The Internist, the Neurologist and the Psychopathologist.
Hitherto, the function of the internist has been to study especially the structure of the modes of reaction of the several component systems of the patient by physical and chemical methods, laying much emphasis upon the fact that anatomical structure and physiological processes are subject to physical and chemical laws. Some attention to the behavior and to the mental experiences of the patients the internist has given, it is true; but the anamnesis of most internists are richer in data regarding intoxications, infections and traumata than in data pertaining the psychobiological reactions, to mental trends, to affective-conative states and to familial and social situations. It is gratifying that some internists are becoming alive to the importance of an all-round study of the patient as a whole. On professor of internal medicine (F. Kraus) has recently written a volume of the “General and Special Pathology of the Person,” or what he calls “clinical syzygiology”.
The neurologist, in turn, has directed his attention especially to the phenomena of motility, sensibility, reflex activity and to changes that are discoverable in these in patients. In the course of his studies. however, he has found himself in a borderland between inner medicine on the one hand and psychiatry on the other. The neurologist and especially the neuropathologist has done much to build a bridge one domain to the other, especially by his studies of the aphasias, the agnosias and the apraxias and of the cerebral pathology underlying them.
The psychiatrist has made a special study of the abnormal mental states of patients; the special direction of his investigations has been toward the psychic rather than toward the somatic side of the “person” that he sees as patient. But the newer psychiatry, in struggling to understand the nature and genesis of abnormal mental states, has departed from the traditional paths of academic psychology and has formed an alliance with “objective psychology” and with general biology.
The modern psychopathologist studies human behavior in general, and interests himself especially in the phenomena of maladaptation of the person as a whole to his environment. He inquires into what he calls the “concrete assets of the person,” observes his performances of biological adaptation, and scrutinizes his methods of coping with emergencies. In his diagnostic inquiries he pays attention to non-mental as well as to mental factors; and in his therapy the attempts to help the patient to better readjustment of his conflicts, his inhibitions, his overexcitations, of his fixations by educating him and by controlling his environment.
Team-Work in Medical Practice.
The knowledge and technique necessary for the thorough study of a (psychophysical) person as a whole has become so complex that it is now beyond the power of a single physician to attain to mastery of all parts of it. The complete analytical and synthetic study of a person, a psychophysical individual, by modern clinical methods demands (1) examinations by experts in the study of the several component bodily systems (respiratory, circulatory, digestive, uro-genital, locomotor, neural, endocrine), (2) technical studies of the biography with special reference to the assets and deficiencies of the associated personality; and (3) an integration of the results of the various examinations into a diagnostic whole that is properly co-ordinated and subordinated. By such a thorough survey only can the modes of reaction of the phenotype or “realized person” be as satisfactorily recognized and the hereditary and environmental factors be as fully appreciated as the present state of clinical knowledge and technique make possible.
That the neuropsychiatrist can be most helpful in contributing to such a comprehensive study, which tries to ascertain (1) the main characters of the genotype or inherited psychophysical mechanism, and (2) the modifications resulting from the patients life experiences and manifest in the present phenotype, goes without saying. For it is the neuropsychiatrist, especially, who consciously makes use of the conception of adaptation or adjustment to internal and external needs. He, more than other members of the diagnostic team, should be familiar with inheritable instinctive tendencies and with the cognitive, affective and conative aspects of the instincts.
He has had, too, in his work, opportunity to learn the kinds of reaction that are common when adaptations are faulty and adjustments are difficult. And when he examines a patient, he tries to ascertain the special forms of psychobiological reactions that he manifests, and to detect the different varieties of imbalance he exhibits. Through ventilative discussions of difficulties with the patient and with the patients family and by means of special inquiries into the role played by situations, he can often account for many of the patients special experiences. He discovers that habits that the patient has formed, whether good or bad, and the various unwholesome attitudes of associates (parents, teachers, comrades ) to which he has been exposed. In all these ways, the
neuropsychiatrist helps to accumulate anamnestic data that can be helpful in diagnosis.
When the results obtained through the examinations of internists, of various medical and surgical specialists, of neurologists and psychiatrists have been collected and arranged, the data can then be critically examined with reference both to the endogenous and the exogenous factors that have been responsible for the production of the special phenotype (or realized person) that the patient represents. It should then be possible to plan a therapy that will pay due attention to the physical, chemical, psychical and situational measures that will most favorably modify the person in the direction of adequate adaptability. In the present state of diagnosis, the knowledge we can gain of a person as a whole is but fragmentary, but we shall work with greater confidence if we are sure that our studies are properly directed.
