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The place of psychiatry in medicine
The Place
of Psychiatry E.
D.
in Medicine
BOND, M.D.
Philadelphia, Pennsylvania
T
HERE is an understanding that the task of any medical specialty is twofold: it must pursue the most intricate investigations in its own field and then bring back to the main body of physicians those findings which are plain, definite and widely useful. Psychiatry is working in its own field through psychoanalysis, experimental management of the interview, insulin and electric shock therapies, group therapy, genetic studies especially of identical twins, and other methods. It must keep alert to new knowledge of the anatomy and physiology of the nervous systems. Some practitioners in this field in order to do good work must cut themselves off from other kinds of medicine and indeed from the usual participation in community life. They live in their ivory towers by necessity but fortunately information about their discoveries can reach the outside world, often through the mediation of other less specialized psychiatrists who can keep in touch with the medical community. There are two aspects of this information which are important to the general practise of medicine: 1. Psychiatrists are piling up evidence that emotions are factors in the diagnosis, treatment and prognosis of the disease of all organs of the body. The idea is not a new one. Dr. Padis, in a recent paper before the College of Physicians, quoted Plato: “Whenever the soul. . . . is in a passionate state, it shakes up the whole body from within and fills it with maladies.” Physiologists have shown that it is the mediation of the autonomic nervous system and the blood which bring about changes in the function of organs. Their controlled experiments are convincing. In fact, the general physician has accepted the power of the emotions as true in physiology but not applicable to his daily practice. In this attitude the physician has -been abetted by his clinical journals which avoid the as if it were not a scientific word “emotion” term. Here are sentences from recent publications: “The reduction in the secretion produced
by complete division of the vagus nerves to the stomach proves that the hypersecretion is neurogenie in character.” This seems to suggest that there is a lesion part way up the vagus nerves. The psychiatrist suggests following through to the real origin of the disturbance-to such an emotion as the anger a man felt when he discovered that a trusted partner had cheated him. Notice also the phrases in a late and good article. “The hypersecretion-is chiefly, if not exclusively, of nervous origin and is abolished by “implicating the central nervous vagotomy”; “the tension and strain of modern system”; life.” There is apparent avoidance of the physiological terms “emotion and the autonomic nervous system.” 2. Into the clinical picture the psychiatrist often or usually brings a second person. This meets with understandable objection from many busy physicians: “Isn’t one body complicated enough? Why must a second be brought in”? But it was a physiologist, Walter Cannon, who brought in a second person to explain a gastric analysis which showed lack of secretion. The patient had been brought to Boston the day before the analysis and her husband had drowned his anxiety by getting drunk and creating a scene of which the patient was deeply ashamed. On another day, with the second person behaving well, plenty of secretion was present. Out of an interest in these two overlapping aspects of the clinical picture-the emotions and the second person who can cause them-comes a view of the patient as a whole person. The psychiatrist is ashamed that in large mental hospitals the individual is lost in a crowd; he is afraid that in general hospitals the growing excellence of investigational procedures which tell so much about every organ may keep a busy physician out of touch with the whole patient and his responses to people about him. More and more the total personality is being recognized, and the following extensions of psychiatric thinking into medicine are noteworthy. Cardiologists report that in spite of the enor-
Place of Psychiatry in Medicine--Bond mous and growing incidence of cardiovascular disease the majority of patients who have symptoms referred to the heart region do not have organic heart disease. Emotions which make a heart light or heavy account for the symptoms of this majority. Anxiety and fear use the heart as their end organ. Gastroenterologists often find about half of their cases functional. Some describe their puzzling patients as “intellectual, neurotic or tense,” a curious commentary on “intellectuals.” Dermatologists find emotional factors in urticarias, eczemas and other diseases. Surgeons are interested in the meanings of pain, and emotions can cause pain. Pediatricians find more sudden and violent body responses to emotions in children than in adults. If this morning we could have looked into the homes of school children all over the country at about 8 A.M., we should have found thousands of headaches, digestive upsets, pains which subsided after 9 A.M., most of them the result of fear of what would happen in school or on the way. And just as a pediatrician or family doctor might well take into his diagnosis the emotions that might in a school child be centered UpOIl 9 A.M., so any doctor in any diagnosis is better equipped if he knows what zero hour his patient is facing. “Doctor, I hope you find something wrong with every gland in my body for it will postpone the fateful decision I have to make !” Here are suggestions that psychiatrists bring back from their own studies of tangled loves and hates: (1) If symptoms hang together to make a clear diagnosis in a reasonable time, regard
emotional factors as minor or negligible. (2) When symptoms are not in step, when they are inconsistent and fluctuating, give emotional factors an even chance with those physical. When these suggestions are neglected, a letter such as the following can come from a surgical to a psychiatric service. “We are referring a woman of 40. Because of a complaint of questionable pain she has had four operations and much novocaine. After two years and because of the recurrent complaint regardless of treatment we are referring her to you with the diagnosis of psycho-neurosis.” This is locking the barn door after the horse was stolen. But when physicians, surgeons and specialists give emotional factors an even chance early in doubtful cases, they are surpassing psychiatrists in the cure of budding neuroses and they are making diagnoses which are a credit to medicine. They are recognizing that any organ in the body can become the loud-speaker for strong emotion. These good results come not from the application of special psychiatric technics but from the change in an attitude of the physician who has recognized the prevailing emotion in a patient and looked for the person who caused it. One internist takes an hour and a half for the first interview and thinks that this saves him time later. Psychiatry’s place in medicine does not stand on psychosomatics alone. In its own field it is discovering and relieving “the exquisite forgotten agonies of childhood,” the deeper origins of prejudice and hostility and unreason. These are contributions to the total health of man, the goal of all medicine.
End of Anniversary Papers
NOVEMBER,
1951
589
of Psychiatry E.
D.
in Medicine
BOND, M.D.
Philadelphia, Pennsylvania
T
HERE is an understanding that the task of any medical specialty is twofold: it must pursue the most intricate investigations in its own field and then bring back to the main body of physicians those findings which are plain, definite and widely useful. Psychiatry is working in its own field through psychoanalysis, experimental management of the interview, insulin and electric shock therapies, group therapy, genetic studies especially of identical twins, and other methods. It must keep alert to new knowledge of the anatomy and physiology of the nervous systems. Some practitioners in this field in order to do good work must cut themselves off from other kinds of medicine and indeed from the usual participation in community life. They live in their ivory towers by necessity but fortunately information about their discoveries can reach the outside world, often through the mediation of other less specialized psychiatrists who can keep in touch with the medical community. There are two aspects of this information which are important to the general practise of medicine: 1. Psychiatrists are piling up evidence that emotions are factors in the diagnosis, treatment and prognosis of the disease of all organs of the body. The idea is not a new one. Dr. Padis, in a recent paper before the College of Physicians, quoted Plato: “Whenever the soul. . . . is in a passionate state, it shakes up the whole body from within and fills it with maladies.” Physiologists have shown that it is the mediation of the autonomic nervous system and the blood which bring about changes in the function of organs. Their controlled experiments are convincing. In fact, the general physician has accepted the power of the emotions as true in physiology but not applicable to his daily practice. In this attitude the physician has -been abetted by his clinical journals which avoid the as if it were not a scientific word “emotion” term. Here are sentences from recent publications: “The reduction in the secretion produced
by complete division of the vagus nerves to the stomach proves that the hypersecretion is neurogenie in character.” This seems to suggest that there is a lesion part way up the vagus nerves. The psychiatrist suggests following through to the real origin of the disturbance-to such an emotion as the anger a man felt when he discovered that a trusted partner had cheated him. Notice also the phrases in a late and good article. “The hypersecretion-is chiefly, if not exclusively, of nervous origin and is abolished by “implicating the central nervous vagotomy”; “the tension and strain of modern system”; life.” There is apparent avoidance of the physiological terms “emotion and the autonomic nervous system.” 2. Into the clinical picture the psychiatrist often or usually brings a second person. This meets with understandable objection from many busy physicians: “Isn’t one body complicated enough? Why must a second be brought in”? But it was a physiologist, Walter Cannon, who brought in a second person to explain a gastric analysis which showed lack of secretion. The patient had been brought to Boston the day before the analysis and her husband had drowned his anxiety by getting drunk and creating a scene of which the patient was deeply ashamed. On another day, with the second person behaving well, plenty of secretion was present. Out of an interest in these two overlapping aspects of the clinical picture-the emotions and the second person who can cause them-comes a view of the patient as a whole person. The psychiatrist is ashamed that in large mental hospitals the individual is lost in a crowd; he is afraid that in general hospitals the growing excellence of investigational procedures which tell so much about every organ may keep a busy physician out of touch with the whole patient and his responses to people about him. More and more the total personality is being recognized, and the following extensions of psychiatric thinking into medicine are noteworthy. Cardiologists report that in spite of the enor-
Place of Psychiatry in Medicine--Bond mous and growing incidence of cardiovascular disease the majority of patients who have symptoms referred to the heart region do not have organic heart disease. Emotions which make a heart light or heavy account for the symptoms of this majority. Anxiety and fear use the heart as their end organ. Gastroenterologists often find about half of their cases functional. Some describe their puzzling patients as “intellectual, neurotic or tense,” a curious commentary on “intellectuals.” Dermatologists find emotional factors in urticarias, eczemas and other diseases. Surgeons are interested in the meanings of pain, and emotions can cause pain. Pediatricians find more sudden and violent body responses to emotions in children than in adults. If this morning we could have looked into the homes of school children all over the country at about 8 A.M., we should have found thousands of headaches, digestive upsets, pains which subsided after 9 A.M., most of them the result of fear of what would happen in school or on the way. And just as a pediatrician or family doctor might well take into his diagnosis the emotions that might in a school child be centered UpOIl 9 A.M., so any doctor in any diagnosis is better equipped if he knows what zero hour his patient is facing. “Doctor, I hope you find something wrong with every gland in my body for it will postpone the fateful decision I have to make !” Here are suggestions that psychiatrists bring back from their own studies of tangled loves and hates: (1) If symptoms hang together to make a clear diagnosis in a reasonable time, regard
emotional factors as minor or negligible. (2) When symptoms are not in step, when they are inconsistent and fluctuating, give emotional factors an even chance with those physical. When these suggestions are neglected, a letter such as the following can come from a surgical to a psychiatric service. “We are referring a woman of 40. Because of a complaint of questionable pain she has had four operations and much novocaine. After two years and because of the recurrent complaint regardless of treatment we are referring her to you with the diagnosis of psycho-neurosis.” This is locking the barn door after the horse was stolen. But when physicians, surgeons and specialists give emotional factors an even chance early in doubtful cases, they are surpassing psychiatrists in the cure of budding neuroses and they are making diagnoses which are a credit to medicine. They are recognizing that any organ in the body can become the loud-speaker for strong emotion. These good results come not from the application of special psychiatric technics but from the change in an attitude of the physician who has recognized the prevailing emotion in a patient and looked for the person who caused it. One internist takes an hour and a half for the first interview and thinks that this saves him time later. Psychiatry’s place in medicine does not stand on psychosomatics alone. In its own field it is discovering and relieving “the exquisite forgotten agonies of childhood,” the deeper origins of prejudice and hostility and unreason. These are contributions to the total health of man, the goal of all medicine.
End of Anniversary Papers
NOVEMBER,
1951
589