The pathology of mind

Preface

The first edition of the Physiology and Pathology of Mind was published in the year 1867, and the second edition in the year following. A third edition of the first part was published in the year 1876 as a separate treatise on the Physiology of Mind. In the order of time and development this volume on the Pathology of Mind is therefore a third edition of the second part; but in substance it is a new work, having been recast throughout, largely added to, and almost entirely rewritten.

The new material which has been added includes chapters on " Dreaming " and on " Somnambulism and its Allied States," subjects which, although they may not perhaps be thought to appertain strictly to a treatise on mental pathology, will be found, when studied scientifically, to throw light upon its obscure phenomena and to help to bridge the gap between it and mental physiology. A perplexing impression was produced on my mind when I first began to study mental diseases — now upwards of twenty years ago — by the isolation in which they seemed to be. On the one hand, treatises on psychology made no mention of them, and gave not the least help towards an understanding of them ; and, on the other hand, treatises on mental disorders, while giving full information concerning them, treated their subject as if it belonged to a science entirely distinct from that which was concerned with the sound mind. Inasmuch as psychological, physiological, and pathovi PREFACE.

logical studies of mind were actually concerned with the sane subject-matter, it was obvious that methods of study which kept the different lines of inquiry entirely apart must be at fault somewhere, and that it would be a right aim, and one full of promise, to endeavour to bring them into relation with one another, and so to make psychology, physiology, and pathology throw light upon and give help to one another. The first edition, as stated in its preface, was the firstfruits of that endeavour, and the present volume, which embodies the results of deeper studies and more ripened experience, is the completion of it. The inclusion in it of chapters on the abnormal mental phenomena which are exhibited in dreams, hypnotism, ecstasy, catalepsy, and like states, is therefore a just part of the fulfilment of the general design.

The same reason will, I trust, be held sufficient to justify the large amount of new and in some regards disputable matter which is included in the chapters on the " Causation and Prevention of Insanity." It seemed proper to emphasise the fact that insanity is really a social phenomenon, and to insist that it cannot be investigated satisfactorily and apprehended rightly except it be studied from a social point of view. In that way only, I believe, can its real nature and meaning as an aberrant phenomenon be perceived and understood. In recasting the plan of the work I have thought it right therefore, in the chapter on Causation, first to treat generally of the etiology of mental derangement from a social standpoint, so fulfilling the requirements of its organic relations, so to speak, in the social organism ; and, secondly, to treat particularly of its pathological causation, so connecting it with the general pathology of nervous disease, and answering the requirements of scientific pathology.

In describing the symptoms of insanity, I have thought it well again, first, to treat it generally as one disease, setting forth the varieties of symptoms which it presents at different

PREFACE. vii

times and at different stages of its course ; and, secondly, to occupy a separate chapter with the delineation of the different clinical groups of mental disorders which are met with in practice and have to he dealt with by the physician. In this way I hope to have met the obligations of a true scientific exposition and the more practical needs of those who have to form an opinion concerning the cause, the course, the probable termination, and the proper treatment of a particular case of disease. Had the chapter on Symptomatology been left out, the omission must needs have entailed a great deal of vague repetition in the description of the clinical groups, with the certain effect of blurring their outlines and features, and of confusing the reader ; had the special chapter describing these groups been omitted, he would have obtained only a vague and general notion of the symptoms of mental derangement, without that more definite and practical acquaintance with its clinical varieties, wbich, now tbat we are able, I think, to delineate their features, ought to form part of a treatise on mental disorders. Whatever be the value of the clinical pictures in this volume, they have certainly been drawn from life, and had space permitted I might have illustrated each line of description by the records of cases.

The full and analytical Index which has been added will serve not only to make reference easy, but will enable the reader to judge what sort of fare he may expect if he is minded to make trial of it.

THE TREATMENT OF MENTAL DISORDERS . 522

THE PATHOLOGY OF MIND.

PATHOLOGY OF MIND.

Chapter I. Sleep And Dreaming

As we pass nearly the third part of our short lives in sleep it is pleasing to think that the time so spent is not misspent nor lost. Sleep marks that periodical suspension of the functions of animal life, or life of relation, during which the organs that minister to them undergo the restoration of energy which is necessary after a period of activity. Waste of substance, which is the condition and the result of active exercise of function, must be repaired during rest ; instead of its being a surprise, therefore, that we sleep, the wonder would be if Ave did not sleep. In the work and thought of the day is given out by degrees the energy which has been stored up during repose. The need of repair is as true of the organic functions, which never seem to sleep, as it is of the animal functions, which sleep through so large a proportion of our lives. For although an organ like the heart seems not to rest day or night from the first moment of action unto the last moment when it ceases to beat more, yet it plainly rests between each stroke, gaining therebj'' in alternating snatches of repose the energy for the next stroke ; and it is really at rest during a longer period than it is in action — has rested more than it has worked when its life-work is ended. If the heart of an animal which is beating regularly when the chest is opened be made to beat slowly by stimulation of its vagus nerve it will go on beating for a long time ; but if its beats are quickened by m irritation of its sympathetic nerve it soon comes to a standstill from exhaustion ; nutritive repair and the removal of the waste products of activity cannot keep pace with the rapid consumption of energy in the accelerated pulsations ; it is exhausted as the gymnotus is exhausted when it has been provoked to repeated electrical discharges and can give no more shocks until it has recruited its energies. The lowest animal forms, which seem not to sleep at all, probably sleep, like the heart, in similar brief snatches of rest. The organism is a self-feeding and self-repairing machine, but it cannot do its repairs when it is in full work ; it must have for its parts, as for its whole, its recurring periods of adequate rest ; and the time comes at last when, like any other machine, it wears out, is no more capable of repair, and when the exhaustion which ensues is death — the sleep during which there is no repair and from which there is no awaking.

The conditions under which we go to sleep, the causes which promote it, and the ill effects which follow the deprivation thereof, are proofs of its true purpose in the animal ecouomy. When we wish to sleep we shut out all external stimuli, as a bird puts its head under its wing, banish all subjects of active thought or feeling, and place our bodies in as complete a state of muscular repose as possible : so sleep comes on insensibly as a deeper rest, not as an abrupt change, stealing upon us as darkness upon daylight. The general causes which produce it are such as exhaust the energy of the nervous system, either through suffering or doing, and so occasion fatigue of body and mind ; they are muscular and mental exertion, when not too prolonged, the weariness which follows great emotional strain, when not too intense, and severe bodily pain. It is true that we may by a strong voluntary effort, or under the spell of an excitement, prolong the usual period of waking, and resist sleep, although we are very sleepy ; but we cannot do so indefinitely, for torpor and incapacity of mental function, delirium, and death are the consequences of an entire deprivation of sleep.

In this connexion it is interesting to ask why we awake — why, once asleep, we do not go on sleeping for ever ? Probably very much as the power of the exhausted electric eel to give a shock revives when restoration of energy has taken place by

I.] SLEEP AND DKEAMING. 3

nutrition during rest. A stimulus to the body, of external or of internal origin, which would have been unfelt daring the deep sleep of exhaustion, or would have only been enough to occasion a dream, suffices, as the sleep becomes light through restoration of energy, to awaken the individual either directly or by the vividness of the dream which it occasions. We should not sleep for ever, I believe, if every external stimulus were shut out ; for the accumulation of nervous energy would awaken us either spontaneously, or on occasion of the least internal stimulus, which, as the organic functions are not suspended, though they are more languid, during sleep, could not be shut out. If these functions regained their full activity they might directly cause waking. On the time at which we awake habit notably has a great influence within certain limits ; when we allow the nervous system so many hours for repose, we accustom it to that allowance, and it learns to do its repairs within the allotted time.

Of what are the physiological accompaniments of the occurrence of sleep we know nothing more than that the circulation of blood through the brain is lowered ; not as cause probably, but as coincident effect of the state of nerve-element. Blumenbach long ago took notice in a man whose skull had been trepanned that the brain swelled with blood and rose into the opening when he was awake and thinking, and sank down again when he fell asleep ; and the experiments of Mr. Durham, who, having removed circular portions of the skull in different animals, and replaced them by suitable watch-glasses, through which he could observe what happened when the animal was awake and when it was asleep, convinced him that there was considerably less blood in the brain during sleep ; its substance then being paler and sinking down, while it reddened and became turgid directly the animal awoke. The fontanelles of young children sink during sleep ; and forcible compression of the carotid arteries in the neck of the adult will induce it. There is an active flow of blood to the part where the stimulus of functional energy attracts and needs it, and when active function is suspended by the recurring necessities of restoring the expended energy by sleep, the circulation of blood falls to the level of i PATHOLOGY OF MIND. [chap.

the mere organic requirements of the brain : the supply answers in fact to the different states of the brain, being active when its functions are active, moderate when they are in abeyance. A short step further lias been made in conjecture. Knowing that different parts of the brain are supplied with blood by different arteries, the main channels of which go on dividing and subdividing into smaller channels until these become capillary, it has been surmised that an active circulation may sometimes be going on in certain vascular areas of the brain while the circulation in other parts of it is lowered to the level of sleep, not otherwise than as local blushings occur elsewhere in the body from vaso-motor dilatations, and that these active local circulations in the brain are the conditions of that modified and irregular activity which constitutes dreaming : one part of the brain is supposed to be more or less awake when the rest of it is asleep.

Recently the theory has been broached that sleep is caused by the accumulation of the products of the oxidation which takes place during activity ; they are not presumably removed so rapidly as they are produced during active function, but are carried away, like the refuse in some cities, during the repose of the night. It is not known what is the exact nature of these combustion-products, but it is assumed that they act upon the nerve-elements very much as carbonic acid does, causing a sort of narcosis when they accumulate. Any condition then which hinders their removal from the brain, such as prolonged activity thereof, will favour sleep ; any condition which accelerates their removal will tend to prevent it.

Sleep is not a constant, but a fluctuating state. There are degrees of sleep, not only of the cerebro-spinal system as a whole, but of its different parts — so many intermediate steps between it and waking; wherefore we may he rightly said to graduate through a twilight-waking into imperfect sleep, and from light slumber into profound unconsciousness. It is hard to say sometimes whether we have been asleep or not ; for the wandering and incoherent ideas and the suddenly arising hallucinations of a grotesque kind which occur just as we are "oinoto sleep are so like the vagaries of dreams, that we know not at all times whether they were part of our waking or of our sleeping life. The stages in the gradually deepening unconsciousness which is produced by opium illustrate very well the gradations in the process of going to sleep : there is first a drowsy feeling which becomes soon an irresistible inclination to sleep ; the person then falls into a slumber from which he may be roused sufficiently to make a reply to a question put to him in a loud voice, thereupon sinking back immediately into sleep, which deepens rapidly into a comatose unconsciousness from which the severest pinching, slapping, and irritation of all kinds hardly avail to elicit more than the least sign of feeling or the briefest responsive movement ; finally he sinks into so deep a coma that he is insensible to anything that may be done to him ; all the tortures which savage ever devised and inflicted upon his enemy, or Christian upon his fellow-believer of a minutely different shade of faith, would not touch him — he is in the unconsciousness of death before death.

One sense goes to sleep aftgr another, each sinking gradually into a deeper slumber, then the spinal cord, and, last of all, the respiratory centre in the medulla oblongata, when the man dies. In the production of insensibility by the inhalation of chloroform or of ether we observe evidence that the person hears after he can no longer see, and that the senses of taste and smell are lost before those of hearing and touch ; and in natural sleep it is obvious that there are similar gradations of unconsciousness, one sense being sometimes more deeply asleep than another, or the spinal cord being awake when the special sensory centres are fast asleep. A lightlysleeping person will sometimes hear apt questions that are cautiously put to him in a familiar voice, and make a reply without waking ; and there can be no doubt that a man will sleep on horseback when the muscles of the back, among other muscles, must be in action, or even sometimes when walking ; he cannot sleep when standing still, because the body will be sure to fall forwards unless it be supported. In like manner when we awake, it seldom, if ever, happens that all our senses awake at the same instant; a sound is heard before the other senses can receive impressions ; indeed they appear commonly to wake successively. When we consider then that natural sleep is not really a fixed and constant quantity, but a fluctuating bodily state in which there are considerable differences in the degree of insensibility of different parts, some being lightly and others deeply asleep at the same time, it will not appear strange that in some dreams active imagination is exhibited and skilful bodily feats performed ; a proof that some mental and motor centres are awake while others are asleep.

The variations of susceptibility of different parts to impressions during sleep is shown again by the ease with which a sleeper may be awakened by a gentle sound or other stimulus to which he is accustomed to respond, when a louder sound or other stimulus that is really more powerful, but which he is not accustomed to take notice of, has no effect upon him. In sleep as in the waking state the ear hears best what it expects to hear. Just as the expectation of a particular impression upon waking sense increases the susceptibility of that sense and the rapidity with which the message is conveyed from the external organ to the central ganglion, so the adaptation of sleeping sense to a particular impression engenders a habit of expectation, so to speak, in the sense, by which its sensibility to the impression is heightened, and this, though gentle, acts upon it with the same efficacy as an extraordinary stimulus would do. If we think of it, we observe that in our daily life impressions are hourly made upon our senses of which we are not in the least conscious, unless for some reason or other we are moved to take particular notice of them ; we are, as it were, asleep to them habitually ; and it is hard to conceive what potentialities of knowledge some of these unperceived impressions contain, and what opportunities of perception we let go by. "VVe live actually in very limited relations with external nature — relations limited not only by the capacities, but by the habits of our senses — and become extremely automatic in our reactions to the few stimuli which are habitually received ; wherefore our intellectual and practical life runs in the main upon a few fixed lines to which we are bound, as animals are constrained by their particidar instincts, and outside which lie vast unsurveyed regions. We perceive only what we attend to, and we attend only to that to which we have, by frequent repetition, organised an adaptation of sense and of suitable motor associations.

Men little consider how mechanical they are in their thought?, feelings, and doings. So fully possessed are they with the fixed but erroneous notion that consciousness is the essential agent in all the purposive things which they do, that they stand amazed when they witness any evidence of intelligent action during the abeyance of consciousness, as in sleep, and look upon it as something marvellous ; whereas the real marvel would be if the organism were entirely to forget its intelligent habits simply because they were not lit up by consciousness. As a matter of fact it does not forget them : it awakes commonly at its accustomed hour whether the person went to bed at his usual hour or later, and awakes at any moment on the occurrence of the least sound to which it is accustomed to awake, as when the mother hears her baby's cry in the night, taking no notice of a much louder sound which it has learned to disregard ; and it awakens instantly on the cessation of a sound to the continuance of which it has been accustomed in sleep, as is exemplified by the well-known story of the miller who awoke when the noise of his mill, which went on through the night usually, ceased in consequence of the breakdown of the machinery.

It has been a disputed question whether sleep is ever quite dreamless, and opposite answers to it have been propounded. Some writers hold that no state of sleep, however sound it be, is without dreaming ; not being able apparently to conceive two different states of sleep so remote from each other as active dreaming and complete suspension of mental function ; infected also probably in some degree by the Cartesian dogma that the mind never can be entirely inactive. Their contention is that when we declare we have not dreamed, the truth is that we have dreamed and have forgotten it ; and they adduce in support of their argument such undoubted facts as these — the rapid and complete way in which the most vivid dream often vanishes from the memory, so that, although we awake with its features clear in the mind, they are gone in a few minutes and cannot be recalled ; the quite accidental way in which some trivial experience of the day will sometimes bring back the recollection of a dream which we had entirely forgotten, and which but for that accident we should have forgotten for ever ; and, lastly, the fact that other persons may have observed in our exclamations and movements during sleep plain evidence that we have dreamt when we, on waking, should be ready to assert confidently that we had not. Due weight may be granted to these facts without admitting that they go the length of proving the position which it is sought to maintain. The weight of evidence, in a case which by the nature of things cannot be decided, I believe to be really on the side of the opinion that the soundest sleep is a dreamless sleep.

The difficulty of conceiving a temporary nullity of mental function one may take leave to dismiss as a lingering prejudice from the metaphysical notion of mind as an exalted spiritual entity whose essence has nothing in common with the low material necessities of the body. When we make the matter one of observation, it cannot be denied that we perceive during sleep all shades of gradation between the most vivid and active dreaming at the one end and the faintest show of evanescent activity at the other end of the scale. What difficulty is there, then, in passing in conception the imperceptible line between the least flutter of activity and a complete nullity of function ? Furthermore, in certain cases of suspended animation or apparent death, as, for instance, when a person is taken out of water in a completely unconscious state, and revives only after energetic efforts at restoration continued for an hour or even for hours, it is as certain as anything can well be that all mental function was abolished from the moment he became insensible unto the moment when sensibility returned. Take again the remarkable case of a blow on the head producing depression of the skull, pressure upon the brain therefrom, and insensibility therewith ; with the raising of the depressed bone by surgical means the person has not only regained consciousness instantly, but has gone on to finish a sentence which he had begun when he was struck down unconscious.1 In profound apoplexy, in the entire insensibility which is produced by chloroform, and in similar

1 In the American Journal of Nervous and Mental Diseases for April, 1877, Dr. Hoy mentions the case of a youth, aged eighteen years, who was struck insensihle by the kick of a horse, his skull being depressed and fractured. After trephining the depressed bone he became sensible. Dr. Hoy took advantage of the hole in the skull to make firm pressure on the exposed brain after asking him a question. As long as the pressure states of complete unconsciousness from other causes, there is not the least reason to suspect that there is any more mental function going on than there is in an animal which has been deprived of its cerebral hemispheres.

Another theory which has been broached with regard to dreaming is that we only dream just as we are going to sleep or just as we are coming out of it — in the transition state into and out of sleep. But this opinion seems on examination to be less tenable than the opinion that we never cease to dream when we are asleep. Were the somnambulist not a positive refutation of it, observation of sleeping persons who show plainly by their actions or their words that they are dreaming and who still go on sleeping, and the fact that we sometimes catch ourselves in the midst of a dream when we are roused suddenly out of deep sleep, would be sufficient to prove it erroneous. Inasmuch as sleep is not a constant but a fluctuating state, it stands to reason that there will often be varying degrees of mental function according to the more or less depth and completeness of it ; there will be sometimes an activity so coherent as to surprise us, at other times an activity of the most partial and incoherent kind, and there will be an entire abeyance of mental function during such deep sleep as that which fell upon Adam when the operation of taking a rib out of his side was successfully performed.

It has been justly remarked that if we were actually to do in sleep all the strange things which we dream we do, it would be "necessary to put every man in restraint before he went to bed ; for, as Cicero said, dreamers would do more strange things than madmen. A dream put into action must indeed look very much like insanity, as insanity has at times the look of a waking dream. In dreaming as in insanity there are the most strange and grotesque deviations from the accustomed sober paths of

continued he remained silent, but the instant it was removed he made a reply, never suspecting that he had not answered at once.

The same gentleman mentions another case of a youth, aged nineteen, who was rendered insensible by the kick of a mare named Dolly. As soon as the depressed bono was removed, he cried, " Whoa, Dolly," with great energy, and then stared about him in amazement, wondering what had happened to him. Three hours had passed since the accident. He was not conscious the mare had kicked ; the last thing which he remembered was that she wheeled round her heels and laid back her ears.

associations of ideas ; the combinations and sequences of ideas do not follow any definite laws, so far as we can discover, but appear often to be quite accidental and transitory: we justly therefore set down the loss of all power over the succession of ideas as one of the leading phenomena of dreaming. It is not true, however, as is sometimes said, that volition is always abolished during dreaming ; for it is certain that we may wake up suddenly out of sleep in consequence of a strong effort of volition which we have made in our dream, as when we strike out at a person who has insulted or assaulted us, and that at other times we do voluntarily restrain the expression of our feelings. I have been brought to the very verge of being hanged on -two or three occasions in my dreams, having wakened up at the last moment before the operation was to be performed, and on each occasion I have been conscious of a determined suppression of any betrayal of fear or other emotional agitation during the preparations for the event. A concrete act of volition of that sort is not impossible in dreams. It is a fair question, however, how far we succeed in accomplishing the volition when it is to do something active, and how near waking we are when we feel it. For it happens in dreams that we find ourselves straining to do something — for example, to strike a blow, to cry for aid, to utter a command, and are perfectly impotent to do it ; and the instant we succeed in liberating our paralysed energies we awake. There is the strongest mental volition, but an utter impotency of motor outcome ; the instant which elapses between the desire or will to do and the waking state being long enough for the occurrence of what seems a much longer drama of impotence in the dream. At the same time it should not be overlooked that a person does not always awake who calls out in his dream, and that we remember dreams in which we imagined ourselves to will and to do what we willed.

Certainly it is true that volition in its highest sense of control over the mental operations is abolished in dreaming, as a moment's reflection will show must needs be the case. For such volition is neither more nor less than the expression i.J k SLEEP AND DREAMING. 11 of the fu^st co-ordinate activity of the mental functions, varying much in quality necessarily according to the development of the functions through previous training, and cannot therefore by the nature of the case consist with the fortuitous concourse of ideas in dreams. It is impossible there can be full use of reflection when most of the habitual trains of thought are suspended in sleep ; an idea that is accompanied with desire is without the means of becoming a reasoned volition in the ordinary way ; it must remain a particular desire, and when it is active, instead of the natural results following through the beaten paths of association, it will rouse some strange, apparently unrelated idea, which being seen as a vision will present itself as a sort of abrupt transformation scene. For the same reason the sense of personal identity, the unity of individual character, is confused and seemingly lost. "We are ourselves and somebody else at the same moment, as other persons seem to be themselves and not themselves, and we do absurd and perhaps transcendently criminal things in the most matter-of-fact way, all the while mildly surprised or not at all surprised at ourselves for doing them. How can there be a clear sense of the unity of the ego, how any conscience, when there is an entire abeyance of that co-ordination of mental function, the self-consciousness of which is the feeling of personal identity ? It is probable enough that when we begin in our dreams to be surprised at the change of identity, and to think about it as odd, we are on the point of waking ; the commencing restoration of the co-ordination of functions being in fact the restoration of the feeling of identity and the occasion of our surprise. But it seems to me that throughout all the vagaries of dreaming there is generally at bottom an obscure feeling or instinct of identity, or else we should not ever be surprised at ourselves when we seem not ourselves, or when we are doing extraordinary things, or even have the sort of personal feeling which we have in whatever odd drama we may be playing a part. The reason I believe to be that the organism preserves its identity notwithstanding that our conscious functions are in the greatest distraction ; although we are asleep the different impressions of our organic or systemic sensibility,