Footnotes:
[[Skip]]
[251] Dublin. See postea.
[252] "Tenth Report of the District, Criminal, and Private Lunatic Asylums in Ireland."
[253] Page 34.
[254] See Report of Select Committee, etc., 1817.
[255] "Description," etc., 1813.
[256] "The accumulation of the number of incurable cases which necessarily must have occurred from time to time in these asylums, had also been overlooked, and has consequently led to the embarrassment which is felt at present with respect to the best mode of providing for them."—Report of the Inspectors, 1843.
[257] "Report from the Select Committee on the Lunatic Poor in Ireland, with Minutes of Evidence taken before the Committee, 1817."
[258] "An Act to provide for the Establishment of Asylums for the Lunatic Poor in Ireland, 1817." Introduced by Mr. V. Fitzgerald, but prepared By Mr. Thos. Spring Rice, M.P. for Limerick.
[259] Repealing 57 Geo. III., c. 106, and 1 Geo. IV., c. 98.
[260] See Twenty-seventh Report of Inspectors of Asylums, May 1, 1878.
[261] Parliamentary Return, ordered to be printed, April 19, 1826.
[262] Parliamentary Papers, Correspondence, etc., between the Home Office and the Irish Government during 1827 on Public Lunatic Asylums.
[263] First Annual Report of the City of Cork Asylum, dated March 1, 1827.
[264] For particulars in regard to the condition of the insane in Ireland in this year, see "Report of the Select Committee appointed to take into consideration the state of the poorer classes in Ireland in relation to Lunatic Asylums, 1830."
[265] "The Report of the Lords' Committee appointed to consider the state of the lunatic poor in Ireland, and to report to the House."
[266] Report of the Lords' Committee.
[267] Orders in Council were in consequence issued for the erection of the new district asylums, under the statutes 1 and 2 Geo. IV. and 7 Geo. IV., c. 14, which will be found on another page.
[268] This Act was preceded by the Select Committee of Lunatic Asylums (Ireland), moved by Colonel Dunne. Dr. Nugent, the Inspector of Asylums, gave in his evidence a minute description of the system under which asylums have been erected in Ireland, and stated that the expenditure on the seven asylums built since 1847 amounted £313,973. In the same year a Commission was appointed to inquire into the erection of district lunatic asylums, which reported in 1856.
[269] The Prisons Act.
[270] See [p. 191]. Irish lunacy is only incidentally noticed in this evidence, which had primary reference to England.
[271] The medical superintendent of the Belfast Asylum, one of the best-managed institutions of Ireland.
[272] Journal of Mental Science, April, 1875.
[273] Dr. Robertson to the Inspector of Lunacy, Report, p. lxxxvii.
[274] From editorial article in Journal of Mental Science, July, 1879.
[275] 8 and 9 Vict., c. 107, s. 15.
[276] Page lxii.
[277] Patients being sent to asylums on the pretext of their being "dangerous lunatics" when not so. See [p. 435].
[278] Page lxviii.
[279] The Dundrum Central Criminal Asylum, recommended by the Committee of the House of Lords in 1843, and established by the 8 and 9 Vict., c. 107, was built at a cost of £19,547, and was opened in 1850 on the south side of the city of Dublin, capable then of holding only 120 inmates. When the writer visited it in 1875, he was very favourably impressed with its condition. Dr. McCabe was at that time superintendent, and has been succeeded by Dr. Ashe.
[280] "Parliamentary Debates," 3rd series, vol. ccxlviii., August, 1879, p. 1822.
[281] Ibid., vol. ccliv., July, 1880, p. 892.
[282] Ibid., vol. cclv., August, 1880.
[283] Op. cit., p. 894.
[284] "Parliamentary Debates," 3rd series, vol. cclx. p. 802.
[285] Op. cit., vol. cclx. p. 810.
[286] It was withdrawn July 8, 1881.
[287] See "The Richmond Asylum Schools," by Dr. D. Hack Tuke, Journal of Mental Science, October, 1875. Also an article in the Journal, April, 1882, by Mr. Fox, the master of the school.
[288] Only those supported by Government. The total number was 112.
[289] In 1873 the number was greater, viz. 664.
[290] The inspectors make a total of 13,051.
[291] Journal of Mental Science, January, 1882.
CHAPTER XI.
PROGRESS OF PSYCHOLOGICAL MEDICINE DURING THE LAST FORTY YEARS: 1841-1881.[292]
If, gentlemen, History be correctly defined as Philosophy teaching by examples, I do not know that I could take any subject for my Address more profitable or fitting than the Progress of Psychological Medicine during the forty years which, expiring to-day, mark the life of the Association over which, thanks to your suffrages, I have the honour to preside this year—an honour greatly enhanced by the special circumstances under which we assemble, arising out of the meeting in this metropolis of the International Medical Congress. To it I would accord a hearty welcome, speaking on behalf of this Association, which numbers amongst its honorary members so many distinguished alienists, American and European. Bounded by the limits of our four seas, we are in danger of overlooking the merits of those who live and work beyond them. I recall the observation of Arnold of Rugby, that if we were not a very active people, our disunion from the Continent would make us nearly as bad as the Chinese. "Foreigners say," he goes on to remark, "that our insular situation cramps and narrows our minds. And this is not mere nonsense either. What is wanted is a deep knowledge of, and sympathy with, the European character and institutions, and then there would be a hope that we might each impart to the other that in which we are superior."
Do we not owe to France the classic works of Pinel and of Esquirol—justly styled the Hippocrates of Psychological Medicine—works whose value time can never destroy; and have not these masters in Medical Psychology been followed by an array of brilliant names familiar to us as household words, Georget, Bayle, Ferrus, Foville, Leuret, Falret, Voisin, Trélat, Parchappe, Morel, Marcé, who have passed away,[293] and by those now living who, either inheriting their name or worthy of their fame, will be inscribed on the long roll of celebrated psychologists of which that country can boast.
If Haslam may seem to have stumbled upon General Paralysis, we may well accord to French alienists the merit of having really discovered the disorder which, in our department, is the most fascinating, as it has formed the most prominent object of research, during the last forty years.
To mention Austria and Germany, is to recall Langermann, Feuchtersleben, Reil, Friedreich, Jacobi, Zeller, Griesinger, Roller, and Flemming, who, full of years and honours, has now passed away.
Has not Belgium her Guislain, Holland her Schroeder van der Kolk, and Italy her Chiaruggi?
And when I pass from Europe to the American continent, many well-known names arise, at whose head stands the celebrated Dr. Rush. Woodward, Bell, Brigham, and Howe (whose many-sided labour included the idiot) will be long remembered, and now, alas! I have to include among the dead an honoured name, over whom the grave has recently closed. Saintship is not the exclusive property of the Church. Medicine has also her calendar. Not a few physicians of the mind have deserved to be canonized; and to our psychological Hagiology, I would now add the name of Isaac Ray. With his fellow-workers in the same field, among whom are men not less honoured, I would venture to express the sympathy of this Association in the loss they have sustained. Nor can I pass from these names, although departing from my intention of mentioning only the dead, without paying a tribute of respect to that remarkable woman, Miss Dix, who has a claim to the gratitude of mankind for having consecrated the best years of her varied life to the fearless advocacy of the cause of the insane, and to whose exertions not a few of the institutions for their care and treatment in the States owe their origin.
Abroad, psychological journalism has been in advance of ours.
The French alienists established in 1843 their Annales Médico-Psychologiques (one of whose editors, M. Foville, is with us to-day), five years before Dr. Winslow issued his Journal, the first devoted to medical psychology in this country, and ten years before our own Journal appeared, in 1853.
The Germans and Americans began their Journals in the following year—1844; the former, the Allgemeine Zeitschrift für Psychiatrie, and the latter the American Journal of Insanity.
I believe that our Association has precedence of any other devoted to Medical Psychology, and it is an interesting fact that its establishment led to that of the corresponding Association in France—a society whose secretary, M. Motet, I am glad to see among my auditors. The Association of Medical Superintendents of American Institutions for the Insane was instituted in 1844; that of Germany in 1864, the subject of Psychology having previously formed a section of a Medical Association.
Returning to our own country, I may observe that when Dr. Hitch, of the Gloucester Asylum, issued the circular which led to the formation of this Association in 1841, almost half a century had elapsed since the epoch (1792) which I may call the renaissance of the humane treatment of the insane, when the Bicêtre in France, and the York Retreat in England, originated by their example an impulse still unspent, destined in the course of years to triumph, as we witness to-day. This triumph was secured, in large measure, by the efforts of two men who, forty years ago, shortly after the well-known experiment at Lincoln, by the late Mr. Robert Gardiner Hill, were actively engaged in ameliorating the condition of the insane. Need I say that I refer to Lord Shaftesbury and Dr. Conolly? The nobleman and the physician (alike forward to recognize the services of the pioneers of 1792), each in his own sphere having a common end in view, and animated by the same spirit, gave an impetus to the movement, the value and far-reaching extent of which it is almost impossible to exaggerate. Lord Shaftesbury,[294] celebrating his eightieth birthday this year, still lives to witness the fruits of his labours, of which the success of the well-known Acts with which his name is associated, will form an enduring memorial. Dr. Conolly was in his prime. He had been two years at Hanwell, and was contending against great difficulties with the courageous determination which characterized him. I do not hold the memory of Conolly in respect, merely or principally because he was the apostle of non-restraint, but because, although doubtless fallible (and indiscriminate eulogy would defeat its object), he infused into the treatment of the insane a contagious earnestness possessing a value far beyond any mere system or dogma. His real merit, his true glory, is to have leavened the opinions and stimulated the best energies of many of his contemporaries, to have stirred their enthusiasm and inflamed their zeal, to have not only transmitted but to have rendered brighter the torch which he seized from the hands of his predecessors. He desired to be remembered after his death by asylum superintendents as one who sincerely wished to place the insane in better hands than those in which he too generally found them; and I hold that, whatever may be our views on what we have chosen to call non-restraint, we may cordially unite in fulfilling his desire.
As the non-restraint system—a term, it must be confessed, which cannot boast of scientific precision, but is well understood—has been the leading, and often engrossing, topic of discussion during the period now under review, I must not omit a brief reference to it. No one will call in question the statement as an historical fact that the Commissioners in Lunacy and the medical superintendents of asylums in this country are, with few exceptions, in favour of non-restraint. Dr. Lauder Lindsay—for whose death, as well as that of Dr. Sherlock and of Dr. White Williams, during the last year, the tribute of sorrowful regret ought, in passing, to be paid—Dr. Lindsay, I say, had only a small following in Great Britain. In Germany, on the other hand, although Griesinger looked favourably upon the system, and Westphal has advocated it, and Brosius has translated Conolly's standard work into German, there has not been a general conversion, as may be seen by the discussion which took place in 1879, at meetings of the Psychological Society in Berlin and Heidelberg. In France, again, although Morel gave it the sanction of his name, and Magnan has practised it recently, there has been within the last twelve months a striking proof of anti-non-restraint opinion among the French physicians, in an interesting discussion at the Société Médico-Psychologique. I wish here only to chronicle the fact, and would urge the necessity of not confounding honest differences of opinion with differences of humane feeling. The non-restrainer is within his right when he practises the system carried to its extremest lengths. He is within his right when he preaches its advantages to others. But he is not within his right if he denounces those physicians, equally humane as himself, who differ from him in opinion and practice. I therefore unite with the observation of Dr. Ray, by whom, as well as by the majority of his fellow-psychologists, the non-restraint system as a doctrine was not accepted, when he wrote thus in 1855, "Here, as well as everywhere else, the privilege of free and independent inquiry cannot be invaded without ultimate injury to the cause."[295]
The arguments in favour of mechanical restraint are clearly set forth by Dr. John Gray, of the Utica Asylum, in his annual report of the present year.
Leaving this subject let me recall to your recollection that when this Association was formed, the care of the insane in England and Wales was regulated by the Gordon-Ashley Act of 1828,[296] which, among other reforms, had substituted for the authority of five Fellows of the College of Physicians, who performed their duties in the most slovenly manner, fifteen metropolitan Commissioners in Lunacy. I find, on examining the Annual Report of these Commissioners issued in 1841, that it does not extend over more than one page and a half! It is signed by Ashley, Gordon, Turner, Southey, and Proctor. They report the number confined in the thirty-three asylums within their jurisdiction as 2490. Their verdict on inspecting them is expressed in half a dozen words, namely, that the "result is upon the whole satisfactory."
"The business of this Commission," they say, "has very much increased, partly by more frequent communications with the provinces (over which, however, they have no direct legal control), and partly by the more minute attention directed by the Commissioners to individual cases with a view to the liberation of convalescent patients upon trial ... and the consequence has been that many persons have been liberated who otherwise would have remained in confinement."
That a state of things in which such an occurrence was possible should be described as on the whole satisfactory, is somewhat remarkable, and in reading this paragraph we cannot but contrast with it the very different result of the investigation made by the Committee of the House of Commons in 1877.
Again, nothing more strikingly marks the change which has taken place in the inspection of asylums than the contrast between the last Report of the Lunacy Commissioners, consisting of a bulky volume of more than four hundred pages, and that of 1841, of a page and a half. In fact, the Reports of the Commissioners form the best evidence to which I can refer of the progress made from year to year in the provision for the insane, and the gradual but uninterrupted amelioration of their condition.
An important advance was made in 1842 by the Act 5 and 6 Vict., c. 87, which provided that provincial houses were to be visited by the Metropolitan Commissioners, as well as those in their own district. They were also to report whether restraint was practised in any asylum, and whether the patients were properly amused and occupied. Not only was a great step forward made by thus extending the inspecting power of these Commissioners to the provinces, but their memorable Report on the state of the asylums in England and Wales in 1844 led to the highly important legislation of the following year (introduced by Lord Ashley)—the Act 8 and 9 Vict., c. 100, which along with the Acts of 1853 (16 and 17 Vict., cc. 96, 97)[297] and 1862 (25 and 26 Vict., c. 111) form, as you are well aware, the Code of Lunacy Law under which, for the most part, the care of the insane is determined and their protection secured.
I should like to have been able to state the number of recognized lunatics in England and Wales forty years ago, but no return exists which shows it. The nearest approach is to be found in the Report just referred to of the Metropolitan Commissioners (1844), in which the number of ascertained lunatics in England and Wales is stated to be about 20,000, of whom only 11,272 were confined in asylums, whereas now there are nearly 55,000. It is difficult to realize that there were then only some 4000 patients in county asylums, these being 15 in number, and that there were 21 counties in England and Wales in which there were no asylums of any kind, public or private. At the present time, instead of 20,000 ascertained lunatics and idiots, we have 73,113—an increase represented by the population of the City of York—instead of 15 county asylums we have 51, with scarcely less than 40,000 patients, instead of 4000; while the provincial licensed houses have decreased from 99 to 59, and the metropolitan increased by 2. The total number of asylums in England and Wales in 1844 was 158,[298] now it is 175—excluding those (3) erected under Hardy's Act. I need not say that these figures do not necessarily point to an increase of lunacy, but may merely represent the increased accommodation which ought to have been provided long before. Into the general question of the spread of insanity I feel that it would be impossible to enter satisfactorily now.
Recurring to the Metropolitan Commissioners' Report, I must observe that while an immense advance took place between 1828, when they were appointed, and 1844, the subsequent advance between the latter date and now is such that we cannot but recognize the extremely beneficial operation of the legislation which has marked this period. It must also be gratifying to Scotch asylum superintendents, knowing as they do the satisfactory condition of the insane in their country in 1881, to be able to measure the progress made since Lord Ashley, in his speech in 1844, moved for an address to the Crown, praying her Majesty to take into consideration the Commissioners' Report, for he there observes, "I believe that not in any country in Europe, nor in any part of America, is there any place in which pauper lunatics are in such a suffering and degraded state as those in her Majesty's kingdom of Scotland." I need not do more than chronicle the fact, in passing, that the reform in Scotland dates, to a large extent, from the appointment of a Royal Commission in 1855, and the action of the Board of Lunacy Commissioners which was established in consequence. Legislation for Ireland and the appointment of inspectors have likewise proved very beneficial in that country. But restricting my remarks to England and Wales, I would observe that the establishment by the Act of 1845 of the Lunacy Board as at present constituted, and the rendering it compulsory upon counties to provide asylums for pauper lunatics, are the chief causes of the improvement to which I have referred, so far, at least, as it has been brought about by legislation.
I will not dwell in detail on the lunacy legislation of these years. To have said less would have been to overlook the salient and most important facts of the period. To have said more would have been to travel over the ground so ably occupied by Dr. Blandford in his Presidential Address three years ago. He, by-the-by, complained of the ever-increasing difficulty each President finds in selecting a subject for his discourse, and then immediately proceeded to effectually lessen the chances of his successors. What the last occupant of this Chair will be able to discover new for his address I do not know. I can only think of the funeral oration over this Association at its obsequies—when its "dying eyes are closed," its "decent limbs composed," and its "humble grave adorn'd,"
"By strangers honour'd, by survivors mourn'd."
On the Board of the Commissioners in Lunacy have sat two members of our profession (one still living), to whose services I wish more especially to refer. I allude to Dr. Prichard and Mr. Gaskell.
Apart from his official work, the former will always be remembered in the republic of letters by his learned contributions to anthropology and the literature of mental diseases, in which he is more especially identified with the doctrine of Moral Insanity. Chronicler of the period in which he enunciated or rather developed it, I cannot avoid a brief reference to a theme which has caused so much heated discussion. As an impartial historian I am bound to admit that his views are still by no means unanimously adopted, and that I am only expressing my own sentiments when I avow that what Latham says of Prichard's "Researches into the Physical History of Mankind"—"Let those who doubt its value, try to do without it"—applies to the teaching contained in the remarkable treatise entitled "Different Forms of Insanity in relation to Jurisprudence," published in 1842. We may well be dissatisfied with some of the illustrations of the doctrine it supports. We may express in different terms the generalization he has made as to the relation of intellect and emotion; but I am greatly mistaken if we shall not from time to time be confronted by facts which instantly raise the question which presented itself with so much force to his acute mind, and which does not appear to me to be successfully met by those who controvert the conclusions at which Prichard arrived. The necessity of admitting in some form or other the mental facts in dispute, is well illustrated by the recent work by Krafft-Ebing on mental disorders. For what does this practised mental expert do? He, although the supporter of mental solidarity and the integrity of the Ego—adverse, therefore, to the psychology in which the theory has been enshrined—feels that he must admit into his classification some term which describes certain emotional or volitional disorders, and can discover none better than "moral insanity"—a practical, though reluctant, admission of the value of Prichard's views after their discussion for forty years. I might also refer as an indication of opinion to a most excellent article in the last number of the Journal by Dr. Savage, who, while recognizing the abstract metaphysical difficulty of conceiving moral as distinct from intellectual insanity, fully admits as a clinical fact the form of mental disease for which Prichard contended, and had he been living he would doubtless have claimed this article as a striking proof of the vitality of his opinions.
One is certainly disposed to exclaim, if observation on the one hand compels us to admit certain mental facts, and the metaphysician on the other declares them to be unmetaphysical, so much the worse for metaphysics!
Mr. Gaskell, in addition to his good work as a reformer at the Lancaster Asylum, where may yet be seen preserved quite a museum of articles of restraint formerly in use in that institution, and his efficient labours as a Commissioner, was also, it may not be generally known, the real cause of the practical steps taken in this country to educate the idiot. It was in 1847 that he wrote some articles in Chamber's Journal, giving an account of Seguin's Idiot School at the Bicêtre, which he had visited and been greatly interested in. These articles had the effect of inducing Dr. Andrew Reed to interest himself in the establishment of a school for idiots in England. The Highgate and Colchester Asylums for idiots were instituted—the origin, as it proved, of the great establishment at Earlswood. All, therefore, that has been done for this pitiable class has been effected during the last forty years. The indefatigable Seguin has passed away during the last twelve months. He pursued to the last, with unabated zeal, a study possessing attractions for only a limited number, and advocated the claims of idiots and imbeciles with unceasing energy in the Old World and the New. Fortunately his mantle has descended upon a worthy successor in the person of his son, Dr. E. Seguin, of New York.
It has necessarily happened that the direction of public attention to the larger and better provision for the insane in all civilized lands has led to much consideration, and inevitably some difference of opinion as regards the form and arrangement of asylums. But all will admit that their construction has undergone a vast improvement in forty years. The tendency at the present moment is to attach less importance to bricks and mortar, and the security of the patient within a walled enclosure, than to grant the largest possible amount of freedom, in asylums, compatible with safety. The more this is carried out, the easier, it is to be hoped, will it be to induce the friends of patients to allow them to go in the earliest stage of the disorder to an asylum, as readily as they would to a hydropathic establishment or an ordinary hospital, to which end medical men may do much by ignoring the stupid stigma still attaching to having been in an asylum. The treatment of the insane ought to be such that we should be able to regard the asylums of the land as one vast Temple of Health, in which the priests of Esculapius, rivalling the Egyptians and Greeks of old, are constantly ministering, and are sacrificing their time and talents on the altar of Psyche.[299]
Most heartily do I agree with Dr. Kirkbride when he says that "Asylums can never be dispensed with—no matter how persistently ignorance, prejudice, or sophistry may declare to the contrary—without retrograding to a greater or less extent to the conditions of a past period with all the inhumanity and barbarity connected with it. To understand what would be the situation of a people without hospitals for their insane, it is only necessary to learn what their condition was when there were none."[300]
In advocating the prompt and facile recourse to an asylum, I include, of course, the cottage treatment of the insane so long ago resorted to by Dr. Bucknill, and extended in so admirable a manner by my immediate predecessor in this chair, whose practical observations last year on the villas and cottages at Cheadle rendered his address one of the most valuable that has been delivered. Moreover, I would not say a word in disparagement of the placing of suitable cases in the houses of medical men, or in lodgings, under frequent medical visitation.[301] I also recognize the value of intermediate or border-land institutions, so long as they are conducted with the sanction of the Commissioners and open to their inspection.
The modern advocacy of the open-door system has been recently brought under the notice of the Association by Dr. Needham, with the view of obtaining a general expression of opinion on a practice, to the wisdom of which he is disposed to demur.
But a less regard for mere bricks and mortar, the removal of high boundary walls and contracted airing-courts, or the introduction of the open-door system, do not lessen the importance of properly constructed asylums. The works of Jacobi in Germany, Kirkbride in America, Parchappe in France, and Conolly in England, must retain their value as classical productions on this subject; while the contributions recently made by Dr. Clouston present not only the general principles of asylum construction, but the minute details of building, in the light of the knowledge and experience of the present day.
I was fortunate in being able to render M. Parchappe some service when he visited England to examine the construction of our asylums. Those who formed his acquaintance on the occasion of this visit may remember his mixed feelings on visiting them, how he demurred on the one hand to what he regarded as too costly and ornamental, while, on the other hand, he liked the English arrangement of the buildings better than the Esquirol-Desportes system. I need not point out that those who have had the planning of the county asylums in England have objected, as well as Parchappe, to the distribution of isolated pavilions upon parallel lines. Parchappe, while far from believing it to be indispensable to make asylums monuments fitted to excite admiration for the richness of their architecture, and indisposed to emulate our asylums, which, he says, only belong to princely mansions, turns nevertheless from the square courts and the isolated pavilions of Esquirol to apostrophize the former in these glowing terms:—
"How much more suited to reanimate torpid intelligence and feeling, or to distract and console melancholy among the unfortunate insane, these edifices majestic in their general effect and comfortable in their details, these grandiose parks, with luxuriant plantations and verdant flowery lawns, whose harmonious association impresses upon English asylums an exceptional character of calm and powerful beauty!"
Whether a stranger, having read this florid description of our asylums, would not, on visiting them, be a little disappointed, I will not stop to inquire. Probably during this or the following week, some of Parchappe's compatriots may answer the question for themselves.
The fundamental question of the separation of the curable and incurable classes has in different countries been earnestly discussed during the last forty years. Kirkbride has entered his "special and earnest protest" against this separation; his own countryman, Dr. Stearns, on the other hand, has lately advocated it. In Germany, where, following the lead of Langermann and Reil, complete separation of the curable in one building was first realized under Jacobi at Siegburg, there has been a complete reversion to the system of combining the two classes in one institution. Parchappe, who opposed the separation of these classes, as illusory if justice is done to the incurable in the construction of the building provided for them, and mischievous if this is denied them, was constrained to admit, however, in view of the enormous number of lunatics in the Department of the Seine, that it was the least of two evils to separate the epileptic and the idiotic from the curable.
In England the separation principle has been recognized in Hardy's Act (30 Vict., c. 6) for the establishment in the metropolis of asylums for the sick, insane, and other classes of the poor, 1867; and, again, in the erection of such an asylum as Banstead for Middlesex—and I am informed by Dr. Claye Shaw, who, from holding the office of superintendent there, and formerly superintending the Metropolitan District Asylum of Leavesden, is well calculated to judge, that the experiment has proved successful, that the patients do not suffer, and that the office of superintendent is not rendered unendurable. Regarded from an economic point of view, it has been found practicable to provide buildings at a cost of between £80 and £90 per bed, which, though not æsthetic, are carefully planned for the care and oversight of the inmates. This includes not only the land, but furnishing the asylum.
Five years ago this Association unanimously adopted a resolution, expressing satisfaction that the Charity Organization Society had taken up the subject of the better provision, in the provinces, for idiots, imbeciles, and harmless lunatics, and the following year carried a resolution, also unanimous, that the arrangement made for these classes in the metropolitan district is applicable in its main principles to the rest of England. But it does not follow that the separation of these classes from the county asylums should be so complete, either as respects locality or the governing board, as in the metropolitan district; and, further, the Association expressed a strong opinion that the boarding-out system, although impracticable in the urban districts, should be attempted wherever possible in the country; the greatest care being taken to select suitable cases, unless we wish to witness the evils which Dr. Fraser has so graphically depicted in his report for 1877 of the Fife and Kinross Asylum. If pauper asylums can, without injury to families, be relieved by harmless cases being sent home to the extent Dr. Duckworth Williams has succeeded in doing in Sussex, and if, as he proposes, they were periodically visited, their names being retained on the asylum books, the enlargement of some asylums might be rendered unnecessary.
But what, gentlemen, would be the best-contrived separation of cases, what would the best-constructed asylum avail, unless the presiding authority were equal to his responsible duties? Now, it is one of the happy circumstances connected with the great movement which has taken place in this and other countries, that men have arisen in large numbers who have proved themselves equal to the task. We witness the creation of an almost new character—the asylum superintendent.
One Sunday afternoon, some years ago, Dr. Ray fell asleep in his chair while reading old Fuller's portraits of the Good Merchant, the Good Judge, the Good Soldier, etc., in his work entitled "The Holy and Profane State," and, so sleeping, dreamed he read a manuscript, the first chapter of which was headed, "The Good Superintendent." Awakening from his nap by the tongs falling on the hearth, the doctor determined to reproduce from memory as much of his dream as possible for the benefit of his brethren. One of these recovered fragments runs thus:—"The Good Superintendent hath considered well his qualifications for the office he hath assumed, and been governed not more by a regard for his fortunes than by a hearty desire to benefit his fellow-men.... To fix his hold on the confidence and goodwill of his patients he spareth no effort, though it may consume his time and tax his patience, or encroach seemingly on the dignity of his office. A formal walk through the wards, and the ordering of a few drugs, compriseth but a small part of his means for restoring the troubled mind. To prepare for this work, and to make other means effectual, he carefully studieth the mental movements of his patients. He never grudges the moments spent in quiet, familiar intercourse with them, for thereby he gaineth many glimpses of their inner life that may help him in their treatment.... He maketh himself the centre of their system around which they all revolve, being held in their places by the attraction of respect and confidence."[302]
And much more so admirable that it is difficult to stay one's hand. You will, I think, agree with me that what Dr. Ray dreamed is better than what many write when they are wide awake, and those familiar with Dr. Ray's career, and his character, will be of the opinion of another Transatlantic worthy (Dr. John Gray, of Utica) that in this act of unconscious cerebration the dreamer unwittingly described himself—
"'The Good Superintendent!' Who is he?
The master asked again and again;
But answered himself, unconsciously,
And wrote his own life without a stain."
In what a strange land of shadows the superintendent lives! But for his familiarity with it, its strangeness would oftener strike him. It becomes a matter of course that those with whom he mixes in daily life are of imperial or royal blood—nay, more, possess divine attributes—and that some who are maintained for half a guinea a week possess millions and quadrillions of gold. He lives, in truth, in a world inhabited by the creatures of the imagination of those by whom he is constantly surrounded—a domain in which his views of life and things in general are in a miserable minority—a phantom world of ideal forms and unearthly voices and mysterious sounds, incessantly disputing his authority, and commanding his patients in terms claiming supernatural force to do those things which he orders them to leave undone, and to leave undone those things which he orders them to do; commanding them to be silent, to starve themselves, to kill, to mutilate or hang themselves; in short, there is in this remarkable country, peopled by so many thousand inhabitants, an imperium in imperio which renders the contest continuous between the rival authorities struggling for supremacy, sometimes, it must be confessed, ending in the triumph of the ideal forms, and the phantom voices, and the visionary sights, which may be smiled at in our studies, and curiously analyzed in our scientific alembics, but cannot be ignored in practice without the occurrence of dire catastrophes, and the unpleasant realization of the truth that idealism, phantasy, and vision may be transformed into dangerous forms of force. It may be said, indeed, that the appropriate motto of the medical superintendent is—"Insanitas insanitatum, omnia insanitas."
With such an entourage it is not surprising if the first residence in an asylum as its responsible head—especially an asylum in the olden days—should disconcert even a physician. A German psychologist once declared, after passing his first night in an institution as superintendent, that he could not remain there; he felt overwhelmed with his position. Yet this physician remained not only over the next night, but for thirty-five years, to live honoured and venerated as Maximilian Jacobi, and departing to leave behind him "footprints on the sands of time," from seeing which, others, in a similar hour of discouragement, may again take heart.
I cannot pass from this subject without enforcing, as a practical comment, the necessity of asylum physicians having a very liberal supply of holidays, so as to insure a complete change of thought from not only the objective but the subjective world in which they live, and this before the time comes when they are unable to throw off their work from their minds, as happened to a hard-working friend of mine, who, even during his holiday among the Alps, must needs dream one night that he was making a post-mortem upon himself, and on another night rose from his bed in a state of somnambulism to perform certain aberrant and disorderly acts, not unlike what his patients would have performed in the day.
I have heard it suggested that superintendents should have six weeks' extra holiday every third year, five of them to be spent in visiting asylums. Whether this is the best way of acquiring an interchange of experience or not, I will not decide, but no doubt the feeling, how desirable it is men should compare notes with their fellow-workers, prompted the founders of our Association (which was expected to be more peripatetic than has proved to be the case) to determine that its members should at its annual meetings carefully examine some institution for the insane.
It is not too much to say that only second in importance to a good superintendent is a good attendant, and of him also Dr. Ray dreamed in his Sunday afternoon vision, and his description is equally excellent.
I am sure that it will be admitted that the last forty years have seen a vast improvement in the character of attendants, and among them are to be found many conscientious, trustworthy men and women, forbearing to their charge and loyal to their superintendent. It is not the less true that for asylums for the middle and higher classes the addition of companionship of a more educated character is desirable, and it is satisfactory to observe that there is an increasing recognition of its importance, as evidenced by the Reports of our asylums.[303]
One word now in regard to the advance in our classification of mental disorders, though I hardly dare to even touch thus lightly upon so delicate a subject, for I have observed that it is one of those questions in our department of medicine—dry and unexciting as it may at first sight seem to be—which possess a peculiar polemical charm.
Few circumstances are more noteworthy than the attacks which have been made upon the citadel of the Pinel-Esquirol classification, the symptomatological expression of the disease—attacks not new forty years ago, but renewed with great force and spirit by Luther Bell in America, and subsequently by Schroeder van der Kolk in Holland, Morel in France, and Skae in Britain. When Dr. Bell asserted that this system of symptoms "would not bear the test of accuracy as regards the cause of the disease or the pathological condition of the sufferer;" that the forms in use "were merely the changing external symptoms, often having scarcely a diurnal continuance before passing from one to another," and constituting a division useless as regards moral or medical treatment—he expressed in a nutshell all the objections since urged against the orthodox classification by the other alienists I have mentioned. These, however, substituted a mixed ætiological or pathogenetic classification, which Bell did not, and this classification is, in its essential characters, on its trial to-day. The wave of thought which bore these attempts to the surface, was a wholesome indication of the desire to look beneath the mere symptom right down to the physical state which occasioned it, and upon which the somatic school of German alienists had long before laid so much stress. The movement has been useful, if for no other reason than that it has concentrated attention afresh and more definitely upon the conditions which may stand in causal relation with the mental disorder, nor has it been without its influence in affecting the terms generally employed in the nomenclature of insanity. At the same time it is very striking to observe how the great types of mental disorder adopted and in part introduced by the great French alienists have essentially held their ground, and if their citadel has had in some points to parley with a foeman worthy of their steel, and even treat with him as an honourable rival, they remain still in possession, and their classification of symptoms seems likely to remain there for long to come. As such, these types are partly founded upon clinical and, to some extent, pathological observation, and may well be allowed with a few additional forms to stand side by side with a somato-ætiological nomenclature, as it grows up slowly and cautiously, reared on scientific observation and research; and had Skae been living he would have rejoiced to hear Mr. Hutchinson assert the other day that in all diseases, "our future classification must be one of causes and not external symptoms, if we would desire to construct anything like a natural system, and trace the real relation of diseases to their origin."
In a sketch, however brief, of the progress of Psychological Medicine since the foundation of this Association in 1841, it would be a serious omission not to notice the important contributions of the late Professor Laycock shortly before as well as after that year. In 1840 he first promulgated the opinion that "the brain, although the organ of consciousness, is subject to the laws of reflex action, and in this respect does not differ from other ganglia of the nervous system."[304] And in a paper read before the British Association, September, 1844, he observed, "Insanity and dreaming present the best field for investigating the laws of that extension of action from one portion of the brain to the other, by which ideas follow each other in sequence, giving as an illustration the case of a patient at the York Retreat, whose will being suspended, he expressed ideas as they spontaneously arose in associated sequence, the combination being singularly varied, but traceable to a common root or centre of impulse." "Researches of this kind," Laycock continues, "whether instituted on the insane, the somnambulist, the dreamer, or the delirious, must be considered like researches in analytical chemistry. The re-agent is the impression made on the brain; the molecular changes following the applications of the re-agent are made known to us as ideas."[305]
Time will not allow me to cite other passages in these remarkable papers, or later ones; but these are sufficient to show the germ at that early period of the doctrine of cerebral reflex action, and the unconscious cerebration of Carpenter, the seeds having been already sown by Unzer and Prochaska, and arising out of it, that of automatic states occasioned or permitted by the abeyance of a higher restraining power—the Will, according to Laycock, in the case he employs as an illustration of his doctrine. His teaching in regard to mental and nervous disorders due to vaso-motor disturbance also deserves recognition.
Dr. Henry Monro, again, in a treatise published in 1851, put forward a theory of the pathology of insanity, the essence of which was that the cerebral masses having lost their static equilibrium exhibit in their functions two different degrees of deficient nervous action (coincidently), viz. irritable excess of action and partial paralysis. He maintained that these two states do not fall alike upon all the seats of mental operations, but that there is "a partial suspension of action" of "higher faculties, such as reason and will," while there is an irritable excess of action of the seats of the more elementary faculties, such as conception, etc., and hence delusions and the excessive rapidity of successive ideas. Dr. Monro compares this condition to a case of paralysis, combined with convulsions; and discusses the question whether the temporary and partial paralysis occurring as he supposes in insanity, "results directly and entirely from excessive depression of the nervous centres of those higher faculties, or partly in an indirect manner from nervous energy being abstracted to other parts which are in more violent exercise at the time."[306]
This, it will be seen, is a still clearer statement of the doctrine that insanity is caused by the depression or paralysis of the higher nervous centres and excessive action of others.
As is well known, Dr. Hughlings Jackson, whose views regarding active states of nerve structures as liberations of energy or discharges, are familiar to us all, has adopted and extended Laycock's doctrine, which he designates as "one of inestimable value," and has urged the importance of Monro's doctrine of negative and positive states in cases of insanity, using the term "insanity" in an exceedingly wide sense. He has pointed out that Anstie and Thompson Dickson have also stated the doctrine that so-called "exaltation of faculties" in many morbid states is owing to "insubordination from loss of control," and that the same was said in effect by Symonds, of Bristol. Adopting the hypothesis of evolution as enunciated by Herbert Spencer, Dr. Hughlings Jackson thinks that cases of insanity, and indeed all other nervous diseases, may be considered as examples of Dissolution, this being, I need not say, the term Spencer uses for the process which is the reverse of Evolution. Insanity, then, according to this view, is dissolution beginning at the highest cerebral centres, which centres, according to Jackson, represent or re-represent the whole organism. There are distinguishable, he believes, cases of uniform dissolution, the process affecting the highest centres nearly uniformly, and cases of partial dissolution in which only some parts of these centres are affected. The dissolution, again, whether uniform or partial, varies in "depth;" the deeper it is, the more general are the manifestations remaining possible. The degree of "depth" of dissolution is, however, but one factor in this comparative study of insanity. Another is the rapidity with which it is effected. To this, Dr. Jackson attaches extreme importance, believing that degrees of it account for degrees of activity of those nervous arrangements next lower than those hors de combat in the dissolution. Another factor is the kind of person to whom dissolution "comes." And the last factor is the influence of circumstances on the patient undergoing mental dissolution. All factors should, of course, be considered in each case, or, as Dr. Jackson characteristically puts it, "insanity is a function of four variables." I refer to these opinions to show the direction in which some modern speculation on the nature of insanity tends, that thus tracing the course of thought in recent years we may see how, step by step, certain views have been reached, some of them generally adopted, others regarded as still requiring proof before they can be accepted.
The negative and positive view of the nature of insanity receives support, I think, from the phenomena of Hypnotism which, about forty years ago, attracted, under the name of Mesmerism, so much attention in England in consequence of the proceedings of Dr. Elliotson in the hospital and college where we meet to-day. This was in 1838, and Braid's attention was arrested by what he witnessed in 1841. It is no reason because we have re-christened mesmerism that we should ignore the merit of those who, as to matters of fact, were in the right, however mistaken their interpretation may have been.
Elliotson recorded some striking examples of induced hallucinations and delusions, and in an article in the Journal in 1866, I endeavoured to show how suggestive similar instances which I then reported are in relation to certain forms of insanity, and also in relation to sudden recovery from mental disease; the conclusion being forced upon us that there may be cases in which no change takes place in the brain which the ablest microscopist is likely to detect, but a dynamic change—one more or less temporary in the relative functional power of different cerebral centres, involving loss or excess of inhibition.
Nor can I, in connection with the reference to cerebral localization, allow to pass unrecorded the researches of Fritsch, Hitzig, and Ferrier, on account of the intimate, although only partial relation in which they stand to mental pathology—a relation promising to become more intelligible and therefore more important as the true meaning of the psycho-motor centres becomes better understood; for that we are only on the threshold of this inquiry must be evident, when men like Goltz, Munk, and other investigators call in question the conclusions which have been arrived at.
But be the final verdict what it may, when I look back to the time when "Solly on the Brain" was our standard work, and then turn to Ferrier's treatise on its functions, to the remarkable works of Luys, and to Dr. Bastian's valuable contribution to the International Series, I cannot but feel how unquestionable has been the advance made in the physiology of the brain, strangely bent as Nature is on keeping her secrets whenever the wonderful nexus which binds together, yet confounds not, mind and brain, is the subject of investigation.
The past forty years have witnessed a great change in the recognition of mental disease as an integral part of disorders of the nervous system, and medical psychology is less and less regarded as a fragment detached from the general domain of medicine. Contributions from all lands have conspired to produce this effect, the somatic school of psychologists in Germany having exerted, probably, the most influence. And we are proud to number in France among our roll of associates a physician who, not only by his pathological researches into diseases of the brain and cord, but by his clinical study of affections closely allied to mental derangement, has by the brilliant light he has thrown upon the whole range of diseases of the nervous system, advanced the recognition of which I have just spoken. I need not say that I refer to our distinguished honorary member, Professor Charcot.
No one will deny that the relations of mind and brain, physiologically and pathologically considered, have in our own country been ably handled by Dr. Maudsley. Those who most widely differ from some of his conclusions will acknowledge this ability, and that his works are expressed in language which, with this author, is certainly not employed to conceal his thoughts. To trace the influence of these writings, and those of Herbert Spencer, Bain, and others of the same school, on the current belief of psychologists would, however, carry me far beyond the legitimate limits of an address, but I may be allowed to observe that here, as elsewhere, we must not confound clearly ascertained facts in biology and mental evolution with the theories which are elaborated from them. The former will remain; the latter may prove perishable hay and stubble, and when we overlook or ignore this distinction, it must be admitted that we expose ourselves to the just rebuke of the celebrated Professor of Berlin when he protests against "the attempts that are made to proclaim the problems of research as actual facts, the opinion of scientists as established science, and thereby to put in a false light before the eyes of the less informed masses, not merely the methods of science, but also its whole position in regard to the intellectual life of men and nations." He is surely right when he insists that if we explain attraction and repulsion as exhibitions of mind, we simply throw Psyche out of the window and Psyche ceases to be Psyche;[307] and when, allowing that it is easy to say that a cell consists of minute particles, and these we call plastidules, that plastidules are composed of carbon and hydrogen, oxygen, nitrogen, and are endued with a special soul, which soul is the product of some of the forces which the chemical atom possesses, he affirms that this is one of those positions which is still unapproachable, adding, "I feel like a sailor who puts forth into an abyss, the extent of which he cannot see;" and, again, "I must enter my decided protest against the attempt to make a premature extension of our doctrine in this manner—never ceasing to repeat a hundred-fold a hundred times, 'Do not take this for established truth.'"[308]
We all believe in cerebral development according to what we call natural laws or causes, and in the parallel phenomena of mind; as also in the arrested and morbid action of brain-power by infractions of laws or by causes no less natural. In this sense we are all evolutionists. The differences of opinion arise when the ultimate relations of matter and mind are discussed, and when a designing force at the back of these laws is debated. But these questions in their relation to mental evolution, as to evolution in general, do not enter the domain of practical science, and are not affected by the degree of remoteness, according to our human reckoning, of this force or "Ultimate Power."
It will not be denied that at least the foundations of the pathology of insanity have been more securely laid in cerebral physiology during the last forty years, in spite of the fact that the relation of the minute structure of the brain to its functions, and the nature of the force in operation, still elude our grasp. The so-called disorders of the mind having been brought within the range of the pathologist, what can he tell us now of the post-mortem lesions of the insane? Can he give a satisfactory reply to the question asked by Pinel in his day, "Is it possible to establish any relation between the physical appearances manifested after death, and the lesions of intellectual function observed during life?"[309]
It is a little more than forty years since Lélut published his work entitled "The Value of Cerebral Alterations in Acute Delirium and Insanity," and Parchappe his "Recherches," to be followed by other works containing valuable contributions to the pathological anatomy of mental disease. To attempt to enumerate the contributions to this department abroad and at home would be simply impossible on the present occasion. I cannot, however, omit to notice how early Dr. Bucknill was in the field, as his laborious examination of a number of brains of the insane to determine the amount of cerebral atrophy and the specific gravity, bear witness, as also his demonstration of the changes which take place, not only in the brain and its membranes, but in the cord, in general paralysis; these observations, along with those of Dr. Boyd, having been fully confirmed by subsequent observers.
I recall here, with interest, a visit I paid eight and twenty years ago to Schroeder van der Kolk at Utrecht, whom I found full of enthusiasm (although racked at the time with neuralgia) in the midst of his microscopical sections. And this enthusiasm I cannot but suspect insensibly coloured what he saw in the brains and cords of the insane, or he would hardly have said, as he did say, that he had never failed during a quarter of a century to find a satisfactory explanation after death of the morbid mental phenomena observed during life.
It must not, however, be forgotten that Parchappe, just forty years ago, was able to speak as strongly in regard to the brains of general paralytics; and that of others he said that it would be nearer the truth to assert that you can, than that you cannot, distinguish between a sane and an insane brain.
Since that period microscopes of higher power have been sedulously employed by European and American histologists, and in our country the example set by Lockhart Clarke has been followed by many able and successful investigators. I had intended to enumerate in some detail the gains of pathological anatomy in cerebro-mental diseases, and to endeavour to apportion to those who have cultivated this field of research their respective merits; but I find it better to consider what is the practical result of these researches. I may, however, so far depart from this course as to mention the memoirs of Dr. J. B. Tuke in the Edinburgh Medical Journal of 1868 and 1869, and elsewhere, on account of their importance in the history of the morbid histology of insanity.
Returning to the practical question of the knowledge now possessed by the cerebral pathologist, I will put into the witness box Professor Westphal and Dr. Herbert Major, as having enjoyed and utilized large opportunities for making microscopic and macroscopic examinations of the insane, and not being hasty—some think the former too slow—to admit the presence of distinctive lesions.
Now, Professor Westphal informs me that he is unable to trace, in the majority of post-mortems of the insane who have not suffered from general paralysis, any morbid appearance of the brain or its membranes, either with the naked eye or the microscope. He maintains that it would be impossible to designate amongst a hundred miscellaneous brains those which have belonged to insane persons, if the cases of general paralysis had been eliminated.
Dr. Major speaks guardedly; but inclines to think that, even putting aside general paralytics, the sane may be generally distinguished from the insane brain. His experience at Wakefield shows that in only seventeen per cent. of the autopsies (excluding general paralysis) the brain showed no decided morbid change. "It must be always remembered," Dr. Major writes, "that the difficulty is not to distinguish between the insane brain on the one hand and a perfectly healthy and vigorous sane brain on the other—the difference between these two extremes is, in my own experience, most striking and startling. The difficulty is to distinguish between the insane brain and that of an individual sane, but in whom the brain is (as in time it may be) anæmic, wasted, or even with tracts of softening. Still," he adds, "I think, generally speaking, the sane organ may be distinguished from the insane, the decision turning largely on the degree of the degenerative or other morbid change."
Again, taking only cases of general paralysis, Professor Westphal holds that in by far the greater number of brains of insane persons dying in an advanced stage, morbid appearances similar to those which he has described in Griesinger's "Archiv. I.," etc., can be traced; the morbid appearances of the cord occurring more constantly than those of the brain.
Dr. Major found that of the post-mortems of paralytics, all displayed appreciable morbid lesions, although in five per cent. of cases they were not typical of general paralysis.
Then coming definitely to the question whether these pathologists have, to any considerable extent, been able to connect the morbid appearances found in cases of insanity with the symptoms, including motor troubles, Dr. Major says that at present he cannot; and Professor Westphal says that he regards "the connection of morbid symptoms with the changes found after death as exceedingly uncertain and doubtful."
I should observe that Dr. Major grounds his statements upon his own recent experience and observation at Wakefield, and that he is not disputing the greater preference shown by certain lesions in general paralysis for particular localities; but only that he does not yet see his way to connect them with the abnormal symptoms present during life. The researches carried on by Dr. Mickle, contributed to our Journal (January, 1876), and those of Dr. Crichton Browne, published with illustrations in the "West Riding Reports," must be regarded along with M. Voisin's large work and Hitzig's article in Ziemssen's "Cyclopædia," as placing before us whatever evidence can be adduced on the relations between the pathology of general paralysis and cerebral physiology. Hitzig, who from his investigations into the cerebral motor centres, and his position in an asylum for the insane, ought to be qualified to judge, surmises that those localities of the brain by the electrical irritation of which in animals he produced epileptiform attacks bearing the closest resemblance to the attacks of paralytics, are affected in general paralysis. He thinks, moreover, that as destruction of these cortical spots causes disturbance of motion, resembling the symptoms pathognomonic of grey degeneration of the posterior columns observed in general paralysis, there is an added reason for assuming this connection.
Dr. Mickle in his recent excellent work on general paralysis has exercised much cautious discrimination in admitting the relation between the symptoms and the alleged psycho-motor centres, and while his researches in a rich field of observation at the Grove Hall Asylum lead him to find some cerebral lesion in every case, especially in the fronto-parietal region, he cautions against the "too ready indictment of motor centres in the cerebral cortex as answerable for the most frequent and characteristic motor impairment, that of the lips, tongue, face, and articulatory organs generally;" fully believing, however, that in the production of these symptoms the cortical lesion is at the very least an important factor. "Whether the principal mental symptoms can be entirely referred," he says, "to the organic changes in certain frontal (and parietal) convolutions—the motor to those of the so-called cortical motor zone—the sensory to those of certain portions of the temporo-sphenoidal and parietal—must remain a matter of question," while in regard to the convulsive attacks, Dr. Mickle has in some cases been "unable to trace a harmony between these and the results of physiological experiment; in other cases they have seemed to harmonize fairly."[310] Dr. Mickle informs me that in the insane other than general paralytics, he has in the majority found some lesion in the brain and membranes.[311]
These results of research in cerebro-mental pathological anatomy and physiology may not seem, when placed side by side with the sanguine opinions of Schroeder van der Kolk and Parchappe, to present so triumphant a proof of progress and solid gain as might be desired or expected, and much, we must admit, has to be done before Pinel's question can be answered with the fulness we should wish. Nevertheless the advance is very considerable, and the best proof of the accumulating knowledge of the morbid histology of the brain and cord in the insane will, I think, be given this week by the collection of microscopical preparations of Gudden, Holler, etc., brought together by the untiring energy of Dr. Savage, including his own at Bethlem Hospital. I have but to point out how impossible such an exhibition would have been forty years ago to give significance to the contrast between 1841 and 1881; thanks to those who, although they may still often see as "through a glass darkly," have so wonderfully advanced the application of microscopic examination to the tissue of the brain, and prepared such beautiful sections of diseased brain and cord.
Another proof of progress might have been given, had time allowed of a reference to what has been done in the study of the brains of idiots, both morphologically and histologically, by Mierzejewski, Luys, and others, these results being sufficient to prove, had we no other evidence, the fundamental truth of cerebro-mental pathology—the dependence of healthy mind on healthy brain.
We are surely justified in expecting that by a prolonged examination of every part of the brain structure, and the notation of the mental symptoms, we shall arrive in future at more definite results; that the locality of special disorders will be discovered, and that the correlation of morbid mental and diseased cerebral states will become more and more complete, that the scientific classification of mental maladies may be one day based upon pathological as well as clinical knowledge, and psychology be founded, in part at least, upon our acquaintance with the functions of the brain. Let us hope, also, even though it be a hope in the sense rather of desire than of expectation, that by these discoveries the successful treatment of mental disorders may be proportionately advanced.
I would now turn to the very important question whether the treatment of the insane has advanced since 1841?
Of course, so far as this includes moral treatment and management, it has advanced in all civilized countries in a manner calculated, all will admit, to cause the liveliest feelings of satisfaction. Putting aside moral treatment, we cannot boast, it must be confessed, of the same unanimity of judgment. If, however, it must be admitted that as respects details, Tot capita, tot sensus, it will be allowed that, notwithstanding the so many heads, and the as many opinions, the general principles of treatment based upon a just view of the general pathology of insanity, are accepted by all. There were too many who, forty years ago, bled freely for mania, and I remember Conolly, at even a later period, complaining of the number of patients brought to him hopelessly demented in consequence of the heroic treatment to which, when maniacal, they had been subjected by men who, no doubt, still believed with Paracelsus when he said, "What avails in mania except opening a vein? Then the patient will recover. This is the arcanum. Not camphor, not sage and marjoram, not clysters, not this, not that, but phlebotomy." Well, this treatment by the Paracelsuses of 1841 has been supplanted by the more rational therapeutics which we witness in 1881.
Dr. Stokes, the highly respected superintendent of the Mount Hope Retreat, Baltimore, thus writes in his last annual report: "Forty years ago, when this institution was opened, large blood-lettings—in the standing, recumbent, or sitting posture, to the amount of thirty or forty ounces—were recommended in acute mania, followed up by local depletion, by leeches, to the number of twenty or thirty, to the temples. The moral treatment, hygienic measures, exercise, and suitable occupation were almost wholly ignored. Drastic purgatives, ... the shower bath, large and frequent doses of tartarized antimony, and mercury to the extent of producing ptyalism, were the most popular remedial agents in the treatment of insanity. This, in general terms, was the system advocated and practised when, forty years ago, this institution entered upon its godlike mission."
If the success of the treatment of insanity bore any considerable proportion to the number of the remedies which have been brought forward, it would be my easy and agreeable duty to record the triumphs of medicine in the distressing malady which they are employed to combat. But this, unhappily, is not the case. Hypodermic injections of morphia, the administration of the bromides, chloral hydrate, hyoscyamine, physostigma, cannabis indica, amyl nitrite, conium, digitalis, ergot, pilocarpine, the application of electricity, the use of the Turkish bath and the wet pack, and other remedies too numerous to mention, have had their strenuous advocates during late years. Each remedy, however, let us hope, leaves a certain residuum of usefulness behind it, though failing to fulfil all the hopes raised on its first trial.
Dr. Ramskill lately avowed his opinion in my hearing that the advent of the bromide has done infinite mischief. Others, attacking chloral, would maintain that while the bromide has slain its thousands, chloral hydrate has slain its tens of thousands. In spite of this, however, Dr. Ramskill, doubtless, continues to employ the bromide; and who would wish to be deprived of chloral, or any other drug, because of its abuse?
"For nought so vile that on the earth doth live,
But to the earth some special good doth give;
Nor aught so good, but strained from that fair use,
Revolts from true birth, stumbling on abuse."
Employed without discrimination, regarded as a talisman in insomnia and excitement—petted, in short, when it ought to have been restrained—chloral became for a time the spoilt child of psychological medicine, and, like other spoilt children, it has disappointed the fond hopes of its parents.
When it is possible for a physician in asylum practice to write as Dr. Pritchard Davies has written this year in our Journal, "On Chemical Restraint," to the effect that chloral, the bromides, and other sedatives are unnecessary, or even injurious; when, on the other hand, we have Dr. Hills replying that his experience at the Norfolk Asylum leads him to an entirely opposite conclusion; and Dr. Stokes, in America, writing thus in his report, after 7425 patients have been under treatment in his asylum, "without wishing to undervalue the great importance of an efficient system of moral treatment, great results can only be expected from a patient and persevering administration of powerful remedial agencies"—I say when such contrary opinions can be expressed by practical men, one feels how impossible it is to dogmatize upon the good effected by pharmaceutical remedies in insanity, and how far we are yet from witnessing a consensus of opinion in regard to their value.
It must be frankly granted that Psychological Medicine can boast, as yet, of no specifics, nor is it likely, perhaps, that such a boast will ever be made. It may be difficult to suppress the hope, but we cannot entertain the expectation, that some future Sydenham will discover an anti-psychosis which will as safely and speedily cut short an attack of mania or melancholia as bark an attack of ague.
Rather must we rest satisfied with the general advance in treatment in a scientific direction. Most of us know asylums where, within forty years and much less, tartarized antimony was in daily use in large doses as a quietus, and where croton oil was administered in addition to black draughts to a surprising extent, all these remedies being now employed only on the rarest occasions. Take an actual example, one of many, in a particular asylum. A few years ago a patient, who had been much excited and very troublesome, was treated in season and out of season with strong purgatives and sedatives. It so happened that he then fell under a new régime, which consisted in knocking off all these medicines and placing him under one attendant's entire supervision. The result was that he became as quiet and docile, though not cured, as any of the inmates of the asylum, and has remained so to the present time. But we may go further, and say that some cases of insanity are cured now which a few years ago would have remained uncured. Indeed, in relation to the associated bodily state, it may be said that specific treatment has been adopted. Remedies, like iodide of potassium, in large doses, are employed in cases in which, from the increased attention directed in recent years to the somatic ætiology of insanity, a causal relation between the physical and mental condition has been recognized, and the mental symptoms have disappeared in the most marked manner; and so again in gouty melancholia, relief has been obtained by appropriate remedies and diet. These are illustrations of the directly scientific application of medicine to medical psychology, and it is in this direction we must hope for a really satisfactory advance.
On the other hand, there are the successes obtained by the employment of drugs without our being able to say why or how they have exerted a curative agency; and it is obvious that as the number of drugs has so much increased during the period over which my survey extends, the chances of hitting on the right remedy are proportionately increased. How often we see one, two, or three drugs exhibited in mania without any result, while a fourth acts like a charm. Only by studying in detail the special characteristics of each case, can we hope to find a clue which will serve as a guide to the treatment of a subsequent one.
In this country, Dr. Clouston has distinctly advanced our knowledge of the action and uses of narcotic remedies by experiments made to determine the effect on maniacal excitement of single doses of certain remedies, stimulants, and food; of, again, the effect on mania of prolonged courses of certain narcotic medicines, along with clinical observations on the effects of the same medicines in all kinds of insanity, and has determined the equivalent value of opium, bromide of potassium, and cannabis indica in the treatment of insanity.
Dr. Savage has experimented with one drug at a time on a number of patients, and has already given to the profession some valuable results in "Guy's Hospital Reports," and the Journal of Mental Science. "The West Riding Asylum Medical Reports" of Dr. Crichton Browne also contain some important experiments with drugs by himself and others; and in this connection I would notice the excellent clinical notes issued from time to time by Dr. Williams and other officers of the Haywards Heath Asylum, which are well worthy of more permanent record in the archives of the Association. I cannot, indeed, understand any one seriously maintaining that we are practically no better off in our medicinal resources now than we were forty years ago.
Whatever differences of opinion may exist in regard to the advantages gained by the introduction of new drugs, one thing is clear, that the employment and, let me add, the repose of patients, well-ordered arrangements, and the tact of the superintendent will oftentimes do more to reduce the amount of excitement and noise in an asylum than tons of chloral and bromide. For example, any one who has visited Hanwell knows that Dr. Rayner anticipates and prevents post-epileptic mania to a very large extent by the simple expedient of keeping patients in bed after their fits, just as he finds forced alimentation of patients rarely necessary when rest is resorted to. It is striking to see how, even in an over-grown asylum and an old building, the results of good management and treatment can be highly satisfactory, and worthy of an institution of such historic fame.
But, after all, the question faces us, are there or are there not more insane persons cured in 1881 than in 1841?
One's first impulse, of course, is to take the statistics of recovery for a certain number of the more recent, and compare them with those of the earlier years, or to take the recoveries of the past forty and place them side by side with those of the previous forty years. The attempt, however, is fraught with so many fallacies that it is dangerous to make such a comparison. In a report of Bethlem Hospital, issued in 1841, Sir Alexander Morison stated—not as anything exceptional—that seventy per cent. of the patients had been discharged cured; while an examination of the recoveries at this hospital for the last ten years shows a much smaller proportion per cent. But I cannot accept these comparisons as proving anything one way or the other, as various causes, quite apart from the comparative success of treatment at different periods, may explain the difference. Take a single asylum, like Hanwell, and compare the recoveries of a later with an earlier period. I find a population so fluctuating in character, in regard to curability, that the comparison becomes utterly worthless, and although it is true that during the last quinquennium 28.1 per cent. have recovered, as against 26.3 per cent. during the first quinquennium of the past forty years, in spite of there having been more incurables received during the later period, the result is not so satisfactory when we divide into certain periods the whole time during which Hanwell has been open (omitting the first four years). It then appears that during two previous periods the recoveries were higher than 28.1 per cent., viz. from 1840 to 1849 and from 1865 to 1874. Thus:—
| 1835-39 (inclusive) | 25.3 |
| 1840-49 | 28.5 |
| 1850-54 | 25.2 |
| 1855-64 | 27.9 |
| 1865-74 | 30.4 |
| 1875-79 | 26.3 |
Or in quinquennial periods throughout:—
| 1835-39 (inclusive) | 24.8 |
| 1840-44 | 26.3 |
| 1845-49 | 32.1 |
| 1850-54 | 25.2 |
| 1855-59 | 30.7 |
| 1860-64 | 27.0 |
| 1865-69 | 30.4 |
| 1870-74 | 30.5 |
| 1875-79 | 26.3 |
If to escape the fallacies connected with the comparison of different periods of the same asylum, we go to the Lunacy Blue Books, we do not get any reliable figures before 1870, on account of transfers having been previously included in the admissions, so that a fair comparison of recent and former recoveries worked on the admissions is impossible.
I have before me the statistics of the Siegburg Asylum, thanks to Dr. Ripping, from its opening to its close; and I find that the recoveries during the first twenty-five years amounted to forty-two per cent., and during the twenty-five years ending with the year 1877, they were forty-six per cent., thus showing an increase of four per cent. in the more recent period. As this asylum, now closed, has admitted curable cases only, these figures are among the few valuable statistics which I have been able to procure.
I have not succeeded in obtaining satisfactory comparative results by adopting, in the mixed asylums of England and Wales, the plan of working the recoveries, not on the total admissions, but on those only deemed curable; but to explain this fully would involve me in more detail than the occasion warrants.
I would add that in the United States, where reasons have been assigned why the statistics of asylums exhibit apparently fewer recoveries in the later than the earlier period of the last forty years, Dr. Pliny Earle has done good service by the remarkable contribution he has made to the question of the curability of insanity,[312] corroborating, at the same time, the somewhat unfavourable conclusion as to permanent recovery which Dr. Thurnam, in a work which will always be a Pharos to guide those who sail on waters where so many are shipwrecked, arrived at, after a laborious examination of the after history of cases discharged recovered from the York Retreat. It is likewise anything but reassuring to find that, out of the total number of lunatics under care in England and Wales, there are at this moment only 3592 who are deemed curable.[313]
Such, gentlemen, is my Retrospect of the Past. Meagre it has necessarily been, though occupying more of your time than I could have wished, but the number of subjects demanding reference must be my excuse.
We found, at the commencement of the period we have traversed, the accommodation provided for the insane scandalously insufficient, and the condition of many of the existing asylums calling loudly for a radical reform.
We witness to-day, throughout the kingdom, a large number of institutions in admirable working order, reflecting the greatest credit upon their superintendents and committees.
We found a wholly inadequate system of inspection.
We witness now a Board of Commissioners, which, without forfeiting the good will of the superintendents, carefully inspects the asylums throughout the provinces as well as the metropolis—as carefully and thoroughly, at any rate, as the same number of men originally appointed to examine into the condition of some 20,000 patients can fulfil a like duty for above 70,000.
We found a resolute attempt being made to carry out and extend the humane system of treatment inaugurated nearly half a century before in France and England.
To-day we witness its success.
And had I had time to sketch the progress in the provision made for criminal lunatics, we should have found that just forty years ago was the commencement of what Dr. Nicolson has named the "Reactionary Period"—during which this Association petitioned the Government (in 1851) to establish a criminal lunatic asylum—followed in 1860 by the "Period of Centralization" or that of Broadmoor—an institution to-day so efficiently superintended by Dr. Orange.
And in what consists the superiority of the new over the old system of treatment—the nineteenth over the eighteenth century?
The old system was mainly one of brute force—the child alike of ignorance and fear.
The new does not indeed dispense with force, but it is a maxim of the reformed school, from which no one, whose opinion carries weight in psychological medicine, whether in America or in Europe, would dissent, that it should be reduced to the lowest possible point, consistent with safety and the good of the patient, and that humanity should dictate the means of repressing, or rather guarding against, violence, both as regards their amount and character.
The old system subjected patients, who underwent any medical treatment at all, to a miserable routine, often determined by the season of the year and the phases of the moon, rather than the condition of the patient.
The new does not pretend to possess a universal formula, or to have discovered the psychologist's stone, but strives to treat each patient according to individual indications.
The old system desired secrecy; the new is not afraid of publicity.
The old system, in short, believed in harshness and darkness; the creed of the new is, "I believe in sweetness and light."
Such are the results achieved for Psychological Medicine.
If this be the Retrospect of the Past, what is the Prospect of the Future? Will the progress of the last forty or the last ninety years be maintained? I trust it will, but one need not be a pessimist to be sensible that the humane treatment of the insane may have its ebb as well as its flow; that so far from its being true that there is a constant and certain tendency to humanity, there is also a strange tendency to relapse into inhuman ways. Vigilance is and always will be required, for if it be allowed to slumber, we but too well know that there is only one direction in which things will go when left to themselves—and that is downhill.
The functions—the mission—of this Association may be regarded from a threefold point of view: first, in relation to insanity and the insane; secondly, in relation to its members; thirdly, in relation to the public.
I.—Under the first are comprised what in the original rules, drawn up by the founders of this Association forty years ago, were stated to be its objects, namely, "Improvement in the management of asylums and the treatment of the insane;" and further, "The acquirement of a more extensive and more correct knowledge of insanity."
Added to the improved management of asylums is the necessity now for making appropriate provision for idiots and imbeciles, and their education so far as practicable, grappling at the same time with the problem how best to provide for the mass of incurable pauper patients in the provinces, and the extension of middle-class asylums, and of cottages in connection with the central institution.
There are, of course, various ways in which the welfare of the patients in asylums can be promoted, by the attention directed by the Association to special points of importance. To instance only one, the occupation of patients, including systematic teaching which Dr. Lalor has so successfully developed in the Richmond Asylum, Dublin. Though very much has been done, there is, all, I think, will agree, room for more sustained effort in this direction. "There is one monster in the world—the idle man," are the words of one who has lately passed beyond the reach of praise or blame, which ought ever to be in the minds of those who direct our asylums. It may be that if more were done in future in the spirit of this apophthegm of the Sage, if not the Saint, of Chelsea, there would be less chance of patients chewing the cud of bitter reflection and dwelling upon the delusions by which they are haunted and harassed.
In proportion as we feel the inadequacy of our means of cure, we must recognize the necessity of studying the ætiology of insanity, including that damnosa hæreditas, which is the cause of causes in so large a number of the cases coming under our treatment. But what induced the ancestral taint? It behoves us to pay more and more attention to those laws of inheritance in general to which Mr. Hutchinson has recently directed attention in his suggestive lectures at the College of Surgeons.
When M. Baillarger proposed that a similar association to this should be established in France, he gave, among other reasons, the advantage which would accrue from discussing this very question. "Every one," he said, "is assuredly decided upon the influence of heredity in the production of insanity (Mr. Buckle had not then written); but in this primary question, how many secondary ones there are which remain unsolved." Since he thus wrote, his own countrymen, Morel and Lucas, have, by their researches, advanced our knowledge, and rendered the task of their successors in the same field easier.
Intemperance also, as a cause as distinct from a symptom of insanity, requires to be more thoroughly examined into, and I am happy to say Dr. Hayes Newington, than whom no one could be better fitted for the task, has prepared a series of questions arranged in a tabular form, which has been before the Statistical Committee, and will appear in the Journal.
Again, there remains for the future the continued research into the causal connection between certain mental symptoms or disorders and accompanying lesions of the brain and cord. Dr. Spitzka, of New York, in the prize essay which he is about to publish, enters carefully into this inquiry, and I am hopeful that his industry and talent will be rewarded by marked success. These and kindred investigations might, no doubt, be pursued in a more methodical manner than is always the case in English asylums. To this end, the appointment of a pathologist, as at Wakefield in our own country, and at the Utica Asylum in America, ought to become general.
Clinical teaching in our asylums admits of much greater development, though they may not be able to meet the demands made upon them, should examinations be required in medical psychology by the examining bodies. To-day the student has fortunately a very different position from that which fell to his lot forty years ago. He has at his command means of research then unknown, as the ophthalmoscope and sphygmograph, and all the modern improvements in the microscope and in preparing sections; and can he not experiment on knee jerks, and a host of reflex and electric phenomena never dreamt of by his predecessors? He has, moreover, the stimulus begotten of the sense that enough has been discovered to indicate how much precious treasure lies hidden beneath the ground he now treads, like the gold-digger whose ardour is quickened and labour repaid by the discovery of the minutest particle of the metal of which he is in search.
II. The second relation in which this Association stands—to its members—suggests that we must needs be alive to legislation affecting the rights of those who are engaged in this department of medicine. This association is not a trades union, but there are various points bearing on their position which have to be considered, as in connection with a Bill like Mr. Dillwyn's, or the matters discussed two years ago at the annual meeting, when brought forward by Dr. Murray Lindsay. It is true that for him who has taken mental science, in its widest sense, as his mistress; for him who has wooed her for her own sake, knowing full well that for him she may hold no dowry in hand or pocket, there is the supreme pleasure arising from study and observation themselves—that recompense which is better than gold, and more precious than rubies. All this is true; but none the less the superintendents of asylums have a right to expect not only that their services shall be adequately remunerated when in harness, but that they may count with certainty upon a fair provision in the evening of life.
III. With regard, thirdly, to the influence of this Association on public opinion, we should be strangely faithless to our mission, if we were not the expositors of the principles in accordance with which the insane ought to be regarded; if we did not endeavour to enlighten the community in the doctrines of true psychological science, and in that philanthropy which is as far asunder as the poles from the fitful pseudo-philanthropy from which our country is unfortunately not free, the wild, ill-regulated, hysterical clamour with which we are epidemically visited, as injurious to the lunatic as it is to the interests of society at large.
This Association, further, ought to continue to bring before the lawyer what it regards as the just test of criminal responsibility; to entreat the educator not to defeat the object of his noble profession by exactions which transgress the limits by which Nature has bounded human capacity; and to warn parents, as Dr. Brigham did in his day with so much zeal, of the dangers to mental health arising from precocious forcing during the early growth of the brain, and with a tenfold greater necessity than when he wrote, in presence of the illimitable folly of examining boards, some of them medical, the members of which have not even the poor excuse of ignorance; and last, but not least, to counsel the teacher of religion against the peculiar dangers which attend his exalted mission, remembering that—
"Virtue itself turns vice, being misapplied."
Various, then, are the functions of our Association. But what, asks the late Sir James Stephen, the eloquent writer in the Edinburgh is a party, political or religious, without a Review? and he replies, "A bell without a clapper." Such a bell would this Association have been without its Journal, and it must gratefully attribute much of its success to the ability with which in the first instance Dr. Bucknill, and subsequently Drs. Robertson, Maudsley, Sibbald, and Clouston, have helped to make an otherwise clapperless bell articulate.
Through this organ of the Association, for which, speaking for my colleague and myself, I would venture to ask your loyal co-operation, much scientific work can be brought before the profession, many questions can be systematically discussed, and the invaluable experience of the superintendents of asylums on practical points be presented to its readers and permanently preserved.
The objects I have mentioned as calling for further attention, and many more, belong to the future of Psychological Medicine, and as I began my address with proposing to review the period bounded by the years 1841 and 1881, I will close it with expressing the hope that when a successor of mine in this office reviews the then vanished period between 1881 and 1921, he will be able to report an accelerated ratio of progress compared with that of the time I have attempted, so inadequately, to survey.
And may the Medico-Psychological Association, which I trust will always be identified with this progress, be about to enter, after its wanderings, "forty years long," a land flowing with milk and honey, won by conquests over ignorance, superstition, and cruelty—the triumphs of the application of humanity and medical science to the relief of mental weakness and suffering.