PSYCHOLOGY : Madness, Badness, Sadness

Madness, Badness, Sadness

            Goering and Hitler displayed an almost maudlin concern for the welfare of animals; Stalin's favorite work of art was a celluloid musical about Old Vienna, called The Great Waltz. And it is not only dictators who divide their thoughts and feelings into unconnected, logic-tight compartments; the whole world lives in a state of chronic and almost systematic inconsistency. Every society is a case of multiple personality and modulates, without a qualm, without even being aware of what it is up to, from Jekyll to Hyde, from the scientist to the magician, from the hardheaded man of affairs to the village idiot. Ours, for example, is the age of unlimited violence; but it is also the age of the welfare state, of bird sanctuaries, of progressive education, of a growing concern for the old, the physically handicapped, the mentally sick. We build orphanages, and at the same time we stockpile the bombs that will be dropped on orphanages. "A foolish consistency," says Emerson, "is the hobgoblin of little minds, adored by little statesmen, philosophers and divines." In that case, we must be very great indeed.

            That all, or even most, human beings will ever be consistently humane seems very unlikely. We must be content with the smaller mercies of unemployment benefits and school lunches in the midst and in spite of an armament race. We must console ourselves with the thought that our inky darks are relieved by quite a number of lights.

            Between Los Angeles and Long Beach, California, there stands a mental hospital which admirably illustrates our blessed inconsistency. Bomber plants and guided-missile laboratories surround it on every side, but have not succeeded in obliterating this oasis of organized and instructed benevolence. With their wide lawns, their tree-lined walks, their scattering of nondescript buildings, the hospital grounds look like the campus of an unpretentious college. The inmates, unfortunately, could never be mistaken for undergraduates and co-eds. The mind is its own place, and their gait, their posture, the distressed or remotely preoccupied expression of their faces reveal them as the inhabitants of dark worlds, full of confusion, fertile in private terrors. But at least nothing is being done in this green oasis among the jets and the rockets to deepen the confusion or intensify the terrors. On the contrary, much good will and intelligence, much knowledge and skill are going into a concerted effort to transform their isolated, purgatorial universes into something happier and more accessible.

            Not long ago a psychiatrist friend took me with him to this oasis. Walking through one of the Disturbed Wards, I found myself suddenly remembering the first occasion on which I had visited a mental hospital. The place was Kashmir, the time more than thirty years ago, and the hospital was actually no hospital, but that part of the local prison which was used for the confinement of maniacs. Naked, unkempt, horribly unwashed, these unfortunates were shut up in cages. Not the spacious enclosures reserved, in zoos, for gibbons and orangutans, but filthy little pens, in which a couple of steps in any direction would bring their occupants to the confining bars. Kashmir is remote, "uncivilized," non-Christian. But let us be in no hurry to flatter ourselves. The horrors I witnessed there, among the Himalayas, were of exactly the same kind as the horrors which my grandfather and his contemporaries could see in any asylum in civilized and Christian England, France or Germany, in civilized and Christian America. Of the many dark and hideous pages of our history, few are more shameful than the record of Western man's treatment of the mentally ill. The story has been told at length in Doctor Gregory Zilboorg's History of Medical Psychology and there are whole libraries of books dealing with special periods and particular aspects of the long martyrdom of the insane.

            The tormentors of the insane have been drawn, in the main, from two professions - the medical and the clerical. To which shall we award the palm? Have clergymen been responsible for more gratuitous suffering than doctors? Or have doctors made up for a certain lack of intensity in their brand of torture (after all, they never went so far as to burn anyone alive for being mad) by its longer duration and the greater number of the victims to whom it was applied? It is a nice point. To prevent hard feelings, let us divide the prize equally between the contenders.

            So far as the mentally sick are concerned, Western history has had only two golden ages. The first lasted from about fifty years before the birth of Christ into the second century of our era; the second began, very hesitantly, in the early years of the nineteenth century and is still continuing. During these golden ages the mentally sick, or at least the more fortunate of them in the more civilized parts of the classical and modern world, were treated with a measure of common decency, as though they were unfortunate human beings. During the intervening centuries they were either ignored, or else systematically tormented, first (on the highest theological grounds) by the clergy, later (for the soundest of medical reasons) by the doctors.

            Let us ask ourselves a question. If I had lived in the eighteenth century, and if I had been afflicted by some mental illness, what would have happened to me?

            What happened to you in those days depended, first of all, on the financial situation of your family. People with money either locked up their insane relatives in some remote corner of the family mansion, or banished them, with a staff of attendants, to an isolated cottage in the country, or else boarded them out, at considerable expense, in a private madhouse run for profit by a doctor or, under medical supervision, by some glorified jailer. Lunatics confined in the attics (like Mr. Rochester's wife in Jane Eyre) or in a country cottage were spared the rigors of medical treatment, which could only be administered in an institution staffed by brawny attendants and equipped with the instruments of coercion. Those who were sent to such an institution were first stripped naked. Mad people were generally kept in a state of partial or complete nudity. Nakedness solved the problem of soiled clothes and contributed, in what was felt to be a most salutary way, to the patient's sense of degradation and inferiority. After being stripped, the patient was shaved, so as to prepare him or her for that part of the treatment which consisted in rubbing various salves into the scalp with a view to soothing or stimulating the brain. Then he or she was taken to a cell, tied down to the bed and locked in for the night. If the patient struggled and screamed, that was a sign of mania; if he reacted with silent resignation, he was obviously suffering from some form of melancholy. In either case he needed treatment and, duly, next morning the treatment was commenced. In the medical literature of the time it was referred to as "Reducing the Patient by Physic." Over a period of eight or ten weeks the victim was repeatedly bled, at least one pound of blood being taken on each occasion. Once a week, or if the doctor thought it advisable at shorter intervals, he or she was given an emetic - a "Brisk Vomit" as our ancestors, with their admirable command of English, liked to call it. The favorite Brisk Vomit was a concoction of the roots of black hellebore. Hellebore had been used in the treatment of the insane since the time of Melampus, a legendary soothsayer, first mentioned by Homer. Taken internally, the toxicologists tell us, hellebore "occasions ringing in the ears, vertigo, stupor, thirst, with a feeling of suffocation, swelling of the tongue and fauces, emesis and catharsis, slowing of the pulse and finally collapse and death from cardiac paralysis. Inspection after death reveals much inflammation of the stomach and intestines, more especially the rectum." The doses prescribed by the old psychiatrists were too small to be fatal, but quite large enough to produce a dangerous syndrome, known in medical circles as "helleborism." Every administration of the drug resulted in an iatrogenic (doctor-induced) disease of the most distressing and painful kind. One Brisk Vomit was more than enough; there were no volunteers for a second dose. All the later administrations of hellebore had to be forcible. After five or six bouts of helleborism, the time was ripe for purgatives. Senna, rhubarb, sulphur, colocynth, antimony, aloes - blended into Black Draughts or worked up into enormous boluses, these violent cathartics were forced, day after day, down the patient's throat. At the end of the two-month course of bloodlettings, vomits and purges, most psychotics were "reduced by physic" to a point where they were in no condition to give trouble. These reductions were repeated every spring during the patient's incarceration and in the meantime he was kept on a low diet, deficient in proteins, vitamins and even calories. It is a testimony to the amazing toughness of the human species that many psychotics survived under this treatment for decades. Indeed, they did more than survive; in spite of chronic undernourishment and periodical reductions by physic, some of them still found the strength to be violent. The answer to violence was mechanical restraint and corporal punishment. "I have seen," wrote Dorothea Dix in 1848, "more than nine thousand idiots, epileptics and insane in the United States, destitute of appropriate care and protection, bound with galling chains, bowed beneath fetters and heavy iron balls attached to drag chains, lacerated with ropes, scourged with rods and terrified beneath storms of execration and cruel blows." The armamentarium of an English asylum of the Early Victorian period comprised "strait-waistcoats, handcuffs, leg locks, various coarse devices of leather and iron, including gags and horrible screws to force open the mouths of patients who were unwilling or even unable to take food." In the Lancaster Asylum good old-fashioned chains had been ingeniously combined with the very latest in plumbing. In 1840 its two Restraint Rooms were fitted up with "rows of stalled seats serving the double purpose of a water closet and an ordinary seat. The patients were secured by hand locks to the upper portion of the stalls and by leg locks to the lower portion." The Lancaster lunatics were relatively well off. The toilets to which they were chained guaranteed a certain cleanliness and the newly installed heating system, of which the asylum was justly proud, preserved them from the long-drawn torture-by-freezing, which was the lot, each whiter, of the overewhelming majority of mentally sick paupers. For while the private madhouses provided a few of the rudimentary creature comforts, the public asylums and workhouses, in which the psychotic "Objects of Charity" were confined, were simply dungeons. (In official documents the phrase, "Objects of Charity" is abbreviated, and the insane poor are regularly referred to as "Objects.") "I have seen them naked," wrote Esquirol of the Objects in French asylums, "and protected only by straw from the damp, cold pavement on which they were lying." And here is William Tuke's account of what he saw in the lunatic ward of an English workhouse in 1811: "The poor women were absolutely without any clothes. The weather was intensely cold, and the evening previous to our visit the thermometer had been sixteen degrees below freezing. One of these forlorn Objects lay buried under a miserable covering of straw, without a blanket or even a horsecloth to defend her from the cold." The feet of chained lunatics often became frostbitten. From frostbite to gangrene was a short step, and from gangrene through amputation to death was only a little longer.

            Lunatics were not merely confined. Attempts were even made to cure them. The procedures by which patients were reduced to physical exhaustion were also supposed to restore them to sanity. Psychoses were thought to be due to an imbalance between the four humors of the body, together with a local excess or deficiency of the vital and animal spirits. The bloodlettings, the vomits and the purges were intended to rid the viscera and the circulatory system of peccant humors, and at the same time to relieve the pressure of the animal spirits upon the brain. Physical treatment was supplemented by psychological treatment. This last was based upon the universally accepted principle that the most effective cure for insanity is terror. Boerhaave, the most influential medical teacher of the first half of the eighteenth century, instructed his pupils "to throw the Patient into the Sea, and to keep him under for as long as he can possibly bear without being stifled." In the intervals between duckings the mentally sick were to be kept in constant fear by the threat of punishment. The simplest and handiest form of punishment is beating, and beating, in consequence, was regularly resorted to. During his psychotic episodes even George III was beaten - with the permission, of course, of his Privy Council and both Houses of Parliament. But beating "was only one form, and that the slightest, of cruelty toward the insane." (I quote the words of the great French reformer, Doctor Pinel.) "The inventions to give pain were truly marvelous." Thus an eminent German doctor had devised a therapeutic punishment, which consisted in tying a rope about the patient's middle, hoisting him to a great height and then lowering him very rapidly, so that he should have the sensation of falling, into a dark cellar, "which was to be all the better if it could be stocked with serpents." A very similar torture is minutely described by the Marquis de Sade, the heroine of whose novel, Justine, is punished for being virtuous (among many other ways) by being dangled halfway down a shaft opening into a cavern full of rats and corpses, while her tormentor of the moment keeps threatening, from above, to cut the rope. That this fiendish notion should have occurred not only to the most famous psychotic of the period, but also to one of its leading psychiatrists, throws a revealing light on our ancestors' attitude toward the mentally sick. In relation to these predestined victims sadistic behavior was right and proper, so much so that it could be publicly avowed and rationalized in terms of current scientific theories.

            So much for what would have happened to me, if I had become mentally sick in the eighteenth, or even the first half of the nineteenth, century. If I had lived in the sixteenth century, my fate might have been even worse. For in the sixteenth century most of the symptoms of mental illness were regarded as supernatural in origin. For example, the pathological refusal or inability to speak was held to be a sure sign of diabolic possession. Mutism was frequently punished by the infliction of torture and death at the stake. Dumb devils are mentioned in the Gospels; but the evangelists made no mention of another hysterical symptom, localized insensibility to pain. Unfortunately for the mentally ill, the Early Fathers noticed this curious phenomenon. For them, the insensitive spots on the body of a mentally sick person were "the Devil's stigmata," the marks with which Satan branded his human cattle. In the sixteenth century anyone suspected of witchcraft would be systematically pricked with an awl or bodkin. If an insensitive spot were found, it was clear that the victim was allied with the devil and must therefore be tortured and burned alive. Again, some mentally sick persons hear voices, see visions of sinister figures, have phantasies of omnipotence or alternatively of persecution, believe themselves to be capable of flying, of being subject to metamorphosis into animals. In the sixteenth century these common symptoms of mental derangement were treated as so many statements of objective fact, so many confessions, explicit or implicit, of collaboration with the Enemy. But, obviously, anyone who collaborated with the Devil had to be tortured and burned alive. And what about the neurotics, particularly the female neurotics, who suffer from sexual illusions. "All witchcraft," proclaim the learned clerical authors of the Malleus Maleficarum, the standard textbook for sixteenth-century inquisitors and magistrates, "all witchcraft comes from carnal lust, which in women is insatiable." From this it followed that any disturbed woman, whose sexual daydreams were more than ordinarily vivid, was having relations with an Incubus. But an Incubus is a devil. Therefore she too must be tortured and burned alive.

            Doctor Johann Weier, who has been called the Father of Psychiatry, had the humanity, courage and common sense to assail the theories and hellish practices of the Catholic theologians and magistrates, and the no-less-ferocious Protestant witch-hunters of his time. But the majority even of well-educated men approved the crimes and follies of the Church. For having ventured to treat the witches' confessions as symptoms of mental illness, Weier was regarded as a diabolical fellow traveler, even a full-blown sorcerer. That he was not arrested, tortured and burned was due to the fact that he was the personal physician of a ruling prince. Weier died in his bed; but his book was placed on the Index, and the persecution of the mentally ill continued, unabated, for another century. How many witches were tortured and burned during the sixteenth century is not exactly known. The total number is variously estimated at anything from one hundred thousand to several millions. Many of the victims were perfectly sane adherents of the old fertility cult which still lingered on in every part of Europe. Of the rest, some were persons incriminated by informers, some the unhappy victims of a mental illness. "If we took the whole of the population of our present-day hospitals for mental diseases," writes Dr. Zilboorg, "and if we sorted out the cases of dementia praecox, some of the senile psychoses, some of those afflicted with general paralysis, and some of the so-called involution melancholies, we should see that Bodin (the great French jurist, who denounced Dr. Weier as a sorcerer and heretic) would not have hesitated to plead for their death at the stake, so similar and characteristic are their trends to those he describes. It is truly striking that the ideational contents of the mental diseases of four hundred years ago are so similar to those of today."

            In the second half of the seventeenth century the mentally sick ceased to be the prey of the clergy and the theologically minded lawyers, and were left instead to the tender mercies of the doctors. The crimes and follies committed in the name of Galen were, as we have seen, almost as monstrous as those committed at an earlier period in the name of God. Improvement came at last in the closing years of the eighteenth century, and was due to the efforts of a few nonconforming individuals, some of them doctors, others outside the pale of medicine. These nonconformists did their work in the teeth of official indifference, sometimes of active official resistance. As corporations, neither the Church nor the medical profession ever initiated any reform in the treatment of the mentally sick. Obscure priests and nuns had often cared for the insane with kindness and understanding; but the theological bigwigs thought of mental illness in terms of diabolic possession, heresy and apostasy. It was the same with the medical bigwigs. Strait jackets, Brisk Vomits and systematic terrorism remained the official medical policy until well into the nineteenth century. It was only tardily and reluctantly that the bigwigs accepted the reforms initiated by heroic nonconformists, and officially changed their old, bad tune.

            Reform began almost simultaneously on either side of the Channel. In England a Quaker merchant, William Tuke, set up the York Retreat, a hospital for the mentally sick, in which restraint was never used and the psychological treatment was aimed, not at frightening the patients, but at bringing them back from their isolation by persuading them to work, play, eat, talk and worship together. In France the pioneer in reform was Doctor Philippe Pinel, who was appointed to the direction of the Bicetre Asylum in Paris at the height of the French Revolution. Many of the patients were kept permanently chained in unlighted cells. Pinel asked permission of the revolutionary government to set them free. It was refused. Liberty, Equality and Fraternity were not for lunatics. Pinel insisted, and at last permission was grudgingly given. The account of what followed is touching in the extreme. "The first man on whom the experiment was tried was an English captain, whose history no one knew, as he had been in chains for forty years. He was thought to be one of the most furious among them. His keepers approached him with caution, as he had in a fit of fury killed one of them on the spot with a blow from his manacles. He was chained more rigorously than any of the others. Pinel entered his cell unattended and calmly said to him, 'Captain, I will order your chains to be taken off and give you liberty to walk in the court, if you will promise me to behave well and injure no one.' 'Yes, I promise,' said the maniac. 'But you are laughing at me. . .' His chains were removed and the keepers retired, leaving the door of his cell open. He raised himself many times from the seat, but fell again on it; for he had been in a sitting posture so long that he had lost the use of his legs. In a quarter of an hour he succeeded in maintaining his balance and with tottering steps came to the door of his dark cell. His first look was at the sky, and he exclaimed, 'How beautiful, how beautiful!' During the rest of the day he was constantly in motion, uttering exclamations of delight. In the evening he returned of his own accord to his cell and slept tranquilly."

            In Europe the pioneer work of Tuke and Pinel was continued by Conolly, Esquirol and a growing number of their followers in every country. In America, the standard bearer of reform was a heroic woman, Dorothea Dix. By the middle of the century many of the worst abominations of the old regime were things of the past. The mentally ill began to be treated as unfortunate human beings, not as Objects. It was an immense advance; but it was not yet enough. Reform had produced institutional care, but still no adequate treatment. For most nineteenth-century doctors, things were more real than thoughts and the study of matter seemed more scientific than the study of mind. The dream of Victorian medicine was, in Zilboorg's phrase, to develop a psychiatry that should be completely independent of psychology. Hence the widespread and passionate rejection of the procedures lumped under the names of Animal Magnetism and Hypnotism. In France, Charcot, Liebault and Bernheim achieved remarkable results with hypnosis; but the intellectually respectable psychiatrists of Europe and America turned their backs on this merely psychological treatment of mental illness and concentrated instead on the more "objective," the more "scientific" methods of surgery.

            It had all happened before, of course. Cutting holes in the skull was an immemorially ancient form of psychiatry. So was castration, as a cure for epilepsy. Continuing this grand old tradition, the Victorian doctors removed the ovaries of their hysterical patients and treated neurosis in young girls by the gruesome operation known to ethnologists as "female circumcision." In the early years of the present century Metchnikoff was briefly a prophet, and autointoxication was all the rage in medical circles. Along with practically every other disease, neuroses were supposed to be due to intestinal stasis. No intestine, no stasis - what could be more logical? The lucky neurotics who could afford a major operation went to hospital, had their colons cut out and the end of their small intestines stitched to the stump. Those who recovered found themselves with yet another reason for being neurotic: they had to hurry to the bathroom six or eight times a day. Intestinal stasis went out with the hobble skirt, and the new vogue was focal infection. According to the surgical psychiatrists, people were neurotic not because of conflicts in their unconscious mind, but because of inflammation in their tonsils or abscesses at the roots of their teeth. The dentists, the nose-and-throat men set to work with a will. Toothless and tonsilectomized, the neurotics, needless to say, went on behaving just as neurotically as ever. Focal infections followed intestinal stasis into oblivion, and the surgical psychiatrists now prefer to make a direct assault upon the brain. The current fashion is shock treatment or, on great occasions, prefrontal lobotomy. Meanwhile the pharmacologists have not been idle. The barbiturates, hailed not so long ago as panaceas, have given place to Chlorpromazine, Reserpine, Frenquel and Miltown. Insofar as they facilitate the specifically psychological treatment of mental disorders, these tranquilizers may prove to be extremely valuable. Even as symptom stoppers they have their uses.

            The green oasis among the jets and the rockets is crammed to overflowing. So are all the other mental hospitals of the Western world. Technological and economic progress seems to have been accompanied by psychological regress. The incidence of neuroses and psychoses is apparently on the increase. Still larger hospitals, yet kinder treatment of patients, more psychiatrists and better pills - we need them all and need them urgently. But they will not solve our problem. In this field prevention is incomparably more important than cure; for cure merely returns the patient to an environment which begets mental illness. But how is prevention to be achieved? That is the sixty-four-billion-dollar question.

(From Esquire Magazine)