_ CHAPTER XIV. NEUROTIC ASTHMA AND THE WILL
"Great minds of partial indulgence
To their benumbed wills."
Troilus and Cressida.
In closing a clinical lecture on bronchial asthma at the University of Marburg some years ago, Professor Friedrich Müller, who afterwards became professor at Berlin, said, "Each asthmatic patient is a problem by himself and must be studied as such; meantime, it must not be forgotten what an important rôle suggestion plays in the treatment of the disease." This represents very probably the reason why so many remedies have been recommended for asthma and have proved very successful in the hands of their inventors or discoverers as regards the first certain number of patients who use them, and yet on subsequent investigation have turned out to be of no special therapeutic value and sometimes indeed to have no physical effect of any significance.
Of course this is said with regard to neurotic asthma only, and must not be applied too particularly to other forms of the affection, though there is no doubt at all that the symptoms of even the most severe cases of organic asthma can be very much modified and often very favorably, by suggestive methods.
The principal feature of asthma is a special form of severe difficulty in breathing. It is known now that the beginning of the affection is always as Strumpell said, "an extensive and quite rapid contraction of the smaller and smallest bronchial branches, that is the terminal twigs of the bronchial tubes." It is not so much air hunger, though there is, of course, an element of that because the lungs are not functioning properly, as an inability to empty the lungs of air already there and get more for respiratory purposes. The spasm in asthma has a tendency to hold the lungs too full of air and produce the feeling of their getting ever fuller and fuller. What the old sea captain said in the midst of his attack of asthma, when somebody sympathized with him because he had so much difficulty in getting his breath, was that he had lots of breath and would like to get rid of some of it. He added, "If I ever get all this breath that's in me now out of me, I'll never draw another breath so long as I live, so help me." The respiration spasm is usually at full inspiration and the effort is mainly directed toward expiration and expulsion of air present using the accessory respiratory muscles for that purpose.
The picture of a man suffering from asthma is that of a patient so severely ill as to be very disturbing to one not accustomed to seeing it. It would be almost impossible for any one not used to the attacks to think that in an hour or two at the most the patient would be quite comfortable and if he is accustomed to the attacks, that he will be walking around the next day almost as if nothing had happened. All that the affection consists in is a spasm of the bronchioles and as soon as that lets up, the patient will be himself again. Some material may have accumulated during the time when the spasm was on which will still need to be disposed of, and there will be, of course, tiredness of muscles unaccustomed to be used in that special way, but that will be all.
We are still in the dark as to what causes the spasms but undoubtedly psychic factors play an important etiological rôle. For a good many people, there is a distinct element of dread as the immediate cause of their asthmatic attacks. Some people have it only when they have gone through some disturbing neurotic experience. Occasionally it is the result of physical factors combined with some psychic element. Cat asthma is not very uncommon and occurs as a consequence of some contact by the individual with a specimen of the cat tribe though usually the large cats, the lions and tigers, do not cause it. There is nearly always, in those who are liable to this form of asthma, a special detestation of cats. There is probably some emanation from the animal which produces the asthmatic fever, just as is true also of horses in those cases where horse asthma occurs. In a few of these latter cases, however, it was noted that the horse asthma did not begin until after there had been some terrifying experience in connection with the horse, as a runaway, a collision, or something of that kind.
Any one who sees many asthmatic cases inevitably gets the impression after a time that their very dread of the attacks has not a little to do with predisposing them. Occasionally the dread is associated with some other organic disturbance, either of heart or kidneys, or oftener still, with some solicitude with regard to these organs and the persuasion that there is something serious the matter with them, though there is at most only some functional disturbance. This is particularly true of cases of palpitation of the heart where there has been considerable dread of organic heart disease. In a certain number of these cases, there is some emphysema present, that is, overdistention of the lungs, such as is seen in high-chested people. Owing to the long anterio-posterior diameter of the chest and the fact that as a consequence it is nearly as thick through as it is wide, this form of chest is sometimes spoken of as barrel-chest. Patients who have it are particularly likely to suffer from asthma if they have any dread of heart trouble or if they are of a nervous constitution.
I have known people with the dread of the dark to get an attack of asthma if they were asked to sleep alone after having been accustomed for years to sleep with somebody in the room. I have known even a physician to have attacks of asthma of quite typical character as the result of a dread of being out after dark which had gradually come over him. I have had a physician patient who was very uncomfortable if alone on the streets of New York, even during the day, and whose symptoms at their worst were distinctly dyspneic or asthmatic. He used to have to bring his wife with him whenever he came to see me for he lived out in one of the neighboring towns, because he was so afraid that he might get an asthmatic attack that would overcome him and he would feel helpless without some one to aid him.
In practically all these cases, the treatment of asthma becomes largely that of treating the accompanying dread. Once the acute symptoms of the attack itself manifest themselves, they have to be treated in any way that experience has shown will relieve the patient. The general condition, however, needs very often an awakening of the will to regulate the life, to get out into the air more than before, to avoid disturbing neurotic elements, and worrying conditions of various kinds. Thin people need to be made to gain in weight, using their will for that purpose; stout people who eat too much and take too little exercise need to have their lives regulated in the opposite direction. In the meantime, anything that arouses the patient to believe firmly that his condition will be improved by some remedy or mode of treatment, will help him to make the intervals between attacks longer and the attacks themselves less disturbing. The will undoubtedly plays a distinct role in this matter which patients who have been through a series of asthmatic attacks recognize very clearly.
The many remedies for asthma which have been lauded highly even by physicians, and that have cured or relieved a great many patients and yet after a while have proved to be without much beneficial effect, make it very clear how much the affection depends on the will power to face it and throw it off. Nothing will be curative in asthma unless the patient has confidence in his power and uses his own will energy to help it. He must overcome the element of dread which occurs in connection with all asthmatic attacks, even those due to organic disease of heart or kidneys. No matter how frequent the attacks have been, there is always an element of fright that enters into an affection which interferes with the respiration. This must be overcome by psychic means to help out the physical remedies that are employed. Sometimes the psychic remedies will succeed of themselves where more material means have failed completely. _