The Barbeian Lectures ON COMMON NEUROSES, OR THE NEUROTIC ELEMENT IN DISEASE AND ITS RATIONAL TREATMENT
PHYSICIAN TO GUY'S HOSPITAL. LECTURE II. GENTLEMEN,—To-night we pass from the neurotic conditions that concern the sentient being as a whole, and which I have inconsequence 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 enables me to group the cases better, and was other conveniences as well. We shall concern ourselves, then, to night with troubles of the thoracic cavity,
... rather with respiratory and circulatory neuroses. And the first group of cases that I have to mention is distinguished by a disposition to more or les severe attacks of paroxysmal oneezing. Such cases are by no means uncommon, and they are very troublesome. I give a short note of some. A young lady comes ûf highly neurotic stock. Her mother suffers from bad sick headaches, and as these have become ess severe they have been replaced by other neuralgic turnr. 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 have bad nightmare. This child is aged fifteen; she is growing fast. She is brought for what arecalled bad colds, but when the account of them is detailed, the attack appears to consist of sudden severe paroxsyms of sneezing, and her nose runs freely. The attacks of sneezing 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 ber-Gelf, and she is well for a time. She has a thin skin, and esily gets chilblains. A second case is that of a lady of lliirty, who is much troubled with violent fits of sneezing and noserunning, which last about two hours every morning. There s 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 asthmatic. 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 handkerchiefs. 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" occasionally, and when her body is warm her fingers and toes are cold. She has most bothering attacks of sneezing, and is often hoarse. The sneezing comes on mostly at night, and in consequence of it she wraps 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 twentynine. Her maternal grandfather had hay fever and asthma. She has had bad sneezing attacks for years. The attacks commence in the early morning and go on till about 11 I A.INI , 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, fond 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 someene 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 hav 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 bad 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 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 they may not have some relation with Raynaud's disease. But however this may be, the affection is a purely neurotic 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 discharge than of the onset of an inflammation. And I think, if we study the nature of these attack?, 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 cf the turbinated bones ; but if we allow that this is so, such a state of things i?, 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-cautery 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 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 all means of this kind are meddlesome and bad surgery, and will never bring us any credit; I will go further, and say that they 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 gocs by the name of 11 clergyman's sore-throat." I must apologise to the laryngologists for putting them so much in the forefront of my offence, but I dare say they will consider what I have to say is only the result of ignorance. I suppose we all come more or less across this ant;ction, and if your experience c is at all like mine, it is of this kind : it occuts in nervous persons ; they are often overworked, and want a holiday. That is a very common complaint, and requires no advice from a specialist; but it often enough occurs in the country f parson who has an easy life and less than enough to do. Now I have talked to several 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 anyone who has been a long-winded preacher, or in one who has the gifo of energetic extempore discourse; it is a disease of the feeble lack-lustre man or 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 or a letter received only the other day from a young effeminate man, who has a good voice, and is going in for singing : 11 I forgot to ask you," he writes, " if I may bathe and swim in the season, because I have been told that it is a very weakening pastime for one who wishes to cultivate the voice." The idea obviously is that the act of singing uses up the vital energy, and that there is no snfliciency for any expenditure 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 certaion I have seen these people having a a nice time of it on the Niviera, 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 180 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 are emphatically not the cases to put through a course of inhalations, of paints, of electric tiekling-worse still, of galvano-cautery. They will go in for anything we advise them, and it is marvellous 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 a great public singer is a very touchy thing no doubt, but the ordinary avocations of those who 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 chat 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 uncommon thing to find ordinary people become hoarse after 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. I assert most positively that they are absolutely independent of the general health, and are due no doubt to some local incoordination 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 treatment 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 there according as the latest fashion dictates (if ib 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 inconvenience to others as well as himself, and often at considerable sacrifice. And while I am on this subject I will say that advice with reference to residence seems to be given often in the most reckless and ill-considered fashion, when we remember how little we really know about suh matters. I must next allude to the people who are 801 ways" catching cold." They are common enough, but here is one such : A man of thirty-nine years. He had a,gue in his youth when he lived down in Essex, but be has got rid of that, and has had very good health until he went to the Easb a year or two ago and got fever (he thinks not malarial) on his way home at Athens. Ever since then he has been subject to colds, and his subjection in this respect gets worse and worse. Sometimes he has cold in the head and sometimes it is a acre-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 cbanges of temperature; and what is the result ? Ib must inevitably be that, kept from all experience of changes of temperature, the surface loses its accommodative power, and in consequence becomes unduly sensitive to any change. Thus instead of a cure au ever-increasing liability to "colds" results. The man who attempts to keep himself in a uniform temperature in the 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.