Neurotic Asthma And Cognate Conditions





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 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 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 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 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.





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