IMPORTANCE OF EARLY TREATMENT. 29 asylum. Until something serious has occurred, the friends hope in a few days the mind will recover its tone. "Unfortunately, this unwillingness to consider the patient sufficiently insane to be sent to an asylum is not confined to the friends of the patient. There have been instances of the magistrates themselves, from the kindest motives, refusing to grant warrants for the admission of a patient, even after he has been examined by a medical gentleman, who has given a certificate of his insanity, because when brought before them he has been able to answer certain questions correctly. The consequence is that from this delay, instead of returning to his friends in a few weeks, which, in all probability, would have been the case if proper medical and moral remedies had at once been applied, he becomes incurable, and remains in the asylum for life, a burden to the parish. In some instances similar delay has been attended with fatal consequences. "It is sincerely hoped that the knowledge of these circumstances will induce an early application to be made for the admission of patients; as, even if the neglect does not prove fatal, it is contrary to every principle of justice and humanity that a fellow-creature, deranged, perhaps only on one point, should, from the want of the early attention of those whose duty it is to watch over him, linger out his existence separated from all who are dear to him, and condemned, without any crime, to be a prisoner for life.” Dr. F. Hawkins, when speaking on the same subject, says: "The importance or rather necessity of recognizing disorders of the head in their early stage, is obvious from the consideration that they can then alone be attacked with any chance of success. In acute cases the period is brief indeed in which the power of art is available. But whether the case be acute or chronic, it is only in the early stage that its precise nature admits of being distinguished with accuracy. In its further progress, from the extensive sympathies of the brain with all parts of the body, so many functions become implicated, and so various are the symptoms which arise, as to preclude arrangement or classification, and defy the art of diagnosis. The aid which in most other cases the sensations of the patient are capable of affording us is lost to us too soon in disorders of the head, until, in their advanced state, they all resemble one another, and present alike a dreary abolition of the powers of animal life. The period, therefore, is highly precious in which these affections admit of being distinguished with precision or treated with any hope of advantage. Let the physician estimate, in all its vital importance, the grave necessity for prompt treatment and decisive remedial mea-. 1 Croomian Lectures, delivered before the College of Physicians, May, 1829. sures, when satisfied that the enemy is at the gates, and has attacked, or is on the eve of assaulting the citadel! Under these circumstances, hesitation, delay or procrastination in bringing the patient within the range of curative measures, is fraught with the direst results, and with the saddest consequences. Let us not wilfully close our eyes to the premonitory signs, however apparently insignificant, slight, transient and fugitive they may appear, of actual mental disorder and brain disease, for it is in this early stage when so much may be effected by judicious medical treatment to check the advance of the fatal cerebral mischief. Having dwelt at some length on the existence of a precursory stage in all affections of the brain and on the importance of watching for the first threatenings of incipient cerebral disorder, I propose to investigate in detail the general character of the premonitory symptoms of encephalic and mental disease. It will be well, however, to premise that I cannot in this work do more than generalize on this wide and expansive subject. When I address myself, in the succeeding volume, to the consideration of specific types of brain disease it will be my object to enter more elaborately into detail and to point out, as far as practicable, the diagnostic premonitory signs of the various organic affections of the encephalon. Many of the symptoms to which I shall refer as valid evidences of incipient brain disorder will be found common to several lesions of this organ, each presenting an essentially different aggregate group of symptoms, as well as distinctive anatomical and pathological charac teristics. Nevertheless, I am of opinion that a general description or résumé of the incipient signs of morbid conditions of the brain before considering individual forms of cerebral disease, will not be without its practical value and importance. Agreeably to this arrangement, I propose to analyze the subject in the following order: 1. MORBID PHENOMENA OF INTELLIGENCE. 3. MORBID CONDITIONS OF SENSATION. This classification of the subject fully recognizes the three physiological functions of the cerebro-spinal system, viz.: DIVISION OF THE SUBJECT. 5. MORBID PHENOMENA OF SLEEP AND DREAMING. 6. MORBID PHENOMENA OF ORGANIC OR NUTRITIVE LIFE, Viz.: a. Digestion and Assimilation. B. Circulation. In conclusion, r. Respiration. 8. Generation. GENERAL PRINCIPLES OF PATHOLOGY, TREATMENT, AND 31 CHAPTER II. MORBID PHENOMENA OF INTELLIGENCE. THE brain, being the material instrument of the intelligence, the physical medium through which the mind manifests its varied powers, it is rational to infer that no changes in its structure or investing membranes can take place, no alteration in the quality of the vital fluid, or anatomical character or calibre of the numerous blood vessels that circulate and ramify through its substance can exist, without, to some extent, interfering with or modifying its psychical functions. Cases, however, are on record, in which serious injury has been done to the brain during life without apparently damaging the intelligence; and considerable encephalic disorganization (as the result of disease) has taken place, without any aberration, exaltation, depression or impairment of the mind having been observed previously to death. If such cases have occurred they must be considered either of a rare and exceptional character, or as pathological curiosities, unless in every instance the alteration of structure be strictly confined to one hemisphere or restricted to the fibrous or conducting part of the nervous structure, the vesicular matter and its minute vessels remaining intact and entirely free from all morbid change or abnormal modification. Is it possible to conceive any great extent of disorganization even in the medullary portion of the cerebral mass, to exist, without implicating, to some degree, the gray matter of the brain, and as a consequence deranging the phenomena of thought? It is not my intention to discuss in this volume the complex questions (physiological and metaphysical) involved in an analysis of the psycho-somatic relation or union between mind and matter, life and organization. It is sufficient for my purpose to affirm, as a postulate, that all structural lesions of the encephalon, its investing membranes and bloodvessels, are associated with some derangement, modification or altered action of the psychical, motorial, or sensorial functions of the great cerebral ganglion, the πρῶτον Αισθήτηριον, or sensorium commune. Softening of the brain, abscesses, tumors, atrophy, induration, and other forms of cerebral disorganization, have, it is alleged, been discovered in the brain after death, without disordering, or even impairing the intelligence. But are not these to be viewed EMOTIONAL EXALTATION AND EXCITEMENT. 33 as unusual and anomalous pathological conditions, in fact exceptions that prove the rule? If the mental and cerebral condition of those who have been represented to have died of organic disease of the brain, apparently in full possession of their intellectual, sensorial, and motorial powers, had been subjected to a close and rigid analysis, some degree of disorder, or impairment of these functions would, I believe, in many cases have been detected. We are too much disposed to form hasty opinions, and to infer, because the patient talks rationally for a time, on ordinary subjects, is under the influence of no appreciable illusion, hallucination, or aberration, that, therefore, the intellect is unclouded, and the brain in a perfectly sound and normal state; yet such apparently healthy psychical, and cerebral manifestations, are quite consistent with the existence of encephalic disease, impairment, and even of actual latent, and concealed mental aberration; and these conditions of the brain, and mind, would, I believe, be more frequently detected, if sufficient time were devoted to their analytical investigation, and accurate pathological and psychical diagnostic tests were scientifically employed by experts, practically acquainted with the art of examining the subtle phenomena of insanity. It has been observed, "that could we see the interior workings of such intellects, they would be found altered, limited, perverted, or changed in some way from their normal condition, although it may not be discovered in their external manifestations. It should be recollected that there are many oddities which are dependent upon cerebral conditions, but which pass for mental peculiarities, and in this way the disordered actions escape notice. Yet the rule will be found logically true, that wherever there has been discovered the trace of organic cerebral change, there must have been disturbed mental manifestations." In every case of disease of the encephalon, particularly if the organic change or pressure be established in the vesicular matter, or in the membranes immediately investing the brain, a disordered, or abnormal state of cerebro-psychical phenomena may, in the incipient stage, on careful examination, be detected. I now proceed to the investigation of the first, or psychical section of the subject. The mind may be in a state of morbid 1. EXALTATION. 2. DEPRESSION. 3. ABERRATION. 4. IMPAIRMENT. These conditions of unhealthy intelligence exhibit in their origin, progress, and termination, a variety of shades and degrees |