On the prevention and treatment of mental disorders

Front matter

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Chap. I. Of the Porms of Mental Disorder . . 46

n. General Causation of Mental Disorders . 76

III. Of their Physical Causes . . . .99

IV. Of their Moral Causes . . . . .119

PAET III.

Chap. I. Of the Treatment of Idiocy . . . .140

II. Of the Medical Treatment of Mental Disorders 151

in. Of their General Treatment .... 205

PREVENTION AND TREATMENT

MENTAL DISOEDEES.

Part I. Inteoductory Chapter

" In England and Wales alone there are more than 30,000 decidedly insane persons, the annual cost of whose maintenance exceeds 1, 000,000 Z* If to this we add the loss of productive labour, the cost of maintaining families thus rendered destitute, the suicidal and criminal acts resulting from insanity, the misery, anxiety, and destruction of domestic happiness which even its minor forms occasion, a mass of suifering will be presented perhaps unequalled by any other source of human affliction. And there is, probably, not a single family in this kingdom which has not, at some period within the memory of its present members, experienced the universality of this evil.

" Unfortunately, too, the proportion of recoveries amongst the inmates of our asylums, notwithstanding ^7 B the improvements introduced in the management of the latter, is still so limited as to be incapable of preventing a rapid accumulation of incurable cases in all establishments of long standing. And of the patients discharged as cured, all retain more or less liability to a recurrence of the disorder, and a large proportion are annually readmitted in a worse mental state, as regards the prospect of recovery, than on their first subjection to restraint." — Thurnam.

There is, moreover, but too much reason to believe that in England and other highly-civilised countries this class of diseases is rapidly on the increase. After a careful discussion of this important question, the late learned and excellent Dr. Pritchard thus reluctantly intimated his acquiescence in the less favourable view of the subject : — ^^ The period is so recent from which accurate knowledge has been obtained in any country, that we are scarcely authorised in determining that insanity is, or is not, any where an increasing evil ; and the reasons pointed out by MM. Pariset and Esquirol in France, and suggested by Halliday and Burrows in this country, explain the apparent increase, or at least prevent our taking the multiplied number of lunatics, and of lunatic establishments, as a full proof that there has been a real augmentation in the numbers of deranged persons. Yet the apparent increase is everywhere so striking, that it leaves on the mind a strong suspicion; and this suspicion, that cases of insanity are far more numerous than formerly, can only be removed by a series of observations that may prove the negative. It is encouraged by the reflection that the state of society is, in most countries, such as appears likely to multiply the exciting causes of madness."*

It is proper to add, that the Metropolitan Commissioners in Lunacy, in their official reports, express a contrary opinion, and refer the apparently increased number of persons of unsound mind to the circumstance of the greater attention now paid to that class of patients, as well as to their reception in registered houses, instead of being, as it were, concealed in private dwellings. But notwithstanding this eminent authority, an idea similar to that of Dr. Pritchard seems to exist among the majority of persons engaged in the treatment and study of insanity, and the experience of Boards of Guardians and other public bodies having charge of the insane, tends to the same conclusion.! In further confirmation of the same view is the fact, that the large county asylums, erected at an immense cost, are generally filled very soon after their completion, and in some instances, as in Middlesex, they have already been found insufficient for the accommodation of the insane poor of the surrounding districts.

* Treatise on Insanity (p. 350).

t " An official report, just published by the parochial authorities of Marylebone, states that insanity has lately increased to such an extent among the working classes, that none but those whose duties bring them in contact with the suiferers can form an idea of its fearful spread. There are now no less than 494 chargeable to the parish. In St. Pancras insanity prevails to an unusual amount, especially among the humbler classes. It is to be hoped that this painful fact will be made the subject of official and medical inquiry, with a view to tracing its origin, and to retard, if possible, its progress." — Lancet B 2

4 INTRODUCTOKY CHAPTEE.

To what end does this tend? Is insanity, like pauperism, crime, and other great social evils, to continue to flourish amongst us without an effort to check its advances ? And can the nation, through its statesmen and its laws, suggest nothing more effective or more hopeful than the multiplication of district asylums, workhouses, and gaols? Local taxation in this country is steadily increasing; the cost of the existing institutions of this character is even now felt to be a most oppressive burden by the middle classes ; and a period of continued commercial depression cannot fail to increase this feeling, even to a dangerous extent. For the conviction will ffain around, that these and similar evils which afflict society are not efiiciently met by existing legislative and administrative efforts. Any attempt to remedy them as hitherto, either by simple repression or by improving the condition of the unfortunate victims after they have become lunatics, criminals, or paupers, is obviously crude, vain, and baseless. And however highly we may respect the motives of those who are indefatigably projecting new institutions of a philanthropic character for the mitigation of the various forms of social evil, every man practically conversant with the existing constitution of society, particularly that of our denser masses of population, must feel and recognise in his own breast that much of that labour of love which has led to the creation of so many reformatory establishments is, as regards its general effect on the nation, but a labour of Sisyphus. It is the application of a mere topical remedy to a foul ulcer

INTEODUCTORT CHAPTER. 5

dependent on constitutional disease, and requiring constitutional treatment. To be thoroughly successful in these efforts we must adopt a less simple, but more eradicating course of action. We must trace each evil to its causes, and pursue them again through all their varieties and ramifications; we must scrutinise and weigh them well, and studyhow best to diminish their respective influences ; we must act upon and against them as well as their effects ; and in order to accomplish this great work, the veil of conventionalism and routine must be drawn aside, and the light of truth and reason allowed to penetrate into the darker recesses of civilised existence.

Let me illustrate, by a quotation from a writer not prone to exaggerate, and at the same time fully qualified to estimate, our existing national defects, the necessity of such an effort.

*' It has been shown," says Porter in his " Progress of the Nation," " that since the beginning of the present century this kingdom has made the most important advances in population, in wealth, and in the various arts of life which are capable of ministering to man's material enjoyments. It is now proposed to consider whether equal advances have been made in regard to his moral condition, and to the general tone of society. If our inquiries on this head do not admit of satisfactory answers — if, while wealth has been accumulated, and luxuries have been multiplied, vice has been thereby engendered and misery increased — the advantages of our progress may well be questioned. An inquiry of this nature, honestly

B 3 and fairly conducted, would in all likelihood lead to conclusions of a mixed and partial character. If we should discover, on the one hand, that the general addiction to gross and sensual vices has been checked and lessened, we might on the other hand be forced to admit that we have lost some portion of the manly virtues by which our ancestors were characterised — that in our daily intercourse we have swerved from the road of honesty and truthfulness into the paths of expediency and conventionalism; that, in our individual strivings after riches and position, the feeling of patriotism has been deadened, until our whole existence has become so tainted by selfishness that we suffer ourselves to view the interests of our country only as they may affect our individual ease or progress. It must be owned that our multiplied abodes of want, of wretchedness, and of crime — our town populations huddled together in ill-ventilated and undrained courts and cellars — our numerous workhouses filled to overflowing with the children of want, and our prisons (scarcely less numerous) overloaded with the votaries of crime, do indeed but too sadly and too strongly attest that all is not as it should be with us as regards this most important branch of human progress" (pp. 630-1). And combining the faith of the Christian with the wisdom of the philosopher, the same writer subsequently remarks : " It is seen, and is beginning to be practically acknowledged, that a great part of the moral evil under which societies are suffering is the offspring of ignorance ; and that without insisting upon any very high degree of perfectibility in human nature, we may reasonably hope that the removal of that ignorance will do much towards restoring moral health to communities, and thus fit them for the rational enjoyment of blessings so increasingly offered for their acceptance.

" To suppose that blessings must necessarily be accompanied by countervailing curses, is to impute a capital deficiency to the intentions of Providence, and amounts to a practical denial of the power, wisdom, and goodness of the Almighty" (p. 632).

Notwithstanding, then, the enormous intellectual advances made during the present age, there probably never was a period in the history of this country when happiness and contentment were less generally diffused throughout the different classes of society. The increasing tendency to the concentration of wealth in the hands of a few necessarily produces discontent among the many; while the incessant striving after social elevation, as one of the results of the more general equalisation of education, the intensity of competition, the love of display so unnatural to the old English character, the introduction of many foreign vices, and the frequent faithlessness of men holding important trusts, have all united to engender a state of feeling in the highest degree injurious to the mental condition of the community. And in investigating the moral causes of insanity we shall discover ample evidence of its frequent origin in the vices of a spurious and hollow civilisation.

On considering, therefore, the increased prevalence of mental disease, the limited curability of its conis 4 firmed forms, and its peculiarly intangible essence, we can with confidence believe that it will be most effectually checked by attention to the circumstances producing it; while it is equally certain that this inquiry will also elicit much important information, and indirectly assist in no slight degree various efforts for the moral and social reformation of civilised communities.

The causes of insanity are moral as well as physical in their nature, national as well as individual in their extent. By whomsoever indicated, therefore, society through its legislators must deal with some, religion through its ministers with others. And if the physician should adopt the earlier stages of inquiry as peculiarly his own, a claim which will, perhaps, be generally recognised, it is evident that the subjects thus proposed for examination, involving as they do several questions of great general importance, connected with the prevalent usages of society and the predominant sentiments elicited by education, must of necessity be treated in a bolder spirit, and with more expanded views, than the ordinary topics of a professional treatise. For it has long been my own conviction, that any really valuable knowledge which we may acquire respecting the prevention and cure of insanity can only be derived from a careful and comprehensive study of all the morbid phenomena of the human mind, and that a principal cause of the unsatisfactory progress hitherto made in this department of medico-moral science is to be found in the limited, and, so to speak, too technical, view of mental disease entertained by the comparatively few eminent pathologists who have as yet directed their attention to the subject.

Diseases of the mind, including all the morbid exaltations, depressions, perversions, and suspensions of those wondrous percipient and reflective faculties which hourly testify to the lofty destinies of the human race, constitute, indeed, a common territory on which the physician and the philosopher, the statesman and the divine, respectively meet to pursue their various but converging courses of beneficial investigation. But while the moral philosopher regards with interest the successive phases of mental disorder, chiefly from their laying bare the workings of the several elements of man's spiritual nature; while the statesman estimates its cost to society, and its relative influence in retarding human progress ; while the divine views it with awe and timidity as one of the inscrutable evils which afflict mankind, the physician is called upon to discharge a more active and more immediately responsible range of duties. He has to interpret the signs of the disease to the general public, and stand between society and its mentally alienated members for the protection of both. He has to assist the legislator in determining the reality of insanity, and in constructing the definitions which assign improprieties of conduct to their respective places in the scale of justice. On him rests virtually the duty of pronouncing a final opinion on the moral responsibility of persons in an uncertain mental state; his judgment, therefore, often decides the question of innocence or guilt, of freedom or restraint ; on him, further, devolves the very important task of tracing each case of insanity to its causes; examining the relative influence of the latter, and thence deciding how far in any instance this affliction is the result of unavoidable bodily disease, or how far it is referable to circumstances over which every individual has more or less control, and for the proper regulation of which he is, therefore, to a certain extent, morally responsible. I^astly, it is the essential province of the physician to ascertain the remedial measures applicable to the treatment of the various forms of mental disorder, and to lay down the rules of life, by attention to which its advent may be most effectually prevented. With powers thus extended, and responsibilities thus multiplied, it is manifestly incumbent on those who assume the direction of all that regards the management of the insane, and the prevention of insanity, to utter in plain and intelligible language their honest convictions, to point out the inexorable connection between any continued violation of moral or natural law and its fearful consequences ; and thus, on the one hand, impart vitality to an inert mass of statistical facts, and add, on the other, the weight of actual experience and the authority of personal testimony to the exhortations of the preacher and the assertions of the moralist.

But these duties, though in the highest degree important to the welfare of individuals and the general happiness of mankind, are not in themselves of a very pleasurable nature. Nor did the investigations into the physical causes of bodily disease recently conducted in this country, reveal a darker

INTRODFCTOEY CHAPTER. 11

back-ground to the boasted picture of modern civilisation than would be afforded by a similar scrutiny of the preventible sources of mental alienation. As the one inquiry disclosed to an astonished and sorrowful public scenes of filth and wretchedness, of compulsory demoralisation and disease, the existence of which had previously been unknown, even so would the other drag to light a number of hideous evils, which have hitherto silently and secretly preyed upon the vital energies of society, polluting and prostrating the very essence of man's nobility. The difficulty of the task is, moreover, greatly increased in the latter case by the circumstance of those evils affecting every section of the community, instead of concentrating their ravages upon the poor to the same extent as the physical causes of bodily disease. And, perhaps, the only hope of effectually checking their growth is to be found in that firm attachment to the general cause of humanity, and that abnegation of selfish and personal interest, which, amidst all their professional toils and personal anxieties, have ever honourably characterised the practitioners of medicine.

But in studying the nature, and endeavouring to check the progress of, mental disease, the physician must look beyond the precincts of the asylum. He must not rest content with there observing the various forms of insanity, recording their progress, and searching for their effects. No one would expect to discover the causes of Typhus in a Fever Hospital, or hope to ascertain the agencies predisposing to malignant cholera by seeing numerous persons previously prostrated by that pestilence. We have alreadylearnt in reference to these diseases, that the most useful field of study is that constituted by the circumstances and associations, the physical and moral conditions, surrounding the masses from which their victims are taken. And in like manner must the science of mental pathology be pursued in its application to preventive medicine. The psychological physician must disregard the narrow formulas of his earlier studies ; he must no longer view this class of diseases with the eye solely of a medical practitioner, because in reality he has to deal with other than mere bodily and physical seats and sources of disorder ; he must invoke and use for the advancement of one great object all the knowledge of mankind which his opportunities, his tastes, his habits, may have enabled him to acquire. The information gleaned by him in the varied fields of professional duty during his intercourse with the rich and the poor, the virtuous and the depraved ; amid alternate scenes of gaiety and sorrow, of splendour and want, must all be made to cast its beneficent light on the sources of the great evil under his consideration. And in proportion as we advance in a more perfect knowledge of man himself, may we hope that true civilisation, true philosophy, and true religion will unite in restraining the worse, and developing the better, parts of his nature, and thus add to the happiness and welfare both of individuals and nations.

It only remains for me to apologise for the very imperfect attempt made in the following pages to carry out the preceding views, and at the same time offer a few practical remarks on the treatment of mental disorders. The subject is one which might well engage the best energies and most profound meditations of a life-time ; and though for ten years I have devoted much attention to its study, and enjoyed considerable opportunities, I am fully aware that opinions formed amid the daily distractions of professional life must necessarily be but approximations to reality. They are, however, expressed without reserve, from a belief that the investigations and comparisons resulting from the collision of ideas are the most efficient instruments for the advancement of truth and correction of error. And it may even in limine be observed that my inquiries respecting the causation of insanity have led me to one important conclusion — a view not flattering to our age, but at the same time encouraging for the future, inasmuch as it tends to show that in the great majority of cases mental disorder is not an inevitable affliction — that its prevention is, to a very considerable extent, in our own hands, and that an improved moral condition of the nation will as surely diminish the prevalence of diseases of the mind, as the removal of noxious physical agencies has been shown to add to the bodily health and vigour of the community.

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Chap. II. Of The General Physiology Of The Nervous

SYSTEM.

For the healthy exercise of the functions of the nervous system, and of the mental actions manifested through its organs, certain vital conditions are requisite, the absence of any one of which is sufficient to induce mental or nervous disorder. Thus the brain and spinal cord, the centres of the nervous organisation, must not only be themselves properly formed and endowed with their characteristic powers, but they must also be duly placed in relation with the other constituent parts of the body, by means of the nervous filaments distributed among its different structures. The normal development or perfect conformation, and subsequent integrity of the various component organs of the nervous system, therefore constitute the first and most essential condition of healthy mental and sensorial existence. If, as sometimes happens, the development of a part of the brain be arrested during foetal life congenital idiotcy or imperfect sensation is the result. And in like manner, if the process of formation of the spinal cord, or of any of the nerves connecting it with the rest of the body, be similarly checked, the parts intended to be supplied by that nerve or by the affected portion of the spinal marrow never possess sensation and motion, and for all the purposes of life are dead and useless. A second indispensable condition for the healthy action of the nervous system is a due supply of arterial blood. But this implies a triple combination of circumstances, for, in the first place, a certain quantity of blood must be contained in the vessels supplying the nervous structures; secondly, the blood present in these vessels must move through them with a certain degree of velocity or amount of impulse; and thirdly, the blood thus circulating must be arterialised and healthy.

It is thus evident that the healthy action of the nervous system is chiefly dependent upon and regulated by the state of the circulation of the blood, and that any disorder of the latter, whether general or local, may at once induce corresponding irregularities in the functions of the former. Of the correctness of this observation the pathology of the nervous system furnishes many illustrations, and we shall repeatedly have occasion to notice the intimacy of the relations existing between these two great moving principles of vitality. It is unnecessary to enumerate the facts which prove how essentially the action of the brain and spinal cord is connected with the proper circulation of the blood through their nutrient vessels, as the physiological law establishing the dependence of the former upon the latter action is universally admitted. But as the applicability of the same law to the action of the cerebro-spinal nerves generally does not appear to have obtained equal recognition, it may not be altogether useless to dwell for a moment upon

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the phenomena which establish a conclusion so important in its relations to the pathology of local disorders of sensation, wherever seated. It is well known that excessive cold retards the motion and diminishes the quantity of the blood circulating through any exposed portion of the body, and thus benumbs the latter, or, in other words, suspends the action of its nerves in the same manner as a tardy circulation through the vessels of the brain, such as that occurring in old age, induces torpor of the mental and sensorial functions. But the truth of the principle contended for may be demonstrated with unmistakable clearness by direct experiment. If the abdominal aorta, through which arterial blood is supplied to the hinder extremities, be obstructed in a living animal, that part of the body is instantly paralysed, both limbs being wholly deprived of sensation and voluntary motion. The nerves of the part are untouched and uninjured, they are still in direct communication with the brain; whence then the paralysis ? It can only arise from the cessation in the supply of arterial blood to the nerves of the affected limbs ; and the correctness of this explanation is verified by the fact of the nervous deprivation disappearing immediately after the removal of the ligature from the artery. Even when the arterial blood has thus been cut off for some time, sensation and voluntary motion have speedily been restored to the paralysed limbs, by again allowing the blood to flow freely into the vessels supplying the affected nervous structures.

The cerebro- spinal nerves distributed throughout the body, which connect the mind with the external world, at the same time that they maintain an intimate union and sympathy between the component parts of the animal organism, should therefore no longer be regarded as mere passive cords, analogous to the wires of the electric telegraph with which they have so often been compared. They possess higher and more active powers : their vital requirements are, as we have seen, identical with those of the brain itself; and in studying their disorders the medical practitioner will do well to bear in mind the possibility of many perverted sensations and local defects of innervation originating in these delicate and exquisitely-endowed media of vital inter-communication. There yet remains to be mentioned another and a negative condition essential to healthy mental and nervous action, which almost flows as a corollary from the physiological law just described, viz.. the absence of any noxious matter or impurity in the blood circulating through this system. And when it is remembered that various poisons, such as carbonic acid, and the elements of certain noxious secretions and excretions, are generated within the body, some in the blood itself, and are capable of producing their injurious effects with as much certainty and uniformity of action as poisonous substances introduced from without, the importance of attending to this source of interference with the healthy action of th.e nervous system must be sufficiently obvious. Even in this necessarily brief review of the conditions requisite for the maintenance of the healthy action of the nervous system, the regular recurrence and normal duration of sleep or periodic repose — the most potent invigoratop

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of the higher functions of that system — must not be forgotten, for its privation, from whatever cause arising, will often be found intimately connected with the production of mental and nervous disorder.

Lastly, it is to be observed that mental and sensorial health is best preserved by the due and regular exercise of the intellectual and moral faculties, in alternation with a certain amount of bodily exertion. But, unfortunately, great errors have prevailed, and still prevail, on this subject from animperfect acquaintance with the peculiarities of man's natural constitution. It should ever be borne in mind that he is literally, and in sober truth, a compound being, having a body with its physical powers and animal instincts, an intellect gifted with vast capabilities, and a soul endowed with sensitive feelings and ardent emotions. Any one of these constituent elements may be exercised and developed to the neglect of the rest, but not without injury to the being as a whole. If the animal part of his nature be unduly indulged, man becomes brutalised and degraded ; if the intellectual faculties be alone cultivated, the bodily powers are enfeebled and the aflPections blunted; and if he yield himself up without restraint to the impulses of emotion and sensibility, the dignity of his nature as a rational being is apt to be cast away, and the peace, stability, and calm enjoyments of existence are more or less permanently destroyed. It is, therefore, only by the regularly-varied exercise of each of these groups of functions that perfect mental health can be obtained and preserved. Corporeal should alternate with intellectual action, and both will be relieved by the moderate indulgence of the affections and expansion of the moral feelings. The same counterbalancing principle or normal necessity for the diffusion of vital exertion will, moreover, be found to extend into each of the minor subdivisions of the mental and nervous functions. The depressing emotions are relieved by those inspiring an opposite state of feelinsj : a chano^e of intellectual labour renders it less debilitating and oppressive, just as the strength of the body as a whole is best conserved by the equal and proportionate development of all its organs and parts. In reference, then, to mental hygiene, we must ever remember that man is not all soul, all intellect, or all body, but a compound of the three. He is, as it were, ever vibrating between the spiritual and material worlds, partaking in his nature of the peculiarities of each. Bound down to earth by the necessities of his corporeal existence, he soars towards heaven by the power of his imagination and the sublimity of his emotions. And hence, while dealing with his mental disorders, we should never forget that there is an immortal spirit within the workings of which we can only imperfectly recognise by its bodily manifestations ; and that the tongue may often be silent, and all indications of emotion and suffering carefully suppressed, whilst the soul within is quivering with morbid sensibility, wasted by secret grief, or festered by corroding suspicion.

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Chap. III. Of The General Pathology Of The Nekyous System

Before entering upon the study of the pathology of mental disorders, it is most essential that a clear and correct idea be formed of the peculiar and complicated relations of the brain. We have seen that for the healthy discharge of its functions, certain physico -vital conditions are requisite, the chief being the natural formation of the organ and the due nutrition and purification of its structures by streams of arterial blood. But even in a sta,te of perfect health the functions of the brain, from their very nature, have a constant tendency to induce more or less disorder in its action. For as the great seat and centre of vital sympathy, it is called upon to receive, and respond to, every vibration indicative of injury or disease, which its attendant nerves may transmit to it from the innumerable organisms of the whole body. And what a boundless field of morbid sensations and other disturbing influences does this connection alone present to the student of cerebral pathology I We have, however, further to remember that the brain, being the instrument of the mind, is most intimately associated with the intellectual and moral parts of our nature, and is consequently liable to be