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By Howard Field, M.D.
In the last quarter of the 19th century American psychiatry, beset by problems, changed its scope from the management of psychotic patients in asylums to the treatment of a broad range of behavioral problems in a variety of settings. One episode in this metamorphosis under duress involved S. Weir Mitchell's address to the 1894 annual meeting of the American Medico-Psychological Association, as APA was then called.
The program committee had wanted to have an important guest lecturer for the organization's golden anniversary meeting and selected Mitchell, a world-renowned neurologist and novelist then at the apex of his fame. His book on the nerve injuries of war was accepted as a standard text at home and abroad. His novels were best-sellers. Following the study of peripheral nerve disease and cerebellar function, he had turned his attention to neurasthenia and hysteria , originating a method of treatment that involved strict bed rest, massage, and a diet of milk. The Mitchell "rest cure" had gained adherents throughout the world.
In his address Mitchell unleashed a stinging barrage. After giving credit to the members for merciful treatment of the insane, he stated that they had fallen behind other medical specialists in knowledge. They had produced no real scientific investigations or publications; adding, "Want of original work [is] the worst symptom of torpor in the asylum. . . . No texts or teaching" had come from the asylum. Case records were inferior to those of general hospitals; patients did not receive physical examinations or discharge instructions. There were no labs, no nurses' training schools. Mitchell felt that isolation in remote locations and lack of clever rivals to criticize or resident physicians to question was stultifying to the specialty. Managing boards were of no help. In state institutions they were appointed by the political spoils system; in private asylums they were self-perpetuating clubs. Physicians were appointed by favoritism, not ability. Once appointed, the superintendent was an absolute ruler in his institution.
Mitchell felt it "wrong to attempt both medical care and business management of the asylum. . . . [I]nsist you are physicians and no more." He added a familiar ad hominem slur: "The cloisteral lives you lead give rise, we think, to certain mental peculiarities." He attacked the very basis of the specialty, saying, "The idea that only the alienist can treat mental illness is wrong. . . . [We] lament the day when the treatment of the insane passed out of the hands of the [medical] profession at large." He went on to strike at the heart of asylum care: "Asylum life is deadly to the insane. . . . [It] should be a last resort, not first."
At the time of Mitchell's speech, asylum psychiatry was under attack because of both public dissatisfaction and professional skepticism. At the same time, the new medical specialty of neurology had arisen, based in part on work by Mitchell and others with patients who had peripheral nerve injuries from war. Neurologists were eager to take over the treatment of the mentally ill from asylum superintendents, whose psychological treatment methods they regarded as hopelessly unscientific.
Mitchell's speech, however, was not the beginning of this struggle, which had been going on for several decades. By the time of Mitchell's address, the bare-knuckle boxing match between psychiatry and neurology had begun to look more like a sedate waltz (with occasional stepped-on toes). Mitchell's speech was remarkable not for its harsh criticism-others had been far more insulting-but for the fact that he was invited by the very group he was criticizing. Those who asked him to speak knew what to expect. His speech represented both a token of change and a lever to force more of it.
In the last quarter of the 19th century, psychiatry, confronted by the choice between change and extinction, began to alter. The organization, at one time restricted to superintendents, admitted other physicians to membership. The name of the organization was changed in 1892. Modest efforts at research began in the more progressive state hospitals. The field split between biological and psychological concepts and remedies and broadened its scope to include novel conditions, such as neuroses and the problems of everyday life, as psychiatrists moved outside the asylum walls to "psychopathic" hospitals and outpatient settings.