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 role 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 role 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 role 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.

{375}

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.

{377}

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.

{379}

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.

SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS

How much the treatment of these so-called chronic rheumatisms depends

on suggestion, in spite of the apparent improbability of anything so

materially discomforting being under the influence of the mind, is

best appreciated from a consideration of the many inert materials that

have been used for the cure of rheumatism. There is, of course, no

more virtue in red flannel than in any other colored flannel, but many

people suffer from rheumatism or rheumatic discomfort whenever they do

not wear red flannel and are sure that it means much for them. Then

there are all sorts of supposed electrical contrivances that do not

generate an ion of electricity. They are effective only through the

appeal they make to the mind. Some men wear electric belts and

attribute their freedom from rheumatic pains to them. Others wear

so-called electric medals or electric shields or electric insoles. Any

number of people in this country wear electric rings on the little

finger of one hand and get marvelous relief from it for their chronic

rheumatism. Some have noted good results from even less likely

objects. There are thousands in this country who carry horsechestnuts

as a preventive against rheumatism, and some of {386} them,

intelligent men and women, are persuaded it lessens their pains and

aches.

In another place I have told the story of the woman who was a sufferer

from rheumatism and who found great relief from carrying a

horsechestnut. As her husband was also a sufferer, she wanted him to

carry one, too, and when he would not, she carried one for him. It is

to be hoped that her conjugal tenderness in this matter had as good an

effect on him as she was sure the propinquity of the horsechestnut had

on her.

The patients' occupations must be regulated by proper advice and

detailed directions, and distractions of various kinds must be

provided to keep their minds from becoming concentrated on certain

portions of their body, emphasizing whatever discomfort is present and

preventing nature's curative processes. Finally, local treatment of

various kinds must be employed suitable to each individual case, that

will remove all mechanical difficulties, disperse congestions, relieve

fatigue and over-tiredness, and make conditions favorable for the

healthy, normal use of joints and muscles.

Many painful affections of joints, sometimes complicated by

immovability, are really psycho-neuroses. Sir Benjamin Brodie once

said that four-fifths of the joint troubles that he saw among the

better classes were hysterical. Sir James Paget thought this an

exaggeration, but confessed that he saw many of them and among all

classes of people. One-fifth of those that he saw in hospital and in

private practice were entirely neurotic. He emphasized the fact that

they must be looked for not only among women but that they are often

found in men and that they are by no means confined to those who are

nervously inclined, the silly young women or the foolish old women,

but that they may be found in special circumstances among the most

sensible people. They are often initiated by an injury which makes it

quite difficult to differentiate them from real joint affections.

Usually, however, there is no redness, nor swelling nor heat with

them, though sometimes one of these symptoms at least may occur with

the redness. The connection between the trivial accident and the large

reaction is usually hard to find and causes a suspicion as to the real

process at work. Often, too, there is a delay of several days or

sometimes weeks after the accident before the neurosis declares

itself. In the meantime it has been getting on the patient's mind.

In general, it must be remembered the patient's attitude of mind in

these cases of pain around joints and in muscles is extremely

important. They have furnished a goodly proportion of the patients on

which quacks and charlatans have fattened. Greatrakes in the

seventeenth century, Mesmer and Perkins, St. John Long, the early

electrotherapeutists, the blue glass faddists, all the various

liniment makers, many of the manufacturers of blood purifiers, and

Eddyism and mental healing besides osteopathy in our day have all

benefited these sufferers for a time and the patients have often been

men and women of education and influence in their communities and have

exerted their influence for the benefit of their supposed benefactors.

The methods of treatment come and go. The promise of the physician or

the healer and the confidence of the patient are the only factors that

are common to all the supposed "cures." If people stay at home without

the air and exercise they should have, if they nurse their ills and

consider that they are sure to get worse, because they labor under

hereditary or constitutional ailments, nothing will benefit them.

{387} If they are convinced that their disease is only local and begin

to go out to see their friends once more, a change comes over the

whole aspect of their disease.

CHAPTER II

OLD INJURIES AND SO-CALLED RHEUMATISM

As people advance in years, it is a common experience that tissues

injured years before are the source of no little discomfort and are

particularly prone to be bothersome during changeable seasons and in

rainy weather. A bone broken when the patient was young may twenty or

thirty years later continue to give warnings of the approach of change

in the weather and be a source of annoyance. A dislocation, especially

if complicated in any way by considerable laceration of the tissues in

the neighborhood of the luxated joint, is sure to be a source of

discomfort of this kind. These painful conditions are generally more

noticeable when patients are run down, or when they have been recently

affected by exhausting disease of any kind, during convalescence from

severe ailments or injuries, or when they are undergoing a special

mental strain. These conditions, like nearly all others worse in damp

weather, are sometimes grouped under the term rheumatism and have been

treated by internal medication. Almost needless to say, such treatment

is sure to fail or to be of only temporary anodyne benefit. As

rheumatic remedies are usually coal-tar products they may even be

distinctly harmful, especially for old patients. It has been shown

that the salicylates, for instance, are much less rapidly eliminated

in the elderly than in the young, in those with defective circulation

or kidney insufficiency than in the well. Their accumulation in the

system causes anemic tendencies and disturbs nervous control.

Just what is the underlying pathological condition in these cases is

not easy to say. In the case of luxations with laceration of tissues

there has undoubtedly been such a disturbance of venous and lymphatic

circulation by the break in continuity of tissues and the resultant

scar tissue, that lymphatic if not also venous congestion occurs

whenever there is any circulatory disturbance. For the maintenance of

normal nutrition of nerve endings a constant flow of blood past them

and a proper action of the lymphatic channels to carry off waste

products is essential. It is easy to understand how much these may be

disturbed in the injuries under consideration. When a bone is broken

there is usually laceration of the surrounding tissues. Owing to the

fixation required to procure proper bony union, the circulation to the

part is much more defective than usual and so the repair of torn lymph

and venous vessels is not as complete as would otherwise be the case.

This seems to explain why such injuries are especially called to the

attention of the patients in damp weather. It is not so much during a

rain storm as some hours before it, about the time when the barometer

begins to drop, that these old injuries become sensitive. Indeed, it

is often said that old persons who have suffered one of these injuries

earlier in life carry a barometer around with them.

Not a few of the lesions called sprains, especially those of the

ankles and {388} wrists, though also of other joints, are often really

breaks of small bones, or at least laceration of ligaments and other

structures. These may long afterward prove a source of pain and

discomfort, worse always in unsettled weather, or after the feet have

been wet, and may seem to be due to some constitutional condition,

though they are merely local. These occur more commonly in women than

in men and the condition needs careful investigation and must not be

put under the vague diagnosis of rheumatism, or the patient will

probably not be improved by the treatment suggested. In all these

cases the general condition must be looked to, and it must not be

forgotten that fat may not mean health, and that increased weight may

be a prominent factor in the production of symptoms in these cases,

especially when individuals live a sedentary life.

There is an important therapeutic method for the prophylaxis of these

conditions that has been attracting attention and yet probably not all

the attention it deserves in recent years. Prof. Lucas-Championniere

of the University of Paris has pointed out that when fractures and

dislocations are treated by the open method with easily removable

apparatus and the employment of massage within a few days after the

fracture, the subsequent discomfort of these lesions is much lessened.

It seems worth while to emphasize this treatment by manipulations and

massage, because it represents a psychotherapeutic factor in the

treatment of these injuries. The hiding away of a limb or a joint for

days and perhaps weeks, while they wonder whether it is getting better

or not is most discouraging to patients. To have the physician see it,

to have him declare that it is getting on well, to have the evidence

of their own senses that conditions are gradually improving, is of

itself a valuable factor for that satisfaction of mind which conduces

to the regular functioning of tissues. Repair undoubtedly goes on

better under such circumstances. Besides, the lack of constriction or

at least its rather frequent periodic relaxation, the airing of the

skin, the regulation of the circulation by massage and manipulation,

all react upon the mind and prevent it from inhibiting trophic

impulses and encourage it to stimulate them in every way.

As to the after-effects of fractures and dislocations as with regard

to all this series of vague pains and aches, the patient's attitude of

mind is of great importance. As they get older their aches and pains

grow worse, partly because circulation is more defective and partly

because they are prone to be much more in the house and the nerves of

patients who are much within doors are always more sensitive than

those of people who are much in the open. If their attention becomes

concentrated on their pains and aches, because of lack of diversion of

mind, then the condition may become a source of serious annoyance.

When these painful conditions develop patients are almost sure to keep

much to themselves and to nurse their ills, and consequently to

increase their discomfort. The circulation to the affected parts must

be stimulated by local treatment, by rubbings, by the milder

liniments, by massage and manipulations, and by local hydrotherapy.

Douches, as hot as can be borne, on the limb followed by cold,

especially if patients are otherwise in good health, will do much to

relieve the stagnant circulation.

Active and vigorous movement while the affected part is supported at

_skin pressure_ (there must be no constriction) is even more valuable

than {389} massage, liniments or douches in the treatment of all these

painful conditions of joints in which there is any scar-tissue.

Wonderful results may be obtained in an old sprain of the wrist, knee

and ankle by covering in the part completely (taking care to surround

the limb) with strips of adhesive strapping simply laid on at skin

pressure, but following exactly every fold or angle of the part, and

then with the part completely covered in this way to urge immediate

and constant exercise. The maintained pressure prevents any tendency

to venous congestion or exudation and favors absorption of fibrous

tissue, and exercise, which should be immediate, is now possible

through the support furnished by the strapping. The re-assumption of

normal active movement molds the old scars, strengthens the muscles

and ligaments and improves the patient's general condition. The relief

afforded _is immediate_, and the cause of relief, a simple mechanical

device, is apparent. Rheumatism is forgotten as the old crutch is

discarded and the patient is able to use the limb with confidence.

Recent sprains or bruises treated in this way recover perfectly and do

not leave old scar tissue to be a future seat of pain.

CHAPTER III

MUSCULAR PAINS AND ACHES

Whenever exposure to cold causes a period of discomfort in almost any

organ, except the teeth and certain definite nerves (for neuralgia has

been taken out of the rheumatism group in recent years) we are sure to

hear the word rheumatism employed in connection with it. To add to the

confusion, the various "specialists" have taken to assuring their

patients that local manifestations in the eyes, in the ears, and in

the nose, for which they can find no good reason, especially if they

are worse in damp weather, are signs of the rheumatic diathesis.

Unfortunately, our supposed knowledge of the uric acid diathesis

became widely diffused, and it is not surprising in the light of the

widespread acceptance of this theory, that muscular pains of all kinds

should have the word rheumatic attached to them, and that patients are

sure that the discomfort is only one manifestation of a severe

constitutional disease, which they cannot but infer will probably make

still more serious trouble for them in years to come, since it seems

to be dependent on conditions beyond their control, such as heredity

and general constitutional traits and their special mode of nutrition,

rather than on local or passing conditions.

Local and Constitutional Conditions.--It cannot be repeated too often

that it is this persuasion as to the constitutional character of the

disease that has in recent years proved a very unfavorable suggestive

element in these cases. Patients think themselves the victims of a

serious diathesis, a deep-seated pathological condition, and attribute

a host of feelings to it that are sometimes rather seriously

disturbing but are really only sensory manifestations of various kinds

in the organs and in the skin and muscles, which would be attributed

to simple local causes--fatigue, faulty mechanical conditions,

etc.--but for the concentration of attention on them.

{390}

_Individual Cases_.--The careful study of these cases is thus

extremely important. They are eminently individual and not to be

grouped together. The exact diagnosis of the various conditions from

which each patient is suffering is of itself a precious factor in

psychotherapeutics. The precise recognition of the condition present

is of immediate avail in helping him to dismiss many of his symptoms,

or at least to keep him from thinking as much of them as he did before

or inevitably will if the older ideas as to the constitutional nature

of his affection are allowed to remain.

Nearly every large group of muscles in the body may be the subject of

these painful conditions. In recent years, perhaps, the muscles most

affected in this way are those that pass around the ankle and give so

much discomfort in cases of flatfoot, or beginning flatfoot

(euphemistically called weak foot), when the plantar arch is yielding.

The manifestations are not only in and around the ankle, but occur in

the calf muscles and even above the knee. These painful conditions

always develop unless the arch is supported. Until recent years it was

rare to discover a bad case of flatfoot in which the patient had not

taken many rheumatic remedies and had not come to the conclusion that

he was the subject of an incurable and probably hereditary

constitutional disease. Flatfoot is likely to cause considerable

deformity in the old, the toes becoming bent and twisted up, and the

subjects of it complain very much of their feet. Flatfoot runs in

families. When the father and mother have complained of what they

called rheumatism in their feet which got worse every year, then the

son and daughter, when they have their first manifestation, conclude

that they are inevitably bound by the stern laws of heredity.

Occupation Aches.--Flatfoot is taken, however, only as an extreme and

therefore striking illustration. Whenever a particular group of

muscles has to do an excessive amount of work, practically always

there is a development of an uncomfortable condition worse on rainy

days and therefore likely to be called rheumatic. Over-use of the arm

at any occupation, in writing, in the use of a file, at an

ironing-board, in sewing, or at anything requiring repeated movements,

will produce it almost inevitably. Especially is this true if the

occupation is carried on without such careful attention to muscular

action as enables the muscles to do their work to the best advantage.

These painful conditions are much more likely to occur in run-down

individuals of nervous temperament, above all if they have been or are

subject to worry. Men who have lost money and now have to do hard

physical work, after previously having lived sedentary lives, and

women whose previous source of support has been withdrawn and who have

to work for a daily wage after former gentle conditions of living, are

especially likely to suffer in this way. The conditions develop on a

neurotic basis or an exhausted nervous system.

Other groups of muscles may also be the subject of these painful

conditions. The large group in the loins, called the lumbar muscles,

which are so important for stooping, for the erect posture and for

lifting, are so commonly the subject of discomfort that a special name

has been applied to their affection--lumbago. In the leg the large

group of muscles supplied by the sciatic nerve are likely to be

affected, and this affection is so common in men who have to bend the

knee and flex the hip at their work that it, too, has received a

special name--sciatica. Besides the arm muscles the groups of muscles

around the shoulder girdle are often unfavorably affected and though

we have not invented {391} a name to cover their conditions, it is so

common that we think of it as a separate entity almost in the same

manner as we think of lumbago and sciatica. In the neck the group of

muscles that rule the movements of the head, especially those at the

side may be affected and the special name of torticollis has been

given. Practically all of these affections are thought of at times as

rheumatic and the ordinary rheumatic treatment is given for them.

There is no doubt that the salicylates will relieve the pain almost at

once, but so will any other coal-tar product and phenacetin,

acetanilid or even antipyrin may be used with good effect. There is no

evidence, however, that these drugs make the underlying condition

better and, indeed, after patients have tried them for a while, unless

the affection is merely passing, they try some other physician and

perhaps are treated the same way with a different form of the drug.

These are the cases that make their way around to a number of regular

practitioners of medicine and then eventually go to some irregular or

quack and sometimes obtain relief where the regulars have failed.

When the irregular succeeds it is always because he has done three

things. First he has persuaded the patient that it is not rheumatism,

with all the unfavorable suggestion that goes with that word, that is,

the matter with him; secondly, he has treated the local condition;

and, thirdly, he has diverted the patient's mind. Local treatment is

often the real secret of his success, though the psychotherapeutic

element is not without distinct benefit.

Mode of Occurrence.--These muscular conditions present themselves

under two forms, acute and chronic. The acute condition occurs almost

suddenly and is accompanied by spasmodic pain and acute discomfort.

Muscles go into spasm to avoid the movement that would necessarily

bring pain with it. A typical example is found in torticollis in which

the patient wakes up some morning to find a stiffness in the muscles

of his neck with limitation of movement much more pronounced on one

side, and this usually gets worse as movements are attempted during

the day. This spasmodic painful condition usually lasts for some days

and suggests all sorts of topical applications and often requires

anodyne drugs. A similar acute condition may be observed in some cases

of lumbago. In this the pain in the loins comes on suddenly, usually

during movement, often in the midst of lifting something that one has

been able to lift without difficulty before. This pain is so sudden,

so unexpected, usually comes entirely without warning and seems so

mysterious in its origin, that it is no wonder the Germans speak of it

as _Hexenschuss_--"witches' shot"--a remnant of the superstition that

a witch, by means of the evil eye or some other maleficent power, or

by sticking pins in a wax image of a victim that had previously been

devoted to the devil, might produce effects upon the person at the

part where the thought was directed or the pin inserted.

These painful conditions, especially when acute, are, as a rule the

consequence of exposure to dampness, or to a draft blowing directly on

the part, usually in damp and changeable weather, and often when the

patient has been sweating just before. The train of events that brings

about the painful condition is not difficult to understand. There is a

disturbance of the normal smooth-running, indeed almost frictionless,

mechanism by which muscles glide over one another. There are

practically a series of joints in all muscular groups so as to permit

just as free a play as possible of muscles over one another. Each

muscle is covered with a glistening membrane so familiar {392} from

our dissecting room days, which secretes a substance resembling a

synovial fluid, to enable muscles to move upon each other without

friction. When, because of exposure to drafts or the evaporation of

moisture on the surface, there is a disturbance of the circulation in

these intermuscular planes, the secretion which prevents the friction

of muscle movements is disturbed. The blood is driven from the surface

and some congestion and consequent heat accumulation occurs in the

muscles, affecting particularly their contiguous layers. As a result,

the muscle surfaces are no longer smooth and the muscles now have not

as free play over one another as before. It is not surprising that,

owing to this, sensitiveness occurs and some spasm develops. This,

however, is thoroughly conservative in character since nature's idea

is to set the part at rest so as to allow the normal condition to be

restored.

This is the pathological condition that underlies these so-called

muscular rheumatisms which develop suddenly. It is important to note,

however, that these conditions develop nearly always in people who

have been over-using or wrongly using the groups of muscles which

become thus affected. The history of a torticollis patient will

usually show that there is some contortion of the muscles of the neck

familiarly practiced by him. Sometimes it will be found that the

patient has the habit of sitting on a particular easy chair in a

special relation to the light and that in order to accommodate himself

to his chair and the light in his reading, the head has to be placed

in such position that the neck muscles are constrained. It is this

that predisposes the patient to the development of the condition which

seems to be so acute and yet is really only an exacerbation of a

chronic condition. Lumbago will develop in men who have been stooping

much, especially for heavy lifting, or in women who scrub or have to

stoop much while cleaning, dusting and the like.

Some interesting muscle pains occur as a consequence of the jostling

movements of various modes of transit. They are particularly

noticeable if an uncomfortable position has been maintained for a

number of hours. People who travel on railroad trains often come with

the story that they _must_ have caught cold on the trip for they have

been sore and achy in many of their muscles since. I have known people

who went on a crowded excursion and had to stand for several hours

confident that, standing in the drafty aisle of the car on their way

home, they had acquired rheumatism. All that had happened was

over-tiredness of muscles on the jolting train which required constant

balancing and unaccustomed muscular exertion. On board sea-going

vessels people often suffer from pains in the loins and in various

trunk muscles, due to the roll of the vessel, especially while they

are asleep. These, too, are likely to be attributed to drafts, or to

some form of rheumatism, or at least to the catching of cold. I have

even seen people sure, because of pains in their loins, that they must

be developing some kidney trouble. After a time they get used to the

swinging motion of the vessel and then their achy muscle tiredness is

relieved.

One now sees affections of the same kind in connection with the

automobile. People who ride for many hours, especially if the riding

is rapid and over a rough road and they are not used to it, are likely

to develop pains and aches which they may attribute to the catching of

cold or to rheumatism or to something of that kind. The muscles of the

trunk are especially likely to {393} suffer. The abdominal muscles may

be quite sore and then later the lumbar muscles develop aches. The

arms suffer if they are held in unusual positions because of the

jolting. The discomfort may be relieved by any of the coal-tar

products, though gentle rubbing with a stimulant such as soap

liniment, always in the direction of the return circulation in the

muscle, will help to relieve the painful condition. The salicylates

are often given for these conditions and relieve the discomfort but

because of their value as anodynes, which they share with the coal-tar

products, and not because of any genuine antirheumatic effect.

Treatment.--Counter-irritation of various kinds, especially the milder

forms, always seems to do good. The underlying therapeutic principle

seems to be that the attraction of blood to the surface lessens the

hyperemia or at least diverts the circulation and permits the

restoration of function and encourages the reintegration of normal

conditions. Rubbings are especially helpful if accompanied by rather

deep pressure from the periphery of the circulation towards the

center. The leg muscles must be rubbed upward, the arm muscles upward,

the neck muscles downward, the trunk muscles generally in the

direction of their return circulation. This would seem to indicate, as

might be expected, that it is the venous circulation especially that

is disturbed in the tired condition of the muscles, that a venous

congestion with interference with the nutrition of nerves accounts for

the aches; hence, a mechanical helping of the circulation is of

benefit. There are some whose opinion is not to be put aside lightly,

who think that the rubbing alone is the most important part of these

external treatments and that the liniments and counter-irritants are

only of secondary importance. Indeed, some consider that the tingling

of the surface is mainly beneficial in making the patient feel that

now that part of the body at least _ought_ to be better.

Liniments for these conditions, however, though introduced on merely

empirical grounds, are very old and have the testimony of many

generations as to their therapeutic efficiency. Whenever that is the

case, it is a serious question to doubt the conclusions that have been

arrived at. The experience of a single generation, and, above all, of

a small group or school of men, no matter how learned or how

scientific they may be, is often fallacious. The experience of many

generations, however, even though no good reason for the benefit

derived from the treatment they suggest can be found, is almost

inevitably correct. After all, though it is usually forgotten, the use

of mercury, of iron, of quinin and of most of the tonics depends on

nothing better than empiricism. In our day the liniments have been

neglected, more perhaps than was proper, considering how many

generations of physicians found them beneficial.

Where it is a neurosis rather than a real disturbance of the

circulation, however, that is involved, the use of a counter-irritant,

by attracting attention more and more to the part, may really do more

harm than good. In nervous people it must be remembered that local

neurosis may occur almost anywhere in the body and that subjective

discomfort alone in these cases must not be taken to signify a

pathological condition, unless the localization is such as to indicate

that a particular group of muscles is affected. The differential

distinction between a pure neurosis and a discomfort due to a true

pathological condition in the intermuscular planes is, that in the one

case a group of muscles is affected, while in the other a locality is

complained of, and {394} while local tenderness is likely to be a

marked source of complaint in the neurosis it is comparatively slight

as a rule in the muscular condition.

For the more chronic soreness and discomfort of muscle groups,

manipulations with massage are of great importance. Undoubtedly the

discomfort and soreness is due in most cases to a disturbance of the

venous or lymphatic circulation of the parts. This interferes with the

nutrition of nerves and leads to nerve sensitiveness from lack of

nutrition, or actual nerve irritation from pressure upon sensitive

nerve endings while in a state of congestion. These conditions may be

relieved by gentle manipulation and by massage, provided always these

measures are not painful. These encourage the circulation and very

soon tend to restore functions. Just as soon as the pain of these

remedial measures or of any mechano-therapy becomes noticeable, it is

not likely that they are doing any good. Pain, of course, must be

judged from conditions and not from the patient's complaints, which

may be due to fear lest pain should be inflicted.

The main point is that local treatment, gentle, simple, yet directed

with the proper therapeutic purpose so as to create a favorable

expectancy in the patient's mind, will do much for these conditions,

which have in many ways been the opprobrium of modern medicine. The

rule has almost been to call them rheumatism, because they were worse

in rainy weather. The word rheumatic instinctively calls up in most

physicians' minds some cut-and-dried formula of internal medication.

So these patients go the rounds of the regular practitioners in

medicine taking a series of these formulae in succession and, as a

rule, not getting any better. Then they go to an osteopath or to a

naturapath, or some other kind of path, have some local massage and

manipulations performed, which restores the circulation of the part,

to some degree at least, and as a consequence they are encouraged to

look for further relief. Not a few of them find the relief they look

for, and it is these cured patients that in many parts of the country

have insisted on securing for the osteopaths legislative recognition

and actually obtained it for them in many cases, just because the

regular physicians have neglected methods of cure ready to hand, but

not made use of, because drugs are allowed to occupy their attention

too exclusively.

Disuse, Atrophy and Pain.--I have seen a striking example of atrophy

and pain due entirely to disuse in the upper part of the leg as the

consequence of a fall. No bone was broken, the man was laid up for

nearly a month from the wrench, and then continued to be somewhat halt

for many years. After nearly twenty years his attention became

concentrated on this limb and then he spared it more and more in his

walking, tilting his pelvis and merely swinging that leg, until there

was a difference of nearly two inches between the size of the thighs.

Of course, under these circumstances any use of the limb brought

fatigue and pain with it. To walk was painful, and he had some

twitchings at night. There was no disturbance of sensation, however,

anywhere and no reaction of degeneration. His knee jerk was slighter

than on the other side, but it was present and the weakness was due to

the loss of power in the muscles. It was only weak in proportion to

the atrophy of the muscles. This atrophy was not trophic in the sense

of any failure of nerve impulses from the central nervous system, but

was due to disuse, that is, it did not come from any nervous lesion,

central or peripheral, nor from any disturbance of circulation, but

from the dwindling of muscles that inevitably {395} comes when they

are not employed for their proper purpose. Power to use depends on

continuance of function.

All sorts of remedies had been employed in his case, but he did not

improve until he was made to understand that there was no bone lesion,

no lesion of nerves or muscles, and that what he needed to do was to

re-exercise his muscles gently but persistently and confidently back

to their normal strength. This was accomplished by exercise and

resisted motion, with care never to fatigue the muscles, but at the

first sign of tiredness to stop, taking up the exercises at first

twice, and then three and four times a day.

As can be readily understood, these curious atrophic muscular

conditions from disuse occur more frequently in the legs than in the

arms. They may, however, occur in the upper extremities and are noted

sometimes in the trunk. After all, certain of the stooping postures of

men as they get old are due to lack of use of the large muscles at the

back with consequent atrophy of them to the extent that makes standing

up straight an effort very fatiguing and even painful. To attempt to

straighten an old man by means of braces will lead to the development

of painful conditions of tiredness if the correction is emphasized. In

the arms the atrophic conditions are not so noticeable because the

arms may be used without having to do the hard work required of the

trunk and leg muscles in holding the man erect. It is the fear of the

strain put upon them by this weight that makes the disuse continue,

since there has come into the mind the thought that the muscles cannot

be used to bear the weight and the burden is thrown on other muscles

with unfortunate results.

Many of these atrophies from disuse are cured by mental influence of

one kind or another. They are the best sources of profit and

reputation of the "healers." Once the patients become persuaded that

they can use a group of muscles if they will, they begin to improve,

and it is only a question of six or eight weeks until they are so much

better that they persuade themselves that they are as well as ever. It

is easy to understand that if a person who has been lame for five to

fifteen years, vainly going to physicians of all kinds, is cured by

some new form of treatment, all the non-medical world is perfectly

sure that there must be much in the new method of treatment.

CHAPTER IV

OCCUPATION MUSCLE AND JOINT PAINS

There is one variety of painful conditions of muscles and joints,

often spoken of as muscular rheumatism or as chronic rheumatism and

frequently the source of so much discomfort that patients feel that

occupations must be given up, even at a great sacrifice. These deserve

a special chapter. They occur in persons who have some occupation

which requires them to use a particular group of muscles a great

number of times during the day. They are most frequent in the arms,

but they may be seen in the muscles of the neck, they occur very often

in the legs and are not at all infrequent in the muscles of the trunk.

Whenever a patient comes complaining of a painful condition in a

particular group of muscles, careful inquiry must be made as to his

{396} occupation, with details of the movements required. These pains

are, of course, as are all human discomforts, worse on rainy days and

in damp seasons, so that this has come to be known as rheumatic

weather. It is easy to assume without further inquiry that they are

rheumatic and this has been done frequently in the past.

There is scarcely any occupation involving frequent and habitual use

of muscles which may not be the source of discomfort if the actions

necessary for it are done in such a way as not to use the muscles to

the best mechanical advantage. In other words, there are a whole group

of occupation fatigues which may take on a character of painful

discomfort if the individual has not been properly trained in the use

of his muscles. This refers not only to the use of muscles in the

accomplishment of rather difficult tasks, but especially for those

that require nice co-ordination for their accomplishment, though they

may not demand the exertion of much muscular energy. In other words,

what we have to deal with are rather painful occupation-neuroses than

muscular fatigue in its proper sense.

Writers' Ache.--Perhaps the most typical example of these is the

painful conditions that may develop in connection with writing.

Writers' cramp is well known and consists in a contraction of muscles

which makes it increasingly difficult to hold the pen properly for

writing and may eventually make it impossible to do so. This is

accompanied by a certain amount of distress, but the writer's

discomfort that is much more common than writers' cramp does not occur

in the fingers, but in the large group of muscles just below the elbow

and may extend even to the shoulder. The pain is of a vague achy

character and as it is worse on rainy days and in damp weather, the

temptation to think of it as rheumatism is very great. It occurs in

people who write very much and rapidly, but especially those who write

in a bad position. Now that the typewriter has come in much less is

heard of it than before among reporters, but it used to be common with

them. There is very little hint that it is due to writing, unless one

makes careful inquiries.

_Gowers' Rule_.--Its occurrence can be lessened to a great extent by

following Sir Wm. Gowers' directions as to writing. Gowers was a

parliamentary reporter before becoming a physician and he learned the

difficulties of much writing and studied out the causes of the

discomfort as well as of the cramp and of the best methods to avoid

it. His rule is to sit on a rather high chair before a rather low

table so that the elbow swings free of the table and the writing is

what is called free-hand. The extent to which Gowers demands this

freedom of the elbow carried may be best appreciated from his

direction that the writing must be done in such a way that if a second

pen were fastened to the elbow, it would write exactly the same thing

that is written by the pen held in the hand. There must not be any

movements of the fingers nor of the muscles of the forearm. All the

movements required from writing must be accomplished from the

shoulder. Just as soon as sufferers from vague aches and discomforts

from much writing learn this method of writing, their aches disappear

to a great extent. My own experience in the matter, when, as a medical

reporter, I often wrote ten thousand words a day, taught me the value

of the suggestion. During one winter I suffered so much from

discomfort in the shoulder that I was sure that I had a progressive

rheumatic affection. Just as soon as I learned to write properly the

trouble was minimized to such {397} a degree that I realized that it

was merely a question of faulty writing. I have noted over and over

again, as is true in my own case, that if there has previously been

any injury in the arm, this discomfort is much more likely to develop

than otherwise.

Occupation Pains and Habitual Muscle Movements.--What is true for

writing is true for any habitual movement of groups of muscles

requiring careful co-ordination. I have seen it in marked form in the

makers of cigars and the strippers of tobacco. I have seen it in men

who do much filing and whose working bench is so high, that pressure

direct from their shoulders cannot be brought into play to supply any

force that is needed in carrying on the filing process. If such a

series of movements as filing is to be accomplished with comfort, then

the arms must be held straight, the force being applied from the

shoulders and not by the exertion of the muscles of the forearm, which

are meant only to guide and not to supply the needed pressure. The

Sloyd methods of working at benches are particularly important for

workmen if they are not to develop these curious painful conditions

which are due to habitual wrong use of muscles, and not to any

diathesis. Any and every form of work must be looked at from this

standpoint. Women often iron at a table or ironing board placed too

high for them, and as a result apply the pressure necessary through

their forearm muscles. If they are at all of nervous constitution they

will suffer rather serious discomfort from this after a time and this

will always be worse in damp weather. I have known women ready to give

up because of the discomfort thus occasioned, who found that they

could work without muscle discomfort for much longer periods, if the

ironing board was placed low enough.

_Arm and Shoulder_.--The occupation aches and discomforts in the arm

and shoulder are very frequent and their variety presents an

interesting study in the individual and his history. I remember once

having three cases present themselves at a dispensary service of the

Polyclinic Hospital on the same day, all presumably suffering from

rheumatism. One of them was a motorman suffering from the occupation

pains that so often come to those who use their arms overmuch, and the

pains seen so frequently, for instance, in baseball pitchers. These

pains are always worse on rainy days and in damp weather. There is of

course a large individual element as the basis of these. Why can one

man pitch nearly every day all season and not suffer with his arm

while another man cannot? We can no more tell the reason for this

difference than we can tell why one man is right-handed and another

left-handed. One individual has a store of nervous energy that serves

him very well. Another has a store of nervous energy that serves him

well enough for his left hand but not for his right hand. The mystery

would seem to be the original endowment of nerve force according to

the individual's constitution. The motorman who suffers severely from

putting on the brake of a heavy car will probably never be able to

continue his occupation with comfort to himself unless his sore arm is

due to some temporary condition, easily recognizable.

A second of my patients with rheumatism complained of his shoulder. He

had been first easily fatigued, then it was painful when he moved

much, most so on rainy days, and finally he had practically lost power

in it entirely. His occupation was that of finisher in a molding

works. He lifted a heavy hammer many hundreds of times a day with his

right arm, striking quick short {398} blows and using mainly his

deltoid muscle in the lifting process. It was just his deltoid that

was affected and the nerve supply had evidently given out. The third

man complained not of his right hand, but of his left and of his

forearm, not his shoulder, having lost power especially on the ulnar

side of his hand. He was a stonecutter, who held a chisel firmly in

his left hand, grasping it mainly with the under or ulnar side of his

hand, and consequently overusing the group of muscles supplied by his

ulnar nerve, leaving that structure open to pathological conditions.

There was just one feature in the history of all three that was the

same. They did not drink alcohol to excess often, but they did take

some whiskey straight every day. The easiest explanation seemed to be

that there was a neuritis set up in the nerves, which their

occupations caused them to use so much, and that, as a consequence,

the low grade neuritis finally developed to such a condition as to

make further use of the muscle supplied by the affected nerves

practically impossible. Just why alcohol will select certain nerves

and not others upon which to exercise its deteriorating influence and

why lead usually affects an entirely different set we do not know. In

the ordinary man of sedentary occupation who walks occasionally, as

his only exercise, his most used nerve is his anterior peroneal. Those

of us who are not used to walking much, know how soon this nerve

complains of fatigue when we take some forced ambulatory effort. It is

this nerve then that with most people is affected by alcohol. But any

nerve that is overused will apparently be affected the same way, and

as many outdoor workers take some whiskey straight pretty regularly,

it is not surprising to find that some of them have an idiosyncrasy

and develop a low grade alcoholic neuritis.

Alcohol, however, is not the only substance that acts thus

insidiously. I was once asked to treat a painter who was suffering

from intense tired feelings in his right forearm. They were always

worse on rainy days, and he had been treated for rheumatism without

avail. He had no signs at all of wrist-drop, there were no suspicious

signs on his gums and he had never suffered from constipation or

anything like lead colic. It seemed far-fetched, then, to say that his

muscles were fatigued mainly because of the irritating presence of

lead in the nerves supplying his right forearm. He slipped on the ice,

however, and sprained his wrist, and the next day turned up with a

typical lead wrist-drop. This fact of having lead poison develop

shortly after an accident is not unusual, just as a sprained ankle may

sometimes be the signal for an outbreak of alcoholic neuritis in the

lower leg which has been preparing for some time, the accident itself

being at least partially accounted for in many cases by the

awkwardness of muscles with disturbed nerve supply.

_Leg Occupation Pains_.--What is true of the arm is also true of the

leg. If a man uses his leg muscles very much and especially at any

mechanical disadvantage, he usually suffers painful discomfort that is

always worse on rainy days. Before the invention of the electric

dental engine, dentists used to suffer from this and the profession

talked about the "dentist's limp." This was also more painful in damp

weather and many of them were treated for rheumatic conditions, though

it was really only over-fatigue.

Neurosis and Neuritis.--There are many cases of painful conditions in

the limbs where it becomes difficult to diagnose between a neurosis

and a neuritis. The usual differential characteristic of tender points

along the course of the {399} nerve cannot be used in many patients

with confidence, because they are prone constantly to respond to the

question "is that tender" in the affirmative. Besides in a neurosis

there always seems to be a hypersensitiveness of the nerves involved

that may simulate the tenderness of neuritis. In a number of obscure

cases I have felt that the condition was a real neuritis when the

development of a corresponding condition on the other side, or relief

on one side followed by development on the other, has led to the

diagnosis of neurosis. Of course, a double neuritis may well occur in

the same nerve on both sides of the body under certain toxic

conditions. Double sciatica nearly always indicates glycosuria.

Diabetes may cause double neuritis in any other much used pair of

nerves. Alcoholic neuritis may manifest itself on both sides.

Ordinarily, however, the transference of symptoms or their spread to

the other side of the body means a neurotic condition.

In some of these cases where it has been difficult to distinguish

between neuritis and neurosis, a change of occupation or some strong

diversion of mind for a considerable period or a change of residence

has proved the beginning of a cure. I have seen what was considered by

experienced physicians to be a chronic low-grade neuritis of quite

intractable form clear up completely as the result of the young woman

being compelled to take up a wage-earning occupation, when it had

always seemed before as though life was going to be smooth and there

was no necessity for her to labor. I know of cases of so-called

neuritis that had been very obstinate to treatment that were cured by

Eddyite treatment. What really happened in these cases was that a

group of muscles used considerably more than usual had produced a

painful tired condition referred to a particular nerve. Just as soon

as the mind's inhibitory action was taken off them by the persuasion

that there was nothing the matter with them the patient proceeded to

get well, gradually progressive use bringing back the normal trophic

condition.

Discomforts of Bursae.--In any consideration of painful conditions in

and around joints, especially in connection with occupations, the

question of the formation and of the inflammation of bursae must be

insisted upon because many of these inflammatory incidents are

confused with joint affections and not infrequently treated as if they

were due to constitutional disturbance. Practically everybody is

familiar with housemaid's knee. Most people know that bunions are

inflammations of the bursae which form over the metacarpo-phalangeal

joint of the big toe whenever there is pressure and irritation of it.

Very few realize, however, that frequently repeated irritations, when

pressure is exerted over other joints and bony projections, will

produce a bursa, and then, if the irritation continues and an

opportunity for infection occurs, there is bursitis. Some of these are

mistaken for other conditions and often have been thought by the

patient to be serious developments of one kind or another with regard

to which there has been much solicitude. An interesting case of this

kind in my experience was that of an Italian organ-grinder who

suffered from the occupation bursa which so often forms over the

anterior superior spine of the ilium because of the frequently

repeated rubbing of the hand and arm as it passes this region while

turning the handle of his instrument. It had finally become inflamed,

and the Italian was much disturbed and he feared that it was

appendicitis.

Other bursae are not commonly seen in America. I have seen bursae over

{400} the elbows of miners, and in one case saw one of these inflamed

so that miner's elbow became a concrete entity. This case had been

taken for an acute inflammatory arthritis with the suspicion of

tuberculosis.

CHAPTER V

PAINFUL ARM AND TRUNK CONDITIONS

Cervical Ribs.--Some interesting cases with painful conditions of the

arms develop as a consequence of the presence of cervical ribs. It

would be more or less naturally expected that trouble of this kind

would occur early in life, but, as a matter of fact, many of the

patients are well on toward thirty or even beyond middle life when the

painful symptoms develop. Cases are practically always at the

beginning diagnosed as rheumatism because the first symptom is likely

to be pain followed by weakness. Even when this quite fruitless

diagnosis is not made, the affection is often declared to be rheumatic

neuritis, though it is really a traumatic neuritis and entirely a

local condition, as are so many of the painful conditions spoken of as

rheumatism. Usually the pain is referred to the inside of the arm and

is described as resembling slight toothache at first and even severe

toothache after a time. It will often be many months or even several

years after the first symptoms before wasting of muscles occurs, but

this practically always follows after a time and even at this stage

some physicians still talk of rheumatic neuritis as affecting the

trophic nerve fibers and causing the muscles to waste. Almost a

differential diagnostic sign in the case of cervical ribs is that

raising the arms above the head nearly always relieves the pain.

Patients usually learn this for themselves because they have been

tempted to place their arms in many positions in order to get relief.

The reason for it is easy to understand as the elevation of the arms

changes the relative position of tissues in the neck and so relieves

pressure.