believe themselves to be sane, imagine that other people think them insane because they are shut up, and fear that they will become mad like other cases whom they consider to be so. This psychological attitude of the sufferer, i.e. the fear that he may become mad, is one cause of the difficulty in getting cases to come voluntarily for treatment. The neurotic knows that he is different from others; he is continually fighting with this knowledge. His symptoms are an attempt to explain himself to others, to tell them why he is like this. He fears insanity. This may appear a far-fetched hypothesis, but when clinical experience proves that the removal of the idea of becoming insane leads to the recovery of the patient and his adjustment to his environment, the hypothesis appears tenable until a better one is advanced. The following cases will illustrate and perhaps make this point clearer:

A man about 60 years of age who was restless at night, continually wandering about without apparent cause, complaining that he was in such intense pain in his abdomen that he could not rest, was brought to the clinic. His friends had the fear that he might do himself some harm. The history was that he had always been rather spoilt. He had had his own way both with his mother and with his wife, and with his own children. He had had no illness until about the year previous when he complained of a vague intestinal pain and eventually an operation for gall stones was performed. The pain before the operation had been called neuralgia. Owing to his attack of gall stones and his rather long period of convalescence he lost his work and he then began complaining of intense abdominal pain; no medicine relieved him. Hiding behind this symptom was the fear that he would go off his head, as a relative had done who was suffering from some vague intestinal trouble. He was assured that he would never be any more off his head than he was at present. An explanation was given of how the idea arose in his mind, with a consequent abatement of his restlessness and also a diminution of his pain. In this particular case, that of a man active all his life who suddenly ceased work, there was a good deal of muscular flabbiness with some distension of the abdomen through flatus. The flatus was the apparent physical cause on which he hung his symptoms. In other words he had 'got the wind up' both physically and psychologically, and the removal of the wind in both senses apparently completed his cure.

The second case was that of a woman, a member of whose family, namely her mother, had previously suffered from melancholia. This woman remained perfectly well till she had an attack of influenza. Following this she had difficulty in concentrating her mind on anything.

Physically she was run down and could not perform her work. She became what is usually termed melancholic, and talked about drowning herself. When first seen at the clinic she appeared miserable, answered questions only in monosyllables and said she was becoming mad. In this case it was found that she was afraid of being like her mother, and that the idea of suicide was that she would sooner be dead than shut up the mental hospital, which was in close proximity to her home. At present she is very much improved and has returned to her work.

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Suicidal tendencies are caused, I believe, in many cases, by the fear of becoming insane. The patient would sooner kill himself than become mad. This hypothesis is borne out by the fact that after this fear is explained away the patient ceases to be suicidal. Many have told me that their suicidal tendencies were caused by the fear of insanity; and certainly of the numerous so-called suicidal cases either admitted as inpatients to the mental hospital or treated as out-patients at the clinic, none up to the present, after treatment, have attempted to commit the act.

The next point for consideration is the class of case coming for treatment at the clinic. To give a list with the diagnosis of each case that has attended since the opening would be of little value, as it would simply be a list of names, and the diagnosis might in many cases be questioned. I propose therefore to divide the cases roughly and rather arbitrarily under three headings:

(1) So-called 'functional' cases, by which I mean cases in which no marked organic or toxic disease can be discovered.

Under this heading various forms of hysteria, neurasthenia, anxiety states, melancholia, mania, manic depressive and obsessional cases, cases of phobia and impulse are included, as the main symptom appears to be of a psychological nature, connected rather with the mental than with the physical life of the patient.

(2) Toxic cases, e.g. syphilitic, alcoholic, encephalitic and puerperal cases. I would include also what are called exhaustion psychoses.

(3) Cases in which there are marked organic degenerative changes, e.g. trauma, senile changes, various vascular lesions, diseases affecting the special senses, or other gross lesions of the nervous system.

This still leaves illnesses like epilepsy and dementia praecox unclassified, and cases of these maladies are probably found in each of the three groups already mentioned.

It is admitted that the above classification is more or less arbitrary, but I think all cases that do come for treatment at the Nervous Disorders Clinic can roughly be grouped under one of these three headings.

At the same time, it should be noted that the division between the three groups is not a hard and fast one. Thus, when a case is designated 'functional,' this merely implies that the symptoms cannot be accounted for by any physical disorder at present known, or that whatever physical disability there is does not seem sufficient to account for the symptoms manifested. The functional group naturally tends to slide into the second or toxic group, and the toxic group in the same way slides into the third

group.

All these groups further present very much the same problem, that is, they are all called 'nervous'; and I think this term 'nervous' is used in much too wide a sense. To illustrate: A patient who has had a definite loss of power due to a breaking of the nerve continuity between the brain. and the muscle is undoubtedly suffering from a disease or injury to the nerve, and is therefore nervous in the strict sense of the word, whereas a person who is suffering from a so-called 'nervous breakdown' may have no symptoms of nerve degeneration except a general apprehension, a fear of they know not what, and a general inability to tackle life. Such patients are told that their "nerves are out of order," whereas in this case it is only a function which is deranged. In fact any psychological departure from the normal is usually designated 'nerves.' As the nervous system is the most highly organized of any system of the human body it seems logical to suppose that its functions may be deranged either by gross changes in the body or by minute changes in the metabolism, but at the same time it is also possible that changes in the environment or influences from the environment causing acute emotion may, and perhaps do, alter physical functions. Instances are the sweat of fear or the vomiting of disgust.

I will now attempt to illustrate the three categories I have mentioned by a description of specific cases:

(1) A case of a girl who was sent to the clinic with a hand which she had not been able to open for three months. The right hand was clenched and the patient said she had no power to open it. An investigation of the case revealed that she had a very great attachment to her father. She had always been given way to and spoilt. Her father had been strict only in one way and that was with reference to her behaviour with the opposite sex. He had, so to speak, instilled into the girl's mind that the male sex, with the exception of himself, were a danger to her. It is not inferred here that this had been done deliberately or consciously, but that such was the sum total of the idea the girl had formed. The girl therefore had had no outlet for her biological feelings for the opposite

sex except her father. Her whole affection had been concentrated on this one person. No ill effects result from this until her father begins to suffer in his health, when the girl, who is in service, becomes worried because she hears that her beloved father is ill. The conflict then arising in her mind is the following: The father is not well-off, she is in service and earning money, therefore she should remain in service to help the father. But because she is in service she cannot get home to see the father, that is to say, her wishes and her ethical sense are at variance. She begins to brood, with the consequence that she does not take any interest in her amusements. She had always previously been an active and rather energetic girl. This loss of physical activity results in slight loss of appetite, and constipation. She catches what is commonly called a cold and has a certain amount of pain in her muscles, especially in that of the right arm. One day she hears that her father is worse. She cannot get permission to go and see him as her mistress is away. She feels ill. The next day when doing her work in the morning she is said to have fainted. When she comes to she cannot open her right hand. It should be noticed that the right arm is the arm she uses most in her work. The right arm also is associated in her mind unconsciously with the fact of an old relative who had a paralysis of that arm. She had hoped she would never be like this old relative. She had during her stage of physical disability also had the fear that if she were ill she would not be able to help the father. Because of her illness and her hand she is sent home. There is here a typical instance of conflict. If she remains well, she cannot see the beloved father as often as she wishes, but if she is ill she cannot assist the father because if she goes home she loses the pay for her work. It should also be noted that till she becomes physically ill, that is to say till she gets the cold, the balance of the conflict seems to be maintained, but when the physical is also affected then comes the breakdown. This patient after the first interview was able to move the fingers which had hitherto been immovable. At the second interview one was able to wash out the dirt that had collected in the clenched hand, the skin then being in a very bad state. The girl began to assist in the treatment and eventually in the course of a few months had completely recovered the use of her hand. With the exception of washing the hand and assisting the movement of the fingers which had naturally become stiff, there was no other treatment employed except psychotherapy. It was on the patient's becoming conscious of the mental mechanisms which had caused the illness that the recovery took place. This case I think illustrates that owing to her early mal-adjustment to environment

by the spoiling of her father she had not been taught to adjust herself to the difficulties of life. Her affections had concentrated unduly on her father. In this case the original cause of the trouble seems to have been entirely psychological; that is to say, the girl could not be with a loved object the whole time, and the fear of losing this loved object was so great that she could not, I can only say unconsciously, stand the conflict. There was an unconscious reason for her illness; for while she had this bad hand she could not work, and so there was nothing to keep her away from her father. She could go home because she was ill, but it was not till the slight physical disability of the cold occurred that she completely broke down. Neither the physical nor the psychological disability by itself appear sufficient to cause the breakdown and yet as she recovered in proportion as her psychological outlook improved, and as it appears in the history that her thought processes were the ones that were primarily involved, one is allowed, I think, to form the hypothesis that the primary cause was psychological and the secondary physical. It is not to be inferred from this case, which is admittedly a simple one. of conversion hysteria, that all cases are so easily dealt with. It is used here merely to illustrate the first group; and as experience shows that many of these cases which have apparently resisted all other efforts do recover by psychotherapy, the hypothesis that emotional states may cause physical manifestations is tenable. Further, it is clear that if this condition had not been relieved, there would have been marked physical changes in the limb, which eventually no method except operation would have been able to remedy. Other cases could be mentioned, but time forbids. All cases are not equally successful, though from experience both among civilians and during the War, it seems that these conversion hysterias are some of the most favourable cases for psychotherapy.

(2) To illustrate the second or toxaemia group, let us take the case of a woman suffering from encephalitis lethargica. She had for several weeks been extremely ill, lying in a condition of semi-stupor. Then she began slowly to recover from her physical malady, but as her physical condition improved her mental condition showed great abnormalities. She was thought to be suicidal, for she ran to the window which she wished to throw up, as she said she heard her husband calling. She said. that people came to see her, and were not allowed to do so. She was restless and required a great deal of nursing, maintaining that people were there in her room who were as a matter of fact not present. Here it was obvious that the patient was living in a condition of unreality. She was resentful of any interference. One remark she made was that she must