A Psychiatric Milestone by Various

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A very great number of phenomena observed in neuroses and psychoses are
in connection with depression and agitation. Convulsive attacks, diverse
fits of agitation, prove to us that before the fit there existed
disproportion between the quantity and the tension of the psychological
forces, and that the spending of forces during the fit re-establishes
the equilibrium. But at the same time, after this spending, one observes
a notable lowering of the mental level, a real psycholepsy. It is very
likely that studies of this kind will produce some day the key of the
epilepsy problem, for vertigos and certain epileptic fits are certainly
phenomena of relaxation, the meaning of which we do not comprehend
because we do not study sufficiently the state of psychological tension
before and after the accidents.

The difficulty of accomplishing superior acts, the exhaustion resulting
from their accomplishment, renders them fearful to the patient who has
the fear, the phobia of these acts, just as he has the terror of that
depression which gives the feeling of the diminution of life. The
shrinking of activity and conscience, phobias, negativisms, generally
take their starting point in this fear of exhaustion caused by some
difficult action. In other cases the patient feels incapable of
accomplishing correctly the reflected acts necessary to social and moral
life, and feeling no longer protected by reflection, he is afraid of
willing or believing something, as one is afraid of walking in a
dangerous path, when one cannot see. The vertigo of life produces itself
like the vertigo of heights, when one is not sure of oneself.

Depressed patients have felt, wrongly or rightly, a certain excitation
after a certain action. Through some curious mechanism, certain acts,
instead of exhausting them, have raised their psychological tension. The
need, the desire to raise themselves inspires them with the wish to
renew such acts, and we behold the impulsions to absorb poisons,
impulsions to command, to theft, to aggression, to extraordinary acts,
varied impulsions which play a great part in psychoses as well as in
neuroses.

I shall not insist any more on a very interesting phenomenon in
connection with the oscillations of the mind and which still plays a
great part in these diseases. I am speaking of the change of feeling
which may accompany the same action in the course of the oscillations of
the mind. At the level with the reflected action, more or less complete,
the thought of an action which appears important and of which one often
thinks, determines interrogations, doubts, scruples. If the individual
descends one degree, if he becomes quite incapable of reflecting and
therefore of doubting, the same action he continues to think about may
present itself under the form of an impulsion more or less irresistible.

There are patients who in the first stage have the fear and horror of
committing an act and who in the second stage are driven to accomplish
it. In other cases a subject may make use of an action as a means of
exciting and raising himself; he seeks it, and the thought of this
action is accompanied by love and desire. Let him become depressed and
he will no longer be able to accomplish this same action without
exhausting himself; he is then reduced to dread it and take an aversion
to it. That which was an object of love becomes an object of hatred.
Thence these turnings of mind that are so often to be observed in the
course of neuroses and psychoses. In a score of my observations the
frenzy of persecution and hatred presents itself as an evolution of
those obsessions of love and domination.

These are very curious facts that one observes in the oscillations of
the mind, in particular when the psychasthenic depression becomes more
serious and transforms itself in psychasthenic delirium, which is more
frequent than one generally imagines. As a rule the properly so-called
psychasthenic has only disorders of the reflection; he doubts but he
does not rave. But under different influences, his depression may
augment, and when he drops below reflection he has no longer the doubts,
the hesitations, he no longer shows manias of love and of direction, he
transforms his obsessions into deliriums and often his loves into
hatreds.

These are a few examples of the perturbations of conduct common to
neurotic sufferers and the diseased in mind. One perceives that the same
laws relating to the diminution of force and the lowering of the
psychological tension intervene in the same way with the one as with the
others. The distinctions, which have been established for social reasons
and practical conveniences, no longer exist when one tries to find, by
analysis of the symptoms, the nature of neuroses and psychoses.

The latter reflection shows us, however, that in certain cases, at
least, there is a certain difference in degree between neuroses and
psychoses. The evolution of the human mind has been formed by degrees,
by successive stages, and we possess in ourselves a series of superposed
layers which correspond to diverse stages of the psychological
development; when our forces diminish we lose successively these diverse
layers commencing with the highest. It is the superior floors of the
buildings that are reached first by the bombardments of the war and the
cellars are not destroyed at first; they acquire even more importance,
as people are beginning to inhabit them. Well, according as the
depression descends more or less deeply, the disorders which result from
the loss of the superior functions and the exaggerated action of the
inferior ones become more and more serious and are appreciated
differently. The superior psychological functions are, in my opinion,
experimental tendencies and rational tendencies. They are tendencies to
special actions in which man takes in account remembrances of former
acts and of their results, in which he enforces on himself by a special
effort obedience to logical and moral laws. A little fatigue and a
slight degree of exhaustion are sufficient for such an action to become
difficult and impossible to prolong for a long time. Furthermore, the
disorders of the experimental conduct or of the rational conduct are
very frequent. These disorders only reach the superior actions which are
not absolutely necessary to the conservation of social order. They can
be easily repaired by inferior acts: if the man does not obey pure moral
principles, at least he can conduct himself in appearance in an
analogous manner through fear of the prison. Also, these disorders of
the superior functions are considered as slight; they are called errors,
or faults, and it is admitted that the subjects remain normal beings.

At the other extremity of the hierarchical series of tendencies the acts
are simply reflex. When the disease descends to this level, when the
elementary acts can no longer be executed correctly, we do not hesitate
either, and we consider these disorders (related with known lesions) as
organic diseases of the nervous system. But between these two terms we
note disorders in behavior which are more difficult to interpret. These
disorders are too grave and too difficult to modify by our usual
processes of education and punishment for us to consider them as mere
errors or as moral faults; they are variable; they are not accompanied
by actually visible lesions and we have trouble in classing them among
the acknowledged deteriorations of the organism. There is the province
of neuroses and psychoses, intermedium between that of rational errors
and that of organic diseases of the nervous system. It corresponds to
the disorders of medium psychological functions, to the group of these
operations which establish a union more or less solid between the
language and the movements of limbs and which give birth to our wills
and beliefs.

Can one establish, in this group, a distinction between neuroses and
psychoses that rests on some more precise notion and that is not limited
to distinguishing them in a legal point of view? A more profound
knowledge of the mechanisms of the will and belief would perhaps permit
us to do so. We are capable of wills and beliefs of a superior order
when we reach decision after reflection. The operation of reflection
which hinders tendencies and maintains them in the shape of ideas, which
compares ideas and which only decides after this deliberation,
constitutes the highest form of the medium operations of the human mind.
Lower, still, there exists will and belief, but they are formed without
reflection, without stoppage of ideas, without deliberation; they are
the result of an immediate assent which transforms verbal formulas into
wills and beliefs as soon as they strike the attention, as soon as they
are accompanied by a powerful sentiment. The immediate assent is the
inferior form of these tendencies.

If one wished to establish a scientific distinction between neuroses and
psychoses, I should say, in a summary fashion, that in neuroses the
reflection alone is disturbed, that in psychoses the immediate assent
itself is affected. The shrinkage of the conscience, doubts, aboulias,
obsessions, scruples are always disorders of the reflected will and
belief. On the contrary, irresistible impulsions, deliriums,
indifferences which suppress desires and only allow elementary
agitations to subsist, show alterations in the immediate assent, in the
will, and the primitive belief and must be considered as psychoses.
Below could be placed the disorders of elementary intelligence, the
disorder of the perceptive and social functions which characterize the
mental deficiencies of imbeciles and idiots. One might also distinguish
these disorders according to the degree of depth the destruction of the
edifice has reached, according to the more or less distant state of
evolution to which the patient goes back. But these psychological
classifications are purely theoretical, and in practice many other
factors intervene which oblige us to consider such a patient as
incapable of doing any harm and such another as dangerous; this is the
only difference to-day between neuroses and psychoses. Later on, without
doubt, we shall be able to substitute for these simply symptomatical and
psychological diagnostics, some etiological and physiological
diagnostics. We shall be able from the very outset to recognize that a
disorder, in all appearance slight and which is not deeply set, presents
a bad prognosis, and we shall be able to foresee a serious and deep
psychosis in the future. To-day, without doubt, one can often
distinguish from the outset the future general paralytic from the simple
neurasthenic. But in the actual state of science this ability to
distinguish is not frequent and the future evolution of a depressed
state can scarcely be foreseen with precision.

Certain individuals pass in a few years from psychasthenic depression
with doubts and obsessions to psychasthenic deliriums with stubbornness
and negativism, then to asthenic insanity with irremediable and complete
want of power. Is it necessary to say that we made a mistake in our
diagnostic and that from the first demential psychosis should have been
recognized? I am not convinced of this: these diseases, excepting a few
cases with rapid evolution, are not characterized from the outset.
Without doubt we must note that these depressions which disturb the
reflective tendencies of young patients in full period of formation,
are dangerous and can bring on still deeper depressions of the
psychological tension. But that evolution is rarely fatal; it can very
often be checked, and it seems to me fair to preserve the distinction
between neuroses and psychoses considered as different degrees of
psychological decadence.

Neuroses are, therefore, the intermedium between the errors and the
faults which appeared to us almost normal, and alienation which seemed
exceptional and distant from us. The first appearances of that
depression which in a continuous manner descends to alienation are to be
found already in the disorders of character which seemed to be quite
insignificant. The miser, the misanthrope, the hypocrite are described
by the writer before they are claimed by the physician. A great number
of neuropathic disorders which I have described are related to the
popular type of mother-in-law. This type is not necessarily that of a
woman whose daughter has married, but the type of a depressed woman of
about fifty, aboulic, discontented with herself and others, domineering,
and jealous, because she suffers from the mania of being loved though
she is incapable of acquiring any one's affection. All exhaustions, all
moral failings have the closest connection with neuroses and psychoses.

These reflections prove to us that the alienist physician should
interest himself more and more in the treatment of neuroses even slight,
to rectifying the disorders of temper, to the education of the young, to
the direction of the moral hygiene of his country. On many of these
points America leads the way; your works of social hygiene, the good
battle you are righting against alcoholism, are examples for us. You are
the new world, younger, not rendered so inactive by secular habits. You
can act more easily than we. We may have the advantage, in the old
world, of the experience of old people and the habit of observation, but
we are slack in reform and action. "If youth had experience and old age
ability," says one of our proverbs. We must remain united and join your
strength to our experience for the greater progress of the studies which
are dear to us and for the greater good benefit of our two countries.

FOOTNOTES:

[Footnote 14: _Cf._ Janet, P., Les nevroses, 1909, p. 370.]

[Footnote 15: _Cf._ Les Medications psychologiques, 1920, I, p. 112.]

[Footnote 16: "Les Nevroses," 1909, p. 384.]

[Footnote 17: _Cf._ Janet, P., "Obsessions et Psychestenic," 1903, vol.
I, p. 997.]

ADDRESS BY
DR. WILLIAM L. RUSSELL

[Illustration: BLOOMINGDALE HOSPITAL, WHITE PLAINS, NEW YORK, 1921]

_The Chairman_: The year 1921 is rich in anniversaries for the New
York Hospital. Next October we plan to celebrate the one hundred and
fiftieth anniversary of the granting of our charter. To-day we are
occupied with the Bloomingdale Centenary. A fortnight ago the
twenty-fifth annual graduating exercises of our Training School for
Nurses were held in this room. This year also marks the decennial of Dr.
Russell's term of office as Medical Superintendent. When his devoted
predecessor, Dr. Samuel B. Lyon, asked in 1911 to be relieved from
active duty and became our first Medical Superintendent Emeritus, we
were most fortunate in securing as his successor Dr. Russell. Coming to
this institution after a broad psychiatric and administrative
experience, he has taken up our special problems with deep insight and
gratifying success. He has selected for his subject this afternoon "THE
MEDICAL DEVELOPMENT OF BLOOMINGDALE HOSPITAL." No one can speak with
greater authority on a theme of which it may be said _quorum magna
pars_--fortunately not only _fuit_--but _est_ and _erit_ as well.

DR. RUSSELL

The object of this celebration is not merely to glorify the past and
least of all is it to laud the present. What we hope from it is that it
will establish a milestone, not only to mark the progress thus far made
but to point the way to a path of greater usefulness. The advances in
medical science and practice and in the specialty of psychiatry during
the past hundred years fill one with wonder and hope. It is worth while
to review them merely to obtain this help. The outlook for the century
to come is, however, so far as can be anticipated, still brighter.

To review the past is, at a time like this, not unprofitable. It may
prevent us, in our zeal for the new, from discarding what is valuable in
the old, and from overvaluing some things which may have outlived their
usefulness. We must be careful that we do not fall into errors similar
to those from which the medical profession was rescued by the movement
of which Bloomingdale Asylum was an offspring. It should be recalled
that the establishment of the asylum was due to the initiative of the
Governors of the New York Hospital, especially Mr. Eddy, rather than to
the active interest and direction of physicians. The object of the
establishment was, according to Mr. Eddy, to afford an opportunity of
ascertaining how far insanity may be relieved by moral treatment alone,
which, he says, "it is believed, will, in many instances, be more
effective in controlling the maniacs than medical treatment." The moral
management he referred to, though advocated by Pinel and a few others,
some of whom were benevolent and intelligent laymen, had not been
accepted by physicians as a distinct form of medical treatment. Few
physicians of the period had accepted management of the mind as
described and practised by Pinel as being a distinct medical procedure,
as having the same value in overcoming mental disorders as the drastic
medical remedies which they were accustomed to employ, or as having any
exclusive healing power. This is clearly shown by the case records of
the mental department of the New York Hospital which have been preserved
since 1817, and of those of Bloomingdale Asylum for some years after its
opening in 1821. It is plainly set forth in Dr. Rush's book on diseases
of the mind, which was first published in 1810 and again in a fourth
edition in 1830. Rush was physician to the Pennsylvania Hospital and his
book was the principal, if not the only, one of the period by an
American author. American physicians like their European brothers, had,
as Pinel observes, "allowed themselves to be confined within the fairy
circle of antiphlogisticism, and by that means to be deviated from the
more important management of the mind." Rush believed that madness was a
disease of the blood-vessels of the brain of the same nature as fever,
of which it was a chronic form. "There is," he says, "not a single
symptom that takes place in an ordinary fever, except a hot skin, that
does not occur in an acute attack of madness." He found in his autopsy
observations confirmation of this view and concludes that "madness is to
phrenitis what pulmonary consumption is to pneumony, that is, a chronic
state of an acute disease." The reason for believing that madness was a
disease of the blood-vessels, which seemed to him most conclusive, was
"from the remedies which most speedily and certainly cure it being
exactly the same as those which cure fever or disease in the
blood-vessels from other causes and in other parts of the body." The
treatment he recommended and which was generally employed was copious
blood-letting, blisters, purges, emetics, and other severe depleting
measures. When Bloomingdale Asylum was established, therefore, the
provision for moral treatment did not contemplate that this should be
applied by the physician or that he should have full control of the
resources by means of which it could be applied. The records do not
indicate that either the physicians or the Governors realized that this
might be necessary or advantageous. The present system of administration
in which the chief physician is also the chief executive officer of the
institution was a result of an evolution which took many years to reach
its full consummation.

Pinel, many years before Bloomingdale Asylum was opened, had shown by
the most careful observation and practice that the management and
discipline of the hospital was a most powerful agent in the treatment of
the patients. The manner in which he was led to this conclusion is a
remarkable example of the scientific method. When he became physician to
the Bicetre he found that the methods of classification and treatment
recommended in the books seemed to be inadequate, and, desiring further
information, he says: "I resolved to examine myself the facts which were
presented to my attention; and, forgetting the empty honor of my titular
distinction as a physician, I viewed the scene that opened to me with
the eye of common sense and unprejudiced observation.... From systems of
nosology, I had little assistance to expect; since the arbitrary
distributions of Sauvages and Cullen were better calculated to impress
the conviction of their insufficiency than to simplify my labor. I,
therefore, resolved to adopt that method of investigation which has
invariably succeeded in all the departments of natural history, viz., to
notice successively every fact, without any other object than that of
collecting materials for future use; and to endeavor, as far as
possible, to divest myself of the influence, both of my own
prepossessions and the authority of others. With this view, I first of
all took a general statement of the symptoms of my patients. To
ascertain their characteristic peculiarities, the above survey was
followed by cautious and repeated examinations into the condition of
individuals. All our new cases were entered at great length upon the
journals of the house." Having thus studied carefully the course of the
disease in a number of patients who were subjected only to the guidance
and control made possible by the management of the hospital under the
direction of a remarkably highly qualified Governor, it came to him with
the force of a new discovery that this man who was not a physician was
doing more for the patients than he was, and that insanity was curable
in many instances by mildness of treatment and attention to the state of
mind exclusively. "I saw with wonder," he says, "the resources of nature
when left to herself, or skilfully assisted in her efforts. My faith in
pharmaceutic preparations was gradually lessened, and my scepticism
went at length so far as to induce me never to have recourse to them,
until moral remedies had completely failed." So convinced did he become
of the significance and importance of the management and discipline of
the hospital in the treatment of the patients, that, when a few years
later, he wrote his "Treatise on Insanity," he states that one of the
objects of his writing it was, "to furnish precise rules for the
internal police and management of charitable establishments and asylums;
to urge the necessity of providing for the insulation of the different
classes of patients at houses intended for their confinement; and to
place first, in point of consequence, the duties of a humane and
enlightened superintendency and the maintenance of order in the services
of the Hospitals."

Pinel's views had apparently not been fully understood or adopted by the
physicians of America at the time Bloomingdale Asylum was planned and
established. Dr. Rush did not mention him in his book, and Mr. Eddy, in
his communication to the Governors of the New York Hospital, referred
only to the writings of Drs. Creighton, Arnold, and Rush and the Account
of the York Retreat by Samuel Tuke.

When Bloomingdale Asylum was opened, the form of organization
introduced was that under which the department at the New York Hospital
had been conducted. Mr. Laban Gardner was made Superintendent or Warden
with two men and three women keepers to aid him in the control and
management of the seventy-five patients. There was an Attending
Physician who visited once a week and a Resident Physician, neither of
whom received salaries. There is nothing in the records to indicate that
in the beginning, the Governors of the Hospital looked upon the moral
treatment of the patients, which was the object for which the
institution was established, as the task of the Physicians. The aim was
to furnish employment, diversion, discipline, and social enjoyment,
without much attempt at precision or close medical direction and
control. For a time the results were considered to be satisfactory. In
1824, however, a joint Committee of the Board reported that they were
impressed by the necessity of improving the moral treatment, and
recommended that two discreet persons be appointed to take charge of
such of the patients as might from time to time be in a condition to be
amused or employed on the farm or in walking exercises in the open or in
classes to be designated by the Resident Physician "with," however, "the
approbation of the Superintendent," who you will recall was not a
physician. These patients were, the report recommends, to be
particularly under the charge of the Resident Physician when thus
employed or amused "out of the Asylum." At this time, the Attending and
Resident Physicians were placed on a small salary, and the Resident
Physician was instructed to "devote a greater portion of his time and
attention to the moral part of the establishment and to communicate to
the Committee such improvements as his experience shall suggest to be
useful and necessary in carrying into more complete effect the system of
moral treatment and to report from time to time to the Committee the
effect of the measure adopted." This seems to have been the beginning of
a realization that the moral management of the patients was inseparable
from medical treatment and must necessarily be the task of the
physician. Seven years after this, in 1831, the Committee found it
advisable to spread upon the minutes an "interpretation and
regulations," relating to the Superintendent and Matron of the Asylum
and to the Asylum physicians, to the effect that the Committee
understood that the regulations "placed the moral treatment on the
physician alone, under the direction of the Asylum Committee, and that
the responsibility remains with him alone, that this treatment commenced
with the reception of the patient, the ward where he shall be placed,
his exercises, amusement, admission of friends, the time of discharge
from the house.... And that all orders to nurses and keepers which the
physicians may think necessary to carry these orders into effect _shall
be communicated through the Superintendent_" (or Warden). In 1832, the
Resident Physician, Dr. James Macdonald, who had just returned from
Europe after having spent a year in visiting the institutions for mental
disorders there, made a report in which he rather significantly referred
to the impracticability of making a sharp distinction between the
medical and moral treatment of the patients, it being difficult to say
where the one ended and the other began, or to put one into successful
operation without bringing in the other. At this time the position of
Attending Physician was abolished and the Resident Physician was made
the Chief Medical Officer of the Asylum. It was not until 1837 that an
amendment to the by-laws regulating the powers of the physician and the
Warden was adopted which gave to the physician the power of appointing
and discharging at pleasure all the attendants on the patients, while to
the Warden was reserved the power of appointing and dismissing all other
employees. Fourteen years had thus elapsed since the opening of the
Asylum before the physician was given control of even the nursing
service. The first Annual Report of the Resident Physician of the
Asylum to be published appeared in 1842. In this, Dr. William Wilson
makes a general statement in regard to the beneficial effects of the
moral as well as the medical treatment pursued in the institution, and
refers particularly to occupations, exercise in the open air, amusement,
religious services, and he asks that a workshop be erected for the men.
It is evident that by this time the authority of the physician in the
management of the institution had been extended and it is perhaps
significant that in his report of the following year Dr. Wilson refers
to a plan for distribution of food which had been evolved in
co-operation with the Warden. Under the direction of Dr. Pliny Earle,
who was appointed physician to the Asylum in 1844, treatment directed to
the mind was further elaborated and systematized, and the place of the
physician in the management of the hospital was more firmly established.

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