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(p. 449) Skin Changes in Relation to Emotional Disorder 

(p. 449) Skin Changes in Relation to Emotional Disorder
Chapter:
(p. 449) Skin Changes in Relation to Emotional Disorder
Author(s):

Donald W. Winnicott

DOI:
10.1093/med:psych/9780190271336.003.0080
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Subscriber: null; date: 16 October 2018

Originally published in St John’s Hospital Dermatological Society Report, 1938, 27, 62–73.

You have done me the honour of inviting me to address you and in doing so you have given me freedom to choose my subject. That you allow me such freedom means, I think, that your Society is making an attempt to keep Dermatology from becoming isolated from other branches of medical science and practice.

It is a commonplace that at its worst Dermatology is an exercise in classification and word-manufacture. At its best it is, of course, an important branch of medicine, tolerant of all other branches, and concerned with the skin as a part of the living and feeling person. The object of this paper will be to emphasise the importance of this latter orientation of skin study. I hope to show that not only the physiology but also the psychology of the living person must be studied if one is to understand the behaviour of the skin in given circumstances, to indicate some reasons why the psychology of the owner of the skin tends to be neglected, and to make tentative suggestions as to classification of skin changes related to feelings.

My double training as physician concerned with children and psycho-analyst has increased my natural tendency to be interested in the person, the personality rather than in tissues as such, or in diseases. I will say at once that there are certain advantages to be gained from such an outlook. I am spared, for instance, the shocks which some of my more tissue-minded colleagues sustain when they see one symptom change over to another apparently unrelated one, affecting in some cases another and entirely different organ or function. Papular urticaria may alternate with enuresis, sucking may change over to nail-biting, pruritus ani may disappear into a melancholic depression; a physician who knows the ill individual is at least in a position to understand (p. 450) such alternations, whereas the specialist who only sees a diseased or healthy organ can only be bewildered when signs and symptoms mutate.

I have mentioned lip-sucking. There is a chronic soreness of the lip with which you are all familiar, which is quite clearly due to, and kept up by a constant moistening of the lip by the tongue and by the mucous membrane of the opposed lip. It would seem to some that once the etiology of this condition has been recognised, therapy is clear and easy. One need do no more than ask or tell the patient to discontinue the habit. But is it so easy?

Actually the forces at work producing this compulsive sucking can be tremendously powerful, and can derive from a very deep layer, so to speak, of the personality. The activation is unconscious. If, through the force of your personality or your enthusiasm, you do succeed in stopping the lip play, you do actually produce another symptom. This other symptom may be less objectionable than the first; one may not even be able to detect it except on close study, but it must be there. The laws of conservation of energy are as inexorable in psychology as in physics. Where there is unconscious conflict there must be some kind of symptom.

In the same way, it may be perfectly clear to you that skin changes are being produced on the fronts of the legs of certain of your patients through their habit of roasting themselves in front of a fire. In certain cases the self-roasting may be an occupational disease, but when the condition is found in a child, it is usually possible to find that the child is moody, which in more psychiatric terms is depressive, and it is not possible to dispel moods by magic. Perhaps I should say that we have to be able to dispel moods by magic if we wish to bring about changes without being in a position to attempt to make radical alterations in the child’s personality, which for me means to employ the psycho-analytic technique.

When we inform our patients that what they bring us is a disease, when we tell them the name of the disease, when we prescribe this and that ointment or lotion, we are using magic, and this is just as true whether there is or is not a rationale for the therapy we choose. There is no gain for the science of medicine if we deny the fact of the magic in medical practice; our aim should be to attempt to keep the magic confined to our patients’ belief in our work and to avoid a belief on our side that what we do magically is scientifically understood or proved because it is effective.

I have so often been successful in temporarily removing one symptom by treating another, the patient being unable to distinguish between treatment for sore throat and for, say, enuresis, that I now find it extremely hard to be certain about the purely physical effect of any drug that has not been pharmacologically established. Probably most dermatologists would confirm these observations out of their own experience. In order to bring this idea into sharp relief I have only to remind you what a tremendously strong therapeutic power any of us can collect simply by bringing ourselves (if we can) to (p. 451) say to the patient that the treatment of the last doctor was absolutely wrong, if not criminal. In a large number of conditions we shall get an immediate symptomatic result if we do this, whatever we prescribe, or even if we recommend a rest from treatment.

In the course of any large specialist experience, a physician gradually becomes aware of the existence of diseases that are temporarily affected irrationally in this way, and so he becomes prepared to learn that there is another way of looking at such diseases according to which there is nothing surprising about their behaviour. For when I use the word ‘irrational’, I only mean that the explanation of a phenomenon cannot be made unless one is prepared to consider the feelings of the individual, and by this I mean especially the unconscious.

To my mind the psychology of the unconscious concerns the doctor as much as anatomy, physiology and bio-chemistry concern him. But psychology (apart from the sterile, academic variety) cannot be taught right away to medical students because they are at an age when they are interested in feelings from the instinctual end, and psychology, if it goes at all deep, tends to stir up anxiety and interfere with the management of instincts. The conclusion to be drawn from this can only be that one of the objects of post-graduate study is the utilisation of the stability that maturity and experience bring to the doctor for a belated instruction in psychological mechanisms. By this time the doctor should be able to stand a familiarity with these mechanisms without too much loss of spontaneity and intuitive understanding.

I do not mean that doctors should aim at becoming psycho-analysts; this must remain the speciality of a few who, for one reason or another, find themselves willing to undergo a long post-graduate training. But there is a great deal of unnecessary confusion in medical practice due to ignorance of simple psychological laws, and what is perhaps more important, the next step in the development of scientific medicine can only come along with the change-over from flight from magic to a scientific attitude towards feelings and towards the psychology of the unconscious.

A certain amount of study of dermatological literature has shown me that the psychological factor has been recognised and has been increasingly allowed for, but I expect it has always been allowed for5,8,13 much more in your practice (especially private practice where you can give more time to a case) than in the literature. O’Donovan13 mentions the fact that in hospital practice one is too rushed to take a proper history. It may have occurred to him that one great obstacle to proper organisation of our out-patient departments (which I have not seen mentioned in the B.M.A. reports) is the need for every physician to be too rushed to be able to reach the psychological factor. To do an out-patient session slowly in a day when only six patients turn up is to become involved in the infinitely complicated psychological state of five of the six patients. In fact, the only patients who are not liable to become an (p. 452) emotional burden are those with a nice, acute, obviously physical lesion with a definite diagnosis and treatment.

And this does not only apply to out-patient departments. On the bus or in the train one no sooner allows a human relationship to develop than one is involved in a complex emotional tangle; the Englishman notoriously refuses to speak to his neighbours, for this reason I suspect, that he does not want to be upset, to be reminded that there are personal tragedies all over the place, that he is not really happy himself; in short—he refuses to be put off his golf.

These considerations have the utmost importance, because they strike at the root of the doctor’s undoubted hatred of psycho-analysis, hatred which is not good for the psycho-analysts and is not good for the progress of medical science.

From what I have said, it is clear that every skin or other bodily phenomenon that has a relation to feelings must have a relation to the whole personality. I cannot overstress this point. One commonly hears of a skin condition kept up for some gain—such as workman’s compensation or in avoidance of a difficult task—such a simple statement carries no weight because we do not believe in it. These may be the conscious feelings, but we get nowhere unless we admit the paramount importance of the unconscious.

Take the simple case of a girl recently seen by me in hospital who had a persistent impetigo of the face which prevented her from attending school. She caught it from her sister, but although ordinary treatment of her sister produced a rapid cure, in her own case the therapy was relatively unsuccessful. It would be quite easy to find descriptions of cases in your literature in which the psychological element was considered to be satisfactorily stated by the comment: ‘Well, the symptom prevented her from attending school’.

One interesting thing about the girl, a quiet lovable child of fourteen years, was that she said that she wanted more than anything to go to school. Personally, I absolutely believed her. She loved her school and her teachers, and she was liked at school, and she had nothing to gain from being at home. This is the Conscious.

It was plain to me, and the child agreed, that she was constantly rubbing the face, and I expect she was doing it in sleep, too. (It is only in the special circumstances of my consultation with her that such a child admits of such things. She could easily have replied to a blunt question by denying that she rubbed her face at all, and she would not have been lying.)

Unconsciously, this child feared something about school very deeply, that she should not be able to do well enough to satisfy some teacher that she loved and whom she imagined to be demanding a very high standard of her. She had missed much school in the past six months, and felt that she could never make up for lost time, and this was especially true because she knew (unconsciously) that she had missed school because of pains which, in their turn (p. 453) were a symptom of her fear of failure to attain an ideal. These are depressive anxieties.

The girl had actually come under my care from the orthopædic surgeon who had spent several months investigating a pain in the small of the back. This pain was real and severe, but the surgeon had at last decided that it could not be explained by any physical disease that he knew.

Investigating this pain, I had found it to be linked up with her unconscious fantasies of what was going on inside her, and also with her memory of a similar pain her mother had had when she was pregnant. Her anxieties about her inside had prevented her from getting any sensible information in regard to menstruation. She thought that she would be overtaken by a terrific and crippling loss of blood, and that this, in some inexplicable way, would introduce her suddenly to a sexual maturity for which she was not in any way ready.

Superficial talks about these things led to temporary cessation of this pain (which had been constant for months), but the impetigo developed, chance having provided the infective sister.

In my rough out-patient handling of the case I attempted to break into the vicious circle by getting the teacher to take the girl back to school in spite of the impetigo. The teacher agreed to do this, with the result that the impetigo healed up immediately. The pain in the back returned and stayed for a short while, but the child kept at school, and was pleased to be able to.

Here we are dealing with a child who is not really very abnormal. Psychiatrically she is a threatened depressive, but at puberty, when alarming things are happening to the body, we must allow the child all sorts of symptoms—periods of depression, exploitations of physical illnesses, neurotic pains, and so on and so on. If we deal with each symptom as it arises with calm, and with an understanding of the place of the little symptom in the whole picture of a child, in this case a child struggling to reach maturity, we serve the child well. If we ourselves react neurotically towards one of the many possible symptoms, we are inviting the child to escape from feeling anxious into neurotic illness, and no doubt doctors have been guilty of much of this inviting the patient to escape from mysterious feelings such as anxiety, guilt and depression to a disease-with-a-name. As a profession we need not feel too guilty, however, because many adult patients demand this of us, and if we do not compromise (seeming to play their game, but all the time watching out for acute or treatable physical illness), they will go to unqualified practitioners of one kind and another, men and women who are not trained to recognise and deal with real physical diseases when they do turn up. We must, of course, allow these unqualified practitioners what is due to them, that they do deliver the goods to their patients, in the shape of a delusion suitable to the occasion, and often effective. If they did not deceive themselves, I should have no quarrel with them.

(p. 454) Much of the profession’s shyness in regard to psychology is part of the attempt to avoid a new delusion. And it is my feeling that the usual presentation of a psychological case history in a medical journal justifies the doctor in his suspicion of psychology, of psychology with absurd simplifications and with an over-stressing of the bad external factor. In this kind of psychology there is just as much denial of the important underlying feelings as there is in the osteopath’s description of exopthalmic goitre as due to a dislocation of cervical vertebræ.

This, then, is my main theme, that the smallest skin lesion, if it concerns the feelings, concerns the whole personality. This has been pointed out in your literature, notably by Ingram and Goldsmith,5,8 but it cannot be too eagerly stressed, and it is very doubtful whether the full implications of this point of view have ever been fully recognised in medical writings.

I come now to a study of the ways in which the skin becomes involved in conscious and unconscious feelings and mental states. In order to make a clear presentation of what can be a highly involved subject I will say that there are two ways in which this can happen.

The first of these is through the fact that the skin becomes involved in the child’s or the adult’s fantasies, comes to stand for this and that, and especially gets bound up with ideas of what is inside the body, what ought to be got in or out of the body, and how this should be done. To the unconscious, and quite openly to the child and to some psychotics, there is great importance in such fantasies. People will devote their lives to nursing an internal organ or an internal named disease, existent, or non-existent; in the same way they will spend on the care of a pet energies which could fairly easily be diverted to the care of a child, or of a country should opportunity present. The point is, what does that organ stand for in the patient’s unconscious? It may stand for almost all that is worth living for, and if anyone doubts this, he must find an alternative theory to explain the facts.

This same principle applies to many skin conditions, whether produced (unconsciously) for the purpose, or whether originally physically determined, and the dermatologist must be prepared for the ‘nursed lesion’, and must realise when he meets it that he is not dealing with a joke, but that he is up against forces so powerful that words like suicide come to the mind of the informed observer.

Equally significant for us is the fantasy of the existence of bad things inside, things so bad that they must be got out at all costs, and again the skin becomes involved, both because the skin can seem to contain these bogies, and also because the urge to get at the badnesses inside may lead to merciless tearing away at skin or mucous membrane in moments of exacerbation of guilt feeling. And when this is a chronic mechanism the patient tries (unconsciously) to make the situation bearable, or disguised, (p. 455) by exploiting the skin-pleasures; what we then see clinically is a kind of compulsive skin masturbation with more or less damage to tissues. This kind of thing can go on for years, resistant to all therapy aimed directly at the skin lesion.

Even such a common and simple association as that between nose-picking and chronic sores (unconsciously maintained by picking) cannot be understood except through recognition of these fantasies and of their supreme importance to the individual concerned.

I was surprised, on reading Sir Walter Langdon-Brown’s paper10 read before this Society, under the title ‘On Getting the Rash Out’, to find no clear reference to this important belief in disease as a bad thing inside that has to be got out, a belief quite separate from a scientific theory of disease, and to be found in every human being. This, the psychological aspect of purgative therapy, would have been entirely relevant to his theme.

I now come to the second way in which the skin can become involved in feelings; indeed, does become involved in feelings and changes of feeling in all of us all the time.17 I refer, of course, to the part played by the skin as an organ of the body in emotional states, such as excitement, whether localised or general, offensive or sexual, temporary and acute or chronic. Other emotions, too, have important skin manifestations, or can have them under specific conditions: rage, fear, apprehensiveness, desire. Perhaps skin-desire is the least recognised, the desire of a wrist for a bracelet, of the skin of the neck for a necklace, or, in certain pervert states, for the hangman’s rope. In certain kinds of patients there is a tremendous (unconscious) skin-longing for injections, so that any therapy that involves skin-puncture is sought after, welcomed, and encouraged by the patient’s presentation to the therapist of tempting remissions of symptom.

The immediate need is for research into the ways in which skin can show excitement. There is already enough known for this to merit a separate paper, but much remains to be done before a moderately complete picture can be presented, and the work must be done by someone who has both dermatological and psycho-analytical training.

Having stated what I believe to be the two main ways in which the skin is liable to be affected by feelings, I propose briefly to apply my theories to a few common conditions.

I should like first to ask you to discuss papular urticaria.6,9,11,19,20 This form of urticaria seems to me to be much more common even than is usually taught. In fact, do any babies escape it? I should think that most babies have at least had a few papules at some time or other during babyhood. It is not when they are ill, or debilitated, that they are specially liable to them.

In fact, is this a disease at all? I have elsewhere suggested20 as a basis for discussion that in papular urticaria we have a form of skin excitement, comparable to the erection of erectile tissue, and that the exciting cause may be (p. 456) anything from a state of general excitement of the child to an external factor such as a parasite or some form of unsuitable clothing. This theory at any rate has the merit of simplicity.

The condition is very deceptive, since the doctor often sees innocent cold papules, the only evidence of whose extreme irritability at other times being the torn-off heads of some of the papules, and in certain cases some scratch marks in the neighbourhood. The actual condition for which the mother brings the child is not so much the skin changes she has noticed as the orgies of scratching which, at their height, are distressing to watch and difficult to cope with. Skilled parents will be able to distract the little child’s attention on to something else till excitement has subsided, or will find they can prevent the worst orgies by avoiding exciting the child before bed-time. Often, however, no such care is really effective, and one is forced to the conclusion that when papular urticaria is a difficult problem, the difficulty is in dealing with the compulsive gratification-mongering.

It seems to me, then, that in papular urticaria one sees a form of skin excitement peculiar to a certain age-period, that when it is severe there is some exploitation of skin-eroticism on account of anxiety, and that when it is very distressing there could always be found to be a big degree of guilt feeling in the child, dramatised in the way I have indicated by the frantic attempts to get badness out of the body by skin-scratching, and this in spite of possible mutilation.

Even if I am wrong in some of my conceptions of this skin condition, I feel that in my statement of my view I have summarised much of what is important in the theory of skin change related to feelings.

It will be noticed that I do not mention dietary or allergic theories in this setting. In fact, I find no value whatever in either of these theories of the etiology of papular urticaria.

Another condition that the dermatologist meets which I should like to consider is one which has lately received recognition as related to psychological disorder, pruritus ani.

In introducing my view of this sometimes distressing itch, I must again remind you that many individuals feel much better for trying to get something they believe to be bad out of their bodies, even if this leads to tissue harm. This is rational only if unconscious fantasy is recognised and given proper importance. As I have already shown, a great need for this self-hurting easily carries with it an exploitation of whatever pleasure can be got from the tissue concerned, and, of course, the anus is a tremendous potential source of pleasure.

There is a group of patients specially liable to this compulsive anus exploitation, and at the same time unable to allow the pleasure to become available because of repression of homo-sexuality. The upshot of all this is that one meets clinically a man who suffers intensely, the excitement and exaggerated (p. 457) anal pleasure having been changed as far as the man’s conscious is concerned, into anal pain. One might say that it would have been much simpler had the repression of anal sensation been complete, but the individual could not endure so severe a loss to his personality, and so recaptured sensation in the form of torturing anal pain and peri-anal itch.

Such a man will implore doctors to treat him by any and every means, and it is a sad comment on medical practice when X-ray scars proclaim over-zealous therapy, which must by the very nature of the illness prove ineffective.

There is a certain similarity between patients who are severe sufferers in this way, and I will describe briefly the case of a man whom I have investigated over a long period by the psycho-analytic technique. This is a working man who came originally on account of ‘depressions’, acute attacks of shyness and confusion coming over him unexpectedly, usually when talking to another man. He had delusions of persecutions, and all the time showed tremendous anxiety about his internal organs and his anus, and the skin around his mouth and anus. At one time he was spending a large proportion of his wages in quack remedies. He is a married man with children, and one of the chief results of his treatment has been his gradually becoming able to show love to his children. He always loved them, but he used to be quite brutal to them. The whole picture is dominated by unconscious homo-sexuality, and in his wife he found someone who could accept all his compulsive hetero-sexuality. His fear of women was so great that he could never let himself be in the position of doubting his potency.

Through analysis he has achieved much more tender love of his wife, and a much less compulsive sexuality.

In spite of quite big external difficulties he has reached a stage in which he keeps well if he sees me fairly regularly. But the instructive thing is what happens if he has to do for many weeks without me. He has very powerful anal desires, of which he is usually conscious to a fair degree—though it took years of analysis for him to reach this. If I do not see him, the anal desire recedes and the itch and pain element appears, and he feels compelled to go round to skin and other hospitals, getting doctors to look at his anus and to do per-rectum examinations.

This man persuades doctors (fairly easily, I may add) to give him all sorts of manipulations and injections and offers of X-ray therapy.

He believes at these times that he has a cancer inside. He feels persecuted by the manipulations which he seeks from doctors, and by the intolerable itch of the anus and perianal skin. He also becomes very sensitive about his face, being constantly in front of the mirror examining the minute cracks at the angles of his mouth. These, alas, the doctors will not take seriously. His localisations of the badness that he believes to be in him include at these times a stuffy nose, and a production of phlegm, the blackness of which is (p. 458) vastly important to him. There is much else in his case which I cannot give here because it would not seem to be immediately relevant.

If we look at this case as a problem of: Where is the badness? we see that when he came to me he had to put the badness outside himself, and so felt people were plotting against him. The treatment (increasing his belief in the goodness in him) has gradually enabled him to accept into himself the badness that belongs there, and while this change is taking place we get his pre-occupation with his body in dramatisation of the unconscious fantasy in terms of his body tissues.

I give this case because of the illustration it has afforded me of the variability of the consciousness of the gratification element in the anal excitement, and the repeated change-over from pain, itching and scratching to desire and gratification and back again.

As a child the man had enjoyed or experienced frequent anal play over a period of many years. Guilt over this continues to be terrific. While itching is felt, the scratching is quite brutal, and much damage to tissue ensues.

A girl of eleven years, an old rheumatic heart case, is highly excitable and is constantly on the edge of deep depression. For two years she has had a serious condition of the scalp which has been called seborrhœa and eczema and other names by a long line of dermatologists. This scalp condition is certainly kept up, if not actually produced, by orgies of head scratching. The girl’s mother, in despair, ties the girl’s hands to her own feet as she lies in bed with her, for only in that way can she be sure of waking and preventing the orgies which occur even while the child is asleep. In one kind of language the scalp has become an erotogenic zone.

Now it happens that this girl has had for many years a most intense horror of infestation, though, as a matter of fact, she has never been infested. Phobia of infestation is fairly well understood, and I need not go into its psychology here.

It is easy to connect up the two conditions, phobia of infestation and compulsive scalp excitement.

The girl is clever, but in order to get her to school, I have had to persuade the headmistress to issue to her a written statement that she shall not have her head examined by the school doctor or nurse, even when in the course of routine inspection all the other girls’ heads are examined.

As a matter of fact, the scalp became diseased when she first heard she would have to be examined. This would offer a clue as to etiology, but it is not clear that any of the dermatologists who had seen her from time to time had taken a good history of the case, or had allowed the mother to describe the sequence of events.

It would not be difficult to show how all these various symptoms, depressive phases, general excitability, local tissue-excitability and phobia of infestation (p. 459) are related to one another; that is, if the whole developing personality is taken into account. But a dermatologist with a limited skin-tissue interest must fail to understand the links between the symptoms, and so must remain out of touch with much that is interesting in the case. Incidentally, he has but little chance of bringing about a cure of the scalp disease.

Details of this kind illustrate the main contentions of my paper, though they prove nothing, and are not intended to prove anything. The dermatology of general practice is largely concerned with cases in which the main factor is a psychological one. Such cases as I have given illustrate my meaning when I state that the usual psychological descriptions are too superficial, and that a deeper understanding than is commonly found has a bearing on management and treatment.

The whole subject of the psycho-physical borderline is of immense importance and interest, and has already been the subject of a very large volume. In the next decade there will be so much written relevant to it that those who are interested will need to choose what to read and what to leave aside. In choosing it will always be safe to leave aside the work that fails to recognise the relation of tissue-changes to the feelings of the whole person, his place in his environment, and the emotional state of his whole personality. It will also be safe to ignore work which does not recognise the supreme importance of the unconscious, and of the unconscious fantasy, and in particular of the identification of the body with the inner world of good and bad objects dramatising love and hate.

It is the difficulty that is universally experienced in the acceptance and absorption of these ideas that has so curiously held up the study of the very thing that the practitioner in touch with clinical problems is shouting for us to explain for him, namely, the relation of a patient’s tissue-changes and function-modifications to his rôle of Human Being.

In my opinion the skin is one of the tissues specially interesting to the clinical research worker, whose interest is in the borderline between physiology and psychology, who is concerned, that is to say, with what keeps together the body and the soul.

Bibliography

1. Allendy, R: ‘A Case of Eczema’, Psycho-Analytic Review, 1932. Vol. 19, p. 152.Find this resource:

    2. Bien, E.: ‘The Clinical Psychogenic Aspects of Pruritus Vulvæ’, Psycho-Analytic Review, 1933. Vol. 20, p. 186.Find this resource:

      3. Bray, G. W.: Recent Advances in Allergy, 1937— ‘Psychological factors in Skin Affections’, p. 103.Find this resource:

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          5. Goldsmith, W. N.: Recent Advances in Dermatology, 1936—‘Mental Influences’, p. 97. (p. 460) Find this resource:

            6. Hallam, R.: ‘Papular Urticaria’, B. J. Derm. 1927, p. 95.Find this resource:

              7. Hurst, A. F.: ‘On Asthma’, Practitioner, 1929. p. 10.Find this resource:

                8. Ingram, J. T.: ‘The Personality of the Skin’. Lancet, 1933, p. 889.Find this resource:

                  9. Kinnear, J.: ‘Urticaria Papulosa’. B. J. Derm., 1933, p. 65.Find this resource:

                    10. Langdon-Brown, Sir Walter: ‘On Getting the Rash Out’, Trans. St John’s Hosp. Derm. Soc., 1937. p. 77.Find this resource:

                      11. MacLeod, J. M. H.: Diseases of the Skin. 1933—‘Pruritus’. p. 633.Find this resource:

                        12. MacCormac, H.: ‘Self-Inflicted Hysterical Lesions of the Skin’, B. J. Derm., 1926, p. 371.Find this resource:

                          13. O’Donovan, W. J.: Dermatological Neuroses, 1927.Find this resource:

                            14. Roxburgh, A. C.: Common Skin Diseases, 1937—‘On Neurodermatoses’, p. 247.Find this resource:

                              15. Sack, W.: ‘On the Psychic and Nervous Component of the so-called Allergic Skin Diseases’, B. J. Derm., 1928, p. 441. ‘Psycho-Therapy and Skin Diseases’. Derm. Wschr., 1927. p. 16.Find this resource:

                                16. Sequeira, J. H.: Diseases of the Skin. 1927, p. 5.Find this resource:

                                  17. Sadger, I.: ‘Skin, Mucous Membrane and Muscle Erotism’, Jahrbuch, III, 1911, p. 525. ‘Sado-Masochistic Complex’, Jahrbuch, V. 1913, p. 467. ‘Contribution to the Understanding of Sado-Masochism’, Inter. Jour., VII, 1926. p. 484.Find this resource:

                                    18. Schilder. P.: ‘Remarks on the Psycho-Physiology of the Skin’, Psycho-Analytic Review, 1934.Find this resource:

                                      19. Winnicott, D. W.: Clinical Notes on Disorders of Childhood. Heinemann 1931 (see Index).Find this resource:

                                        20. Winnicott, D. W.: ‘The Dynamics of Skin Sensation’, Brit. Jour. Children’s Diseases, XXXI, 1934, p. 5.Find this resource:

                                          No attempt is made to include a series of references to general psycho-analytic principles.

                                          Discussion

                                          The President thanked Dr Winnicott for his interesting paper, and said that it was very good of him to tackle such a difficult subject in the short time that the Society gave him to prepare and read it. Dr Winnicott had indicated various attitudes and ideas regarding the behaviour of the skin which would give food for considerable thought to dermatologists. With regard to papular urticaria, in connection with which Dr Winnicott said he thought that it was an expression of excitement of the skin and more specifically connected with the desire to get out some form of badness or guilt, the President asked at what age did such ideas, even sub-conscious, begin to develop. If the cause was a psychological one how could we explain the marked seasonal influence that is common in this condition? A classification of dermatoses of known and unknown ætiology was most desirable but extremely difficult, as one’s ætiological knowledge was constantly having to be revised. An example of this is to be found in acne vulgaris; the staphylococcus and acne bacillus were confidently believed to be the causative agents, but now much more importance (p. 461) was being attached to endocrine influences and, if this is admitted, then we must admit emotional influences, too.

                                          Dr Griffith said that it seemed to him that anybody who had had experience in mental diseases would recognise similarities to the cases that had been described by Dr Winnicott. In such cases the important factor appeared to be a family history of abnormal mentality. Many of these cases who consulted dermatologists had strong psychological factors, such as syphilophobia, parasitophobia, pruritus ani and vulvæ and other phobias and delusions, and no blood tests or other proofs would disillusion them. These symptoms were the signs of grave mental diseases, and many of these cases became suicidal or inmates of mental institutions.

                                          Dr Silcock said he was very interested in Dr Winnicott’s remarks on papular urticaria. In his (the speaker’s) opinion the two main factors concerned in the etiology of this disease were:—

                                          1. 1. A thermogenetic one with a tendency for the rash to appear in warm weather. The condition could also be artificially excited by raising the temperature of the room in which the child was; by overclothing and by any of the febrile ailments of childhood.

                                          2. 2. An allergic factor, yet unknown. Might be associated with gastro-intestinal disturbance, e.g., faulty assimilation, incorrect feeding, or even intestinal worms.

                                          With regard to infantile eczema, the infants were usually bright-eyed with brisk reflexes responding to slight skin irritation by scratching, etc., of the affected parts. If from any cause the general condition of the child was poor, the eczema tended to disappear temporarily only to return when normal health was regained. As an instance of this he mentioned a case which he saw recently in which the child had been given a course of intra-muscular injections of a substance, stated to be a cure for many kinds of eczema and other skin complaints in adults. As a result the child developed marked diarrhœa, becoming very dehydrated and emaciated. The eczema died away temporarily, but the child almost died permanently! Probably the skin condition cleared up for a while as the child’s reflexes were too weak to respond to any stimuli—skin or otherwise. He regretted that Dr Winnicott had not referred to the psychological factor in skin diseases and sweating, e.g., hyperidrosis and anidrosis. It was well known that when miners were put on new jobs, even less laborious than their old ones, they sweated profusely for the first few days until they got used to their work. As the relative temperatures of both dry and wet bulb thermometers under their new conditions were more favourable to decreased sweating, this early reaction clearly demonstrated the presence of a psychological factor. Rosacea was another disease distinctly associated with a psychological (p. 462) element and possibly sweating also, inasmuch as both factors have a vaso-dilator effect. The psychological aspect in occupational dermatitis and artefacts of the skin had already been referred to by Drs H. MacCormac and W. J. O’Donovan. In occupational dermatitis the psychological factor was always difficult to assess, and in artefacts equally difficult to detect. In some definite cases of mental disorder, seen in the mental hospitals in Leicestershire, he had seen lesions with much destruction of tissue and absolutely no pain. As a contrast one frequently saw cases of what are called neurotic pruritus in which the subjective symptoms are in indirect proportion to the superficial skin signs. With regard to pruritus, both generalised and local, he invariably found that if a patient appeared with a carefully guarded collection of debris, which he said had ‘worked out of his skin’, then the neurotic element accounted for 100 per cent of his condition. It was an enormous field that Dr Winnicott had tried to plough up in one short hour, but he had certainly succeeded in hoeing over much dermatological ground in that time.

                                          Dr Wigley said he would like to support the President in thanking Dr Winnicott for giving such interesting and at times arresting views. There was certainly much food for thought in Dr Winnicott’s paper. He entirely agreed with one of Dr Winnicott’s remarks that the relative proportions of psychological trauma and physical disability in any given case depended very largely on the point of view taken by the doctor dealing with the case. This state of affairs was not infrequently seen, even in cases of occupational dermatitis, as had been brought out in the recent discussion on that subject in Edinburgh. Following on what Dr Griffith had said, he mentioned the well-known example of the patient who had never itched more than the rest of his fellows, who developed scabies and is cured, but continues to itch and worry his doctor about it for the next six months or a year. Most dermatologists would agree that there is a large ‘psychological’ element in this type of patient, but why has an apparently normal individual become abnormal? Is there such a thing as a normal individual, and if so, how would Dr Winnicott define it?