A Doctor's Journal
The Floor That Moved
By MILES HOWARD HE New Yorker had an excellent article I lately on the case of a lady with vertigo. One evening, as her husband came in with the drinks before dinner, she felt the floor 'sort of shake, or sink'; it lasted only a moment, 'just an eyeblink. But the floor definitely moved.' She told her hus- band, and he commented on' the way old build- ings stretched and settled, and gave her the drink. Then she began to have more and worse attacks. The axis of the tale was the patient's perplexity and fear—fear of the unknown, as nobody seemed able to diagnose her illness, or at any rate tell her what it was. Her doctor read out the reports from the specialists she had seen, who all used the same phrase `Impression: Essentially normal: `I'll never forget that phrase,' the patient said. `It got to be a kind of litany. It sounds so comforting and reassuring. But it isn't. At least not to me. It was terrifying. It couldn't mean that I was normal, because I wasn't. I was just the reverse. I became convinced it meant I was miserably sick, and no- body had the faintest idea why.'
The doctor decided on an EEG—a test of the electrical activity of the brain; he told her he hall wondered whether the cause of her vertigo was a tumour of the brain. The test was done, and its report read 'Essentially normal: 'You can imagine the chill that ran up my spine. Even the thought of brain tumour is frightening. I was cold to the bone. I just sat there.' And then at last the illness was given a name : aural vertigo, or Meniere's disease, after a French otologist, Prosper Meniere. It wasn't due to tumour, or any other `organic' disturbance.
Afterwards; the patient remarked that of all the things the doctor had said, the most important made the least impression. As she said, for weeks she had been living with the notion of death; she had felt doomed. Yet when she learned that her illness was not very serious, she scarcely reacted at all. 'What left me simply weak with relief was knowing the truth at last. My trouble was no longer a mystery. At least, it had a name. What a difference that made! And I wasn't alone—there were thousands more in the same boat' Aural vertigo is not uncommon. In the end the symp- toms dwindled and disappeared. Her husband saw that first. He said to her, `You must be feeling better. You never look scared any more now.'
A number of morals can be drawn from this little case-history. First, that it is unwise, and un- kind, to tell patients they are `normal,' or 'have nothing wrong,' when they come along with symptoms which they know very well to be real. Perhaps the doctor is lacking in empathy, or is bored or irritated with his job, or uneasy in the presence of illness he thinks may be of emotional origin—whatever the reason, it is much' more likely to be in him than in the patient.
If the patient suspects organic disease, and is worried, but proves to have none, then of course it is proper to explain that the symptoms are not caused by any infection, or growth, or physical maiady; they are real, and perhaps disabling, but they rest on a disturbance of function, not of structure, and it is then the joint task of doctor and patient to seek out the roots of that disturb- ance, or to handle it in some other appropriate way. If the patient with persistent backache is told there is nothing wrong with him, he is likely to think (a) that the doctor is incompetent, (b) that he has some grave disease, so grave that he cannot be told what it is, (c) that the doctor thinks he is 'neurotic' (this quaint, old-fashioned term still being very much in use) and 'imagining' the back- ache—as if anyone would imagine a backache!' Such an assertion by the doctor is not therapeutic; it is anti-therapeujic—it leaves the patient worse off than before: baffled and resentful, perhaps guilty, but still suffering.
Secondly, what has stress got' to do with attacks of aural vertigo? A year or two ago, I'd have re- turned a verdict of Not Proven on this. Having seen only a few patients with it, and these for a short time, I could make no judgment. Over the last six months, I have had the opportunity of fol- lowing the course of tlfe illness in a man whom I have come to know well, and admire. When he came to me first, his Meniere attacks were quite severe and troublesome; they seemed to come 'out of the blue.' However, when we were able together to explore the conditions of his life, it soon became clear that each major attack, and the minor symp- toms too, were related to certain emotional 'pres- sures' arising from two sources, one in his work and one in his home.
Looking back over the story, I was reminded of one of the wise comments made by Dick Scott of Edinburgh : that the better the doctor gets to know his patient, the more likely it is that he will make a diagnosis of stress disorder. This is a clinical 'hunch' that many of us have had for years, but Scott and his team proved it in their statistical examination of episodes of illness over twelve months, in a group practice that is the basis for the teaching of general medicine at the Uni- versity. So in one patient at least aural vertigo is a stress response; if that can be true for one person it can be true for, others too.
The importance of knowing this is that it enables one to do something for the patient. It must be very frustrating, and depressing, for the physician to say to the sick person, Too bad about your symptoms. I wish I could help you, but I can't. Perhaps they'll pass off with the change of life (or change of house, or change of husband, or whatever).' The physician who believes that there is nothing to be done about headache, for instance, is in a difficult position; if all he can do is prescribe some phenobarbitone, , and send the patient away, how does he deal with his own feel- ing of inadequacy? I suppose he rationalises it, by, repeating to himself the comforting phrase 'This is a constitutional disorder, characteriSed by periodic attacks of headache, with remissions between,' as if it were like the English climate, and beyond his control.
Yet another subject for study; the state of rnjnd of doctors who believe that stress disorders are untreatable.
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