Physicians recommended and employed in State mental hospitals, 1940-Continued

The American Psychiatric Association recommends 1 physician for each 200 resident patients plus 1 physician for each 100 annual admissions.

2 Incomplete reporting.

Source: Patients in Mental Institutions, 1940, U. S. Bureau of the Census, pp. 14, 56, 59.

STATEMENT OF DR. GEORGE S. STEVENSON, MEDICAL DIRECTOR, NATIONAL COMMITTEE FOR MENTAL HYGIENE

Mr. PRIEST. Will you give the reporter your name and title, Dr. Stevenson?

Dr. STEVENSON. George S. Stevenson; I am medical director of the National Committee for Mental Hygiene, which is a voluntary organization concerned with the advancement of psychiatric training and research and service to the mentally ill, and the promotion of mental health.

Mr. PRIEST. You may proceed, Doctor.

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Dr. STEVENSON. Mr. Chairman, and gentlemen of the committee, the bill under consideration has been the aim for years of those concerned with mental health and has the whole-hearted endorsement of authorities in that field. My own experience offers little qualification to speak of the administrative pros and cons of a matter of this sort, so I will devote myself chiefly to its purposes and program.

Traditionally in this country psychiatric services have been almost exclusively under public auspices-first the county, then State, as counties have proved unequal to the task of providing treatment and other services beyond custody. Now we hope it will also be national in certain respects, as the States have proved unequal to the need for research, training of personnel, and prevention.

The Federal Government has already, through the Public Health Service and the Census Bureau, undertaken on a more adequate basis certain functions that we in the National Committee for Mental Hygiene formerly carried, such as the survey service to State mental hospitals, at the request of States, and the gathering of statistics on the mentally ill. Certain functions encompassed in the bill are now performed in token fashion by the National Committee for Mental Hygiene, but the limitations of private effort bespeak the assumption of training and research in a way that will more adequately meet the need quantitatively.

The importance of the field of the bill: Mental illness does not rank high as a cause of death, but looms very large as a cause of incapacitation and absorbs a large percentage of the budget of States giving adequate service to the mentally ill. In 1941 the total expenditures in the United States in State hospitals were $142,282,480. Approximately 28 percent of the cost of State government in New York State is for this field. The current total budget for New York State is $163,000,000, of which $48,000,000 is for mental hygiene services. Capital expenditures for postwar construction in this field are 9 percent of the projected total.

The inadequacy of even our huge expenditures is evidence in the fact that many States spent far below the average of $306.62 per annum per capita-with Massachusetts spending $437.47 and Kentucky $146.11. That this expenditure is inadequate is evidenced again and again in that inadequate provision-far oftener than malice has resulted in the mistreatment of patients sometimes to an extent that is uncomfortably close to the foreign atrocities with which we have been shocked.

The number of patients in institutions for the mentally handicapped is steadily increasing probably more through greater provision than through a decline in our national sanity. It now stands at about 600,000, and on any day is approximately equal to the number of patients in all other hospitals combined. This figure does not include those mentally ill who are in special wards of our general hospitals, nor does it include that vast number of nervous patients-nervous stomachs, nervous hearts, and so forth-that occupy general medical facilities but are more and more being recognized by the doctor of internal medicine as requiring psychiatric treatment.

In that connection I might at this point read a letter which I received yesterday from a professor of medicine at Cornell.

DEAR MR. STEVENSON: I am writing you concerning bill H. R. 2550 for the establishment of a national neurospychiatric institute. From the medical standpoint, no greater problem will face our country than the appropriate consideration

of neuropsychiatric disorders. It should have the highest priority in postwar planning. In addition, it is an urgent necessity that long-neglected neuropsychiatric problems receive constant study.

As an internist, I see continually the intimate relationship between physical ills and psychological and emotional disturbances. I am sure the impetus given to this work by the establishment of an appropriate agency in the Federal Government would be of lasting benefit.

You have my permission to use this letter in any way which would aid in expediting the passage of this important measure.

Sincerely yours,

Mr. PRIEST. What is Dr. Barr's title?

DAVID BARR.

Dr. STEVENSON. He is a professor of medicine at Cornell University. Mr. PRIEST. Thanks.

Dr. STEVENSON. Our institutions for mental deficiency have, by conservative estimate, one inmate for every nine mental defectives in the community, and likewise most of the nervous patients are not in hospitals but are struggling in vain to live happily and effectively with the help of doctors whose training has included little on this problem.

There are certain retardants to progress. The assumption of mental hygiene responsibility by the States is of long duration and well established. The mental hospital all too often is badly isolated. The size of the hospitals, the desire to avoid prying eyes, the need for occupation and acreage, have tended to set these hospitals off by themselves, away from community, away from other hospitals, away from research centers and from medical schools. They have for this reason not progressed as readily as they might have done, or rarely have they progressed, but only under the impetus of unusual leadership. They need an outside lift such as H. R. 2550 might give.

The status of psychiatric research: For a problem of the size indicated, the research aspects have been sorely neglected. One disease, dementia praecox, which occupies half the population of our mental hospitals, was given continuous and concerted investigation in only one place 10 years ago. At that time the Scottish rite, thirty-third degree, northern jurisdiction, adopted this as a field of interest and has made $45,000 to $50,000 available through the National Committee for Mental Hygiene for research annually. This, again, has been as nothing compared to the problem but is a Godsend compared with past effort. Foundations have been similarly generous, and many hospital and university members have given of their time without pay, but this is far from a satisfactory way of dealing with a disorder that attacks youth and so often holds him down until old age and death intervene. Another and smaller fund has been made available through the National Committee for Mental Hygiene for studies in the more important types of problems that I have referred to abovethe nervously ill in our general hospitals or in the community-socalled psychosomatic cases.

These researches should, of course, be continued, for they have a freedom that can circumvent the formalities embracing public moneys for research, but they cannot be our main reliance. Public support of psychiatric research is inescapable if we are to progress. Scientific progress fortifies all States, and so is a legitimate function of the United States Public Health Service.

What research might be undertaken under the provisions of H. R. 2550? There are some who tend to think of research at its best as

being a combined effort on a problem of the best brains obtainable. There are others who think that research at its best is the result of the free operation and implementation of the individual creative mind-the garret investigator. If one inspects carefully the contributions that have really been made heavily to human welfare, he finds that neither of these is exclusively research at its best but that both forms of research are an essential part of the productive research process. Penicillin, the discovery of the internal composition of the atom, the revelations of the hidden aspects of the psychology of man, the creation of the radio tube, are discoveries of the garret investigator who went his own way untrammeled by tradition. But the product of the garret investigator tends to be crude, unassayed, uncertain, and costly. It takes the organized processes of research to turn the products of genius into values for mankind. Research under the United States Public Health Service, through a central research institute, would tend to be an especially organized, collaborative sort, but the provisions of this bill are such that there is nothing to prevent the Public Health Service through this institute from offering a garret to the garret investigator, whether at Bethesda, at some university, or under some more humble auspices.

Should this bill become law, shall we immediately strain our thinking in order to organize projects to which these funds may be applied? That will not be necessary. Give me the record of any psychiatric patient, or even one from the fields of medicine, education, welfare, and health, and I will show figuratively that patient is crying out for a serious solution of problems at present unsolved by scientific investigation. It is not a question of whether there are problems in need of solution. It is rather to decide which ones we can tackle first and essentially which ones we can find the personnel to prosecute. For example:

Through the Social Security Act, our Federal Government is putting old age on the shelf before it is really old. This has all of the appearance and, in fact, often the realities of a pleasant respite after a life's work, but it can become just the opposite, for retirement and stagnation in the middle and late sixties is conducive to rapid decline. The Air Force has shown vividly how, when the old principle of bed rest and inactivity was supplanted by one of activity, both the period of illness and the percentage of relapse were reduced. There is incentive to apply this principle experimentally and with moderation to old-age retirement.

Our Children's Bureau has done outstanding work in behalf of the prematurely born infant, but pediatricians well know that their efforts with these babies are often neutralized by the inaptness of a parent to whom the salvaged baby has been restored. The study of parental inaptness in such cases is essentially psychiatric. It is a study that should be of value to every general practitioner in the country and of course to his patients.

Research in the field of mental deficiency, in spite of the fact that it bears heavily upon 1 percent of the population, does not fill enough pages to keep a moderately sized monthly scientific journal going, and paralleling this there is no organized provision for the preparation of personnel in this field.

Several years ago I visited 75 research centers in the field of psychiatry throughout the country. Some were extremely modest centers, but in all of these there were only two that could be said to be

carrying on a consistent research program in the field of epilepsy, and one of these two was among the more modest endeavors. These are just a few samples of what might be done under this bill. To attempt to list all of the specific projects would be an interminable job.

The status of psychiatric training: For the most part, psychiatric training has been left to chance. Periodically the National Committee for Mental Hygiene and the American Psychiatric Association have surveyed conditions and promoted improvement. Our medical schools have not begun their curriculum based upon the need as seen in the failures of medicine. If they had, psychiatry would occupy a more sizable place in the allotted time. Neither the amount nor the type of training has been adequate to prepare the average doctor to cope with the psychiatric problems that come to his everyday attention. The graduate is ill-prepared then to proceed with postgraduate training in psychiatry. He must as a rule start from scratch after his general internship by getting a residency in a mental hospital. Too often he does this not for the attractiveness of the field or of the education that will be afforded him, but because it is a job that pays fairly in money and maintenance. He is poor after 8 years of paying for tuition.

We have attempted to bring before the prospective psychiatrist a knowledge of those hospitals that will offer him real training, but the list of such is small, and our resources for visiting these hospitals and looking over their educational offerings and making contact with prospective residents is sufficient only to show what could be done with adequate resources. What I have said of psychiatrists could be paraphrased for nurses, attendants, social workers, psychologists, and other auxiliary personnel. This is crucial. This is crucial. It is crucial not only to get good treatment for these sick people but to our own national morality, which can be calloused by the neglect of such patients, and I feel strongly that we cannot now, of all times, stand for anything approaching even in miniature the atrocities which are high in our consciousness today.

Following a good residency, the budding psychiatrist may wish to give special attention to children, to court cases, to industry, to teaching, to one of a number of other special aspects of this field. In Philadelphia they have pitifully small provision for training in legal psychiatry for courts, penal and correctional institutions, but it is our total national resource. The National Committee for Mental Hygiene has 10 or so fellowships for training in child or community outpatient psychiatry, when, to meet our national problem, 200 per year would be needed. We have fellowships for refresher training and the polishing up of the brilliant lights, the potential leaders in the field$10,000 per year. Its value is in showing what can be done with such help. It does not relieve us of the almost daily demand for personnel which we cannot supply.

There is one point I think I might make here in addition, and that is that the trained personnel is not centered in the State which uses the personnel. In most instances the State which employes personnel has not entered into the training. There is really a need for a national program, rather than anything limited to one State, and I think in that respect it differs from public education.

The status of the preventive services: Under the provisions of this bill it will be possible for the Federal Government to assist in the