Liverpool, Birmingham, &c., present the sources of disease in a proportional scale, and almost take away the hope of materially bettering the condition of the working classes, till labour is better paid, and the people become convinced of the imprudence of early marriages, and the dire effects of redundant population! I. TRAITÉ DE PATHOLOGIE CEREBRALE. Par Scipion Pinel. Paris. 1844. 8vo. pp. 560. A Treatise upon Cerebral Pathology. By Scipio Pinel. II. FIRST, SECOND, THIRD, FOURTH, AND FIFTH REPORT OF THE RESIDENT PHYSICIAN OF THE COUNTY OF MIDDLESEX PAUPER LUNATIC ASYLUM AT HANWELL, 1839-43. III. REPORTS OF SIR ALEXANDER MORISON, Visiting Physician of the Surrey Lunatic Asylum. 1842-43. IV. GENERAL REPORT OF THE ROYAL HOSPITALS OF BRIDEWELL AND BETHLEM. 1844. V. REPORT OF THE METROPOLITAN COMMISSIONERS IN LUNACY TO THE LORD CHANCELLOR. 1844. In resuming the analysis of M. Pinel's new work, commenced in our last number, we have combined with it some consideration of the various "Reports," the titles of which are mentioned above, as tending to illustrate some of the subjects treated of in the latter part of the volume. Moreover, they are very important documents in themselves, as exhibiting not only what can be, and what has been done for the improved management of the insane, but also how much yet remains to do, before this can be considered as placed upon a satisfactory footing. It is understood that the Minister is about to introduce, during the ensuing session, some comprehensive measure for the provision, regulation, and inspection of the various classes of establishments for the reception of lunatics: and, judging from the report of the Metropolitan Commissioners, founded upon evidence derived from their recent visitation tour, not before it is needed. There are, it seems, 20,893 lunatics under confinement in England and Wales, of whom 16,821 are in the condition of paupers. Of this latter number 7,482 are alone provided for in receptacles especially devoted to the insane, the remaining 9,339, remaining in the workhouses, under, for the most part, every possible disadvantage. Even the magnificent establishment at Hanwell, and notwithstanding its dormitories are inconveniently crowded, is unable to supply the wants of the county in which it is situate; for while, in 1843, beds were made up for 1000 patients, the number of lunatics to be provided for amounted to 1429. Altogether there are 166 Lunatic Asylums in England and Wales, of which seventeen only are county asylums, 11 are supported in part by subscription, 1 is a military and one a naval hospital, and 136 are private asylums, licensed by the provincial magistrates or the Commissioners of Lunacy, forty-four of these latter establishments receiving paupers as well as private patients. Add to all this, the very considerable number of persons who are residing in private apartments under the surveillance of a keeper, and submitted to no system of inspection whatever, and of whose numbers therefore no return can be made, and we observe that there is indeed an immense mass of helpless misery to be legislated for. The Report not only demonstrates the lack of accommodation which exists, but the urgent necessity of a more rigid system of inspection. Licensed Asylums, whose management the magistrates have pretended to superintend, have been found by the Commissioners, in many instances, to be most disgracefully conducted: the patients not only being surrounded by the most disgusting filth, but subjected to all the cruelties of the ultra-coercive system, and that at a period when we had fondly imagined the employment of the fetter, the leg-chain, the restraint-chair, and the lash was forever exploded. How slow is the progress of human improvement! It will be recollected that M. Pinel arranges the affections of the brain into four classes, each distinguished by the derangement of some principal function of the organ. Thus there are Lesions of the Understanding; of the External Senses and General Sensibility; of the Propensities and Instincts; and of Voluntary Motion. The first we have already considered, and proceed to pass the others in brief review. CHAP. V. LESIONS OR PERVERSIONS OF THE InstinctS AND The love of life is the strongest of the instincts implanted within our organization; and it is upon it, and upon all tending to encourage its development, that our laws and social institutions are based. But this instinct has its diseased manifestations, just as the understanding has its maladies. All the chimerical fears of hypochondriasm may be produced when its diseased condition is but slight, while, when the perversion becomes complete, we have suicide, a desire for self-destruction, just as imperious as is the instinct of self preservation in a normal condition of the cerebral functions. Or, again, a desire to kill others becomes another symptom of the disease, a homicidal mania actuated by no motive whatever. 1. Hypochondriasis.-The author suggests that as this and similar affec. tions are characterized by exaggerated fears concerning health and life, biophobia would be a more appropriate appellation; and we may thus speak of slight or severe biophobia instead of hypochondriasis, suicidal biophobia, homicidal biophobia, &c. Certainly a worse term than hypochondriasis can hardly be chosen. Of all the causes of this distressing disease, M. Pinel considers an hereditary predisposition as the most prominent, "for if we go back to a period prior to the invasion of the disease, we find these patients, or their relatives, have been capricious, choleric. dull, or merry, without apparent reason, very liable to a variety of nervous ail ments, and that there have been members of the family afflicted with insanity or epilepsy." He regards the disease as essentially an affection of the central portions of the brain, and that the serious accompanying affections of the thoracic and abdominal viscera are but the results of an aggravated degree of this cerebral lesion. 2. Suicide. This species of suicide, resulting from a perversion of the instinct of self-preservation, is to be distinguished from suicide occurring in the insane, consequently upon illusions. Suicide is sometimes, as in the example of puerperal women, an acute affection, the desire of destruction continuing for some days, and then, if its fulfilment has been prevented by active surveillance, passing off and the patient becoming cured. At other times the act has been long premeditated, the instinctive love of life struggling against the effects of the lesion. The torment of an incurable disease, the long wished-for leisure after an active life, the state of mind resulting from an exhaustion and abuse of sensual pleasures, or from the operation of various physical and moral influences, may one and all lead to this imperious desire of self-destruction. Occasionally we see persons surrounded by every comfort and means of happiness, place their affairs in order, take leave of their friends, and destroy themselves-some unperceived circumstance having in them given rise to this perversion of the instinct. Mutual suicide, generally occurring in the case of persons of opposite sex, influenced by love or extreme distress, has become very prevalent in France, to which the injudicious publicity given to these events in the newspapers has doubtlessly contributed. No age seems exempt; for suicide is committed from the age of 12 to that of 80, and the wells at the Bicêtre have been closed in consequence of the increasing propensity among the aged persons for throwing themselves into them. The contagious effect of examples of suicide is indeed well known, and at some periods the affection has become epidemic. The act of suicide is usually preceded for a considerable space of time by some of the various symptoms of hypochondriasis; but after a while the desire of death as a means of escape from real or imaginary misery becomes the dominant idea, and is dwelt upon with pleasure. But months or years of irresolution are sometimes passed in a constant struggle with this propensity, until the physical frame and mental power of resistance are worn out. In the acute form, no matter what the means of death, it is sought with avidity, and sometimes with incredible cunning; but, in the chronic form, some particular mode of destruction is determined upon, and none but it, as well as a certain time, place, &c. will suffice. Perhaps about one-half of those persons who attempt suicide, do not succeed; and the revulsion engendered by the panic they are then seized with, often operates as a, at least temporary, and sometimes permanent means of cure. The author believes modern civilization to be a great encourager of suicide, by reason of the forbearance which it manifests towards those who attempt it, and the notoriety it obtains for them in the public prints. He contrasts with this the rigid laws of the Greeks, Romans, and St. Louis. The disposition to suicide existing in many insane persons has always proved a source of much inquietude to their friends and attendants; and the adoption of the most rigid restraint was long considered as the only safeguard. It will be seen that prevention by this means must be rarely practicable, for the very instruments of restraint have been often converted into means of destruction; and it is a most happy circumstance, that in proportion as coercion of this description has been disused, the proportionate number of cases of suicide has diminished, and the number of cures augmented. This is the concurrent testimony of all modern insane estab. lishments. The Bethlem Report states: "The experience of the last year adds another confirmation to the now generally received opinion, that mechanical restraint is an exciting cause of suicidal propensities; and though it may for a time restrain the attempt, it fosters and strengthens the desire it is intended to control. During the last year, so large a number as 81 patients, or more than 28 per cent. of those admitted, were reported as having suicidal tendencies; and 37, or 13 per cent. had actually attempted suicide prior to admission; and it is highly creditable to the officers of the hospital, and an indisputable proof of the vigilance of the attendants, that no attempt at suicide has occurred during the year. The last case of suicide was that of a female in 1840: no case amongst the males has occurred since 1822. No stronger evidence can be given of the tendency of mechanical restraint to excite suicidal attempts than that supplied from the records of the hospital; from which it appears that during 20 years, from 1750 to 1770, when every patient was under restraint, the suicides were in the proportion of 1 in 202, whereas, during the last 20 years, the proportion has only been 1 in 963." 53. Dr. Conolly's Second Report from Hanwell contains some valuable observations upon this head. "Nine suicidal cases are among the admissions of the past year. It affords gratification to the physician to be enabled to state, that in all of these cases means have been found to soothe and comfort the minds of the patients, and, apparently, to reconcile them to life. Their restraints have in all cases been immediately removed, and in no case resorted to again. They have been watched, so long as it was deemed necessary, during the day, placed in rooms with other patients by night, and frequently visited. Every instrument of danger, or obvious means of self-destruction, has been kept out of their way; and no measure likely to restore cheerfulness has been omitted. This is the general plan resorted to. But in almost every case of this kind the bodily health is manifestly disordered; and when proper remedial means are applied, the propensity to suicide is weakened, or disappears. Redness of the tongue; disinclination for food; irritable bowels; feebleness and emaciation; cold hands and feet; are not uncommon symptoms. In other cases, a loaded tongue, obstinate constipation, and appearances of hepatic disorder, are observed. Both of these descriptions are chiefly applicable to patients between 40 and 50 years of age. When submitted to proper remedial treatment, they commonly improve, although very slowly; the health being usually, or at least often, impaired beyond the hopes of perfect restoration. It is impossible for attention to these patients to be too vigilant, but not at all impracticable to establish such systematic vigilance on the part of the officers and attendants as will afford security. To torment these unhappy patients with bodily restraints, would only fix the morbid determination more deeply in their minds. Disposition to suicide is not uncommon in women at a much earlier age, and is usually associated with some uterine irregularity, to which may be added moral causes of various kinds." 40. 3. Homicide. This is a perversion of the affective faculties, which is often accompanied by a complete integrity of the intellectual powers. It frequently precedes suicide; and, where this is not the case, the homi cide often voluntarily delivers himself into the hands of the law. These cases of motiveless homicide are the most frequent, and to be distinguished from those in which the intellectual powers are perverted, and murder is perpetrated under some delusion. Esquirol, Gall, and other authors, cite abundant examples of each of these forms. This distinction, however demonstrable to the scientific inquirer, has been received with difficulty in courts of justice; and is obviously open in its practical working to abuses. Nevertheless, no fact is better established now than that this impulse to kill may exist independently of delusion, and yet uncontrollable by its unhappy subject, who has been often known to seek the assistance of others to save himself or them when he has found the paroxysm approaching. These persons, if properly watched, and separated from sources of irritation, may frequently become cured of these terrible propensities. Dr. Pinel dwells upon the importance of an improved study of this disease in reference to legal medicine, and records some of the confused and contradictory conclusions the courts of law have arrived at, parallel instances of which could easily be supplied from this country also. Much practical difficulty attends the case. "It is certain that such monstrous actions must at first carry terror into the minds of the administrators of justice, who fear lest every criminal may shield himself under the impunity of these examples. For, often in homicidal mania, as in crime, there is premeditation, hesitation, a consciousness of murder. It is only from the conjunction of circumstances which have preceded, accompanied, and followed the act of homicide, that evidence and conviction of non-culpability, and of the true character of the mania, can be obtained. The physiology of the brain is as yet too recent. Too short a time has elapsed since it has taught us that the affective, like the intellectual faculties, are but the expression of its normal condition, and may become solely the subjects of perversion, just as certain functions of the understanding may-for this knowledge to have penetrated among the masses and become vulgar: but it will do so." 322. 4. As this perversion of the affective faculties may occur as a grave disease in one possessed of his reasoning powers, so may it complicate the condition of those in whom these too have become perverted. Thus it is by no means uncommon in the insane; and it has been observed that those who were, prior to their insanity, of a mild demeanour and good moral conduct, form the majority of the subjects. 5. Incendiary Mania.-Marc pointed out this example of the destructive instinct in 1823, and numerous cases corroborative of the propriety of referring it as the above to the perversion of the affective faculties. The affection is frequently propagated by imitation, and often rages almost epidemically. At the commencement of insanity many patients are seized with the desire of destroying by fire; while, in other cases, individuals, possessed of reason, but of limited capacity, take great delight in committing the act. The following observation was confirmed during our recent trials for incendiarism in many instances. “Individuals of a very limited capacity may be made the instruments of malefactors for the accomplishment of their guilty designs. It is for a trifling reward, a piece of bread, often as a mere joke, that these weak beings allow themselves to be persuaded. They may be termed thoughtless incendiaries. Others |