Changing Concepts Of Health And Disease With Reference To Psychosomatic Medicine

Diseases with physical manifestations could be divided into organic and functional. Organic diseases were regarded as real, objective, and the proper object of study by scientific medicine. They had physical causes, which either had been or would be elucidated as a result of increasingly thorough study by physical chemical, and bacteriological methods.

I do not think anything I shall say is new; much of it has been better said before, and some of it is very old-so old indeed that there always is a chance it may be mistaken for new. But I am encouraged to hope that, even so, it may fulfill the terms of the Bradshaw Trust, which states simply that a lecture shall be given in memory of Dr. William Wood Bradshaw on a subject connected with medicine or surgery.

As a starting-point I propose to try to put into words some ideas about the nature of disease which seemed to be taken for granted in the medicine I was taught nearly twenty-five years ago. It was assumed, so far as I could see, that there were things or entities called diseases, which could be studied and treated as such. Some of these arose in and affected the mind, and were the province of psychiatrists. Others arose in and affected the body, and were the province of physicians, surgeons, and various specialists.

Diseases with physical manifestations could be divided into organic and functional. Organic diseases were regarded as real, objective, and the proper object of study by scientific medicine. They had physical causes, which either had been or would be elucidated as a result of increasingly thorough study by physical chemical, and bacteriological methods. In the investigation of a disease the object was to find “the cause” and to deal with it. There was little or no interest in functional disorder. Functional symptoms seemed usually to be regarded either as invented or imaginary or as rather mysterious and discreditable states which in some way affected inferior personalities.

I do not think, as a student, I heard the word “psychosomatic”, which is not surprising, for this actual word was apparently first used in 1926. Within a few years, however, it was suggested that certain physical diseases for which no satisfactory cause could be found, and which were becoming increasingly noticeable as important sources of disability, were psychosomatic in nature.

This appeared to mean that the structural changes found in the body were caused by a disordered mind. This possibility was eagerly seized on by a few, but denied or ignored by the many who believed that real organic disease had little or nothing to do with the mind and would ultimately yield its secrets to the methods of physics, chemistry, and bacteriology.

Though stated baldly and perhaps over simplified, I believe that is a fair summary of some of the main ideas about disease which were more or less taken for granted in the medicine I was taught. If any of my teachers should say they took nothing of the kind for granted, I can only say that this was what an average student gathered, not so much perhaps from what they said as from what they did not say.

One saw, of course, that many of ones teachers did treat their patients as persons rather than as mere vehicles of disease, but I believe this was more an expression of humanity than an indication that they accepted such an approach as necessary to the understanding of disease.

Ideas still taken for granted

I believe that some at least of the ideas I have outlined are still taken for granted by many persons engaged in academic medicine, by which for the purpose of this lecture I mean medicine as taught in under-graduate teaching schools. I will not waste time in defending this latter statement at length, but would refer to two recent articles by eminent teachers in under- graduate schools.

The one lists what he calls the five common causes of disease; in born and inherited abnormalities; excess of a chemical agent in the environment; deficiency of a chemical substance; infection or infestation by viruses, bacteria, fungi, or animal parasites; and physical trauma. He thinks it possible that the important diseases of unknown aetiology, such as the rheumatic diseases, peptic ulceration, and ulcerative colitis, will turn out to be due to these same causes, acting singly or in combination but entertains the “possibility that there exists a group or groups of diseases the causation of which we do not comprehend, or comprehend but dimly.”

His statement of what he calls the psychosomatic hypothesis which is at least commendably brief is that it “attributes disease to certain abnormal states of the mind.” This hypothesis is then immediately dismissed along with that of focal sepsis as unworthy of serious consideration by scientific medicine. “The small amount of critically established fact”, he says “on which these two hypothesis were based can probably be accounted for on the fact that the condition of any patient suffering from a chronic disease deteriorates when there is superadded infection or disturbance of the mind” (Pickering, 1950).

The other, speaking of the place of psychotherapy in the treatment of peptic ulcer says: “In this connection it should be recognized that, while many neurotics invent digestive disturbances, the ranks of genuine ulcer cases contain no higher proportion of neurotics than does the population at large. Most ulcer patients, indeed, are the reverse of neurotic. They may be anxious and worried, but they never invent symptoms, generally make light of their suffering, and rarely give up work unless the pain is intolerable” (Illingworth, 1952).

I would like to assure the authors of these in many ways admirable lectures that I have picked on theirs out of many others I could have chosen, not from any personal animosity, but simply because they happen to illustrate my thesis that certain ideas which seemed implicit in what I was taught are still current in academic medicine to-day.

I believe these ideas are almost without exception open to serious objections. I shall now examine some of them further, and in doing so review in an admittedly eclectic manner some paper which seems to me to illustrate changing ideas. In particular I wish to examine a common misapprehension that there is something called the psychosomatic hypothesis, which holds that abnormal mental states can cause physical disease. This will involve at least some references to the idea of diseases as entities, to the idea of cause in medicine, and to the problem of the relationship between mind and body.


It was and often still is assumed that there are entities called diseases which can be studied and treated as such. But if we think about it, it seems obvious that we cannot observe diseases; we can only observe diseased persons during life or the mortal remains of diseased persons after death.

Nosological classification may be a necessary convenience for purposes of orderly description, but we have come to think and often to act as if the states it describes exists as entities which can be studied and health with apart from the person who is diseased. One might almost feel one had to apologize for mentioning some thing so apparently trite and obvious were it not that much current teaching and action appears to be based on the opposite assumption.

Causes in Relation to Medicine.

I have already said that it seemed to be assumed, when I was a student, that organic diseases had physical causes, and by this there was often implied a single cause, The cause of lobar pneumonia was the pneumococcus. The cause of cirrhosis was alcohol, and so on. The business of diagnosis was to find the cause of the disease, and the object of rational treatment was to remove it. When the cause was unknown, only symptomatic or empirical treatment was possible. I have perhaps laboured these illustrations to show that we really did seem to think in terms of single causes, though we cannot have gone very far in considering the implications of this view.

The idea of cause is a complicated one, and many people much better qualified to do so than I have written about it relation to medicine. However (1934), for instance, speaking of the kind of examples of cause and effect I have just mentioned, says: “However, not one of these examples is truly a case of cause and effect. Not only is the effect antecedent events, but each of these antecedent events is produced by the interaction of another two.

If we are to be accurate we must than recognize not a cause but an endless multiplicity of causation, which is extremely confusing. There never is, in fact, a cause but always relationship. And a little later on he says: “It is today generally agreed in theory, although not always recognized in practice, that disease is essentially an interaction between seed and soil, in both of which there is a convergence of a sequence of related events, from the association of which the effect is developed.”

What we can observe, he says, is a series of events connected and related through the medium of time, stretching back into the past and forward into the future. If a bus runs over my leg I may say that the impact of the bus is the cause of the fracture of my femur. More accurately, the event may be described as the intersection of two time sequences in which the bus time-sequence crosses the leg time-sequence. “If we seek causes we find two causal time chains: what caused the bus to do as he did; what caused the leg to be where it was, and what caused the leg eventually to heal. These are not truly to be regarded as being causes, but as a series of related time-effects.”

R R Bomford