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.