A Plea for the Scientific Study of Insanity
Authors: J. B. Tuke
Journal: BMJ (1891)

Care of the Insaiie.hlistory of the Study of Insanity.-TheReliance placed on Psycho- logy.-ItsInszsfficiency as a Basis for the Study of Insanity.-Insanity a Symptom prodluced by many Morbid Conditions.-The Etiological Method of Investigation.-Illustrated by the Study of Over-excitation.-PhysiologicalI1.ypercemia of the Cor- tex.-Transition to a Patholoqical Condition.-TheLymphatic Stystem.-Mania and Melancholia related to the Intensity of the P'athological Process.-Secondar.yDisturbances of Brain Nutrition.-Treatment.-TheDangers of Amusements.-TheNeed for Well-trained Hospital Staffs.-Hfospitalsfor the In- sane.I COmE to ask you to consider a question of the highest im- portance, not onily to the medical profession, but to the public aIt large; that qluestioni is, Does tlle studly of insanity occupy that position ini the realm of medicinie which it ought to occupy?In my opiniioni it does not; it does not stand on the same level as other departments of medicine, and is regarded by the profession and the public as in a great measure dis- associated from theni.It las been often said that general and so-called psycliatric mediciine stand divorced.With tllis statement I cannot agree, for the simple reason that I do not believe the two have ever been formally joined in the bonds of matrimony; and the object of this address is to sh1ow, first, the causes aild consequences of separation; secondly, how union may be brought about, and the results whlichl may be anticipated from it.The main reason why this union lhas never occurred is that tlhe study of insanity lhas Inot been conducted on tlle same principles as those oIn which general medicine has been founded.Anatoiny, plhysiology, and patlhology have been almost, if not entirely, ignored; and psychology lhas afforded, in association witlh clinical imp)ressions, the institutes of so- called psychiatric mediciine.Brief reference to the Ihistoiy of the subject will enable us to understand how this has come about.The study of insarity in any form is barely a lhundred years old.The revulsion of public feeling against the system of cruelty and neglect under which the insane had suffered for centuries produced at the end of the last century a great change in their condition.The large proportion were rele- gated to asylums, wlhere for the first time they came under the supervision of medical men.Almost inevitably the prominent symptom-mental aberration-forced itself on the minds of these observers, and their patients grouped them- selves according as the prominent symptoms were exaltation, depression, or obfuscation of feeling.Nomenclature was based entirely on psychological considerations, and, although a large variety of suclh classifications were advanced, they all resolved themselves practically into the one enunciated two thousand years before by Hippocrates.The vaiieties of in- sanity were considered under the terms mania, melancholia, and dementia, whichl, to all intents and purposes, assumed, in the mind of the profession aind the public, the position of diseases.This position of matters necessarily served to con- centrate attention unduly on the psychological aspect of the condition, and to keep in the background the study of the physical conditions, of wlhich the mental aberrations were mere symptoms.The one exception to this rule was general paralysis of the insane, which was marked off as a distinct pathological entity, possessing a fairly consistent etiology, symptomatology, and pathology.So strong was this psycho- logical influence, and so long did it continue unchecked, that we find in the Official Nomenclature of Diseases drawn up in 1871 by a Joint Committee of the Royal College of Physicians of London, all the insanities (general paralysis included) ranged under the head of Disorders of the Intellect, of wlich six were enumerated-mania, melancholia, dementia, para- lysis of the insane, idiocy, imbecility.Surely notlhing could show more thorouglily to what an exorbitant extent psyclhology lhad dominated the study, and had inf{luenced the pro- fession, than this forinal renunciationi of any connection betweeln disease and insanity on the part of suchl an important medical body, whichl empphasised its opinion by designating the insanities " disorders."Thaniks to the works of Van der Kolk, AMorel, and certain members of the Scottislh school, this nosology was materially clhanged in the issue of 1881, when the same body advanced a fairly good, althlough somewhat confused, system of nomenclature, based partly on etiology, partly on psychology, and partly on clinical cen- siderations.