Psychotherapy

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 them, intelligent men and women, are persuaded it lessens their pains and aches.

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

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

Many painful affections of joints, sometimes complicated by immovability, are really psycho-neuroses. Sir Benjamin Brodie once said that four-fifths of the joint troubles that he saw among the better classes were hysterical. Sir James Paget thought this an exaggeration, but confessed that he saw many of them and among all classes of people. One-fifth of those that he saw in hospital and in private practice were entirely neurotic. He emphasized the fact that they must be looked for not only among women but that they are often found in men and that they are by no means confined to those who are nervously inclined, the silly young women or the foolish old women, but that they may be found in special circumstances among the most sensible people. They are often initiated by an injury which makes it quite difficult to differentiate them from real joint affections. Usually, however, there is no redness, nor swelling nor heat with them, though sometimes one of these symptoms at least may occur with the redness. The connection between the trivial accident and the large reaction is usually hard to find and causes a suspicion as to the real process at work. Often, too, there is a delay of several days or sometimes weeks after the accident before the neurosis declares itself. In the meantime it has been getting on the patient's mind.

In general, it must be remembered the patient's attitude of mind in these cases of pain around joints and in muscles is extremely important. They have furnished a goodly proportion of the patients on which quacks and charlatans have fattened. Greatrakes in the seventeenth century, Mesmer and Perkins, St. John Long, the early electrotherapeutists, the blue glass faddists, all the various liniment makers, many of the manufacturers of blood purifiers, and Eddyism and mental healing besides osteopathy in our day have all benefited these sufferers for a time and the patients have often been men and women of education and influence in their communities and have exerted their influence for the benefit of their supposed benefactors. The methods of treatment come and go. The promise of the physician or the healer and the confidence of the patient are the only factors that are common to all the supposed "cures." If people stay at home without the air and exercise they should have, if they nurse their ills and consider that they are sure to get worse, because they labor under hereditary or constitutional ailments, nothing will benefit them. If they are convinced that their disease is only local and begin to go out to see their friends once more, a change comes over the whole aspect of their disease.

CHAPTER II

OLD INJURIES AND SO-CALLED RHEUMATISM

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

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

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

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

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

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

As to the after-effects of fractures and dislocations as with regard to all this series of vague pains and aches, the patient's attitude of mind is of great importance. As they get older their aches and pains grow worse, partly because circulation is more defective and partly because they are prone to be much more in the house and the nerves of patients who are much within doors are always more sensitive than those of people who are much in the open. If their attention becomes concentrated on their pains and aches, because of lack of diversion of mind, then the condition may become a source of serious annoyance. When these painful conditions develop patients are almost sure to keep much to themselves and to nurse their ills, and consequently to increase their discomfort. The circulation to the affected parts must be stimulated by local treatment, by rubbings, by the milder liniments, by massage and manipulations, and by local hydrotherapy. Douches, as hot as can be borne, on the limb followed by cold, especially if patients are otherwise in good health, will do much to relieve the stagnant circulation.

Active and vigorous movement while the affected part is supported at skin pressure (there must be no constriction) is even more valuable than massage, liniments or douches in the treatment of all these painful conditions of joints in which there is any scar-tissue. Wonderful results may be obtained in an old sprain of the wrist, knee and ankle by covering in the part completely (taking care to surround the limb) with strips of adhesive strapping simply laid on at skin pressure, but following exactly every fold or angle of the part, and then with the part completely covered in this way to urge immediate and constant exercise. The maintained pressure prevents any tendency to venous congestion or exudation and favors absorption of fibrous tissue, and exercise, which should be immediate, is now possible through the support furnished by the strapping. The re-assumption of normal active movement molds the old scars, strengthens the muscles and ligaments and improves the patient's general condition. The relief afforded is immediate, and the cause of relief, a simple mechanical device, is apparent. Rheumatism is forgotten as the old crutch is discarded and the patient is able to use the limb with confidence.

Recent sprains or bruises treated in this way recover perfectly and do not leave old scar tissue to be a future seat of pain.

CHAPTER III

MUSCULAR PAINS AND ACHES

Whenever exposure to cold causes a period of discomfort in almost any organ, except the teeth and certain definite nerves (for neuralgia has been taken out of the rheumatism group in recent years) we are sure to hear the word rheumatism employed in connection with it. To add to the confusion, the various "specialists" have taken to assuring their patients that local manifestations in the eyes, in the ears, and in the nose, for which they can find no good reason, especially if they are worse in damp weather, are signs of the rheumatic diathesis.

Unfortunately, our supposed knowledge of the uric acid diathesis became widely diffused, and it is not surprising in the light of the widespread acceptance of this theory, that muscular pains of all kinds should have the word rheumatic attached to them, and that patients are sure that the discomfort is only one manifestation of a severe constitutional disease, which they cannot but infer will probably make still more serious trouble for them in years to come, since it seems to be dependent on conditions beyond their control, such as heredity and general constitutional traits and their special mode of nutrition,

Local and Constitutional Conditions.—It cannot be repeated too often that it is this persuasion as to the constitutional character of the disease that has in recent years proved a very unfavorable suggestive element in these cases. Patients think themselves the victims of a serious diathesis, a deep-seated pathological condition, and attribute a host of feelings to it that are sometimes rather seriously disturbing but are really only sensory manifestations of various kinds in the organs and in the skin and muscles, which would be attributed to simple local causes—fatigue, faulty mechanical conditions, etc.—but for the concentration of attention on them.

Individual Cases .—The careful study of these cases is thus extremely important. They are eminently individual and not to be grouped together. The exact diagnosis of the various conditions from which each patient is suffering is of itself a precious factor in psychotherapeutics. The precise recognition of the condition present is of immediate avail in helping him to dismiss many of his symptoms, or at least to keep him from thinking as much of them as he did before or inevitably will if the older ideas as to the constitutional nature of his affection are allowed to remain.

Nearly every large group of muscles in the body may be the subject of these painful conditions. In recent years, perhaps, the muscles most affected in this way are those that pass around the ankle and give so much discomfort in cases of flatfoot, or beginning flatfoot (euphemistically called weak foot), when the plantar arch is yielding. The manifestations are not only in and around the ankle, but occur in the calf muscles and even above the knee. These painful conditions always develop unless the arch is supported. Until recent years it was rare to discover a bad case of flatfoot in which the patient had not taken many rheumatic remedies and had not come to the conclusion that he was the subject of an incurable and probably hereditary constitutional disease. Flatfoot is likely to cause considerable deformity in the old, the toes becoming bent and twisted up, and the subjects of it complain very much of their feet. Flatfoot runs in families. When the father and mother have complained of what they called rheumatism in their feet which got worse every year, then the son and daughter, when they have their first manifestation, conclude that they are inevitably bound by the stern laws of heredity.

Occupation Aches.—Flatfoot is taken, however, only as an extreme and therefore striking illustration. Whenever a particular group of muscles has to do an excessive amount of work, practically always there is a development of an uncomfortable condition worse on rainy days and therefore likely to be called rheumatic. Over-use of the arm at any occupation, in writing, in the use of a file, at an ironing-board, in sewing, or at anything requiring repeated movements, will produce it almost inevitably. Especially is this true if the occupation is carried on without such careful attention to muscular action as enables the muscles to do their work to the best advantage. These painful conditions are much more likely to occur in run-down individuals of nervous temperament, above all if they have been or are subject to worry. Men who have lost money and now have to do hard physical work, after previously having lived sedentary lives, and women whose previous source of support has been withdrawn and who have to work for a daily wage after former gentle conditions of living, are especially likely to suffer in this way. The conditions develop on a neurotic basis or an exhausted nervous system.

Other groups of muscles may also be the subject of these painful conditions. The large group in the loins, called the lumbar muscles, which are so important for stooping, for the erect posture and for lifting, are so commonly the subject of discomfort that a special name has been applied to their affection—lumbago. In the leg the large group of muscles supplied by the sciatic nerve are likely to be affected, and this affection is so common in men who have to bend the knee and flex the hip at their work that it, too, has received a special name—sciatica. Besides the arm muscles the groups of muscles around the shoulder girdle are often unfavorably affected and though we have not invented a name to cover their conditions, it is so common that we think of it as a separate entity almost in the same manner as we think of lumbago and sciatica. In the neck the group of muscles that rule the movements of the head, especially those at the side may be affected and the special name of torticollis has been given. Practically all of these affections are thought of at times as rheumatic and the ordinary rheumatic treatment is given for them. There is no doubt that the salicylates will relieve the pain almost at once, but so will any other coal-tar product and phenacetin, acetanilid or even antipyrin may be used with good effect. There is no evidence, however, that these drugs make the underlying condition better and, indeed, after patients have tried them for a while, unless the affection is merely passing, they try some other physician and perhaps are treated the same way with a different form of the drug. These are the cases that make their way around to a number of regular practitioners of medicine and then eventually go to some irregular or quack and sometimes obtain relief where the regulars have failed.

When the irregular succeeds it is always because he has done three things. First he has persuaded the patient that it is not rheumatism, with all the unfavorable suggestion that goes with that word, that is, the matter with him; secondly, he has treated the local condition; and, thirdly, he has diverted the patient's mind. Local treatment is often the real secret of his success, though the psychotherapeutic element is not without distinct benefit.

Mode of Occurrence.—These muscular conditions present themselves under two forms, acute and chronic. The acute condition occurs almost suddenly and is accompanied by spasmodic pain and acute discomfort. Muscles go into spasm to avoid the movement that would necessarily bring pain with it. A typical example is found in torticollis in which the patient wakes up some morning to find a stiffness in the muscles of his neck with limitation of movement much more pronounced on one side, and this usually gets worse as movements are attempted during the day. This spasmodic painful condition usually lasts for some days and suggests all sorts of topical applications and often requires anodyne drugs. A similar acute condition may be observed in some cases of lumbago. In this the pain in the loins comes on suddenly, usually during movement, often in the midst of lifting something that one has been able to lift without difficulty before. This pain is so sudden, so unexpected, usually comes entirely without warning and seems so mysterious in its origin, that it is no wonder the Germans speak of it as Hexenschuss—"witches' shot"—a remnant of the superstition that a witch, by means of the evil eye or some other maleficent power, or by sticking pins in a wax image of a victim that had previously been devoted to the devil, might produce effects upon the person at the part where the thought was directed or the pin inserted.

These painful conditions, especially when acute, are, as a rule the consequence of exposure to dampness, or to a draft blowing directly on the part, usually in damp and changeable weather, and often when the patient has been sweating just before. The train of events that brings about the painful condition is not difficult to understand. There is a disturbance of the normal smooth-running, indeed almost frictionless, mechanism by which muscles glide over one another. There are practically a series of joints in all muscular groups so as to permit just as free a play as possible of muscles over one another. Each muscle is covered with a glistening membrane so familiar from our dissecting room days, which secretes a substance resembling a synovial fluid, to enable muscles to move upon each other without friction. When, because of exposure to drafts or the evaporation of moisture on the surface, there is a disturbance of the circulation in these intermuscular planes, the secretion which prevents the friction of muscle movements is disturbed. The blood is driven from the surface and some congestion and consequent heat accumulation occurs in the muscles, affecting particularly their contiguous layers. As a result, the muscle surfaces are no longer smooth and the muscles now have not as free play over one another as before. It is not surprising that, owing to this, sensitiveness occurs and some spasm develops. This, however, is thoroughly conservative in character since nature's idea is to set the part at rest so as to allow the normal condition to be restored.

This is the pathological condition that underlies these so-called muscular rheumatisms which develop suddenly. It is important to note, however, that these conditions develop nearly always in people who have been over-using or wrongly using the groups of muscles which become thus affected. The history of a torticollis patient will usually show that there is some contortion of the muscles of the neck familiarly practiced by him. Sometimes it will be found that the patient has the habit of sitting on a particular easy chair in a special relation to the light and that in order to accommodate himself to his chair and the light in his reading, the head has to be placed in such position that the neck muscles are constrained. It is this that predisposes the patient to the development of the condition which seems to be so acute and yet is really only an exacerbation of a chronic condition. Lumbago will develop in men who have been stooping much, especially for heavy lifting, or in women who scrub or have to stoop much while cleaning, dusting and the like.

Some interesting muscle pains occur as a consequence of the jostling movements of various modes of transit. They are particularly noticeable if an uncomfortable position has been maintained for a number of hours. People who travel on railroad trains often come with the story that they must have caught cold on the trip for they have been sore and achy in many of their muscles since. I have known people who went on a crowded excursion and had to stand for several hours confident that, standing in the drafty aisle of the car on their way home, they had acquired rheumatism. All that had happened was over-tiredness of muscles on the jolting train which required constant balancing and unaccustomed muscular exertion. On board sea-going vessels people often suffer from pains in the loins and in various trunk muscles, due to the roll of the vessel, especially while they are asleep. These, too, are likely to be attributed to drafts, or to some form of rheumatism, or at least to the catching of cold. I have even seen people sure, because of pains in their loins, that they must be developing some kidney trouble. After a time they get used to the swinging motion of the vessel and then their achy muscle tiredness is relieved.