases out of ten, when 
 individuals come complaining of their liver, it is the 
 individual, not it, that is at fault, and that to make such 
 people really well it is necessary to replenish the spirit 
 that animates them and at the same time regulates the 
 blood flow in the inmost recesses of their vitals. 
 
 And, for example, one disease that I would shift from 
 
COMMON NEUROSES. 127 
 
 the shoulders of the liver to those of the nervous 
 system is of all others perhaps at first sight the 
 most unlikely — viz., gall-stones. It has long seemed 
 to me that, although we talk and see much of this 
 disease, we are almost absolutely in ignorance as to 
 why these concretions form. " A sluggish liver forms 
 thick bile" may be sufficient for some minds, but 
 why should the liver be sluggish ? It is usually sup- 
 posed that these concretions form in those of sedentary 
 habits and of stout build. But this is not by any 
 means so, and I assert that it is at least as often that 
 gall-stones occur in the neiirotic, and in a physique 
 that is the thinnest of the thin. Moreover, I have 
 also been struck with the frequency with which people 
 will tell you that their troubles in this respect first 
 began in connection with, or after, worry of one kind 
 or another. And when we come to think about it, 
 although it may seem at first sight far-fetched to 
 drag in the nervous system for such a tangible and 
 remote affection as gall-stones, it is quite otherwise, 
 for there is nothing more reasonable than the sup- 
 position that, the nervous energies being at a low 
 ebb, or frittered away in a restless anxiety, the liver, 
 which admittedly must require a large supply of 
 nervous current to enable it to get through its work, 
 is too torpid, its various changes are carried on slowly 
 and performed badly, the cholesterine that should 
 remain in solution is thrown down, perhaps formed 
 in too great abundance, and thus the stone is set 
 
128 COMMON NEUROSES. 
 
 a-going. There is nothing in such a train of reason- 
 ing that is anywhere outside irreproachable doctrine, 
 and, in my opinion, nothing that is not highly 
 probable. If this is so, what is the use of stimulating 
 the liver ? And although such a practice is endorsed 
 by ages of custom, if we retire into ourselves and 
 think the matter out for ourselves by the light of our 
 experience, can we say for certain that the blue pill, 
 the podophyllin, the salines, the Carlsbad salts, and 
 so on, have accomplished the work that we entrusted 
 to their care ? I think that, were it so, we should 
 know more than we do of the why and the how of 
 the formation of these concretions ; whereas, in truth, 
 we know nothing of these two points, and we must fain 
 confess that as yet we have not got behind the most 
 obvious syinptoin of some disease of which we still 
 remain in absolute ignorance. 
 
 I may add here a few words on the subject of sick- 
 headache or migraine ; because, although it more 
 fittingly belongs to the group of cerebral neuroses 
 treated of in the first lecture, it more often, or at any 
 rate very often, comes before me as a disease that is 
 supposed to be due to a sluggish liver, or perhaps is 
 the effect of an excess of uric acid in the blood. Either 
 way, the patient is too apt to diet himself strictly, and 
 to make his diet list sparer — and yet more spare — 
 and that is not the way to cure most migraines. It 
 would be more true to say that this disease is never 
 due to those supposed partial abrogations of function 
 
COMMON NEUROSES. 129 
 
 on the part of the liver, than that it is ; for although 
 it is often associated with such conditions, neither 
 the one nor the other — " the liver " nor the uric acid 
 — is the substantive disease : they and the headache 
 are alike due to some deeper-lying causes. 
 
 Migrainous subjects mostly come from the ranks 
 of temperate livers — who very often work their brains 
 to exhaustion. Within the limits of wholesome food 
 they require to live well, while the remedies that do 
 them good are such as have a distinct effect upon the 
 cerebral hemispheres and the nutrition of the nerve 
 elements — viz., sleep, rest, tea ; guarana, cannabis 
 indica, antipyrin, and so on. While of remedies that 
 do something to control the frequency of the attack 
 are such brain foods as cod-liver oil and alcohol, and 
 nerve tonics such as arsenic, strychnine, phosphorus 
 and iron. 
 
 And now I have done. In taking leave of my 
 subject, let me reassert what has been the aim in 
 these lectures. It was, in giving a clinical exposition 
 of the common neuroses, to lay stress on the very 
 certain fact that there are limits to the treatment of 
 this class of diseases by drugs and operations, and 
 that there are many conditions in which the cure 
 must come mainly from within, our function in 
 chief being to call out this dormant power. I have 
 endeavoured to insist, because I am sure at the 
 present day we are too likely to forget, that the 
 highest position we can take is to cure people by 
 
 9 
 
I30 COMMON NEUROSES. 
 
 advice rather than by drugs, to make the public pay 
 for the use of our brains, and not for a prescription of 
 so many ounces of physic. Drugs have their own 
 field, but they are our instruments only ; of them- 
 selves they have no vitality, and a sound common 
 sense — may I say a robust physiology ? — has a larger 
 mission even than they in the treatment of disease. 
 There is a time to give drugs, and even to give them 
 with a free hand, but there is equally a time when 
 advice only is needed, and not physic — ^shall I stop 
 there ? no, when to give drugs is quackery ! Ye^s, 
 there are times when to give medicine is to give 
 poison, for it sends the poor patient on a hunt for 
 health which no physic will procure, and it lets slip 
 the opportunity — in the exigencies of human pain, and 
 of suffering of all kinds, too seldom fit — of pointing 
 the ignorant to a future of medicine which both for 
 them and for us is an ideal to be hoped for, to be 
 striven for. I am not one of those who think that if 
 we c6uld conceive of a future for Medicine in which 
 drugs should bear no part the function of the doctor 
 would be gone. Rather do I hold that as the level 
 of health of a community is permanently raised, 
 so is he emancipated for a sphere of larger use, of 
 still more liberal aims, of nobler purpose. But that 
 is a subject for a future Harveian lecturer. For me 
 it must be enough to press the conviction I hold 
 that the large class of ailments that has formed the 
 subject of these lectures admits of treatment, and 
 
COMMON NEUROSES. 131 
 
 ought to be treated, with a minimum of drugs ; and 
 that if we could but prevail on the neurotic to see 
 and to believe this, there is many a one who is now 
 passing a life of aimless and too often hopeless 
 invalidism to whom we might certainly promise, in 
 language that many of them know too well, — 
 
 " Soon will come the great awaking, 
 Soon the rending of the tomb, 
 Then the lessening of all shadows, 
 And the end of toil and gloom." 
 
 But that end is not yet. Will it ever be ? I must 
 sorrowfully confess that the prosaic side of life suggests 
 a couplet from another source : — 
 
 " But when you see that blessed day, 
 Then order your ascension robe." 
 
 None the less we still can say, " Come from the four 
 winds, O breath, and breathe upon these slain that 
 they may live." 
 
INDEX. 
 
 PAGE 
 
 Abdominal Neuralgia . 88, ii8 
 
 Absent-mindedness . , 24 
 
 Angina pectoris . . 68, 85 
 
 neurotic form of . .88 
 
 Angina, pseudo . . .92 
 
 Anorexia nervosa . . , loi 
 
 Ascarides . . . .116 
 
 Asthma . . . 46, 53 
 
 Auditory vertigo . . .18 
 
 Blushing . . . IS, 77 
 Brain collapse . . . .34 
 Breakfast — importance of as 
 
 a meal ..... 105 
 Bullous erythema of neurotic 
 
 origin . . . . .84 
 
 Catarrh of the stomach 
 Cautery, the galvano, of the 
 
 nose in asthma 
 Cerebral fever . . . . 
 Cerebral sensations. . ll 
 Change of type in disease 
 Chlorosis . . . . 
 
 Circulation, " the feeble 
 Clergyman's sore throat 
 Cold-catcher, the 
 Colds, susceptibility to 
 Colitis, membranous 
 
 96 
 
 • 47 
 
 • 41 
 18, 24 
 
 • 7 
 . 94 
 
 24, 82 
 . 48 
 
 • 52 
 . 28 
 
 • 115 
 
 PAGE 
 
 Collapse, cerebral . . -34 
 
 Constipation . . . .ill 
 
 Copaiba for ascarides and 
 
 mucous diarrhoea . • 1 1 7 
 
 Crises, abdominal . . .88 
 
 gastric . . . .88 
 
 thoracic . . . .88 
 
 Cures, asthma . . . 64, 67 
 
 Deafness, the, of noisy occu- 
 pations. . . r .11 
 Depression of spirits . . 23 
 Diarrhoea, mucous . . -US 
 
 nervous . . . ■ 115 
 
 Disease, change of type in . 7 
 Dread of society . . 14, 16 
 Drugs, differences of response 
 
 to in social strata . ■ 1 1 
 
 Duration of life . . .6 
 Dyspepsia, atonic . . -95 
 
 flatulent . . . -95 
 
 gouty .... 95 
 
 nervous . . . -95 
 
 Dysphonia clericorum . . 48 
 
 Emaciation of nervous origin 38 
 Erythema, bullous . . .84 
 
 Fainting 
 
 14, 24, 78 
 
 133 
 
134 
 
 INDEX. 
 
 Fatigue . 
 Feet, coldness of 
 Fever of cerebral origin 
 Fidgets, the 
 Finger dying . 
 Flatulent colic 
 Flushing . 
 Formication . 
 
 Gall Stones . 
 
 Galvano cautery of the nose 
 
 in asthma 
 Gastric catarrh 
 Gastric crises . 
 Gastro-pulmonary fever in in 
 
 fancy 
 Glycosuria 
 Graves' disease 
 
 Habit, the inhalation 
 the pill-taking — its phy- 
 siology 
 Hsematuria 
 Hay-fever 
 
 Headache . . .18, 
 Heart consciousness 
 
 cramp . 
 
 irregular action of . 
 
 the nervous 
 
 weakness 
 
 PAGE 
 
 31 
 
 82 
 
 41 
 
 14 
 
 82 
 
 108 
 
 15 
 24 
 
 127 
 
 47 
 96 
 
 78,88 
 
 112 
 120 
 46 
 128 
 68 
 86 
 70 
 70 
 69 
 
 Infantile asthma . . -57 
 Inhalations for asthma . 64, 67 
 Insanity, harshness of skin in 117 
 Insomnia . . . . 20, 108 
 
 Irregularity of heart . . 70 
 
 Kidney, movable 
 neuralgia of 
 
 Life, duration of 
 
 120 
 119 
 
 PACK 
 
 Liver, the torpid . . . 125 
 Loss of memory . . .23 
 
 Memory, loss of . . -23 
 
 Meniere's disease . . .18 
 
 Migraine . . .128 
 
 Morbid flushing . . .15 
 
 Movable kidneys . . .120 
 
 Mucous diarrhoea . . ■ nS 
 
 Mucous disease . . .116 
 
 Nervous dyspepsia . . 96 
 
 Nervous heart, the . . 70 
 
 Nervousness, the, of overwork, 
 
 glycosuria, excess . . 70 
 Neuralgia, abdominal . 88, 118 
 
 ovarian . . .124 
 
 renal . . . .119 
 
 spinal . . . .30 
 
 uterine . . . .124 
 
 Neurasthenia .... 5 
 Neuroses, cerebral . . -14 
 
 the, of special callings . 12 
 
 Neurotic element, the, in dis- 
 ease ..... 5 
 Neurotic vomiting . . . 107 
 
 in children . . 107 
 
 Numbness . . . -24 
 
 Obesity, the dietetic treatment 
 
 of 40 
 
 Opium in the nervous . . 1% 
 
 Ovarian neuralgia . . . 124 
 
 Pain 
 
 Painful kidneys 
 
 Palpitation of heart 
 
 Paroxysmal sneezing 
 
 Pemphigus 
 
 Pins and needles, sensation of 
 
 24 
 121 
 
 74 
 44 
 84 
 24 
 
INDEX. 
 
 135 
 
 Pneumonia due to cerebral 
 
 injury 41 
 
 Pseudo-angina . . -92 
 
 Psoriasis . . .84 
 
 Pyrexia from cerebral injury 41 
 
 Raynaud's disease 
 
 47, 
 
 Sensations, cerebral 
 
 
 18 
 
 Sexual hypochondriasis 
 
 
 30 
 
 Sleeplessness . 
 
 . 20, 
 
 108 
 
 Sneezing, paroxysmal 
 
 
 44 
 
 Snuffing — its lesson as regards 
 
 
 asthma 
 
 
 62 
 
 Society, dread of 
 
 14 
 
 16 
 
 Spasmodic asthma . 
 
 46 
 
 53 
 
 Spine, neuralgia of . 
 
 
 30 
 
 weakness of . 
 
 
 25 
 
 Strata, the neuroses of the 
 
 different social . . .10 
 Sweating, morbid . . • IS 
 Syncope of cerebral origin 37, 80 
 
 Tabes dorsalis, gastric crises in 88 
 Thoracic crises . . .88 
 
 Tic 125 
 
 Tinnitus . . . . .18 
 Tremors . . . . 24, 77 
 Type, change of, in disease . 7 
 
 Uterine neuralgia 
 Vertigo, auditory 
 
 124 
 18 
 
 Wasting of nervous origin . 38 
 Weak heart, the . . .66 
 
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