Psychotherapy

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 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 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 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 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 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 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 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.