What do Histories of Cases of Insanity Teach us Concerning Preventive Mental Hygiene During the Years of School Life?
The Psychological Clinic Vol. II. No. 4. June 15, 1908. :Author: Dr Adolf Meyee,
Director of the Pathological Institute of the New York State Hospitals; and Professor of Psychopatliology, Cornell University Medical School.
Mental hygiene has made decided strides in our schools during the last decade. To be sure, the work so far accomplished has had little bearing on the psychological problem of adult mental efficiency. It has veiy properly occupied itself first with those impediments which must be removed to make teaching itself possible, i.e. the correction of disorders of vision and hearing, the avoidance of over-fatigue and other causes of wear and distraction, the regulation of sedentary work and play, the maintenance of general health and nutrition, not to mention the problem of faulty ventilation which so often spoils the clear-headedness of a pupil. In the main, chief attention has been paid to the physical machine, while no adequate provision has been made for its proper direction and control. As a result many will stumble and perhaps fall at the critical period of individual development, when most of the concrete difficulties of mental life arise, such as the direction and balancing of instincts, the shaping of convictions, and the adaptation of one’s capacity to the many possibilities and impossibilities presenting themselves in real life. Here is evidently another problem of which we are forced to take cognizance, the attainment of mental balance. The study of those pronounced mental disorders of adolescence and adult life, which appear to be the magnified results of fate and poor hygiene, should teach us much that will incidentally add to the efficiency and happiness of those who are not so seriously involved or threatened. What does at times fatal harm, is often enough a mere hindrance in a life; it may make just the difference between wholesome success and getting along with discomfort, a difference which may grow to be serious and is bound in any event to cause the failure of many a good effort.
To what extent these more remote issues of mental hygiene can become a matter of concern in the school years is a question worth consideration. It seems to me that a knowledge of modes of miscarriage is best fitted to show us the weak spots of our mental mechanisms. None of our organs are perfect. We can only ask that they be fairly efficient. And in this respect our mental organ is no exception. It is the finest product and the very climax of our evolution, but much attention and patient culture are needed to enable it to cope with the difficulties of ordinary existence, not to mention those realms in which originality, aggressive and productive activity, or conflicting passions and instincts are wont to play an important role. It behooves every workman to discover the weaknesses and limitations of the tools 011 which he must rely, and the first step toward a mental hygiene is an adequate knowledge of the weaknesses and limitations of the individual mind, and of the places at which we do well to provide for braces and balancing material. This knowledge of the limitations of mental capacity and adaptability brings with it not only a direct practical gain, it furnishes also a glimpse into the psychology of modern psychopathology that is itself of 110 small value. Our experience with the phenomena of mental life must be extended. We need adequate forms of expression in which to incorporate the results of a widened experience, as well as properly arranged and classified facts to make clear the significance of our conclusions. That the Ilerbartian psychology, for instance, with its way of seeing some facts, furnished valuable principles to the pedagogue, nobody but a partisan would dispute. That the principles, and still more the plain facts of modern psychopathology, furnish us with some practical and helpful standpoints, I hope to be able to show. What principles to guide our action and to shape our teaching are we taught under the merciless whip of disease, and through the encouraging experiences of therapeutics ?
To understand the significance of my appeal for mental hygiene from the psychological side, it must be borne in mind that psychopathology is beginning to assign a definite role not only to the growth, nutrition and possibly extraneous diseases of the brain, but also to those brain conditions which we know and use only as mental states and mental activities in the sense of a dynamic psychology. We are beginning to consider as legitimate material of science what common sense lias taught us and the teacher has long used in practice. We want to know the effect of certain activities and reactions on subsequent life, and also whether by modifying mental attitudes and habits we may not be able to avert trouble in the future.
Not all the mental disorders which are classified together under the one term, insanity, are equally pertinent and instructive. When we endeavor to consider the various forms of mental inadequacy in a way that will make clear to the educator their chief points of difference, we are able to distinguish three main groups. In the first group are states and conditions of mere defect, which a person may carry through life without progressive damage, unless some special strain occurs. These include the idiocies, the imbecilities, and the more limited defects of sensory or other mechanisms. An imbecile who has found his level can easily get along in safety. His trouble is merely a residual disorder, not a progressive, or as we say, an active one.
In the second group we find those active disorders which are due in some way to extra-psychological disturbances of metabolism of the nervous understructure and the nutrition generally, ?the intoxications (alcohol and drug disorders), the auto-intoxications (such as the deliria and states of confusion, or fear, or suspicion, that occur during or following infective fevers, or that follow exhaustion), and in addition certain special diseases of the nervous system (especially general paralysis, arteriosclerosis, senile dementia, etc.).
In the third group we find that which is of special interest to us in this paper, viz., disorders essentially of the mental sphere, either progressive or episodic. These are disorders of those adjustments of the organism which consist in the proper mental reactions. Among these we may perhaps distinguish the logical, the emotional, and the volitional reactions or modes of adaptation, to use ‘terms which do not deviate too far into medical psychobiology. I refer to those depressions which are a mere exaggeration of an otherwise normal reaction, to hysterical disorders, and especially to those peculiar stupors and delusional and other developments which depend partly on inherited or acquired types of mental endowment, but more especially on factors which by themselves are mentally upsetting, although at times helped along by incidental physical disorders. These disorders of the mental sphere are those which concern us in this present discussion. The most serious affections which fill our hospitals for the insane are due to those difficulties of instinctive and emotional adaptation, which form both theoretically and numerically the most important types of psycho-biological problems. We may admit that approximately ten per cent of the admissions to hospitals for the insane suffer from general paralysis or paresis, and about twenty per cent from alcoholic psychoses, that is to say, from disorders with a plainly bacterial or toxic non-mental factor as the exciting link?to be sure also based primarily upon a deviation of instincts, but rather upon an excess of what is considered sane enough to be tolerated as a mere social evil, namely, alcoholism and irresponsible sexual relations entailing risk of venereal infection. But at least thirty per cent of the admissions seem to make up a group of disorders of the more ‘personal, instinctive adjustments involving a miscarriage of instincts through lack of balance,?dementia prcecox.1 This type of mental disorder is peculiarly liable to lead to permanent collapse, and is one in which the so-called psychogenic factors are especially prominent. To be sure, even this group of psychoses is referred by many to auto-intoxications, and to other hypothetical assumptions, while the simple laws of disturbance of the proper activity and anabolism and catabolism of the nervous system would give adequate explanation.2 Certainly the number of those is increasing who agree with me that the bulk of the manifestations subsumed under the caption of dementia praecox may be most practically expressed as the inevitable and natural development from a deterioration of habits, partly due to developmental defects of the mental endowment, but in part at least to the clashing of instincts and to progressively faulty modes of meeting difficulties, and the disability of a proper balance of anabolism and catabolism which they entail.
Looking over the records of sufficiently studied cases, I find that the children who later developed abnormal reactions of the type of dementia prsecox were peculiar, rather than defective in the sense which we have in mind when speaking of those who are backward or retarded. Furthermore, I find that as a rule we are concerned less with aggressive mischief (which is more apt to lead lA precocious or early dementia in contradistinction to the dementia of senility.
2Anabolism and catabolism imply the constructive and destructive changes during nutrition and growth on the one hand and function on the other; metabolism includes both the integrative and the disintegrative processes of a chemical nature.
to the truant school and to social delinquency) than with repression, and with what is at times characterized as “depth of thought”. The children affected are the very ones whom a former generation might have looked upon as model children. Allow me to present a few brief histories of patients, in which I shall refer more particularly to facts observed in the years of school life. I purposely abstract the statements of the cases in the language of the original histories.
The first case is a school girl of sixteen, coming from a family of ignorant Russian Jews, without any history of insanity in the family. The parents considered her a bright child, but of an unusually quiet disposition. Beginning about four years ago, a gradual change manifested itself in the patient; she became abnormally quietj grew dull and apathetic in her behavior. She seemed in poor physical health, was easily irritated, occasionally bad crying spells, sometimes laughed without apparent reason,?she lived with her mind turned inward. She exhibited lazy traits, slept a great deal and refused to do errands for her mother, giving as an excuse that she was not dressed well enough to go out. The patient had been in the public schools for nearly two years. A note from her teacher states that while the patient was well behaved, she was very dull, noticeably peculiar in her manner, and of an unsocial disposition. Four months before admission she was examined by a school physician and ordered to report to the officer of the Board of Health. This appeared to frighten her; she feared deportation, remained home from school, and it was difficult to get her out of the house at all. She would stand for hours at a time gazing out of the window, occasionally she talked excitedly, or repeated one word over and over again.
Two months before admission to the hospital she ceased to talk. She remained in bed and slept most of the time. She finally became excited, threw herself about, struck and kicked anyone who approached her, yet remained mute. With us she showed a simple stupor, at times with drooling, but of late she has begun to take up a little work when requested, but remains mute.
While this child attracted the attention of the school physician, it was evidently only when too late, and with results that merely aggravated the difficulty.
On looking over a number of records I find the following remarks about several other patients during their years at school:?
L. H. was giddy and backward in school, excessively timid and bashful; masturbation from ten years. N. B. was very quiet, sleepy; of inefficient mentality; seclusive, shy, retiring.
M. O’N. was bright; later was discontented and shiftless; masturbation. L. L. said, “I seemed awfully stupid and dreamy.” Although diligent, she failed of promotion. R. S. learned slowly and was seclusive.
Another very frequent type is the one furnished by the following case, who i3 said to have developed normally during childhood, though she was looked upon as a “nervous child/’ easily startled and subject to bad dreams:
She began school at seven years, was smart, and applied herself well, but at the age of eleven she seemed to be failing and was thought to be studying too hard. She grew thin, seemed nervous, and complained of headaches. At twelve she was in poor health. After she began to menstruate at fourteen, she brightened up, had fewer headaches, and seemed to be in better health. Her sister never suspected any disordered sexual habits, but the patient says that she began to masturbate when nine years old; and she has probably continued this up to the present time (masturbation observed in the hospital). Its effects and whether or not it had anything to do with the failure at school, the headaches, and the later difficulty over work, cannot be definitely determined retrospectively. The patient says, “It spoiled all my youth, and my life. I wasn’t like other girls. I didn’t want to go out anywhere,” ?and therewith she probably hit the truth. She was disappointed at home, for some time dreamt of becoming a teacher, but soon sank into hypochondriacal ruminations and finaly, at twenty-one, after useless operations, passed into a confused religious excitement followed by stupor, in which she sits inactive and irresponsive, with the top-heavy and yet empty notion of being good, of saving the world, etc.
I have used purposely the expressions which the histories contain, that is, the terms in which the facts were submitted and thought of by the friends or teachers. What is mentioned would probably appear to the routinist as quite unimportant and trifling, and it is only through an examination of these expressions in the light of later events of a plain and serious mental disorder, that they gain their proper value.
I wish to be clearly understood here. A very sane human instinct forbids borrowing trouble. We realize that there are many children who show the traits mentioned, and possibly we know that some of our friends manifested traits like seclusivePREVENTIVE MENTAL HYGIENE. 95 ness, occasional day-dreaming, and discrepancies between thought and action. It must be admitted that these traits alone are not sufficient indications of inevitable failure. On the other hand, we insist that those who can take and heed a warning will be saved from danger by a timely recognition of what risks there are. A knowledge of the mode of development of some of the graver mental disorders must help us to discriminate those traits of character that should serve as warnings to be heeded. A good instance of this is furnished by an analysis of the cases of dementia prtecox. The lesson which these cases teach will be lost only upon those who close the road to investigation with the prevalent idea that these cases develop through some fatal necessity, as the result of what some choose to call the laws of degeneracy. These supposed laws, however, are conclusions drawn from statistics that have been collected without reference to whether anything was done for the patient or not. Admitting the importance of the mental traits, it may be contended that the small accomplishment of traditional pedagogy in its efforts at prevention argues for the belief that these cases would have failed in any event. But let me ask, are not these traits usually slighted, and are they not most difficult to treat, and is not a better knowledge of the facts necessary to their satisfactory treatment? The laws of degeneracy are based, in part at least, upon cases and facts concerning which the last word of a practical psycho-biology has not yet been spoken. There is no reason to assume that the mental reactions of cases presenting “symptoms of degeneracy” are essentially different from the mental reactions of normal persons. We need not assume any special or unusual toxic agency in order to account for the tenacity of these symptoms. Consider in this connection how difficult to eradicate from even the normal mind are superstitions and queer ideas, not to speak of peculiar religious or political conceptions. These ideas are only less harmful than the reactions we have been considering, because they happen to occur in domains of thought and action wherein the patient is less likely to be involved in practical tangles, for the very good reason that society ordinarily avoids encouraging them, whereas the more harmful directions aro those in which few or no corrective helps are offered. We can, therefore, understand that a pedagogy with a knowledge of the principles may achieve what the ordinary pedagogy has failed to accomplish as yet. This achievement will come less as the result of attempts at eradication than through the more rational method of furnishing such timely protection and balancing material as will make dangerous tendencies harmless.
A consideration of carefully studied cases of dementia prascox convinces me that in reality we have to do with a perfectly natural, though perhaps unusually persistent development of tendencies difficult to balance. Evolution’s method of trial and rejection will lead some children into a reading craze, others into mere day-dreaming of an apparently indifferent, though often fantastic kind, and still others into sexual imagination, which in passing, it may be well to remark, is often as serious if not actually more serious than the often harmless abnormal sexual practices by themselves. All these tendencies are common traits of adolescence, usually offset in one way or another by the more natural and sociable children. The correction comes from more powerful attractions exercised in an opposing direction by better instincts; or the consequences of the failure to meet the requirements of actual life may call for a halt. Here the very habits of the patient, the loss of sense for the real, and the abnormal satisfaction in mere dreaming and good resolutions, encourage a mere dodging of the consequences rather than the giving up of the harmful instincts. To those who meet with failure, there come as further burdens the comparison of themselves with others and the resultant feeling of being at a disadvantage. These feelings are especially strong in those who have ventured or have been hoisted above their level, and they are augmented by a natural irritation at being reminded of the disadvantage under which they labor,?an irritation which is added to that which is the natural outcome of brooding over disappointments and incapacities. In the real failures, we then find a covering up, rather than a correction of the harmful yaernings. There develops an insidious tendency to substitute for an efficient way of meeting the difficulties, a superficial moralizing and self-deception, and an uncanny tendency to drift into so many varieties of shallow mysticism and metaphysical ponderings, or into fantastic ideas which cannot possibly be put to the test of action. All this is at the expense of really fruitful activity, which tends to appear as insignificant to the patient in comparison with what he regards as far loftier achievements. Thus there is developed an ever widening cleavage between mere thought-life and the life of actual application such as would bring with it the corrections found in concrete experience. Then, under some strain which a normal person would be prepared for, a sufficiently weakened and sensiPREVENTIVE MENTAL HYGIENE. 97 tive individual will react with manifestations which constitute the mental disorders constituting the “deterioration process” or dementia prsecox. Unfinished or chronically sub-efficient action, a life lived apart from the wholesome influence of companionship and concrete test, and finally a progressive incongruity in meeting the inevitably complex demands of the higher instincts,?this is practically the formula of the deterioration process.
It is interesting to watch nature’s way of coping with these incongruities of development. Very often the traits which we are analyzing appear in pupils of relatively good endowment. The result is then, often enough, merely a so-called nervous prostration, a temporary break-down, or a mere slump in which the patient goes through a period of relative inactivity during which he gets a chance to find himself and to emerge gradually from the ill-adjustment, but unfortunately too often with broken ambitions, a disappointment to himself, his friends, and his teachers. These cases show us nature’s plan: she uses a period of invalidism which furnishes temporary protection against the harsher demands that would have to be met in an environment of normally healthy persons,, and affords opportunities for a gentle acquisition of balancing material. It is our duty toward those of less fortunate assets to provide a more timely and more rational reduction of the demands made upon them and to supply them with the balancing material which will rescue at least a certain number of them who would otherwise completely fail.
To those who think that it is scarcely worth while to trouble ourselves over the few who would fall by the wayside anyhow, I can address no stronger plea than to urge that what often leads to complete breakdown in some, will partly spoil the life of others, or at least seriously interfere with their success. What appears as though seen through a magnifying glass in the serious deteriorations, is met with on a smaller scale as frequent impediments. Consequently, any increase in our knowledge is bound to help us to formulate the best possible hygiene of conduct even for the normal. It will make us realize that the ordinary principles of work and rest, of exercise and its influence upon our readiness to meet the ordinary demands of life, must also be applied to the more personal issues of our life, where we are concerned with the training of character, and with the storing up of energy with which to meet the inevitable conflicts of both the individual and the social instincts of a more complex nature. It is in this sense that I have lately spoken of the solidarity of mental hygiene and ethical conceptions.
I cannot expect to do more than indicate very briefly some of the methods of treating the type of conditions herein referred to. The psychologists have scarcely touched as yet the most interesting chapters of psychology, those that deal with the evolution of instincts in the individual and the methods of controlling and guiding them through their inevitable conflicts. The problem is first presented in tangible form where we follow the development of habits, the mutual reinforcing of inhibitory influences upon one another, and their compatibility and incompatibility. We there feel the need of principles which would guide us in measuring the capacity of a child to acquire and balance new habits. The study of defectives and failures brings home to us most forcibly a fundamental fact of economics,?that certain persons are adequately endowed for small demands, but are bound to fail under an excessive demand. There would be far more happiness and real success in mental hygiene, if more people would realize that at every step, every person can do something well and take a satisfaction in doing it, and that this satisfaction in something done is to be valued as ten times greater than the satisfaction taken in mere thought or imagination, however lofty. Most failures in life are persons who withdraw from straightforward and wholesome activity into seclusion, into flights of imagination, or so-called “deep-thought,” all of which tends to make ordinary concrete activity appear as shabby and inferior.. To find pleasure in mere activity, however humble, is a safer ideal and constitutes to my mind the basis of what is sometimes called the Anglo-Saxon superiority. It must be remembered that thought at its very best is only a link in a chain of events leading up to some final achievement. Its real and lasting fulfilment is found only in action.
Janet has constructed an interesting hierarchy of mental functions. His study of psychasthenia3 brings him to the conviction that complete action is the most difficult and highest function. I am tempted to add that completed action is the first essential for rest and for beginning something new. I thus come to describe the development of dementia prsecox as being essentially a deterioration of the instincts of action. It consists in a substitution of inefficient and faulty attempts to avoid difficulties rather than meet them by decisive action. The seclusiveness is usually a poor method of seeking protection ^vhich might be obtained in other 3A word, meaning literally mental weakness, recently introduced to designate various forms of mental debility, not amounting to insanity.
ways less likely to lead to cumulative trouble. If opportunities for doing and accomplishing simple and enjoyable things could be furnished, mere dreams of doing and accomplishing things would be less tempting. Otherwise for lack of the steadying control exerted by real activity there results a scattering of thought and with it the odd dissociations constituting dementia prsecox: a splitting not into the picturesque multiple personalities that tempt the novelist, but into mere grotesque fragments of mentality, which become well nigh unintelligible to one who is unfamiliar with psychopathological analysis. The wildest and most incongruous products of constructive imagination parade in the patient’s mind, and the symptoms of dementia prsecox stand before us as the natural evolution of miscarried mental development. The study of imbecility teaches us that if the defective only finds his level, there is no danger of further complication, but where nature is not kind enough to take away the temptations and ambitions, as well as the capability for a successful adjustment, we find often enough that imbecility is superseded by dementia prsecox. Here we must apply nature’s principle of protection. We must find the proper level for the child, and for a time at least withdraw it from unhappy and untimely comparison, from the strain of disappointment, from inactivity and from poorly balanced flights of imagination.
One of my most urgent suggestions would be to take seriously every falling off in efficiency of the pupil, and to consider not only the nutrition, and the condition of the eyes and the possible existence of adenoids, but also the more intimate needs of self-direction. It would be well to submit to the school physicians many of the requests that are made for relief from studies. Headaches are an excellent barometer of practical mental hygiene; even where physical causes are found and removed, headaches in children are almost always an evidence of blundering by the child, by the parents, or by the school.
I should like to insert here as further illustrations of what is needed, a number of cases kindly communicated to me by Dr August Hoch: 1: “At school, in the rather problematic setting of a church home, the patient had no ambition, no stability of purpose, is said to have disliked work, and always laid this to headaches and the like. Besides, she was untruthful. All these are statements of a teacher who added that nothing seemed to take a deep hold of her. When twenty she became silent, sat about apparently dreaming, and did nothing; then developed the catatonic stupor, which soon terminated in dementia.” This is the result with a child evidently placed in a wholly unsuitable, probably excessively repressive environment and kept in a mood of discord for years.
2: “The patient is said to have been retiring, modest, shy; had to be driven to play. The parents say that the other child they have is aggressive, while the patient was not; that the other looked out for herself, while the patient relied on others. She was always afraid she had not done things right, and told other children that they must obey their parents. She was ashamed of her menstruation, and studied too hard. When thirteen she became inactive, lost interest, also was dissatisfied with things, got rattled at school and could not do her work. Then followed occupation with and vague talk about deep subjects, such as ‘why does the universe exist?’ and so on. By fifteen she was gravely deteriorated”?plainly the victim of forced competition with a sister of wholly different endowment. 3: “It is claimed that especially since the age of eight, after measles, she did not grasp things so readily as before; she was self-conscious, felt awkward, especially socially, and was very sensitive about it; but said little in regard to it, and in general talked very little. The mother says that in this respect she was like her father, from whom you never could get anything, or, as she put it, ‘Man hat nie etwas aus ihm herausbringen konnen.’ Besides that, she often sat brooding, was uncommonly systematic and ‘finicky.’ At about the age of fifteen a seclusiveness became more marked. At seventeen she went to a fortune teller, who told her she would go insane, which prediction preoccupied her much. At eighteen she fell in love, and her love was not reciprocated, and then she became careless, apathetic, and deteriorated rapidly, presenting a great many phenomena of blocking delusions, catatonic states and the like.” To sum up, I should urge that we spread among teachers and pupils a realization of the fact that knowledge must be a knowledge of doing things, and next a knowledge ready for doing things. Even in cultivating the instincts of play and pleasure we must aim to make as attractive as possible those games and diversions which require decision and action, and carry with them a prompt demand for correction of mistakes and reward for achievement: actual play with others and for others, and not the play of mere rumination. We further must aim to find levels of activity with moderate demands and well within the limitations of even the less brilliant or less vigorous children and yet giving full enough satisfaction to remain attractive and truly stimulating.
It is lamentable to hear youngsters, encouraged by their elders, refuse to do certain things because they already know how to do them. When doing things becomes less attractive than knowing things, an avenue for disappointment if not for failure has been opened before the pupil. It is evidently the plain duty of those who have to map out curricula and those who have to advise as to the life of children who are in danger, to see that the doing of things is made infinitely more attractive than is usually the case. I do not see why the success of efforts directed toward this object should not appear more glorious than, or at least as glorious as, the devising of some new plan of cramming the pupil with the subjects of a conventional curriculum. Thus it is that through training in wholesome action as well as in physical culture a real hygiene is making its way into the schools. It would probably be wrong, and certainly Utopian, to expect that schools should create special classes for every special emergency. I rather look forward to the establishment of school hospitals, or hospital schools, which will undertake at the proper time the investigation of special difficulties presented by certain cases, and provide for the training of the child and the parents. At the same time, a more careful study of levels of capacity and of ways of making the easier levels sufficiently attractive and full of meaning, may well become a matter of serious co-operation between the pedagogue and the psychopathologist.
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