Functional Phenomena in Organic Disease

ONE of my treasured possessions is a notebook, the clinical lectures of a very great teacher who had a clear, and one might say, a classifying mind. He dearly loved tables of contrast between the various forms of disease, and a classical example is his table of the points of difference-fifteen in number-between functional and organic nervous disease. I suppose it was my own fault, but certain misconceptions seem to have been present in my mind as a result of that sharp line of cleavage. First, that "functional" phenomena affected only the nervous system and were in the main the concern of the neurologist. Secondly, that these two con(ditions were mutually exclusive; patients were either the sheep with a diagnosable-if often intractable-organic disease, or the goats with a stigmatic label "functional," and there the matter ended. No specific enquiry into the cause for these disturbances of function was made; most cases were treated with potassium bromide and hope, and a few with the forcible application of cold water. More rarely, an(l then only in such clearly defined cases as hysterical hemiplegia, was six weeks seclusion prescribed on the lines advocated by Weir Mitchell. At that time, thirty years ago, some diseases were regarded as functional which are now recognised to be organic. In the 1912 edition of Osler's "Medicine," Parkinson's disease and chorea are classified with epilepsy, hysteria, and neurasthenia, under the vague heading "general and functional diseases." And here, perhaps, I should give what I think is a reasonable definition of "a functional phenomenon"-it is a disturbance of physiological process, which is not due to any known pathological lesion of the body. This definition excludes those disturbances of function which are universally regarded as due to toxaemia, but even these are apparently linked up with the psychical constitution of the individual. There appears to be an increasing tendency among psychiatrists to seek for focal sepsis as a cause of psychoses. Indeed, Graves (1938) regards it as the common cause of the functional insanities. Elfeld (1940) found that, of 483 consecutive admissions to Delaware State Hospital, 155 were diagnosed as psychoses due to some definite physical defect, 64 to toxic conditions, including alcohol, and 8 to metabolic disorders; therefore, nearly fifty per cent. were due to physical causes. The "constitutional" factor varies with the individual: while all of us are depressed when we have influenza, some are relatively cheerful, and others wallow in self-pity. One patient with pneumonia mav have delirium and recover, another may remain clear-minded until he dies; just as one alcoholic gets cirrhosis of the liver and another gets delirium tremens. Certain organic diseases produce disturbances of function which are so closely associated with them as to be almost specific for them, but even these have their pitfalls. Not every patient with grandiose delusions has G.P.I., for chronic