A Psychiatric Milestone Part 3

Modern Hospital, XIV, 197, Chicago, 1920.]

_The Chairman_: We had hoped to receive to-day the greetings of our sole elder sister among American inst.i.tutions, the Pennsylvania Hospital, of Philadelphia, which since its foundation in 1751 has pursued a career much like our own, treating mental cases in the general hospital from the very beginning, and since 1841 maintaining a separate department for mental diseases in West Philadelphia. Dr. Owen Copp, the masterly physician-in-chief and administrator of that department, was to have been here, but unfortunately has been detained. Our morning exercises having come to an end, Dr. Russell asks me to say that your inspection of the occupational buildings and other departments of the Hospital is cordially invited; a pageant ill.u.s.trative of the origin and aspirations of the Hospital will be given on the adjoining lawn; and that after the pageant our guests are desired to return to the a.s.sembly Hall, where we shall have the privilege of listening to addresses by Dr.

Richard G. Rows, of London, and Dr. Pierre Janet, of Paris, who have come across the Atlantic especially to take part in this anniversary celebration.

ADDRESS BY DR. GEORGE D. STEWART

[Ill.u.s.tration: BLOOMINGDALE ASYLUM

As it appeared in 1894 when it was discontinued and replaced by Bloomingdale Hospital at White Plains, New York.]

AFTERNOON SESSION

_The Chairman_: For the first seventy-five years of its existence the New York Hospital was the nearest approach to an academy of medicine that the city possessed. When the now famous New York Academy of Medicine was established in 1847, a friendly and cordial co-operation between the two inst.i.tutions arose, and while the activity of this co-operation is not as p.r.o.nounced as it was, we still cherish in our hearts a warm regard for that ancient ally in the cause of humanity. Its President, Dr. George D. Stewart, the distinguished surgeon, has come to extend the greetings of the medical profession of New York City.

DR. STEWART

The emotions that attend the birthday celebrations of an individual are often a mixture of joy and sadness, of laughter and of tears. In warm and imaginative youth there is no sadness and there are no tears, because that cognizance of the common end which is woven into the very warp and woof of existence is then buried deep in our subconscious natures, or if it impresses itself at all, is too volatile and fleeting to be remembered. But as the years fall away and there is one less spring to flower and green, the serious man "tangled for the present in some parcels of fibrin, alb.u.min, and phosphates" looks forward and backward and takes in both this world and the next. In the case of inst.i.tutions, however, the sadness and the tears do not obtain--for a century of anniversaries may merely mean dignified maturity, as in the case of Bloomingdale, with no hint of the senility and decay that must come to the individual who has lived so long. This inst.i.tution was founded one hundred years ago to-day; the parent, the New York Hospital, has a longer history. Bloomingdale, as a separate and independent concern, had its birthday a century ago.

It is curious to let the mind travel back, and consider what was happening about that time. Just two years before the news had flashed on the philosophical and scientific world that Oersted, a Danish philosopher, had caused a deflection of the magnetic needle by the pa.s.sage near it of an electric current. The relation between the two forces was then and there confirmed by separate observations all over the civilized world. This discovery probably created more interest at that time than Professor Einstein's recent announcement which, if accepted, may be so disturbing to the principia of Newton and to our ideas of time and s.p.a.ce. There can be no doubt that the practical significance of Oersted's experiment was much more widely appreciated than the theory of Einstein, for an understanding of the latter is confined, we are told, to not many more men than was necessary to save Sodom and Gomorrah. Its immense practical significance, however, could have been foreseen by no man, no matter with what vision endowed. Just two years prior to the founding of this inst.i.tution the first steamboat had crossed the Atlantic and in the same year that great conqueror, who had so disturbed the peace of the world which was even then as now slowly recovering from the ravages of war, breathed his last in Saint Helena, yielding to death as utterly as the poorest hind.

In 1815, Bedlam Hospital in South London was converted into an asylum for the insane who were at the time called "lunatics." The name Bedlam is a corruption of the Hebrew "Bethlehem"--meaning the House of Bread--and while the name popularly came to signify a noisy place it was the beginning of really scientific treatment for the tragically afflicted insane. While the treatment of the insane in Europe was being steadily raised to a higher plane of efficiency, America has also reason to be proud of her record in this respect. During all the years that have followed, Bloomingdale has been an important factor in the medical world of New York.

There are two phases of its existence which might be emphasized--first, it was founded by physicians; even then and, of course, long before doctors had proven that they were in the forefront in the promotion of humanitarian activities. Medicine has always carried on its banners an inscription to the Brotherhood of Man. It is worthy of note that when Pinel and Tuke had begun to regard mental aberration as a disease and to provide scientific hospital treatment therefor, American physicians, prepared by study and experimentation, were ready to accept and apply the new teachings.

A second phase of great importance is that inst.i.tutions like Bloomingdale have promoted the study of psychology far more than any other factor, particularly because in them the personality stripped of some of its intricacies, the diseased personality, permits a.n.a.lysis, which the normal complex has so long defied. That it is high time that mankind was undertaking this knowledge of himself is particularly emphasized by the unrest and aberrance of human behavior now startling and disturbing the whole world. If mankind does not take up this self study as Trotter has said, Nature may tire of her experiment man, that complex multicellular gregarious animal who is unable to protect himself even from a simple unicellular organism, and may sweep him from her work-table to make room for one more effort of her tireless and patient curiosity. Psychology should be taught to every doctor and to every lettered man.

Digressing for a moment, to every one capable of understanding it, there should be imparted a knowledge of that simple economic law announced from the Garden of Eden after the grounds had been cleared and the gates closed: "By the sweat of thy brow thou shalt earn thy bread." The economic phase indeed const.i.tutes a highly important aspect of modern psychology, for abnormal elements are antisocial, and from pickpockets to anarchists flourish on the soil of pauperism. The key-note of the future is responsibility. To the educated and enlightened man who still asks, "Am I my brother's keeper?" Cain has bequeathed a drop of his fratricidal blood; and he who spurns to do his share of the world's work, electing instead to fall a burden upon the community, deserves the fate of the barren fig-tree.

However, amidst the social unrest, buffeted and perplexed by the cross currents of our time, we should not be pessimistic but should look forward with courage, parting reluctantly with whatever of good the past contained and living hopefully in the present. As Ellis says: "The present is in every age merely the s.h.i.+fting point at which past and future meet, and we can have no quarrel with either. There can be no world without traditions; neither can there be any life without movement. As Herac.l.i.tus knew at the outset of modern philosophy, we cannot bathe twice in the same stream, though as we know to-day, the stream still flows in an unending circle. There is never a moment when the new dawn is not breaking over the earth, and never a moment when the sunset ceases to die. It is well to greet serenely even the first glimmer of the dawn when we see it, not hastening toward it with undue speed, nor leaving the sunset without grat.i.tude for the dying light that once was dawn."

So to-day I bring to you from the New York Academy of Medicine felicitations on your one hundredth anniversary and greetings to your guests who have come from all over the world to join in your birthday celebration.

ADDRESS BY DR. RICHARD G. ROWS

_The Chairman_: Besides the Royal Charter, the New York Hospital is indebted to Great Britain for invaluable encouragement and financial aid in our natal struggle in Colonial days. Dr. Rows has added charmingly to that debt by journeying from London to take part in these exercises. His subject will be, "THE BIOLOGICAL SIGNIFICANCE OF MENTAL ILLNESS."

As Director of the British Neurological Hospital for Disabled Soldiers and Sailors, at Tooting, he is giving the community and the medical world the benefit of his rich professional experience in the trying years of war as well as in peace, and gaining fresh laurels as he marches, like Wordsworth's warrior, "from well to better, daily self-surpast."

DR. ROWS

I must first express to you my keen appreciation of the high honor you have conferred on me by inviting me to come from England to address you on the occasion of the centenary celebration of the opening of this Hospital.

It is perhaps difficult for us to realize what resistances lay in the way of reform at that time, resistances in the form of long-established but somewhat limited views as to the nature of mental illnesses, as to whether the sufferer was not reaping what he had sown in angering the supreme powers and in making himself a fit habitation for demons to dwell in; in the form of a lack of appreciation of the need of sympathy for those who, while in a disturbed state, offended against the social organism or in the form of an exaggerated fear which compelled the adoption of vigorous methods of protecting the social organism against those who exhibited such anti-social tendencies. The men and women of the different countries of the world who recognized this and made it the chief of their life's duties to spread a wider view of such conditions and to insist that the unfortunate people should be regarded and treated as fellow human beings will ever command our admiration.

By the courtesy of Dr. Russell I have had an opportunity of seeing the pamphlet in which are recorded the efforts of Mr. Thomas Eddy in the year 1815 to move his colleagues to consider this matter.[13] The result of those efforts was the establishment of an inst.i.tution on Bloomingdale Road.

Various changes followed until we arrived at the Bloomingdale Hospital of to-day with its large and trained staff of medical officers, who, while still recognizing the difficulties of the task, are imbued with a hope of success which has arisen on a basis of wider knowledge, but which was unknown to many of their predecessors. To have the opportunity of joining with you in celebrating the big advance made a hundred years ago, of exchanging ideas with you with regard to the difficulties which still confront us, whether in America or in England, and which demand a united effort on the part of all who are interested in the scientific investigation of the subject, cannot fail to afford one the liveliest satisfaction.

In the brief history of the Hospital prepared by Dr. Russell we find the recommendations of another reformer, Dr. Earle, who in 1848 was evidently still not satisfied with the treatment provided for the sufferers from mental illness.

Both Mr. Eddy and Dr. Earle were influenced by their observation that even in those suffering from mania much of their behavior could not be described as irrational. If you will allow me I will quote a sentence of two from each.

Mr. Eddy said: "It is to be observed that in most cases of insanity, from whatever cause it may have arisen or to whatever it may have proceeded, the patient possesses small remains of ratiocination and self-command; and although they cannot be made sensible of the irrationality of their conduct or opinions, yet they are generally aware of those particulars for which the world considers them proper objects of confinement." With reference to treatment Dr. Earle said: "The primary object is to treat patients, so far as their condition will possibly permit, as if they were still in the enjoyment of the healthy exercise of their mental faculties."

To superficial observation these suggestions might well have appeared as the phantasies of dreamers and perhaps at the present day their importance is not always fully appreciated. Recent advances in knowledge, however, have led us beyond the moral treatment recommended a hundred years ago and have enabled us to see that a more important truth underlay these suggestions.

We are all familiar with the frequent difficulty we encounter in our efforts to discover the actual mental disturbance which is supposed to exist in our patients. It is often a question of wit against wit as between patient and doctor, and not infrequently a rational and intelligent conversation may be maintained on an indifferent subject.

The fact too that the disturbance is so frequently only temporary suggests that the loss of rational control is a less serious phenomenon than was generally supposed and we know that the control can be frequently restored by a period of rest or by a helpful stimulus. Quite recently a patient who in hospital had been confused, undisciplined, abusive, and threatening, was removed to a house of detention. The shock of finding himself, as he said, amongst a lot of lunatics, led him to face reality from a fresh point of view. He admitted that it had taught him a lesson and when he revisited the hospital, if not entirely grateful to us for the experience, he evidently bore no ill will.

But not only is it necessary to recognize what rational powers remain to the patient, we must also inquire how much in their disturbed mental activity can be considered a rational reaction to the stimuli which have operated, and still may be operating, on them.

In connection with this I would suggest that there are two aspects to be considered. First, what is the standard according to which we are to judge them? Secondly, to what extent are the reactions of the patient abnormal in kind to the driving stimulus? They may perhaps be reckoned abnormal in degree, but, to what extent, if at all, are they abnormal in kind?

It may be readily admitted that the behavior of those suffering from mental illness offends against conventional usages and is anti-social.

It must also be recognized that amongst human beings living in aggregates some conventional usages must be evolved and insisted on in order to insure the greatest good of the greatest number. These usages are regarded not merely as protective measures for the body corporate, but they are also supposed to indicate a beneficial standard for the individual. But such a standard being adopted, observation is liable to be limited so much to results without sufficient attention being given to the causes which had led to those results.

By the recent advances in scientific knowledge and in methods of investigation we have been led to see that the conditions under consideration cannot be understood without a study of the mechanisms on which mental activity depends and without discovering the psychic and physical causes, arising from without and from within, which have disturbed the function of these mechanisms. We have learned that these illnesses do not arise from one cause alone and that they are the result of influences to which we all may be subject to some degree.

The originator of these modern methods, Prof. Freud, has stimulated us to regard the ordinary symptoms of mental illnesses as directing posts indicating lines to be investigated, and he and others have suggested various methods which may usefully be employed.

It is essential that we carefully distinguish what are primary from what are secondary symptoms. Two thousand years ago a physician, [Transcriber's note: original reads 'physican'] Areteus, pointed out that mania frequently commenced as melancholia, and he drew attention to the extreme frequency of an initial depression in cases of mental illnesses. But he did not offer any explanation of this initial state.

Such an initial state may perhaps be, to a certain extent, understood if we a.s.sume that the first evidences of mental disturbance consist in some difficulty in carrying out ordinary mental processes, some difficulty in exercise of the function of perceiving, thinking, feeling, judging, and acting, and that any disturbance of the harmonious activity of these functions must give rise to an emotional condition of anxiety and depression. Some such disharmony will, by adequate investigation, be found in a large number of cases to exist in the early states of the illness and will be appreciated by the patient before there occur any obvious signs, any outward manifestations of disability.

But in any disharmony which may occur it must be recognized that the mental mechanisms affected are those with which the patient was originally endowed, which he has gradually trained throughout his past experience and which he has employed more or less successfully up to the time the illness commenced. There is no new mechanism introduced to produce a mental illness, but a putting out of gear of those common to the race and their disturbance is the result of the action of influences which may befall any one of us, unbearable ideas with which some intense emotional state is intimately a.s.sociated. The normal function of these mechanisms, simple at first and remaining fundamentally unaltered, although possibly much modified gradually by added experiences from within and without, depends on the maintenance of a harmonious balance between stimuli received and emotional reaction and motor response to those stimuli so that the feeling of well-being may arise.

If from any cause there occurs a failure to appreciate the stimuli clearly, if the emotional reactivity be disturbed, if the sense of value becomes bia.s.sed in one direction or another so that the response is recognized by the patient as abnormal there will result a disharmony and a feeling of ill-being of the organism. Under these conditions the processes of facilitation along certain definite lines and inhibition of all other lines--processes which are essential to clear consciousness--will become difficult or perhaps impossible and a mental illness will develop. In the slighter degrees the disharmony may be known to the patient without there being any outward manifestation to betray the conflict going on within. In the severe degrees the mental activity of the patient may be under the control of some dominant emotional state so that it may be impossible for him to adapt himself to his surroundings in a normal manner although his behavior may not appear so irrational when we know the stimuli affecting him. Within these extremes we discover all degrees of disturbance, and all varieties of signs and symptoms may be encountered.

But the signs which become obvious to superficial observation are, to a large extent, secondary products. The primary symptoms are felt by the patient as a disturbance of the capacity to perceive, to think, to feel, to judge, and to act, and with these disabilities there will be a.s.sociated a certain degree of confusion and anxiety which cannot fail to appear as the result of such alterations of function.

The obvious signs may represent merely a more intense degree of the primary affection, disturbed capacity together with some confusion and anxiety; or they may represent efforts on the part of the patient to overcome or to escape from the disturbance or to explain it to himself.

And now the total lack of knowledge of the processes on which mental activity depends, the altered standard of judgment due to some degree of dissociation, and the necessity of obtaining relief in some way or other will have much to do with determining the character of the symptoms with which we are all familiar. So many factors are concerned in the production of these secondary characters that it is difficult to a.s.sign to the symptoms their true value or to decide whether they possess much value at all with regard to the fundamental disturbance which const.i.tuted the primary illness. So often they appear to be mere rationalizations, mere false judgments on the part of the patient; they thus form subjects for investigation rather than fundamental const.i.tuents of the illness.

We, therefore, must not accept the outward and visible signs at their face value but attempt to discover what past experiences in the life of the patient have led to such disturbance of function, to such a change in his mental activity.