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."