c>^^ ■I'^^y^i-^ a^c- ELEMENTS PSYCHOLOGICAL MEDICINE. y AN INTRODUCTION TO THE PRACTICAL STUDY OF INSANITY, ADAPTED FOR STUDENTS AND JUNIOE PEACTITIONERS. DANIELjNOBLE, F.R.C.S., MEDICAL OFFICER TO THE CLIFTON HALL RETREAT ; AM> LECTURER ON PSrCHOLOGICAL MEDICINE AT THE CHATHAM-STREET SCHOOL OF MEDICINE, MANCHESTER. L N D O.N : JOHN CHUKCHILL. 18.53. fEancljestcr: 3|rinteB bg (CbarUs Simms v'egro 239 CONTENTS. XXI PAGE And in other peculiarities of the Eaces of mankind . . . 240 Varieties proper to particular families 240 Case of the porcupine-man 241 Pathological tendencies originating with apparent spon- taneity may become hereditary 242 Insanity no exception to this law 243 LECTURE VII. Exciting Causes and Physical Treatment. Exciting causes of Mental Derangement 244 Physical causes 244 245 245 245 249 Physiological causes Moral causes Illustrations of Physical causation And of Physiological Moral causes are the most frequent 252 Insanity from moral causes an apparent consequence of Civilisation 253 Commences "generally in painful Emotional excitement 255 Illustrative instance of this 255 Autobiographical narrative by a patient 257 Principles of Therapeutical management 269 Ordinary division of Treatment into Physical and Moral 270 Circumstances which necessitate physical treatment ... 271 Incidental proof from these, of the non-speciality of the study of Psychological Medicine 272 Division of treatment into physical, physiological^ and moral 272 Character of treatment largely deter iiined by Etiological considerations 273 XXU CONTENTS. Page Cases originating in meclianical injury require Physical treatment 273 Insane patients usually intolerant of depletion 274 Delirium not a necessary sign of Inflammation 274 Mental maladies analogous to nervous ailments 275 Undue disposition to treat by depletion, in instances of maniacal excitement 276 Anodynes may become necessary 277 The stomach and bowels demand attention 277 Kecapitulation of Physical treatment in cases physically induced 278 Physical treatment in cases induced by Physiological agency 279 And in cases Morally induced 283 Kecapitulation of Physical treatment generally 288 LECTURE VIII. MoBAx Management of the Insane Moral treatment of Insanity 290 Casesin which such treatment is exclusively indicated 291 Objections which may be urged to the efficacy of purely Moral treatment 291 The general duties of a Medical adviser 292 Influence of the morale upon the pTiysiqiie 295 Striking examples of this influence 295 Eeneficial agency of grateful mental impressions 297 Their action in modern systems of Quackery 297 The success of Quackery a proof of the value of Psychical influences 299 Direct advantages of Moral influences in insanity 299 Lcedentia to be withdrawn, and adjuvantia to be furnished 300 CONTENTS. XXIU PAGE Proper course to be pursued witli cases of Notional insanity 301 Erroneous ideas on this subject by non-professional persons 304 Insane patients have often exalted Emotional sensibility 305 Danger of disregarding this 306 Especial care required in the convalescent stage 307 Beneficial influence of Occupation 307 Influence of past associations 307 Anecdote in illustration 308 Notional Illusions at times to be tolerated 310 Beneflcial eflect, in some instances, of carefuUy combating them 310 Cases in illustration 311 Importance of careful and instructed Attendants 312 Moral treatment of Intelligential insanity 313 Dementia not to be hastily regarded as permanent ... 315 Illustrations of the value of this rule 316 Management of Idiots 317 Beneficial efiects obtainable 318 Modification of treatment demanded in each individual case of disordered Intelligence 319 Treatment of Emotional insanity 319 The value of Self- Control, in recovery from insanity and in warding-ofi* threatened attacks 321 Physical restraint ordinarily mischievous 322 The honor of demonstrating this largely due to Pinel and ConoUy 323 Instances in which it is allowable 323 Value of the periods of intermission during treatment... 324 Removal from home to an Asylum very often indispensable 325 Cases in which this is contra-indicated 325 Cases indicating removal 327 Negative advantages of an Asylum 328 XXIV CONTENTS. PAGE Its positive curative agency ... 329 Eationale of its effects upon the mind 330 The Association of Ideas 380 Power of Sensations and Emotions to reproduce Ideas by association 332 And of Ideas to reproduce Emotions and Sensations . . . 333 Anecdote in illustration 333 Importance of the Law of Association, in the moral management of the insane 334 Its power to invert the manifestations of individual character 335 And the aspect of surrounding circumstances 336 Illustrative explanation of the phenomena 337 Practical conclusion to be deduced 338 General Formula of Treatment 339 iPsigffioloflifal Mt'Huim. LECTURE I. Introduction. Psychological Medicine is that branch of the Healing Art which deals with dis- eases of the Mind, psychology being a word of Greek derivation which signifies a discourse on the soul. Although the constituted medical authorities of this kingdom do not require a distinct course of lectures upon this division of our art, I have been requested by the lecturers B Z INTRODUCTION. of this School to take it up, and to deliver a brief course upon the pathology and treatment of mental diseases. I have had great pleasure in complying with that request. I know that a very large proportion of medical students are but little impressed with the responsi- bilities which, in after life, they may be called upon to assume with reference to patients afflicted with disorders of the mind; and I am sure that great numbers commence practice with absolutely no ac- quaintance with this branch of medicine, and entirely devoid of those particular habits of thought which qualify for its successful practical study. Psychological Medicine, it is true, may be regarded as a specialty in the practice of our profession. On this account, some may contend that it will be quite time enough to study the subject, when the necessity for more than a passing acquain- tance with it shall have become apparent. INTRODUCTION. 3 It may be said that a very small pro- portion of practitioners have to do with asylums for the insane, and that the ma- nagement of eases of insanity rarely occurs in the routine of private practice; and, therefore, that a general acquaintance with its leading phenomena and with the meaning of terms is very nearly all that most medical men are ever likely to want. Such a view of things is quite superficial and very unsound. Facts will not bear it out. In the first place, if it be true that the treatment of insanity is limited to physicians and surgeons connected with lunatic establishments, is not the manage- ment also of several other departments of medicine limited very generally to a small proportion of practitioners? Ophthalmic surgery, in actual practice, falls to the lot of a small number; operative surgery, in its higher branches, is not usually prac- tised by the profession at large ; and forensic medicine is rarely mastered ere- i 4 INTRODUCTION. ditably, excepting by a very few to whom facilities for acquiring the proper expe- rience have, in great measure, arisen accidentally. Indeed, as society advances in ci\'ilisation, and as communities become more numerous and more densely aggre- gated, the tendency to specialisation of medical practice becomes developed cor- respondingly. Division of labour thus obtains in our profession, as in the other vocations which involve the more material relations of business and society- Yet, notwithstanding this truth, there is no sensible student, who, because he had no precise prospect of becoming sur- geon to an ophthalmic hospital, or to the operative department of a general one, or of realising in his future career some marked advantages in departmental prac- tice of any kind, would think it right for one moment to neglect opportunities for learning the elements and groundwork of the several branches, according as they INTRODUCTION. 5 should be afforded in the period of his academic pupilage. Now, it is certain that your chances of being called upon to treat disorders of the mind, systematically and continuously, are just as great as those of your becoming connected, as surgeons, with an ophthal- mic hospital, or indeed, as physicians or surgeons, with any particular division of practice. If, then, during your attend- ance at a medical school, you deem it right and expedient to prepare yourselves for all the accidental occasions of profes- sional success that may arise hereafter, it certainly is not wise to neglect the forma- tion of an acquaintance with the prin- ciples that must constitute your guide in the practical study of mental diseases. But whatever be the position which each or all of you may realise in after life, the occasion will certainly arise, when you will either have to exercise some discriminating judgment with respect to 6 INTRODUCTION. cases of insanity, or you will manifest what will undoubtedly be deemed a dis- creditable ignorance. It is not in lunatic asylums only, that mental disorders have to be dealt with. In the common course of family practice, unhappily, these in- stances perpetually occur; and the ordi- nary medical attendant is expected to be able at least to discriminate between the delirium of fever, meningitis, or alcoholic abuse, and those aberrations of the intel- ligence and morbid states of the aifec- tions, which may exist independently of or beyond those causes. He will be ex- pected, moreover, to distinguish between a derangement that is of a temporary cha- racter and attributable to causes clearly removable, and one which is of uncer- tain duration and little to be influenced by the mere action of medicines. Fur- ther, the family medical attendant is always expected to form some decided opinion as to whether, when insanity is INTRODUCTION. 7 ascertained to exist, there is peril to the patient or to those about him ; and as to whether the nature of the case is such as to demand a removal to some establishment for the insane. Instances involving these several consi- derations arise in the common course of practice, and aptly illustrate the need that exists, on the part of every medical man, for some more exact and extended know- ledge of the subject than is likely to be attained, if you trust simply to the occasional and accidental opportunities of learning it which the future may supply. Moreover, there is neither physician nor surgeon who is exempt from the chances of a place in the witness box, from which, in forensic investigations, he may have to subject his acquaintance with this topic and his dialectic skill to the searching and obdurate scrutiny of some keen-sighted and antagonistic lawyer. There are many examples of medical men being made to 8 INTRODUCTION. look somewhat ridiculous upon going through such an ordeal ; and there are very few, indeed, who can pass it with- out scathe. There is yet another illustration which I will adduce, as exhibiting, in a further point of view, the practical necessity which exists for the student to regard Psycholo- gical Medicine as a department of his profession with which he must establish some precise and scientific acquaintance. The subject of Insanity is one which, of late years, has received considerable attention from the legislature; and there is a commission existing, upon the au- thority of acts of parliament, for super- vising and, in some measure, regulating establishments for the confinement of the insane, — a very just provision in the in- terest of the unhappy patients, and a circumstance protective against injurious suspicion of all who are parties to the detention of a lunatic. INTRODUCTION. 9 Well, it is required by law that no one shall be received, as an inmate, either into a public or private institution for the insane, unless the fact of insanity be attested by two medical practitioners, physicians, surgeons, or apothecaries, who shall have visited separately from each other. The law thus distinctly recog- nises the discrimination of such instances, as being within the duty of every medical man. And it must be remembered that a certificate that a certain person named is insane, will not suffice ; the opinion must not only be stated, but the parti- cular facts and circumstances which au- thorise the opinion must be recited. And it is within my own knowledge how largely this requirement of the law be- trays in some cases the ignorance, and in others the inaccurate modes of thought, of many otherwise estimable members of the profession. Copies of every certificate furnished 10 INTRODUCTION. under these circumstances have to be for- warded to the office of the Lunacy Com- missioners in London, when, if the certifi- cate be defective or unsatisfactory, it is re- turned as being so : that is to say, if the data supplied by the attesting practitioner in authorisation of his professional opinion do not sufficiently bear it out, the friends of the patient are likely to become ac- quainted with the fact; and any want of information, or any inexactitude of ex- pression, displayed upon so very embar- rasing and delicate a topic, will assuredly have no tendency to advance the reputa- tion of the medical attendant. I will exemplify these observations by adducing two or three instances of defec- tive certificates, which were returned for correction by the Lunacy Commissioners, and will point out the circumstance wherein the defect exists. They concern certain persons admitted into the Lu- natic Asylum at Clifton Hall, near this INTRODUCTION. 11 city, an establishment of which I am the medical officer. In the subjoined statements the patients' names are of course omitted, as also the medical sig- natm'es. One certificate runs thus : — " That A. B. is an insane person, and that I have formed this opinion from the fol- lowing facts, viz:, that he has, in addi- tion to other signs of insanity, evinced a suicidal tendency." Now, mark the im- perfections of this certificate. The attest- ing practitioner is required to state, definitely, the particular facts which jus- tify the inference of insanity; in the instance just cited, however, there is no fact whatever adduced ; the conclu- sions only are set forth. Mention is made of "other signs of insanity," but the Commissioners demand to know the nature of those signs, — what they are. Then again, there has been "evinced a suicidal tendency." But by what cir- 12 INTRODUCTION. cumstance evinced? Moreover, the law of the land does not regard the suicidal disposition, in itself, as evidence of un- sound mind ; there is the well-known verdict of felo de se, which is followed by a distinct legal penalty; and the at- tempt even at self-destruction is punish- able by law, and is actually punished in consequence. Here, though you should make good the fact of a " suicidal ten- dency," you do not prove insanity ; you may rather be incriminating the person whose best interests you are anxious to save. Another defective certificate is ex- pressed as follows : — " Having on various occasions seen her in a highly excited and violent state, being dangerous to her- self and those around her." Here, you will observe, there is no fact of insanity stated. Violence and excitation, although often accompanying and modifying this state, need not form its outward expres- INTRODUCTION. 13 sion ; to constitute insanity, something must exist beyond. If violent and ex- cited people, even when dangerous to themselves and others, were always to be reputed mad, lunatic asylums would largely increase in numbers, and would more than rival our magnificent prisons. Ira furor brevis est is an adage of the old Roman times, and is true now as then ; but " furor " does not always imply mental unsoundness, in the legal and pa- thological sense. Here is another attestation, qualified as follows: — "Her extremely excitable state, evidently arising from great debility, and from her being exceedingly suspicious of all parties in attendance upon her." After what has already been stated, I need only remark, that neither the excitability which results from debility, nor a suspicious dis- position, of themselves constitute insanity. Examples like the foregoing are not at all of unfrequent occurrence, but very c 14 INTRODUCTION. much the contrary. I should hope, how- ever, that enough has now been said to impress you with the conviction that Psy- chological Medicine should not be omit- ted from your studies. It is perfectly true that, in this branch of medicine as in every other, practical skill can only be gained by actual expe- rience. Lectures of themselves can never communicate a just and complete appreci- ation of the phenomena of insanity. Ne- vertheless, verbal instruction will do more to promote a true and exact estimate of the subject, than will be found to be the case in most other divisions of practical medicine. A preparation for the business of observation is more necessary, undoubt- edlv, in this class of diseases, than in anv other. The particular facts that have to be observed and understood, are not usu- ally of a character readily made out and plainly intelligible : in many instances, they constitute a veritable riddle, unless INTRODUCTION. 15 there be a previously -acquired principle of interpretation to guide the student ; and this principle can only be obtained by some approach to a correct apprehen- sion and comprehension of the phenomena of consciousness, and by the association of these with physiological and patholo- gical laws. In Surgery and ordinary Me- dicine, there is very much that strikes the senses at once, and is therefore more or less understood from the beginning. In Psychological Medicine the preliminary study requires a considerable abstraction of thought from objects purely sensible. A direction of the mind to things not vi- sible and tangible, is, as we all know, a mental discipline to which medical stu- dents are but little subjected. Yet it is certain that, without some previous in- formation respecting Mind and its indi- vidual differences of manifestation under varying circumstances, it is quite impos- sible to benefit, scientifically, by observ- 16 INTRODUCTION. ing cases of mental aberration. The study of this mental physiology must always, it is clear, be a subject of abstract thought, consisting very much in reflexion upon one's own consciousness. Hence, to ob- serve successfully the operations of mind, whether in its general manifestations, or in its individual peculiarities, or in its morbid irregularities, there must needs be some aptitude for the duty previous- ly attained. And as the due prepara- tion consists mainly in a certain dis- cipline of thought, necessarily wrought through the instrumentality of language, — in communicating instruction upon Psy- chological Medicine, the importance of lectures is sufficiently obvious. In this point of view, then, the usefulness and the need of lectures preliminary to prac- tical study, are probably greater — cer- tainly not less — than in other depart- ments of practical medicine, where the disturbance may be of a nature more physical. INTRODUCTION. 1 7 Some such considerations as these, I beUeve, have been entertained by my col- leagues in their recognition of the grow- ing importance of an acquaintance with Psychological Medicine ; and they have constituted the reasons which have led them to establish the present course of lectures. Any labour which their prepa- ration may have given me will have been cheerfully bestowed, if I can, in any mea- sure, succeed in realising the anticipations that originated them, — if I shall, in any degree, accomplish a benefit to the student in the progress of his career. An enquiry that naturally arises, con- cerns the more precise meaning to be at- tached, in these lectures, to Psychological Medicine. Psychology having reference, etymologically, to the soul, it may be demanded — Can the soul, an immaterial essence, become diseased? In reply I need only to observe, in the first instance, that physiologists and pathologists have no pro 18 INTRODUCTION. fessional vocation to teach theology, to whose domain it rightly belongs to treat upon the soul as a pure spirit. With the soul, independent of its bodily associate, natural science has nothing to do. In phi- losophical investigation, we can deal with the conscious principle only as manifested in functional connexion with the corporeal organisation ; and psychical agency so ex- isting is, by the usage of speech, desig- nated mind. It would be most absurdly out of place, for me here to discuss the vexed question concerning the intimate essence of things. We have faith in the simplicity and spirituality of the soul, and the body we know to be formed of matter occupying space. These separate prin- ciples we uniformly observe to constitute an organic unity. The action of this orga- nisation being perverted, leads to disease ; and this perversion, displayed in functional disorder of the mind, developes the class of diseases with which Psychological Medi- INTRODUCTION. 19 cine is concerned. Thus, mental opera- tions, in the present sphere of existence, taking place under normal or physiological conditions, we regard mental maladies as resulting from disordered or pathological states of the bodily organisation. Insanity, as all are aware, is the generic term which comprehends this class of dis- eases ; and I very much doubt if any de- finition that can be given, will suggest to the student a clearer understanding of the subject, than does the term itself In almost every department of knowledge, definitions have been given that utterly defeat the intention of all definition, which is to render the subject more intelligible than it was before; and this is remark- ably so in the matter of insanity. If any of you will take up some trea- tise upon the subject, and carefully attend to the definitions which are supplied, you will be but little likely, I am sure, to de- duce from them any very exact significa- 20 INTRODUCTION. tion ; you will not be certain that you un- derstand precisely what the authors mean. A notable illustration of this obscurity of definition, may be cited from an author named Harper, who wTote upon the sub- ject towards the close of the last century, and who is quoted with great respect by the celebrated Pinel. It is writ : — "I will take upon me to define and pronounce the proximate cause and specific existence of insanity, to be a positive immediate dis- cord in the intrinsic motions and opera- tions of the mental faculty, exerted above the healthful equilibrium ; its exact seat to be in the prime movement, and its precise extent just as far as the nervous power conveys its influence." This consti- tutes, certainly, a somewhat extreme case ; but many other definitions that have been given of insanity are very nearly as com- plex, vague, and unintelligible. For convenience, and with reference to the views which I shall advance in the INTRODUCTION. 21 course of these lectures, I will venture upon a very brief definition of my own, and will define insanity to consist in chronic disorder of the brain, inducing perversion of ideas prejudicial to, or de- structive of the freedom of the will. Of course it may be objected to this definition, that it defines nothing — that every part of it requires itself to be defined. I am well aware that numer- ous questions underlie the category which I have advanced, apparently so simple. What, it may be asked, is the kind of dis- order said to exist in the brain in a chro- nic form ? Is it inflammation, or some other recognized pathological condition ? And, again, what must we understand by perversion of ideas ? Further, how is freedom of the will to be determined, so that its abolition or impairment may be appreciated ? In reference to these points, I have to observe, first, that the exact or essential 22 INTRODUCTION. alteration in the cerebral structure which produces insanity, is not as yet made out ; next, that by perversion of ideas I under- stand either mental illusions originating false notions, or combinations of thought at variance with the common sense of mankind; and, moreover, that on ques- tions of free will and its loss or deterio- ration, the intuitions of a healthy mind will almost always decide aright. With arguments about fatalism, moral liberty, philosophical necessity, and so on, I have here no concern. K a person should con- tend that the earth is over his head and not beneath his feet, or that two and two make five, of course we leave him hope- lessly to his folly; science and philosophy can never be expected to rid him of the delusion. In like manner, when it is said, or argued, that man is not free, that our volitions are necessitated, we have the pri- mary facts of consciousness to rest upon in maintainins: that we are free ; and the INTRODUCTION. 23 universal consent of unsophisticated huma- nity will concur. As Dr. Johnson once said, — we feel that we are free, and there is an end of it. Once more, then, I define insanity to consist in "chronic disorder of the brain, inducing perversion of ideas prejudicial to, or destructive of, the free- dom of the will." If an individual talk incoherently, and form false and erroneous estimates of the world within, or of the world external to himself, his ideas are thoroughly per- verted, and there is destruction of all freedom of will; he is insane, and the actions flow, not from volition proper, but from impulses accidental. If a person la- bour falsely under the impression that he has offended against the laws of his coun- try, and that the officers of justice are upon his track, he becomes fearful, suspi- cious, and oftentimes remorseful; his ac- tions reflect these feelings, he is insane; the ideas are perverted, and the will is 24 INTRODUCTION. enslaved. Another patient regards his legs as made of glass, and, acting consist- ently up to this false notion, scarcely dares to exert himself, or exercise locomotion ; no matter how accurate his perceptions, or sound his judgments, in all other respects, he is pro tanto insane from the perverted idea; and so far there is prejudice to the freedom of the will. In another instance, a hopeless melancholy falsely suggests the certain prospect of some overwhelming ruin, — it may be temporal or eternal; the patient, unable to endure existence, commits suicide ; he was insane, — the ideas were perverted, moral liberty was prejudiced. The Searcher of hearts alone can decide the extent to which, in these eases, freedom of the will is lost. You see an adult with a head of the baby size ; he can realise ideas but very imperfectly, and is all but unable to effect their combina- tion; he is an idiot, and consequently incapable of exercising w^ill. INTRODUCTION. 25 When some disorder or imperfection of thought is discovered to exist, and when this state of things reacts upon the moral disposition, or has arisen from some depravation of this latter so as to preju- dice moral liberty, what proof have we that the brain forms the organic seat of disease? This inquiry introduces us to a very important topic closely connected with the subject of these lectures ; and it is one which should receive some satis- factory solution before we advance further, since we cannot otherwise proceed with profit and advantage. Writers upon Insanity have not been agreed upon this point. Various portions of the organism have been fixed upon as its especial seat. Some have referred it to the abdominal viscera ; others to the heart; and others again to the organic nervous system of the great sympathetic. These several allocations have each, in their day, been maintained with some D 26 INTRODUCTION. plausibility. In the present advanced state of physiology, however, we may re- ject very summarily these positions as altogether untenable. It is true enough that serious mischief, in these structures, may coexist with mental derangement, and may constitute, indeed, the principal source of many of the symptoms pre- ceding an attack; nevertheless, whenever there is manifestation of actual insanity, undoubtedly there is lesion of a more im- portant organ. What is disease? We define it most simply as altered function, — as consisting in some deviation from the natural, physiological action of the corpo- real organs ; and this deviation forms the subject matter of patholog}^ It is quite certain that neither the abdominal viscera, nor the heart, nor the great sympathetic system of nerves, constitute the organic instrument of the mind ; and hence, how- ever derangements of the intelligence, or other indications of insanity, maybe asso- I INTRODUCTION. 27 ciated with lesion of those structures, its organic seat must be looked for elsewhere. Mental disease is not an alteration of their functions. Before we enter upon more precise dis- cussion of the pathology of mental de- rangement, I think that we may, not un- profitably, recapitulate the principal points of evidence which establish the doctrine that the brain and the higher portions of the nervous system are subservient to the manifestations of consciousness ; a doc- trine which, in its results, renders the con- clusion inevitable that insanity consists, essentially, in perversion of the functions of the brain, — that the true locality of psychological disease is within the head. There is probably no proposition in phy- siology more firmly established, than that the Brain is the organ of the Mind, — un- derstanding by this phraseology that the encephalic organisation forms the material condition under which, in the present life, 28 INTRODUCTION. psychical agency displays itself. Facts of every kind attest the truth of this doc- trine. Wherever there are observed une- quivocal signs of consciousness, the pre- sence of a brain and nervous system is inferred. Self-consciousness, in the order of nature, would seem to be universally manifested through the instrumentality of brain ; a communication with the outer world being established and maintained by the agency of nerves. On these gene- ral propositions, physiologists are mainly agreed. Among speculative philosophers, some will be found who contend that the soul of man, the immaterial principle of his nature, can, in some of its attributes, display activity in complete independence of bodily organisation ; this, however, is a hypothesis which may safely be disre- garded, in reference to our present state of being, seeing that it is opposed to all conclusions of experience, and to the opi- nions of those whose antecedent studies . INTRODUCTION. 29 give weight to the judgments which they form. The office of the brain and nervous sys- tem, then, is to subserve the superior and special properties of animal life ; and it is ascertained as a fact (which in the ab- sence of positive knowledge might have been inferred) that a remarkable and ob- viously adapted modification of the sub- servient tissues coincides with variations in the animal type. Thus, at the lower end of the scale, insects and the mollusca have so inconsiderable a development of the nervous structure, that some have con- ceived them to be devoid of its crowning constituent, denying that they possess a brain. This, however, must be a mistake. If they have consciousness, it must operate through some organisation ; and whatever be the form or locality of this latter, it must, because of its functions, constitute the analogue of what all acknowledge to be brain in the higher classes of animals. \ 30 INTRODUCTION. In ascending the scale, and coming to fishes, we observe a decided advance in the organisation of brain and nervous system. Whilst, in the invertebrata, the actual brain is hardly distinguishable from the ganglial termination of the nerves of sense, — in fishes, with which the verte- brated series commences, nervous masses, corresponding to the cerebral hemispheres and the cerebellum in the mammals, be- come apparent ; and with these coincide instincts more marked, and shades of in- telligence in its lower forms. The yet higher power, and the varied states of consciousness, which birds exhibit, corres- pond with increased development of the cerebral structure ; the proportion of this to the size of the body, to the ganglia of the nerves, and to the spinal cord, far sur- passing that which exists in fishes. In the mammalia, the advance which is made in the organisation of brain is very re- markable. Its magnitude, absolutely and INTRODUCTION. SI relatively, greatly exceeds the correspond- ing structure in the inferior tribes ; and the hemispheres begin to assume a con- voluted and more complex appearance. Indeed, the law obtains throughout the whole animal series, commencing with the very lowest creatures, and ascending till we arrive at Man : — the loftier the psy- chical attributes, the more highly organ- ised is the associated brain. Not only is there agreement among physiologists with respect to the general truths just cited, but yet another law in relation to this subject is very generally recognised, which may thus be stated : — Size, or amount of nervous tissue, consti- tutes a direct element of functional power ; in conformity with which law, a very small head, — one greatly below the aver- age dimensions, — is always accompanied with mental imbecility. Moreover, dis- ease, or mechanical injury of the brain, very rarely fails to perturb mental action. 32 INTRODUCTION. Medicines, too, which act upon the ence- phalon, always interfere with the exercise of mental powder. Indeed, in every point of view, the evidence exhibiting the or- ganic conditions of mental activity, is so abundant and multifarious that the pro- position may fairly be regarded as indis- putable. The conclusion, then, results inevitably, that the seat of insanity is the cerebrum, — that mental disease is altered function of the brain. But disease of the brain does not, in every case, provoke insanity. There are cerebral maladies which do not give rise to mental derangement. Simple conges- tion, some forms of inflammation, certain tuberculous affections, and even serous accumulations in the venticles, will often exist, without perverting thought so as to prejudice moral liberty. Still these facts are not in opposition to the doctrine that the brain subserves the mental operations; for the exercise of the mind is nfiarly al- INTRODUCTION. 33 ways influenced in some way or another, though insanity may not arise, as a con- sequence of such affections as those just cited. There are few persons, however, who are not aware that the term Insanity includes more than a single form of mental dis- ease. Every body has heard of idiocy and dementia — of mania and monomania — of melancholia and fatuity; and, besides these denominations, which are applicable to certain varieties, numerous others are employed by systematic writers to desig- nate the particular divisions established by themselves. Authors who are attached to a favourite psychological system or arrangement of the mental faculties, will generally clas- sify diseases of the mind in accordance with the philosophy which they have adopted; and they will speak of a form of insanity connected, specifically, with the individual mental faculties. After 34 INTRODUCTION. much thought bestowed upon the ques- tion in this particular point of view, and after carefully watching the phenomena of insanity in order to arrive at some solution of it satisfactory to myself, I have come to the conclusion that, in the present state of our knowledge, there can be framed no accurate or complete nosology of mental diseases, because there is not as yet discovered any particular physiology of the brain scientifically ac- cordant with psychological systems; that is to say, that our acquaintance with the separate functions of different parts of the encephalon is not such as to enable us to rest our estimate and classification of mental diseases upon some detailed and extended cerebral physiology. Upon this subject I shall, in the next lecture, offer some further remarks, and shall endea- vour to ascertain how much in the phy- siology of the encephalon may be regarded as established, and what we must reject INTRODUCTION. 35 as insufficiently supported by scientific evi- dence. I adopt this proceeding, because the discussion is intimately related to the views which I have been led to entertain upon the pathology of insanity. 36 PHYSIOLOGY OF THE BRAIN LECTURE 11. Physiology of the Brain and Nervous System. i A VERY important question in relation to the several kinds of Insanity, may thus be stated : — To what extent has the distinct- ness in function of particular divisions of the encephalon been made out? Many attempts have been made, at va- rious times, to connect cerebral physiology with some determinate analysis of the mental faculties; that is to say, systems have at different periods been constructed, suggesting the same sort of interdepend- AND NERVOUS SYSTEM. 37 ence between the several faculties of the mind and particular parts of the brain, as that which we know to obtain between the five external senses and their sub- servient nerves. The cerebral physiology in connexion with analytical psychology, which originated with Dr. Gall, however, is that which has commanded the largest share of attention from the profession, partly on account of the great things it appeared to promise, and partly on ac- count of the sound method of investiga- tion — that of induction — by which its author professed to have discovered it. It is the system of Phrenology to which I allude ; a system which, in its complete- ness and as popularly understood, cannot, I am convinced, be sustained by a just philosophy. I will briefly sketch the idea which I entertain, when I speak of phrenology as a system. I refer to it as taught by its prominent advocates who comprehend, in 38 PHYSIOLOGY OF THE BRAIN \ their teaching, not only physiology and psychology, but philosophy and the prac- tical affairs of life. As all may be aware, it is asserted that, by observing the dif- ferent forms of head and peculiarities in the mental and moral characters of indivi- duals, and by noting correspondences in these respects, the separate and funda- mental faculties of the mind have almost all been determined; and that some thirty- five or thirty-six of these can be arranged and watched in their manifestations with substantially the same accuracy as the five external senses: further, that all the inherent distinctions in the mental and moral disposition of individuals, were traceable to the configuration of head as indicative of the direction in which par- ticular regions of the brain were deve- loped; and that character could be pre- dicated, very satisfactorily, by studying the relative proportions in which the indivi- dual organs of the faculties are developed, AND NERVOUS SYSTEM. 89 and by reasoning upon the influence of external circumstances upon the combina- tion. In the estimation of the more ardent champions of the phrenological school, there is scarcely a difficulty in moral phi- losophy, metaphysics, or psychology, that does not receive its solution in phreno- logy. Even questions of government, po- litical economy, and social progress, are all thought to be within the domain of this system. It has been stated again and again by phrenological writers of cele- brity, that none of these topics can satis- factorily be dealt with, if their doctrines be not accepted for the removal of diffi- culties and the illumination of obscurities. Insanity, it is affirmed, becomes, through the aid of phrenology, a comparatively simple branch of medical investigation. These are the pretensions which ultra- phrenologists set up for their cerebral physiology ; and a system so distinct, so 40 PHYSIOLOGY OF THE BRAIN detailed, so potent and universal in its application, cannot, I am well convinced, make good its claims. If personal character, as dependent purely upon natural disposition, were something readily ascertainable ; and if the share which the individual faculties of the mind possess in contributing to the formation of character, were determina- ble with something Hke moderate preci- sion ; if, at the same time, the size of distinct portions of the brain could be verified to the same extent ; and if multi- plied observations had demonstrated some imiformity in the results, as claimed by phrenologists ; this cerebral physiology, it must be admitted, would have been established as a fact. And this is a cir- cumstance quite independent of the ques- tion, as to how far phrenology may, in this case, be practically available in the business of life ; that is to say, phreno- logy may be true as a physiology of the AND NERVOUS SYSTEM. 41 brain, and yet phrenologists may have per- verted its truths in reasoning upon its applicability, in attempting to trace it to its remote consequences. Now my own conviction is, and has al- ways been, that Phrenologists, in reason- ing concerning the facts of phrenology, have gone sadly in advance of the pre- misses ; that Phrenology, in a word, as it is popularly understood, constitutes a mix- ture of error and truth, the former pre- ponderating largely. I have no faith, and never had, in the notion that science and philosophy, by the aid of phrenology, would regenerate the world, or, in any extraordinary degree, contribute to social progress. Conviction in the justice and accuracy of much that Gall recorded as a fact, I have had for many years; but I had never very much faith in the addi- tional facts professed to have been dis- covered by his successors. The leading phenomena that were cited by the earlier 42 PHYSIOLOGY OF THE BRAIN school of phrenologists, I have myself verified, — a matter quite apart from any interpretation which the phenomena them- selves may rightly receive. For example : any one, who with moderate attention will examine the forms and dimensions of different heads, will very soon perceive that one which is excessively diminutive can never exercise ordinary intelligence ; that a very small forehead never cha- racterises persons eminent for their think- ing, but that usually a capacious front and vigorous intellect go together ; that a head very high and broad in the coro- nal region, is commonly associated with great natural morality in particular indi- viduals ; and, on the contrary, that a low contracted head is most ordinarily found upon the slioulders of depraved criminals. Again, it will be seen that a large occipital and basilar development is very generally found in persons of strong animal propensities. More par- AND NERVOUS SYSTEM. 43 ticular correspondences, indeed, may be noticed ; for instance, the crown of the head is usually very much elevated from the opening of the ear, in persons of great natural self-reliance ; again, as regards the intellect and the forehead, the higher re- gion comes out principally in those who are remarkable for their powers of thought and reflection, and the lower region in such as are inquisitive and distinguished for their stores of knowledge. Some other coincidences, moreover, are observable be- tween mental character and configuration of head ; but the foregoing illustrations sufficiently exemplify the facts that may be verified without difficulty. The enquiry next arises: — What con- clusions become fairly deducible from such circumstances ? Can the phrenological theory be sustained, of separate organs for the individual faculties of the mind ? — Upon these points I would observe that, reasoning from abundant data, it has al- 44 PHYSIOLOGY OF THE BRAIN ready been admitted, as a scientific truth, that the brain is the organ of the mind. And there is no Physiologist, who experi- ences a difficulty in admitting that its dif- ferent parts may fulfil different functions. Independently of direct observations, there is antecedent probability, indeed, that divi- sions of the brain have some correspond- ence with particular mental aptitudes. And it is quite certain that, in a very large proportion of cases, the form of the head shows the direction in which the cerebral hemispheres are developed. These propo- sitions, which will generally be admitted, must lead every candid mind to allow that there may be some truth in phrenolog}\ For my own part, I conceive the inference to be warranted, that, in some way or an- other, the anterior lobe of brain maintains an especial connexion with the intellect ; that the superior convolutions, in like manner, have some organic association with the higher sentiments; and that the AND NERVOUS SYSTEM. 45 posterior portion of the cerebral mass, is peculiarly connected with the more animal propensities of our nature. But admitting these conclusions as true, I am far from believing that, even to the extent of the three regions, we have, in the size and configuration of the head, any thing like an exact measure of the respective psy- chical capacities and inherent tendencies ; for it may be certainly predicated that in- timate conditions of quality, inappreciable by external signs, largely affect both func- tional power and activity. But what remains to be said concerning the theory of separate cerebral organs? Influenced by the present advanced state of our knowledge of the brain and ner- vous system in man, and still more by certain facts in comparative anatomy, I have been led to the conclusion that it should at least be rejected as unproved. Yet I formerly thought differently, and freely avowed my opinion. If without 46 PHYSIOLOGY OF THE BRAIN adequate grounds I adopted this opinion, my doing so was largely owing to the confidence which I had in the observations and reasonings of others. And, truly, if all that is recorded in phrenological books could be relied upon, much of the argu- ment that is founded upon it would not only be plausible but just. My own later observations, conducted as they have been, without bias or prepossession, do not certainly satisfy me; for I have been quite unable to establish the minute dis- tinctions, and to verify the more detailed statements, set forth by thorough going partisans. I cannot, under these altered circumstances, now profess myself to be an adherent of what is commonly under- stood by the phrenological system. For some years, indeed, my confidence in the scientific character of phrenology has gradually weakened. As I have grown older, I have had occasion to become better acquainted with the diffi- AND NERVOUS SYSTEM. 47 culties of determining, with any thing like precision, the inherent and relative strength of particular talents and disposi- tions in different individuals; and I have found that accurate estimates of cerebral developement, according to the phreno- logical theory, are not so very readily made, even by those most experienced in cranioscopic investigations. Indeed, the perpetual variation amongst phrenologists themselves, in this respect, demonstrates that the process of verifying or falsifying their statements, is much more difficult than they themselves would represent it. It is obvious, moreover, upon reflection, that, in many instances, it is impossible to determine from actions what is their source in the recesses of the human breast ; and it is a fact that we are all prone to attribute the conduct of persons to mo- tives which we associate with the cha- racter we have in our own minds assigned to them. Phrenologists, seeing the deve- 48 PHYSIOLOGY OF THE BRAIN lopment of some particular organ in un- due proportion, have no difficulty in re- cognising its assumed mental associate, even in the most indifferent circumstances. Altogether, I feel myself bound to say, the organology of Gall's doctrine must be abandoned. Honesty and candour compel me to this admission, though with some reluctance, for it involves the recan- tation of opinions for many years enter- tained and avowed. If candid and careful examination of the facts necessary for elucidating the question had realised the high expecta- tions of the earlier disciples of Gall, an immense boon would have been gained to physiology, more especially in its relations to the study and practice of Psychological Medicine ; but a more extensive and prac- tical acquaintance with the phenomena of insanity has militated, in my own mind, against the phrenological theory of sepa- rate organs. AND NERVOUS SYSTEM. 49 At one period, nevertheless, the cere- bral physiology of Gall, even in many of its minuter details, obtained a very ex- tensive and creditable reception in the ranks of the profession. Physicians and surgeons enjoying considerable celebrity in this country, on the Continent, and in the United States, did not hesitate to de- clare their conviction that, substantially, it was true. As evidence of the progress that was made in our own country, the circumstance may be adduced, that it was advocated by the principal medical perio- dicals published in London, including The Lancet and the Quarterly Journals edited by Dr. Forbes and Dr. James Johnson. Of the popularity which phrenology once had, and has yet to a great extent, I make no account; I deem this to have been its condemnation, rather than its recommen- dation. It is not the exact, the severe, and the profound, that commends itself to 50 PHYSIOLOGY OF THE BRAIN I the multitude; but the facile, the super- ficial, and the plausible. I will add a few words concerning the premature success of the phrenological system, and upon the fact of its unmis- takeable decline in the estimation of our profession. The eminently scientific cha- racter of many of Gall's researches into the anatomy and physiology of the brain and nervous system, the decidedly philo- sophic spirit displayed in the tone of much that he wrote, and the important additions which he undoubtedly made to the then current knowledge of the sub- jects of his investigation, were all circum- stances accrediting him to the profession as a faithful observer and accurate inter- preter of nature. Then there were the in- genuity and the lucidity of Spurzheim's speculations, and the comprehensive rea- sonings of Dr. Andrew Combe and Mr. George Combe. There was, moreover, a boldness and an earnestness in their ar- AND NERVOUS SYSTEM. 51 guments claiming for the phrenological system an extensive applicability in so many practical relations of life, — argu- ments which, containing much truth, it would have been very often difficult, with- out great labour, to confute. All these things constituted obvious reasons why many, in the first instance, accepted Phre- nology so largely upon trust. When I have had the opportunity of conversing with undoubtedly able men, especially of the medical profession, who avowed their conviction of the truth of phrenology, I have always noticed that, whilst uneducated charlatans recognise no difficulties either in judging of character or in estimating cerebral development, they, on the contrary, have constantly spoken with distrust of their ability to decide in these respects; shewing, plainly enough, that their adhesion resulted from the confidence which they have placed in the more prominent apostles and disciples 52 PHYSIOLOGY OF THE BRAIN | of the system, rather than from any ac- curate or careful investigations made by themselves. In my own instance, many circum- stances have utterly destroyed my confi- dence in the observations and the judg- ment of large numbers of the phrenolo- gists; amongst others, I may adduce the striking fact that the ranks of almost every philosophical folly of the present era, so distinguished in this point of view, have been largely recruited from the ex- piring phrenological school — teachers and disciples alike. Some have become apostles or partisans of the water cure; others of clairvoyance and mesmeric pre- vision ; and some, again, of homoeopathy ; whilst a few, I believe, have gone over to the spiritual rappers ! With the same men, there continues the same turn of mind, — the excessive credulity, the rea- diness to see whatever is looked for, and to wink at, or most elaborately to explain AND NERVOUS SYSTEM. 53 away, every thing which makes against the adopted faith; the same bigotry too, and the same restless spirit of propagan- dism. If I have dwelt upon this subject at somewhat undue length, it is because I have been anxious to give reasons for the decline of phrenology, both in my own estimation, and in that of others of our profession, who formerly anticipated other results. In this place I will seize the occasion for supplying a brief summary of what I deem to be the existing state of our know- ledge upon the physiology of the Brain and Nervous System, distinguishing that which is only probable from what may be regarded as satisfactorily made out. I pursue this course, because for the due ap- preciation of mental maladies it is more important, of course, to have clear infor- mation of the positive and the true, than to have pointed out the exaggerated or 54 PHYSIOLOGY OF THE BRAIN the false. And, as I have before stated, all scientific advance in the study of in- sanity, must necessarily be guided by a sound knowledge of the physiology of the structures essentially concerned in mental disease. I must take it for granted that all who now hear me are acquainted with the general anatomy of the brain and nervous system. And you are aware that, whilst the structural appearances and constitu- tion of these have a certain general simi- larity, there is yet an obvious divisibility of the tissues into two distinct kinds — the grey and the white matter ; a divisibi- lity which applies alike to the encephalon, the spinal cord, and the nerves. The dif- ference in these nervous substances is not an affair of colour only; it refers also to their intimate structure and organisation; the white matter is made up of bundles of tubular fibres, whilst the grey is composed of aggregated cells, and is often denomi- AND NERVOUS SYSTEM. 55 nated the vesicular neurine. To collec- tions of this vesicular substance, the term ganglion is very generally applied, be- cause the knots of nervous matter which were formerly supposed to give origin to the nerves, and which are distributed so largely throughout the body, are vesi- cular in their composition. And thus the identity in structural constitution has led to employment of the word ganglion as a common term, although the ganglionic or spheroidal form is not at all essential, as was at one time supposed, to the consti- tution of what is now called ganglionic substance. Physiological and patholo- gical researches have rendered it more than probable, that the vesicular and the fibrous substances have, universally, se- parate and distinct offices in the animal economy ; the ganglionic structures being the source of functional change^ and the fibrous matter being simply for the con- duction of impressions originating in the 56 PHYSIOLOGY OF THE BRAIN fonner. This theory, in the promulgation of which Mr. Solly shares probably in the most eminent degree, is now received very generally as scientific truth. In the anatomical structures within the head, various collections of grey, or ve- sicular, matter are discovered, with large quantities of the white, fibrous substance interposed. There is all the certainty that is attainable upon such a subject, that the several ganglionic masses in the encepha- lon subserve different functions, and that the office of the white matter is to bring these masses into mutual relation and harmonious action. In studying the vital characteristics of man and animals, aided by the lights of anatomy and physiology, we become in- terested, in an especial manner, by the phenomena which exhibit themselves in movement and other expressions of con- scious activity ; and, in deducing conclu- sions concerning the springs and the qua- AND NERVOUS SYSTEM. 57 lities of particular actions and phenomena, we are necessarily guided very much by the analogies gained in the introspection of ourselves. Thus premising, I will now pursue the several processes which take place through the instrumentality of the brain and nervous system, — commencing with the simpler manifestations of nervous function, and proceeding, by ascent, until we attain the more elevated displays of psychical capability. Although not actually demonstrated, it is yet a tolerably certain inference, that, distributed largely and very minutely along the whole cutaneous and mucous surfaces, there is vesicular neurine ; this forms the peripheral expansion of nervous filaments, and may be likened to the structure of the retina as it expands itself behind the vi- treous humour. When an irritant impres- sion is made upon the surfaces thus sup- plied, a respondent movement ensues, un- less the controlling and restraining influ- 58 PHYSIOLOGY OF THE BRAIN ence of the will, or some other qualifying circumstance, prevent it; and this move- ment does not necessarily involve any consciousness whatever. The impression wrought upon the superficial vesicular substance is conveyed by white nervous filaments to the grey matter of the spinal cord, in which a vital change arises — an influence which expends itself in a downward direction and, through other filaments, induces muscular contraction. Phenomena so simple as the foregoing can only be witnessed in decapitated animals, or in cases wherein, from accident or dis- ease, the communication is broken be- tween the brain and spinal cord. Move- ments taking place under these cu'cum- stances have been denominated reflex, excito-motory, and automatic ; none of these expressions constitute very exact de- finitions; provided, however, the function designated be rightly appreciated, the par- ticular term employed is not of so much AND NERVOUS SYSTEM. 59 consequence. The purpose of the spinal axis, and its reflex function, is undoubt- edly the conservation of the organism, through excitation of the movements of respiration, and also by its governance of the various orifices of ingress and egress, and by its contribution to the integrity of certain other processes in which reflex movements participate. A few remarks may here be made as to the ganglia of the sympathetic system of nerves. These are scattered largely throughout the body; in front of the vertebral column they form two distinct and regular chains — the whole being con- nected by nervous filaments extended in all directions, and especially accompanying the blood vessels. The functions of this portion of the nervous system are some- what obscure. Consciousness, certainly, has no place in its ordinary exercise at least. It probably communicates a sus- ceptibility to certain motions involved in 60 PHYSIOLOGY OF THE BRAIN the organic functions of circulation, nu- trition, and secretion ; an influence not needed for the simple accomplishment of these processes, but required in the animal economy, in order that they may become related with, and in a measure be subor- dinated to, the higher operations of the brain and nervous system. The nerves and ganglia of the five ex- ternal senses constitute the instruments whereby the primary and more simple forms of consciousness display themselves. Vesicular neurine distributed upon the lining membrane of the nostrils possesses a specific sensibility to odorous matters; the impression which these make is con- veyed by conducting fibrous filaments to the hulbi olfactorii — the ganglionic cen- tres wherein the sense of smell is called into exercise. The retina is composed of vesicular neurine; visual impressions are candied along the course of the optic nerves, and attain the corpora quadri- AND NERVOUS SYSTEM. 61 gemina, which there is every reason for concluding to be the ganglia of sight. Ve- sicular neurine, spread largely within the internal ear, receives the vibratory undu- lations constituting the external cause of sound ; the fibrous filaments of the au- ditory nerve conduct the influence to certain grey nuclei in the posterior pyra- mids of the medulla oblongata, that form the ganglia of hearing. The vesicular termination of nervous filaments upon the lingual surface and the palate are spe- cifically impressed by sapid particles, and the impression being passed along fibrous filaments to the proper ganglionic centre (yet undetermined), induces the conscious- ness of taste. The four modes of consciousness just recounted, being accomplished by distinct nerves and by organic apparatuses limited to particular regions of the body, have been denominated the special senses. But there is developed a sense-con- G 62 PHYSIOLOGY OF THE BRAIN sciousness which is not limited to any par- ticular organ, but which may be said to pervade the entire fabric ; it comprehends that general sensibility which resides prin- cipally in the cutaneous and mucous sur- faces, and, to a less extent, the interior structures. It is by it we appreciate the state of the muscles, — obtain the mus- cular sense, as it has been called. This " common sensation " is best illustrated by the simple notion of resistance. Its vari- ous modifications comprise the several im- pressions essential to ideas of the hard, the soft, the rough, the smooth, the pain- ful, the titillatory, and so on. This fifth sense is also awakened through the ve- sicular extremities of fibrous filaments. Whether the grey expansion and white cords engaged in common sensation be the same as those which subserve the spinal reflex function, is a question yet undecided. This much, however, is cer- tain : the communicated impression as- AND NERVOUS SYSTEM. 63 cends along the posterior columns of the spinal cord, and attains a grey, vesicular centre — the ganglia of common sensation. Physiologists are not agreed upon the struc- tures which fulfil this office; they must, however, like the other sensory ganglia, be somewhere at the base of the cranium ; and, for my own part, I am disposed to think that some portion of the cerebellum constitutes the encephalic centre of com- mon sensation. Many years ago, Foville assigned this function to the entire organ ; and others have, with great plausibility, advocated the same notion. The anato- mical connexion between the restiform bodies and certain ganglionic masses within the cerebellum, favours the idea which I have advanced ; and there are va- rious physiological and pathological facts and considerations which corroborate it. It is a view, moreover, which would seem to reconcile, in a great degree, the doctrine of Gall with that of Flourens. 64 PHYSIOLOGY OF THE BRAIN The former, as every body is aware, taught that the cerebellum is the organ of the sexual instinct; and the latter, supported by most modern physiologists, states that its office is to co-ordinate muscular action, as in balancing the body and other such instinctive acts. Now, if some portion of the cerebellum subserve ordinary feeling, its influence upon the function imputed to it by Gall, is conceivable, without the adoption of his actual teaching. The facts receive another explanation. In the other view, regarding the muscular office of the cerebellum, the explanation may be af- forded by reference to the existence of its cortical grey matter, which may determine some influence to the muscles responsively to their feeling; it being generally held that the muscular sense comes from their possessing common sensation, though in a less degree than the skin. However all this may be, it is certain that this fifth sense must have ganglia ; and it cannot AND NERVOUS SYSTEM. 65 be doubted that these, through the spinal cord, are in some sort of connexion with every sentient structure. All the sensory ganglia, it may here be noticed, besides their instrumentality in inducing the simpler forms of conscious- ness, react upon the muscular system when stimulated from without; and that, too, in apparent independence of thought or volition. The movements thus arising, Dr. Carpenter very aptly designates con- sensual; they are seen when the daz- zled eye withdraws, instinctively, from the light ; when the startle follows upon a loud and unexpected sound; and when the young infant, from contiguity to its mother's bosom, exhibits restlessness, provoked by the odour of the mammary fluid. These muscular actions are reflea; as to their modes of occurrence ; but they differ from the spinal reflex acts in being, in their nature, attended with conscious- ness ; and they differ from ordinary move- 66 PHYSIOLOGY OF THE BRAIN ments in the circumstance that neither! ideas, nor will, nor mental emotion, pro- perly speaking, are concerned in their pro- duction. But Man is much more than a sentient and instinctive animal. Sensations supply the primitive material for ideas, or those mental perceptions of external things and their qualities, which constitute the basis of all positive knowledge ; and which, once in the mind, can be reproduced and employed in reasoning. The consciousness of objects, facts, and circumstances, in the reception and com- bination of ideas, has without doubt some cerebral instrumentality for its manifesta- tion; and evidence from all sources, ana- tomical, physiological, and pathological, points to the cortical grey matter of the brain, investing the convolutions, as sup- plying the requisite organic conditions — a structure to which has been applied, very appropriately, the term hemispherical ganglia. AND NERVOUS SYSTEM. 67 White matter intervenes between the ve- sicular neurine of the sensory ganglia and that of the cerebral convolutions ; the con- scious impressions received by these former may be regarded as ascending along the white fibres, and, on the grey summit being attained, developing changes in its con- dition which minister to the intelligence. Ideas arise. If we reflect upon the pro- cesses that go on within our own minds, there is no difficulty in distinguishing be- tween a sensation and an idea ; or in mark- ing the sequential origin of the latter. How often do we find that, when the full consciousness of sensation is obtained, the idea suggested by it does not follow until many seconds, or even minutes, after- wards. You hear the utterance of cer- tain words, as sounds; their signification does not strike you; no effort of atten- tion is made ; yet, suddenly, the sense breaks in upon your intelligence. The correlated physiological phenomena may 68 PHYSIOLOGY OF THE BRAIN I thus be stated. The auditory ganglia take up the sentient impression at once ; its passage upwards to the region of thought is delayed ; presently, however, its natural course is freed from hindrance, and it at- tains the hemispherical ganglia, forming, or awakening, ideas in the mind. The anterior convolutions would appear from cranioscopic facts to be especially con- cerned with those ideas and combinations of thought, which flow from science and philosophy; the superior convolutions with classes of ideas, or states of the intelli- gence, related to the higher sentiments, as of justice, veneration, and benevolence ; and the posterior convolutions would seem to be operative in combinations of ideas and habits of thinking, referring them- selves, more particularly, to the lower af- fections and propensities of our nature. The doctrine of separate organs in relation with distinct faculties, however probable, cannot, as I have already said, be regarded as established truth. AND NERVOUS SYSTEM. 69 As bearing and shedding light upon many of the phenomena of insanity, I will here set forth certain views founded on what may be called cerebral reflex action, recently enunciated by my friend Dr. Carpenter, and incorporated in the last edition of his Human Physiology, and which I cannot but deem to be sub- stantially sound. Actions become determined sometimes by the prevalence of ideas, where neither sensation, nor emotional states, nor voli- tion, exert any influence ; the accomplish- ment of such actions seems to be quite as automatic as the movements which are consensual. In the transition -state be- tween sleeping and waking, there is great fertility in the development of anomalous trains of thought — disorderly successions of ideas, receiving no governance what- ever from the will. Yet, in these circum- stances, muscular movements and other phenomena will frequently take place, re- 70 PHYSIOLOGY OF THE BRAIN spondent purely to the dominant idea. An attractive object is before the imagi- nation, and a grasp is made to attain it: here there is no selection among motives, — no will ; the act is altogether impulsive, prompted by the idea. In certain irregu- lar kinds of sleep, and in somnambulism spontaneously arising or induced by arti- ficial processes, the mind can at times be literally played upon, so as to educe par- ticular acts contrived beforehand ; these being suggested by communication of the correspondent idea, which becomes en- tirely dominant. Whisper that the sleeper is insulted, his head becomes elevated in disdain ; intimate that you are about to excite his benevolence, and he will show himself liberal in gifts ; and so on. Elec- tro-biological phenomena, as they have been absurdly called, furnish abundant il- lustrations of these things. There are actions and movements, in these eases, which obviously arise without being di- AND NERVOUS SYSTEM. 71 rectly prompted by sensation, emotion, or volition. They are, in a manner, reflew^ and Dr. Carpenter proposes to designate them ideo-motor, Ideo-dynamic would pro- bably constitute a phraseology more ap- propriate, as applicable to a wider range of phenomena. But there are large masses of vesicular neurine entering into the constitution of the encephalon, of which as yet no men- tion has been made, and which, neverthe- less, must have important functions in the display of psychical energy. There are several tracts of grey matter near the base, that have probably some connexion with particular instincts — of hunger and thirst, for example : but I allude, more especi- ally, to the Optic Thalami and the Corpora Striata. These are ganglionic structures intimately communicating, in the ascend- ing direction, with the cortical grey matter of the hemispheres, and, downwards, with the spinal cord ; in each case, through the 72 PHYSIOLOGY OF THE BRAIN medium of white fibrous substance. The office of these bodies has not been de- cisively made out. Physiologists differ in their opinion upon the question. It is most probable, however, that the Optic Thalami, notwithstanding their designa- tion, have no immediate share in the pro- duction of vision. Dr. Carpenter, and some others, think that they are most likely the ganglia of common sensation. I differ from this view% for many rea- sons. It would, however, be tedious and out of place to argue this point, at any length, upon this occasion. I have my- self a strong persuasion that the struc- tures under consideration form the gang- lia of that inner sensibility, which ideas, rather than external impressions, call forth ; I regard them as the seat of the emotions. Their locality, midway as it were, between the hemispherical and the sensory ganglia; their universal and very close connexion, by means of the central AND NERVOUS SYSTEM. 73 white mass of the brain, with the grey ex- pansion of the convolutions ; and their fi- brous communication with the spinal cord, constitute good anatomical reasons for the opinion of their function which I have been led to entertain. The necessity, upon psychological grounds, for separating the emotional sensibility, as evinced in grief, joy, hope, fear, pride, vanity, affection, and so on, from the sensibility of the five senses, is sufficiently obvious ; and the distinctness of these states of conscious- ness from all necessary activity of the in- telligence, however dependent upon ideas primarily, is very clear to the self- ob- server. Hence, every antecedent proba- bility would suggest the speciality of ner- vous centres ; and, as already stated, I regard the Optic Thalami and Corpora Striata as the organic site of all sensi- bility that is internal and emotional. An emotion may be regarded as being in the same relation to thought, as are the H 74 PHYSIOLOGY OF THE BRAIN five external senses to their correlated im- pressions. Dr. Carpenter defines this re- lation in the following terms : " The ideas which are excited by sensations, if associ- ated with feelings of pleasure and pain, constitute the emotions." Upon this point, I differ from Dr. Carpenter, who, I think, does not sufficiently recognise the speciality of emotional sensibility, for which, on ac- count of its distinctness and separateness, there must, I conceive, be proper nervous centres, — most probably, as before said, in the Optic Thalami and Corpora Striata. I may exemplify my own view of the case by very simple illustrations. If I am made to laugh through being tickled, the ganglia of common sensation react consensually ; if I laugh from suggestion of a ridiculous idea, some other ganglionic structure, I submit, must physiologically be concerned in pro- duction of the laughter ; if I suffer from tic doloureux one day and from profound grief upon another, all the testimony ( AND NERVOUS SYSTEM. 75 which consciousness affords would confirm the idea of intrinsic difference under the respective circumstances. Indeed, I con- clude from numerous data, a small propor- tion of which only I here adduce, that the ganglia of emotional sensibility are psy- chologically and anatomically distinct from the ganglia which minister to the five ex- ternal senses.^ ^ The author has observed, with much satisfaction, that his views concerning the physiology of the optic thalami and corpora striata have been adopted as pro- bable, on metaphysical grounds, by Mr. Morell, the able author of " A Critical History of Modern Spe- culative Philosophy," and other learned works. In his recently published volume, on " The Elements of Psychology," the following occurs in a marginal note, p. 102 : — "I am indebted to my friend, Mr. Noble, for the suggestion that the actual centre of the emo- tions is to be fixed in the optic thalami and the cor- pora striata. This would harmonize extremely u ell with the whole observed development of our know- ledge, which, commencing with a physical impulse, appears next in the form of an incipient mental sen- sibility, and then expands into distinct notions or ideas ; which ideas can, then, in their turn, react upon the emotions." 76 PHYSIOLOGY OF THE BRAIN As ideas and sensations may react in muscular movements and other vital phe- nomena, where other psychical conditions do not share in their production, so it is with the emotional states. Actions often arise immediately and exclusively from the influence of this inner sensibility. Thus, intelligence arrives suddenly of the death of some one beloved ; the auditory ganglia, through the appropriate nerves, receive the sounds significant of the fact; the physiological change thus brought about has its influence conveyed onwards, and it attains the hemispherical ganglia. Hereupon, apprehension of the circum- stance ensues, and the ideas developed may be said to work downwards upon the emo- tional centres ; violent weeping takes place as the natural expression of grief, undeter- mined by the will, and probably in opposi- tion to it. Clearly enough, movements indicative of emotion are not unconscious, reflex acts ; they are not simply consen- AND NERVOUS SYSTEM. 77 sual, as when we startle from a loud noise ; they are not attributable to the mere presence of an idea; but they issue from proper psychical states of their own. When we regard the connexion of the Optic Thalarai and Corpora Striata with all parts of the vesicular investment of the cerebral convolutions, a new interpreta- tion of certain cranioscopic facts becomes suggested. If the various faculties, sen- timents, and affections, as they are usually called, be subjected to a close analysis, they may be studied, I think, in two very distinct relations — instinctive and intelli- ^PMtial, When some particular sentiment conduces to outward manifestation, it may operate mainly through the idea, or mainly through the emotion. For example, w^e will take the propensity for food. This disposition may induce feeding from the inner sense of hunger, or, as in the glul^ tonous epicure, from activity of the fancy delighting itself with ideas of luxurious 78 PHYSIOLOGY OF THE BRAIN dishes and voluptuous viands. Again, let us analyse the workings of pride. This disposition may show itself in pure haughti- ness, sensuously experienced ; or the ideas of self-importance governing the man may sufficiently attest the pride of his spirit, even though the emotion should be but little experienced. The destructive ten- dency supplies another and very obvious illustration. There is wrath, and there is cruelty: the former is an emotional expe- rience, as when destruction is done in pas- sion; and the latter contemplates with complacency the idea of demolition, as in certain acts of incendiarism : wrath per- turbs the inner sensibility, and explosively exhausts itself; whilst cruelty effects its purpose in cold blood. I conceive that, in this way, the several mental states which have been designated faculties, sentiments, and propensities, have two distinct rela- tions, anatomically and psychologically, — superiorly, with states of the intelligence I AND NERVOUS SYSTEM. 79 in the hemispherical ganglia, and, infe- riorly, with the feelings in the optic tha- lami and corpora striata ; and these dif- ferent modes of consciousness may be de- signated, respectively, the psychical pole of the faculties, and the corporeal or somatic pole. Of course, in what I have just advanced, there is much speculation ; nevertheless, if this were the place, I could adduce plau- sible reasons and facts in its support. The views I have expressed, moreover, cor- respond remarkably with physiological and pathological phenomena, particularly in reference to psychological medicine. According to the account, then, which I have given of vital operations, in the fulfilment of which the brain and nervous system participate, reflex movements with- out consciousness issue from the grey mat- ter of the spinal cord and from the sym- pathetic ganglia; consensual actions from the sensory ganglia; ideo-dynamic pheno- 80 PHYSIOLOGY OF THE BRAIN mena result from limited influence of the^ hemispherical ganglia ; and those which are emotional from the optic thalami and corpora striata. But what must be said of the Will, — that attribute of humanity which supplies the basis of moral responsibility, and the weakening or destruction of which consti- tutes so essential a feature of all insanity ? Certainly, the will can be regarded neither as a faculty apart from other states of the mind, nor as mixed up particularly with any distinct and special ganglionic structure. In the language of Mr. Morell : "An act of the will embodies the effort of the whole man, implying, at the same time, intelligence, feeling, and force ; phy- siologically speaking, this state of mind will stand in correlation with the total affection of the nervous system We regard it as an expression of the totality of our organic power, the whole governing the parts and directing to the fulfilment of one purpose." AND NERVOUS SYSTEM. 81 I would guard my younger auditors, and all who are inexperienced in this kind of thinking, against any impression that the Soul, the conscious principle within us, is susceptible of any true, actual division. If there be one characteristic, which, more than another, may be said to distinguish spirit from matter, it is its absolute unity. We have the same assurance from pure consciousness, that the me which thinks is not composed of parts, as we have from sense that bodies have extension. There is no place for argument here. If any one by reading, or over-exertion of his mind, have obscured his native intuitions concerning these subjects, we must not look to logic for his being set right ; we must advise a temporary cessation from reading and thinking upon them ; and trust to nature, under the influence of mental repose with fresh air and exercise, for the restoration of a healthy tone of thought. Distinctness in the organic instruments 82 PHYSIOLOGY OF THE BRAIN implies no corresponding divisions in the conscious principle which they sub- serve. In all psychical phenomena, the whole mind acts ; faculties, sentiments, and aftections are states of consciousness — phases only of the one undivided and indi- visible mind. It is the whole mind that hears and sees; it is the same complete mind which receives ideas, and recals them in memory ; it is the one conscious entity that loves, fears, and hopes ; it is still the same principle, the soul, that performs the highest mental operations, in abstracting, combining ideas, reasoning and judging; finally, and in one word, it is the imma- terial spirit which wills. There is nothing in the physiological study of the brain and nervous system which ought to suggest the approaches even of materialism. Whilst here below, the actions of the spirit occur through organic intervention. A thousand circum- stances prove the fact ; yet is it no more AND NERVOUS SYSTEM. 83 the case that the material brain is the thinking principle, and the separate parts divisions of the soul, than it is true that the music of the lyre inheres in the instru- ment, and that the melodies which art can elicit from it, are self-produced by the particular strings. 84 GENERAL PATHOLOGY LECTURE III. General Pathology of Insanity. I Insanity consists in disorder of the func- tions of the Brain. This proposition, as a conclusion from data supplied in the pre- vious lectures, is inevitable. The brain, however, is the subject of many diseases, which do not produce mental derange- ment. But when pathological alteration of this organ causes, for some length of time, a disturbance in the mental opera- tions, of a character to prejudice the pro- per control over actions, then the ailment, by law and custom, is designated Insanity. OF INSANITY. 85 No reasonable doubt can exist as to the physical site of mental derangement, so far, at least, as concerns its relation to the Encephalon. Yet there have been authors and practitioners who have had some dif- ficulty in admitting this doctrine, owing to what they deem to be the want of corro- boration from morbid anatomy. Thus Jacobi, Nasse, Flemming, and others, have been influenced by the consideration that, in the bodies of insane patients, anatomi- cal lesions are discovered more frequently in the viscera than in the brain ; that, in fact, this latter sometimes exhibits no alter- ation at all, whilst, on the contrary, very decided change is apparent in the organs of nutrition. The precise lesion, indeed, which the encephalon sustains in disor- dered mind, has not been determined. But in many of our investigations, and in much of our reasoning, we are most of us very apt to conceive that a more intimate correspondence exists between changes I SG GENERAL PATHOLOGY found in the organs after death and the symptoms of disease appreciable during life, than the actual state of things war- rants. Marks of inflammation or venous congestion, tubercles, cysts, collections of water, induration and softening of tissue, have again and again been discovered in examination of the dead brain, where there has been no insanity. But, still, ac- cording to the statistics of establishments for treatment of the insane, in every hun- dred bodies inspected after death, a state of cerebral congestion is found in twenty- five instances ; induration of the structure of the brain is witnessed in somewhere about the same proportion; and atrophy of the encephalic tissue in about eleven cases. It must be admitted that there is no form or degree of mental derangement, which has not been known to exist unac- companied by any physical changes re- vealed by the scalpel after death. Never- theless, it is beyond all question, that the OF INSANITY. 87 injury which constitutes the immediate cause of insanity is in the brain. In some! departments of practical medi- cine, it is true, there subsists an admi- rable relation between sensible alterations of structure and their symptoms during life ; take chest-diseases, for example. Still, in the case of many organs besides the brain, the pathologist who looks to morbid anatomy for every explanation, will be seriously disappointed; for as a matter of fact, the relations between the main seat of diseases and the irregular manifestations to which particular diseases lead, are most uncertain and variable — bidding defiance to every attempt at suc- cessful classification. A set of symptoms will often display themselves, referable to some obvious change that may be de- tected after death ; and the very same symptoms, so far as an observer can judge, will, in another case, be dependent upon some very different condition of the struc- 88 GENERAL PATHOLOGY tures, as revealed by post-mortem inspec- tion. It will not unfrequently happen that the central disease shall originate external indications that direct the medi- cal observer's attention far more to the organs secondarily or sympathetically af- fected, than to those which are the sub- jects of permanent physical change, notice- able after death. Moreover, some very vital structure shall become so seriously affected by disease as to induce a fatal ter- mination, and yet no very material altera- tions in its appreciable characteristics be afterwards witnessed ; and, on the other hand, deep and iiTeparable changes in the organisation will, at times, have advanced to the most serious lengths, without any very sensible alteration in the functional manifestations. Cases have occurred in which complete destruction of the ante- rior columns of the spinal cord appeared to have taken place, without loss of volun- tary motion in the parts below ; whilst OF INSANITY. 89 a similar destruction of the posterior co- lumns has occurred without corresponding lesion of sensibility. There are instances in which the whole thickness of the cord has undergone softening, and apparent dis- integration, without the destruction of the functional connexion between the ence- phalon and the parts below the seat of the disease. Again, whilst blindness from pa- ralysis of the optic nerve dependent upon recognisable fault in its tissue, or in that of its connexions, will sometimes come on ; at others, the exciting cause may be the presence of intestinal worms implicating the visual apparatus only by sympathy. How very little constancy of relation sub- sists between some very notable derange- ments of the functions of the stomach, and the changes found in its stru(jture after death. Most troublesome dyspepsia ex- ists sometimes, and the patient dies from some other disease ; very often, in such cases, there is no change discoverable in 90 GENERAL PATHOLOGY the stomach itself. On the other hand, thickening of its mucous membrane, and even ulceration of this tissue, may prevail to an extent capable of producing death, and yet, during life, no great amount of indi- gestion may show itself. I remember the case of a personal acquaintance occurring sixteen years ago, where there had been a long continued liability to paroxysms of intense headache ; in one of these the face became flushed and excited, convulsions ensued, and the patient died. The symp- toms had directed the notice of the at- tendant practitioner to the head ; and, when the convulsions occurred, blood was rapidly drawn from the arm, and death very shortly took place, as if from collapse. I assisted at the post-mortem examination. Within the head, not the slightest trace of disease was to be found ; but, on examin- ing the interior of the stomach, its lining membrane was observed to be thickened, indurated, and very slightly ulcerated ; OF INSANITY. 91 and this state of things was considered by all present to have constituted the essen- tial disease. Yet the patient had expe- rienced dyspeptic symptoms only of a very ordinary character, certainly, much less severe than such as often co-exist with a state of stomach evincing no structural change. Cases innumerable of sudden death are on record, wherein no appreci- able lesion either of the heart or nervous centres can be discovered. In Tetanus and Hydrophobia, which present the greatest uniformity in their respective symptoms, the most assiduous necroscopic researches have not yet revealed any unvarying organic changes. Indeed, the impossibility of establishing a systematic connexion be- tween post mortem appearances and signs of disease during life, has of late become so apparent, that fears may be entertained of the coming generation falling into an extreme opposed to that of ours, and, in- stead of giving an almost exclusive heed to 92 GENERAL PATHOLOGY. 1 the indications of morbid anatomy, with- holding from its revelations that just measure of importance which is its due. Still it is right and expedient that we should start with correct notions upon this point ; and from all that I have seen and read, I believe that every form of insanity may arise and run its course, without the cerebral tissue presenting morbid appear- ances after death; and, further, that, whilst in mental maladies every kind of organic change may at times be determined, the same alterations are to be found in other diseases where their signification is totally different. For those who cannot reconcile such circumstances with the doctrine that insanity consists in disordered function of the brain, I will cite, in addition to all that has been said, the words of that great morbid anatomist and distinguished patho- logist, Andral, who, in reference not merely to the brain but to the nervous system at large, says, "The nervous centres may be OF INSANITY. 93 injured in any of their functions without the anatomist being able to discover any alteration." The encephalon, like other organs en- gaged in the fulfilment of animal life, has, besides the execution of its higher and more peculiar functions, its vegetative life to sustain, involving its disintegration by waste, and renewal by nutrition ; and these processes may be perverted by lesions of the circulation, of absorption, of secre- tion, and so on, without there being any coincident derangement of the loftier, the psychical, attributes. Hence scrofulous states of the brain may exist, without any disturbance or perversion of the mind. Some forms of inflammation may also be present, without inducing disorder of the intelligence. Inflammation may arise in the progress of insanity, and be intimately associated with it, but it does not compre- hend the essence of the malady. In acute meningitis, in fever that implicates the 94 GENERAL PATHOLOGY brain, and in delirium tremens, there is great mental disturbance ; and in these maladies post-mortem changes are notice- able in the encephalon : but we do not recognise insanity in such cases, because the pertm'bation of mind that characterises them is but of temporary duration, and an obvious accident of the physical malady. If obscuration of vision arise from some transient cause, we do not call it amau- rosis ; if diminution of muscular vigour take place from some passing circumstance, we do not recognise paralysis. The term Insanity, both in its legal and pathological bearings, is restricted ordina- rily to that mental derangement which comes from other causes than the more usual forms of cerebral disease, notwitb standing that these are very frequently accompanied by abeiTations of the intelli- gence. When we hear, or speak, of a per- son rambling or talking incoherently in fever, we look upon the mental disturb- OF INSANITY. 95 ance as only one link in the chain of morbid phenomena, and we call it de- lirium; and this, we know, will disappear with the primary malady. Or, when the question arises concerning the delirium resulting from alcoholic abuse, we attach the psychical disorder to well known phy- sical causes and conditions, and commonly anticipate with confidence, a restoration to healthy cerebral action, upon withdrawal of the exciting causes and subjecting the patient to proper medical treatment. The delirium of fever and of alcoholic abuse is, simply, part and parcel of the general disturbance of the whole system ; but with insanity the case is different. This latter may be ushered-in by fever, inflammation, delirium tremens, or any other acute dis- ease ; it is, however, only when the mental derangement has established itself indepen- dently of ordinary disease, that we must regard it as insanity. In a few words, so long as we can ally the cerebro- mental 96 GENERAL PATHOLOGY perversion with causes transient and ob- viously removable, we call it delirium ; when there exists, underlying the phe- nomena, something beyond these, we pro- nounce it insanity. It is very important that clear ideas should be entertained upon this subject. I have myself known practitioners, able and intelligent in other respects, painfully confuse these very different conditions. Impressed with their earlier lessons about phrenitis and mania, as discussed by older writers and lecturers, they have identified, in their own minds, pathological states so different, as arachnoid inflammation and psychical disease, where the latter has been associated with no recognisable physical disturbance. A grave error in practice results from this kind of confusion. The medical attendant may be led to bleed, blister, purge, and mercurialise, in in- stances in which, by this proceeding, utter destruction may occur to the patient's prospects of ultimate recovery. OF INSANITY. 97 Assuming that the cerebral physiology set forth in the preceding lecture is sub- stantially true — and that it is so in its more important features, I think there can be no doubt, — we must come to the con- clusion that insanity, which involves always some perversion of thought, is an aftection especially of the hemispherical ganglia, that is, of the vesicular neurine investing the cerebral convolutions. Into alteration of the function of these structures, indeed, the morbid phenomena more particularly resolve themselves. Although mental derangement, as before observed, has no necessary connexion with inflammation, tuberculosis, or any of the familiar pathological states of tissue, it is never- theless followed in many cases, (as an ulterior result,) or at least is accompanied, by very marked lesions discovered post- mortem. The labours of numerous French pathologists, including Bayle, Voisin, Lal- lemand, and Foville, have established the K 98 GENERAL PATHOLOGY fact, that, in the large proportion of in- stances, where structural changes have been found in the encephalon, the grey cortical substance of the hemispherical convolutions has been the site. And so far morbid anatomy supplies corroboration of the position just taken with regard to the more particular structure affected in mental maladies. But still, of the essential change of a physical nature which obtains in the great majority of cases, we are en- tirely ignorant. It is not improbable that, hereafter, the microscope may reveal some valuable information in this respect; as yet, however, the observations made with its use, have been quite inconclusive ; no morbid appearances peculiar to insanity having been discovered. Apart, however, from all considerations of morbid anatomy, insanity proper may safely be regarded as functional disorder of the vesicular neurine of the cerebral convolutions. In attempts to localise the malady more particularly. OF INSANITY. 09 according to its various forms, our guid- ance, in the present state of knowledge, must principally be sought in physiology. We must infer the several ganglia, or tracts of grey matter, to be implicated, according to the indications we discover of perver- sion of what we deem to be their parti- cular functions. Having advanced thus far, — having defined Insanity to consist in chronic disorder of the brain inducing perversion of ideas prejudicial to or destructive of the freedom of the will, — and having attained the conclusion, mainly from phy- siological considerations, that its organic seat is in the grey substance of the cerebral hemispheres, — I will now describe and explain its characteristic symptoms. Before you pronounce a person to be insane, be sure that you have no signs present, either of fever, or of encephalic in- flammation, or of an hysterical paroxysm. If, in accompaniment of some mental 100 GENERAL PATHOLOGY illusion, of rambling and incoherence, or any other depravation of the intelligence, or if, along with perilous violence or some other preternatural state of the emotions, you have head-ache, heat of scalp, and a quick pulse, you have probably to deal with phenomena transient and incidental. The perversion of ideas or of the moral sensibility, may be symptomatic only of cerebral inflammation, or of some febrile affection. And, in cases where no especial predisposition to insanity exists, you may reasonably prognosticate a return to right reason under appropriate medical ma- nagement. If you observe laughing and shrieking by turns, succeeded by temporary calm after a gush of tears, you will soon dis- cover from the history of the ease, even though the pulse be excited, that you have simply to deal with hysteria. Or, if this diagnosis from any circumstance remain doubtful, vou should still make no mention OF INSANITY. 101 of madness, however wild or absurd the patient may be. Do not, I repeat, call the ailment insanity, or talk of a removal to an asylum. Not only your own inter- ests, but the happiness of your patient's friends, may be seriously compromised in these eases, if you do not exercise an unusual amount of prudence and circum- spection. If your diagnosis of hysteria have been correct, a very brief period will restore the mental balance, — most likely the first sleep of any notable duration. But if the symptoms of fever, or of ence- phalic inflammation, subside; or if the hysteric paroxysm pass away; if the ap- petite return, and sound and periodic sleep be restored ; and if, closely follow- ing upon these circumstances, the custom- ary strength be recovered, and yet the mental derangement persist, your diagnosis must then be insanity. And this will be especially the case, if the aberration shew itself in some fixed or determinate form. 102 GENERAL PATHOLOGY In these instances, the primary malady, both in its etiology and progress, very often is ordinary acute disease, which degenerates, under circumstances of pre- disposition, into actual insanity; just as common inflammation of a joint may be- come scrofula in a strumous habit of body ; or as a blow upon the breast, occasioning swelling and pain in the first instance, may develope some carcinomatous affec- tion. The precise characters which particular forms of insanity may assume, are varied almost to infinity. Nearly every writer makes divisions and classifications of his own. But, however satisfactory at first sight these may occasionally appear, in- stances perpetually occur that constitute anomalies refusing all place in theoretical categories. Nevertheless, however much the individual eases may be modified by temperament, by the predisposing and ex- citing causes, or by peculiar complications, OF INSANITY. 103 certain general features are always observ- able; and the more prominent of these I will now sketch. In a very large number of cases, there will have been noticed, long before the full development of the mental malady, and for some time before its recognition, some- thing unusual either in the manner of the patient, or in his looks, or in his habits. He will have been referred-to as odd, ec- centric, moping, self-willed, or crotchetty. Nothing is more common, when mention is made of some insane person, by those who were acquainted with him prior to the attack, than to hear expressions of this kind : " He was always queer ; " or, " There was for a long time a singular look about his eyes;" or, "I thought that he had be- come very eccentric;" or, "He was long considered an oddity ; " or, " He was for some months very depressed and taciturn ;" or, "Latterly indeed I could not understand him, he was so changed." Very likely, 1 04 GENERAL PATHOLOGY. these sayings are often the expression of an after-thought ; sometimes, they are pro- bably exaggerations ; still, in a sufficiently large proportion of instances, they repre- sent the facts of the case. Eccentricities and peculiarities, indeed, when contrary to the earlier demeanour and habits, consti- tute the premonitory symptoms of insanity ; as do, also, sudden and remarkable changes of temper and moral disposition ; just as languor, debility, and unrefreshing sleep, form the precursors of some febrile malady. It is this preliminary stage, which, in an especial manner, demands the most careful discrimination and judicious management. It very rarely happens, indeed, that mental derangement renders itself very obvious at once. Probably this is never the case, excepting when it is attributable to acute disease or to mechanical violence done to the head. In all ordinary in- stances, it arises in some such manner as that which I have just sketched; gradually OF INSANITY. 105 progressing, until its true nature becomes unmistakeable. A singular timidity, or some remarkable distrust and suspicion, show themselves; or there is great rest- lessness of disposition, or some anxiety, or an extraordinary sensibility. If the episto- lary correspondence come under notice, the greatest light will be shed upon the actual mental condition. In most cases, the letters bear the imprint of distressing influences : we read of painful sacrifices, fatal circum- stances, bitter regrets, frightful uncertainty, unpardonable faults, a broken heart, infa- mous creatures, horrible ideas, malignant intentions, misfortunes, persecutions, tor- ments, maledictions, the scaffold, moral reprobation, eternal flames, and so on, — states of mind evincing serious distur- bance, not only of the hemispherical ganglia, but of the emotional centres of internal sensibility. The intimate sympathy subsisting amongst all the collections of vesicular lOG GENERAL PATHOLOGY iieurine, from the grey matter of the cerebral convolutions down to that which regulates the functions of the spinal cord, supplies very satisfactory explanation of the wide-spread mischief, which, upon the invasion of insanity, so often pervades the greater part of the nervous system. In watching the several phenomena which successively arise, the advances are fre- quently traceable from one ganglionic centre to another, in the order of their physiological succession or elevation. At times, the attention wdll first be arrested by some little irregularity of muscular action; there may be twitchings and catches in the fibres and tendons, immediately owing to disturbance of the digestive organs. The ganglionic struc- ture of the cord thus becoming unduly irritated, very soon reacts upon the sensory ganglia through the afferent nerves, and produces sensations which are abnormal. Impressions of this kind very readily ascend, OF INSANITY. 1 07 SO as to influence the hemispheres; and the mind, anxiously and closely attending to them, forms at length an entirely erro- neous idea: — there is something in the abdomen that is alive. A whole train of false notions hereupon ensues. The dis- ordered ganglia of the convolutions, work- ing downwards, painfully influence the optic thalami and corpora striata (assuming that my own view of their functions is correct) ; emotions of disgust and dread follow ; the intelligence becomes more and more weakened ; no reasoning will remove the morbid impression; the patient seeks for relief in vain; profound melancholy ensues; for some strangely conceived rea- son a poisonous potion is imbibed, and self destruction results. The coroner's jury re- cords a verdict of " suicide whilst labouring under mental derangement." In other cases, a morbid exaltation of one or more of the special senses reveals impending disease of the mind. From 108 GENERAL PATHOLOGY internal causes acting upon the auditory ganglia, a person hears sounds that are unwonted and strange. The hemispheres participate in the over-excitement, and the fancy gives sense and significance to the sounds: — demons articulate, and the pa- tient is pursued by them. The emotional ganglia now share in the morbid excita- bility, and there is terror and despair ; the judgment becomes entirely subordinated to these false but painful impressions; and the patient sinks at last into hope- less and melancholic imbecility. There are instances in which a serious lesion of one of the nervous centres origi- nates epileptic paroxysms, the reiterated occurrence of which may so perturb the brain and nervous system at large, as to produce insanity ; the successive stages being severally traceable from dulness of perception, through weakened memory and impaired judgment, to utter fatuity. Very often the insanitv resultant in such cases, OF INSANITY. 109 displays an utter destruction of psychical energy, moral sensibility, and mental power alike. Exemplifying another class of cases, a person may confuse his ideas and intelli- gence by reading beyond the grasp of his powers and capacities. He begins to con- struct strange theories of the world and its architecture; he suspects the earth's crust to be formed of paper, beneath which there is a gulf that is unfathomable. A consistent timidity marks his every action ; he dares scarcely advance a step. The intelligence and the emotions being alike perverted, the patient is thoroughly insane. Another feeble-minded philosopher inte- rests himself with metaphysical theories; his ideas concerning substance and exist- tence become false and absurd ; there is no matter; he has doubts of external reali- ties — of objects, time, and space; he is reserved and introspective, probably supi- cious and timid; he becomes unfit to 110 GENERAL PATHOLOGY raanage his own affairs, and he is declared mad by a commission of lunacy. In many instances, the starting point will be in the emotive centres. Com- mercial ruin, I will suppose, actually takes place; sorrow and painful anxiety of course succeed, degenerating into settled melancholy; religious ideas, in themselves true, become disfigured and exaggerated: the patient's calamities are a special judg- ment of God, and he is himself under the peculiar wrath of Heaven. Thus the in- telligence becomes weakened, and the emotional sensibility disordered. The remedy is sought-for through an imagina- tion blackened by despair; the curse is removable, but only by a fearful expiation; the dearest and most beloved friends must perish by the patient's own deed; and he must consummate the sacrifice by self- immolation. It is not very often that the higher faculties of the inteUigence are the first OF INSANITY. Ill to give way. Occasionally, however, this is the case ; and then by descent, so to speak, the morbid influence attacks the lower forms of consciousness as the ma- lady progresses. A weakened judgment begins to show^ itself; the will no longer exhibits its wonted firmness; the ideas run disorderly on ; the moral nature sus- tains perversion; the sensations are de- praved; and the mind becomes a total wreck. Phenomena such as these which I have thus hypothetically adduced, constantly characterise the progress of insanity ; and this progress displays an action and re- action amongst the several phases of mind, remarkably correspondent with the physiology of the nervous centres ex- plained in the last lecture. I do not mean that the symptoms of mental de- rangement follow each other always in precisely the ascending or descending series; because, whilst the starting-point 112 GENERAL PATHOLOGY may be in any of the ganglionic centres, the reciprocal relations and interdepend- ence subsisting by means of the white substance between the different collections of grey matter, are such that either of them may, in a state of morbid action, gradually or abruptly communicate the influence to the others. Cases have fre- quently arisen within my own experience, which the sketches just rendered very much resemble ; and the psychical fea- tures which they set forth, are correlative with the pathological changes which may be assumed to obtain in the progress of disease from one ganglionic centre to another. In exemplification of these phenomena, I will here cite passages from a letter ad- dressed to myself by one of the male pa- tients in the Clifton Hall establishment, whilst convalescing. The case was very remarkable in many respects. " You wished me," says the patient, "to write OF INSANITY. 113 a few lines respecting myself, but I pre- sume more particularly about my com- plaint (thank God, now quite gone). It originated from over anxiety, over study, and too close application to business." From this extract it will be seen that the causes of the malady, in the estima- tion of the patient, were such as would operate prejudicially upon the brain and entire nervous system. He goes on: "It began about a year and a half ago by a faintness, or dizziness, and a terrible prickly feeling in my head, causing me about every fortnight to faint and be- come quite unconscious and insensible to every thing about and around me, for perhaps four or six months." The symp- toms of faintness and dizziness would indi- cate lesion probably of the sympathetic nervous system; and the prickly feeling referred-to would point to some functional disturbance in the ganglia of common sensation. An aggravation of this latter 114 GENERAL PATHOLOGY state is shown in what follows: "After that time it came upon me more fre- quently, and too soon caused my mental powers to be considerably weakened, as well as creating in my body much violent painr The patient goes on : " About ten months ago I was recommended by Mr. A. B., our surgeon, to try Southport, which I found to do me good ; and after staying some three weeks, thinking further change might benefit me, went for two months to Derbyshire, (my native place,) not doubting but it would recruit me, which it did in a great degree, but not so much as I, and my parents, wished and hoped. I then came home and found my- self still far from well. Father and all ray family did their utmost to bring me round at home; but, alas! they found it impossible, and they, though reluctantly, were obliged to send me here." The patient is not very orderly in his narration, for he only begins to speak of his mental OF INSANITY. 115 alienation, in reference to the period of his departure from home. He says: "The day I left home, I thought the authorities had prepared a gibbet for me, in St. Ann's Square, (I think now it was a very unlikely place,) and I was of course much averse to leaving." Here is the first men- tion of some distinct mental illusion, the presence of which we must regard as in- dicative of morbid action in the hemisphe- rical ganglia. The next phase of the malady, as detailed in the narrative, ex- hibits painful excitation of the emotive sense, and correlative disturbance, we must assume, of the appropriate ganglia: " They had the greatest difficulty," the pa- tient goes on, "to get me to sleep alone, I having such strange and fearful freaks in my poor head. I was so afraid that I hardly dared go from one room to another, being afraid of darkness. I can't well recollect any thing that transpired here the first month or two, save this, that 116 GENERAL PATHOLOGY. every time I was permitted to go into the yard, wild beasts would come any moment to devour me." The next state- ment evinces perverted function of the visual ganglia — thus : " I even saw them approaching with my eyes open in the day time, and w^as in dreadful agony the whole time. As I lay on my sleepless bed at night, I saw, and sometimes felt, as it were, bears hugging me, and demons ap- pearing to me." The narrative now goes back in the order of time ; and the bodily and mental conditions experienced before his removal, are again the subject of de- scription. He says : " I thought my body was daily wasting away, and often prayed for a release out of my sufferings, which were great and grievous, but I still lingered on. I w^as often troubled with saliva flow- ing out of, and down my mouth, even whilst conversing wdth my parents, so much so, as to stop my utterance very frequently. I had, owing to this, a great aversion to OF INSANITY. 117 being in their company at that time, being displeased if they ever talked in my pre- sence. Indulged in much melancholy^ and went to the kitchen, garden, or elsewhere, to brood over my doleful thoughts and complaint. They noticed my despondency, which coming on more and more, soon were afraid to leave me out of their sight. They did all that kind parents could do, paying me every possible attention." This terminates the patient's detail of his suffer- ings. He concludes as follows : " The last three or four months, T have had none of that dizziness, but find my head much clearer than ever it was in my existence. The salubrious fresh air does me much good. I always had been too fond of re- maining in the house when at home. It being out of my way to write many letters, this perhaps will hardly be worth perusal. I can with great truth truly say, my affliction was not from any sins of omission or commission, but that it was 118 GENERAL PATHOLOGY, ETC. sent for good from God, He chastening those He loves." This, with the ordinary subscription, closes the communication. The interest attaching to the foregoing narrative becomes enhanced by the fact of its being the production of the patient, and written before the mental convales- cence was complete. The case, even as imperfectly recounted above, furnishes an illustration of derangement of nearly all the nervous centres — tending thus to ex- emplify, and in some measure to corrobo- rate, much of the preceding physiology and pathology. VARIETIES, ETC. 119 LECTURE IV. Varieties and Particular Character- istics OF Insanity. In proceeding to discuss the more dis- tinctive features of Insanity, the difficulty of establishing some satisfactory classifica- tion becomes experienced. Artificial ar- rangements of mental maladies to any extent may, of course, be accomplished, by separating in groups the cases wherein particular sets of symptoms are found in combination; but the results to which a proceeding of this kind has hitherto led, are of no great value in a scientific point 120 VARIETIES AND PARTICULAR of view. If we had the same sure and definite acquaintance with the several func- tions of the separate parts of the encephar lie ganglia, as we have, for instance, with the individual structures in the chest, we might rest our division of cases, and erect our special pathology, upon a more de- tailed and exact physiology than we can under present circumstances. And if our actual knowledge were so far advanced, we might reasonably expect more enlarged aids in practically dealing with the whole subject. In the investigation of thoracic affections, we diagnose, not only the organ affected and the kind of morbid change, but the particular tissue involved. If we are informed, upon being first consulted, that a patient has an ailment in the chest, we proceed to find out, not merely what is its nature, but the distinct organ and tissue implicated; and the indications afforded possess a value that is both practical and theoretical. And thus chest CHARACTERISTICS OF INSANITY. 121 affections, including diseases of the heart, lungs, and membranes, can be arranged in categories, possessing scientific interest and suggestive of useful application. But as regards the encephalon, whatever ap- proaches to accuracy we may make in our attempts to determine the functions of the separate ganglionic masses, the particular connexion between these functions and dis- tinct psychical states too often escapes us when we experience the need for scientific precision. And yet the entire bearings of special forms of mental derangement can only be estimated pathologically, when they are investigated and appreciated in their physical as well as in their moral relations. If the exact offices of different parts of the several ganglionic masses which enter into the constitution of the encephalon were ascertained, a corresponding arrange- ment of mental diseases might be looked for. As a completeness of this kind, how- ever, does not attach to the present state M 122 VARIETIES AND PARTICULAR of our physiology, we must take the near- est approaches attainable in that direction. And that physiology of the brain, pro- pounded in a former lecture as something more than rationally hypothetical, I shall employ, in the further consideration and arrangement of the phenomena of Insanity. This physiology, I quite think, furnishes a basis for the purposes of classification, equal, if not superior, to any other that has been advanced. The observation of actual cases of mental derangement cer- tainly becomes facilitated by its adoption ; at any rate, my own experience would suggest this to be the case. The psychology so much insisted upon by phrenologists, is certainly one to the merit of which every candid mind ac- quainted with it, will bear testimony. A division of the conscious functions into intellectual faculties, moral sentiments, and animal propensities, is doubtless in a great degree conformable to nature; and CHARACTERISTICS OF INSANITY. 123 some of the phrenological subdivisions are founded, most probably, upon fact. All this is true, and may have place to a greater extent than I should myself be willing to admit as proved, — a question, however, apart from the cranioscopy asso- ciated with it. But, excellent as the phrenological psychology at large in so many respects is, I am constrained to say that, in my own later and more ex- tended experience, it has not yielded that guidance and assistance in attempts at scientific arrangement of psychical mala- dies, which I formerly thought might be the case. I must state, moreover, that I have not noticed that coincidence between configuration of the head and what is com- monly designated partial insanity, which phrenological statements would suggest; nor have I, in watching the particular phenomena, been enabled to associate in- dividual cases with disorder of one or more of the faculties, to an extent corro- 124 VARIETIES AND PARTICULAR borating, in any material measure, the phrenological analysis. A division and classification of cases resting upon permanent differences and exact definition, I believe to be impracti- cable to any extent. We may abstract and arrange particular phenomena, so as to bring them more distinctly under re- cognition; but when we investigate them in their concrete realities, the very best schemes are found to be imperfect and unsatisfactory. All writers and statistical records have their cases of Mania, Melan- cholia, Dementia ; and other familiar terms are constantly employed. These, how- ever, do but exhibit the more salient groups of the pathological picture; and, in many instances, they have little more fixedness than so many dissolving views. For a case of melancholia may become one of mania, and, conversely, mania may become melancholia ; or the two affections may be present simultaneously. Again. CHARACTERISTICS OF INSANITY. 125 mania may degenerate into dementia; or characteristics of the two states may dis- play themselves at the same time. Insa- nity is not unfrequently a periodic malady ; and at each of its returns, the ailment may assume new phases. An ordinary case, indeed, may, in its progress, take on nu- merous and very different forms. In proceeding to arrange the phenomena of insanity, I shall refer to so much of the previously explained physiology of the brain, as may connect itself with the classification which I shall adopt. I have said that the peripheral grey matter of the cerebral hemispheres forms, in the highest degree of probability, the organic structure wherewith the inherent conscious principle exercises itself with ideas and intellectual processes generally; and that certain ganglionic masses nearer the base — most likely the corpora striata and the so-called optic thalami — are concerned in the production of emotional sensibility. I 126 VARIETIES AND PARTICULAR propose, then, in the further discussion of the symptoms of mental disease, to recog- nise three divisions. In the first place, I shall group together those cases in which some false or perverted idea so rivets itself in the mind as to constitute an illusion which gives rise to confusion between the products of imagination and positive realities, — erroneous notions, in fact, of which the mind by no effort of reason can get rid : such a state of things, for my present purpose, may be called notional insanity, involving some derange- ment of the hemispherical ganglia. Next, I shall speak of instances in which, from some weakening or depravation of intel- lectual energy, there is a primary perversion of the intelligence, quite irrespective of any fixed or characteristic delusion ; and this mental condition we may designate intelligential insanity. In this class of cases also, the hemispherical ganglia form the seat of the affection; in what way. CHARACTERISTICS OF INSANITY. 127 however, the pathological state of these ganglia differs from that which obtains in the former category, I do not form any opinion. Lastly, I shall treat of that larger class which comprises the great majority of cases, where the prominent derangement is obviously in the emotive sense and correlated ganglia, and which may be said to constitute emotional in- sanity. These particular conditions, I may repeat, are seldom found isolated and present uniformly through the entire course of any one case ; they are mixed, and run into each other. I only distin- guish and separate them, for the purpose of engaging your attention with the more notable features which prevail in mental maladies, and which may be taken as re- presentative of the various morbid states of consciousness. An illustration of the threefold division just made is readily afforded. I will take for the example the varying circumstances 128 VARIETIES AND PARTICULAR of homicide. Every one knows that this is frequently committed under the influ- ence of disordered mind. The verdict of juries acquits, on the ground of insanity. Such medical men as see nothing but theory and speculation in psychological medicine, conceive that, the accused being pronounced mad, there is an end of the matter; and the Phrenologists tell us that the slaying was done under morbid excitement of the destructive propensity. Yet it is quite certain that a maniac may perpetrate a homicide under very diffe- rent psychological conditions. A person takes away life under the influence of some false notion, which has settled it- self in his mind as an insane illusion; he may believe that, like Abraham, he has a vocation from heaven ; there may be no passion, no emotion ; he may have full consciousness of what he is about, and of the consequences of his act. This is what I mean by notional insanity. An- CHARACTERISTICS OF INSANITY. 129 other person commits a similar act with- out any distinct or serious motive at all, from pure imbecility of mind, and pro- bably in perfect ignorance of the import of his deed, plunging a knife into the throat of some sleeping victim, possibly deeming it to be a very amusing dis- posal of the blade ; here would be a perpetrator of homicide, whilst labouring under intelligential insanity. A third, a furious maniac, slays a fellow-creature in a paroxysm of rage, or under a specific impulse to destroy life; here would be emotional insanity. Instances character- ised as above are not of rare occurrence, and they exemplify by one and the same overt act very different pathological states. In employing the term notional in qualification of a class of cases, I refer to those in which some unwonted and erroneous perception, or idea, has se- cured so firm a hold upon the conscious- ness as to have become like an actual 130 VARIETIES AND PARTICULAR reality, — a notion with respect to which the patient cannot be set right by appeals to reason or to common sense. Errors of sensation of com-se may arise, without any tendency to insanity, which is only recog- nised when the morbid impression per- verts thought. The celebrated bookseller, Nicolai, of Berlin, for years was the sub- ject of visual hallucinations ; he was a constant ghost-seer; for a long period, a day never passed over his head without spectres of all kinds appearing to him, — "black spirits and white, blue spirits and grey." He was an educated, well-in- formed, and strong-minded man, and knew that derangement of the optic nervous system was the cause; and no perversion of ideas ensued. He, himself, indeed, pub- lished a most interesting account of the case, the greater part of which may be read in that curious and interesting work. The Philosophy of Apparitions, by the late Dr. Hibbert Ware. Moreover, if a person CHARACTERISTICS OF INSANITY. 131 be in ignorance of the true nature of such hallucinations, and in consequence believe them to correspond with objective reali- ties, he is not to be accounted insane, be- cause the notion is perfectly natural and accordant with common sense, until the affected person has been enlightened upon the subject. An uneducated woman, a few years ago, saw an acquaintance killed by the fall of some scaffolding; the im- pression made upon her was both vivid and profound; in two or three weeks she began to see the deceased in bodily form, and was rendered nervous and wretched. I was consulted about her, and strove to set the poor woman right, as to the delu- sive nature of her vision. I hope that I succeeded, but I only saw her once and am unable to say. I did not, however, consider the person insane. Nevertheless, without doubt, if the morbid impression fixed itself, and became a settled notion, uninfluenced by any representation that 132 VARIETIES AND PARTICULAR might be made to her, subjugating at the same time both reason and moral sensibi- lity, the result would rightly be deemed insanity. Again, a person may become troubled with some remarkable sounds in the ears, but he is not on this account reputed to be insane. If, however, the morbid per- ception determine some false notion of an ineradicable character, — if the patient, for example, be persuaded, and cannot be con- vinced to the contrary, that some noisy bird occupies the interior of his head, — he is notionally insane; thus it may happen that perversion of the auditory sense may suggest to some unhappy patient that demons are whispering wicked words, urging frightful blasphemies against the Most High. Or, again, it may be that some abnormal state of the senses gene- rally conducts to the idea that an alien force compels to deeds of outrage, as, for instance, the morbid act of killing, or of CHARACTERISTICS OF INSANITY. 133 setting fire to a large building, without passion, without vengeance, without regret, and without imbecility. A large number of the eases to which the designation monomania has been ap- plied, are rightly included in the category now under discussion. This expression monomania has, of late years, become familiar to all the world; it is quite a fashionable term; and the sense, indeed, in which it is commonly understood is suf- ficiently accurate. It is applicable to all those instances wherein the delusion turns altogether upon one notion, or a single set of notions. Monomaniacs will thus fancy sometimes that, within themselves, there are other persons, not themselves, urging them to obedience and destroying their free agency. In some cases, persons ima- gine themselves to be heirs to large for- tunes, or to titles, or to have some other connexion with the great ; you cannot argue them out of their erroneous notions; N 134 VARIETIES AND PARTICULAR you will, very generally, irritate them, if you attempt to set them right ; and yet these people will very often both reason and act with their ordinary propriety in all matters unconnected with their delusion. I have at this time a lady under my care at Clifton Hall, who is unmarried and about forty-seven years of age, and who for a long period was actively engaged in business. She retu'ed upon a moderate competency, and went to live alone : the prejudicial influence of a change of this kind is very well known. Excessive va- nity and delusive conceits very soon arose ; the idea possessed her that she was about to be man-ied to a gentleman with whom she had not even an acquaintance, and her conduct became very absurd in conse- quence. Next, her notion was that she was the representative of an ancient and noble family, and that she herself was under the immediate guardianship of Queen Victoria. The climcuv having now CHARACTERISTICS OF INSANITY. 135 been attained, I suppose she can go no higher, for this latter idea, indeed, seems to have obtained exclusive power over her. All causes of dissatisfaction she will refer to Her Majesty, and she can only be influenced to any course of conduct when believing that the direction comes immediately from the Queen. At this time, her personal appearance, expression of countenance, and general manners, do not suggest that she is insane; her conversation on ordinary topics seems coherent and rational : but touch upon her supposed relations to the Queen, or any topic that springs out of the parti- cular delusion, — the mental aberration at once becomes revealed, and this with most garrulous prolixity. The phenomena characterising this " notional insanity," as, for the purpose of these lectures, I denominate it, are very various; it is not always that the illusion is of a settled or uniform character. Even 136 VARIETIES AND PARTICULAR whilst perfectly lucid upon many matters, and reasoning correctly upon all if you concede the false data, the patient will en- tertain the most diverse, extravagant, and incongruous ideas, and be as completely under their government as the somnam- bulist is seen to be, when displaying the ideo- dynamic phenomena. Such facts form a problem sufficiently curious, alike for the psychologist and the physiologist. That a man who is thoroughly sensible in the affairs of his business, and in all the ordinary events of life, should at the same time believe that he is a prophet or an emperor, or that a second spirit is associ- ated with his body, or that his arms are made of earthenware — constitutes a cir- cumstance, indeed, that would be incredible if examples of this kind were not the sub- ject of constant experience. A gentleman lately left the establishment with which I am connected, who was exceedingly intel- ligent, well educated, and extensively in- CHARACTERISTICS OF INSANITY. 137 formed upon scientific subjects ; he was, moreover, a very close and logical rea- soner. If you discoursed with him upon science or philosophy, you would never find that he enunciated an incorrect prin- ciple ; and yet this gentleman believed himself to have a special mission from the Almighty to reform and purify the Christian religion. In connexion with this morbid idea, he would utter all kinds of absurdities ; his power of rational concep- tion vanishing altogether, when he was under the influence of his insane notion. At first view, it is very difficult to con- ceive of cerebral disease distorting the mind, as it were, with reference to one set of conditions only. It will be seen, how- ever, upon reflection, that such instances do not violate the analogies of general pa- thology. The stomach will exhibit idiosyn- crasies, refusing sometimes to digest some single article of food, and yet disposing of every thing else with the customary 138 VARIETIES AND PARTICULAR facility. The lungs will occasionally receive some injury in their functions from the at- mosphere of a particular place. Dr. Bree mentions the case of a gentleman, who stated that he never slept in the town of Kilkenny without being attacked by asthma ; whilst a certain Lord Ormond rarely. escaped a fit when he slept in any other place. A case is on record of a person in whom an asthmatic attack was brought on by the smell of guinea-pigs ; and another, where contact with the fur of a hare would produce illness for seve- ral days afterwards. Individual gangha will at times evince a curious inaptitude for particular impressions. Dr. Dalton was unable to distinguish colours like other people — a peculiarity which takes rank as a physiological fact, and which, not being uncommon, is now known as " Daltonism." A still closer analogy is afforded by loss of memory for some par- ticular class of ideas, consequent very CHARACTERISTICS OF INSANITY. 139 often upon injuries of the brain. In- stances of this kind are perfectly analogous to some of the more remarkable cases of monomania, wherein the mind loses its natural capability only under the influence of particular notions. Sometimes an entire series of false no- tions holding coherently together will take possession of the insane, and these will be carried out consistently in all the trains of thought, and in the whole conduct of the patient ; the reasoning faculties tracing the illusions to their natural consequences. A patient of mine recently fancied himself to be in heaven; all his feelings and notions were correspondent; the persons about him became celestial beings, in his estimation ; and reverence, love, and joy characterised his language, countenance, and general deportment. Again, a maniac not unfre- quently becomes impressed with the false idea that he is possessed of boundless wealth; his actions comport, very ratio- 140 VARIETIES AND PARTICULAR iially, with the morbid notion; he is pro- fuse and lavish past measure. Finally, I comprise in the designation of notional insanity, all those examples of mental aberration which depend essen- tially upon erroneous ideas rather than upon debility or disorder of the more purely intellectual faculties, — upon de- ranged perception and false notions, rather than upon defective power of combining these latter intelligentially. These instan- ces form the class of cases to which writers refer when, prematurely generaUsing, they assert that madmen reason correctly from erroneous premises. Intelligential Insanity, as I have de- nominated the second division of mental maladies, consists either in preternatural diminution of the power of combining the ideas which arise in the mind, so as to prevent the evolution of thought with due spontaneity; or in some deterioration of this power, tending to vitiate and derange CHARACTERISTICS OF INSANITY. 141 the intellectual operations. This defini- tion will be rendered more intelligible by the citation of an analogy which language, the symbol of thought, supplies. Whilst notional insanity may be represented by error in the use of individual words, that which is intelligential may be likened to a defect in the power of combining them rightly together. The phraseology of Mrs. Malaprop illustrates the former ; whilst specimens of what are called cross-read- ings may exemplify the latter. Intelligential insanity is thus a state of things which may, in a direct manner, weaken moral liberty, or, may do so indi- rectly, through the unwonted control over actions which is thereby conceded to the emotive sense. Of this class of cases I shall make subdivisions, in order to afford, with the greater clearness, the suitable explanation of the conditions signified. The conventional terms idiocy and de- mentia will express the negation, and the 142 VARIETIES AND PARTICULAR deterioration or destruction, of the intelli- gence; and mania, as the term is usually employed, its aberration or derangement. Idiocy is the word commonly used to signify the congential privation of intel- ligence. It is that condition of complete imbecility which causes its unfortunate subject occasionally to be called a "natu- ral," or an "innocent;" expressions not very w^ell chosen, but intended, I presume, to designate the harmlessness which marks this unhappy state of being. Although the pure idiot is practically devoid of intel- lectual power, — judgment and reason having no existence that is appreciable, — he seems quite capable of reacting upon sensational and instinctive influences, both consensually and ideodynamically. The ideas, however, w^hich contribute to the modifications of consciousness, are little more than the reflex of impressions from without; spontaneous control over them, there is none ; volitional energy cannot be CHARACTERISTICS OF INSANITY. 143 recognised as present; and moral liberty, in such cases, must be deemed a nonentity. The idiot, indeed, must be regarded as humanity blighted; and yet the unfortunate creature will sometimes, for long years, endure life among his fellow beings, more depressed in the scale of psychical capa- bility than the brute which perishes. The physical conditions which determine this distressing pathological result are various ; not unfrequently, the fault lies in excessive smallness of the encephalon, and then there is witnessed upon the shoulders of an adult man, a head no larger than that of a young infant; when this state of things is found, hopeless and irremedi- able imbecility always exists. The most complete example of this kind which I remember to have seen and ex- amined, came under my notice in the year 1834. It was the case of an idiot, the son of a labourer, born in Prestwich in the year 1814, and who was, consequently, 144 VARIETIES AND PARTICULAR twenty years of age when I had the op- portunity of investigating his psychical condition. Mr. George Wilson, of this city, brought forward the youth at the rooms of the Phrenological Society then existing in Manchester, and afterwards published very interesting particulars of the case in the Edinburgh Phrenological Journal, The head of the poor lad was certainly not larger than that of a child under twelve months old. In his child- hood, the instinctive and consensual ac- tions did not begin to establish themselves until an unusually late period ; and no de- velopment whatever of reasoning power exhibited itself, although conduct and movements simply reflecting the idea of the moment were sufficiently distinct. The great deficiency of brain was observ- able in the upper portion of the forehead, and universally, indeed, in the region of the cerebral convolutions. If the ence- phalic mass had been visible to the eye, I CHARACTERISTICS OF INSANITY. 145 one could imagine that the cortical grey substance of the hemispheres would have been found lamentably deficient. In 1834, when I saw him, the youth measured five feet six inches, and weighed about nine stone, seeming at the same time to enjoy good bodily health. For a considerable period after birth, he was said to have been very small and helpless, and he was three years old before he walked. He was still older before he learned to say "mother," a term which for a consider- able time he applied to every member of his family. When about seven years old, he became very passionate, and be- gan to swear, a habit which he had not lost at the period of my seeing him. Although twenty years old, he was in- capable of dressing himself He was fond of his meals, with which he never appeared satisfied ; and was, moreover, greatly addicted to beer, in which he had been very improperly indulged. On one o 146 VARIETIES AND PARTICULAR occasion, Mr. Wilson offered him some sweet-meats wrapped in paper, whereupon he devoured the paper and contents indis- criminately. He had scarcely any voca- bulary, and no power of conversation at all. There was so little force of charac- ter about him, that he willingly submit- ted to the governance of a little girl, a member of the same household. Like a young child, he would strike when offended; and there was a certain fear- lessness about him, proceeding, however, rather from inability to foresee danger, than from any actual courage: thus, Mr. Wilson, one day, saw him pursue a large dog and imitate its barking, and when he had provoked its snarl he seemed highly delighted. The absolute privation of every quality that could be considered proper to the intelligence, was well evinced on one occasion, when some mischievous persons undressed him, and persuaded him to go into the river for the first time in his life. CHARACTERISTICS OF INSANITY. 147 He walked senselessly in, until he was nearly out of his depth ; and he would have proceeded onwards, but the approach of his godmother, who had the care of him, deterred him. He was apparently ignorant of the value of money. When some copper coins were placed upon a table and left before him, he showed no desire to take them. One evening, at the Phrenological Society, the members laid before him a penny and a halfpenny, — like young infants, he could appreciate the meanings of words better than he could express them, — and he was asked which he would have. On successive occasions, he placed his finger upon both coins. He did not seem disposed to seize the money, nor to express regret at not receiving it. The complete subordination of this poor youth, indeed, to animal instincts and sensations and simple ideas, was exhibited in his every action, which always reflected the dominant impression of the moment ; all 1 148 VARIETIES AND PARTICULAR will or spontaneity being altogether un- recognisable. If he became possessed of a penny, he would march forthwith to the place where others, under similar circum- stances, had conducted him on former occasions; on seeing an article which he wanted in exchange, he would always, when there were two or more, choose the largest piece in preference ; that con- sumed, he would move away. Another object would attract his attention, and he would survey it for a moment T\dth every appearance of curious delight. And so he would pass on, alternately noticing and wandering, until the sense of hunger, or the friendly hand of his attendant, would draw him home. He knew very few things by name; yet if his eye was directed to an object, and he was told to reach it to you, he would do so. His attendants could never succeed in teaching him to button or unbutton his own clothes. Altogether, this case furnished a remark- CHARACTERISTICS OF INSANITY. 149 able example of entire negation of intel- lect, with a very observable presence of instinctive, consensual, and ideo-dynamic phenomena, which, indeed, constituted the sum of this unhappy person's conscious career. Besides congenital smallness of head, idiocy may have for its cause certain in- nate faults of intimate structure, seeing that this utter absence of intelligence may be sometimes detected where the ence- phalon exhibits nothing abnormal in point of magnitude. Certain scrofulous taints would appear to be capable of originating this condition. I have seen the offspring of scrofulous parents grow up in the full perfection, apparently, of their animal na- ture, and yet the intellect remain perfectly null ; a|id that, too, where neither cranial form nor size were abnormal. I am not aware that pathological anatomy has made out the essential physical character- istics of this condition. It is notorious 150 VARIETIES AND PARTICULAR that convulsions in infancy will frequently deteriorate the cerebral tissue, so as to render it unfit for intellectual operations. In some instances, hydrocephalus of a chronic character destroys the capability of sound mental manifestation, whilst it constitutes no hindrance to the fulfilment of all the nutritive and more purely animal functions. Dementia, in its actual phenomena, is identical, in great measure, with idiocy; in both conditions, the essential feature consists in the absence or notable dimi- nution of intelligential power. Whilst idiocy, however, may be considered the abortion of mind, dementia is its wreck or extinction. This latter state con- stitutes the not unusual termination of all the forms of insanity, and is a very frequent result of epileptic fits. Morbid alterations, indeed, of almost any kind, going on in the cerebral structure, may ultimately produce it. \ CHARACTERISTICS OF INSANITY. 151 There is witnessed this remarkable difference between idiocy and dementia, that whilst, in the former state, there is an absolute poverty of ideas, in the latter there is very generally a retention, to a great extent, of such as existed in the mind prior to its overthrow. But they are under no control; they arise in no orderly sequence, and combine at ran- dom ; words are uttered devoid of all de- finite meaning, and having no intelligible relation to the circumstances of the patient. An enduring but shadowy dream, of a very incongruous character, may suggest some notion of the sort of consciousness which obtains in this variety of mental malady. In cases of this kind, it often happens that the physical necessities of the body are entirely disregarded, and that the patient is even insensible to the ordinary calls of nature, — a condition of humanity than which it is impossible to conceive any thing more deplorable. In 152 VARIETIES AND PARTICULAR . . . . 1 extreme examples of this kind, it is reasonable to suppose that all the gan- glionic centres are more or less damaged, inasmuch as their functions appear to be so largely and enduringly perverted. It is yet remarkable how, in some cases, with total wreck of the intelligence, there continues a certain degree of soundness in the emotive sense; all the actions which depend immediately upon the inner sensi- bility, as also the movements which are consensual, being executed after the cus- tomary manner. I have at this time a patient w^ho furnishes a striking example of this state of things. It is the case of a gentleman who, at twenty-one years of age, was possessed of a handsome fortune, which he squandered in dissolute habits. He is now about forty years old, and has for some years been entirely demented. He seems incapable of all intelligible con- versation ; to the simplest question, he will respond in some irrelevant phraseology; CHARACTERISTICS OF INSANITY. 153 and neither by associating with others, nor by exhibiting interest in particular pur- suits, does he show any sustained opera- tion of mind whatsoever. He was at all times remarkable for his politeness and gentlemanly bearing; and the complete- ness with which he retains these charac- teristics is most interesting. He is a per- fect master of his toilet, and maintains himself singularly clean in his person, and neat in his attire. His demeanour, on all occasions, is not only correct, but is marked by a singular delicacy. If any one enters his apartment, he rises with gracefulness and gives the appropriate salutation with elegance ; nothing, appa- rently, would induce him to resume his seat, if a lady were standing in his pre- sence. He is very devout, and often to be found upon his knees ; and if spoken to in this attitude, he will never reply without previously rising in the most reverential manner ; and whilst in devotional exercise, 154 VARIETIES AND PARTICULAR he will spontaneously enunciate the words of prayer with accuracy, and with just the appropriate degree of emotion ; yet, if you were to ask him to recite the words of prayer, you would receive in return a silly laugh and some unmeaning phrase. He will appear to be studying the Book of Common Prayer with great earnestness, but you discover that he has the table of contents, or a blank leaf, before his eyes. So long as this unfortunate man is under the influence of his emotional nature, his expression of countenance gives no indi- cation of his unhappy state, — make but the slightest appeal to the intelligence, and idiotic insanity becomes revealed at once. He is equally well-conducted over his meals, and with all propriety attends to the natural calls. A case of this kind receives a pathological explanation by aid of the cerebral physiology set forth in a previous lecture. The intelligential func- tions appearing to be all but paralysed, 1 CHARACTERISTICS OF INSANITY. 155 but the emotional sensibility continuing; so the cortical grey matter of the brain we may assume to have sustained pro- found and irreparable mischief, whilst the sensory and emotive ganglia are compara- tively unaffected. Mania is the last of the subdivisions which I have made of the intelligential forms of insanity. Although the term is one applicable and actually applied to all the varieties, it designates, in a more especial manner, those instances in which there is not so much destruction, or de- fect, of mind, as some derangement of its proper harmony. In such cases, it can- not justly be said that the brain is not fertile in ideas, or that these have dimi- nished vigour; it is in their disorderly combination, and in their withdrawal from a just subordination to the will, that this condition essentially consists. The examples of rambling and incohe- rence in discourse, evinced very often by 156 VARIETIES AND PARTICULAR what has not inaptly been denominated a diarrhcBa of words, generally fall within this category. In the slighter instances of mania, the patient will break off his subject in the midst of a narrative or of conversation, and will pass abruptly to some other with which the previous one has no sort of connexion, and then again to another ; exaggerating realities most ridiculously, and suggesting conclusions that have no reasonable relation with the incongruous premises. The mental images which the patient forms, indeed, may be Hkened to the fragmentary toys of the kaleidoscope, assuming a disposition very much at random, and exhibiting, in the groupings, results fantastic, strange, and grotesque. In the severer forms, the patient goes wildly on, talking and gesticu- lating in the most unconnected and un- meaning manner, and showing sometimes complete incapacity to fix the attention; these more intense examples of mania, CHARACTERISTICS OF INSANITY. 157 unless recovery be speedy, very generally pass on to dementia. Mania, as here de- scribed, is a very frequent form of mental disease, and it may exist in all degrees of severity; its precise phases are innu- merable. Notional illusions almost always arise, more or less, in the progress of the malady; arising, however, from the gen- eral disorder of ideas only, they have not a fixed, settled, and defined character, as in the class of cases wherein they form the leading feature; they do not, as it were, take absolute possession of the con- sciousness, and become reflected in all the mental processes ; they resemble rather the vague and erroneous groupings of inward impressions which are found to take place in a dream. I shall probably convey to persons inex- perienced in mental diseases, a clearer idea of what I have described as mania, by reading a letter addressed to myself by a patient at Clifton Hall, written p 158 VARIETIES AND PARTICULAR at mj request, and professing to give some account of himself. The writer is a young man, about twenty-six years of age; at the date of the letter he was convalescing from a second attack. The production evinces that inharmonious ex- ercise of the intelligence, which I have adduced as the distinguishing characteristic of that variety of insanity of which I am now treating. The entire communication is too lengthy for insertion in this place ; but as the purpose with which I cite it requires that passages should not be given detached, I will furnish the text uninter- rupted from the commencement of the latter half of the letter, which supplies a graphic and lively illustration of that derangement of thought just discussed. The communication is as follows : — " I began my letter by stating that man was endowed with a will of his own, and that at times that will was allowed full and free action. Such I may say has CHARACTERISTICS OF INSANITY. 159 been my lot. I have been allowed to taste of the pleasures of the world as far as my circumstances would admit; the consequence was, I turned away disgusted with the idol pleasures of the day, to seek something more pure and more genial to my feelings, which I found in Religion, or in the pure Gospel of Christ as preached by men duly ordained to the office, having received the true light, and not a mere or hollow bauble, as some account our re- ligion. But the farther I traverse, I find there is still more than the mere, outward faith. We have the evidence. And now I come to the cause of my illness, if you term it so. I will give you to understand that, for a month or two before I left home, I was acting in the same way as we do here now. I will say further, it is for the cause of God and His Church if I may so speak, (I have acted in private,) but I also saw the same symptoms in others before I left home, which satisfied 160 VARIETIES AND PARTICULAR as to the justice of my proceedings which caused me to be doubly bold and gave me strength. "Floods, storms, and tempests do not come for nothing. Those who are taught by the Spirit look upon these things as evidences of its presence with power. Perhaps you are not aware we had a flood here during my first illness ; tliis is a secret I have not divulged to any mortal, but such was the case; and well have I every cause to know it, because I was troubled at the rising of the waters, and a railway engine passed through the water, which I know to be a fact, in a similar manner to which it did at Samlesbury, if I am not mistaken at the name of the place. This fact was an intimation to me of something of importance being enacted ; I can't say I know what. Now I will give you an idea what my feelings were on the Tuesday before I came here on the Thurs- day. I dressed and went my usual [way?] CHARACTERISTICS OF INSANITY. 161 with as cheerful a countenance as was my wont to do, found things much as usual; but on my return towards [home?] I began to feel heavy, as if some weight had been laid upon me. I called upon a party, the name of J. H., grocer, Deansgate, passed usual compliments and talked, when, be- hold you, I felt a pressure or weight be- hind me reaching from my hat, which it caused to move back, and I felt the sensa- tion on me. I said to myself, This will do ; because I thought this was further evidence for me, that I must be accepta- ble, in some way, to this Invisible agency or Supreme agency. I looked round to see if I was not mistaken, but could see no- thing, so I bade him good bye and walked off, and gradually the weight left me, but after I felt dull and exhausted. On my way home, I met one of the ministers of the Old Church in Cross Street, who moved to me, and smiled ; this I thought as singular as conduct I had ever dis- 162 VARIETIES AND PARTICULAR played. I did not return the salutation ; I was in no humour at the time. Thus the day passed off without any thing of further [interest?] At night, I went to the theatre; such performance I liked very much. Returned home at the closing time direct, and received a good saucing for being so late. The idea, a young man of twenty-six years of age being scolded for stopping out till eleven o'clock. " This treatment caused me to weep bitterly, not from the sauce, but for the manner in which it was delivered; got supper, and went to bed ; don't remember the incidents of the night. I got up early, and went round by Cheetham Hill in my slippers, turned by St. Chad's, and came round by St. Michael's home ; bought some cigars, and smoked one before break- fast; went to office, could not maTce my notes out cmTedli/, but managed it by close application what I did. Took my Bible and a small book called Polynesia, or the CHARACTERISTICS OF INSANITY. 1 6S Unknown World ; have not read much of it. Went by railway to Burnley, read the Bible to the people in the train, and explained, — in what manner I don't know. Spent the day rather singular. Dined and got tea at the Bull Inn. A Mr. H. Cooke took tea with me; stood treat for the other two. All the four came to Man- chester, as I persuaded them the perform- ance at the theatre was very good. I tore my over-coat, and left it with Mr. M. ; up- braided him about being too fond of his glass; threw my hat out of the railway train. On arrival in Manchester, found myself very weak, took a coach, went home, all the circumstances between which as of which I know. " In conclusion, I say I was actuated by a power superior to my own, and not by own self will. — I remain, yours, most res- pectfully, J. H." 164 VARIETIES AND PARTICULAR LECTURE V. Varieties and Particular Character- istics OF Insanity — continued. In the varieties of mental derangement described in the last lecture, — in the cases wherein the presence either of notional illusions or of marked disturbance of the intelligence, constitutes the leading cha- racteristic, — we are led by considerations both physiological and pathological to re- gard the hemispherical ganglia as the spe- cial site of the ailment. But whether the several modifications which these varieties offer, involve distinct portions of the grey CHARACTERISTICS OF INSANITY. 1G5 matter of the convolutions, or consist ra- ther in some difference of pathological alteration which the affected structure un- dergoes, I feel it impossible to say. I am unacquainted with any facts capable of throwing satisfactory light upon the sub- ject, and unprepared with any speculations tending to elucidate it ; I shall, therefore, not pursue this topic, but proceed to the discussion of the third division of mental maladies which I have proposed, — those of which perturbation and depravation of the emotional sensibility constitute the distinguishing feature. A very large proportion of the actual cases of insanity are classifiable most ap- propriately in this category, which may include all the examples wherein, with dis- ordered thought, there is largely associ- ated some perversion of the emotive sense. This may be exalted or depressed to the extent of disease, or morbidly depraved in some other notable manner ; and there is 166 VARIETIES AND PARTICULAR good reason for believing that, with such states of the inward feeling, pathological changes in certain ganglionic masses at the base of the brain are connected. This class of mental maladies, like the instances of monomania, supplies many a case which constitutes a moral riddle, perplexing alike to the physician, the philosopher, and the jurist. Questions the most intricate, in- deed, become raised in discussions of the phenomena, and these refer themselves both to philosophy and medicine; and difficulties of various kinds, legal and mo- ral, beset the path of those whose duty it is to deal practically with these questions. As my present purpose, however, is to treat of Psychological Medicine as a de- partment of practice, I shall avoid the discussion of all topics properly within the domain of medical jurisprudence. When the inner sensibility, be it senti- ment, passion, or propensity, exhibits itself in an extraordinary manner, we are led to CHARACTERISTICS OF INSANITY. 167 suspect Insanity. Unusual or motiveless acts of kindness; strange and unwonted developments of the devotional sense ; pride and vanity, shown in methods out- rageous and grotesque ; likings manifested in curious fashions, and dislikings where the circumstances and previous states of mind would cause the opposite feeling to be expected; singular and distressing timidity, with or without some real or apparent cause; anger and fury, uncon- trollable; these, and other such demon- strations, naturally lead to the suspicion at least of Insanity; and the more so, if they be at variance with the moral antecedents of the patient, and if they admit of no satisfactory explanation from external circumstances. In all such in- stances of morbid emotion, where they can rightly be designated insanity, I am convinced that perversion of ideas obtains; and, that this can almost always be de- tected, either as cause or consequence, 168 VARIETIES AND PARTICULAR when the cases are closely watched. I reserve a more extended discussion of this point, however, until this lecture is further advanced. If melancholy, or excessive joy, or some curious caprice, exist, that is only of a temporary and normal kind, an elucidation that excludes the idea of insanity will readily be attained. I will illustrate this assertion by taking the instance of melan- cholic depression. When this state of mind displays itself in a natural manner, and when it has been superinduced by sufficient cause, the resultant affliction may thoroughly subdue the individual, may render him for a season powerless for active or useful exertion, and mav seem, indeed, to have prostrated the whole moral being. But watch the sequel. You will commonly see that, in a very brief space of time, the afflicted person will, in some de- gree, become himself again; the acute sense of painful emotion will cease, — \}CiQ 'passion CHARACTERISTICS OF INSANITY. 169 will have become exhausted; to return, however, again and again. Exacerbation and mitigation alternate with each other; the intervals of sorrow gradually lessen- ing, and its intensity diminishing, always progressively. In that melancholy, how- ever, which is morbid, the state of things just described is much less observable. Most generally, there is a fixedness and a permanence in the moral depression, always calculated to arrest attention ; and when this is long continued, particularly in persons who inherit some tendency to insanity, the ideas will almost surely sus- tain perversion. One idea may take ex- clusive possession of the mind, have its just importance ludicrously exaggerated, or beget a whole train of affiliated fancies, bewildering the imagination and deranging the intelligence. If loss of worldly sub- stance has produced the melancholy, the Union Workhouse may loom in the dis- tance ; if it has been occasioned by domes- Q 170 VARIETIES AND PARTICULAR tic bereavement, blank despair may ensue, and the idea of a chastening visitation may so absorb the thoughts, as to suggest, by exaggeration, the notions of God's curse and irretrievable perdition. Attempts at suicide very often place these cases beyond all manner of doubt, even to the relatives and immediate friends, who are always reluctant to admit the fact of insanity. In well-marked examples of this kind, the destruction or impairment of moral responsibility is recognized universally. This train of circumstances, as I have before observed, exemplifies a very fre- quent form of emotional insanity. The depth and permanence of feeling I refer to, are not always to be found in melan- cholia, as instances of this kind are tech- nically denominated. Both here, and in other derangements of the emotive sense, the morbid state of feeling will sometimes undergo remission, whether it be depres- sion or turbulent joy, timidity or fury, or CHARACTERISTICS OF INSANITY. 171 any other disturbance of this nature. In all cases, however, there is either some inadequacy of external cause, or an irregu- larity in the manifestations, contrasting, not only with the course usually to be noticed in regard to the emotions, but very frequently also with the antecedent con- duct of the particular patient. There have been many attempts to classify, systematically, the instances of emotional insanity, at times in subservience to psychological theories, and at others according to the prominent characteristics distinguishing groups of cases. Writers whose observations have been guided by the phrenological views, believe themselves able to establish distinctions of insanity according to the division which they recog- nise of cerebral parts and mental faculties. Authors belonging to other philosophical schools determine their arrangement very generally by the speculations which have obtained currency with them. And others 172 VARIETIES AND PARTICULAR again, unwedded to any hypothesis, and being men of extensive experience and sound intelligence, have proposed distinc- tions according to the predominance of certain striking symptoms. Dr. Guislain, of Ghent, whose recently published work evinces an extraordinary familiarity with all the phenomena of insanity, and whose practical acquaintance with this depart- ment has been immense, describes at least some fifty or sixty varieties of the kind of cases which I have here classed as emotional. I take the actual fact to be this : — any division, provided it embraces ac- curate descriptions of cases, may be made to look plausible; because, in the mind deranofed, the same unceasins: varietv in the emotive manifestations may be wit- nessed, as is found to characterise the mind in health. All states of feeling that have their normal displays, may show themselves under perverted aspects CHARACTERISTICS OF INSANITY. 173 in disease. Every disposition which we call moral, excellent, or religious, may, in mental disease, exhibit itself in some Ictinwonted manner. A man from exalta- tion or depravation of conscience may become insane ; he may be ridiculously scrupulous and entertain fantastic notions of duty, and be rendered remorseful by the pettiest infractions of supposed obliga- tions. I had under my care for a short time, some years ago, a lady whose moral sense became pained at a circumstance so slight as the accidental transit of her pocket handkerchief over a shop counter, believing that something, though it were but atomic, must have been brought away that did not belong to her. The lady was afterwards for some months in a private establishment under the care of the late Sir William Ellis, and recovered. Numerous cases present themselves in which lavish prodigality in acts of kindness forms a distinguishing feature. 174 VARIETIES AND PARTICULAR Devotional maniacs abound every where. Again, all that we stigmatise as little, mean, and contemptible, when existing naturally, may arise as disease ; and it is notorious that many persons who, in their right mind, are upright, generous, and can- did, become, whilst insane, shuffling, par- simonious, and cunning. And, moreover, all those acts which we reprobate as wicked and sinful, may result also from morbid perversion of the emotional nature, and may really constitute the evidence of disease. Cunning, lying, thieving, homi- cide, incendiarism, and every conceivable deed prohibited by the Decalogue, con- stantly characterise the insanity of par- ticular patients. Indeed, the emotive sense may become affected in its relations to any class of ideas so as to give rise to any extravagance of outward conduct, either by exaltation, by depression, or by some anomalous depravation. There now becomes raised a point of CHARACTERISTICS OF INSANITY. 175 considerable importance, which is this: — Does disordered emotion, dependent upon pathological states, of itself constitute in- sanity ? Is there, in fact, a moral insanity, as taught by Esquirol, Prichard, and some others, where there is no intellectual error, either in the formation of notional illu- sions, or in derangement of the reasoning faculty? Before advancing to the consi- deration of this question, I may observe that, certainly, the nervous centres may any of them become the seat of disease, without implicating the others. Thus, depravation of any of the five external senses may separately exist ; deafness may be present without the disturbance of the visual function, there may be neu- ralgia without chorea, and so on. In like manner, disease of the emotive ganglia may prevail, without communicating its influence to the ganglionic investment of the cerebral convolutions. We see this to be the case in certain forms of hysteria. 176 VARIETIES AND PARTICULAR with which, indeed, sympathethic states of the sensory ganglia are much more fre- quently associated than sympathetic affec- tions of the hemispheres. See with what grave earnestness the nervous female will speak of ailments in great measure imaginary, but suggested to her thoughts by depraved sensation. Spasms and sink- ings and vapours and bile perpetually trouble her repose; and very insignifi- cant symptoms become elevated to the dignity of disease that is organic. Such patients most commonly belong to the well-paying classes of society; and fine sources of income they constitute to the apothecary; they would never have done with their draughts and their pills and their doses of every kind. Fashionable quackeries, such as homoeopathy et id fjenus 07nne, spring into existence respon- sive to these unhappy states of the emotive sense; in physic, as in commerce, supply and demand maintain corresponding rela- CHARACTERISTICS OF INSANITY. 177 tions. The upright and intelligent phy- sician detects the true state of the case ; he sees, in the vagaries of hysterical women, neither morbid states of the viscera, nor mental derangement in any accurate sense of the word; but very often he sees spoiled "children of a larger growth," who are anxious principally to excite the solicitude of their family or their friends, thus delighting to encourage, rather than disposed to repress, their disordered sensi- bilities. The practitioner whose sagacity enables him rightly to appreciate these in- stances, and who is conscientious enough to avoid pandering to caprice, and suffi- ciently self-possessed to maintain a de- meanour of dignified indifference to all exhibitions of vain conceit and morbid de- ceit, will much more effectually mitigate these imaginary ailments by his honorable and straight-forward conduct, than will the practitioner who furnishes new mo- tives for a continuance of the game, by 178 VARIETIES AND PARTICULAR affecting to combat some serious malady, in drawing upon the resources of the apothecary, or in sanctioning any current medical folly of the day. In considering this question of emo- tional disorder, I may remark that there can be no doubt that, occasionally, serious and even morbid derangement of temper, appetite, or other inclination, may have place, under the influence of which per- sons may take away life, and perpetrate atrocities and extravagances of every kind; and this too in cases where there is no perversion of ideas. But have we then, in such cases, to recognise Insanity? And is there freedom of will under these cir- cumstances ? I think we may fairly allow that depra- vation of the emotional consciousness, like corresponding states of the instinctive and sensational, may at times produce impulses to action so powerful, as literally to enslave the will, and leave it in some respects CHARACTERISTICS OF INSANITY. 179 powerless for resistance. The violence of pain, it is well known, may be such as to necessitate movement or expression that is ordinarily free, gesticulation and the involuntary shriek for example. We know, moreover, that certain instinctive acts which result from natural inclinations, and are rightly subordinate to the intelli- gence, become yet, from vicious habits, morbid as it were, and absolutely uncon- trollable; drunkeness and profligacy of every description, supply the illustration. But are we to regard the drunkard and the profligate as insane, whilst the understand- ing continues in its complete integrity ? I know there are persons who maintain that sin and crime have, morally, no exist- ence ; but that deeds and mental states constituting what we designate such, are always the result of pathological condi- tions. Consistently enough, these people would transform prisons into hospitals, and criminals into patients; physical and 180 VARIETIES AND PARTICULAR mental improvement being the only aim and plea of corrective discipline. The very notion of retributive desert is scoffed at, as an antiquated absurdity, unworthy of an enlightened age. I have no sort of sympathy with such views, and I am quite assured that they are radically and totally unsound. Society, I am well con- vinced, would never hold together, were such a philosophy to have any general application in actual life. Now, I regard emotional disorder that is unaccompanied by perversion of ideas, very much in the same light as that in which I look at analogous states of the sensations and the instincts ; the influence of the disorder in such circumstances may be sufficiently powerful to overcome the will, and so in some sense to weaken moral liberty. But who can estimate the precise measure of individual culpa- bility, but He who searches the reins and the heart? For my own part, I would CHARACTERISTICS OF INSANITY. 181 never characterise such cases as insanity, so long as the reason evinced itself unim- paired, and the apprehension of facts and circumstances occurred quite naturally. There may be disease in the emotive gan- glia when disorder arises in the emotional consciousness, just as visual hallucinations and neuralgia testify of disease in the sensory ganglia; and, undoubtedly, reason and common sense alike suggest under such circumstances, that volitional spon- taneity is more or less interfered with. Indeed, the law of the land recognises diminution of moral freedom in certain emotional states, which it does not regard as insanity. When homicide takes place in a paroxysm of ebullient rage, it is not deemed to be murder, nor is it punished as such; it is simply manslaughter. And there is one combination of circumstances, I believe, in which the slaying of a fellow creature is not even punished as crime; the excitants to wrathful emotion being 182 VARIETIES AND PARTICULAR SO fearful as, in the estimation of the law, to deprive the subject of it of all accountability. But, even here, the plea of justification is not held to be insanity. Some years ago, by the kindness of Mr. Close, surgeon, of this city, I had the opportunity of investigating a very instruc- tive case of what I deem to be disease of the emotive ganglia, implicating voluntary movement also, and in other ways weaken- ing the efficiency of volition. I took notes of the case at the time, and gave the written statement to Dr. Carpenter, who has inserted it in the last edition of his Human Physiology, As the account practically exemplifies a great deal that has preceded, I will introduce it in this place : — "Mr. R., aged forty-one years, of a sanguine-nervous temperament, a married man, and father of several children, the youngest being but two months old, exhi- bited the following symptoms, first expe- CHARACTERISTICS OF INSANITY. 183 rienced in a slight degree about five years ago, and since then having become much aggravated. There was partial paralysis of voluntary motion upon the left side, exhibiting under ordinary circumstances the customary phenomena; but there was this peculiarity, — that although volition was comparatively powerless, any incident- excitor impression of an unusual charac- ter, by provoking, as it were, consensual action, would give effect to the voluntary intention; thus, when the affected arm was raised by another to a certain height, the patient was unable by mere volition to elevate it still more ; but if the hand were smartly struck, or blown upon, either by himself or by another, movement of a prompt character would at once ensue, and that too in conformity with the voli- tional effort. Upon inquiry, moreover, it appeared that any unwonted impression upon the internal as well as the external senses, was capable of leading to a reaHsa- 184 VARIETIES AND PARTICULAR tion of the effort, vainly attempted by the mere will ; hence, by accomplishing the commencement of a run, or trot, by aid of some undue impression, he could go on. He stated, on the case being proposed, that if, in utter paralysis of voluntary power over the muscles, a hundred-pound note were suddenly placed before his vision, and he were told that on seizing it the same should be his, he would at once be equal to the requisite effort. When in health Mr. R. stated that he had excellent con- trolling power over the emotions, but that now the pleasure and the pain attendant upon their excitation were exalted, and the consensual phenomena quite irresistible; and, on further inquiry, it appeared that, in the matter of laughing and crying, he exhibited very much of the hysterical condition. In early life, Mr. R. had been what is called a free liver, both in regard to women and to alcoholic stimulants." Whatever be the preponderance of emo- CHARACTERISTICS OF INSANITY. 185 tional disturbance in cases that we must regard as actual insanity, I myself feel convinced that some derangement of thought is constantly its associate; and, indeed, in my own view of the subject, perversion of ideas forms an essential feature in all cases; and if this be not manifest in the conversation of the pa- tient, it will be so in some unwonted extravagance of conduct or of manner. Morbid states of the emotive ganglia may determine strange inclinations, melancholic depression, or furious excitement, under the influence of which erroneous trains of thought will spring up by suggestion, as it were, from the depraved sensibility, and correspond in their character with it. Or, notional illusions may constitute the initiatory malady, and these, in their pro- gress, may determine disturbance of the emotions. A person becomes low-spirited Avithout obvious or adequate cause; it may be a pathological state ; if so, there 186 VARIETIES AND PARTICULAR will very likely arise some error, or serious exaggeration, in his estimate of the world without. I have at this time two ladies under my care for melancho- lia, and they are both of them firmly impressed with the idea that they have sustained utter loss of property, and that ruin is imminent. In one of the cases, low spirits have led to the false notion; in the other, real losses became exag- gerated into beggary, and in the sequel have produced a morbid depression of spirits. The correlated physiology will consist of action and reaction, through conducting white fibres, between the he- mispherical and the emotive ganglia. Be- sides the communication of an influence in the ascending direction from the emotive to the hemispherical ganglia in disease, morbid excitement may pass from the former to the nervous centres below, determining movements and acts which form their appropriate expression. Hence CHARACTERISTICS OF INSANITY. 187 many insane persons will refuse their food, and most obstinately close the teeth against its admission within the mouth; others will make grotesque and quite meaningless contortions of visage. Fur- ther, the insane will gesticulate impul- sively, will bite, tear, pluck, climb, and execute other acts, — the abnormal mani- festations of cerebral and nervous activity. At this time, I have a patient who, from time to time, conceives himself to be the Saviour of mankind ; at these periods, he becomes violent and furious, vociferating at the top of his voice, denouncing those about him as demons, and inflicting per- sonal injury if not withheld, under the perverse notion that he is in combat with wicked angels. Phenomena of this cha- racter are but rarely of any durable occur- rence; more generally they are to be noticed, intercurrently, in the course of the malady. Undoubtedly, it is often very difficult, 188 VARIETIES AND PARTICULAR as a writer in the British mid Foreign Medico- Chirurgical Review, for October 1852, observes, "to detect the disorder in the ideas or the intellect, particularly in the earlier stages; but a well-conducted analysis of the phenomena rarely fails to eUcit a correct diagnosis." Thus, when conduct of an extraordinary and unac- countable kind ensues, there is generally found at bottom some sentiment or inward persuasion that it ought to be so, and yet the conversation may not betray it. Six years ago, I had to deal with the case of a young man, about twenty-one years of age, who, shortly before I saw him, had become reserved, disdainful, and totally changed in disposition in other respects. No per- version of ideas was apparent, excepting from his demeanour. Attempts to gain an explanation were quite vain; still the intuitive good sense of those about him suggested that he was not in his right mind. An accident at length brought out CHARACTERISTICS OF INSANITY. 189 the fact. This youth, the son of a pub- lican, believed himself to have the Queen Dowager for his true parent, and was in- dignant at being temporarily deprived of his birth-right. The draft of a letter to his supposed mother having been left acci- dentally on the table, was read by his friends, and the mystery of his eccentrici- ties became revealed. I have sometimes wondered whether the Royal name of Charles Stuart, which the patient bore, had any thing to do with the direction which his delusion took. It very often happens that a person profoundly melancholic never exhibits the least trace of irrationality or of notional illusions, and that after some months he takes away the life of some other, and expiates the deed by suicide. Here, it may be said, there is disordered emotion, and diminished moral liberty, — insanity, in fact, — and yet without perversion of ideas. I reply to this position by stating 190 VARIETIES AND PARTICULAR a case that, some years ago, was painfully within my own experience : — Mrs. L. was a highly intelligent lady, thoroughly well educated, and one of the most excellent persons in all respects that I ever knew. I had been acquainted with her from early youth, and on her marrying and coming to reside in Manchester, she became my patient, and the mother of several children. In the autumn of 1845, her husband, a merchant, failed in busi- ness, and Mrs. L. with her children went for a temporary residence to her father's house, near Preston. Depression of spirits soon set in ; it assumed the character of a settled melancholy. Several times I went over to see her ; but neither to myself nor to any one else, did she betray the least error of thought. So she went on till February, 1847, when one evening she called up her five children and gave to each of them a poisonous potion, under the pretence of administering medicine. CHARACTERISTICS OF INSANITY. 191 Only one of the children died, the others being saved by spontaneous vomiting. Hours in advance of her slain child, how- ever, she was herself in eternity, having thrown herself into an adjoining river im- mediately after administering the deadly drink. Whence proceeded this deplorable issue? It was an instance, some will say, of purely moral insanity. But listen to certain facts which elucidate this case. About nine years before, this lady had sustained a recognised attack of insanity, brought on by domestic affliction occurring soon after parturition; upon this occasion, she had attempted suicide by throwing herself into a pond. Her recovery from this first attack was speedy and complete. In the long interval of mental sanity that fol- lowed, she had occasion to explain to me freely the morbid state of consciousness which she had experienced. Her persua- sion had been most firm and intimate, that 192 VARIETIES AND PARTICULAR the curse of God was over her, and that the light of His countenance was totally withdrawn. Her sense of misery and deso- lation was indescribable. One remedy, and one only, was before her as a means of reconciliation, — the destruction of those she held most dear, and the expiation to be consummated by suicide. There can be no doubt whatever that this delusion had returned in the second attack, though never betrayed. The result rendered it a matter scarcely short of demonstration. It very frequently happens, indeed, that the conversation for months can be brought to manifest no sort of mental delusion, when the conduct of the patient, the ex- pression of his countenance, and the whole demeanour, are in every way calculated to suggest its presence. I have, at this time, a youth under my care, who, from the slightest circumstance affecting his nervous system, becomes fearfully irrascible, most revengeful, and well nigh demoniacal. CHARACTERISTICS OF INSANITY. 193 Even when a boy not out of his teens, he more than once rendered himself highly dangerous, once indeed attempting to stab. Unless moral discipline be well maintained, he betrays great debasement of feeling, and would delight to indulge in gross in- temperance. With careful management, however, he can be rendered docile, tracta- ble, and even affectionate. There is con- siderable mental acuteness; conversation reveals neither illusions nor deranged in- telligence ; he has a capital memory, with some taste for reading ; he takes great interest in the seasons, and in changes of weather, as indicated by the barometer and thermometer; he has also some taste for languages, and reads French with facility. Here again there might seem to be a case of emotional insanity, without perversion of ideas. Yet a child would hardly look this patient in the face without recognising him as " wrong in the head." There is an alternation between a gloomy scowl s 194 VARIETIES AND PARTICULAR and a foolish smile ; there is no fixity of purpose; he seems in no way disquieted to live in a lunatic asylum; and when promised that, on some given day, he shall dine at his father's house, in charge of the proprietor, he simply assents with an air of indifference ; and, all day long, he goes about slouching from his room to the garden, and up and down as if in sullen abstraction. Under circumstances of this kind, I never can believe that the current of thought flows naturally on, even though perversion of ideas cannot be de- termined from the words uttered. There must surely, in such a case, be some dis- turbance beyond that merely of the emo- tive sensibility. It may one day come out. It happens many times, in homicidal derangement, that oddity of temper and eccentricity of conduct, alone show them- selves for a considerable period; when fi- nally the patient may kill his owti child ; then, perversion of thought becomes mani- CHARACTERISTICS OF INSANITY. 195 fest. He will talk in some such strain as this: — There was something within me urging it as a duty to slay my child; I know all about it, and all that I thought whilst doing it. On other occasions, pa- tients, who have long been a painful pro- blem to their relations and friends, begin to talk of being inspired; they hear voices; they become filled with terrible ideas ; and very often, indeed, they exhibit the most malignant hatred against their best friends. In practically investigating the history of this class of cases, it is generally diffi- cult to determine whether the perturba- tion commences in the region of thought or in the seat of the emotions, — in the hemispherical or in the emotive ganglia; in either case, the actual phenomena are very much the same. When emotional insanity exhibits itself with great fury or excitement, there is no mistake more frequent than to see, in such instances, either a congested state of the 196 VARIETIES AND PARTICULAR brain or some inflammatory condition of the cerebral membranes. Independently of other circumstances demonstrating this error, the result of post-mortem inspec- tions is to show that, even in the most violent and aggressive forms of insanity, four times out of five, not the slightest congestion or inflammation are discover- able. Systematic writers divide and classify the instances of emotional insanity to a very large extent; establishing separate species, in some cases according to the class of ideas with which the morbid sen- sibility is in relation, and, in others, ac- cording to the severity and durability of the malady. Thus, the propensity to steal, occurrino; as disease in certain forms of insanity, becomes recognised as a distinct variety, and is called clepto -mania \ the insane inclination to burn — the patient setting fire to buildings, corn-ricks, and other valuable property — has been deno- CHARACTERISTICS OF INSANITY. 197 minated pi/ro-mania ; when dispositions of a lascivious character are displayed as the predominant feature in the deranged, the term eroto-mania is applied ; if religious feeling largely preponderate in particular instances, the case is denominated religious madness ; and so on. I have before observed that distinctions and varieties based upon this principle, may obtain without limit, because every phasis of consciousness that is realisable — be it notional, intelligential, or emotional — be it the expression of the intellect, of virtuous dispositions, or of vice — may form the predominant characteristic of in- dividual instances of insanity. All states of mind that arise naturally, may exist in mental derangement to an extent that gives distinctiveness to particular examples. And if observers be so minded, this method of constituting classes and sub-classes may be pursued with great advantage. The dis- tinctions may lead to useful and valuable 198 VARIETIES AND PARTICULAR categories; which, assuming them to rest upon facts faithfully observed and accu- rately described, will serve as beneficial guides to the student who is practically investigating the subject. But, still, divisions of this kind have not a complete scientific value, seeing that they rest upon no well-defined physiolo- gical foundation, and, consequently, can develope no very exact pathology; they constitute rather the analogues of our an- tiquated systems of nosology, like those of Cullen and Mason Good, — excellent arrangements of groups of symptoms, but not indications of a natural separateness in species. Then, again, it is with cerebral disorder producing mental disease, as it is with pathological changes in the organs and structures generally. Individual instances of mental disease, from the commencement to the termination, may show every con- ceivable variation of intensity and dura- CHARACTERISTICS OF INSANITY. 199 bility. The attack may be sudden, short, and violent ; then the case will be deemed acute. Or, it may be that the symptoms are of gradual development, exhibiting themselves slowly and almost impercep- tibly, going on for years without notable change, and without any characteristic that exhibits decided severity ; then, of course, there is chronic insanity. Under other cir- cumstances, the invasion is by paroxysms, when after a brief lapse of time the mind resumes, apparently at least, its natural functions; the paroxysms, however, re- turning again and again with correspond- ing intervals of subsidence, — lucid inter- vals, as they are denominated ; then we have recognised intermittent or periodic insanity. If, in this latter set of cir- cumstances, some violent or expressive emotion displays itself abruptly, impulsive insanity is spoken of. Cases of this kind are sometimes very curious; the emotive disturbance is inwardly felt by the patient 200 VARIETIES AND PARTICULAR in its inchoate state, and the by-standers are warned of the same by the sufferer's own mouth. I had once an instance of this kind, and had occasion to witness the phenomena; the patient warning me to take care, for the impulse to do violence was at hand ; and then for a few seconds, or a minute probably, threatening me with most impassioned tones and malignant gesticulation. The several modifications and variations just referred to, charac- terise disease of all the bodily organs, especially when the nerves supplying them are largely implicated ; and, certainly, they constitute no peculiar feature in cerebro- mental disease. Yet differences of this nature, also, are very often made the basis of division and classification ; and usefully so, too, provided the distinctions set forth are not advanced with higher pretensions than they are entitled to. I stated in an earlier lecture that, adopt what distinctions we may in mental CHARACTERISTICS OF INSANITY. 201 disease, every variety may characterise particular cases in their progress. For example, the division which I have myself made in these lectures may have the illustrations almost entirely supplied by a single instance ; presenting, at one time, what I have called notional derangement ; at another, the intelligential variety; and, again, the emotional. At this time, I have a patient who first came under my care about fifteen months ago. He then exhibited much rambling in speech and in- coherence of thought, with pleasant gaiety of disposition, rather than any painful, depraved, or over excited state of the emotive sense. The case then, at that time, according to my own division, was of the intelligential kind, and of the sub- division mania. In a few months, the maniacal symptoms subsided, and a child- ishness of manner and disposition ensued, the gaiety being exchanged for a certain quiet seriousness; the case thus verging 202 VARIETIES AND PARTICULAR upon dementia. Next, the patient, who is a gentleman somewhat advanced in years, became profoundly melancholic and de- spondent ; and thus disturbance of the emotional sensibility was rendered the pre- dominant feature. Within the last few weeks, he has become possessed with the idea, that something dreadful is about to happen to him; that he has committed some serious crime, he does not exactly know what ; and that his personal arrest is imminent. Now, in this latter point of view, the case becomes notional insanity. It is curious and interesting psychologi- cally, but still distressing on the score of humanity, to watch the fearfully appre- hensive look with which the poor old gen- tleman stealthily regards every opening of the door of his apartment, — he who, a year ago, though a maniac, was obviously happy and delighted with existence. It must be borne in mind, however, that in the several changes and modifi- CHARACTERISTICS OF INSANITY. 203 cations which cerebro- mental maladies undergo, — regarding either the particular tissue affected, or the intensity, duration, or periodicity of the ailment itself, — there is no peculiarity which renders them, in their nature, different from diseases of other structures and organs. I will exem- plify this remark, by tracing the progress of events in very many chest affections. A weakly person catches cold, — Bronchitis occurs ; but, presently, this becomes only a secondary affair, inflammation of the sub- stance of the lungs, — Pneumonia, comes on; just as these ailments are passing away, there is an invasion of Pleuritis; and on the subsidence of this, there is probably Hydro-thorax. And the readi- ness with which acute disease of any organ may assume the chronic form, and vice versa, and with which it may become in some instances intermittent and periodic, is matter of universal experience. Hence the facility of metamorphosis, in respect 204 VARIETIES, ETC. of psychical disease resulting from patho- logical states of the encephalon, is simply somewhat greater than in corresponding conditions of organs and structures less delicate and refined in their texture. AVith the present lecture I conclude that portion of my subject which compre- hends the description of the several kinds of mental derangement. My purpose in what I have hitherto said, has been, first of all, to render my accounts of disease, faithful transcripts of observable pheno- mena; and next, to elucidate, so far as practicable, the pathology of mental ma- ladies by such light as the physiology set forth in the second lecture would supply. DIAGNOSIS, ETC. 205 LECTURE VI. Diagnosis, Prognosis, and Etiology. The diagnosis, on the one hand, between what custom and the law consent to desig- nate Insanity, and the mental aberration which is merely symptomatic of some well understood physical derangement, such as fever or delirium tremens; and, on the other, between insanity and eccentricity, or extravagance of disposition and con- duct; is, in many instances, not quite so simple an affair as at first sight it might appear. Very often, it is only by atten- tion to the history and the combined 206 DIAGNOSIS, PROGNOSIS, circumstances of the case, that you can establish a diagnosis with reasonable cer- tainty and accuracy. When, for example, you are called to a patient who is labouring under violent excitement, and who is rambling in deli- rium which, you are told, is but of two or three days' duration ; and particularly when the case displays heat of skin, quick pulse, and suffused eyes, you may naturally be led to suspect that it is one of inflamma- tion, either of the brain or its membranes. But when you are informed that the deli- rium and the violence have several times intermitted for two or three hours, and that then the patient was calm and even depressed, without any undue heat of skin; and that food, moreover, at such periods was taken, and with apparent relish ; you are led to abandon as untenable your diag- nosis of encephalic inflammation. You learn, further, that the patient has not only no confirmed habit of drunkenness, AND ETIOLOGY. 207 but that he is decidedly sober and temper- ate in the use of alcohol; you cannot, under such circumstances, pronounce the case to be delirium tremens. Again, the ailment cannot be hysteria; the patient's sex may, or may not, be against it, but the symptoms have an incompleteness upon this theory, — there is no globus, no cha- racteristic irregularity of the general sen- sibility, nothing in fact to substantiate the notion of hysteria. You learn, moreover, that, although the actual outbreak was recent and sudden, there had for some time previously been reserve and sullen- ness manifested by the patient; that this disposition was unnatural to him; that, from being frank and open, he had become timid and suspicious ; that his likings had been gradually superseded by dislikings; and, altogether, that he had rendered him- self a source of perplexity and distress to his friends and relations. When you elicit all these several qualifying circumstances, 208 DIAGNOSIS, PROGNOSIS, which exclude the notion of ordinary physical disease, and correspond rather with the usual history and development of Insanity, you may safely comprehend the instance within the category. Of course, diseases like fever, meningeal inflammation, delirium tremens, and hyste- ria, may determine the origin of some true mental malady, or may arise intercurrently, just as other diseases may; they are not, however, to be confounded with the insa- nity itself; and the diagnostic marks of this latter are those which I have just indicated. Simple as these distinguishing character- istics may appear whilst I describe them, I have yet known medical men, highly respectable and intelligent, fail to appreci- ate them in actual practice. A gentleman was attacked with inflammation of the brain and its membranes, delirium and fever being prominent symptoms; he was twice bled from the arm, the head was shaved. AND ETIOLOGY. 209 and the scalp blistered; he was purged, also, with calomel; the delirium still con- tinuing, having been present altogether for forty-eight hours, two medical men of good standing certified to the patient's insanity, and he was accordingly removed. He died in thirty-six hours afterwards. A post-mortem inspection sufficiently revealed the true nature of the case. Another gentleman became violent and aggressive, having for some time previously displayed symptoms threatening insanity; he was seen by the family medical attend- ant, and treated by depletion ; he became worse ; very soon the true character of the ailment was detected, and the patient was removed. From the subsequent progress of this case, I am sure that an error was made in the first instance, in diagnosis of the actual pathological state, and that neither inflammation, nor irritation, nor congestion of the encephalon, had place in this instance ; and, consequently, that pro 210 DIAGNOSIS, PROGNOSIS, tanto the early treatment was pernicious rather than otherwise. I have reason to think that the transient mental aberration constituting one of the phases of the hysterical condition, is often mistaken for insanity proper. Many years ago, I made a mistake of this kind in the case of a young lady, and spoke of the propriety of removing her to an asylum, to the great sorrow and distress of her family, — when the patient suddenly got well. I never attended either her, or any of her connexions afterwards. There exists a greater difficulty, how- ever, in distinguishing Insanity from cer- tain irregularities of mental manifestation, which, although characteristic or premoni- tory of several of its forms, do not neces- sarily involve that calamity. For exam- ple;— How would you discriminate between Melancholia in the technical sense of that word, and excessive but natural depression of spirits? And in what way would you AND ETIOLOGY. 211 make the diagnosis between personal ec- centricity, and some kinds of monomania ? And how would you establish a distinc- tion between actual vice, and deeds which resemble it only, the insanity of the perpe- trator freeing him from guilt. I must observe, in the first instance, with reference to these points, that the diagnosis at times is sufficiently difficult ; and there are numerous medico-legal ques- tions arising in connection with these con- siderations, which constitute an abundant source of error and confusion. But it is not within my present purpose to enter into the depths of this argument; it will be quite sufficient if I give you some lead- ing views as a preparation to enable you to judge for yourselves, hereafter, when responsibilities come upon you in reference to cases of embarrassing diagnosis. Suicide, unhappily, is a frequent crime or misfortune, as the case may be, in all civilised communities. It is preceded. 212 DIAGNOSIS, PROGNOSIS, as the rule at least, by notable depression of spirits ; and the enquiry constantly arises, whether the wretched victim was, or was not, in his right mind ? This prac- tical question concerns all classes of medi- cal men. Every member of the profession is at all times liable to be called upon, to give some authoritative opinion upon the subject, and one which he can support by reasons. In this state of things, the im- portance is very obvious, of an accurate diagnosis between simple depression of spirits, and the technical melancholia. In forming a judgment myself upon this matter, I should first examine the relation subsisting between the moral depression and its ascertainable cause ; seeking to dis- cover the antecedent circumstances which had produced the apparent despondency, and to determine how far they were con- ducive to such a result in ordinary experi- ence. If it were obvious that, in the great majority of instances at least, they were AND ETIOLOGY. 213 utterly inadequate to produce the effect, I should begin to suspect disease. If, coin- cidentally with this conclusion in my own mind, it became revealed that the patient's temper and disposition had undergone some remarkable change in the common relations of life, — such as love of particular friends having, causelessly, been super- seded by hatred or by indifference, — the suspicion would become strengthened. If, moreover, there were symptoms of nervous irritability, such as startings in sleep, im- pulsive soliloquy, or other such pheno- mena, the evidence would receive further confirmation. If to all these circumstances, were added comparative forge tfulness of the original cause and a melancholic mani- festation predominant in some other direc- tion, I should have little hesitation in deciding that a patient was insane. And if it should happen that the hereditary predisposition was known to exist, the cumulative proofs, in my own mind, would amount to demonstration. 214 DIAGNOSIS, PROGNOSIS, I should have no difficulty in establish- ing the diagnosis, because perversion of ideas might not be apparent ; if the con- ditions and circumstances before referred to were present, I should have no doubt whatever that disordered thought existed in some form or another ; how difficult of detection sometimes this is found to be, I have already set forth and illustrated. In this class of cases, it very often happens that the patient is morbidly anxious to conceal the particular illusion by which he is haunted; indeed, it is incredible sometimes what efforts he will make that nothing of this kind should escape him. Patients by their excessive ingenuity in this respect, will so conduct themselves as sadly to try the patience of persons investigating the precise character of their maladies. Sometimes they will play their part successfully for so long a time as at length to procure their liberty; but scarcely is this accorded to them, when the con- AND ETIOLOGY. 215 cealment becomes practised no longer, and the patients abandon themselves to their morbid extravagances. This species of cunning, practised by the insane, is com- mon to numerous varieties of mental de- rangement. Thus then the diagnosis between the melancholia which constitutes so extensive a species of insanity, and the melancholy which is the natural expression of pro- tracted grief from reasonable causes, may be summarily stated as follows: — In melan- cholia, the circumstances are dispropor- tionate to the result; and the ulterior development of the emotional state, be- comes referrible, very often, to classes of ideas that have no immediate relation with the primary facts occasioning the mental distress ; the moral disposition, in other respects, is found to have undergone some notable change, not to be accounted for by ordinary influences; and, moreover, there are often physical signs of nervous irrita- 216 DIAGNOSIS, PROGNOSIS, bility or cerebral disturbance; and, lastly, an hereditary tendency to mental aber- ration is, in many cases, discovered to exist. I have, more especially, selected this form of insanity to exemplify the circum- stances of diagnosis, because of its exces- sive frequency, and because of the im- mense importance of accuracy in such cases, seeing that melancholic patients so often evince a suicidal tendency, and this too, in many instances, when it is least suspected by unskilful or inexperienced observers. Sometimes there is considerable diffi- culty in discriminating between mental disease and eccentricity of conduct and demeanour ; and in cases of this kind me- dical men are expected to judge, precisely as in other varieties of insanity; and hence it is important that some clue to the diag- nosis should be furnished. When in some unusual manner there AND ETIOLOGY. 217 are manifestations of pride, reserve, or sus- ceptibility of offence; or when strange peculiarities, fantastic caprices, and oddity of temper, begin to show themselves ; very often there arises painful anxiety, as to whether or not they supply indications of incipient insanity. In many such instances, the diagnosis is far from easy. If, under- lying the suspicious phenomena, some notional illusion be ascertained, or some enfeeblement of the intelligence, the men- tal derangement is verified at once; but the perplexity and the uncertainty attach to those instances in which such perver- sion of ideas cannot be detected. Under these circumstances, the diagnosis must be influenced by several considerations. The inquiry should be directed, in the first instance, to ascertain whether or not some hereditary tendency exist; then it should be ascertained whether the peculiarities noticed indicate depravation of the moral temperament, or simply ea;aggeration ; in u 218 DIAGNOSIS, PROGNOSIS, the latter case, there is less probability of insanity than in the former. Again, it is of great consequence to make out whether the suspicious symptoms have ex- hibited themselves gradually or suddenly, and whether spontaneously and from in- ward causes, or from some previous dis- ease or mechanical injury ; the probability of actual derangement is greater, when alterations in disposition or demeanour associate themselves, or stand in any kind of relation, with recognised disease or injury of the head. Any remarkable change, however, in conduct and temper, that has no rational correspondence with antecedent circum- stances, is always of itself sufficient to ex- cite more or less of apprehension; the more formidable, of course, as the suspi- cious phenomena become multiplied. It need hardly be said that the singularities of temper and eccentricities of conduct which may naturally characterise any per- AND ETIOLOGY. 219 son, have nothing to do with insanity; still, if they are discovered, to any great extent, in the member of some family noto- riously prone to mental derangement, they very often constitute the expression of this tendency. As a matter of fact, indeed, oddity and eccentricity do very often show themselves in families which are largely predisposed to disease of this kind, in cases even where no actual outbreak at any time succeeds. In society, persons are frequently en- countered, not devoid either of information or of intelligence, whom yet, from silliness of manner and general weakness of charac- ter, every one regards as fools. Are we to regard such people as insane? Cer- tainly not. The fool of society has merely some unfortunate speciality of tempera- ment, at all times characterising him ; the state of the insane is novel, and at variance with the antecedents. The former knows his peculiarities, and will probably tell you 220 DIAGNOSIS, PEOGNOSIS, that he is under no obligation to concur with other people in his views and his tastes ; he may be somewhat flighty, capri- cious to a ridiculous extent, and may per- petrate numerous absurdities ; there are limits, however, which he will never ex- ceed, certain rules of propriety which he will observe, and circumstances and per- sons he will always respect. The deranged person, with whom the character just de- scribed is liable to be confounded, can pro- bably not take care of his own person, or even manage his own affairs, — signs at all times of diseased mind, when discovered in conjunction with other moral proofs, any of which considered separately, are ordinarily insufficient for the diagnosis. When the question is between vice and insanity, the difficulty of coming to an accurate decision is sometimes very great. To do any thing like full and complete justice to this branch of our inquiry, would occupy several lectures rather than a sec- AND ETIOLOGY. 221 tion of one ; and, moreover, the discussion would involve so many details and such extended argument, that an attempt there- at would be out of place upon the present occasion. I will content myself, under these circumstances, with observing that, where conduct of a flagrantly wicked cha- racter constitutes the outward manifesta- tion of insanity, rather than the expression and the evidence of wilful vice, there have usually been premonitory symptoms, with periods of remission, during which the patient has been entirely himself; but the most general test is supplied by the com- parison of his character and conduct with his former self. If the formerly kind and truthful man, exhibit a malicious and lying habit; if the good and the religious, be- come blasphemous and cruel; or if the sober and the chaste, along with other suspicious symptoms, display the love of alchohol and addict themselves to lewdness, you have strong presumption that insanity 222 DIAGNOSIS, PROGNOSIS, is present. But let me here reiterate, vice is not disease, neither is exalted passion. The course of wickedness differs materially from that of mental maladies; which latter exhibit, very generally, a stage of invasion, one of remission, and a certain periodicity. After all, the decisive point to establish in all doubtful cases, is perversion of the ideas. And, for this purpose, nothing sur- passes the value w^hich attaches to written documents. Often enough, when the en- tire conduct and the discourse do not reveal an absolutely morbid state, the letters betray it. I have exemplified this fact in previous lectures. It is curious to consult such letters, which generally con- tain a series of expressions that perfectly indicate the disorder of thought, as well as the particular depravation of the emo- tive sense. Before taking leave of the question of diagnosis, I would remark that there are many situations, wherein both the reason AND ETIOLOGY. 223 and the imagination bring forth strange ideas, and suggest sometimes fantastic and ridiculous trains of thought ; but, in these cases, we do not recognise mental derange- ment, because the person concerned is under no mistake as to their true charac- ter ; he knows very well that his thoughts are odd and his passing conceptions ridicu- lous. If it were otherwise, if, in spite of decisive evidence, the patient adhered per- tinaciously to some notional illusion, we should of course regard him as insane. I now proceed to say a few words con- cerning the prognosis of Insanity. And, in the first place, it may be stated that it is with mental diseases as with all others, — some cases supply very readily the means of forming a judgment respect- ing their issue, others are more difficult to pronounce upon; and, regarding some again, there is really no opinion to be formed, upon which the slightest reliance can be placed. 224 DIAGNOSIS, PROGNOSIS, In estimating the probable result of a mental malady, the presence or absence of hereditary taint must always be deemed a significant fact; as is the case, indeed, when the prognosis has to be established in reference to all diseases that connect themselves in any way with consanguinity. The deeper and the more widely spread in a family the taint is discovered to be, the less favourable, cceteris paribus, must be the prognosis. Again, the circumstances distinguishing the invasion are of great importance in their bearings on the prog- nosis. If an acute disorder of the whole system, or if some cerebral malady attended with fever, have constituted the beginning of the mental aberration, the prognosis is more favourable, than when, without any remarkable physical derangement, the alienation of mind has slowly exhibited itself, — almost imperceptibly at the onset, but advancing progressively to confirmed insanity. When the malady arises from AND ETIOLOGY. 225 physical violence sustained by the head, the prognosis is very uncertain, as lesions of the encephalon, of a very serious cha- racter, may, in this way, be caused, which do not reveal their precise nature by any certain symptoms. The moral causation constitutes an all- important circumstance, in reference to the probable issue of mental disease. When the mind has been overthrown by sudden and overwhelming calamity, the prospects of recovery are very great ; the more so, if the patient be young, and of active and vigorous constitution. When, however, the mind, after long protracted cares and anxieties, unrelieved by intervals of reviving hope, at length breaks down, having long withstood the causes in con- tinuous operation, the prognosis is usually most unfavorable ; and more especially so when, as commonly happens, the physical energies have become correspondingly de- pressed. 226 DIAGNOSIS, PROGNOSIS, The actual symptoms, irrespective of the antecedents, do not supply any very marked indications to guide the prognosis. I have seen recovery in cases which seemed most hopeless, judging from the condition of the moment, whilst in others that, in the first instance, might have been deemed slight and transient, I have seen the dis- order continue for years, and ultimately assume an undoubtedly permanent charac- ter. It is impossible, in fact, to form a decided opinion with respect to the issue of insanity, if a single link in the chain of circumstances be overlooked. The causes, moral and physical, predisposing and exci- ting ; the history of the invasion and pro- gress; the actual state, and the reactions taking place under influences of every kind, — must all be known, and rightly appreciated, if an opinion is to be formed of the slightest value. What I have just said will apply gener- ally to the question of prognosis. It will AND ETIOLOGY. 227 be well, however, before leaving this divi- sion of our subject, to indicate some par- ticular phenomena that bear upon the probable issue of individual cases. Thus, the supervention of depression of spirits upon violent and excited states of the emotive sense, is frequently the sign of approaching convalescence. Those pa- tients, however, who are melancholy, rest- less, and dissatisfied, from the beginning, always praying for permission to quit the establishment in which they may have been placed, do not recover, as a rule, so readily as those who, at the onset, shout, sing, break, tear, and perpetually make an uproar. When patients of this latter class, along with other indications of improve- ment, begin to manifest revived affection for their relatives, and a consequent wish to return home, the prognosis is very favorable. But when the language of the patient gradually loses order and arrangement; 228 DIAGNOSIS, PROGNOSIS, when his features collapse, or lose their natural expression ; when, if you speak to him, he hardly catches your meaning; when his answers are incoherent; when he appears to have lost personal regard for those whom he previously loved ; still more, when the evacuations begin to be passed unconsciously and involuntarily, — the most unfavorable prognosis must be deduced, and particularly if this state of things have established itself by slow de- grees. If, however, the patient's natural affec- tions return very generally, and especially the regard for his own family ; if he begin to display some reasonable anxiety con- cerning his affairs, after previous indiffer- ence, — the signs are undoubtedly good, even though a multitude of morbid acts should continue, and seem to indicate the contrary. It is a conclusion of experience, that a partial restoration of the reason and of AND ETIOLOGY. 229 the power of disputation, especially if it be sudden, is of no very favorable augury, in the absence of a return of the natural sen- sibility. Integrity of the emotive sense, indeed, is the circumstance upon which, practically, medical men who have the charge of the insane always rely with the greatest confidence in the matter of prog- nosis. I do not propose to enter into detail, concerning the Statistics of Insanity : first, because of themselves they show but little ; and, again, because they do not bear very immediately upon the pathology and treat- ment. I will content myself with stating that, in large Hospitals, about forty-five per cent., as a general rule, leave cured ; the remainder either quitting the estab- lishment, or dying, still insane. The statistical results in well-conducted Private Asylums are usually more favor- able; a fact, I apprehend, that is attri- butable to several circumstances. The 230 DIAGNOSIS, PROGNOSIS, patients are of a better class, and presum- ably of a better condition; and, the numbers being limited, greater care and attention to the particular constitution of individual patients can be given. I have arranged the results of one hundred and twenty-one cases, taken consecutively in the order of their admission to the establishment with which I am connected; and the figures which exhibit the issues are as follow : — Admitted. Recovered. Eemoved. Dead. Bemainini Males... 72 35 5 20 12 Females 49 33 3 4 9 121 68 8 24 21 It will be noticed that, in these statis- tics, the results are much more favourable in regard to the female sex than to our own, — a consequence, probably, of the greater pliancy and mobility of the female nervous system. In general, I believe, sta- tistical tables display readier and more nu- merous cures with women than with men. I now proceed to speak, in somewhat AND ETIOLOGY. 231 greater detail, respecting the constitutional origin and the exciting causes of insanity. The circumstances bearing upon these points are various, and sometimes are of a physical, and sometimes of a moral nature. The first noticeable fact having reference to the predisposition to mental derange- ment, is its hereditary character. I very much doubt whether any other class of diseases exhibits this feature so remark- ably. Of the cases that come within the observation of medical men, nearly two- fifths, upon minute inquiry, can be made out as belonging to this category. But when it is considered how very unwilling families commonly are to acknowledge the fact of hereditary tendency ; and how anxi- ous they are even to conceal the occurrence of individual cases ; and how resolved, very frequently, the friends of patients are, not to recognise in any kind of way, the exist- ence of the least hereditary fault of this kind, — it becomes a matter of certainty 232 DIAGNOSIS, PROGNOSIS, that the predisposition exists in a much larger proportion of instances than statis- tical data would suggest. I am of opinion, indeed, that no pathological state exempli- fies more strikingly the communicabiHty by generation of morbid tendencies, than Insanity. In what particular temperament, or constitution of body, this vicious ten- dency inheres, or in what manner it comes first into existence, are questions involved, to a great extent, in difficulty and uncer- tainty. Assuredly, none of the recognised temperaments or habits of body can be said to have an especial connexion with it. Persons of robust, muscular, and appa- rently healthy constitution, seem to be just as liable to mental disease, as those of a scrofulous and weakly habit of body. Ex- cepting that persons of great nervous exci- tability are subject, in a high degree, to functional disorder of every kind, they do not appear to have any unusual proneness to derangement of mind. AND ETIOLOGY. 233 When hereditary tendency to insanity exists, then, it becomes necessary to as- sume that some peculiar proneness to dis- ordered action inheres in the cerebral and nervous structures, not compromising sen- sibly the organisation at large ; but of the precise nature of this tendency we are as yet ignorant. Concerning the origin, how- ever, of the hereditary predisposition, we are not altogether in the same obscurity. The marriages taking place among near relatives, — the "breeding in and in," as the phraseology runs, when applied to cat- tle, — constitute a well known source of family tendency to mental disease. Even when the immediate issue of such unions exhibits no actual insanity, there is reason for thinking that the tendency is trans- missible, — to become apparent, probably, in the "third and fourth generation." Imbecility of mind, rather than active dis- ease, is the most usual result under such circumstances. A great deal of interesting 234 DIAGNOSIS, PROGNOSIS, and decisive evidence upon this point has been collected. I could cite some striking instances that have occured within our own locality, but for obvious reasons I think it better to refer you to statements already pubHshed. For example, Dr. Rowe, in his Report on Idiocy in Massachusetts, sets down one-twentieth of the whole number of cases to the marriage of first cousins. From seventeen such marriages, there were ninety-five children, of whom no less than forty-four were idiotic, — to say no- thing of those who were deformed, deaf, blind, and unhealthy. Another circumstance determining the origin of constitutional predisposition, is the moral conduct of the father or mother, or both. It is something more than plau- sible speculation, which makes out that the physical and moral condition of parents, at the commencement of embryonic exist- ence, influences, in some degree, the in- tegrity of the offspring. It is very rare AND ETIOLOGY. 235 that healthy children are born, when both father and mother are of drunken habits ; and the result very often shows itself in a faulty cerebral organisation. Mr. Bally, the artist, had formerly, in his collection, casts of the dwarfish heads of some six or seven idiotic children, born in succession, the issue of persons perpetually intoxi- cated. Dr. Guislain, in his recent work, states that, within his knowledge, a whole family of maniacs were born of a woman who, every day of her life for many years, got drunk to the last excess. She had never been herself insane, nor her hus- band, nor any member of either family ; so that here was established a whole genera- tion of descendants congenitally deranged, as the consequence of their mother's deplo- rable wickedness and folly. Of the lowest class of Idiots, Dr. Rowe found three- fourths to be the offspring of intemperate parents. The presence of syphilis in the system 236 DIAGNOSIS, PROGNOSIS, of the parent, especially if the mercurial cachexia be superadded, may operate at times very much in the same way. The author just quoted states that he knew a man of excellent constitution, who mar- ried, and had in the first instance children born in very good condition. During his married career he contracted a venereal ailment, which continued a long time, and which required the reiterated employment of mercury. Whilst this was going on, he had two children, and after his cure he had three others. One of the children, born whilst he was undergoing the anti- syphilitic treatment, was an idiot; the others continued healthy both in body and mind. There is good reason for believing that, in the case of insanity, as in other forms of inherited disease, even if the tendency to disordered action in the brain and nervous system do not display itself at birth or in early life, the slightest injury may give AND ETIOLOGY. 237 effect to it so as to produce derangement of mind. And a predisposition once estab- lished, the liability may be communicated to succeeding generations, just as happens with regard to constitutional maladies in general. There is no doubt whatever that, in many instances, the hereditary liability has had its origin after some such manner. It is certain, moreover, that injurious excitement of the mind, and particularly of the moral nature, especially when this is long continued and painful, has much to do with originating cerebral disease, not only in the direct subject of such excite- ment, but also in the offspring. Excessive grief long protracted, successive shocks to the emotional sensibility, sustained and painful exertion of the intellectual facul- ties, are all causes which weaken the tone of the encephalic structures, and influence the mental functions prejudicially. It is very conceivable that, existence commenc- ing in such a state of parental mind, the 238 DIAGNOSIS, PROGNOSIS, disposition to insanity may arise. During the terrible period of the first French Re- volution, when the very destruction of society itself seemed at hand, and when horror and alarm were the almost unin- terrupted lot of large numbers, the fre- quency with which young infants were attacked with convulsions, and with which hydrocephalic idiots were born, and cach- ectic states of the brain and nervous sys- tem witnessed, was remarkable in the highest degree ; all tending to show the immense effect of the parental mind, even in its temporary and transient states, upon the psychical condition of offspring com- mencing their existence under such cir- cumstances. Exact and extended details deduced from individual instances, are, upon a subject of this kind, very difficult to procure, for obvious reasons. 1 am sure, however, that no medical practition- er, who shall avail himself of such oppor- tunities as may present themselves acci- AND ETIOLOGY. 239 dentally to him, can go on very long with- out a recognition of the principle just enunciated and briefly exemplified. In the great majority of instances, how- ever, where the congenital predisposition to insanity exists, it arises, we know not in what manner, nor from w^hat class of external causes. But this we know : when any peculiarity of anatomical structure, or of physiological action, or of pathological tendency, has once originated in genera- tion and in the progress of embryonic de- velopment, it very often becomes trans- mitted to posterity, both immediate and remote. Let us take an example so simple as complexion. The Albino's descent can be frequently traced to parents or ances- tors distinguished by the like physical cha- racteristics ; but then the peculiarity is sometimes seen to arise spontaneously, as it were, and to be transmitted by propaga- tion as an hereditary feature. The black secretion in the skin of the Negro is 240 DIAGNOSIS, PROGNOSIS, continued through successive generations, whatever be the climate inhabited; it originated in the earlier times of human existence, before the periods of history, but we do not know precisely in what way ; and the same may be said of that of other varieties of mankind — the Mon- gol, the Malay, and so on: these races maintaining their characteristic hue and other physiological peculiarities from ge- neration to generation. Sometimes, in particular families, curious varieties have sprung up, such as supernumerary fin- gers; this variety, in ancient Rome, was so common as to become designated by a peculiar name; and the Sedigiti are mentioned by Pliny and other eminent au- thorities. Sir Anthony Carlisle has care- fully traced the history of one such family through four generations. Its name was Colburn ; and the peculiarity was brought into the family by the great-grandmother of the youngest examined; it was not AND ETIOLOGY. 241 regular, but only attached to some children in each generation. The most remarkable instance, probably, of peculiarity arising without appreciable cause, and then being continued as an he- reditary variety, occurred in a family of the name of Lambert, in the course of the last century. I refer to the case of the porcupine-man, and his descendants. The founder of this extraordinary race was first exhibited when a boy by his father, in 1731, and came from the neighbourhood of Euston Hall in Sussex. Mr. Machin in that year described him, in the Philosophical Transactions, as having his body covered with warts as thick as pack-thread, and half an inch long. When he was forty years of age, he had had six children, every one of whom, at the same period, nine weeks after birth, had presented the same peculiarity ; and the only surviving one, a boy eight years old, was exhibited with his father. In 1802, the children of this boy Y 242 DIAGNOSIS, PROGNOSIS, were exhibited in Germany, displaying the same peculiarity. In these curious cases, the whole of the body, excepting the palms of the hands, the soles of the feet, and the face, was covered with a series of horny excrescences of a reddish brown colour, hard, elastic, and about half an inch long, which rustled against one another when rubbed with the hand. Once a year this horny clothing was shed, and its falling-off was accompanied with some degree of un- easiness. It also yielded to the action of mercury, which was tried for the purpose ; but in both cases it gradually retiu'ned after a very short period. As then with anatomical and physiolo- gical peculiarities, unaccountably arising in individuals, and then transmitted to the descendants, so it is with pathological ten- dencies. Gout, scrofula, affections of the heart, and certain other diseases, are un- doubtedly hereditary. Their causation, in many instances, can be made out ; but very AND ETIOLOGY. 243 often their origin can neither be accounted for nor explained ; and yet, by generation, they become the characteristics of particu- lar families. It is just the same thing with insanity. Although, in some cases, con- siderable light may be shed upon its con- stitutional origin and hereditary tendency ; in a larger number, certainly, the difficulty is quite as great as that which is experi- enced in attempts to trace upwards the origin of other predispositions and pecu- liarities, anatomical, physiological, or pa- thological, which happen to become the heritage of posterity. 244 EXCITING CAUSES AND LECTURE VII. Exciting Causes and Physical Treatment. The exciting causes of mental derange- ment are numerous, and very various; some of these, for distinction's sake, may be called physical, some physiological, and others moral. I would restrict the term physical to those circumstances which act upon the brain through mechanical vio- lence done to the head. Alcoholic ex- cesses, the abuse of narcotics, errors in diet, defective nutrition, sexual excesses, long protracted watchings and loss of rest, PHYSICAL TREATMENT. 245 the retrocession of erysipelas or gout in persons predisposed to insanity, are causes which may be designated physiological. And the occurrences which operate pain- fully and injuriously upon the conscious- ness in the first instance, so as to disturb the emotive sensibility, or in any way pervert the natural action of the mind, constitute the moral causes of insanity. There are many cases upon record, — and they constantly come before those who have the treatment of insane patients, — in which the mind has been overthrown by injuries affecting the head. Sometimes these exert their influence by mechanical mischief directly done to the encephalon through fracture of the skull, leaving the patient a maniac on recovery from the more immediate effects; and, at others, through the remoter consequences of con- cussion, a serious result showing itself some time after the accident. In either of these ways, there is no form or variety 246 EXCITING CAUSES AND of mental aberration that may not be occa- sioned, whether regard be had to the pre- cise characters assumed, or to the progress and duration of the malady. I had a very interesting case last au- tumn, in which mental derangement re- sulted from cerebral concussion. A youth, nineteen years of age, leaped from a hay- stack of considerable height, situated with- in an enclosed space, which was very limited, and would necessitate a somewhat perpendicular fall ; and there can be little doubt that, to some extent, he came upon his flat feet ; a circumstance which, for ob- vious reasons, would be likely to produce some degree of concussion of the brain. The youth, however, made no complaint at the time; and from what has transpired since, it does not appear that he felt more than a little stiffness of the back for a few days. But, at the expiration of a fortnight, he became restless and excitable, and eccentric in his conduct, with inability to PHYSICAL TREATMENT. 247 sleep. After two or three days' continuance of these symptoms, delirium supervened, with heat of scalp, and flushed face, but there was no great elevation of the pulse. Under ordinary treatment, the acute symp- toms vanished in three or four days ; the appetite for food and the strength returned; periodic and refreshing sleep also; and he was able to take exercise in the open air. But he was left a maniac ; talking all sorts of nonsense, and rambling in the most incoherent manner, exhibiting grimace and other absurdities of demeanour. At the expiration of a month, he was removed to Clifton. There had been remission of the symptoms on two or three occasions prior to his leaving home, giving the friends and myself cause to think that reason was re- stored. Letters, however, written by the patient at these periods, painfully unde- ceived us. He was three months at the asylum, and left it perfectly well. Six months have passed away since his reco- 248 EXCITING CAUSES AND very, and not the slightest trace of relapse has been noticed. All the allied circum- stances of this case place the origin and the nature of it beyond doubt. One of the most respectable and influen- tial merchants of this city, told me, a short time ago that, one day forming a member of a hunting party, he made a leap, the extent of which he had miscalculated, and fell with his horse. He rose unhurt, re- mounted, continued the sport, and joined the party at dinner, not sensibly the worse for the accident. Between two and three weeks after the occurrence, he suddenly felt himself nervous and unquiet, exclaim- ing that he was either in need of a doctor or a lunatic asylum, and hereupon became delirious. A medical man was sent for; leeches were applied to the head, and the treatment was followed up. In a few days, the gentleman was quite well. He expresses his own conviction that, if active measures had not been promptly taken, he would have been a maniac for life. PHYSICAL TREATMENT. 249 Alcoholic excesses constitute a very fre- quent cause of insanity, operating physiolo- gically, it is presumable, upon the vitality of the blood and the proper nutrition of the nervous centres. In this country, where intemperance of this kind is un- happily so prevalent, a very large propor- tion of patients owe the origin of their disorder to drunken habits long continued. Besides delirium tremens, protracted suffi- ciently long to constitute and be considered a species of insanity, any variety of mental aberration may arise from this cause. Very generally, however, marked deprava- tion of the emotive sensibility is observed in cases brought on by alcoholic abuse; and foolish, turbulent joy, or profound depression of spirits, is often to be wit- nessed as characterising these instances. But any form of insanity may occur under such circumstances, varying with the idio- syncrasies of particular patients. The inordinate use of narcotics, such as 250 EXCITING CAUSES AND opium and tobacco, is undoubtedly preju- dicial to the brain and nervous system, and should therefore be avoided by all persons concerning whom there is the least apprehension of insanity. I alluded to errors in diet as being among the physiological causes of insanity ; and there are numerous cases upon record in which obstinate dyspepsia, not of cere- bral origin, was the circumstance imme- diately inducing the malady ; a result which may be occasioned in two ways, — either by deteriorating the blood, and so causing a vitiated fluid to circulate through the brain, or by the sympathetic influence which gastric irritation is known to exert upon the structures within the head. The frequency of mental imbecility among pauper lunatics is readily accoun- ted for, when we consider the wretched diet and the miserable sanitary conditions to which they are so largely subjected. PHYSICAL TREATMENT. 251 Defective hygiene under all circumstances, indeed, is a fruitful source of insanity, as well as of scrofula. Sexual excesses, and spermatic losses of undue frequency, however brought about, notoriously depress the nervous power, and thereby weaken the intelligence. Paraly- sis of an asthenic character, and dementia, have not uncommonly been brought about by vices of this nature. Insufficiency of sleep for any length of time, by debilitating the system in general, but the brain in particular, is a dangerous trial for any person to pass through, who is at all predisposed to mental disease. The physiological changes that arise in the female system after parturition, seem to be unusually productive of insanity, where the predisposition inheres. The occurrence of gout in an acute form, or of erysipelas, in a patient whom you may suspect of congenital liability to insanity, is a circumstance fraught with 252 EXCITING CAUSES AND some anxiety. One of the best marked cases of chronic mental derangement I remember to have witnessed, followed the retrocession of erysipelas in the head and face, in the instance of a young lady whom I knew to have inherited the tendency. The circumstances and conditions just enumerated, I have called the physiologi- cal causes, in contradistinction alike to the physical and the moral; because, in the production of insanity, their action is not mechanical and direct, but mediate through the organic functions, and taking place also without any immediate influence being exerted upon the consciousness, either through the ideas or the emotive sense. The moral causes of insanity, however, are recognised as by far the most frequent and the most effective in their operation. And, generally speaking, the more exalted and the more advanced is the civilisation of any community, the more abundant are diseases of the mind. Humboldt says that. PHYSICAL TREATMENT. 253 among the savages of America, he looked in vain for their existence. Indeed, as education, the arts and sciences, the philo- sophical, political, and social ideas of Eu- rope, prevail, the proportion of mental maladies seems to increase. For, after all, what distinguishes prominently our mo- dem civilisation? Is it not the perpetual craving after moral and mental excite- ment? Everybody wishes to be somebody, at least in the estimation of those by whom he is surrounded. No one is satisfied with his actual condition, but aspires to one that is more elevated. The slightest intel- lectual taste, or vivacity of fancy, at once suggests to its possessor that he has a mis- sion, which is never regarded as finished ; he must always advance, and of course encounters circumstances and obstacles which provoke his envy and mortify his ambition. Women and men are in this respect alike, differing only in the direc- tion which the mental activity takes. Our 254 EXCITING CAUSES AND thoughts are full of schemes, of novelties in science and in medicine, of projects of reform and amelioration. We strive sys- tematically and habitually to procure grati- fication to the emotive sensibility, and the result but too often is mental irritation, and dissipation of our fondest illusions. In this state of things it will readily be conceived that, in a large proportion of cases, the commencement of insanity is attended with a painful state of the feel- ings and the affections. Melancholy, in- deed, ushers in numerous instances which, in their progress, assume other character- istics. The operation of the exciting cause, when moral, is very generally upon the emotive sense in the first place, rather than upon the ideas, which become per- verted subsequently. Nevertheless, exces- sive exertion of the intellectual faculties very often produces a prejudicial strain upon the cerebral tissue, and may directly occasion derangement of the intelligence, PHYSICAL TREATMENT. 255 displaying itself particularly in foolish the- ories, and in marked enfeeblement of the higher mental faculties. As I have just observed, however, the passions, the affections, and the sentiments are almost always the first to give way : and cases of this kind constitute at once the most serious, uncertain, perplexing, difficult, and distressing of all. Moral causes, in an especial manner, act upon those who are predisposed congenitally : and, in such circumstances, repeated family bereavements, and crosses in love, are par- ticularly effective with the female sex. What is technically called Melancholia, forms, as might be anticipated, the ordinary variety so induced ; and when the malady is fairly established, its more striking mani- festations have not, very often, any dis- tinguishable relation with its origin. At the present time I have a patient who is a lady of great natural talents and accom- plishments; she displays no remarkable 256 EXCITING CAUSES AND symptom externally, excepting a refusal to take food, with an expression of counte- nance indicating the most confirmed and blank despair. Some years ago she sus- tained a disappointment in love, and be- came despondent and suicidal. For more than five years, she has never voluntarily taken a particle of nutrition ; and, since I have kno^Ti her, the ailment would appear to have concentrated itself upon the one idea of inability to take food. From morning till night, every two or three minutes, she sorrowfully ejaculates " I can't have," and these are the only words I have at any time heard her utter. With our own sex, the moral causes of insanity arise, most commonly, from hopes blighted, ambition disappointed, pe- cuniary reverses, and business anxieties; all these circumstances operate most pow- erfully where the pre-existing tendency is found. Before closing the discussion of this PHYSICAL TREATMENT. 257 branch of our subject, I will introduce the account of a very interesting case, given in the patient's own words. The subject of the malady is a gentleman of talent and education, but unfortunately was always of an irritable, jealous disposition, to which, after his marriage, he gave way by enter- taining the most causeless and preposterous suspicions of his wife. The case itself ex- hibits the persistence of intelligence and mental acuteness, notwithstanding the no- tional illusions, self-evidently absurd, with which the patient is possessed. It shows, moreover, the progress from perturbed feehng to perverted thought, accomplished by a species of suggestion in the way I have described in a foregoing lecture. The document is rather lengthy, but I think the interest attaching to it will amply compensate for the time it will occupy in perusal. It was written for pre- sentation, either to the visiting Magistrates or Lunacy Commissioners, in protestation 258 EXCITING CAUSES AND against what the patient regards as his unjust and illegal detention : " Is it possible that men can perpetrate an injustice in England by incarcerating a rational man in an Asylum for Lunatics without being brought to condign punish- ment? Ever since I have had the com- prehension to understand the laws of my country, I have placed reliance on the just and impartial manner in which they are administered. Yet in this apparently free country, where the liberty of the sub- ject is held up to the gaze of admiring Europe, I am taken from my friends and family, from my business and the ordinary avocations of life, and immured in Clifton Lunatic Asylum; all means of communi- cation with my friends, or a magistrate, denied me. Even if a man's mind should suffer from the depressing influences by which he is surrounded, it is no evidence of insanity. After reading this, you will exclaim, This is a monstrous injustice ; let PHYSICAL TREATMENT. 259 US investigate why it has been deemed necessary, or conducive to promote the welfare of a rational man or his near con- nexions, that two medical men should arrogate to themselves the despotic power of signing a false and unjust certificate reflecting upon the rationality of a free- born Englishman, a native of the enlight- ened town of Manchester, an honorable tradesman, and a man of education and social position. Is it irrational to draw conclusions from passing events? Is it a delusion to express a conviction warmly? Is it insanity to feel indignant at unjust treatment? I say, it is not. Why am I said to be laboring under a delusion? I will minutely and circumstantially detail what has led those near and dear to me, rashly to entertain ideas totally false and unwarrantable. Ideas are the seeds which, sown on a fruitful soil, are the great pro- ducers of a fruitful harvest, but which planted in an ignorant mind are the germs 260 EXCITING CAUSES AND of folly and delusion. I will now state facts that have come under my own notice, and which have induced me to conclude that I have been foully slandered, and that some base accusation, which shuns the light of day and of truth, has been made against me ; with its mysterious purport I have been kept in the most profound igno- rance. One Saturday night in November last, between the hours of ten and eleven o'clock, I was returning from to my home in , and when opposite the end of Lane, on the left hand side in Road, I was abruptly accosted by name by a man of whom I had no previous know- ledge. I said sharply, What do you want ? He then said, I was under the surveillance of the police ; and that if I would go to Mr. Beswick, the chief superintendent, on the following day, Sunday, he would cor- roborate this statement. He further told me that a cab left town every night when I did, to put the police on the alert that PHYSICAL TREATMENT. 261 I was coming; and further, to prove the truth of his statement, he said, if I would notice on the following morning, I should see men at short intervals make peculiar motions which he indicated, signifying ' That's him' — meaning me. Further, that he was a poor man, and that he should call upon me in a month or six weeks and expect a reward of twenty pounds. He then made a quick retrograde movement, and on looking forward I saw a policeman in the distance, but being agitated and excited I did not speak to him, but got home quickly." I will here interrupt the patient's narra- tive to state that there is good reason for thinking that no occurrence, even resem- bling what is here set down, took place. It is probable that something of the kind was dreamt; for it was never mentioned to his family on returning home any even- ing, nor was any excitement betrayed as if the gentleman had been frightened at 262 EXCITING CAUSES AND night. It was first mentioned on a Sun- day morning as having occurred the even- ing before, and great restlessness and pain- ful vivacity of manner characterised him at the time of telling his supposed adven- ture. The patient goes on : — " On reflecting, I came to the conclusion the man's statement was very absurd, and that it would have ended either in an at- tempt to garrotte me, or to obtain money on false pretences, which failed in conse- quence of the opportune appearance of the policeman. On the following morning, however, on leaving my house, I did, to my great astonishment, notice the motions indicated. They were evidently signifi- cant, and not involuntary. I then made an appointment to see Mr. Beswick, at five o'clock in the afternoon. During the day, I saw these significant motions frequently repeated. On explaining these facts to Mr. Beswick, he said the thing was mani- festly very absurd, and characterised it as PHYSICAL TREATMENT. 263 a gross and fraudulent attempt upon me, also that I was not under any surveillance at all, and that from the respectability of my own position and family connexion, it was absurd to suppose so for one moment. I requested Mr. Beswick to let me see his detective officers, so that if any of them had played this trick upon me, I might re- cognise them. To this he readily assented. On the following morning, Monday, I call- ed at Mr. Beswick's private office, where I saw eight detective officers. I failed in recognising any of them. It was agreed that an officer in plain clothes should on that night and the following morning, fol- low me to and from my place of business home, and if I again met the man, I was to give him into custody. Nothing of im- portance did occur then. But, afterwards, I noticed the same and other significant motions, repeatedly. Feeling within myself the knowledge of conscious rectitude, I de- termined not to see these signs. At last 264 EXCITING CAUSES AND they were forced on my notice by men approaching near my person, giving a loud Ahem ! and then making a significant mo- tion. The last and most disgusting treat- ment I have been subjected to, was by almost every individual I met, making a loud guttural sound and spitting as near my person as possible without soiling my clothes; and when expectorating, the ex- pression of their faces indicating disgust and contempt. Judge then my feelings, my sufferings, mental and physical. Un- conscious of any wrong said or done to my fellow creatures, in a criminal sense, the intensity of my mental sufferings I cannot describe. I knew I had failings, inherent in human nature, but nothing that was injurious to the community. In addition, my acquaintances shunned my approach; my friends appeared to be un- usually cordial, as if I had just returned after a lengthened absence. My servants were not respectful in their manner ; all PHYSICAL TREATMENT. 265 this, which I have explained to my friends, forced upon me the conclusion that, as an upright man, I ought to demand an inves- tigation into the cause of so base and malignant a conspiracy. This acting on a sensitive and nervous temperament, pro- duced serious physical illness. At first, I attributed this to deleterious drugs ad- ministered in my food. Various circum- stances confirmed this opinion. Still, to persist in this, would criminate those whose happiness is a first consideration with me ; therefore having had the benefit of medical advice from men of established reputation in this town, I will adopt their conclusions in preference to my own, however opposed to my own convictions. They say my dis- ease was gastric fever. Then let it be gastric fever. During the time I suffered from disease, my mind was clear, my con- versation rational. To prove this, get an opinion from who attended on me day and night for eleven days; he is an AA 266 EXCITING CAUSES AND invalid's nurse, his residence, I think, is , or you may get it at the Infirmary. ; Two dear friends of mine saw me during ray illness ; ask either of them if my con- versation was irrational, or if they would testify on oath, that I laboured under a delusion that would justify my detention in a mad house. The gentlemen's names andad dress are Thomas and James . My father, to whom, from his invariable kindness and affectionate atten- tion through life, I cannot attribute bad motives, brought me here under the pre- tence of an investigation of the circum- stances which had caused those significant signs. I came with confidence in my father's word, for he never previously practised deception towards me, and I ex- pressed to him and a Mr. S. who accom- panied us, the great pleasure and relief I felt that my actions were now going to be investigated ; instead of which, how can I express the profound and terrible emotions, PHYSICAL TREATMENT. 2()7 the horror which seized me, when I found my father a consenting party to my con- finement in a lunatic asylum. Even then I felt pity for my father, the expression of anguish on his face was painful to witness. But when that parent whom I still love, whom I still reverence as the author of my being, when he stated that his life was in danger from me, from my violence, I who never raised a finger against him in my life, I who rather than do so would have my right arm withered by paralysis, my emotions were then deplorable. I felt a desire to die, that death might end my sufferings. Nothing but a profound con- viction that the Almighty would speedily release me from the house of bondage, even as my ancestors, the children of Israel, were released from Egyptian slavery ; no- thing but this solemn conviction and the fear of God, has enabled me to withstand the wish for death, the desire, the craving, to terminate existence. 268 EXCITING CAUSES AND " After being confined to bed for nearly three weeks, I was recruiting rapidly; having been out of doors for two days, and having made arrangements to go to Brighton for a fortnight, I was brought to a lunatic asylum, my rights as a British subject violated, and, to secure my impri- sonment in a lunatic asylum, the Habeas Corpus Act \dolated. I am daily in hopes of seeing the commissioners or the magis- trates. It is hope alone that cheers the violated rights of an Englishman. I feel a conviction the course taken never will be sanctioned by you ; if it is, I will appeal to the Secretary of State. "I feel convinced my father has been duped by others; he has not had good health lately, and although a perfectly rational man, and possessed of strong sense and sterling worth, he must have been used as a tool to carry out the base views of others whom I could name, but regard for my children's welfare prevents me. PHYSICAL TREATMENT. 269 " Melancholy thoughts depressing. Liberty thou art a blessing ; Slavery so great a crime, A powerful pen can not define." And with this doggerel, improvised, I presume, the somewhat prolix account terminates. It illustrates, very well, the origin and progress of this form of insa- nity, — perturbation in the emotive sense in the first instance, leading to delusions related in their character to the morbid sensibility. Having now given the general charac- teristics of mental derangement ; and hav- ing stated the circumstances distinguishing it from disease more purely physical with which it is likely to be confounded; and having explained, moreover, the principal conditions which qualify the prognosis, and enumerated the more prominent causes which determine mental maladies, I will proceed to describe the principles of Thera- peutical management demanded by this 270 EXCITING CAUSES AND class of cases. I say, principles of manage- ment, for really it is very often a species of education that is required, rather than medical treatment, in the ordinary sense of the phrase. It consists, indeed, in efforts for a long time sustained, to ameliorate the condition of the insane in all respects, moral and physical. The treatment of insanity is ordinarily considered under two heads, — physical and moral; the former being intended to correct the more purely physical derange- ment with which the mental malady may be associated, and the latter being directed more immediately to the intelligence and the inner sensibility of the patient. In a considerable number of cases, little benefit is to be expected from the more ordinary appliances of practice; on the contrary, mischief will undoubtedly result very often from the ill-considered use of blood-letting, counter-irritation, and drugs of every kind. , The circumstances which indicate the PHYSICAL TREATMENT. 271 just employment of physical measures in mental diseases, require a very careful dis- crimination ; having reference, not so much to the peculiar features of the psychical malady itself, as to the particular constitu- tion of the patient, his temperament, the past history of the case, and the existing state of his general health. If physical treatment of an energetic character is to be successful, — if its efficacy, indeed, is to be distinctly recognised, — it is almost always in the earlier stages of the ailment. And as mental diseases do not usually subject the sufferers to the discipline of an Asy- lum, until they become confirmed, indivi- dual instances perpetually arise in the prac- tice of those who have no special connexion with this department of medicine ; and that, too, precisely in the stage which demands powerful and decided measures, if at all. There are few practitioners who have not occasionally to deal with the precursory symptoms, associated or not, as the case 272 EXCITING CAUSES AND may be, with other disease; and, assuredly, the inexperienced are beset with embar- rassments of every kind. And we have here a combination of circumstances sup- plying very obvious and powerful reasons for cultivating this branch of the profes- sion, and one, moreover, showing that Psy- chological Medicine is not so entirely a speciality as some persons find it conve- nient to maintain. In discussing the treatment of particular classes of cases, I will divide the subject according to the external causes by which they have been induced, — physical, physi- ological, and moral. With reference not only to psychological but to general medi- cine, indeed, I have long thought that if practitioners attended more to the indica- tions supplied by the primary causes of disease, and attached a somewhat less con- sideration, relatively at least, to its ulti- mate physical effects as revealed by morbid anatomy, the science would gain in com- PHYSICAL TREATMENT. 273 pleteness, whilst the art would be rendered more just and available, and, in conse- quence, better calculated to alleviate the ills and the sorrows " which flesh is heir to." Suppose that a patient has received some violent injury to the head ; of course, the treatment must be that which is demanded by a sound and judicious sur- gery. Delirium, or stupefaction, as the case may be, characterises very commonly this class of cases in the earlier stages. Suppose, however, that, after the subsi- dence of all fever, and all heat of scalp, and after the appetite and digestion have re- turned, the wandering or some other irre- gularity of mental manifestation continue, how must you proceed in the physical management of your patient ? I have no hesitation in saying that, unless there be some very unusual plethora, or local con- gestion, more harm than good will be done by further depletion. Local blood- 274 EXCITING CAUSES AND letting, in the beginning of such cases, is generally highly useful ; but afterwards, when a settled derangement seems esta- blished, nothing but mischief can follow its use, unless there be some special reason for it. It is very rarely right, indeed, to deplete in insanity, particularly by opening a vein. Maniacs have been interrogated, during their convalescence, concerning their own experience after general blood-letting ; and the replies have been something after this fashion : It was after being bled that I ceased to know what I did, and what was going on about me ; it was after losing blood that I went right out of my mind. The emotive sen- sibility almost always becomes painfully exalted after blood-letting; the face is blanched, the pulse is small, and the pupils somewhat dilated. It is a great mistake to assume that, because the delirium continues, inflamma- tion is its necessary, or even its probable PHYSICAL TREATMENT. 275 cause. It cannot be repeated too often, that the highest excitement may charac- terise the cerebral acts, without there being so much as irritation of the brain, in a physical sense. A state of debiHty, even, may bring about these phenomena. Perversion of the intelligence and de- praved sensibility may result from the most opposite states of the encephalic cir- culation. Mental maladies, altogether, are very analogous to ordinary nervous ailments, — as regards their duration, their seeming spontaneity in many instances, the absence of inflammation, and the bad effects of debilitating treatment. The an- alogy, moreover, is maintained in the oscil- latory course of a mental malady, in the periodicity of its paroxysms, in the ab- sence of fever, in the continuance of nutri- tive energy, and in the absence, ordinarily, of organic alterations attributable to the psychical disorder. We have mental aberration in delirium 276 EXCITING CAUSES AND tremens, and also in certain forms of hys- teria, yet we do not bleed in these cir- cmnstances; opium and stimulants are rather administered. Yet when epileptic symptoms accompany maniacal excitement, there is a great disposition among practi- tioners to draw blood; the more ^dolent the convulsions, or the more distinct the state of coma, and (let it be said) the less the acquaintance with nervous and mental maladies, the more likely is the medical attendant to deplete. In such cases, the treatment rarely exercises a beneficial in- fluence upon the symptoms; and if it render the paroxysms less violent, it pro- bably increases their frequency, and leads on to dementia. With reference, there- fore, to all these considerations, it must not be deemed anomalous that, after a time, heroic treatment should cease to be of service, even in many instances of trau- matic injury, notwithstanding a persistence of delirium. PHYSICAL TREATMENT. 277 But although depletion under such cir- cumstances — when you are trembling for the permanent integrity of your patient's mind — may no longer be necessary, the physical management of the case is likely to demand, for a long time, considerable care, and the patient will require con- stant watching. If the nights be passed restlessly, the judicious administration of opium, or morphia, may become necessary; care being had that this remedy be not repeated too often, otherwise its efficacy in calming the brain and nervous system will not be realised; but cerebral congestion, with aggravation of all the symptoms, may be the consequence. Then the stomach and bowels demand constant attention, for any depravation of their functions almost always reacts prejudicially upon the en- cephalon. The diet must be bland and nutritious; if there should be disinclina- tion to take food from some mental cause, the resistance must be overcome in the B B 278 EXCITING CAUSES AND mildest possible way, or marasmus may ensue. The bowels, if constipated, should be relieved by some mild aperient, once or twice a week; but all catharsis must be guarded against; this latter would not only reduce the patient's powers, and dete- riorate the xis medicatrij?, but the intesti- nal irritation that might be induced, would be pretty certain to influence, injuriously, the susceptible brain. In a few words, I would sum up the physical treatment of insanity produced by mechanical violence, thus: — Be constantly on the watch for phy- sical indications, and act accordingly ; but do not expect to remedy the mental aber- ration by bleeding, counter-imtation, pur- gatives, or mercurials, excepting in so far as the psychical affection may be associated with and dependent upon well-understood pathological conditions, which active treat- ment may be likely to remove ; let these conditions, however, be sufficiently obvi- ous, and irrespective of the mere wander- ing of intellect. PHYSICAL TREATMENT. 279 When mental derangement has been induced, or aggravated, by the abuse of alcohol, of opium, or of tobacco, by sensual excesses, by protracted watching, defective hygiene, or other causes that I have called physiological, the first proceeding, in the treatment of such cases, must of course be a withdrawal of the exciting cause. It will be in vain that you establish a course of medicine, or a plan of physical manage- ment, unless the patient be removed alto- gether fi-om the agency that has produced his malady. If drunken habits have over- thrown the reason, they must be cor- rected; I do not say by an absolute and sudden withdrawal of all fermented liquors; this is a matter for deliberation ; the abuse, however, — the drunkenness, — must be given up at once. In like manner, opium or tobacco must have their use moderated and be gradually withdrawn, whenever they have exerted a pernicious influence either in originating or in aggravating the malady. 280 EXCITING CAUSES AND Some difficulty will generally arise in this respect; for it is a remarkable fact that numerous insane patients, and persons not themselves insane but belonging to families predisposed by inheritance, dis- play an unconquerable liking for nervine stimulants. Nevertheless, firmness must be exercised in prohibiting these noxious indulgences, gradually, or all at once, ac- cording to circumstances. If the patient be aged, and the circulation feeble, an abrupt withdrawal of alcohol, after exces- sive indulgence has become a habit, may be injurious; in the young and middle- aged, however, there is seldom any mis- chief to be apprehended from the decisive course, — total abstinence at once. Again, where either opium or tobacco has long been indulged-in to excess, a sudden ces- sation may, in some instances, render re- freshing sleep impossible for a dangerous length of time. In examples of this kind, a careful circumspection is needed ; a gra- PHYSICAL TREATMENT. 281 dual diminution of quantity, day by day, frequently, indeed usually, enables the pa- tient ultimately to arrive with impunity at an entire discontinuance. The habit of snuff-taking, also, to which the insane are greatly addicted, must receive the same consideration ; painful congestion about the head might result from a restriction too unqualified in the first instance. Where loss of rest from excessive em- ployment, or from over-anxiety, has prece- ded, and been influential in, the production of insanity, it becomes a very nice question whether anodynes should be administered, or purely hygienic measures be trusted to, for obviating habitual wakefulness. There can be no doubt that, in many instances of this kind, the acetate or muriate of mor- phia is a most valuable medicine, given at intervals of two or three nights, in doses capable of procuring six or eight hours' refreshing sleep. Previous to its employ- ment, however, care should be taken to re- 282 EXCITING CAUSES AND lieve cerebral congestion if present, either by leeches, cold applications, or mild aperi- ents, according to circumstances. Fur- ther, it will be necessary to mitigate by medicines, so far as practicable, any gastro- intestinal derangement which may contra- indicate the preparations of opium. With reference, indeed, to all cases in the production of which physiological causes have been influential, the removal of such causes, so far as practicable, is the pre- requisite of all successful treatment. And regarding the physical mischief w^ith which, in particular instances, the mental malady may be associated, the therapeutical princi- ples are very much the same as those which guide our practice in corresponding states unconnected with insanity ; the entire aim of physical treatment being, in fact, to re- duce the cases as much as possible to those of purely psychical disorder ; and in this process of reduction, we sometimes succeed in dissipating the malady altogether. PHYSICAL TREATMENT. 283 When the causes of mental aberration have been almost exclusively moral, very often there still precedes and accompanies the attack, considerable disorder of the general health, for the correction of which physical treatment may be demanded. Head-ache and watchfulness, palpitation of the heart, irritation of the stomach and bowels, and other symptoms of an allied character, frequently usher -in, and pre- cede, the invasion of insanity. And al- though such morbid states of the system may have some independent origin, they are sufficiently often the bodily result of the mental perturbation; this latter ex- hibiting itself in general derangement of the nervous system, even before the insa- nity itself becomes unmistakeably revealed. In the treatment of this class of cases, the influence of our ordinary remedies is much less than where the bodily symptoms have originated in causes more purely physical. For example, the head-ache which precedes 284 EXCITING CAUSES AND or accompanies insanity from moral causes, especially if unaccompanied by fever or heat of scalp, is much less likely to be bene- fited by depletion of any kind, than when the exciting cause has been of a different character. Altogether, indeed, it may be observed, that disorder commencing in the brain and nervous system, under the influ- ence of circumstances which operate pri- marily upon the consciousness, will only bear depletion in very exceptional in- stances. In the ordinary course of practice, it may be noticed how indifferently supported both purgatives and blood-letting are, in the highly susceptible nervous temperar ment, and in all ailments that have been brought on by care and anxiety of mind. If a person consult you, with irritation of the gastric mucous membrane arising from gluttonous excess, you will remove it by leeches applied to the epigastrium, and a temporary abstinence from solid food and PHYSICAL TREATMENT. 285 stimulating drinks. If, however, the like derangement come before you as the result of a moral cause, you will obtain no re- sultant advantage from such treatment ; the patient's cure must be rather pro- moted by moral agency. You will urge the necessity of removing, so far as pos- sible, the causes productive of mental anxiety ; and you will probably advise the invalid to go to the sea-side for change of air, as you may say, but in great measure for change of scene, and in order that grateful impressions upon the mind may take the place of those which are painful. It may yet be necessary, in such a case, that mild medicines should precede, or ac- company, the moral treatment of nervous dyspepsia, with a view to the removal of retained excreta or vitiated secretion. It is precisely upon the same principle, that physical treatment may be needed in insanity brought on by moral causes. If your patient have head-ache either imme- 286 EXCITING CAUSES AND diately before or during the presence of mental derangement, it is but rarely that you will procure advantage either by bleeding or blistering. If, however, he be plethoric, and display very obvious signs of cerebral congestion, it will be well to attempt relief by local blood-letting ; but, even w^hen attained, the relief, under the circumstances, will most likely not be per- manent. The principal benefit of the practice will consist in diminishing the chance of ulterior mischief such as the su- pervention of epileptic or apoplectic symp- toms, to which plethoric persons, when insane, are sufficiently prone. In like manner, the administration of opiates in any form will probably be mischievous, rather than otherwise, in the attempted relief of bad nights, unless prescribed with the fullest consideration of all the quali- fying circumstances. If a person begin to show signs of nervous exhaustion from want of sleep, exhibiting symptoms, indeed, PHYSICAL TREATMENT. 287 bordering upon delirium tremens, it will be right to procure rest by anodynes. Care, however, should be taken that a habit be not established; if there be not reserve in this respect, not only will the good anticipated not be realised, but the tone of the cerebral structures may be still further weakened, and the recuperative powers of nature be debilitated propor- tionately. Let any medical man consult his expe- rience in matters of this kind, where the patients have not been insane. All of us, very likely, at one time or another, have been consulted for sleeplessness arising from grief or anxiety of mind ; and there are few who have not occasionally given opiates, unseasonably, in these circum- stances; and I am sure that the conclu- sion will have been very generally attained, that anodyne medicines do but exert a modified control over restlessness that is attributable to moral causes. Exactly the 288 EXCITING CAUSES AND same qualifications will obtain in the phy- sical treatment of all the other functions. Ordinary remedies must not be expected to procure that relief for particular symp- toms, which, if the result of more physical agency, they may readily receive. Hence, derangement of the stomach, palpitation of the heart, nervous irritability, visceral disturbance, and other such states, must be approached very rarely by depletion of any kind, and always carefully by medicinal means at all, when the nervous energy is in any way disturbed by agency that is m.oral. In recapitulation of the physical ma- nagement of the insane, I would briefly resume as follows : — For mere symptoms of mental aberration, you will do well to avoid physical treatment altogether, ex- cepting such as the principles of hygiene would suggest. Act upon the pathologi- cal state of the system by drugs, bleeding, or counter-irritation, according to sound PHYSICAL TREATMENT. 289 principles of medical practice. Do not as- sume that, because you have perverted cerebral function, you have to deal with inflammation. And remember that even physical mischief arising from moral agency, is influenced most effectually by a therapeutic method that corresponds with its origin and cause. cc 290 MORAL MANAGEjMENT LECTURE VITI Moral Management of the Insane. The just and scientific treatment of per- verted consciousness, — of Insanity purely considered, is by influences and agency that address themselves directly to the consciousness itself The proper therapeu- tical management of unsound mind is one that is moral. Whatever may have been the circumstances that have given rise to any of the forms of insanity, physical treatment, — in which category I include all the more ordinary appliances of medi- cine, — can only deal with physical in- OF THE INSANE. 291 dications. As these become fulfilled by judicious and effective measures, the men- tal derangement will sometimes pass away concurrently. If, however, mental aberra- tion remain behind, you will only frustrate your purpose, if, without obvious and ade- quate cause, you continue active medical treatment. But I have been asked, when in consul- tation under these circumstances : — Will you simply leave the case to nature ? Will you look on, and do nothing? And the notion involved in this enquiry has been reasoned out in some such manner as this : Surely with deranged function, there is some alteration in the substance of the brain, for disease must always depend up- on change in the condition of structure, — it is at least reasonable to suppose so ; hence, although in these cases we have evidence neither of fever, nor of local in- flammation, is it not right to go on with our remedies, in the expectation of touch- 292 MORAL MANAGEMENT ing the evil at last? In this reasoning, abstractedly regarded, I quite concur ; but I differ from controversialists so arguing, in the signification which is to be attached to the term remedies. I submit that medical men must not, in their practice, be regarded as leaving off treatment, or abandoning remedies, be- cause blood-letting, counter-irritation, and drugs, may cease to be employed. It is but a low estimate to form of the medical character, to recognise, in the physician or the surgeon, merely the apothecary, or the cupper. It is the office of the medical adviser to guide and direct his patients at all times, and under all circumstances, in the matter of health and disease ; pointing out to them when in health the way to continue so, and when sick the course whereby health may be recovered; and whatever the process which the preser- vation of health or the removal of sick- ness may involve, it is the practitioner's OF THE INSANE. 293 business to prescribe. This may be simply a day or two's rest in bed, or it may be a tour for recreation; it may be a more generous diet, or one that is somewhat abstemious ; a course of purgative drugs may be indicated, or a temporary use of bitters or of steel ; an extended and more diversified social intercourse may be the requirement, or a partial withdrawal from excitement of this description; it may be an engagement of the mind in some spe- cial pursuit, encouraging hope, and ex- citing pleasing anticipation; or it may happen that a certain wild enthusiasm needs to be moderated. But whatever it be, if it influence health, or be likely to provoke or to alleviate disease, it comes clearly within the province of the medical man. And so long as he engages himself in watching his patient for the patient's own good, so long as he regulates the acts generally as well as the fhy sic-taking parti- cularly, the physician cannot be said to 294 MORAL MANAGEMENT leave his patient to nature, or to be look- ing -on with a virtual abdication of his proper functions, even though for weeks he may never prescribe a drug. The experience of every one, medical or lay, must have led to a recognition, in a greater or less degree, of the intimate re- lation that subsists, in the human constitu- tion, between the morale and the physique. And it must be remembered that, in a great many instances, change in function, and coincident alteration of a sensible cha- racter in the organisation, can be accom- plished by agency that is altogether moral. What so often suffuses the face abruptly, bringing the blood rapidly and abundantly to it? the emotion of shame, an affection purely moral. Severe and protracted thought will cause head-ache and cerebral congestion. Sudden fear will induce pal- pitation of the heart, and has been known, indeed, to suspend its action entirely, so as to cause death as promptly as hydro- OF THE INSANE. 295 cyanic acid would do. The keenest appe- tite in the world will vanish immediately upon the receipt of painful intelligence. Sorrow and grief will occasion, sometimes, relaxation of the bowels. The most remarkable physical results will sometimes occur to particular organs, by dwelling long, continuously, and pain- fully upon their functions; and local dis- ease has been known to ensue, suddenly, upon lively and distressing emotions. M. Ridard relates the case of a man, thirty years of age, who was affected with stone in the bladder, and who saw a patient die by his side, after being operated upon for the same complaint. The man's imagina- tion became excited ; his thoughts were constantly fixed upon the operation which he, himself, expected to undergo, and upon the probable death that would follow ; and, in fact, without any operation at all, he died at the end of a month, affected with gangrene both of penis and scrotum. A 296 MORAL MANAGEMENT case is recorded of a woman who, after seeing her daughter violently beaten, was seized with great terror, and suddenly be- came affected with gangrenous erysipelas of the right breast. A still more remark- able illustration of local disorder of nutri- tion, occasioned by powerful emotion, is afforded by Mr. Carter, in his recently published and interesting little work on Hysteria. The case is narrated as follows: "A lady, who was watching her little child at play, saw a heavy window-sash fall upon its hand, cutting off three of the fingers; and she was so much overcome by fright and distress, as to be unable to render it any assistance. A surgeon was speedily obtained, who, having dressed the wounds, turned himself to the mother, whom he found seated, moaning, and com- plaining of pain in her hand. On ex- amination, three fingers, corresponding to those injured in the child, were discovered to be swollen and inflamed, although they OF THE INSANE. 297 had ailed nothing prior to the accident. In four-and-twenty hours, incisions were made into them, and pus was evacuated ; sloughs were afterwards discharged, and the wounds ultimately healed." Moral circumstances, as all experience testifies, are equally potent for good. Pleasing and delightful emotions, serene and joyous impressions, will restore the drooping energy of most of the animal fiinctions; reanimating and invigorating the whole system. Head-aches, nervous irritability, impaired digestion, and chro- nic derangement of the mucous mem- branes, are largely under the influence of this kind of agency; and the excite- ment of hope, with immunity from the wear and tear of harassing and habitual thought, plays a part in recovery from disease, to an extent little imagined by many persons, until lately. Do not let us deceive ourselves. When sick persons fly to the fashionable systems 298 MORAL MANAGEMENT of quackery, — tired of their lingering ail- ments, and disgusted with drug treatment protracted unduly, — they do very often, in fact, get well; and that too from the course which they have pursued. It often hap- pens, in such instances, that leaving off medicine, when the period for its beneficial use has gone by, removes a source of physiological perturbation. Then the res- pite obtained, temporarily, from the com- mon cares of life, — a concomitance very generally of quack-seeking, — gets rid of a psychical agency that is undoubtedly inju- rious. And, in almost every instance, the supervention of a totally new and some- what delightful state of mind, made up of hope, wonder, and admiration, constitutes a moral therapeia, Avhich consummates the beneficial agency. And the result, very often, is the redemption of the patient from sufferings long endured. A foolish world, delighting to think itself wise and philosophical, talks of homoeopathy, hydro- OF THE INSANE. 299 pathy, kinesipathy, and other such delu- sions; the actual truth which underlies these follies of a day, is not appreciated by the popular mind ; the medical philsopher, however, discovers, amidst the surprising phenomena which modern credulity and im- posture develope, a material and weighty fact, — that psychical influences control and modify the animal functions, and exert a powerful action in the treatment of disease. If then therapeutics purely mental, exert- ing their action primarily upon the con- sciousness, tend to restore the healthy con- dition of organs, by their indirect effects upon the physical frame, how much more likely is it, a priori, that such treatment should have an advantageous influence in the case of ailments which consist, essen- tially, in perversion of the consciousness itself. And, indeed, experience proves that the curative management of Insanity- proper is rightly and altogether moral. Hence, when local derangement has been 300 MORAL MANAGEMENT rectified, and when the general health has been restored to the condition best attain- able in the circumstances, our paramount attention must rest upon the moral and mental peculiarities of the case; and we must interfere, by physical measiu'es, only when some new and corresponding indica- tion justifies the proceeding. The Moral Treatment of Insanity is, in principle, exactly the same as that which is pursued by the judicious and well in- structed practitioner in the management of ordinary disease ; that is to say, it com- prises negative requirements, in with- drawal of the Icedentia or circumstances hurtful, — and a positive course, in furnish- ing the adjuvantia or things that aid in recovery. Every condition that is preju- dicial to the disordered mind must be removed; and agreeable diversion of thought, with new and pleasing impres- sions upon the feelings, must, where pos- sible, be brought about ; just as in more OF THE INSANE. 301 physical maladies, we withdraw causes of irritation, and, by acting upon the more healthy parts of the organism, strive to procure a derivation, and ultimate sub- jugation, of the disease. In the treatment of all forms of mental derangement, this principle kept steadily in view, will render itself the guiding thread in our moral ma- nagement of these cases. It will be obvious, then, that whatever be the folly or absurdity of the ideas which a notionally insane patient may entertain, the attempt should never be made to dis- abuse him by contradiction, by appeal to his senses, or by reasoning, if the proceed- ing give rise to the slightest irritation ; it would not only defeat its purpose, but the painful excitement likely to follow would certainly aggravate and probably compli- cate the affection. If a person fancies that he is King of England, you will rarely gain any thing by telling him that he is not; you will simply wound his amour propre, D D 302 MORAL MANAGEMENT and distress his feelings by communicating to him the sense of offended dignity. If a patient imagines that his limbs are made of glass, it is very generally useless to refer him to the sight or the touch that he may be undeceived. Were the perceptions at all times capable of rectifying such per- verted ideas, notional insanity would never become established. A person whose mind has been absorbed in money-speculations, conceives himself to be in the possession of great wealth, and acts consistently with this false idea ; you will be but little likely to set him right by appeals to his judgment and reasoning faculty. A lady who has adopted the unfounded notion that she is the object of a tender attachment on the part of some person, will not be disabused even by the most explicit denial of the existence of any such feeling. In all such instances, you must draw off your patient's mind from the particular illusions; and taking advantage of ascertained tastes and OF THE INSANE. 303 capacities, engage his attention with sub- jects calculated to interest and to please ; avoiding all unnecessary allusion to the morbid notions, and letting them wear themselves out, as it were, rather than causing them, by external provocation, to be in any way aggravated or sustained. When the malady has attained its sta- tionary period, or the stage of decline, it is of great importance to interest the patient's mind with studies and amuse- ments congenial with his natural capacity, previous habits, and tastes; and, in the case of the labouring classes, with employ- ment that is familiar to them and for which they display a relish. In large pauper asylums, the most beneficial results, I believe, have been obtained by engaging the inmates in various handicraft works. But such a proceeding would very often be injurious in the case of persons whose antecedents are entirely different. I have sometimes been amused with the 304 MORAL MANAGEMENT conversation of non-medical persons, whose official duties have led them occasionally to visit lunatic asylums. Knowing nothing of principles of management, and reason- ing from what they have seen in pauper asylums, they have asked, in all simplicity, whether with respect to private establish- ments it would not be well to make the patients work, — signifying, with their hands menially; and whether, moreover, it would not be a good thing to cut the patients' hair immediately upon their ad- mission, and thoroughly to wash them in a bath, — suggestions very ridiculous, but proceeding partly from good feeling, and partly from ignorance or thoughtlessness. In certain instances, it may be beneficial to cut the hair ; but when this is done, of course it should be rightly timed, and not be abruptly executed upon patients just entering an asylum for educated people. As to baths, they are undoubtedly useful in the physical treatment of the insane, on OF THE INSANE. 305 the general principles of hygiene, — warm baths for the most part being useful in the earlier periods, and cold in the convalescent stage. But just imagine a delicate ner- vous lady, always accustomed to command and to have her will deferentially regarded, or a gentleman whose previous career has been one of authority and rule; imagine such persons, possessing their ordinary in- telligence and customary sensibility (apart from the special features of their malady) abruptly seized on admission, their heads cropped, and themselves, per fas aut nefas, plunged into a bath ! In the case of pau- pers, there would be nothing unwonted or discordant in this course. In a very large proportion of instances, the insane have their emotional nature painfully exalted. It is quite a mistake to think that lunatics are, ordinarily, in any thing like the condition of idiots; it is most important to keep this circum- stance in mind. Some years ago, the wife 306 MORAL MANAGEMENT of a patient at Clifton Hall died; the patient was highly sensitive, and his gen- eral health somewhat precarious. The death, with great propriety, was concealed from him for two years, as no good pur- pose could possibly result from a contrary course. A magistrate, during an official visit, became acquainted with these facts, and having, I suppose, some theory to support, disapproved of what he chose to consider a species of deceit. It was right, he maintained, that the patient should know. He was warned by the pro- prietor that serious consequences might follow the disclosure. No ! no ! it was proper that he should be told; and he would tell him. And he did tell him. Convulsions soon after seized the patient, and he died ! It would be well if, in the exercise of jurisdiction, people would keep themselves within the limits of their know- ledge. Ne sutor ultra crepidam. In directing the mental pursuits of con- OF THE INSANE. 307 valescent patients, careful discrimination should be exercised. In the selection of books for perusal, and in the choice of natural objects to create an interest, there should always be a certain adaptation to the actual condition of the particular pati- ent; regard being had, at the same time, to his previous circumstances, habits, tastes and capacities. It is sometimes difficult to decide this point, in any individual instance; the principle, however, should be always kept in view. Occupation, indeed, either of the hands, the senses, or the intelligence, contributes, in a remarkable degree, to soothe emotion and tranquillise disordered passion. With the convalescent insane, it is a veritable anodyne ; and as such it should be rendered available in Psychological Medicine, and not by unskilful management be converted into a mental irritant. It is curious to witness, at times, the influence of past associations in reviving 308 MORAL MANAGEMENT what have been called the automatic pro- cesses of mind ; and, without doubt, the circumstance may, very frequently, be made to influence mental vigour and to hasten recovery. I will here supply an anecdote which exemplifies this principle very strikingly. The facts occurred some years ago in this neighbourhood, but not in the establish- ment with which I am connected. From the source of my information, however, I am certain of their having occurred as stated. A clero^vman laboured under the delu- sion that he had committed unpardonable sins, and was not worthy to take food. For six weeks he had pertinaciously acted upon this idea, and had refused all nou- rishment; nutriment, in the liquid form having been systematically forced upon him. A brother clergyman, and a per- sonal friend, happening to visit the neigh- bourhood to preach, called upon the pa- OF THE INSANE. 309 tient, who expressed a strong wish to preach in the place of his friend. The proprietor of the establishment in which he was confined, expecting no particular result, stated that he should preach, if he would only make a good dinner of his own accord. And he did so. Hereupon, it was decided to go on with the experiment ; and the insane clergyman went to church, ascended the pulpit, and preached a most excellent sermon. On returning, however, he lapsed into his previous state, and for thirteen weeks never voluntarily took a meal, with the exception just mentioned. Nevertheless, he recovered permanently in a few months afterwards, and performed his clerical duties for many years. In some cases of what I have denomi- nated notional insanity, the false ideas having possession of the brain cannot be altogether ignored, without producing greater mischief than would result from some sort of recognition of them. In cer- 310 MORAL MANAGEMENT tain instances, the patient may be so entirely engaged with them, that your disregard will irritate him exceedingly. Under such circumstances, he must be humoured. You must indulge him in his notions by a species of passive endurance. But you are not called upon, nor indeed would it be right, to foster or encourage them. Thus, if a patient's attention can- not be withdrawn from the delusion that he carries two heads on his shoulders, you must not pooh ! pooh ! Your replies, and your conduct generally, whilst conversing or otherwise dealing with him, should cor- respond with his morbid fancy, — just to the extent of maintaining him free from irritating excitement, and stopping short of every thing calculated positively to support or strengthen the delusion. In some instances, however, the morbid notion may be successfully combated, either by some very obvious demonstra- tion, or by a simple argument, or by a OF THE INSANE. 311 little pleasant banter. Of the effects pro- duced, an opinion may be formed from the influence apparently exerted upon the pa- tient's temper, and from the greater or less tenacity with which the delusion is ad- hered to. Pinel gives an account of an insane person who was in a large asylum, and fancied himself to be the Holy Ghost. There happened, at the time, to be two other inmates possessed with the same idea. The latter were brought into the presence of the former, who very soon discovered, in conversation, the speciality attaching to his fellow patients. He be- gan to muse; observed, first to one, "You say you are the Holy Ghost :" then to the other, "and you say you are the Holy Ghost: but then," he said to himself, "I am the Holy Ghost." Still soliloquising, he asked, "Can there be three Holy Ghosts?" And from this interview, he became cured of his delusion. 312 MORAL MANAGEMENT Guislain relates the case of a joung woman who had been under his care, entertaining the conviction that the Al- mighty ought to give her another soul, — that of a different person. Every day, he questioned her in a somewhat derisive tone: "And your soul, my young lady?" At the end of a month, she was disconcerted when so addressed ; the blood would man- tle her cheeks, and then she would smile in her turn. After a while, she begged the physician to let the subject drop ; and in a very short time, the recovery was complete. Guislain says, he is certain that her cure was accomplished by the method which he adopted of treating her delusion. In carrying out the principles of treat- ment now explained and exemplified, there are required, of course, kind, considerate, and well-instructed attendants; because errors of conduct upon their part, in them- selves apparently trivial, may constitute OF THE INSANE. 313 serious occasions of detriment in the case of many mental maladies. When a patient labours under any of the varieties of what I have called intelli- gential insanity, — when, for example, he seems to have lost, in a measure greater or less, the power of so combining his ideas as to form a judgment upon the common events of life, or to maintain any thing like a consistent or definite relation with the external world, — the moral treatment of the mental disorder still keeps up the closest anology with the scientific treat- ment of ordinary disease. If there be a w^ild rambling of thought, and incoherence of discourse, evincing not only derange- ment but undue excitement of the intelli- gence, the patient should be permitted to exhaust himself He should neither be influenced by outward causes to maintain the unwonted activity of mind, nor yet re- ceive, in most cases at least, so much as a moral coercion for the purpose of check ; E E 314 MORAL MANAGEMENT this, indeed, would very generally produce cerebral irritation. An influence should be exerted upon the emotive sense, calculated, in its nature, to produce tranquillity and calm. Soothing tones of voice, with simple and persuasive gesture, should be employed for this purpose. Every thing like reason- ing or command should be avoided. When the violence of symptoms has abated, there should be no attempt to rouse, or call forth, the higher mental faculties by direct agency. The intelli- gence should rather be influenced by a careful and judicious provocation of the observing powers, so that agreeable and reinvigorating trains of thought may arise, as it were, spontaneously. If you attempt prematurely to restore the proper balance of the intelligence, by reference to the antecedent habits of mind, by argument, or by ill-timed appeals to the judgment, you will not only fail, but in all probability you will aggravate the disorder. OF THE INSANE. 315 When the first excitement has been sub- dued, and when there is prostration of the mental powers as if from debility, act as you would in corresponding states of ordi- nary bodily derangement. Supply pabulum that is mild and nutrient, rejecting that which is too rich and stimulating. Carry on the patient step by step, by appeals to his senses, by judicious and pleasing con- versation, and by the aid of amusements and books carefully selected. If the malady go on to dementia, — if total wreck of the intelligence supervene, — there is frequently softening of the brain, or some other mischief of an organic cha- racter. In such cases, there is very little to be done, beyond maintaining the pati- ent's general health in the best possible condition, by hygienic and other means. But the presence either of total or partial dementia of a permanent character, should not be assumed too hastily, especially when the patient is young. Such a conclusion 316 MORAL JklANAGEMENT is too apt to result in premature abandon- ment of the just means for effecting a cure. Guislain mentions a case of reco- very, under judicious management, of a patient, after twenty-eight years of neglect, who had been improperly regarded as irre- mediably demented. At this time there is a gentleman in the institution at Clifton, about thirty-one years of age, who has been insane for up- wards of sixteen years, and whose history is briefly as follows. He was naturally of a sullen and morose disposition, and he be- came still more so under the influence of mental derangement. He was for many years imder decidedly bad management, and was regarded as a dangerous and intractable lunatic; in bed he was every night restrained by a leg-lock, and the animal wants alone were attended to. He has been in his present situation for nearly three years, and has become a very com- panionable and communicative person. OF THE INSANE. 317 He is fond of books, and amuses himself in a variety of ways. He takes great interest in the politics of the day, reading the Times and other newspapers with great eagerness. He retains the information which he acquires, and exhibits some little skill in ratiocination. He has had perfect self-control for some months. And, last Christmas, he went, in company with an attendant and another patient, to see the pantomime, and was very much the better for the recreation. Before concluding these remarks on the treatment of intelligential insanity, I will say a few words on the management of idiots, — a process which is very much one of general education. I need hardly observe that, of my own knowledge, I have very little to state upon this division of the subject. In well-regulated esta- blishments for the improvement of this unhappy class of persons, I believe, how- ever, that very extraordinary results have 318 MORAL MANAGEMENT been obtained. I understand that, by great care, very stupid idiots may be trained to notions of etiquette and the more ordinary duties of politeness; they may be taught to raise the hat and to inquire after the health of persons to whom they speak; also to distinguish the days of the week, and the hours of the day. They may be made, moreover, to know a little of the relative value of coins; and a few even will learn something of a foreign language. Sentiments of respect may be established for that which naturally com- mands it; and notions of good and evil may, in some instances, be inculcated suc- cessfully. Of course, to accomplish these results, there may be required years of incessant solicitude, and a patience little less than angelic ; otherwise, what is gained one day will be lost the next. And, indeed, under most circumstances, the ameHora- tion which it has taken years to realise, may be dissipated in as many weeks, if the OF THE INSANE. 319 efforts be not sustained uninterruptedly. It is said to be so, at any rate, with the great majority of idiots. It is stated of some, however, that their progress is suffi- ciently real to be durable, even when the tuition and surveillance have been with- drawn. I must here remind my auditors that, on the present occasion, I am but expound- ing and discussing the principles of treat- ment. The particular modifications de- manded by individual cases can only be appreciated, when all the circumstances and details are actually before us. I proceed to make a few general remarks on the method of dealing with Emotional insanity, as I have called it. In instances in which there is melancholic depression of spirits, and exaltation or depravation of any of the affections or sentiments, one purpose must be kept steadily in view. Every thing that is calculated to excite or provoke the particular emotion which is 320 MORAL MANAGEMENT under morbid influence, should be avoided or withdrawn; and every thing that is fitted to counteract the ailment, should be made to fall in the patient's way. When he is overwhelmed or prostrated by melan- choly, the train of ideas associated with this state of mind should be broken, and allusions to the real or supposed causes should never be made but with unusual care and delicacy. The thoughts should be directed into other channels; and this should be accomplished with great care and consideration, and not by attempts of a bold and direct character, which would almost inevitably fail in their purpose. If paroxysms of grief develope themselves from time to time, they must be allowed to exhaust themselves. The collapse and despondency likely to succeed, should not be rudely disturbed. The moment of re- action, be this ever so slight, should be ren- dered available for acting upon the mind revulsively. If possible, thoughts should OF THE INSANE. 321 be suggested to the patient's intelligence, of a nature adapted for drawing him out of himself as it were, and for producing some permanent reaction, and thus deter- mining to healthful activity the mental faculties in general. Moreover, when voli- tional control over the ideas is in some degree recovered, he should be made aware of the power which every person naturally possesses, and should exercise, over his own current of thought; and how, by voluntary efforts, he should direct his attention to objects and pursuits calculated to establish states of mind foreign to his depression. The extent, indeed, to which an individual can influence his moral sen- sibility through his thoughts, has a great deal to do both with final restoration to mental soundness, and with warding off threatened attacks of insanity. It is the constant brooding over depressing ideas that gives them such a hold upon the mind as to disturb its balance. Some 322 MORAL MANAGEMENT people notoriously nurse their grief, as if it were some pet child. The application of these principles in conducting the moral management of the melancholic, will have to be varied inde- finitely, according to the varying charac- teristics of individual cases. If a person show himself violent and abusive, feroci- ous and destructive, you must not aggra- vate still further the morbid irritability by chastisement, mechanical restraint, or phy- sical coercion of any kind ; a proceeding of this nature, under ordinary circumstances, will only produce more painful manifestar tions of the disorder. Generally speaking, if this be avoided, the undue excitement will exhaust itself. It may return peri- odically, but it will pass away most usu- ally without mischief In the intervals, the patient, very probably, will become susceptible of countervailing influences; and these must be brought to bear upon him, accordantly with the views already explained. OF THE INSANE. 823 It is one of the achievements of modern medicine, to have discovered that physical coercion and restraint can almost be dis- pensed with, in the management of the insane; and to Pinel in France, and to Conolly in our own country, the honor is largely due, of having effected this very important reform in the treatment of men- tal derangement. I must not, however, be understood to represent that, under all circumstances, physical restraint can be avoided. There are occasions when, whatever be the evils which attach to the proceeding, it becomes indispensable. If a patient be perilous to himself, or likely to injure seriously those about him, he must of course be restrained, as the least of two evils. But the coercion that is exercised must only be such as is necessary for its purpose. It must not be inflicted as chastisement; there must not be the semblance of vindictive- ness. But if, in the individual case, there 324 MORAL MANAGEMENT remain sufficient reason and conscience to render the patient susceptible of moral influences, — capable of appreciating the retributive; in this case, regret for the WTong done, and an apprehension of pro- tracted restraint, will sometimes operate beneficially. I am now referring to un- wonted restrictions upon personal liberty, and not to restraint and coercion which involve any physical suffering. There is nothing that concerns the treatment and management of the insane, which demands a nicer discrimination, than this legitimate exercise of coercion. Not only are know- ledge and judgment and great firmness of character demanded, but temper also and kindness and an intuitive sagacity in de- tecting the precise mental condition of the patient at the moment. When violence of an outrageous kind occurs in paroxysms, of course the periods of intermission must be turned to all possi- ble account ; every effort being made to OF THE INSANE. 325 determine the anticipated excitement in other directions. And the moment when this excitement is supposed to be at hand, should be especially watched, in order that restraint may be practised just at the right time, or be superseded entirely by preoccu- pation of the mind. In carrying out the details of the treat- ment, it is quite indispensable, in a large majority of cases, that insane patients be removed from home, and placed in circum- stances where every appliance for their relief is available, as in a well-conducted asylum. But before dwelling upon the reasons that render this proceeding so important, I will briefly indicate the cases that de- mand it more particularly; previously re- ferring, however, to those wherein it is at least useless, and often improper. When mental imbecility of a perfectly harmless character has existed from birth, and where the subjects of this affliction are F F 326 MORAL MANAGEMENT tractable, and contented, and affectionately disposed, at home, I consider that not only does no good reason exist for sending them to an asylum, but, when avoidable, I should regard such a measure in some instances as a positive hardship and cruelty; and more especially in the case of imbecile adults, whose habits have become formed, and whose affections are fixed. Of course, I do not refer to special establishments for training and educating idiot children ; but to ordinary asylums. In the dementia senilis which occasionally comes on, slowly and gradually, at a comparatively early period, especially afler the more severe trials of life, I see no good reason what- ever for removal to an asylum. No ex- pectations of cure can rest upon such a step ; the patient's own safety, or that of his friends, is compromised in no way by his remaining at home; and, ordinarily, there is no just reason at all for removing such a person. OF THE INSANE. 327 There is another class of patients, to place whom in an asylum, I am sure, is most unwarrantable and injurious; I al- lude to recent cases, wherein symptoms of an acute character reveal the presence of some inflammatory condition. The rea- sons will be apparent from what has been already advanced in the preceding lecture ; acute symptoms always demand repose, and freedom from unnecessary ex- citement. Of course, removal to a lunatic establishment, and the attentions exclu- sively of strangers, would, under such circumstances, be injurious, and only to be tolerated in the case of the destitute poor, as the least of two evils. In all cases, however, which are dis- tinguished by notional illusions, or by ma- niacal symptoms that do not obviously involve cerebral or meningeal inflamma- tion, or by morbid states of the emotive sense, it is almost invariably necessary to convey the patient to a special establish- 328 MORAL MANAGEMENT ment, — a proceeding whicli is demanded as a measure of safety alike to himself and to his attendants, and as a measure facili- tating the employment of the proper agen- cies for effecting recovery. The patient's proper safety, together with that of his friends, constitute what may be called the negative advantages of detention in a lunatic asylum. Indeed, the self-infliction of injury, in some in- stances, can only be guarded against under such circumstances. I refer not only to those cases in which the suicidal tendency exists, but to those moreover in which, without a most prejudicial exercise of phy- sical coercion, the patient cannot be pre- vented, during some exacerbation of his malady, from doing to himself, or to others, serious bodily mischief In establishments purposely constructed, there are padded rooms so adapted, that lunatics, when in them, cannot do themselves any harm ; particularly if the hands be gently secured OF THE INSANE. 829 in muffs, or, in cases of great severity, if the arms be carefully placed in appropri- ately-fashioned sleeves. The proper faci- lity, moreover, and aptitude for watching and guarding the patients who are danger- ous to themselves or others, can only be realised by trained and experienced attend- ants. But, in the management of the insane, deprivation of personal liberty, as secured in a lunatic establishment, is a positively curative agency. No other means of cure are comparable with it. The moral influ- ence exerted by such a measure is attribu- table, in a great degree, to the new mental career which it initiates. The very con- straint which, in many instances, is felt to be so irksome, may operate beneficially ; the shock to the sensibility which is thus produced reacts very often upon the will, and prompts to a new and more healthful action. In this way, sometimes, morbid conceit, petulance, and depravation of the 330 MORAL MANAGEMENT emotive sense, become dissipated, and give place to the suggestions of reason and re- flection. These results may be developed speedily or slowly, as the case may be. An attentive consideration of some of the ordinary phenomena of our conscious natm'e, will render the moral influence of removal from home still more apparent and explicable. The actual state of habitual conscious- ness, at given periods, and under special circumstances, forms a kind of unity with regard to modes of thoug:ht, the current of ideas, the feelings and the sensations, to an extent and in a way which, though constantly recognised, is but rarely the subject of systematic reflection. Every one has heard, and speaks, of the associa- tion of ideas ; a phrase by which it is under- stood that thoughts unconnected in their nature, and differing in their relations, which have yet largely occupied the mind at particular times, under circumstances OF THE INSANE. 331 that have linked them together as it were, will recal one another, by suggestion. Thus, in instances where an idea belonging to the past spontaneously arises, or becomes provoked by some accidental occurrence, the whole train of thought with which it had been associated at some former period, will very often return to the mind. You visit some favourite locality, — one from which you have long been absent, one where in childhood you had loved to sport and play; well does every one of you know the mental phenomena^ which ensue ; multitudinous events and circumstances, many of them probably half-forgotten, rush rapidly and vividly to the thoughts. This familiar fact exemplifies the association of ideas. But the actual association comprises not only the ideas, but every impression that is characterised by consciousness; sensations and emotions, ideas and intellectual opera- tions, all maintain the same reciprocal 332 MORAL MANAGEMENT relation. Carry your thoughts back to some past season of exhilaration and joy, or of sorrow and grief; think with sufficient in- \ tensity and concentration thereupon ; and, in a greater or less degree, you will pro- j voke the old familiar emotions, pleasurable or painful. And not only will this be the case, but if the process meet with no inter- j ruption, there will come back to memory the friends and companions of days gone by ; the amusements also and your severer pursuits ; the very music of the hour, and insignificant details of your occupations long past. There are illustrations more remarkable still. Let but a simple sensa- tion be experienced, — a notable scent or peculiar sound, — but one with which you were familiar at some earlier era; here- upon, for a brief period, old times will revive in the memory, and an entire state of consciousness be felt, greatly resembling that which characterised the past. And how very clearly is all this observed, when OF THE INSANE. 333 we come to melody, to the sight of old faces, or to the reading of some book of childhood ; every idea, sentiment, or affec- tion, experienced of old, returns to the mind, in a measure, once more ; the very sensations, even without external material cause, will at times be reproduced. When I was myself nine years of age, and placed in circumstances somewhat trying for a child, I had given to me cer- tain sweet-meats of notable flavour. Con- suming them at a time of mental perturba- tion, I experienced a marked indigestion; and corresponding sensations arose in the throat as the consequence. For years afterwards, when placed in the like cir- cumstances, the old sensation was repro- duced ; I was troubled as if from the badly digested sweets. These phenomena, which illustrate the unity of our conscious states, in reference to sensations and ideas, the emotions and the intelligence, under given circumstances, 334 MORAL MANAGEMENT supply the elementary facts upon which rests an important principle affecting the moral management of the insane. It be- comes very often necessary, not only to withdraw the particular excitants of the mental malady, but to break up, as it were, the whole circle of conscious impressions with which those excitants have been asso- ciated in idea. If a mother, for example, has been driven insane by the loss of child- ren, it is not sufficient that you breathe not their names; it is not sufficient that every relict of the lost ones be removed from sight ; it is not sufficient simply to ex- clude the immediate provocations ; all the relations of the inner consciousness should be changed ; the aggregate of thought and feeling should be dissolved, and constructed anew, so far as possible. In the class of cases to which I refer, — and a large class it is, — whatever was experienced about the period when the insanity set in, will act upon the mind, when recalled, very much OF THE INSANE. 335 like the immediate cause itself, — every allied circumstance reflecting its hue. To go back to our illustration. The deceased children's clothes, the toys, the nursery, the house, the friends habitually seen at the period of bereavement, any speciality in the business-occupation, even the most insignificant fact, will recal the dominant impression, from having been associated with it in time and circumstance. In every form of insanity, especially if originating in moral rather than in physi- cal or physiological agency, this principle is seen to obtain. See what happens in the earlier stages, when mental derange- ment makes its invasion. The whole cha- racter often undergoes change. Not only do notional illusions arise, and painful states of the emotive sense referring them- selves to particular ideas, but the gay become melancholy and the melancholy gay ; love becomes turned into hatred ; pursuits previously carried on with delight, 336 MORAL MANAGEMENT cease to interest, and even become abhor- rent ; and why is all this ? Because every impression, from whatever source derived, if it be mentally associated with that which has produced the disease, reacts upon it and aggravates its characteristics. If the insanity be of a painful nature, — and it is the observation of Esquirol, that mental alienation is but rarely induced by joyous impressions, — every thing which was in the mind at the origin of the attack, becomes painful ; hence the dislike which so often arises to the immediate friends, even to those who were best beloved. If the mental disease assume a cheerful and pleasing character, corresponding pheno- mena will transpire. A religious enthu- siast mounts on the wings of his morbid fancy, and attains the abodes of the blessed; love, reverence, and admiration, arise in his mind towards all persons, — not only such as were previously indifferent, but even such as were absolutely disliked. OF THE INSANE. 337 All this is very conceivable, and re- ceives its explanation in familiar experi- ence. You had once an occasion of great and memorable rejoicing; your feelings, from strong excitement, almost carried you beyond yourself; music that, heretofore, you heeded not, distinguished the occa- sion ; — ever afterwards, that same music will be sure to recal much that you felt in that season of delight. And the same thing occurs when your hearts have been rent by affliction. You flee from your choicest pleasures, if they remind you of it. It is precisely the same with the phenomena of mental derangement. For a time, there should be a complete severance from old and familiar associa- tions. A new life must commence. The mind, alike in its active and passive states, should, in some sense, be created anew. Other habits, other feelings, must be in- duced. And thus, by moral alteratives, so GG 338 MORAL MANAGEMENT to say, we must hope, and strive, to restore the mens sana in corpore sano. It is only by removal from home, and detention in some suitable establishment, that we can, in most cases, cause to arise a totally new order of thoughts and feelings competent to engage the mind, and trans- port the patient, as it were, into another world. Sometimes his complainings, his new desires, his supplications, his humi- liation, and his tears, dissipate the very principle of his malady ; and, by this proceeding, the natural affections and the reason very often develope themselves anew. And thus the patient's desire for freedom, and his wish to revisit friends and relations, determine a course of thought and feeling at variance with and antago- nistic to the peculiar features of his ma- lady ; in this way operating as a powerful moral revulsive. I have now brought this lecture, and OF THE INSANE. 339 with it the Course, to a termination ; and, in taking leave of the subject for the pre- sent, 1 will endeavour to comprise the treatment of insanity and the entire ma- nagement of the insane, in a brief formula of a few words. This I subjoin, and with it I conclude : — Deal with the physical characteristics which may accompany insanity, as you would deal with them under other cir- cumstances, and act in correspondence with sound principles of medical practice ; always remembering that, with high ner- vous susceptibility, depletion will be but indifferently tolerated, — more especially when the ailment refers itself to causes essentially psychical. For the relief of insanity itself, properly considered, trust almost entirely to hygienic and moral treatment ; withdrawing circumstances likely to aggravate the special features of individual cases, and supplying to the 340 :\roRAL management, etc. mind such objects of attention and exci- tants to activity as may be best calculated to arouse and sustain a new and more healthful mode of operation. ^i&e isntf. Charles Simras and Co., Printers, Manchester. DatQ Due *««'J/'W ainynv 1 1 11 4 1 ttl 'i •-0 ^'"■pw' ^ Uiii '-^'^ JUN 8 RtfU ^ PRINTED IN U. S. A 1 54