The main disturbing feature of the affection is the dread of the development of serious crippling conditions in the hands or in the large joints.

As a rule, after a time the nodes cease to grow, and then a period of remission sets in that lasts for many years and there may be no recrudescence of the affection. This remission is delayed if the patients allow themselves to run down in general health. It is apparently hastened by getting the patients up to normal weight and removing any factors that disturb their general health. If the patients' minds are properly disposed, the neurotic symptoms that sometimes develop as the result of over-solicitude about their condition are done away with, the patients are more comfortable, and even the progress of the disease is inhibited.

ACUTE PROGRESSIVE ARTHRITIS

The second variety of the affection is a general progressive arthritis which usually begins with fever, redness, and swelling, involving especially the smaller joints. The diagnosis of the disease can almost be made on the fact that its favorite locations are the jaw and the joints of the spine. It is a much more serious affection than Heberden's nodes. In its beginning it often simulates acute rheumatism. It occurs particularly in people who are run down for any reason, in young women who have recently come to the country and are working as domestics, in young men who have recently changed their occupation from indoors to outdoors and are not used to the inclemencies of the weather. On the other hand, it occurs rather often in young persons of {424} both s.e.xes used to living and working out of doors who take up an occupation in a damp interior.

The fever usually runs a lower course than that of genuine acute articular rheumatism, the pain is not favorably affected by salicylates, and the duration of the disease is generally longer. This affection always leaves its marks on the joints and there are always recurrences. It is, indeed, the confusion of this quite distinct disease with acute articular rheumatism that has given the latter affection the bad name it has in many minds as a producer of deformities. Arthritis deformans or general progressive arthritis is always a crippling disease; acute articular rheumatism has for its surest diagnostic sign, when the complete history of the case is known, the fact that it leaves no mark after it except, unfortunately, that so often seen in the heart.

CHRONIC ARTHRITIS DEFORMANS

The third type of arthritis deformans is the chronic slow running type which involves many joints before the process is complete. One form of this, commonly seen in old men, called osteoarthritis, is often confined to the hip joint, and often produces considerable deformity.

Another form is more common in women. It begins in middle life by deformities in the terminal joints of the fingers and the carpo-metacarpal joints of the thumbs. Bony outgrowth takes place until the joints become almost or quite useless. It spreads from the joints primarily affected to the elbows, the knees and occasionally involves other joints. The disease has no favorable course, but is progressive, and there is great discomfort, marked disability, aches and pains particularly in rainy weather and, finally, the patient may become quite helpless.

Preliminary Stage.--An early symptom a.s.sociated with arthritis deformans of chronic character is likely to be a distinct loss of muscle power, which may be the first symptom in cases that have no acute beginning. The patient notices that he is unable to hold a satchel as he did before, or that quite unaccountably it drops from him. There may be a loss of control over muscles and especially small muscles that attracts the patient's attention. He finds that he cannot hold a book as he used to, or that it is difficult to pick up small objects. He finds it hard to turn a door handle or to pull a cork, although the pulling action may be perfect, but the ability to insert the corkscrew is lacking. These symptoms are p.r.o.ne to be intermittent.

They are most noticeable when the patient is tired, or after a damp day, or a succession of damp days, when he is not feeling well. It will usually be found that a joint, the affection of which is missed unless it is carefully looked for, that between the radius and ulna has become affected, and as a consequence there is a difficulty in supination. The lesions are different from those which occur in lead poisoning but at the beginning the symptom complexes may easily be confused.

This form of arthritis deformans, in its earlier and its later stages, is a source of unfavorable suggestion as regards other affections. Its first symptoms may be thought neurasthenic, and if it is so called, those who hear the diagnosis and see the later developments will conclude that neurotic symptoms {425} can lead to serious sequelae. On the other hand, the painful tiredness that is always worse in damp weather may be termed rheumatism and be a correspondingly unfavorable suggestion. Patients who develop aches and pains as a consequence of occupations, or through the relaxation of joint tissues, are most uneasy because of the confusion of the later stages of this disease with rheumatism. This must be recalled by the physician if he would be successful in treating such pains and aches; for not a little of the discomfort is due to an exaggerated mental impression of their significance. This of itself often proves sufficient to keep the patients from the exercise that would relieve many of their secondary symptoms, at least, and serve to make their discomfort more bearable.

Course of Chronic Arthritis.--The course of chronic arthritis deformans is always interesting. It is never as serious as the prognosis at the beginning seems to indicate, and it always has intermissions which, in most cases, become favorable remissions with such improvement that the patients feel encouraged, though they never get entirely well. Six rather typical cases have been under my eyes for from five to fifteen years. In all of them the course was slow and the progress of the disease vague at the beginning; and it was difficult to say how the affection began, or what was its cause, and apparently nothing would stop its advance. After a time all of them became discouraged and began to go the rounds. Almost without exception the physicians told them that they were incurable, and nearly all of them received unfavorable prognoses either directly from the physician or from hints sometimes dropped to friends, or from the att.i.tude of the physician toward them. Much of this discouragement proved unjustified by the actual progress of the disease for many years. While they got but scant encouragement from regular physicians, nearly all of them received hopeful suggestions from irregulars and were, as a rule, for the time being, somewhat bettered by the treatments suggested by these, no matter what they were.

Every one of these six cases, as was to be expected under the circ.u.mstances, went through a period of intense discouragement, with loss of appet.i.te, partly from confinement to the house, partly from thinking so much about themselves, partly from lack of exercise and, in general, from their morbid mental condition. As a consequence of the loss of appet.i.te, or, at least, of failure to eat in the midst of discouragement, severe constipation developed in five of the six cases and this further complicated the situation. They ran down very much in weight, and this emphasized the apparent size of the hypertrophic nodosities in their joints and weakened their muscles to such an extent that even under good conditions they found it difficult to move. After a time, usually many months, sometimes a couple of years, something happened to make them realize that while they were crippled and were going to be deformed, they still might find much in life that was not to be despised. Then they began to pick up in weight, their muscles got firmer, their nodosities seemed to disappear because the soft tissues around them filled out, though in most cases some of the material previously laid down actually was or seemed to be reabsorbed, perhaps as a consequence of the patient's better metabolism.

Neurotic Additions.--All of these patients are now in much better physical and, above all, in much better dispositional states than they were during the first year or two at the beginning of their disease.

While they allowed {426} themselves to run down in weight they were supremely miserable, with many neurotic pains and aches that were extremely hard to relieve, they had tendernesses and sorenesses on rainy days, usually attributed to their rheumatic conditions but really due to intense depression of the nervous system, with a constant tendency to exaggerate slight pains and aches into torments, and in general were invalids, a burden to themselves and others. They have improved to a noteworthy extent so as to become cheerful, reasonably happy in their power to help others, interested in many things and, in at least two of the cases, accomplishing more actual good for those around them than they probably would if their lives had continued to be the conventional existences that they had been before their arthritis came to them. This reminds one of Dean Stanley's famous expression that life looks different when viewed from a horizontal position. He used the expression with reference to fatal illness, but it might well be applied to any ailment that makes people think seriously and keeps them from occupations only with frivolous things. One of these patients is a source of consolation to many friends, who are much better in health than she is, who bring their troubles to her, and who marvel at her power to make the best of things.

The prognosis for cure is extremely unfavorable, but the prognosis for a reasonable amount of happiness and a large amount of usefulness is, in my experience, excellent and though, of course, new habits will have to be formed and new ways of looking at life a.s.sumed, if this can be quietly and persuasively made clear to the patient early in the case, much of the more or less inevitable suffering that the patient will have to endure may be lessened.

The older the patient, as a rule, the better the prognosis in these cases. As with regard to diabetes, tuberculosis and many another affection, every year after fifty adds to the prospect that the patient's ordinary span of life will not be much shortened and that the symptoms will not be severe. Occasionally the disease develops in patients who have been extremely healthy until they were well past sixty. I have in mind particularly a patient who did not begin seriously to suffer from the disease until she was sixty-eight. Then for two or three years she was very miserable, mainly because she had been very active and she feared that the disease would cripple her. It did bring about a considerable limitation of her activity. Ten years have pa.s.sed, however, and she is still able to be about, and, though now well on the way to eighty, in good weather she still attends to various duties that take her outside of her home and occupies herself with many interests.

I was never able to tell her that she would be better. I a.s.sured her from the beginning, however, that she would never be so much worse as she imagined, and that she would never be actually crippled. During the early stages of the disease, her discouragement and, above all, the diminution of activity, the lack of exercise and occupation of mind and the over-occupation with herself, made her not only mentally miserable but seriously interfered with many bodily functions.

TREATMENT

In the treatment of arthritis deformans the most important object is the general health of the patient. Owing to the confinement, the pains, which {427} are often worse at night, cause disturbance of sleep which reacts upon the general health. As a result of depression and discouragement, patients are p.r.o.ne to loss of appet.i.te. This is sometimes looked upon as a symptom of the disease, but it is not a direct symptom except during the acute stage when there is fever, and is due rather to the changed conditions in which the patients live and the mental influences that surround them. If the patient loses in weight, as is so often the case, the effects are likely to be more serious, for the remission is delayed and is less complete in its consequences. Above all, it is important not to disturb the diet of the patient in such a way as to interfere with nutrition. Owing to the supposed rheumatic element, meat, or at least red meat, is occasionally taken out of the diet by the recommendation of the physician. Whenever this is done, harm results. There is a definite tendency to anemia, which will be emphasized by an exclusively vegetable diet, especially in those accustomed to eat meat freely. As a rule, there is much more need to encourage the patient to eat than to limit the diet in any way. Patients must rather be advised to take a generous mixed diet and to consume about as much meat and the same varieties as before. Tinkering with the diet has never been known to do any good for arthritis deformans and often does harm. The drinking of large quant.i.ties of water seems to do more than almost anything else to help these patients into a better frame of body and mind.

Their neurotic symptoms are, as a rule, even more important than their joint symptoms, and if the neurotic symptoms can be cured, as they usually can without much difficulty, the patients feel much better.

Systematic Exercises.--As soon as the acute stage has pa.s.sed patients should be encouraged to take some systematic exercise in spite of the discomfort that is a.s.sociated with it. Unless muscles are moved regularly deformities in bad position will result and there will be crippling which can be avoided in most cases. It is sometimes difficult to secure exercises for the small muscles that are involved and definite occupations are better than artificial exercises. For the fingers, for instance, I find that the best thing is knitting. By this I mean using the old-fashioned knitting needles for the making of stockings, wristlets, jackets, and the like. Crocheting is also of some use, but it does not give employment to as many of the small muscles as knitting. If the knitting is done with old-fashioned yarn from which the lanolin has not all been extracted, some of this substance comes off on the fingers during the movements a.s.sociated with knitting. This seems to do good by rendering the joints more supple and the muscles more easy of movement. At least the suggestion is very helpful to the patients.

Electricity and Mechano-therapy.--Electricity has been much praised, but whatever good it accomplished has always seemed to me to be confined to the exercise afforded the muscles. Its use, however, serves to keep up the patient's hope.

Mechano-therapy often does good and some of the Zander machines are likely to be useful. Pulleys and weights for the shoulders and arms have their place and resisted movements serve to restore muscles to function which they had lost during the time when the joints were worst. Their use helps to bring the joint into the most available conditions.

Something that has distinct hope in it must always be done for these patients. For this local treatment means more than anything else.

Unfavorable {428} suggestions keep flowing in upon him from the failure of medicine, and serve to concentrate his attention on his condition and make him think that nothing can benefit him. Often the physician finds that his patient has been to someone else, who did some simple thing that brought relief of symptoms, at least for a time, and restored his confidence to such a degree that he felt much better for a time at least. These ailments are emphasized by advancing years and, though we cannot prevent decay of tissue, we can keep the patient's mind from inhibiting still further the functions of the impaired tissue.

General Condition.--The patient's general condition must be made as good as possible. For this outdoor air is the most important factor.

It increases impaired appet.i.te, makes sleep more restful and easy, and gives one of the best occupations of mind that can be obtained. Of course, changes in the weather will bring discomfort. Where it is possible, such patients must be sent to climates as equable as possible. Such a change of climate during December, January and February will often make them very comfortable, and the distraction of mind, with the possibility of getting out in the mild climate, will diminish their sensitiveness and be more powerful factors in the dissipation of their aches and pains than the climate itself. Where people cannot be sent away from home, the securing of corresponding distractions means a great deal. The one thing necessary for the physician is to keep the patient from brooding upon himself and his ills and to find other occupations of mind for him.

CHAPTER X

COCCYG.o.dYNIA

CoccyG.o.dynia, or, as it is sometimes called, coccydynia, is a painful affection of the coccyx or bony end of the spinal column. It usually results from trauma, as a fall on the b.u.t.tocks on an icy pavement, or particularly a fall in coming down stairs in which the main portion of the impact is on the seat. Occasionally it follows horseback riding.

It is said to be on the increase among women who ride astride.

Occasionally it is reported after severe labor, particularly when the head of the child was very large, or after first labor when the coccyx has been beforehand bent inward somewhat abnormally and is pushed out by the oncoming head. It seems to develop with special frequency in nervous people who have to sit much, particularly if they sit on unsuitable chairs. The chair seat with the ridge in the center which has been introduced in recent years is sometimes blamed. Occasionally, on the other hand, it is said to come from sitting on heavily cushioned chairs, particularly leather chairs which do not allow of much transpiration and cause a feeling of uncomfortable heat.

There are, indeed, so many different causes suggested, sometimes of quite opposite or even contradictory effects, that it seems evident that the main element in the disease is some predisposition to sensitiveness in this region which is exaggerated and emphasized by the cause that is blamed. It occurs particularly in women, though it is occasionally seen in delicate or neurotic men. Sufferers from it sometimes find it impossible to sit for any length of time. {429} Even lying down, especially if they lie on their backs, becomes a source of pain. Various operations, such as the reposition in place of the bent coccyx, or even the removal of the tip of the coccyx, have been suggested. Some reported cures are to be found in the literature.

These are mainly surgical cures, however, that is to say, the patient recovered from the operation, was seen for a month or two afterwards, and was then on a fair way to complete recovery. Some of us who have had to treat these cases afterwards for painful conditions apparently due to the scar of the operation, or to a neurotic condition closely corresponding to the old coccyG.o.dynia, are not so confident of the value of an operation, though probably in purely traumatic cases surgical intervention is of value.

In most cases the sufferers are women who have little to do, who have much time on their hands to think about themselves, and who usually receive abundant sympathy from friends and relatives. In one case under my observation the death of a husband and the discovery that his estate was much less than had been antic.i.p.ated, so that his widow had to take up a wage-earning occupation, did more in a short time than all the treatment that had been employed before to relieve her discomfort. She had been quite unable to move around at times, especially in rainy weather, and was something of an invalid during all the winter, but now she was able to go out to work every day and had very little trouble. Her affection originally dated from a fall on an icy sidewalk and her fear to go out in the winter seemed to be dependent on the dread of another fall. She realizes now that practically all her former trouble was due to over-attention to a discomfort which is still present, but which she is now able to forget, except at times when she is alone after there have been worries and troubles that have reduced her power to control her nerves. In young girls an injury to the coccyx by a fall on the b.u.t.tocks will often leave tenderness for months or even years, but if attention is distracted from this and the patient is not allowed to concentrate her mind on it and does not hear of the awful possibilities of coccyG.o.dynia--a mouth-filling Greek name in which we map out our ignorance, and which seems to carry with it such a weight of pathology--she will probably recover completely.

CoccyG.o.dynia often resembles hysterical c.o.xalgia or the hysterical arthritises, and seems sometimes to be due to the fact that there is a natural or traumatic abnormal mobility of the coccygeal vertebrae which, owing to concentration of attention, has developed into a neurosis a.n.a.logous to the corresponding condition in a joint. There are undoubtedly cases in which a real pathological lesion exists, but these are comparatively few. In this, as in other joint and bone affections with vague pains likely to be worse on rainy days, the word rheumatism is often mentioned, but it has no proper place. Treatment that will put the patients into good general condition--never local unless there is objective indication--outdoor air and exercise with rea.s.surance of mind and distraction of the attention are the important therapeutic agents. Patients with much time on their hands do not readily get well, while those who are busily occupied seldom suffer for long.

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SECTION X

_GYNECOLOGICAL PSYCHOTHERAPY_

CHAPTER I

MENTAL HEALING IN GYNECOLOGY

All physicians are convinced of the good that has been done by the extension of the application of surgery to women's diseases during the pest generation. On the other hand, there are probably very few, except the ultra-specialists, who are not quite sure that there has been too much surgery in gynecology, and that many a woman has been operated on without sufficient reason and without definite indications. In suitable cases surgery is sometimes life-saving and is often the only means of relief for suffering that is seriously disturbing the general conditions and is making life unbearable. Its very possibilities of good, however, have led to abuses. From the abuse of a thing, the old Latins used to say, no argument against its proper use can be derived, and this is eminently true of gynecological surgery. It will not belittle the great benefit that operative work has been to state how much of auxiliary good may be accomplished by the use of psychotherapy in gynecology.

Many a woman who is operated on is benefited only for the time being, and her old symptoms return after a time. Dr. Goodell, one of our first great gynecologists, used to warn his students insistently that women had many organs outside of the pelvis. The individuality in gynecology is extremely important. Some women suffer what they describe as excruciating pain or unbearable torture from pathological conditions that other women do not notice at all. Very often these women either have no real interest in life and are so self-centered that they emphasize their feelings by dwelling on them, or else their attention has been attracted to some sensation not necessarily pathologic and then by concentration of mind on it they so disturb vasomotor conditions and the nutrition of nerves that the condition does become a veritable torture and apparently demands surgical intervention. It is possible to cause a hyperemia in the skin by thinking about certain portions of it, and the genital organs are particularly p.r.o.ne to be influenced by mental states. If for any reason a woman gets her mind on her genital tract and becomes persuaded that there is a pathological condition in it, symptoms will develop until an operation seems inevitable. But the operation will bring relief only for a while, and then her mind will find something else to dwell on and produce similar symptoms.

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Place of Psychotherapy.--To fail to try to sway the mind by all the methods and auxiliaries outlined in the earlier chapters of this work before suggesting an operation to a woman is to neglect a most important means for relief in many gynecological cases. There is scarcely any pathological condition from which women may suffer that does not become worse as the result of the depressing influence of much thinking about it, and that is not made better by a change in their mind that makes them realize the possibility of being well again. The most important preliminary to operation is the promise of complete relief through surgery. The acme of suggestion is reached in the preparation for operation with its constant encouragement and then the congratulations after the operation. Then come the weeks of convalescence during which the same strong suggestion is constantly at work making the patient sure that she must be better. All this serves to add tone to the system, invigorates the appet.i.te and puts patients in the best possible mental att.i.tude to bring about a favorable result. Indeed, the ten or fifteen pounds in weight that such patients gain during their convalescence, especially when they have been under weight before, is often the most beneficial result of their hospital experience.

If the same patients had been given the same promise that they would surely be cured, and then had been removed from depressing home influences and bothersome trials and labors, and been told that what they needed for complete recovery was to gain in weight; if they had then been visited by friends who congratulated them on the fact that now at least they were going to be better and their symptoms were going to disappear, and if they had gained the fifteen pounds that came in convalescence after their operation, most of them would have recovered quite as completely as by the operation from many of their vague gynecological difficulties. This is, of course, true only of cases where there are not very definite indications for surgical intervention. But in a certain number the symptoms are so vague that operation is decided upon rather with the hope than the a.s.surance of benefit; and it is particularly in these that psychotherapy is useful and must be given a thorough trial.