PSYCHOSOMATIC MEDICINE AND THE BRAIN-MIND RELATIONSHIP

Saturday PSYCHOSOMATIC MEDICINE AND THE BRAIN-MIND RELATIONSHIP* D.M. Oxon.,

Lord BRAIN D.Sc., D.C.L., LL.D., F.R.C.P., F.R.S.

CONSULTING PHYSICIAN TO THE LONDON AND MAIDA VALE HOSPITALS

different philosophical views about the the mind and the brain. Some hold between relationship that they are two separate entities, which interact; others that they are the same entity, of which we become aware from different aspects; and there is a third view, that mental activities and brain activities are mutually independent, but parallel with one another. Although this third view had distinguished supporters in the last century, it does not explain anything which cannot be explained in terms of one of the other two, and it adds to the difficulty of a complex problem by itself failing to show how the supposed parallelism between mental and physical activities is established and maintained. It does not seem to have many supporters today. Either of the other views, which we may call the interactionist and the THERE

are

15

August 1964

part in the sexual activity necessary for the survival of the species. Thus it is not surprising that we find the cortical receptive areas for smell and taste anatomically closely related to regions concerned with behaviour. But the rhinencephalon is anatomically and physiologically related with higher levels of the nervous system, represented by various areas of the cerebral cortex, and with lower levels represented chiefly by the hypothalamus. These points can best be illustrated by considering the neural basis of various emotional drives separately.

Rage

and

Aggression

It is many years since Bard (1928) observed that lesions cephalad to the hypothalamus in cats led to the manifestation of all the physical signs of rage-a condition which he termed " sham-rage "-and that lesions which interrupted the connections between the hypothalamus and lower levels of the nervous system were followed by Recent experimental states of abnormal tranquillity. work, using indwelling electrodes in the otherwise intact cat, has shown that there is a localised area in the hypofrom which all the physical manifestations of thalamus double-aspect hypotheses respectively, can give an can be elicited by electrical stimulation (De Molina rage account of psychosomatic disorders which is quite adequate and Hunsperger 1962). Since this is a circumscribed for ordinary needs. So for our present purpose there is no need to choose between them, nor indeed to area, we may conveniently term it a hypothalamic centre for rage. Experimental work by Bard and Mountcastle consider this philosophical problem further. (1948) has shown that this centre is under complex The Neurological Basis of Emotion higher control. If the whole of the neocortex of cats All psychosomatic disorders are regarded as related on with the exception of certain rhinencephalic structures is their psychological side to emotion. So it is essential, if removed, the animals subsequently show abnormal we are to discuss them in terms of the mind-brain passivity. If, however, the rhinencephalic structures are to about the also relationship, begin by saying something removed, the animals show anger on rather slight of basis emotion. There are still a neurological good provocation. This suggests that, in the absence of the about obscurities but has been this, learnt, neocortex, some remaining part of the forebrain conmany enough especially during the last twenty-five years, to enable us tinuously exerts an inhibitory effect on the hypothalamic to give a broad and accurate outline of the brain structures rage centre. Furthermore, what the authors describe as which are active when we experience emotion, and we " an extraordinary and lasting depression of the threshold can also understand a fair amount about their interaction. of the rage-reactions was produced by restricted bilateral We may begin with the rhinencephalon, which more removals that included the amygdaloid nuclear complex The term and much of the cortex of the pyriform lobe ". It is also or less corresponds to the limbic lobe. " " that it is rhinencephalon implies functionally related concluded that since no normal cat is ever as placid as to the nose-that is, to the sense of smell. This is not the animals from which the neocortex has been removed, a of it since small is the this mugt normally antagonise the suppressive action of only part altogether accurate, of the direct recipient impulses from olfactory organ; and those forebrain structures which are responsible for the consequently there has been some discussion among passivity. Bard and Mountcastle speculatively try to neurophysiologists as to precisely what is meant by the harmonise these facts by suggesting that the area of the term. But there is a good biological reason for using it amygdala acts as a funnel through which inhibitory to describe the higher cerebral centres concerned with influences exert a suppressing action on the rage centre, the and that the neocortex also exerts a facilitating and the of emotion-namely, biological importance and in relation to the survival senses excitatory influence which bypasses the region of the olfactory gustatory both of the individual and of the race. For in all mammals amygdala. Fear and Avoidance smell and taste-the latter sense being, of course, to a of modes of sensation Kluver and very large extent, olfactory-are Bucy (1937) showed that removal of the the greatest importance in relation to feeding; and in lobe renders monkeys abnormally fearless. temporal from the the insect to living organisms, higher Stimulation of the amygdala, on the other hand, may up mammals, the sense of smell often plays an essential lead to manifestations of fear, and fear is a well-recognised * symptom of an epileptic attack originating in a disPaper read at the Sixth European Conference on Psychosomatic Research, Athens, May 6-9, 1964. charging lesion in the temporal lobe. Denny-Brown and 7355

326 Chambers

(1958)

have shown that

Autonomic Components of Emotional Behaviour

parietal lobectomy in

the animal to turn avoiding reactions of the limbs on the side opposite to the lesion; and after bilateral ablation the whole behaviour of the animal is changed, so that avoidance becomes the usual reaction to stimuli, even food, which normally attracts. This would suggest that fear and avoidance are reactions to external events which depend upon the integrity of the temporal lobe. SexualBehaviour

monkeys, when unilateral,

The autonomic components of emotional behaviour familiar to need emphasis. One or two points, however, are perhaps worth mentioning. Changes in blood-pressure and respiration can, of course, be evoked by electrical stimulation of various regions of both frontal and temporal lobes; but such focal stimulation is highly artificial, since normally these autonomic reactions occur as integral parts of emotional behaviour. Such observations, however, do indicate what disturbances of function may happen as a result of overactivity of such autonomic pathways, and in a recent paper Melville et al. (1963) described cardiac ischaemic changes and arrhythmias produced by hypothalamic stimulation in cats. It may be relevant also to quote a recent summary of the effects of emotional stress upon the gastrointestinal tract:

causes

away from the examiner and show

are too

Kluver and Bucy also found that temporal-lobe removal in monkeys resulted in hypersexuality. And this has been shown to occur in cats too after temporal-lobe lesions. This overactivity is observed both when the animals are alone and when they are with others, and in males is directed to other animals of either sex. It has been shown that there is a hypothalamic centre concerned with sexual behaviour which is under the control of higher levels of the nervous system, particularly in the temporal lobe. What has been termed a mating centre has been demonstrated in the anterior hypothalamus in cats. This responds to endocrine as well as to neural stimuli. Thehypersexualityin male monkeys and cats which occurs after the removal of temporal-lobe areas has been shown to be dependent upon the male sex hormone. Anoestrus can be produced in the cat by lesions of the hypothalamus, rostral to the ventromedial nuclei, and this type of anoestrus is without effect on ovulation and fails to respond to exogenous cestrogens. Lesions of the ventromedial nuclei, or premammillary lesions, or destruction of the mammillary bodies, cause a different type of anoestrus which is due to ovarian atrophy secondary to hypopituitarism, and in this type of anoestrus there is a normal behavioural response to exogenous oestrogens (Sawyer and Robison 1956). Harris, Michael, and Scott (1958) have shown that the area of the nervous system which responds to oestrogen is highly specific. The implantation of small amounts of stilbcestrol in the posterior hypothalamus of ovariectomised cats led to the full development of sexual behaviour. Maternal behaviour has also been shown to depend upon the integrity of the medial and basal part of the forebrain.

"

Salivary secretion can be increased or decreased. Also, composition of the saliva changes. Secretion of gastric juices is easily influenced by anger, joy, anxiety states, etc. The change in secretion is associated with, or preceded by, changes in motility. Secretion of intestinal juices and bile has been reported to fluctuate under emotional stress. Anger and hostility lead to hyperactivity of the colon; fear, to immobilisation (Eliasson, 1960).

the

"

noteworthy, too, that-no doubt through disorder high autonomic control-acute ulceration of the oesophagus, stomach and duodenum may follow brain damage. It is

of

Influence of Higher Cortical Levels

Feeding and Drinking

Another observation first made by Kluver and Bucy that temporal-lobe lesions in monkeys led to abnormal oral behaviour, the animals showing strong oral tendencies in examining available objects (licking, biting gently, chewing, touching with the lips, " smelling "). There were also changes in eating habits, particularly a lack of discrimination, such that the animal would readily accept and consume articles of diet upon which it did not usually feed, and this tendency may be associated with excessive appetite. Similar changes have been observed after experimental temporal-lobe lesions in cats. At the hypothalamic level, a centre has been found responsible for feeding. After destruction of the lateral hypothalamus, animals fail to eat; but there is also believed to be a medial area concerned with satiety, and medial lesions lead to overeating and obesity. As in the case of the rage centre, stimulation of the lateral mechanism in unanaesthetised animals causes them toI feed. A similar centre in the hypothalamus has been held responsible for drinking, and the paraventricular nuclei are believed to be the site of osmoreceptors concerned inL the regulation of the body fluids (Brobeck 1960).

was

.

Upon Behaviour The temporal lobe has other functions than those which we have so far considered. It receives important associational pathways from other parts of the cortex, particularly from the visual cortex; and electrical stimulation in the conscious patient in the course of operation for epilepsy has shown how readily visual scenes may be evoked from the temporal lobe. The temporal lobe is also concerned in visual discrimination, and one of the prominent symptoms observed after temporal lobectomy in the monkeys by Kluver and Bucy, and confirmed by later observers, was a failure to discriminate objects visually, which they regarded as akin to visual agnosia. Then, much recent work indicates that parts of the temporal lobe, particularly perhaps the hippocampal gyrus, the fornix, and the mammillary bodies, play an important part in the neurological basis of memory. After destruction of this region, usually bilaterally but occasionally unilaterally, the patient loses the capacity to remember new experiences, although events which happened before the acquisition of the lesion may be remembered as well as previously (Scoville and Milner 1957, Adams et al. 1962). I spoke at the beginning of the primary importance of smell and taste for many living organisms, but in many of these vision also comes to be equally important, particularly in the detection of food and the avoidance of predators. Thus we may see in the association pathways linking the visual cortex with the temporal lobe a means whereby the visual perception of objects evokes the appropriate behavioural response, and the role of the temporal lobe in the storage of memories seems to be involved in the modification of behaviour by experience through the process of learning. What part do the frontal areas of the forebrain play in behaviour? The existence of anatomical connections between the frontal lobes and the hypothalamus and temporal lobes, and the effects of experimental lesions,

327

show that the frontal lobes influence the basic instinctive and emotional drives. The operation of prefrontal

leucotomy has taught us a good deal about their functions in man: in animals it is less easy to infer, and there is still much to be learnt about it in respect of both. Pribram (1960) dealing with highest-level cerebral activities in animals, distinguishes between the posterior and the frontal intrinsic systems, as serving different aspects of the problem-solving process. Posterior intrinsic sector resection-i.e., damage to the temporoparieto-occipital region-interferes with differentiative behaviour during search. Such lesions, he says, affect the delineation of a problem. Frontal intrinsic sector resection interferes with intentional behaviour after search is completed; such lesions affect the economic solution of a problem. Many years ago Jacobsen (1936) showed that lesions of the frontal lobe caused a monkey to have severe and permanent difficulty with tasks involving recent memory. Weiskrantz et al. (1962) have recently confirmed this, using an ingenious electrical technique which produces a reversible deficit. The last thirty years have added a great deal to our knowledge of temporal-lobe function; perhaps the next thirty will do the same for the frontal lobe and demonstrate that it, too, has many and varied activities.

probably

The

Anatomy

of Feeling

It would seem, then, that judging from these various types of experiment’ in animals of different species, emotional behaviour depends upon centres of activity in the hypothalamus; and, as Masserman (1943) suggests, these are probably to be regarded as " reinforcing and coordinating the neural and hormonal mechanisms of conative and emotional expression." We have also seen that these hypothalamic centres are controlled in a complex fashion by the cerebral cortex. But we have still to consider other factors in their regulation. The central reticular alerting formation, which is concerned not only with waking, sleeping, and consciousness itself but also with the selective control of attention, has been shown to operate not only as a homoeostatic mechanism but also as determining the selective response of the organism to stimuli. Moreover, as a homoeostatic mechanism, the reticular formation reacts not only to nervous impulses but also to changes in the chemical state of the body; and, as we have already seen, these may also influence specific emotional reactions

(Dell 1963). There has from time to time been discussion as to the precise anatomical basis of emotional feeling, and Papez (1937) suggested a possible site. It is easy here to be misled by words, and it could be argued that there is no such thing as emotion: there are only specific emotions. This indeed is part of the general question of " the localisation of consciousness ". Perhaps all we can usefully say is that at some level of intensity the activity of the pathways we have been considering as concerned in the instinctive drives leads to the conscious experience we call emotion. So far we have been talking in terms of anatomical structures and their functions. We may ask at this point whether there is any significance in the close anatomical relationships of the structures subserving the functions we have been discussing. Anatomical juxtaposition is not necessarily physiologically significant, but I think it is so in this case from the biological-that is, an evolutionary

- standpoint. In the evolution of the nervous system, though old structures may have been modified, and new ones superimposed upon them, and though there has sometimes been a transference of functiop from one part to another, the significant thing is that so much of the original pattern remains and, what is more, remains endowed with its original functions. So in the rhinencephalon and the hypothalamus we are looking at organisations of great evolutionary antiquity, and there is some evidence that in man they still underlie those basic instinctive drives and emotional tensions which he shares with many of his evolutionary predecessors.

Language

and Emotion

But we must go on to ask how man differs from them. A fundamental difference is his possession of language. The essence of language is the use of symbols. The

higher animals, particularly

the

anthropoid

apes,

com-

municate with each other to a limited extent; but only man is able to use a sound or a combination of sounds to stand for something else, and is therefore able to communicate with his fellows about things in their absence. A century ago, Hughlings Jackson distinguished between the propositional and the emotional use of speech, and this distinction has been developed and popularised by some recent authorities. But it may easily be misleading. Words themselves are neither propositional nor emotive, but only the use which is made of them; and a propositional statement may be strongly emotive. I make this point because of the great importance of words in relation to psychosomatic disease. Sarkisov (1964) says that all human conditioning takes place through the medium of words. However that may be, electrophysiological studies have provided striking illustrations of the psychosomatic influence of words. Rushworth (1962) has been studying electromyographically the blink reflex, elicited by tapping the forehead between the eyes. He found that the muscular contraction which constituted the response contained two components, one earlier and one later, in the electromyogram. The later one, which he identified physiologically with the avoiding-reaction system, soon disappeared by habituation on repetition of the stimulus. But if the subject was told that the stimulus was going to be painful, though in fact it was not, the avoidingreaction component reappeared and then could not be extinguished by habituation. Thus the physiological automatic and unconscious reaction to a stimulus was influenced by what the subject was told, and this influence remained, even though experience rapidly showed that the information was incorrect. Similar observations have been made by Hagbarth and Finer (1963) on the nociceptive reflexes of the lower limbs in man. They demonstrated the same two phases in the motor response, the first a spinal reflex, the second employing longer and probably. cerebral paths; and regarded the latter as an avoiding reaction. Under hypnotic suggestion the second reaction could be abolished if the subject was told that the limb was anaesthetic, and enhanced if he was told it was hyperalgesic. In a patient with hysterical anaesthesia, the second component was absent in the anaesthetic limb, but present in the opposite limb which had normal sensation. It is necessary to recognise what may be described as different levels of language. We know that for many primitive peoples words are credited with remarkable potencies, and may play an important part in magic, and

328

be the subject of taboos. At this psychical level, words therefore have a kind of autonomy, and produce effects, which are not to be explained in terms of higher levels, where they are used, for example, scientifically. The body image is a term with several connotations. Not only does it represent what I am at any moment aware of as my body, or part of it, but it may include rational or irrational ideas which endow different parts of the body with a particular emotional significance. Prescientific thinking provides familiar examples of this, as when the heart, or bowels, for example, were regarded as the sites of particular psychological functions. Though scientific thinking may have to some extent replaced these old ideas by more rational ones, nevertheless earlier irrational notions may survive. At this pre-rational level of thought, parts of the body may acquire a symbolic significance in the emotional life, and may then become the site of symptoms or of disordered function which gives rise to symptoms. Some such ideas are reflected in the metaphors of current language: when, for example, a particular problem is described as a headache, or a person as a pain in the neck, or one speaks of being sick of a situation. Someone expressed a profound truth when, by altering two letters, he turned Pascal’s " Le coeur a ses raisons " (the heart has its reasons) into " Le corps a ses raisons " (the body has its reasons). Psychosomatic medicine is largely concerned with understanding the body’s reasons, which it expresses through this type of symbolism, in which the pre-rational use of words may play a part. The Nature of Psychosomatic Disorders

We have

something of the anatomical and mechanisms which underlie emotion and physiological the instinctive drives, how closely they are correlated, and how in man they may be modified by his capacity for language and symbolic representation. We have noted examples of the close links between the nervous and endocrine systems; and the existence of pathways by which emotions, and the ideas which evoke them, can influence visceral activity of many kinds. We are left with the problem why psychosomatic disorders should occur in some people rather than in others, and by what perversion of normal physiology they are produced and maintained. I shall not discuss the first in detail. It raises a difficult question of statistical correlation of psychological traits, which are themselves difficult to delineate and measure, with the incidence of the psychosomatic disorder under consideration. In the interpretation of psychosomatic disorders there is room for many approaches, and scope for several levels of investigation. We may think in terms of infantile emotional orientations; or of physiological displacements, with which we are already familiar in the displacement activities of birds and animals; or of symbolisation, an approach which may be particularly fruitful in the understanding of pain of psychogenic origin, and some skin disorders. Or we may think in terms of conditioned reflexes or disordered learning, which leaves behind habitual reactions of unconscious origin. Physiologically we may interpret some disorders as disturbances of homoeostasis produced by emotion, so that the relevant activities are set at an abnormal level, as may be the case in some forms of thyrotoxicosis. Or we may inquire whether transitory, and at first reversible, changes resulting from stress may not lead to irreversible disorders of structure and function. But, however specialist seen

individual approach may be, it can, I believe, only be enriched by seeing it as part of a comprehensive view of body and mind, intertwined in what the poet Donne calls " that subtile knot, which makes us man ".

our

REFERENCES

Adams, R. D., Collins, G. H., Victor, M. (1962) in Physiologie de l’Hippocampe. Paris. Bard, P. (1928) Amer. J. Physiol. 84, 490. Mountcastle, V. B. (1948) Res. Publ. Ass. nerv. ment. Dis. 27, 362. Brobeck, J. R. (1960) in Handbook of Physiology. Sect. 1: Neurophysiology (edited by J. Field); vol. 2, p. 1197. Baltimore. Dell, P. (1963) in Progress in Brain Research. Vol. 1. Brain mechanisms (edited by G. Moruzzi, A. Fessard and H. H. Jasper); p. 82. —

Amsterdam. De Molina, A. F., Hunsperger, R. W. (1962) J. Physiol. 60, 200. Denny-Brown, D., Chambers, P. A. (1958) Res. Publ. Ass. nerv. ment. Dis. 36, 35. Eliasson, S. G. (1960) in Handbook of Physiology. Sect. 1: Neurophysiology

(edited by J. Field); vol. 2, p. 1163. Hagbarth, K. E., Finer, B. L. (1963) in Progress in Brain Research. Vol. 1 (edited by G. Moruzzi, A. Fessard and H. H. Jasper); p. 65. Amsterdam.

Harris, G. W., Michael, R. P., Scott, P. P. (1958) in Ciba Foundation Symposium on the Neurological Basis of Behaviour; p. 236. London. Jacobsen, C. F. (1936) Comp. Psychol. Monogr. 13, no. 3. Klüver, H., Bucy, P. (1937) Amer. J. Physiol. 119, 352. Masserman, J. H. (1943) Behavior and Neurosis. Chicago. Melville, K. I., Blum, B., Shister, H. E., Silver, M. D. (1963) Amer. J. Cardiol. 12, 781. Papez, J. W. (1937) Arch. Neural. Psychiat. 38, 725. Pribram, K. H. (1960) in Handbook of Physiology. Sect. 1: Neurophysiology (edited by J. Field); vol. 2, p. 1323. Rushworth, G. (1962) J. Neurol. Neurosurg. Psychiat. 25, 93. Sarkisov, S. (1964) in Growth and Maturation of the Brain (edited by D. P. Purpura and J. P. Schade); p. 30. Amsterdam. Sawyer, C. H., Robison, B. (1956) J. Clin. Endocrinol. 16, 914. Scoville, W. B., Milner, B. (1957) J. Neurol. Neurosurg. Psychiat. 20, 11. Weiskrantz, L., Mihailovic, L., Gross, C. G. (1962) Brain, 85, 487.

GASTRIC COOLING IN THE TREATMENT OF BLEEDING FROM ŒSOPHAGEAL VARICES G. WALKER M.B. Lond., M.R.C.P. MEDICAL REGISTRAR

R. WILLIAMS Lond., M.R.C.P.

M.D.

LECTURER IN MEDICINE

R. E. CONDON

E. N. THOMPSON

M.D. Rochester

M.B. Lond., M.R.C.P.

GUGGENHEIM FELLOW

ASSISTANT LECTURER

M.D.

SHEILA SHERLOCK Edin., F.R.C.P., F.R.C.P.E. PROFESSOR OF MEDICINE

From the

Department of Medicine, Royal Free Hospital, London, W.C.1

--- ---- -1

THE management of acute bleeding from oesophageal varices in patients with cirrhosis presents many difficulties, and there are disadvantages in all the current therapeutic methods. Vasopressin (’ Pitressin ’) has been used with success (Shaldon and Sherlock 1960), but there is a definite risk of inducing ischxmic changes in the myocardium, and the reduction of liver blood-flow (Shaldon et al. 1961) is undesirable. Compression of varices by the Sengstaken tube (Sengstaken and Blakemore 1950), though frequently controlling the hxmorrhage, often leads to oesophageal ulceration and to pulmonary and other complications (Read et al. 1960), and it is extremely unpleasant for the patient. Intragastric hypothermia was initially used as a means of achieving whole-body cooling (Barnard 1956, Holt et al. 1958), but it was subsequently applied to the treatment of upper gastrointestinal haemorrhage and ulceration (Wangensteen et al. 1958). A cooling fluid is circulated from a refrigeration unit to an intragastric balloon. Two distinct procedures can be used-gastric freezing, in which the temperature of the fluid entering the stomach is set at —20°C, and gastric cooling, in which a temperature of 0°C is employed. In 1959, Wangensteen et al. reported that gastric cooling at 0°C would control haemorrhage from oesophageal