DR. BARKER
We have met to-day to celebrate the hundredth anniversary of the founding of a hospital that, in its simpler beginnings and in its evolution to the complex and highly organized activities of the present, has served an eminently practical purpose and has played an important rôle in the development of the science and art of psychiatry in America. I desire, as a representative of general medicine, and, especially, of internal medicine, to add, on this occasion, my congratulations to those of the spokesmen of other groups, and, at the same time to express the hope that this institution, historically so significant for the century just past, may maintain its relative influence and reputation in the centuries to come.
The interest taken in psychiatry by the general practitioner and by the consulting internist has been growing rapidly of late. Some of the reasons for this growth of interest and heightening of appreciation I have drawn attention to on an earlier occasion.[[4]] Psychiatry as a whole was for a long time as widely separated from general medicine as penology is to-day, and for similar reasons. It was a long time before persons that manifested extraordinary abnormalities of thought, feeling, and behavior were regarded as deserving medical study and care, and even when a humanitarian movement led to their transfer from straight-jackets, chains, and prison cells to "asylums for the insane," these institutions were, for practical reasons, so divorced from the homes of the people and from general hospitals that psychiatry had, and could at the time have, but little intercourse with general medicine or with general society. Mental disorders were moral and legal problems rather than biological, social, and medical problems. Their genesis was wholly misunderstood, and legal, medical, social, religious, and philosophic prejudices went far toward preventing any rational scientific mode of approach to the questions involved or any formulation of investigative procedures that promised to be fruitful. Even to-day the same prejudices are all too inhibitory; but thanks to the unprecedented development of the natural sciences during the period since this hospital was founded, we are witnessing, in our time, a rapid transformation of thought and opinion concerning both the normal and the disordered mind, a transformation that is reaching all circles of human beings, bidding fair to compel the strongholds of tradition and prejudice to relax, and inviting the whole-hearted co-operation of workers in all fields in a common task of overcoming some of the greatest difficulties by which civilization and human progress are confronted. And though the brunt of this task is borne and must be borne by the shoulders of medical men, physicians assume the burden cheerfully, now that they know that they can count upon the intelligent support and the cordial sympathy of an ever-enlarging extra-medical aggregate. No better illustration could be given, perhaps, of the change in the status of psychiatry in this country and in the world than the contents of the programme of our meeting to-day at which a distinguished investigator from London tells us of the biological significance of mental disorders, an eminent authority from Paris explains the relationship between certain diseases of the nervous system and these disorders, and a leading psychiatrist of this country speaks upon the contributions of psychiatry to the understanding of the problems of life. Psychiatry, like each of the other branches of medicine, has come to be recognized as one of the subdivisions of the great science of biology, free to make use of the scientific method, in duty bound to diffuse the knowledge that it gains, and privileged to contribute abundantly to the lessening of human suffering and the enhancement of human joys. General practitioners of medicine and medical specialists—at least the more enlightened of them—welcome the developing science of psychiatry, are eager to hasten its progress, and will gladly share in applying its discoveries to the early diagnosis, the cure, and the prevention of disease.
That the majority of medical and surgical specialists and even most of the widely experienced general practitioners, though constantly coming in contact with major and minor psychic disturbances, are, however, still far from realizing the full meaning and value of the principles and technic of modern psychology and of the newer psychiatry must, I fear, be frankly admitted.[[5]] But dare we blame these practitioners for their ignorance of, apathy regarding, and even antipathy to, the psychic and especially the psychotic manifestations of their patients? Ought we not rather to try to understand the reasons for this ignorance, this apathy, and this aversion, all three of which seem astonishing to many of our well-trained psychologists and psychopathologists? Are there not definite conditions that explain and at least partially excuse the defects in knowledge and interest and the errors in attitude manifested by those whom we would be glad to see cognizant and enthusiastically participant? Psychiatrists, who have taught us to understand and rescue various types of "sinners" and "social offenders" will, I feel sure, avoid any moralistic attitude when discussing the shortcomings of their brethren in the general medical profession, and will, instead, seek to discover and to remove their causes.
As an internist who values highly the gifts that modern psychology and psychiatry have been making to medicine, I have given some thought to the conditions and causes that may be responsible for these professional delinquencies that you deplore. Though this is not the time nor the place fully to discuss them, the mere mention of some of the causes and conditions will, perhaps, contribute to comprehension and pardon, and may serve to stimulate us all to livelier corrective activity. Let me enumerate some of them:
(1) A social stigma still attaches, despite all our efforts to abolish it, to mental disorders and has, to a certain extent, been transferred to those that study and treat patients manifesting these disorders.
(2) The organization of our general education is very defective since it fails to make clear to each student man's place in the universe and any orderly view of the world and man; it fails adequately to enlighten the student regarding the processes of life as adaptations of organisms to their environment, man, himself, being such an organism reacting physically and psychically to his surroundings in ways either favorable or unfavorable to his own preservation and that of his species; it fails to teach the student that the human organism represents a bundle of instincts each with its knowing, its feeling, and its striving component, that what we call "knowledge" and what we call "character" are gradual developments in each person, and that if we know how they have developed in a particular person we possess clues to the way that person will react under a given stimulus, that is to say, what he will think, how he will feel, and how he will act; and it fails, again, properly to instruct students regarding the interrelationships of members of different social groups (familial, civic, economic, occupational, ethical, national, racial, etc.); in other words, our general educational organization is as yet far from successful in inculcating philosophical, biological, psychological, and sociological conceptions that are adequate symbols of reality.
(3) Though our medical schools have made phenomenal advances in the organization and equipment of their institutes and in provision for teaching and research in a large number of preclinical and clinical sciences, they have up to now almost wholly ignored normal psychology, psychiatry, and mental hygiene. The majority of the professors in these schools are so absorbed by the morphological, physical, and chemical aspects of their subjects, that students rarely get from them any inkling of the psychobiological aspect, any adequate knowledge of human motives, or any satisfactory data regarding human behavior, normal or abnormal.[[6]] It is only recently and only in a few schools that psychiatric clinics have been established as parts of the teaching hospitals, that medical students have been able to come into direct contact over an appreciable period of time with the objects of psychiatric study, that the psychic manifestations of patients have received any direct and particular attention in the general medical and surgical wards, and that there has been any free and constant reciprocal exchange of thought and opinion between students of the somatic on the one hand and students of the psychic on the other.
(4) The language of the psychiatrist is unique and formidable. The names he has applied to motives and impulses, to symptoms and syndromes, are foreign to the tongue of the general practitioner who is so awed by them that he withdraws from them and remains humbly reticent in a state of enomatophobia; or, if he be more tough-minded, he may be amused by, or contemptuous of, what he refers to as "psychiatric jargon" or "pseudoscientific gibberish." There is, furthermore, a dearth of concise, authoritative, well-written text-books on psychiatry, and the general medical journals rarely print psychiatric papers designed to interest the average practitioner. The most widely diffused psychiatric reports of our time are the sensational news items of the daily press.
(5) The overemphasis of psychogenetic factors to the apparent neglect of important somatogenic factors by some psychiatrists has tended to arouse suspicion regarding the soundness of the opinions and methods of psychiatric workers in the minds of men thoroughly imbued with mechanistic conceptions and impressed with the results of medical researches based upon them. The ardor of the psychoanalysts, also, though in part doubtless justified by experience, has, it is to be feared, excited a certain amount of antipathy among the uninitiated.
(6) The fears of insanity prevalent among the laity and the repugnance of patients to any idea that they may be "psychotic" or "psychoneurotic" (words that, in their opinion, refer to "imaginary symptoms," or to symptoms that they could abolish if they would but "buck up" and exert their "wills") undoubtedly exert a reflex influence upon practitioners who put the "soft pedal" on the psychobiological reactions and "pull out the stop" that amplifies the significance of any abnormal physical findings.
(7) Psychotherapy, to the mind of the average medical practitioner, is (or has been) something mysterious or occult. He uses much psychotherapy himself but it is nearly always applied unconsciously and indirectly through some form of physical or chemical therapy that he believes will cure. He is usually quite devoid of insight into the effect of his own expressed beliefs and bodily attitudes upon the adjusting mechanisms of his patients. Conscious and direct psychotherapy is left by the average practitioner to New Thoughters, Christian Scientists, quacks, and charlatans. If he were to use psychotherapy consciously and were to receive a professional fee for it he would feel that he was being paid for a value that the patient had not received. A highly respected colleague once privately criticised a paper of mine (read before the Association of American Physicians) on the importance of psychotherapy. "What you said is true," he remarked; "we all use psychotherapy but we are a little ashamed of it; and it is better not to talk about it." Even he did not realize that every psychotherapy is also a physical therapy.
(8) The rise of specialism, through division of labor and intensification of interests restricted to limited fields, in practical medicine, the necessary result and to a large extent also a cause of the rapid growth of knowledge and technic has brought with it many advantages, but also some special difficulties, among them (a) the impossibility any longer of any single practitioner, unaided, to study and treat a patient as well as he can be studied and treated by a co-ordinated group whose special analytical studies in single domains are adequately synthesized by a competent integrator, and (b) in the absence of such group work, the tendency to one-sided study, partial diagnosis, and incomplete and unsatisfactory therapy. Through the rise of specialism, it is true, psychiatry itself has arisen and the psychiatrist, like the skilled integrating internist, is interested in the synthesis of the findings in all domains, for only through such synthetic studies, such integration of the functional activities of the whole organism, is it possible to gain a global view of the patient as a person, to make a complete somatic, psychic, and social diagnosis, and to plan a regimen for him that will ensure the best adjustment possible of his internal and external relationships.[[7]]
Working in a diagnostic group myself as an integrating internist, I have been much helped by the reports of personality studies made by skilful psychiatrists; these are linked with the special reports on the several bodily domains (cardiovascular, respiratory, hæmic, dental, digestive, urogenital, locomotor, neural, metabolic, and endocrine) in order finally to arrive at an adequately co-ordinated and (subordinated) total diagnosis from which the clues for an appropriate therapeutic regimen can safely be drawn. If group practice is to grow and be successful in this country, as I think likely, groups must see to it that psychiatry, as well as the other medical and surgical specialties, is properly represented in their make-up.[[8]] From now on, too, general practitioners should, as Southard emphasized, be urged to be at least as familiar with the general principles and methods of the psychiatrist as they are with those of the gynecologist, the dermatologist, and the pædiatrist.[[9]] Well organized group-diagnosis and general will then help to counteract the inhibiting influence of earlier isolated specialism upon the appreciation of psychiatry.
This enumeration of some of the causes of the ignorance and apathy (existent hitherto) in the general profession regarding psychiatry may perhaps suffice as explanation. These causes are, fortunately, rapidly being removed. We are entering upon an era in which psychiatry will be recognized as one of the most important specialties in medicine, an era that will demand alliance and close communion among psychiatrists, internists, and the representatives of the various medical and surgical specialties.
The internist and the psychiatrist will ever have a common interest in the obscure problems of etiology and pathogenesis of diseases and anomalies that are accompanied by abnormalities of thought, feeling, and behavior. Progress in this direction is bound to be slow for the studies are exceptionally complex and there are many impediments to be removed. Though the problems are deep and difficult, they are doubtless soluble by the mind of man, and they exert an uncommon fascination upon those who visualize them. Causes may be internal or external, and are often a combination of both. The tracing of the direct and indirect relationships between these causes and the abnormal cerebral functioning upon which the disturbances of psychobiological adjustment seem to depend is the task of pathogenesis. The internist who has studied the infantile cerebropathies with their resulting imbecilities, syphilis followed by general paresis, typhoid fever and its toxic delirium, chronic alcoholism with its characteristic psychoses, cerebral thrombosis with its aphasias, agnosias, and apraxias, thalmic syndromes due to vascular lesions with their unilateral pathological feeling-tone, frontal-lobe tumors with joke-making, uncus tumors with hallucinations of taste and smell, lethargic encephalitis with its disturbance of the general consciousness and its psychoneurotic sequelæ (lesions in the globus pallidus and their motor consequences), pulmonary tuberculosis with its euphoria, and endocrinopathies like myxoedema and exophthalmic goitre with their pathological mental states, is encouraged to proceed with his clinical-pathological-etiological studies in full assurance that they will steadily contribute to advances in psychiatry. The eclectic psychiatrist who is examining mental symptoms and symptom-complexes ever more critically, who is seeking for parallel disturbances in physiological processes and who considers both psychogenesis and somatogenesis in attempting to account for psychobiological maladjustments will welcome, we can feel sure, any help that internal medicine and general and special pathology can yield.
These studies in pathogenesis and etiology are fundamentally necessary for the development of a rational therapy and prophylaxis. Already much that is of applicable value in practice has been achieved. The internist shares with the psychiatrist the desire that knowledge of the facts regarding care, cure, and prevention of mental disorders may become widely disseminated among medical men and at least to some extent among the laity. Experts in psychiatry firmly believe that at least half of the mental disturbances now prevalent could have been prevented, if, during the childhood and adolescence of those afflicted, the facts and principles of existing knowledge and the practical resources now available could have been applied.
We have recently had an excellent illustration of the benefits of applied psychiatry in the remarkable results achieved during the great war through the activities of the head of the neuropsychiatric division of the Surgeon General's office and his staff[[10]] and those of the senior consultant in neuropsychiatry and his divisional associates in the American Expeditionary Force. In no other body of recruits and in no other army than the American was a comparable success arrived at, and the credit for this is due to American applied psychiatry and its wisely chosen official representatives.
The active campaign for the preservation of the mental health of our people and for a better understanding and care of persons presenting abnormal mental symptoms carried on during the past decade by the National Committee for Mental Hygiene marks a new epoch in preventive medicine.[[11]]
The prevention of at least a large proportion of abnormal mental states through the timely application of the principles of mental hygiene is now recognized as a practically realizable ideal. Many important reforms are now in process throughout the United States, no small part of them directly attributable to the active efforts of our leading psychiatrists and to our National Committee's work. The old "asylums" are being changed into "hospitals." Psychiatric clinics are becoming attached to teaching hospitals and psychiatric instruction in the medical schools is being vastly improved. The mental symptoms of disease now receive attention in hospitals and in private practice and at a much earlier stage than formerly. Even the courts, the prisons, and the reformatories are awakening to the importance of scientific psychiatry; before long penology may be brought more into accord with our newer and juster conceptions of the nature and origin of crime, dependency, and delinquency. That schools of hygiene and the public health services must soon fall into line and consider mental hygiene seriously is obvious. The objection sometimes made that the practical problems are too vague, not sufficiently concrete, to justify attack by public health officials is no longer valid. In no direction, probably, could money and energy be more profitably spent during the period just ahead than in the support of a widely organized campaign for Mental Hygiene.[[12]] Psychiatrists can count upon internists and general practitioners to aid them in educating the public regarding the nature and desirability of this campaign.
Man is now consciously participating in the direction of his own evolution. To cite England's poet laureate, who, you will recall, is a physician: "The proper work of his (man's) mind is to interpret the world according to his higher nature, and to conquer the material aspects of the world so as to bring them into subjection to the spirit."
FOOTNOTES:
In an address at the seventieth annual meeting of the American Medico-Psychological Association, 1914, entitled "The Relations of Internal Medicine to Psychiatry."
Cf. Polon (A.) "The Relation of the General Practitioner to the Neurotic Patient," Mental Hygiene, New York, 1920, IV, 670-678.
Cf. Paton (S.) Human Behavior in Relation to the Study of Educational, Social, and Ethical Problems. New York, 1921. Charles Scribner's Sons, p. 465.
Cf. Meyer (A.), "Progress in Teaching Psychiatry," Journal A.M.A., Chicago, 1917, LXIX, 861-863; see also his, "Objective Psychobiology, or Psychobiology with Subordination of the Medically Useless Contrast of Medical and Physical," Journal A.M.A., Chicago, 1915, LXV, 860-863; and, "Aims and Meanings of Psychiatric Diagnosis," Am. Journal of Insanity, Baltimore, 1917, LXXIV, 163-168.
Cf. "The General Diagnostic Survey Made by the Internist Cooperating with Groups of Medical and Surgical Specialists," New York Medical Journal, 1918, 489,538,577; also, "The Rationale of Clinical Diagnosis," Oxford Medicine, 1920, vol. I, 619-684; also, "Group Diagnosis and Group Therapy," Journal Iowa State Medical Society, 113-121, Des Moines, 1921.
Cf. Southard (E.E.), "Insanity Versus Mental Disease"; the Duty of the General Practitioner in Psychiatric Diagnosis, Journal American Medical Association, LXXI, 1259-1261, Chicago, 1918.
Cf. Bailey (P.), "The Applicability of Findings of Neuro-psychiatric Examinations in the Army to Civil Problems," Mental Hygiene, New York, 1920, IV, 301; also "War and Mental Diseases," Am. J. Pub. Health, IX, 1, Boston, 1919.
Cf. Salmon (T.W.), "War Neuroses and Their Lesson," New York Medical Journal, CIX, 993, 1919; also, "The Future of Psychiatry in the Army," Mil. Surgeon, XLVII, 200, Washington, 1920.
Cf. "Origin, Objects, and Plans of the National Committee for Mental Hygiene" (Publication No. 1, of the National Committee, New York City); and, "Some Phases of the Mental Hygiene Movement and the Scope of the Work of the National Committee for Mental Hygiene," in Trans., XV, Internal. Congr. for Hygiene and Demography, III, 468-476, (1912), Washington 1913.
Cf. Russell (W.L.) "Community Responsibilities in the Treatment of Mental Disorders." Canad. J. Ment. Hygiene, 1919, I 155—.
Hincks (C.M.), "Mental Hygiene and Departments of Health," Am. J. Pub. Health, Boston, IX, 352, 1919; Haines (T.H.), "The Mental Hygiene Requirements of a Community: Suggestions Based upon a Personal Survey," Mental Hygiene, IV, 920-931, New York, 1920.
Beers (C.W.), "Organized Work in Mental Hygiene," Mental Hygiene, 567, New York, 1917, also, Williams (F.E.), "Progress in Mental Hygiene," Modern Hospital, XIV, 197, Chicago, 1920.
The Chairman: We had hoped to receive to-day the greetings of our sole elder sister among American institutions, the Pennsylvania Hospital, of Philadelphia, which since its foundation in 1751 has pursued a career much like our own, treating mental cases in the general hospital from the very beginning, and since 1841 maintaining a separate department for mental diseases in West Philadelphia. Dr. Owen Copp, the masterly physician-in-chief and administrator of that department, was to have been here, but unfortunately has been detained. Our morning exercises having come to an end, Dr. Russell asks me to say that your inspection of the occupational buildings and other departments of the Hospital is cordially invited; a pageant illustrative of the origin and aspirations of the Hospital will be given on the adjoining lawn; and that after the pageant our guests are desired to return to the Assembly Hall, where we shall have the privilege of listening to addresses by Dr. Richard G. Rows, of London, and Dr. Pierre Janet, of Paris, who have come across the Atlantic especially to take part in this anniversary celebration.
ADDRESS BY
DR. GEORGE D. STEWART
