Treatment.—Mental Persuasion.—The patient must be made to realize that his affection is not rheumatism, but is due to local conditions. Just as soon as a patient's mind is relieved by being made to appreciate that certain habits in his occupation, or certain local conditions that can be corrected, [{406}] are responsible for much of his discomfort, then that discomfort is much easier to bear. Even in cases where actual neuritis has developed, or where there have been changes in the intermuscular planes bringing considerable disability, the aches caused by these will be much more bearable if the patient's mind is set at rest as to the real significance of the condition. No condition should be called rheumatic unless at some time in the history of it there was an acute inflammatory condition with Galen's classical symptoms—tumor, color, rubor and dolor. Pain alone is never sufficient to justify the diagnosis. Painful disability is usually due to local causes.
Treatment of Acute Symptoms.—For acute symptoms, the coal tar products may be used and usually afford distinct relief. They include all the old-fashioned salicylates as well as certain more recent compounds, such as aspirin. Phenacetin, however, though usually not thought of in this connection, is an excellent remedy for the discomfort. These drugs should be used freely so as to give relief from the painful condition. The fact that they afford relief, however, should not be taken as an argument that the condition is rheumatic. Rheumatism, as we know it, is an acute infectious disease and there is no reason in the world for saying that the salicylates or cognate drugs are specifics in this affection. They relieve the pain, but just in the same way they would relieve the pain of toothache or of any other painful condition. After the acute symptoms are removed, the condition that remains may be treated in various ways, by massage, by local applications, and by such manipulations as will restore the normal circulation of the part. Care must be taken, however, to distract the patient's mind from the local condition after a time, or mental influence, by interfering with the capillary circulation, may inveterate the symptoms. It is not good to keep patients at rest, though rest, of course, is always indicated if there is much discomfort. Sometimes, however, the discomfort is really due to the fact that muscles have not been used for some time and so are easily fatigued and may ache even under ordinary use. In this case, a gradual restoration of the muscles to normal strength by progressively increased exercise is important.
Counter-Irritation and Its Suggestive Value.—Personally, I have found the use of turpentine particularly efficacious in connection with suggestion. The old-fashioned system of ironing seems to do more good than any ordinary application of turpentine. For this a piece of flannel wrung out in warm water has some turpentine scattered over it and then is placed on the affected loins or back of the thigh and covered by another piece of flannel, and a hot flat-iron is rubbed over it. The physical effect is a considerable hyperemia, but the effect upon the patient's mind is especially interesting, the unusualness of the mode of application adding decidedly to the effect. It must not be forgotten, however, that there are some people who are over-susceptible to the influence of turpentine, and its use is followed by a rash.
Lumbar and Sciatic Psychoneuroses.—Many cases of lumbago and sciatica are really psychoneuroses. They develop exactly as psychoneurotic conditions do in the abdomen or in joints. Not infrequently there is some accident or injury, some sprain or strain, or exposure to dampness or draft, that serves as the occasion. The Germans group all these occasions together under the word "insult." The "insult" produces little physical effect but after some days or sometimes weeks, the slight discomfort present secures the center of [{407}] attention and then the patient suffers from what seems to be severe pain and often inability to move or use muscles. Even when there is true sciatica or lumbago, that is, a genuine low-grade neuritis of the lumbar or sciatic nerves, most of the symptoms may come from the associated psychoneurosis. This is proved to be so by the fact that such patients are often cured, for the time being at least, by some shock or fright or sudden excitement, that makes them move, forgetful of the pain and inability from which they suffered just before. Besides, such cases are often cured by inert remedies of many kinds, by local applications that have no specific effect, and by various methods of treatment which cannot be responsible for the recovery. The amelioration of the condition is due to the mental influence accompanying the methods of treatment and the reassurance of the patient's mind.
Diversion of Attention.—Almost anything that produces a continuous succession of sensations on the surface of the affected area that attract and hold the attention of the patient may prove a valuable therapeutic suggestion and even eventual relief from symptoms that have proved obstinate to more rational treatment. Liebault, the well-known founder of the Nancy school of hypnotic therapeutics, tells in his "Thérapeutique Suggestive," that he has frequently cured lumbago by the simple recommendation of a rather stiff piece of paper to be applied over the patient's loins. The rationale of this treatment seems to be that the patient's attention is attracted to the skin surface by the sensations constantly produced by it and attention is distracted from other feelings deeper in the muscles. It often happens that after an acute lumbago has run its course, there is left a chronic achiness only partly physical and largely psychoneurotic. Some of it is undoubtedly due to the habit, formed during the acute period, of keeping the muscles quiet, in order to avoid the spasmodic pain that occurs on movement. Patients cannot, as it were, let go of their muscles, and their discomfort is largely due to holding them in a cramped position. The sensation produced by the paper on the cutaneous nerves distracts the attention and brings about relaxation of the muscles with decrease of discomfort and gradual relief of all symptoms.
The paper acts as a constant source of suggestion for the cure of the psychoneuroses when the affection is purely psychoneurotic. The mind has become concentrated on the idea of pain and discomfort in this region and needs another thought to occupy itself with so as to neutralize this. Wearing the paper with the assurance, for instance, that because of its impermeability to air it keeps the part more thoroughly protected from variations of temperature and from such possibilities of transudation as have before been possible, serves to lift patients out of themselves and affords relief. Whenever the sensation produced by the paper is noted, there is a renewal of the suggestion and its curative effects. There are many plasters that have obtained the reputation for curing lumbago. It is doubtful whether any of these have sufficient medicaments on them to be of any serious pharmaceutic significance. They are mostly rubber plaster. The presence of this and the consciousness of the sensation produced by it acts as favorably as does Liebault's sheet of paper.
Mechanical Agents.—It must not be forgotten, however, that a large sheet of adhesive plaster firmly applied may act as a mechanical therapeutic agent, somewhat in the same way that strips of adhesive plaster relieve the pain of pleurisy, or are helpful in a sprained ankle or a knee. The muscles may be [{408}] held rather firmly together and so there is no necessity for constant attention to prevent spasmodic pain. Undoubtedly some of the newer large-sized adhesive plasters produce an excellent effect in this way. If, besides, the patient has the feeling that they must be doing him good because of materials in their composition, the psychoneurotic elements are more readily relieved. The old idea was that such plasters drew out the pathological elements to the surface whence they were dissipated. There is no truth underlying this thought.
In the old days blisters were applied rather freely to these regions and the actual cautery was often employed. Both of these therapeutic processes are likely to do good in chronic cases, but much more from their psychic than their physical effects. The actual cautery is not used nearly so much as it ought to be in chronic muscular and neurotic conditions, for the mental effect of its application and the distraction of attention to the skin surface while the cauterized areas are healing are excellent remedies.
There are other counter-irritant procedures of the same kind that have been used with reported successes in many cases. Hot needles, for instance, if pushed deeply into the muscles, often have an excellent effect. Some years ago a distinguished surgeon insisted that both lumbago and sciatica might be cured in many cases by the insertion of needles deeply into the muscles. He argued that what happened was that these needles brought about an equilibrium of electricity in the muscular structures which had somehow been disturbed. Deep injections of water into the muscles also do good. Stretching of nerves has been applied with reported success. After a time all of these measures fail, however, because somehow after the novelty of the treatment wears off for the physician, the patient's mind is not sufficiently impressed and then the former results are not secured. Where there are actual neuritic processes present they will almost surely fail. So many of these cases are almost pure psychoneuroses, however, that it is little wonder that anything which produces a strong impression on the mind and leaves after it some condition that attracts attention and so furnishes favorable suggestion will almost surely cure even chronic conditions for which all sorts of physical remedies, employed on rational grounds, have failed.
Anything that modifies the circulation, even to a slight degree, or by causing a reaction in the local vaso-motor state, alters previous conditions, tends to enable the patient to control the affected part. These psychoneurotic conditions in large muscles help us to understand what happens in organic diseases. There is a physical element that must be modified, but unless a strong influence is brought to bear upon the mind so as to arouse all its capacity for control, the cure will not come. Anyone of a dozen things, however, may be used in this way and often when one fails another will succeed. In obstinate cases of lumbago and sciatica if necessary a number of these forms of treatment should be used successively.