The Delusions of the Insane: Their Real Nature as a Means of Diagnosis
Akt. VII.? :Author: Jambs George Davey, M.D., BRISTOL.
The object of the following- remarks is to call attention to a circumstance of not infrequent occurrence, and of a nature calculated to interfere with that harmony of feeling and reci- procity of action so desirable as between the asylum pro- prietor or superintendent and the official inspectors, the visiting magistrates more especially.
My experience as a proprietor of a private asylum has extended over a period of twenty-three years about, and from time to time a question has been raised as to the insanity of a patient under my care. This question I have ever found has been hedged around with certain views so purely artificial, and so far away from the laws of mental science, that it has been quite impossible for me to accept the conclusions arrived at by the visitors; or, in other words, to agree with the advice given? involving, it may be, the removal or discharge of the patient. Such cases are more than likely to occur where the visiting justices include a gentleman who has been, or is, of the legal profession. The visiting magistrates with whom I have been officially concerned did through long years include a retired barrister; one who dearly loved his old calling, and looked to the law of lunacy, as reflected in the too famous Questions and Answers of the Peers and Judges, bearing date 1842, as all-important and truthful. Now the gentleman referred to did some good service in his time, and promoted by his zeal and praiseworthy efforts?made some twenty odd years since ?the good cause of the insane in many particulars; therefore I can desire only to speak of him with due respect. In these remarks it will be seen that no allusion is made to the Com- missioners in Lunacy, nor to the many among the visiting magistrates, from whom I have to acknowledge the reception of much courtesy and consideration; but to one only of the latter, whose duty it is to inspect asylums beyond the more immediate jurisdiction of the first-named.
As I have said, a question has been raised, from time to time, covering my residence at Northwoods, as to the insanity of a patient under my care; and in each instance of the kind some unpleasantness has arisen. If, as is too likely to happen, a difference of opinion has begotten discourteous, if not angry words?if each visit made or examination gone into Las provoked feelings the reverse of friendly?-if whatever confidence on ‘either side towards the other existed has dimin- ished, even in a small degree?it is, of course, most desirable to recognise, with no loss of time, the cause or starting-point of such ” difference of opinion,’’ with the view to its removal. The annexed case of A. B. (so to designate it) is a good example of the ” question ” referred to, because it takes in, on the one side, the legal fiction comprised in this same ” Law of Lunacy,” whilst, on the other, it ignores those teachings of medical science with which psychologists are familiar. I may premise?the question of the insanity of A. B. was decided in the negative, because only she manifested no positive or satisfactory sign of ” delusions.’’
A. B. was admitted at Northwoods in the usual formal manner?that is to say, the ” order ” and ‘? statement,” as well as the ” medical certificates,’’ were all as the law requires. The facts of the case were duly set forth in the proper place; the indications of impaired mind were registered, i.e. the several signs of insanity, as they were revealed to me, were recorded after the most approved manner. In my report of A. B. on her admission are seen these words: “She appears on first looking at her to be free from mental dis- order; but there are various small yet conclusive ways in which she reveals the presence of much cerebral mischief.” It is added, in due course, ” She lefuses her food, and much difficulty is experienced in feeding her. There is great ema- ciation. Through the night A. B. is restless and sleepless. She will persist in retaining her urine so long and so per- sistently that the catheter is of necessity brought into request. Her state is one of childishness; she requires much looking after, and urging to the simplest acts of attention to her own immediate wants. Without the slightest force of character, with an apathy which nothing can overcome, and which infuses itself into each act of her existence, she will, as the general rule, neither eat nor drink, neither get up nor go to bed, neither go out nor return when out, neither dress nor undress, and so on in everything. Her capricious wants and morbid fancies so press on her and influence her for evil that much and constant care and management are required.”
Such a form of words was held to be unsatisfactory and inconclusive. The visitors, urged thereto by the retired lawyer before referred to, would regard A. B. as one sane and fit to be discharged. After several long and tedious visits, and after much not very agreeable correspondence, the visitors incurred the responsibility of discharging my patient; and so it turned out that a much afflicted lunatic was removed from the necessary care and control to the family circle, wherein those nearest and dearest to each other?including the patient?were rendered, for a time, really miserable. A. B., said the visitors, is nowhere stated to have had delusions; such are not proved to have been present during her stay at North woods, or not until a certain time subsequent to the commencement of our especial enquiries into the state of mind of A. B. We therefore take leave to doubt their presence altogether.
This statement was not, indeed, what may have been looked for; but with matters of a personal character this paper has nothing to do.
My case book records this fact, viz. A. B. is discharged by order of the visitors, it being their opinion that she was and is not of unsound mind, but simply nervous; but very opposite are the expressed opinions of the family medical attendant, the mother, and of myself.
The present is an opportunity too good to be lost, inasmuch as it illustrates very clearly the antagonism of law and medicine ?of lawyers and doctors. The whole case may be used, and rightly used, as a sign or index of the present bad times, and as evidence in favour of other and more truthful views in regard to asylums and the insane.
The retired lawyer had, doubtless, his excuses; he was trained in the law’s defects and very shortcomings, and what could have been expected of him else than that we have seen. He confined his attentiou to the state of the ” consciousness ” of A. B. He looked no further or deeper down than the state of the knowing faculties. He asked himself thus : Is the lady before me ” able to distinguish right from wrong ” ? and so on. Convinced of the soundness of Leonard Shelford’s teachings ” Concerning Lunatics,” Mr. declared that a ” sound mind is one wholly free from delusion; an unsound mind, on the contrary, is marked by delusion.” In other words, ” the true criterion, the true test, of the absence or presence of insanity ” …” may be comprised in a single term, namely, delusion.” In ignorance of the mind in a state of health, he was unable to appreciate the many and diverse springs of human thought and action. The strong affections of our being, their force in moulding the character, their ever-widening influence over the speech and actions of man, now moving him to virtue and now to vice, and putting him, ever and anon, away from or outside the fair promptings of his mere knowledge of things, these were as nothing in this lawyer’s comprehension. It could not take in the first cause of that master passion concerning which Pope sang so charmingly and so well; and whereby one man is seen to realise the merits of an Oberlin, a Melanchthon, a Basil Montague, or a Howard, and another the demerits of a Pope Alexander, a Palmer, the Eighth Henry of England, or a Eajah of Bitpoor.
Furthermore, it did not, as the result in good part of a defective training, take in the prime fact, to be proven each succeeding hour by a really thoughtful man, that the ever- active sympathies or emotions of our being, rather than the crude measure of our intellects, it is which go to form our likes and dislikes, our preferences for this or that. Doubtless the like or the wish is ever the father to the thought. The vain wish?the vanity?which is said to have prompted the Prince Henry to ” hunger” for his father’s ” empty chair” ere even his ” hour was ripe,” and in spite of the knowledge of those kingly cares of ” Henry IV.,” which ” had fed upon his body ” and ” eat the bearer up,” affords a strong example of the fact. An equally apt illustration of the workings of the emotional mind is seen portrayed in the lad Walter, ? Uncle Sol’s kind friend,” the ” master passion,” i.e. the affections, in whom are thus eloquently referred to:
” As Walter sped along, intent only on the distress and anxiety of his kind relative, everything seemed altered. _ There were the usual entanglement and noise of carts, drays, omnibuses, wagons, and foot passengers; but the misfortune that had fallen on the wooden mid- shipman made all things strange and new. Houses and shops were different from what they used to be, and bore Mr. Brogley s warrant on their fronts in large characters. The broker seemed to have got hold of the very churches, for their spixes soaied into the sky with an unwonted air. Even the sky itself was changed, and had an execution in it plainly.”
It is evident that Shakspeare and Dickens read the human mind aright; with such a knowledge of its healthy charac- teristics as these great men have displayed, it is very unlikely they would have fallen into the error in regard to the exist- ence or not of delusions among the insane now complained of. If it is important in every case of doubtful insanity to accept as the groundwork of our enquiry the knowledge thus indicated, in regard to the mental operations, as they occur to the sane, then indeed may lawyers extend their studies to the poets and novelists?accepting, as we may, the two here named as the highest type of their respective excellences.
Having regard to the facts of the case here considered, what hope remained that the retired barrister would do else than repu- diate the ” emotional theory of insanity ” ? That we accept it as the basis of our reasonings, and as the starting-point of our many means of control of our patients, is not infrequently urged as a proof of its importance. Vain indeed are our endeavours to persuade some that neither ” consciousness ” nor the ability to distinguish right from wrong constitutes any- thing like a reliable test of either the sanity or the responsibility of an individual; in other words, that the state of the knowing and reflective faculties is an indifferent criterion of a sound mind and of man’s power to duly control himself. It is to be feared that that time is yet looming in the distant future when the many outside our speciality, yet near to and touching us in virtue of their office-bearing, will see that the great majority of those really insane are so because only their moral natures, i.e. their affections, have taken on either an exalted or abnormal action ; and that this state of tilings it is which, as the rule, constitutes the very pith and substance of mental disorder in each one of its many varieties.
However it well becomes us to hasten, as best we can, the . advent of truth; and to demonstrate the grounds on which psychologists affirm?
1st. That the history of mental disease is the history, for the most part, of a perverted moral sense, the cause of which is to be found in either grief, disappointment, fright, losses in business, domestic trouble, anxiety, and so on.
2nd. That insanity has first manifested itself in the patient by some unusual or capricious state of the feelings or emotions, some excessive indulgence of the passions or propensities, con- stituting rather an exaggeration than an alteration of the natural character, the knowing faculties remaining unaffected. 3rd. That the first person who becomes aware or conscious of the impending affliction is the sufferer himself; and that, knowing it, he strove, but in vain, to hold onto his self-control, so fast receding from his grasp.
4th. That if delusions, so called, make their appearance in the course of the malady (a matter by no means certain) these are found harmonising with some dominant and deranged feeling or emotion or propensity, constituting the mere effect of a pre-existing cause.
5th. That if in the absence of the necessary care and con- trol, any criminal act is attempted, the same ought to be looked upon as an indication, not of an impaired understanding, not of an inability to distinguish right from wrong, but of a temporary and abnormal excess of emotion or passion, whereby all con- trolling power is lost, and the patient is reduced to a mere automatic or machine-like existence.
6th. That if recovery succeeds to all this, then will it be observed that its approach is marked through the feelings or affections; that their unusual or capricious state becomes ” small by degrees and beautifully less,” until the natural character is yet again reached.
There can be no kind of difficulty in coming to these several conclusions, if it be borne in mind that the many primitive faculties of the mind having their seat or location in just as many portions of the grey matter of the convolutions, it must follow that each one of such primitive or indecomposable faculties?whether or not they relate to the emotional or intel- lectual man?must depend for its healthy manifestation, or otherwise, on the especial tone or quality of a distinct portion of brain matter; and, in this case, it follows that the in- dividuality or peculiar nature of any given case of cerebro- mental disorder will be dependent on what distinct portions of the brain or on what ” organs” are attacked, their number and size. For example, those parts or portions of grey con- voluted matter underlying* the several primitive faculties, known as self-esteem^ or pride, venevcition} and clestvuctiveness, may each of them take on an exalted or depraved action, may become diseased, and ultimately reach so great and painful an intensity that the speech and actions of the patient may over- come all bounds, and realise the common features of acute mania. Now the first sign or symptom of disease so located is expressed by an unusual and extraordinary display of either pride, religious enthusiasm, or anger. If the abnormal action continue unabated, it may or may not happen that a delusion will become superadded to the first indications of mental de- rangement, constituting, as it were, an apology for the osten- tatious deportment, or fanaticism, or extieme anger, or cruelty of disposition. In each of the instances imagined the delusion is seen to be in harmony with the preceding and morbid affection of a part or ” organ of the brain, and not only so, but to express the especial puipose or function of such ” organ.” It is on these grounds we come to appreciate, as we should, the thousand and one delusions of madmen, their vain imaginings and assumed personifications, and to reg’ard them as so much morbid colouring, devised or accepted volun- tarily, for the most part, for or on behalf of their deranged moral feelings, or?which is much the same thing?as a real and tangible ideal of their several innate, involuntary, and morbid impressions. If, as has been shown, the sane man?him in the exercise of the mens scina in corpore sctno?is not proof against the strong influence of his emotions over the intel- lectual powers, it must not be expected that the insane man? him with the unsound mind?is proof against the same emo- tions, or has not his intellect more and more deeply tinged by his passing loves and joys, his surging hopes and wild ambitions. 94 THE delusions op the insane.
However, both theory and practice go to show that a ” delu- sion ” regarded as a symptom or indication of insanity is most uncertain; that when found to exist, it is, not infrequently, temporary only; and that whilst it may complicate an early and mild cerebral affection, it may not be present in brain disease of long standing and of much severity.
It is now thirty years since I penned these words, viz.: ” A delusion, so called, holds much the same relation to the insane mind as a simple prejudice does to the mind of bim said to be in the enjoyment of one sane and healthy. The delusion, like the prejudice, does not, or need not, imply a bona fide belief; they are alike thus far, they indicate the presence of some innate and dominant affection or passion wherewith the psy- chical nature of both, the sane and insane, is imbued.” …. ” In fact, this delusion test is altogether a fallacy; a large number of insane persons are without delusion of any kind, have been insane five, ten, or fifteen years, but during the whole period of their disorder have not manifested anything like a delusion. This mere symptom of cerebro-mental disease is not always present, and when it does show itself, it very much more commonly than otherwise expresses only the nature of the predominant feelings in the patient; and with these it is always in harmony, as cause and effect are ever seen to be.” …” An insane female, once under my care, was remarkable for the very high opinion she had of herself; her self-esteem it was which gave the character to her deep and long-standing- affliction. This patient called herself a Queen ; she would not infrequently occupy herself in marking her apparel ‘ V. R. Buckingham Palace.’ After devoting much care to this self- imposed task, she would be very angry, and express considerable annoyance at what she called her stupidity. This old lady seemed so to indulge her delusion as to exhaust it. With her pride was a prejudice, and thus she deluded herself. That she ever believed herself a queen I never could persuade myself. In fact, I have taken, at various times of my life, considerable pains to get at the real state of the minds of patients said to have delusions of different kinds, and I am induced to conclude that, in by far the majority of cases, they do not themselves believe in the delusions attributed to them.”
It would be more than ungracious were I to omit the fact that reformers?aye, and good ones?are to be found in the ranks of the lawyers. The minds of a few such are of a widely different calibre to that of the retired barrister so often referred to. A reference to the famous trial of McNaughten, for the murder of Mr. Drummond, shows that the present Lord Chief Justice Cockburn, who in 1843 conducted the defence of the delusions of the insane. 95
McNaugliten, acting under the authority and guidance of our profession of, for instance, the late Dr F. Winslow, Spurzheim, Combe and Ray?dissented entirely from the views made public by the peers and judges, in the several Questions and Answers already alluded to, and echoed to even this present time. In the defence of the prisoner, these words occur: ” It is now I believe, a matter placed beyond doubt that madness is a disease of the body, proceeding from the cerebral organisation; ?rirl tint the knowledge of the disease can only be precisely and accuratelv ascertained by those who have made the study of this disease, and of its pathology, the object of long reflection, of diligent investigation, and of attention and experience ” How can we ” it is asked, ” who are brought into contact only with thp sane?how can we be competent to judge of the nice and shadowy distinctions which mark the boundary Une between mental soundness and mental disease… . . ank God, continued the Lord Chief Justice, ” science and humanity have reached the dreary abodes of those miserable beings-the insane ; and whilst the one has poured the ba m of consolation into the bitter cub the other has held the light of science over our hitherto imperfect knowledge, lias ascertained the true existence of the diseise, and has marked its boundary in order to the restoration of the sufferer.” . ? ? ? “Propositions and maxims arose during the times of ignorance-and thus alone can I explain the crude maxims, inapplicable to all the forms of the disease, which are everywhere laid down. He added t The insane, though phrenzied at the time on one point, may show the highest degree of subtlety on that point, and be in the full possession of the ratiocinative powers upon every other point. The madman may, in carrying out his fell purpose, not only show himself perfectly aware of the nature of right and wrong, and in every way competent to manage his own affairs, and dis- cbarge all the relations of life, but will in so doing exhibit all the skill forethought, subtlety, and cunning of an individual in the -possession of his ordinary faculties.”
The entire aim of this successful defence of McNaugliten was to prove that, the human mind being compounded of many primitive faculties or powers, any one of them is liable to derangement?the remainder preserving more or less their normal state of being; and if so, it must happen to us to witness examples of, say, a becoming self-respect degenerate into a deplorable and absorbing egotism and pride; the mild and fascinating demeanour of the sincere Christian exchanged for the rancour and intolerance of fanaticism; a necessary caution or prudence pass into a painful and uncontrollable timidity and suspicion; and so on to the end.
The late Lord Erskine lias given to the world very similar testimony against the theories embraced by the Law, and in favour of Nature as we have come to read it. When discussing the legal aspect of insanity, so to speak, we find these words, viz.: ” If a total deprivation of memory is intended to be taken in a literal sense of the word?if it is meant that to protect a man from punishment he must be in such a state of prostrated intellect as not to know his name, nor his condition, nor his relation towards others?that, if a husband, he should not know he was married, or, if a father, could not remember that he had children, nor know the road to his house, nor his pro- perty in it?then no such madness ever existed in the world.” … . “It is idiotcy alone which places a man in this helpless condition, where, from an original mal-organisation, there is the human frame alone, without the human capacity.” …. ” Among the insane there are those who have not only had the most perfect knowledge and recollection of all the relations they stood in towards others, and of the acts and circumstances of their lives, but have been, in general, remarkable for their general intelligence, their subtlety, and acuteness.” …. ” Reason is not driven from her seat, but distraction sits down upon it along with her, and holds her trembling upon it, and frightens her from her propriety.”
How certainly do the words of the great lawyer named remind us of the piteous exclamation of Coleridge, ” There is no hope for me ; my case is a species of madness, only that it is a derangement and utter impotence of the volition, and not of the intellectual faculties! “
Moore and G-eorge Eliot have, it would seem, realised the same too painful position of Coleridge in the persons of Zuleika and Hetty Sorel. In the poet’s charming descrip- tion of his much-loved heroine we find these few yet eloquent words, viz. :
” The mind was still all there, but turned astray : A wand’ring bark, upon whose pathway shone All stars of heaven save the guiding one.” Those acquainted with George Eliot’s ” Adam Bede” will, without doubt, recognise in the highly wrought confession made to Dinah, and put by the author, or rather authoress, into the mouth of the unfortunate Hetty, a kindred ” mind turned all astray,” and ” wandering with no guiding star” towards its inevitable and sad doom.
One word more?if the preceding remarks will help the removal of one source of misapprehension on the part of those to whom we, or many of us, owe an allegiance; if what has been said will promote the acceptance of a more correct estimate of the nature of the ” delusions” of the insane under our imme- diate care, and render more easy and clearer the diagnosis of madness?then surely may we anticipate a more desirable and pleasant relationship, and a better understanding, as between the ” Visitors ” and ourselves. Moreover, when this much has been attained, it will follow that the removal or discharge of patients from our care will find a better excuse and a fairer explanation than is now occasionally found in the mere absence of ” delusions,” so called, in him or her insane.
NO. I.?NEW SERIES. H
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