SUGGESTION AS TO SYMPTOMS
Besides the value of suggestion for the general condition in tuberculosis many of its symptoms can be treated best by changing the mental attitude of the patient towards them and giving him a proper appreciation of their significance. Most symptoms are likely to produce exaggerated reactions, especially in patients who are over-solicitous about themselves. Not a few of the symptoms are really nature's attempts at compensation, or the result of conditions which show a natural disposition to bring about a cure. Fever, for instance, produces lassitude and great fatigue on exertion, and patients are prone to think that this means weakness or exhaustion. It is really only an indication of the necessity for rest, and is brought about by nature's refusal to supply all the demands of the muscles for nutrition, at a time when the febrile condition is burning up a lot of extra material. Far from being a disadvantage, weakness is a decided advantage in this condition.
Hemorrhage.—Probably no symptom that occurs in connection with tuberculosis is more influenced by the mental attitude than hemorrhage. It is a most disturbing incident. Even in quite small amounts it upsets the patient seriously and, of course, in large amounts it is a source of profound disturbance even to the most placid of patients. Excitement always adds to it. Probably no physical means that we have at command can be depended on to control it. Ergot used to be popular, but such physiological action as it exerts, so far as we know the drug, would seem to be likely to do as much harm as good.
Other remedies have gradually lost favor in the hands of those who have had most experience with the symptom and gallic acid and supra-renal extract, the older and newer remedy, are now little depended on. Two things are important—to secure lower blood pressure and lessened pulmonary activity. For these opium in some form is undoubtedly the best drug; and then a placid state of mind on the part of the patient must be secured as far as possible. The scare in these cases, in so far as it is relaxing, is rather favorable than unfavorable for the patient. In addition, it is necessary to insist on absolute quiet and silence and then to allay all reactionary excitement. It is important to make patients realize that while hemorrhage is a serious complication, it is by no means so serious as is usually thought.
Many cases of tuberculosis that eventually run a slow course are ushered in by hemorrhage, or have it as a very early manifestation. It is surprising how many people have had hemorrhage as a symptom and live to tell of it thirty or forty years later. This was not due to any mistake of diagnosis, for a generation ago tuberculosis was more likely to be missed when actually present than to be diagnosed when absent. Indeed, this tendency for the cases in which hemorrhage occurred to run not so fatal a course as others was a fact that seemed to an older generation of physicians to require explanation. They suggested that possibly the hemorrhage swept out with it some of the virulent elements from the lungs and so lessoned the infection. From what we now know this is a doubtful explanation, but it seems not unlikely that a frank hemorrhage might reduce the amount of toxins in the circulation and so in an early stage of the disease give nature a fresh start in resistive vitality.
What is much more likely, however, is that the occurrence of early hemorrhage made it easier for the patients to appreciate the seriousness of the affection and brought them to accept advice as to proper precautions. Under ordinary circumstances it is difficult and used to be even more so in the past to make the patient understand at the beginning of the affection the necessity for giving up indoor occupations and living the outdoor life with the care for nutrition that is so important if the case is to be improved. Hemorrhage scared them into submission. In the old days it was the first positive symptom of consumption. Now we have many others, and instead of following the advice of over-solicitous relatives that we should not tell patients what is the matter with them, we tell them frankly and secure such care of the health as will bring about improvement. Probably nothing illustrates so well the necessity for thus influencing the patients' minds into caring for themselves as the fact that the hemorrhagic cases, as a rule, do better than the others. All of this can be used to make the minds of patients much less disturbed than they would otherwise be by this alarming symptom.
Cough.—In the chapter on [Coughs and Colds] we have outlined how much coughing may depend on suggestion, or habit, or on the tendency to yield to slight bronchial irritation when there is no real necessity for it. Most tuberculous patients cough much more than is necessary. This is always somewhat dangerous for them since it disturbs their lungs, has a tendency to distribute tubercle bacilli in their lungs, or in the air around them, and may by efforts at expulsion lacerate affected blood vessels and produce hemorrhage. Whenever cough is productive it should be indulged in, for it removes material that should not be allowed to accumulate. Unproductive coughing, however, can usually be controlled by training.
It is particularly at the beginning of phthisis that the control of coughing by suggestion is important. There are many little coughs, "hacks" as they are sometimes called, frequently repeated by those in a very early stage of pulmonary tuberculosis and which are consequent upon irritation either of pulmonary nerves or of pulmonary tissues, but that are quite unnecessary, as a rule, if a little attention is paid to suppressing them. As a warning sign they are excellent, but the patient should be taught not to indulge in them. Coughing tends to prevent nature's curative reaction and the contraction of pulmonary tissues which may take place around a lesion. In beginning consumption, even where there is but slight infiltration, we know from the observation of the movements of the diaphragm either by the X-ray or directly by Litton's method that its excursions on the affected side are shortened. Coughing is in direct opposition to this setting of the lung at rest and therefore should be controlled; however, as our drug remedies are likely to disturb the stomach, whose healthy function is so important in these cases, the use of the mind in the control of the cough is of the greatest value.
Thoracic Discomfort.—Complaints are often made by the tuberculous of pains in the thorax. Ordinarily the discomfort is supposed to be due to the lung condition, and it is assumed that it is either actually in the lung itself or in the pleura, or communicated from them by reflex to the muscles. In most cases, however, patients complain of pain on the side that is either not affected at all or least affected. If they have been told that the other side is suffering most from tuberculosis, they are prone either to think that now the [{362}] well side is being invaded or else that their physician is making a mistake, and both thoughts are seriously discouraging. The reason for the pains on the well or the better side, however, are easy to understand. As far as possible, as can be readily demonstrated by the X-rays or seen in the observation of the so-called Litten's phenomenon—the excursions of the diaphragm—nature puts the ailing lung at rest and the diaphragm moves much less on that side than on any other. In order to make up for the lack of breathing in this side the other lung does compensatory work. This over-stretches the muscles of the thorax on the well side and causes some over-work in them. The consequence is a tiredness which may become fatigue; in damp weather this may be even painful. Just why damp weather has this particular effect on muscles is not surely known. Muscular action is probably accomplished with more difficulty in damp weather because of the relaxing effect of moisture on tissues and circulation. Reassurances may be given them, then, that will keep them from thinking seriously of the significance of these pains except as an index of nature's compensatory efforts. The painful conditions instead of causing discouragement will, then, be a source of encouragement. It must not be forgotten that rubbing with some gentle stimulant, soap, liniment, or the like, will greatly improve the thoracic muscles in these cases, but the rubbing must be done gently and by someone else beside the patient, for it is only beneficial if done from before, backwards, in order to help the return venous circulation which runs in that direction in the external respiratory muscles.
Altitude.—There is a marked difference between the amount of water which finds its way out through the lungs at varying altitudes. At sea level an ordinary patient will lose during the night about 300 cc, that is, something more than half a pint of water, through his respiratory tract. At an altitude of 5,000 feet, however, this amount is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet it is half as much again as it is at sea level. This copious giving off of water has a marked effect on the lungs. It constitutes one of the reasons why altitude is a favorable element in the treatment of tuberculosis. Only beginning cases of tuberculosis, however, are able to stand the additional work thus put on them, though a slight elevation, up to 2,000 or even 3,000 feet, rather seems to be of benefit to all cases. How far-reaching the effect of this extra loss of fluid is, is appreciated from the concentration of blood which takes place and which produces a blood count of 8,000,000 red cells at a mile of altitude in patients who, at the sea level, have no more than 4,500,000. Such patients, of course, need much more water and fluids generally to be comfortable than when living lower down.
Suggestion and Treatment.—There are many accessory suggestions with regard to food that serve to confirm the patient in the idea that abundance and variety of food must be taken if the battle with the disease is to be won. To patients who find milk difficult to take, it must be explained that a copious amount of fluid in the system is needed in order to make coughing easier. So milk serves a therapeutic as well as a nutritional purpose. In the same way it may be explained that fats, such as bacon and cream, help to keep the bowels from becoming constipated and constipation inevitably disturbs the appetite.
Explanations as to the advisability of being out of the city and in a portion of country not very thickly populated, in order to avoid the possibilities of secondary infection with other respiratory diseases and bacteria of various [{363}] kinds, will make a patient understand the necessity for leaving town. It may be helpful, also, to insist on the value of living at some elevation above sea level as an aid to expectoration.
Cough is the symptom that many of these patients fear most, and a promise of any amelioration of it by a simple change of location helps them to make the sacrifice of city life for a while. Some patients who have been benefited by a stay in a sanatorium come back with a relapse of their symptoms. They dread to return to the sanatorium and think they can care for themselves as well at home, since they know what the regulations are, though it may be evident to the physician that they are losing ground in their city environment. It is well worth while to give them a careful explanation of what we know of the effect of altitude upon consumptives who have sufficient reactionary power to stand it.
Negative Suggestions.—Some suggestions are valuable for the prophylaxis of complications. For instance, tuberculous patients must be warned not to indulge in breathing exercises without the express consent of the physician. So much is said in popular literature as to the value of breathing exercises that many a patient suffering from tuberculosis thinks that, not only may they be indulged in with impunity, but that they will surely do good and can do no possible harm. Nothing could be more erroneous. Many localized lesions have been diffused in this way and there is always danger that the strain will cause hemorrhage. Patients must be warned also to avoid any possible condition in which they might have to over-exert themselves. Because of the dust inevitably breathed during automobile riding, this pleasure must be denied to tuberculous patients as a rule, but even when they have recovered sufficiently so that this may be permitted they must be warned not to take long rides into the country lest the breaking down of the machine should place them under the necessity of walking a long distance. This idea should also be emphasized for rowing excursions, or trips by motor boat, for occasionally they lead to serious and exhausting exposure.
One negative suggestion should be given at the very initial stage to every patient in whom the presence of pulmonary tuberculosis has been recognized. This should be a warning to exercise the greatest care against permitting the development of constipation. Tuberculous patients must never strain at stool. Almost necessarily a certain number of tubercle bacilli are swallowed every day whenever pulmonary tuberculosis is at all active and they are constantly present in the digestive tract. If tuberculous patients then strain at stool, little abrasions of the mucous membrane of the rectum are caused in which tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are common among the tuberculous and rectal fistulas often give much bother. When a tuberculous patient develops such a condition, a period of depression and discouragement will follow, for there is a curious tendency to depression associated with all lesions of the rectum. A pulmonary patient who has been doing well will often fail to make progress for months after the development of even a small ischio-rectal abscess.
CHAPTER III
NEUROTIC ASTHMA AND COGNATE CONDITIONS
For the consideration of its psychotherapy asthma may be divided into two forms—symptomatic and essential, or neurotic, asthma. Symptomatic asthma is a difficulty of breathing, the result of some interference with the circulation, as by heart disease, or with the oxidizing power of the blood, as by kidney disease, or various blood conditions, or from direct interference with respiration from some pulmonary affection. Essential asthma is not dependent on any organic condition, but is an interference with breathing without any distinct pathological condition in the lungs themselves or in the general circulation. There may be some emphysema, but not enough to account for the respiratory difficulty. It is spoken of as neurotic asthma, and the most careful investigations made of individuals who have died during a seizure has failed to give any sure pathological basis for the affection. Certain accompanying phenomena are worthy of note. The most interesting of these are Curschmann's spirals, which usually occur in the form of translucent pellets very characteristically described by Laennec as pearls. They are evidently formed in the finer bronchioles and show that the affection extends to the terminal portions of the bronchial system. In connection with these the so-called asthma crystals first described by Charcot and Von Leyden and sometimes called by their combined names are often found. Besides, there are a large number of eosinophiles in the sputum itself entangled within the filaments of the spirals and an eosinophila of the blood.
Etiology.—Not only are we ignorant of the reasons for these phenomena but there is even some doubt as regards the mechanism of the respiratory spasm itself. There is a general impression that the paroxysm is due to incapacity to inspire because of a paroxysmal spasm of the respiratory muscles. Gee in his "Medical Lectures and Aphorisms" [Footnote 30] rather leans towards the explanation that suffering is due not to any inability to fill the lungs but to incapacity to empty them when they have become over-distended with air. He tells the story related by Dean Swift of the old man whose barrel-shaped chest was fixed in spasm so full of air that the patient could not find room for the slightest additional breath. "If I ever get this air that is in me out," the patient declared to the Dean, "I will never take another breath."
[Footnote 30: Frowde, Oxford Univ. Press. 1908.]
It is important to differentiate symptomatic from neurotic or essential asthma. In symptomatic asthma the only assured treatment of the condition must come through amelioration of the organic condition causing the symptoms. Cardiac and renal asthma respond promptly to remedies which relieve critical conditions that may be present in the heart or kidneys. It must not be forgotten, however, that respiration is readily disturbed by mental influences. Where cardiac or renal disease causes interference with respiration this is much emphasized by the patient's unfavorable mental attitude toward it, or much relieved by keeping him from worrying over his condition. Even symptomatic asthma, then, has a definite place in psychotherapeutics, though [{365}] it would be serious not to recognize the underlying conditions and treat them. If the patient's attitude of mind is one of discouragement, the respiratory difficulties will continue to be a marked symptom of the case, even though the proper remedies for the relief of cardiac or renal conditions are administered.
Symptomatic Picture.—What is likely to be one of the most disturbing experiences of the young physician early in practice, especially if he has not before seen a typical case, is to be called to a patient suffering from a severe attack of asthma. Often the sufferer is sitting up in bed so as to get all the air possible, and, though the windows are wide open, he is gasping for breath, usually pleading for more air with a tense, anxious expression, starting eyes, and the sweat pouring from his forehead, while the accessory muscles of respiration, deeply engaged in moving his thorax to move air enough to keep him from stifling, emphasize his dyspnea. Occasionally a degree of cyanosis develops that is quite startling for the untrained observer. Most of those who see the symptomatic picture for the first time think that death is impending, and the patient himself, if he has not had a series of attacks, will fear a fatal termination. It appears impossible to believe that the next morning, within six or seven hours of this, the patient will, as a rule, be quite well and walking round in the enjoyment of apparent good health.
As a rule, the worse these cases seem in their intensity and the more the patient is anxious, the more surely are they merely of functional nervous origin; above all, the more complaints of lack of air and of fear of impending death that are made, the more likely is the patient to be all right within a few hours. Asthma looks as though it must be due to some serious organic condition. Of course, in many cases of difficult breathing, even with asthma-like attacks, there are underlying serious conditions of heart and kidneys that are extremely dangerous. As a rule, however, these do not produce the woeful pictures of purely neurotic asthma. Even when the basis of the asthma is an emphysema, which of itself is not dangerous and is quite compatible with long life, the attacks, though frequent and severe, are usually not so serious looking as those in which absolutely no pathological condition of the lungs, or heart, or kidneys can be found, and, indeed, in which there is absolutely no organic change to account for the extremely uncomfortable and even terrifying symptoms.
Mental Influence.—In the medical literature of asthma there are abundant proofs that the attitude of mind of the patient towards his affection means very much. There is the story, thoroughly vouched for, of the two friends stopping at a little country hotel late at night. One of them was a neurotic subject, who, whenever he remained for some time in a stuffy atmosphere, was likely to have a severe asthmatic attack. The quarters assigned to them proved to be one of the cramped little rooms with a single small window that occasionally are found in the attics of country inns in England. During the night the patient of asthmatic tendencies had one of his attacks and begged his friend to open the window. The friend, suddenly roused from sleep, did not remember the position of the window and, the night being very dark, he felt for it and finally found it. He could not raise the sash and he could not move it either inward or outward and there seemed no way of getting it open. His friend was insistently clamoring for air with that tone of despair and [{366}] dread of impending death so characteristic of the young, inexperienced asthma sufferer. Unable to get the window open, the sympathetic companion finally took his shoe and smashed the glass. The relief was immediate. Scarcely had the crash of the broken glass been heard before the patient gave an audible sigh of relief. When his friend went over to him he felt so much better that it was rather easy for the sufferer to persuade him that nothing more would be needed and that he should go back to bed. In the morning, when the friend awoke, his first glance, directed by the sunlight that came streaming into the window, was toward the broken panes of the night before. To his surprise it was not broken. Wondering what had happened, he looked round the room to find that he had smashed two panes in an old bookcase set into the wall, and that it was the breaking of the glass with the suggestion of free ingress of air that it involved and not any real provision of fresh air that had cured his friend's asthma so promptly.
Suggestion.—When much-vaunted cures for asthma are analyzed, many of them are found to depend more on suggestion than on any other element. Various forms of cigarettes are used, comparatively innocuous in themselves, and certainly of no strong therapeutic action, yet they work marvels in loosening the spasm that comes over the lungs in asthmatic attacks. Any sort of a cigarette will do at the beginning. I have seen dried grape-vine stems work very well in the country, especially in young women to whom the idea of smoking anything was strongly suggestive. Cubebs cigarettes have the same effect on older people. Doubtless there is some relaxing action in the smoke. This is not enough, however, to account for the effect produced without mental influence. After cubebs have been tried for a period and begin to lose their efficacy, then other materials that produce a pungent smoke or have a certain sensory action, as stramonium leaves, may be used, and will also have the marvelous power of cubebs. After a time, however, they, too, lose their efficacy, and, as a rule, each successive cigarette that is tried has less power than the first to control the difficulty of breathing.
The more one hears of cures for asthma, and the longer one has experience with these cases, the clearer does it become that there is a large suggestive element in every successful treatment. If a piece of ordinary blotting paper be dipped in a strong solution of saltpeter and allowed to dry, it will, if touched by a lighted match, burn slowly without flame, but with the production of heavy, thick smoke. The therapeutic elements in this are not very strong, but the suggestive element, when a room gets full of it, is intense and is cumulative. Very probably the thick smoke, rich in nitrites, has some tendency to relax the spasm in the lungs which causes the asthmatic seizure, but after a time the remedy fails and something else has to be tried. In many cases, when first used, it almost works a miracle. This is the simplest type of suggestive treatment for asthma.
Mental Shock.—Any strong mental influence, especially if accompanied by the suggestion of assured relief, is likely to do much for asthma of essentially neurotic character, and indeed is more powerful in dispelling the symptoms of the seizure than almost any other means that we have. Sometimes even things absolutely indifferent which produce a profound mental impression, prove curative. There are many stories of men in the midst of a severe asthmatic seizure being suddenly roused by the cry of fire, or an alarm of some [{367}] kind near them, having the spasmodic conditions disappear as if by magic. Occasionally where attacks of asthma recurred regularly on successive nights for a considerable period, travel on a railroad train or anything else which occupied the attention much, prolonged the interval between seizures and sometimes put an end to the series of attacks. The more one knows of asthma the more one realizes how much its occurrence depends on mental influences of many kinds in association with various reflex irritations, some of them very distant from the respiratory tract and comparatively trivial in their effects on other people.
Loss of Control.—Occasionally in elderly neurotic people over-fatigue induces an attack of asthma about the time that sleep becomes deep. This usually occurs after the first hour or two of sleep. The inhibitory power of the nervous system over spasmodic contraction of the lung tissues seems lost in deep sleep and then the asthmatic condition develops. The greater the effort to breathe the more intense does the contraction become, until the antispasmodic effect of the presence of a lessened amount of oxygen and an abnormal quantity of carbon dioxide in the blood makes itself felt. In many cases these patients will be relieved of the tendency to such spasm by taking a cup of coffee. This stimulates the general circulation and minimizes the reflex tendency which centers in their respiratory tracts. Such patients after taking an amount of coffee that would keep ordinary people awake all night, sink in the course of half an hour into a quiet, restful sleep and awake quite refreshed. This is not entirely suggestive, but suggestion plays an added role in the relief of all the symptoms.
Treatment.—Varied Cures.—We do not mean to say that asthma is entirely amenable to suggestive treatment, but we emphasize the mental influences in its production and its cure. A new and almost infallible cure is announced nearly every year for asthma, as for tuberculosis. Sometimes this is some new treatment for the nose, occasionally it is a novel method of treating the throat, but reflexes from a great many other organs not at all in touch with the respiratory system have also been supposed to be productive of asthma, and their treatment has been followed by relief from this trying condition. Washing out the stomach, for instance, has been followed by prolonged cessation of asthmatic attacks. In children it is claimed that occasionally the correction of eye-strain by the proper glasses has cured neurotic asthma. There are those who have had cases where the relief of long-continued constipation had a like therapeutic result and there are other and even more curious claims for curative effect in this affection.
Negative and Positive Suggestion.—Any condition in the human body that sets nerves in tension and requires constant inhibition may lead to such a cumulative effect of repression that reaction follows and explosion takes place. In particularly susceptible individuals, irritable respiratory centers may be affected with consequent asthmatic seizures. The direct treatment of the respiratory tract to secure ease of respiration often does away with the liability to asthma by direct prevention. If patients, especially young patients, are mouth-breathers the clearing out of the throat and nose so as to insure normal breathing can naturally be expected to lessen any tendency to asthma. In the same way treatment of irritative or degenerative conditions in the throat and larynx, as well as in the nose, may be considered directly curative. On [{368}] the other hand, there is no doubt that many of the slight ameliorations of intranasal conditions suggested by enthusiastic specialists as curing asthma do not have any direct therapeutic influence but owe their efficacy to the strong suggestion of the operator's assurance on the patient's mind that this treatment has cured asthma in many cases and will surely cure him.
Drugs and Suggestion.—The medicines that are especially effective in asthma of neurotic origin are those which also have a large suggestive influence because of their taste or their effects upon the system. Hoffman's anodyne is an efficient antispasmodic and is wonderfully effective in relieving the tendency to asthma. I have always felt, however, though I have given it freely, that a large element in its effectiveness was its particularly disagreeable taste and odor and then its excretion through the lungs with a certain sense of well-being allied somewhat to the intoxication that comes from the inhalation of ether. I have seen asthmatic tendencies in young women greatly relieved by the use of valerian. Undoubtedly this remedy, like the compound spirits of ether, is antispasmodic in action, yet to a much less degree than Hoffman's mixture, and over and over again I have noted that in pill form, though given in large doses, it was not as effective as if given in liquid form when its nauseating smell added distinctly to its suggestive influence. The drug itself does good but it is distinctly helped by the influence upon the patient's mind of its taste and, above all, of its aroma. The elixir of ammonium valerianate being particularly unpleasant is likely to be more beneficial to these patients.
Climatotherapy and Suggestion.—The climatic treatment of asthma has received much attention. Change of scene and environment nearly always does good. Different patients, however, require very different conditions. Of two cases of neurotic asthma in which no diagnostic differences can be found, one will improve at the seashore or on a sea voyage, while the other will be made worse by such a change though probably the asthma will be improved in the mountains or in some dry climate. Even moving from one part of a city to another has brought great improvement in asthma. Sometimes there were good reasons for this, as, for instance, when an investigation showed that the patient had previously been living above a bakery from which there came a good deal of hot air and flour dust. Some people are actually improved by close contact with human beings in rather crowded quarters. I have known a settlement worker to experience great relief from asthma when living in the slums. Where there is intense occupation of mind, especially if combined with the suggestion that now the asthma ought to be better, seizures will be less frequent and less severe. All sorts of places in the mountains and by the seashore have acquired reputations as relieving asthma which were justified by many cured cases and yet they have lost this reputation. Whenever there are many sufferers together, the expectancy of relief seems to do great good.
CHAPTER IV
DUST ASTHMA, SEASONAL CATARRH, HAY FEVER
Grouped under the term "hay fever" there are probably as many different affections as there are under the term "chronic rheumatism." There are [{369}] people who, in the springtime, as soon as the weather gets warm, suffer from what is popularly called hay fever. This is often called "spring catarrh" or "rose cold" and seems often to be associated with the pollen of flowers. Then there are people whose hay fever, as it is called, develops about the first of June and continues to be bothersome until the middle of July, when there is a remission of symptoms, though in dry prolonged hot periods after that the affection may recur. It seems as if, at the beginning of the heated term, the warm, dry dusty air irritates their nostrils very much, while after some weeks they gradually become used to this and the reaction is not so violent. Then there are the regular hay-fever patients whose affection occurs principally in haying time, during August and September, though most of them have not been near hay pollen, and the disease is an affection of dwellers in cities rather than in the country, of indoor livers more than of farming people, who might be expected to suffer most from the supposed cause, hay pollen. Even where pollen is directly concerned in its causation it is probably oftener the pollen of the rag weed rather than that of hay that is responsible for it.
There are two elements in the disease apparently of equal importance. One of these is a strictly local condition interfering with respiration in some way, or with the circulation to the mucous membrane of the nose and the lachrymal ducts. The other is an individual over-sensitiveness so that there is an exaggerated reaction to irritation. Some of this is mental, that is, is due to expectancy, or to the persuasion that this reaction is sure to occur under certain circumstances. As a consequence, attacks of hay fever are reported even after a distant view of a hayfield, or of rose cold due to the sight of an artificial rose, and of other recurrences that show the power of the mind to bring about at least a beginning of symptoms.
While the first or physical element in the etiology of dust catarrh can be treated successfully by various means, it is important to get the mind of the individual in a favorable state so as to enable him to obtain better control over his vaso-motor system which is so much influenced by emotions and thoughts. It is this latter element in the causation of the disease that has been successfully treated by the many remedies that for a time have had reported success in the cure of hay fever yet afterwards proved to be of no benefit because they had lost their influence over the patients' minds.
In a review of Morell MacKenzie's book "Hay Fever, with an Appendix on Rose Cold," Dr. J. N. MacKenzie [Footnote 31] has some paragraphs on hay fever which, though written twenty-five years ago, are worth recalling for a proper understanding of the disease. He preferred to call the disease rhinitis sympathetica or coryza vaso-motoria periodica, names which are much better descriptive terms and have no unsubstantiated suggestions of etiology in them.
[Footnote 31: American Journal of Medical Sciences, 1886.]
According to our conception, the so-called nasal reflex neuroses, whether taken singly or collectively, as the cause of the ensemble of phenomena known as "hay fever," may be regarded as the protean manifestation of a morbid condition to which we have given the name rhinitis sympathetica, and which is characterized by a hyperesthetic condition of the vaso-motor nerve centers linked to a peculiar excitability of the nasal cavernous tissue. For, if we inquire what condition or conditions is common to them all, and what morbid process is capable of producing them, either singly or in combination; how phenomena apparently [{370}] so widely different in character and anatomical sphere of operation may be traced to a solitary source, we find the answer in certain more or less clearly defined changes in the nasal apparatus and in a certain exalted state of the sympathetic nervous system, to which latter we instinctively turn as the organ most conspicuously concerned in the evolution of purely reflex acts. In whatever relation the local nasal affection and the condition of the sympathetic stand to each other in the matter of cause and effect, they must both be regarded as inseparable factors in the production of the phenomena under consideration. It matters not to what hypothesis the path of speculation may lead. Of this we can be reasonably sure, that in the production of the characteristic symptoms of this disease, a certain excitability of the nasal passages is necessary, plus an exalted state of the central nervous system.
Dr. MacKenzie calls attention particularly to the erectile character of the tissues mainly involved in all these forms of dust catarrh and dwells on the rôle that mental influence always plays in the phenomena noted in such tissues. This with the vaso-motor elements in the affection which are so largely also under the control of the emotional nature make it clear that the pathology of the affection must be considered from this standpoint and, therefore, its therapy also.
Dr. MacKenzie continues:
From our present knowledge of the disease, it seems difficult to escape the conclusion that its pathology is intimately interwoven with a morbid condition of the vaso-motor sympathetic, and probably a hypersensitive state of the nerve centers themselves. When we recall the fact that in the famous section of the sympathetic in the neck by Claude Bernard, symptoms similar to, or closely allied to, the phenomena of hay fever were produced; when we reflect upon the results reached by Prevost in his experiments on the spheno-palatine ganglion, is there not a clue to lead us through the labyrinth of our difficulties to a rational solution of the question? . . .
. . .In the human body, wherever erectile tissue is found, it is intimately related to reflex or sympathetic acts; there seems to be connected with it a certain receptivity to reflex producing impressions, a certain power of reflex excitability dependent upon its structure and functions. It is thus peculiarly a tissue of sympathy in which we may most satisfactorily study the mechanism of purely reflex or sympathetic acts. Now it seems to us that, as the nasal corpora cavernosa belong to this class of sympathetic tissues, there will be little difficulty in explaining the rôle which they play in the paroxysms of an affection which is probably connected with, if not dependent upon, an excitation of the sympathetic nerve centers, and in more clearly defining the intimate relation which its erection bears to the reflex manifestations of the disease under review.
These considerations explain the heredity of the affection in many cases, since it is dependent on defects that may be family traits, yet they also enable us to understand how slight lesions of the nasal mucous membrane may be the center from which radiate the underlying pathological conditions of the disease.
Railroad Asthma.—There is a form of dust asthma which deserves special attention here because it is due to modern conditions and helps to an understanding of the etiology. It occurs in sensitive persons when they travel on railroad trains in warm weather, particularly if it has been dry for several days and dust is abundant. It has been called railroad asthma or railroad catarrh by the English and the Germans, but the condition has no necessary connection with the railroad. It occurs as a consequence of the infiltration into railroad cars of fine dust during the passage of the train. [{371}] I have seen it in those who had made long trips over dusty roads in automobiles, though the dust of the railroad seems finer and more penetrating. It develops just as much at the end of a long train as if the passenger spent most of the journey in the car next the engine and apparently it makes no difference whether the engine burns hard or soft coal. They use soft coal almost exclusively in England and Germany, but one sees cases of it here after travel on roads that burn hard coal and are especially cleanly in this respect. Soft coal adds somewhat to the amount of dust and therefore this increases the irritation, but there is nothing specific about coal dust. It is surprising how severe the symptoms may be. I have seen a patient who had traveled continuously for four days across the continent who had so much photophobia when he alighted from the train, that he was almost unable to open his eyes, and it was not until twelve hours had passed that he could open his eyes with any comfort, yet at the end of two days practically all the symptoms had passed off.
Prof. Fraenkel, professor of laryngology and rhinology at the University of Berlin, who was one of the first to classify the condition among the affections related to "hay fever," described certain features of it very well in a clinical lecture reported in International Clinics, Vol. II, Ninth Series, 1899. As a rhinologist he insists on the nasal conditions that underlie the affection yet suggests that the nasal hyperemia may be due to reflexes of one kind or another. The basis of these is undoubtedly very often an emotional condition of the patient, a dread of dust, an expectancy of symptoms and a consequent exaggerated reaction. Unorganized dust produces asthma, but organic materials bring more severe and lasting effects, partly because of the mental effect of odors and other sensory conditions in connection with them.
The Personal Element and Power of Suggestion.—The history of these asthmas and other symptoms produced by odors and dust make it clear that the more that is known about the disease the surer it becomes that there is a large personal element, usually dependent on a certain frame of mind, in the cases. Some people are affected by one form of irritant, some by another, some by pollen, others by animal emanations, and not a few by a persuasion of the likelihood of suffering from these things, since occasionally the sight of an artificial product produces a like result. Certain classes suffer much more than others. Those who are much confined to the house and who are especially prone to reflection upon themselves and their feelings form the great majority of the patients. In old days the monks were favorite victims, in modern times literary folk, students, and those who have the time and the inclination for reading and introspection are particularly likely to suffer. How much the mental element may account for in these cases is not clear, but it stands for much more than has been thought and there seems no doubt that more relief of symptoms is afforded by diversion of mind and change of dwelling quite apart from external conditions than in any other way. It is important to remember that no specific dust but almost any kind of dust produces these conditions in sensitive persons.
Dr. MacKenzie describes an interesting case in which all the symptoms were produced by the presence of an artificial rose. The story is so striking and he has told it so well that I prefer to tell it in his own words. I may say, however, that the clinical history of the case was typical. About the end of [{372}] May or the beginning of June every year the patient suffered from a coryza preceded for a few days by an indefinite sense of general depression with a disagreeable feeling of heaviness in the head. Sometimes there were chilly feelings and general malaise. The catarrhal stage commenced with profuse watery discharge from the nostrils, copious flow of tears with redness of the conjunctiva, itching of the puncta lacrymalia and photophobia. The exterior of the nose, especially at the tip, became intensely red and toward the close of the attack the cuticle desquamated. There was a short, dry, hacking cough relieved by sneezing, an intense tickling sensation in the throat, the voice became husky, the pharynx dry, the ears stopped up and tinnitus occurred. Her attacks continued most of the summer and were always brought on by the pollen of any plant and above all by the smell of a rose. It was, indeed, an example and of the most aggravated form. She was brought to Dr. MacKenzie in consultation and I leave him to tell the rest of the story.
Decidedly skeptical as to the power of pollen to produce a paroxysm in her particular case, I practiced the following deception upon her, which still further confirmed me in that belief. For the purpose of the experiment I obtained an artificial rose of such exquisite workmanship that it presented a perfect counterfeit of the original. To exclude every possible error, each leaf was carefully wiped, so that not a single particle of foreign matter was secreted within the convolutions of the artificial flower. When the patient entered my consultation room, she expressed herself as feeling unusually well. The evening before she attempted to wear some roses, but had been obliged to remove them from her dress, as they had produced a great deal of discomfort. Apart from this incident she had been perfectly comfortable for several days and nights. Her conjunctivae were normal, the nasal passages free, and there was nothing to indicate the presence of her trouble. She conversed with me for some time about her case and on general topics, speaking in the most encouraging manner concerning the progress she was apparently making toward recovery. I proceeded to remove the slight slough from the cautery operation, which lay loose in the nostril, and made an application to the mucous membrane, and all without exciting the slightest tendency to reflex movements. After I felt sure that such tendency was absent, I produced the artificial rose from behind a screen, where it had been secreted, and, sitting before her, held it in my hand, at the same time continuing the conversation. In the course of a minute she said she must sneeze. This sensation was followed almost immediately by a tickling and intense itching in the back of the throat and at the end of the nose. The nasal passages at the same time became suddenly obstructed, and the voice assumed a hoarse nasal tone. In less than two minutes the puncta lacrymalia began to itch violently, the right and afterward the left conjunctiva became intensely hyperemic and photophobia and increased lacrymation supervened. To these symptoms were added, almost immediately, itching in the auditory meatuses and the secretion of a thin fluid in the previously dry nasal passages. In a few minutes the feeling of oppression in the chest began with slight embarrassment of respiration. In other words, in the space of five minutes she was suffering from a severe coryza, the counterpart of that which the presence of natural roses invariably produced in her case. An examination of the throat and nasal passages was then made. The right nostril was completely obstructed by the swollen, reddened, irritable, turbinated structures; the left was only slightly pervious to the air current; both were filled with a serous-looking fluid. The mucous membrane of the throat was also injected, but did not exhibit the same amount of redness and irritability found in the nasal passages. As the discomfort was rapidly increasing, and as I considered the result of the experiment sufficiently satisfactory. I removed the rose and placed it in a distant part of the room. When told that the rose was an artificial one, her amazement was great, and her incredulity on the subject was only removed upon personal examination of the counterfeit [{373}] flower. She left my office with a severe coryza, but also with the assurance that her disease was not altogether irremediable. A few days later she called to see me again, and on that occasion she buried her nostrils in a large, fragrant specimen of the genuine article and inhaled its pollen without the slightest tendency to the production of reflex acts.
There is but one conclusion that can be drawn from this: that suggestion plays a large rôle in the relief of the symptoms of the disease. If patients once become persuaded that something will do them good, then it surely does. It is true that this good effect will usually not persist, but that is because after a time conditions conspire to make the suggestion fail of its purpose. This does not at all imply that hay fever, or just catarrh as I prefer to call it, is imaginary. The relief of our most serious and fatal diseases with profound pathological lesions, such as tuberculosis, may well be brought about by suggestion. After all, just the same story is told about consumption and its many remedies as of hay fever and its many "cures." However, the most important therapeutic element so far discovered for the treatment of hay fever is evidently suggestion. If the patient's mind can only be brought to a favorable attitude in which the discouragement incident to imperfect oxidation can be greatly lessened, then relief of many of the symptoms will be afforded and under favorable conditions the patient will deem himself cured. Undoubtedly the large amount of attention given to hay fever, the gathering of these patients in particular localities, the repetition of the story of their symptoms to each other, the body of literature that has gathered around hay fever and is read with such avidity by those who are pleased to call themselves its victims, adds to the unfavorable suggestions and inveterates the symptoms, exaggerates the nasal hyperemia and makes the general condition worse.
I am the more positive about the influence of suggestion, favorable and unfavorable, in the affection after having carefully noted the conditions in certain patients from year to year for a number of years. I became interested in it because it is a family affection and several sisters as well as myself are sufferers from it. At the beginning, when the real nature of the trouble is not recognized, there is a year or two of considerable general discomfort, though not much local disturbance. Then comes the realization of what the recurrent affection is and a period of distinct depression during its continuance. Eventually it begins to be appreciated that a number of local applications will lessen the symptoms from day to day and that there need be no apprehension of serious sleep disturbance, or of any lasting effect upon the general health, the affection becomes quite bearable and, while still annoying, is no longer the object of particular solicitude.
CHAPTER V
DYSPNEA—CAT AND HORSE ASTHMA
There is a class of cases of difficulty of breathing allied to asthma and often called by that name, the study of which throws light on the origin and the relief of neurotic asthma. These cases are usually accompanied by such a sense of oppression on the chest that breathing becomes labored and, to some [{374}] extent at least, the accessory muscles of respiration have to be called into play. The most typical cases are connected with the mental influence produced by the presence of some particular animal, the cat being the most frequent and the horse not rare, or with emanations from these animals, when there seems to be some physical nexus between the animal and the symptoms.
Cat Asthma.—The symptoms associated with cats are rather common, and they occur at the sight or touch of the animal, but may be the result only of its presence which in some way the patient is able to recognize without sight of him. Shakespeare's expressions in a number of places, such as "I could endure anything before but a cat" and "some that are mad if they behold but a cat," shows that the affection was commonly recognized at that time and that the reason for it was considered unknowable, for Shakespeare says, "There is no firm reason to be rendered why he cannot abide ... a harmless necessary cat."
Dr. Byron Bramwell in his "Clinical Studies," Vol. I, page 107, has an interesting paragraph with regard to these curious asthmatic conditions which develop in the presence of animals of various kinds. He sums up many of the curious features of this affection as reported by various good observers. Many more people than we would be apt to think are affected by it. He says:
In some persons the smell of a horse or of a cat produces an attack of asthma. Some years ago I repeatedly saw a young gentleman who invariably had an attack of asthma if he went near a stable or a horse. He was so susceptible that he was unable to drive in a cab or a carriage; when traveling from place to place, while sending his traps from the station to the hotel in a cab, he himself was obliged to walk.
Dr. Goodhart mentions a similar instance which occurred in the practice of Prof. Clifford Allbutt. Dr. Goodhart also mentions a remarkable case of "cat asthma":
I have known of two cases of cat asthma. In one of them the existence of cats is the bane of life, for before accepting an invitation she is obliged first to ask, "Is there a cat?" [Footnote 32] An attack of urticaria and coryza followed by asthma has been noticed to come on within ten minutes of having stroked a cat. At other times, sitting in a room in which there was a cat, without any actual contact with it, was sufficient to produce a bad attack, beginning within ten minutes of entering the room.
[Footnote 32: A case of this kind came under observation as this book was nearly ready for the press. The patient, a young woman in an office, had to refuse a vacation with a wealthy friend in Florida, because she knew that friend could not be separated from her pet cats, five in number, and the patient would have been intensely miserable were she near them, so that even the joys of Florida in the winter did not make up for the constant, intolerable discomfort they would have caused her.]
There are two forms of this intolerance of a cat. One of them takes on the character of a dread and is discussed in the chapter on [Dreads]. The other is accompanied by dyspnea or asthma with a sense of discomfort and tightness of the chest that cannot be overcome. It is not merely an imagination, for sometimes even when they cannot see the cat, or at times when friends have been careful to exclude cats from the room, these people become impressed with the idea that a cat is near and a search usually shows that their impression is true, though just what was the means through which they came to know it is difficult to understand.
Dr. Weir Mitchell's review of the subject of "Cat Asthma and Allied Conditions" in a paper read before the Association of American Physicians brought out many curious details. There is no doubt about the power to recognize the presence of the unseen cat. Besides the respiratory oppression, some patients develop urticarial lesions and occasionally even conjunctivitis and a catarrhal condition of the nasal mucous membrane. These seem to be due to the direct irritant effect of animal emanations. As the symptoms of rose cold or hay fever have sometimes developed after the sight of an artificial rose, or even, it it said, the picture of a hay field, so, in some of these cases, the sight of a picture of a cat has produced at least some of these symptoms. Probably the most interesting feature of the affection is that the large cats, the tiger and the lion, do not have any effect on the patient. There seems to be no doubt, then, that the mind plays an important role in the matter and that relief must be secured through mental influence.
In some of these cases a careful searching of the past of the patient will show that there has been some terrifying incident connected with the cat. In one case in my own experience the patient's earliest recollection, and the first time that death was brought home to her, was when a favorite bird was killed by a cat. Ever after that she had a horror of the animals, the family cat had to be disposed of, and her family never had another. She used to suffer from a severe dyspnea at the sight of a cat and was sure that she could recognize its presence without having seen it. She mentioned a number of occasions on which that had been true. The very idea of living where a cat could come near her was appalling. She was sure that she was even waked by the mere propinquity of a cat if by any chance one got into her room at night, though without any noise.
A change in her material circumstances compelled her to teach in private families. Under these circumstances her cat detestation made difficulties for her. I suggested, since she had had no feeling toward cats before the bird incident, that probably her symptoms were due to suggestion and an acquired habit of mind and that she might by discipline overcome them. She was sure that would be impossible. With determined effort, however, and practice in withstanding her feelings in the presence of cats she finally learned to overcome practically all of her feelings so that though it still requires an effort she can even pick up a cat and stroke it. I have had several other patients with less marked forms of the affection who have by self-discipline overcome their feelings to a great degree. It is always well to search the past of these patients in order to find out whether there may not be a dominant idea derived from some unfortunate experience, which acts as an auto-suggestion in the production of their symptoms of constriction of the chest and sometimes even the recurrence of the swelling of the mucous membrane of the nose that produces difficulty of breathing. Whenever this can be found, contrary suggestion can be given and the patients can be persuaded to try, by frequently repeated auto-suggestion, to relieve themselves of the trouble.
Occasionally these curious manifestations of a catarrhal or asthmatic character in the presence of cats occur in people who like cats. Dr. Taylor in his "Types of Habit Neuro-Psychoses" published in the Proceedings of the Massachusetts Medical Society, 1896-98, tells the story of a young woman in whom he saw conjunctivitis developing while she was fondling a cat. In many cases [{376}] besides the hyperemia of the nose and of the respiratory mucous membrane generally there is marked injections of the ocular conjunctiva. It is rather difficult to understand the phenomena of asthmatic attacks in connection with cats and other animals in terms of a habit formed, because at some time asthmatic or hyperemic manifestations occurred in association with the handling of these animals and that then, somehow, suggestion works to reproduce the same symptoms in the presence of the animals later; but this is undoubtedly the only rational explanation that we have for many of these cases. It represents the most helpful explanation, so far as treatment is concerned, for by means of suggestion either in the waking state or in the first stage of hypnosis, in many cases relief can be brought to these patients. Repeated profound hypnotism is a vaunted remedy for these conditions in the hands of professional hypnotists, but serious physicians who have tried hypnotism do not recommend it. It helps for a time but relapse follows. Only continued suggestion and a carefully cultivated habit of self-discipline and control succeed.
Horse Asthma.—The cases of dyspnea in connection with horses are not less interesting. Occasionally, even when all aversion is absent, emanations from horses are capable of producing a curious effect on certain individuals. How much of this is psychic is not clear. I was once consulted with regard to a patient who suffered from asthma whenever she went to a dance. It mattered not how careful she was in not exposing herself to night air, or in wrapping herself up warmly; invariably a few hours after her return home, she was wakened from sound sleep by an attack of difficult breathing that required the opening of windows and the use of the accessory muscles of respiration in order to satisfy her air hunger, and even then her symptoms were quite alarming to herself and her friends. At first, her asthma was thought to be due to sudden changes of temperature in going out into the air after the dancing, and various devices were tried to lessen the shock of the cold to the respiratory mucous membrane. None of them had any effect. Then it was thought that the dust of the ball-room made the difference and so she was forbidden to dance. After a time it was found, however, that if she went out in the evenings to social functions, whether she danced or not, or though she avoided completely being in dusty rooms or where many people were moving, she still had the attacks a few hours after she returned home.
Finally it was noted that these attacks of asthma also occurred on several occasions after she had been out riding during the day in a carriage. Then one evening after a rather long intermission free from attacks, in spite of directions and her fears, she went to a ball, but owing to circumstances went and returned by trolley instead of, as usual, in the family carriage. That night she had no attack of asthma. Experiments were made then and it was found that whenever she rode behind horses she suffered from an attack of asthma during the following night. The attack was evidently not due to suggestion. The story illustrates the necessity for carefully analyzing all the circumstances of an asthma patient and making sure that some one of these curious and unusual conditions are not at work, for if they are, the only possible curative treatment is by influencing the patient's mind, first by demonstrating the cause of the affection and then by training in self-control to reduce the reaction.
Recently I have been consulted with regard to a physician who has developed in a rather curious manner a sensitiveness to the presence of horses. As an interne at a hospital during an epidemic of diphtheria he took a dose of diphtheria antitoxin for immunizing purposes. The amount injected was 750 units, the remainder of the dose of 1,500 units contained in the phial being given to the nurse who had charge of the cases. She suffered absolutely no ill effects, so that the manifestations in his case were entirely due to idiosyncrasy and not to anything in the serum itself. Within fifteen minutes after taking the injection the mucous membrane of his nose became so congested as to make it impossible for him to breathe through his nostrils and the mucous membrane of his soft palate was seriously disturbed in the same way. His face became much swollen, the edema affecting particularly his eyelids and his lips and hundreds of wheals appeared all over the body. Fortunately the edema did not affect the larynx, or the issue might have been fatal, or would surely have required intubation. His pulse became extremely rapid and weak, there was marked dyspnea, and whenever the patient sat up there was fainting or a distinct tendency to it.
Under active stimulation and elimination the symptoms rapidly passed off so that the only noticeable edema the next morning was in the eyelids and lips, which, however, also disappeared within twenty-four hours. Up to this time the physician had never been bothered by any tendency to hay fever or to asthma and there is no history of either of these affections in his family. Thereafter, however, though quite without his anticipating it, and, indeed, the first symptoms were incomprehensible, he became extremely sensitive to emanations from horses. When he rides behind a horse for some distance his conjunctivae become injected, the nostrils become congested and difficulty of breathing sets in with a sense of constriction of the chest. These subside as soon as he gets away from the presence of the horse and has washed himself thoroughly. He suggests that he has become sensitized to horse serum and, as it did not exist before his experience with diphtheria serum, he, of course, connects that incident with the present tendency. It is easy for such a case to have its real significance entirely missed and, of course, treatment by prophylaxis, the most efficient form, would then be out of the question.
Other Forms.—Apparently at times human emanations or some peculiarity of odor seems to influence asthmatic conditions. I have been told by a good observer—a physician—of two brothers who had an attack of asthma whenever they visited each other. At first this was attributed to something in the air or some other condition of the visit. After a time it was found to occur under varying circumstances, but that the one essential was the association with each other.
Treatment.—The more one knows about asthmatic conditions the more does it become clear that special study of individual cases is extremely important for any definite knowledge of the causation in a particular case. Without a knowledge of the cause the treatment is very unsatisfactory and in the meantime the unfavorable suggestion of the recurrence of the attacks acting upon the patient sometimes disturbs the general health. To remove this unfavorable influence must be the first care of the physician and then if the real cause can be found, favorable suggestion and modifications of the mode of life, with self-discipline and control of the mental attitude and of the [{378}] nervous system, may greatly aid in the reduction not only of the number of attacks and of the severity of the symptoms, but finally lead to complete eradication of the affection.
Mental control to some degree can be obtained and it has even been suggested that if the emanations from an animal cause physical symptoms, gradually increased dosage of them, beginning with very small amounts, that is, short periods of association with the animals in question, may gradually lead to the production of an immunity to them as it does even to the much more serious results of snake poison. Certainly some patients seem to have succeeded in bringing relief to themselves by this means and it is worth while remembering in the therapy of the affection, if for no other reason than the strong suggestion that goes with it.
SECTION IX
PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM
CHAPTER I
PAINFUL JOINT CONDITIONS—PSEUDO-RHEUMATISM. [Footnote 33]
[Footnote 33: The position here taken, that acute articular rheumatism never leaves a mark after it, is entirely due to the observation that whenever cases were seen in which sequelae were noted, there always seems to the writer to be question of something else besides simple acute articular rheumatism—a complication. Subsequent pathological investigation may show that occasionally acute articular rheumatism does to some extent disorganize joint tissues. Personally, however, I have the feeling that there are a number of different kinds of acute arthritis, probably three or four, and that most of them leave no pathological condition in the tissues. Perhaps we shall be able to differentiate the severer forms and recognize them from the beginning, as we have already done with regard to scarlatinal, gonorrheal, influenzal and other so-called rheumatisms. For practical purposes it certainly seems better to emphasize the fact that chronic rheumatism following an attack of simple acute arthritis is so rare as to be negligible.]
Many painful conditions in connection with joints give rise to more or less continuous or frequently repeated discomfort, which often leads patients to think that there are serious pathological factors at work, or that some progressive disease condition has obtained a hold of them. Many of these painful conditions are due entirely to local causes: to over-exertion, to the wrong use of muscles, to the exercise of joints under unfortunate mechanical conditions and the like. Just so long as people are assured that an ailment is local, is not likely to be followed by serious impairment of function, that the discomfort of it is only temporary, and, above all, just as soon as they get rid of the notion of a progressive constitutional malady, they are content to bear even annoying pain without much complaint, and, what is more important, without such discouragement and worry as may impair the general health. Unfortunately, it is the custom to call most of these vague painful conditions "rheumatism," unless there is some other patent cause for them. Especially is this done if the symptoms happen to be worse in rainy weather, or in damp seasons. Rheumatism is always thought of as a progressive constitutional disease, and the very idea of it produces an unfortunate sense of depression.
Exaggeration of Significance.—Toothache, for instance, unless it is allowed to nag for a long time, awakens no dreads and consequently fails to produce the corresponding depression and discouragement, seen so often in connections with conditions much less painful, but associated with the thought of the possibility of serious developments. "Omne ignotum pro magnifico," what is not well understood is always exaggerated, was Cicero's summing up of the tendency of the human mind to make the significance of misunderstood things greater than they really are. It is particularly true of painful [{380}] conditions of the body, and the tendency must be combated if patients are to be relieved. This must be done not alone because along this way lies relief of suffering, since not a little of the discomfort is due to the mental concentration consequent upon the dread, but because, also, the discouraged state of mind interferes with the trophic influences that go down from the central nervous system to the periphery to keep it in good health and to restore function when there is anything out of order. In a word, the exaggeration of significance so likely to influence such patients for ill must, as far as possible, be removed for their immediate relief as well as ultimate cure.
Rheumatism, Gout, Catarrh.—There are three words in popular medical language which can be made to include more diseases and explain more symptoms than any others. Their meaning has become so indefinite that they now convey very little information, though they are much used—and abused. They are: rheumatism, gout and catarrh. Curiously enough all three of them when their etymology is studied mean the same thing as far as their derivation goes. Catarrh from [Greek text] the Greek word to flow down and rheumatism from [Greek text] the Greek verb to flow are terms that correspond exactly in etymology to gout, which is probably derived from gutta, the Latin word for drop—referring to the excess of secretion that is supposed to occur in the disease. All of these have for their basic idea, in etymology at least, an increase of secretion. A generation or two ago, the word rheumatism included a host of disparate painful affections, and was even more sadly abused than now, though its abuse has not ceased. The word catarrh is now at its acme of abuse. Gout has been pushed somewhat into the background by the other two. Any one of these three terms carries with it, in the popular mind, a connotation of progressive constitutional involvement which is not justified by anything that physicians know with regard to these diseases.
The Uric Acid Diathesis.—The usual supposedly scientific explanation of a decade ago for many of these vague pains and aches classed as chronic rheumatism was that they developed on the basis of an excess of uric acid in the system. Advance in chemistry has completely obliterated the significance of the observation on which the theory of a uric acid diathesis, as it was so learnedly called, as an explanation for these conditions was founded. After uric acid there came for a time the theory of an excess of lithic acid, the so-called lithemia or American disease of a few years ago. These are, however, merely pseudo-scientific hypotheses and the more physicians know of chemistry the less they talk about them. Many practitioners, however, continue to accept this universal explanation which makes diagnosis so easy and which is supposed to be so suggestive for treatment. There are various remedies that are claimed to reduce the uric acid content of the blood or the system, and then there are various changes of diet that are supposed to do the same thing. These two systems of treatment and the combination of them have constituted the main therapeutic resource of many physicians for these so-called rheumatic cases, though their success has been anything but what they hoped for.
Diet Tinkering.—Tinkering with diet has been particularly harmful in these cases. Over and over again I have seen patients who had lost considerably in weight because they had had all the supposed acid-forming elements removed from their diet. In many physicians' minds this seems to include most of the starches, as well as the fruits and many meats. Without any [{381}] potatoes, with only a limited amount of bread, with a warning as to red meats, and occasionally even some distrustful remarks with regard to butter, it is not surprising that the patients lost weight, that muscles became weaker, that painful conditions became severer, and that, above all, the patients' minds became less capable of bearing whatever discomfort is present. Besides, constipation intervenes with its train of consequences and patients become miserable, lose sleep often because of insufficient nutrition and actual clamoring on the part of their gastrointestinal tract for food. I have seen a man who was not much over normal weight to begin with lose twenty-five pounds, nearly one-sixth of his weight, while being dieted for vague pains (worse on rainy days) that were really due to his occupation, but that had been diagnosed as "rheumatic," consequent upon the uric acid diathesis, for which coal tar products were prescribed over a long period and his diet strenuously regulated. This has become as much of an abuse as the old-time purgings and bleedings.
Irregular Treatment.—As we have said, this group of cases constitutes the most frequent and abundant source of profit for quacks and charlatans and irregular practitioners generally. The naturapath, the osteopath, whom we have already mentioned, for to these cases he owes most of his success in appealing to legislatures for recognition, the irregular electropath, many supposed diet specialists, and even the special shoemaker, have reaped a rich harvest from these patients. The reason why they have done so is that, as a rule, they have at once reassured the patients that their condition was not seriously progressive and have promised them certain relief from their ailment. Usually various local measures, such as St. John Long's liniment of one hundred years ago and many of its successors, or the mechanotherapy and the massage and the manipulation of the osteopaths of the present day, have been employed with consequent restoration of circulatory disturbances to normal conditions and, in general, the setting up of better mechanical employment of muscles than was possible before. If so-called chronic rheumatism is to be treated successfully and this opprobrium of medicine, as it has been called, is to be removed, it can only be done by a careful analysis of the ills of each individual patient and a definite determination as to just what local pathological condition is at work and not by a slip-shod diagnosis of rheumatism with immediate recourse to a supposed or assumed theoretic diathesis for the explanation of its etiology.
Differentiation of Joint Conditions.—The local conditions that give rise to painful conditions of joints are most diverse in character. There was a time when all of the infectious joint affections had the term rheumatism applied to them. Even at present it is not unusual to hear of scarlatinal or gonorrheal or influenzal rheumatism. What is meant, of course, is that the microbes of these specific diseases have for some reason found a lowered resistive vitality in one of the joints, or perhaps several of them, and have set up an inflammatory disturbance. These specific arthritises are now definitely separated from the rheumatism group and it seems clear that in the near future we shall have rheumatism itself divided up into a series of diseases. By this I mean that even where there is the redness, the swelling and the fever of true inflammation of joints, it is not always due to one microbe, but to various microbic agents, and so we shall have various forms of rheumatism. At present we are prone to speak of many of the neuritises as rheumatic, but it is probable that [{382}] here a series of varying microbic infections will be found, some of them much more serious than others, most of them capable of complete cure, though some of them will tend to leave pathological conditions in nerves that are more or less crippling.
Painful Joint Affections.—These pains and aches occur particularly in the old and those who have been hard muscle workers, in those who have been exposed much to the elements and especially in the subjects of old injuries. All of these conditions, one way or another, have left their mark upon tissues so that the nerves do not receive proper nutrition, especially when there is considerable exertion or in rainy weather.
There are a number of reasons why rainy weather produces this effect. The humidity of the atmosphere lessens evaporation. This disturbs heat conditions in the tissues, for evaporation is the most important element in heat dissipation. This leads to the accumulation of heat in the parts and conduces to congestion. Any tissue of lowered vitality will be affected by this and nerves become oversensitive. Besides, it seems probable that the fall in the barometer with the lessened pressure from without makes a difference in the circulation. There is a general feeling of depression in wet weather and apparently the circulation is not so active. It is particularly slow at the surface of the body and in the terminal portions, so that the hands and feet are likely to be cold. Just as soon as the barometer goes up somewhat these conditions cease to be active and there is restoration of the circulation to its previous condition. Besides, it seems not unlikely that dampness produces some relaxation of muscles, so that it is more difficult to make them contract, and consequently they are used at a greater mechanical disadvantage and painful tiredness more readily ensues. All sensitive tissues become more sensitive in rainy weather, though in the case of toothache or neuralgia, for instance, we do not think of connecting this with the word rheumatism.
Classes of Sufferers.—In persons who are over-thin or over-stout complaints of joint discomfort are not uncommon. In the first case they are due to the fact that muscles working around joints are not strong enough to accomplish their normal purposes. In the other cases, owing to the weight of the body, the muscles are overstrained. In a number of stout people the muscles do not increase proportionately to the size of the frame, much of the extra weight being in the shape of adipose tissue that constitutes a grievous burden. In people who run rapidly to either of these conditions of disturbed nutrition—thinness or stoutness—complaints are particularly likely to be heard. Familiar examples are often seen in the tuberculous who have lost weight rapidly or in convalescents from typhoid fever who are much thinner than they were before they took to their beds. On the other hand, those who gain in weight rapidly after typhoid fever or some other such pathological incident, or who, as the result of careful sanatorium treatment, put on twenty pounds in the initial stage of tuberculosis, may have similar discomforts to complain of in and around their joints.
Heredity of Rheumatism.—The strongest unfavorable suggestion which most patients have is that their ailment, whatever it is, is hereditary and therefore not amenable to treatment. Nothing is more amusing to one who knows the present-day status of opinion in biology with regard to heredity than the frequent declaration that rheumatism is hereditary. Probably [{383}] nothing is commoner than to have a patient who is suffering from some vague, painful condition in muscles or joints, especially if that condition is worse on rainy days, declare that it must be rheumatism because father or mother suffered from rheumatism. I took the trouble to analyze in more than a dozen cases the rheumatism that was supposed to exist in the preceding generation, and found that it consisted of everything from pains due to old injuries and especially dislocations or fractures, through the various deformities connected with flatfoot, up to and including the worst manifestations of arthritis deformans. The condition in the parents supposed to be hereditary is never genuinely rheumatic.
There is just as much sense in talking of hereditary pneumonia as of hereditary rheumatism. Perhaps there is an hereditary lack of resistance in the pulmonary tissues of some people that predisposes them to pneumonia. It must not be forgotten that a century ago, or even less, it was not uncommon to hear that certain people had hereditary tendencies to lung fever. We know now that these were tendencies to tuberculosis and not to true pneumonia. We know, besides, that tuberculosis itself is not hereditary and that probably even the predisposition to it is not specifically hereditary.
As can be readily understood, the question of heredity in rheumatism is extremely important for psychotherapy, since the persuasion that their affection is inherited always produces an unfavorable effect upon patients' minds. In the old days, when tuberculosis was universally considered to be hereditary, a patient was likely to think himself the victim of an hereditary condition which could not be cured and which inevitably led to a fatal termination. Something of the same idea, though the immediate outlook is not so gloomy, is likely to follow the persuasion that rheumatism is hereditary. The question of heredity, of course, is bound up with that of rheumatism being a constitutional disease dependent on hyperacidity or some other pathological condition of the blood. Acute rheumatism, that is, acute arthritis, is an acute, infectious disease due to a microbe. This ought to dispose of any question of heredity in it. Chronic rheumatism is supposed to be related to acute rheumatism and to represent, as it were, a low-grade enduring condition such as in sudden accessions gives rise to acute rheumatism.
So-called Chronic Rheumatism.—In these cases it is always a question whether the condition which causes the pain and discomfort is genuine chronic rheumatism or not. I am one of those who doubt whether we have any genuine, definite symptom-complex that should be termed chronic rheumatism. I have seen many ailments called chronic rheumatism. Any painful condition in the neighborhood of the joint that is worse on rainy days is likely to be labeled rheumatism and, because the salicylates are supposed to be a specific for rheumatism, treated with large doses of these drugs. These relieve the pain, as do any other coal tar products, but it is hard to understand how they are ever supposed to do any good for the underlying pathological conditions. The most noteworthy characteristic of acute rheumatic arthritis is that it leaves no mark upon the joints that were affected by it. These get completely better and the patient has no disability, no deformity, and there usually remains not even the slightest sign of there having been a serious inflammatory condition within the joints.
In this it resembles pneumonia rather strikingly. True lobar pneumonia [{384}] clears up completely and the man has no symptoms once he has come through the convalescence. There are certain diseases affecting the joints, especially the arthritises in connection with various infectious diseases and the arthritis which accompanies acute arthritis deformans, in which there are serious sequelae and sometimes even complete disorganization of the joint. It is by these after-effects alone that we are sometimes able to differentiate genuine rheumatic arthritis from these other very different affections which resemble it so closely. Just the same thing is true of pneumonia. There are pneumonias that run a course at the beginning strikingly like true lobar pneumonia but which do not have a frank crisis and in which the lungs are seriously affected afterwards. We know now that in these cases it is not an uncomplicated pneumococcus pneumonia that has been at work, but either some other infection or else true pneumonia with a complication. Very often a dormant tuberculosis causes true pneumonia to run a different course from that which it ordinarily follows, and this, as a complication, leaves its serious mark upon the lungs.
Recurrence.—In some cases there seems to be a tendency for the "rheumatic" disease to recur. This also is true of pneumonia. This does not so much indicate, however, any loss of special tissue vitality as a certain loss of vital resistance to a particular microbe. Certainly this tendency is not sufficient to make us think of chronic rheumatism or use that term any more than we would, under similar conditions, talk of chronic pneumonia or of chronic diphtheria, though both of these affections have a tendency to leave a lack of resistive vitality. In a number of cases, subacute rheumatism runs a course that is very bothersome and annoying and that is quite intractable, with relapses and sequelae, but even this is entirely different from the ordinary idea of chronic rheumatism. It is probable that these cases, like the pneumonias that do not end by crises, are complicated by some other condition in the joint that leads to reinfection.
Unclassified Forms.—It is possible that in a certain number of cases for which as yet we have no name but rheumatism, there is a virulence of the microbic factor that brings about some joint disorganization. This, however—and the cases are very rare—is probably an affection to which the name of rheumatic arthritis will not be given when we know more of the disease and its cause. There are probably many forms of acute rheumatic arthritis due to varying microbes which will eventually be divided into groups, as we have made groups in the typhoid series of diseases and in the scarlet fever group and hope to do with other diseases.
The Individual Case and Reassurance.—The main role of psychotherapy in these affections is to set patients' minds at rest as far as possible, by pointing out exactly what is the matter with them and keeping them from worry, discomfort, and even interference with their physical condition by over-solicitude. It is important to know every detail of the patient's occupation, of his habits, of his environment, of his exercise, and, above all, of his individual peculiarities of structure in the neighborhood of joints, so as to decide exactly what is the matter with him, and not be satisfied with the easy but unscientific diagnosis of rheumatism, which may mean much but usually means nothing.
Unless such reassurance is given, and especially if the ordinary drug treatment for so-called chronic rheumatism is persisted in, after a time these [{385}] patients, unimproved by salicylate treatment, wander off to all sorts of irregular practitioners and form the greater part of the lucrative clientele of quacks and advertising specialists in the cure of chronic diseases. More probably than any other class of cases do they support the irregulars. Osteopathy has particularly appealed to a great many of these patients. It has done it in two ways. The first and most important probably by its effect upon the mind of the patients. Osteopaths immediately proceed to reassure the sufferers that their affection is not rheumatism, but some local condition dependent upon either a subluxation of the vertebra which, according to the founder of osteopathy, constitutes the basis of ninety-five per cent. of all the ills to which human nature is heir or upon some joint or muscle condition which can be corrected by manipulation or massage. These patients have, as a rule, been suffering a good deal before this from the thought that they were afflicted with a progressive constitutional condition which would almost inevitably cripple them. Often they have seen patients who were suffering from arthritis deformans in its worst forms and advanced stages; they have heard this called rheumatism and they have concluded that it was only a question of time when they would be in the same condition. There is no good reason to speak of such conditions as rheumatic. They are entirely local, the hope of relief between attacks is by properly applied massage and passive movements which facilitate the blood supply in the neighborhood, and the best applications at the time of discomfort are the various rubefacients which stimulate the circulation in the parts, call the blood to the surface, and prevent that congestion in the neighborhood of small nerves which is the cause of the aches or pains. These affections take on a much more serious character in the minds of patients as soon as the word rheumatism is mentioned. To tell them that the condition is entirely local, has no tendency to spread, has nothing to do with any constitutional condition, and can be relieved by local measures and the improvement of the general health, will often bring the patient a good measure of relief.