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Authors: Edward Shorter

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So, nerves were not all negative.
Neurosis IsIntroduced

The eighteenth century was the era of the great classifiers of natural phenomena, whether the Swedish botanist Carl Linnaeus’s taxonomy of plants in 1735 or French physician Fran ç ois Boissier de Sauvages’ classification of human diseases in 1763. Above, we saw the Scotsman William Cullen trying his hand at classification in 1769.

In Europe the term “neurosis” received a major boost when French psychiatrist Philippe Pinel included the term in his own nosology of illness in 1798. Paris was then seen as the epicenter of the learned world, and Pinel’s Nosographie philosophique proposed “n évroses” as the “fourth class” of diseases. Neuroses for Pinel more or less mirrored Cullen’s scheme, which he had translated into French, including vesaniae [major mental illnesses], spasms, convulsions, pains, “comatose affections,” and paralyses. “The brain, the cerebellum, the spinal cord and the nerves are without doubt the prime organs for the origin of these varied disease pictures.”
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The writing of Cullen and Pinel combined to insert “neurosis” into the medical vocabulary by the early nineteenth century. The term did not take the medical world by storm, in the later way of “neurasthenia,” because it embraced such a vast range of psychiatric and neurological phenomena. (Neurasthenia, as we shall see, was much more specific, and materially rewarding as well. It became the intellectual basis of an entire world of expensive private psychiatric clinics.) Yet early on, neurosis did enjoy a certain amplitude. In 1823, for example, C.-H. Machard, chief of hospital services in the little French town of Dô le on the Doubs River in the Jura Department—a complete nobody in other words—said in his “medical topography” that “Hypochondria, hysteria and in general the various névroses are the lot of those people here with temperaments fatigued by excess and psychological afflictions.” Happily, such conditions were not common in Dô le, he said.
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How did neurosis differ from psychosis? In the beginning, the meaning was the exact opposite of that we assign today. In 1845 in his textbook of psychiatry, Ernst von Feuchtersleben, 39 years old and secretary of the Medical Society of Vienna, took a new run at defining the difference between psychiatric and neurological illness, because until then the term “neurosis” embraced both. Neurosis, said Feuchtersleben, was as Cullen and Pinel had described, the entire range of illness having a physical basis in the brain. Yet some disorders had primarily mental symptoms, although situated in the brain, and Feuchtersleben proposed calling them “psychoses.” (Later usage reversed this completely, making “neuroses” the minor mental illnesses and “psychoses” the major.) Feuchtersleben wrote that “Every psychosis is simultaneously a neurosis, because without the agency of the nervous system no change in psychic expression could emerge; but not every neurosis is at the same time a psychosis, as the examples of convulsions and pain very well demonstrate.”
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It is actually hard to think of a neurological illness that does not have some kind of psychiatric symptoms, but Feuchtersleben’s idea was that apparently organic illnesses such as epilepsy (which he called “neuroses”) had no mental symptoms, whereas all behavioral symptoms, such as mania (“psychoses”), must have a basis in the brain. In the next half century there would be a dramatic upturn in the use of the term “neurosis,” but in the modern sense, not in Feuchtersleben’s.

Nerves and the Abdomen

From the very beginning, interest in the symptoms of nervous illness had a somatic side, and for a century and a half this interest was centered on the stomach and intestines. This is not to hold these early writers up to ridicule for the falseness of their ideas, but to reinforce the point that “nerves” had an irreducible bodily dimension: The condition has never been just a “mental illness.”

In his First Lines in 1769 Cullen said, as we have seen, that “vapours or low spirits” were the same thing as “hypochondriasis,” a kind of minor depression dependent on “a certain state of the body.” Yet the curious thing about Cullen’s hypochondriasis was that it was localized not in the mind but in the stomach. What was the cause of hypochondriasis? In many cases it was “dyspepsia … a symptom of the affection of the stomach.”
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This is interesting. Here we have a major medical writer telling us that the seat of an important mental malady is in the stomach. It is actually not far fetched that nervous illness of the mind and brain might have a connection to the digestive tract. The stomach and colon have quite a refined nervous system of their own, and several hormones that serve as nerve transmitters in the gut, such as cholecystokinin (CCK), are also neurotransmitters in the brain. One observer said, “Gastroenterologists are just psychiatrists that look like doctors.”
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As the nerve story gets going in the eighteenth century, not only are the bowels closely associated with the brain, they are thought to be among the primary causes of nervous illness. The humoral doctrines of the day easily associated mental symptoms with gastrointestinal events. Among the earliest writers was Richard Blackmore, London society physician and poetaster (whose “heroick poem in ten books” was attacked by a contemporary scribe whom Dr. Samuel Johnson pronounced “more tedious and disgusting than the work which he condemns.”
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) In 1725 Blackmore composed A Treatise of the Spleen and Vapours in which he presented hypochondriasis, “vulgarly called the Spleen,” as attended with a long suite of abdominal complaints: “First, a depraved disposition of the stomach, and an impaired digestive faculty,” the organ “filled and distended with storms of hypochondriacal winds … This receptacle, and the inferior neighbouring parts, seem a dark and troubled region for animal meteors and exhalations, where opposite steams and rarified juices contending for domination, maintain continual war.” And mentally, what were these patients like? They were not psychotic or demented. “Yet a considerable inequality is observed in the operation of their intellectual faculties; for some seasons they discover great impertinence and incoherence in their thoughts, and much obscurity and confusion in their ideas, which happens more often, and lasts longer in those who are far gone in this whimsical distemper. These patients are likewise very various and changeable in their judgment, and unsteady in their conceptions of persons and things.” Blackmore described an almost manic-depressive temperament in these hypochondriacal patients: “Sometimes they are gay, cheerful, and in good humour; and when raised and animated with wine, they acquire an extraordinary degree of mirth … But though these delightful scenes exhilarate the hypochondriacal man, yet when they are past, his spirits are exhausted and sunk; and suddenly relapsing into his dull and lifeless melancholy, he pays dear for his transient, voluptuous satisfactions.”
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Let us say you are a man with a “gouty humor” and a temperament disposed to melancholy: This unhappy combination of humor and temperament might lead you, said Edinburgh’s Robert Whyte in 1765, to develop “a great depression of spirits and sometimes very uneasy distracting thoughts,” a reference to suicide. But in a patient with a different constitution, the same humor might produce gastrointestinal upset rather than thoughts of suicide. Or “low spirits in hypochondriac and hysteric cases may be frequently owing to some morbid matter in the blood, flatulent and improper ailments, or other causes affecting the stomach and bowels with a particular sensation, which, though not painful, nevertheless is attended with great dejection of mind.” Thus did low spirits, melancholy, and flatus all come together. There was, however, good news for sufferers: “When low spirits or melancholy have been owing to long continued grief, anxious thoughts, or other distress of the mind, nothing has done more service than agreeable company, daily exercise, especially travelling, and a variety of amusements.”
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As we wrestle with these issues today, we do well to keep this cheery advice in mind.

Whyte, like most of his contemporaries, moved within the hypochondriasis frame: troubles supposedly associated with the intestines, meaning below the hypochondrium (under the diaphragm), that produced mental changes. In the world of nerves, hypochondriasis was often the diagnosis par excellence for men. The preferred diagnosis for women was “hysteria.” Only later did hypochondriasis take on the exclusive meaning of preoccupation with the risk of falling ill.

In Domestic Medicine in 1769, Buchan assigned hypochondriasis to “men of a melancholy temperament … in the advanced periods of life.” Among the causes, “the suppression of customary evacuations … obstructions in some of the viscera, as the liver, spleen, etc.” The remedy? “The general intentions of cure, in this disease, are to strengthen the alimentary canal, and to promote the secretions.”
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Thus, for the public, it was self-understood in the eighteenth and nineteenth centuries that brain and bowels were linked. In 1814 Lord Byron wrote to an undoubtedly riveted Lady Melbourne of his taste for pleasure: “I began very early and very violently—and alternate extremes of excess and abstinence have utterly destroyed—oh! unsentimental word! my stomach—and as Lady Oxford used seriously to say a broken heart means nothing but bad digestion. I am one day in high health—and the next on fire or ice—in short I shall turn hypochon driacal—or dropsi cal—whimsical I am already.”
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The nineteenth century accented strengthening the constitution through spa and seaside treatments. In 1845, Edward Bulwer Lytton, seeking succor at the spa at Malvern for his weakened nerves, said, “I was thoroughly shattered. The least attempt at exercise exhausted me. The nerves gave way at the most ordinary excitement—a chronic irritation of that vast [gastrointestinal] surface we call the mucous membrane, which had defied for years all medical skill, rendered me continually liable to acute attacks … ”
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As with many patients at the hydros, the healing waters calmed the irritated membranes and restored nervous strength.

And sea bathing! Louis Verhaeghe, a spa doctor in Ostende, Belgium, explained in 1850 how beneficial it would be for hypochondriasis, a disease seen mainly in men with digestive problems such as his patient, “le docteur M,” 43 years old, from a large German city: “He fell ill as a result of excessive fatigue accompanied by some reversals of fortune. His digestive process was at first painful and gave rise to a great malaise. Thousands of belches emitted from his mouth during the passage of the food through his stomach; then his head became heavy; he had palpitations sometimes in the region of the heart, sometimes in the epigastrium. Constantly pursued by fear of being stricken with a grave disease of the abdominal organs, possibly incurable, the patient became gloomy, oneiric [rêveur], and nothing could distract him. During the day, chimerical terrors assailed him; at night, his sleep was troubled by terrifying dreams.” After 9 months of this “painful existence,” Doctor M finally sought help at Ostende, a seaport and watering place in West Flanders, where under the guidance of Dr. Verhaeghe a course of sea-bathing soon restored him. Dr. M was, according to his medical advisor, a typical “nervous” patient, with hypochondriacal symptoms attributable to the digestive tract.
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These beliefs in bowel function as a cause of nervous and mental disease lingered long in medicine, perhaps with some justification, although there were excesses: Toward the turn of the century at Ticehurst Asylum, a private psychiatric hospital for the better classes in England, it was standard practice to administer laxatives therapeutically. “We have had many strikingly rapid recoveries by unloading the intestines in cases of subacute, sometimes almost amounting to typical acute mania.” The administration of a large dose of olive oil, per mouth or per rectum, worked wonders said superintendent Herbert Newington in 1901.
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Today, there is considerable evidence that patients with depression have more than their share of gastrointestinal upset. In 1990 a team of psychiatrists at the University of Iowa led by Michael Garvey found that among 170 patients with a diagnosis of major depression, 27% had constipation associated with their depression.
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There is a substantial literature on the role of psychological factors in the irritable bowel syndrome,
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and the historical evidence as well gives every reason to think that this combination of constipation, diarrhea, and abdominal pain has been a regular companion of nervous conditions.

At a symposium in 1959, Willi Mayer-Gross, a refugee from the Holocaust who became director of a mental hospital in Scotland and at 71 years old was one of the grand old men of British psychiatry, said, as the discussion wandered toward somatic symptoms, “The fact that the digestion, or more broadly the intestinal tract, is so closely linked up with depression has been known for a long time … Such symptoms can be thought of as the shields or disguises of a depressive illness. I find an astonishingly large number of patients who have come to me finally with depression who have been investigated extensively for gastro-intestinal disorder.”
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Whether the depression was masked by the gastrointestinal symptoms, or whether all these symptoms, mental and somatic alike, were part of a larger parcel of nervous illness, was not debated at the symposium. But the generation of psychiatrists and physicians who preceded the participants believed it, and maybe they were right.

The Heyday of Nervous Illness

To launch nerves center stage, something more was needed than anatomy. A physiological basis for the concept that weak and irritated nerves caused nerve disease was supplied in 1844 by a young German psychiatrist named Wilhelm Griesinger, then 27 years old and a resident in the Department of Medicine of the University of Tü bingen; Griesinger had just finished a 2-year stint as an assistant physician at a nearby mental hospital and was full of theories about mind and brain. “It is much less pathological anatomy than physiology that causes brain disease in insanity.” To be sure, he continued, psychiatry had labored for years under physiological theories that implicated the spine, in “spinal irritation,” but the real problem lay in the “irritable weakness” (reizbare Schwä che) of the brain itself. “ … Early exhaustion gives rise to conditions of weakness and pain.”
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We could not imagine that the ratiocinations of such a young and unheralded scholar would have such an impact. Yet Griesinger, alternating between internal medicine and psychiatry, went on to have a brilliant career, becoming professor of psychiatry in Zurich in 1861 and in Berlin in 1864. The first edition of his textbook, published in 1845, had moderate success; the second edition in 1861 became the leading international textbook of psychiatry and firmly established the biological doctrine that “mental disease is brain disease.”
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Nerves sailed forward in history under the banner of irritable weakness.

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