Read at the Annual Meeting of the Medical Society of the State of New York, at Albany, April 18, 1922.
As a rule, the time of medical society meetings is best occupied by reports of concrete experiences in the study of single patients or of groups of patients and in the description of new methods of diagnosis and therapy and the recital of the results of their application. But, on occasion, it may be worth while to admit to the program of paper that deals with more general considerations merely in the hope of stimulating thought or investigation. With the latter object in view, I have chosen for my topic, “The Neuropsychiatrist and the Study of a Person as a Whole”.
Aims of Medicine
Medicine, as science and art, has as its object the acquisition of knowledge concerning health and disease and the practical application of that knowledge to the preservation of health and the prevention of disease, to the cure or to the arrest of disease when it develops, and to the amelioration of the suffering of persons who may be attacked by disease, whether curable or incurable. Medicine keeps in view the ideal of human beings possessed of an abounding vitality, endowed with capacities compatible with the leading of personally happy and socially serviceable lives, persons able to adapt themselves satisfactorily to their environment. That this goal is a distant one, everyone knows.
That medicine will ever reach the goal is improbable. That it is making strides toward it, however, is certain and gratifying. Neuropsychiatrists, like other specialists and like general workers, desire to contribute their share to progress toward the ideal.
Man, the Most Complex of Integrates.
Of all the co-ordinated systems of activities in the world, the most complex is that of living man. Nor is there any study more difficult than that of man. The study of the ether and of electrons is abstruse enough to occupy all the energies of the physicist. The study of atoms and of molecules, with utilization of the knowledge concerning electrons that the physicist supplies, provides work throughout his life for the chemist. The biologist, in turn, makes use of the knowledge that physicists and chemists supply in his study of the simpler and the more complex biointegrates that we call “living organisms.”
Finally, the physician studies man, the highest and most complex of all living creatures, applying the knowledge and technique of the physicist, the chemist supply in his study of the simpler and the more complex biointegrates that we call “living organisms.” Finally, the physician studies man, the highest and most complex of all living creatures, applying the knowledge and technique of the physicist, the chemist and the biologist to the solution of his problems.
The neuropsychiatrist, in particular, has to deal with the structure and functions in health and in disease of the most highly organized part of man, namely the multi-neuronic integrate known as the nervous system; the object that he studies is the most complicated of mechanisms. The task that he has set for himself might well appeal a Titan. When the neuropsychiatrist realizes the double nature of his problem, the study of nervous systems on the one hand and the study of conscious personalities on the other, he must be deeply impressed both with his difficulties and his responsibilities. The neuropsychiatrist, perhaps more than other medical men, is well prepared to understand and to appreciate the significance and the difficulties attendant upon the study of “a person as a whole”.
Biological View of Man.
Medical men have been so intent upon the study of symptoms and signs, upon the establishment of clinical syndromes, upon improving classifications of disease, upon investigation of the origin of various forms of injuries to man, and upon devising new methods of diagnostic exploration, that they have, to some extent, lost sight of the larger, biological conceptions of man.
They have been so interested in the structure and functions of the component parts of man, that they have neglected man as a whole organism. The integrated, psychophysical person is something more than the mere summation of his component parts.
Biology herself has, in recent years, entered upon a new epoch. In the nineteenth century, she devoted herself to the study of the most important biological research has been that which has investigated the origin of individuals (Conklin). Experimental studies of heredity and of development have thrown much light on this problem and the knowledge acquired is rapidly changing opinions regarding to personality of man, regarding human behavior, and regarding race betterment. Man is coming to recognize not only that development may be controlled but that also heredity is subject to definite natural laws,a knowledge of which may be turned to racial profit. Evolution is becoming, to a certain extent, a self-conscious process.
Genotype and Phenotype.
A person, say a patient, entering a physicians office, is the resultant of reactions between two sets of factors, or causes, the first set being those represented by the “zygote,” or organization resulting from fusion of the germ plasm of the sperm cell with that of the ovum, the second set being those represented by all other influences or conditions. We refer to the first set as hereditary or constitutional factors; to the second set as environmental influences. The germinal makeup, composed of a complex of “genes,” is known as the genotypic constitution, or, briefly, as the genotype. What will develop out of this genotype depends, first, upon the structure and potentialities of the genotype itself, and, second, upon the influences (external to it) with which it reacts. The realized person that is the resultant of reactions between the genotype and its environment is known as the phenotype (Johannsen).
Thus a given genotype in contact with an environment gives rise, as development proceeds, to something that is ever changing. The genotype determines, in general, the modes of reaction of the organism; its constituent factors are responsible for the direction and guidance of the development.
The actual reactions that occur depend also, however, upon the environment that the genotype meets. The genotype is the original whole; the succeeding stages of development are secondary wholes, modifications of the original whole dependent has and the qualities of mind that he exhibits are both resultants, in the determination of which hereditary influences and environmental influences have been so-decisive factors.
The behavior of the person as a whole, his psychical and physical manifestations, are evidences of continuously disturbed vital equilibria. What we know as “adaptation” is change of equilibrium corresponding to a new situation. In the more adequate pheno-types the successive changes of equilibria, or readjustments, favor self-preservation, race continuance and race elevation. In the less adequate phenotypes, they may result in self injury, may tend to race extinction or may lead to social harmfulness. What we call good behavior or good conduct of a person is that by which the “self” is realized in the service of “society”.
Physical and Psychical.
Viewed from the biological standpoint, the physical aspect and the psychical aspect of the person are equally interesting. The neuropsychiatrist desires to know as much as he can both of the bodily makeup of the person and of his mental personality, for the structure of functions of the bodily organs on the one hand and the characteristics of the associated personality on the other are determined by reactions between the genotypic constitution and the extrinsic stimuli that act upon it. Whether we pay attention in a given instance more to the psychical manifestations or more to the physiological processes depends upon the mode of investigation that we wish to employ at the moment.
Every patient is a unique, human individual. No other person precisely similar physically or psychically has ever existed, or ever will exist. This singularity of the patients.
body and mind should be kept ever in view. A differential anthropography has to deal with processes and conditions that are peculiar to the psychophysical individual.
If we study the reactions between the phenotype and its environment, and pay attention especially to those that differentiate it from other phenotypes, we get clues to the general laws to which the particular individual is subject. Though the genotypic constitution has been fixed at the beginning and decides the general direction of the psychophysical reactions, nevertheless, the organic sub-stratum is undergoing constant change; owing to reactions with the environment and in the behavior of the person there will be recognizable not only marks of genotypic source but also marks of environmental source. Each single patient has its own special ways of establishing equilibria between himself and the environment. Only by keeping these biological facts in mind shall we make progress in the direction of the development of our knowledge of the pathology of constitution.
