A Psychiatric Milestone by Various

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(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, haemic, 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
paediatrist.[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 sequelae (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 [Transcriber's note: original reads
'Committe'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:

[Footnote 4: In an address at the seventieth annual meeting of the
American Medico-Psychological Association, 1914, entitled "The Relations
of Internal Medicine to Psychiatry."]

[Footnote 5: _Cf._ Polon (A.) "The Relation of the General Practitioner
to the Neurotic Patient," Mental Hygiene, New York, 1920, IV, 670-678.]

[Footnote 6: _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.]

[Footnote 7: _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.]

[Footnote 8: _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.]

[Footnote 9: _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.]

[Footnote 10: _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.]

[Footnote 11: _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.]

[Footnote 12: _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

[Illustration: BLOOMINGDALE ASYLUM

As it appeared in 1894 when it was discontinued and replaced by
Bloomingdale Hospital at White Plains, New York.]

AFTERNOON SESSION

_The Chairman_: For the first seventy-five years of its existence the
New York Hospital was the nearest approach to an academy of medicine
that the city possessed. When the now famous New York Academy of
Medicine was established in 1847, a friendly and cordial co-operation
between the two institutions arose, and while the activity of this
co-operation is not as pronounced as it was, we still cherish in our
hearts a warm regard for that ancient ally in the cause of humanity. Its
President, Dr. George D. Stewart, the distinguished surgeon, has come to
extend the greetings of the medical profession of New York City.

DR. STEWART

The emotions that attend the birthday celebrations of an individual are
often a mixture of joy and sadness, of laughter and of tears. In warm
and imaginative youth there is no sadness and there are no tears,
because that cognizance of the common end which is woven into the very
warp and woof of existence is then buried deep in our subconscious
natures, or if it impresses itself at all, is too volatile and fleeting
to be remembered. But as the years fall away and there is one less
spring to flower and green, the serious man "tangled for the present in
some parcels of fibrin, albumin, and phosphates" looks forward and
backward and takes in both this world and the next. In the case of
institutions, however, the sadness and the tears do not obtain--for a
century of anniversaries may merely mean dignified maturity, as in the
case of Bloomingdale, with no hint of the senility and decay that must
come to the individual who has lived so long. This institution was
founded one hundred years ago to-day; the parent, the New York Hospital,
has a longer history. Bloomingdale, as a separate and independent
concern, had its birthday a century ago.

It is curious to let the mind travel back, and consider what was
happening about that time. Just two years before the news had flashed on
the philosophical and scientific world that Oersted, a Danish
philosopher, had caused a deflection of the magnetic needle by the
passage near it of an electric current. The relation between the two
forces was then and there confirmed by separate observations all over
the civilized world. This discovery probably created more interest at
that time than Professor Einstein's recent announcement which, if
accepted, may be so disturbing to the principia of Newton and to our
ideas of time and space. There can be no doubt that the practical
significance of Oersted's experiment was much more widely appreciated
than the theory of Einstein, for an understanding of the latter is
confined, we are told, to not many more men than was necessary to save
Sodom and Gomorrah. Its immense practical significance, however, could
have been foreseen by no man, no matter with what vision endowed. Just
two years prior to the founding of this institution the first steamboat
had crossed the Atlantic and in the same year that great conqueror, who
had so disturbed the peace of the world which was even then as now
slowly recovering from the ravages of war, breathed his last in Saint
Helena, yielding to death as utterly as the poorest hind.

In 1815, Bedlam Hospital in South London was converted into an asylum
for the insane who were at the time called "lunatics." The name Bedlam
is a corruption of the Hebrew "Bethlehem"--meaning the House of
Bread--and while the name popularly came to signify a noisy place it was
the beginning of really scientific treatment for the tragically
afflicted insane. While the treatment of the insane in Europe was being
steadily raised to a higher plane of efficiency, America has also reason
to be proud of her record in this respect. During all the years that
have followed, Bloomingdale has been an important factor in the medical
world of New York.

There are two phases of its existence which might be emphasized--first,
it was founded by physicians; even then and, of course, long before
doctors had proven that they were in the forefront in the promotion of
humanitarian activities. Medicine has always carried on its banners an
inscription to the Brotherhood of Man. It is worthy of note that when
Pinel and Tuke had begun to regard mental aberration as a disease and to
provide scientific hospital treatment therefor, American physicians,
prepared by study and experimentation, were ready to accept and apply
the new teachings.

A second phase of great importance is that institutions like
Bloomingdale have promoted the study of psychology far more than any
other factor, particularly because in them the personality stripped of
some of its intricacies, the diseased personality, permits analysis,
which the normal complex has so long defied. That it is high time that
mankind was undertaking this knowledge of himself is particularly
emphasized by the unrest and aberrance of human behavior now startling
and disturbing the whole world. If mankind does not take up this self
study as Trotter has said, Nature may tire of her experiment man, that
complex multicellular gregarious animal who is unable to protect himself
even from a simple unicellular organism, and may sweep him from her
work-table to make room for one more effort of her tireless and patient
curiosity. Psychology should be taught to every doctor and to every
lettered man.

Digressing for a moment, to every one capable of understanding it, there
should be imparted a knowledge of that simple economic law announced
from the Garden of Eden after the grounds had been cleared and the gates
closed: "By the sweat of thy brow thou shalt earn thy bread." The
economic phase indeed constitutes a highly important aspect of modern
psychology, for abnormal elements are antisocial, and from pickpockets
to anarchists flourish on the soil of pauperism. The key-note of the
future is responsibility. To the educated and enlightened man who still
asks, "Am I my brother's keeper?" Cain has bequeathed a drop of his
fratricidal blood; and he who spurns to do his share of the world's
work, electing instead to fall a burden upon the community, deserves the
fate of the barren fig-tree.

However, amidst the social unrest, buffeted and perplexed by the cross
currents of our time, we should not be pessimistic but should look
forward with courage, parting reluctantly with whatever of good the past
contained and living hopefully in the present. As Ellis says: "The
present is in every age merely the shifting point at which past and
future meet, and we can have no quarrel with either. There can be no
world without traditions; neither can there be any life without
movement. As Heraclitus knew at the outset of modern philosophy, we
cannot bathe twice in the same stream, though as we know to-day, the
stream still flows in an unending circle. There is never a moment when
the new dawn is not breaking over the earth, and never a moment when the
sunset ceases to die. It is well to greet serenely even the first
glimmer of the dawn when we see it, not hastening toward it with undue
speed, nor leaving the sunset without gratitude for the dying light
that once was dawn."

So to-day I bring to you from the New York Academy of Medicine
felicitations on your one hundredth anniversary and greetings to your
guests who have come from all over the world to join in your birthday
celebration.

ADDRESS BY
DR. RICHARD G. ROWS

_The Chairman_: Besides the Royal Charter, the New York Hospital is
indebted to Great Britain for invaluable encouragement and financial aid
in our natal struggle in Colonial days. Dr. Rows has added charmingly to
that debt by journeying from London to take part in these exercises. His
subject will be, "THE BIOLOGICAL SIGNIFICANCE OF MENTAL ILLNESS."

As Director of the British Neurological Hospital for Disabled Soldiers
and Sailors, at Tooting, he is giving the community and the medical
world the benefit of his rich professional experience in the trying
years of war as well as in peace, and gaining fresh laurels as he
marches, like Wordsworth's warrior, "from well to better, daily
self-surpast."

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