THE PSYCHIC ASPECTS OF BRONCHIALASTHMA

Review and Sy~thesis of the Literature BY ROBERT B. SAMPLINER~ M. D.

One of the most characteristic concepts of our modern civilization is the idea that everything in the present is true, and that everything from the past is a delightful, but useless, museum-piece. This concept finds some of its strongest adherents in the field of science. Thus, contemporary theories or facts are the only ones that have any significance; the speculations of past scholars are only to be scoffed at. There is nothing so outmoded as the scientific textbook of 20 years ago. This attitude is proper if we are to progress at all, but it makes for a great many pursuits of scientific will-o'-the-wisps which lead us into the bog of acceptance of a truth as Truth itself. Nowhere is this better seen than in the periodic fads which sweep over tile practitioners of medicine. The exponents of these fads generally attempt to treat all diseases by their new touchstone. This tendency towards superficiality has often made us forget the patient for the disease. We have many specialists who are eminently capable of treating one disease, or one organ system, according to the dogmata of one school or another, but relatively few men who are interested in the patient as a whole. To many medical men the patient is a collection of cells, or organs, or a physiological system. His psychic background is not considered by them as a proper field for medical thought. The converse is sometimes, but less often, true of the psychiatrist who is apt to forget that the patient really has a body which may malfunction, and which may need his knowledge of medicinals in order to correct some deficiency. The doctrine of separation of the individual into psyche and soma has led us into so many grave errors that it is high time we abandon it for the more fruitful attitude that we are dealing primarily with human beings, not with diseases. Today very few physicians would deny the allergic basis of asthma. But we are all so busy calling asthma an allergic disease that we have almost entirely neglected to question what is allergy and what is an allergic patient. What peculiarity makes some individuals sensitive to substances which are entirely harmless to the great majority of people? If we look into the outmoded textbooks

522

T H E I~SYCHIC ASPECTS OF B R O N C H I A L A S T H M A

of the past, before we knew the term " a l l e r g y , " some light may be shed which is unfiltered by the lens of our present knowledge and may show our familiar landscape in unaccustomed relief. In the works of Van Helmont 1~ (1577-1644) asthma is called a " n e r v o u s disease." This viewpoint was upheld by Willis 14 and Floyer 6 (1698), both of whom suffered from the disease. Laennec, ~ who distinguished bronchial from cardiac asthma, reports a case of bronchial asthma which was invariably brought on by the dark and was relieved by lighting the room. E v e n today cases of "all e r g y " to heat and cold are reported by various authors. These cases could scarcely be attributed to the circulation of allergens in the blood. On the other hand, the literature abounds with cases which are caused by allergens and are cured by their removal. It is highly desirable that some common ground should be found between these undoubted allergic cases and those due to some cause other than allergy. The quickest way to discover a connection between two diverging roads is to go to the fork. The fork here is obviously the mechanism of bronchial asthma of whatever cause. Asthma is a disease characterized by contraction of the nmscles of the smaller bronchioles, and, perhaps, by secretion into these bronchioles. It is known that these nmseles contract in response to stimulation of the parasympathetic portion of the autonomic nervous system. That this is the case is borne out by the striking relief which epin e p h r i n e - - a stimulator of the sympathetic nervous system--affords to sufferers from an attack of bronchial asthma. W. Langdon-Brown TM quotes H u r s t ~' to the effect that tile vagal nucleus may be stimulated by peripheral excitation such as pressure on the nasal septum, by foreign proteins circulating in the blood (the allergens), or by psychic stimuli. The following diagram, after Iturst, illustrates this relationship. Jelliffe '~ speaks of the levels at which the vegetative nervous system may be affected as: (1) the " b i o c h e m i c a l " or "physicochemical" (allergy), (2) the " p e r i p h e r a l reflex" or "sensorimot o r " level (stimulation of the nasal septum, etc.) and (3) the " p s y chological" or " p s y c h i c a l " level. He f u r t h e r states that stimuli on one of these levels may so alter the threshold of the other levels tlmt subliminal stimuli at those levels will produce a response.

523

R O B E R T B . SA1VfPLII~ER~ 1Vf. D.

j, 51, , , d "

e,ce

P a r a s y m p a t h e t i c effects m a y be b r o u g h t about, of course, either by stimulation of the p a r a s y m p a t h e t i c , or by depression of the sympathetic. According to Jelliffe's concept, therefore, if a p a t i e n t is allergic to some substance and has, in addition, a psychic disturbance he will react to f a r smaller a m o u n t s of the allergen in question than he would ordinarily. If his psychic d i ~ c u l t y can be resolved, he m a y have no m o r e attacks of a s t h m a although r e m a i n i n g sensitive to the allergen. A psycho-physico-chemieal explanation of the m e c h a n i s m of" a s t h m a is given by L a u d e n h e i m e r 3~ who t r e a t e d his patients with exercise and hypnosis : PSYCHIC-I-Physical* Physical ~-PSY CttI C Reversible Action and Respiration Of PSYCHE I. AFFECT causes change of the I. Voluntary acceleration of resrespiratory curve, depth, and piratory rhythm causes AFfrequency (Zoneff and MeuFECT (Wundt, Heyer). mann.) t II. PAIN or PSYCHIC EXII. Hyperventilation, forced expiration (Heyer), increases CITE1V[ENT lowers the CO2tension in the blood (Straub, COs-tension of alveolar air, and produces AFFECTIVE Beckmann) ; the sensitivity of EXCITEMENT and with apthe respiratory center is inpropriate breathing technique creased, hence increased venin predisposed individuals) tilation. typical symptoms of asthma (Tahna, Strubing). *The physical starting links, viz., end link~ of the chain, arc m a r k e d by it~dic.% the psychic links by C A P I T A L S . t i l l D u n b a r , H. Flanders.

524

T H E P S Y C H I C ASPECTS OF B R O N C H I A L A S T H M A

III. PSYCHIC STIMULI may, via vasovegetative centers, spontaneously or in hypnosis, lead to most serious spastic-exudative (pseudo - anaphylactic) symptoms and to typical asthma. IV. SLEEP, VIZ., TIREDNESS, increases C02-tension in blood (Straub), decreases the sensitivity of the respiratory center, hence produces slowing of respiration.

III.

Allergic stimuli may, over the reverse pathway (body fluids, colloidal disequilibrium, hormonal influence, etc.) lead to anaphylactic shock, bronchospasm, exudation, asthma and ANXIETY. IV. Slowing of respiration (with relaxation of the respiratory muscles) through exercise or suggestion leads to tiredness, viz., sleep [and under HYPNOSIS to lasting lowered sensitivity of the respiratory center].

The secondary effect of allergens is proven by patients of Moos, ~ and of Wittkower and Petow ~'~ in whom were found, at the first visit, Curschmann's spirals, Charcot-Leyden crystals, and eosinophilia in the sputum, eosinophilia in the blood, and who had positive skin tests for various substances. W h e n treated by psychotherapeutic methods they were cured of their asthma, the Curschm a n n ' s spirals, Charcot-Leyden crystals, and eosinophilia disappeared from the sputum, the blood eosinophils dropped to normal, but the skin tests remained positive. The patients could now, however, be exposed to these substances with impunity. Wittkower and Petow claim that asthma always has a psychic basis. This is often found only in the first attack, or it may be most evident at that time. The psychic factors m a y manifest themselves at first only in dyspnea. They state, in addition, that psychic factors cause supersensitivity, or raised excitability, to all stimuli. They state also that bronchial asthma is never caused by bodily overexertion per se but that, in addition, psychic factors are always present. These concepts are of g r e a t value in the u n d e r s t a n d i n g of the role of the psychic factors in bronchial asthma. The psychic factors behind bronchial asthma m a y be of various sorts and may be expressed in m a n y fashions. These factors may be : (1) A conditioned reflex which causes the reproduction of an

ROBERT B. SAM,PLINER~ M. D.

525

asthmatic attack whenever the circumstances accompanying a previous attack are repr(~duced. The attacks which are brought on by the smelling of an artificial flower which the patient believes is real is a classical example of this type. (2) The expression of a mental con[lict with the organ in which the con/lict is expressed [ortuitously or purpose/ully selected. This selection often is found to be the lungs in a patient with a phthisiophobia, or it may be an organ which is " i n f e r i o r , " for example, weakened by a previous bronchitis. According to Sadger, s8 organic predisposition denotes a failure to have repressed or withdrawn the erogeneity which is possessed by all parts of the body primitively and which is normally finally concentrated only in special zones, or it may be due to a reacquirement of erogeneity by some special organ system. In bronchial asthma there is a special erogeneity of the respiratory tract from the nose to the bronchioles. The organ may, on the other hand, have acquired a significance in the psychoanalytical sense and be selected for its significance. There are cases on record in which the turgescence of the nose in asthma is identified by the patient with turgescence of the penis, hence an erection. (Such cases are reported by OberndorP ~ and by Dunbar.'-") A single female patient of 62 years recently seen by me who is now suffering from manic-depressive psychosis (a large incidence of asthma in patients with manic-depressive psychosis is stressed by many authors) states that her asthma started following the death of her mother, to whom she was very much attached. This death left her with the care of an aged father and a blind brother. She said that she had so much to do that she was always breathless and that this brought about her asthma. Although her physician at that time mentioned other causes she refuses to believe otherwise. Her own opinion of the cause of her disease shows how little below the surface the real factors must lie. She further stated that she first came to the hospital to escape these cares. It does not seem illogical to see superficial common factors in the etiology of her asthma and her depression--deeper in her personality the unresolved Oedipus situation plays its role. (3) The ~.se of the disease by the asthmatic for the purpose of gaining his own conscious ends. This teleological type of case oc-

526

T H E PSYCHIC ASPECTS OF BROI~-CHIAL A S T H M A

curs v e r y often in the literature, a l t h o u g h R o g e r s o n ~ r e g a r d e d this type as v e r y r a r e in his series of children. I n a case which I have p e r s o n a l l y observed for a p e r i o d of about twelve years, the patient, who is the y o u n g e r of two sons, has invariably used his a s t h m a as a m e a n s of obtaining his goal. He was always a sickly child, a n d finally, after an attack of bronchitis at the age of seven, a diagnosis of bronchial a s t h m a was made. F r o m the time when the initial diagnosis of a s t h m a was made, the boy's every wish was indulged by his oversolicitous parents. I early observed t h a t whenever the p a t i e n t was t h w a r t e d , his reaction would be " L e t me do this, or I'll get a s t h m a , " or " D o n ' t touch me, or I ' l l have a s t h m a , " a n d to be sure he " g o t a s t h m a . " Some of the attacks were exceedingly severe, some v e r y light. Change to a m o r e equitable climate was w i t h o u t benefit as were r e p e a t e d a t t e m p t s to control the disease by elimination diets or by desensitization. The only time that he was ever free f r o m a s t h m a t i c attacks over a p r o l o n g e d period was when, at the age of nine years, he was sent to a b o y s ' school. There he ate all kinds of food, came in contact with animals to which he was sensitive, but never h a d an attack d u r i n g the two years t h a t he spent at the school. R e m o v a l f r o m the school was followed by a r a p i d r e s u m p t i o n of the a s t h m a t i c attacks. W h e n his p a r e n t s finally came to the conclusion t h a t he was an extremely spoiled a n d selfish child, and m u s t be t r a i n e d at all costs, his a s t h m a became v e r y m u c h worse. B u t when he f o u n d t h a t an asthmatic attack would no longer p r o c u r e him i m m u n i t y f r o m p u n i s h m e n t , or the things t h a t he desired, his attacks began to occur much less frequently antl were nlilder. The self-predictability of his attacks was the most striking f e a t u r e of his disease. His attacks were always preceded by difficulty in b r e a t h i n g which seemed to be a matter of his will, although when an attack was well developed it was obvious t h a t he couht do n o t h i n g about it. U n f o r t u n a t e l y for this patient, his attacks h a d p e r s i s t e d for so long before any enlightened a p p r o a c h to the p r o b l e m was made, t h a t he was left with a far advanced e m p h y s e m a . (4) The result of suggestion or imitation. Schultz ~'~ discusses the case of a suggestible boy who slept in the same room with his m o t h e r for a p e r i o d of nine years, and witnessed h e r attacks. During the last eight of those years, he also h a d asthma. W h e n the

ROBERT B. S A M P L I ~ E R , IV[. D.

527

boy was removed from his home, the asthma stopped, and has never recurred over a period of several years. (5) The result of psychic trauma. This is quite understandable if it is considered how often our emotions are reflected in respiration. We " h o l d our breath from t e r r o r , " and breathe rapidly from excitement. In a great m a n y patients it has been found that the p r i m a r y attack occurred in some especially significant emotional situation. Subsequent attacks recur when a similar emotion is experienced, either in actuality or in t h o u g h t - - h e n c e the great number of attacks which develop during the night while the patient is dreaming. Dunbar quotes Fenichel, ~4 who writes that sometimes the "conflicts which were once waged between the individual and reality are now carried on between the patient and his respiratory a p p a r a t u s . " This type of case is v e r y closely allied to the anxiety state with hyperventilation syndrome; m a n y of these patients hyperventilate just before the attack is precipitated. Gliebe ~ recently saw a patient in the University of California Clinic whose attacks started with cough and hyperpnea. Wheezing followed and then a true hyperventilation syndrome. The patient stated that she obtained relief by the use of her own will power. The attacks which lasted an average of 45 minutes came on with the excitelnent of getting her husband to work and her children to school in the morning. She was very greatly benefited by the use of ammonium chloride and breathing exercises. Treatment of the psychically determined cases of bronchial asthma m a y be of m a n y kinds. It m a y be directed either at the symptoms or at the individual himself. Symptomatic t r e a t m e n t consists in breathing exercises, but this is also a mode of suggesttion since the patient believes that he will have no more asthma. Persuasion and waking suggestion Have often been used with great success. The objection to these forms of t r e a t m e n t is that they leave the cause undetermined and, although they m a y relieve the asthma, the patient still has difficulties which must be expressed in some other fashion. Cases are reported in which the cure of the asthma was followed by new symptoms in other systems, or even flight into a psychosis. Still another method of t r e a t m e n t is posthypnotic suggestion. The mode of action m a y be either the suggestion per se, or an alteration, which m a y be permanent, of the *Gliebe, P. A.--Personal Communication.

528

THE PSYCHIC ASPECTS OF BRONCHIAL ASTHMA

sensitivity of the autonomic nervous system by the hypnosis. The objection to its use is that the patient may relinquish his symptoms but finds that he Still needs some means of expression of his conflict and may either seek new symptoms or regress. A far better method is the use of hypnosis for ihvestigation of the conflict--the so-called psychocatharsis. No objections can be raised against a well conducted investigation of this sort, the type of psychotherapy preferred being an individual question. Finally, the method of psychoanalysis can be used. This seems to be the most rational of all the methods: the patient is investigated, his conflict is brought into consciousness (or his difficulties are resolved if they do not amount to an actual psychic conflict) and he is advised to solve his conflict objectively. The admission of the presence of the conflict and its rationalization resolves the conflict. He then has no need for his symptoms and, therefore, relinquishes them. The methods of psychotherapy in bronchial asthma are of no use to us, if they accomplish nothing. That, however, is not the case. The literature abounds with improvements and with actual cures which have been effected by psychotherapy alone, or by psychotherapy ir~ connection with drug therapy. Pollnow, Petow and Wittkower ~4 survey 45 published cases in which psychotherapy has been used: (The following table and its quoted analysis has not, to the author's knowledge, been available previously in English.) TABLE 1. From H. Pollnow, H. Petow and E. Wittkower* Number Author

Title Zur Lehre vom Asthma bronchiale. Dtsch. reed. Wschr. 1922, 1347

Case

of cases number 1 1

I.

Costa

II.

Forel

Der tIypnotismus. 7. Stuttgart, 1918, S. 274

Aufl.

]

2

IIL

Hahn

Psychische Infektion als Ursache nerv(iser s~heinbar hereditSrer Erscheinungen. Dtsch. reed. Wschr. 1925, 949

l

3

IV.

Heyer (u. Bulger)

MSglichkeiten und Grenzen der Psychotherapie bei Organneurosen. Dtsch. Z. Nervenheilk. 98, 125 (1927)

4

4 5 6 7

*Author's translation.

529

ROBERT B. SAMPLINER~ M. D. V.

Hilger

VI.

Jacobi

VII.

Kronfeld

VIII.

Liepmann

IX.

X.

LSwenstein

Marcinowski

XI.

Ma~

XII.

Mohr

XIII.

Moos

XIV.

Reichmann

XV.

XVI.

R~Jmer (u. Kleemann)

Sehultz Schultz

Die Hypnose und die Suggestion. S. 164. J e n a : 1909 Asthmabehandlung mit I-Iypnose. Dtsch. med. Wschr. 1926, 452 Psychotherapie S. 218, Berlin: 1924 Dcutung und Heilung einer Zwangsneurose und einer hysterisehen Neurose. Intel~at. Z. Psychoana]. 1927, 64 Asthma und Psychotherapie. Med. Klin. 1926~ 995

8 9 10

11 12

13 14 15 16 17

Die Heilung eines schweren Falles yon asthma dutch Psychoanalyse. J. f. psychoanalyt. u. psychopathol. Forschg. 5, 2, 529, (1913) Psychogenit~t u. Psychotherapie d. Asthma bronchiale. Dtsch. med. Wschr. 1923, 477 Psychophysische Behandlungsmethoden. S. 104. Leipsig: 1925 Ober den Weft der Behandlung der Psyche bei inncren Erkrankungen, ihre Methoden u. ihre Erfolge. Ther. Gegenw. 1921, 213 Zur Psychopathologie des Asthma bronchiale. Med. Klin. 1922~ 1091 Das Asthma und seine Bchandlung. Dtsch. Arch. klin. Med. 155, 307 (1927)

Die seelisehe Krankenbehandlung. S. 232, 288. J e n a : 1922 Praktischer Arzt und Psyclmtherapie

18 19 20 21 22 23 24

25

2 4

26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

530 XVII. XVIII.

T H E PSYCHIC ASPECTS OF BRONCHIAL ASTtIM:& Stegmann Stekel

gur Aetiologie des Asthmas bei Kindern. Med. Klin. 1908, 1113 NervSse Angstzustiinde und ihre Ilehandlung. 3. Aufl. S. 94, 101, 102. 1921

2 3

41 42 43 44 45

They analyze the data in the following fashion (numbers in parentheses refer to case numbers in table) : The material consists of 45 cases, which are published by 18 authors. Thirty-seven cases have data about the length of the sickness before the beginning of the psychotherapy. One case came for treatment in the first attack (10). Two eases were ill for several months (9, 30). In 5 cases the asthma had lasted ] to 2 years (7, 26, 29, 42, 45), in :17 cases had lasted 3 to 10 years (1, 3, 5, 8, 12, 13, 17, 18, 19, 20, 21, 25, 27, 33, 35~ 41, 43), in 8 cases 10 to 20 years (2, 15, 22, 23, 28, 31, 32) 40), and in 4 cases 30 to 35 years (4, 16, 34, 36). In the history of 15 cases, bron ~cahitis is expressly mentioned (4, 5, :11, 15, 17, 18, 19, 20, 22, 28, 30, 35, 36, 41, 42), in 8 cases of these it is an original bronchitis with the (subsequent) 4evelopment of the astlLma (4, 5, 17, 20, 22, 28, 30, 41). Objective asthma findings are mentioned in 23 cases (1, 2, 4, 5, 10, 12, 15, 17, 20, 21, 22, 23, 24, 27, 28, 29, 3:1, 32, 33, 35, 36, 41, 42, 45). In 9 eases asthma is found in the ascendency (3, 4, 13, 14, 22, 23, 25, 29, 31). A constitutional psychopathy, or at least psychopathic features are mentioned in 23 cases (1, 3, 4, 6, 7, 10, 11, 15, ]6, 20, 22, 23, 24, 26, 2~, 30, 31, 33, 34, 35, 36, 39, 40). An initial psychic conflict or an initial psychic trauma was found 12 times (4, 5, 10, 18, 24, 29, 30, 31~ 32, 37, 38, 41). The classification according to therapeutic procedure gives the following results: Medical procedures are expressly mentioned in 22 cases (1, 4, 5, 7, 10, 13, 14, 17, 18, 21, 22, 23, 26, 28, 29, 31, 32, 33, 34, 36, 41, 45). It is expressly mentioned that they were discontinued during psychotherapy in ]0 c~scs (1, 4, 5, 7, 17, 18, 26, 28, 29, 45). Nerve-point massage was used in 3 cases (4, 5, 7). Breathing exercises (were employed) in 8 cases (:1, 4, 5, 7, :10, 21, 22, 31). Hypnosis was used in 20 cases (1, 2, 3, 8, 9, 10, 11, 14, 15, 16, 17, 18, 19, 27, 29, 3:1, 41, 42, 44, 45). Among them 4 cases were found whicll were handled by psychoc~'ttharsis, and 5 cases in which single attacks were stopped hypnotically (1, 3, 27, 29), and (8, 17, 18, 27, 45). Waking suggestion was used in 1 case (43). Persuasion (was employed) 8 times (1, 7, 14, 16, 17, :18, 19, 39, 40). Conflict analysis* was undertaken 18 times (1, 5, 11, 12, 13, 16, 21, 22, 24, 26, 27, 28, 30, 31, 32, 33, 34, 38). Six times psychoanalysis was used (4, 6, 15, 17, 23, 30). In 12 cases psychologic methods were employed (11, 16, 18, 25, 29, 35, 36, 37, 39, 4:1, 42, 43). *Confllet analysis means psychoanalysis for only a few sessions without attemp|ing to reach the basic factors, or which is aimed only at putting the conflict aside.

ROBERT B. SAMPLINER, M . D .

531

The psychotherapeutic results are presented in the following fashion : I.

From the viewpoint of healing: The treatment was without result in 2 cases (15, 16). Three cases wore designated by the authors as improved (11, 23, 45). Relapses after the "healing" were found in 15 cases (1, 3, 7, 12, 16, 19, 20, 26, 27, 28, 29, 30, 33, 36, 41). " H e a l e d " without relapse were 23 cases (2, 4, 5, 6, 9, 10, 13, 18, 21, 22, 24, 25, 31, 32, 34, 35, 37, 38, 39, 40, 42, 43, 44). II. From the viewpoint of followup: Twenty-seven cases contain special data about the followu I) (1 2, 3, 4, 5, 6, 9, 10, 12, 13, 18, 20, 21, 22, 24, 26, 27, 28, 29, 30, 31, 33, 34, 40, 41, 42, 44). Seven cases were observed at least one year (1, 2, 3, 10, 24, 28, 42). Fifteen cases were observed one year and longer (4, 5, 7, 9, 12, 13, 20, 21, 22, 26, 31, 33, 40, 41, 44). Of these 5 cases were observed 3 years and longer (20, 21, 22, 33, 41). And, again, of these, 2 cases 5 years and longer (22, 41). Observed, without definite time data, but over a long time, were 5 eascs (18, 27, 29, 30, 34).

F r o m a perusal of this record, little doubt can be left of the effectiveness of psychotherapy in bronchial asthma (and in any of the states which are controlled by the autonomic nervous system). Because asthma is a disease which leads, when allowed to run an unchecked course, to definite physical changes, it is important that it be successfully treated from its earliest stages. If allowed to continue under symptomatic treatment the patient will progress to outspoken emphysema, chronic bronchitis, or even status asthmaticus (which is apt to be fatal at any time), and then very little can be done for him. Because asthmatics usually receive the benefits of psychotherapy only after other means of t r e a t m e n t has failed, Gillespie ~ pleads that every asthmatic be given a psychic workup by a competent psychiatrist, in addition to his medical examination. It is only in this fashion that we can decide early enough to prevent organic complications which patients come u n d e r the classification of psychogenic asthma. As to methods of therapy I have little to say. The wisest and most logical therapeutic method would seem to be a comprehensive one, aimed at both allergic and psychic factors. Actual desensitization m a y be of value. The one p a r a m o u n t consideration is that the patient is a personal-

532

THE

PSYCHIC

ASPECTS

OF BRONCHIAL

ASTHI~A

ity and personalized treatment will be best for him. If this concept be embraced, the actual mode of treatment can be left to the clinical acumen of the physician. Utica State Hospital Utica, N. Y. REFERENCES

Historival 1. 2. 3. 4. 5. 6.

7. 8.

9.

10. 11. 12. 13.

14.

B e r k a r t , J. B.: On A s t h m a - - I t s Pathology a n d Treatment. Churchill, London, 1878. Bree, R. : Practical I n q u i r y Into Disordered Respiration, Distinguishing Convulsive Asthma. Humphrles, Philadelphia, 1811. Coke, F . : Asthma. Wood, New York, 1923. Dobeli, I t . : Winter C~ugh, C a t a r r h , Bronchitis, E m p h y s e m a a n d Asthma. Lindsay, Philadelphia, 1872. : Asthma, Its N a t u r e a n d Treatment. Smith, London, 1886. Floyer: Quoted in Wittkower, E., a n d Petow, H . : Beitr~ge zur Klinik des Asthma bronchiale u n d v e r w a n d t e r Zust~nde I V Z u r Psychotherapie des Asthma bronchiale. Zeitschr. f. Kiln. Med., 110:701, 1929. Hayes, T. : Observations on H o o p i n g Cough a n d Asthma. M u r r a y , London, 1786. K a h n , ~M. H . : Historical survey of o u r knuwledge of bronchial asthma. Medical Life, 35:109, March, 1928. L a e n n e c : Quoted in Wlttkower, E., a n d Petow, H . : Beitr~ige zur K]inik des Asthma bronchiale u u d v e r w a n d t e r Zust~nde I V Z u r Psychotherapie des Asthma bronchiale. Zeitsehr. f. Kiln. Med., 110:701, 1929. Osler, William: Modern Medicine. Lea and Febiger, Philadelphia a n d New York, 1925-1927, t h i r d edition. Salter, H. H . : On A s t h m a - - I t s Pathology a n d Treatment. Blenchard, Philadelphia, 1864. Stolkind: H i s t o r y of bronchial asthma a n d allergy. Proc. Roy. Soc. Med., 2 6 : 1 1 2 0 , 1933. V a n HeImont: Quoted in Wittkower, E., a n d Petow, H . : Beitrllge z u r Klinik des Asthma bronchiale a n d v e r w a n d t e r Zust~inde IV Z u r Psychotherapie des Asthma bronchiale. Zeitschr. f. Klin. Med., 110:701, 1929. Willis: Quoted i n Wittk~wer, E., a n d Petow, H . : Beitriige zur Klinik des Asthma bronchials u n d v e r w a n d t e r Zust~nde I V Z u r Psychotherapie des Asthma bronchiale. Zeitschr. f. Klin. Med., 110:701, 1929.

General 15. 18. 17. 18. 19. 20. 21. 22. 23.

B r a u n s , W . : Z u r B e h a n d l u n g der allergischon E r k r a n k u n g e n , insbesondere des H e u f i e b e r s . ~Med. Welt, 7:559, April 22, 1933. Brown, W. L a n g d o n : Proc. Roy. Soc. Med., Pt. 1 6 : 3 , p. 1, 1923. : Physiological Principles in Treatment. William Wood a n d Co., New York, 1980. Costa, N.: Z u r Lehre yon A s t h m a bronchiale. Deutsche Med. W c h n s c h r . , 4 8 : 1 3 7 4 , 1922. Duke, W . W . : J . Lab. a n d Clin. Med., 1 3 : 2 0 , 1927. D u n b a r , H . F. : Emotions a n d Bodily Changes. Columbia University Press, New York, 1938, seoond edition. , : Psychoanalytic notes relating to syndromes of a s t h m a a n d h a y fever. Psychoan. Quart., 7:25, J a n u a r y , 1938. Engelen, P . : Psychosomatische Asthmabehandlnng. Deutsche Med. Wchnsehr., 58:1508, September 29, 1935. Feinberg, S. M. : Asthma, H a y Fever a n d Related Disorders. Lea a n d Febiger, Philadelphia, 1933.

R O B E R T B. S A ] V [ P L I N E R 3 1VL D.

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24.

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