A Letter from America
Dr Macfie Campbell’s letter to Miss Fox, which we print below, seemed of such general interest, that we obtained his permission to publish it in this number of the magazine. As our readers are, no doubt, aware, Dr Macfie Campbell is Professor of Psychiatry at Harvard Medical School, and Director of the Boston Psychopathic Hospital. We should welcome in our next number any correspondence on the subject from the medical profession in England. Dear Miss Fox,
I must apologise for my long delay in answering your letter of May 13th. I regret that the demands on my time make it impossible for me to write any special article for ” Mental Welfare.” You ask me in your letter about the position of the study of mental deficiency in the medical curriculum.
As a matter of fact, I do not know of any special course in a medical school dealing with mental defect as distinct from mental disorders. The medical curriculum, as you probably know, has been getting more and more crowded, and there is a swing in the direction of simplification rather than of further complication of the curriculum. Even in regard to mental disorders only a few medical schools in the United States make adequate provision for instruction in this branch of medicine. Even where some provision is made for systematic lectures and demonstrations, the clinical facilities are apt to be somewhat restricted, and very frequently the only clinical material is that of the nearest hospital for mental disorders (” asylums ” in the older terminology). Such cases have usually been admitted under the ordinary legal form of commitment, and represent the more advanced and less hopeful forms of mental disorder. In few medical schools are there adequate hospital facilities for the student to study and follow the treat- ment of the minor forms of mental disorder and to see such cases in an out-patient department. Very frequently medical students are given some clinical psychiatry without previously having had any instruction in psychology, which is about as reasonable as to begin the study of clinical medicine in the wards without having had any systematic instruction in physiology.
At the Harvard Medical School the students get a preliminary course in medical psychology in their first year and in their third year they get their clinical psychiatry. During that third year the class is divided into sections of eight students; each group of eight spends the forenoon for a period of two weeks in the Boston Psychopathic Hospital in immediate contact with the clinical material. In the fourth year students can take an elective course in psychiatry, spending either the forenoons or the whole day in the Boston Psychopathic Hospital, and the students have especially appreciated the opportunity of using this period for work in the out-patient department where they come into contact with incipient cases of mental disorder, with atypical personalities in transitory difficulty, with children who either have nervous symptoms or have some mental defect, and with an extremely rich clinical material. On graduation the student has an opportunity of a position as resident physician in the Boston Psychopathic Hospital if he wishes to get some additional training in psychiatry.
At the John Hopkins Medical School, which has its own hospital, the clinical facilities are admirable owing to the institution of the Phipps Psychiatric Clinic in 1913. In the medical curriculum considerable attention is given to medical psychology and an adequate period is allowed for clinical psychiatry. The out- patient department of the Phipps Clinic offers a most useful material for the instruction of students,
At Cornell Medical School in New York the systematic instruction is allowed a fairly generous amount of time, and the clinical demonstrations are given on a special service of a large state hospital (’’ asylum “), which is reserved for the investigative work of the Psychiatric Institute.
As Yale Medical School has, at present, no adequate clinical facilities, the Dean prefers to make no pretence of giving adequate training in psychiatry, and the subject is dealt with in a somewhat meagre way in a few lectures. The need of adequate clinical facilities at Yale is keenly felt, and it is only a matter of time until it has suitable facilities.
The teaching of psychiatry in the other medical schools and the clinical facilities available are very variable, and I shall not go into further detail in the matter.
It is becoming generally recognised in medical educational circles that medicine has, in the past, neglected seriously the personal aspect of human ailments and that the sick patient rather than the disease should be the main interest of the practising physician. It is being generally recognised that in order to under- stand the personal factors of disease psychiatry should get a much more important position than it has previously occupied. The lesson which the war gave on the importance of the neuroses has left its impression.
From the point of view of hospital facilities, it seems to me time that we got rid of peculiar mediaeval associations which hang round the word ” mental.” A mental patient is a sick person and a sick person coming to a general hospital of considerable size should be able to find the attention that is required for his special variety of ailment. A few large hospitals may be without certain depart- ments, but the genera! principle should be that any hospital which claims to be at all complete in its equipment should have available the specialised personnel required for the great run of human ailments. There are some conditions which may not be suitable for a general hospital. Infectious disorders may require to he quarantined in separate departments or separate hospitals. Extremely noisy, or otherwise disturbing behaviour may make it equally necessary to refer other patients to special hospitals. There is no reason, however, why a patient should be refused admission to a hospital because he or she is a mental ” patient, and the present discrimination of the hospital administrative staff and the nursing staff against this group of patients is a serious flaw in our present health facilities.
The majority of patients suffering from mental symptoms can be looked after adequately in special wards of general hospitals, and for a great number of mental patients a well equipped out-patient department would be of very great benefit. The free admission of such patients to the wards of the general hospital and to the out-patient department would give the medical student a touch with the realities of sickness which would do more to free him from the mediaeval traditions that cluster round this subject than any series of lectures. The pro- vision of such facilities would do more to free the community from the incubus of mistaken and detrimental prejudices than any form of propaganda. “W ith such provision the community would come to realise that mental disorders are to be looked upon as ailments that require frank recognition and early treatment, and to take the necessary measures for utilising the facilities provided for these. As a special topic within the wide field of handicapped human personalities, the subject of mental defect is very important. In dealing with cases of mental disorders, the estimation of the constitutional equipment of the individual is extremely important, and in many cases it is evident that the constitutional equipment shows a flaw of one kind or another, meaning lessened resistance to this or that type of environmental stress. Some cases show their inferiority by their liability to physical invalidism, others have an inferiority in emotional stability and in response to ethical demands, others have an inferiority in regard to the intellectual functions. The problem of those who are constitutionally inferior in regard to intellectual endowment is a practical problem of considerable economic and social importance which requires special institutional arrangements.
From the point of view of the medical curriculum, however, this group of constitutionally handicapped individuals seems most appropriately studied in con- nection with other forms of mental handicap and disorder. It is doubtful whether the undergraduate can be expected to do more than grasp the general principles involved in this group and to receive some indication as to the social importance of it. In his work in neuropathology he has an opportunity of becoming more or less familiar with some of the structural conditions which may be at the basis of severe degrees of mental defect.
In the course on medical psychology at the Harvard Medical School the constitutional equipment of the individual is discussed and the role played by the intellectual functions in adaptation to the environment, the school environ- ment, the industrial environment, the social environment. In the course of the clinical work carried out by the various sections, the students spend one forenoon in having intelligence tests carried out and in discussing their application. In the clinical demonstrations the conditions of primary intellectual defect are referred to only incidentally.
While I doubt whether the special anatomical, clinical and social problems of mental defect can be introduced into the crowded curriculum of the undergraduate, I think that in the Department of Psychiatry there should be facilities for giving any student or graduate, who wishes to prepare himself along special lines, the necessary facilities.
At Harvard Dr F. L Wells, Ph.D., is an instructor in the Department of Psychiatry and is at the same time in charge of the psychological laboratory of the Boston Psychopathic Hospital. Besides carrying on experimental work on the emotions, he is devoting a great deal of time to work at psychometrics and to the instruction of graduate students in such problems.
While, therefore, I realise the very great importance of mental defect as a public health problem, and see the important contribution which can be made to it by the medical profession, I do not think that, as a special topic, mental defect can receive very much attention in the ordinary undergraduate curriculum. The medical student at best is only learning methods and beginning to get some training in handling the tools of his craft. The curriculum does not pretend to cover the whole field, but should emphasise methods and principles and give some perspective as to the relative importance of the facts already available.
Thus, in his medical course, the student will not only learn about the anatomy and embryology of the central nervous system, he will also learn about pre-natal and obstetrical injuries and about infantile liabilities such as meningitis, con- vulsive disorders, trauma, etc. In his medical psychology and in his clinical psychiatry he will learn to appreciate the importance of the instinctive and the emotional factors and to give attention to the constitution and to genetic deter- minants ; he will learn to study the important environmental factors and the way in which human nature reacts to stress and strain. A graduate with this pre- liminary training should naturally have facilities for training himself more specific- ally for work in the field of mental defect. He would require to do special work in psychometrics and to become familiar with the whole problem of intelligence tests. Courses of this nature are frequently available in the Department of Psychology. He will also wish to have some special opportunity of taking up in detail the psvchopathology of childhood. The lack of any adequate course in this subject in almost all schools is very striking.
On graduation, however, the time for spoon-feeding- has long” passed, and a graduate should be able to utilise the opportunities afforded by a good institu- tion. He will there find the clinical material; he knows something of the methods of investigation, and it depends on him to focus his problem and to work at it in a purposeful manner. From the constructive standpoint he may take up not so much problems of etiology as problems of training and management. This involves not only psychometric tests and analysis of the personality but analysis of various types of occupation and study of various environments. 1 he problem of placing the child in the suitable environment is important, and can best be approached by one who is familiar with the psychopathology of childhood. We have now, fortunately, got away from the simple but hopeless formula that all defective children have to be segregated in institutions. Dr Fernald has done a great deal to convince people that the large majority of the mentally defective have got to be looked after -,n the community, and, under kindly super- vision and with adequate early training, they may become useful members of society. The problem of adequately dealing with mental defect in the community involves, therefore, facilities for early diagnosis, for adequate training and for kindly and skilled supervision, when the children are later placed in the com- munity.
For early diagnosis, systematic survey of the children while at school is obviously the reasonable procedure. For those children who require institutional facilities, well run institutions with good opportunities for manual training are required. In order that, after some training, these children may be started along in the community, a corps of social service workers with good training in psychiatric social service is necessary.
The above is what I should consider a reasonable and perfectly practicable plan for the adequate management of the problem of mental defect, with its ramifications into delinquency, vagrancy, alcoholism and venereal disease. It is obvious that in this work the medical profession must take a leading part and that the medical school should be prepared, by developing adequately its Depart- ment of Psychiatry and by correlating its work with that of the Department of Psychology, to send out graduates who will do creditable work in relation to the problem we are discussing.
Yours truly, C. MACFIE CAMPBELL.
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