ON THE MEDICAL TREATMENT OF INSANITY

Forbes Winslow
1852 The Lancet  
321 name, now connected with St. George's Hospital, and President of our College. Before him, Le Cat had imagined a kind of lithotome gorget, which cut on one side, and appears like a combination of Hawkins's gorget with the lithotome cache of frere Come. The form of Hawkins's gorget is not very unlike the original iustrument of De Romanis, (of which I show you a drawing,)* but differs from it in having a cutting edge along the right side. This instrument has been variously modified by B. Bell,
more » ... Desault, Cline, Cruikshank, Scarpa, and Abernethy, but it were useless to occupy your time with a notice of these modifications, as, with three or four exceptions-splendid exceptions I admit-the use of the gorget is abandoned. I shall proceed at our next meeting to a description of the lateral operation, such as it is performed at the present day in this country, and on the Continent. I cannot conclude without informing you that since we last met,t this hospital has been recognised by the Royal College of Surgeons. When the governors at large become acquainted with this important fact, they will, I am confident, take speedy steps for the establishment of a medical school in the fullest sense of the term; in the meanwhile it will be the earnest endeavour of my colleagues and myself to make this hospital an efficient school of clinical instruction. Hnmrrw in the preceding portion of my lecture endeavoured to establish what I conceive to be an important and necessary preliminary point, it is now my province to bring under your notice generally a sketch, a mere outline, of my own views as to the pathology and medical treatment of insanity. Before referring to this part of my subject, I would premise that no right estimate will be entertained of the importance of these investigations unless we apply to the study of the diseases of the brain, and the cure of its disorders, the same enlarged and general principles which guide us in the investigation and treatment of the affections of other organic structures. An error of some magnitude has been committed by those who consider insanity to be a special, uniform, specific, and peculiar malady, justifying us in placing those afflicted with the disease out of the ordinary nosological scale and sphere of medical practice. Again, it is necessary that we should, before being able to appreciate the effect of medical treatment, entertain just and enlightened views as to the CURA-BILITY of INSANITY. I now speak from a somewhat enlarged experience, from much consideration of the matter, and I have no hesitation in affirming that, if brought within the sphere of medical treatment in the earlier stages, or even within a few months of the attack, insanity, unless the result of severe physical injury to the head, or connected with a peculiar conformation of chest and cranium, and an hereditary diathesis, is as easily curable as any other form of bodily disease for the treatment oj which we apply the resources of our art, It is a lamentable error to suppose, and a dangerous, a false, and unhappy doctrine to promulgate, that the disordered affections of the mind are not amenable to the recognised principles of medical science.::: I again declare it to be my positive and deliberately formed opinion, that there are few diseases of equal magnitude so suscep-* Vide Fig. 70 , p. 296.. t This lecture was delivered on the 18th of August ; the preceding lecture on the 4th. t 11 You do not pretend to em-e insanity?" exclaimed a gentleman of considerable intelligence to me, whilst detailing the particulars of a distressing attack occurring in a member of his own family ; " for," he continued, 111 heard Dr. -positively declare, in a public lecture, that he lamentea to be obliged to say, that in the cure of insanity, little or no good resulted from medical treatment., Sad and fatal doctrine ! Whilst recently visiting Bethlehem Hospital, to see, at the request of their friends, two patients ir. that establishment, I heard a foreigner who had been inspecting the asylum observe, whilst talking of the medical treatment of insanity, that it was quite a mistake to have a portion of the asylum set apart for the " incurable patients." "The word "incurable," in reference to insanity," he continued "should never be 2ised.11 I would much prefer pinning my faith to the doc. trine of the foreigner than to that of the English physician, who attemptec to weaken our confidence in the curability of insanity by means of medicine tible of successful medical treatment in the incipient form as those implicating the normal action of thought. The vast amount of incurable cases of insanity which crowd the wards of our national and private asylums, is pregnant with important truths. In the history of these unhappy persons-these lost and ruined mindswe read recorded the sad, melancholy, and lamentable results of either a total neglect of all efficient curative treatment at a period when it might have arrested the onward advance of the cerebral mischief, and maintained reason upon her seat; or of the use of injudicious and unjustifiable measures under mistaken notions of the nature and pathology of the disease. In no class of affections is it so imperatively necessary to inculcate the importance of early and prompt treatment, as in the disorders of the brain affecting the manifestations of the mind. I do not maintain that our curative agents are of no avail when the disease has passed beyond what is designated the " curable stage." My experience irresistibly leads to the conclusion that we have often in our power the means of curing insanity, even after it has been of some years' duration, if we obtain a thorough appreciation of the physical and mental aspects of the case, and perseveringly and continuously apply remedial measures for its removal; but I cannot dwell too strongly upon the vital necessity of the early and prompt exhibition of curative means in the incipient stage of mental derangement ;-" Principiis obsta : sero medicina paratur Cum mala per longas convaluere moras."-Ovin. It becomes necessary, before proceeding to the consideration of the practical division of my subject, that I should briefly refer to the morbid anatomy of the brain in insanity. It is not my intention to cite the conflicting opinions of writers of repute in reference to this section of pathology; neither shall I attempt to reconcile the varied and contradictory statements of eminent pathologists who have investigated this important subject. With these prefatory observations, I will concisely submit to you the conclusions to which I have arrived in relation to this much-vexed question. I believe insanity (I am now referring to persistent insanity, not those transient and evanescent forms of disturbed mind occasionally witnessed) to be the result of a specific morbid action of the hemispherical ganglia, ranging from irritation, passive and active congestion, up to positive and unmistakable inflammatory action. This state of the brain may be confined to one or two of the six layers composing the hemispherical ganglia ; but all the layers are generally more or less implicated, in conjunction with the tubular fibres passing from the hemispheres through the vesicular neurine. This specific inflammation, from its incipient to the more advanced stage, is often associated with great vital and nervous depression. It is, like analogous inflammations of other structures, not often accompanied by much constitutional or febrile disturbance, unless it loses its specific features, and approximates in its character to the inflammation of active cerebritis or meningitis. This state of the hemispherical ganglia is frequently conjoined with active sanguineous circulation and congestion, both of the substance of the brain and its investing membranes. The morbid cerebral pathological phenomena-viz. the opacity of the arachnoid, the thickening of the dura mater, its adhesions to the cranium, the depositions so often observed upon the convoluted surface of the hemispheres, and on the meninges,the hypertrophy, scirrhus, the cancerous affections, the induration, the depositions of bony matter in the cerebral vessels and on the dura mater, the serous fluids in and the ulcerations upon the surface of the ventricles, the alterations in the size, consistence, colour, and chemical composition of the vesicular neurine and fibrous portion of the brain-are all, in my opinion, the results, the sequelea, more or less, of that specific inflammatory condition of the hemispherical ganglia to which I have referred. It does not necessarily follow that the fons et origo mali of insanity is invariably to be traced to the brain. The preliminary morbid action and irritation are often situated in the heart, the stomach, the liver, the bowels, the lungs, or the kidneys, the brain being secondarily affected; nevertheless, in all cases inducing actual insanity, the hemispherical ganglia are involved in the morbid action. The most recent pathological doctrine propounded to explain the phenomena of insanity-I refer to the views of a recent writer*that derangement of mind is the effect of loss of nervous tone," and that this loss of nervous tone is " caused by a premature and abnormal exhaustibility of the vital powers of the sensorium"conveys to my mind no clear, definite, or precise pathological idea. It is true that we often have, in these affections of the brain and disorders of the mind, " loss of nervous tone," and °' exhaustion of vital power;" but, to my conception, these are but the effects of a prior morbid condition of the encephalon, the sequelœ of specific inflammation of the hemispherical ganglia. To argue that ; * Dr. H. Munro.
doi:10.1016/s0140-6736(02)61289-9 fatcat:hve2ajf3xffhzcut6zfgrilueq