Psychotherapy Part 46

[Footnote 33: The position here taken, that acute articular rheumatism never leaves a mark after it, is entirely due to the observation that whenever cases were seen in which sequelae were noted, there always seems to the writer to be question of something else besides simple acute articular rheumatism--a complication.

Subsequent pathological investigation may show that occasionally acute articular rheumatism does to some extent disorganize joint tissues. Personally, however, I have the feeling that there are a number of different kinds of acute arthritis, probably three or four, and that most of them leave no pathological condition in the tissues. Perhaps we shall be able to differentiate the severer forms and recognize them from the beginning, as we have already done with regard to scarlatinal, gonorrheal, influenzal and other so-called rheumatisms. For practical purposes it certainly seems better to emphasize the fact that chronic rheumatism following an attack of simple acute arthritis is so rare as to be negligible.]

Many painful conditions in connection with joints give rise to more or less continuous or frequently repeated discomfort, which often leads patients to think that there are serious pathological factors at work, or that some progressive disease condition has obtained a hold of them. Many of these painful conditions are due entirely to local causes: to over-exertion, to the wrong use of muscles, to the exercise of joints under unfortunate mechanical conditions and the like. Just so long as people are a.s.sured that an ailment is local, is not likely to be followed by serious impairment of function, that the discomfort of it is only temporary, and, above all, just as soon as they get rid of the notion of a progressive const.i.tutional malady, they are content to bear even annoying pain without much complaint, and, what is more important, without such discouragement and worry as may impair the general health. Unfortunately, it is the custom to call most of these vague painful conditions "rheumatism," unless there is some other patent cause for them. Especially is this done if the symptoms happen to be worse in rainy weather, or in damp seasons. Rheumatism is always thought of as a progressive const.i.tutional disease, and the very idea of it produces an unfortunate sense of depression.

Exaggeration of Significance.--Toothache, for instance, unless it is allowed to nag for a long time, awakens no dreads and consequently fails to produce the corresponding depression and discouragement, seen so often in connections with conditions much less painful, but a.s.sociated with the thought of the possibility of serious developments. _"Omne ignotum pro magnifico,"_ what is not well understood is always exaggerated, was Cicero's summing up of the tendency of the human mind to make the significance of misunderstood things greater than they really are. It is particularly true of painful {380} conditions of the body, and the tendency must be combated if patients are to be relieved. This must be done not alone because along this way lies relief of suffering, since not a little of the discomfort is due to the mental concentration consequent upon the dread, but because, also, the discouraged state of mind interferes with the trophic influences that go down from the central nervous system to the periphery to keep it in good health and to restore function when there is anything out of order. In a word, the exaggeration of significance so likely to influence such patients for ill must, as far as possible, be removed for their immediate relief as well as ultimate cure.

Rheumatism, Gout, Catarrh.--There are three words in popular medical language which can be made to include more diseases and explain more symptoms than any others. Their meaning has become so indefinite that they now convey very little information, though they are much used--and abused. They are: rheumatism, gout and catarrh. Curiously enough all three of them when their etymology is studied mean the same thing as far as their derivation goes. Catarrh from [Greek text] the Greek word to flow down and rheumatism from [Greek text] the Greek verb to flow are terms that correspond exactly in etymology to gout, which is probably derived from _gutta_, the Latin word for drop--referring to the excess of secretion that is supposed to occur in the disease. All of these have for their basic idea, in etymology at least, an increase of secretion. A generation or two ago, the word rheumatism included a host of disparate painful affections, and was even more sadly abused than now, though its abuse has not ceased. The word catarrh is now at its acme of abuse. Gout has been pushed somewhat into the background by the other two. Any one of these three terms carries with it, in the popular mind, a connotation of progressive const.i.tutional involvement which is not justified by anything that physicians know with regard to these diseases.

The Uric Acid Diathesis.--The usual supposedly scientific explanation of a decade ago for many of these vague pains and aches cla.s.sed as chronic rheumatism was that they developed on the basis of an excess of uric acid in the system. Advance in chemistry has completely obliterated the significance of the observation on which the theory of a uric acid diathesis, as it was so learnedly called, as an explanation for these conditions was founded. After uric acid there came for a time the theory of an excess of lithic acid, the so-called lithemia or American disease of a few years ago. These are, however, merely pseudo-scientific hypotheses and the more physicians know of chemistry the less they talk about them. Many pract.i.tioners, however, continue to accept this universal explanation which makes diagnosis so easy and which is supposed to be so suggestive for treatment. There are various remedies that are claimed to reduce the uric acid content of the blood or the system, and then there are various changes of diet that are supposed to do the same thing. These two systems of treatment and the combination of them have const.i.tuted the main therapeutic resource of many physicians for these so-called rheumatic cases, though their success has been anything but what they hoped for.

Diet Tinkering.--Tinkering with diet has been particularly harmful in these cases. Over and over again I have seen patients who had lost considerably in weight because they had had all the supposed acid-forming elements removed from their diet. In many physicians'

minds this seems to include most of the starches, as well as the fruits and many meats. Without any {381} potatoes, with only a limited amount of bread, with a warning as to red meats, and occasionally even some distrustful remarks with regard to b.u.t.ter, it is not surprising that the patients lost weight, that muscles became weaker, that painful conditions became severer, and that, above all, the patients'

minds became less capable of bearing whatever discomfort is present.

Besides, constipation intervenes with its train of consequences and patients become miserable, lose sleep often because of insufficient nutrition and actual clamoring on the part of their gastrointestinal tract for food. I have seen a man who was not much over normal weight to begin with lose twenty-five pounds, nearly one-sixth of his weight, while being dieted for vague pains (worse on rainy days) that were really due to his occupation, but that had been diagnosed as "rheumatic," consequent upon the uric acid diathesis, for which coal tar products were prescribed over a long period and his diet strenuously regulated. This has become as much of an abuse as the old-time purgings and bleedings.

Irregular Treatment.--As we have said, this group of cases const.i.tutes the most frequent and abundant source of profit for quacks and charlatans and irregular pract.i.tioners generally. The naturapath, the osteopath, whom we have already mentioned, for to these cases he owes most of his success in appealing to legislatures for recognition, the irregular electropath, many supposed diet specialists, and even the special shoemaker, have reaped a rich harvest from these patients. The reason why they have done so is that, as a rule, they have at once rea.s.sured the patients that their condition was not seriously progressive and have promised them certain relief from their ailment.

Usually various local measures, such as St. John Long's liniment of one hundred years ago and many of its successors, or the mechanotherapy and the ma.s.sage and the manipulation of the osteopaths of the present day, have been employed with consequent restoration of circulatory disturbances to normal conditions and, in general, the setting up of better mechanical employment of muscles than was possible before. If so-called chronic rheumatism is to be treated successfully and this opprobrium of medicine, as it has been called, is to be removed, it can only be done by a careful a.n.a.lysis of the ills of each individual patient and a definite determination as to just what local pathological condition is at work and not by a slip-shod diagnosis of rheumatism with immediate recourse to a supposed or a.s.sumed theoretic diathesis for the explanation of its etiology.

Differentiation of Joint Conditions.--The local conditions that give rise to painful conditions of joints are most diverse in character.

There was a time when all of the infectious joint affections had the term rheumatism applied to them. Even at present it is not unusual to hear of scarlatinal or gonorrheal or influenzal rheumatism. What is meant, of course, is that the microbes of these specific diseases have for some reason found a lowered resistive vitality in one of the joints, or perhaps several of them, and have set up an inflammatory disturbance. These specific arthritises are now definitely separated from the rheumatism group and it seems clear that in the near future we shall have rheumatism itself divided up into a series of diseases.

By this I mean that even where there is the redness, the swelling and the fever of true inflammation of joints, it is not always due to one microbe, but to various microbic agents, and so we shall have various forms of rheumatism. At present we are p.r.o.ne to speak of many of the neuritises as rheumatic, but it is probable that {382} here a series of varying microbic infections will be found, some of them much more serious than others, most of them capable of complete cure, though some of them will tend to leave pathological conditions in nerves that are more or less crippling.

Painful Joint Affections.--These pains and aches occur particularly in the old and those who have been hard muscle workers, in those who have been exposed much to the elements and especially in the subjects of old injuries. All of these conditions, one way or another, have left their mark upon tissues so that the nerves do not receive proper nutrition, especially when there is considerable exertion or in rainy weather.

There are a number of reasons why rainy weather produces this effect.

The humidity of the atmosphere lessens evaporation. This disturbs heat conditions in the tissues, for evaporation is the most important element in heat dissipation. This leads to the acc.u.mulation of heat in the parts and conduces to congestion. Any tissue of lowered vitality will be affected by this and nerves become oversensitive. Besides, it seems probable that the fall in the barometer with the lessened pressure from without makes a difference in the circulation. There is a general feeling of depression in wet weather and apparently the circulation is not so active. It is particularly slow at the surface of the body and in the terminal portions, so that the hands and feet are likely to be cold. Just as soon as the barometer goes up somewhat these conditions cease to be active and there is restoration of the circulation to its previous condition. Besides, it seems not unlikely that dampness produces some relaxation of muscles, so that it is more difficult to make them contract, and consequently they are used at a greater mechanical disadvantage and painful tiredness more readily ensues. All sensitive tissues become more sensitive in rainy weather, though in the case of toothache or neuralgia, for instance, we do not think of connecting this with the word rheumatism.

_Cla.s.ses of Sufferers_.--In persons who are over-thin or over-stout complaints of joint discomfort are not uncommon. In the first case they are due to the fact that muscles working around joints are not strong enough to accomplish their normal purposes. In the other cases, owing to the weight of the body, the muscles are overstrained. In a number of stout people the muscles do not increase proportionately to the size of the frame, much of the extra weight being in the shape of adipose tissue that const.i.tutes a grievous burden. In people who run rapidly to either of these conditions of disturbed nutrition--thinness or stoutness--complaints are particularly likely to be heard. Familiar examples are often seen in the tuberculous who have lost weight rapidly or in convalescents from typhoid fever who are much thinner than they were before they took to their beds. On the other hand, those who gain in weight rapidly after typhoid fever or some other such pathological incident, or who, as the result of careful sanatorium treatment, put on twenty pounds in the initial stage of tuberculosis, may have similar discomforts to complain of in and around their joints.

Heredity of Rheumatism.--The strongest unfavorable suggestion which most patients have is that their ailment, whatever it is, is hereditary and therefore not amenable to treatment. Nothing is more amusing to one who knows the present-day status of opinion in biology with regard to heredity than the frequent declaration that rheumatism is hereditary. Probably {383} nothing is commoner than to have a patient who is suffering from some vague, painful condition in muscles or joints, especially if that condition is worse on rainy days, declare that it must be rheumatism because father or mother suffered from rheumatism. I took the trouble to a.n.a.lyze in more than a dozen cases the rheumatism that was supposed to exist in the preceding generation, and found that it consisted of everything from pains due to old injuries and especially dislocations or fractures, through the various deformities connected with flatfoot, up to and including the worst manifestations of arthritis deformans. The condition in the parents supposed to be hereditary is never genuinely rheumatic.

There is just as much sense in talking of hereditary pneumonia as of hereditary rheumatism. Perhaps there is an hereditary lack of resistance in the pulmonary tissues of some people that predisposes them to pneumonia. It must not be forgotten that a century ago, or even less, it was not uncommon to hear that certain people had hereditary tendencies to lung fever. We know now that these were tendencies to tuberculosis and not to true pneumonia. We know, besides, that tuberculosis itself is not hereditary and that probably even the predisposition to it is not specifically hereditary.

As can be readily understood, the question of heredity in rheumatism is extremely important for psychotherapy, since the persuasion that their affection is inherited always produces an unfavorable effect upon patients' minds. In the old days, when tuberculosis was universally considered to be hereditary, a patient was likely to think himself the victim of an hereditary condition which could not be cured and which inevitably led to a fatal termination. Something of the same idea, though the immediate outlook is not so gloomy, is likely to follow the persuasion that rheumatism is hereditary. The question of heredity, of course, is bound up with that of rheumatism being a const.i.tutional disease dependent on hyperacidity or some other pathological condition of the blood. Acute rheumatism, that is, acute arthritis, is an acute, infectious disease due to a microbe. This ought to dispose of any question of heredity in it. Chronic rheumatism is supposed to be related to acute rheumatism and to represent, as it were, a low-grade enduring condition such as in sudden accessions gives rise to acute rheumatism.

So-called Chronic Rheumatism.--In these cases it is always a question whether the condition which causes the pain and discomfort is genuine chronic rheumatism or not. I am one of those who doubt whether we have any genuine, definite symptom-complex that should be termed chronic rheumatism. I have seen many ailments called chronic rheumatism. Any painful condition in the neighborhood of the joint that is worse on rainy days is likely to be labeled rheumatism and, because the salicylates are supposed to be a specific for rheumatism, treated with large doses of these drugs. These relieve the pain, as do any other coal tar products, but it is hard to understand how they are ever supposed to do any good for the underlying pathological conditions.

The most noteworthy characteristic of acute rheumatic arthritis is that it leaves no mark upon the joints that were affected by it. These get completely better and the patient has no disability, no deformity, and there usually remains not even the slightest sign of there having been a serious inflammatory condition within the joints.

In this it resembles pneumonia rather strikingly. True lobar pneumonia {384} clears up completely and the man has no symptoms once he has come through the convalescence. There are certain diseases affecting the joints, especially the arthritises in connection with various infectious diseases and the arthritis which accompanies acute arthritis deformans, in which there are serious sequelae and sometimes even complete disorganization of the joint. It is by these after-effects alone that we are sometimes able to differentiate genuine rheumatic arthritis from these other very different affections which resemble it so closely. Just the same thing is true of pneumonia. There are pneumonias that run a course at the beginning strikingly like true lobar pneumonia but which do not have a frank crisis and in which the lungs are seriously affected afterwards. We know now that in these cases it is not an uncomplicated pneumococcus pneumonia that has been at work, but either some other infection or else true pneumonia with a complication. Very often a dormant tuberculosis causes true pneumonia to run a different course from that which it ordinarily follows, and this, as a complication, leaves its serious mark upon the lungs.

_Recurrence_.--In some cases there seems to be a tendency for the "rheumatic" disease to recur. This also is true of pneumonia. This does not so much indicate, however, any loss of special tissue vitality as a certain loss of vital resistance to a particular microbe. Certainly this tendency is not sufficient to make us think of chronic rheumatism or use that term any more than we would, under similar conditions, talk of chronic pneumonia or of chronic diphtheria, though both of these affections have a tendency to leave a lack of resistive vitality. In a number of cases, subacute rheumatism runs a course that is very bothersome and annoying and that is quite intractable, with relapses and sequelae, but even this is entirely different from the ordinary idea of chronic rheumatism. It is probable that these cases, like the pneumonias that do not end by crises, are complicated by some other condition in the joint that leads to reinfection.

Uncla.s.sified Forms.--It is possible that in a certain number of cases for which as yet we have no name but rheumatism, there is a virulence of the microbic factor that brings about some joint disorganization.

This, however--and the cases are very rare--is probably an affection to which the name of rheumatic arthritis will not be given when we know more of the disease and its cause. There are probably many forms of acute rheumatic arthritis due to varying microbes which will eventually be divided into groups, as we have made groups in the typhoid series of diseases and in the scarlet fever group and hope to do with other diseases.

The Individual Case and Rea.s.surance.--The main role of psychotherapy in these affections is to set patients' minds at rest as far as possible, by pointing out exactly what is the matter with them and keeping them from worry, discomfort, and even interference with their physical condition by over-solicitude. It is important to know every detail of the patient's occupation, of his habits, of his environment, of his exercise, and, above all, of his individual peculiarities of structure in the neighborhood of joints, so as to decide exactly what is the matter with him, and not be satisfied with the easy but unscientific diagnosis of rheumatism, which may mean much but usually means nothing.

Unless such rea.s.surance is given, and especially if the ordinary drug treatment for so-called chronic rheumatism is persisted in, after a time these {385} patients, unimproved by salicylate treatment, wander off to all sorts of irregular pract.i.tioners and form the greater part of the lucrative clientele of quacks and advertising specialists in the cure of chronic diseases. More probably than any other cla.s.s of cases do they support the irregulars. Osteopathy has particularly appealed to a great many of these patients. It has done it in two ways. The first and most important probably by its effect upon the mind of the patients. Osteopaths immediately proceed to rea.s.sure the sufferers that their affection is not rheumatism, but some local condition dependent upon either a subluxation of the vertebra which, according to the founder of osteopathy, const.i.tutes the basis of ninety-five per cent. of all the ills to which human nature is heir or upon some joint or muscle condition which can be corrected by manipulation or ma.s.sage. These patients have, as a rule, been suffering a good deal before this from the thought that they were afflicted with a progressive const.i.tutional condition which would almost inevitably cripple them. Often they have seen patients who were suffering from arthritis deformans in its worst forms and advanced stages; they have heard this called rheumatism and they have concluded that it was only a question of time when they would be in the same condition. There is no good reason to speak of such conditions as rheumatic. They are entirely local, the hope of relief between attacks is by properly applied ma.s.sage and pa.s.sive movements which facilitate the blood supply in the neighborhood, and the best applications at the time of discomfort are the various rubefacients which stimulate the circulation in the parts, call the blood to the surface, and prevent that congestion in the neighborhood of small nerves which is the cause of the aches or pains. These affections take on a much more serious character in the minds of patients as soon as the word rheumatism is mentioned. To tell them that the condition is entirely local, has no tendency to spread, has nothing to do with any const.i.tutional condition, and can be relieved by local measures and the improvement of the general health, will often bring the patient a good measure of relief.

SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS

How much the treatment of these so-called chronic rheumatisms depends on suggestion, in spite of the apparent improbability of anything so materially discomforting being under the influence of the mind, is best appreciated from a consideration of the many inert materials that have been used for the cure of rheumatism. There is, of course, no more virtue in red flannel than in any other colored flannel, but many people suffer from rheumatism or rheumatic discomfort whenever they do not wear red flannel and are sure that it means much for them. Then there are all sorts of supposed electrical contrivances that do not generate an ion of electricity. They are effective only through the appeal they make to the mind. Some men wear electric belts and attribute their freedom from rheumatic pains to them. Others wear so-called electric medals or electric shields or electric insoles. Any number of people in this country wear electric rings on the little finger of one hand and get marvelous relief from it for their chronic rheumatism. Some have noted good results from even less likely objects. There are thousands in this country who carry horsechestnuts as a preventive against rheumatism, and some of {386} them, intelligent men and women, are persuaded it lessens their pains and aches.

In another place I have told the story of the woman who was a sufferer from rheumatism and who found great relief from carrying a horsechestnut. As her husband was also a sufferer, she wanted him to carry one, too, and when he would not, she carried one for him. It is to be hoped that her conjugal tenderness in this matter had as good an effect on him as she was sure the propinquity of the horsechestnut had on her.

The patients' occupations must be regulated by proper advice and detailed directions, and distractions of various kinds must be provided to keep their minds from becoming concentrated on certain portions of their body, emphasizing whatever discomfort is present and preventing nature's curative processes. Finally, local treatment of various kinds must be employed suitable to each individual case, that will remove all mechanical difficulties, disperse congestions, relieve fatigue and over-tiredness, and make conditions favorable for the healthy, normal use of joints and muscles.

Many painful affections of joints, sometimes complicated by immovability, are really psycho-neuroses. Sir Benjamin Brodie once said that four-fifths of the joint troubles that he saw among the better cla.s.ses were hysterical. Sir James Paget thought this an exaggeration, but confessed that he saw many of them and among all cla.s.ses of people. One-fifth of those that he saw in hospital and in private practice were entirely neurotic. He emphasized the fact that they must be looked for not only among women but that they are often found in men and that they are by no means confined to those who are nervously inclined, the silly young women or the foolish old women, but that they may be found in special circ.u.mstances among the most sensible people. They are often initiated by an injury which makes it quite difficult to differentiate them from real joint affections.

Usually, however, there is no redness, nor swelling nor heat with them, though sometimes one of these symptoms at least may occur with the redness. The connection between the trivial accident and the large reaction is usually hard to find and causes a suspicion as to the real process at work. Often, too, there is a delay of several days or sometimes weeks after the accident before the neurosis declares itself. In the meantime it has been getting on the patient's mind.

In general, it must be remembered the patient's att.i.tude of mind in these cases of pain around joints and in muscles is extremely important. They have furnished a goodly proportion of the patients on which quacks and charlatans have fattened. Greatrakes in the seventeenth century, Mesmer and Perkins, St. John Long, the early electrotherapeutists, the blue gla.s.s faddists, all the various liniment makers, many of the manufacturers of blood purifiers, and Eddyism and mental healing besides osteopathy in our day have all benefited these sufferers for a time and the patients have often been men and women of education and influence in their communities and have exerted their influence for the benefit of their supposed benefactors.

The methods of treatment come and go. The promise of the physician or the healer and the confidence of the patient are the only factors that are common to all the supposed "cures." If people stay at home without the air and exercise they should have, if they nurse their ills and consider that they are sure to get worse, because they labor under hereditary or const.i.tutional ailments, nothing will benefit them.

{387} If they are convinced that their disease is only local and begin to go out to see their friends once more, a change comes over the whole aspect of their disease.

CHAPTER II

OLD INJURIES AND SO-CALLED RHEUMATISM

As people advance in years, it is a common experience that tissues injured years before are the source of no little discomfort and are particularly p.r.o.ne to be bothersome during changeable seasons and in rainy weather. A bone broken when the patient was young may twenty or thirty years later continue to give warnings of the approach of change in the weather and be a source of annoyance. A dislocation, especially if complicated in any way by considerable laceration of the tissues in the neighborhood of the luxated joint, is sure to be a source of discomfort of this kind. These painful conditions are generally more noticeable when patients are run down, or when they have been recently affected by exhausting disease of any kind, during convalescence from severe ailments or injuries, or when they are undergoing a special mental strain. These conditions, like nearly all others worse in damp weather, are sometimes grouped under the term rheumatism and have been treated by internal medication. Almost needless to say, such treatment is sure to fail or to be of only temporary anodyne benefit. As rheumatic remedies are usually coal-tar products they may even be distinctly harmful, especially for old patients. It has been shown that the salicylates, for instance, are much less rapidly eliminated in the elderly than in the young, in those with defective circulation or kidney insufficiency than in the well. Their acc.u.mulation in the system causes anemic tendencies and disturbs nervous control.

Just what is the underlying pathological condition in these cases is not easy to say. In the case of luxations with laceration of tissues there has undoubtedly been such a disturbance of venous and lymphatic circulation by the break in continuity of tissues and the resultant scar tissue, that lymphatic if not also venous congestion occurs whenever there is any circulatory disturbance. For the maintenance of normal nutrition of nerve endings a constant flow of blood past them and a proper action of the lymphatic channels to carry off waste products is essential. It is easy to understand how much these may be disturbed in the injuries under consideration. When a bone is broken there is usually laceration of the surrounding tissues. Owing to the fixation required to procure proper bony union, the circulation to the part is much more defective than usual and so the repair of torn lymph and venous vessels is not as complete as would otherwise be the case.

This seems to explain why such injuries are especially called to the attention of the patients in damp weather. It is not so much during a rain storm as some hours before it, about the time when the barometer begins to drop, that these old injuries become sensitive. Indeed, it is often said that old persons who have suffered one of these injuries earlier in life carry a barometer around with them.

Not a few of the lesions called sprains, especially those of the ankles and {388} wrists, though also of other joints, are often really breaks of small bones, or at least laceration of ligaments and other structures. These may long afterward prove a source of pain and discomfort, worse always in unsettled weather, or after the feet have been wet, and may seem to be due to some const.i.tutional condition, though they are merely local. These occur more commonly in women than in men and the condition needs careful investigation and must not be put under the vague diagnosis of rheumatism, or the patient will probably not be improved by the treatment suggested. In all these cases the general condition must be looked to, and it must not be forgotten that fat may not mean health, and that increased weight may be a prominent factor in the production of symptoms in these cases, especially when individuals live a sedentary life.

There is an important therapeutic method for the prophylaxis of these conditions that has been attracting attention and yet probably not all the attention it deserves in recent years. Prof. Lucas-Championniere of the University of Paris has pointed out that when fractures and dislocations are treated by the open method with easily removable apparatus and the employment of ma.s.sage within a few days after the fracture, the subsequent discomfort of these lesions is much lessened.

It seems worth while to emphasize this treatment by manipulations and ma.s.sage, because it represents a psychotherapeutic factor in the treatment of these injuries. The hiding away of a limb or a joint for days and perhaps weeks, while they wonder whether it is getting better or not is most discouraging to patients. To have the physician see it, to have him declare that it is getting on well, to have the evidence of their own senses that conditions are gradually improving, is of itself a valuable factor for that satisfaction of mind which conduces to the regular functioning of tissues. Repair undoubtedly goes on better under such circ.u.mstances. Besides, the lack of constriction or at least its rather frequent periodic relaxation, the airing of the skin, the regulation of the circulation by ma.s.sage and manipulation, all react upon the mind and prevent it from inhibiting trophic impulses and encourage it to stimulate them in every way.

As to the after-effects of fractures and dislocations as with regard to all this series of vague pains and aches, the patient's att.i.tude of mind is of great importance. As they get older their aches and pains grow worse, partly because circulation is more defective and partly because they are p.r.o.ne to be much more in the house and the nerves of patients who are much within doors are always more sensitive than those of people who are much in the open. If their attention becomes concentrated on their pains and aches, because of lack of diversion of mind, then the condition may become a source of serious annoyance.

When these painful conditions develop patients are almost sure to keep much to themselves and to nurse their ills, and consequently to increase their discomfort. The circulation to the affected parts must be stimulated by local treatment, by rubbings, by the milder liniments, by ma.s.sage and manipulations, and by local hydrotherapy.