Psychotherapy Part 45

Dr. MacKenzie calls attention particularly to the erectile character of the tissues mainly involved in all these forms of dust catarrh and dwells on the role that mental influence always plays in the phenomena noted in such tissues. This with the vaso-motor elements in the affection which are so largely also under the control of the emotional nature make it clear that the pathology of the affection must be considered from this standpoint and, therefore, its therapy also.

Dr. MacKenzie continues:

From our present knowledge of the disease, it seems difficult to escape the conclusion that its pathology is intimately interwoven with a morbid condition of the vaso-motor sympathetic, and probably a hypersensitive state of the nerve centers themselves. When we recall the fact that in the famous section of the sympathetic in the neck by Claude Bernard, symptoms similar to, or closely allied to, the phenomena of hay fever were produced; when we reflect upon the results reached by Prevost in his experiments on the spheno-palatine ganglion, is there not a clue to lead us through the labyrinth of our difficulties to a rational solution of the question? . . .

. . .In the human body, wherever erectile tissue is found, it is intimately related to reflex or sympathetic acts; there seems to be connected with it a certain receptivity to reflex producing impressions, a certain power of reflex excitability dependent upon its structure and functions. It is thus peculiarly a tissue of sympathy in which we may most satisfactorily study the mechanism of purely reflex or sympathetic acts. Now it seems to us that, as the nasal corpora cavernosa belong to this cla.s.s of sympathetic tissues, there will be little difficulty in explaining the role which they play in the paroxysms of an affection which is probably connected with, if not dependent upon, an excitation of the sympathetic nerve centers, and in more clearly defining the intimate relation which its erection bears to the reflex manifestations of the disease under review.

These considerations explain the heredity of the affection in many cases, since it is dependent on defects that may be family traits, yet they also enable us to understand how slight lesions of the nasal mucous membrane may be the center from which radiate the underlying pathological conditions of the disease.

Railroad Asthma.--There is a form of dust asthma which deserves special attention here because it is due to modern conditions and helps to an understanding of the etiology. It occurs in sensitive persons when they travel on railroad trains in warm weather, particularly if it has been dry for several days and dust is abundant.

It has been called railroad asthma or railroad catarrh by the English and the Germans, but the condition has no necessary connection with the railroad. It occurs as a consequence of the infiltration into railroad cars of fine dust during the pa.s.sage of the train. {371} I have seen it in those who had made long trips over dusty roads in automobiles, though the dust of the railroad seems finer and more penetrating. It develops just as much at the end of a long train as if the pa.s.senger spent most of the journey in the car next the engine and apparently it makes no difference whether the engine burns hard or soft coal. They use soft coal almost exclusively in England and Germany, but one sees cases of it here after travel on roads that burn hard coal and are especially cleanly in this respect. Soft coal adds somewhat to the amount of dust and therefore this increases the irritation, but there is nothing specific about coal dust. It is surprising how severe the symptoms may be. I have seen a patient who had traveled continuously for four days across the continent who had so much photophobia when he alighted from the train, that he was almost unable to open his eyes, and it was not until twelve hours had pa.s.sed that he could open his eyes with any comfort, yet at the end of two days practically all the symptoms had pa.s.sed off.

Prof. Fraenkel, professor of laryngology and rhinology at the University of Berlin, who was one of the first to cla.s.sify the condition among the affections related to "hay fever," described certain features of it very well in a clinical lecture reported in _International Clinics_, Vol. II, Ninth Series, 1899. As a rhinologist he insists on the nasal conditions that underlie the affection yet suggests that the nasal hyperemia may be due to reflexes of one kind or another. The basis of these is undoubtedly very often an emotional condition of the patient, a dread of dust, an expectancy of symptoms and a consequent exaggerated reaction. Unorganized dust produces asthma, but organic materials bring more severe and lasting effects, partly because of the mental effect of odors and other sensory conditions in connection with them.

The Personal Element and Power of Suggestion.--The history of these asthmas and other symptoms produced by odors and dust make it clear that the more that is known about the disease the surer it becomes that there is a large personal element, usually dependent on a certain frame of mind, in the cases. Some people are affected by one form of irritant, some by another, some by pollen, others by animal emanations, and not a few by a persuasion of the likelihood of suffering from these things, since occasionally the sight of an artificial product produces a like result. Certain cla.s.ses suffer much more than others. Those who are much confined to the house and who are especially p.r.o.ne to reflection upon themselves and their feelings form the great majority of the patients. In old days the monks were favorite victims, in modern times literary folk, students, and those who have the time and the inclination for reading and introspection are particularly likely to suffer. How much the mental element may account for in these cases is not clear, but it stands for much more than has been thought and there seems no doubt that more relief of symptoms is afforded by diversion of mind and change of dwelling quite apart from external conditions than in any other way. It is important to remember that no specific dust but almost any kind of dust produces these conditions in sensitive persons.

Dr. MacKenzie describes an interesting case in which all the symptoms were produced by the presence of an artificial rose. The story is so striking and he has told it so well that I prefer to tell it in his own words. I may say, however, that the clinical history of the case was typical. About the end of {372} May or the beginning of June every year the patient suffered from a coryza preceded for a few days by an indefinite sense of general depression with a disagreeable feeling of heaviness in the head. Sometimes there were chilly feelings and general malaise. The catarrhal stage commenced with profuse watery discharge from the nostrils, copious flow of tears with redness of the conjunctiva, itching of the puncta lacrymalia and photophobia. The exterior of the nose, especially at the tip, became intensely red and toward the close of the attack the cuticle desquamated. There was a short, dry, hacking cough relieved by sneezing, an intense tickling sensation in the throat, the voice became husky, the pharynx dry, the ears stopped up and tinnitus occurred. Her attacks continued most of the summer and were always brought on by the pollen of any plant and above all by the smell of a rose. It was, indeed, an example and of the most aggravated form. She was brought to Dr. MacKenzie in consultation and I leave him to tell the rest of the story.

Decidedly skeptical as to the power of pollen to produce a paroxysm in her particular case, I practiced the following deception upon her, which still further confirmed me in that belief. For the purpose of the experiment I obtained an artificial rose of such exquisite workmanship that it presented a perfect counterfeit of the original. To exclude every possible error, each leaf was carefully wiped, so that not a single particle of foreign matter was secreted within the convolutions of the artificial flower. When the patient entered my consultation room, she expressed herself as feeling unusually well. The evening before she attempted to wear some roses, but had been obliged to remove them from her dress, as they had produced a great deal of discomfort. Apart from this incident she had been perfectly comfortable for several days and nights. Her conjunctivae were normal, the nasal pa.s.sages free, and there was nothing to indicate the presence of her trouble. She conversed with me for some time about her case and on general topics, speaking in the most encouraging manner concerning the progress she was apparently making toward recovery. I proceeded to remove the slight slough from the cautery operation, which lay loose in the nostril, and made an application to the mucous membrane, and all without exciting the slightest tendency to reflex movements. After I felt sure that such tendency was absent, I produced the artificial rose from behind a screen, where it had been secreted, and, sitting before her, held it in my hand, at the same time continuing the conversation. In the course of a minute she said she must sneeze.

This sensation was followed almost immediately by a tickling and intense itching in the back of the throat and at the end of the nose. The nasal pa.s.sages at the same time became suddenly obstructed, and the voice a.s.sumed a hoa.r.s.e nasal tone. In less than two minutes the puncta lacrymalia began to itch violently, the right and afterward the left conjunctiva became intensely hyperemic and photophobia and increased lacrymation supervened. To these symptoms were added, almost immediately, itching in the auditory meatuses and the secretion of a thin fluid in the previously dry nasal pa.s.sages.

In a few minutes the feeling of oppression in the chest began with slight embarra.s.sment of respiration. In other words, in the s.p.a.ce of five minutes she was suffering from a severe coryza, the counterpart of that which the presence of natural roses invariably produced in her case. An examination of the throat and nasal pa.s.sages was then made. The right nostril was completely obstructed by the swollen, reddened, irritable, turbinated structures; the left was only slightly pervious to the air current; both were filled with a serous-looking fluid. The mucous membrane of the throat was also injected, but did not exhibit the same amount of redness and irritability found in the nasal pa.s.sages. As the discomfort was rapidly increasing, and as I considered the result of the experiment sufficiently satisfactory. I removed the rose and placed it in a distant part of the room. When told that the rose was an artificial one, her amazement was great, and her incredulity on the subject was only removed upon personal examination of the counterfeit {373} flower. She left my office with a severe coryza, but also with the a.s.surance that her disease was not altogether irremediable. A few days later she called to see me again, and on that occasion she buried her nostrils in a large, fragrant specimen of the genuine article and inhaled its pollen without the slightest tendency to the production of reflex acts.

There is but one conclusion that can be drawn from this: that suggestion plays a large role in the relief of the symptoms of the disease. If patients once become persuaded that something will do them good, then it surely does. It is true that this good effect will usually not persist, but that is because after a time conditions conspire to make the suggestion fail of its purpose. This does not at all imply that hay fever, or just catarrh as I prefer to call it, is imaginary. The relief of our most serious and fatal diseases with profound pathological lesions, such as tuberculosis, may well be brought about by suggestion. After all, just the same story is told about consumption and its many remedies as of hay fever and its many "cures." However, the most important therapeutic element so far discovered for the treatment of hay fever is evidently suggestion. If the patient's mind can only be brought to a favorable att.i.tude in which the discouragement incident to imperfect oxidation can be greatly lessened, then relief of many of the symptoms will be afforded and under favorable conditions the patient will deem himself cured.

Undoubtedly the large amount of attention given to hay fever, the gathering of these patients in particular localities, the repet.i.tion of the story of their symptoms to each other, the body of literature that has gathered around hay fever and is read with such avidity by those who are pleased to call themselves its victims, adds to the unfavorable suggestions and inveterates the symptoms, exaggerates the nasal hyperemia and makes the general condition worse.

I am the more positive about the influence of suggestion, favorable and unfavorable, in the affection after having carefully noted the conditions in certain patients from year to year for a number of years. I became interested in it because it is a family affection and several sisters as well as myself are sufferers from it. At the beginning, when the real nature of the trouble is not recognized, there is a year or two of considerable general discomfort, though not much local disturbance. Then comes the realization of what the recurrent affection is and a period of distinct depression during its continuance. Eventually it begins to be appreciated that a number of local applications will lessen the symptoms from day to day and that there need be no apprehension of serious sleep disturbance, or of any lasting effect upon the general health, the affection becomes quite bearable and, while still annoying, is no longer the object of particular solicitude.

CHAPTER V

DYSPNEA--CAT AND HORSE ASTHMA

There is a cla.s.s of cases of difficulty of breathing allied to asthma and often called by that name, the study of which throws light on the origin and the relief of neurotic asthma. These cases are usually accompanied by such a sense of oppression on the chest that breathing becomes labored and, to some {374} extent at least, the accessory muscles of respiration have to be called into play. The most typical cases are connected with the mental influence produced by the presence of some particular animal, the cat being the most frequent and the horse not rare, or with emanations from these animals, when there seems to be some physical nexus between the animal and the symptoms.

Cat Asthma.--The symptoms a.s.sociated with cats are rather common, and they occur at the sight or touch of the animal, but may be the result only of its presence which in some way the patient is able to recognize without sight of him. Shakespeare's expressions in a number of places, such as "I could endure anything before but a cat" and "some that are mad if they behold but a cat," shows that the affection was commonly recognized at that time and that the reason for it was considered unknowable, for Shakespeare says, "There is no firm reason to be rendered why he cannot abide ... a harmless necessary cat."

Dr. Byron Bramwell in his "Clinical Studies," Vol. I, page 107, has an interesting paragraph with regard to these curious asthmatic conditions which develop in the presence of animals of various kinds.

He sums up many of the curious features of this affection as reported by various good observers. Many more people than we would be apt to think are affected by it. He says:

In some persons the smell of a horse or of a cat produces an attack of asthma. Some years ago I repeatedly saw a young gentleman who invariably had an attack of asthma if he went near a stable or a horse. He was so susceptible that he was unable to drive in a cab or a carriage; when traveling from place to place, while sending his traps from the station to the hotel in a cab, he himself was obliged to walk.

Dr. Goodhart mentions a similar instance which occurred in the practice of Prof. Clifford Allb.u.t.t. Dr. Goodhart also mentions a remarkable case of "cat asthma":

I have known of two cases of cat asthma. In one of them the existence of cats is the bane of life, for before accepting an invitation she is obliged first to ask, "Is there a cat?"

[Footnote 32] An attack of urticaria and coryza followed by asthma has been noticed to come on within ten minutes of having stroked a cat. At other times, sitting in a room in which there was a cat, without any actual contact with it, was sufficient to produce a bad attack, beginning within ten minutes of entering the room.

[Footnote 32: A case of this kind came under observation as this book was nearly ready for the press. The patient, a young woman in an office, had to refuse a vacation with a wealthy friend in Florida, because she knew that friend could not be separated from her pet cats, five in number, and the patient would have been intensely miserable were she near them, so that even the joys of Florida in the winter did not make up for the constant, intolerable discomfort they would have caused her.]

There are two forms of this intolerance of a cat. One of them takes on the character of a dread and is discussed in the chapter on Dreads.

The other is accompanied by dyspnea or asthma with a sense of discomfort and tightness of the chest that cannot be overcome. It is not merely an imagination, for sometimes even when they cannot see the cat, or at times when friends have been careful to exclude cats from the room, these people become impressed with the idea that a cat is near and a search usually shows that their impression is true, though just what was the means through which they came to know it is difficult to understand.

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Dr. Weir Mitch.e.l.l's review of the subject of "Cat Asthma and Allied Conditions" in a paper read before the a.s.sociation of American Physicians brought out many curious details. There is no doubt about the power to recognize the presence of the unseen cat. Besides the respiratory oppression, some patients develop urticarial lesions and occasionally even conjunctivitis and a catarrhal condition of the nasal mucous membrane. These seem to be due to the direct irritant effect of animal emanations. As the symptoms of rose cold or hay fever have sometimes developed after the sight of an artificial rose, or even, it it said, the picture of a hay field, so, in some of these cases, the sight of a picture of a cat has produced at least some of these symptoms. Probably the most interesting feature of the affection is that the large cats, the tiger and the lion, do not have any effect on the patient. There seems to be no doubt, then, that the mind plays an important role in the matter and that relief must be secured through mental influence.

In some of these cases a careful searching of the past of the patient will show that there has been some terrifying incident connected with the cat. In one case in my own experience the patient's earliest recollection, and the first time that death was brought home to her, was when a favorite bird was killed by a cat. Ever after that she had a horror of the animals, the family cat had to be disposed of, and her family never had another. She used to suffer from a severe dyspnea at the sight of a cat and was sure that she could recognize its presence without having seen it. She mentioned a number of occasions on which that had been true. The very idea of living where a cat could come near her was appalling. She was sure that she was even waked by the mere propinquity of a cat if by any chance one got into her room at night, though without any noise.

A change in her material circ.u.mstances compelled her to teach in private families. Under these circ.u.mstances her cat detestation made difficulties for her. I suggested, since she had had no feeling toward cats before the bird incident, that probably her symptoms were due to suggestion and an acquired habit of mind and that she might by discipline overcome them. She was sure that would be impossible. With determined effort, however, and practice in withstanding her feelings in the presence of cats she finally learned to overcome practically all of her feelings so that though it still requires an effort she can even pick up a cat and stroke it. I have had several other patients with less marked forms of the affection who have by self-discipline overcome their feelings to a great degree. It is always well to search the past of these patients in order to find out whether there may not be a dominant idea derived from some unfortunate experience, which acts as an auto-suggestion in the production of their symptoms of constriction of the chest and sometimes even the recurrence of the swelling of the mucous membrane of the nose that produces difficulty of breathing. Whenever this can be found, contrary suggestion can be given and the patients can be persuaded to try, by frequently repeated auto-suggestion, to relieve themselves of the trouble.

Occasionally these curious manifestations of a catarrhal or asthmatic character in the presence of cats occur in people who like cats. Dr.

Taylor in his "Types of Habit Neuro-Psychoses" published in the _Proceedings of the Ma.s.sachusetts Medical Society_, 1896-98, tells the story of a young woman in whom he saw conjunctivitis developing while she was fondling a cat. In many cases {376} besides the hyperemia of the nose and of the respiratory mucous membrane generally there is marked injections of the ocular conjunctiva. It is rather difficult to understand the phenomena of asthmatic attacks in connection with cats and other animals in terms of a habit formed, because at some time asthmatic or hyperemic manifestations occurred in a.s.sociation with the handling of these animals and that then, somehow, suggestion works to reproduce the same symptoms in the presence of the animals later; but this is undoubtedly the only rational explanation that we have for many of these cases. It represents the most helpful explanation, so far as treatment is concerned, for by means of suggestion either in the waking state or in the first stage of hypnosis, in many cases relief can be brought to these patients. Repeated profound hypnotism is a vaunted remedy for these conditions in the hands of professional hypnotists, but serious physicians who have tried hypnotism do not recommend it. It helps for a time but relapse follows. Only continued suggestion and a carefully cultivated habit of self-discipline and control succeed.

Horse Asthma.--The cases of dyspnea in connection with horses are not less interesting. Occasionally, even when all aversion is absent, emanations from horses are capable of producing a curious effect on certain individuals. How much of this is psychic is not clear. I was once consulted with regard to a patient who suffered from asthma whenever she went to a dance. It mattered not how careful she was in not exposing herself to night air, or in wrapping herself up warmly; invariably a few hours after her return home, she was wakened from sound sleep by an attack of difficult breathing that required the opening of windows and the use of the accessory muscles of respiration in order to satisfy her air hunger, and even then her symptoms were quite alarming to herself and her friends. At first, her asthma was thought to be due to sudden changes of temperature in going out into the air after the dancing, and various devices were tried to lessen the shock of the cold to the respiratory mucous membrane. None of them had any effect. Then it was thought that the dust of the ball-room made the difference and so she was forbidden to dance. After a time it was found, however, that if she went out in the evenings to social functions, whether she danced or not, or though she avoided completely being in dusty rooms or where many people were moving, she still had the attacks a few hours after she returned home.

Finally it was noted that these attacks of asthma also occurred on several occasions after she had been out riding during the day in a carriage. Then one evening after a rather long intermission free from attacks, in spite of directions and her fears, she went to a ball, but owing to circ.u.mstances went and returned by trolley instead of, as usual, in the family carriage. That night she had no attack of asthma.

Experiments were made then and it was found that whenever she rode behind horses she suffered from an attack of asthma during the following night. The attack was evidently not due to suggestion. The story ill.u.s.trates the necessity for carefully a.n.a.lyzing all the circ.u.mstances of an asthma patient and making sure that some one of these curious and unusual conditions are not at work, for if they are, the only possible curative treatment is by influencing the patient's mind, first by demonstrating the cause of the affection and then by training in self-control to reduce the reaction.

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Recently I have been consulted with regard to a physician who has developed in a rather curious manner a sensitiveness to the presence of horses. As an interne at a hospital during an epidemic of diphtheria he took a dose of diphtheria ant.i.toxin for immunizing purposes. The amount injected was 750 units, the remainder of the dose of 1,500 units contained in the phial being given to the nurse who had charge of the cases. She suffered absolutely no ill effects, so that the manifestations in his case were entirely due to idiosyncrasy and not to anything in the serum itself. Within fifteen minutes after taking the injection the mucous membrane of his nose became so congested as to make it impossible for him to breathe through his nostrils and the mucous membrane of his soft palate was seriously disturbed in the same way. His face became much swollen, the edema affecting particularly his eyelids and his lips and hundreds of wheals appeared all over the body. Fortunately the edema did not affect the larynx, or the issue might have been fatal, or would surely have required intubation. His pulse became extremely rapid and weak, there was marked dyspnea, and whenever the patient sat up there was fainting or a distinct tendency to it.

Under active stimulation and elimination the symptoms rapidly pa.s.sed off so that the only noticeable edema the next morning was in the eyelids and lips, which, however, also disappeared within twenty-four hours. Up to this time the physician had never been bothered by any tendency to hay fever or to asthma and there is no history of either of these affections in his family. Thereafter, however, though quite without his antic.i.p.ating it, and, indeed, the first symptoms were incomprehensible, he became extremely sensitive to emanations from horses. When he rides behind a horse for some distance his conjunctivae become injected, the nostrils become congested and difficulty of breathing sets in with a sense of constriction of the chest. These subside as soon as he gets away from the presence of the horse and has washed himself thoroughly. He suggests that he has become sensitized to horse serum and, as it did not exist before his experience with diphtheria serum, he, of course, connects that incident with the present tendency. It is easy for such a case to have its real significance entirely missed and, of course, treatment by prophylaxis, the most efficient form, would then be out of the question.

Other Forms.--Apparently at times human emanations or some peculiarity of odor seems to influence asthmatic conditions. I have been told by a good observer--a physician--of two brothers who had an attack of asthma whenever they visited each other. At first this was attributed to something in the air or some other condition of the visit. After a time it was found to occur under varying circ.u.mstances, but that the one essential was the a.s.sociation with each other.

Treatment.--The more one knows about asthmatic conditions the more does it become clear that special study of individual cases is extremely important for any definite knowledge of the causation in a particular case. Without a knowledge of the cause the treatment is very unsatisfactory and in the meantime the unfavorable suggestion of the recurrence of the attacks acting upon the patient sometimes disturbs the general health. To remove this unfavorable influence must be the first care of the physician and then if the real cause can be found, favorable suggestion and modifications of the mode of life, with self-discipline and control of the mental att.i.tude and of the {378} nervous system, may greatly aid in the reduction not only of the number of attacks and of the severity of the symptoms, but finally lead to complete eradication of the affection.

Mental control to some degree can be obtained and it has even been suggested that if the emanations from an animal cause physical symptoms, gradually increased dosage of them, beginning with very small amounts, that is, short periods of a.s.sociation with the animals in question, may gradually lead to the production of an immunity to them as it does even to the much more serious results of snake poison.

Certainly some patients seem to have succeeded in bringing relief to themselves by this means and it is worth while remembering in the therapy of the affection, if for no other reason than the strong suggestion that goes with it.

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SECTION IX

_PSYCHOTHERAPY IN THE JOINT AND MUSCULAR SYSTEM_

CHAPTER I

PAINFUL JOINT CONDITIONS--PSEUDO-RHEUMATISM. [Footnote 33]