Hypnotism.—How much pure psychotherapy may mean for many of these obstinate cases of lumbago and sciatica can be appreciated from the many reports of cures by hypnotism or by suggestion in a light hypnoidal state, or occasionally, under favorable circumstances, even in the waking state. One of these cases, indeed, is responsible to some extent for the French interest in hypnotism which attracted so much attention in the last quarter of the [{409}] nineteenth century. Prof. Bernheim of the University of Nancy had seen a case of sciatica in which every therapeutic means at his command had failed. As the result of disuse the leg was emaciated and possessed little muscular power. It looked as though the man would never be able to regain the use of it properly. Dr. Liebault succeeded in curing the patient by light hypnotic sleep, in which the suggestion that he would be better was given while the physician stroked the limb. After the first seance the patient was able to use the leg better and the discomfort was greatly decreased. Further seances with Dr. Liebault brought further improvement until finally the condition was cured. Prof. Bernheim, who knew how intractable these cases are, had the case called particularly to his attention and naturally wanted to learn more about the method by which it had been brought about. Liebault's methods had been quite contemned by the regular faculty before. After a series of experiences under Dr. Liebault's direction Prof. Bernheim became enthusiastic over the use of hypnotism as a curative agent and this led to the publication of his well-known work "De la Suggestion et ses Applications dans la Thérapeutique." [Footnote 34] It was the interest aroused at Nancy that led Charcot to take up hypnotism, and while he came to very different conclusions, there is no doubt that the work at Nancy meant much for our knowledge of suggestion in both waking and hypnotic state in therapeutics.

[Footnote 34: On Suggestion and its Applications in Therapeutics.]

CHAPTER VII
PAINFUL KNEE CONDITIONS

Most of the painful knee conditions of which patients complain are not directly due to true pathological conditions either of the knee joint itself or of its neighboring structures, but rather to affections of other portions of the leg that set a special strain upon the knee and, above all, to various kinds of foot disturbances. The erect position is maintained principally by a nice balance of nervous and muscular energy in the knee joint and its surrounding structures. Any irregular sensory or motor impulses to the knee-joint or to the muscles of the thigh will disturb the absolute equilibrium of the flexors and extensors and will make standing painful or even impossible. Whenever a morbid condition requires a different use of the muscles and tendons around the knee from that to which they are accustomed, fatigue readily ensues, and aches and even tenderness in muscles and tendons develop as the result of the over-exertion. These collateral conditions must not be overlooked in the diagnosis and treatment of painful knee conditions.

Etiological Factors.—Even a slight sore on one foot will give rise to considerable achy fatigue of the knee of the opposite leg, because, consciously or unconsciously, we stand much more on that leg, use it more in walking, and spare the other because of the pain induced by use of the foot. Above all, throwing more weight on the other leg causes us to use muscles a little abnormally with consequent soreness. This painful fatigue is most likely to be felt around the knee, though it may extend to the hip and even the lumbar [{410}] region of the well side if the foot continues to be spared for a number of days. Particularly will this be true if there is anything the matter with the big toe, on which so much of the use of the foot depends. An ingrowing toenail will not infrequently give so much discomfort to the well knee and hip as to make the patient sure that there must be some rheumatic or other condition at work in these joints. The serious affection of the joint which the patient apprehends is found to be no more than a sympathetic fatigue induced by having to use his feet, or one of them, a little differently from usual, perhaps because of some condition that leads him to spare them. To call the patient's attention to this is of itself therapeutic.

Inequality of Legs.—The effort required for standing and the accurate balance of the muscles involved in it is such that any mechanical disturbance of the feet or legs or even a trivial pathological condition causes painful fatigue. It must not be forgotten, for instance, that the presumption that human limbs are of exactly the same length is not confirmed by accurate measurements. There is an average difference of probably half an inch in length between the limbs of normal persons, and there may be even a difference of more than an inch before deformity is said to be present. The longer limbs are likely to do more work and are, therefore, more subject to fatigue and consequent complaint. One of the reasons why we can distinguish persons by their gait even at a distance is that the difference in the length of their limbs makes noteworthy characteristics in their walk.

High Heels.—People who are used to walking in a natural manner and who don a pair of high-heeled shoes for the first time are sure to complain of pain in the calf and knee, because the high heels require them to hold the knee more rigid and in a somewhat different position from that required when the persons stand under ordinary circumstances. It is the unusual in muscular effort that gives rise to the extreme fatigue which becomes positive pain if it is allowed to continue. It is curious how small a raising of the heel will cause discomfort. Over and over again I have known the careless putting on of rubber heels to be responsible for pains around the knee, which in damp weather were the source of so much discomfort that it was hard to persuade the patient that he was not suffering from rheumatism or some serious incipient pathological condition.

Unusual Occupations.—Joint pains often develop after the patient has been doing something quite unusual and putting an unaccustomed strain upon his muscles. I have often seen dispensary patients whose knee pains began after there had been a family moving. In the course of the removal of household goods, both men and women are likely to help in hanging pictures, in taking them down, in moving heavy furniture and other occupations of this kind which make them extremely tired. If there is any tendency to relaxation of joint structures the tiredness may manifest itself as a sense of painful discomfort. The knees are particularly likely to suffer if there is a relaxed condition anywhere in the leg. It must be remembered that the laxity of tissue which predisposes a patient to weak or flat feet will have a tendency to produce some looseness of fiber, at least, also in the tissues around the knee. The patient may not have a wabbling knee, nor may he be able to overextend the limb, but still there will usually be some noticeable relaxation of the tissues which will help in the production of the painful condition by [{411}] making exaggerated calls upon the muscles in order to keep the joint in proper position in spite of the over motion in it.

The disturbance is most frequent in waiters, store clerks, tailors' cutters and fitters, bench men in the trades, and in all those who have to spend much time on their feet. I have seen many such ready to give up their occupations, though they had no other resource and the future looked very blank, indeed, away from their work. It was difficult at first to persuade them that a slight yielding of the arch had so changed mechanical conditions in the use of the muscles of the leg as to produce such pains. But as soon as they were put in a condition where their arch was not allowed to sink, they were at once relieved of their discomfort to a great extent. The question of treatment is discussed more fully in the chapter which follows on [Foot Troubles].

An interesting set of painful conditions around the knee develops in a class of people in whom it might least be suspected of being due to over-exertion connected with their occupations. These are lecturers, clergymen, teachers, and others who, for several hours each day, are on their feet in a position from which, as a rule, they do not move, but stand almost perfectly quiet. A distinguished laryngologist has pointed out that not infrequently men who come to be treated for the chronic laryngitis, which is known as clergymen's sore throat, but which is seen so frequently in those who have to talk in the open air, auctioneers, cart-tail orators about election time, and in lecturers to large audiences who do not know how to use the voice, also complain of grievous discomfort from painful knee conditions which often makes the ascent or descent of stairs a painful task. He attributes the simultaneous occurrence of these conditions to some blood dyscrasia, uric acid, or the like, affecting the two most used sets of muscles and organs, the legs and the vocal cords. Whenever I have seen this condition—and circumstances have brought me into intimate personal relations with many clergymen and lecturers—the trouble at the knee has been due to some yielding of the plantar arch, while the laryngeal condition, if present, was due to an erroneous mode of using the voice consequent upon lack of proper training.