Elements of psychological medicine; an introduction to the practical study of insanity

Front matter

<i> Ll ! Dr / s

THE GIFT Or HIS DAUGHTER.

Edith Agnes Salter

Preface

The circumstances which led to the preparation and delivery of the Lectures of which this volume is composed, being stated in the Introduction, the Author has only here to add, that he has been led to publish them by the request made to him, at the close of the Course, on the part of his medical brethren, who constituted a large proportion of his auditory.

In acceding to the request, it was the Author's first intention to work up the substance of what he had written into a small systematic treatise, rather than to publish the Lectures as such. On consideration, however, he was led to think that, for the purposes of elementary instruction, there would be an advantage in retaining the original form; and, accordingly, with some slight emendations, the Lectures are published as delivered.

VI PREFACE.

It is very well known that medical students, on the eve of commencing practice, have extremely little acquaintance with Psychological Medicine; and very many remain through life almost entirely ignorant of the subject. Indeed, well-educated persons out of the profession will frequently judge as soundly concerning the mental condition of a patient, as many who are within it.

The deficiency of Hospitals available for practical instruction, forms a great hindrance to the student, who, were the fact otherwise, might be disposed to cultivate this branch of Medicine. Information contained in books, or conveyed by lectures, may prepare the mind for practically investigating the subject ; but unless the teaching receive some verification in actual experience, it is of little permanent advantage.

Lunatic Asylums in this country, whether public or private, are but rarely accessible for the purposes of clinical study. The difficulty of obviating this circumstance would appear to be regarded as insuperable by our Colleges and Universities, since no provision of any kind is made by them for educating the future physician and surgeon in a practical knowledge of Insanity. Hence medical men who possess adequate information upon this branch of the

PREFACE. Vll

profession, are necessarily self-educated to a great extent. The superintendent of an asylum has at times to receive his first practical lessons in his own hospital ; and, occasionally, I believe, the first book upon Insanity that is read, is taken up after the charge of insane patients has been assumed. Indeed, the fact is but little overstated when it is said, that many practitioners have no acquaintance at all with either the theory or the practice of Psychological Medicine.

The anomaly of this state of things becomes very apparent, when it is considered that the earlier diagnosis and treatment of psychical disease is nearly always the duty of the ordinary medical attendant of families. And it is generally in the incipient stage, that decisive measures have to be adopted. If mismanagement at this period from any cause take place, the most serious mischief may ensue, and permanent insanity often thus becomes established.

This anomaly becomes still more striking, when the subject is considered from a legal point of view. The personal freedom of individuals can always be taken away, if two medical men certify to the fact of insanity. This is the law ; and yet there is no qualification enforced for the exercise of so responsible a duty. The custom-

Vlll PREFACE.

ary training of medical students, and the routine avocations of the practitioner, certainly do not provide this qualification. Anatomy and Physiology, as generally studied, Materia Medica, Obstetrics, and ordinary clinical teaching, have very little bearing upon perversions of the intelligence and disorders of the moral sense.

Yet the whole subject of Insanity is virtually, as well as conventionally, the concern of the Medical profession. The just interpretation of all morbid phenomena, mental not less than corporeal, can only be accomplished by the aid of physiology ; and the applicability of systems of treatment, particularly in difficult and doubtful cases, can only be estimated under the guidance of principles of General Pathology.

It may be said that, although the medical student receives no formal instruction in this department during his pupilage, there is a valuable literature open to him when released from the constraints of his curriculum; and that opportunities for gaining practical information may then be procured, if the taste and capacity lie in that direction. Undoubtedly this is true to a great extent. But, in the estimation of the present writer, there is, both in the literature and in the opportunities for gaining experience, an absence of sufficient correspondence

PREFACE. IX

between these and the previous studies; the transition from the latter being too abrupt, for them to be rendered adequately conducive to a comprehension of the phenomena of Insanity.

The many excellent works that already exist upon the subject, are generally of too high a character for initiatory study; being, for the most part, contributions to our knowledge of the subject under particular aspects, rather than treatises for conveying elementary instruction.

This little work which is now offered to the profession, claims no higher merit than that which belongs to an attempt to supply a want which the Author believes to have been experienced. He designs it simply as an Introduction, arranged upon a plan that shall take the student up, as it were, at the point where the completion of his lectures and hospital attendance leaves him. He has connected the pathology of mental maladies as much as possible with the present state of our knowledge of cerebral physiology ; and has explained the principles of treatment by constant reference to those more general ones which are applicable in the ordinary practice of medicine, — principles with which the advanced student ought to be

X PREFACE.

acquainted. It would have been a departure from the elementary character which he has desired to preserve throughout, if he had taken more than a passing glance at recent researches and views regarding the peculiar psychical influences of perverted blood and disordered sympathies, in the production of Insanity. The subject is one, however, which in a more comprehensive disquisition would demand a very careful and methodic examination.

Of the imperfect manner in which the intention has been carried out, no one can be more sensible than the Author. He submits his volume, however, with very moderate pretensions. If it fail to realise the slight expectation which he has formed, that it may fill up a deficiency in the literature of his profession, he may experience some little disappointment, but certainly no mortification.

The change which the Author's views have undergone regarding the phrenological theory, is stated and explained in the second lecture. He deems it right to mention, in this place, that his doubts of the validity of Phrenology (as commonly understood) were first occasioned by perusal of an Article by Dr. Carpenter, in the British and Foreign Medical Review, about seven years ago, criticising a former work of his

PREFACE. XI

own. Having been thus led to the conviction that the whole question required a re-examination upon his own part, unbiassed observation and more careful reflection have caused him to abandon much that he had previously admitted and defended, and to recognise the general truthfulness of the doctrines laid down by Dr. Carpenter in that article and in his systematic treatises, as the basis on which alone any correct physiological Psychology can be erected. And as to certain conclusions with respect to which he has been led to differ from that distinguished physiologist, he is equally conscious of the obligation under which he lies to him, for having developed what he considers to be the surest and most comprehensive method of conducting this difficult investigation.

The Author anticipates that objections will be made to the limitation involved in his definition of Insanity; the designation being applied by him to those instances alone, in which there is perversion of ideas. It is affirmed by many eminent writers, that there are certain disordered states of the emotions to 'which the term Insanity is properly applicable, though the intelligence continues absolutely unaffected ; that — in many hysterical subjects, for example, there is emotional insanity, without there being

Xll PREFACE.

either mental illusions or impairment of the reasoning faculties.

Undoubtedly, cases of disordered feeling exist, independently of, and unconnected with, perverted thought. Numerous examples of this condition are supplied by Hypochondriacal and Hysterical patients, whose conduct, alike with respect to themselves and towards others, becomes influenced to an extent, and in a manner, showing, not merely an exaltation or perversion of some particular set of feelings, but a corresponding weakness of volition. The Author conceives, however, that when morbid sensibility systematically induces actions, not only eccentric and irregular, but opposed in their character to the moral antecedents of the patient, there always exists some perversion of ideas. In the following lectures, this topic is briefly discussed, but at very inadequate length; and the limits of a Preface do not allow of any supplementary illustration or argument.

Practically, it is always difficult to draw the boundary line between what are commonly considered purely Nervous maladies, and diseases of the Mind, on account of the connection subsisting amongst all the nervous centres and the correlated psychical states. The problem is as difficult to solve, in many instances, as the

PREFACE. X1U

one concerning the dawnings of consciousness in particular series of animated beings, or that regarding the point in the ascending scale where animal life should first be recognised.

In order that the whole subject should receive a just elucidation, a comprehensive treatise on Psychological Medicine would require to be written, — one that should embrace morbid affections of both Brain and Nervous System, — and which, commencing with the simplest manifestations of nervous derangement, should ascend, progressively, to the most complicated forms of Mental Disorder.

The Author's design, however, in the present work, has been to treat only of what is commonly understood by Insanity, or Mental Derangement, — the condition, in fact, so recognised by law and custom, — in such a manner as to introduce the topic, in a scientific form, to those who have previously given it no special consideration.

September, 1853.

Contents

LECTURE I.