Psychotherapy

Supposed After-effects .—At times a patient suffering from some exhausting or serious disease, consumption, heart disease or the various forms of Bright's disease, will be discouraged by remembrance of the fact that in earlier years he allowed himself for some time to fall into the habit of self-abuse. If he has read, and very few men have not, some of the literature issued by the advertising "specialists" and has heard the unfortunately exaggerated ideas commonly entertained with regard to the influence on health of this habit, he will become more or less disheartened by the idea that he thus undermined his constitution and that one reason why he is not able to react better against his affection is that he seriously diminished his resistive vitality. This idea must, of course, be overcome or it will act as a constant source of unfavorable suggestion, lessening appetite, tending to disturb sleep, banishing peace of mind to some extent and thus inhibiting the patient from releasing such stores of vital energy for his recovery as would surely be in his power under favorable conditions.

Female Habits.—The habit is more rare in women than in men, but when it occurs is a little harder to break. In men it usually develops in youth, but oftenest in women who are past thirty-five and unmarried. In these cases it is much harder for the patient to regain self-control, because the class of women patients who acquire such a habit have less character, as a rule, than the men who fall into the same condition. In all sex matters, once passion is aroused or habit formed, the woman is likely to lose control of herself more than is the man. Even in women, however, it is not only possible, but under favorable circumstances, quite easy to secure a break in the habit, though relapses are more frequent than in men. Certain occupations seem particularly to favor the development of the habit. These are mainly sedentary occupations that can be followed without the necessity for such attention as to prevent the mind from wandering off into thoughts that may prove provocative of sexual sensation. Dressmakers seem particularly likely to suffer from the affection, and those who run sewing-machines are predisposed by the movements involved in their occupation to the development or, at least, to the persistence of the habit.

For women even more than men religion and the motives it supplies are the most efficient factors for the ultimate cure of the habit. In general, the greater difficulty of overcoming it in them is due in no small degree to the fact that they live indoors much more than men, often have sedentary occupations, and are more frequently alone. These afford opportunities for introspection and for the harboring of thoughts that lead to relapses into the habit. Besides, women are more prone to read novels and stories relating to sex problems and the details of sex murder trials and the like which constitute ever-recurring sources of mental erethism. If their habits can be modified, especially if they can be made to realize the necessity for being out in the air as much as possible, and for keeping their windows open at night, as well as for thorough cleanliness—for every gynecologist notes the necessity for this and how frequently it happens that neglect of it leads to irritability of the external organs that is of itself a serious factor—then it would be no more difficult for women to overcome the habit and get beyond the relapses than it is for men. Sometimes we have to overcome a morbid dread of touching themselves even for cleansing purposes which allows the accumulation of irritant material and predisposes to relapse.

Sexual Perversion.—Sexual perversions are sometimes considered as different from sexual neuroses, but such they really are. They are oftener due to habit than to anything deeper. Much has been said about the unfortunate natural inclination of some people to indulge in sexual perversion, but such talk partakes of the nature of similar remarks with regard to habits of other kinds. The alcohol habit, for instance, is formed by many men as the result of their environment and a weakness of character, with lack of resolution to support themselves in self-denial when they are tempted to drink. In recent years it has been only too often the custom to excuse or to justify many of these cases. There are a few persons in whom, owing to weakness of character, alcoholism is more or less inevitable if occasions for indulgence occur. And in the same way there has been much maudlin sentimentality wasted on sexual perverts, as if most of these men could not avoid the actions that the rest of humanity abominates. There are, perhaps, a few individuals who because of a failure on the part of nature to define sex in them properly—as if she had not quite made up her mind which sex they should belong to—are more to be pitied than held to account for their delinquencies in this matter. Compared to the whole number of sexual perverts, however, these are very few. Under the protection of the pity awakened for these, a large number of others find quasi-justification for their acts.

Anyone who knows much about these patients realizes that their story is, as a rule, very different from what it would be if they were inevitably impelled to the commission of the acts in question. Many of them had the greatest abhorrence for it at the beginning, were attracted to it out of curiosity and morbid sexualism, because they had allowed themselves to think and read and dream about sex matters overmuch. They are usually idle people who do not take life seriously and who have an inordinate curiosity about sex subjects. At the beginning the commission of the perverted sexual act was associated with an intensely deterrent rather than an attractive feeling, but gradually this was overcome and a contrary habit has been formed. It is difficult to break this habit and to get away from the morbid sexual ideas that have been allowed to develop and grow strong in connection with it.

This opinion is somewhat different from that held by many men who are recognized as authorities on this subject and who find many excuses in the nature of their patients for these perversions. If it is recalled, however, that whenever wealth has brought luxury to a people and luxury has brought over-refinement, such sex perversions have been particularly noted, it will be realized that not nature, but the ways of men are responsible for their development. Whenever men pay much attention to their bodies, exercise for the sake of their muscles, bathe not for cleanliness but for luxury, sex perversions become common in history. The story of Greek love is well known. Corresponding conditions developed at Rome under similar circumstances. According to good authorities, the English universities became tainted with it a generation ago. Our athletic clubs in this country have rightly or wrongly fallen under suspicion in this matter, though the tendency to exaggeration with regard to such things, and popular credulity in such matters must be recalled. Some confirmatory evidence undoubtedly there was. Sexual perversions then would seem to be due in most cases to definite conditions and our knowledge suggests readily what should be the prophylaxis.

In the course of some studies with Professor Magnan at L'Asile Ste Anne in Paris I saw a number of these curious cases of sexual divagations, exhibitionism, sex perversions and similar conditions. Some of his cases were clearly curious examples of natural tendency, at least, to mental hermaphroditism. Occasionally men of normal development otherwise have a woman's waist and woman's torso above the waist, and many womanly coquettish ways that point to this curious mixture of sexes. Occasionally women are lacking in all the sex characteristics of the upper portion of the body, have no breasts and have the hirsute characteristics of men on the face and even on the chest. In such cases one may be tempted to let one's pity override one's better judgment and feel that resistance to the temptations to indulge in perverted sexual feelings may be so difficult for these people as to be almost impossible. Even in such cases, however, under Magnan's gentle tutelage, under his faithful care and sympathy, men and women lost most of the tendency to commit unnatural acts and certainly found it easier to live normal lives than before.

For the majority of these sexual perverts, however, it is as with regard to drug addictions, alcoholism, and obesity, just a question of willing not to indulge in certain appetites that serves to help them. There is no doubt that it is a difficult matter to break a habit that has become a second nature, and it is almost impossible that it should be accomplished without a number of relapses. If the patient really wishes to correct the evil habit, however, this is perfectly possible.

The talk of a third sex with homo-sexual inclinations is quite beside the mark. Certain of this class have a weakness of intellect and of will that is at the root of their trouble, but not a few of them pride themselves on their intellect and will power in most other things and must not be permitted to deceive themselves as to their weakness and its significance. It is not nature but self that is at fault and the disease can be completely eradicated.

SECTION XIII

SKIN DISEASES

CHAPTER I

PSYCHOTHERAPY IN SKIN DISEASES

The place of mental influence in the treatment of skin diseases will be best realized from the role that we know the mind plays in the production of various skin manifestations. There is a whole series of skin affections which depend to a considerable extent on mental conditions, worries, anxieties, shocks, frights and the like, and a number of skin affections that have been labeled hysterical which occur in nervous persons, due to over-attention to self and their conditions. It has been well said that it is possible to make the feet warm by thinking about them. Certainly attention to any part of the skin surface causes a tingling and hyperemia may follow. Blushing is an illustration of mental influence on the skin, and anything that would tend to make this endure for some time would give rise to erythematous conditions. We know the creepy, uncomfortable, hot feelings that come over us in times of suppressed excitement when we are waiting for something to happen; and, on the other hand, there is a pallor and tremor that accompanies fright or fear, which points to mental influences over the vasomotor system in the skin.

Urticarias.—Certain skin diseases, especially those allied to the urticaria group, are prone to occur in connection with excitement and worry. In the chapter on Neurotic Intestinal Affections attention is called to the fact that many patients who suffer from intestinal idiosyncrasies and have excessive reactions to special kinds of food, as cheese, strawberries, or the like, sometimes also suffer from skin lesions and intestinal disturbance through worry or excitement. While preparing for examinations or undergoing some physical trial or suffering from worry or anxiety such persons may have urticaria or even wheals on the skin. There may be some dietary disturbance to account for them, but they would not occur, or at least would not be so serious and annoying, but for the disturbed mental condition. Under these circumstances dermatographia is a common manifestation. It used to be considered a symptom of many physical conditions, but will occur in almost any nervous person during the course of an examination by a strange physician or when some important medical decision is pending.

Eczema.—Not only these passing conditions of the skin, however, but more lasting affections have been connected with mental disturbance. Probably every skin specialist has noted in a number of his cases that a first attack of eczema came after a period of worry or excitement, or sometimes followed directly on a fright. When relief from the condition has been brought about by treatment, relapses occur during periods of business worry or family anxiety or mental stresses of one kind or another. Cabinet crises in England are found to be likely to be followed by the recurrence of eczematous conditions in older members of the Cabinet or by first attacks in some of those whose skin has been irritated by some internal condition. Unless business worries can be removed or family anxieties allayed the cure of eczema becomes a difficult matter. Men or women who worry about their eczematous condition apparently prolong it. This is particularly true if they have little to do and are likely to be much occupied with themselves and their condition.

Herpes.—Herpetic conditions resemble urticaria in their response to mental conditions. Herpes preputialis and herpes progenitalis occur particularly in people who worry over the possibility of some infection of the genitals. The lesions are likely to be indolent until the state of mind with regard to them is relieved by reassurance as to their comparatively innocuous character. Even herpes zoster is prone to come on after a period of worry and anxiety. It is due to infection, but the infection becomes more possible after a lowering of resistive vitality in the nervous system. This is particularly true as regards herpes facialis. It has been noted again and again that facial neuralgia is most likely to occur after fright, deep emotion, or prolonged anxiety. Treatment of these cases will only be successful if the mental state is set right. This is particularly true with regard to Bell's palsy. Patients who worry much about it and who fear that it may have lasting results are likely to prolong its course and to put off complete cure for a good while.

Vasomotor Disturbance.—There is a series of skin affections connected directly with the vasomotor system of the skin which are largely under the influence of emotional or mental factors. These represent particularly the milder forms of Raynaud's disease and the parallel forms of Weir Mitchell's disease. In the one case there is a spasm of the arterioles causing what the French call "dead fingers," and in the other paralysis of the vasomotor system with venous congestion in the parts. They are seen particularly in persons of highly nervous organization and especially after periods of emotional strain or stress. There is a series of affections related to these, characterized by numbness, paresthesiae, going to sleep of the fingers or members, tingling, and even milder forms of itchiness—sometimes dignified as pruritus—which are largely due to mental factors. Some physical condition will need to be corrected, but they will only disappear if the mind is set at rest and if the patient is kept from occupying his attention much with them. Concentration of attention will make them chronic.

Scurvy.—Scurvy is not usually thought of as a skin disease, though it has many local manifestations on the skin and mucous membrane. It is a deep nutritional disturbance of such nature that it would seem the mind could have but little influence over it. When scurvy was common, however, it was often noticed that any change of attitude of mind in affected persons brought amelioration or deterioration of condition. Scurvy develops with special virulence during discouragement; it gets better with the dawn of hope. It has been known to be much improved by the prospect of a naval engagement when all the sick men wanted to get into the fighting. The famous case of the Siege of Breda in 1625 is often quoted. The city was about to capitulate because so many of the soldiers were suffering from the disease. The Prince of Orange, however, sent word that a new and powerful remedy had been discovered that was sure to cure the affection, and that he had secured some of it and it would not be long before they would all be well. What he sent was a remedy that had been used with indifferent success for scurvy when taken in large doses. He could send only enough to give a few drops to each patient. This small dose was wonder-working in its effect and proved to have the healing virtue of a gallon of the liquor. Most of the patients got better and surrender was put off.

Warts.—A striking evidence of the influence of the mind upon the skin is given by what we know of warts. All sorts of charms have been not alone suggested for them but found to work in certain cases. Lord Bacon in his "Natural History" tells the story of the charming away of warts and exemplifies it by his own experience. When he was about sixteen a number of warts—at least 100—came out upon his hands. One of these had been there from childhood. The manner of their cure he details as follows:

The English Ambassador's lady, who was a woman far from superstition, told me one day she would help me away with my warts; whereupon she got a piece of lard with the skin on, and rubbed the warts all over with the fat side; and amongst the rest that wart which I had from my childhood. Then she nailed the piece of lard, with the fat towards the sun, upon a post of her chamber window, which was to the south. The success was that within five weeks' space all the warts went away, and that wart which I had so long endured for company. But at the rest I did not marvel, because they came in a short time, and might go away in a short time again; but the going away of that which had stayed so long doth yet stick with me.

Lucian, the Greek satirist, tells that warts were cured by magic in his time. Carpenter in his "Human Physiology," page 984, says: "The charming away of warts by spells of the most vulgar kind belonged to those cases which are real facts, however they may be explained." Dr. Hack Tuke in his "Influence of the Mind Upon the Body" says: "In visiting a county asylum some years ago my attention was directed to several of the patients who were pestered with warts and I solemnly charmed them away within a specified period. I had quite forgotten the circumstance until on revisiting the institution a few months afterwards I found that my practice had been followed by the desired effect and that I was regarded as a real benefactor." This feature of the method of removing warts, setting a date before which they shall disappear, is noted in most of the successful charms. Dr. Tuke tells of a case in which a gentleman on shaking hands with a young lady noticed that she had many warts. He asked her how many she had; she replied about a dozen, she thought. "Count them, will you," said the caller; and taking out a piece of paper he solemnly took down her counting, remarking: "You will not be troubled with your warts after next Sunday." Now it is fact that by the day named the warts had disappeared and did not return.

Neurotic Pigmentation.—Pigmentation occurs very commonly as the result of neurotic conditions. Dr. Champneys, in his article on "Pigmentation of the Face and Other Parts, Especially in Women," in St. Bartholomew's Hospital Reports, Volume XV, has illustrated this very thoroughly. The pigmentations of women during the phases of genital life, menstruation, pregnancy, the menopause and the fact that eunuchs are usually fair and fat, while deep pigmentation in the white race is usually associated with sexual irritability, all make interesting studies in this subject. From comparative anatomy and physiology the influence of the nervous system over pigmentation has been very well illustrated. Brücke in 1851 established the influence of the nerves on the color of the chameleon and of the frog, and there have been many confirmations of his work. Pouchet, in 1876, in the Journal de l'Anatomie et de Physiologie proved that fish gained the power of changing color by practice and lost it by disuse. The influence in most cases, animal and human, which produces pigmentation is exerted by the nervous system through the vascular supply. The duskiness that sometimes comes with emotion, the pallor that accompanies strong mental disturbance, as well as the blushing states, show that the vasomotor system can be influenced in every part. Pigmentation often seems only a consequence of local continuance of such disturbance. Many of the feminine patients in whom even deep discolorations around the eyes occur in connection with menstruation are typical neurotic individuals. It is worry in combination with the physical disturbance that produces the pigmentation. There are some cases on record where emotional states have caused loss of pigment in the negro or other colored races, or in the hair, as when, in well-substantiated cases, people's hair has become white in a single night. In every case of pigmentary disturbance, then, the individual must be carefully studied and as far as possible all emotional disturbance must be eliminated. Without this other treatment usually fails.

Pruritus.—Pruritus in the old is often a bothersome symptom. All sorts of remedies, internal and external, are recommended for it and successes are reported with them. Whenever there are many remedies for a symptom complex, it usually means that the suggestive element in all of them is large. For pruritus the influence of the patient's mind is extremely important. Often it will be found that these old patients are getting out scarcely at all, but are living in close confinement in their rooms, the air of which is scarcely ever changed. I have known even the keyholes to be stuffed and arrangements made by which the cracks between the door and the frame were rendered impervious to air. In these cases the most important feature of any treatment is to secure a proper amount of air. Sir Henry Thompson, the great English surgeon, in his advice how to grow old successfully, written when he himself was over 80, suggested that the cells of the skin needed an air bath every day. He advised that men should make all their toilet arrangements for the day without any garments on. Washing, the preparation of clothing, shaving, and whatever else was done in the early morning was to be accomplished after the night clothes were taken off and before other clothes were put on. He lived to be well above eighty and was sure that this practice had been of help to him. Stimulating rubbings, if done gently and without the production of too much reaction, will always benefit these people.

If old people have no interest, nothing that attracts their attention, and if they once develop pruritus their mind gets concentrated on their cutaneous sensations and it will be impossible to relieve them by any treatment until their minds get occupied with something else. Anyone who wants to sit in a chair for a few minutes and think about his cutaneous sensations will soon realize how vividly these can be brought to mind and how annoying they can become. To sit and think of a portion of the body is to want to scratch it before long. Scratching produces a flow of blood to the surface that adds to the itchy feeling. The only way to get away from it is to get the mind occupied with something else. Of course, where circulation is weak because of failing heart or disturbed because of arteriosclerosis, treatment directed to these conditions should be employed, but the influence of the mind on blushing and skin feeling must not be forgotten.

When pruritus develops in the old in connection with phases of arterial degeneration—its most intractable form—it is important to remember that diversion of mind is the most important therapeutic agent that we have. The old have few diversions. They have given up their ordinary occupations, they are often no longer interested in reading, friends whom they used to know have died, and they are left a great deal to themselves. Under these circumstances anything the matter with them brings about a concentration of attention. This is even more true if they have been very well in earlier life and have had practically no experience with sickness.

Hysterical Cutaneous Conditions.—There are certain cracks of the skin with ulcerative lesions which occur in hysterical patients in the neighborhood of the knuckles that represent a phase of unfavorable influence of the mind. When these patients begin to worry or be anxious they know that these skin lesions will follow. Expectancy seems to make it certain that the lesions will come and attention adds to their chronicity. It has been noted that "chapped hands," especially when accompanied by deep cracks in cold weather, are made worse by anxiety or worry. In many neurotic patients it is impossible to treat such conditions satisfactorily unless the patient's mind can be put at ease. It is surprising how intractable these conditions can be, but that is usually because all the physician's attention is devoted to the skin instead of a considerable portion of it being given also to the patient's mental and nervous condition.