A Psychiatric Milestone by Various

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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 institution 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 assume 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 associated. 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 biassed 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
associated 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 assign
to the symptoms their true value or to decide whether they possess much
value at all with regard to the fundamental disturbance which
constituted 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
constituents 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.

It will possibly be of some assistance to provide one or two examples in
order to demonstrate the importance of the past experiences as agents
capable of producing such alterations.

The first case will illustrate the results produced by the development
of a dominant emotional tendency during early childhood. The patient up
to the fifth year of her life had been an ordinary, normal child,
attached to her mother, fond of her nurse, interested in her toys.
During the next two years she endured much bad treatment at the hands of
a new nurse which produced such an impression on her that she felt she
was a changed child. This nurse, described to me by the patient as a
handsome woman, having met the inevitable man, used frequently to meet
him clandestinely. The child was neglected, was sometimes left alone, on
one occasion in a graveyard, but she was forbidden to mention the
subject to any one under threats of being carried away by a "bogey-man."
The child became very frightened by this, to such an extent that one
night she had a severe nightmare in which a "bogey-man" came to carry
her away. At the end of two years a profound change had taken place in
her which she now describes thus: "I was a changed child; I was
separated from my mother and could no longer confide in her nor did I
wish to do things for her as I had done before; I could not enjoy my
toys; I had no confidence in myself; I was not like other children." And
from that time on, as girl and as woman, she has never felt that she has
been like others of her sex. Such a condition, being started and
confined by repetition, interfered with her free development and it was
remarkable how many incidents occurred in her life to confirm the
disability, but the germ of her serious breakdown thirty years later was
laid in her fifth and sixth years.

The second case is that of a patient who, as a child, had some
convulsive attacks. She was therefore considered delicate and was
thoroughly spoiled. When nearly thirty she lived through a sexual
experience which caused extreme anxiety; she broke down and was admitted
to an asylum. After admission she looked across the dormitory and saw a
head appearing above the bed-clothes, the hair of which had been cut
short for hygienic reasons. With a memory of her sexual indiscretion
still vivid in her mind she jumped to the conclusion that she was in a
place where men and women were crowded together in the same room. She
got out of bed, refused to return to it, fought against the nurses and
was transferred to a single room, with the mattress on the floor and the
window shuttered. She wondered where she was and came to the conclusion
that she was in a horse-box. Then arose a feeling of terror that she
would be at the disposal of the grooms when they returned from work. The
sound of heavy footsteps of the patients passing along the corridor to
the tea-room suggested that the grooms were returning and that her room
would soon be invaded. The feeling of terror increased and she tried to
hide in the corner, drawing the mattress and clothes over her. And so
on.

Months later when I had my first interview with her, her sole remark
during the hour was "How can I speak in a place like this?" This was
repeated almost without intermission throughout the hour. It formed a
good example of the origin of the process of perseveration, a process
frequently adopted by the patient to guard against the disclosure of a
troublesome secret.

If we attempt to trace out some of the mechanisms employed in these two
cases we shall see that in response to definite stimuli each reacted in
a manner which cannot be considered abnormal in kind. It was normal
reaction for the child to be distressed at being separated from her
mother in such a way, to be frightened by being left in the graveyard
alone, or at the threat of her being carried away by a "bogey-man" if
she dared to mention anything of the clandestine meetings to her mother.
It was not very abnormal that after her sexual experience the other
patient while still in a confused state caused by the intense emotional
condition of anxiety, should, on seeing a head with the hair cropped
short, jump to the conclusion that there was a man in a bed in the same
ward with herself, or that she should feel frightened and wish to leave
the room.

The mental activity in each case depended on mental content, that is,
memory of past experiences with their intense emotional states which
acted as the driving force and also made the recall of the experience go
extremely easy. The further developments after being placed in the
single room with mattresses on the floor and the window shuttered were
rationalizations also based on mental content, _i.e._, on the memory of
rooms somewhat similar to that in which she found herself and of the use
of such rooms. It is interesting to note also in the first case that in
her wildest delirium during an acute attack she lived through episodes
of her past life. One example may be given. In the course of her
delirium she thought that a "blackbird" had flown to her, touched her
left wrist and taken away all her vitality. This depended on an
experience of her going to Germany when a girl and meeting a young
German officer whom she did not like. A few years later she went to
Germany and met the officer again. Without going into full details I may
say that on one occasion when walking with him he seized her left wrist
with his right hand and attempted to kiss her; she struggled fiercely
and ran from him. Here we see that not only is her delirium based on a
past experience, but that the whole memory is symbolized in the
"blackbird" which was the emblem of the German nation in whose army the
officer was then serving. Connected with this there was also another
unpleasant episode which dated from her tenth year. Much of her delirium
was worked out in such a way that most of the details could be traced
back to experiences of her earlier life.

But however absurd her statement regarding her being touched by a
"blackbird" and all her vitality removed might appear to superficial
observation, it must be admitted that when we know the mental content of
that patient, we cannot but see that at any rate it was not so
irrational. And not only was this recognized by the doctor, but, and
this is much more important, by the patient herself.

It is, therefore, the mental content which must be discovered before
doctor or patient can understand the disability and before any common
ground between the two can be found. And when the mental content is
known it will be easy to recognize the affective condition of the
patient to be a normal response. It will also be specific and if intense
will dominate the patient. "Why is it I can never feel joy as I used to
do?" was the pathetic inquiry of the patient dominated by a feeling of
misery and fear. Was it not for the reason that being dominated by
misery and fear, joy could find no place? The emotion of misery because
of its intensity could more or less inhibit the feeling of joy, but joy
could not inhibit the misery.

No repetition of the memory of the unpleasant experiences with their
associated emotion of misery and fear led to the formation of a habit of
mind and feeling. And when once such a habit of mind is established it
is remarkable by what a host of stimuli received in ordinary daily life
the cause of the disturbance can be recalled.

This question of stimuli deserves further notice. It is not so difficult
to realize the mechanism by which a stimulus which clearly crosses the
threshold of consciousness can lead to a given reaction. But it is
perhaps difficult to imagine how so many stimuli which do not cross the
threshold of consciousness or which, if they do, are not recognized by
the patient at the time as having any reference whatever to the special
memory can yet set the memory mechanism into action. The result may not
be seen till after the relapse of some considerable period of time, as
in the case of a man who for years had been disturbed by terrific
nightmares, based on the idea of snakes coming out of the ground and
attacking him. He complained one day that he was much worse, that three
nights before he had had the worst nightmare of his life. On being
questioned as to what could have suggested snakes to him he could not
tell. A few minutes later he said: "I think I know the cause now. I
spent the evening before I had that nightmare with a sergeant who had
returned from the service in India." This friend amongst other things
had mentioned that whenever they were about to bivouac they had to
search every hole under a stone and every tuft of grass to see that
there were no snakes there. This, which had been received as an ordinary
item of information, had been the stimulus which had set his memory
mechanism into action and the nightmare between two and three o'clock in
the morning had been the result.

The result in many instances is evidenced by an emotional state alone
and the actual memory of the original experience may not come into
consciousness. Many examples of this might be given. The sound of a
trolley wheel on a tram wire in one case gave rise to terror instead of
its normal reaction, viz., that of satisfaction at getting to the
destination quickly and without effort. This terror was produced because
the sound on the wire resembled that of a shell which came over, blew in
a dugout, killed three men, and buried the patient. No memory of this
incident came into consciousness, only a terror similar to that
experienced at the time of the original incident was experienced. Or,
the time four o'clock in the afternoon could act as a stimulus to arouse
an emotional state of misery similar to that experienced at the same
time of day during an illness some years previously. Or, passing the
house of a doctor when on a bus could produce a sudden outburst of
anxiety, giddiness, and confusion; the patient had been taken into that
house at the time of an epileptic attack. Or, showing photographs of the
front could lead to an epileptic attack which was based on the memory of
the time when the patient was wounded in the head; this has occurred on
two separate occasions separated by an interval of some months. Or,
noticing a familiar critical tone in a remark made at a dinner-table
could lead to an acute change of feeling so that the subject who,
before dinner, had felt she would like to play a new composition on the
piano so as to obtain the opinion of the guest who had exhibited the
critical tone, after dinner felt incapable of doing so. Her feelings had
been hurt on many former occasions by critical remarks made by him in
that tone. The critical remarks were not called to memory but there
arose the feeling that under no circumstances could she play that piece
to him.

Of special importance also are the experiences of childhood. An unhappy
home or unjust treatment as a child may warp the development of the
personality, lead to a lack of self-confidence, to the predominance of
one emotional tendency, and so prevent that balanced equilibrium which
will allow a rapid and suitable emotional reaction such as we may
consider normal. This may lead to a failure of development or a loss of
the sense of value, because the existence of one dominating emotional
tendency so often produces a prejudiced view which may render a just
appreciation of our general experience almost impossible and may
seriously disturb our mental activity.

And if, as Bianchi suggests, all mental activity depends on a series of
reflex actions, or, as Bechterew and Pavlov have insisted, a series of
conditioned reflexes becomes established, it will assist us to
understand how such stimuli can give rise to mental disturbances, to
mental illnesses. We shall see that there may be something of real
importance underlying such remarks as "I felt I was a changed child"; or
"It is because of the treatment I received from my father that I have
taken life so seriously." "I have never imagined that what I went
through in my childhood could so influence me now"; or "I have never had
confidence in myself and often when I have appeared vivacious and
interested I have had an awful feeling of incapacity and dread within
myself."

The outward and obvious manifestations, therefore, are not necessarily a
true index of our mental and emotional conditions. This is true of all
mental illnesses, even the most severe.

One patient who had been in an asylum more than ten years illustrated
this in a most striking manner. His outward manifestations led one to
feel that he thought he possessed the institution in which he was
confined and also the surrounding property and that the authorities were
a set of usurpers and thieves who kept him incarcerated in order that
they might enjoy what was really his money and his property. On one
occasion I said to him, "George, what is that incident in your life
which you cannot forget and which has troubled you so seriously?" The
reply was a flood of abuse. I put the question to him several times
without getting any further answer, but when I came to leave the ward,
George came up behind me and whispered over my shoulder, "Who told you
about it?" No abuse, no shouting as usually occurred, but a whisper,
"Who told you about it?" Was not George running away from a memory with
its emotion which was unbearable to an idea which allowed him to be
angry with others instead of with himself? Many examples of this might
be given and really might be found by us in our own experience. It is
the mental content which is important, a mental content which can be
recalled by various stimuli, and which will be more persistently with us
the more intense is the emotion associated with it.

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