ANXIETY NEUROSIS

439 clinical concentration camps. The local doctors are to be swept out; the consultant staffcan go. The hospital is to be used for selected specialties and staffed by expert teams. Local people may be admitted if they fit the right pigeon-hole ; otherwise, the conveyor belt will take them to another part of the county, where their particular disease is dealt with. Presumably the woman with fibroids who also has a hernia and a running ear will suffer the fate of Csesar’s Gaul. May I appeal to those who are pushing these ideas to pause a moment and ask themselves if they really pay more

than

lip

service to the

conception

of the

family

doctor Because we must know, now, where we stand. We want your vision of the future. Sir, translated into action. W. EDWARDS. Ashtead, Surrey. ANXIETY NEUROSIS am,—i nave

articles

read

wren

interest

une

two illustrative

neurosis appearing in your issues of Aug. 13 and 20. I am convinced from my own experience of the reactions of various doctors to this type of disorder that one of the greatest obstacles to the treatment and cure of neurotic illness lies in the difficulty many doctors have in accepting the validity or the reality of these disturbances, and all the misery they produce. They wish to deny the existence of anxiety of an intensity or duration beyond that encompassed by their own experience, and they fail to understand that feelings so engendered may be strong enough to overcome a level of social responsibility comparable with their own. Even when forced, by overt changes in the behaviour of the patient, to admit that something is wrong, most of them regard it as a sort of moral lapse to be covered up, or shooed away by reassurance or by a fatherly homily on " pulling up one’s socks." Owing to his excessive the is too guilt ready to reinforce a moralistic patient only attitude, and he makes further attempts at repression, which may be superfLcially successful but which really intensify conflicts and symptoms. Some will then develop irrational or antisocial behaviour, which excites in the baffled doctor a desire to chastise. This may well be a factor in the present disproportionate popularity of electroconvulsive therapy and such mutilating operations as leucotomy-not to mention the general corrective attitude towards patients in mental hospitals. It seems that these reactions in the doctor result from his unawareness or misunderstanding of the nature of the mental state in a neurotic or psychoneurotic illness ; or from his fear of feeling helpless if he once admits that the patient does have such difficulties, and that these can, in fact, interfere greatly with his personal happiness and to a lesser extent with his social conduct and usefulness. Patients are testifying to facts, and the widespread incidence of emotional difficulties in the community at large bears them out. To deny these facts is unscientific. Doctors must accept them if they are to have a better understanding of the causation, treatment, and prevention of mental illness. Both writers of the " Disabilities " articles made it quite clear that an anxiety neurosis is an illness affecting the emotions, and not primarily interfering with either the intelligence or the social responsibility of the patient. About 90% of the disturbance consists in subjective emotional phenomena of an extremely unpleasant nature, which are not manifest to the casual observer, or are " " apparent only in the guise of peculiarities such as unsociability, bad temper, indecisiveness, or obsessional traits. Thus if a major breakdown is to be avoided, it is essential that the doctor should listen to, believe, and take seriously what the patient says. In an attempt to explain to some of my colleagues the subjective clinical picture of my own anxiety state, I on

anxiety

’

wrote down the following observations, which may be worth repeating in support of the evidence in the articles. The subjective symptomatology could be defined as the changes in the general view of life," which rose and fell, with variable frequency and velocity, but with invariable continuity and order, within the following span : (1) ecstasy ; (2) enthusiasm ; (3) pleasure ; (4) tolerability ; (5) intermittent uneasiness ; (6) frank low-grade anxiety ; (7) spasms of severe anxiety with fear or guilt"; (8) established anxiety with intolerable " or " hopeless " periods of panic ; (9) anguish ; (10) fatalistic unreality with compulsions. Each of these stages had its accompanying physical, intellectual, and emotional aspects, which I will not describe here ; but the well-defined directional pattern indicated the organisation underlying a genuine pathological entity, and this gave the lie to the " black magic " explanation which I, and others of my acquaintance, had been wont to accept regarding neurotic

symptoms. There

nothing, at least in the first seven or eight stages, fundamentally different from the experiences of many people under various external stresses and strains. The unusual features were the duration and severity of the disturbance (stages 7, 8, and 9 being predominant for hours or days at a time, and hardly twenty-four hours’ consecutive " tolerability being experienced over a period of many months) ; and the absence of any rational explanation, in the material circumstances, for the panic reactions. Psycho-analysis provided the rational explanation by linking up the buried conflicts of the past with the panics of the present ; and when was

emotional

as

attained, the dissolve.

well

panics

intellectual fusion of these is do not have to be conquered-they

as

A FELLOW-SUFFERER. CHRONIC AND UNEXPLAINED ŒDEMA

SiR,—With reference to the article by Dr. Whitfield and Professor Arnott in your issue of Aug. 6, I should like to suggest an additional method of treatment for chronic oedema, which has proved, in my experience, more satisfactory than any of those mentioned. It consists in the use of radiant heat applied to the legs for about half an hour, followed by careful massage and some exercises against resistance. This should be followed by bandaging the patient’s legs and allowing him to walk about freely. P. S. FLEISCHMANN. London, BY.1. -

.

-

MIGRAINE

SiR,—Dr. Hay’s letter of Aug. 20 draws attention to

that-contrary to the opinion of manyentirely resistant to therapy. Vasoconstrictors and anti-histamine drugs when given early enough will prevent the onset of attacks in some cases ; but they do nothing to alter the pathological

the

fact

migraine

is not

condition which is the cause of the disease. For the it is the perpetual fear of headache that is so depressing, since no future arrangement is ever safe from interference. Migrainous attacks can be divided broadly into two classes : (1) those with an underlying endocrine dysfunction (typified by the " menstrual migraine " of women, but present in men too) ; and (2) those associated with histamine sensitivity, which by some unknown mechanism appears to result in hemicranial arterial dilatation. It is true that some cases resist all forms of therapy. But the success of treatment with anterior-pituitary-like

patient

or

with hista-

Moffat, W. M. J. Amer. med. Ass. 1937, 108, 612. Lancet, 1942, i, 448 ; Med. Pr. 1944, 211, 302.

Leyton, N.

hormones in 1.

cases

of endocrine mÜfraine.1