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    Psychosomatic Disease and the "Visceral Brain"Recent Developments Bearing on the Papez Theory of Emotion

    PAUL D. M A C L E A N , M.D.

    IN most of those diseases where emotional statesare thought to be etiologically related to focalor systemic lesions, it is generally assumed thatthe pathologic process is mediated by the auto-

    nomic nervous system and the humoral mechan-isms under its control. There is considerableexperimental and clinical evidence to support suchan assumption. But little information has accumu-lated to indicate by what mechanism the emotionscan so act on autonomic centers as to lead to dis-eases as diverse as essential hypertension, pepticulcer, asthma, etc.

    The first part of this paper will be devoted to areview of certain neuroanatomic and neurophy-siologic evidence now at hand that contributes tothe understanding of emotional mechanisms andpoints to a variety of ways by which the affective

    qualities of experience could act on autonomiccenters. In the subsequent section it will be sug-gested how this evidence perhaps ties in with someof the current psychodynamic formulations regard-ing those psychosomatic diseases where lesions arepresent.

    The problem pertaining to emotional mechan-isms is basically one of communication in thecentral nervous system. It may be assumed thatmessages from both without and within the or-ganism are relayed to the brain by nervous im-pulses traveling along nerve fibers and possibly byhumoral agents carried in the blood stream. Ulti-mately, however, any correlation of these messagesmust be a function of a highly integrated body of

    Presented before the Staff Meeting of the PsychiatricService, Massachusetts General Hospital, January n , 1949.

    From the Department of Neurology and Psychiatry ofthe Harvard Medical School and the Psychiatric Service ofthe Massachusetts General Hosp ital, Boston.

    I wish to acknowledge my great indebtedness to Dr.Stanley Cobb for providing the opportunity to carry onthese and other studies pertaining to psychosomatic medi-cine. I also wish to express my sincere appreciation to Dr.James W. Papez for demonstrating to me many of theanatomical structures dealt with in this paper, as well asfor permission to refer to certain unpublished data. I wantto thank both Dr. Cobb and Dr. Papez for reading thismanuscript and offering their valuable criticism.

    neurones capable of sorting, selecting, and actingupon various patterns of bioelectrical activity. Theindications are that both the experience and theexpression of emotion are the resultant of the

    association and correlation of a wide variety ofinternal and external stimuli whose messages aretransmitted as nervous impulses in cerebral an-alyzers. The manner in which these impulses cangive rise to the subjective feeling of emotion re-mains a complete mystery. But in the light of whatis known about the capacity of small electricalcharges to trip large scale mechanisms into action,it is more readily understood how nervous im-pulses set going the various phenomena associatedwith emotional expression.

    The hypothalamus is considered to be the headganglion of the autonomic nervous system (31).On the basis of investigations showing the roleof the hypothalamus in sham rage (6, n ) it hasoften been inferred in the literature on psycho-somatic medicine that this nerve center is responsi-ble both for the experiencing and expression ofemotion. Masserman, however, has amassed consid-erable evidence to show that whereas the hypo-thalamus is the main neural center for mediatingthe expression of emotion, it does not share in theexperiencing of emotion (46). Although the thal-amus probably participates in a crude awarenessof somesthetic sensations, (38) the present evi-dence indicates that only the cerebral cortex iscapable of appreciating all the various affective

    qualities of experience and combining them intosuch states of feeling as fear, anger, love, and hate(cf. 15, 46, 52, 69).

    To emphasize the role of the cerebral cortex inthe experiencing of emotion, however, is to re-quire one to stress at the same time its connectionswith the hypothalamus, the effector mechanism ofemotional expression. In the light of this it is aninteresting and significant observation that theneopallium, despite its forming most of the cere-bral mantle, has (as far as is known at the presenttime) comparatively little autonomic representa-tion. If one accepts Yakovlev's interpretation that

    the orbitomesial surface of the frontal lobes be-VOL. XI, NO. 6

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    MacLEANlongs to the mesopallium (79, 80) ,1 there remainsonly a relatively small area of the neocortexnamely, the rostral part of the motor cortexfrom which autonomic responses can be obtainedby appropriate stimulation (31). The anatomicpathways over which these responses are mediatedhave yet to be ascertained. There are known to berelay circuits from the frontal lobes to the hypo-thalamus by way of the septal nuclei and medialforebrain bundle (cf. Fig. 2), as well as throughthe dorsomedial nuclei of the thalamus and theperiventricular system (70); but the anatomic de-tails of these fiber connections are still obscure. Itis only within the last two years, as the result offurther microanatomic studies (50) and physio-logic neuronography (74), that there has beenany clear indication of direct pathways to thehypothalamus.

    The difficulty in demonstrating pathways be-tween the neopallium and the hypothalamus is inmarked contrast to the ease with which one canpoint to many and strong connections between theold brain (rhinencephalon) and the hypothalamus,some of which, such as the fornix, are almost thediameter of a pencil (cf. F igs. 1 and 2) .

    On the strength of this intimate relationship ofthe phylogenetically older cerebral structures withthe hypothalamus, together with certain experi-mental and clinical considerations, Papez in 1937published a paper called "A Proposed Mechanismof Emotion" in which the theory was advanced"that the hypothalamus, the anterior thalamicnuclei, the gyrus cinguli, the hippocampus andtheir connections constitute a harmonious mechan-ism which may elaborate the functions of centralemotion, as well as participate in emotional ex-pression (52).

    General Considerations of the Papez TheoryThe theory expressed in this paper has done

    much to revive interest in the rhinencephalon. AsPapez . observed, many of the structures he listedas being involved in emotional experience havecommonly been "represented as dealing with somephase of the olfactory- functio n." H e felt that th erewas "no clinical or other evidence to support thisview."

    To be sure, the doubt has long been expressedthat the cingulate gyrus should be included as partof the rhinencephalon (19). It has been noted that

    339not only this gyrus, but also the hippocampalsystem, are present in such forms as the dolphinand the porpoise where the sense of smell is ab-sent.2 Furthermore, it is remarkable that in manwhere the olfactory bulbs are small compared withmacrosmatic animals, the hippocampal formationand the cingulate gyrus reach their greatest de-velopment (9). Recently Brodal, in a review deal-ing with the hippocampus and related structures,has concluded that only a compartively small partof the cerebral cortex usually assigned to therhinencephalon is directly involved in olfaction( 9 ) . On the basis of extensive comparative studies,C. Judson Herrick maintained that the rhinen-cephalon, in addition to mediating the sense ofsmell, served as a nonspecific activator for all cor-tical activities, influencing appropriately, in an ex-citatory or inhibitory capacity, such functions asmemory, learning, and affective behaviour (30).

    The mechanism of emotion proposed by Papezwill require further elaboration during the courseof this paper. Briefly, the concept, as first pre-sented in 1937, is formulated as follows (see Figure1 ) : "The central emotive process of cortical originmay . . . be conceived as being built up in the

    hippocampal formation and as being transferredto the mammillary body and thence through theanterior thalamic nuclei to the cortex of the gyruscinguli. The cortex of the cingular gjrus may belooked on as the receptive region for the experi-encing of emotion. . . . Radiation of the emotiveprocess from the gyrus cinguli to other regions inthe cerebral cortex would add emotional colouringto psychic processes."

    In the light of subsequent experimental findings,Papez's delimitation of this region in the experi-encing of emotion strikes one today as a consider-able tour de force. For, other than the known com-

    parative and neuroanatomy of this region, therewas little experimental data to support his thesis,and the clinical evidence was more suggestive thandefinitive. He emphasized that lesions directly in-volving or impinging on the anatomic circuitshown in Fi gure 1 caused a variety of symptomsthat were confined largely to the affective be-haviour of the individual. Starting with the hip-pocampal formation (cf. Figs; 1, 2, and 4), Papeznoted that in rabies where the disease appears tohave a predilection for the hippocampus and cere-bellum, the patient is subject to anxiety, appre-hensiveness, and paroxysms of rage or terror. I

    1 Transitional cortex between "old" brain and "new"brain.

    NOVEMBER-DECEMBER, 1949

    2 See 9, 19, 69 for review and further references.

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    34 VISCERAL BRAIN

    FIG. I.The shaded area of cortex represents what was formerly known as the limbic lobe ofBroca and subsequently termed the rhinencephalon by Turner. It corresponds to what isarbitrarily referred to in this paper as the visceral brain. M, mammillary body. AT, anteriorthalamic nucleus.

    might add that both the "dreamy state" and epi-

    leptic automatisms indicate that the hippocampalformation and associated structures are concernedin emotional experience. Hughlings Jackson, whopreferred the term "dreamy state" to "intellectualaura," described the condition as a kind of "doubleconsciousness" or "mental diplopia" (32). It wasas though the individual had the sense of beingin contact with reality, but at the same time hadthe feeling he was experiencing a dream or some-thing that had happened before (deja vu). Jack-son associated the dreamy state with "discharges"or lesions in the uncinate region. In the experienceof Penfield and Erickson the lesion responsible for

    the dreamy state has usually been situated deepwithin or underneath the temporal lobe (58). Theyhave stressed that the sense of reminiscence thatoccurs with discharges in this region is often"onlythe feeling3 which normally accompanies the actof remembering."

    Patients subject to epileptic automatisms per-form bizarre acts for which they have no memory.These seizures, as well as the dreamy state, arefrequently associated' with a variety of visceral,emotional, and other sensory manifestations. Theremay be a visceral aura such as a sense of smell,taste, epigastric uneasiness, or asphyxia. Chewing

    8 Italics mine.

    and tasting movements, grinding the teeth, etc.,

    may accompany the seizure. The author has seenone case where a feeling of hunger and frequencyof urination and bowel movements persisted for aday or more following a seizure. Crude auditorysensations or peculiar visual impressions are some-times present. A feeling of fear or terror may ac-company the visceral aura, or may be the onlypremonitory symptom.' As Jackson noted, "Theoccurrence of gastric and intestinal symptoms insome cases of uncinate fits with abnormal emo-tional states is obviously significant" (32). Patientswith automatisms are commonly afflicted by se-vere emotional and psychologic disturbances (ner-vousness, obsessive thinking, depression etc.,)between seizures. Since the introduction of elec-troencephalography it has been shown that in thetype of epilepsy under discussion there are ab-normal electrical discharges arising in the regionof one or both temporal lobes (27, 33). The author,in association with Arellano, has demonstrated, byuse of special leads at the base of the brain, thatin a majority of the patients studied the origin ofsuch discharges was nearer the electrodes in thevicinity of the basilar part of the rhinencephalonthan those recording from the scalp (45a).

    Papez cited a number of references to show thatpreservation of the nervous pathways from themammillary bodies, through the anterior nuclei

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    MacLEANof the thalamus to the cingulate gyrus, are neces-sary to a state of vigilance and wakefulness in bothman and animal. By inference, therefore, this cir-cuit would be concerned in affective behaviour.The involvement of the mammillary bodies inKorsakoff's psychosis and Wernicke's syndromealso suggests the significance of this pathway inthe elaboration of emotional experience (9). Inlight of the bearing of emotional factors in essen-tial hypertension, it is pertinent that stimulationin what appears to be the region of the mam-millotegmental tract will produce in the cat a greatrise in blood pressure (13).

    In reference to the possible emotional functionof the cingulate gyrus, Papez noted that tumors ofthe corpus callosum impinging on it are often as-sociated with changes of the personality, loss ofaffect, and various degrees of somnolence andstupor. He also referred to one case where asoftening of the left paracentral lobule and cingu-late gyrus was accompanied by a marked dis-turbance in the emotional realm.

    In view of the part played by smelling andmouthing in sexual activity, it is interesting thatthese various elements of experience may have theopportunity to be associated in the regions definedby Papez. The precuneus (see Fig. 1) whichbroadens out posteriorly from the cingulate gyrusis continguous with the sacral representation inthe paracentral lobule. Papez has "noted that inthe two sexes the precuneus shows a greater dif-ference in size than any other portion of the cortex,being more highly developed in the male," and hassuggested that representation of the sex organsmay be localized there (52). Further support forthis speculation is suggested by the remarkablecase of nymphomania reported by Erickson in1945 (20). The patient was a 55-year-old woman

    who for more than ten years complained of apersistent "passionate feeling." Later she developedconvulsions. It is notable that perfume was thoughtto exaggerate her symptoms. At operation she wasfound to have a hemangioma of the right para-central lobule which anatomically is just above thecingular gyrus and ahead of the precuneus. Pen-field has described a patient with a lesion of thetemporal lobe who exhibited sexual ideas as acomponent of his dreamy state (59).

    Recent Developments in NeurophysiologyBearing on the Papez Theory

    Since 1937 there have appeared a number ofexperimental reports which would lend support to

    NOVEMBER-DECEMBER, 1949

    341Papez's thesis that the rhinencephalon plays afundamental role in the affective sphere. Perhapsthe most striking observations are those of Kliiverand Bucy on a series of monkeys deprived of bothtemporal lobes (36). It is important to stress thatwhere only one lobe was removed or where bi-lateral lesions spared the rhinencephalon, the ani-mals failed to show significant changes in theirbehaviour. The bilaterally lobectomized animals,on the other hand, presented a dramatic picture.

    Formerly wild and intractable, they became docileand showed neither signs of fear nor anger. Theywould not fight or retaliate when abused by othermonkeys, and obviously would not have survivedin a natural habitat. They displayed also what theauthors refer to as "psychic blindness," "oraltendencies," and "hypermetamorphosis," a kind ofcompulsive behaviour. It was as though they couldno longer discriminate between objects that wereeither potentially dangerous or useful to them.The "hissing tongue" of a snake or feces might beselected as readily for examination as a piece offood. Such an animal would go around its cage,and as if by compulsion smell and mouth every-thingdirt, feces, nail, foodthat captured its

    attention. Unless the object was edible, it wouldbe immediately dropped. If presented with a naila hundred times in succession, the animal wouldsmell and mouth it in each instance as thougih hehad not examined it before. Finally, these animalsshowed striking changes in their sexual behaviour.They appeared hypersexed, masturbated exces-sively, sought partnership with male or female in-discriminately, and manifested bizarre oral-sexualbehaviour.4 It is interesting that many of thesephenom ena: described by Kliiver and Bucy werenoted sixty years ago by Brown and Schafer, whoperformed similar ablations, but their significancewas not appreciated (See Ref. 10).

    In 1940 Spiegel and co-workers reported a num-ber of acute experiments in which they claimedthat appropriate lesions in various parts of therhinencephalon would produce in cats or dogs thepicture of sham rage (70). They emphasized that

    * Th e tempora l Iobectomy as performed in these experi-ments spared part of the hippocampal formation posteriorto the lesion. This should be kept in mind when thepossible correlation of sexual and visceral sensations in'this region receives further discussion. The indications arethat these animals could still smell and taste; on an anatomicbasis it is conceivable that some gustatory, olfactory, andother visceral sensations could have been transmitted fromthe septal nuclei and parolfactory area to the remainingdentate gyms and hippocampus by fibers passing over thecorpus callosum (see Fig. 2).

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    34 2

    the lesions must be bilateral. Such lesions whenconfined to the olfactory tubercles, orthe* anteriorportion of the amygdaloid complex, or to partsof the hippocampus and fornix (see Fig. 2), allled to manifestations of the rage reaction. Thesefindings are reminiscent of those of Fulton andIngraham, who in 1929 described rage reactionsin cats following bilateral, prechiasmal lesions atthe base of the brain (25). These lesions probablyinvolved rhinencephalic structures in the regionof the olfactory tubercles. Bard and Mountcastle,in chronic preparations on cats, have confirmedthe findings of Spiegel et al. in reference to the

    amygdala (7). In contrast to the observations of

    VISCERAL BRAIN

    Kliiver and Bucy on the monkey, however, theseinvestigators report that bilateral temporal lobect-omy in the cat "leads to savageness."6 They havenoted that a removal of the entire neocortex resultsin a state of "placidity" provided rhinencephalicstructures are not significantly damaged. It is theiropinion that the amygdala acts as a "funnel"through which inhibitory influences originating inthe cingular gyrus, the neocortex, and the amygdalaitself, exert a suppressing action on brain stemmechanisms.

    5 Perhaps less of the hippocampal formation was removed

    in these experiments.

    Suprocoltosor Sfr/

    1 H i p p o c o n , p o i

    FIG. 2.A schematic representation of the relationship of the main subcortical structures andconnections of the rhinencephalon, drawn as though all of them could be seen from the medialaspect of the right hemisphere, with the intervening tissue dissolved away. The composite wassuggested by illustrations from W. J. S. Krieg's functional Neuroanatomy (Philadelphia, TheBlakiston Company, 553 pp.), but for diagrammatic purposes some of the added or alteredconnections have been given an arbitrary course. Abbreviations: A.T., anterior nucleus ofthalamus; D.B., diagonal band of Broca; H., habenula (a part of the epithalamus); I.P., inter-peduncular nucleus; L. Str., lateral olfactory stria; M., mammillary body (a part of the posteriorhypothalamus); M.F.B., medial forebrain bundle; M. Str., medial olfactory stria; Olf. Bulb,

    olfactory bulb; Sep., region of the septal nuclei; Str. Med., stria medullaris; Tub., olfactorytubercle (head of the caudate immediately underneath).

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    MacLEANAs regards hypertension it is pertinent to note that

    stimulation of the anterior perforated space, which isposterior to the olfactory tubercle, will cause "sharprises" in the blood pressure of the monkey (65).In the same animal stimulation in the region ofthe hippocampal gyrus produces vocalization andvagal-like vasomotor changes that last well beyondthe cessation of the stimulus (67). In one instanceChapman et al. have had the opportunity to stimu-late the region of the temporal pole in man andfound there resulted a considerable rise of boththe systolic and diastolic blood pressure (12).

    Recently the cingulate gyrus has been subjectto extensive experimental investigation. The re-sults of experiments on the dog (37) and themonkey (69, 75) have been fairly consiste nt, andestablish this part of the brain as an importantautonomic center. In light of the bearing of emo-tion on asthma, it should be noted that the an-terior part (area 24) of the cingular gyrus canexert a powerful vagal effect on respiration. A con-siderable rise of blood pressure can also be ob-tained by appropriate stimulation of this area.Besides its influence on visceral activity, area 24can exert a profound effect on the electrical activityof the brain as well as the body musculature (5,69 , 75): According to McCulloch, area 24 sendsimpulses by way of the caudate to the thalamuswhich block spontaneous thalambcortical activityand cause a suppression of electrical activity of thecortex (49). And Ward has presented evidence toshow that area 24 is able, through its connectionswith the reticular substance in the brain stem, toinhibit all motor activity (75). These mechanismssuggest a possible explanation of how intense emo-tion could paralyze both thought and action.Finally, ablation of area 24 in the macaque is saidto cause a loss of fear of man and other changes

    of affective behaviour peculiar to the monkey

    is now recognized that a great number ofautonomic responses can be obtained from theorbitomesial surface of the frontal lobes (4, 41).Yakovlev maintains that this part of the brainis as much a part of the mesopallium as thecingulate gyrus, and along with the latter "maybe looked upon as part of the highest representa-tion of visceral functions" (80). Appropriate stim-ulation of this area will cause inhibition of respira-tion, rise of blood pressure, and decrease in tonusof the gastric musculature (4). Livingston et al.have recorded a considerable rise of the bloodpressure in man after stimulation at a criticalfrequency in this region (42). Finally, it is highly

    NOVEMBER-DECEMBER, 1949

    significant that stiras the posterior hypothalamus anqy^along the sympathetic chain to the k i a ^ )produce a blanching, and hence ischemiaj5*^ t n erenal cortex (16 ). If emotion found chronic ex-pression over these pathways, it is conceivable howthe renin enzyme system could be so activated asto lead to persistent hypertension.

    The island of Reil, which lies buried beneaththe frontal and temporal lobes, is also intimatelyassociated with the rhinencephalon. But all onecan emphasize here is how little is known aboutthe comparative neurology, neuroanatomy, andphysiology of this region. Penfield has indicatedin recent lectures that the insula is concerned withgastrointestinal sensation and function. Experi-ments are now under way at the Laboratory ofPhysiology at Yale which suggest that the orbit-omesial surface of the frontal lobes, the anteriorinsula, the temporal pole, and the pyriform-amygdaloid complex are mutually related in theirbearing on autonomic activity and emotional be-haviour (26, 35; see also Ref. 48).

    Possible Anatomic, Physiologic, andPsychologic Correlates

    Th e recognition tha t the cerebrum is an out- 'growth of the olfactory brain is obtrusive evidenceof the part played by the sense of smell in theevolutionary development of the vertebrate (29).Srnell not only has a fundamental role in obtain-ing food, but warns the animal of enemies; itparticipates in the sexual functions of. ma ting andcopulation (30). In primitive forms where lifeseems to be a matter of incorporating or beingincorporated, it is the medial olfactory tract lead-ing to correlation centers for smell, taste, and sen-

    sations from the mouth and viscera that shows thegreatest development in size (3 ) (cf. F ig. 2). Smell Itherefore m ight be thoug ht of as an oral sense, j,mo re broadly as a visceral sense. In the course of'phylogeny, as other senses exert a greater influencein directing the movements of the animal, thelateral olfactory tract leading to the "olfacto-so-mat ic"6 correlation center in the pyriform lobe7

    becomes larger than the me dial tract ( 3, 34 ). Al-though, in the ascension to higher forms, therhinencephalon yields more and more control over

    6 A term used in comparative neurology. Somatic, in

    this instance, refers to the body exclusive of the viscera.7 Refers to the forward pear-shaped expansion of thehippocampal gyrus.

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    [the neocortex, its per-fections with lower autonomic

    centers st?g'gest 's' t h a t it continues to dominate inthe safari- of visceral activity. Hen ce the rhinen-

    maght be justifiably considered a visceraland will be so referred to in the remainder-paper to distinguish it from the neocortexholds sway over the body musculature and

    erves the functions of the intellect.primitive forms the visceral brain provides

    the highest correlation center for ordering theaffective behaviour of the animal in such basicdrives as obtaining and assimilating food, fleeingfrom or orally disposing of an enemy, reproducing,and so forth. From anatomic and physiologic con-siderations previously referred to as well as thoseabout to be mentioned, it might be inferred thattihe visceral brain continues to subserve such func-tions in higher forms, including man. Some of theneuroanatomy of the visceral brain that may haveto do with the correlation of feeding and sexualactivities and their bearing on affective states will

    . be dealt with presently in more detail. As a pre-^, liminary, it w ill serve to point u p the problems dis-. oussed in this paper if it is first indicated h ow theB' "primitive brain pe rhaps ties in with beha viour tha t

    has been so often described as primitive, or in-fantile, in patients with psychosomatic illness(40, 45, 64). Psychiatrists have resorted to theseadjectives probably because so much of the in-formation obtained from these patients has to dowith material whic h in, a Freud ian sense is assignedto the oral and oral-anal level, or, as one mightsay all inclusively, the visceral level. In practicallyall the psychosomatic diseases such as hypertension,peptic ulcer, asthma, ulcerative colitis, that have-been subject to fairly extensive psychiatric investi-

    gation, great emphasis has been placed on the"oral" needs, the "oral" dependencies, the "oral"drives, etc., of the patient (71, 76). These oralfactors have been related to rage, hostility, fear,insecurity, resentment, grief, and a variety of otheremotional states. In certain circumstances, for ex-ample, eating food8 may be the symbolic repre-sentation of psychologic phenomena as diverse as1) the hostile desire to eradicate an inimical person,2) the need for love, 3) fear of some deprivationor punishment, 4) the grief of separation, etc. Itwill be useful to refer subsequently to theexcessiveoral manifestations of hostility and anger as "vis-ceral aggression"; of insecurity and fear, as "vis-ceral fear"; of a feeling of dependence, as "visceral

    VISCERAL BRAMneed," etc. It is to be noted that many of theseemingly paradoxical and ridiculous implicationsof the term "oral" result from a situation, mostclearly manifest in children or primitive peoples,where there is a failure or inability to discriminatebetween the internal and external perceptions thatmake up the affective qualities of experience (77).

    !_ Visceral feelings are blended or fused with whatthe individual sees, hears, or otherwise senses, insuch a way that the outside world is often experi-enced and dealt with as though it were incorpor-ated. Thus the child looking at a leaf may say,"It tastes green" (cf. 77). Or the primitive may at-tribute a feeling of anguish to a squirming animalin his stomach. On the basis of interview materialit is claimed that the patient with psychosomaticillness deals with the affective qualities of experi-ence very muc h as a child or a primitiv e. In regard .to interpersonal relationships, for examp le, such a 'patient may give evidence of a symbolic sort thathe either identifies with, or seeks to master, otherindividuals by a process of incorporation. Hence hisemotional life often becomes a matter of "inviscer-ating" or "exviscerating." It is as though such a -

    person never "learned to walk" emotionally. A fewof the psychodynamic formulations relating to psy-chosomatic disease will be touched on in the con-cluding pages.

    The best way to comprehend the anatomy ofthe visceral brain and to derive a relatively dear Ipicture of its tangle of connections with the hypo-thalamus and lower centers (cf. Fig. 2), is toconsider it from the standpoint of comparativeneurology. Space does not permit, however, atracing of its history from the stage in primitivevertebrates where it is so diffusely connected with,the epithalamus and hypothalamus as to be iridis-

    tinguishable, to the point of development in manwhere the exuberant growth of the neocortex rele-gates it backward and downward into the mesialand basal parts of the cerebrum (3). Anatomicemphasis therefore will be given to such of itsstructures as may have a bearing on the correlationof emotional experience.

    Bucy and Kliiver have remarked that "of all theareas of the cortex the temporal is anatomicallythe one to which the term 'association area' is mostsuited" (10). But it is generally not recognizedthat such a statement applies particularly to thehippocampal formation9 in. the ba sal part s of th e

    8 Or indulgence in drugs, alcohol, etc.

    9 The designation "hippocampal formation" is used inthis paper to include the hippocampal and dentate gyri,the hippocampus and the amygdala (cf. Fig. 4).

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    MacLEANtemporal lobes.kHere, as we shall subsequently see,the possibility exists for correlating not only ol-factory, gustatory, and other visceral sensations,but auditory, visual, somesthetic, and, perhapssexual, sensations as well (57). And once corre-lated in the hippocampal gyrus, the impressionscan be discharged through the motor cortex of thehippocampus, or the nuclei of the amygdala. )

    The motor cortex of the hippocampus is in-folded longitudinally into the inferior horn of thelateral ventricle, presumably as the result of ex-panding cortex around it (3). The dentate gyrus,which suggests a receptive type of cortex and whichmay serve as a visceral correlation center,10 liesalong most of the medial side of the hippocampusand discharges its impressions into it. The hippo-campal gyrus, which also has attributes of a sen-sory type of cortex is contiguous with the entirelateral aspect of the hippocampus, and projects tothe motor cells of the latter through the transi-

    1 0 The dentate gyrus is the only part of the hippocampalformation absent in anosmatic animals. Comparative neurol-ogy suggests that it is the first cortical association area forsmell, taste, and sensations from the mouth and viscera.It receives afferents from the primitive smell-taste-visceralnuclei in the septal region by way of the longitudinal striaerunning over the corpus callosum (cf. Figs. 2 and 3), aswell as afferents from the hippocampal gyrus.

    anterioramygdala

    tional region known aiportion is intimately(cf. Figs. 2 and 4).

    According to Lorente de No, Cajal wasHhe firstto note that in addition to the angular bundle iyomthe olfactory area, the subiculum of the hippcampal gyrus receives two other large contributions^one from the cingulum and one frompracallosal striae. I had the opportunity toPapez dissect out these and other associatioof the rhinencephalon and the temporal lob!gross dissection the cingulum is a most impressbundle. It is possible that fibers passing in it couldinterconnect the hippocampal formation with thewhole length of the cingulate gyrus. If the Papeztheory is correct, the cingulum could carry sexualimpressions, among others, to the hippocampalregion. The supracallosal striae possibly conveyvisceral sensations from the primitive smell-taste-visceral nuclei in the septal region (3) (cf. Figs.2 and 3).

    Dr. Papez indicated that there is ample oppor-tunity for auditory and somesthetic sensations topass by way of association fibers to the hippocampalgyrus. He also pointed out fibers coming by wayof the lingual gyrus from the part of the visual

    cortex where the periphery of the retina is repre-sented. He noted that it is objects that move in

    FIG. 3.Explanation in text. HYP, indicating the anterior, middle, and posterior divisions ofthe hypothalamus. Directly above are the three subdivbions of the right anterior nucleus of thethalamus.

    NOVEMBER-DECEMBER, 1949

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    VISCERAL BRAIH'

    PREDOMINANTLY

    PDMSYMPATHETIC .

    (Fttdmj, digestion,elimination, sleep, etcj I

    - H I P P O C A M PA L F O R M AT I O NMocLra

    riG. 4./1 diagram co indicate cne anatomical ana possiDie iuncuonai reiationsnips oc variousparts of the hippocampal formation. The latter designation is used in this paper to include thehippocampal and dentate gyri, the hippocampus and the amygdala.

    the periphery of our vision that most startle andalarm us.11

    The anatomic pathways by which olfactory im-pulses are carried to the hippocampal formationhave been fairly w ell established (1 4, 23, 43, 44, 61,62). It is not at all dear, however, how the othervisceral sensations, which patients with lesionsinvolving the deep or under part of the temporallobes experience, reach this area. Ruch and Pat-ton have claimed from experiments in the monkey

    that the para-insular cortex of the operculum hasprimacy as a taste center (63), but the possibilityexists that taste, as well as smell and other vis-ceral sensations, have multiple cortical representa-tion. The comparative neurologists suggest thattaste and other visceral sensations from the septalregion could reach the hippocampal formation byway of the diagonal band of Broca and the

    1 1 Is it possible that here may be a partial neuroanatomicexplanation for such psychologic phenomena as anxiety anddelirium frequently occurring in the sick with the onset ofdarkness;/ the menta l state of the paranoid wh o feels he isbeing attacked from the periphery; or more generally thefear and apprehension that is commonly associated withthe unseen both in the present and the future?

    amygdala, or the supracallosal striae (3, 34) (seeFig. 2). Dr. Papez has evidence that area 38 onthe tip of the temporal lobe may receive a visceralprojection of vagal origin by way of the centralmedial and central nuclei of the thalamus, theinferior thalamic peduncle, and the amygdala (54,

    55, 56).Figure 3 is a highly schematic diagram to dem-

    onstrate the number of sensory systems streaminginto this region. The hippocampus has been ex-

    ternalized in the form of the little sea horse, afterwhich it got its name from Arantius who firstdescribed it in 1587 (37). The layer of largepyramid cells in the hippocampus suggests a key-board on which the various elements of the sen- ,sorium can play. In the diagram the arch of the .fornix has been straightened out to clarify thedirection of impulses going to the hypothalamus,anterior nuclei of the thalamus, and the cingulargyrus. Most of the fibers in the fornix are said to 'terminate in the mammillary bodies (2); but otherparts of the hypothalam us and rhinenceph alon, as \well as the epithalamus and basal ganglia, also*receive contributions (cf. F ig. 4).f Th e diagramemphasizes that the hippocampal gyrus may serve

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    MacLEANas affectoceptor cortex and the hippocampus asaffectomotor cortex, somewhat analogous to thesomatic sensory and motor gyri of the neocortex.^.The lobulations on the hippocampus, which sug-gested the body segments of the sea horse toArantius, conceivably might represent parcella-tions of different functions (57). Perhaps someday an "animunculus" will be drawn for thisregion.

    It has not been possible to include the amygdala. in the diagram in Fig. 3. As previously stated, this

    structure is intimately associated with the anteriorpart of the hippocampal gyrus (cf. Figs. 2 and 4).It is often emphasized that the olfactory fibers,unlike those of other sensory systems, have noknown primary projection to the thalamus. Whenone regards the amygdala from the standpoint ofits phylogeny and anatomy (3, 14, 34, 72), how-ever, it is evident that it is a thalamus-like relaystation for olfactory stimuli (as well, probably, asother visceral impressions) to the archipallium.One therefore might as justifiably refer to it as anolfactory thalamus as to designate the convention-ally known thalamus the optic thalamus. Theefferent fibers from the nuclei of the amygdalaproject in large measure to the region of theseptum and the anterior hypothalamus (22, 34,7 2 ) .u It is notable that these latter regions havebeen implicated in such highly coordinated vis-cerosomatic acts as defecation, urination, etc. Sincethe amygdala seems to project predominantly tothe parasympathetic centers of the hypothalamus,and the hippocampus to the sympathetic, is itpossible that these respective parts of the visceralbrain are mutually antagonistic? Might the shamrage associated with bilateral lesions of theamygdala result in part from the release of thehippo cam pus' and the posterior hypothalamus tosympathetic discharge? The possibly antagonisticrelationship between the amygdala and hippocam-

    pus has been indicated in Figure 4.It is important to stress that there is an over-

    lapping of the three main fiber systems cominginto the subiculum of the hippocampal gyrus (44).

    . Th er e a re also longitudinal fibers associating thehippocampal ' formation through out its entirelength. In the light of these observations, there isa possible neuroanatomic mechanism to explainsome of the seemingly paradoxical overlapping(or synaesthesia) of the various qualities con-tributing to emotional experience. The overlapping

    of oral and sexual behaviour, for instance, must be1 2 Especially the pre-optic nuclei.

    NOVEMBER-DECEMBER, 1949

    347

    m ore t ha n a fo rtu ito us ^ ^ ^ ^ ^ ^ ^ ^ B th is pa rtof the brain i t is po ssi M eT t^c ^^ BB po w sexualinci tations co uld stim ula te ^ 6rujlfer difftise feelingof visceral yearning thatvwould make thevjndivid-ual seek to mouth and incorporate the object ofits desire. According to intensity, the sex-hurige\rpattern might lead anywhere-.from gentle kissinto the deviate forms of oral-sexual b e h a v i o ^to such bizarre psychotic manifestationswoman eating her menses. Likewise, therage pattern susceptible to sexual firing migl

    press itself in all gradations from aggressive,sadistic behaviour to sex-murder and mutilation.In regard to the influence of other sensations, itis possible that disturbing impressions from therealm of vision, hearing, etc., could generate ap-propriately either visceral need, visceral fear, orvisceral aggression. To use a crude analogy, it isas though the various elements of the sensoriumwere gathered together in the hippocampal gyrusand placed on a party line. The ringing of the bellfor one party, particularly if persistent and intense,might bring one or more of the other parties tothe phone. Much of the gossip going back andforth in this area is what we have commonly cometo associate with the id, the beast, or sin in man(e. g. gluttony, lechery, etc.). In the light of thisit is interesting that through the large uncinatefasciculus, the frontal lobes "stand guard" overthis region. Could it be that feelings of guilt arefomented-' here? It may have more tha n lhd esignificance that the uncinate fasciculus is ap-parently involved in lobotomy (51)., In the preceding discussion it has been im-plicitly assumed that the hippocampal formationprovides the kind of analyzer that can derive uni-versals from the particulars of experience andrelate them symbolically in the experience of emo-

    tion. But in the light of current concepts ofservomechanisms, it is pertinent to questionwhether or not the primitive structure of thehippocampal formation allows such an assumption.In his recent book on Cybernetics, Professor Wienerhas indicated that a machine having to deal withthe recognition and choice of forms may be servedby a scanning mechanism in conjunction with acentral clocking device (78). McCulloch and Pittshave presented evidence to show that a structureexists in the auditory and visual cortex for scan-ning, and it was postulated that reverberatingthalamocortical circuits provided the necessary

    clocking device or sweep mechanism (60). Theirsis the first reasonable explanation of how the brainis able to recognize auditory and visual forms. One

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    aat a sweep circuit existsar and the parietooccipital13

    etween the dorsomedial nuclei andcortex, whereby the patterns of elec-built up in the sensory areas are car-

    dong the association gyri, somewhat analogousmoving letters across the light bulbs of a

    sign board (53).But when one comes to consider the temporal

    lobes (exclusive of the auditory area) in the lightof such a possible scanning mechanism, one finds

    a deficiency of the necessary neural apparatus. Oneof the anatomic enigmas is the apparent absenceof projections from the thalamus to the temporallobes save for the small acoustic area (48, 73). Thiswould indicate that no central clocking device wasavailable to the greater part of the temporal region.As previously noted, however, the amygdala hasa thalamus-like relationship with the archipallium.The large lateral nucleus of the amygdala deservesparticular attention in regard to the present prob-lem. It develops pari passu with association nucleiof the thalamus (57) and reaches its greatest sizein man (17). And like the pulvinar and dorso-medial nucleus of the thalamus it receives no pro-jection from sensory systems (34, 72).14 Sincemany of its fibers appear to run in the externalcapsule, it is possible they may be distributed tovarious parts of the temporal lobe, including thehippocampal formation. If this were true, theremight exist a potential sweep mechanism for this

    jsbrtex.

    But regardless of any scanning and sweepmechanism that may exist, the cortical cytoarchi-tecture of the hippocampal formation indicates thatit would have little efficiency as an analyzer com-pared with the neocortex. When Lorente de Noundertook his studies of die cerebral cortex, hestarted with this region because, as he noted, itprovides the simplest type of cortex (43). In theregio entorhinalis of the mouse, for example, only30 types of cells can be differentiated as com paredwith more than 60 in its most complicated corticalstructure. Finally, it should be emphasized thatthe cortex of the hippocampal formation has asimilar architecture throughout its entire lengthand presents the same general picture in all mam-mals from mouse to man (44). On the basis ofthese observations one might infer that the hippo-campal system could hardly deal with information

    VISCERAL BRAINin more than a crude way, and was^possibly tooprimitive a brain to analyze language.. Yet it mig hthave the capacity to participate in a nonverbal typeof symbolism. This would have significant implica-tions as far as symbolism affects the emotional lifeof the individual. One might imagine, for ex-ample, that though the visceral brain could neveraspire to conceive of the colour red in terms of athree-letter word or as a specific wave length oflight, it could associate the colour symbolicallywith such diverse things as blood, fainting, fight-

    sing, flowers, etc. Therefore if the visceral brainwere the kind of brain that could tie up sym-bolically a number of unrelated phenomena, andat the same time lack the analyzing ability of theword brain to make a nice discrimination of theirdifferences, it is possible to conceive how it mightbecome foolishly involved in a variety of ridiculouscorrelations leading to phobias, obsessive-compul-sive behaviour, etc. Lacking the help and controlof the neocortex, its impressions would be dis-charged without modification into the hypothala-mus and lower centers. Considered in the light ofFreudian psychology, the visceral brain would have

    many of the attributes of the unconscious id. Onemight argue, however, that the visceral brain isnot at all unconscious (possibly not even in certainstages of sleep16), but rather eludes the gra sp ofthe intellect because its animalistic and primitivestructure ma\es it impossible to communicate inverbal terms. Perhaps it were more proper to say,therefore, it was an animalistic and illiterate brain.

    If the visceral brain functioned in the realm ofemotion in the manner described, certain puzzlingaspects of the psychologic status of patients withpsychosomatic disease would be more readily un-derstood. It strikes one as paradoxical, for example,that such patients often advance to superior at-tainments in the intellectual sphere, and at thesame time, according to some psychiatrists, showevidence that their emotional life has been arrestedat or near the oral level. This would suggest thatmore attention should be directed toward factorshaving to do with the emotional development ofthese individuals during infancy and childhood.

    1 8

    Inclusive o a small area of temporal cortex.1 4 There is the possibility, however, that part of thisnucleus may receive a visceral contribution by way of theinferior thalamic peduncle (54, 55, 56).

    1 5 The role of the rhinencephalon in sleep presents a _fascinating problem when considered in the light of com-parative zoology and neurophysiology. Animals without aneocortex appear to sleep at irregular intervals. The basal >electroencephalogram in man (involving leads near thebasilar rhinencephalon) recorded during early sleep has a

    different appearance from the tracing obtained in the regionof the neocortex, resembling more the waking type of record(personal observation). It has been suggested that dream-ing is a function of the temporal lobes (58).

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    MacLEANIt has been stated that the first directed act the

    child performs on coming into the world is tosmell and root its way to its mother's breast (i).If hungry it cries, and it may be predicated in thisinstance that both hunger and crying are mani-festations of insecurity in its new environment. Ifits hunger is unsatisfied, the instinctual patterns ofresponse appear limited and stereotyped. It mayscream in anger and bite the mother's breast, or ifneglected for a long period lapse into a wailingtype of cry. Once fed and satisfied, it becomesplacid and goes to sleep. During the infantile stage;

    the majority of its preoccupations continue to beassociated with obtaining food and being fed. Itwould not be unreasonable to suppose thereforethat in its emotional development the act of beingfed would symbolize for it being loved and caredfor; whereas the contrary situation would be as-sociated with feelings of insecurity, resentment andanger.16 Once the child begins to sit up and toshare in the activities of the home, its oral andvisceral sensations must obviously fall into greaterassociation with those of the eye, the ear, and thebody wall. Stimuli from the genitalia would alsobe integrated with these other sensations. (Feelingsirom bladder and bowel, of course, fall into thevisceral category.) Although the child might livein an environment where all the requirements forfood were satisfied, the harsh voice or look of re-jection would have the opportunity in the hipp'o-campal formation to be associated with the oraland visceral sense, and thereby serve as the stim-ulus to arouse visceral fear, visceral need, or vis-ceral aggression. To cite examples of the greatvariety , of ways ange r, resentm ent, feelings of re-jection, etc., reflect themselves in the eating habitsof a child, and are therefore symbolically a func-tion of the visceral brain, would not only be time-consuming, but also result in belaboring much that

    is well known. It should be stressed that the possi-bility exists for anger or fear to generate hunger aswell as a paralysis of the desire to eat. Such a sit-uation, as well as the symbolic content, is oftenmore clearly evident in adults than in children.I might mention, for example, a hyptertensivepatient, who after a violent quarrel with her sister,proceeded to a restaurant and ate what she de-

    1 8 It may prove pertinent to the problem under discus-sion that, according to Flechsig, the process of myelinationin the cerebrum commences in the eighth month ofintrauterine life and involves first the afferent fibers passing

    to the somesthetic area in the postcentral gyrus and theafferent fibers to the hippocampal formation (see 28, p.74)-NOVEMBER-DECEMBER, 1949

    349scribed as the biggest meal of her life. It is notunusual for persons with obesity to admit theyconstantly "nibble" or eat excessively because theyfeel "nervous," "anxious," or "frustrated."

    The question arises in reference to psychoso-matic disease whether or not patterns of emotionalbehaviour leading to excessive visceral expressionare repeated so often in childhood as to becomepermanently ingrained in the visceral brain, withthe result that they are perpetuated in later life.The combined studies of neuroanatomists andneurophysiologists during the past fifty years haveled to a fascinating concept of how transient mem-ory is kept alive in the b rain (18 , 21, 43, 47, 60,61 , 7 8 , ) . "

    This in turn may have a bearing on permanentmemory. Transient memory is postulated to be afunction of the self-reexciting chains of neuroneswhich exist at all levels of the nervous system (43)and which allow the electrical impulses transmit-ting information of a transitory sort to reverberatein a fixed pattern until they are dissipated in thedischarge of an effector circuit. It is possible thatif a certain electrical pattern of information wereto reverberate for a prolonged period or at repeated

    intervals in a neuronal circuit, the nerve cells (per-haps, say, as the result of enzymatic catalysis in thedendritic processes at specific axone-dendriticjunctions) would be permanently "sensitized" torespond to this particular pattern at some futuretime. Such a mechanism would provide for onevariety of enduring memory in a way that is re-motely analogous to a wire recorder. These hypo-thetical considerations suggest how oft-repeatedchildhood emotional patterns could persist to exertthemselves in adult life. They would also indicatethe problems facing the psychiatrist in dealingwith old memory patterns; to dissipate the im-pulses of an old memory reverberating in a circuitis not to affect the memory of the cell. But thepossibility exists that new patterns of behaviourmay be learned that could modify the old.

    Only brief reference can be made to some ofthe psychodynamic formulations that have beenmade in regard to those psychosomatic diseaseswhere lesions are present. In essential hypertensionit has been postulated that the patient suffers"chronic unexpressed rage" because of his inabilityeither to satisfy his "oral" demands (e. g., failureto elicit the love and protection of a dominatingparental figure) or his ambitious, independentstrivings (66). In patients with peptic ulcer un-

    1 7 See (8) for a review.

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    350conscious "oral," dependent needs (e. g. cravingfor continued maternal care) are said to stand inconflict with the conscious struggle to achieve in-dependenc e and success (7 1, 76 ). Similarly, theasthmatic patient is described as being in an emo-tional dilemma where lingering "oral" dependenceon a parent makes it impossible to fulfill his strongdesire for emancipation (24). It has been suggestedthat asthmatic breathing is a form of wailing orcrying which occurs whenever the patient is facedwith the crisis of deciding to break the parentaltie. The "inclination" to primitive behaviour inpatients with ulcerative colitis has been noted byLinde man n (40).^ It mig ht be generalized thatthese patients manifest the primitive psychologicstate where other individuals are identified with,or mastered by, a process of incorporation.lUnsat-isfactory identification or unsuccessful masterybecause of lingering resentment, anger, etc., maylead to a feeling of visceral turmoil, and defecationbecomes the symbolic expression of the desire toextrude and rid from the body the incorporatedfigure. The part played by symbolic incorporationand defecation in grief reactions of patients withuleerative colitis has received the attention ofLindemann and his co-workers. In a psychiatricand psychoanalytic study of patients with rheuma-toid arthritis Ludwig has observed that these in-dividuals "are unable to express their very strongemotions, but instead react to emotional crises withintense autonomic activity, in a manner whichelosely resembles the primitive and poorly organ-ized techniques of mastery by destruction and in-gestion described in the traumatic neuroses" (45).

    It is not the purpose here to defend or criticizethese formulations, but rather to indicate that amechanism (possibly involving dominantly in-herited neural patterns) may exist in the visceralbrain to account for the phenomena described. It

    might be imagined that the "rage" of the hyper-tensive patient, arising out of unsatisfied "oral"demands, has a similar mechanism to the rage-producing hunger in the animal. In both instancesthe visceral brain might be postulated as participat-ing in the release of the hypothalamus to sym-pathetic discharge (cf. Fig. 4). But in the hyper-tensive the conscious need for restraint would ex-ert through the neocortex an inhibition of thesomatic expression of rage for which the auto-nomic respons'es are brought into play, and sointerfere with the physiologic safety valve of mus-cular activity. On the other hand, the "emotionalhunger" of the patient with peptic ulcer might becon sidere d' as chronically activating that part of

    VISCERAL BRAINthe visceral brain which is linked to the hypothala-mic nuclei governing gastric function, with theresult that the stomach is being constantly pre-pared for food (cf. Fig. 4). Similarly one mightspeculate about possible mechanisms for asthma,uleerative colitis, and other diseases where theemotions are thought to contribute to the develop-ment of lesions.

    Psychotherapeutic Considerations

    Preliminary to a few comments on therapy, itshould be remarked that one of the striking ob-servations regarding the patient with psychoso-matic illness18 is his apparent intellectual inabilityto verbalize his emotional feelings. Anatomicallyit would appear that the intellect could obtain in-formation from the visceral brain directly on thecerebral level by way of the long and short associ-ation fibers, or otherwise be left to determine atsecond hand from feed-back signals what messagesthe visceral brain had discharged autonomously tolower centers. In the psychosomatic patient it would

    almost seem there was little direct exchange be-tween the visceral brain and the word brain, and

    that emotional feelings built up in the hippo-campal formation, instead of being relayed to theintellect for evaluation, found immediate expres-sion through autonomic centers. In other words,emotional feelings, instead of finding expressionand discharge in the symbolic use of words andappropriate behaviour, might be conceived as beingtranslated into a kind of "organ language." Sucha concept would have a bearing on some of thedifferences that have been noted between patientswith psychoneuroses and those with psychosomaticillness. The former are claimed by the analysts tohave an emotional disturbance involving more thegenital, rather than the oral, stage of development.Furthermore, they are said to have a greater facil-ity than psychosomatic patients in giving verbalexpression to, and "acting out" their emotionalfeelings. Perhaps this facility affords a reductionof traffic on the autonomic circuits and therebyhelps to ward off the development of lesions.

    If the psychosomatic patient is inarticulate abouthis emotional feelings, and if, as indicated, thevisceral brain is an animalistic and illiterate brain,one would not expect at the beginning of psy-chotherapy to accomplish a great deal by verbal

    1 8 Here again we have reference particularly to thatvariety of psychosomatic diseases where lesions are present.See introduction.

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    MacLEANmethods. Rather, at the onset of therapy, such asituation would suggest an emphasis on those ac-tivities of the doctor that have a "disalarming"effect on the patientsuch for example as thedoctor's kindly manner, his interest, toneof voice,etc. In other words these activities would involvethe kind of things that have been hypothesizedashaving meaning for the visceral brain, and whichclinically are regarded as supportive measures.After a good patient-doctor relationship was onceestablished, on e might progress gradually to theverbal methods involved in insight therapy.

    Summary

    A notable deficiency attendant on psychosomatictheory at the present time is the inability to pointto a mechanism of emotion that would accountforthe variety of ways th e effective qualities of ex-perience may act on autonomic centers. The firstpart of this paper reviews certain neurophysiologicand neuroanatomic evidence nowat hand that con-tributes to the understanding of emotional mech-anisms. There are indications that the phylogeneti-cally old brain (classically known as the rhinen-

    cephalon an d arbitrarily referred to in this paperas th e "visceral brain") is largely concerned withvisceral and emotional functions. This regionofthe brain appears to be so strategically situatedasto be able to correlate every form of internal andexternal perception. In other words, the possibilityexists in this region for bringing into associationnot only oral (smell, taste, mouth) an d visceralsensations, but also impressions from the sex or-gans, body wall, eye, and ear. And in contrast tothe neopallium, the rhinencephalon has many andstrong connections with the hypothalamusfor dis-.charging its impressions.

    These relationships and alleged functionsof therhinencephalon have far-reaching implicationsforpsychiatry. For they indicate that though ourintellectual functions are carriedon in the newestand most highly developed part of the brain, ouraffective behaviour continues to be dominated by

    . a relatively crude and primitive system. This situ-ation provides a clue to understanding th e differ-ence between what we "feel" and what we "know."

    In th e remainder of the paper it is suggestedhow the mechanisms referred to may be related to"oral" an d visceral factors that are brought intoplay in the experience and expression of emotionby the patient with so-called psychosomatic disease*

    In view of recent developments in electronicsand cybernetics arid the light these sciences have

    351

    shed on neurophysiology, one can no longer becontent to think of dynamic psychologicphe-nomena as existing apart from th e restrieri'onsofordered neural mechanisms.

    1. ALDRICH, C. A.: Ancient pfWeises in scientific age.Feeding aspects. Am. J. D is. Child. 6 4 : 714-722,1942. ' .

    2. ALLEN, W. F.: Degeneration in the dog's mammillarybody an d Amman's horn following transection ofthe fornix. J. Comp. Neurol. 80: 283-291, 1944.

    3. ARIENS KAPPERS, C. U., HUBER, G. C, and CROSBY,E. C : Th e Comparative Anatomy of the NervousSystem of Vertebrates, Including Man. Ne w York,The Macmillan Company, 1936, 2 vols., pp. 864,865-1845.

    4. BAILEY, P., and SWEET, W. H. : Effects on respiration,blood pressure and gastric motility of stimulation oforbital surface of frontal lobe. J. Neurophysiol. 3 :276-281, 1940.

    5. BAILEY, P., VON BONIN, G., DAVIS, E. W., GAROL, H .W ., MCCULLOCH, W. S., ROSEMAN, E., SILVEIRA, A. :Functional organization of the medial aspect of theprimate cortex. J. Neurophysiol. 7 : 51-55, 1944.

    6. BARD, P.: A diencephalic mechanism for the expres-sion of rage with special reference to the sympatheticnervous system. Am . J. Physiol. 84: 490-513, 1928.

    7. BARD, P., and MOUNTCASTLE, V. B.: Some forebrainmechanisms involved in expression of rage with spe-cial reference to suppression of angry behavior. Re-search Publ., A. Nerv. & Ment. Dis. 2 7 : 362-404,1948.

    8. BRAZIER, M. A. B.: Neural nets and integration of be-haviour. To appear in: Perspectives in Neuropsy-chiatry, London, H. K. Lewis, Ltd., 1949.

    9. BRODAL, A.: The hippocampus and the sense of smell.A review. Brain 7 0 : 179-222, 1947.

    10. BUCY, P. C, and KLUVER, H .: Anatomic changes sec-ondary to temporal lobectomy. Arch. Neurol. &Psychiat. 4 4 : 1142-1146, 1940.

    11. CAKNON, W. B., and BRITTON, S. W.: Studies on the

    conditions of activity in endocrine glands. XV Pseud-affective medulliadrenal secretion. Am. J. Physiol.

    72: 283-294, 1925.12. CHAPMAN, W. P., LIVINGSTON, K. E., POPPEN, J. L.:

    An observation of the effect on blood pressure ofelectrical stimulation of the tips of temporal lobe inman. To be published.

    13. CHU, H. N ., and Loo, Y. T.: On vasomotor centers inthe forebrain and the midbrain. Chinese J. Physiol.11 : 295-300, 1937.

    14. CLARK, W. E. L., and MEYER, M .: The terminal con-nexions of the olfactory tract in the rabbit. Brain70: 304-328, 1947.

    15. COBB, S.: Borderlands of Psychiatry. Cambridge,Har-vard University Press, 1943, pp. 166.

    16. CORT, J. H.: Personal communication in: Research Publ.,A. Nerv. & Ment. Dis. 27 : 405-417, 1948.

    17. CROSBY, E. C, and HUMPHREY, T .: Studies of the

    vertebrate telencephalon. 11. The nuclear pattern ofthe anterior olfactory nucleus, tuberculum olfac-

    NOVEMBER-DECEMBER, 1949

  • 8/7/2019 MC Lean Psychosomatic

    15/16

    352torium and the amygdaloid complex in adult man.]. Comp. Neurol. 7 4 : 309-352, 1941.

    18. DUSSER DE BARENNE, J. G., and MCCULLOCH, W. S.: 37.

    The direct functional interrelation of sensory cortexand optic thalamus. J. Neurophysiol. 1 : 176-186,1938. 38 .

    19. EDINGER, L.: The Anatomy of the Central NervousSystem of Man c:d of Vertebrates in General, (tr., 39.W . S. Hall), Philadelphia, F. A. Davis Company,1899, pp. 446. 40 .

    20. ERICKSON, T. C : Erotomania (nymphomania) as anexpression of cortical epileptiform discharge. Arch.Neurol. & Psychiat. 5 3 : 226-231, 1945. 41.

    21. FORBES, A., COBB, S., and CATTELL, H .: Electrical stu-

    dies in mammalian reflexes. HI. Immediate changes

    in the flexion reflex after spinal transection. Am. J.Physiol. 65: 30-44, 1923.

    22. Fox, C. A.: The stria terminalis, longitudinal associa- 42 .tion bundle, and precommissural fornix fibers in thecat. J. Comp. Neurol. 7 9 : 277-295, 1943.

    23 . Fox, C. A., MCKINLEY, W. A., and MAGOUN, H. W. :

    An oscillographic study of olfactory system of cats. 43-J. Neurophysiol. 7 : 1-16, 1944.

    24. FRENCH, T. M., ALEXANDER, F. , et al.: Psychogenic

    Factors in Bronchial Asthma. Psychosom. Med. 44-Monograph, No. 2, 1941.

    25. FULTON, J. F., and INGRAHAM, F. D. : Emotional dis-

    turbances following experimental lesions of the baseof the brain (pre-chiasmal). Am. J. Physiol. 9 0 :353. "929.

    26. FULTON, J. F., PRIBRAM, K. H., STEVENSON, J. A. F.,

    and WALL, P. D. : Interrelations between orbitalgyms, insula, temporal tip, and anterior cingulate.Tr. Am. Neurol. A. 74, 1949 (in press).

    27. GIBBS, E. L., GIBBS, F. A., and FUSTER, B. : Psycho-

    motor epilepsy. Arch. Neurol. & Psychiat. 6 0 : 331-339. 1948.

    28. GRAY, H .: Anatomy of the Human Body. (Ed. 24).Ed . by W. H. Lewis. Philadelphia, Lea an d Febiger,1942, pp. 1428. 4 g

    29. HERRICK, C. J.: A sketch of the origin of the cerebralhemispheres. J. Comp, Neurol. 32: 429:454, 1921.

    30. HERRICK, C. J.: The functions of the olfactory parts ofthe cerebral cortex. Proc. Nat. Acad. Sc. 1 9 : 7-14,J933- 50 .

    31. HOWELL'S Textbook, of Physiology. (Ed. 15). Ed. byJ. F. Fulton. Philadelphia, W. B. Saunders Company,1946, pp. 1304. 5 I .

    32. JACKSON, J. H., and STEWART, P.: Epileptic attacks witha warning of a crude sensation of smell and withthe intellectual aura (dreamy state) in a patient who -. 52 .had symptoms pointing to gross organic disease ofthe right temporo-sphenoidal lobe. Brain 22: 534- 53,549. 1899-

    33. JASPER, H., and KERSHMAN, J.: Electroencephalographicclassification of the epilepsies. Arch. Neurol. & 54.Psychiat. 45: 903-943, 1941.

    34. JOHNSTON, J. B .: Further contributions to the study ofthe evolution of the forebrain. J. Comp. Neurol. 3 5 :337-48i, 1923. 55 .

    35. KAADA, B. R., PRIBRAM, K. H., and EPSTEIN, J. A.:Respiratory and vascular responses in monkeys fromtemporal pole, insula, orbital surface and cingulate 56 .gyrus. J. Neurophysiol. 12: 347-355, 1949. 57 .

    36. KLUVER, H., and BUCY, P. C : Preliminary analysis of 58 .

    VISCERAL BRAIMfunctions of the temporal lobes in monkeys. Areh.Neurol. & Psychiat. 4 2 : 979-1000, 1939.

    KREMER, W. F. : Autonomic an d somatic reactions in-duced by stimulation of the angular gyrus in dogs.J. Neurophysiol. 1 0 : 371-379, 1947.

    LASHLEY, K. S.: The thalamus an d emotion. Psychol.Rev. 45: 42-61, 1938.

    LEWIS, F. T.: The significance of the term hippocam-pus. J. Comp. Neurol. 3 5 : 213-230, 1923-1924.

    LINDEMANN, E.: Psychiatric problems in conservativetreatment of ulcerative colitis. Arch. Neurol. & Psy-chiat. 5 3 : 322-324, 1945.

    LIVINGSTON, R. B., FULTON, J. F., DELGADO, J. M. R.,SACHS, E., BRENDLER, S. J., and DAVIS, G. D.: Stim-ulation and regional ablation of orbital surface of

    frontal lobe. Research Publ., Nerv. h Ment. Dis. 2 7 :405-420, 1948.LIVINGSTON, R. B., CHAPMAN, W. P., LIVINGSTON, K. E.,

    and KRAINTZ, L.: Stimulation of orbital surface ofman prior to frontal lobotomy. Research Publ.,Nerv. & Ment. Dis. 27 : 421-432, 1948.

    LORENTE DE N6, R.: Studies on the structure of thecerebral cortex: I. The area entorhinalis. J. Psychol.Neurol. 45: 381-438, 1933.

    LORENTE DE N6, R.: Studies on the structure of thecerebral cortex: II. Continuation of the study of theammonic system. J. Psychol. Neurol. 4 6 : 113-177,1934.

    LUDWIG, A. O.: Psychiatric studies in patients withrheumatoid arthritis. To be published.

    , MACLEAN, P. D., and ARELLANO, A. P.: Basal lead

    studies in epileptic automatisms. EEG Clin. Neuro-physiol. 2, 1950 (in press).MASSERMAN, J. H.: Behavior and Neurosis. An Experi-

    mental Psychoanalytic Approach to PsychobiblogicPrinciples. Chicago, University of Chicago Press, 1943,pp. 269.

    MCCULLOCH, W. S., and PITTS, W .: A logical calculusof the ideas immanent in nervous activity. Bull.Math. Biophysics 5 : 115-133, 1943.

    MCCULLOCH, W. S.: The functional organization of thecerebral cortex. Physiol. Rev. 2 4 : 390-407, 1944.

    MCCULLOCH, W. S.: Some connections of the frontallobe established by physiological neuronography.Re-search Publ., A. Nerv. & Ment. Dis. 27: 95-105, 1948.

    METTLER, F. A.: Extracortical connections of primatefrontal c erebral cortex; c orticofugal connections. J.Comp. Neurol. 8 6 : 119-166, 1947.

    MEYER, A., BECK, E., and MCLARDY, T .: Prefrontalleucotomy: A neuro-anatomical report. Brain 7 0 :18-49, 1947-

    PAPEZ, J. W .: A proposed mechanism of emotion. Arch.Neurol. & Psychiat 3 8 : 725-743, 1937.

    PAPEZ, J. W.: Structures and mechanisms underlyingthe cerebral functions. Am . J. Psychol. 57: 291-316,1944-

    PAPEZ, J. W .: Fiber tracts of the amygdaloid region inthe human brain, from a graphic reconstruction offiber connections and nuclear masses. Anat. Rec.

    91 : 294, 1945.PAPEZ, J. W .: Human Growth and Development. Ithaca,

    N. Y., The Cornell Cooperative Society, 1948,pp .164.

    PAPEZ, J. W.: Unpublished data.

    PAPEZ, J. W.: Personal communication.PENFIELD, W., and ERICKSON, T. C : Epilepsy and

    VOL. XI, NO. 6

  • 8/7/2019 MC Lean Psychosomatic

    16/16

    MacLEANCerebral Localization. Springfield, Illinois, Charles CThomas, 1941, pp. 623.

    59. PENFIELD, W .: Discussion in : Arch. Neurol. 8t Psychiat.53 : 226-231, 1945.

    60. PITTS, W., and MCCULLOCH, W. S.: HOW we know

    universal;. Th e perception of auditory and visualforms. Bull. Madi. Biophysics 9 : 127-147, 1947.

    61. RAM6N Y CAJAL, S.: Studien fiber die' Hirnrinde desMenschen. (Tr. from the Spanish by J. Bresler.)Leipzig, J. A. Barth, 1900-1906, 5 vols.

    62. RAM6N Y CATAL, S.: Histologie du systeme nerveuxdeI'homme et des vertSbres. (Tr. from the Spanish byL. Azoulay.) Paris, A. Maloine, 1909, 1911, 2 vols.,pp. 799. 823.

    63. ROCH, T., and PATTON, H. D. : The relation of thedeep opercular cortex to taste. Federation Proc. 5 :89-90, 1946.

    64. RUESCH, J. : Th e infantile personality; the core problemof psychosomatic medicine. Psychosom. Med. 10:134-144, 1948.

    65 . SACHS, E. JR., and BRENDLER, S. J.: Some effects ofstimulation of the orbital surface of the frontal lobein the dog and mon\ey. Federation Proc. 7 : 107,1948.

    66. SAUL, L. J.: Hostility in cases of essential hypertension.Psychosom. Med. 1 : 153-161,1939.

    67. SMITH, W. K. : The results of stimulation of the uncusand adjacent portions of the hippocampal gyrus.Federation Proc. 3 : 42, 1944. ,

    68. SMITH, W. K.: Th e results of ablation of the cingularregion of the cerebral cortex. Federation Proc. 3 :42-43, 1944.

    35369. SMITH, W. K.: Th e functional significance of the

    rostral cingular cortex as revealed by its responseto electrical excitation. J. Neurophysiol. 8 : 241-255,1945-

    70. SPIEGEL, E. A., MILLER, H. R., and OPPENHEIMER,M. J. : Forebrain and rage reactions. J. Neurophysiol.3 : 538-548, 1940.

    71. Studies in Psychosomatic Medicine. (Ed. by F. Alex-ander and T. M. French.) New York, The RonaldPress Company, 1948, pp. 568.

    72. VAN DER SPRENKEL, H. B.: Stria terminalis andamygdala in the brain of the opossum {Delphi!virginiana). J. Comp. Neurol. 4 2 : 211-254, 1926.

    73. WALKER, A. E.: Th e Primate Thalamus. Chicago, Uni-

    versity of Chicago Press, 1938, pp . 321.74. WARD, A. A. JR., and MCCULLOCH, W. S.: The pro-

    jection of the frontal lobe on the hypothalamus. J.Neurophysiol. 1 0 : 309-314, 1947.

    75. WARD, A. A. JR. : Th e cingular gyrus: Area 24 . J.Neurophysiol. 1 1 : 13-23, 1948.

    76. WEISS, E., and ENGLISH, O. S.: Psychosomatic Medi-cine. Philadelphia, W. B. Saunders Company, 1943,pp. 687.

    77. WERNER, H .: Comparative Psychology of Mental De -velopment. Ne w York, Harper and Brothers, 1940,pp. 510.

    78. WIENER, N .: Cybernetics, or Control and Communica-tion in the Animal and the Machine. Ne w York,John Wiley and Sons, Inc., 1948, pp. 194.

    79. YAKOVLEV, P. I.: Motility, behavior, and the brain. J.

    Nerv. & Ment. Dis. 107: 313-335, 1948.80. YAKOVLEV, P. I.: Personal communication in : ResearchPubl., A. Nerv. & Ment. Dis. 27 : 405-417, 1948.

    American Society for th e Study of SterilitySterility Award

    The American Society for the Study of Sterility is offering an Annual Award of $1,000, knownas the Ortho Award, for an Essay on the result of some clinical or laboratory research pertinentto the field of sterility. Competition is open to those who are in clinical practice as well as toindividuals whose work is restricted to research in basic fields or full-time teaching positions.The Prize Essay will appear on the Program of the forthcoming Meeting of the AmericanSociety for the Study of Sterility, which is to be held at the Sir Francis Drake Hotel in SanFrancisco on June 24 and 25, 1950.

    Full particulars may be obtained from the Secretary, Dr . Walter W. Williams, 20 MagnoliaTerrace, Springfield, Massachusetts. Essays must be in his hands by April 1, 1950.

    NOVEMBER-DECEMBER,1949