Thoracic Discomfort.—Complaints are often made by the tuberculous of pains in the thorax. Ordinarily the discomfort is supposed to be due to the lung condition, and it is assumed that it is either actually in the lung itself or in the pleura, or communicated from them by reflex to the muscles. In most cases, however, patients complain of pain on the side that is either not affected at all or least affected. If they have been told that the other side is suffering most from tuberculosis, they are prone either to think that now the {362} well side is being invaded or else that their physician is making a mistake, and both thoughts are seriously discouraging. The reason for the pains on the well or the better side, however, are easy to understand. As far as possible, as can be readily demonstrated by the X-rays or seen in the observation of the so-called Litten's phenomenon—the excursions of the diaphragm—nature puts the ailing lung at rest and the diaphragm moves much less on that side than on any other. In order to make up for the lack of breathing in this side the other lung does compensatory work. This over-stretches the muscles of the thorax on the well side and causes some over-work in them. The consequence is a tiredness which may become fatigue; in damp weather this may be even painful. Just why damp weather has this particular effect on muscles is not surely known. Muscular action is probably accomplished with more difficulty in damp weather because of the relaxing effect of moisture on tissues and circulation. Reassurances may be given them, then, that will keep them from thinking seriously of the significance of these pains except as an index of nature's compensatory efforts. The painful conditions instead of causing discouragement will, then, be a source of encouragement. It must not be forgotten that rubbing with some gentle stimulant, soap, liniment, or the like, will greatly improve the thoracic muscles in these cases, but the rubbing must be done gently and by someone else beside the patient, for it is only beneficial if done from before, backwards, in order to help the return venous circulation which runs in that direction in the external respiratory muscles.
Altitude.—There is a marked difference between the amount of water which finds its way out through the lungs at varying altitudes. At sea level an ordinary patient will lose during the night about 300 cc, that is, something more than half a pint of water, through his respiratory tract. At an altitude of 5,000 feet, however, this amount is almost doubled, and at 10,000 feet is almost trebled. At 2,000 feet it is half as much again as it is at sea level. This copious giving off of water has a marked effect on the lungs. It constitutes one of the reasons why altitude is a favorable element in the treatment of tuberculosis. Only beginning cases of tuberculosis, however, are able to stand the additional work thus put on them, though a slight elevation, up to 2,000 or even 3,000 feet, rather seems to be of benefit to all cases. How far-reaching the effect of this extra loss of fluid is, is appreciated from the concentration of blood which takes place and which produces a blood count of 8,000,000 red cells at a mile of altitude in patients who, at the sea level, have no more than 4,500,000. Such patients, of course, need much more water and fluids generally to be comfortable than when living lower down.
Suggestion and Treatment.—There are many accessory suggestions with regard to food that serve to confirm the patient in the idea that abundance and variety of food must be taken if the battle with the disease is to be won. To patients who find milk difficult to take, it must be explained that a copious amount of fluid in the system is needed in order to make coughing easier. So milk serves a therapeutic as well as a nutritional purpose. In the same way it may be explained that fats, such as bacon and cream, help to keep the bowels from becoming constipated and constipation inevitably disturbs the appetite.
Explanations as to the advisability of being out of the city and in a portion of country not very thickly populated, in order to avoid the possibilities of secondary infection with other respiratory diseases and bacteria of various {363} kinds, will make a patient understand the necessity for leaving town. It may be helpful, also, to insist on the value of living at some elevation above sea level as an aid to expectoration.
Cough is the symptom that many of these patients fear most, and a promise of any amelioration of it by a simple change of location helps them to make the sacrifice of city life for a while. Some patients who have been benefited by a stay in a sanatorium come back with a relapse of their symptoms. They dread to return to the sanatorium and think they can care for themselves as well at home, since they know what the regulations are, though it may be evident to the physician that they are losing ground in their city environment. It is well worth while to give them a careful explanation of what we know of the effect of altitude upon consumptives who have sufficient reactionary power to stand it.
Negative Suggestions.—Some suggestions are valuable for the prophylaxis of complications. For instance, tuberculous patients must be warned not to indulge in breathing exercises without the express consent of the physician. So much is said in popular literature as to the value of breathing exercises that many a patient suffering from tuberculosis thinks that, not only may they be indulged in with impunity, but that they will surely do good and can do no possible harm. Nothing could be more erroneous. Many localized lesions have been diffused in this way and there is always danger that the strain will cause hemorrhage. Patients must be warned also to avoid any possible condition in which they might have to over-exert themselves. Because of the dust inevitably breathed during automobile riding, this pleasure must be denied to tuberculous patients as a rule, but even when they have recovered sufficiently so that this may be permitted they must be warned not to take long rides into the country lest the breaking down of the machine should place them under the necessity of walking a long distance. This idea should also be emphasized for rowing excursions, or trips by motor boat, for occasionally they lead to serious and exhausting exposure.
One negative suggestion should be given at the very initial stage to every patient in whom the presence of pulmonary tuberculosis has been recognized. This should be a warning to exercise the greatest care against permitting the development of constipation. Tuberculous patients must never strain at stool. Almost necessarily a certain number of tubercle bacilli are swallowed every day whenever pulmonary tuberculosis is at all active and they are constantly present in the digestive tract. If tuberculous patients then strain at stool, little abrasions of the mucous membrane of the rectum are caused in which tubercle bacilli find a favorable nidus. Ischio-rectal abscesses are common among the tuberculous and rectal fistulas often give much bother. When a tuberculous patient develops such a condition, a period of depression and discouragement will follow, for there is a curious tendency to depression associated with all lesions of the rectum. A pulmonary patient who has been doing well will often fail to make progress for months after the development of even a small ischio-rectal abscess.
For the consideration of its psychotherapy asthma may be divided into two forms—symptomatic and essential, or neurotic, asthma. Symptomatic asthma is a difficulty of breathing, the result of some interference with the circulation, as by heart disease, or with the oxidizing power of the blood, as by kidney disease, or various blood conditions, or from direct interference with respiration from some pulmonary affection. Essential asthma is not dependent on any organic condition, but is an interference with breathing without any distinct pathological condition in the lungs themselves or in the general circulation. There may be some emphysema, but not enough to account for the respiratory difficulty. It is spoken of as neurotic asthma, and the most careful investigations made of individuals who have died during a seizure has failed to give any sure pathological basis for the affection. Certain accompanying phenomena are worthy of note. The most interesting of these are Curschmann's spirals, which usually occur in the form of translucent pellets very characteristically described by Laennec as pearls. They are evidently formed in the finer bronchioles and show that the affection extends to the terminal portions of the bronchial system. In connection with these the so-called asthma crystals first described by Charcot and Von Leyden and sometimes called by their combined names are often found. Besides, there are a large number of eosinophiles in the sputum itself entangled within the filaments of the spirals and an eosinophila of the blood.
Etiology.—Not only are we ignorant of the reasons for these phenomena but there is even some doubt as regards the mechanism of the respiratory spasm itself. There is a general impression that the paroxysm is due to incapacity to inspire because of a paroxysmal spasm of the respiratory muscles. Gee in his "Medical Lectures and Aphorisms" [Footnote 30] rather leans towards the explanation that suffering is due not to any inability to fill the lungs but to incapacity to empty them when they have become over-distended with air. He tells the story related by Dean Swift of the old man whose barrel-shaped chest was fixed in spasm so full of air that the patient could not find room for the slightest additional breath. "If I ever get this air that is in me out," the patient declared to the Dean, "I will never take another breath."
[Footnote 30: Frowde, Oxford Univ. Press. 1908.]
It is important to differentiate symptomatic from neurotic or essential asthma. In symptomatic asthma the only assured treatment of the condition must come through amelioration of the organic condition causing the symptoms. Cardiac and renal asthma respond promptly to remedies which relieve critical conditions that may be present in the heart or kidneys. It must not be forgotten, however, that respiration is readily disturbed by mental influences. Where cardiac or renal disease causes interference with respiration this is much emphasized by the patient's unfavorable mental attitude toward it, or much relieved by keeping him from worrying over his condition. Even symptomatic asthma, then, has a definite place in psychotherapeutics, though {365} it would be serious not to recognize the underlying conditions and treat them. If the patient's attitude of mind is one of discouragement, the respiratory difficulties will continue to be a marked symptom of the case, even though the proper remedies for the relief of cardiac or renal conditions are administered.
Symptomatic Picture.—What is likely to be one of the most disturbing experiences of the young physician early in practice, especially if he has not before seen a typical case, is to be called to a patient suffering from a severe attack of asthma. Often the sufferer is sitting up in bed so as to get all the air possible, and, though the windows are wide open, he is gasping for breath, usually pleading for more air with a tense, anxious expression, starting eyes, and the sweat pouring from his forehead, while the accessory muscles of respiration, deeply engaged in moving his thorax to move air enough to keep him from stifling, emphasize his dyspnea. Occasionally a degree of cyanosis develops that is quite startling for the untrained observer. Most of those who see the symptomatic picture for the first time think that death is impending, and the patient himself, if he has not had a series of attacks, will fear a fatal termination. It appears impossible to believe that the next morning, within six or seven hours of this, the patient will, as a rule, be quite well and walking round in the enjoyment of apparent good health.
As a rule, the worse these cases seem in their intensity and the more the patient is anxious, the more surely are they merely of functional nervous origin; above all, the more complaints of lack of air and of fear of impending death that are made, the more likely is the patient to be all right within a few hours. Asthma looks as though it must be due to some serious organic condition. Of course, in many cases of difficult breathing, even with asthma-like attacks, there are underlying serious conditions of heart and kidneys that are extremely dangerous. As a rule, however, these do not produce the woeful pictures of purely neurotic asthma. Even when the basis of the asthma is an emphysema, which of itself is not dangerous and is quite compatible with long life, the attacks, though frequent and severe, are usually not so serious looking as those in which absolutely no pathological condition of the lungs, or heart, or kidneys can be found, and, indeed, in which there is absolutely no organic change to account for the extremely uncomfortable and even terrifying symptoms.
Mental Influence.—In the medical literature of asthma there are abundant proofs that the attitude of mind of the patient towards his affection means very much. There is the story, thoroughly vouched for, of the two friends stopping at a little country hotel late at night. One of them was a neurotic subject, who, whenever he remained for some time in a stuffy atmosphere, was likely to have a severe asthmatic attack. The quarters assigned to them proved to be one of the cramped little rooms with a single small window that occasionally are found in the attics of country inns in England. During the night the patient of asthmatic tendencies had one of his attacks and begged his friend to open the window. The friend, suddenly roused from sleep, did not remember the position of the window and, the night being very dark, he felt for it and finally found it. He could not raise the sash and he could not move it either inward or outward and there seemed no way of getting it open. His friend was insistently clamoring for air with that tone of despair and {366} dread of impending death so characteristic of the young, inexperienced asthma sufferer. Unable to get the window open, the sympathetic companion finally took his shoe and smashed the glass. The relief was immediate. Scarcely had the crash of the broken glass been heard before the patient gave an audible sigh of relief. When his friend went over to him he felt so much better that it was rather easy for the sufferer to persuade him that nothing more would be needed and that he should go back to bed. In the morning, when the friend awoke, his first glance, directed by the sunlight that came streaming into the window, was toward the broken panes of the night before. To his surprise it was not broken. Wondering what had happened, he looked round the room to find that he had smashed two panes in an old bookcase set into the wall, and that it was the breaking of the glass with the suggestion of free ingress of air that it involved and not any real provision of fresh air that had cured his friend's asthma so promptly.
Suggestion.—When much-vaunted cures for asthma are analyzed, many of them are found to depend more on suggestion than on any other element. Various forms of cigarettes are used, comparatively innocuous in themselves, and certainly of no strong therapeutic action, yet they work marvels in loosening the spasm that comes over the lungs in asthmatic attacks. Any sort of a cigarette will do at the beginning. I have seen dried grape-vine stems work very well in the country, especially in young women to whom the idea of smoking anything was strongly suggestive. Cubebs cigarettes have the same effect on older people. Doubtless there is some relaxing action in the smoke. This is not enough, however, to account for the effect produced without mental influence. After cubebs have been tried for a period and begin to lose their efficacy, then other materials that produce a pungent smoke or have a certain sensory action, as stramonium leaves, may be used, and will also have the marvelous power of cubebs. After a time, however, they, too, lose their efficacy, and, as a rule, each successive cigarette that is tried has less power than the first to control the difficulty of breathing.
The more one hears of cures for asthma, and the longer one has experience with these cases, the clearer does it become that there is a large suggestive element in every successful treatment. If a piece of ordinary blotting paper be dipped in a strong solution of saltpeter and allowed to dry, it will, if touched by a lighted match, burn slowly without flame, but with the production of heavy, thick smoke. The therapeutic elements in this are not very strong, but the suggestive element, when a room gets full of it, is intense and is cumulative. Very probably the thick smoke, rich in nitrites, has some tendency to relax the spasm in the lungs which causes the asthmatic seizure, but after a time the remedy fails and something else has to be tried. In many cases, when first used, it almost works a miracle. This is the simplest type of suggestive treatment for asthma.
Mental Shock.—Any strong mental influence, especially if accompanied by the suggestion of assured relief, is likely to do much for asthma of essentially neurotic character, and indeed is more powerful in dispelling the symptoms of the seizure than almost any other means that we have. Sometimes even things absolutely indifferent which produce a profound mental impression, prove curative. There are many stories of men in the midst of a severe asthmatic seizure being suddenly roused by the cry of fire, or an alarm of some {367} kind near them, having the spasmodic conditions disappear as if by magic. Occasionally where attacks of asthma recurred regularly on successive nights for a considerable period, travel on a railroad train or anything else which occupied the attention much, prolonged the interval between seizures and sometimes put an end to the series of attacks. The more one knows of asthma the more one realizes how much its occurrence depends on mental influences of many kinds in association with various reflex irritations, some of them very distant from the respiratory tract and comparatively trivial in their effects on other people.
Loss of Control.—Occasionally in elderly neurotic people over-fatigue induces an attack of asthma about the time that sleep becomes deep. This usually occurs after the first hour or two of sleep. The inhibitory power of the nervous system over spasmodic contraction of the lung tissues seems lost in deep sleep and then the asthmatic condition develops. The greater the effort to breathe the more intense does the contraction become, until the antispasmodic effect of the presence of a lessened amount of oxygen and an abnormal quantity of carbon dioxide in the blood makes itself felt. In many cases these patients will be relieved of the tendency to such spasm by taking a cup of coffee. This stimulates the general circulation and minimizes the reflex tendency which centers in their respiratory tracts. Such patients after taking an amount of coffee that would keep ordinary people awake all night, sink in the course of half an hour into a quiet, restful sleep and awake quite refreshed. This is not entirely suggestive, but suggestion plays an added role in the relief of all the symptoms.
Treatment.—Varied Cures.—We do not mean to say that asthma is entirely amenable to suggestive treatment, but we emphasize the mental influences in its production and its cure. A new and almost infallible cure is announced nearly every year for asthma, as for tuberculosis. Sometimes this is some new treatment for the nose, occasionally it is a novel method of treating the throat, but reflexes from a great many other organs not at all in touch with the respiratory system have also been supposed to be productive of asthma, and their treatment has been followed by relief from this trying condition. Washing out the stomach, for instance, has been followed by prolonged cessation of asthmatic attacks. In children it is claimed that occasionally the correction of eye-strain by the proper glasses has cured neurotic asthma. There are those who have had cases where the relief of long-continued constipation had a like therapeutic result and there are other and even more curious claims for curative effect in this affection.
Negative and Positive Suggestion.—Any condition in the human body that sets nerves in tension and requires constant inhibition may lead to such a cumulative effect of repression that reaction follows and explosion takes place. In particularly susceptible individuals, irritable respiratory centers may be affected with consequent asthmatic seizures. The direct treatment of the respiratory tract to secure ease of respiration often does away with the liability to asthma by direct prevention. If patients, especially young patients, are mouth-breathers the clearing out of the throat and nose so as to insure normal breathing can naturally be expected to lessen any tendency to asthma. In the same way treatment of irritative or degenerative conditions in the throat and larynx, as well as in the nose, may be considered directly curative. On {368} the other hand, there is no doubt that many of the slight ameliorations of intranasal conditions suggested by enthusiastic specialists as curing asthma do not have any direct therapeutic influence but owe their efficacy to the strong suggestion of the operator's assurance on the patient's mind that this treatment has cured asthma in many cases and will surely cure him.
Drugs and Suggestion.—The medicines that are especially effective in asthma of neurotic origin are those which also have a large suggestive influence because of their taste or their effects upon the system. Hoffman's anodyne is an efficient antispasmodic and is wonderfully effective in relieving the tendency to asthma. I have always felt, however, though I have given it freely, that a large element in its effectiveness was its particularly disagreeable taste and odor and then its excretion through the lungs with a certain sense of well-being allied somewhat to the intoxication that comes from the inhalation of ether. I have seen asthmatic tendencies in young women greatly relieved by the use of valerian. Undoubtedly this remedy, like the compound spirits of ether, is antispasmodic in action, yet to a much less degree than Hoffman's mixture, and over and over again I have noted that in pill form, though given in large doses, it was not as effective as if given in liquid form when its nauseating smell added distinctly to its suggestive influence. The drug itself does good but it is distinctly helped by the influence upon the patient's mind of its taste and, above all, of its aroma. The elixir of ammonium valerianate being particularly unpleasant is likely to be more beneficial to these patients.
Climatotherapy and Suggestion.—The climatic treatment of asthma has received much attention. Change of scene and environment nearly always does good. Different patients, however, require very different conditions. Of two cases of neurotic asthma in which no diagnostic differences can be found, one will improve at the seashore or on a sea voyage, while the other will be made worse by such a change though probably the asthma will be improved in the mountains or in some dry climate. Even moving from one part of a city to another has brought great improvement in asthma. Sometimes there were good reasons for this, as, for instance, when an investigation showed that the patient had previously been living above a bakery from which there came a good deal of hot air and flour dust. Some people are actually improved by close contact with human beings in rather crowded quarters. I have known a settlement worker to experience great relief from asthma when living in the slums. Where there is intense occupation of mind, especially if combined with the suggestion that now the asthma ought to be better, seizures will be less frequent and less severe. All sorts of places in the mountains and by the seashore have acquired reputations as relieving asthma which were justified by many cured cases and yet they have lost this reputation. Whenever there are many sufferers together, the expectancy of relief seems to do great good.
Grouped under the term "hay fever" there are probably as many different affections as there are under the term "chronic rheumatism." There are {369} people who, in the springtime, as soon as the weather gets warm, suffer from what is popularly called hay fever. This is often called "spring catarrh" or "rose cold" and seems often to be associated with the pollen of flowers. Then there are people whose hay fever, as it is called, develops about the first of June and continues to be bothersome until the middle of July, when there is a remission of symptoms, though in dry prolonged hot periods after that the affection may recur. It seems as if, at the beginning of the heated term, the warm, dry dusty air irritates their nostrils very much, while after some weeks they gradually become used to this and the reaction is not so violent. Then there are the regular hay-fever patients whose affection occurs principally in haying time, during August and September, though most of them have not been near hay pollen, and the disease is an affection of dwellers in cities rather than in the country, of indoor livers more than of farming people, who might be expected to suffer most from the supposed cause, hay pollen. Even where pollen is directly concerned in its causation it is probably oftener the pollen of the rag weed rather than that of hay that is responsible for it.
There are two elements in the disease apparently of equal importance. One of these is a strictly local condition interfering with respiration in some way, or with the circulation to the mucous membrane of the nose and the lachrymal ducts. The other is an individual over-sensitiveness so that there is an exaggerated reaction to irritation. Some of this is mental, that is, is due to expectancy, or to the persuasion that this reaction is sure to occur under certain circumstances. As a consequence, attacks of hay fever are reported even after a distant view of a hayfield, or of rose cold due to the sight of an artificial rose, and of other recurrences that show the power of the mind to bring about at least a beginning of symptoms.
While the first or physical element in the etiology of dust catarrh can be treated successfully by various means, it is important to get the mind of the individual in a favorable state so as to enable him to obtain better control over his vaso-motor system which is so much influenced by emotions and thoughts. It is this latter element in the causation of the disease that has been successfully treated by the many remedies that for a time have had reported success in the cure of hay fever yet afterwards proved to be of no benefit because they had lost their influence over the patients' minds.
In a review of Morell MacKenzie's book "Hay Fever, with an Appendix on Rose Cold," Dr. J. N. MacKenzie [Footnote 31] has some paragraphs on hay fever which, though written twenty-five years ago, are worth recalling for a proper understanding of the disease. He preferred to call the disease rhinitis sympathetica or coryza vaso-motoria periodica, names which are much better descriptive terms and have no unsubstantiated suggestions of etiology in them.
[Footnote 31: American Journal of Medical Sciences, 1886.]
According to our conception, the so-called nasal reflex neuroses, whether taken singly or collectively, as the cause of the ensemble of phenomena known as "hay fever," may be regarded as the protean manifestation of a morbid condition to which we have given the name rhinitis sympathetica, and which is characterized by a hyperesthetic condition of the vaso-motor nerve centers linked to a peculiar excitability of the nasal cavernous tissue. For, if we inquire what condition or conditions is common to them all, and what morbid process is capable of producing them, either singly or in combination; how phenomena apparently {370} so widely different in character and anatomical sphere of operation may be traced to a solitary source, we find the answer in certain more or less clearly defined changes in the nasal apparatus and in a certain exalted state of the sympathetic nervous system, to which latter we instinctively turn as the organ most conspicuously concerned in the evolution of purely reflex acts. In whatever relation the local nasal affection and the condition of the sympathetic stand to each other in the matter of cause and effect, they must both be regarded as inseparable factors in the production of the phenomena under consideration. It matters not to what hypothesis the path of speculation may lead. Of this we can be reasonably sure, that in the production of the characteristic symptoms of this disease, a certain excitability of the nasal passages is necessary, plus an exalted state of the central nervous system.
Dr. MacKenzie calls attention particularly to the erectile character of the tissues mainly involved in all these forms of dust catarrh and dwells on the rôle that mental influence always plays in the phenomena noted in such tissues. This with the vaso-motor elements in the affection which are so largely also under the control of the emotional nature make it clear that the pathology of the affection must be considered from this standpoint and, therefore, its therapy also.
Dr. MacKenzie continues:
From our present knowledge of the disease, it seems difficult to
escape the conclusion that its pathology is intimately interwoven
with a morbid condition of the vaso-motor sympathetic, and probably
a hypersensitive state of the nerve centers themselves. When we
recall the fact that in the famous section of the sympathetic in the
neck by Claude Bernard, symptoms similar to, or closely allied to,
the phenomena of hay fever were produced; when we reflect upon the
results reached by Prevost in his experiments on the spheno-palatine
ganglion, is there not a clue to lead us through the labyrinth of
our difficulties to a rational solution of the question? . . .
. . .In the human body, wherever erectile tissue is found, it is
intimately related to reflex or sympathetic acts; there seems to be
connected with it a certain receptivity to reflex producing
impressions, a certain power of reflex excitability dependent upon
its structure and functions. It is thus peculiarly a tissue of
sympathy in which we may most satisfactorily study the mechanism of
purely reflex or sympathetic acts. Now it seems to us that, as the
nasal corpora cavernosa belong to this class of sympathetic tissues,
there will be little difficulty in explaining the rôle which they
play in the paroxysms of an affection which is probably connected
with, if not dependent upon, an excitation of the sympathetic nerve
centers, and in more clearly defining the intimate relation which
its erection bears to the reflex manifestations of the disease under
review.
These considerations explain the heredity of the affection in many cases, since it is dependent on defects that may be family traits, yet they also enable us to understand how slight lesions of the nasal mucous membrane may be the center from which radiate the underlying pathological conditions of the disease.
Railroad Asthma.—There is a form of dust asthma which deserves special attention here because it is due to modern conditions and helps to an understanding of the etiology. It occurs in sensitive persons when they travel on railroad trains in warm weather, particularly if it has been dry for several days and dust is abundant. It has been called railroad asthma or railroad catarrh by the English and the Germans, but the condition has no necessary connection with the railroad. It occurs as a consequence of the infiltration into railroad cars of fine dust during the passage of the train. {371} I have seen it in those who had made long trips over dusty roads in automobiles, though the dust of the railroad seems finer and more penetrating. It develops just as much at the end of a long train as if the passenger spent most of the journey in the car next the engine and apparently it makes no difference whether the engine burns hard or soft coal. They use soft coal almost exclusively in England and Germany, but one sees cases of it here after travel on roads that burn hard coal and are especially cleanly in this respect. Soft coal adds somewhat to the amount of dust and therefore this increases the irritation, but there is nothing specific about coal dust. It is surprising how severe the symptoms may be. I have seen a patient who had traveled continuously for four days across the continent who had so much photophobia when he alighted from the train, that he was almost unable to open his eyes, and it was not until twelve hours had passed that he could open his eyes with any comfort, yet at the end of two days practically all the symptoms had passed off.
Prof. Fraenkel, professor of laryngology and rhinology at the University of Berlin, who was one of the first to classify the condition among the affections related to "hay fever," described certain features of it very well in a clinical lecture reported in International Clinics, Vol. II, Ninth Series, 1899. As a rhinologist he insists on the nasal conditions that underlie the affection yet suggests that the nasal hyperemia may be due to reflexes of one kind or another. The basis of these is undoubtedly very often an emotional condition of the patient, a dread of dust, an expectancy of symptoms and a consequent exaggerated reaction. Unorganized dust produces asthma, but organic materials bring more severe and lasting effects, partly because of the mental effect of odors and other sensory conditions in connection with them.
The Personal Element and Power of Suggestion.—The history of these asthmas and other symptoms produced by odors and dust make it clear that the more that is known about the disease the surer it becomes that there is a large personal element, usually dependent on a certain frame of mind, in the cases. Some people are affected by one form of irritant, some by another, some by pollen, others by animal emanations, and not a few by a persuasion of the likelihood of suffering from these things, since occasionally the sight of an artificial product produces a like result. Certain classes suffer much more than others. Those who are much confined to the house and who are especially prone to reflection upon themselves and their feelings form the great majority of the patients. In old days the monks were favorite victims, in modern times literary folk, students, and those who have the time and the inclination for reading and introspection are particularly likely to suffer. How much the mental element may account for in these cases is not clear, but it stands for much more than has been thought and there seems no doubt that more relief of symptoms is afforded by diversion of mind and change of dwelling quite apart from external conditions than in any other way. It is important to remember that no specific dust but almost any kind of dust produces these conditions in sensitive persons.
Dr. MacKenzie describes an interesting case in which all the symptoms were produced by the presence of an artificial rose. The story is so striking and he has told it so well that I prefer to tell it in his own words. I may say, however, that the clinical history of the case was typical. About the end of {372} May or the beginning of June every year the patient suffered from a coryza preceded for a few days by an indefinite sense of general depression with a disagreeable feeling of heaviness in the head. Sometimes there were chilly feelings and general malaise. The catarrhal stage commenced with profuse watery discharge from the nostrils, copious flow of tears with redness of the conjunctiva, itching of the puncta lacrymalia and photophobia. The exterior of the nose, especially at the tip, became intensely red and toward the close of the attack the cuticle desquamated. There was a short, dry, hacking cough relieved by sneezing, an intense tickling sensation in the throat, the voice became husky, the pharynx dry, the ears stopped up and tinnitus occurred. Her attacks continued most of the summer and were always brought on by the pollen of any plant and above all by the smell of a rose. It was, indeed, an example and of the most aggravated form. She was brought to Dr. MacKenzie in consultation and I leave him to tell the rest of the story.
Decidedly skeptical as to the power of pollen to produce a paroxysm in her particular case, I practiced the following deception upon her, which still further confirmed me in that belief. For the purpose of the experiment I obtained an artificial rose of such exquisite workmanship that it presented a perfect counterfeit of the original. To exclude every possible error, each leaf was carefully wiped, so that not a single particle of foreign matter was secreted within the convolutions of the artificial flower. When the patient entered my consultation room, she expressed herself as feeling unusually well. The evening before she attempted to wear some roses, but had been obliged to remove them from her dress, as they had produced a great deal of discomfort. Apart from this incident she had been perfectly comfortable for several days and nights. Her conjunctivae were normal, the nasal passages free, and there was nothing to indicate the presence of her trouble. She conversed with me for some time about her case and on general topics, speaking in the most encouraging manner concerning the progress she was apparently making toward recovery. I proceeded to remove the slight slough from the cautery operation, which lay loose in the nostril, and made an application to the mucous membrane, and all without exciting the slightest tendency to reflex movements. After I felt sure that such tendency was absent, I produced the artificial rose from behind a screen, where it had been secreted, and, sitting before her, held it in my hand, at the same time continuing the conversation. In the course of a minute she said she must sneeze. This sensation was followed almost immediately by a tickling and intense itching in the back of the throat and at the end of the nose. The nasal passages at the same time became suddenly obstructed, and the voice assumed a hoarse nasal tone. In less than two minutes the puncta lacrymalia began to itch violently, the right and afterward the left conjunctiva became intensely hyperemic and photophobia and increased lacrymation supervened. To these symptoms were added, almost immediately, itching in the auditory meatuses and the secretion of a thin fluid in the previously dry nasal passages. In a few minutes the feeling of oppression in the chest began with slight embarrassment of respiration. In other words, in the space of five minutes she was suffering from a severe coryza, the counterpart of that which the presence of natural roses invariably produced in her case. An examination of the throat and nasal passages was then made. The right nostril was completely obstructed by the swollen, reddened, irritable, turbinated structures; the left was only slightly pervious to the air current; both were filled with a serous-looking fluid. The mucous membrane of the throat was also injected, but did not exhibit the same amount of redness and irritability found in the nasal passages. As the discomfort was rapidly increasing, and as I considered the result of the experiment sufficiently satisfactory. I removed the rose and placed it in a distant part of the room. When told that the rose was an artificial one, her amazement was great, and her incredulity on the subject was only removed upon personal examination of the counterfeit {373} flower. She left my office with a severe coryza, but also with the assurance that her disease was not altogether irremediable. A few days later she called to see me again, and on that occasion she buried her nostrils in a large, fragrant specimen of the genuine article and inhaled its pollen without the slightest tendency to the production of reflex acts.
There is but one conclusion that can be drawn from this: that suggestion plays a large rôle in the relief of the symptoms of the disease. If patients once become persuaded that something will do them good, then it surely does. It is true that this good effect will usually not persist, but that is because after a time conditions conspire to make the suggestion fail of its purpose. This does not at all imply that hay fever, or just catarrh as I prefer to call it, is imaginary. The relief of our most serious and fatal diseases with profound pathological lesions, such as tuberculosis, may well be brought about by suggestion. After all, just the same story is told about consumption and its many remedies as of hay fever and its many "cures." However, the most important therapeutic element so far discovered for the treatment of hay fever is evidently suggestion. If the patient's mind can only be brought to a favorable attitude in which the discouragement incident to imperfect oxidation can be greatly lessened, then relief of many of the symptoms will be afforded and under favorable conditions the patient will deem himself cured. Undoubtedly the large amount of attention given to hay fever, the gathering of these patients in particular localities, the repetition of the story of their symptoms to each other, the body of literature that has gathered around hay fever and is read with such avidity by those who are pleased to call themselves its victims, adds to the unfavorable suggestions and inveterates the symptoms, exaggerates the nasal hyperemia and makes the general condition worse.
I am the more positive about the influence of suggestion, favorable and unfavorable, in the affection after having carefully noted the conditions in certain patients from year to year for a number of years. I became interested in it because it is a family affection and several sisters as well as myself are sufferers from it. At the beginning, when the real nature of the trouble is not recognized, there is a year or two of considerable general discomfort, though not much local disturbance. Then comes the realization of what the recurrent affection is and a period of distinct depression during its continuance. Eventually it begins to be appreciated that a number of local applications will lessen the symptoms from day to day and that there need be no apprehension of serious sleep disturbance, or of any lasting effect upon the general health, the affection becomes quite bearable and, while still annoying, is no longer the object of particular solicitude.
There is a class of cases of difficulty of breathing allied to asthma and often called by that name, the study of which throws light on the origin and the relief of neurotic asthma. These cases are usually accompanied by such a sense of oppression on the chest that breathing becomes labored and, to some {374} extent at least, the accessory muscles of respiration have to be called into play. The most typical cases are connected with the mental influence produced by the presence of some particular animal, the cat being the most frequent and the horse not rare, or with emanations from these animals, when there seems to be some physical nexus between the animal and the symptoms.
Cat Asthma.—The symptoms associated with cats are rather common, and they occur at the sight or touch of the animal, but may be the result only of its presence which in some way the patient is able to recognize without sight of him. Shakespeare's expressions in a number of places, such as "I could endure anything before but a cat" and "some that are mad if they behold but a cat," shows that the affection was commonly recognized at that time and that the reason for it was considered unknowable, for Shakespeare says, "There is no firm reason to be rendered why he cannot abide ... a harmless necessary cat."
Dr. Byron Bramwell in his "Clinical Studies," Vol. I, page 107, has an interesting paragraph with regard to these curious asthmatic conditions which develop in the presence of animals of various kinds. He sums up many of the curious features of this affection as reported by various good observers. Many more people than we would be apt to think are affected by it. He says:
In some persons the smell of a horse or of a cat produces an attack of asthma. Some years ago I repeatedly saw a young gentleman who invariably had an attack of asthma if he went near a stable or a horse. He was so susceptible that he was unable to drive in a cab or a carriage; when traveling from place to place, while sending his traps from the station to the hotel in a cab, he himself was obliged to walk.
Dr. Goodhart mentions a similar instance which occurred in the practice of Prof. Clifford Allbutt. Dr. Goodhart also mentions a remarkable case of "cat asthma":
I have known of two cases of cat asthma. In one of them the existence of cats is the bane of life, for before accepting an invitation she is obliged first to ask, "Is there a cat?" [Footnote 32] An attack of urticaria and coryza followed by asthma has been noticed to come on within ten minutes of having stroked a cat. At other times, sitting in a room in which there was a cat, without any actual contact with it, was sufficient to produce a bad attack, beginning within ten minutes of entering the room.
[Footnote 32: A case of this kind came under observation as this book was nearly ready for the press. The patient, a young woman in an office, had to refuse a vacation with a wealthy friend in Florida, because she knew that friend could not be separated from her pet cats, five in number, and the patient would have been intensely miserable were she near them, so that even the joys of Florida in the winter did not make up for the constant, intolerable discomfort they would have caused her.]
There are two forms of this intolerance of a cat. One of them takes on the character of a dread and is discussed in the chapter on Dreads. The other is accompanied by dyspnea or asthma with a sense of discomfort and tightness of the chest that cannot be overcome. It is not merely an imagination, for sometimes even when they cannot see the cat, or at times when friends have been careful to exclude cats from the room, these people become impressed with the idea that a cat is near and a search usually shows that their impression is true, though just what was the means through which they came to know it is difficult to understand.