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, 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.
But the basis of the condition is not completely understood when we have apparently arrived at the psychic cause of the disturbance.
It is recognized that the emotions are accompanied by physical changes, changes which are specific for each emotional state. The physical changes which normally are associated with fear differ from those of joy or anger. This has been appreciated for a long time but recent researches have recalled other reactions to us. Reactions in the internal glands which further knowledge will probably prove to be of great importance, in fact to form an integral part of the sum of activities, connect with mental processes. The secretions of the glands exert an influence on the sensibility and reaction of the organs connected with psychic phenomena and their functions themselves are affected by reactions occurring in the nervous system. Revival of a memory may thus affect the functions of these glands, and the changes produced in them may react on the sensibility and reactivity of the nervous mechanisms. If this be so, it will be evident that the organism works as a whole, that a disturbance of one organ may interfere with the function of another and that in the repetition of all these influences we may find an explanation of the chronicity of many of these illnesses. A study of the activities and interactivities of all the organs of the body is therefore essential and must be made before we shall understand the biological significance of mental illness.
FOOTNOTES:
See [Appendix III], p. 200.
ADDRESS BY
DR. PIERRE JANET
The Chairman: Our country may be hesitating a little—I hope it will not be for long—in joining a league of nations to prevent war, but there can be no doubt of our immediate readiness to co-operate internationally to prevent and reduce disease. Our distinguished guest from gallant France, Dr. Pierre Janet, professor in the College of France, evidently feels confident of our sympathy and willingness to collaborate in this latter respect, for he has ventured across the ocean, with Madame Janet, in response to our urgent invitation. His introduction to an audience of American psychiatrists would be quite out of place. His fame as a pathological psychologist has circled the world. In the science of medicine he is a modern Titan. For to-day's address he has chosen as a subject, "The Relation of the Neuroses to the Psychoses."