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Progress Of Psychological Medicine During The Last Forty Years 1841 And 1881





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, Trelat, Parchappe, Morel, Marce, 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
Medico-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 fuer 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 Bicetre 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 Societe Medico-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 Bicetre, 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 L80 and L90 per bed, which, though not
aesthetic, 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 aetiological 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-aetiological 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 Lelut 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) anaemic, 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 "Cyclopaedia,"
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 te





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