The direct reason for the late development of the disease is probably

the ossification of the cervical rib and the pressure of this hard,

bony substance upon the roots of the brachial plexus. When the disease

occurs as early as the age of 30 there is likely, for some reason, to

have been a preceding loss of weight. Patients are run down and then,

either because there is a precocious calcification as a consequence of

deterioration of tissue, or because the loss of substance in the

muscles in the neighborhood makes the nerves more likely to be pressed

upon, the first symptoms develop. There is only one way definitely to

decide the diagnosis. That is to have a careful skiagraph, or, in case

of negative results, several of them taken, in order to determine the

presence or absence of cervical ribs. Not all the cases of cervical

ribs give symptoms and in one recently published series of 26 cases

just one-half presented symptoms and the other half did not, but all

these vague cases of pain in the arm, especially if any tendency to

atrophy manifests itself, should be examined from this standpoint.

_Local Conditions_.--The subjective symptoms in these cases often

include {401} much more than pain. There may be numbness and the hands

often feel cold, though they do not become blue. As a rule, indeed,

the arms are more affected than the hands, though not infrequently one

of the hands becomes more sensitive to injuries than the other and, as

a rule, both hands do not heal well after injury. Even scratches take

a long time to heal and slight abrasions cause skin lesions that are

more or less indolent for some time before healing. Any fresh injury,

even of slight degree, puts back healing much more than would

ordinarily be the case. In fact, most of the so-called tendency not to

heal is local rather than constitutional. When a patient complains

that though his or her tissues used to heal rapidly now they are very

slow to heal, it is well to think of nephritis or diabetes but it is

especially important to know the local conditions.

Pleural Adhesions.--Another interesting cause of pains in the arms is

the possible contraction of adhesions of the pleura and surrounding

tissues at the apices of the lungs and the spreading by continuity of

a low-grade inflammation even to the lower roots of the brachial

plexus. A certain number of cases of this kind have been reported in

which there seems to be no doubt of the diagnosis. In these, the early

symptoms were pains or aches in the arm followed by some weakness of

muscles and even some trophic disturbances. Ordinarily the condition

has been very acute as, for instance, a pneumonia when the first

symptoms were noticed. In the course of the exudation and the

contraction of the inflammatory exudate the brachial plexus is

interfered with. This, like the cases referred to the presence of a

cervical rib, emphasizes the necessity for thoroughly studying local

conditions in order to understand the meaning of painful conditions in

the arms. It is easy to say the word rheumatism, while it requires

time and careful investigation to find the real pathological factor at

work; but the difference in the value of the two diagnoses for both

patient and physician can be readily understood.

Other Conditions.--Besides these, there are the various conditions

discussed in other chapters of this section--old injuries, breaks and

dislocations, so-called sprains with laceration of tissues, and any

serious pathological condition that has affected the tissues deeply.

An old periostitis, for instance, will leave an arm rather easily

liable to the development of various painful conditions. Of course, a

tuberculous process anywhere in the arm will produce a like effect. An

arm that has had a lead neuritis will often be uncomfortable in rainy

weather for long after and a crutch palsy may, in the same way, leave

the arm sensitive. The musculo-spiral palsies that occur from lying on

the arm when drunk, or that are seen sometimes in coachmen who wrap

the reins around their arms--a Russian custom--or the nerve conditions

seen in patients who have suffered from an anesthetic nerve-pressure

disturbance, may all be at the bottom of subsequent painful

conditions, worse in rainy weather. The only sure rule is to

individualize the cases and make an exact diagnosis. The etiology will

probably suggest itself if the history is carefully taken.

In these cases the most important treatment is to disabuse the

patient's mind of the idea that there is rheumatism, or any other

constitutional ailment present, and to make him realize that the

trouble is entirely local. After this, the strengthening of the

affected muscles must, as far as possible, be secured by local

measures and exercises.

{402}

CHAPTER VI

LUMBAGO AND SCIATICA

Any affection involving discomfort, pain, ache, or disability of the

large muscles in the lumbar regions is likely to be called lumbago,

not only by patients but by physicians. Any condition that makes it

painful to use the upper part of the lower limb and especially the

group of large posterior leg muscles just below the nates is called

sciatica. These are commonly supposed to be typical "chronic

rheumatisms." Anything in this region that is the source of discomfort

on rainy days and comes especially to the working man who has been

exposed to the elements, or that follows a wetting or the wearing of

damp clothes, is confidently classified as a chronic rheumatic

condition. Almost needless to say any such conclusion as to the

heterogeneous groups of symptoms that occur in these regions, far from

adding to our knowledge, rather confuses the situation. There is an

assumption that we know something about them when we call these

conditions either lumbago or sciatica, but unless each individual case

is carefully investigated and its conditions studied so as to get at

their true etiology, it is almost impossible to treat them

successfully. While the general practitioner of medicine of the

regular school often fails in his treatment of them, these affections

are among the most fruitful sources of revenue for the irregular

practitioners.

It was particularly for pains and aches in the back that St. John

Long's liniment proved so efficacious about a century ago. So-called

lumbago and sciatica patients were among the most frequent callers on

Perkins in the days of the famous tractors and many of them received

great relief. In our own time these constitute a class of patients who

go from physician to physician and who finally are cured or relieved

by some irregular practice which we know contains nothing especially

remedial, but the advocates of which somehow succeed in persuading

these patients that they must be better than before. Most old people

have some aches and pains in either the lumbar muscles or the large

muscles at the back of the thigh. Many of them are relieved by

massage, but still more of them find relief in the rubbings and

manipulations of the osteopaths, and they are great advertisers of the

relief that has been afforded them and they have helped much in

securing such state recognition as has come to the systems they

thought curative in their cases. Eddyism has been helpful to a certain

number of them. Fads of various kinds catch still others. Evidently

these intractable cases deserve to be studied from the standpoint of

what mental influence can do for them.

Conditions Mistaken for Sciatica or Lumbago.--Needless to say, a large

number of conditions occur which may be called sciatica or lumbago,

but which are due to the most varied causes. An affection of any of

the joints in this neighborhood will produce pain to which is often

added tenderness and occasionally swelling, and nearly always

disability. Disease of the lower part of the lumbar spine due to

tuberculosis is often in its earlier stages called lumbago. Indeed,

without careful investigation showing that there is a special point of

tenderness, some irregular fever and that the muscles are in spasm

{403} to protect the underlying joints from use, it is difficult to

decide just what is the affection in a particular case. I have seen

three physicians diagnose a one-sided tenderness and pain in muscles

with disability as lumbago, when the course of the disease proved that

it was tuberculosis of the sacro-iliac joint. Any of the bones or

joints in this neighborhood may give rise to pain, tenderness and

spasm of muscles and it is important not to make the facile diagnosis

of lumbago, unless careful investigation has eliminated all underlying

organic conditions.

There are other conditions not infrequently mistaken for lumbago or

sciatica which are interesting. Needless to say unless they are

definitely recognized there will be no relief afforded for any

discomfort of a permanent character, though the coal-tar products will

give temporary surcease of pain. Occasionally internal hemorrhoids

produce an achy discomfort in the lower part of the back that is

described as lumbago, and unless the physician is careful to

investigate he may tentatively accept that diagnosis. Proper

regulation of the bowels and the use of gluten suppositories will

often practically cure the condition, though there will be relapses

whenever constipation returns. Chronic posterior urethritis sometimes

simulates painful conditions very low down in the back or in one hip

or the other. Usually in that case there is a chronic inflammatory

condition in the seminal vesicle on the side to which the symptoms are

referred. Occasionally over-distention of the seminal vesicles, as

seen in widowers who have been accustomed for many years to regular

evacuation of them, may cause so much pain and disability in the

region of the hip on one side as to be mistaken first for lumbago and

then even for tuberculous hip joint disease. Artificial emptying of

the seminal vesicle by milking through the rectum will usually afford

relief. In all of these cases as soon as the exact diagnosis is made,

the patient's mind is relieved of a serious burden of anxiety and it

is usually not difficult to bring a great measure of relief.

_Old Injuries and Discomfort_.--Many of the painful conditions

described as lumbago are due to old injuries, to wrenches and sprains

in this region due especially to heavy lifting and to the laceration

of ligaments from over-exertion.

_Typhoid Spine_.--Protracted cases of typhoid are sometimes followed

by pain in the lumbar or sacral regions, developing usually after a

slight jar or shock, sometimes after a fall or even following a severe

injury, which are really the result of the physical condition of the

patient. Stiffness, aching discomfort on movement and sometimes

tenderness on pressure are present. Often there are associated

neurotic symptoms of various kinds. This used very commonly to be

considered rheumatism and occasionally one still sees cases so

labeled. On the other hand, much more serious conditions, as Pott's

disease, abscess of the liver, or some form of spondylitis, may be

suspected. Absence of temperature is almost the rule and usually is

the pathognomic differential against these. The whole condition is

usually a neurosis though there may be some perispondylitis. The

treatment is to increase the patient's nutrition, which has usually

suffered to a marked degree, and get the mind off the condition in the

back. Concentration of attention on it will make it very

uncomfortable, so that even heavy doses of opiates will scarcely

relieve the discomfort, and this emphasis of attention will further

disturb the mind and develop neurotic {404} symptoms. Diversion of

attention, gentle movements, plenty of air, and regulation of the

functions of the body will bring about a cure.

Stooping Occupations.--Occupations are especially important in lumbago

and people who have to stoop much, above all those who do hard work in

a stooping position--lifting, pushing, sawing, planing, and the

like--are particularly prone to suffer. Miners working where the

height of the vein does not permit them to stand up are commonly

subject to it. Any one who has to assume, or has the habit of

assuming, a stooping posture for long hours may suffer from lumbago.

Constrained position predisposes more than hard work. Tailors, though

in a sedentary occupation, often suffer from it.

SCIATICA

Etiology.--What has been said of lumbago applies to a great extent

also to sciatica. There are a number of different affections which

have come to be grouped under the term sciatica. Here, much more

frequently than in the lumbar region, the cause of the pain is a true

neuritis. This may be of many forms. Occasionally it is syphilitic in

origin; whenever the sciatica is double it commonly develops on a

basis of diabetes, while in many cases it is of an infectious nature.

There is no special reason to think that there is a rheumatic

infection of the nerve, though inasmuch as rheumatic arthritis is

probably due to infections by many different kinds of microbes, it may

well be that some of these play a role in sciatica. There is no good

reason, however, why the word rheumatism or the term chronic

rheumatism should be applied either to lumbago or to sciatica.

Certainly there is no reason in any definitely known etiology of the

affections. Each individual case must be studied carefully. Always

these are local and not constitutional conditions, and usually

something in the patient's occupation, or in his habits of life, helps

us to understand the development of sciatica or lumbago and gives the

most valuable hints for treatment.

Men who shovel much and who bend one knee as they stoop in shoveling

will often suffer, though more frequently in the leg which they do not

bend than in the other. The same thing is true for men who use one

foot to run a lathe or a small printing press, or anything of that

kind. They must be taught to alternate in the use of their limbs.

_Pressure_.--Occasionally direct pressure upon the nerve is the cause

of the disturbance. I once was asked to see in consultation an elderly

lady who had complained very much, first of discomfort and then

numbness in her legs, until finally she lost all power in them below

the knees. The affection was considered to be some sort of creeping

paralysis. I found that her favorite chair, an old-fashioned cushioned

easy chair, allowed her to sink down so that the edge of the wood seat

frame pressed upon her just where the sciatic nerve comes closest to

the surface. As soon as the habit of sitting on this chair was changed

her numbness and inability to use her limbs began to disappear.

_Alcoholic Neuritis_.--In both lumbago and sciatica one underlying

factor is often present. This is the consumption of undiluted whiskey

in considerable quantities. Outdoor workers are prone to take an

occasional glass of whiskey, especially in the winter time, and a

copious quantity of malt liquors in the summer. Both of these

predispose to the development of a low-grade {405} neuritis in

susceptible individuals. Alcohol is said to have an idiosyncrasy for

the anterior tibial nerves. That only means, as a rule, however, that

these nerves are more frequently affected by alcoholic neuritis than

others in the body. The reason for this special location of the

affection is that in people who stand and walk much, this constituting

their main form of exercise, these nerves are much used. They are

probably in such people (that is, if the intensity of impulses that

pass through them be taken into account) the most used nerves in the

body. It is this that makes them most susceptible to alcohol. In

people who stoop much or who have to work hard in stooping postures,

the nerves in the lumbar region and those that make up the sciatic

trunk are over-used. This makes them more susceptible to pathological

influences than others, hence the tendency for neuritis to develop in

them.

_Intrapelvic Causes_.--Sciatica may be due to various pathological

conditions within the pelvis. Women with fibroid tumors are

particularly likely to suffer from it. Their removal by operation does

not always assure against the occurrence of sciatic troubles. I once

saw an obstinate case of sciatica in which there was a story of a

fibroid having been removed years before and, though there were no

signs of any recurrence of the growth of another, there were some

adhesions in the region, and there was an obstinate constipation

particularly likely to have as one symptom an accumulation of fecal

material in the rectum until it was very hard. The keeping of the

bowels open meant more than anything else for the relief of the

sciatica. This patient subsequently died from what was diagnosed by a

well-known French surgeon as rupture of the bowels. This was probably

due to the adhesions that occurred after the old operation, done

without any regard to the possible development of such a sequela, some

twenty years ago. The sciatica was undoubtedly connected with the

group of disturbed conditions within the pelvis.

_Position at Work_.--In this case, as in others that I have seen, the

position assumed while at work seemed to have been an appreciable

factor in the production of the pain in the limb. The lady made her

living by writing and often wrote on a board resting on her knee--a

feminine, not a masculine habit. This brought pressure to bear upon

the right limb a little more than the other and then, when she crossed

her knees in order to put the writing board on top of the knee, this

side seemed to be used more than the other.

This question of the position in occupation, even though sedentary, is

very important. I have seen a strikingly typical case of the so-called

_neuralgia paresthetica_, the achy condition of the outside of the

thigh with some anesthesia and paresthesia, occur in an old lady who

still retained the girlish habit of sitting on her foot while she did

crocheting. I have often seen achiness of muscles of the trunk develop

in persons who read much in a cramped position because of the reading

light being too low or otherwise wrongly placed for group reading.

Whenever a patient has to stand much on one foot while doing

something, it is important to remember that there should be

alternation in the use of the limbs; otherwise sciatica and lumbar

pains will often develop, usually on the side corresponding to the

limb that is kept rigid.

Treatment.--_Mental Persuasion_.--The patient must be made to realize

that his affection is not rheumatism, but is due to local conditions.

Just as soon as a patient's mind is relieved by being made to

appreciate that certain habits in his occupation, or certain local

conditions that can be corrected, {406} are responsible for much of

his discomfort, then that discomfort is much easier to bear. Even in

cases where actual neuritis has developed, or where there have been

changes in the intermuscular planes bringing considerable disability,

the aches caused by these will be much more bearable if the patient's

mind is set at rest as to the real significance of the condition. No

condition should be called rheumatic unless at some time in the

history of it there was an acute inflammatory condition with Galen's

classical symptoms--_tumor, color, rubor_ and _dolor_. Pain alone is

never sufficient to justify the diagnosis. Painful disability is

usually due to local causes.

_Treatment of Acute Symptoms_.--For acute symptoms, the coal tar

products may be used and usually afford distinct relief. They include

all the old-fashioned salicylates as well as certain more recent

compounds, such as aspirin. Phenacetin, however, though usually not

thought of in this connection, is an excellent remedy for the

discomfort. These drugs should be used freely so as to give relief

from the painful condition. The fact that they afford relief, however,

should not be taken as an argument that the condition is rheumatic.

Rheumatism, as we know it, is an acute infectious disease and there is

no reason in the world for saying that the salicylates or cognate

drugs are specifics in this affection. They relieve the pain, but just

in the same way they would relieve the pain of toothache or of any

other painful condition. After the acute symptoms are removed, the

condition that remains may be treated in various ways, by massage, by

local applications, and by such manipulations as will restore the

normal circulation of the part. Care must be taken, however, to

distract the patient's mind from the local condition after a time, or

mental influence, by interfering with the capillary circulation, may

inveterate the symptoms. It is not good to keep patients at rest,

though rest, of course, is always indicated if there is much

discomfort. Sometimes, however, the discomfort is really due to the

fact that muscles have not been used for some time and so are easily

fatigued and may ache even under ordinary use. In this case, a gradual

restoration of the muscles to normal strength by progressively

increased exercise is important.

_Counter-Irritation and Its Suggestive Value_.--Personally, I have

found the use of turpentine particularly efficacious in connection

with suggestion. The old-fashioned system of ironing seems to do more

good than any ordinary application of turpentine. For this a piece of

flannel wrung out in warm water has some turpentine scattered over it

and then is placed on the affected loins or back of the thigh and

covered by another piece of flannel, and a hot flat-iron is rubbed

over it. The physical effect is a considerable hyperemia, but the

effect upon the patient's mind is especially interesting, the

unusualness of the mode of application adding decidedly to the effect.

It must not be forgotten, however, that there are some people who are

over-susceptible to the influence of turpentine, and its use is

followed by a rash.

_Lumbar and Sciatic Psychoneuroses_.--Many cases of lumbago and

sciatica are really psychoneuroses. They develop exactly as

psychoneurotic conditions do in the abdomen or in joints. Not

infrequently there is some accident or injury, some sprain or strain,

or exposure to dampness or draft, that serves as the occasion. The

Germans group all these occasions together under the word "insult."

The "insult" produces little physical effect but after some days or

sometimes weeks, the slight discomfort present secures the center of

{407} attention and then the patient suffers from what seems to be

severe pain and often inability to move or use muscles. Even when

there is true sciatica or lumbago, that is, a genuine low-grade

neuritis of the lumbar or sciatic nerves, most of the symptoms may

come from the associated psychoneurosis. This is proved to be so by

the fact that such patients are often cured, for the time being at

least, by some shock or fright or sudden excitement, that makes them

move, forgetful of the pain and inability from which they suffered

just before. Besides, such cases are often cured by inert remedies of

many kinds, by local applications that have no specific effect, and by

various methods of treatment which cannot be responsible for the

recovery. The amelioration of the condition is due to the mental

influence accompanying the methods of treatment and the reassurance of

the patient's mind.

_Diversion of Attention_.--Almost anything that produces a continuous

succession of sensations on the surface of the affected area that

attract and hold the attention of the patient may prove a valuable

therapeutic suggestion and even eventual relief from symptoms that

have proved obstinate to more rational treatment. Liebault, the

well-known founder of the Nancy school of hypnotic therapeutics, tells

in his "Therapeutique Suggestive," that he has frequently cured

lumbago by the simple recommendation of a rather stiff piece of paper

to be applied over the patient's loins. The rationale of this

treatment seems to be that the patient's attention is attracted to the

skin surface by the sensations constantly produced by it and attention

is distracted from other feelings deeper in the muscles. It often

happens that after an acute lumbago has run its course, there is left

a chronic achiness only partly physical and largely psychoneurotic.

Some of it is undoubtedly due to the habit, formed during the acute

period, of keeping the muscles quiet, in order to avoid the spasmodic

pain that occurs on movement. Patients cannot, as it were, let go of

their muscles, and their discomfort is largely due to holding them in

a cramped position. The sensation produced by the paper on the

cutaneous nerves distracts the attention and brings about relaxation

of the muscles with decrease of discomfort and gradual relief of all

symptoms.

The paper acts as a constant source of suggestion for the cure of the

psychoneuroses when the affection is purely psychoneurotic. The mind

has become concentrated on the idea of pain and discomfort in this

region and needs another thought to occupy itself with so as to

neutralize this. Wearing the paper with the assurance, for instance,

that because of its impermeability to air it keeps the part more

thoroughly protected from variations of temperature and from such

possibilities of transudation as have before been possible, serves to

lift patients out of themselves and affords relief. Whenever the

sensation produced by the paper is noted, there is a renewal of the

suggestion and its curative effects. There are many plasters that have

obtained the reputation for curing lumbago. It is doubtful whether any

of these have sufficient medicaments on them to be of any serious

pharmaceutic significance. They are mostly rubber plaster. The

presence of this and the consciousness of the sensation produced by it

acts as favorably as does Liebault's sheet of paper.

_Mechanical Agents_.--It must not be forgotten, however, that a large

sheet of adhesive plaster firmly applied may act as a mechanical

therapeutic agent, somewhat in the same way that strips of adhesive

plaster relieve the pain of pleurisy, or are helpful in a sprained

ankle or a knee. The muscles may be {408} held rather firmly together

and so there is no necessity for constant attention to prevent

spasmodic pain. Undoubtedly some of the newer large-sized adhesive

plasters produce an excellent effect in this way. If, besides, the

patient has the feeling that they must be doing him good because of

materials in their composition, the psychoneurotic elements are more

readily relieved. The old idea was that such plasters drew out the

pathological elements to the surface whence they were dissipated.

There is no truth underlying this thought.

In the old days blisters were applied rather freely to these regions

and the actual cautery was often employed. Both of these therapeutic

processes are likely to do good in chronic cases, but much more from

their psychic than their physical effects. The actual cautery is not

used nearly so much as it ought to be in chronic muscular and neurotic

conditions, for the mental effect of its application and the

distraction of attention to the skin surface while the cauterized

areas are healing are excellent remedies.

There are other counter-irritant procedures of the same kind that have

been used with reported successes in many cases. Hot needles, for

instance, if pushed deeply into the muscles, often have an excellent

effect. Some years ago a distinguished surgeon insisted that both

lumbago and sciatica might be cured in many cases by the insertion of

needles deeply into the muscles. He argued that what happened was that

these needles brought about an equilibrium of electricity in the

muscular structures which had somehow been disturbed. Deep injections

of water into the muscles also do good. Stretching of nerves has been

applied with reported success. After a time all of these measures

fail, however, because somehow after the novelty of the treatment

wears off for the physician, the patient's mind is not sufficiently

impressed and then the former results are not secured. Where there are

actual neuritic processes present they will almost surely fail. So

many of these cases are almost pure psychoneuroses, however, that it

is little wonder that anything which produces a strong impression on

the mind and leaves after it some condition that attracts attention

and so furnishes favorable suggestion will almost surely cure even

chronic conditions for which all sorts of physical remedies, employed

on rational grounds, have failed.

Anything that modifies the circulation, even to a slight degree, or by

causing a reaction in the local vaso-motor state, alters previous

conditions, tends to enable the patient to control the affected part.

These psychoneurotic conditions in large muscles help us to understand

what happens in organic diseases. There is a physical element that

must be modified, but unless a strong influence is brought to bear

upon the mind so as to arouse all its capacity for control, the cure

will not come. Anyone of a dozen things, however, may be used in this

way and often when one fails another will succeed. In obstinate cases

of lumbago and sciatica if necessary a number of these forms of

treatment should be used successively.

_Hypnotism_.--How much pure psychotherapy may mean for many of these

obstinate cases of lumbago and sciatica can be appreciated from the

many reports of cures by hypnotism or by suggestion in a light

hypnoidal state, or occasionally, under favorable circumstances, even

in the waking state. One of these cases, indeed, is responsible to

some extent for the French interest in hypnotism which attracted so

much attention in the last quarter of the {409} nineteenth century.

Prof. Bernheim of the University of Nancy had seen a case of sciatica

in which every therapeutic means at his command had failed. As the

result of disuse the leg was emaciated and possessed little muscular

power. It looked as though the man would never be able to regain the

use of it properly. Dr. Liebault succeeded in curing the patient by

light hypnotic sleep, in which the suggestion that he would be better

was given while the physician stroked the limb. After the first seance

the patient was able to use the leg better and the discomfort was

greatly decreased. Further seances with Dr. Liebault brought further

improvement until finally the condition was cured. Prof. Bernheim, who

knew how intractable these cases are, had the case called particularly

to his attention and naturally wanted to learn more about the method

by which it had been brought about. Liebault's methods had been quite

contemned by the regular faculty before. After a series of experiences

under Dr. Liebault's direction Prof. Bernheim became enthusiastic over

the use of hypnotism as a curative agent and this led to the

publication of his well-known work "De la Suggestion et ses

Applications dans la Therapeutique." [Footnote 34] It was the

interest aroused at Nancy that led Charcot to take up hypnotism, and

while he came to very different conclusions, there is no doubt that

the work at Nancy meant much for our knowledge of suggestion in both

waking and hypnotic state in therapeutics.

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

CHAPTER VII

PAINFUL KNEE CONDITIONS

Most of the painful knee conditions of which patients complain are not

directly due to true pathological conditions either of the knee joint

itself or of its neighboring structures, but rather to affections of

other portions of the leg that set a special strain upon the knee and,

above all, to various kinds of foot disturbances. The erect position

is maintained principally by a nice balance of nervous and muscular

energy in the knee joint and its surrounding structures. Any irregular

sensory or motor impulses to the knee-joint or to the muscles of the

thigh will disturb the absolute equilibrium of the flexors and

extensors and will make standing painful or even impossible. Whenever

a morbid condition requires a different use of the muscles and tendons

around the knee from that to which they are accustomed, fatigue

readily ensues, and aches and even tenderness in muscles and tendons

develop as the result of the over-exertion. These collateral

conditions must not be overlooked in the diagnosis and treatment of

painful knee conditions.

Etiological Factors.--Even a slight sore on one foot will give rise to

considerable achy fatigue of the knee of the opposite leg, because,

consciously or unconsciously, we stand much more on that leg, use it

more in walking, and spare the other because of the pain induced by

use of the foot. Above all, throwing more weight on the other leg

causes us to use muscles a little abnormally with consequent soreness.

This painful fatigue is most likely to be felt around the knee, though

it may extend to the hip and even the lumbar {410} region of the well

side if the foot continues to be spared for a number of days.

Particularly will this be true if there is anything the matter with

the big toe, on which so much of the use of the foot depends. An

ingrowing toenail will not infrequently give so much discomfort to the

well knee and hip as to make the patient sure that there must be some

rheumatic or other condition at work in these joints. The serious

affection of the joint which the patient apprehends is found to be no

more than a sympathetic fatigue induced by having to use his feet, or

one of them, a little differently from usual, perhaps because of some

condition that leads him to spare them. To call the patient's

attention to this is of itself therapeutic.

_Inequality of Legs_.--The effort required for standing and the

accurate balance of the muscles involved in it is such that any

mechanical disturbance of the feet or legs or even a trivial

pathological condition causes painful fatigue. It must not be

forgotten, for instance, that the presumption that human limbs are of

exactly the same length is not confirmed by accurate measurements.

There is an average difference of probably half an inch in length

between the limbs of normal persons, and there may be even a

difference of more than an inch before deformity is said to be

present. The longer limbs are likely to do more work and are,

therefore, more subject to fatigue and consequent complaint. One of

the reasons why we can distinguish persons by their gait even at a

distance is that the difference in the length of their limbs makes

noteworthy characteristics in their walk.

_High Heels_.--People who are used to walking in a natural manner and

who don a pair of high-heeled shoes for the first time are sure to

complain of pain in the calf and knee, because the high heels require

them to hold the knee more rigid and in a somewhat different position

from that required when the persons stand under ordinary

circumstances. It is the unusual in muscular effort that gives rise to

the extreme fatigue which becomes positive pain if it is allowed to

continue. It is curious how small a raising of the heel will cause

discomfort. Over and over again I have known the careless putting on

of rubber heels to be responsible for pains around the knee, which in

damp weather were the source of so much discomfort that it was hard to

persuade the patient that he was not suffering from rheumatism or some

serious incipient pathological condition.

_Unusual Occupations_.--Joint pains often develop after the patient

has been doing something quite unusual and putting an unaccustomed

strain upon his muscles. I have often seen dispensary patients whose

knee pains began after there had been a family moving. In the course

of the removal of household goods, both men and women are likely to

help in hanging pictures, in taking them down, in moving heavy

furniture and other occupations of this kind which make them extremely

tired. If there is any tendency to relaxation of joint structures the

tiredness may manifest itself as a sense of painful discomfort. The

knees are particularly likely to suffer if there is a relaxed

condition anywhere in the leg. It must be remembered that the laxity

of tissue which predisposes a patient to weak or flat feet will have a

tendency to produce some looseness of fiber, at least, also in the

tissues around the knee. The patient may not have a wabbling knee, nor

may he be able to overextend the limb, but still there will usually be

some noticeable relaxation of the tissues which will help in the

production of the painful condition by {411} making exaggerated calls

upon the muscles in order to keep the joint in proper position in

spite of the over motion in it.

The disturbance is most frequent in waiters, store clerks, tailors'

cutters and fitters, bench men in the trades, and in all those who

have to spend much time on their feet. I have seen many such ready to

give up their occupations, though they had no other resource and the

future looked very blank, indeed, away from their work. It was

difficult at first to persuade them that a slight yielding of the arch

had so changed mechanical conditions in the use of the muscles of the

leg as to produce such pains. But as soon as they were put in a

condition where their arch was not allowed to sink, they were at once

relieved of their discomfort to a great extent. The question of

treatment is discussed more fully in the chapter which follows on Foot

Troubles.

An interesting set of painful conditions around the knee develops in a

class of people in whom it might least be suspected of being due to

over-exertion connected with their occupations. These are lecturers,

clergymen, teachers, and others who, for several hours each day, are

on their feet in a position from which, as a rule, they do not move,

but stand almost perfectly quiet. A distinguished laryngologist has

pointed out that not infrequently men who come to be treated for the

chronic laryngitis, which is known as clergymen's sore throat, but

which is seen so frequently in those who have to talk in the open air,

auctioneers, cart-tail orators about election time, and in lecturers

to large audiences who do not know how to use the voice, also complain

of grievous discomfort from painful knee conditions which often makes

the ascent or descent of stairs a painful task. He attributes the

simultaneous occurrence of these conditions to some blood dyscrasia,

uric acid, or the like, affecting the two most used sets of muscles

and organs, the legs and the vocal cords. Whenever I have seen this

condition--and circumstances have brought me into intimate personal

relations with many clergymen and lecturers--the trouble at the knee

has been due to some yielding of the plantar arch, while the laryngeal

condition, if present, was due to an erroneous mode of using the voice

consequent upon lack of proper training.

Sufferers of this kind must be warned not to stand absolutely

immovable while addressing an audience. Some men stand without moving

during a whole hour's lecture. This is unfortunate, for it obstructs

the return circulation through the tense muscles, for the venous

circulation was intended to be helped by muscular contraction. Many a

man finds, as he comes down from pulpit or platform, that his knees

are stiff and sore, though a moment before he knew nothing about it.

The failure to notice any discomfort before is of itself an example of

the influence of the mind over the body for the relief of pain.

Associated Lumbar Discomfort.--The painful condition around the knee

which develops when high heels are worn is almost sure to be

accompanied by pains, or at least a tired feeling, in the back. If we

convince the patient that the trouble is due merely to a derangement

of the mechanism involved in maintaining the erect posture we shall

have scant need of medicine or even of local treatment. But as the

pain is much worse on rainy days, owing to the relaxation of the

muscles, we must be careful to remove the patient's suspicion that the

pain must have a rheumatic origin. The restoration of normal

mechanical conditions with the removal of the cause will prevent the

{412} recurrence of the affection, and if some discomfort remains, the

patient will not worry, and the muscles will gradually grow accustomed

to the strain upon them. Of course, these conditions of discomfort are

more common in those who are not naturally strong, who are run down,

who are under-weight, or whose neurotic tendency will make any

irritation seem worse than it is.

Heavy and Light Patients.--Two classes are likely to suffer more than

others from these conditions. They are the people who are overweight

and the people who are underweight. Those who are overweight exert

much more effort to maintain the erect posture than ordinary people,

and, besides, in most adipose persons the distribution of weight is

such that a disproportionate amount of it is carried forward of the

normal center of gravity. High heels cause a further tilting forward

that has to be counter-balanced, and that, at least at the beginning,

gives rise to muscular discomfort. In people who are underweight the

nutrition of the muscles has suffered, and, as a consequence, they are

not able to support the frame as well as before. In them the

additional effort necessitated by the tilting tendency of high heels

is particularly felt because such people are nearly always among the

neurotically inclined.

Muscle Disuse.--Sometimes treatment of these conditions seems to lead

up to the disuse of certain muscles and the over-use of others. I

followed for several years an interesting case of this kind in which

the course of the affection was so typical as to deserve to be

recalled. A fuller account of the case occurs in my paper on

"Rheumatism versus Muscular and Joint Pains" in _The American Journal

of the Medical Sciences,_ August, 1903.

In that case the joint symptoms caused by the pinching of a loose

cartilage within the joint occurred suddenly on two or three

occasions, so that a surgeon deemed it wise to put the knee in

plaster. As a consequence, some atrophy of the muscles of the leg

occurred, and a halt became habitual in the gait. Through this halting

gait, the muscles of the back on the same side were also spared and

thus became somewhat atrophied. Painful conditions developed in the

muscles of the other side of the back from the over-use necessary to

compensate for the condition on the less-used side. All of the muscles

on the affected side became painful, apparently because of the

atrophic condition to which they were reduced.

The young man, though with the best of good will, was utterly unable

to conquer the tendency to halt in his gait, and so the muscles

remained under-exercised and were used at a mechanical disadvantage,

with the usual painful result. He went to at least two prominent

orthopedic surgeons, who assured him that all he needed was confidence

in himself to walk straight, and that then the normal condition of the

muscles and absence of pain would result. But their directions were

absolutely without result. He went through the hands of masseurs, of

osteopaths, of rubbing quacks of all kinds, and suffered at least two

attacks of artificial eczema as a consequence of the use of turpentine

liniments, but he remained after it all in what he considered to be an

intensely miserable condition. These cases are practically always

cured by definite exercise of the muscles of the affected limb so as

to bring them back to their normal tone. It requires special attention

for this purpose, however, and the patient's mind must be brought to

understand that at first the unaccustomed use of muscles will cause

discomfort, but that this will disappear after a time. These patients

are persuaded that they must be "cured" to get well.

{413}

CHAPTER VIII

FOOT TROUBLES

The more physicians see of affections of the feet and of painful

conditions of the legs due to foot troubles the more they realize that

the human faculty of the erect position becomes the source of many

discomforts unless care is taken of the muscular apparatus of the

legs. There are few people engaged in standing occupations who do not

suffer from their feet. These achy sensations are especially

bothersome if the patient is run down in health, or is in the midst of

worry or irritation from physical or mental stress. Even under

favorable conditions there are few who reach old age without serious

foot troubles or without, at least, some deformity of the feet, which,

by preventing or limiting exercise, have an important influence upon

the general health. Careful analysis of the conditions that develop

will convince an observer that yielding of the joints of the foot has

much to do with the deformities and that the wearing of unsuitable

shoes rather than any internal pathological condition is responsible

for the foot troubles that are so common.

Foot Deformities in All Classes.--An Englishman who visited this

country, and who had ample opportunity to observe our people, declared

after seeing the bathers at Newport, that there were two interesting

peculiarities of American masculine anatomy--the deformity in their

feet and the appearance of having swallowed a watermelon whole and

retained it within them. The latter condition has doubtless much to do

with the causation of the former. Inactive lives, overeating, and the

overweighting of flaccid limbs that are not capable of bearing even

their normal burden, complicated by tight and ill-fitting shoes, give

rise to the deformities of the toes that are so common--hammer toes,

over-riding toes, bunched toes, twisted toes, bent toes. Examples of

most of these are sure to be seen wherever we observe our men and

women bathing. The Englishman's observation was of our so-called

better class--at least, our leisure class. Ordinarily, it is assumed

that clerks, waiters, and others, who have to stand upon their feet

are the principal sufferers from foot deformities. They are, but they

are not alone, and a goodly proportion of the population suffers in

this way.

Mechanical Factors.--The most important deformity in these cases is a

yielding of the arch of the foot with consequent flattening of the

instep and lengthening of the foot. This overstretches especially the

flexer tendons which run underneath the arch, produces bunions, and

gives occasion for the development of corns. The pull upon the flexor

longus hallucis which runs along the inside border of the foot, gives

rise to the bunion by pulling the big toe outward--in the direction of

least resistance. The pressure upon the tendons of the flexor longus

digitorum pedis causes the smaller toes to bend somewhat, and this

gives rise to projecting angular points on which corns readily form.

Besides, the imperfect action of the muscles of the foot consequent

upon the fall of the arch gives rise to plantar corns and callouses

that are often painful. The living cushion of muscle which is the best

protection against injury, while walking or running, has its vitality

interfered with by {414} the fall of the arch and the consequent

blocking of the return circulation through the thin walled veins. This

gives rise to cold feet and, in those who stand much, to the tender

feet that are now so much complained of and for which so many foot

powders and appliances are advertised.

Confusion of Rheumatism and Foot Troubles.--Most foot troubles are

reflected up the leg because muscles have to be overused or used at a

serious mechanical disadvantage. This combined discomfort of foot and

leg is readily referred to rheumatism. Some of the pains produced by

yielding of the arch are in the ankle, some are in the calf, some in

the tissues around the knee, and some even in the muscles and tendons

above the knee. It is much easier to say "rheumatism" than to

investigate carefully and differentiate the conditions that may be

present. Out of forty successive patients who came to the dispensary

of the Polyclinic Hospital of New York complaining of rheumatism,

eighteen were suffering from flatfoot. Out of twenty-four who thought

they had rheumatism in the feet or legs eighteen proved to be cases of

flatfoot. Of the others, one was suffering from that rare disease

meralgia paresthetica, two were suffering from sciatic neuritis, one

was suffering with sub-acute joint trouble consequent upon pinching of

a cartilage within the knee joint, and one had a painful condition

consequent upon an old dislocation of the ankle due to a fall,

accompanied by considerable laceration of the soft tissues. Analyses

of the cases left no room for the so-called chronic rheumatism which

had so easily covered all the cases at the beginning.

It was not unusual to see patients who had consulted many physicians

and taken all sorts of internal and external remedies for the

rheumatism that they supposed was causing their discomfort, yet who

had nothing more than flatfoot. Their condition had become so bad that

some of them had actually given up occupations that required them to

stand. Merely following the advice to wear flatfoot braces in their

shoes relieved these patients almost as if by magic. There was no need

to measure them particularly; all they needed was an ordinary set of

flatfoot braces. Some of them needed only a pair of good shoes, but

the metal braces were advised to make sure that there would be a firm

support for the arch of the foot. No wonder the "magic shoe-maker" had

such success in New York a few years ago.

Nearly always the shoes worn by dispensary patients are of the worst

kind, considering the condition. The patients' feet are often cold,

and they think this is nature's demand for heavy shoes, so they buy

heavy shoes and large sizes so as to be sure they will not hurt their

feet. This clumsy footgear allows the arch to drop still further

because no proper support is furnished, and the foot-trouble becomes

more poignant. Then working people nearly always wear older shoes on

rainy days, and this makes two elements for discomfort instead of one.

The yielding arch is already a source of discomfort which is more

noticeable in rainy weather because any affection around a joint is

more bothersome at such times. The support that a new pair of shoes

affords to the arch is lacking when what are so aptly termed "sloppy

weather shoes" are worn, and the consequence is that the patient is

particularly miserable in damp weather.

Unfavorable Disease Suggestions.--Of the cases in my experience of

so-called rheumatism in the legs, over one-half are due either to

flatfoot or to the incipient yielding of the arch which is called weak

foot. Rheumatism is {415} most commonly held accountable for the

condition, though gout comes in for its share of blame with quite as

little justification. Occasionally some even more serious pathological

condition is appealed to. I have seen the tendency to passive

congestion in the feet with slight swelling around the ankle

consequent upon the yielding of the arch called kidney trouble in

spite of the fact that there was nothing in the urine to justify any

such diagnosis. I have even known the coldness of the feet, which is

likely to be a symptom of the disturbed circulation consequent upon

the yielding of the arch, attributed to heart disease. As we shall

see, most of the curious deformities of the old that make locomotion

so difficult and so painful are due to a breaking down of the arch

just after middle life and then to a progressive deformity of the

foot. The mechanics of the support of the body are sadly interfered

with when the arch yields, for bones are pushed out of place and

ligaments and tendons are lengthened in order that the foot may

accommodate itself to the new conditions. In nearly all these cases

the patients are prone to say that they are sufferers from rheumatism.

This diffuses and inveterates the notion which is a source of many

unfavorable suggestions, that rheumatism is a curious progressive

crippling disease which begins insidiously but advances remorselessly

and eventually leaves its victim a prey to deformity.

Gout and Flatfoot.--Bunions consist originally of an enlargement of a

bursa over the proximal end and the inner side of the big toe in order

to protect the bone and joint from friction. If the irritation is

continued, the proximal end of the first phalanx may enlarge, though

usually this is preceded by a series of attacks of more or less acute

inflammation of the bursa, when the bunion is said to "become

sensitive." I have seen these attacks called gout so often that I feel

sure that much of the gout reported in this country is nothing more

than bunions. There is true gout, and it is probably almost as

frequent with us as it is in England, but many of the so-called cases

are really flatfoot associated with development of the bunion that so

commonly occurs as the arch yields.

I was once asked to see a physician's wife who was thought to be a

sufferer from gout. Long ago Oliver Wendell Holmes said that, as the

shoemaker's children are likely to wear the worst shoes of the

village, so the doctor's family is likely to take the least medicine,

that is, be subjected to the least formal medication. The physician

had seen the more or less acutely swollen and red enlargement of the

base of the big toe, and heard his wife complain of the severe pain

associated with it, and had suggested the possibility of gout. After

rest in bed and the administration of salicylates and colchicum, the

pain subsided and the redness and much of the swelling disappeared.

This was a typical illustration of one event following another without

causal relation. The succession of events was taken as a therapeutic

test of the diagnosis of gout, and the patient was advised to regulate

her diet so as to prevent the further accumulation of urates or uric

acid in her blood. She was warned about eating red meat, about taking

acid fruits, and about the acid fermentation of starchy vegetables.

The main result of eating only white meat is apt to be simply a

limitation in the amount of meat eaten, because white meat is less

savory and after a time palls on the appetite. In the same way fruit

was largely eliminated and sweets were taken out of the diet and

vegetables were limited.

{416}

As she did not escape recurrent attacks of soreness in her bunion,

while at the same time there were achy feelings in her foot, she took

up the careful study of the dietary for gouty patients which she found

in the books in her husband's library. So many things have seemed

possibly deleterious for gouty people that it is not surprising that

after a time nearly everything worth eating except a few cereals and

milk and eggs had to be eliminated and she began to suffer from

inanition. Then, after a time, came constipation, due to the

insufficient amount of residue in her intestines, and this, partly by

physical action but largely by mental suggestion, still further

diminished the appetite for food, and a loss of over twenty pounds in

weight was the result. The weakening of the general muscular system

consequent upon this loss emphasized the trouble with the foot and the

painful condition at the base of the big toe became more marked.

The supposed necessity for more exercise in the open air led her to

walk long distances and in order to prevent her feet from hurting her,

as she thought, she wore roomy shoes, distinctly too large. This is

one of the common mistakes of people whose feet bother them, and it is

just the wrong thing to do, since a snug, well-fitting shoe provides

both support and protection. It is not surprising that the attacks of

sub-acute bursitis became more frequent and more painful.

It was then that I saw her, and, as I feared to disturb the family

harmony by suggesting that the whole trouble was a bunion and

flatfoot, I compromised by saying that, while there might be some

gout, there was undoubtedly flatfoot, and if she would wear the proper

sort of shoe and stop limiting her diet so strenuously, and cease

suggesting to herself that she had a progressive gouty affection that

would lead to deformity and decrepitude, she would soon be much

better.

It required tact to make her look favorably on this advice, after all

that she had gone through during months of limited diet and enforced

exercise. Though not quite convinced, she was ready to try the new

method. She began to be better as soon as she was fitted with a pair

of shoes that supported her arch and as soon as her increased

nutrition began to make itself felt. At the end of two weeks she was

able to give up the remedies for constipation that she had been using

for nearly a year, while at the end of four weeks she had regained ten

pounds of weight and felt much better.

Several years have passed since I saw her professionally and

occasionally I hear from her only to be told what a great measure of

relief it afforded her and how much better she has been as a

consequence of a few simple directions with regard to her feet. I have

seen at least a dozen of cases of so-called gout in educated people

which followed almost exactly the same course and yielded promptly to

the same treatment. The hardest symptom about these cases to cure is

the cherished mental conviction that they are the victims of

constitutional disease, either gout or rheumatism, to which all their

symptoms are attributed. They are cases for psychotherapy more than

any other form of therapeutics and need for a considerable period to

have repeated assurances of the entirely local character of their

affection.

Bunions and Flatfoot.--The etiology and preventive treatment of a

bunion has always seemed to me to bear a closer relation to a flat

foot than to anything else. The flatfooted man has nearly always a

tendency to bunions. The {417} explanation of this is not difficult if

one traces the relation between the tendons that run around the arch

to the big toe. The usual etiological explanation, however, is that in

youth short shoes were worn which initiated a tendency to divert the

big toe inward toward the other toes. But there are many reasons

against this explanation. Anyone who tries will find that it is

practically impossible to wear shoes that are so short that the big

toe is crowded back. Women are more apt to shorten their shoes than

men, yet women suffer both from flat feet and from bunions much less

than men. The reason for this seems to be that the forward position

with the elevation of the heel of the shoe supports the arch and gives

the shoe a shape more fitted to the normal foot than is found in the

masculine flat-heeled shoe. Besides, this form of shoe maintains its

shape better, and then, too, women are not so prone to wear old

so-called comfortable shoes as are men.

The mechanism of the formation of the bunion in many cases seems to

be, that the large toe, instead of lying straight along the inner edge

of the foot, is pushed or pulled toward the other toes. If this

process began from the wearing of pointed shoes, especially if such

shoes did not have a straight line on the inside, conditions within

the foot would soon tend to emphasize it. If the adductor hallicis

once gets the habit of contracting rather strongly, as it is likely to

do through the irritation set up by the yielding of the arch, it will

be hard for its opposing muscles to counteract it. More important than

this, however, is the fact that the tendon of the flexor longus

hallucis runs along the inner border of the foot and is particularly

affected by the yielding of the arch. For it works at a decided

mechanical disadvantage under the new conditions and is stretched in

such a way as to pull forcibly and constantly upon the big toe,

necessarily turning it more and more outward as the arch continues to

yield. The dropping of the arch makes the distance from the heel to

the toe longer than before and the tendon pulls the toe as far outward

as possible to compensate for this, as the distance to its insertion

is thus made somewhat shorter.

The yielding of the arch lengthens the foot and puts the tendons of

all the flexors on the stretch. All of them have a tendency to bend

the toes, and as this action is constant, gradually the tendons of the

extensors become over-stretched and these muscles are not capable of

exerting their full force in overcoming the action of the flexors. The

flexor longus digitorum has a tendency to cause a bending of the small

toes, and as it also runs across the foot it pulls the toes somewhat

inward, that is, toward the big toe. This crowding leads to hammer

toes and over-riding. The big toe, however, is maintained in a state

of extension by its firm, full contact with the sole of the shoe and

with the floor when walking barefoot. The one direction in which it

can yield rather readily is outward toward the other toes because this

shortens the distance between the end of the toe and the heel. The

pressure put upon the flexor longus hallucis will have a tendency to

cause this, for it is over-stretched by the yielding of the arch and

keeps constantly pulling on the big toe until that member has a

distinct flexion outwards.

This makes the metacarpo-phalangeal joint prominent and then nature

proceeds to protect it by a water cushion, a special bursa due to the

formation between layers of connective tissue of a pocket in which

some serum is constantly present. One can scarcely admire enough this

provision of nature by {418} which she protects prominent bony points

whenever they are subject to much irritation or to such use as would

cause injury to important structures below. If continued pressure

continues to be irritating, however, the water cushion proves

unavailing and an inflammation of the overlying skin occurs with

occasionally a spreading of infectious agents from the surface into

the serum pocket below. This serum is such a good culture medium that

an acute abscess is likely to form--the acute bursitis of the

surgeons.

Rarer Foot Troubles.--Besides bunions, a number of other deformities

of the feet occur as a consequence of the yielding of the arch. All

the toes are likely to bend rather acutely, and the points of them are

pressed against the shoe, while the knuckles, so to speak, are made

prominent and are more likely to be subject to corns than would

otherwise be the case. Besides, the displacement of the big toe toward

the little toes leads to a crowding of the toes together, and this

gives rise to soft interdigital corns and to a lowered resistive

vitality which may be the predisposing factor to slight infections of

various kinds that will make the patients miserable. Such affections

may appear negligible, a matter for the chiropodist, and not deserving

the physician's attention; but they mean so much for the comfort of

the patient and the prevention of exercise through sore feet reacts so

deleteriously on the general health that these minor ailments become

important and merit careful attention. Dr. Emmet tells the story of

the old family servant, always grumpy and complaining, who, when he

had the many blessings of life pointed out to him, confessed that the

Lord had been very good to him, but said, "The Lord knows He takes it

out of me in soft corns."

_Hammer Toes--Clam Toes_.--Nature has provided a wonderful mechanism

in the arch of the foot and the anatomical relations of the toes to

support the weight of the body firmly, gracefully, and comfortably;

yet any yielding of any part of it leads to a disturbance of its

delicate mechanical relations and, consequently, to ever-increasing

deformity. Hammer toes are typical examples of what such a disturbance

may lead to. One of the toes becomes pressed downward between two

others. This over-stretches the extensor muscles and tempts the

unbalanced flexors to contract. As the extensor muscles become, after

a time, unable to work in the constantly bent toes, they atrophy to

some extent and then the flexor muscles pull the toe farther and

farther down until there is no possibility of its being straightened

at all. Now, if the flexor tendons are cut and the toe straightened

the atrophic extensor muscles will not hold it in that position, and

when the flexors grow together the old condition will reassert itself.

In the meantime, muscle changes in the neighboring toes have also

taken place. With no resistance on one side of them, they become bent

sidewise over the hammer toe, and so their muscles on one side are

overstretched and on the other side become contracted. After a time it

is impossible to correct this series of deformities which are being

constantly increased and emphasized by the weight of the body above.

Present-day Shoes.--In recent years we have heard much more than

heretofore about foot troubles. As the old-fashioned shoes were

carefully made by skilled shoemakers to fit the feet of one individual

and not to conform to some supposed ideal pedal extremity, they

supported the feet much better than do the modern cheap machine-made

shoes. These custom shoes lasted a long time, and, after they were

once molded to the foot, the wearer was not {419} disturbed for many

months by the process of having to become accustomed to another shoe.

The many advertisements in quite recent times of foot powders and

other artificial relief for the foot show that people are suffering

much more than before, or, at least, are less able to bear the

discomfort. These powders, however, are not likely to do good in the

long run, since they tempt the wearers to stand the discomfort against

which they do furnish a certain amount of soothing. It is much better,

however, for the sufferer to find the cause of the discomfort and to

remove it if possible, for otherwise it will lead to constantly

growing displacement of bones and muscles and may eventually even

bring on actual and ever-increasing deformity. [Footnote 35]

[Footnote 35: How much deterioration of the tissues of the foot may

be brought about by improper footwear and, above all, by sedentary

life and the substitution of the trolley car for the exercise of

walking, is well illustrated by the functions that are lost. The

child can use its adductor and abductor muscles for the toes quite

as well as for the fingers. Those who go barefooted retain those

muscular powers. Some time we will be able to influence young folks'

minds enough to keep them from sacrificing all the more delicate

muscular powers of their feet to the fashion of small or curiously

shaped shoes. Armless men learn to use their feet almost as hands,

they write, pick up small articles, oven play musical instruments.

Some people have special muscular faculties, as, for instance, the

power to displace certain tendons and bring them back with a snap

which makes a distinct sound. The Fox sisters, to whom we owe the

origin of modern spiritism, confessed that this was the way they

produced their spirit rapping. Some mediums can, it is said,

dislocate the tendon of the flexor longus hallucis onto the edge of

its grove and then bring it back with a snap. Others can produce

partial toe dislocations which by muscular power are suddenly

reduced with a dull noise like the sound of a gloved hand rapping

beneath the table.]

Prophylaxis.--The most important means of prophylaxis in these cases

is to have patients who must assume the standing position for some

hours each day, exercise their legs rather vigorously. If teachers,

lecturers, and the like, have to stand for a long time, it is

important that on the way to and from their occupations they should

not have to stand up in cars nor assume cramped and uncomfortable

positions. It would be better for them to walk rapidly for several

miles rather than ride in a standing or a constrained position. If

they are convinced of the necessity for exercise, there is much less

likelihood of the development of the severer discomfort that is

sometimes very discouraging. It is particularly difficult to make

women understand this; yet, once they have found how much relief is

afforded by vigorous exercise, they are likely to overdo it and thus

run the risk of incurring ills quite as serious as those consequent

upon not taking enough. In nervous people the nagging discomfort of a

yielding arch will sometimes (just as eye strain does) produce reflex

headaches, constipation, lack of appetite, and apparently predispose

to the frequent recurrence of migrainous headaches. I have, in not a

few cases, seen these conditions relieved by rational treatment of the

foot condition.

Circulatory Disturbances Due to Flatfoot.--An interesting direct

consequence of flatfoot is the disturbance of the venous circulation,

which is likely to bring about some swelling of the feet and nearly

always considerable coldness and numbness, particularly in the winter

and, above all, on damp days during cold weather. The swelling of the

feet makes the patient think--sometimes at the suggestion of his

physician--of kidney trouble or heart trouble, and sometimes it is

hard to persuade him that there is nothing serious the matter with

these important organs. The disturbance of the circulation further

leads to numbness, to some anesthesia, and to paresthesia. Corns and

especially callouses grow more readily between the toes, and patients

who are prone to read about such ailments may conclude that they are

suffering from hypesthesia {420} and hyperesthesia due to some serious

progressive organic nervous disease. I once had a woman patient

discourse learnedly to me about these things who was sure that she had

the beginning of some incurable spinal disease. Locomotor ataxia was

the least she might expect from her description of her feelings. What

I found was flatfoot. Raising her arch cured her.

The cold feet and the numbness, to call them by simple Saxon names

which will not disturb patients, may sometimes keep them awake. In the

chapter on Insomnia we suggest that the best thing for this is to

secure a return of the circulation either by exercises, or by wearing

a flatfoot brace during the day, or by putting the feet in water as

hot as can be comfortably borne and keeping them there for a quarter

of an hour. Of these means exercise is the best. Raising up on the

toes after the shoes are off and coming down on the outside of the

foot strengthens the muscles, pulls the bones of the arch firmly

together and encourages the circulation. For beginning flatfoot this

is a curative measure and it is the natural mode of treatment for the

coldness and numbness of the feet. Rubbing, also, is good for the feet

in order to restore the circulation, but patients are inclined to rub

downwards while they should rub upwards in order to help the hampered

venous circulation. The thin-walled veins are more likely to be

compressed by any disturbance of tissues than are the firm-walled

arteries, and it is to help the veins that our remedial measures must

be directed.

Secondary Consequences.--The secondary consequences of flatfoot are

interesting. It is surprising how many people who frequently suffer

from sprains of the ankle have some yielding of the arch as a

predisposing factor to that condition. Two classes seem to suffer

frequently from sprained ankle--those with yielding arches and those

with high insteps. Apparently there is weakness in the excess in both

directions. Very flatfooted people apparently do not suffer so

frequently from sprained ankles as those in whom there is only an

incipient yielding of the arch. They seem to have learned to walk more

circumspectly. Perhaps, too, their well-known tendency to toe outward

lessens their liability to turning on their ankle. The effects of

sprains of the ankle in people with weak foot last, as a rule, longer

and leave more weakness after them than they do in ordinary cases.

This, of course, might be expected, but it is surprising how often the

significance of beginning flatfoot fails to be noticed even by the

physician. I have seen rather frequently cases of so-called chronic

rheumatism in which there is a series of stories of sprained ankle

because of the assumed weakness of the ankle from supposed rheumatism,

when the whole case can be summed up in a yielding arch.

Exercises.--If the arch has not yielded much, it is often unnecessary

to prescribe flatfoot braces or arch supports of any kind, unless

perhaps at first. After the first soreness has passed off, exercises

may be employed to strengthen the muscles. As we have said, the

patient should rise on his toes and then come down slowly on the

outside of his feet. He may be instructed to sit with his feet--not

his legs--crossed, the feet resting on their outer edges. He may be

shown how even various slight movements of his toes, almost without

moving his shoes at all, will strengthen the muscles that pass around

the arch, which, thus strengthened, will hold the bones of the arch

firmly together and prevent further yielding. There is, at the present

day, a tendency to recommend too freely the wearing of flatfoot braces

or arches. After all, these are {421} only crutches and should not be

worn unless absolutely necessary. If the arch can be strengthened--as

it can be in many cases--so as to bear the body weight without

discomfort, then this is much the better treatment. If the arch is

restored the feet are in a more natural condition, while artificial

support leaves the muscles without that exercise which will preserve

their functions. Flatfoot braces may be necessary, but only if

absolutely necessary should they be advised, and palliative measures,

such as exercise, manipulations, and rubbings, should be given a fair

trial after the unfavorable suggestions as to his foot condition have

been removed from the patient's mind.

Significance of Foot Troubles.--We have devoted much space to foot

troubles--more, perhaps, than will seem justified to the minds of many

physicians. We have done so, however, because of the firm conviction

that the feet are the source of more discouragement and depression of

mind than any other part of the body. Life very often takes on another

aspect when foot troubles are relieved. In the old, progressive

deformities of the feet consequent upon mechanical disturbance are

probably the source of more discomfort, and by their interference with

exercise and outing, the cause of more ill-feeling and even

disturbance of health than any other single factor. Even life may be

shortened by the confinement or limitation of movement consequent upon

bad feet. Above all, the idea that any constitutional trouble, or

hereditary disease, is at the bottom of their affliction must be

removed, and then these patients are encouraged to live their lives

more fully and with more happiness for themselves and others. Hence

this long chapter.

CHAPTER IX

ARTHRITIS DEFORMANS

Arthritis deformans has unfortunately been called by several names

besides the descriptive term which, in the present state of our

knowledge, is the most suitable for it. We do not know its cause. We

do not well understand even the predisposing factors in its causation.

Hence, the term arthritis deformans, which declares simply that it is

an inflammatory condition of the joints producing deformities, exactly

fits it. It has often been spoken of by such names as "rheumatic

arthritis," or "rheumatoid arthritis," and, above all, by the

unfortunate term "rheumatic gout." Many of the worst suggestions that

attach to the word rheumatism are founded on these ill-chosen

designations. Arthritis deformans was supposed to be connected with

rheumatism or with gout, or perhaps to be due to a combination of the

two. In a majority of the cases there is no history of either true

gout or rheumatism to be obtained from the patient, and where a

rheumatic or gouty history does occur, it is either quite indefinite

or it is clear that arthritis deformans developed in a gouty or

rheumatic subject, that is, following genuine gout or rheumatism, just

as it might develop in any other individual without any causal

connection between it and the other affections.

Supposed under the old theory to be a constitutional, probably a

blood disease, patients who saw the ugly, crippling deformities

produced by it and {422} then heard the word rheumatism used in

connection with it were prone to think of this as the terminal stage

of all the severe rheumatic conditions. As a matter of fact no

evidence that we have shows that the disease has any connection with

chemical modifications of nutrition or metabolism; nor, above all, has

the so-called uric acid diathesis or any other superacidity of the

blood any etiological connection with it. It has always seemed to me

to be clearly a nervous arthropathy, as the lesions are almost without

exception more or less symmetrically distributed. The joints that

suffer are commonly the smaller ones in corresponding positions on

opposite sides of the body, and they run a definite atrophic course

sometimes with the preceding phase of hypertrophy that is so

characteristic of the trophic lesions of an affection produced by a

disease or defect of the nervous system. This symmetrical distribution

constitutes the best possible evidence that arthritis deformans is not

a nutritional disease and, above all, is not due to chemical changes

in the blood.

The affection exists in at least three forms and there is a growing

persuasion that there are even more varieties of it that will have to

be separated by clinical observation.

There is a good study of the three types of the disease in _Guy's

Hospital Reports_, Vols. 56-57, London, 1902. The article is entitled

"Acute Rheumatoid Arthritis," but there seems no reason for applying

the word rheumatoid to the group, especially since there is no proved

connection with rheumatism and no similarity, except in the case of

acute deforming arthritis in which at the beginning it may be

difficult to differentiate the two affections.

HEBERDEN'S NODES

The most familiar form is named Heberden's nodes, from the great

English physician who first made a special study of it. The affection

is characterized by an enlargement of the sides of the distal

phalanges with small, hard nodules, "little hard knobs", as Heberden

called them, developing at these points. They are more frequent in

women than in men. Evidently neither hard work nor exposure nor

excesses in eating or drinking occasions them. They occur in all

classes, the poor and rich, manual workers as well as professionals.

It is rare to find them on one hand alone, though it is not at all

rare to find them affecting solely the little fingers of each hand. I

have seen several cases where surgical intervention had been attempted

on one little finger because of the deformity produced when the node

originally appeared. When I asked if there was not some trace of a

similar condition on the other hand I was told there was not, yet I

have been able to show that the first signs, at least, of a

corresponding growth already existed on the little finger of the other

hand. In the two cases in which my attention was called to a slight

enlargement on one side before anything developed on the other, my

tentative prophecy that corresponding nodosities would grow on the

other side was fulfilled during the following years.

While this form of the disease is a true arthritis deformans it seems

to be entirely separate from the progressive forms which we shall

speak of later. The nodes increase in size and occasionally develop on

all of the fingers, but usually never spread beyond the phalangeal

joints. There is a tradition in the {423} medical profession of

England, where this affection has been observed with care for some two

hundred years, that sufferers from these nodes commonly live to long

life. This is not founded on any theory, but is an actual observation.

There is also a tradition, though I cannot vouch for its truth, that

the people who are thus affected have some sort of immunity to

tuberculosis, or at least good resistive vitality against a rapidly

running tuberculous process.

I have had at least a score of Heberden's nodes cases under

observation for more than ten years and some of them for nearly twenty

years, and have been surprised at the slowness with which the process

develops. A year often makes no change in the size of the nodes, and I

have seen cases where after five years the photograph showed no

difference. The lesions are often exquisitely symmetrical so that the

question of the origin of the affection in the spinal cord constantly

crops up, for that is the symmetrical influence in the body. There

are, however, no other symptoms that point to involvement of the cord

in any way. Most of these patients have suffered more from worry about

it than from their affection. It is another case of "having many

troubles most of which never happen."

Some of my patients are physicians, and all of them have consulted

other, some many other, physicians. As a consequence, many of them

have taken to various diets, especially eliminating certain foods and

liquids with the idea that this might stop the progress of the

disease. I have never known any change of diet or any abstinence from

liquids or solids that seemed to make the slightest difference, though

I have seen a number of cases that were considerably worse than they

would have been if the diet had not been tinkered with to such an

extent as seriously to disturb nutrition.

The main disturbing feature of the affection is the dread of the

development of serious crippling conditions in the hands or in the

large joints.

As a rule, after a time the nodes cease to grow, and then a period of

remission sets in that lasts for many years and there may be no

recrudescence of the affection. This remission is delayed if the

patients allow themselves to run down in general health. It is

apparently hastened by getting the patients up to normal weight and

removing any factors that disturb their general health. If the

patients' minds are properly disposed, the neurotic symptoms that

sometimes develop as the result of over-solicitude about their

condition are done away with, the patients are more comfortable, and

even the progress of the disease is inhibited.

ACUTE PROGRESSIVE ARTHRITIS

The second variety of the affection is a general progressive arthritis

which usually begins with fever, redness, and swelling, involving

especially the smaller joints. The diagnosis of the disease can almost

be made on the fact that its favorite locations are the jaw and the

joints of the spine. It is a much more serious affection than

Heberden's nodes. In its beginning it often simulates acute

rheumatism. It occurs particularly in people who are run down for any

reason, in young women who have recently come to the country and are

working as domestics, in young men who have recently changed their

occupation from indoors to outdoors and are not used to the

inclemencies of the weather. On the other hand, it occurs rather often

in young persons of {424} both sexes used to living and working out of

doors who take up an occupation in a damp interior.

The fever usually runs a lower course than that of genuine acute

articular rheumatism, the pain is not favorably affected by

salicylates, and the duration of the disease is generally longer. This

affection always leaves its marks on the joints and there are always

recurrences. It is, indeed, the confusion of this quite distinct

disease with acute articular rheumatism that has given the latter

affection the bad name it has in many minds as a producer of

deformities. Arthritis deformans or general progressive arthritis is

always a crippling disease; acute articular rheumatism has for its

surest diagnostic sign, when the complete history of the case is

known, the fact that it leaves no mark after it except, unfortunately,

that so often seen in the heart.

CHRONIC ARTHRITIS DEFORMANS

The third type of arthritis deformans is the chronic slow running type

which involves many joints before the process is complete. One form of

this, commonly seen in old men, called osteoarthritis, is often

confined to the hip joint, and often produces considerable deformity.

Another form is more common in women. It begins in middle life by

deformities in the terminal joints of the fingers and the

carpo-metacarpal joints of the thumbs. Bony outgrowth takes place

until the joints become almost or quite useless. It spreads from the

joints primarily affected to the elbows, the knees and occasionally

involves other joints. The disease has no favorable course, but is

progressive, and there is great discomfort, marked disability, aches

and pains particularly in rainy weather and, finally, the patient may

become quite helpless.

Preliminary Stage.--An early symptom associated with arthritis

deformans of chronic character is likely to be a distinct loss of

muscle power, which may be the first symptom in cases that have no

acute beginning. The patient notices that he is unable to hold a

satchel as he did before, or that quite unaccountably it drops from

him. There may be a loss of control over muscles and especially small

muscles that attracts the patient's attention. He finds that he cannot

hold a book as he used to, or that it is difficult to pick up small

objects. He finds it hard to turn a door handle or to pull a cork,

although the pulling action may be perfect, but the ability to insert

the corkscrew is lacking. These symptoms are prone to be intermittent.

They are most noticeable when the patient is tired, or after a damp

day, or a succession of damp days, when he is not feeling well. It

will usually be found that a joint, the affection of which is missed

unless it is carefully looked for, that between the radius and ulna

has become affected, and as a consequence there is a difficulty in

supination. The lesions are different from those which occur in lead

poisoning but at the beginning the symptom complexes may easily be

confused.

This form of arthritis deformans, in its earlier and its later stages,

is a source of unfavorable suggestion as regards other affections. Its

first symptoms may be thought neurasthenic, and if it is so called,

those who hear the diagnosis and see the later developments will

conclude that neurotic symptoms {425} can lead to serious sequelae. On

the other hand, the painful tiredness that is always worse in damp

weather may be termed rheumatism and be a correspondingly unfavorable

suggestion. Patients who develop aches and pains as a consequence of

occupations, or through the relaxation of joint tissues, are most

uneasy because of the confusion of the later stages of this disease

with rheumatism. This must be recalled by the physician if he would be

successful in treating such pains and aches; for not a little of the

discomfort is due to an exaggerated mental impression of their

significance. This of itself often proves sufficient to keep the

patients from the exercise that would relieve many of their secondary

symptoms, at least, and serve to make their discomfort more bearable.

Course of Chronic Arthritis.--The course of chronic arthritis

deformans is always interesting. It is never as serious as the

prognosis at the beginning seems to indicate, and it always has

intermissions which, in most cases, become favorable remissions with

such improvement that the patients feel encouraged, though they never

get entirely well. Six rather typical cases have been under my eyes

for from five to fifteen years. In all of them the course was slow and

the progress of the disease vague at the beginning; and it was

difficult to say how the affection began, or what was its cause, and

apparently nothing would stop its advance. After a time all of them

became discouraged and began to go the rounds. Almost without

exception the physicians told them that they were incurable, and

nearly all of them received unfavorable prognoses either directly from

the physician or from hints sometimes dropped to friends, or from the

attitude of the physician toward them. Much of this discouragement

proved unjustified by the actual progress of the disease for many

years. While they got but scant encouragement from regular physicians,

nearly all of them received hopeful suggestions from irregulars and

were, as a rule, for the time being, somewhat bettered by the

treatments suggested by these, no matter what they were.

Every one of these six cases, as was to be expected under the

circumstances, went through a period of intense discouragement, with

loss of appetite, partly from confinement to the house, partly from

thinking so much about themselves, partly from lack of exercise and,

in general, from their morbid mental condition. As a consequence of

the loss of appetite, or, at least, of failure to eat in the midst of

discouragement, severe constipation developed in five of the six cases

and this further complicated the situation. They ran down very much in

weight, and this emphasized the apparent size of the hypertrophic

nodosities in their joints and weakened their muscles to such an

extent that even under good conditions they found it difficult to

move. After a time, usually many months, sometimes a couple of years,

something happened to make them realize that while they were crippled

and were going to be deformed, they still might find much in life that

was not to be despised. Then they began to pick up in weight, their

muscles got firmer, their nodosities seemed to disappear because the

soft tissues around them filled out, though in most cases some of the

material previously laid down actually was or seemed to be reabsorbed,

perhaps as a consequence of the patient's better metabolism.

Neurotic Additions.--All of these patients are now in much better

physical and, above all, in much better dispositional states than they

were during the first year or two at the beginning of their disease.

While they allowed {426} themselves to run down in weight they were

supremely miserable, with many neurotic pains and aches that were

extremely hard to relieve, they had tendernesses and sorenesses on

rainy days, usually attributed to their rheumatic conditions but

really due to intense depression of the nervous system, with a

constant tendency to exaggerate slight pains and aches into torments,

and in general were invalids, a burden to themselves and others. They

have improved to a noteworthy extent so as to become cheerful,

reasonably happy in their power to help others, interested in many

things and, in at least two of the cases, accomplishing more actual

good for those around them than they probably would if their lives had

continued to be the conventional existences that they had been before

their arthritis came to them. This reminds one of Dean Stanley's

famous expression that life looks different when viewed from a

horizontal position. He used the expression with reference to fatal

illness, but it might well be applied to any ailment that makes people

think seriously and keeps them from occupations only with frivolous

things. One of these patients is a source of consolation to many

friends, who are much better in health than she is, who bring their

troubles to her, and who marvel at her power to make the best of

things.

The prognosis for cure is extremely unfavorable, but the prognosis for

a reasonable amount of happiness and a large amount of usefulness is,

in my experience, excellent and though, of course, new habits will

have to be formed and new ways of looking at life assumed, if this can

be quietly and persuasively made clear to the patient early in the

case, much of the more or less inevitable suffering that the patient

will have to endure may be lessened.

The older the patient, as a rule, the better the prognosis in these

cases. As with regard to diabetes, tuberculosis and many another

affection, every year after fifty adds to the prospect that the

patient's ordinary span of life will not be much shortened and that

the symptoms will not be severe. Occasionally the disease develops in

patients who have been extremely healthy until they were well past

sixty. I have in mind particularly a patient who did not begin

seriously to suffer from the disease until she was sixty-eight. Then

for two or three years she was very miserable, mainly because she had

been very active and she feared that the disease would cripple her. It

did bring about a considerable limitation of her activity. Ten years

have passed, however, and she is still able to be about, and, though

now well on the way to eighty, in good weather she still attends to

various duties that take her outside of her home and occupies herself

with many interests.

I was never able to tell her that she would be better. I assured her

from the beginning, however, that she would never be so much worse as

she imagined, and that she would never be actually crippled. During

the early stages of the disease, her discouragement and, above all,

the diminution of activity, the lack of exercise and occupation of

mind and the over-occupation with herself, made her not only mentally

miserable but seriously interfered with many bodily functions.

TREATMENT

In the treatment of arthritis deformans the most important object is

the general health of the patient. Owing to the confinement, the

pains, which {427} are often worse at night, cause disturbance of

sleep which reacts upon the general health. As a result of depression

and discouragement, patients are prone to loss of appetite. This is

sometimes looked upon as a symptom of the disease, but it is not a

direct symptom except during the acute stage when there is fever, and

is due rather to the changed conditions in which the patients live and

the mental influences that surround them. If the patient loses in

weight, as is so often the case, the effects are likely to be more

serious, for the remission is delayed and is less complete in its

consequences. Above all, it is important not to disturb the diet of

the patient in such a way as to interfere with nutrition. Owing to the

supposed rheumatic element, meat, or at least red meat, is

occasionally taken out of the diet by the recommendation of the

physician. Whenever this is done, harm results. There is a definite

tendency to anemia, which will be emphasized by an exclusively

vegetable diet, especially in those accustomed to eat meat freely. As

a rule, there is much more need to encourage the patient to eat than

to limit the diet in any way. Patients must rather be advised to take

a generous mixed diet and to consume about as much meat and the same

varieties as before. Tinkering with the diet has never been known to

do any good for arthritis deformans and often does harm. The drinking

of large quantities of water seems to do more than almost anything

else to help these patients into a better frame of body and mind.

Their neurotic symptoms are, as a rule, even more important than their

joint symptoms, and if the neurotic symptoms can be cured, as they

usually can without much difficulty, the patients feel much better.

Systematic Exercises.--As soon as the acute stage has passed patients

should be encouraged to take some systematic exercise in spite of the

discomfort that is associated with it. Unless muscles are moved

regularly deformities in bad position will result and there will be

crippling which can be avoided in most cases. It is sometimes

difficult to secure exercises for the small muscles that are involved

and definite occupations are better than artificial exercises. For the

fingers, for instance, I find that the best thing is knitting. By this

I mean using the old-fashioned knitting needles for the making of

stockings, wristlets, jackets, and the like. Crocheting is also of

some use, but it does not give employment to as many of the small

muscles as knitting. If the knitting is done with old-fashioned yarn

from which the lanolin has not all been extracted, some of this

substance comes off on the fingers during the movements associated

with knitting. This seems to do good by rendering the joints more

supple and the muscles more easy of movement. At least the suggestion

is very helpful to the patients.

Electricity and Mechano-therapy.--Electricity has been much praised,

but whatever good it accomplished has always seemed to me to be

confined to the exercise afforded the muscles. Its use, however,

serves to keep up the patient's hope.

Mechano-therapy often does good and some of the Zander machines are

likely to be useful. Pulleys and weights for the shoulders and arms

have their place and resisted movements serve to restore muscles to

function which they had lost during the time when the joints were

worst. Their use helps to bring the joint into the most available

conditions.

Something that has distinct hope in it must always be done for these

patients. For this local treatment means more than anything else.

Unfavorable {428} suggestions keep flowing in upon him from the

failure of medicine, and serve to concentrate his attention on his

condition and make him think that nothing can benefit him. Often the

physician finds that his patient has been to someone else, who did

some simple thing that brought relief of symptoms, at least for a

time, and restored his confidence to such a degree that he felt much

better for a time at least. These ailments are emphasized by advancing

years and, though we cannot prevent decay of tissue, we can keep the

patient's mind from inhibiting still further the functions of the

impaired tissue.

General Condition.--The patient's general condition must be made as

good as possible. For this outdoor air is the most important factor.

It increases impaired appetite, makes sleep more restful and easy, and

gives one of the best occupations of mind that can be obtained. Of

course, changes in the weather will bring discomfort. Where it is

possible, such patients must be sent to climates as equable as

possible. Such a change of climate during December, January and

February will often make them very comfortable, and the distraction of

mind, with the possibility of getting out in the mild climate, will

diminish their sensitiveness and be more powerful factors in the

dissipation of their aches and pains than the climate itself. Where

people cannot be sent away from home, the securing of corresponding

distractions means a great deal. The one thing necessary for the

physician is to keep the patient from brooding upon himself and his

ills and to find other occupations of mind for him.

CHAPTER X

COCCYGODYNIA

Coccygodynia, or, as it is sometimes called, coccydynia, is a painful

affection of the coccyx or bony end of the spinal column. It usually

results from trauma, as a fall on the buttocks on an icy pavement, or

particularly a fall in coming down stairs in which the main portion of

the impact is on the seat. Occasionally it follows horseback riding.

It is said to be on the increase among women who ride astride.

Occasionally it is reported after severe labor, particularly when the

head of the child was very large, or after first labor when the coccyx

has been beforehand bent inward somewhat abnormally and is pushed out

by the oncoming head. It seems to develop with special frequency in

nervous people who have to sit much, particularly if they sit on

unsuitable chairs. The chair seat with the ridge in the center which

has been introduced in recent years is sometimes blamed. Occasionally,

on the other hand, it is said to come from sitting on heavily

cushioned chairs, particularly leather chairs which do not allow of

much transpiration and cause a feeling of uncomfortable heat.

There are, indeed, so many different causes suggested, sometimes of

quite opposite or even contradictory effects, that it seems evident

that the main element in the disease is some predisposition to

sensitiveness in this region which is exaggerated and emphasized by

the cause that is blamed. It occurs particularly in women, though it

is occasionally seen in delicate or neurotic men. Sufferers from it

sometimes find it impossible to sit for any length of time. {429} Even

lying down, especially if they lie on their backs, becomes a source of

pain. Various operations, such as the reposition in place of the bent

coccyx, or even the removal of the tip of the coccyx, have been

suggested. Some reported cures are to be found in the literature.

These are mainly surgical cures, however, that is to say, the patient

recovered from the operation, was seen for a month or two afterwards,

and was then on a fair way to complete recovery. Some of us who have

had to treat these cases afterwards for painful conditions apparently

due to the scar of the operation, or to a neurotic condition closely

corresponding to the old coccygodynia, are not so confident of the

value of an operation, though probably in purely traumatic cases

surgical intervention is of value.

In most cases the sufferers are women who have little to do, who have

much time on their hands to think about themselves, and who usually

receive abundant sympathy from friends and relatives. In one case

under my observation the death of a husband and the discovery that his

estate was much less than had been anticipated, so that his widow had

to take up a wage-earning occupation, did more in a short time than

all the treatment that had been employed before to relieve her

discomfort. She had been quite unable to move around at times,

especially in rainy weather, and was something of an invalid during

all the winter, but now she was able to go out to work every day and

had very little trouble. Her affection originally dated from a fall on

an icy sidewalk and her fear to go out in the winter seemed to be

dependent on the dread of another fall. She realizes now that

practically all her former trouble was due to over-attention to a

discomfort which is still present, but which she is now able to

forget, except at times when she is alone after there have been

worries and troubles that have reduced her power to control her

nerves. In young girls an injury to the coccyx by a fall on the

buttocks will often leave tenderness for months or even years, but if

attention is distracted from this and the patient is not allowed to

concentrate her mind on it and does not hear of the awful

possibilities of coccygodynia--a mouth-filling Greek name in which we

map out our ignorance, and which seems to carry with it such a weight

of pathology--she will probably recover completely.

Coccygodynia often resembles hysterical coxalgia or the hysterical

arthritises, and seems sometimes to be due to the fact that there is a

natural or traumatic abnormal mobility of the coccygeal vertebrae

which, owing to concentration of attention, has developed into a

neurosis analogous to the corresponding condition in a joint. There

are undoubtedly cases in which a real pathological lesion exists, but

these are comparatively few. In this, as in other joint and bone

affections with vague pains likely to be worse on rainy days, the word

rheumatism is often mentioned, but it has no proper place. Treatment

that will put the patients into good general condition--never local

unless there is objective indication--outdoor air and exercise with

reassurance of mind and distraction of the attention are the important

therapeutic agents. Patients with much time on their hands do not

readily get well, while those who are busily occupied seldom suffer

for long.

{430}

SECTION X

_GYNECOLOGICAL PSYCHOTHERAPY_

CHAPTER I

MENTAL HEALING IN GYNECOLOGY

All physicians are convinced of the good that has been done by the

extension of the application of surgery to women's diseases during the

pest generation. On the other hand, there are probably very few,

except the ultra-specialists, who are not quite sure that there has

been too much surgery in gynecology, and that many a woman has been

operated on without sufficient reason and without definite

indications. In suitable cases surgery is sometimes life-saving and is

often the only means of relief for suffering that is seriously

disturbing the general conditions and is making life unbearable. Its

very possibilities of good, however, have led to abuses. From the

abuse of a thing, the old Latins used to say, no argument against its

proper use can be derived, and this is eminently true of gynecological

surgery. It will not belittle the great benefit that operative work

has been to state how much of auxiliary good may be accomplished by

the use of psychotherapy in gynecology.

Many a woman who is operated on is benefited only for the time being,

and her old symptoms return after a time. Dr. Goodell, one of our

first great gynecologists, used to warn his students insistently that

women had many organs outside of the pelvis. The individuality in

gynecology is extremely important. Some women suffer what they

describe as excruciating pain or unbearable torture from pathological

conditions that other women do not notice at all. Very often these

women either have no real interest in life and are so self-centered

that they emphasize their feelings by dwelling on them, or else their

attention has been attracted to some sensation not necessarily

pathologic and then by concentration of mind on it they so disturb

vasomotor conditions and the nutrition of nerves that the condition

does become a veritable torture and apparently demands surgical

intervention. It is possible to cause a hyperemia in the skin by

thinking about certain portions of it, and the genital organs are

particularly prone to be influenced by mental states. If for any

reason a woman gets her mind on her genital tract and becomes

persuaded that there is a pathological condition in it, symptoms will

develop until an operation seems inevitable. But the operation will

bring relief only for a while, and then her mind will find something

else to dwell on and produce similar symptoms.

{431}

Place of Psychotherapy.--To fail to try to sway the mind by all the

methods and auxiliaries outlined in the earlier chapters of this work

before suggesting an operation to a woman is to neglect a most

important means for relief in many gynecological cases. There is

scarcely any pathological condition from which women may suffer that

does not become worse as the result of the depressing influence of

much thinking about it, and that is not made better by a change in

their mind that makes them realize the possibility of being well

again. The most important preliminary to operation is the promise of

complete relief through surgery. The acme of suggestion is reached in

the preparation for operation with its constant encouragement and then

the congratulations after the operation. Then come the weeks of

convalescence during which the same strong suggestion is constantly at

work making the patient sure that she must be better. All this serves

to add tone to the system, invigorates the appetite and puts patients

in the best possible mental attitude to bring about a favorable

result. Indeed, the ten or fifteen pounds in weight that such patients

gain during their convalescence, especially when they have been under

weight before, is often the most beneficial result of their hospital

experience.

If the same patients had been given the same promise that they would

surely be cured, and then had been removed from depressing home

influences and bothersome trials and labors, and been told that what

they needed for complete recovery was to gain in weight; if they had

then been visited by friends who congratulated them on the fact that

now at least they were going to be better and their symptoms were

going to disappear, and if they had gained the fifteen pounds that

came in convalescence after their operation, most of them would have

recovered quite as completely as by the operation from many of their

vague gynecological difficulties. This is, of course, true only of

cases where there are not very definite indications for surgical

intervention. But in a certain number the symptoms are so vague that

operation is decided upon rather with the hope than the assurance of

benefit; and it is particularly in these that psychotherapy is useful

and must be given a thorough trial.

_Pain Relief_ .--It is often set down as a maxim of gynecologic

practice, that pain which cannot be relieved except by recourse to

dangerous or habit-forming drugs is an indication for operation. Pain,

however, is a relative matter and, as we have shown in the chapter on

Pain, its intensity depends not a little on the patient's attitude of

mind towards it. When there is discouragement and depression, pain

becomes insufferable, and what was borne quite well at the beginning

may now prove intolerable. Whenever occupation of mind can be secured,

however, pain is diminished in intensity.

Reputed Remedies and Suggestion.--Probably the most striking indirect

testimony to the value of mental influence and especially of

frequently repeated suggestion in gynecology is found in the recent

history of various much-advertised remedies that have been sold in

enormous quantities for all the ills of women. The composition of

these remedies is not, as is popularly supposed, a great mystery. They

have all been analyzed and their ingredients are well known. As a

rule, they contain only simple tonic drugs that have absolutely no

specific effect on the genital organs, but that are stimulating to the

general system. There has been much surprise at the definite evidence

{432} furnished by expert investigators, that the principal ingredient

in most of them--certainly their most active element--is the alcohol

they contain, which, until the passage of the pure food and drug law,

was in such considerable quantities that practically each

tablespoonful of these favorite remedies for women was equal to half

an ounce of whisky. No wonder that this gave an immediate sense of

well-being which rose in most of those unused to alcohol to a feeling

of exaltation. The patient was sure beyond contradiction that she

could feel the effects of the medicine! Of the after effects, the less

said the better, but there is no doubt that many women acquired the

alcohol habit through indulgence in these nostrums.

Illusory as was this sense of well-being, it sufficed in many cases to

relieve women of discomfort that had become so serious, to their minds

at least, that they feared an operation would be necessary.

Undoubtedly many of the testimonials given to such remedies are

founded on actual experiences of this kind in which patients were sure

that they were cured of serious ills. Where alcohol is not the chief

ingredient of these remedies, some other tonic stimulant is employed,

and it has proved sufficient to make the patients feel, or at least

suggest to themselves, that they must be better. This has given them

courage to take more exercise and get more out into the air, and

consequently relieves them of many physical symptoms that had

developed because they thought they were the subjects of some serious

ailment and must be solicitously careful of their health. The idea of

care for the health in many persons' minds seems to be to do as little

as possible of external, useful work and to occupy themselves

principally with their internal concerns. They stay in the house too

much and in so doing disturb nearly every physical function. Perfectly

well people, if confined with nothing to interest them, become

short-circuited on themselves and develop all sorts of symptoms,

physical and mental.

The Mind as a Factor in Gynecological Affections.--A gynecologic

incident of any kind may become to many women such a center of

attention that it is impossible for them to distract their minds from

it, and every symptom or feeling that can by any stretch of thought be

connected with the genital system becomes greatly exaggerated. Young

women, whose menstruation has been perfectly regular, may have it

disturbed by fright, grief, a change of environment, getting the feet

wet, or something of that kind. At immediately succeeding periods

their fear of bad effects will of itself influence unfavorably the

conditions in their genital system. They have always had more or less

discomfort, but now this discomfort becomes difficult to bear because

of the fear that there may be further serious consequences of the

disturbing incident in their menstrual life. It occupies all their

attention; instead of deliberately trying to disregard it, they fear

that, if they should do so, they would be allowing some progressive

condition to gain a hold on them which would lead to serious results.

One is apt to see this condition in young married women who have had a

miscarriage in their first pregnancy and who fear that there will be

serious results from it. If they have been much disturbed by the

miscarriage, they may lose in weight, and then a number of subjective

symptoms in their genital life will appear. Though their menstruation

appears regularly, lasts the usual time, and is neither more scanty

nor more profuse than before, and {433} though their physical

conditions are normal as ever, they suffer from bearing down pains and

feelings and backache just before menstruation begins; their ovarian

regions become sensitive and, if they are constipated, their right

ovarian region is likely to become tender, and they develop a set of

symptoms that seems to call for surgical interference. If, however,

they are put in conditions where they have some other occupation

besides themselves and their ills, it is surprising how the case will

clear up. They gain in weight, their subjective symptoms disappear and

especially they lose the persuasion, so common among them, that any

betterment of their symptoms is due to their getting used to the

pathological condition present and not to any real improvement of it.

Treatment.--In the treatment of gynecological conditions such as are

not necessarily indications for operation, the most important

consideration is to reassure the patient's mind and secure the

discipline of self-control. If patients are under weight this

condition must be corrected. If they are in an unfortunate environment

it must be modified, as far as possible. If they are without

occupation this must be provided for them. Dominant ideas and morbid

auto-suggestion must be overcome--not always an easy task, yet always

possible if patience, tact, and skill are exercised. They must be made

to realize that the women of the past, before the development of

modern gynecology, not only lived useful lives without any of the

modern gynecological operations, but that most of them were quite

happy in so doing. Even though many of them had physical symptoms, the

lack of unfavorable suggestion as to the significance of these

prevented mental exaggeration, and morbid dwelling on them was not

allowed to produce such a deterioration of the physical condition as

to emphasize the pathological conditions. This does not mean that

women may not have to be operated on, and, when that is necessary, the

operation should be determined on and performed with no more delay

than is proper to put the patients into suitable physical condition.

But many operations that are undertaken without definite indications

merely because the women complain, and it is hoped that an operation

will somehow prove of relief, would be replaced with much more final

satisfaction and relief by properly directed psychotherapy.

There are many minor pathological conditions such as slight cystic

enlargements, hyperemias with tenderness, slight displacements of the

ovary, slight dislocations of the uterus or twistings of it that can

often be successfully treated the same way. After all, what is

considered the normal condition of the feminine internal organs is

only an average reached from observation and many deviations from this

average cannot be considered abnormal. Many a woman living practically

without symptoms, or certainly without such symptoms as to justify an

operation, has pathological conditions of her internal organs worse

than those for which operations are sometimes suggested because

over-sensitive women complain of their symptoms. The rule must be

first to relieve the over-sensitiveness and then to determine whether

an operation is necessary or not. Pain alone, unless it is of a

disabling character or reacts upon the physical health, is not a

sufficient indication for operation.

{434}

CHAPTER II

PSYCHIC STATES IN MENSTRUATION

One does not need to be a physician to be familiar with the curious

psychic states which develop or are accentuated during the menstrual

period. Practically all the peculiarities of the individual are

emphasized at this time and if there are any special neurotic

conditions or psychic anomalies these become quite marked. All the

dreads, for instance, are more noticeable at this time. Women who at

all times feel uncomfortable on looking down from a height are likely

at this time to be quite overcome by fear and be unable to approach

any position from which they might look down for a distance. Women who

are afraid of horses, yet conquer their dread sufficiently to ride

behind them, cannot do so, or only with great difficulty, during the

menstrual period, and the same is true of the dread of cats or other

animals. Misophobia, the dread of dirt, may be particularly emphasized

at this time and servants are puzzled as to what has come over a woman

who was not so punctilious in the matter a short time before.

Irritability.--Dr. Charcot, the famous French nerve specialist, used

to say that for a day or two before menstruation and during the first

day or two of their period many women were not quite responsible. This

is not merely an exaggeration of French contempt for women, for

Moebius, the distinguished German neurologist, insisted that there is a

certain physiological mental disturbance with distinct hampering of

the faculty of judgment (Schwachsinn) normally associated with

menstruation.

Few physiologists or gynecologists agree with these extreme views, but

there is no doubt that many of the troubles which business men

experience with women in their employ begin with hasty words spoken at

these periods when the real reason for the irritability is not known.

The consciousness of this on the part of some women saves them from

much undesirable friction by making them more careful at these

periods. Many a domestic misunderstanding begins at these times and is

unfortunately allowed to continue because the real reason for it--the

instability of disposition due to menstruation--is not recognized.

Lack of Inhibition.--There is no doubt that, except in women of the

most stable physical and psychic character, a notable lack of

inhibition characterizes all their actions at this time. To think that

this is universal, however, would be a mistake. Healthy women deeply

occupied with something they like often pass through menstruation

absolutely undisturbed, and this is particularly true of the mothers

of families. In spite of its exaggeration, it is well to keep the

great French specialist's expression in mind, for it helps to explain

many things that produce much suffering in the world. This is

particularly true now that women are working more and more out of

their homes at occupations which often make strenuous calls on them

just at periods of the month when they should have more rest than

usual. The consequence often is the development of a highly neurotic

condition in which psychic {435} symptoms are likely to be prominent

as well as a tendency to exaggerate the significance of their feelings

which is disturbing to the patient and may even disturb the physician.

Exaggeration of Sensitiveness.--The most striking feature of this is

the tendency to exaggerate the meaning of physical symptoms which they

have often borne with for a good while without much inconvenience, but

which now appeal to them as of serious significance. Any uncomfortable

feeling is likely to be dwelt on to such an extent as to be called an

unbearable ache or even an excruciating pain, and the patient is prone

to connect it with some serious pathological process in the region in

which it is felt. If a woman has been reading about some special

ailment, or, above all, has been listening to the tale, usually

neither plain nor unvarnished, of a friend's medical woes, she is

almost sure to think that there must be something seriously wrong with

herself. Many a supposed chronic indigestion had its origin in nothing

more than the uncomfortable feelings in the stomach region during

menstruation, which call attention to that organ and then, by morbid

introspection, lead to the exaggeration of various sensations that

have always been present but have hitherto been disregarded.

It is a good rule to neglect symptoms that develop during the

menstrual period and not to treat them directly until it is plainly

seen that they persist afterwards; for symptomatic treatment at this

time will cause an over-attention to the condition. And we should be

careful not to suggest to a woman at this time that her symptoms may

be due to some pathological condition in an important organ. Such a

suggestion will almost surely be accepted seriously and dwelt on so

much as to become an auto-suggestion that may lead to the disturbance

of the function of the organ in question because of the surveillance

over it. The diagnosis must be put off until menstruation is over in

order that the exaggeration of this period may be eliminated. If this

were more commonly done and if women were advised to counteract their

feelings at this time as far as possible by occupations of interest to

them, there would be much less need of medication. As between rest and

strenuous work during the menstrual period, work is probably always

the better. Rest with nothing to do emphasizes morbid introspection to

such a degree as to make even ordinary feelings unbearable.

_Symptomatic Conditions_.--It is interesting to note how often

affections that are always present give symptoms only during the

menstrual period or just before it. Many women, however, suffer

considerably about the time of the menstrual period from an extremely

tired, painful condition of the leg below the knee which is really due

to flatfoot. At other times it gives them little annoyance. Old

dislocations and sprains are particularly likely to give bother at

this time. All the occupation pains and aches are emphasized.

Tiredness becomes a torment. This extreme over-sensitiveness extends

to physical ills of all kinds, even those that are trivial. For

instance, corns and bunions become almost unbearable, especially if

there is any change of the weather with moisture in the air about the

time of menstruation. Teeth become sensitive and often will ache when

there is little that the dentist can find the matter with them. Women

are often suffering from teeth that are supposed to be quite

intractable because of over-sensitiveness, while in reality it is only

at these certain times that the over-sensitiveness is present.

{436}

Over-reactions.--Even habitual actions which are accomplished without

much difficulty at other times are likely to be a source of annoyance

about this period. If a young woman has to call out figures or read

off lists of names, she soon becomes hoarse, her voice becomes husky

and it requires more effort to accomplish her work than at other

times. Complaint of sore throat is common about this time, and if

there have been any recent changes in the weather this is almost sure

to be a premonitory symptom of menstruation. Singers and elocutionists

are likely to find their occupations particularly trying at this time

and actresses are seldom without considerable physical discomfort that

makes playing difficult and unsatisfactory. This happens in all

occupations requiring frequently repeated use of particular muscles.

Piano-players and typewriters find that their fingers become sensitive

at this time. This sensitiveness of the ends of the fingers may become

so marked as to prevent these usual occupations, or at least may

require their limitation.

Physical Basis of Psychic States.--The physical basis of these

troubles is probably more responsible for them than has been thought,

though the mental state renders the individual more susceptible to

annoyances of any and every kind. Careful weighing seems to show that

there is a gain in weight amounting sometimes to three to five pounds

toward the end of the menstrual month. This is accompanied by a sense

of fullness that is perhaps an actual plethora, as if nature were

manufacturing a superabundance of blood in anticipation of the loss.

This produces a systemic hyperemia. It is well known that hyperemic

areas are more sensitive than tissues in ordinary condition and this

seems to be the case in menstrual life. This renders the nervous

system more active and irritable and the nerve endings more sensitive.

With the menstrual loss this physical condition is relieved and then

there is a return to normal with a loss of weight only partly due to

the actual blood loss and somewhat to increased excretion in

perspiration, in transpiration through the lungs and through all the

emunctories.