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.
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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