PSYCHOLOGICAL ASPECTS OF DERMATOLOGY


Psychology, are salutary correctives to such a viewpoint. Through these branches of medicine an effort is being made to assess the extent to which a patients own behaviour is a cause of his illness in the fields of both mental and physical disorders and diseases. It is, therefore, a matter of the utmost importance to have a clear and unprejudiced a concept of mind- body relationship as is humanly possible.


During the last twenty centuries, and partly at least due to Christian teaching, the growth of interest in medicine has tended to parallel increasing compassion and sympathy for the individual, and particularly the weak individual, as compared t the State, and at the expense of its more virile members. The main function of the doctor was to succour the ailing and to make representation on their behalf to the strong. Unfortunately, even such laudable aims as these, if carried to the extreme, can constitute a danger to the continuance of the race as is shown in a pending crisis in this modern age.

Here, over the past dozen years, the healthy has been persuaded not only to share equally their good with the sick but to grant them more than they apportion to themselves. The resources of the fit are being increasingly depleted on the demands of the their sponsors the doctors, the clergy, and the politicians. Innumerable institutions are now occupied in maintaining and perpetuating the existence of hopeless imbeciles, while many a surgical ward is filled with semiconscious invalids of advanced years where, regardless of expense, searching investigations and surgical procedures are carried out with the object of adding a few months to a life that has already run its full.

It seems to me that much of the present unbalanced attitude to sickness stems from a development of medical science whereby the impression is fostered in the man in the street that an illness is a sheer accident, usually a haphazard assault by micro- organisms, for which the patient bears little or no personal responsibility. Psychology, and more recently, the psychosomatic approach.

Psychology, are salutary correctives to such a viewpoint. Through these branches of medicine an effort is being made to assess the extent to which a patients own behaviour is a cause of his illness in the fields of both mental and physical disorders and diseases. It is, therefore, a matter of the utmost importance to have a clear and unprejudiced a concept of mind- body relationship as is humanly possible.

The investigations of many who are devoted to this problem are coloured by instruction they themselves had in the first decade of life. The interpretation of their findings is tied to a faith that the body of man is inhabitated by a soul, psyche or some such supernatural element with the capacity, through conscious or unconscious processes, of adjusting the organism in its entirety to its environment.

The logical sequence of this belief is that in illness the psyche deliberately produces a state of maladjustment or ill-health to serve an end. The psyche thus becomes a somewhat sinister creature for whom it is difficult to retain compassion with the result that psychoanalytical literature constantly exhorts a kindly and sympathetic attitude on the part of the analyst.

Now it is not my intention to waste your time with such highly controversial material as arguments for and against the existence of an immortal soul in the body of man; but I do ask you to consider on some future occasion, dispassionately and at your leisure, the impact on body-mind relationships of the most recent experimental work on the functions of the most recent experimental work on the functions of the higher nervous centres as carried out by Pavlov and his followers. A physiological approach discounts the metaphysical and confines itself to what is known and demonstrable of the functions of the body and nervous system.

In the course of this discourse I have repeatedly made physiological interpretations of mind-body interrelationships. Two further illustrations may help to clarify this method. First, if a dangerous reptile were to appear in this room, that part of mental activity which we think of as free-will could direct our voluntary musculature, notably the limbs, to take protective measures; but this free-will has no direct jurisdiction over what kind of emotions we shall feel or what changes will occur in our endocrines and viscera.

The emotions, which depend on inborn factors and the totality of our past lives, will vary from excitement in one person to terror in another; and the nature of these emotions will determine the visceral changes. It is not in accord with human experience to state that we have the power to remain calm or feel fear at will, or that the rate of our heart beat or activity of our kidneys is under our control. Such claims are based on primitive theological aspirations and are essentially efforts to glorify the psyche.

The second illustration is of the dog, kept chained to a post in a yard for six months, where he is constantly teased by small boys who throw stones. The dog will gradually become vicious, growing especially allergic to small boys with handfuls of pebbles. The degree of viciousness will vary in different breeds of dog and to a lesser extent, among particular dogs of the same breed. A human being so treated would tend to develop similar characteristics.

The season a teased creature becomes vicious is connected apparently with the presence of a physiological mechanism, which, like other physiological mechanisms, came into being in the first place because it had a survival value. When a mode of behavior, like viciousness, is thus acquired by the conditions under which the subject lived it is not easily extinguished. The physiologist could not agree that viciousness in dog or man is the product of a psyche electing to be wicked.

So far as dermatitis is concerned, this disease could be viewed physiologically as a skin reaction to the repetitive effect, in some people, at least, of resentment, self-pity and anger. As, in all likelihood, the illness has survival value, it is doubtful if the patient would be benefited by removal of the eruption, were this possible, before the offending emotional state had subsided. The problem is further complicated in long-standing cases by the possibility, perhaps through late infection by micro-organism, of irreversible skin damage which may maintain the eruption despite changes in the emotional tone.

TREATMENT

In the Oxford Dictionary treatment is defined as “action or behavior towards a person” and as “management in the application of remedies.”

Therapists of varying persuasions advocate many different methods of actions towards sick persons, some with and some without the use of material remedies; and all claim, no doubt justifiably, a considerable measure of success. Although even those techniques which are most hallowed by time and by the greatest number of followers often appear mutually irreconcilable when taken at their face value, they will, I think, readily be seen have a common factor when viewed in the light of the central theme of this paper.

If it is true that a particular constellation of feeling tones is a salient cause of dermatitis, and that it results, not from psychical wishes, but as the response of a person to environmental forces, then any technique which reduces or abolishes the culpable feelings is likely to have a curative effect. Without intending to deprecate the views or claims of any therapeutic body I propose to examine critically a few of the techniques in common usage, and also to appraise the impact of the technique on the feelings and emotions of the patient.

Today the most popular method begins with the consultation when the patient describes his symptoms. This is followed by a physical examination carried out by the doctor which may be extended, if deemed necessary, by the aid of the hospital ancillary services. Finally, drugs are administered. These include vitamins (often in the absence of any of any known deficiency), inorganic salts (many of which could scarcely be absorbed by plants, let alone human beings), and a variety of stimulants and sedatives.

In the good doctor-patient relationship, recalled by the taking of each dose of medicine and inspired by painstaking examinations, it is obvious that the patient experiences changes in feeling. The desire to achieve such changes is freely admitted, in fact, when a stimulant or sedative is prescribed.

Physiotherapy is another common technique. Here, over lengthy periods, and accompanied by physical exertion on the part of the therapist, the patients body is the object of attentive care. Claims are made in respect of the curative action of heat, cold, forms of electrical energy and massage; but it is as clear as in the case of drug technique that these administrations produce changes in the sensorium. Much the same could be said of what the osteopath claims to do and what the actually does.

In the psychoanalytical field it is suggested that improvement depends largely on a lessening of tension achieved by repressed material being taken from the subconscious to the conscious mind. However, the analyst will be the first to concede the necessity for a good transference situation and the need for long hours of sympathetic communication, before those who have broken down at the higher levels are noticeably benefited.

In the homoeopathic technique the therapist listens to the tale of the patients every unpleasant sensation, and meticulously equates them with a remedy. In addition, and equally careful physical examination is performed. It would be a grave mistake to discount the effect of those procedures on the patients state of feeling.

Then there are the great healers, usually outwith the ranks of the medical profession, who claim to heal the sick through spiritual agencies. These practitioners, though wanting in scientific knowledge or critical assessment, are often possessed of infinite compassion and pity for the weak. Through this great love an ecstatic exaltation is aroused in the patient akin to that experienced in a love affair.

In submitting to any of these techniques the patient has not taken active steps to alter the pressure of his environment in his favour beyond acquiring a relationship with the therapist. He is cured, but relapses before long and must return to be re- cured. The situation closely resembles that of the young child when he recoils, bruised and battered from his contact with the outer world, back to his mother. She employs drug therapy, physiotherapy and psycho-therapy in giving him a sweet to suck, in stroking and fonding his body and in murmuring words of love and hope. His feeling change from despondency to confidence and he is ready to re-enter the fray.

As the child grows older, however, the good mother tries to equip him more effectively to find for himself pleasure, satisfaction and success in his environment. She cannot improve his hereditary endowment by granting him a more attractive appearance, a keener intellect, a more virile body or a livelier wit; but she can help him to make the best of the tools at his command. For instance, if he is unpopular with playmates and censured by teachers, she may enable him to gratify his need of esteem by advising him to admire the accomplishments of his fellows instead of boasting of his own, and of paying attention to his work in class and at home.

The doctors role is not dissimilar to the good mothers. He also is entitled to exploit the techniques of prescribing a medicine to be swallowed, of referring him to a masseur to be stoked and of encouraging him by the spoken word; but if the cure is to have real permanence he must do more. He can learn much by prompting the patient to talk of his domestic situation, his work and his associates and can deduce from the information received and the way it was given something of how the patient feels and has been feeling. If it should emerge that the patient is in a predicament which renders a healthy attitude impossible, his escape from it should be the easier from an appreciation of its significance. Such advice as the doctor can advance stems from his own first hand knowledge of life itself, rather than from his technical training.

My own therapeutic career is strewn with failures. Its first ten years were spent in blotting out symptoms with drugs in accordance with the orthodox teaching of the time. Then contact with homoeopathy led to the quest of the total symptoms picture and stimulated an interest in the whole man; but I could not stop short at the discovery of the drug which fitted the symptoms. When I learned, for example, that some women felt worse before, others during, and yet others after the menstrual period I had to seek a reason.

Then came my association, and later, friendship with Dr. James Halliday while he was engaged in his work on psychosomatic concepts. For a time I viewed the psyche in the manner of the orthodox psychological school, and found it a Herculean task to engender a spark of sympathy for those misfits whose lives were punctuated with endless complaints, despite constantly muttering to myself, “Without Charity I am nothing.” Latterly I found peace in the belief that the chronic sick are the victims of circumstance.

When they find themselves wed to an emotionally incompatible mate, or in jobs for which they are manifestly unsuited, they did not choose so and thus try to make their lives intolerable and their bodies the subject of biochemical imbalance and ever-recurting discomfort. They just lacked the wisdom or, perhaps, the good fortune to do what was best for themselves. The better we learn to know them, and the more effectively we help them to know themselves, the better we serve as doctors.

G. Gladstone Robertson