The Chairman:—The Johns Hopkins Medical School lends us also to-day Dr. Lewellys F. Barker, its Professor of Clinical Medicine. Dr. Barker has done so much to define and settle the contradictions of mind and matter, and has clarified so much, and in fields so varied, as teacher, research worker, and practitioner, that we welcome this opportunity of listening to his discussion of "The Importance of Psychiatry in General Medical Practice."
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.