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CHANGING CONCEPTS IN PSYCHIATRY By
Although there should be no interest in life greater than that which would give us an insight into our own nature, casual reflection shows how little thought we have given to it. Someone has very tritely remarked that the things closest to us we knew about first, and the things closest to us we know very little about, even today. That is, we have known considerable of an accurate nature concerning the stars and constellations, their speed of movement, direction, etc., from the time of the early Greeks, but the nature of our own makeup and conduct has been left for the last quarter of a century for anything like intensive study. Each field of preventative medicine, as far as I know has had its origin in the field of pathology or disease for only when the toll, through death, became unbearable great did scientific medicine exert its maximum efforts toward the discovery of causes. With this knowledge, it was possible in most cases to cure, and in some to prevent. What is true of our knowledge of physical disease strictly speaking, e.g. Yellow Fever, Typhoid Fever, Diphtheria, Tuberculosis, etc., is just as true of what is unfortunately termed “mental” diseases. Mental disease is as old as the human race, and its earliest history is that of disease in general, for much mystery and superstition surrounded every form of sickness. All ancient peoples believed all disease to be a form of punishment which was inflicted for sins and wrongs committed, or an indication of displeasure on the part of the deities they worshipped. What today is known to be mental disease was very generally believed to be a form of demonical possession, and therefore, for centuries no medical measures were applied to relieve the sufferings of the mentally ill, but various forms of exorcism and conjuration were practiced. It has been suggested that mental diseases did not play a prominent part in ancient history owing to the fact that the law of the “survival of the fittest” automatically eliminated the insane and defective. As Tuke, (Tuke, D. Hack: A Dictionary of Psychological Medicine, 1892) says, “They perished in the course of nature or were stamped out of existence; many of the perverse and morally insane were stoned to death; war destroyed a large number of feeble persons; while the Romans deliberately, and in the interests of the race, threw down from the Tarpeian Rock the children who were unfit to live.” The Papri of the fifteenth century before Christ show clearly that the doctrine of demonical possession was generally entertained at that time. One of the earliest attempts to explain the origin of mental diseases perhaps was that of Plato. “There are two kinds of madness, one arising from human diseases, and the other from an inspired deviation from established custom.” Hippocrates had some very clearly defined views on this subject; “As long as the brain is at rest a man enjoyed his reason; but the depravement of the brain arises from phlegm and bile, either or which you may recognize in this manner: Those who are mad from phlegm are quiet, but always doing something improper. If the madness be constant, these are the causes thereof; but if terrors and fears assail, they are connected with derangement of the brain, and the derangement is owing to its being heated. And it is heated by bile when it is determined to be the brain along the blood vessels running from the trunk, and fear is present until it returns again to the veins and trunk, when it ceases. He is grieved and troubled when the brain is unreasonably cooled and contracted beyond its want. It suffers this phlegm, and from the same affection the patient becomes oblivious.” An interesting theory which he evolved was that the appearance of varicose veins or hemorrhoids tended to relieve the patient’s mental suffering most likely by distraction. The influence of the moon, as well as the stars, was spoken of by Hippocrates and admitted by Galen. To these ideas we owe the word “lunacy” which appeared in the laws of England in 1921, and which I am sorry to add, is still present in our Kentucky law today. However, there was a bright spot or two in early times as relates to the cure of the mentally ill, but apparently the brightness was of short duration. As far back in history as 860 B.C. there is record that many of those afflicted with mental illness repaired or were carried to the temples of Saturn in Egypt and of Aesculapius in Greece, to be relieved of their torments by the priest, who made a study of their disorders and applied measures to relieve the symptoms. The temples were situated for the most part in mountainous and healthy places and as near as possible to medicinal springs. The priests in ancient Egypt employed not only their supposed all potential spiritual agencies for restorative purposes, but also employed such powerful aids as the influence of music and the beautiful nature and in art, together with healthy recreation and agreeable occupation. The treatment at the temples had many of the remedial features of the treatment of today, suggestion, kindness, occupation, music, and recreation. Later, a member of the Greek Medical School publicly condemned the excessive use of bodily treatment of the insane. He advocated the importance of music and kindly treatment as well as employment that patients be stimulated to self regulation of their mental powers. Centuries later, in the Middle Ages, the idea was prevalent in Europe of regarding insane as possessed by demons which must be cast out to effect restoration. This absurd superstition led to the adoption of cruel forms of punishment and even torture. Hippocrates, a Greek physician, who lived in 460 B.C., appears to have been the first to understand these disorders, for he declared his belief that mental disease was a disturbance of the function of the brain. Enlightenment of ancient times respecting this unfortunate class was followed by such ignorance as is known to have prevailed during many succeeding centuries. Long pilgrimages were made to the shrines of particular saints who were believed to have had great influence in mental restoration and where through exorcism and prayer, miraculous cures were claimed to have been affected. Superstitious Beliefs Far into the Middle Ages, the practice of medicine was left to monks. In the days of ancient Greeks, psychology was recognized as a department of medical study but in the so called dark ages, crude superstitions were incorporated into the healing art. During the 16th century and far advanced into the 17th, demonology and witchcraft were generally believed in. James VI of Scotland, afterward King of England, wrote a dissertation on “demonology.” Toward the close of the 16th century, certain medical authorities began to openly rebel against these accepted doctrines whereupon they were severely censored by Royal James for what he was pleased to term their “damnable opinions.” As late as 1716, a woman and her daughter were sentenced to death at Huntington by an English Bench of Judges for “selling their souls to the devil.” Evidences that Mohammadens did not entirely neglect the insane is brought out by the fact that in the 15th century Spain, then the center of learning, seemed to have taken the lead in providing for this class. The treatment, however, was cruel to the extreme and was based on the general belief that the insane were possessed of evil spirits. They were burned to death, scourged and tortured in order to expel the demons. A general revolution had taken place within the past few generals in methods of caring for the insane. Where they were once treated as wild beasts, a few years later the mentally ill were chained in cells and dungeons in which the poisoned atmosphere often hastened death. In some cases they were exhibited in cages to the public where they were often irritated and tormented. Those who were not deemed dangerous to the public safety were left to roam about the country in a pitiable condition. Reforms of Pinel The Herculean labors of Pinel were needed to lessen the chains of the miserable occupants of the Bicetre in Paris, an act which revealed to the world the striking superiority of kindly treatment over the torture to which the insane men and women at that time were subjected in different parts of Europe. In 1792 Pinel was appointed superintendent of the Bicetre where there were 200 male patients who were believed to be incurable and also uncontrollable. There he found 53 men languishing in chains. He made many appeals to commune for power to release theses unfortunate beings and authority was unwillingly yielded. Reforms extended to Saleptriere, an institution for women. The monstrous fallacy of cruel treatment was being exposed. Governmental agencies were instituted with a view to the attainment of better treatment and in different countries almost simultaneously, the provision of suitable accommodations for the insane was believed to be a state of necessity. At this time there was an experimentation with treatment, strange devices were used, some being absurd, other being highly injurious. About this time in England, in the city of York, William Tuke, a member of the Society of Friends, aroused by conditions in the York County Asylum, became active in raising funds to establish a retreat for members of the Friends Society who were or should become mentally afflicted. In 1796, York Retreat was opened for reception, care and treatment of mental patients. All restraint was abandoned, and sympathetic care in quiet, pleasant surroundings with some forms of industrial occupation were provided. The names Pinel and Tuke will be forever associated with the humane treatment of the insane. They demonstrated conclusively that when restraint and brutal authority were abolished and treatment by kindness was substituted, the management of these patients became far less difficult. In America, during the 18th century, little consideration appears to have been given to the mentally ill, and whenever custodial care became necessary, it was provided at the minimum attention, labor and expense. Many of them were permitted to roam about the streets, where they were subjected to many forms of ill treatment, or to wander about the country exposed to all sorts of hardships and dangers. Some were cared for in alms houses while the more unruly and disturbed were placed in cages, pens or in jails with other disorderly persons and criminals. One name will forever be associated with the movement for the proper housing, care and treatment of the mentally ill in this country. In 1841 Miss Dorothea Lynde Dix, a school teacher in Somerville, Massachusetts, hearing of the deplorable condition of a few lunatics who were confined in the East Somerville jail, made a thorough investigation and found them in the dead of winter confined in the dark, poorly ventilated and heated cells, where frost was white on the walls, and scantily clothed because in their frenzy they had torn away their clothing. She embodied the results of her inspections which she presented to the Legislature of Massachusetts. Here statements were verified and immediate reforms initiated. The Miss Dix proceeded to go from state to state at their request and so aroused the public conscience that the laws which governed the treatment of the mentally sick were radically changed for the better. She also extended her efforts to Canada and to Europe. On the continent, especially in Germany and France, intensive work was being carried on in relation to those suffering from mental diseases. The expression of this development is perhaps best represented by the research work and publications of Professor Kraeplin whose classification of mental diseases, with few modifications, is followed today in this country by our more progressive state hospitals, private sanitaria and psychiatrists in private work. Understanding of Causes Although this apparent progress was made, the understanding of the causes of mental diseases was a long way from being satisfactory, for in 1911 Clouston made a statistical study of 11,346 cases admitted to the Royal Edinburg Mental Hospital in the course of 35 years and found a long list of causes shown in the hospital reports. They included nursing, disordered menstruation, self abuse, sexual excess, surgical operations, bronchitis, protatic disease, lupus, commencing menstruation, transference of morbid action from other organs to the brain, excessive tobacco smoking, chloroform inhalation, excessive number of children, religious excitement, marriage, changes of residence, sedentary habits, political excitement, bad temper, the Queen’s Jubilee, etc., etc. He concludes: “Bad heredity, congenital defects, and previous attacks are the great predisposing causes, and that alcohol, the crises of life, epilepsy, the various forms of brain poisons and the gross brain and nervous diseases constitute the mass of exciting causes. Together they account for over seventy percent of the defects and diseases of the mind that come under my observation.” It will readily be observed that fundamentals were almost entirely lost sight of and non-essentials overemphasized. The studies of Mayer, Kraepelin, Freud, Adler, Jung, Sleuler, and many others have shown that in manic-depressive insanity, dementia praecox and various other psychoses, we are dealing with very definite constitutional conditions, morbid temperaments, personality defects, etc., which are responsible for the maladadjustments leading to the development of psychoses. Any upsetting factor is merely the “straw that breaks the camel’s back.” Evolution of Modern State Hospitals in America Hand in hand with the development of the understanding of the nature and causes of mental diseases, and to a degree preceded, the development of the state hospital program. The first asylum which we find mentioned in history was once said to have been erected by the monks in Jerusalem in the latter part of the fifth century. 1732 is the initial point in the hospital treatment of the insane in America when a small hospital provided for physicians, medicine, and free care for the insane. 1768 the first institution designed and used exclusively for mental diseases was in Williamsburg, Virginia. 1791 the New York Hospital provided the earliest hospital care of mental diseases in New York. 1797 Baltimore, Maryland – incorporated a hospital. During the 19th century, the movement of private hospital care for the mentally ill spread rapidly so that today every state without exception has now recognized the necessity of making provision for the treatment and care of mental diseases. In 1824 the Easting State Hospital in Lexington, Kentucky was founded. It was the eighth hospital to be founded in this country. England The history of treatment of the insane in England is one of protracted struggle between forces of humane and enlightening civilization on the one hand and of a formidable conservation on the other. In 1547 Bethlehem Hospital was converted by Henry VIII into an asylum or “dungeon house” and became known as Bedlam. Sixty patients were accommodated. In 1657 it was removed to Moorfields; the building was erected to accommodate 152 inmates. In 1812 it was again found necessary to change the site. At this time a more modern structure was built in St.George’s Field. In 1820 Bedlam was one of the great sights of London, for keepers were allowed to exhibit the most boisterous and violent of the patients, charging a fee which they retained for their own personal use. In 1887 there were three district asylums under direction of Metropolitan Asylum Board. Catherham and Leavesden were for chronic insane while Darenth provided for schools for idiot children. The Metropolitan Board was designed to bring about a better classification of the dependent classes by removing the insane from the overworked and ill adopted workhouses. Colony Hatch Asylum, 1881, situated six and one half miles north of London, containing 160 acres, accommodated 900 men and 1300 women; there was a chapel in which Catholic and Jewish services were held once a month; there were no appliances for mechanical restraint for women. Hanwell Asylum, situated seven and one half miles northwest of London, Dr. Connelly had tried to demonstrate the practicability of non-restraint principle in the treatment of insane. Here were received violent, troublesome and dangerous cases. As the general rule, no mechanical or chemical restraint was used. Sunday services were observed and there were morning and evening worship during the week. Danstead Lunatic Asylum, erected in 1877, was also directed by a committee of visitors. Acute as well as chronic cases were received. Little restraint was used except for surgical reasons. The overcrowded conditions caused an unhappy atmosphere. A medical superintendent who had four assistants presided over the asylum. Leavesden Asylum, seventeen miles northwest of London, was opened in 1870. It then accommodated 1,638 but was later enlarged to accommodate 2,000. This asylum was for harmless, pauper lunatics. A medical superintendent was in charge. Means of restraint were leather gloves and strong dresses. According to all appearances, humane treatment was used; cleanliness prevailed everywhere in the institution. Caterham Metropolitan received pauper patients like the above institutions, no mechanical restraint was used. Patients were sometimes put in seclusion. On the whole, cleanliness prevailed in the institution. Haywards Heath, situated thirty-seven miles south of London, was opened in 1859; both acute and chronic cases were admitted; infirmary ward had 38 beds; there were two suicidal and epileptic dormitories. Each patient received one-half pint of beer at dinner. “Wet and dry packing” was practiced for medical reasons and was the only form of mechanical restraint. Congenial employments were provided, 76% of the insane being usefully employed. Wards were equipped with books, etc. Walking parties were one type of recreation used. Brookwood Asylum, near Woking, Surrey, was an asylum mainly for pauper patients. The medical superintendent controlled the selection and retention of his subordinate. Acute and chronic cases were accepted. Epileptics were under watchful and systematic supervision by night and day. There was an absence of ordinary methods and restraint. Seclusion was not used since 1871. Dr. Brushfield believed that restraining contrivances only increased excitement. Each patient was weighed upon entrance and at different times during this stay at the asylum. |