560 ASPIRIN ON TRIAL

modifications necessary : thus the name D. rickettsia var.conori is suggested for the rickettsia causing fièvreboutonneuse in North Africa and the Mediterraneanzone. Further, the generic name " Rickettsia " cannotbe allowed for what are at present called rickettsiarumiitaittium, R. bovis, 2?. ovina and B. canis. Sincethese rickettsias of ruminants and the dog differ bothmorphologically and biologically from those of the

typhus-spotted-fever group, the separation is wellmerited. The differences in morphology can be easilyappreciated by a comparison of the photomicrographsillustrating Alexander and Mason’s papers with thatgiven by Schulz 4 in his communication of the discoveryof P. ovina in South Africa. It is questionable alsowhether the rickettsias of Australian and American Qfever should not be placed in a separate genus. Thegeneral name " rickettsia " and " rickettsiosis " couldhowever be retained since all would obviously be specificgenera of the family Rickettsiaceae.

ASPIRIN ON TRIAL

Ix 1937 the citizens of the United States consumed5,143,672 lb. of aspirin.5 This works out at 48 five-graintablets per head of population. If we assume thatAmerican infants took a negligible amount, adults muston an average have taken rather more than one aspirintablet every week, and it is safe to assume that the tastefor aspirin here is much the same. Yet recent work hasshown that knowledge of the possible harmful effects ofaspirin is far from being complete. After taking it

patients often complain of heartburn and epigastricdiscomfort presumably because of liberation of a smallquantity of salicyclic acid in the stomach by the gastrichydrochloric acid. Douthwaite and Lintott 6 have shownby gastroscopic studies that particles of aspirin lying onthe mucous membrane of the stomach may produceirritation resulting in local hyperaemia and even sub-mucous haemorrhage, but they deliberately allowed theparticles to come into contact with the gastric mucosa.The physician usually prescribes aspirin to be takenafter food, and the foodstuff exercises a protective action.Douthwaite and Lintott point out that " if taken afterfood or with milk, it probably has no deleterious effect."They have also shown that calcium aspirin (which ismuch more soluble than ordinary aspirin) causes onlyslight gastric irritation, and there is a good case forrecommending that patients suffering from diseases of thestomach should use this or one of the other neutralaspirins when aspirin would normally be indicated.

Various constitutional upsets have also been attributedto aspirin from time to time. Prickman and Buchstein 7say that aspirin hypersensitiveness is the most commonform of drug allergy ; they emphasise the disastrouseffects of aspirin on sensitive subjects and urge specialcaution in asthmatics with nasal polyps, and peoplewho have a family history of allergy. They are able toquote. four instances of severe reactions among asth-matics which ended fatally. The potential dangers ofalmost any drug are such that we should not be undulyimpressed by rare untoward reactions, and it is not

surprising that an allergist should be emphatic about theill effects of some drugs that the general practitionerregards as eminently safe. Opinions differ, moreover,as to the incidence of aspirin hypersensitiveness. Gard-ner and Blanton 8 have reviewed the histories of 467private and hospital patients more than half of whomwere asthmatics ; they agree that dangerous and evenfatal reactions may occur in sensitive persons and advisefull precautions in allergic subjects ; but they add that

4. Schulz, K. Ibid, p. 287.5. Drug and Cosmetic Industry, 1938, 43, 27, quoted by Prickman

and Buchstein.6. Douthwaite, A. H. and Lintott, G. A. M. Lancet, 1938, 2, 1222.7. Prickman, L. E., Buchstein, H. F. J. Amer. med. Ass. 1937, 108, 445.8. Gardner, E. and Blanton, W. B. Amer. J. med. Sci. September,

1940, P. 390.

not more than 2 out of 1000 are susceptible to aspirin,and violent reactions are even less frequent.The lot of analgesics is not a happy one. Compara-

tively recently the corpses of acetanilide and amidopyrinewere laid to rest. And now laboratory pharmacologistsare beginning to make sepulchral references to the

toxicological possibilities of phenazone and phenacetin.Practitioners are justified in defending the humbleaspirin, for it remains one of the most useful drugs intheir dispensaries.

DYSPHAGIA IN CARDIOVASCULAR DISEASETHE barium-filled oesophagus is now recognised as of

the greatest value in cardioscopy,l but there is still littleavailable information as to the effect on swallowing ofpressure on the oesophagus from enlargement of theheart or great vessels. In a well-known textbook ofdifferential diagnosis the only cardiovascular causes ofdysphagia mentioned are aneurysm of the aorta anddysphagia lusoria, due to compression of the oesophagusby congenital anomalies of the great vessels. Thisquestion has now been investigated by Bloomfield 2who points out that there are five cardiovascular lesionswhich may produce, or at least be associated with,dysphagia-dilatation of the left auricle, pericardialeffusion, aneurysm of the aorta, dissecting aneurysm, andsuch congenital anomalies as right-sided aortic arch,double aortic arch, and aberrant right subclavian arterv.Of these by far the most common is aneurysm of theaorta, and particularly of the descending aorta. Evenso, dysphagia is rare in this condition compared withdyspnoea due to compression of the air-passages.Bloomfield points out that severe, persistent dysphagiain a patient with an aortic aneurysm is often of graveprognostic significance, since it may indicate either afalse aneurysm or a threatened rupture into the aeso-phagus. In dissecting aneurysm dysphagia is probablycommon but is overshadowed by other more distressingsymptoms, though Bloomfield suggests that in thedifferential diagnosis of coronary thrombosis and dis-

secting aneurysm the presence of dysphagia supportsthe latter. Reports of dysphagia in patients with peri-cardial effusion are rare, but when this symptom is presentit probably means that the effusion is a large one, for itrequires a considerable degree of pressure to compressthe oesophagus enough to interfere with deglutition.So far as enlargement of the left auricle is concerned itis only in cases of what Bramwell 3 describes as " aneu-rysmal dilatation of the left auricle " that one wouldexpect much pressure on the oesophagus. In the courseof routine screening of patients with mitral stenosis grossdistortion of the oesophagus as a result of pressure froman enlarged left auricle is often seen, but in only a fewis there any delay in the passage of barium down theoesophagus, and a very small minority of these complainof any difficulty in swallowing. Bloomfield records sucha case, in which dysphagia was a prominent symptomand concludes that in this instance the dysphagia wasprobably due to cesophageal spasm secondary to pressureby the enlarged left auricle. This question of the extent towhich dysphagia is due to direct compression or to spasmof the oesophagus deserves further investigation, for inspasmodic cases therapeutic relief should not be impossible.

1. See Evans, W. The course of the œsophagus in health, and indisease of the heart and great vessels. Spec. Rep. Ser. med.Res. Coun., Lond. No. 208. 1936.

2. Bloomfield, A. L. Amer. J. med. Sci. September, 1940, p. 289.3. Bramwell, J. C. and Duguid, J. B. Quart. J. Med. 1928, 21, 187.

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561ANXIETY NEUROSIS

Special Articles

ANXIETY NEUROSIS *

BY G. W. B. JAMES, M.C., M.D. Lond., D.P.M.COLONEL A.M.S.; PHYSICIAN FOR MENTAL DISEASES TO ST. MARY’S

HOSPITAL; RESIDENT PHYSICIAN AT MOORCROFT HOUSE,HILLINGDON

AMONG the nervous casualties of the last war weremany cases with rather mysterious physical symptomswhich were eventually correlated with anxiety. Duringthe years which immediately followed the term " anxietyneurosis" passed into common medical use ; in factanxiety neurosis is now in danger of replacing theneurasthenia of the early nineties as a polite portmanteaufor almost any mental disease. Some psychiatrists haveabandoned the struggle for clarity by grouping differentconditions under the heading " anxiety states." In thetextbooks the terms " psychoneurosis " and " neurosis "are used, if at all, in a conflicting manner, and one of thelatest adopts an entirely new terminology and gives theneuroses and psychoneuroses a fresh description under" merergasias."In his original paper Freud (1895) clearly set out the

symptoms of anxiety neurosis, which included generalirritability, an anxious state of expectation, acute anxietyattacks, and what he called anxiety equivalents, whichare the somatic symptoms of the neurosis--disordersof the heart’s action and of digestion and respiration,tremors and shuddering and so on. He also mentionedvertigo and the development of various fears, which heconfined to those concerned with common physiologicaldangers (fears of snakes or fire, for instance) and fearsabout locomotion-for example, fear of collapse in thestreet or an inability to walk unaccompanied. The

description is constantly confirmed in practice, but thediscussions of the last forty-five years have been sofocused on the setiological aspect of Freud’s paper as toput his admirable clinical account of anxiety neurosis inthe background.

I am using the term neurosis as meaning a conditionpresenting mental and physical symptoms for which noorganic cause can be found. The word " anxiety " inconnexion with neurosis is short for morbid anxiety.Anxiety is associated with many conditions of body andmind ; it is closely allied to the emotion of fear and theinstinct of flight or escape, which can be looked on asnormal and fulfilling an essential biological function.Similarly one may speak of normal anxiety ; for example,it is normal to feel anxiety if the savings of a lifetimeare involved in a financial crash over which one has nocontrol, and such a phrase as " I am anxious to catch the6.15 " is a matter of common speech. Both examplesclearly suggest that uncertainty about loss of both thesavings and the train arouses the unpleasant emotionalfeeling that we all know as anxiety. Perhaps one mayexpress anxiety as an emotional state closely allied tofear, accompanied by numerous somatic sensations andaroused especially by situations in which uncertaintyand insecurity are prominent.Anxiety is also seen in certain cardiac diseases, in some

states of delirium, in acute and chronic epidemicencephalitis, and as an equivalent or post-paroxysmalphenomenon in some epileptics. It is experienced bypatients with phobias (unreasoning fear of cats or inabil-ity to cross a bridge, for instance) and in compulsivethinking and acting or obsessions. In my opinion theseare better)classed as psychoneuroses, with mental causesaccessible only to special methods of investigation andincidentally requiring much experience and skill fortheir successful treatment.

* Based on a paper read at a meeting of the Medical Society ofLondon in April, 1940.

ORIGINS OF THE ANXIETY

Freud originally said that the anxiety of anxietyneurosis was due to sexual excitation without adequateoutlet or gratification, and pointed out the frequency ofmorbid anxiety symptoms in engaged couples, in widowsand in partners practising coitus interruptus. He madeit appear that frustration of instinctive activity can giverise to anxiety, with its somatic symptoms ; as if theinstinctual tension, aroused and then denied outlet,found its way into the viscera in some unexplained way.This conception of frustrated instinct as a source ofanxiety has always seemed to me useful and practical;but there seems no reason to confine it to the sexualinstinct. It can surely be extended to the three groupsof inherited behaviour patterns or instincts with whichman is endowed-the herd instinct, the sex instinct andthe instinct of self-preservation. Conflicts betweenthese instinctive groups include the common one betweensex and the requirements of the herd, and the specialsoldier’s conflict between self-preservation and the herddictates of discipline, patriotism and duty.In anxiety neurosis the patient’s physical and mental

symptoms are accompanied by the manifestations ofmorbid anxiety either in localised attacks or as a constantemotional state. The essential eetiological factors areto be found in his life situation and can be summarisedas the result of frustration of, or conflict between,instinctive needs. His account of his condition is oftenfocused on his somatic symptoms ; there is a curiouslack of interest in the psychic or anxiety element of hisstory. As a result the examiner may easily miss theemotional factor altogether and the patient is treated fororganic disease. The outpatient departments of ourhospitals are full of anxiety neurotics, many of themadequately treated by the traditional bottle of medicine.Others, who are not so successfully and easily dealt with,make an extensive tour of the special departments andfinally arrive with a bulging dossier of notes at thedepartment of the hospital psychiatrist, whose task isrendered formidable by the chronicity of the condition.One may also be misled by the patient insisting that hiscondition dates from an infection, an operation or

an accident, when in fact these are but secondaryfactors. Of the infections, influenza is especiallyhard-worked.

CASE I.-A man of 39 complained of insomnia, palpitations,and crippling attacks of " nerves." He was tremulous,irritable, unable to make up his mind and was on sick leavefrom his service. He dated his symptoms from an operationfor dental extraction undergone after his arrival at home fromtropical service three months before. Inquiry elicited theconfession that he had taken too much alcohol for somemonths before his return home. On the surface it looked asif residence in the tropics, alcohol and the dental operationwere the principal setiological factors. At later interviews,however, it was revealed that he had had cause to fearinfidelities on the part of his wife, to whom he was

devoted. This marital situation was cleared up by frankdiscussion with both parties and the anxiety symptomsdisappeared.CASE 2.-A married woman of 25, pregnant with her first

child, fell down a flight of steps in her house. She was put tobed and recovered well. Soon afterwards she began to

develop tremulousness, rapid pulse and an unreasoning fearthat her baby would be an idiot. On inquiry it appeared that

her husband’s grandmother lived in her house and took up agreat deal of her time and attention, being somewhat senile.The young woman had, not unnaturally, wished that the oldlady might die. She felt such thoughts to be wicked andbegan to fear that an unnatural mother would produce anunnatural child.

Among 21 cases diagnosed as anxiety neurosis, takenserially from outpatient practice at St. Mary’s during1939, there were 11 females and 10 males. The youngestwas 19, the eldest 42. They gave the following conditionsas the origin of their symptoms : illness, 2 ; operations,2 ; accidents, 3 ; bereavements, 2 ; unemployment