PSYCHOLOGICAL ASPECTS OF DERMATOLOGY


The characters or personalities of these three patients contained similar features, and their experiences prior to the outbreak of illness were strikingly alike. They were upright and good – living men keenly conscious of their own virtue and rectitude; the skin disease followed closely some disaster; and, in the belief that their misfortunes were utterly undeserved, they harboured an acute sense of injustice.


Mr. President, Ladies and Gentlemen,

Firstly, I wish to express my thanks and appreciation for the great honour, of which I am quite unworthy, entailed in the privilege of addressing this Congress.

My interest in the importance of psychological factors in the aetiology of skin disease was aroused initially by a conversation with Dr. J.L. Halliday in the course of which he described his findings in three consecutive cases of dermatitis. All three were men in late middle life. None had a history of dermatitis. In each the onset had been dramatic in the rapidity with which the eruption had spread over the body surface and the failure of the methods of treatment hitherto employed to bring about alleviation.

The characters or personalities of these three patients contained similar features, and their experiences prior to the outbreak of illness were strikingly alike. They were upright and good – living men keenly conscious of their own virtue and rectitude; the skin disease followed closely some disaster; and, in the belief that their misfortunes were utterly undeserved, they harboured an acute sense of injustice. Halliday approached the problem by applying the principles of aetiology now associated with his name, and later labelled the condition, “Jobs Dermatitis”.

Many of you will no doubt be familiar with these principles and their value as a guide to the student of cause and effect. They contain these questions to be answered by the diagnostician who concerns himself with aetiology.

1. What kind of person is this?

2. Why did he take ill when he did?

3. When did he take ill how he did?

4. What purpose does the illness serve?

5. What is the prevalence of the illness?

This association of ideas – Job and dermatitis – was brought back to his memory when some months later I encountered the following persons.

CASE I.

A Jewish storekeeper, aged 66, had had extensive “eczema” for three years. Almost the whole of his skin had been involved at one time or another. The onset had been sudden and the dermatitis had spread rapidly, accompanied by intolerable itching. In the first year he had consulted his family doctor and three or four dermatologists. In the past two years he had attended weekly at an outpatient department.

Life Situation.

He was living alone in a single apartment, Twenty – five years ago at the age of 41, he had married a beautiful girl aged 17, an orphan without dowry. Five months after the marriage she had given birth to a daughter – not his child. He had forgiven her and brought up the child as his own. He had lavished kindness and money on both wife and daughter.

He had been successful in business and owned two retail shops besides having an interest in a wholesale establishment. Except for a few hundred pounds, he had placed all his assets, including his business, in his wifes name. Five years ago, when he was 61, she, then aged 37, had formed an attachment with another man, is possessed her husband of his entire fortune, and sacked him from his own business, Litigation had followed and dragged on for two years. His capital has been exhausted, which prevented him from contesting the matter further. At this point his skin eruption had made its first appearance.

As he related his story, he repeatedly emphasized his goodness to his wife and the rectitude of his past life. He seemed also to link his past business and material success with his righteous way of living.

Treatment.

In the course of discussion I said to him, “You will no doubt have heard of Job?” He replied, “Doctor, I was born and brought up in Russia. I knew the book of Job almost by heart before I was 14 years old.” I said, “Then you will remember that he was the most prosperous man in the land and that he regarded his great wealth as no more than a just reward for his righteousness? And you will remember how thieves and robbers stole his flocks and herds and burned his crops, and how a whirlwind destroyed his seven sons and three daughters.

You will remember also how his soul was torn in pieces. It was beyond his comprehension how such disaster could befall a man so good as he, who believed the tall of his riches was the measure of his righteousness. You will remember what happened to him. His body itched and oozed intolerably. so has yours.”

He was greatly moved and said nothing for a few minutes. Then with tears in his eyes he informed me that I was the first person to give him some inkling into the real nature of his trouble.

Late in the evening of the day on which this interview occurred, his friend, who had sent me to him and who vouched for the truth of his story, in a state of great agitation and indignation, informed me, that an hour or so after my visit, two psychiatrists, sent by the patients wife, had called, certified him insane and removed him to a mental institution. This step was taken because of his behaviour on the previous day when he had hurled a brick through the plate glass window of one of the furrier shops formerly owned by him and where his wife was then attending to customers.

About a year later I learned that, after a flare up of the dermatitis during the weeks following my discussion with him, the skin condition had settled down and that there had been no recurrence. No medicine had been administered by me.

This case tended to confirm Hallidays hypothesis in respect of the first three fields of inquiry, namely, the kind of person he was, the time of onset and the mode of illness. Having experienced strongly and over a lengthy period of time an emotional constellation centered on the belief that he had been most unjustly wronged, his bodily reaction had apparently been dermatitis.

What of question 4 – What purpose does the illness serve? After a period of rumination I asked myself one day, “Why do we weep when we do?” The answer seemed to be that, when we look at something too sad to bear, tears fill the eyes with the purpose of shutting out the painful scene, thereby protecting the integrity of the central nervous system in its highest and perhaps most delicate form of functioning.

It seems reasonable enough, in the present connection, to advance the suggestion that dermatitis with its wealth of distracting unpleasant sensations could be viewed as a physiological mechanism, analogous to weeping and evolved to preserve the sanity of a mind obsessed with an intolerable load of a mixture of self – pity and anger. If this assumption is correct one would anticipate an ebb and flow on the part of the eruption as the intensity of the feelings aroused by Fates harsh blows were forgotten or recalled to memory. This in fact occurred in this case.

Finally a correlation between the emotional state discussed above and dermatitis could not be fully established unless it fulfilled the law of prevalence, that is, gave an answer to question 5. Is it possible from the study of a service of cases of dermatitis to uncover in them a more than average incidence of resentment, self – pity and anger. From my own experience of patients with the disease I believe that his is so. For example, I know of no group of patients less disturbed by the likelihood of hurting the feelings of their medical advisers.

They are foremost in suggesting to their general practitioners that they should be referred to a skin specialist, brazenly implying incomparably greater merit in such a personage. In quick succession they will consult one therapist after another, invariably being more ready to criticize than to praise his predecessor. When one dares, after history taking, to infer that the cause of the illness might lie in the patient himself, there are no patients so likely to demonstrate their high content of aggression in their being intensely allergic to the merest whisper of weakness in themselves. They do this not only by personal demeanour, often reaching rudeness, but by exhibiting an aggravation after interview.

INITIAL EXACERBATION AS RESPONSE TO

PSYCHOLOGICAL APPROACH

In the early days of my association with homoeopathy it had been put to me that the aggravation of symptoms so often encountered after the administration of medicine, amounted to proof of the material activity of the infinitely small dose in a sensitive person. Indeed, it was claimed that this reaction of initial aggravation, not only went far to substantiate the basic principles of Homoeopathy, but also showed a wise choice of drug. I saw no reason to doubt these claims until my experience with dermatitis.

It is my custom in treating a patient with chronic illness to instruct that the administration of medicine commence on the following morning. I found that many of these persons with skin disease exhibited a severe aggravation within seven or eight hours of case – taking, that is, before any medicine had been taken. During the middle nineteen forties when I was very interested in fitting dermatitis into an aetiological pattern, and so, of course, seeing many patients with this affliction, my two partners used to plead with me to lay off these dermatitis people unless I myself were on duty during the coming night!

G. Gladstone Robertson