Esquirol (1772-1840). The influence of Esquirol was as radical for
the scientific study of the subject as had been that of Pinel for the
humane treatment of the sufferers. Esquirol threw himself into the
task of founding properly conducted asylums, and he produced in 1838
his monumental work _On Mental Diseases considered in their Medical,
Hygienic, and Legal relations_. It is the first important, rational,
scientific treatise on the subject. Esquirol abandoned the barren type
of speculation that had characterized previous works on the subject
and devoted himself to the systematic collection of data. He was able
to sketch out some of the main forms of insanity, including that now
known as ‘General Paralysis of the Insane’. This disease was finally
differentiated by one of his pupils. Another pupil of Esquirol was the
first to succeed in the training of idiots. The main school of French
alienists is descended from Esquirol. In the early forties his work
resulted in the foundation of journals and societies devoted to the
study of Insanity in France, England, the United States, and Germany.
England was behind France in her treatment of the Insane. Not until
1828 were there proper laws governing their certification. In 1844 the
great and good Lord Shaftesbury (1801-85), the seventh Earl, brought in
his Bill establishing the Board of Lunacy Commissioners with the duty
of inspecting all lunatic asylums. It was a subject to which that great
philanthropist gave much thought. The same period saw also an awakening
in the United States, where Miss Dorothea Lynde Dix (1802-87) carried
on a very successful campaign for the better treatment of the insane
and the establishment of proper houses for their reception. Her labors
resulted in the foundation of many asylums on a reformed model in the
United States and Canada. In 1845 the provision of asylums out of the
local rates was made compulsory on the local Justices in England.
The late sixties and early seventies saw in every country a further
change for the better in the treatment of the Insane. The causes of
this improvement were two. On the one hand, Insanity came generally
to be recognized as a group of diseases which, like other diseases,
have usually a traceable physical basis. On the other hand, the great
improvement of the system of nursing under the inspiration of Florence
Nightingale (pp. 298-300) began to reach the asylums. In 1877 there
was a Parliamentary investigation into the care of the Insane in
England and Wales, and in 1890 the duties of asylum administration were
transferred from the Justices to the County Councils. This has resulted
in an immense improvement in the accommodation and treatment of the
insane poor in England. At the same time the order of a magistrate
became necessary for the consignment of a private patient to an asylum.
In 1913 provision was made for the mentally defective, who do not come
within the Lunacy Act. Lastly, with the establishment of a Ministry of
Health in 1917, the general control of the Insane has passed to that
body.
Many types of insanity have been traced to an organic cause in the
Nervous System itself. The Morbid Anatomy, both coarse and microscopic,
of some of these diseases has become recognized. Chief among them is
the well-known condition known as ‘General Paralysis of the Insane’.
During the intensive study of the factors in the causation of Insanity
it has become clear that in some groups, as in General Paralysis, which
is always preceded by Syphilis, a ‘toxic cause’ is at work. Other
types of toxic insanity are due to the actual intake of a poisonous
substance. This is sufficiently evident in cases which are associated
with Alcoholism. There is also evidence that in a considerable
number of cases toxic conditions result from perversion of metabolic
processes, or, again, are associated with ‘deficiency’ states (pp.
302-8). This is a very hopeful finding, since by removing the toxic
cause, or by remedying the deficiency, relief may be possible.
Much less hopeful is the outlook with those forms of insanity,
especially common in the adolescent, which are of the nature of a
perversion of development. Such is the large group known as ‘Dementia
praecox’. These cases almost invariably originate from a mentally
unsatisfactory stock. This is less so with the Epileptic insane, though
a considerable proportion of epileptics may be classed with those
who are born mentally defective and are liable to give rise to a bad
stock. Whatever view may be taken of the question of the artificial
limitation of human fertility, it is almost impossible to imagine that
the free breeding of these classes of defectives, epileptics and their
congeners, will continue unchecked in any civilized community.
The general care and treatment of the insane has improved out of
all knowledge during the last quarter of a century. It is probable
that there is now no class of sick person who is more skilfully and
considerately cared for.
From time to time an alarm is raised at the rapid increase in Insanity,
and it is a fact that the proportion of certified insane has been,
for some time, steadily rising. A considerable part of this rise is
certainly due to the greater willingness of the insane themselves to
enter an asylum, and of their friends to allow them to do so. Part of
the rise in numbers of the insane is due to their increased length of
life under improved treatment. It must be remembered that more than 90
per cent. of the insane in England and a similar percentage in other
countries are paupers, who are not readily discharged as they have no
means of support. Mild mental cases and the senile insane go now to
the improved asylums. Before they would have been kept at home or sent
to a rate-supported or a State infirmary. The general conclusion of
those best qualified to judge is that Insanity, if increasing at all,
is doing so only very slowly.
[Illustration: FIG. 127. ‘THE RETREAT’ NEAR YORK FOUNDED IN 1792
being the first institution in England where the insane were accorded
humane and scientific treatment.]
§ 16. _The New Movement in Psychology._
During the last half-century various new points of view have entered
into our conception of Mind and its disorders. The evolutionary view
of the origin of man, which was brought to wide notice by Charles
Darwin, not only in his _Origin of Species_ of 1859 but also in his
_Descent of Man_ of 1871 and his _Expression of the Emotions_ of 1872,
has given rise to new ideas as to the nature of many instincts and
emotions. These views have been co-ordinated with our knowledge of
lower types of man, both in his existing state and in his extinct and
fossil forms. Much that we call Insanity has been found to be related
to what is normal in other and less developed environments. The Mind,
breaking free from its habitual restraints, ‘reverts to a lower type’.
There is a constant though unconscious ‘conflict’ in the mind, which is
variously resolved.
Whole schools of Psychology have arisen in the discussion of the nature
and resolution of these conflicts. Sigmund Freud of Vienna (1856-)
takes the leading place among those who have dealt with this subject.
He holds these conflicts to be rooted in sex and has introduced
the method of _Psycho-analysis_, which lays great stress on the
subconscious or unconscious element in mental life. Largely under the
direction of C. G. Jung of Zürich (1875-), preventive and curative
measures, based on this view, have been introduced into medicine.
It has been established that painful experiences, lurking in the
unconscious mind, disturb the equilibrium of health. Such disturbance
is often of the nature of a struggle to repress into the unconscious
unpleasant memories which are tending to surge up into the conscious.
The psycho-analyst seeks to release the repressed experience into the
conscious. The recognition and consideration that follow a success in
this attempt is often far less painful than the repression. Persistent
unreasonable fears on the part of adults, but especially of children,
are frequently thus dispersed.
The importance of suitable environment to children has always been
recognized. But a new significance has been given to the mental
impressions received in infancy by cumulative evidence of harmful
results in the adult life of events in the early years of life that
are seemingly forgotten. This recognition of the enduring character of
mental impressions has led to a movement for the better instruction of
mothers, and has thus been a factor in the remarkable development, in
recent years, of work for infant welfare.
It is recognized, moreover, that certain instincts--such, for
example, as the self-regarding instinct and the sex instinct--must
have expression. Mere repression of such instincts is always harmful,
but they are susceptible of a process of transformation, technically
known as _sublimation_, to an almost indefinite extent. Thus the
self-regarding impulse need by no means lead to the inconvenience and
discomfort of others, but, rightly guided, may develop into a sense
of personal responsibility for the welfare of others. So, too, sex
instinct is but one aspect of that creative vital activity on which
depends the continuance not merely of the human race but also of the
culture that the race has built up. The sex instinct is thus habitually
sublimed into other creative channels, and there are many altars,
beside those of Venus, at which young men and women may kindle their
essential fires.
§ 17. _The Revolution in Nursing._
During the Middle Ages, and in Catholic countries after the
Reformation, attendance on the sick in Hospitals and elsewhere was the
task of religious sisterhoods. In Protestant countries the absence of
these sisterhoods necessitated the employment of women specially for
the purpose. The task was not an attractive one, nor did any social
distinction attach to it. The profession of nurse became despised
and was followed, for the most part, by a low and illiterate type of
woman, though midwives were sometimes better educated and of a higher
class (p. 180). The great philanthropists of the eighteenth century
(pp. 171-72) could do little to improve the nursing profession.
The conditions of employment formed the root of the evil. The vast
improvement that has resulted in health and happiness to our whole
population from the improvement in the character and training of nurses
is probably seldom realized, even by medical men. Yet it may reasonably
be doubted whether all modern medical and surgical advances put
together--apart from Preventive Medicine and Infant Hygiene--have saved
as many lives as the Reform of Nursing.
The reader may gain some insight into the life of a nurse from the
conditions that prevailed until beyond the middle of the nineteenth
century at a very good and well-managed English provincial hospital,
the Radcliffe Infirmary at Oxford. The salary of a nurse was £5 a
year. There was no distinction between a nurse and a domestic servant.
One nurse only was the allowance for a ward of seventeen patients. A
nurse’s day began at 6 a.m. The wards were cleaned till 7, when a bell
was rung and each nurse had to bring down her ashes and sift them under
the direction of the porter, who then gave her coals for the day. She
took breakfast with the patients, who helped her, so far as they were
able, with the ward work. At 2 p.m. she went to the servants’ hall,
where she had her dinner in company with the servants on daily hire.
During the dinner the ward was left in charge of a patient. After
dinner she took away a plate of meat and vegetables for her supper. For
the night there was normally only one nurse for the whole hospital of
about 100 beds. There were no regular holidays, and the nurse was never
allowed to leave the hospital before 6 p.m. The practice of nurses
receiving gratuities from patients continued till 1870 and even beyond.
Those patients who wished to secure a nurse’s early attention for their
dressings gave tips, those who did not frequently had to wait.
What sort of woman could such a system produce? That some nurses at
least were kind and skilful, even under such conditions, is a fact, and
is pleasing evidence of the natural goodness and wisdom that reside in
the human heart. Many, however, can have been no better than Sairey
Gamp and Betsy Prig.
The first important reform in Protestant countries began in Germany,
through the influence of Elizabeth Fry (p. 171). In 1822 Theodor
Fliedner (1800-64), the young pastor of the church at Kaiserswerth, a
little town on the Rhine near Düsseldorf, visited England and was much
impressed by Elizabeth’s teaching and example. Returning to his charge,
he devoted himself to the spiritual and physical care of jail-birds. In
1833 he and his devoted wife Frederica (1800-42) opened a refuge for
discharged female convicts. From them the couple turned their attention
to the sick poor. The conception of an organized body of specially
trained women crossed their minds. In 1836 they opened a small hospital.
At this hospital six young women of the most spotless character were
induced to serve as ‘deaconesses’. It was their duty to perform all
the tasks of the hospital in rotation. The physicians who attended the
hospital gave them instruction. The Kaiserswerth idea rapidly spread
and the ‘Kaiserswerth Deaconesses’ became and remain an important
order, which is still occupied in good works in many parts of the
world. The conception of the order is different from that of most
religious orders in that the members make no attempt to withdraw from
the world, and marriage is not forbidden to them. Moreover, the duties
of the Kaiserswerth deaconesses are rather different from and more
varied than those of a sick-nurse. They include teaching, both secular
and religious, nursing, household duties, management of children and
convalescents. In 1865 a preparatory school for probationers was opened.
In England Anglican orders of a somewhat similar character were formed
in the forties and fifties. In 1850 and 1851 Florence Nightingale
(1820-1910), who was a lady of good social rank, visited Kaiserswerth,
and went through a regular training there. She was profoundly impressed
by the extremely high character of the deaconesses, most of whom were
only peasant women. The next three years she spent in writing and in
examining hospitals in her own country.
Florence Nightingale’s opportunity came with the outbreak of
the Crimean War in 1854, and the rapid breakdown of the medical
services, which contained no women nurses. The French had a number
of ‘religieuses’ to nurse their sick, and a feeling of shame arose
in England at the neglect and mismanagement of the British sick and
wounded. The Secretary of State for War asked Florence Nightingale to
go to the Crimea to organize a nursing service. She left at once with
thirty-eight nurses whom she selected personally. Ten of these were
Roman Catholic sisters and all the others had had nursing experience.
From that event dates the Revolution in Nursing. Florence Nightingale
performed marvels under conditions of great difficulty (Fig. 128) and
in the face of determined opposition. She returned home in 1856 a
national heroine. She had no difficulty in establishing a school and
home for nurses at St. Thomas’s Hospital in London in 1860. The example
was followed by the other London hospitals.
Florence Nightingale was a woman of the most powerful will and an
admirable organizer and administrator. Her system of nursing contained
many new features, not quite all of which have stood the test of time.
That nursing rapidly and steadily improved from the moment she was in
authority cannot at all be doubted. Looking back, it is apparent that
the immediate success of her methods was due to two main factors. First
was her capacity to secure women of high character and good social
position to accept positions of responsibility. Second was her removal
of the control of the nursing staff entirely from the hands of men into
those of women. Her influence soon passed across the Atlantic, and she
was associated with the United States Sanitary Commission and the women
who took charge of army nursing during the American Civil War.
While Florence Nightingale was reforming Nursing, her contemporary,
Mary Carpenter (1807-77), was applying herself to the kindred task
of looking after neglected children, establishing Reformatory and
Industrial Schools and improving the position of Indian women. She
obtained a large measure of public support and exercised considerable
influence in America, which she visited in 1873. Many other
distinguished and devoted women worked on similar lines.
Among the indirect results of the activity of Florence Nightingale was
the establishment at Geneva in 1864 of the International Red Cross
Committee, the branches of which have done good service in many wars
and have been no less useful in peace.
Florence Nightingale opposed anything in the way of State registration
of nurses. Concentrating on a high ideal of competence and character
for the nurse, she failed to grasp some of the secondary effects of
her own scheme. A large nursing service is now a necessity in every
civilized country, as a result of her efforts and example. Having
regard to human imperfections, we can as little hope that every woman
who nurses will be a born nurse, devoted to her task, as that every
doctor or teacher will have a natural vocation for his work. In an
imperfect world mankind must protect itself against the incompetent and
the unfit. Registration is a way--doubtless an imperfect way--of doing
this. A Nurses’ Registration Act became law in England in 1919.
There have been many improvements in the details of the training of
nurses, incident on the changes in Medicine and Surgery during the last
half-century. Apart from these, the main improvements in Nursing have
been due firstly to an increased interest in the welfare and health
of the nurse herself, and secondly to the recognition that Nursing is
a profession for which, as for Medicine, some preliminary scientific
knowledge should precede professional training. Thus, the very long
hours of the nurse have of late been reduced, and in the best schools
instruction is now given to nurses in Anatomy, Physiology, Hygiene,
Bandaging, and Cookery, before the commencement of actual hospital work.
Further developments will probably be along the lines of State and
Municipal Nursing Services. Since Health is a public as well as a
private concern, the same must be true of the training and work of
nurses.
[Illustration: FIG. 128. FLORENCE NIGHTINGALE RECEIVING WOUNDED AT
SCUTARI
_From a painting by Jerry Barrett_]
§ 18. _Some Modern Physiological Concepts of Clinical Import._
The vast activity in the sciences of Physiology and Pathology during
the last fifty years, and their repeated divisions into independent
sciences, each prosecuted by its own specialists, have yielded many
ideas which have been imported into the clinical practice of Medicine.
It is impossible to say which of these are of permanent value. All
previous ages have had to discard part of the practice and a large
proportion of the medical ideas that have been handed down to them, and
there is no reason to suppose that the age that follows us will differ
from those which have gone before us. Some ideas that have entered
Medicine from the physiological laboratory, pushed by interested
parties or seized on in despair by physicians at a loss for a line of
treatment, are already seen by men of experience and judgment to be no
permanent addition to our store. Other lines of physiological thought
are still under discussion by them.
There are, however, certain physiological conceptions which, apart from
their general implications in the economy of the body, have received
such wide application that their future, as an organic part of medical
practice, seems assured. Certain of these conceptions demand discussion
in even the most cursory survey of medical development.
(a) _Ductless Glands and Internal Secretions._
The nature and action of the various glands of the body has been a
classical physiological field. Malpighi (pp. 116-20) was the first to
investigate the structure of these organs, and he was followed by many
others. It became evident that many glands, such as the liver, the
salivary glands, and the tear glands, are provided with ducts or tubes,
which carry off the characteristic secretion of the glands. These
secretions can be examined with comparative ease--as happened early
with the secretion from the stomach, or ‘gastric juice’ (pp. 146-48),
and later with the secretion of other glands. There remain, however,
certain glands unprovided with ducts. The action of such ‘ductless
glands’ long remained a mystery. Of these the type is the ‘Thyroid
gland’. Much of our physiological knowledge of this organ, together
with the conception of its function as indispensable to normal life,
has come through Surgery.
It had long been known that certain symptoms were associated with
enlarged Thyroid gland or ‘Goitre’. Attempts to remove the organ
surgically were made after the introduction of antiseptic methods.
Goitre is particularly common in Switzerland, and it is not remarkable
that the technique of the very dangerous operation for the surgical
removal of goitres was first perfected by Swiss surgeons, among whom
Theodor Kocher (1841-1917) has taken the first place. The study of
cases that had had their Thyroid glands removed gave a clue to the
nature and action of the gland.
It was found that those surgically deprived of the Thyroid gland
develop abnormal slowness in movement and response. The temperature is
low, the pulse small, the muscles are torpid and sometimes rigid, and
there is a failure in ordinary fine muscular movements. The patient
shows a thickening and swelling of the skin and presents a dull and
very characteristic appearance. When the operation was performed on
one whose growth was not yet complete, development was checked. Such a
patient remains infantile or childish both in body and mind.
The conditions were recognized by Swiss surgeons in the seventies
as resembling those of a spontaneous disease to which the name
_Myxoedema_ was attached. Further the close relationship both of the
surgical and of the spontaneous condition to the state of idiocy known
as _Cretinism_ came gradually into view. In Switzerland, as in other
parts of Europe, stunted beings known as _Cretins_ had long been known.
These defectives are sometimes goitrous, sometimes without a Thyroid
gland, but their general appearance and condition is an exaggerated
version of what has been described for those with Thyroid glands
removed (Fig. 129).
[Illustration: FIGS. 129 and 130. CRETINOUS INFANT BEFORE AND AFTER
THYROID TREATMENT.
_From the Collection of the Royal College of Surgeons._]
The result of these observations was to direct the attention of
physiologists to the Thyroid gland. It was soon found that the symptoms
of Thyroid deprivation could be experimentally produced in animals.
Moreover, it was shown by Moritz Schiff of Berne (1823-1890), in
1884, that the results of the removal of the Thyroid might be avoided
if the animal were fed regularly on an extract of the glands. The
results were soon applied to man and have led to one of the greatest of
medical triumphs. By its means sufferers from myxoedema and cretinism
can be either cured or improved. A drivelling and idiotic cretinous
child, adequately treated with Thyroid, enters on a normal process
of development. The improvement is almost incredible, and the child
rapidly passes into a healthy and happy state, so that it is literally
true to say that his own parents would not recognize him (Fig. 130).
Further, the gland may be given in excessive doses, and a condition
produced that closely resembles a well-known pathological condition
known as ‘Exophthalmic Goitre’, which is similarly susceptible of
experimental investigation.
The facts here enumerated justify the deduction that the Thyroid
gland secretes something which is essential to normal well-being. The
organ has no duct, and the secretion is, therefore, never normally
thrown out of the body. The Thyroid is, in fact, an organ of what is
called ‘internal secretion’. Investigations on this secretion led to
the isolation of the active principle as a pure compound known as
_Thyroxin_ in 1916. The story of the Thyroid has recently (1926) been
rounded off by the preparation of Thyroxin synthetically. The synthetic
product has been given with effect in cases of Myxoedema.