It is important, therefore, to consider these cases as really needing medical care. For their treatment the most important consideration is prophylaxis, not alone of the habit itself, but of each of the acts.

Prophylaxis of the habit is an ethical question that we can scarcely do justice to here. Prophylaxis of the acts requires consideration of the physical and moral factors that predispose to their commission.

While the habit may have secured such deep control that the patient almost despairs of relief from it, when care is taken to remove physical and moral predispositions the conquest of the habit becomes comparatively easy. Over and over again I have seen cases that have lasted for years in which the patients were surprised at the ease with which they were able {486} to drop the habit just as soon as they took the measures necessary to prevent predisposing conditions.

Breaking the Habit.--Once physical factors predisposing to it are removed, the habit is not so hard to break as it would seem to be from the suggestions to that effect made in sensational literature. It is neither so deleterious in its physical effects nor so deteriorating as regards character as is usually stated. Anyone with a reasonable amount of firmness can break it off if he really resolves to. Over and over again I have seen patients quite surprised at the ease with which they were able to avoid the practice for weeks once they made up their minds in the matter. Indeed this is one of the unfortunate features in completely conquering the habit. It is comparatively so easy to break it off when the mind is made up that there comes the feeling that now it must be absolutely facile to keep away from it. This is, however, never true. Relapses are extremely easy. If the patient allows himself to read vicious books, or suggestive literature of any kind, or permits himself an indulgence in the reading of several columns of the account of a s.e.x murder trial, or goes to see a s.e.x problem play with its suggestions, or exposes himself to s.e.xually exciting conditions of any kind, he will be almost sure to lapse into the old habit.

Relapses are almost inevitable. But it is easier to break the habit the second time than it was the first and it becomes increasingly easy if the patient keeps up the effort of regulating his life so as to avoid the occasions of the habit. Relapses are quite as sure to occur as with regard to alcoholism if occasions for the taking of liquor are not sedulously avoided. The patient always seems to need a confidant--someone to whom he can go for help and who a.s.sures him of the ability that he has to overcome himself if he only will. The practice of confession in the Roman Catholic Church makes it comparatively easy for serious people of that faith to overcome the habit. The physician must be taken into confidence in the same way and for a time, at least once a week, the patient may have to be perfectly frank with regard to his condition in order to have the help afforded by such confidences. The physician can often, particularly at the beginning, make the physical conditions such as to help in the breaking of the habit. Bromides taken to the extent of a dram or more a day are almost a specific for superirritability of the nervous system, and if taken for two or three weeks the patient will usually have little or no difficulty in overcoming the habit. They are not of much avail after this time unless the patient's character has been aroused to determined helpfulness in the matter.

In obstinate cases it may be necessary to have a patient come every day, or at least every second day, for some time and give an account of how he has succeeded in resisting his habit in the interval. At least he must be asked to report whenever there is a lapse. It is surprising how much the antic.i.p.ation of having to tell someone else of a drop back into the habit means in helping the patient eventually to overcome it. Very slight motives serve to cause relapses, but almost any external personal aid, if pursued with confidence, will avail effectually to break it. I talk from an experience of many cases and know how much can be accomplished even though patients insist that they have tried all the resources of their will power and of prayer without avail. They have really not tried, they have not willed in reality; sometimes they {487} have reached a point where they cannot will without the moral support of another personality. This can be readily supplied to them by a firm, sympathetic physician whom they respect. It will take time to overcome the tendency to relapse whenever the will is relapsed, but the habit itself can be broken without much difficulty in a few days.

Certain times are particularly dangerous for relapses into the habit.

These are just before going to sleep at night and before getting out of bed in the morning. At these times the mind must be occupied or else the patient will almost surely find his habit recurring. Often the habit of reading in bed, properly supported by pillows and with abundant light at an angle that makes reading easy, seems to be good for these patients, because they may read until their eyelids get heavy, then pull the chain of their light to extinguish it and turn over to sleep. In the morning prompt rising after waking is important.

Bed clothes that are too heavy and too great warmth of clothing predispose to s.e.xual excitation and must be avoided. The room should be cool rather than warm and the mattress rather hard.

The more tired the patient is the less liability will there be to difficulty in these matters. But air is even more important than exercise in giving the tiredness which superinduces deep sleep. A lessening of the normal amount of oxygen seems to relax the inhibitory power of the higher centers over the s.e.xual centers in the cord.

People who are drowned, those who are hanged, and those whose supply of oxygen is shut off by the inhalation of the heavier gases are likely to have involuntary seminal emissions. These are probably consequent upon the shutting off of the air.

The important element in the treatment is to make the patient feel that, if he really wants to, he can conquer in this matter. The old motives of fear, and especially fear of physical consequences, were quite unworthy, and inasmuch as they had any effect rather produced a deterioration of character than a strengthening of it. The patient must understand that if he is a man he can overcome it. Religious motives will help much. I do not know that I have ever seen a case where religious motives were not the most important element in the cure, but that may be due to the conditions in which I have been placed. I have seen a number of these cases in men and women because clergymen have sent them to me in order that they might be helped in the work of reform, and while there are many relapses and some had apparently given up the effort in despair of their power to overcome themselves, nine out of every ten of those who have seriously faced the problem have succeeded in overcoming themselves, and as a result have a better knowledge of their own characters and more respect for themselves. They are better men in every way than if their improvement had come about through selfish fear of physical consequences.

After Cure.--After the habit of self-abuse has been conquered the seminal vesicles will have a tendency to evacuate themselves rather more frequently than before and as a consequence they will nag at certain s.e.xual nerve endings. They are used to having their contents emptied and distention is followed by rather ready evacuation. During the course of this evacuation s.e.xual thoughts are awakened in dreams and this may lead to dream states in which there seem to be lapses into the old habit. This const.i.tutes a serious difficulty in getting rid of the habit entirely in young and vigorous men. They may even become disheartened by it. It should be explained to them that they must let {488} contrary habits form gradually and permit nature to accommodate herself to the new state of affairs. The bromides are a useful adjunct for body and mind.

_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 const.i.tution 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 appet.i.te, 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 cla.s.s 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 s.e.x matters, once pa.s.sion 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 circ.u.mstances, 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 s.e.xual 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 p.r.o.ne to read novels and stories relating to s.e.x problems and the details of s.e.x murder trials and the like which const.i.tute 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. {489} Sometimes we have to overcome a morbid dread of touching themselves even for cleansing purposes which allows the acc.u.mulation of irritant material and predisposes to relapse.

s.e.xual Perversion.--s.e.xual perversions are sometimes considered as different from s.e.xual 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 s.e.xual 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 s.e.xual 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 s.e.x in them properly--as if she had not quite made up her mind which s.e.x 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 s.e.xual 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 s.e.xualism, because they had allowed themselves to think and read and dream about s.e.x matters overmuch. They are usually idle people who do not take life seriously and who have an inordinate curiosity about s.e.x subjects. At the beginning the commission of the perverted s.e.xual act was a.s.sociated 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 s.e.xual 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 s.e.x 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, s.e.x perversions become common in history. The story of Greek love is well known.

Corresponding conditions developed at Rome under similar circ.u.mstances. 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. {490} Some confirmatory evidence undoubtedly there was. s.e.xual 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 s.e.xual divagations, exhibitionism, s.e.x 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 s.e.xes. Occasionally women are lacking in all the s.e.x characteristics of the upper portion of the body, have no b.r.e.a.s.t.s 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 s.e.xual 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 s.e.xual perverts, however, it is as with regard to drug addictions, alcoholism, and obesity, just a question of willing not to indulge in certain appet.i.tes 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 s.e.x with h.o.m.o-s.e.xual inclinations is quite beside the mark. Certain of this cla.s.s 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.

{491}

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 ill.u.s.tration 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 p.r.o.ne 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 circ.u.mstances 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 pa.s.sing 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 {492} 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 rea.s.surance as to their comparatively innocuous character. Even herpes zoster is p.r.o.ne 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 Mitch.e.l.l'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 att.i.tude 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, {493} 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 Amba.s.sador's lady, who was a woman far from superst.i.tion, 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'

s.p.a.ce 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 circ.u.mstance until on revisiting the inst.i.tution 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 ill.u.s.trated 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 a.s.sociated with s.e.xual irritability, all make interesting studies in this subject. From comparative {494} anatomy and physiology the influence of the nervous system over pigmentation has been very well ill.u.s.trated. Brucke 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.