will sometimes set off the explosion of a train of sexual symptoms.
Every physician has probably had some young man come to him with the
look and the tone that there was something the matter that he knew was
serious and would affect all his after life. The patient then goes on
to say that he wants to know all and is brave enough to face it, and,
though he has lost sleep for two or three nights and is not looking
well for the present moment because his health has been disturbed by
the loss of sleep, still he has the strength to know the worst and it
is to be told him and he will bravely battle on in spite of the
suffering that must come. Or he will submit to a serious operation if
it is necessary for his relief. With a prelude like this, the
inexperienced physician might expect strangulated hernia or some
preliminary symptoms of brain tumor, but what he usually finds is a
varicocele, and a small one at that. By chance the patient has
discovered it and slept none the following night, went round in an
agony of dread next day meaning to go to a physician, but too fearful
to be told the worst, losing another night's sleep and then finally
coming to a friend to be told all the ill that is in store for him.
There is no need for alarm in these cases; they merely illustrate the
role of the mind disturbing the body. Nearly one-fourth of the male
world carries its {474} varicocele around with it and never bothers
about it. A few sensitive individuals are annoyed by a sense of weight
and a feeling of distention from congestion in connection with it. In
a few, because of special pathological conditions or congenital
defects, the varicocele becomes so large that it has to be supported
by a special bandage. In people who ride horseback, in athletes, and
those who indulge in severe exercise, this sort of a bandage may be
necessary or at least may make the wearer more comfortable even in
slighter forms of the affection. Severe cases may be much relieved by
it.
On first discovery of his varicocele nearly every young man, because
of concentration of attention on it, is so much annoyed that he thinks
he must wear a bandage. After a time, however, he often finds that the
bandage itself is a source of more annoyance than the varicocele, and
then he learns to forget it and its feelings--and that is all about
it.
I have dwelt on this succession of events that takes place so often
with regard to varicocele, because it is typical of the effect that an
affection of the sexual organs has upon the mind. It exerts an
unfavorable influence entirely disproportionate to the physical cause
that is at work. If, as sometimes happens, a young man hesitates to
confide in some one capable of undeceiving him with regard to the
supposed significance of his affection, he may work himself into a
decided nervous condition and lose much weight before he discovers his
mistake. This physical running down confirms his exaggerated notion of
the significance of the affection. He is sure that it constitutes the
reason why he is losing weight and declining in health and he rather
congratulates himself on the fact that he discovered the cause so
shortly before the serious effects began.
If under these conditions he places himself in the hands of any of the
men who advertise themselves as curing "men's diseases," or as
relieving the "awful" symptoms that are likely to follow varicocele,
instead of being reassured he will be told that he has come just in
time and that while his cure will require a long time and will cost a
great deal of money, yet it can surely be effected. In nothing can men
or women be more easily imposed upon than with regard to affections
involving their sex organs. They lose their power of judgment and
their control over their feelings and so plunge sometimes into
profound depression. Every year we have a number of suicides among
young men, the most important element in whose depression is due to
unrelieved occupation of mind with the thought that they are suffering
from some incurable sexual disease which will unsex them, and that
even death is to be preferred to the alternative of being recognized
generally--as they are sure they will be--as sexual defectives.
As a rule, these young men are suffering from only some slight ailment
that could be easily cured if they were frank about their state of
mind and described their symptoms to a reputable physician. Oftener
than not their supposed ailment is something so common as to be of no
significance, so far as any serious results may possibly be
anticipated, and their only real ailment is the mental condition which
has developed because of concentration of mind on this one phase of
organic life and the consequent inevitable exaggeration of symptoms
and feelings. It is sometimes not easy to disabuse them of their
unfortunate notions, but there is probably no set of cases in medicine
where psychotherapeutics means more than it does with regard to the
curious {475} neurotic and psychic conditions which develop in those
who are suffering from any sexual ailment, real or imaginary.
Long Prepuce.--Much has been said in recent years about the influence
of a long prepuce in the male in producing various reflexes the
effects of which may be seen in serious disturbance of even distant
organs. The kidneys are sometimes said to be thus reflexly affected,
and occasionally the digestion and the bowels--even, sometimes, mental
processes are said to be influenced unfavorably by the diffusion of
reflexes from the irritation consequent upon this sensitive structure
being too long. A whole system of nosology exists in some minds due to
an over-long prepuce. There are, of course, cases in which
circumcision should be performed. There is a larger number of others,
however, in which the redundant prepuce is neither adherent nor
constricted and is only slightly longer than it should be.
Occasionally something arouses the attention of the possessor of the
redundant tissue and he gets the idea that it is the source of reflex
irritation even for distant parts of his organism. It is an
interesting study in suggestion to see how symptoms develop in various
organs as a consequence of the cultivation of this thought. Urination
becomes frequent, the patient even wakes at night to urinate and the
urine, as in many neuroses, becomes more abundant and of lower
specific gravity--the typical nervous urine of the hysterical, and
there may be much worry and emotional disturbance.
These symptoms, however, are not effects of the long prepuce, but are
results of the neurotic influence of concentration of mind on it. It
will often be advisable, in young men particularly, to have
circumcision performed, but in most cases this is unnecessary, and if
the patient can be made to understand how the symptoms have developed
he will learn a precious lesson in not interfering with his functions
by over-attention to them. Of course, there are many surgeons who will
continue to hold, as they seem to now, that nature was quite at fault
in the production of this organ and that it should be removed in
nearly every human being. The majority of men, however, have lived
their lives quite well and happily without such intervention and there
are certain inconveniences attached to the condition which remains
after operation that may in their way be quite as bothersome as the
symptoms due to the long foreskin.
Psychic Impotence.--An important sexual neurosis, at least in the eyes
of sufferers from it, is what physicians have come to know as psychic
impotence. Young married men, because of over-anxiety with regard to
themselves for a number of reasons, but without any physical factor to
disturb them, find it impossible to complete the sexual act. Naturally
this creates a serious disturbance of mind. The patient will either
hurry to a physician at some place on his wedding tour, or his wedding
tour will be shortened and he will return to consult a friend. He
presents a lively picture of despair. He has not been sleeping, his
appetite is disturbed, he feels lassitude and weakness, and if he has
a lively imagination he is inclined to think that the fatal
termination of some serious nervous disease of which he has heard, and
which is accompanied by the symptom of sexual impotence, is impending
over him. His condition is quite pitiable, though largely imaginary.
_Reassurance_.--The treatment of the condition is not so difficult as
it might seem if the patient has a reasonable confidence in his
physician. If he {476} goes to an advertising "specialist," as
occasionally happens, because he concludes that the ordinary physician
cannot know all the details of these intricately complex nervous
diseases, he is sure to suffer severely in general health before cure
is obtained. His morbid ideas will be fostered because he is ready to
pay any amount of money in order to stop the progress of the presumed
serious disease. An investigation of these "specialists" in New York,
made a few years ago by a committee of the New York County Medical
Society, showed to what an extent the terrors of these unfortunate
patients are exploited for monetary reasons.
A physician of even a little experience in these matters, however,
recognizes at once the entirely neurotic character of the case and by
reassurance soon enables the young man to dispel many of his worst
terrors. His general health can be regulated, his constipation, which
so frequently exists, is relieved, and he can be told, what is very
true, that the excitement consequent upon the preparations for his
wedding and the exhaustion due to the overwork so frequently necessary
in order to enable him to take the time off for his wedding journey,
have made him so nervously irritable that the ordinary mechanism of
the sexual act, which is extremely delicate and requires nice
co-ordination for proper function, has been disturbed. Just as soon as
this fatigue and the over-excitement of mind consequent upon the
unfortunate experience are mitigated his potency will return. This
assurance can be given almost at once.
His fears, however, will delay his recovery. His dread of incapacity
will become an obsession. Probably the most effective means of
treating this is to forbid him to attempt the sexual act for a
definite length of time, say two or three weeks. This must be
impressed upon him. There is a good reason for insisting that he shall
not irritate his already excited sexual system by such attempts.
Usually at the end of a week or ten days he will come back with a
smiling look of confidence in himself and his physician, to confess
that he has violated the injunction, but that he was not disappointed
as before.
_Subconscious Obsession_.--In most of these cases the young men have
been victims of sex habits of some kind or of drug addictions, and
they have heard that occasionally individuals who have had such
experiences may suffer from sexual impotence later in life. This is a
strong suggestion to them and in some cases becomes a haunting
obsession, and produces the unfavorable effect upon the organism. It
is necessary to remove this obsession before a cure can be effected.
The patient's confidence must be obtained and the physician's
personality and persuasive powers used to change his point of view.
Occasionally I have seen cases in which the patients themselves seem
to be scarcely aware of this strong suggestion or obsession at work in
them. It seemed to be more or less subconscious. An idea with regard
to the evil effects of the old habit had been implanted and remained
in their minds, occasionally making itself felt but more often
apparently lying dormant. In these cases it is important that the
physician should make this underlying factor clear to the patient. In
some of these cases hypnosis is necessary. Usually the hypnoidal
condition, with suggestions in the waking state, is all that is
necessary and ordinary suggestions will often effect the purpose
completely.
Organic Impotence.--Certain forms of sexual impotence are really
preliminary signs of serious organic nervous disease. Sometimes it is
the first {477} symptom of paresis or of locomotor ataxia. Oftener it
is a very early symptom of syphilitic spinal myelitis. In practically
all of these cases, however, there is a history of syphilis and the
presence of this should always be a warning not to think of functional
or psychic impotence until the possible influence of the syphilis
itself or of some of the parasyphilitic diseases is thoroughly
excluded. Unfortunately, not a few people who have had syphilis are
nervous and anxious about themselves and by their very anticipation of
possible developments may auto-suggest themselves into a state in
which these symptoms will develop. It is cases of neurasthenia that
develop after secondary syphilis in persons who have been studying
syphilis and its possible effects, which present the most difficult
problems in diagnosis that come to the nerve specialist. Many
simulated symptoms are unconsciously developed and this makes
differential diagnosis extremely hard. As a rule, the psychic
impotence is merely functional and patients need reassurance more than
anything else.
Nocturnal Emissions.--One of the sexual neuroses that gives rise to a
high degree of solicitude centers around the question of involuntary
seminal emissions. Young men who are living normal healthy lives and
who are in robust health with no indulgence of sexuality are likely to
experience more or less regular involuntary emissions. If for any
reason they become nervous or anxious about their sexual functions,
especially at times when they are under much mental strain, these
phenomena of emptying the seminal vesicles may occur rather
frequently. If they have been reading some of the literature, or
hearing some of the exaggerated notions that are often expressed with
regard to the evil effects that may come from this, they are likely to
suffer much mental anxiety over it. Occasionally they lose sleep,
frequently they feel so wearied and worried the day after the
occurrence as to be disturbed at their work, sometimes they are sure
they are so tired that they are unable to fulfill their ordinary
duties, and I suppose every physician has known young men who were
even sure that the loss of the seminal fluid was seriously interfering
with health, hampering many physical functions and bringing them to an
untimely grave. They had no appetite and in consequence of not eating
enough they were constipated and then a whole round of physical
troubles, headache, lassitude, over-fatigue, to which they are almost
sure to add loss or disturbance of memory, began to annoy them.
In those cases it is not the physical effect of any loss of seminal
fluid that is the disturbing factor of their health, but their worry
over the losses. Just as soon as their minds can be taken off the
subject, the supposed physical effects begin to disappear. So long as
the solicitude continues the emissions themselves increase in number
and the condition is made worse. These patients must be taught that in
every normal healthy man in whom there is no regular occasion for the
emptying of the seminal vesicles, nature provides for an evacuation
about every ten days or two weeks. In some it is more frequent than
this. In those who are much indoors and in whom oxidation processes
are low this emptying takes place more frequently. In those who lead a
sedentary life with the consumption of much proteid food the same
thing seems to be true. Any anxiety about it is sure to cause frequent
repetition of the evacuation processes. Over-solicitude about the
bladder will have just the same effect. If the patient will take his
mind off the subject, will eat normally, will get out in the air more
than before, tiring himself thoroughly {478} if he is young and
vigorous, and will not allow the sexual side of his being to be
excited by stories or pictures, plays or voluntary thoughts, his
affliction will soon disappear.
_Prophylaxis_.--Certain directions are helpful and by occupying the
patient's mind will overcome certain physical factors that underlie
the affection. It is important that the bladder should not be allowed
to be full, above all, not to be over-distended at night. Some care
should be exercised in not taking too much to drink shortly before
going to bed and the bladder should be faithfully emptied before
retiring. The weight of a large amount of urine in the bladder
pressing down upon the seminal vesicles situated below and behind it
causes them to contract rather easily. This is particularly true if
the patient sleeps on his back and occasionally in certain
over-irritable patients for a time at least an arrangement may have to
be made by means of small pillows that will prevent him from sleeping
on his back. On the other hand, it must not be forgotten that too
great abstinence from fluid will cause the urine to be more
concentrated and this will irritate the bladder and either wake the
patient up at night, which of itself is undesirable, or else will
cause congestion in the prostatic region which will irritate the
seminal vesicles to the point of evacuation. While five or six glasses
of water a day should be taken besides the ordinary fluid taken at
meals, the only regulation necessary is of the amount of fluid taken
in the evening after the last meal, that is, if more than three hours
intervene before retiring for the night.
Besides the physical conditions in the bladder, an accumulation of
fecal material in the rectum may cause irritation of the seminal
vesicles. It is important, moreover, to remember that thoroughly free
movements of the bowels, by preventing to a great extent the
reabsorption of material from the intestines which may prove irritant
when excreted through the kidneys and when present in the bladder, is
of itself an excellent therapeutic measure in cases of irritability of
the genital organs. The setting of the patient's mind to thinking
about his rectum, his bowels, and his bladder instead of his genital
tract is an excellent psychotherapeutic measure that will soon bear
fruit.
The consumption of various foods, condiments and drinks enters into
the underlying condition which produces frequent emissions. We have
already suggested that the use of a large amount of proteid materials,
especially in people who live a sedentary life, often predisposes to
this condition. An abundance of the carbohydrates, however, by
supplying more heat than is necessary may have a like effect. Certain
spices seem to predispose to irritability of the sexual system. Red
pepper has always seemed to those who saw much of these cases to be
particularly at fault. Mustard, curries, peppers generally, however,
and even other spices seem to have a corresponding effect. As a rule,
young folks suffering from this disturbance or from the tendency to
eroticism in other ways should be warned about this irritation of
spices. In neurotic individuals tea and especially coffee has the same
effect. Probably this is only an indirect influence of tea upon the
nerve centers, making them more irritable, but coffee, by raising the
blood pressure, seems to have a direct unfavorable effect.
All alcoholic drinks are contraindicated in these cases and must be
forbidden. Certain of them seem to be more harmful than others.
According to French tradition warm wine or mulled ale as it is used in
England is {479} especially likely to excite sexuality. Warm alcoholic
drinks of any kind are absorbed more rapidly than are cool drinks,
which is the main reason in modern times for having these liquids
cooled so that they will not be absorbed too rapidly and disturb the
equilibrium. Champagne also has, by tradition, a special effect,
sometimes said to be due to the increased hyperemia of the stomach
induced by the carbonic acid gas and the consequent more rapid
absorption.
The prohibition of spices and alcoholic drinks has a good effect in
itself. It acts constantly as a suggestion to the necessity for care
and guard over one's self. Besides the exercise of self-denial
necessary to keep away from the use of such substances, especially
under present social conditions, is of itself a good training that
strengthens the will against certain tendencies to indulgence in
sexual thoughts which predispose to the frequent emptying of the
seminal vesicles.
_Erotic Dreams_.--Very often these nocturnal seminal emissions are
associated with erotic dreams. Patients are inclined to attribute the
occurrence of these dreams to some fault of their own or to consider
that they are at least in some way responsible for them. This thought
often becomes a source of serious worry, making their condition worse.
A study of this question has convinced me that in most cases there is
practically no responsibility in the matter. Pressure on the seminal
vesicles by an over-full bladder, or a distended rectum, leads to the
production of nervous stimuli around which the erotic dream-ideas
gather. A straightforward explanation of this will relieve many
patients' minds, and keep them from bothering about the subject in
such a way as to make their genital tract even more sensitive than it
is because of their concentration of attention on it.
Sexual Mental Troubles.--In our generation sex occupies a great deal
of attention. Sexual tendencies are emphasized by suggestive reading
of all kinds and by forced attention to sex matters. Most of the
successful novels deal with the so-called sex problem, our plays are
to a great extent sex problem plays and our newspapers are full of sex
crimes and sexual divagations of many kinds. This acts as a strong
incitement to sexuality and represents exactly the opposite of what
nature intended in the matter. As a consequence, all the tendencies to
over-solicitude with regard to sexual affections and all that
instability of mind and over-reaction to all forms of irritation that
comes in the midst of sexual excitation are noted. This seriously
disturbs the minds of many patients and makes their health as well as
their morals worse than they should be. The neurotic conditions seen
in those who occupy their leisure with erotic subjects are fostered by
this unfortunate over-attention to sexual matters. For general
prophylaxis the physician needs to throw all the weight of his
influence toward the correction of unfortunate tendencies in our
present-day life and healthier subjects of thought should be
encouraged.
We often hear it said in our time that the great fact of life is sex.
Indeed, this has been insisted on _ad nauseam_ in recent years. There
is no doubt that without the sex element the race would not continue
under the present dispensation. If sexual feelings did not mean so
much to the generality of men and women it is doubtful whether
marriage would be the success that it is, though so much is said
nowadays about its failure. The analogy with all the beings lower in
the scale than man shows how imperative and prominent {480} in life
this instinct is and how much it signifies. Those who insist so much,
however, on sex as the one great fact of life seem to forget that
there are many other natural functions of quite as much importance to
the individual at least, if not to the race. Without eating neither
the individual nor the race could go on. Neither would the race go on
without eliminating waste products. If there is one thing that our
consideration of the problems of psychotherapy has made clear it is
that whenever any of these animal facts of life is made much of and
occupies attention to the exclusion of higher ideas, there is sure to
be trouble. It matters not how apparently automatic and completely
spontaneous a function may be, if exaggerated attention is given to
it, it is sure to be disturbed in its functions and cause serious
troubles in the organism.
There is no need further to illustrate this with regard to such
physiological necessities as feeding and excretion. At present the
world is much occupied with sex problems because, unfortunately, its
attention has been focused on this subject. Physicians, particularly
if they are paying attention to nervous patients, are likely to know
many individuals who have food problems, diet problems, digestion
problems, bowel problems, and many others of similar nature because
they have been focusing their attention on these functions of their
being.
The most distinguished psychiatrist of our generation, certainly the
man whose works have done most to open up new vistas for us in mental
diseases and who has added not only new knowledge but new
possibilities of development, visited this country not long since and
said, "Oh! here in America you are sex mad." He added, "I knew that we
were madly following sex problems in Europe, but I thought that in
this country, with so many other things to occupy the minds of men and
women, you were not bothered so much with sex problems." What he said
represents the impression of nearly every thoughtful foreigner who is
surprised to find that wealth and luxury have brought to us this same
degenerate interest in things sexual that occupies the so-called upper
classes and their imitators in Europe.
Livy, the Roman historian, said long ago, "Whenever women become
ashamed of the things they should not be ashamed of, it will not be
long before they will begin not to be ashamed of the things they
should be ashamed of." Whenever in history men and women have occupied
themselves, not with the rearing of families, but with the suppression
of families to as great an extent as possible, sex problems have
always become emphasized. The woman who is a mother, and especially
many times a mother, usually has no trouble at all about sex problems
and no tendency to have "affinities." With her there is usually no
question of sex as the central factor of life nor of any other of the
curious nonsense that has been talked about this matter as the result
of giving sex a place of importance that it does not deserve. Until
there is a reform in this matter we can look for many "neurotic,
erotic and tommy-rotic" tendencies, as they have been called, due to
over-attention to one set of organs. Any organic system in the body
would be disturbed by such attention, but the sexual system is
particularly susceptible to suggestion.
The state of affairs thus emphasized is the result of interfering with
an animal instinct. It will make itself felt properly and secure the
due exercises of function if allowed to pursue the even tenor of its
way under reasonable {481} control, but if it is fostered, thought
about, discussed, excited in various ways, pampered by indulgence and
perversion, it runs away with nature. The gourmet who constantly
thinks about food, plans new modes of exciting the appetite, studies
savors and odors in order to satisfy a palate that has been
artificially stimulated, gets a certain animal enjoyment out of his
food that other people do not; but he usually overeats, loses his
appetite, and with it any real satisfaction in eating, and suffers
from indigestion as a consequence of indulgence, so that the suffering
much more than compensates for any slight additional pleasure that he
has enjoyed. Besides, man is an essentially intellectual being, and
occupation with the things of sense, that will manage themselves very
well if let alone, takes up just so much of the precious time that
should be devoted to other things to attain that satisfaction that
makes life well worth living. Sexuality cultivated with the degree of
attention that certain people devote to feeding, becomes a pest, ruins
intellectual effort, hurts initiative, leads to the most serious
disappointments in life and is the most fruitful cause of despondency
and suicide that we have besides being the origin of many social evils
that still further complicate life.
One great modern nation has debauched its literature to such an extent
that probably the major portion of its books treat of sex and sex
problems. Practically all of its esthetic expression has been
seriously hurt by the same fault. Its painting, its sculpture, its
dramatics, its art of all kinds, have all gone the same road. The
result is seen in the lowered moral fiber of its people. A recent
census report showed that the nation has reduced some 20,000 in
numbers and that this was only the beginning of the race suicide. They
have been thinking, talking, writing, painting, chiseling, acting sex
problems, but in the only phase of life in which sex really counts it
has been so pushed into the background or perverted that there it is
failing utterly to accomplish its one legitimate purpose. The younger
generation as they grow up are given the idea that they are missing
the most wonderful thing in life unless they have memorable sex
experiences. These experiences must be varied in order to satisfy the
artificial appetite that has been created. As a consequence, family
life and the real meaning of love and the affection of man for woman
rooted in the depths of their nature is spoiled by mere animal passion
and its passing expression.
Nature's own attitude with regard to over-attention to sex matters
must not be forgotten. The purely sexual organs have been pushed into
the background to as great an extent as possible and are intimately
associated in both sexes with one of the two ugly excretory functions,
urination, and placed in close relationship with the structures which
subtend the other--defecation. Evidently nature intended that they
should be the subject of as little attention as possible.
Unfortunately, the paying of attention to them to any great extent
lessens somewhat of the disgust naturally aroused by the excretory
functions with which they are associated. Nature has provided as far
as possible for deterrence from over-interest. One might expect that
cleanliness and the cultivation of the feelings of refinement would
serve as auxiliaries in the repression of sex indulgence. The lessons
of history are that usually the great bathing nations have been most
sexually divagant. Among the Greeks and the Romans the ugliest sex
habits and proclivities found a place--among peoples who devoted
themselves to the cleanliness of the body. The classes {482} who bathe
most are often those with the strongest tendency to sexuality.
Refinement instead of lessening the tendency to sexual indulgence
rather increases it.
Education and the development of intellectuality, far from being a
barrier to sexual divagations, seem to predispose to the exaggeration
of the significance of sex in life, unless the individual has a
well-balanced character or has been thoroughly grounded in ethical
principles. The ugly stories of Greek love at a time when the Greeks
were at the climax of culture, as well as what we know about the
relations of the freedmen to their masters among the Romans during the
classical period, is all confirmed by the revelations of corresponding
tendencies in recent generations among the intellectual classes even
at the universities. Development of mind apparently does not
neutralize to any extent these sexual tendencies. Evidently the rule
of life for health's sake must be to push sexuality as much into the
background of the mind as nature has put the sex organs in the human
body. Reason does not protect knowledge but increases suggestion. Only
absorbing occupation of mind with other subjects that will bring about
neglect of these functions, as of all other physiological functions,
leaving them to nature, serves to keep them in their proper place and
condition.
CHAPTER III
SEXUAL HABITS
As was emphasized in the preceding chapter, sexual symptoms are
usually the subject of so much worry and disturbance of mind and
become the center of so much unfavorable suggestion, that the only way
to ameliorate the conditions which develop is by securing relaxation
of the attention and diversion of mind. Mental influence is much more
important than any other remedies that we have at our command in these
cases, not only for their relief but for their ultimate cure.
A state of depression of mind similar to that which develops in
patients frightened by seminal emissions is often seen in those who
have for some time indulged in the habit of self-abuse. Rather
frequently a physician, especially if he is known to be interested in
nervous diseases, has to listen to the story of a patient who is sure
that his health is completely undermined and that his future is the
darkest possible, because of this habit in younger days. Usually the
patient is a young man who has been reading some of the literature of
the advertising "specialists" who distribute reading matter which
pictures appalling and almost irretrievable effects from such sexual
habits. The consequence is that the patient is in highly nervous
condition, has lost his appetite, is not sleeping well, is avoiding
society, because he fears that some one may recognize his condition
and its cause, and he is really in a pitiable state. Such patients are
usually sure that little can be done for them. Sometimes they have
already been through the hands of several "specialists," particularly
of the mail-order variety, and the literature provided for them and
the letters written to them have all helped to make them worse and
much more solicitous about themselves.
{483}
Unfortunately some of the exaggerated notions with regard to the
effect of these habits that are so widely diffused by the exploiters
of the young have been adopted by moralists with the idea that they
can thus deter youth from certain practices and scare the victims of
such habits out of them. It is extremely doubtful, however, whether
self abuse of itself, unless practiced in very early years or indulged
in to a degree that is possible only in those of unbalanced mind, ever
works anything like the serious harm that is claimed. Certainly
physicians who are most familiar with its results are not ready to
confirm the opinions usually advanced as to the awful harmfulness of
the practice. Personally, I have had a number of patients confess to
me that they had indulged in the habit to some extent for twenty years
and longer and yet had never suffered anything more than passing
physical discomfort. It is unfortunate, then, that the exaggerations
of the quack should by receiving the approval of the well-intentioned
moralists, be emphasized so as to add to the neurotic disturbance of
mind which makes these patients so miserable and for a time may
seriously interfere with their health. Occasionally even suicides are
reported in which the underlying motive seems to have been the dread
on the part of a young man that a sexual habit has so undermined his
health that cure is impossible and that physical and mental
deterioration to a marked degree is inevitable. The opinions of
conservative physicians tend to show that there is no good reason for
thinking that in normal healthy persons such habits ever have the
serious effects thus set forth.
Patients can be assured that whatever evil effects follow the practice
will not remain after it has been given up. There are no serious
enduring sequelae, with one or two exceptions in very special cases,
that perhaps should be noticed. Most men of considerable experience in
the matter are now decidedly of the opinion that self-abuse does not
produce any more serious consequences than the same amount of ordinary
sexual intercourse. It is possible for sexual intercourse indulged in
excessively, as it sometimes is in early marital life, to produce the
same feelings of exhaustion, lack of control over the vasomotor system
and disturbance of the gastro-intestinal tract which are noted in
self-abuse. In both cases the symptoms promptly disappear upon proper
regulation of life. This is a very different opinion from that which
used to be expressed in this matter and it is given only after due
deliberation and consultation of many authorities both in writing and
orally. Its expression, far from taking away one of the best deterrent
motives against the practice, rather forces an appeal to the manliness
of the individual. The motive of fear never accomplishes much, while a
frank statement of the real condition may be greatly helpful.
While the habit of self-abuse as indulged in by the ordinary
individual practically never has the awful consequences that have been
sometimes pictured as resulting from it even long after its cessation,
there is no doubt that it is productive of many physical symptoms
during the time of its indulgence. There is almost sure to be a
discouraging lassitude and a tendency to exhaustion after even
comparatively small efforts. While this is true for ordinary muscular
efforts it is also true for other bodily functions that involve
muscular activity. In recent years we have learned that of the stomach
functions the motor is more important than the chemical. In the bowels
the motor function is extremely important. There are likely to be
disturbances, then, in the gastro-intestinal tract as a consequence of
the muscular condition that {484} develops in those patients. Probably
more important even than the physical, however, are the psychic
results of the habit. The patient feels discouraged and cast down at
his inability to conquer himself and is likely to avoid such exercise
and diversion of mind as would make normal healthy function possible.
Mental Disturbances.--It is the custom to say that mental
deterioration almost surely follows the habit. Those familiar with
mental cases often see self-abuse practiced with serious results by
young folks whose mentality is deteriorated. In these cases the
practice was indulged in with great frequency and with direct physical
consequences, such as loss of sleep, of appetite and the like. It is
not the habit, however, that has caused the mental deterioration. The
young patients are going crazy, but not because of self-abuse. Their
habit of self-abuse had originated and become exaggerated because they
were already mentally unbalanced. Their extreme indulgence in it is
especially due to their lack of control over themselves, because they
are not possessed of strong will power with regard to any thing. A
vicious circle is formed and the insane young man gradually deepens
his insanity by hurting his physical condition through over-indulgence
in the habit and all this further lessens his self-control; but were
it not for the original mental weakness the habit would not have been
indulged in to so great an extent.
Effect on Prostate.--There is one phase of the ill effects of
self-abuse that it is well to recall as having the confirmation of men
of large experience and conservative views. There is a definite
impression among specialists in genito-urinary diseases that
enlargement of the prostate in some cases is due to the frequently
repeated irritation and the prolongation of that irritation of the
prostate during the practice of self-abuse. When such men as Bangs and
Keyes are agreed on a subject of this kind, then even though in a
certain number of cases the changes in the prostate leading to its
enlargement are evidently inflammatory, it is well to consider that
the functional over-activity of the gland superinduced by the practice
may lead at least to an enlargement of the glandular elements with the
consequent interference with urination which so frequently comes in
old age.
Physical Factors.--Besides mental elements that predispose to the
formation of sexual habits there are physical factors that are
important in these cases. They must be particularly looked for and
treated carefully if found, or there can be little hope of relief for
the conditions. The most prominent of these is the existence of a long
foreskin, especially if its opening is small, thus leading to the
retention of urine, the deposition of urinary salts with the formation
of preputial concretions or so-called calculi. These are intensely
irritant, cause frequent itching and thus predispose to these sexual
habits. Even where the preputial opening is free and allows egress of
urine without residue, the accumulation of smegma often causes
considerable irritation and if the most scrupulous cleanliness with
cleansing at least once a day is not maintained, irritative conditions
arise, especially in hot weather, that may give occasions for sex
habits.
Under these conditions the habit is sometimes seen in extremely early
years. The youngest case I ever saw occurred in a child not quite
nineteen months old whose mother said that for several months she had
noticed certain curious actions that she could scarcely understand
until finally the truth dawned on her. Then she was morbidly sensitive
about it, sure that the habit was due {485} to a fault of her own and
it was some time before she consulted a physician. This was her fourth
child and, strange as it may seem, it was only at the conception of
this child that she first knew what sexual pleasure was. She feared
that her feeling had been in some way sinful and that as a consequence
of her sin this curious habit had developed in such early years in her
baby boy. As is usually the case in these instances, I found that the
prepuce was very tight indeed, having scarcely more than a pinhole
opening in it. During urination this ballooned and there remained in
the pouch-like process at the end of the penis a certain amount of
residual urine after every urination. From this urinary salts had been
precipitated and had formed scaly concretions which remained in the
preputial pouch and were extremely irritant. As a consequence of this
irritation the baby had been very itchy and it was in the endeavor to
relieve the itching by the natural process of scratching that the
pleasure of the sensations aroused had been discovered and the sexual
habit had been formed.
Not infrequently in young men a condition resembling this to some
degree at least is found and then, of course, the question of its
removal must be taken up at once. It is surprising how often in youths
in their late teens concretions are seen. The constant irritation
makes it practically impossible for the patient to keep his hands from
the parts, and so circumcision is absolutely necessary. Not
infrequently when the preputial condition is not nearly so bad this
operation may also be at least advisable if not necessary. The matter
of cleanliness must be attended to, preferably after getting up in the
morning and not before going to bed at night, for the reaction after
cold water may cause congestion of the organ. After a time the
frequent use of cold water seems to make the parts much less reactive
to irritation of any kind.
Physical Effects.--The super-excitation of nerves consequent upon the
more or less general erethism that is induced, lessens resistive
vitality. Victims of the habit are more liable to colds, to various
infectious diseases, and are subject to fatigue and lassitude, with
incapacity to work to their full power. They lose control over their
vasomotor system to some extent as a result of this systemic erethism.
They blush easily, they perspire easily, there is a tendency in many
of them to flash as if of heat and cold, they become pale under
excitement or anger more than formerly, they are likely to suffer from
cold hands and feet, and the surface of the body is inclined to be
cold and as a consequence patients are tremulous. This represents a
waste of nervous energy and as a consequence sleep may be disturbed
and digestion interfered with.
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 sex murder trial, or goes to see a sex problem play with
its suggestions, or exposes himself to sexually 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 assures 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 anticipation 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 sexual 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 sexual 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 sexual nerve endings. They are used to having their contents
emptied and distention is followed by rather ready evacuation. During
the course of this evacuation sexual thoughts are awakened in dreams
and this may lead to dream states in which there seem to be lapses
into the old habit. This constitutes 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 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. {489} 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. {490} 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.
{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 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 {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 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, {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 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 {494} anatomy
and physiology the influence of the nervous system over pigmentation
has been very well illustrated. Bruecke 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 {495}
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.
Artefact Skin Lesions.--Of course artefact skin lesions produced by
the application of carbolic acid or nitric acid or ammonia or some
other chemical irritant, or by rubbing with pumice stone, or with the
thumb as schoolboys make what in my schooldays were called "fox
bites," are skin lesions connected with a special state of mind and so
deserve a mention here. The physician finds them under the most
unexpected circumstances at times and in patients apparently above all
suspicion of their self-infliction. They can only be prevented by
changing the patient's state of mind, though this is scarcely what is
ordinarily thought of in psychotherapy. Where skin lesions are
atypical it is well to bear in mind the possibility of this curious
condition.
The Mind in Dermatotherapy.--I have had old dermatologists assure me
that they felt that the mind influenced materially the course of many
forms of skin disease. Younger dermatologists are prone to be
localists; as they get older the treatment of the patient's general
condition is felt to be more important; after twenty years of
experience they realize the place of psychotherapy in the treatment of
their cases. What is said here is only meant to be suggestive, but
certainly sufficient data are supplied to make it quite sure that the
mind greatly influences skin conditions and must always be treated if
success, especially in chronic cases, is to be secured. I have seen
confidence in a particular physician or remedy do much for even the
most sloughing and obstinate psoriases. Eczema follows the same law.
If psychotherapy can help in the treatment of conditions that are so
often intractable, it must surely not be neglected in other cases.
{496}
SECTION XIV
_DISEASES OF DUCTLESS GLANDS_
CHAPTER I
DIABETES
Diabetes is an affection of metabolism definitely recognized as due to
serious organic changes, though existing in several forms. We are not
as yet absolutely sure whether there may not be quite different
organic diseases in the various forms. Of one thing clinical
experience has given us assurance, that the condition of the patient's
nervous system is extremely important. While certain forms of diabetes
are due to pancreatic changes and others perhaps to changes in the
liver or other abdominal organs, the nervous system itself can affect
the consumption and excretion of sugar within the body. Certain
injuries, especially, as pointed out by animal experiments, irritation
of the floor of the fourth ventricle may produce passing diabetes. The
symptom may also occur in connection with states of the nervous
system. Glycosuria, or the passage of sugar in the urine, may occur
simply as alimentary glycosuria; and while this is usually due to an
excess of sugar in the diet, the glycosuria itself is predisposed to
by neurotic conditions in the patient. Diabetic patients are made
worse by worry of any kind and particularly by solicitude about
themselves and their ailment. Hence, the place that psychotherapy has
in the treatment of the disease.
Unfavorable Suggestion.--In most cases of diabetes, however, probably
the most important factor in the production of symptoms is the serious
disturbance of mind. The patient has an incurable disease and is
frankly told so. For the physician the word "incurable" means only
that his remedies are as yet inefficient in preventing certain
nutritional or metabolic disturbances, and that these will be likely
to continue in spite of all he can do. For the patient "incurable"
means that he has a disease for which the doctor confesses that he can
do nothing--which is not true--and that it is almost surely
progressive, while the many reports of death from diabetes of which he
hears only confirm the impression that he has not long to live and
that most of the time remaining will have to be spent in irksome care
of himself and almost superhuman self-denial.
As a consequence of this train of unfavorable suggestions, the history
of practically every case of the milder form of diabetes in older
people contains a period in which, shortly after the discovery that
they had the disease, they suffered more severely from it than at any
other time. As a rule, the discovery was accidental. The occurrence of
a succession of boils, the development of a {497} carbuncle,
occasionally an intractable eczema or a great itchiness of the skin,
or an irritation of the external urinary organs, the occurrence of
cramps at night, or neuralgia pains, have led to an examination of the
urine and the finding of a considerable quantity of sugar. As a rule,
the patients are at once put on a diet containing little starch and no
sugar, and after a short time most of the bothersome symptoms of the
diabetes have ceased. Their own worry, however, the strictness of the
regimen, the craving for starches, the decrease in weight from the
limitation of diet, have made them profoundly miserable. Their
feelings have been translated into the definite conclusion that the
disease must still be making progress since they feel so miserable,
and they have suffered more from their mental state than from their
diabetes.
This is as true of physicians themselves when they are sufferers from
diabetes as of ordinary patients. Indeed, it seems that physicians
make themselves more profoundly miserable because of their supposed
knowledge of the disease than other people do. I have had the
confidences of more than a dozen physicians who were sufferers from
diabetes, and all of them admitted that they had suffered more from
their scare over the disease and from trying to maintain a sugar-free
diet than from the effects of their ailment. The lowering of nutrition
reacts upon the nervous system, already laboring under the strain of
the persuasion that an incurable disease is present, and the
consequence is a whole series of nervous and often mental symptoms,
especially of the depressive kind, that still further disturbs
digestion, interferes with peristalsis, causes constipation or
alternate constipation and diarrhea, leads to wakefulness at night,
inability to concentrate attention and a constant state of worry. All
this reacts upon the system and further increases the diabetes, that
is, the inability to use sugar properly, and adds to its elimination
through the urine.
Favorable Suggestion.--Just as soon as these patients realize that
people have often had considerable quantities of sugar--two per cent.
or more--in their urine for years without serious consequences and
that most diabetics die, not from the affection itself, but from
intercurrent disease, the reassurance of mind which ensues makes their
nervous system cease to be a factor in the further disturbance of
metabolism and they are able to consume more starch and sugar without
increasing the amount of sugar in their urine. This is not true, of
course, for the severe diabetes that attacks young people. These run a
rather rapid course and usually end in from one to two years in
diabetic coma or some complication connected directly with the
diabetes.
Danger of Over-treatment.--To strive to keep the urine of diabetic
patients free or nearly free from sugar is practically always sure to
produce a serious effect upon general nutrition and to disturb the
patient's mind and nervous system. Very often, however, an attempt of
this kind is made. Doctors who suffer from diabetes are too prone to
watch their urine carefully from day to day and this only emphasizes
their solicitude about themselves, impairs their digestion, and
produces such preoccupation of mind that all their functions are sure
to be disturbed. After a time they learn that their general condition
is a more important question than the amount of sugar in their urine.
If they can maintain their weight with reasonable freedom from the
secondary symptoms of diabetes, then the primary symptom--the amount
of sugar in the urine--may be almost or quite neglected.
{498}
Interval Treatment.--Van Norden has pointed out that if diabetic
patients are occasionally made to observe for a couple of weeks at a
time an absolute diet, these intervals seem to form a new
starting-point for metabolism and enable the patient to increase his
power of utilizing sugar and consequently to diminish his pathological
elimination of it. Patients look forward with interest to these
periods, provided that in the intervals they are allowed a certain
amount of starch; and each one of them seems a landmark on the road to
recovery. There is a strong element of suggestion in this that acts
very favorably and greatly influences the actual power of such
intermissions to help nature recover her lost metabolic faculties.
This is certainly a better method of treatment than the attempt to
keep up an absolute diet which so easily produces the other evil of
nervousness that adds to the diabetes, so that there is question of
choosing between two evils, and the lesser evil includes particularly
the reassurance of the patient.
The Individual in Diabetes.--While diabetes is a question of
glycosuria and usually of hyperglykemia, and the consumption of any
form of cane sugar or of starch convertible into it, will usually
increase the diabetic tendency, not all the forms of starch which may
change into cane sugar have the same effect in all individuals or
undergo the same modifications. Some patients, for instance, stand
milk better than others and may take large quantities of it so that
there is less craving for starchy foods. Most patients can take
potatoes better than bread even when there is the same equivalent of
starch in each. Those who have been accustomed to potatoes from their
early years sometimes stand them well and may be able to take them
almost with impunity. I have noted in several cases that the Irish and
Scotch, accustomed to oatmeal from their early years, seem to be able
to take notable quantities of this food when suffering from diabetes
without having a marked increase of sugar in the urine.
There are forms of sugar that satisfy the craving of patients for
sweets and may be taken in considerable quantities without seriously
disturbing metabolism. Honey is one of these, its sugar occurring in
the form of mannite, and there are other substances related to it that
probably can be employed to advantage. It must not be forgotten that
what seems to be sugar in the urine of certain patients, that is,
grape sugar, has proved on more careful investigation to be one of the
other chemical forms of sugar. We have a number of cases of pentosuria
on record in which patients were excreting penatomic sugar, but had
not glycosuria, though their urine responded to the ordinary tests for
this. It seems well not only to be sure of the diagnosis in these
cases, but to use what we have learned to make patients feel that
their condition though not curable is by no means hopeless. Care must
be exercised to take advantage of every possible individual
peculiarity for reassurance, for the extension of the diet in any
possible way, and for the satisfaction of the cravings which are so
likely to come to these patients. Some of their craving is really due
to the suggestion that they cannot have a particular article of diet.
Whenever any human being knows that he cannot have a thing, the liking
for it grows by suggestion and then it may become an obsession. To be
allowed even small quantities of it is often enough to enable patients
to overcome this and at least put them in a better state of mind.
Physical Condition.--The most important element in the treatment of
{499} the less severe cases of diabetes is exercise in the open air.
Whatever the ultimate solution of the mystery of diabetes may be,
there is no doubt but that the muscles are an important factor in our
disposal of sugar within the body. The material which is burned up in
the muscles during movement is a form of sugar derived directly from
the starch and sugar ingested. When diabetics exercise freely much
more of their sugar is consumed within the body and much less of it
eliminated through the kidneys than when very little or no exercise is
taken. It is interesting to note the difference in the amount of sugar
in the urine when patients are taking abundant exercise and when they
are taking practically none. Even on a much more liberal diet the
percentage of sugar is likely to be less in the exercising patient.
One of the results of the diabetic scare is likely to be almost a
cessation of muscular exercise. This is partly due to the fact that
one of the results of diabetes in many cases is a sense of fatigue in
the muscles on comparatively little exertion. Indeed, this is
sometimes the first symptom that is noted and that calls the attention
of the patient to the fact that there is something seriously wrong
with him.
This occurs when there is a serious disturbance of sugar metabolism so
that the patient who consumes large amounts of starch and sugar is
excreting most of it. Just as soon as the diet is made a little more
rigid and the sugar metabolism improves, then exercise can be taken
and will benefit the patient. This is particularly true of women
suffering from diabetes whose depression on being told that they are
suffering from an incurable disease tempts them to remain within
doors; the frequent tendency to urination further adds to their
disinclination to go out. Under these circumstances they lose their
appetites, do not sleep well, and become highly nervous, thus
increasing their diabetic tendency. If they are required to go out and
take exercise in the open air and rather long riding or walking
periods every day, their general health will at once improve and the
diabetes will become more manageable. I have seen this happen without
exception even in patients well beyond middle age, and I am convinced
that it is the diversion of mind as well as the salutary tiredness and
thorough oxidation consequent upon outdoor exercise that is the best
possible remedial measure for these cases.
Solicitude.--It is important that diabetic patients should not be
bothered by frequent reports upon their urine. Their improvement and
the reduction of the amount of sugar excreted is at best but slow, and
is subject to many variations. While improvements, especially at the
beginning, are sources of great encouragement, the deteriorations that
are likely to be rather more frequent are prone to overweigh the good
effects and eventual discouragement results. It is not from the urine
but from the general condition that the improvement in the diabetic
condition is to be judged. So long as the patient feels strong, gains
in weight (when they do not belong to the obesity type of diabetes),
the diabetes itself is almost sure to be improving, even though there
may be discouraging periods as regards the amount of sugar eliminated.
Dangers of Rigid Diet--There are more dangers in a rigid diet than in
a certain amount of liberty in the consumption of starches and sugars.
The craving for these becomes so strong as to make life intolerable to
many people unless a certain amount of these substances is allowed. It
is rather easy to manage limitation while it is almost impossible to
be sure that {500} patients will practice absolute denial. Besides,
the almost complete absence of starches and sugars, even though their
place is supplied by the fats, always seems to predispose patients to
the development of the acid intoxication which results in the coma
often so serious an incident of diabetes. It is for this reason
particularly that mild diet regulations are clinically more judicious
than the absolute denial which on chemical and physiological grounds
seems to be the scientific ideal. A rather good therapeutic method is
to have the patients maintain a rigid diet for some ten, fifteen or
twenty days and then leave them practically without restrictions for
the rest of the month. Continuous restriction of diet becomes
appalling. Looking forward to a period when they can eat as other
people do relieves the tedium, and makes it much easier to keep the
restrictions. The mental influence of this moderate treatment is very
favorable and encourages the patients in the thought that after all
their disease is not so serious. This is the most important element in
psychotherapy.
CHAPTER II
GRAVES' DISEASE
Graves' disease, sometimes called Basedow's disease, though the Irish
physician has a right to the name by priority, is often called
exophthalmic goitre, because this term is descriptive of the two most
marked symptoms. It must not be forgotten, however, that there are
cases in which there is no exophthalmos and even no goitre, at least
no enlargement of the thyroid gland that can be demonstrated
externally. It is said that in these cases there must be an
enlargement of the thyroid bound down by fascia and concealed by other
structures of the neck so that it does not appear externally. It is
probable, however, that there are cases of true Graves' disease
without enlargement of the thyroid yet with the characteristic tremor,
rapid heart and the mental symptoms of the affection.
Etiology.--The symptoms of the affection often develop after a period
of excitement or worry, or at critical times in life, if sorrow or
misfortune proves a burden. Responsibility sometimes has a like
effect. I have seen a woman patient on several occasions in the last
fifteen years develop marked symptoms of Graves' disease when she was
placed in a position of responsibility involving worry, while in the
intervals when pursuing a simple ordinary life without trouble of mind
no symptoms were present. Occasionally a fright seems to be at least a
predisposing cause for the development of the symptoms. Emotional
strains, mental stresses, play a large part in occasioning Graves'
disease, though the cause of it is probably deeper in some structural
defect. In recent years nearly all the medical attention has become
concentrated on the idea that the disease is primarily due to
hyperthyroidization. More detailed study, however, has shown that
other ductless glands are probably also concerned in the etiology. The
adrenals particularly seem to be associated closely with the thyroid
and Graves' disease may be due to some disturbance of the
co-ordination between these glandular systems. The thymus gland is
usually {501} persistent in these cases and this must represent
something in the affection and at one time the use of thymus substance
for therapeutic purposes seemed to confirm this idea. The parathyroids
have also been called into question and their use in therapeusis seems
to justify this to some extent, though probably we know too little
about them to be able to say anything definite in the matter.
Even though the affection may be due directly to hypersecretion of the
thyroid, it is possible that the mental and nervous state may be
closely concerned in the etiology. Some patients have had an enlarged
thyroid for years, without any symptoms of Graves' disease. Then
during a time of stress and worry or anxiety and responsibility
symptoms of the affection develop. The circulation of the thyroid is
under the control of the cervical sympathetic. It is possible that
this may be affected by states of mind to such an extent as to cause
an increase of the circulation in the thyroid and as a consequence
more of the thyroid secretion may get into the blood stream and
produce its effect. Under these circumstances anything that would
allay the excited mental condition and thus neutralize the unfavorable
effect of the cervical sympathetic would cure or at least relieve
Graves' disease.
The affection is about five times as frequent among women as it is
among men. This has sometimes been attributed to the fact that there
seems to be some more or less direct correlation between the sex
organs in women and the ductless gland systems. It has often been
pointed out that the thyroid is likely to be engorged at the time of
menstruation and, indeed, there are those who have attributed some of
the symptoms of tremulousness, irritability, and tiredness at this
time to over-functioning of the gland. In women who have borne a child
the thyroid is usually somewhat enlarged. Good authorities in
obstetrics have insisted that they could pick out of a group of women
in evening dress, those who had borne children, from the appearance of
their necks. Probably this is an exaggeration, but there is no doubt
that the thyroid is intimately related to the genital functions in
women. It has been said that a direct connection could be traced
between disappointments in love or in sexual matters and the
development of Graves' disease. To put much stress on this would
easily lead to mistaken conclusions, though it represents a principle
that should be recalled in certain cases of the affection. The
frequency with which slighter disturbances of the thyroid occur in
connection with the common genital incidents of female life and their
comparative insignificance for health or strength, should make for the
holding of a not too serious prognosis in the affection.
Symptomatology.--There are four cardinal symptoms of the disease:
rapid heart action, tremor, enlargement of the thyroid, and
exophthalmos. At least two of these are largely dependent on mental
influences. There are certain accompanying symptoms that are of
importance and supposed to be connected directly with the disease,
though oftener they can be traced to the influence of the state of the
patient's mind upon the organism. Emaciation is common. It is due to
the fact that the appetite is likely to be seriously disturbed by
anxiety and solicitude. Anemia develops as a consequence and there may
be slight fever which is sometimes inanition fever. Attacks of
vomiting and diarrhea occur intermittently and sometimes there is
constipation. The disturbance of eating consequent upon the affections
seems largely {502} responsible for these. The disturbance of the
vascular system gives rise to flashes of heat and cold and often to
profuse perspiration. Certain of the symptoms of the menopause can be
compared rather strikingly with those of Graves' disease and have been
attributed to the disturbance of the external secretion of the ovaries
which are now known to act as ductless glands as well as genital
organs.
With the exception of the enlargement of the thyroid and the
exophthalmos, all of the symptoms of Graves' disease are of a kind
that can be produced in states of excitement with nothing more present
than a functional neurotic condition. It is true that the tremor is
characteristic and differs from that of hysterical patients, being
finer and at the rate of a little more than eight to the second. The
rapid heart action, however, and the disturbance of the general
circulation which causes flushing and pruritus and the sense of
nervousness, as if the patients were in a constant state of fright,
are always characteristically neurotic. The changes in disposition,
often in the line of irritability, sometimes with severe mental
depression, seem in many cases to be only a mental reaction to the
patient's solicitude. The weakness of the limbs which sometimes
amounts to a giving away of the legs, is connected with the tremor,
but seems to be neurotic rather than of any more serious character. In
spite of all our study of the affection its place among the neuroses
must still be reserved for it, at least as regards many cases, and its
treatment must be conducted with that idea in mind.
Diagnosis.--The disease is easy to recognize when fully developed. At
the beginning of cases, however, and in certain abortive types of the
affection which the French have called _formes frustes_, the diagnosis
may be difficult. Usually the first symptom is tremor and this of
itself will often serve, especially in association with general
symptoms of nervousness, to make the diagnosis. Tremor with
tachycardia puts the case beyond doubt, as a rule, though of course it
must not be forgotten that hysteria may simulate rather closely this
much of the disease.
The abortive types of the affection are important because they
masquerade as forms of psychoneurosis, hysteria, and the like, though
the patients are not suggestible, have very definite, not variable,
symptoms and get better and worse according to the variations in the
underlying affection. Occasionally they seem to be associated with
certain other forms of neurotic conditions, especially those with
vascular disturbances. There may be tinglings in the ends of the
fingers, occasionally with suffusion, erythromelalgia--Weir Mitchell's
disease--and even a tendency to the white "dead fingers" as the French
call them, of Raynaud's disease. It seems not unlikely that further
study will show that many of these affections involving disturbances
of the vasomotor system are connected in some special way.
Prognosis in Young Patients.--Some of the cases, especially in young
people, are likely to seem quite discouraging and apparently to
justify even a serious operation. I have in mind a young woman seen
some fifteen years ago when she was about seventeen. The prominence of
the eyes, the enlargement of the thyroid, the tremor and the rapid
heart were all marked. The symptoms had been growing worse for over a
year and the outlook was serious. Ten years later I saw her in another
city in perfectly normal health, married and happy and the mother of
two healthy children. The only trace {503} apparently of the
disturbance of the thyroid to be noted in the family was that her
children got their teeth very late, her first child, a boy, not
cutting his first tooth until after he was fifteen months old. In
every other way, however, the boy was perfectly well, rugged and
strong, having passed through his summers without any serious
disturbance and not being a particularly nervous or excitable child.
Such complete relief from symptoms after the condition had been so
grave would ordinarily have seemed quite out of the question. It
emphasizes the fact that for Graves' disease as it occurs among young
growing people, where perhaps the thyroid does not grow in proper
proportion to the rest of the body, but for some reason overgrows, the
prognosis of the case may seem to be much worse than it really is.
Treatment.--The story of the various methods of treatment that have
been reported as successful for Graves' disease serve to show very
well how much the affection must depend upon psychic and neurotic
conditions, for most of them have been positive in action at the
beginning when their suggestive influence was strong, and quite inert
after they had lost their novelty and their power to influence the
mind. Sometimes even slight operations as on the nose, the removal of
polyps, or of a spur on the septum, or an enlarged turbinate, have
been found to bring relief of the symptoms of Graves' disease even in
marked cases. Operations upon the tonsils have had a like effect and
even shortening of the uvula has been reported as curative. A
generation ago applications of iodin to the goiter were reported to
have good effects. In lancing the goiter, sometimes evidently a cyst
was punctured, but sometimes the lance was only followed by a slight
issue of blood, yet the affection was favorably modified. More serious
operations have followed by complete relief of symptoms for a time,
though relapses are not infrequent and occasionally the patient was
not relieved, though apparently all the conditions present were
similar to those of other patients in whom the operation produced
excellent results.
The medical treatment of Graves' disease demonstrates interestingly
the power of suggestion. About fifteen years ago a distinguished
English observer announced that he was getting good results in the
treatment of Graves' disease by the administration of thyroid
substance. At that time our present theories with regard to
hyperthyroidization as the etiology of the affection had not been
formulated, though some vague connection between the thyroid secretion
and the symptoms had been accepted. A number of patients were improved
by taking thyroid. Other observers found, however, that not only were
their patients not improved, but they seemed to be worse as the result
of the thyroid feeding. The English physician therefore was asked to
say exactly how he obtained his material and prepared it for his
patients. Organo-therapy was then new and it was found that the orders
given to the butcher for thyroid had been filled by him according to
the directions by furnishing portions of a large gland situated in the
neck of the calf. This was the thymus, and not the thyroid. Thymus was
then deliberately used for a while and there were some reported good
successes while the treatment was new and strongly suggestive. After a
time it proved to be of no avail.
A number of biological remedies were tried after this. Personally,
after having made some studies of the parathyroids while in Virchow's
laboratory, I resolved to try material from those glands. The first
two patients to whom {504} the material was given, with a careful
explanation of the theory on which it was administered, proceeded to
obtain relief from their symptoms and an intermission in their
disease. Just as soon as I purposely omitted to explain to patients
how much might be expected from this new remedy and failed to make
suggestions founded on the parathyroids, no improvement was noted. In
the first two cases this had been more or less necessary in order to
determine whether the patients could stand the doses suggested, which
began very low and were gradually increased. The material seemed to
have no ill effects, however, and a definite dosage could be used
without the necessity of taking patients into one's confidence.
A number of serums of one kind or another were reported as beneficial
for Graves' disease. It was admitted that they did not benefit all the
cases, but that in certain cases they did much good. Practically all
of these were strikingly more efficient in their discoverers' hands
than when used by anyone else. Thyroids were removed from animals and
after some time serum from these animals, supposed to be of lower
thyroid content, was injected into human beings with the idea of
reducing the hyperthyroidization or perhaps neutralizing it by some
substance present in the serum. One very interesting observation on
most of these cases deserves remark. The animals deprived of their
thyroids, such as goats and sheep, lived on absolutely unhurt by the
operation, and as one experimenter expressly noted, sold for more
money after being kept for a year under observation than they had cost
him before dethyroidization.
Most of our biological remedies for Graves' disease then are strongly
reminiscent of the therapy of the affection in older times. It was
particularly for Graves' disease, or at least for nervous symptoms
closely resembling Graves' disease--those of fright, nervousness,
irritability and tremor--that various more or less terrifying
procedures and particularly deterrent substances were employed in
medicine. These patients, for instance, were cured by the touch of a
hanged criminal, and particularly by the touch of their goiter to the
mark on his neck. It was especially for them that _Usnea_, the moss
gathered from the skull of a criminal who had been hanged, was of
benefit when administered internally. Mummy as a remedial substance
remained in common use until well on into the latter half of the
eighteenth century in England.
In older times a dead snake wrapped around the neck was said to be an
excellent remedy for goiter and especially those cases of goiter that
caused symptoms of fright and nervousness. Evidently anything that
produces a strong effect upon the patient's mind may prove helpful.
Perhaps the suggestion enables the mind to control the cervical
sympathetic and by that means the circulation in the thyroid gland,
thus lessening the amount of blood that flows through and therefore
the amount of secretion that is carried out. There is no doubt but
that the sympathetic is largely under the influence of the emotions
and that through it very important effects may be worked out in
various structures. There seems no other possible explanation for the
uniformly reported success of remedies when their suggestive power is
strong and their failure quite as invariably later even in the same
cases.
_Operations_.--In recent years operations for the removal of portions
of the enlarged thyroid have become popular and some very successful
results have been reported. Those of us who know how easy it is to
influence the minds of {505} patients in Graves' disease favorably
hesitate as yet to pronounce definitely with regard to the indication
for operation except under such conditions of pressure in the neck or
projection of the eyeballs as may lead to serious symptoms. Not all
the operators have been as successful as some who made a specialty of
the affection. I have personal information which shows a number of
unsuccessful cases after operation and the records of conservative
surgeons as published indicate this. Unfortunately, a great many cases
have been reported within a few months as cured; if they were
comparatively without symptoms, surgical intervention is considered to
have been eminently successful. For, be it noted, very few are
entirely without symptoms, even after operation.
Dr. William H. Thompson in his book on "Graves' Disease" points out
that even so good an operator and so thoroughly conservative a surgeon
as Kocher reports cases of Graves' disease as cured, which are still
exhibiting symptoms that would make the medical clinician hesitate to
agree with him and, indeed, rather lead him to expect that under the
stress of worry and excitement there may be redevelopment of the
symptoms. As the number of cases operated upon has increased there has
been a growing feeling that relapses might be expected in certain
cases even after removal of large portions of the thyroid gland. The
fact of the matter is that we do not understand as yet what is the
underlying pathological significance of the symptoms grouped under the
term Graves' disease. When there are severe symptoms, as extreme
exophthalmos, greatly enlarged thyroid pressing upon the important
neck structures, or serious disturbance of nutrition, an operation is
always needed; but as yet we cannot be sure that it will produce even
complete or lasting relief.
Many patients have been greatly benefited by operation, some of them
perhaps permanently, but we need more of the after-history of these
patients covering a long period of time, to be sure that the results
flow entirely from the operation. There was a time when operations
were reported as doing quite as much good for epilepsy as they are now
for Graves' disease. As we have pointed out, a number of operative
procedures that had nothing to do with the underlying basic pathology
of the disease have proved the occasion for considerable improvement
or sometimes what might be called a cure for a prolonged period. We
can be sure, as a rule, that patients will be benefited immediately
after operations. The rest, with care, the strong suggestion, the
aroused feeling of expectancy, the confidence in the surgeon, all this
would do much of itself. It remains to be seen how much more than this
the operation does.
_General Condition_.--The treatment of patients suffering from Graves'
disease consists largely in having them take up some occupation that,
while reasonably absorbing, does not make too great a demand upon
them. Often when they complain most of their symptoms they are below
normal weight and the first indication is to have them brought back to
it. I have seen such cases over and over again almost entirely without
symptoms when they were up to normal weight and with a good many
symptoms when they were below normal. It would be easy to theorize as
to why this is so, but the observation is the most important
consideration for practical purposes, and we are not yet in possession
of enough scientific knowledge with regard to the thyroid or {506} its
possible connection with other organs that have an internal secretion,
to be able to say anything definite about it.
After weight and nutrition the most important indication is sleep. It
is impossible for patients to get along with less than eight or nine
hours of sleep. Most of them are much better if they have nine or ten
every night. Late hours are particularly prejudicial to them. They are
tired if they have been on their feet all day and they should be
encouraged to take more sleep than others. Sleep is one of the most
important considerations for sufferers from the abortive forms of
Graves' disease and they must be encouraged to take it in the quantity
that they need. This can only be decided by their feeling.
_Diversion of Mind_.--Much more than other nervous people these
patients need encouragement and require diversion of mind. They are
prone to be discouraged, rather tired, and easily tempt themselves
into a routine in which there is little recreation and no diversion.
For them more than for most other patients it is necessary to
prescribe that twice every week they shall have some engagement
different from their ordinary routine to which they look forward for
several days. This looking forward to a break in the routine does much
to make life more livable for them and must be encouraged in every
way. As to what the diversion is to be must depend entirely on the
character of the individual. Some find complete diversion of mind in
the theater or even in vaudeville. Others are bored by this after a
while and need other recreations. I have known people who were bored
by the theater find an evening a week spent in helping a poor person
or an afternoon devoted to a visit to a hospital ward or to an ailing
friend an excellent diversion. Some of those who do not care for the
theater like music and are helped by it. As a rule, however, one must
be careful about the indulgence of music for neurotic people since it
seems to exert a serious emotional strain on many of them and as the
phrase goes "takes a good deal out of them." This is particularly true
for younger people who have a passion for music. Older people may be
trusted more in this matter and the attendance on concert and opera,
which is looked upon as a social duty by some, giving them an
opportunity to greet friends and to display their gowns and jewels, is
a harmless diversion of mind.
_Mental Treatment_.--Graves' disease is, then, as we have said,
especially likely to be influenced by the patient's state of mind.
Nothing disturbs patients more than the declaration sometimes made by
physicians that their condition is incurable or that they will have to
doctor for it for many years. This must be avoided because our present
knowledge does not justify any such positive declarations. Most cases
of Graves' disease, while not particularly amenable to treatment by
specific drugs, are very much improved if the patient's general health
is brought up to the best standard and if all sources of worry and
emotion are eliminated, as far as possible. Nothing is more serious
for them, however, than the suggestion that they will not get well.
Probably no one has ever seen a mild case of Graves' disease that did
not improve so much as to be practically well after the lapse of some
time. Recurrences take place, but if all sources of worry and
irritation of the digestive tract and over-tiredness are removed, then
patients will stay free from their symptoms for surprisingly long
periods. Old people do not have these {507} favorable remissions so
much as the young, but under twenty there can be, as a rule, definite
promise of decided improvement and sometimes of results that seem like
complete cure. For patients under thirty there is every reason to
think that if they are in a run-down condition when the disease is
first noted remissions of symptoms can be looked for lasting for long
periods, during which they will be comparatively well.
_Diet Suggestions_.--The changes in diet necessary to bring
improvement in Graves' disease are different for individual patients.
Prof. Mendel, in Berlin, found in his extensive experience that meat
does not seem to be disposed of well by these patients and acts
somewhat as an irritant. He reduces the meat taken and usually allows
it at but one meal. If patients get on well as vegetarians, meat is
gradually eliminated from their diet. On the other hand, there are
patients who seem to develop Graves' disease during a vegetarian diet.
Very often it will be found that there is an intermittent constipation
and diarrhea in these cases, and that the bowels will act much better
if a certain amount of meat is given, and then the symptoms of Graves'
disease remit, as a rule. As in most of the major neuroses, as is
known so well in epilepsy, any irritative condition of the digestive
tract will surely revive neurotic manifestations and make many of the
major neuroses much worse than they were before.
{508}
SECTION XV
_ORGANIC NERVOUS DISEASES_
CHAPTER I
PSYCHOTHERAPY OF ORGANIC NERVOUS DISEASES
Since we know that the basis of many nervous diseases is an
obliteration of certain cells of the brain or of the spinal cord, or
certain tracts of the central nervous system through which impulses
must pass if they are to be effective as motion, sensation or function
in some other form, we realize that we cannot recreate these portions
of highly organized tissue and that therefore organic nervous diseases
are beyond the action of any remedies we now know or may even hope to
discover.
The development of pathology has shown us that once there has been
serious nephritis or cirrhosis of the liver certain portions of the
glands are destroyed and therefore there cannot be any question of
cure. There is no possibility of redintegration of destroyed tissues
when they are of highly organized character, and so the patient will
always be maimed. One might as well talk of causing an amputated
finger to grow again as talk of curing diseases that involve
destruction of specialized cells. When this first dawned on modern
medicine as the result of the careful study of pathology a period of
therapeutic nihilism developed during which physicians trained in the
pathological schools were prone to distrust drugs entirely, or at
least to a very great degree. The effect of this wave of nihilism has
not entirely disappeared in our time, though we have learned that even
where serious damage to an organ has been done by disease we may still
hope to compensate for defect of tissue by stimulation of other organs
and to replace its function by certain physiological remedies or
biological products; and if we can do nothing more, we can at least
alleviate the symptoms which develop as a consequence of the organic
affection.
Nature's Compensation.--Physicians are prone to forget nature's
wonderful powers of compensation. Apparently even some regeneration
may take place in diseased organs of highly organized type if the
patient's general condition is kept up to its highest point of
nutritive efficiency. How far this may go we do not know, but
observations show some marvelous examples of unexpected regeneration.
These counteracting processes can be stimulated sometimes by drugs,
but oftener they can be best brought into play by keeping the patient
in just as good condition of body and favorable condition of mind as
possible for a prolonged period, so that nature accustoms herself to
the defect and her powers of compensation have full play.
{509}
Unfavorable Suggestion.--What is true of organic diseases of all kinds
is especially true of organic nervous diseases, and in spite of the
fact that most of these are essentially incurable, so much can be done
for patients that their condition is made more tolerable and indeed
some of them improved to such an extent that they consider themselves
quite relieved of their organic affection. One of the most serious
burdens that the patient laboring under an organic nervous disease has
to suffer is the consciousness drummed into him by successive
physicians, by his reading, and by every possible means of suggestion,
that his malady is incurable. This makes every symptom as severe in
its effects as it can possibly be. Hope does not buoy up and
discouragement weighs down every effort of the organism to compensate
for the serious defect under which it is laboring. Nothing can be done
for the disease itself, but much can be done for the patient. Many of
the symptoms from which the patient suffers most are really due to his
own discouragement, to that sluggish condition which develops in his
body as a consequence of his lack of hope, to the absence of exercise
and of air and of diversion of mind consequent upon the gloom that
settles over him when he is told that his condition is incurable.
_Adventitious Symptoms_.--If the adventitious symptoms that are always
present in cases of organic nervous disease are eliminated, if the
conditions which develop from the unhygienic condition in which the
patient lives because of his discouragement and retirement are
removed, as a rule he feels so much better that it is hard to persuade
him that some change has not come in his underlying nervous disease
and that a process of cure is not at work. It is because of this that
irregular practitioners so often succeed in apparently doing much more
for these patients than the regular physician. The irregular does not
insist on the incurability of the disease, but, on the contrary, he
promises a cure. He then proceeds to relieve many bothersome symptoms
that are quite extraneous to the underlying disease, but thus makes
the patient ever so much more comfortable than before, gives a
cheerful air to his life for a time, makes him sleep better as a
consequence and it is not surprising that the patient thinks that his
disease has been bettered, if not cured.
Suggestive Prophylaxis.--While we are optimistic just as far as
possible since genuine nervous disease has declared itself, it must
not be forgotten that we can by suggestion and warning often prevent
or delay the development of nervous degenerations. This, too, is
psychotherapy and must be employed wherever it seems advisable.
Post-syphilitic nervous conditions of so many kinds are likely to
develop that it is important to warn the patients who are sufferers
from this disease from taking up the more strenuous forms of
existence. This may seem an exaggerated view of the condition, but it
is amply justified by the results of the opposite rule of life in
almost any physician's experience in city practice. A man who has had
syphilis must be warned of the danger, one may almost say likelihood,
if he takes up any of the professions in which there is much mental
strain and nervous worry, that he will almost surely not live out the
normal span of life without some serious nervous incident. Locomotor
ataxia, and, above all, general paralysis develop, as a rule, in men
who, having had syphilis, have some occupation in life that calls for
considerable mental strenuosity, and involves excitement and worry.
Actors, brokers, soldiers and sailors, speculators of all kinds,
race-track gamblers, these are the classes from {510} which victims of
paresis and locomotor ataxia are particularly recruited. People who
have suffered from syphilis and who live the ordinary unemotional life
of a teacher, or a merchant, or a writer, do not, as a rule, develop
the postsyphilitic and parasyphilitic conditions.
Precocious apoplexy is especially likely to occur in patients who have
had syphilis and who have then spent themselves at very hard work. I
doubt if hard work alone, without some such antecedent condition, ever
produces this result. Of course, it is not alone syphilis, but other
serious conditions which affect the nervous system that ought to be
guarded against in this same way. If there has ever been any affection
of the kidneys, as a complication, for instance, of scarlet fever,
then it has always seemed to me to be the duty of the family physician
to warn such patients that their kidneys are more prone than those who
have not suffered from such an incident to break down under any severe
strain that may be put upon them by worry, especially worry following
a period of strenuous work. In these cases the affection of the
kidneys nearly always makes itself felt in the nervous system, and
especially in the brain, and so this warning has a proper place here.
Where there has been severe cerebro-spinal meningitis this warning
seems also to be needful, though here our records have not been kept
with sufficient care to enable us to speak positively of the necessity
for the warning.
Treatment.--It is important to remember that as physicians we do not
treat disease but patients. We _care_ for patients, that is the real
etymological significance of the Latin _curare_, we do not cure
diseases in the modern sense that has come to be given to that term,
of completely removing the _materies morbi_ and setting the patient on
his feet once more just as well as he was before his illness.