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.
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. Brücke in 1851 established the influence of the nerves on the color of the chameleon and of the frog, and there have been many confirmations of his work. Pouchet, in 1876, in the Journal de l'Anatomie et de Physiologie proved that fish gained the power of changing color by practice and lost it by disuse. The influence in most cases, animal and human, which produces pigmentation is exerted by the nervous system through the vascular supply. The duskiness that sometimes comes with emotion, the pallor that accompanies strong mental disturbance, as well as the blushing states, show that the vasomotor system can be influenced in every part. Pigmentation often seems only a consequence of local continuance of such disturbance. Many of the feminine patients in whom even deep discolorations around the eyes occur in connection with menstruation are typical neurotic individuals. It is worry in combination with the physical disturbance that produces the pigmentation. There are some cases on record where emotional states have caused loss of pigment in the negro or other colored races, or in the hair, as when, in well-substantiated cases, people's hair has become white in a single night. In every case of pigmentary disturbance, then, the individual must be carefully studied and as far as possible all emotional disturbance must be eliminated. Without this other treatment usually fails.
Pruritus.—Pruritus in the old is often a bothersome symptom. All sorts of remedies, internal and external, are recommended for it and successes are reported with them. Whenever there are many remedies for a symptom complex, it usually means that the suggestive element in all of them is large. For pruritus the influence of the patient's mind is extremely important. Often it will be found that these old patients are getting out scarcely at all, but are living in close confinement in their rooms, the air of which is scarcely ever changed. I have known even the keyholes to be stuffed and arrangements made by which the cracks between the door and the frame were rendered impervious to air. In these cases the most important feature of any treatment is to secure a proper amount of air. Sir Henry Thompson, the great English surgeon, in his advice how to grow old successfully, written when he himself was over 80, suggested that the cells of the skin needed an air bath every day. He advised that men should make all their toilet arrangements for the day without any garments on. Washing, the preparation of clothing, shaving, and whatever else was done in the early morning was to be accomplished after the night clothes were taken off and before other clothes were put on. He lived to be well above eighty and was sure that this practice had been of help to him. Stimulating rubbings, if done gently and without the production of too much reaction, will always benefit these people.
If old people have no interest, nothing that attracts their attention, and if they once develop pruritus their mind gets concentrated on their cutaneous sensations and it will be impossible to relieve them by any treatment until their minds get occupied with something else. Anyone who wants to sit in a chair for a few minutes and think about his cutaneous sensations will soon realize how vividly these can be brought to mind and how annoying they can become. To sit and think of a portion of the body is to want to scratch it before long. Scratching produces a flow of blood to the surface that adds to the itchy feeling. The only way to get away from it is to get the mind {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.
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.
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.