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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