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Physical and Psychical Factors in Disease.
971
THE
LANCET.
LONDON: SATURDAY, NOVEMBER 4, 1922.
and Psychical Factors in Disease. THE weighty impetus given to the study of psychopathology by five years of warfare, with its limitless
Physical
clinical material, is not yet dissipated. That permanent benefit has thereby accrued both to patient and physician cannot be gainsaid ; clearer insight into the working of mental mechanisms has been followed by a surer therapeutic touch on the part of the latter and by corresponding satisfaction in respect of the former. Some at least of the mental mysteries of other times have become the commonplaces of
to-day, but augmentation and popularisation of knowledge have their disadvantages. Repression. complex-formation, and the unconscious motive are now juggled with by experts both within and without the professional ranks, while patients themselves often evince a scarcely surprising familiarity with the psychological terminology of the moment. Literature, journalism, and the drama add their weekly quota to a mass from the incubus of which there seems no escaping. Survey of the present situation gives the observer an impression of a diversion of this current of thought and research in two opposite directions. Sighing for other worlds to conquer, te psychological extremist is, in the political jargon of the day, moving to the left, and claiming a psychological origin not merely for mental disease properly so called, but also for epilepsy, "
"
disseminated sclerosis, and other morbid states whose
precincts have not hitherto been invaded to any extent by the apostles of emotion. In turn, realms supposedly sacred to the psychologist are being beset by the forces of the endocrinologist and the physiologist. Swayed by the pressure thus brought to bear, we find not a few supporters of psychological theory are now edging to the right, admitting the influence of mind on body to have been exaggerated, and willing to concede a greater role in the genesis of
"
mental disorder to the agency of factors which cannot except by abuse of language be described as psychical. The centre party is represented by such authorities as Sir MAURICE CRAIG, who maintains in his Bradshaw Lecture, published on another page, that all physical diseases have a concomitant mental change, just as all mind disorder is associated with variations in the bodily functions. Fundamental differences in the attitude of mind of the exponents of these diverging schools prevent any genuine reconciliation. In his brilliant address before the British Association this year Sir CHARLES SHERRINGTON has encroached further, from the physiological side, on the outworks of the psychological die-hardthan many of his precedessors ; the physiological habit of mind is not to be shaken, though the phenomena coming under observation seem in one sense to he of a different order from those produced by the neural activity, say, of the spinal cord. On the other hand, unconvinced by the objective study of neurosis, by investigation of endocrine and vegetative systems, by the psychical concomitants of structural disease, the true-blue psychologist sticks to his guns : emotional assault is the precursor of nervous disturbance; abnormal ideation modifies structure ; the epileptic fit is the "
expression of an unconscious desire to retreat from reality to the sanctuary of the maternal uterus ; with a normal vita sexualis no neurosis is possible.
With this conflict of view, with the evidence before him-extremists’ attitude aside-of flux in psychological opinion, where does the general practitioner stand ? We commend to his notice Sir MAURICE CRAIG’S mature counsels, that safety lies in a via media, as always ; the regular interaction of mind and body in health, proclaimed by proverbs as old as the human race, has its counterpart when one or other is diseased. If he has a bent for physical explanation, a bias in favour of materialistic interpretation, he will be impressed by the mental symptoms of toxaemias and toxi-infective states, by the changes in character and personality not infrequently seen in cases of cerebral tumour, by the loss of higher psychical qualities of the arteriopath and the organic dement ; yet let him not seek in a visionary cellchange the basis of a mysophobia, in the mystery of a speculative biochemical defect the reality of an emotional shock. The physician, again, whose attitude of mind leads him to prefer psychical to physical aetiology, should beware of overlooking, as Sir MAURICE CRAIG instances by way of illustration, a collection of pus in a preoccupied concern with the patient’s mental confusion and hallucinations. Delighted as he may legitimately be in tracing an anxiety neurosis to a forgotten incident of childhood, in replacing a maladaptation to the facts of life by a wiser and saner mental outlook, hours of misplaced psycho-analytic enthusiasm may be saved by a urinary test or a glance at the optic discs. Fortunately, clinical wisdom and therapeutic skill do not depend on ability to fathom the deep places of psycho-physical interaction. Whatever views the individual physician holds of the pathogenesis of diseased states, no prepossession in respect of theory will save him from his own condemnation should he fail to make his examinations as complete as practicable, or should he concentrate on one symptom or group of symptoms with which he is familiar to the exclusion of others which patient investigation would never have allowed him to miss.
entirely
IT is
The Menstrual Cycle. regarded as certain that menstruation
is upon the presence and functional activity of the ovaries, but its exact relation to ovulation is still doubtful. Recent investigations on ovarian internal secretion tend to make the problem more complex rather than more simple. The mechanism of menstruation may indeed be under the control of a concert of internal secretions of various endocrine glands. The strict relation to ovulation would now be difficult to sustain, in view of the accumulating evidence that the whole metabolic activity of the woman follows a monthly curve which reaches its acme just before the appearance of the flow. Dr. C. CHISHOLM regards! the flow itself not as the culminating event in the cycle, but rather the result of the climax. Dr. R. W. JOHNSTONE, indeed, suggests! that there is some real truth in the ancient Mosaic view that menstruation is an excretory process, possibly designed to get rid of substances heaped up against the occurrence of pregnancy. This view falls in substantially with that of the UniversitatsFrauenklinik in Giessen, as set forth by Dr. A. SEITZ in an interesting paper2 summarising the work rof now
dependent
1 The Practitioner’s Encyclopædia of Midwifery and the Diseases of Women. Oxford Medical Publications. 1921. 2 Medizinische Klinik, August 6th, 1922, p. 1013.
THE
LANCET.
LONDON: SATURDAY, NOVEMBER 4, 1922.
and Psychical Factors in Disease. THE weighty impetus given to the study of psychopathology by five years of warfare, with its limitless
Physical
clinical material, is not yet dissipated. That permanent benefit has thereby accrued both to patient and physician cannot be gainsaid ; clearer insight into the working of mental mechanisms has been followed by a surer therapeutic touch on the part of the latter and by corresponding satisfaction in respect of the former. Some at least of the mental mysteries of other times have become the commonplaces of
to-day, but augmentation and popularisation of knowledge have their disadvantages. Repression. complex-formation, and the unconscious motive are now juggled with by experts both within and without the professional ranks, while patients themselves often evince a scarcely surprising familiarity with the psychological terminology of the moment. Literature, journalism, and the drama add their weekly quota to a mass from the incubus of which there seems no escaping. Survey of the present situation gives the observer an impression of a diversion of this current of thought and research in two opposite directions. Sighing for other worlds to conquer, te psychological extremist is, in the political jargon of the day, moving to the left, and claiming a psychological origin not merely for mental disease properly so called, but also for epilepsy, "
"
disseminated sclerosis, and other morbid states whose
precincts have not hitherto been invaded to any extent by the apostles of emotion. In turn, realms supposedly sacred to the psychologist are being beset by the forces of the endocrinologist and the physiologist. Swayed by the pressure thus brought to bear, we find not a few supporters of psychological theory are now edging to the right, admitting the influence of mind on body to have been exaggerated, and willing to concede a greater role in the genesis of
"
mental disorder to the agency of factors which cannot except by abuse of language be described as psychical. The centre party is represented by such authorities as Sir MAURICE CRAIG, who maintains in his Bradshaw Lecture, published on another page, that all physical diseases have a concomitant mental change, just as all mind disorder is associated with variations in the bodily functions. Fundamental differences in the attitude of mind of the exponents of these diverging schools prevent any genuine reconciliation. In his brilliant address before the British Association this year Sir CHARLES SHERRINGTON has encroached further, from the physiological side, on the outworks of the psychological die-hardthan many of his precedessors ; the physiological habit of mind is not to be shaken, though the phenomena coming under observation seem in one sense to he of a different order from those produced by the neural activity, say, of the spinal cord. On the other hand, unconvinced by the objective study of neurosis, by investigation of endocrine and vegetative systems, by the psychical concomitants of structural disease, the true-blue psychologist sticks to his guns : emotional assault is the precursor of nervous disturbance; abnormal ideation modifies structure ; the epileptic fit is the "
expression of an unconscious desire to retreat from reality to the sanctuary of the maternal uterus ; with a normal vita sexualis no neurosis is possible.
With this conflict of view, with the evidence before him-extremists’ attitude aside-of flux in psychological opinion, where does the general practitioner stand ? We commend to his notice Sir MAURICE CRAIG’S mature counsels, that safety lies in a via media, as always ; the regular interaction of mind and body in health, proclaimed by proverbs as old as the human race, has its counterpart when one or other is diseased. If he has a bent for physical explanation, a bias in favour of materialistic interpretation, he will be impressed by the mental symptoms of toxaemias and toxi-infective states, by the changes in character and personality not infrequently seen in cases of cerebral tumour, by the loss of higher psychical qualities of the arteriopath and the organic dement ; yet let him not seek in a visionary cellchange the basis of a mysophobia, in the mystery of a speculative biochemical defect the reality of an emotional shock. The physician, again, whose attitude of mind leads him to prefer psychical to physical aetiology, should beware of overlooking, as Sir MAURICE CRAIG instances by way of illustration, a collection of pus in a preoccupied concern with the patient’s mental confusion and hallucinations. Delighted as he may legitimately be in tracing an anxiety neurosis to a forgotten incident of childhood, in replacing a maladaptation to the facts of life by a wiser and saner mental outlook, hours of misplaced psycho-analytic enthusiasm may be saved by a urinary test or a glance at the optic discs. Fortunately, clinical wisdom and therapeutic skill do not depend on ability to fathom the deep places of psycho-physical interaction. Whatever views the individual physician holds of the pathogenesis of diseased states, no prepossession in respect of theory will save him from his own condemnation should he fail to make his examinations as complete as practicable, or should he concentrate on one symptom or group of symptoms with which he is familiar to the exclusion of others which patient investigation would never have allowed him to miss.
entirely
IT is
The Menstrual Cycle. regarded as certain that menstruation
is upon the presence and functional activity of the ovaries, but its exact relation to ovulation is still doubtful. Recent investigations on ovarian internal secretion tend to make the problem more complex rather than more simple. The mechanism of menstruation may indeed be under the control of a concert of internal secretions of various endocrine glands. The strict relation to ovulation would now be difficult to sustain, in view of the accumulating evidence that the whole metabolic activity of the woman follows a monthly curve which reaches its acme just before the appearance of the flow. Dr. C. CHISHOLM regards! the flow itself not as the culminating event in the cycle, but rather the result of the climax. Dr. R. W. JOHNSTONE, indeed, suggests! that there is some real truth in the ancient Mosaic view that menstruation is an excretory process, possibly designed to get rid of substances heaped up against the occurrence of pregnancy. This view falls in substantially with that of the UniversitatsFrauenklinik in Giessen, as set forth by Dr. A. SEITZ in an interesting paper2 summarising the work rof now
dependent
1 The Practitioner’s Encyclopædia of Midwifery and the Diseases of Women. Oxford Medical Publications. 1921. 2 Medizinische Klinik, August 6th, 1922, p. 1013.