“Literature of “Psychosomatic Medicine”.
The literature on so-called psychosomatic medicine – I shall come back to that term later – is already considerable, and I shall not attempt to review more than a very little of it, partly because such an attempt would need to occupy at least several lectures, and partly because I believe it would be unprofitable. For I suspect that a persons attitude to what may be called the psychosomatic method in medicine depends less on an intellectual evaluation of the literature than on his attitude to neurosis.
Just as an overtly neurotic patient tends to arouse irrational feelings in most of us, so does the suggestion that illness, needless to say in ourselves as well as in our patients, can be fully explained only when psychological and physical factors are taken into account. We resist this suggestion as applied to ourselves, and we tend to deny it in our patients.
Earlier I quoted an article by Pickering (1950) in which he dismissed what he called the psychosomatic hypothesis in a few lines on the ground that the small amount of critically established fact on which it was based could be explained in other ways. But in doing this he makes an assumption: he assumes, it seems to me, that a satisfactory account of the causation of disease states, or some of them has been, or can be, given in purely physical terms; and that it therefore behoves those who are interested in the so-called psychosomatic hypothesis to prove their case by proving critically established fact.
But this is a big assumption, and I would ask those who make it to consider carefully in how many chronic diseases can they give a satisfactory account of the aetiology in purely physical terms? We come to nearest to giving such an account, I suppose in nutritional deficiencies and in certain chronic infections, where again one factor in the environment is of particular importance. But is that factor, even in these instances, the whole story? A great deal is known, for instance, the whole story?
A great deal is known, for instance, about the tubercle bacillus; but can we really explain on humoral grounds why some people become ill with tuberculosis while others do not, and, of those who do become ill, why in some the process is a arrested while in others it is not? I doubt if we can, and I believe that studies of personal factors which may be concerned in the onset and course of tuberculosis such as those of Wittkower (1949) and of Day (1951, 1952), even though they do not amount to “Critically established fact”, are still of great interest and importance in this connection.
I would like to suggest that we may equally, and indeed with much more reason, start from the historically older and philosophically more satisfactory assumption that illness is a state of the whole man – in the sense that it is a state of a body-mind unity, and ask those who doubt the importance of psychosomatic method to establish their case by giving a satisfactory account in purely physical terms of the aetiology of even one of the chronic conditions which are at present described as of unknown aetiology. Peptic ulceration, ulcerative colitis, hypertension with all its sequelae , rheumatoid arthritis, and asthma to name but a few, await such an explanation.
But, it may be said, since rheumatoid arthritis can now be dramatically if not completely relieved by supplying the substance cortisone, we can surely regard rheumatoid arthritis as a purely physical abnormality, curable by physical means. And doesnt this make the complicated and difficult psychosomatic approach unnecessary?
Those who use this kind of argument are confusing mechanism with aetiology. The discovery of cortisone and A.C.T.H. has brilliantly illuminated, or bids fair to illuminate, the physico- chemical mechanism of rheumatoid arthritis amongst other things, but it has brought us no nearer being able to answer the question why a given person is taken ill with rheumatoid arthritis or how this illness can be prevented – just as the discovery of insulin and vitamin B12 had led to very great advances in our knowledge of the physico-chemical mechanism of diabetes and pernicious anaemia without telling us why some people develop these conditions or how they may be prevented.
Medicine in undergraduate teaching schools, as Halliday puts it, has shown hitherto a distinctly mechanismic bias, in the sense that it has devoted enormous energy to the explanation of the mechanism of disease in physico-chemical terms, relatively less to the environment, and still less to the person. But there are signs that this is changing. There have been, for instance, numerous psychological studies of personality types in different illnesses, notably the very extensive contributions of Dunbar (1943), and her colleagues from the psychiatric and medical divisions of Columbia University.
My own feeling is that these and other personality studies, though of great interest, are somewhat inconclusive in that they seem to depend so greatly on the subjective interpretations of the observer, and it remains to be seen whether independent observers will always find the same personality types or range of types in the same illnesses. At the same time a start has been made on the more accurate study of physical types by means of Sheldons method of somato-typing (Tanner, 1949).
To my mind the outstanding recent contribution to the study of man, rather than mechanism, has been the work of Wolf, Wolff, and their colleagues and Cornell University Medical Colleges, over that last 10 to 15 years.
For details of their methods and results one must read at least their two monographs (Wolf and Wolff, 1943; Grace, Wolf, and Wolff, 1951). Very briefly, one patient with a gastrostomy and four with prolapsed colonic mucosa were studied over considerable periods.
The rate of blood flow, as judged by colour changes in the mucosa, and secretory and motor activity of the stomach and colon were measured in a variety of circumstances, and notes made on the effect upon them of ordinary physiological stimuli, of drugs, of the patients life situation, and sometimes of emotionally coloured happenings, either occurring spontaneously or provoked deliberately during the course of the experiments.
I believe these are important studies for several reasons. They were performed on man, and intact man, except for the accident by which either gastric or colonic mucosa was visible. Instead of trying to standardize the conditions of their experiment by avoiding the complication of using conscious human subjects, or by what might be called eliminating the human factor, these observers standardized all the other conditions of their experiments so far as possible and deliberately set out to study, among other things, the effects on the stomach and colon of human situations and emotions.
What emotion the subjects were actually experiencing in the different experimental situation had, of course, to be inferred. But, given that the authors inferences were substantially correct, their results are of the greatest interest. I would like to mention one or two points which seem particularly relevant to my lecture. In an animal preparation the actions of a drug are usually constant and predictable. In these observations on man there are several instances where this was not so, and there the actual effect of a drug appeared to depend not on its pharmacological action but on the meanings of its administration to the particular subject.
This is seen most clearly in the account of the effects of the intravenous administration of atropine on the colon in three of the subjects with colostomies. In two subjects who were thought to be in a state of relative security and relaxation the injections were accepted with apparent equanimity, and their effect was a profound decrease in motor activity of the colon and some blanching of the colour of the mucosa, as would be expected on pharmacological grounds.
In a third subject, who resented the experiment, the same intravenous dose of atropine was followed by a great increase in motor activity and in colour of the mucosa – changes which had been found previously in states of anger – and, though the atropine produced its expected effects on the salivary secretion and circulatory system, at no time was there any pallor or diminution in the motor activity of the colon. It appears that in this instance the physiological effect of the resentment aroused by the injection of the drug predominated over its expected pharmacological effect.
This observation is in fact a particular instance of something which appears throughout these studies – namely, the important and often predominant effect on the subjects gastric and colonic function of the relationship existing at the time between the observer and the subject or, in more general terms, the physician and the patient.
Another point I would like to mention is the authors finding that the colonic changes in anger and hostility were greatest in the two of the four patients who had conspicuous difficulty in expressing their feelings (and these incidentally were the two of the four patients who suffered from ulcerative colitis). This again only confirms what has long been held by psychiatrists, but the demonstration that the actual changes in the colon were greatest in those who appeared to be suppressing their anger in new and impressive.
I believe this study is important not only for its content, but because it represents a new departure – the measurement changes in function in the organs of man, in health and disease, in relation to life situations and emotional states. It may well be the beginning of a new chapter in our understanding of illness.
It seems inescapable that sooner or later we shall come, or indeed we shall be driven by the economic pressure of the cost of sickness, to regard the prevention of disease and promotion of health as more important than the curative or more often palliative medicine to which at present we devote so much more attention. One of the main difficulties seems to be that we have no clear idea of what constitutes health. So far as I can remember, health was not mentioned when I was a student. The mechanismic view of disease which was then the rule left no room for a concept of health, other than in terms of no disease.
Just as a machine which was in working order ran, so the body was regarded as healthy so long as there was no break-down or disease. But good health is something more than no disease, and we can all recognize it when we see it, even though we cannot say just what constitutes it or how to go about getting it. I believe it is our professions lack of concept of health, other than as a state of no disease, that leaves the way open for widespread exploitation of the average persons natural desire to enjoy as good health as he can.
My object in raising this question is not to attempt to settle the meaning of health. We are asked to believe, indeed, that this has already been done by the World Health Organization, which has laid it down in most authoritative and uncompromising terms that “health is a state of complete physical, mental and social well-being; and not merely the absence of disease and infirmity”.
Here, adds its Director-General, as a kind of warning to meddlesome intruder, is one word concerning the meaning of which the dictionaries will not have to worry from now on (Brock chisholm, 1949). I need not spend time on this definition (with its necessary implication that all of us are sick, since none of us enjoy complete physical, mental and social well-being), because it has already been ably examined and criticized by Curran (1952). With all deference to the Director-General of the World Health Organization, I believe we are still far from a satisfactory idea of what constitutes health.
The Oxford Dictionary defines health first as “soundness of body; that condition in which its functions are duly discharged”, and gives as a further meaning “spiritual, moral or mental soundness”. I imagine it would be generally agreed that health cannot be fully explained in physical terms, and, whatever opinion we hold about disease health is certainly psychosomatic.
One of the most interesting discussions of health and disease I know of, occurs in a small book by Crew (1949) on Public and Personal Hygiene. After pointing out that the individual must be capable of adjusting himself to the conditions and circumstances of his external physical and social worlds, he defines health “as that state of the individual in which harmony exists between the various component parts of himself and between the individual as a whole and the circumstances and condition of his external world”.
This definition is a distinct advance, but does not seem entirely satisfactory for at least two reasons: first, no one enjoys complete harmony either in himself or with his external world; and, secondly health is not so much a state of harmony as the product of a process of continuous adaptation or adjustment, by which a reasonable degree of harmony is maintained. The nearest I can get to an explanation of health – I would not say a definition – is that a persons health depends first on the constitution he is born with, and then on the success he has in constantly adjusting either himself to his environment or his environment to himself, so that a reasonable degree of harmony is maintained both within himself and between himself and the social and material world in which he lives.
But my object is raising this question was not to attempt to settle the meaning of health. It was to point out the need for such a concept, and some of the difficulties in formulating it – difficulties which are, I believe, intimately connected with the questions that I have been discussing. It is no accident that academic medicine has no concept of health; for the mechanismic idea of disease leaves no room for one, other than in terms of no disease, which is clearly inadequate.
I would now like to try to pull together some of the apparently disconnected threads of my discursive and eclectic review of some changing concepts in medicine.
Thinking in medicine seems too often to be based on unexamined or insufficiently examined assumptions. It seems often to be taken for granted, for instance, as I have tried to point out, that we can usefully study diseases rather than diseased persons; that all disease or most diseases can be explained in terms of direct mechanical cause and effect; and that diseases can be divided into physical and psychological, with the implication that so-called physical diseases can be studied and treated satisfactorily by exclusively physical methods. In general these individual assumptions add up to a main one, that disease – no one seems to have worried much about health – can be explained in mechanismic or physico-chemical terms.
The rise of so-called psychosomatic medicine, which in America appears already to have assumed very considerable proportions, can best be regarded in a social sense as a revolt against this main assumption; and it is significant that this revolt has coincided with a growing tendency among some physical scientists to question how much their methods can be expected to explain. Strictly, as I have also tried to emphasize, there can be no such thing as psychosomatic disease, for these terms involve a confusion between the methods of examination and the objects of study.
Health and disease are necessarily psychosomatic, so there cannot be part of medicine or some diseases which are psychosomatic. What the psychosomatic method does insists or rather reiterates, for its teachings are as old as medicine is that in health and disease man must be studied by both physical and psychological methods. It is perfectly true that, in some, much information may be given by physical and little by psychological methods, and in others much by psychological and little by physical methods; but we must not be tempted to conclude from this that there are physical diseases and psychological diseases.
It is often assumed that there is an antithesis of some kind between science and art in medicine. If one were to hazard a guess, a time will come when this too will be regarded as having been a mistaken assumption. When this has happened we shall recognize sciences of pathology, pharmacology, experimental medicine, and so on (for many aspects of disease are explicable in terms of mechanism); and possibly a science of psychology.
But strictly clinical medicine will, I believe, regarded neither as an art nor as a science in itself, but as a special kind of relationship between two persons, a doctor and a patient. It will be recognized that this relationship is the essential feature of clinical medicine; and that the degree of success that it has depends, as in other human affairs, on the skill with which both science and art are called to its aid.