Mind and Body

THE ATLANTIC

BY STANLEY COBB, M.D.

THE ills imposed on man’s body by the conspiracies of fate have been a subject for poets and storytellers for ages. The Greeks drew tragic nets about their heroes; situations forced them to commit acts for which they suffered mentally and physically. To the Greeks, gods, demons, and witches were responsible. Two thousand years later, Shakespeare saw the play of human passions more subtly. He described their effects on the bodies of his characters, and even suggested psychotherapy in some instances.

In more modern times, physicians describe emotional reactions in their professional writings: “Under the active stage of anger, the following train of phenomena will be displayed in greater or lesser strength. The heart now aroused beats quickly and forcibly and the blood, rushing impetuously to the head and surface, the brain becomes heated, the face flushed, the lips swollen, the eyes red and fiery, the skin hot, and literally may it be said we burn with anger.”

This quotation is from a wonderful book by Dr. William Sweetser, professor of the Theory and Practice of Physik at Bowdoin Medical School. It was published in 1843, and the title runs: Mental Hygiene, or an Examination of the Intellect and Passions, designed to illustrate their Influence on Health and Duration of Life. Speaking of the effect on the digestive tract, Dr. Sweetser goes on to say: ”Anger destroys the appetite, and checks or disorders the function of digestion. Let one receive a provocation in the midst of his dinner, and the food at once loses all its relish for his palate. Dr. Beaumont, who had under his charge a man with a fistulous opening into his stomach, so that the interior of this organ could actually be inspected, remarked that anger, or other serious mental emotions, would sometimes cause its inner, or mucous coat, to become morbidly red, dry and irritable; occasioning, at the same time, a temporary fit of indigestion.”

William Beaumont was the real pioneer in the physiology of the emotions. He was an army surgeon, stationed at Fort Crawford on the upper Mississippi River during the 1820s. One day a Canadian trapper who had been shot through the stomach was brought to him. He grasped this opportunity with great imagination, and there in the wilderness made his classic observations of the physiology of digestion. A hundred and twenty years later, in New York, Dr. Harold Wolff found a similar patient. With modern techniques he elaborated the findings of his backwoods predecessor and wrote his own classic, A Man and his Stomach. Sweetser’s collection of observations and stories concerning the effects of the passions was the forerunner by almost a century of Helen Flanders Dunbar’s scholarly and closely documented Emotions and Bodily Changes, published by the Macy Foundation in New York in 1935. During that century, medicine took on the form of a science. Between 1850 and 1900, however, the great light shed on medicine by advances in bacteriology, microscopical pathology, and surgery cast its shadow on psychology. The majority of physicians were convinced that all diseases would be explained by the microscope; little was heard of psychology and the possibility that thoughts and feelings might affect medical symptoms.

Reproduced by permission of the World Publishing Company from SYMBOLS, SIGNS AND SIGNETS by Ernst Lehner.

Syphilis as a cause of mental disease had been suspected for a century. The discovery of its true role in psychiatry was both a great advance in knowledge and an inhibitor of psychological understanding. “Softening of the brain” (also known as paresis, general paralysis of the insane, and dementia paralytica) was one of the first clinical pictures to be recognized. Until the recent development of antibiotic treatment, this disease caused much of the severe mental illness that sent patients to fill our mental hospitals. There were many theories as to the cause of paresis. Early in the nineteenth century, “the strain of modern life" was blamed, as well as head injury, excessive mental work, alcohol, and venery. Syphilis was not seriously considered as a cause until 1857. Clinical observation and inoculation experiments made it seem probable. The Wassermann test for syphilis, developed in 1906. clinched the matter by showing that over 90 per cent of patients with paresis had “positive" reactions. If any doubters remained after this, they had to accept the discovery at the Rockefeller Institute by Noguchi and Moore in 1913 of the syphilitic spirochete within the brain. This was a research triumph and made investigators hopeful that all mental disorders could eventually be explained by bacterial and other injuries to the brain. Such speculation consolidated a group of psychiatrists and neurologists into a mechanistic school, and they were later to be known as “organicists.” They had little interest in psychology.

In the years around 1900, psychiatry was stirring in its cocoon. For a hundred years it had been a special branch of medicine, the first “speciality.” because of the necessity of isolating lunatics in asylums. This was a matter of taking queer and disturbing persons out of an unsympathetic population; it had little to do with treatment. A few dedicated physicians gave their lives to caring for these unfortunates, but too many of the retreats were little better than prisons. Kraepelin in Berlin made the first effective move to bring order out of chaos. By keen clinical observation he grouped the inmates of the madhouse into different categories of disease and was thus able at least to prognosticate with some accuracy whether or not a patient might recover. But his interests were largely in clinical classification and the changes found in the brains of those who died in asylums. He was greatly impressed by the findings in paresis. He did not think that life experience, personality, and emotions had much to do with mental breakdown. In short, he did not believe in psychogenesis. Finally his authoritative systematization was opposed by some younger psychiatrists, who dubbed it “Imperial German Psychiatry.”

DYNAMIC PSYCHIATRY

The group that gradually formed in opposition to the organicists was composed of good thinkers who understood the problems of the psychiatric hospitals but had broad training outside. Psychiatry had been bound within the walls of the asylums. Freud, Bleuler, and Janet in Europe, and Putnam, Meyer, and Prince in America gave impetus to the stirrings for liberation. Their dynamic psychological interpretations of mental illness began the great change which took a large part of the practice of psychiatry out of the mental hospitals and into private offices and general hospitals.

As early as 1908 Meyer wrote, “And it has become my conviction that the development of some mental diseases are rather the results of peculiar mental tangles than the results of any coarsely appreciable and demonstrable brain lesions or poisonings.” His comprehensive view of psychiatry was developed largely between 1900 and 1915. It was probably influenced by Freud’s ideas concerning the neuroses, but Meyer worked in large hospitals in New York and Baltimore and was more concerned with severe mental illness. His concept of the psychological precipitants preceding mental breakdown permeated all modern psychiatric thought. No psychiatrist would now study a patient without trying to learn about his pre-psychotic personality. Meyer preached the necessity for gathering all pertinent facts about a patient and seeing not only the mental disorder in the patient but the “he” or the “she" who is ill, in the setting of his or her life situation, The importance of psychogenesis was emphasized not as the cause of mental disorder but as one factor to be carefully weighed. Facts concerning heredity, body build, medical status, and any other relevant data were all considered.

Freud’s contributions between 1893 and 1938 have gone beyond medicine and have affected the thinking of most literate people. His approach was clinical, bringing in the techniques of free association and prolonged day-by-day analysis. His important concepts included the theory of drives, repression, the unconscious mechanisms, the development of sexuality in infant and adult, and ego development. Indeed, a rich and disturbing set of ideas! The simplest of them, the idea of unconscious motivation, was profoundly distasteful to the Victorian culture of the century’s end, with its worship of individualism, will power, and Protestant morals.

In fact, one of the charges against Freud and all dynamic psychiatrists has been that by explaining abnormal human behavior they condone it and take away from a person his choice and “free will.” It is charged that they take away responsibility and preach fatalism. This is a strange accusation against those who are trying to free men from their unconscious motivations and compulsions; against earnest physicians who are striving to help their patients toward maturity and toward altruistic behavior in place of their childish, neurotic, and antisocial reactions.

The dynamic psychology of today can be traced back to several lines of thought, dimmed between 1847 and 1900 but emerging slowly as the end of the century approached. Those who used hypnotism and studied the effects of suggestion and emotions on the bodily functions did something to keep psychological theory alive. Oliver Wendell Holmes, between 1856 and 1885, wrote three novels which showed much insight into personal problems, forecasting some of Freud’s contributions. Elsie Venner is the best known but least psychological. A Mortal Antipathy and The Guardian Angel describe quite specifically the effects of frights in infancy upon the later development of personality. Holmes explained that he considered his colleagues in the medical profession not yet ready to accept such psychological truths; therefore, he did not publish them in medical journals but disguised them in what he called his “medicated novels.” In 1899 James Jackson Putnam lectured to the Massachusetts Medical Society on “Not the Disease Only, But Also the Man.” But in 1911 he was booed at a meeting of the American Neurological Association for supporting Freud’s views. Few medical scientists were brave enough to challenge the ascendancy of the microbe.

Darwin in 1873 had written a remarkable book, describing emotional reactions as important biological phenomena, but it was not until forty years later that two great physiologists contributed to this field. Pavlov, in Russia, studying memory and learning in dogs, added much to our knowledge of emotions. Walter B. Cannon, in Boston, was the first investigator who seriously took up the problem of the physiology of the emotions. He made it a profound and respected study and published a book in 1915 entitled Bodily Changes in Pain, Hunger, Fear and Rage: An Account of Recent Researches into the Function of Emotional Excitement.

Nowadays, when every educated person absorbs some of the concepts of psychogenesis and motivation in general reading, and when every medical student learns something more about them in his early psychiatric studies, it does not seem possible that Kraepelin so recently dominated psychiatry. The fact that psychological reactions could be dynamic was made brutally clear to hundreds of army medical officers during World War I. They saw with their own eyes that violent emotion could and did cause severe illness. Soldiers were brought to hospitals with paralyzed limbs, deafness, blindness, and loss of the sense of smell — all caused psychologically and curable by psychotherapy. Even such medical diseases as goiter and diabetes were seen to be precipitated by fear and stress. These medical officers returned to become practicing doctors, but they had learned about psychogenesis and were willing to listen sympathetically to the teachings of psychiatry and physiological psychology.

PSYCHOSOMATIC MEDICINE

Gradually a body of knowledge was brought together that became known as psychosomatic medicine. This is not a specialty, but rather a comprehensive approach to medical problems which attempts to evaluate all pertinent factors, particularly the personal and psychological. It is a field for research where medicine and psychiatry meet. The term “psychosomatic” was first used by Heinroth in 1818. In the late 1920s it was reborn, and reached maturity when the American Psychosomatic Society was formed in 1944. What it is all about is best explained by giving a case history:

Mary Brown, age twenty-five, came to the Massachusetts General Hospital because of painful finger tips on both hands with small ulcerations of the skin. She was suffering from Raynaud’s disease, a disorder of the nervous system and blood vessels in which the small arteries of the hands and feet undergo periods of abnormal contraction. This shuts off the blood supply to the fingers or toes: they turn white, and later, as the arteries relax, they become swollen, blue, and painful. If the periods of arterial spasm are prolonged, the lack of oxygen supply through the blood may cause death of the tissues. The first result is ulceration of the skin, which may spread dangerously. The attacks are usually brought on by cold or anxiety. The best treatment is to avoid cold and anxiety, but this is often impossible, so surgery is employed. The nerves that cause contraction of the responsible arteries are cut near their exit from the spinal canal. With these nerves gone, spasm of the arteries becomes impossible.

Mary looked worn and older than her years but still retained a certain youthful attractiveness of manner. She was from a fishing village in Rhode Island, where her Portuguese parents had brought her up in a decaying Yankee culture. Considering her race, she had always been a reserved child and kept her sorrows to herself. Her mother died when she was twelve, and she immediately took over responsibility for her three younger brothers. Two years later her father remarried, and this she seemed to accept as inevitable. At the age of seventeen she married a man several years her senior; in spite of squabbles, they had a good relationship and much happiness. At the end of a year a son was born, and for the next two years things went along reasonably well. Then she learned that her husband had been already married, that the former wife was alive, and that her marriage was illegal. The shock was great, but she decided to stick by her husband. They planned to separate for a year, during which he would get a divorce from his wife and then legally marry our patient. During the year of separation he visited her too frequently and impregnated her. The plans for divorce and remarriage failed. He went to California; she tried to produce an abortion by taking ergot, but failed. She then married a local fisherman, much older than herself, because she needed a home and protection. Shortly after this marriage, the second son was born and rather gracefully accepted by the new husband. Three years later she became pregnant by her second husband.

Her first attack of Raynaud’s disease occurred under the following circumstances: She had been for some time carrying on a correspondence with her first husband. Her second husband had forbidden the continuance of this correspondence, but she kept it up despite him. On a hot summer day in 1933 she had gone to the post office expecting to find a letter from her first husband. When she asked for the mail, the clerk said that her husband had already called and taken it. This meant to her that her second husband had found the letter; she believed that he would have recognized it and opened and read it, and she feared the consequences. She knew that he would resent the tone in which her first husband wrote to her. Badly frightened and trembling, she went out into the street. There she formed a plan of drowning herself and the two boys. At the same time, while she was trembling, fearful, and forming ideas of suicide, she noticed that the little finger of her right hand was numb and white, while the fingernail was blue. She was so struck by this change in her little finger that she went into a grocery store and showed it to an acquaintance. This condition continued for about an hour.

Her second attack occurred on the ensuing day: her husband revealed to her that he did, indeed, have the intercepted letter. She demanded that he give it to her; he refused; there was a scene. Then she went to the dock with her two sons, intending to drown herself and them. As she stood by the water with her two boys, she noticed that the fingers of both her hands had become blue and painful. Then a man appeared on the dock, preventing her from carrying out the suicidal plan. She again attempted abortion by taking medicine, but failed and went through with the pregnancy.

After this sudden onset, the patient had such attacks almost daily. During the first year of her disease, only the finger tips were affected, but later the disturbance extended to the mid-palm of both hands and simultaneously involved both feet, which became white and cold but did not ache as did her hands. During these attacks, the patient felt her heart pounding hard and fast, and there was a dull pain in that region. Her fingers became puffy, her feet swelled, and she had increasing difficulty in closing her fists. Small ulcerations appeared on the finger tips. The attacks occurred when she was cold, tired, hungry, or scared.

Three years after the onset of her disease, operations were performed, first on the vasomotor nerves of the left hand, and then on the right. The ulcerations healed as the circulation improved, and the attacks of arterial spasm ceased. She was referred to one of the hospital psychiatrists for psychotherapy.

No one knows why some persons are susceptible to Raynaud’s disease and others are not. Heredity may play a part. Cold is the usual stimulus that sets off an attack, but in cases like that of Mary Brown the precipitating cause was clearly psychological. A thought leads to fear, and the emotion sets off nerve impulses which traverse the nerve to the artery and make it shut down. A normal and necessary function has gone too far. In this case, the surgeon stopped the ulceration and pain in the fingers. The psychiatrist and social worker carried on to relieve the emotional stress.

From the practical standpoint, psychosomatic medicine is the field where the psychiatrist can work with the medical man or surgeon for the benefit of the patient. From its very nature, it is a cooperative and comprehensive endeavor and would lose all meaning if it became a specialty. Physicians and investigators have become increasingly interested in the field, because in the last twenty years new facts have been found in neurology, psychology, and physiology that increase our understanding of complicated human situations.

I remember clearly the meeting at which the American Psychosomatic Society was organized. Dr. Meyer was present and much interested, although he could not approve of the name “psychosomatic.” He said rightly that the two words, “psyche” and “soma,” even joined in one, emphasized our illogical way of thinking of mind and body as different and separate things. Twenty years later we are still working to educate physicians to look on a man as a unified organism. Thinking of mind and body as separate leads to slighting one or emphasizing the other, to the detriment of the patient.

Take, for example, a man who has been seen by me over the last ten years — a carpenter and cabinetmaker of seventy-five, retired, living alone, and with decreasing ability to continue his beloved handicraft. He complained of “restless legs” at night, with muscular spasms and jerks that interfered with sleep. There was a history of old injury to the neck, and X ray revealed a severe, destructive arthritis of the cervical vertebrae. This explained the symptoms, but not their great exaggeration whenever his loneliness and fear of the future made him tense and anxious. He was helped by a combined treatment of orthopedic neck traction, careful use of drugs, and occasional psychiatric talks. But he kept coming back to me in frantic doubt, asking, “Doctor, is this physical, or am I neurotic?” My painstaking explanation always improved the situation for a while. I told him that he certainly had arthritis of the neck and explained how anxiety made muscular tension and therefore increased his spasms and insomnia. Nevertheless, he kept shopping around for new opinions. These usually took one side or the other and lacked a comprehensive grasp of his illness. So they confirmed his neurotic fear, and he kept coming back to me with the same old question.

If we, as practicing physicians, do not really believe in the unity of mind and body, we either think, “There’s nothing wrong with this patient; it’s only nerves,” or we ride the other hobby and in our enthusiasm for psychotherapy overlook symptoms that could be relieved medically. It is a common situation to find a patient incapacitated because a small pain he could well live with — if given understanding support — has been built up into much suffering. I never saw a patient with purely imaginary pain.

A large part of the art of medicine is understanding people. In 1927 Francis W. Peabody, in his lecture at the Harvard Medical School on “The Care of the Patient,” declared that the art of medicine and the science of medicine were not antagonistic but supplementary. He pointed out that the physician who attempts to take care of a patient while neglecting his emotional life is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment. Dr. Peabody died before psychosomatic medicine was talked about, but like all great and benevolent physicians, he understood it well.

In many medical communities, young physicians are taught to spend more time collecting data from the laboratory than quietly listening to the patient tell his story in his own words.

There has been a tendency to leave this to the psychiatrist. This is an unfortunate result of specialization, because many patients who seem to have straightforward medical or surgical problems are not given a chance to talk. Psychiatrists have learned to listen. Leaders in the teaching of psychosomatic medicine, such as Franz Alexander, Carl Binger, and Felix Deutsch, have done much to keep the human side of medicine alive. But the emphasis has been to teach this art as part of psychiatry. It should be a cornerstone of medicine.